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 A

Explanation

A. Protect the IV bag from exposure to light: Nitroprusside is light-sensitive and degrades when exposed to light, reducing its potency and effectiveness. It must be protected with an opaque covering.

B. Keep calcium gluconate at the client’s bedside: Incorrect. Calcium gluconate is used to treat hyperkalemia or calcium imbalances, not for nitroprusside administration.

C. Attach an inline filter to the IV tubing: Incorrect. An inline filter is not typically required for nitroprusside.

D. Monitor blood pressure every 2 hr: Incorrect. Continuous or frequent monitoring (every 5-15 minutes) is necessary due to the rapid effects of nitroprusside on blood pressure.

A. Administer flumazenil to the client. B. Monitor the client's IV site for thrombophlebitis. C. Initiate seizure precautions for the client. D. Evaluate the client for further suicidal behavior.

Correct Answer is A

Explanation

A. Flumazenil is the antidote for benzodiazepine overdose and should be administered to reverse the effects of diazepam.

B. Monitoring the IV site is important but not an immediate priority in this situation.

C. Seizure precautions are not the primary concern after benzodiazepine overdose.

D. Evaluating for suicidal behavior is important but comes after stabilizing the client.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 min ago. The client is lethargic and a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?

Correct Answer is A

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.