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

Administer Ibuprofen 200 mg PO.

Elevate the affected forearm with pillows.

Place a nonadherent dressing on the right knee abrasion.

Review cast care instructions with the child's parents.

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

Explain the cast application procedure to the child.

Answer and Explanation

Correct Answer : A,B,E

Rationale:

A. Administer Ibuprofen 200 mg PO: The child reports a pain score of 5/10 and is requesting pain medication. The provider has prescribed ibuprofen PRN for this level of pain. Prompt administration supports comfort and reduces inflammation associated with fracture and swelling.

B. Elevate the affected forearm with pillows: Elevation helps reduce edema by promoting venous return and lymphatic drainage. Given the child's worsening edema in the forearm and fingers, this is a priority to minimize complications like compartment syndrome.

C. Place a nonadherent dressing on the right knee abrasion: Although dressing the abrasion is a reasonable intervention, it is not a priority at this stage. The abrasion is not actively bleeding or infected, so attention should remain on managing neurovascular risk and pain.

D. Review cast care instructions with the child's parents: This is an important educational step, but it is not a current priority since the cast has not yet been applied. Priority actions should focus on pain, swelling, and circulation while awaiting casting.

E. Apply ice packs to the fingers and along the right forearm: Ice helps manage pain and inflammation by vasoconstriction, limiting fluid accumulation in tissues. Applying it early post-injury is crucial to controlling swelling in a fractured limb.

F. Explain the cast application procedure to the child: Preparing the child for a future procedure is helpful but not immediately necessary. At this point, pain control and reduction of swelling take precedence to prevent complications and stabilize the injury.

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Correct Answer is B

Explanation

Rationale:

A. "Apply the ointment to the skin every 4 hr.": Nitroglycerin topical ointment is applied every 6 to 8 hours, depending on the provider's instructions. Applying it every 4 hours may increase the risk of side effects such as hypotension or tolerance due to excessive dosing frequency.

B. "Spread the ointment in a thin, even layer.": The medication should be applied in a thin, consistent layer to allow for proper absorption through the skin. The dose is usually measured and spread using applicator paper, avoiding rubbing or massaging it in.

C. "Apply the ointment to the forearm.": The preferred application sites are hairless areas of the chest, back, or upper arms. The forearm is not typically used due to variability in absorption and the presence of thinner skin and more movement.

D. "Massage the ointment into the skin.": Nitroglycerin ointment should never be massaged into the skin. Massaging can lead to unpredictable absorption rates and an increased risk of hypotension or headache due to rapid systemic absorption.

A. Hypotension B. Hypovolemia C. Cardiogenic shock D. Left ventricular failure

Correct Answer is D

Explanation

Rationale:

A. Hypotension: Hypotension is typically associated with decreased preload and low PAWP rather than elevated values. An elevated PAWP reflects increased pressure in the left heart, which does not occur with simple hypotension alone.

B. Hypovolemia: Hypovolemia leads to decreased circulating blood volume, reducing preload and PAWP. It is typically marked by low filling pressures, not elevated wedge pressures.

C. Cardiogenic shock: Although cardiogenic shock can be associated with elevated PAWP due to poor cardiac output and fluid backup, it is not as specific a marker as left ventricular failure, which directly affects PAWP.

D. Left ventricular failure: Elevated PAWP reflects increased pressure in the left atrium and pulmonary circulation, which is a hallmark of left-sided heart failure. This elevation occurs because the failing left ventricle cannot efficiently pump blood forward.

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

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