This is an 11-month-old male with a 2-day history of fussiness, increased nasal secretions, and cough. The baby is 24.3 lb. (11 kg). He was born at 34 weeks gestation and spent several weeks in the neonatal intensive care unit for poor feeding.

He is currently up to date on vaccinations and is meeting appropriate developmental milestones. The parents deny that he takes any medications at home.

Review H and P and flow sheet.

Select which assessment findings indicate that the baby has an increased fluid requirement. Select all that apply.

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 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 nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

A client who has been taking allopurinol prophylactically comes into the clinic with reoccurring gout attack episodes in left ankle. The healthcare provider changes the prescription to febuxostat. Which instruction should the nurse include in the discharge teaching?

The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication?

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement 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 has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

Exhibits

For each client statement, click to highlight the statement(s) below that require follow up teaching by the nurse.

"I am at high risk for post-traumatic-stress disorder because I have acute stress"

"I can use holistic approaches like meditation to help my symptoms." 

"I can learn to manage my thoughts better through therapy." 

"Many people have the same response to a stressful situation as I am having"

"This diagnosis means that I am crazy." 

"I will probably need to be on medication for the rest of my life." 

A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. Which teaching should the nurse provide?