A school nurse is assessing a child and notes various bruises on the child's body that are unexplained. Which of the following actions should the school nurse take?

Arrange for a meeting with the child's guardians tomorrow.

Notify the president of the school board.

Ask the child's peers about the bruises

Report the findings to child protective services.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Arrange for a meeting with the child's guardians tomorrow: Meeting with the guardians may be appropriate later, but initially, the nurse must follow mandatory reporting laws. Waiting to meet could delay protection for the child and place them at further risk.

B. Notify the president of the school board: Reporting to school administration does not replace legal obligations to report suspected child abuse. The school board president is not the appropriate authority for immediate child protection.

C. Ask the child's peers about the bruises: Questioning peers is inappropriate and could violate privacy or compromise the investigation. The nurse should not attempt to investigate the situation personally.

D. Report the findings to child protective services: As a mandated reporter, the nurse is legally required to report any suspected child abuse immediately to child protective services. This action ensures the child’s safety and initiates an official investigation.

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

Explanation

Rationale:

A. Magnesium sulfate: Magnesium sulfate does not have significant interactions with warfarin and is not contraindicated. It can be safely administered with appropriate monitoring, making it safe in this context.

B. Ibuprofen: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding when taken with warfarin. It inhibits platelet function and can potentiate anticoagulation, making it contraindicated.

C. Cetirizine: Cetirizine is an antihistamine that does not significantly affect coagulation or interact with warfarin. It can be safely used with warfarin under normal circumstances.

D. Gingko biloba: Gingko biloba can increase the risk of bleeding by inhibiting platelet aggregation. Clients on warfarin should avoid herbal supplements like gingko that can potentiate anticoagulation effects.

E. Aspirin: Aspirin has antiplatelet effects and can significantly increase the risk of bleeding when combined with warfarin. Concurrent use is generally contraindicated unless specifically approved and closely monitored by the provider.

A. Crusting of exudate on the incisional line B. Mild swelling under the sutures near the incisional line C. Partial separation of the upper part of the incisional line D. Pink-tinged coloration on the incisional line

Correct Answer is C

Explanation

Rationale:

A. Crusting of exudate on the incisional line: A small amount of dried exudate forming a crust along the incision is a normal part of the healing process and typically does not indicate infection or complication. It protects the tissue underneath and usually resolves with routine hygiene, so it does not require immediate reporting.

B. Mild swelling under the sutures near the incisional line: Mild localized swelling is expected in the early postoperative period due to inflammation and tissue repair. This is a common finding and generally resolves as healing progresses, making it a normal assessment observation.

C. Partial separation of the upper part of the incisional line: Partial dehiscence is a serious complication that can lead to infection, evisceration, or delayed healing. This finding requires prompt notification of the provider for immediate intervention, which may include wound closure, protective dressing, or surgical management.

D. Pink-tinged coloration on the incisional line: Light pink coloration along the incision indicates normal healing and adequate perfusion of the tissue. It reflects healthy granulation tissue formation and is expected in the early stages postoperatively, so it does not require urgent reporting.

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Body System	Findings
Neurological	Reports that dizziness and palpitations started 2 months ago. Alert and oriented to person, place, and time
Cardiovascular	Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally. Capillary refill time 5 seconds for all extremities. Reports no pain with palpation of thorax.
Respiratory	Fatigue and dyspnea with exertion started 1 week ago. Lungs clear to auscultation bilaterally
Vital Signs	Heart rate 105/min Respiratory rate 20/min Blood pressure 164/92 mm Hg Oxygen saturation 96% on room air

A school nurse is assessing a child and notes various bruises on the child's body that are unexplained. Which of the following actions should the school nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for warfarin. When reviewing the client's current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply)

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

Explanation

A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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