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 ["13"]
Explanation
gtt/min = (mL/hr x gtt/mL) / 60
Plugging in the given values, we get:
gtt/min = (50 x 15) / 60
gtt/min = 750 / 60
gtt/min = 12.5
Rounding to the nearest whole number, the answer is 13.
Correct Answer is D
Explanation
- A. Diarrhea is not an adverse effect of amitriptyline, which is a tricyclic antidepressant (TCA). Diarrhea may be caused by other factors, such as infection, food intolerance, or stress. Therefore, this choice is incorrect.
- B. Frequent urination is not an adverse effect of amitriptyline either. Frequent urination may be a sign of diabetes, urinary tract infection, or other conditions that affect the kidneys or bladder. Therefore, this choice is also incorrect.
- C. Excessive salivation is not an adverse effect of amitriptyline as well. Excessive salivation may be due to increased production of saliva, difficulty swallowing, or mouth irritation. Therefore, this choice is incorrect too.
- D. Blurred vision is an adverse effect of amitriptyline and other TCAs. Amitriptyline can cause anticholinergic effects, such as dry mouth, constipation, urinary retention, and blurred vision. These effects are more pronounced in older adults and can impair their daily functioning and quality of life. Therefore, this choice is correct and the nurse should identify it as an adverse effect of the medication.
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