The nurse is continuing to care for the adolescent.
Admission Assessment
1400:
Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.
Which of the following prescriptions should the nurse anticipate from the provider?
Elevate the right leg above heart level.
Prepare the adolescent for surgery.
Remove the splint.
Apply ice to the affected extremity.
The Correct Answer is B
A. Elevate the right leg above heart level. This is contraindicated for the adolescent because elevating the leg above heart level can increase blood pressure in the injured area and worsen bleeding and swelling.
B. Prepare the adolescent for surgery. This is anticipated for the adolescent because they have an open fracture with bone displacement, which requires surgical intervention to reduce the risk of infection and complications.
C. Remove the splint. This is contraindicated for the adolescent because removing the splint can cause further damage to the bone and soft tissues and increase pain and bleeding.
D. Apply ice to the affected extremity. This is contraindicated for the adolescent because applying ice can decrease blood flow to the injured area and impair healing and sensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A is correct because ginger tea is an herbal remedy that has been shown to reduce nausea and vomiting in pregnancy.
B is incorrect because ginger tea does not have any effect on breast tenderness, which is a common symptom of pregnancy caused by hormonal changes.
C is incorrect because ginger tea does not have any effect on headaches, which can be caused by various factors such as dehydration, stress, or caffeine withdrawal in pregnancy.
D is incorrect because ginger tea does not have any effect on urinary frequency, which is a common symptom of pregnancy caused by increased blood volume and pressure on the bladder.
Correct Answer is D
Explanation
A. Instructing a staff member to maintain a log of emergency care provided is not the first action that the nurse should take. This is an important task, but it can be done later, after ensuring the safety of the staff and children and providing immediate care to those who need it.
B. Applying cervical spine collars to children who have suspected neck trauma is not the first action that the nurse should take. This is a priority intervention, but it can only be done after surveying the scene for potential hazards and making sure that it is safe to approach and touch the children.
C. Notifying guardians of the emergency and injuries to their children is not the first action that the nurse should take. This is a necessary step, but it can be delegated to another staff member or done after providing initial care to the children.
D. Surveying the scene for potential hazards to staff and children is the correct answer. This is the first action that the nurse should take, according to the principles of emergency care. The nurse needs to assess the situation and ensure that there are no dangers such as fire, electricity, gas, or falling debris that could harm anyone at the scene. The nurse also needs to determine how many children are injured, how severe their injuries are, and what resources are available to help them.
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