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 B
Explanation
A. Muscle stiffness is not a common or serious adverse effect of ibuprofen. Ibuprofen is an anti-inflammatory drug that can reduce pain and stiffness caused by arthritis.
B. Stomach pain or bloody stools are signs of gastrointestinal bleeding, which is a serious and potentially fatal adverse effect of ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause ulceration, perforation, and hemorrhage of the stomach or intestines . The nurse should ask the client about any gastrointestinal symptoms and advise them to avoid alcohol, smoking, and other NSAIDs while taking ibuprofen.
C. Dry cough is not a common or serious adverse effect of ibuprofen. Dry cough is more likely to be caused by angiotensin-converting enzyme (ACE) inhibitors, which are used to treat hypertension and heart failure.
D. Increase in urine output is not a common or serious adverse effect of ibuprofen. Ibuprofen can cause renal impairment, which can lead to decreased urine output, not increased urine output. The nurse should monitor the client's renal function tests and fluid balance while taking ibuprofen.
Correct Answer is C
Explanation
Choice A reason:
"I will avoid using my microwave oven at home because of the ICD."This statement is incorrect. Using a microwave oven does not interfere with the functioning of an ICD. It is safe for clients with ICDs to use microwave ovens.
Choice B reason:
"I can hold my cell phone on the same side of my body as the ICD."This statement is incorrect Holding a cell phone on the same side of the body as the ICD should not cause any harm or interfere with the device's functioning.
Choice C reason:
"I will wear loose clothing over my ICD." This statement is correct and demonstrates understanding of the teaching. Wearing loose clothing over the ICD helps prevent excessive pressure or friction on the device and reduces the risk of dislodging the ICD leads or causing discomfort.
Choice D reason:
"I will soak in the tub rather than showering." This statement is incorrect. Avoiding showers is not necessary for clients with ICDs. Taking showers is generally safe for individuals with ICDs, as the device is designed to be waterproof and withstand such conditions.
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