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 {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The client is at risk for experiencing electrolyte imbalance due to the vomiting. Persistent vomiting during pregnancy, especially with significant weight loss, can lead to electrolyte imbalances such as hypokalemia, hyponatremia, or metabolic alkalosis. This can result from the body's inability to retain essential minerals and fluids. The client’s reported diet of minimal food intake, primarily consisting of toast and pretzels, indicates inadequate nutrition and potential for further exacerbation of these imbalances.
The significant weight loss of 6.8 kg (15 lb) within a month and continuous nausea and vomiting are concerning symptoms that warrant immediate medical evaluation. The nurse’s advice to seek a provider’s assessment underscores the need for timely intervention to address potential complications, ensure maternal and fetal health, and possibly prescribe antiemetic medications or other treatments to manage symptoms.
Correct Answer is C
No explanation
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