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 D
Explanation
A is incorrect because IV tubing for total parenteral nutrition should be changed every 24 hours to prevent infection.
B is incorrect because abdominal distention is not an expected effect of total parenteral nutrition. It could indicate a complication such as fluid overload or bowel obstruction.
C is incorrect because gastric residual is not relevant for total parenteral nutrition, which bypasses the gastrointestinal tract.
D is correct because weight measurement is an important indicator of fluid balance and nutritional status for clients receiving total parenteral nutrition.
Correct Answer is B
Explanation
Choice A reason:
Discarding the first 10 mL of urine is a common practice for obtaining a urine sample for certain tests, but it is not specifically necessary for a urine culture. In a urine culture, the goal is to obtain a sample directly from the bladder to identify any bacteria present, so discarding the initial urine is not necessary.
Choice B reason
Donning sterile gloves prior to the procedure is the appropriate action for the nurse to take. When catheterizing a toddler for a urine culture, it is essential to maintain a sterile procedure to reduce the risk of infection and ensure the safety of the child. Using sterile gloves is a crucial step in preventing contamination during the catheterization process.
Choice C reason
The size of the catheter (12-French) mentioned in option C may not be appropriate for a toddler. The size of the catheter used for a toddler would generally be smaller, depending on the age and size of the child. The appropriate catheter size should be determined based on the child's age and condition.
Choice D reason
EMLA cream is a topical anaesthetic cream used to numb the skin before certain procedures. While it might be appropriate in some cases, it is not typically used for catheterization procedures in toddlers. Catheterization is a quick procedure, and using EMLA cream may not be necessary or practical in this situation.
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