A 4-month-old with hydrocephalus is admitted to the hospital for shunt revision. When assessing for increased intracranial pressure, the nurse should observe the child for which finding(s)? Select all that apply.

A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.

The nurse is performing a musculoskeletal assessment with a client. Which action(s) should the nurse implement when performing passive range of motion (PROM) exercises with a client? Select all that apply.

Patient Data

The nurse is anticipating which additional medications the healthcare provider may prescribe for the client to manage side effects while on morphine sulfate.
Select the 3 medications that would be most appropriate to manage the side effects of morphine sulfate.

The nurse is planning care for a client who has a fourth degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

The caregiver of a toddler is concerned about the frequency of ear infections and states, "The pediatrician said my child's ear tubes are small and short. What can I do about this?" Which action should the nurse take?

The nurse is caring for a client whose BMI is 35 kg/m². Which condition(s) is/are the client at greatest risk of developing? Select all that apply.

An infant who weighs 22 lbs. receives a prescription for amoxicillin 20 mg/kg/day PO in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with each dose? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)

Patient Data

Review H and P and nurse's notes.

Click to highlight which assessment finding(s) should the nurse attend to right away?

Admitted client.

Vital signs

Temperature: 96.9° F (36.1° C) internal probe via urinary catheter

Heart rate: 128 beats/minute, sinus tachycardia (ST)

Respirations: 14 breaths/minute

Patient Data

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg

Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2)

The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a PIV line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members. The client opens her eyes to verbal stimuli and follows verbal commands.