The nurse is continuing to care for the child.
Administer Ibuprofen 200 mg PO.
Elevate the affected forearm with pillows.
Place a nonadherent dressing on the right knee abrasion.
Review cast care instructions with the child's parents.
Apply ice packs to the fingers and along the right forearm.
Explain the cast application procedure to the child.
Correct Answer : A,B,E
Rationale:
A. Administer Ibuprofen 200 mg PO: The child reports a pain score of 5/10 and is requesting pain medication. The provider has prescribed ibuprofen PRN for this level of pain. Prompt administration supports comfort and reduces inflammation associated with fracture and swelling.
B. Elevate the affected forearm with pillows: Elevation helps reduce edema by promoting venous return and lymphatic drainage. Given the child's worsening edema in the forearm and fingers, this is a priority to minimize complications like compartment syndrome.
C. Place a nonadherent dressing on the right knee abrasion: Although dressing the abrasion is a reasonable intervention, it is not a priority at this stage. The abrasion is not actively bleeding or infected, so attention should remain on managing neurovascular risk and pain.
D. Review cast care instructions with the child's parents: This is an important educational step, but it is not a current priority since the cast has not yet been applied. Priority actions should focus on pain, swelling, and circulation while awaiting casting.
E. Apply ice packs to the fingers and along the right forearm: Ice helps manage pain and inflammation by vasoconstriction, limiting fluid accumulation in tissues. Applying it early post-injury is crucial to controlling swelling in a fractured limb.
F. Explain the cast application procedure to the child: Preparing the child for a future procedure is helpful but not immediately necessary. At this point, pain control and reduction of swelling take precedence to prevent complications and stabilize the injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. The client has a wound dressing saturated with sanguinous drainage after it was reinforced: Continued sanguineous drainage that saturates reinforced dressings just 2 hours post-op may indicate active bleeding or hemorrhage. This is an urgent finding that requires immediate provider notification for assessment and possible intervention.
B. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication: A pain score of 2 reflects adequate pain control following intervention. This is an expected and desirable outcome and does not require provider notification.
C. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter: A urine output of 50 mL/hr is within normal limits and suggests appropriate renal perfusion. No immediate action or provider notification is required based on this finding.
D. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied: This oxygen saturation level indicates adequate oxygenation with supplemental oxygen and is within expected postoperative parameters.
Correct Answer is B
Explanation
Rationale:
A. Insert the catheter into the foot: While the scalp and foot veins may be used in infants, foot veins are less preferred in mobile infants due to the risk of dislodgement. Site selection should prioritize accessible and secure veins, often in the hand or scalp.
B. Obtain a 24-gauge catheter: A 24-gauge catheter is the appropriate size for infants due to their small and delicate veins. It minimizes trauma during insertion and allows for adequate flow while reducing the risk of vein damage.
C. Use gauze to cover the IV insertion site: Transparent dressings, not gauze, are preferred for covering IV sites in infants. They allow for continuous visualization of the site to detect signs of infiltration or infection promptly.
D. Monitor the IV site every 8 hours: IV sites in infants should be monitored much more frequently due to their higher risk of infiltration, dislodgement, or phlebitis. Hourly monitoring is standard practice, especially in high-acuity or pediatric settings.
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