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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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C"]

Explanation

Rationale

A. High in sodium due to pickling, which is not suitable for someone with hypertension.

B. Recommended because fresh fruits are low in sodium and high in potassium and other nutrients beneficial for managing blood pressure.

C. Recommended because they are low in sodium and rich in potassium, fiber, and nutrients that support cardiovascular health.

D. Cottage cheese is high in sodium and should be avoided or consumed in moderation.

E. Generally high in sodium, which should be limited or avoided in the diet of someone with hypertension.

A. Monitor blood glucose level. B. Maintain strict intake and output. C. Assess warmth of extremities. D. Keep head of bed raised 45 degrees.

Correct Answer is B

Explanation

Rationale

A. Monitoring blood glucose levels is important, especially in critically ill patients, as hyperglycemia can worsen outcomes in septic shock. However, it is not the most critical intervention in the immediate management of septic shock.

B. Monitoring intake and output (I/O) is essential for assessing fluid balance, which is crucial in managing septic shock. Maintaining a strict I/O helps in determining fluid resuscitation needs and evaluating response to treatment. This intervention is important but may not be the most critical initially.

C. Assessing warmth of extremities is important as it helps in evaluating peripheral perfusion, which can be compromised in septic shock. Cold extremities can indicate poor tissue perfusion and may prompt the need for interventions such as fluid resuscitation.

D. Keeping the head of the bed elevated to 45 degrees is a specific intervention aimed at improving oxygenation and respiratory function, particularly in patients who may be mechanically ventilated or at risk of respiratory compromise. While this is an important intervention, it is not directly related to managing septic shock itself.

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Actions to take

Parameters to monitor

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Correct Answer is ["B","C"]

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?

Correct Answer is B

Explanation

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?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take? Reference Range: High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?