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 ["A","D","E"]
Explanation
A. Vitamin A plays a role in the development and maintenance of epithelial tissues, promoting wound healing.
B. Vitamin B12 is important for nerve function and red blood cell production but not directly related to wound healing.
C. Vitamin D is essential for calcium absorption and bone health.
D. Vitamin C is essential for collagen synthesis, a key component of connective tissue and wound healing.
E. Vitamin E acts as an antioxidant and may contribute to tissue repair.
Correct Answer is D
Explanation
A. While discomfort can occur, it is not an expected or acceptable part of end-of-life care. Effective pain management is a key priority, and discomfort should be addressed promptly to ensure the client’s comfort and dignity.
B. While true, this statement does not directly address the expectation of discomfort at the end of life.
C. While pain can be present in older adults, the statement does not specifically address the end-of-life context.
D.Fear of addiction is a common concern among clients and families, even at the end of life. Nurses should educate clients and families about the importance of managing pain effectively and emphasize that addiction is not a concern when opioids are used appropriately for end-of-life care. This helps alleviate anxiety and encourages adherence to prescribed pain management regimens.
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