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A nurse is caring for a 9-year-old child at a clinic.

Exhibits

The nurse reviews the assessment findings.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Assessment

Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.

Vital Signs

Temperature 36.8° C (98.2° F)

Heart rate 102/min Respiratory rate 22/min

BP 100/60 mm Hg

Oxygen saturation 98% on room air

Respirations easy and unlabored

Right forearm and fingers are edematous

Ecchymotic area noted on outer aspect of the forearm

Radial pulse +2

Fingers slightly cool to touch

mild "tingling" sensation

Child verbalizes a pain level of 4 on a scale of 0 to 10

Multiple areas of bruising are noted on lower extremities in various stages of healing

Oxygen saturation 98% on room air

Answer and Explanation

The Correct Answer is ["B","C","E","F","H"]

Assessment

Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.

Vital Signs

Temperature 36.8° C (98.2° F)

Heart rate 102/min

Respiratory rate 22/min

BP 100/60 mm Hg

Oxygen saturation 98% on room air

Rationale:

Edema in the right forearm and fingers: The edema, particularly in the right forearm, may indicate a possible fracture or soft tissue injury. This requires immediate follow-up, including further assessment, potential imaging (e.g., X-ray), and intervention to rule out bone fractures, compartment syndrome, or significant tissue damage.

Fingers slightly cool to touch: This could indicate compromised circulation to the fingers, potentially due to swelling or a more serious injury like a fracture causing compression or vascular injury. Immediate follow-up is necessary to assess for any signs of impaired circulation, which could require urgent medical intervention.

Mild "tingling" sensation in the fingers: The tingling sensation might indicate nerve involvement or compression, which could be related to a fracture or soft tissue injury. Immediate follow-up is needed to assess for nerve damage or compartment syndrome, both of which require timely management to prevent long-term damage.

Multiple areas of bruising in various stages of healing: While this finding does not require immediate follow-up in the context of the current injury, it could raise concerns about possible underlying issues such as bleeding disorders or abuse. Although not an immediate concern, this warrants further investigation in the longer term.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. A cool mist tent may be helpful for other respiratory conditions but is not the priority in epiglottitis.

B. Suctioning the oropharynx can cause further airway irritation and increase the risk of airway obstruction.

C. Epiglottitis can rapidly lead to airway obstruction, and intubation may be necessary to secure the airway.

D. Obtaining a throat culture is contraindicated as it may trigger airway closure.

A. Place a warm, moist compress on the site. B. Insert a new IV catheter distal to the discontinued IV site. C. Apply a pressure dressing at the IV site. D. Express drainage from the IV site and send it to be cultured.

Correct Answer is A

Explanation

A. Place a warm, moist compress on the site: This helps reduce the inflammation associated with phlebitis by promoting blood flow to the affected area and easing discomfort.

B. Insert a new IV catheter distal to the discontinued IV site: Incorrect. The site with phlebitis should not be used for a new IV insertion. A new, unaffected site should be chosen.

C. Apply a pressure dressing at the IV site: Incorrect. A pressure dressing is not required for phlebitis unless there is active bleeding.

D. Express drainage from the IV site and send it to be cultured: Incorrect. Expressing drainage is not a standard practice for phlebitis unless there is an indication of infection and purulent drainage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse include in the plan nurse take?

Correct Answer is C

Explanation

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following findings should the nurse identify as the priority?

A nurse manager is addressing reports of conflict within a nursing unit. The nurse should identify which of the following situations as an example of interpersonal conflict?

A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the report received during the shift report. Which of the following actions should the nurse take?

A nurse working in the emergency department (ED) is admitting a client. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's ___1___ evidenced by the client's ___2___.

A nurse is caring for a client who is in the active phase of labor and has decided to have a natural childbirth. Which of the following pain management techniques should the nurse suggest?

A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?

A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?

A nurse is caring for a client. Exhibits Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed ______ and will need to be monitored for _________.