The nurse is continuing to care for the child.

Exhibits
Select the 3 priority actions that the nurse should take.

Elevate the affected forearm with pillows.

Administer Ibuprofen 200 mg PO.

Place a non adherent dressing on the right knee abrasion.

Review cast care instructions with the child's parents.

Explain the cast application procedure to the child.

Apply ice packs to the fingers and along the right forearm.

Answer and Explanation

Correct Answer : A,B,F

Rationale:
A. Elevate the affected forearm with pillows: Elevation helps reduce swelling and promotes venous return, which is critical in the immediate management of a fracture to prevent complications such as increased edema or impaired circulation.

B. Administer Ibuprofen 200 mg PO: The child reports pain at a level of 5, meeting the prescription threshold. Administering analgesia promptly helps manage discomfort and supports cooperation with further interventions, such as casting.

C. Place a nonadherent dressing on the right knee abrasion: While wound care is important, the abrasion is minor and not the most urgent concern. Prioritization focuses on the fractured limb and pain management.

D. Review cast care instructions with the child's parents: Education is important but is not the immediate priority before the cast is applied. It can be provided after the child is stabilized and pain is managed.

E. Explain the cast application procedure to the child: While preparing the child psychologically is important, immediate interventions to reduce pain and swelling take precedence over anticipatory teaching.

F. Apply ice packs to the fingers and along the right forearm: Ice helps reduce swelling and pain in the acute phase of the fracture. Applying ice in combination with elevation supports circulation and comfort while awaiting casting.

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Correct Answer is A

Explanation

Rationale:
A. Ask an experienced nurse to assist with the procedure: Seeking assistance from an experienced nurse promotes patient safety and supports proper skill development. The newly licensed nurse can observe, perform the procedure under supervision, and ensure that the client receives competent care while staying within professional practice boundaries.

B. Delegate the task to an assistive personnel: Tracheal suctioning is a sterile and invasive procedure that requires nursing judgment and assessment, which are outside the scope of practice for assistive personnel.

C. Identify that the task is in the scope of RN practice and perform the suctioning: Although tracheal suctioning is within an RN’s scope, the nurse should not perform it independently without adequate training or supervision.

D. Refuse to take the assignment: Refusing the assignment entirely is inappropriate because the nurse has a duty to provide care within their level of competence. Instead, the nurse should seek guidance and supervision to safely complete the procedure.

A. "You can continue to use the diaphragm you used before your pregnancy." B. "Place the transdermal birth control patch on your upper outer arm." C. "The lactation amenorrhea method is effective for your first year postpartum." D. "You should avoid vaginal spermicides while breastfeeding."

Correct Answer is B

Explanation

Rationale:
A. "You can continue to use the diaphragm you used before your pregnancy.": The diaphragm must be refitted after childbirth due to changes in vaginal and cervical anatomy, so continued use without refitting is not recommended.

B. "Place the transdermal birth control patch on your upper outer arm.": The patch should be applied to areas such as the abdomen, buttock, upper torso, or upper outer arm—but not if breastfeeding, as it contains estrogen, which can reduce milk production.

C. "The lactation amenorrhea method is effective for your first year postpartum.": This method is only effective for the first 6 months postpartum, provided the mother is exclusively breastfeeding and has not resumed menses.

D. "You should avoid vaginal spermicides while breastfeeding.": Vaginal spermicides can be used while breastfeeding. They do not affect milk production or the baby. However, they are not as effective as other methods of contraception and are often used in combination with other methods, such as condoms or diaphragms

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The nurse is continuing to care for the child. Exhibits Select the 3 priority actions that the nurse should take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly licensed nurse is caring for a client who requires tracheal suctioning, which is a procedure the nurse has not performed in practice. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum and requests information about contraception. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching?

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A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?

A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

The nurse is continuing to care for the child.

Exhibits
Select the 3 priority actions that the nurse should take.