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

Exhibits

Select the 3 priority actions that the nurse should take.

Place a nonadherent dressing on the right knee abrasion.

Administer Ibuprofen 200 mg

Apply ice packs to the fingers and along the right forearm.

Elevate the affected forearm with pillows.

Review cast care instructions with the child's parents.

Explain the cast application procedure to the child.

Answer and Explanation

Correct Answer : B,C,D

A. Place a nonadherent dressing on the right knee abrasion: While minor abrasions should be cleaned and dressed, it is not a priority compared to managing the child's pain and fracture care.

B. Administer Ibuprofen 200 mg: Ibuprofen is an appropriate analgesic and anti-inflammatory medication to manage the child's pain (rated 5/10) and reduce swelling. Prompt pain relief is essential for the child’s comfort.

C. Apply ice packs to the fingers and along the right forearm: Applying ice helps reduce edema, pain, and inflammation at the fracture site. It also minimizes soft tissue damage.

D. Elevate the affected forearm with pillows: Elevating the arm helps reduce swelling and promotes venous return, which is essential for minimizing discomfort and preventing complications like compartment syndrome.

E. Review cast care instructions with the child's parents: Reviewing cast care is essential but should be done after the cast is applied, not at this stage of care.

F. Explain the cast application procedure to the child: This is important but not an immediate priority. The nurse should first address pain, swelling, and proper limb positioning before discussing the procedure.

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Correct Answer is D

Explanation

A. Informing the client about pharmacological pain management contradicts her decision for a natural childbirth.

B. Encouraging family to leave during pain is unnecessary and may reduce support, which is essential for coping during labor.

C. Breathing techniques are helpful, but exhaling deeper than inhaling may not be appropriate for ventilation; rhythmic breathing is typically encouraged.

D. Hydrotherapy (such as warm baths or showers) is a natural pain management technique that can promote relaxation and decrease labor pain.

A. "Make sure to use nearby furniture to support yourself when walking to the bathroom." B. "I will have the physical therapist ambulate you to the bathroom." C. "Tell me what concerns you have about using a bed pan." D. "You have to use the bed pan for your own safety."

Correct Answer is C

Explanation

A. Encouraging the client to use furniture for support is unsafe, especially for a client on complete bed rest.

B. Physical therapy is not typically called for immediate assistance to use the bathroom and is impractical for an end-of-life client.

C. Exploring the client’s concerns allows the nurse to understand and address the emotional or psychological distress associated with using a bed pan.

D. Simply instructing the client to use a bed pan without addressing their concerns may seem dismissive and fail to provide emotional support.

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A nurse is caring for a 9-year-old child at a clinic. Exhibits Select the 3 priority actions that the nurse should take.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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

Exhibits

Select the 3 priority actions that the nurse should take.