The nurse is continuing to care for the child.

Exhibits
Select the 3 priority actions that the nurse should take.

Elevate the affected forearm with pillows.

Administer Ibuprofen 200 mg PO.

Place a non adherent dressing on the right knee abrasion.

Review cast care instructions with the child's parents.

Explain the cast application procedure to the child.

Apply ice packs to the fingers and along the right forearm.

Answer and Explanation

Correct Answer : A,B,F

Rationale:
A. Elevate the affected forearm with pillows: Elevation helps reduce swelling and promotes venous return, which is critical in the immediate management of a fracture to prevent complications such as increased edema or impaired circulation.

B. Administer Ibuprofen 200 mg PO: The child reports pain at a level of 5, meeting the prescription threshold. Administering analgesia promptly helps manage discomfort and supports cooperation with further interventions, such as casting.

C. Place a nonadherent dressing on the right knee abrasion: While wound care is important, the abrasion is minor and not the most urgent concern. Prioritization focuses on the fractured limb and pain management.

D. Review cast care instructions with the child's parents: Education is important but is not the immediate priority before the cast is applied. It can be provided after the child is stabilized and pain is managed.

E. Explain the cast application procedure to the child: While preparing the child psychologically is important, immediate interventions to reduce pain and swelling take precedence over anticipatory teaching.

F. Apply ice packs to the fingers and along the right forearm: Ice helps reduce swelling and pain in the acute phase of the fracture. Applying ice in combination with elevation supports circulation and comfort while awaiting casting.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. Initiate fibrinolytic therapy: Fibrinolytic therapy, such as tissue plasminogen activator (tPA), is most effective when administered within a 3- to 4.5-hour window from the onset of ischemic stroke symptoms. Early administration can dissolve the clot, restore cerebral blood flow, and improve neurological outcomes.

B. Place the client in a supine position: Clients with ischemic stroke are usually positioned with the head of the bed elevated 15–30 degrees unless contraindicated. Supine positioning can increase intracranial pressure and risk aspiration, which may worsen neurological status.

C. Prepare the client for a chest x-ray: A chest x-ray is not a priority in acute ischemic stroke management. Immediate neuroimaging, typically a CT scan, is required to differentiate ischemic from hemorrhagic stroke before initiating fibrinolytic therapy.

D. Insert an indwelling urinary catheter: Inserting a catheter is not indicated as an initial intervention for acute stroke unless the client is unable to void or requires strict output monitoring. Priority actions focus on neuroprotection and reperfusion therapy.

Correct Answer is []

Explanation

Rationale for Correct Choices

• Opioid intoxication: The client’s shallow respirations, bradycardia, hypotension, slurred speech, and pinpoint pupils are classic signs of opioid overdose. The history of oxycodone use and recent psychosocial distress further support this diagnosis. Central nervous system depression from opioids suppresses respiratory drive and leads to decreased level of consciousness and low oxygen levels.

• Obtain a prescription for naloxone: Naloxone is a pure opioid antagonist that reverses respiratory and neurologic depression caused by opioid toxicity. Its rapid onset can restore breathing and consciousness, though repeated dosing may be necessary due to its short duration of action compared to most opioids.

• Prepare to initiate mechanical ventilation: The client’s respiratory rate of 10/min and oxygen saturation of 90% indicate inadequate ventilation. Mechanical ventilation may be required to maintain oxygenation and carbon dioxide elimination until the opioid’s effects subside or naloxone takes full effect.

• Respiratory rate: Monitoring respiratory rate allows evaluation of the client’s recovery and response to naloxone. Respiratory depression is the leading cause of death in opioid overdose, so continuous observation ensures early detection of deterioration or recurrence of hypoventilation as naloxone wears off.

• Pupillary reaction: Pinpoint pupils are a key diagnostic indicator of opioid intoxication. Assessing pupil size and reactivity helps determine neurologic improvement following reversal therapy. Dilation of pupils after naloxone administration signifies recovery from opioid-induced central nervous system depression.

Rationale for Incorrect Choices

• Stimulant intoxication: Stimulant toxicity causes symptoms such as tachycardia, hypertension, hyperreflexia, and dilated pupils, which contrast with the bradycardia, hypotension, and miosis seen in this client. The assessment findings are inconsistent with stimulant use.

• Alcohol intoxication: While alcohol can cause CNS depression, it does not typically produce pinpoint pupils. The presence of severe respiratory depression, bradycardia, and low blood pressure more strongly indicates opioid overdose rather than alcohol toxicity.

• Opioid withdrawal: Withdrawal symptoms include tachycardia, hypertension, restlessness, and hyperreflexia—not CNS or respiratory depression. The client’s vital signs and presentation do not align with withdrawal.

• Anticipate administering clonidine: Clonidine is used to manage opioid withdrawal symptoms, not overdose. In this scenario, the priority is reversing respiratory depression, not mitigating withdrawal discomfort.

• Collect a blood sample for ethanol level: While alcohol use disorder is part of the history, current findings point to opioid intoxication. Measuring ethanol level would not guide immediate life-saving interventions.

• Obtain prescription for restraints: The client is sedated and hypoventilating, not agitated or combative, so restraints are unnecessary and potentially harmful. The priority is airway and breathing support, not behavioral control.

• Ethanol level: Monitoring ethanol level is not relevant in an opioid overdose and would not help assess respiratory or neurologic recovery. The focus should remain on parameters directly affected by opioids.

• Hyperreflexia: Opioid toxicity causes depressed reflexes, not heightened reflexes. Monitoring hyperreflexia would not provide meaningful information about the client’s progress.

• Cardiac arrhythmias: While opioids can depress cardiac function, arrhythmias are not a primary concern in opioid intoxication. Respiratory and neurologic parameters provide more critical indicators of client improvement.

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The nurse is continuing to care for the child. Exhibits Select the 3 priority actions that the nurse should take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has manifestations of an ischemic stroke that began 2 hr ago. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is []

Explanation

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The nurse is continuing to care for the child.

Exhibits
Select the 3 priority actions that the nurse should take.