Exhibits

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Check capillary refill on bilateral upper extremities.

Administer ondansetron 4 mg IV.

Inspect the bandage for drainage.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Based on the provided information, here are the interventions the nurse should perform:

Check capillary refill on bilateral upper extremities. - Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
Administer ondansetron 4 mg IV. - Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
Inspect the bandage for drainage. - Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.

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Correct Answer is A

Explanation

Choice A rationale

The patient vomiting at home for 3 days prior to surgery is crucial information that the PACU nurse should report. This could indicate a pre-existing condition or complication that needs to be addressed in the patient’s post-operative care plan.

Choice B rationale

While the patient refusing to take ice chips despite complaining of dry mouth is an important observation, it is not as critical as the patient’s pre-operative condition (vomiting for 3 days). The refusal of ice chips could be addressed through patient education and encouragement.

Choice C rationale

The presence of peripheral pulses and full range of motion in both legs is expected and normal in a post-operative patient, unless there were complications during surgery that could affect these observations. Therefore, this information, while important, is not as critical as the patient’s pre-operative condition.

Choice D rationale

The condition of the patient’s abdomen (soft, bowel sounds absent) and the absence of bleeding on the dressing are expected observations in a patient who has undergone an exploratory laparotomy. These observations, while important, do not provide additional critical information that the PACU nurse should report.

A. Advise the parent to reduce the infant’s fruit intake for 24 hours. B. Recommend the parent to clean with soap and water at each diaper change. C. Instruct the parent to change the child’s diaper more frequently. D. Encourage the parent to apply lotion with each diaper change.

Correct Answer is C

Explanation

Choice A rationale

Reducing the infant’s fruit intake for 24 hours is not the best approach in this situation. While certain fruits can cause diarrhea, the parent reports no signs of watery stools. Therefore, this intervention may not address the issue of the red and raw diaper area.

Choice B rationale

Cleaning with soap and water at each diaper change can actually worsen the condition. Soap can dry out the skin and disrupt the skin’s natural barrier, potentially leading to more irritation. It’s generally recommended to use water and a soft cloth, or a gentle non-soap cleanser, to clean the diaper area.

Choice C rationale

Changing the child’s diaper more frequently is the most appropriate intervention. A wet or dirty diaper can irritate the skin, leading to diaper rash. By changing the diaper more often, the skin is kept clean and dry, which can help the rash heal.

Choice D rationale

Applying lotion with each diaper change is not typically recommended for diaper rash. Some lotions can contain fragrances or other ingredients that can further irritate the rash. Instead, a barrier cream or ointment, such as one containing zinc oxide, is often recommended.

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Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?

Correct Answer is C

Explanation

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Exhibits

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.