A nurse is caring for an adolescent.
Admission Assessment
1400:
- Adolescent brought to emergency department by parents following a fall while skateboarding.
- Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
- Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.
- Abdomen soft and nontender with active bowel sounds in all four quadrants.
- Right lower extremity with open wound and displaced bone.
- Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.
Select the 4 findings that require follow-up.
Blood pressure
Capillary refill
Pedal pulse
Heart rate
Skin temperature
Pain
Correct Answer : B,C,E,F
A. Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires follow-up or not.
B. Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
C. Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
D. Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
E. Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
F. Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason
"I can use natural-skin condoms to prevent sexually transmitted infections." This statement is incorrect. Natural-skin or lambskin condoms are not recommended for preventing sexually transmitted infections (STIs). They may provide some protection against pregnancy but do not effectively protect against STIs. Clients should use latex or polyurethane condoms to reduce the risk of STIs.
Choice B reason
"I can use petroleum jelly as a lubricant with the condom." This statement is also incorrect. Petroleum jelly (Vaseline) and other oil-based lubricants can damage latex condoms, leading to a higher risk of breakage or failure. Clients should use water-based or silicone-based lubricants with latex or polyurethane condoms.
Choice C reason:
"I can re-use the condom one time after initial use." This statement is incorrect. Condoms are designed for single-use only. Reusing a condom increases the risk of breakage, failure, and the transmission of STIs or unwanted pregnancy. Clients should always use a new condom for each sexual act.
Choice D reason:
"I can store the condoms in the drawer of my nightstand." This statement is correct because it indicates that the client understands the proper storage of condoms. Storing condoms in a cool, dry place, such as a drawer or a condom case, helps protect them from damage or deterioration, ensuring they remain effective when needed.
Correct Answer is B
Explanation
Choice A reason:
Discarding the first 10 mL of urine is a common practice for obtaining a urine sample for certain tests, but it is not specifically necessary for a urine culture. In a urine culture, the goal is to obtain a sample directly from the bladder to identify any bacteria present, so discarding the initial urine is not necessary.
Choice B reason
Donning sterile gloves prior to the procedure is the appropriate action for the nurse to take. When catheterizing a toddler for a urine culture, it is essential to maintain a sterile procedure to reduce the risk of infection and ensure the safety of the child. Using sterile gloves is a crucial step in preventing contamination during the catheterization process.
Choice C reason
The size of the catheter (12-French) mentioned in option C may not be appropriate for a toddler. The size of the catheter used for a toddler would generally be smaller, depending on the age and size of the child. The appropriate catheter size should be determined based on the child's age and condition.
Choice D reason
EMLA cream is a topical anaesthetic cream used to numb the skin before certain procedures. While it might be appropriate in some cases, it is not typically used for catheterization procedures in toddlers. Catheterization is a quick procedure, and using EMLA cream may not be necessary or practical in this situation.
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