The nurse is continuing to care for the adolescent.
Provider Prescriptions
1415:
X-ray of right leg shows open fracture of the right proximal tibia
Surgery consult
Morphine 4 mg IV every 2 hr as needed for pain.
The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?
The adolescent's parents have concerns regarding the surgery.
The adolescent's blood pressure is 131/89 mm Hg.
The adolescent reports severe pain.
The adolescent has not voided in 4 hr.
The Correct Answer is A
A. Addressing parental concerns is crucial, especially for informed consent. If the parents are not comfortable or have unresolved questions, it could delay or prevent the surgery from proceeding.
B. While this blood pressure is slightly elevated, it is not an immediate concern that would typically prevent surgery.
C. Although severe pain is important to manage, it may not require immediate reporting unless it is unmanageable or indicates a serious problem.
D. While the lack of voiding in an immobile patient is a concern and could indicate urinary retention, it is not necessarily a finding that would prevent surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.
B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.
C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.
D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.
Correct Answer is D
Explanation
- A playpen is a portable enclosure that provides a confined space for a child to play in. It can be useful for keeping a child safe and supervised when the caregiver is busy or needs a break, but it should not be used as a substitute for active play or interaction with the caregiver or others.
- A 2-year-old child is in the developmental stage of toddlerhood, which is characterized by rapid physical, cognitive, social, and emotional growth. Toddlers are curious and eager to learn about the world around them, and they need opportunities to explore, experiment, and manipulate objects and materials. They also need stimulation, guidance, and feedback from their caregivers and peers to develop their language, problem-solving, and social skills.
- Keeping a 2-year-old child in a playpen for long periods of time or to prevent them from getting dirty can have negative effects on their development and well-being. It can limit their physical activity, creativity, and independence, and it can cause boredom, frustration, or resentment . It can also interfere with their atachment and bonding with their caregiver, as well as their self-esteem and self-image.
- Therefore, the practical nurse (PN) should use the statement "Children need time to actively explore their environment" in responding to this concern about using a playpen. This statement reflects the developmental needs and rights of the child, and it encourages the caregiver to provide a more stimulating and supportive environment for the child. It also implies that getting dirty is not a problem, but rather a natural and healthy part of play and learning.
- Therefore, option D is the correct answer, while options A, B, and C are incorrect. Option A is incorrect because it is judgmental and may offend or discourage the caregiver.
Option B is incorrect because it is not true that playpens provide a sense of security for the child, as they may feel isolated or restricted in them.
Option C is incorrect because it is not true that playpens provide a safe environment for a toddler, as they may pose hazards such as entrapment, suffocation, or injury from falling or climbing out of them.
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