Patient Data

Exhibits

Review H and P, nurse's notes, and laboratory results.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

Answer and Explanation

The Correct Answer is []

Potential condition: Polycythemia

Actions to take

Have the parents increase the child's caloric intake: Polycythemia in children with tetralogy of Fallot can be managed by ensuring adequate hydration and nutrition. Increasing caloric intake helps support growth and development and can prevent excessive erythrocytosis.

Take the child's vital signs: Regular monitoring of vital signs, including heart rate, respiratory rate, blood pressure, and temperature, is essential to assess the child's cardiovascular status and response to treatment.

Parameters to monitor

Oxygen saturation: Monitoring oxygen saturation helps assess the adequacy of pulmonary blood flow and oxygenation in a child with tetralogy of Fallot and polycythemia.

Weight: Monitoring weight is crucial to assess growth and nutritional status. Children with tetralogy of Fallot may have poor weight gain due to increased metabolic demands and potential feeding difficulties.

Nursing Test Bank

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Correct Answer is ["18"]

Explanation

(Desired Dose * Volume of IV Bag) / (Concentration of Drug in IV Bag * Time) = Infusion Rate.

For the given prescription, the calculation would be: (900 units/hr * 500 mL) / (25,000 units) = 18 mL/hr.

Therefore, the nurse should program the infusion pump to deliver 18 mL/hr.

A. Clarify that all STIs are transmitted through sexual intercourse. B. Explain that reinfections occur from sex with untreated partners. C. Provide counseling that most contraceptives protect against infection. D. Emphasize that using safe sex practices removes the risk of STIs.

Correct Answer is B

Explanation

Rationale

A. This statement is partially true as most sexually transmitted infections (STIs), including syphilis, are primarily transmitted through sexual intercourse. However, not all STIs are exclusively transmitted through sexual contact.

B. Syphilis is caused by the bacterium Treponema pallidum and can be transmitted through direct contact with a syphilitic sore (chancre) during vaginal, anal, or oral sex. If a person has syphilis and engages in unprotected sex with a partner who is not treated, they can potentially contract or transmit the infection again, leading to reinfection.

C. While contraceptives such as condoms provide protection against unintended pregnancy and some STIs, including syphilis, they do not offer complete protection against all STIs. Condoms are effective in reducing the risk of transmission of syphilis when used consistently and correctly, but they are not 100% protective.

D. Using safe sex practices, such as consistent and correct use of condoms, reduces the risk of acquiring or transmitting STIs, including syphilis. Safe sex practices also include mutual monogamy and regular testing for STIs, especially for those who have multiple sexual partners or engage in high-risk sexual behaviors.

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Actions to take

Parameters to monitor

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["18"]

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

Correct Answer is B

Explanation

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?