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 D

Explanation

Rationale:
A. Conduct the assessment before drying the newborn: Performing the assessment before drying exposes the newborn’s wet skin to cooler air and surfaces, increasing heat loss through evaporation, not conduction. The newborn should always be thoroughly dried immediately after birth to conserve body heat.

B. Check the newborn's rectal temperature every hr: Frequent temperature monitoring does not prevent heat loss; it only identifies hypothermia after it occurs. Additionally, rectal temperature measurement may cause mucosal injury and is not routinely recommended for newborns.

C. Place the newborn in an open crib for the initial assessment: Placing the newborn in an open crib exposes the infant to cooler air and surfaces, increasing heat loss through convection and conduction. The initial assessment should occur under a radiant warmer to maintain thermal stability.

D. Cover scale with warm blankets when weighing the newborn: Covering the scale prevents conduction heat loss, which occurs when the newborn’s skin comes into contact with cold surfaces. Using a warm blanket or pad ensures the infant’s body heat is preserved during weighing or handling.

A. Encourage the client to watch television. B. Teach the client how to meditate. C. Administer a dose of atomoxetine to decrease anxiety. D. Sit with the client to provide a sense of security.

Correct Answer is D

Explanation

Rationale:
A. Encourage the client to watch television: Distracting the client with television is not effective during an acute panic attack. The client may be too anxious to focus, and this approach does not provide emotional support or safety.

B. Teach the client how to meditate: Teaching meditation is a long-term coping strategy and is not helpful during an acute panic attack, when the client requires immediate support and reassurance.

C. Administer a dose of atomoxetine to decrease anxiety: Atomoxetine is used to treat attention-deficit/hyperactivity disorder (ADHD) and is not indicated for acute anxiety or panic attacks. Medications for acute panic typically include fast-acting benzodiazepines if prescribed.

D. Sit with the client to provide a sense of security: Providing a calm presence and sitting with the client helps reduce feelings of fear and isolation. This intervention offers immediate emotional support, reassurance, and a sense of safety during the panic episode.

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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 nurse is performing a head-to-toe assessment on a newborn. Which of the following actions should the nurse take to prevent heat loss through conduction?

Correct Answer is D

Explanation

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Correct Answer is D

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.