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.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A reason:

Natural loss of deciduous teeth is incorrect. Natural loss of deciduous teeth, also known as baby teeth, usually begins around the age of 5 or 6 years. At the age of 2, a toddler would still have their baby teeth.

Choice B reason:

This is a normal finding in toddlers. It is common for toddlers to have a protruding abdomen due to their body composition and the normal development of their abdominal muscles.

Choice C reason:

Head circumference exceeds chest circumference: In a typical 2-year-old toddler, the head circumference should be less than the chest circumference. The head grows rapidly during infancy and slows down as the child grows older, leading to a cage in the head-to-chest ratio.

Choice D reason:

The fontanels, or soft spots on the skull, usually close by the end of the first year. By age 2, the fontanels should be closed or very close to being closed, and they would not typically be palpable.

A. Assess fluid intake every 24 hr. B. Ambulate three times a day. C. Assist with deep breathing and coughing. D. Monitor the incision site for findings of infection.

Correct Answer is C

Explanation

A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.

B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.

C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.

D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take?

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?