The practical nurse (PN) is monitoring a 5-year-old following a fracture of the ulna. For which situation should the PN seek immediate intervention by the registered nurse (RN)?
The child likes to wiggle the fingers on the hand of the affected side.
The child's radial pulse volume on the affected arm is difficult to palpate.
An accurate respiratory rate cannot be measured because of the child's crying.
The parents of the child are requesting that the child receive an analgesic.
The Correct Answer is B
This could indicate reduced blood flow to the affected arm, which may be a sign of compartment syndrome. Compartment syndrome is a serious condition that requires immediate intervention by a registered nurse (RN). The other options may also require intervention, but they are not as urgent as the situation described in option B.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The newborn assessment finding that the practical nurse (PN) should report to the charge nurse immediately for a 24-hour-old infant is a heart rate of 100 beats/minute. The normal heart rate for a newborn is between 120-160 beats/minute. A heart rate of 100 beats/minute is below the normal range and may indicate a problem such as hypothermia or an infection. The PN should report this finding to the charge nurse immediately so that appropriate action can be taken to address the issue. The other assessment findings listed may also be important to monitor, but a heart rate of 100 beats/minute is the most urgent and requires immediate attention.
Correct Answer is D
Explanation
The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.
Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.
Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.
Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.
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