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 C

Explanation

Rationale:
A. Red meat: Red meat is often high in saturated fat and cholesterol, which can contribute to hypertension and cardiovascular disease. Regular consumption may increase blood pressure and arterial stiffness, so clients with hypertension should limit or avoid it.

B. Canned black beans: Although beans are generally healthy, canned varieties are often high in sodium, which can worsen hypertension. Unless the beans are labeled low-sodium or rinsed thoroughly before eating, they can contribute to elevated blood pressure.

C. Fish: Fish, especially fatty varieties like salmon or mackerel, are rich in omega-3 fatty acids, which support cardiovascular health by reducing inflammation and improving lipid profiles. Including fish in the diet promotes heart health and helps manage blood pressure effectively.

D. Cheese: Cheese contains significant amounts of sodium and saturated fat, both of which can increase blood pressure and cardiovascular risk. Clients with hypertension should consume cheese in moderation or select low-sodium, low-fat varieties when possible.

A. Wrap their arms under the client's axilla to transfer the client. B. Use a powered lift to transfer the client. C. Use a gait belt to transfer the client. D. Use a sliding board to transfer the client.

Correct Answer is B

Explanation

Rationale:
A. Wrap their arms under the client's axilla to transfer the client: Manually lifting a heavy, dependent client by placing arms under the axilla is unsafe and can cause serious musculoskeletal injuries to both the nurse and the client.

B. Use a powered lift to transfer the client: A powered mechanical lift is the safest and most appropriate method for transferring a 136-kg (300-lb) client who cannot assist. It prevents strain on healthcare workers, reduces the risk of falls, and ensures a smooth, controlled transfer from bed to chair.

C. Use a gait belt to transfer the client: A gait belt is used only for clients who can bear some weight and actively assist in the transfer. Since this client is unable to help, using a gait belt would not provide adequate support or safety during the transfer process.

D. Use a sliding board to transfer the client: Sliding boards are designed for clients who have upper body strength and can assist by lifting or shifting themselves during the transfer. In this case, the client’s inability to assist makes a powered lift the only safe and feasible option.

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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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The nurse is continuing to care for the child.

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