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A nurse is contributing to the plan of care for an adolescent client.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Diazepam can cause side effects, especially drowsiness, even with a single dose.
B. One of the common side effects of diazepam is drowsiness, and the client should be advised not to operate heavy machinery or engage in activities requiring alertness until the effects are known.
C. Avoiding foods that contain tyramine is more relevant for certain antidepressant medications, not diazepam.
D. Grapefruit juice is known to interact with certain medications, but it does not inactivate diazepam.

A. High BP and low pulse rate B. Low BP and high pulse rate C. High BP and high pulse rate D. Low BP and low pulse rate

Correct Answer is B

Explanation

A. Hypovolemic shock typically results in low blood pressure (BP) and a compensatory increase in pulse rate to maintain cardiac output.
B. Low BP and high pulse rate are characteristic findings in hypovolemic shock, reflecting decreased circulating blood volume.
C. High BP is not a typical finding in hypovolemic shock; the BP tends to decrease due to reduced blood volume.
D. Low BP and low pulse rate are not consistent with the compensatory response seen in hypovolemic shock.

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A nurse is contributing to the plan of care for an adolescent client. Exhibits Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.

Nursing Test Bank

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A nurse is contributing to the plan of care for an adolescent client.

Exhibits

Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.