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A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

The nurse is teaching a child with type I diabetes mellitus to administer insulin. The child is receiving a combination of short acting and long acting insulin. The nurse knows that the child has appropriately learned the technique when the child:

A nurse in the emergency department (ED) is caring for a 13-year-old client who presented with right lower quadrant abdominal pain, nausea, and fever.

Medication Administration Record

0630:

0.9% sodium chloride at 97 mL/hr

Diagnostic Results

0650:

WBC count 22,000/mm3 (5,000 to 10,000/mm3) RBC count 4.5/mm3 (4.0 to 5.5/mm3)

Hgb 14 g/dL 9.5 to 14 g/dL)

Hct 44% (30% to 40%)

Platelets 350,000/mm3 (150,000 to 400,000/mm3)

C-Reactive Protein 1.8 mg/dL (less than 1.0 mg/dL)

Nurses' Notes

0600:

Client presents to the ED with guardian. Client reports that they began having pain around their "belly button" the previous evening around 2100. Reports that pain is now in right lower quadrant and became worse earlier this morning, Reports nausea. Abdomen soft with tenderness to palpation in right lower quadrant. Bowel sounds positive in all four quadrants. Verbalizes increase in pain when right hip is flexed and rotated internally. Rates pain as 6 on a 0 to 10 pain scale.

0620:

Notified provider of client's arrival and assessment data. Prescriptions received.

0630:

IV started in right forearm x 1 stick with 22-gauge cathalon. Securement device and tegaderm placed. Infusing 0.9% sodium chloride 97 mL/hr via IV pump. CBC and C-Reactive Protein drawn and sent to lab.

0700:

Client reports increase in right lower quadrant pain, rating pain as 9 on a 0 to 10 pain scale. Vomits 50 ml gastric contents into basin.

Vital Signs

0600:

Temperature 37.7° C (99.9° F). Pulse rate 98/min, strong and regular. Respiratory rate 22/min, blood pressure 124/64 mm Hg, oxygen

saturation 99% on room air.

Height: 163 cm (5 ft 4 in)

Weight: 56.7 kg (125 lb)

0700:

Temperature 38.4° C (101.1° F). Pulse rate 112/min, strong and regular. Respiratory rate 24/min, blood pressure 138/88 mmHg, oxygen saturation 98% on room air.

Provider Prescriptions

0620:

Start 0.9% sodium chloride IV

Infuse IV fluids at 97 mL/hr

Draw CBC and C-reactive Protein

Notify provider of lab results

The nurse has notified the provider of the client's 0700 assessment data and lab results. Which of the following prescriptions should the nurse anticipate? (Select all that apply.)

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

A 5-year-old child has a cardiac catheterization via the femoral artery. Which assessment would be most important to complete after the procedure?

A nurse is caring for an infant whose guardian reports intermittent vomiting for several days.

Findings upon admission:

Nurses Notes

Guardian reports infant has been forcefully vomiting after feedings. Guardian states the emesis is so forceful that it often lands 3 to 4 feet away. Infant is very fussy and rooting and sucks vigorously on a pacifier.

Vital Signs

Axillary temperature: 38.2° C (100.8° F)

Heart rate: 152/min

Respiratory rate: 30/min

Physical Examination

Mucus membranes are dry. Anterior fontanel depressed and soft. Small amount of urine noted in the diaper, which is dark in color. Upper portion of the abdomen is distended. Bowel sounds auscultated in all four quadrants. Palpable olive-shaped mass noted in the right mid-abdominal region.

Diagnostic Results

Ultrasound examination of the abdomen shows a mass that encircles the pyloric canal consistent with hypertrophic pyloric stenosis.

Which of the following actions should the nurse take? (Select all that apply)

The nurse notices that a child is spitting up small amounts of blood in the immediate postoperative period after a tonsillectomy. What would be the best intervention?

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?

A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms?