The nurse is continuing to care for the 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.

Which of the following prescriptions should the nurse anticipate from the provider?

Elevate the right leg above heart level.

Prepare the adolescent for surgery.

Remove the splint.

Apply ice to the affected extremity.

Answer and Explanation

The Correct Answer is B

A. Elevate the right leg above heart level. This is contraindicated for the adolescent because elevating the leg above heart level can increase blood pressure in the injured area and worsen bleeding and swelling.

B. Prepare the adolescent for surgery. This is anticipated for the adolescent because they have an open fracture with bone displacement, which requires surgical intervention to reduce the risk of infection and complications.

C. Remove the splint. This is contraindicated for the adolescent because removing the splint can cause further damage to the bone and soft tissues and increase pain and bleeding.

D. Apply ice to the affected extremity. This is contraindicated for the adolescent because applying ice can decrease blood flow to the injured area and impair healing and sensation.

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Correct Answer is C

Explanation

A. February 1 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.

B. February 8 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, minus seven days is February 8, plus one year is February 8 of the following year.

C. February 15 is the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.

D. February 22 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus seven days is February 22, plus one year is February 22 of the following year.

A. Remove indwelling urinary catheter when no longer indicated. B. Elevate affected limb at chest level. C. Assist the adolescent with ambulation from bed to chair. D. Perform neurovascular assessments every hour. E. Apply warm packs to right extremity for the first 24hrs

Correct Answer is ["A","C","D"]

Explanation

A. Remove indwelling urinary catheter when no longer indicated: This action prevents urinary tract infections and promotes bladder function.

B. Elevate affected limb at chest level: This action is contraindicated because it increases venous pressure and edema in the affected extremity, which could compromise blood flow and nerve function.
C. Assist the adolescent with ambulation from bed to chair: This action prevents complications such as deep vein thrombosis, pulmonary embolism, pneumonia, and constipation by enhancing circulation, respiration, and bowel motility.
D. Perform neurovascular assessments every hour: This action monitors for signs of impaired blood flow or nerve function in the affected extremity, such as changes in color, temperature, sensation, movement, or pulse.
E. Apply warm packs to right extremity for the first 24hrs: This action is contraindicated because it increases blood flow and edema in the affected extremity, which could compromise blood flow and nerve function.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

Correct Answer is C

Explanation

Correct Answer is ["A","C","D"]

Explanation

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