A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately?
A client who has a burn injury to an estimated 5% of his leg and is crying
A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation
A who is a client 1 day postoperative and has a temperature of 37.5° C (99.5° F)
A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing
The Correct Answer is D
D. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing.
A significant drop in blood pressure when changing positions from lying to standing may indicate orthostatic hypotension, which can be a sign of dehydration, blood loss, or other underlying medical issues. This can be a cause for concern, especially if the client is an adolescent, as it may lead to decreased perfusion of vital organs and may require immediate medical attention.
The other options are as follows:
A. A client who has a burn injury to an estimated 5% of his leg and is crying - While it's essential to assess and address the client's pain and comfort, this finding does not indicate an immediate need for medical attention. Pain management and wound care can be addressed based on the severity of the burn and the client's pain level.
B. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation - This finding is concerning, and the nurse should notify the provider to reassess pain management and evaluate for potential complications related to the fracture. However, it may not require immediate medical attention unless there are signs of severe pain or complications.
C. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F) - A slight increase in temperature in the immediate postoperative period may not be unusual and can be attributed to the normal inflammatory response after surgery. The nurse should continue monitoring the client's temperature and report any further changes or additional signs of infection or complications to the provider.
Overall, while all findings should be addressed and managed appropriately, the significant drop in blood pressure (option D) should be reported immediately due to the potential implications for the client's overall health and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When providing teaching to a parent of a child with celiac disease, the nurse should recommend food choices that are gluten-free. Celiac disease is an autoimmune disorder triggered by the ingestion of gluten, which is a protein found in wheat, barley, rye, and their derivatives. Gluten damages the small intestine lining in individuals with celiac disease, leading to various gastrointestinal and nutritional issues.
The correct food choice for a child with celiac disease is B. Rice. Rice is naturally gluten-free and can be a safe and nutritious option for individuals with celiac disease. Other gluten-free options include corn, quinoa, oats (certified gluten-free oats), potatoes, and many fruits and vegetables.
A. Barley: Barley contains gluten, which is harmful to individuals with celiac disease. It should be avoided in the child's diet.
C. Rye: Rye also contains gluten and should be avoided in the child's diet. It can cause damage to the small intestine in individuals with celiac disease.
D. Wheat: Wheat is a primary source of gluten and is strictly off-limits for individuals with celiac disease. It is essential to avoid all wheat-containing products, including bread, pasta, and baked goods.
Correct Answer is ["260"]
Explanation
To calculate the total fluid intake, we need to convert all the measurements to milliliters (mL) and then add them up:
1 cup = 240 mL
1 oz = 30 mL
Given fluid intake:
Juice: ½ cup = 0.5 * 240 mL = 120 mL
Gelatin: 3 oz = 3 * 30 mL = 90 mL
Ice pop: 1 oz = 1 * 30 mL = 30 mL
Ginger ale: 20 mL
Total fluid intake = 120 mL + 90 mL + 30 mL + 20 mL = 260 mL
So, the nurse should record 260 mL as the child's fluid intake.
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