A nurse is contributing to the plan of care for an adolescent client.
Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.
Provide oxygen at 6 L/min via nasal cannula.
Apply cold compresses to joints.
Perform passive ROM exercises.
Administer IV fluids
Obtain consent for a blood transfusion
Restrict fluid intake to 1,400 mL/day
Administer meperidine
Encouraging bedrest
Correct Answer : B,C,G,H
A. Providing oxygen at 6 L/min via nasal cannula is not indicated based on the information provided. The client denies shortness of breath, and vital signs are within normal limits.
B. Applying cold compresses to joints can help reduce swelling and alleviate pain in the extremities.
C. Performing passive range of motion (ROM) exercises is appropriate to maintain joint flexibility and prevent contractures.
D. Administering IV fluids is not explicitly indicated based on the information provided. Fluid management should be individualized based on the client's condition and underlying factors.
E. Obtaining consent for a blood transfusion is not necessary unless the client has severe anemia or bleeding.
F. Restricting fluid intake to 1,400 mL/day may cause dehydration and electrolyte imbalance.
G. Administering meperidine (a narcotic analgesic) may be considered for pain relief.
H. Encouraging bedrest is appropriate to minimize joint stress and promote healing, especially when there is pain and swelling in the extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
To answer this question, we need to use the formula:
mL = (dose ordered / dose available) x mL available
Plugging in the values from the question, we get:
mL = (50 mg / 25 mg) x 5 mL
mL = 2 x 5 mL
mL = 10 mL
Therefore, the nurse should administer 10 mL of hydroxyzine oral suspension.
Correct Answer is D
Explanation
A. DIC is not a genetic disorder but is often secondary to other conditions.
B. In DIC, platelet count decreases rather than increases.
C. While heparin may be used in the treatment of DIC, it is not a lifelong therapy, and its use depends on the specific clinical situation.
D. DIC involves abnormal coagulation, with consumption of clotting factors and fibrinogen, leading to both bleeding and thrombosis.
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