A nurse is caring for a 7-year-old male client who sustained a traumatic injury to the left leg after being struck by a lawnmower while playing outside.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
TRALI is a life-threatening condition associated with blood transfusion. The client’s symptoms, including trauma and low hemoglobin, indicate the need for transfusion. TRALI can cause acute respiratory distress shortly after transfusion. Early intervention can improve outcomes. Recognizing the signs of TRALI is essential in such scenarios.
Rationale for actions
Administer oxygen: Oxygen supplementation can help manage hypoxemia associated with TRALI. It ensures adequate oxygenation during respiratory distress. Monitor for respiratory distress: Continuous assessment helps detect worsening symptoms. Early detection can prompt timely intervention. Rationale for parameters: Oxygen saturation: Monitoring SpO2 provides real-time information on the patient’s oxygenation status. It helps determine the effectiveness of oxygen therapy. Heart rate: Tachycardia can indicate worsening respiratory distress or hypoxemia. Monitoring heart rate is crucial for early detection of complications.
Rationale for incorrect conditions
Transfusion-associated circulatory overload (TACO): TACO involves fluid overload, leading to cardiac symptoms. However, this client’s presentation suggests acute lung injury, not fluid overload. Incorrect conditions (others): Abandonment: Not applicable as the client was brought to the hospital and received care. Physical abuse: No evidence of physical abuse in this case. Self-neglect: The client is a child, and the injury was accidental, not due to neglect. The parents brought him to the hospital promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Noting the date and time of the behavior is the first step in addressing the issue, providing a record for future reference and ensuring accuracy in documentation.
Choice C rationale
Planning for scheduled break times helps address potential reasons for the behavior, offering a structured solution to prevent recurrence and improve overall workflow.
Choice B rationale
Evaluating the UAP for signs of improvement is the final step, assessing whether the implemented interventions have been effective and if further actions are needed.
Correct Answer is C
Explanation
Choice A rationale
Pedal edema is an assessment related to heart failure or peripheral vascular disease but is not specifically connected to the adverse effects of prasugrel, which is an antiplatelet medication that primarily affects blood clotting processes.
Choice B rationale
Measuring body temperature can help detect infections or fever, but it is not a primary assessment for the adverse effects of prasugrel. The medication's adverse effects are more closely related to bleeding risks.
Choice C rationale
Prasugrel, an antiplatelet medication, increases the risk of bleeding. Observing the color of urine can help detect hematuria, an indication of internal bleeding, making it a critical assessment for clients taking this medication.
Choice D rationale
Assessing skin turgor is generally used to evaluate hydration status, not to monitor for adverse effects of prasugrel. This assessment would not provide relevant information about bleeding risks associated with prasugrel use.
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