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 B

Explanation

Rationale:
A. Decreased serum uric acid: In preeclampsia, serum uric acid levels are elevated, not decreased, due to reduced renal clearance and tissue ischemia. Increased uric acid is often one of the earliest laboratory indicators of preeclampsia.

B. Increased protein in urine: Proteinuria is a key diagnostic feature of preeclampsia resulting from glomerular endothelial damage that increases permeability to proteins. The presence of protein in the urine reflects kidney involvement and helps distinguish preeclampsia from gestational hypertension.

C. Increased platelet count: Preeclampsia is typically associated with thrombocytopenia (low platelet count) due to platelet aggregation and consumption within damaged blood vessels. An increased platelet count would not be expected in this condition.

D. Decreased BUN: In preeclampsia, renal perfusion is reduced, leading to elevated BUN and creatinine levels. A decrease in BUN would indicate improved kidney function, which is inconsistent with the pathophysiology of preeclampsia.

A. Mottled skin B. Constricted pupils C. Restlessness D. Cheyne-Stokes respirations

Correct Answer is C

Explanation

Rationale:
A. Mottled skin: Mottling is typically a late sign of poor perfusion or approaching death and does not indicate pain. It reflects circulatory changes rather than discomfort requiring analgesia.

B. Constricted pupils: Constricted pupils may result from certain medications or neurological changes, but they are not a reliable indicator of pain. Pupillary changes alone do not guide pain management.

C. Restlessness: Restlessness is a common manifestation of pain in clients receiving palliative care, especially when verbal communication is limited. Administering prescribed pain medication can help alleviate discomfort and improve comfort.

D. Cheyne-Stokes respirations: This irregular breathing pattern occurs in advanced illness or near end-of-life and is not an indicator of pain. It reflects neurological or metabolic changes rather than discomfort requiring analgesia.

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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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The nurse is continuing to care for the child.

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