Exhibits

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.

The client is a 7-year-old with spastic cerebral palsy (CP) admitted to pre-op for heel cord lengthening. Child has cognitive and speech delays. Experiences absent seizures numerous times daily according to parent. Surgery went well for bilateral heel cords lengthening. The nurse is updating the plan of care.

Select 5 findings that would require immediate action prior to the nurse administering this pain medication

The healthcare provider prescribes 5% Dextrose Injection, USP with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Reference Range

• Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
• Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

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

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)

The nurse at the 9-month visit reviews the child's height, weight, and feeding progression history.

What should the nurse advise the parents concerning the child's nutrition? Select all that apply

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea.

Vital Signs

Heart Rate-beats/minute- 110 Respirations - breathes/minute- 28 Blood Pressure – mmHG- 80/60

Arterial blood gases (ABGs)

Ph- 7.34

PaCO2- 34 mmHg

HCO3- 20 mmol/L

pO2- 90 mmHg

Electrolytes Results

Sodium

130 mEq/L(mmol/L) Potassium

2.5 mEq/L (mmol/L) Chloride

95 mEq/L (mmol/L)

Reference Range:

Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Chloride [98 to 106 mEq/L (98 to 106 mmol/L)]

PaCO2 [35 to 45 mm Hg]

HCO, [21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg)

The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.)

Review H and P and nurse's notes.

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

The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?