A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?

Six weeks after the birth of a child with Trisomy 21, the parents return to the prenatal clinic for a follow-up visit. They have spoken with a genetic counselor, but are still unsure about the risk of having another child with Trisomy 21. The couple brings literature from the counselor with them, and asks the nurse to explain it. Which action should the nurse take?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?

A female client is admitted with complaints of abdominal pain, loss of appetite, and a weight loss of 25 pounds (11 kg) in the last four months. During the admission assessment, the client tells the nurse that she has no interest in playing cards with her friends anymore and feels worthless most days. Which nursing problem should the nurse address first?

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L (129 mmol/L), glucose 54 mg/dl (2.97 mmol/L) and potassium 5.3 mEq/L (5.3 mmol/L).

When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication?

Reference Ranges

• Sodium [Reference Range: Adult 136 to 145 mEq/L (136 to 145 mmol/L)
• Glucose (Reference Range: 0 to 50 years: 74 to 106 mg/dl. (4.1 to 5.9 mmol/L))
• Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who reports a pounding headache. Which action should the nurse take?

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Review H and P and nurse's notes.

What are the first four actions that the nurse should take?

The parents are at the bedside and state that each parent thought the other parent was watching the child. They are not sure how long he was in the pool or how he might have fallen in. The temperature of the pool was cool as the temperature outside was about 64 °F (17.8 °C).

Placed a cervical collar with the assistance of the physician. The child's pulse is 121 beats/minute, the airway is patent, and there are no signs of any bleeding.

Review H and P, nurse's note, laboratory results, orders, and imaging studies. What complications should the nurse monitor for in the next 6 to 8 hours? Select all that apply.