A nurse on a cardiac care unit is caring for a preschooler.

• Hospital Day 1, 17:38: Medication Administration Record.
• 20:15: Received 4-year-old child with an exacerbation of heart failure.
• Family reports history of congenital mitral stenosis.
• Breath sounds with wheezing noted in bilateral lower lobes.
• Nonproductive cough noted.
• Dyspnea with respiratory rate 30/min.
• Oxygen at 2 L/min applied per nasal cannula.
• Telemetry applied: Sinus rhythm at rate 116/min. Abdomen soft, nontender.
• Bowel sounds positive in all 4 quadrants. Lower extremities with 2+ edema noted.
• Pedal pulses palpable bilaterally.
• Peripheral saline lock intact to right forearm with no signs and symptoms of infection.
• Weight 26 kg (44 lb). Increase in dyspnea noted with orthopnea.
• Nasal flaring with respiratory rate of 36/min.
• Lung sounds with wheezing noted throughout.
• Lower extremity edema 3+ to bilateral lower extremities.
• Extremities cool with decreased skin pigmentation noted.
• Peripheral pulses weak bilaterally.
• Jugular vein distention noted.
• Provider notified.

Received prescription for additional dose of furosemide. The client is at risk for developing:

A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa.

Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?

A nurse is caring for a school-age child who has leukemia.

0900: Custom Nursing Assessment.
1000: Vital Signs: Child is awake and alert but not talkative.

Child was brought in for an ongoing upper respiratory infection for the last 2 months that will not go away. Parents report the child’s leukemia has been in remission for more than a year.
Bruising noted on the child’s shoulder, thighs, and back.

Parents are not sure where it came from.
Diagnostic Results: Child’s breath sounds clear with subcostal retractions.

Oxygen saturation is 92% on room air.
Child’s skin is pale and petechiae noted on trunk and thighs.

Child states, “I feel like I can’t breathe.”. Bed raised to high-Fowler’s, oxygen applied and provider notified.

Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.

Increased heart rate.

Discomfort at the puncture site.

A nurse is monitoring a client following a thoracentesis.

The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

A nurse is providing teaching to a client who has coronary artery disease. Which of the following statements should the nurse include in the teaching to explain the correlation between changes in the coronary arteries and manifestations that occur?

A nurse is providing teaching to a client who has atrial fibrillation and reports dizziness and palpitations. Which of the following should the nurse understand is the cause of these manifestations?

A nurse is caring for a client who was recently admitted and has symptomatic bradycardia.

Temperature: 36.6°C (97.8°F). Apical pulse: 42/min.
Respiratory rate: 26/min.
Blood pressure: 104/68 mm Hg.

Oxygen saturation: 94% on room air.

Complete the following sentence by using the list of options.

The nurse is caring for the client immediately following the insertion of the permanent pacemaker. The nurse should monitor the client for:

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A nurse is educating clients about breast cancer at a community health event. Which of the following statements should the nurse include in the training?

A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?