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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 C

Explanation

A. The dosage of opioid narcotics is not unlimited and should be carefully titrated to the client's pain level.
B. Opioid narcotics are not restricted solely due to the risk of addiction, especially in end-of-life care where effective pain management is a priority.
C. This statement emphasizes the importance of maintaining a stepwise approach to pain management, preserving options for effective pain control.
D. The use of opioid narcotics is not restricted solely to when death is imminent; it depends on the client's pain and symptom management needs.

A. Instruct the client on use of call light. B. Apply an ambulation alarm to the client’s leg. C. Apply restraints to the client PRN. D. Raise the four side rails of the client’s bed. E. Check on the client hourly

Correct Answer is ["A","B","D","E"]

Explanation

A. Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B. Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.

C. Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D. Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.

E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at the end of life. The client’s partner is concerned about using opioid narcotics to manage the client’s pain Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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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.