1. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops
... [Show More] to 60%. Choose the interventions that the nurse shouldperform. Select all that apply.
1. Call a code blue.
2. Notify the registered nurse.
3. Place the infant in a prone position.
4. Prepare to administer morphine sulfate.
5. Prepare to administer intravenous fluids.
6. Prepare to administer 100% oxygen by face mask.
Answers: 2, 4, 5, and 6.
2. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client careactivities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.
1. Assessing the client’s bowel sounds
2. Providing skin care following bowel movements
3. Evaluating the client’s response to antidiarrheal medications
4. Maintaining intake and output records
5. Obtaining the client’s weight.
Answer: 2, 4, and 5.
3. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptomswould the nurse expect the child to demonstrate? Select all that apply.
1. Head tilt
2. Vomiting
3. Polydipsia
4. Lethargy
5. Increased appetite
6. Increased pulse
Answer: 1, 2, 4.
4. Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client toexhibit? Select all that apply:
1. Sweating
2. Low PCO2
3. Retinopathy
4. Acetone breath
5. Elevated serum bicarbonate
Answer: 2, 4.
5. A client has died, and a nurse asks a family member about the funeral arrangements. The family memberrefuses to discuss the issue. The nurse’s appropriate action is to:
1. Show acceptance of feelings.
2. Provide information needed for decision making.
3. Suggest a referral to a mental health professional.
4. Remain with the family member without discussing funeral arrangements.
Answer: 4.
6. A 16-year-old child is brought to the emergency department by his mother with a complaint that the childjust experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply.
1. Diazepam (Valium)
2. Alprazolam (Xanax)
3. Gabapentin (Neurontin)
4. Ethosuximide (Zarontin)
5. Carbamazepine (Tegretol)
6. Methylphenidate (Ritalin)
Answers: 3, 4, and 5. [Show Less]