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 ["B","D","E"]

Explanation

A. Blood pressure – The client's blood pressure of 114/56 mm Hg is within an acceptable range and does not indicate hypotension or hypertension.

B. Temperature – A temperature of 38.6°C (101.5°F) is indicative of fever, which is concerning in a client undergoing chemotherapy due to their increased risk of infection (febrile neutropenia). Prompt evaluation and intervention are necessary to prevent sepsis.

C. Potassium level – The client's potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L) and does not require immediate intervention.

D. WBC count – The client's WBC count has decreased to 3,800/mm³, which is below the normal range (5,000 to 10,000/mm³), indicating leukopenia. This places the client at a higher risk for infection, requiring close monitoring and potential interventions.

E. Breath sounds – The presence of crackles at the lung bases suggests possible pulmonary complications, such as fluid overload, infection (e.g., pneumonia), or early signs of acute respiratory distress syndrome (ARDS). This finding warrants further assessment and intervention.

A. A client who has a fracture and is in balance suspension traction. B. A client who is bedridden and wears a hearing aid. C. A client who is ambulatory and receiving oxygen. D. A client who uses a wheelchair and is confused.

Correct Answer is C

Explanation

A. A client in balance suspension traction requires more time and assistance, making them a lower priority.

B. A bedridden client requires significant help and is less mobile, lowering their priority.

C. A client who is ambulatory and receiving oxygen is at risk of immediate danger if the oxygen supply poses a fire hazard. They can be evacuated quickly and independently.

D. A client in a wheelchair and confused may require more time and resources for evacuation.

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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.

Nursing Test Bank

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Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is C

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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.