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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","D","E"]

Explanation

Rationale:

A. Polydipsia: Polydipsia, or excessive thirst, is commonly associated with hyperglycemia due to osmotic diuresis caused by high blood glucose levels. It is not a typical feature of hypoglycemia.

B. Tremors: Tremors are a hallmark symptom of hypoglycemia. They result from the body's adrenergic (sympathetic) response to low blood glucose levels, which triggers the release of epinephrine to raise glucose.

C. Acetone breath odor: A fruity or acetone breath odor is associated with diabetic ketoacidosis, a complication of hyperglycemia, not hypoglycemia. It indicates ketone buildup due to fat metabolism in the absence of insulin.

D. Inability to concentrate: Cognitive impairment, such as confusion or difficulty concentrating, is a neurological symptom of hypoglycemia. The brain relies heavily on glucose, and low levels affect its function quickly.

E. Diaphoresis: Sweating is a common autonomic symptom of hypoglycemia due to activation of the sympathetic nervous system. It often occurs early in a hypoglycemic episode and is a critical sign to monitor.

A. A client who has dementia and is incontinent of urine B. A client who is 2 days postoperative following orthopedic surgery C. A client who has a T-tube following an open cholecystectomy D. A client who has had a recent myocardial infarction

Correct Answer is A

Explanation

Rationale:

A. A client who has dementia and is incontinent of urine: This client has multiple contributing factors, cognitive impairment limits repositioning and self-care, while urinary incontinence increases skin moisture and maceration, promoting skin breakdown and pressure injury formation.

B. A client who is 2 days postoperative following orthopedic surgery: Although this client may have limited mobility, they are typically on a monitored recovery path with interventions like repositioning, early ambulation, and pain management, reducing their overall risk.

C. A client who has a T-tube following an open cholecystectomy: This client is generally alert, mobile with assistance, and able to communicate needs, which lowers their risk of pressure injury compared to more dependent individuals.

D. A client who has had a recent myocardial infarction: This client may be monitored in bed rest initially, but cardiovascular stability and mobility often improve quickly with treatment, making their pressure injury risk moderate rather than the highest among the group.

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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 is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is assessing a group of clients at risk of developing a pressure injury. The nurse should identify that which of the following clients is at the greatest risk?

Correct Answer is A

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.