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- An older adult arrives at the emergency department with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are a temperature of 96.4 'F, heart rate 124 beats/minute, respirations of 16 beats/minute, and blood pressure of 75/38 mmHg. Which intervention is the most important for the nurse to implement? A. Maintain strict intake and output B. Monitor blood glucose level C. Keep the head of the bed 45 degrees D. Assess warmth of extremeties41. A newborn with esophageal atresia has just returned from surgery to place agastrostomy tube. Which nursing diagnosis will the nurse use to plan the care for thisclient?A. Risk for imbalanced nutritionB. Risk for deficient fluid volumeC. Risk for impaired thermoregulationD. Risk for ineffective gas exchange1. Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function? A. Assessing dietary intake B. Decreasing fluid intake C. Providing limited physical activity D. Turning, coughing, and deep breathing 2. A 12-year-old boy was admitted to the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing interventions should be included in the care plan for the client? A. Room temperature reduction B. Fluid restriction of 2,000 ml/day C. Axillary temperature measurements every 4 hours D. Antiemetic agent administration
- F. Weighing the client daily at the same time and in the same clothes. 5. Molly, with suspected rheumatic fever, is admitted to the pediatric unit. When obtaining the child's history, the nurse considers which information to be most important? A A fever that started 3 days ago B. Lack of interest in food C. A recent episode of pharyngitis D. Vomiting for 2 days20) The second day after an 8-year-old child with a cardiac defect repair is transferred from the pediatric intensive care unit, the nurse observes the child's weight and respirations have increased. Which intervention is most important for the nurse to implement? A. View the daily weight graph. B. Restrict intake or oral fluids. C. Decrease IV flow rate. D. Assess bilateral lungs sounds. I47-A 12-year-old boy was admitted to the hospital two days ago due to hyperthermia. His nursing interventions should be included in the care plan for the client? A. Room temperature reduction B. Fluid restriction of 2,000 ml/day C. Axillary temperature measurements every 4 hours D. Antiemetic agent administration 48- While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should: A. Notify the doctor B. Look for other signs of abuse C. Recognize this as a normal finding D. Ask about a family history of Tay-Sachs disease
- A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this pro-cess? Select all that apply. a. Participate in the decision-making process by offering the family information about the advantages and disadvan-tages of continued ventilatory support. b. Explain to the family what will happen at each phase ofthe weaning and offer support.c. Check the orders for sedation and analgesia, making surethat the anticipated death is comfortable and dignified. d. Tell the family that death will occur almost immediatelyafter the patient is removed from the ventilator.e. Tell the family that the decision for terminal weaning of apatient must be made by the primary care provider.f. Set up mandatory counseling sessions for the patient andfamily to assist them in making this end-of-life decision.When the nurse is talking with a client who is experiencing "lightening." the client would most likely state which of the following? a. "lcan breathe easier now." b. I don't have to urinate as often now." c. My lower back pain is gone now. d. My feet are more swollen than before."The nurse is caring for a toddler with large, unrepaired ventricular septal defect and heart failure. Which assessment findings should the nurse expect? A. Hypotension B. Tachycardia 45) @ She 46) Am to I U 9 В states that when she kisses her baby, the intants skin taste saltv. 2 C. Pulse oximetry reading within defined limits. D. Blood pressure variance across extremities #3 L 54 $ R 07 2⁰ % 5 T 6 are Y & U in * 00 ( -O Tics PASSI
- A client will be sent home on diuretic therapy and has a prescription for liquid potassium chloride (KCl). What teaching will the nurse provide before the client goes home? a. Do not dilute the solution with water or juice; drink the solution straight. b. Increase the use of salt substitutes; they also contain potassium. c. Report any weakness, fatigue, or lethargy immediately. d. Take the medication immediately before bed to prevent heartburn. Why letter c is the correct answer and explain why other options are incorrectA 10-year-old female student sought consultation due to her problem of increasing weight and fat deposition. Which the following nurse health teaching interventions is most appropriate? a. Low fat diet to prevent fat deposition b. Increased exercise to control weight gain c. Give assurance that the changes are normal d. Dietary measures to control weight gainA nurse is assessing a client with suspected gout. Which of the following would support a diagnosis of gout? Select all that apply 1. Elevated serum uric acid level 2. A swollen, red joint 3. Reports of moderate fatigue 4. Distal extremities cool totoucho5. Pain associated with movement of the affected extremity 6. Intolerance of dairy products