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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 D

Explanation

A. The duration of time in the bathtub should be based on the client's tolerance but should not exceed 20 minutes.
B. Water temperature should be warm but not excessively hot to avoid burns or discomfort.
C. Bath oils can make the bathtub slippery and increase the risk of falls. They should be avoided.
D. Providing non-slip bath strips enhances safety and helps prevent the client from slipping in the bathtub.

A. "Let's talk about what activities you are going to participate in tomorrow." B. "This is something you should discuss with your parents when they return." C. "You need to focus on getting better instead of what may or may not happen." D. "Let's talk about it. Tell me more about what you are thinking."

Correct Answer is D

Explanation

A. Avoids the child's question and deflects to a future topic.
B. Defers the conversation and may not address the child's immediate concerns.
C. Minimizes the child's feelings and concerns about the future.
D. Encourages open communication and allows the child to express feelings and fears.

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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.

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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.