Vati Remediation

A nurse concludes that additional teaching about the Diabetic Sick Rule is needed when the mother of the child states which of the following?

"I will take my child blood sugar every 6 hours."

The nurse is assessing the family dynamics of a widow with end stage terminal cancer. Which statement made between the adult children would best indicate the need for further teaching

"It does not matter what we think, the living will says 'do not resuscitate'."

expected findings for hypercalcemia

**NEUROMUSCULAR ● Decreased reflexes ● Bone pain ● Flank pain if renal calculi develop **CARDIOVASCULAR ● Dysrhythmias ● Increased risk for blood clot **GI: Anorexia, nausea, vomiting, constipation **CENTRAL NERVOUS SYSTEM ● Weakness, lethargy ● Confusion, decreased level of consciousness

A 36-year-old client is prescribed digoxin for heart failure. What are two (2) contraindications for the use of digoxin?Suggested Pharmacology Learning Activity: Heart Failure

-Contraindicated in clients who have disturbances in ventricular rhythm, including ventricular fibrillation, ventricular tachycardia, and second-and third-degree heart block. -Use cautiously in clients who have hypokalemia, partial av block, advanced heart failure, and impaired kidney function.

A nurse is educating a client on how to perform Kegel exercise therapy for urinary incontinence. Which of the following points should be included in teaching? Select all that apply.

-During exercises, tighten pelvic muscles for a count of 10 and then relax for a count of 10 -Improvement in incontinence may be seen after 6 weeks of exercise therapy.

A charge nurse is planning to utilize a nurse from the hospital's float pool. Which of the following are disadvantages to float pools? Select all that apply.

-Float pools result in a lack of continuity of client care -Float pools are not a solution to the long-term staffing shortages.

List three (3) best practices to prevent injury when moving a client up in bed.

-Have 1 or more staff members assist with positioning clients. -Prepare the environment by removing obstacles prior to the procedure. -Be aware that the safest way to lift a client is with assistive equipment.

A nurse is caring for a newborn client who is experiencing severe hyperbilirubinemia. Which of the following are symptoms of kernicterus? Select all that apply.

-Hypotonic -lethargy

Findings for acute glomerulonephritis

-Mild to severe hypertension -low grade fever -vomiting -encephalopathy

Gross motor skills by age 3

-Rides a tricycle -jumps off bottom step -stands on one foot for a few seconds

A nurse is caring for a client diagnosed with hyperemesis gravidarum. Which of the following are expected findings for this client? Select all that apply

-Weight loss -Dehydration

Client education for celiac disease

-eat foods that are gluten-free (milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh meats and fish, dried beans) -Read labels on processed products have gluten as an ingredient. -Read labels and research nonfood products (lipstick, communion wafers, vitamin supplements), which can also have gluten as an ingredient.

What are characteristics of the fetus that are reviewed to determine the biophysical profile (BPP) during an ultrasound? Select all that apply.

-fetal tone -qualitative amniotic fluid volume

manifestations for hypoglycemia

-headache and blurred vision -seizures leading to coma -shakiness, pallor, cool skin, -irritability

gross motor skills by age 5

-jumps rope -walks backward with heel to toe -throws and catches a ball with ease.

Nursing role in advanced directives

-provide written information regarding advanced directives -document the client's advanced directives status -ensure that the advanced directives reflect the client's current decisions -inform all members of the health care team of the client's advance directives

Gross motor skills by age 4

-skips and hops on one foot -throws ball overhead. -catches ball reliably.

risk factors for nutrition during pregnancy

.Adolescents might have poor nutritional habits (a diet low in vitamins and protein, not taking prescribed iron supplements)

aortic stenosis

A narrowing of the aortic valve ● INFANTS: Faint pulses, hypotension, tachycardia, poor feeding tolerance ● CHILDREN: Intolerance to exercise, dizziness, chest pain, possible ejection murmur

APGAR scoring

A= appearance (color all pink, pink and blue, blue [pale]) P= pulse (>100, < 100, absent) G= grimace (cough, grimace, no response) A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent)

A nurse is admitting a client diagnosed with posttraumatic stress disorder (PTD) to the mental health unit. The client is confused and disoriented. When developing a plan of care, which of the following would be the priority intervention for this client?

Accept and make the client feel safe

Measles, mumps and rubella vaccine (MMR)

Administer doses at 12 to 15 months and 4 to 6 years - administer one dose at 12 to 15 months and 4-6 years or two doses administered a minimum of 4 weeks apart if administered after age 13 years.

A nurse is caring for a client who is being treated with internal radiation. Which nursing interventions are appropriate for this client? Select all that apply.

Always face the radiation source., Assign the client to a private room with a private bath., Encourage visitors to stay at least 6 feet from the client.

intraprocedure for amniocentesis

Assist client into a supine position, and place a wedge under their right hip to displace the uterus off the vena cava, and place a drape over the client exposing only the abdomen

nursing intervention for diabetes mellitus

Assist with an exercise plan. ◯ Children active with team sports will require a snack 30 min prior to activity. ◯ Prolonged activities will require food intake every 45 to 60 min ◯ Encourage sugar‑free, noncaffeinated liquids to prevent dehydration

a nurse is collecting data on a 5-month-old infant. Which of the following is an expected finding?

Babinski reflex present

therapeutic procedure for clubfoot

Castings ● Series of castings starting shortly after birth and continuing until maximum correction is accomplished. ● Weekly manipulation of the foot to stretch the muscles with subsequent placement of a new cast. ● Following casting, a heel cord tenotomy is usually performed followed by a long leg cast for 3 weeks. ● After 6 weeks, a Denis Browne bar that connects specialized shoes can be applied to maintain the correction and prevent recurrence. NURSING CARE ● Assess neurovascular status. ● Perform cast care. CLIENT EDUCATION ● Proper cast care. ● Follow-up care for cast changes. ● Change diapers frequently ● Check for decrease circulation (pallor and coldness) and notify the provider

ongoing care for therapeutic procedures to assist with labor and delivery

Continuously monitor FHR patterns to assess for bradycardia and variable decelerations during the version and for 1 hr following the procedure

A nurse is caring for a client being discharge home who has hemophilia. Which of the following points would be taught to the parents prior to discharge?

Dress toddlers in extra layers of clothing.

A nurse is teaching a client about the procedure for ostomy care. What should be included?

EQUIPMENT ● Pouch system (skin barrier and pouch) ● Pouch closure clamp ● Barrier pastes (optional) ● Gloves ● Washcloths ● Towel ● Warm water ● Scissors ● Pen PROCEDURE ● If a wound ostomy continence nurse is not available, educate the client about stoma care. ● Perform hand hygiene. ● Put on gloves. ● Remove the pouch from the stoma. ● Inspect the stoma. It should appear moist, shiny, and pink. The peristomal area should be intact, and the skin should appear healthy. ● Use mild soap and water to cleanse the skin, then dry it gently and completely. Moisturizing soaps can interfere with adherence of the pouch. ● Apply paste if necessary. ● Measure and mark the desired size for the skin barrier. ● Cut the opening 0.15 to 0.3 cm (1 ⁄18 to 1 ⁄8 in) larger, allowing only the stoma to appear through the opening. ● If necessary, apply barrier pastes to creases. ● Apply the skin barrier and pouch. ● Fold the bottom of the pouch and place the closure clamp on the pouch. ● Dispose of the used pouch. Remove the gloves and perform hand hygiene ​

A nurse is caring for a client with respiratory syncytial virus (RSV). The nurse is aware that which of the following strategies would not prevent the spread of infection?

Encouraging children to participate in school activities.

What interventions should a nurse take when caring for a client with a wound evisceration?

Evisceration and dehiscence require emergency treatment. ● Call for help. Notify the provider immediately due to the need for surgical intervention. ● Stay with the client. ● Cover the wound and any protruding organs with sterile towels or dressings soaked with sterile normal saline solution to decrease the chance of bacteria invasion and drying of the tissues. Do not attempt to reinsert the organs. ● Position the client supine with the hips and knees bent. ● Observe for indications of shock. ● Maintain a calm environment. ● Keep the client NPO in preparation for returning to surgery

A nurse is caring for a surgical client who is prescribed neostigmine for treatment of -myasthenia gravis. List two (2) potential adverse effect the nurse should be aware of while providing this treatment

Excessive muscarinic stimulation. Cholinergic crisis

A nurse is caring for a neonate diagnosed with a congenital heart defect. Which of the following signs and symptoms would the nurse note if the client was experiencing heart failure? Select all that apply.

Feeding difficulties, Mottling, Tachypnea

gastrointestinal system and bowel function post partum

Flatus is common after a cesarean birth. Encourage the client to ambulate or rock in a chair to promote passage of flatus, and to avoid gas-forming foods. Antiflatulence medications can be required.

The nurse is conducting a physical examination of a 2-month-old with suspected pyloric stenosis. Which finding indicates pyloric stenosis?

Hard, moveable "olive-like mass" in the upper right quadrant

An 8-year-old child was admitted to the hospital for possible shunt malfunction. The child has been diagnosed with hydrocephalus since birth. The nurse understands which of the following are symptoms of increased intracranial pressure? Select all that apply.

Headache, Increased cluminess, Vomiting

A nurse is preparing for a procedure with a client who has a latex allergy. What action should the nurse take regarding this allergy?

If the patient has latex allergy, then the team must use latex-free gloves, equipment, and supplies. Most facilities use non latex gloves.

A nurse is providing instructions for car seat safety to parents of an infant. The nurse should include which of the following? Select all that apply.

Infants should be rear facing until they weigh 9.1kg (20 lbs)., A five point restraint system is recommended for car seats.

A nurse is caring for a client of the Buddhist faith who has just given birth to a stillborn infant. Which of the following interventions is most appropriate?

Inquire about any rituals the parents would like to perform at this time

A client has been taking epoetin alfa to stimulate RBC growth for 5 days. Identify two (2) lab values the nurse will monitor to assess therapeutic effect.Suggested Pharmacology Learning Activities: Growth Factors

Iron levels, Hgb and Hct.

A client who is suffering from delusions states, "I can't stay in group today. I am expecting the governor to be here any minute!" The nurse leading the group responds, "I understand, but right now it is time for group and we expect everyone to attend." Which of the following explains why the nurse's statement would be considered therapeutic?

It articulates what is expected without reinforcing the delusion

A nurse is caring for a newborn whose mother is an alcoholic. Describe withdrawal symptoms this newborn may exhibit.

Jitteriness, irritability, increased tone and reflex responses, seizures

A nurse is caring for a client diagnosed with osteomyelitis. The nurse would expect which of the following findings during the assessment? Select all that apply.

Leukocytosis, Positive wound cultures, Elevated erythrocyte sedimentation rate

List the steps for mixing a short acting and long acting insulin in the same syringe.

List the steps for mixing a short acting and long acting insulin in the same syringe. 1. Draw air (equal to the prescribed number of units. 2. inject are into long acting Insulin-being careful not to be making contact with the insulin. 3. Draw air (equal to the prescrived number of units) again with the same needle. 4. Inject air into short acting insulin. 5. Turn the short acting insulin bottle upside down to draw the prescribed number of units. 6. Insert needle (with short-acting insulin) into long acting insulin and draw prescribed number of long acting insulin units. 7. Drawing the insulin in this order prevents the possibility of accidently injecting the long acting insulin into the short acting insulin vial.

evaporation

Loss of heat as surface liquid is converted to vapor. Gently rub the newborn dry with a warm sterile blanket (adhering to standard precautions) immediately after delivery. If thermoregulation is unstable, postpone the initial bath until the newborn's skin temperature is 36.5° C (97.7° F). When bathing, expose only one body part at a time, washing and drying thoroughly

Digoxin teaching

Many remember to hold digoxin for HR < 60 in adults, but don't know for children and infants. Hold for HR < 70 in children and HR < 90 in infants. Did you know there are herbals that interact with warfarin? Remember the 4 G's: ginseng, garlic, ginkgo biloba, and ginger

asthma

Monitor for shortness of breath, dyspnea, and audible wheezing. An absence of wheezing can indicate severe constriction of the alveoli

A nurse is teaching a community health class on communicable diseases to adolescents. During the discussion on infectious mononucleosis, which statement would lead the nurse to conclude that further teaching is needed?

Mononucleosis is a bacterial infection."

A nurse is caring for an infant prescribed digoxin. The client's apical heart rate is 88 beats per minute. Which of the following interventions should the nurse take? Select all that apply.

Obtain a rhythm strip to assess for heart block., Withhold the medication., Notify the physician.

A nurse is helping parent's select appropriate independent activities for their 8-year-old child. Which of the following would be an appropriate activity?

Providing frequent trips to the library

A client is refusing to take morning medications. How should the nurse respond?

Respect the client's right to refuse any medication. Explain the consequences, inform the provider, and document the refusal.

complications of status asthmaticus

Respiratory failure Persistent hypoxemia related to asthma can lead to respiratory failure. NURSING ACTIONS ● Monitor oxygenation levels and acid-base balance. ● Prepare for intubation and mechanical ventilation as indicated

skin care for communicable diseases

SKIN CARE ● Provide calamine lotion for topical relief. ● Keep the skin clean and dry to prevent secondary infection. ● Keep the child cool, but prevent chilling. ● Dress the child in lightweight, loose clothing. ● Give baths in tepid water. ● Keep the child's fingernails clean and short. ● Apply mittens if the child scratches. ● Teach good oral hygiene. A sore throat can be managed with analgesics, lozenges, and saline rinses. ● Change linens daily.

cost-effective

Strategies that achieve optimal results in relation to the money spent to achieve those results. In other words, cost‑effective means "getting your money's worth." Example: Spending increased money on staff training for transmission‑based precautions, resulting in the increased and effective use of PPE for client care. These actions have the end result of a decrease in infection transmission and an overall savings in the cost of caring for clients who would have acquired these infections.

client teaching on montelukast

Take montelukast once daily at bedtime. For exercise-induced bronchospasm, take 2 hr before exercise. If taking daily montelukast, do not take an additional dose for exercise induced bronchospasm

A nurse is educating a client who is scheduled for a nonstress test (NST). Which of the following statements are correct? Select all that apply

The NST can easily be performed in an outpatient setting

What should the nurse observe when evaluating a client's use of a cane?

The client holds the cane on the stronger side of the body Proceeding with Ambulation: 1. the patient stands with weight evenly distributed between the feet and the cane 2. The cane is held on the patient's stronger side and is advanced 4-12in (10-30cm) 3. Supporting weight on the stronger leg, advance the weaker leg forward, parallel with the cane 4. Supporting weight on the weaker leg, advance the stronger leg forward, ahead of the cane 5. The weaker leg is moved forward until even with the stronger leg along with advancement of the cane

A nurse is preparing to discharge an older adult client to the home of a family member while recovering from hip surgery. Which of the following may negatively affect the client's adjustment to living with family members?

The family is insisting on maintaining financial control for the client.

negotiation

The focus is on a win‑win solution or a win/lose‑win/ lose solution in which both parties win and lose a portion of their original objectives. Each party agrees to give up something and the emphasis is on accommodating differences rather than similarities between parties.

therapeutic procedure for phototherapy

The newborn's bilirubin should start to decrease within 4 to 6 hr after starting treatment.

Identify and describe the types of complicated grief

Types of complicated grief include chronic, exaggerated, masked, and delayed grief. ● Complicated grief involves difficult progression through the expected stages of grief. ● Usually, the work of grief is prolonged. The manifestations of grief are more severe, and they can result in depression or exacerbate a preexisting disorder. ● The client can develop suicidal ideation, intense feelings of guilt, and lowered self-esteem. ● Somatic complaints persist for an extended period of time.

lab tests for nephrotic syndrome

Urinalysis/24-hr urine collection ● Proteinuria: present; up to 15 grams of protein in a 24-hr specimen ● Hyaline casts ● Few RBCs ● Oval fat bodies ● Increased specific gravity Blood chemistry Hypoalbuminemia: reduced blood protein and albumin Hyperlipidemia: elevated blood lipid levels Hemoconcentration: elevated Hgb, Hct, and platelets Possible hyponatremia: reduced sodium level Glomerular filtration rate: normal or high Total calcium: decreased Erythrocyte sedimentation rate (ESR): increased

A nurse is caring for a client who has MRSA in a wound. Which of the following infection control precautions should be initiated? Select all that apply

Wear a protective gown when entering the client's room., Don clean gloves when delivering the client's meal tray., Use a face shield when irrigating the client's wound.

A nurse has provided discharge education to a school age client and his parents following a radius fracture with cast application. Which of the following statements by the client's parent indicates a need for additional teaching?

When we get home we will use a hair dryer to finish drying the cast.

A nurse is planning community education focusing on the principles of first aid. Which of the following strategies is likely to be most effective with adolescent learners?

actively involve the participants in practice of techniques

findings of hypocalcemia

alteration in bowel movement -diarrhea is a result of radiation to the abdominal area. Some chemotherapeutic agents can cause constipation. If mobility and nutrition decrease, the child is more likely to develop constipation.

adverse effects of chemotherapy

anorexia, nausea, vomiting. .

postpartum blues

can occur in up to 85% of clients during the first few days after birth and generally continues for up to 10 days. It is characterized by mood swings, tearfulness, insomnia, lack of appetite, and a feeling of letdown. A parent can experience an intense fear, anxiety, anger, and inability to cope with the slightest problems and become despondent. Postpartum blues typically resolves in 10 days without intervention. Feelings of sadness ● Lack of appetite ● Sleep pattern disturbances ● Feeling of inadequacies ● Crying easily for no apparent reason ● Restlessness, insomnia, fatigue ● Headache ● Anxiety, anger, sadness PHYSICAL ASSESSMENT FINDINGS: Crying

There are different parenting styles that are exhibited within a family. Which of the following parenting styles is exhibited when a parent states, "My child can play video games for one hour a day after his homework is completed"?

democratic

preeclampsia

is GH with the addition of proteinuria of greater than or equal to 1+. Report of transient headaches might occur along with episodes of irritability. Edema can be present.

Durable power of attorney for healthcare

is a legal document that designates a health care surrogate, who is an individual authorized to make health care decisions for a client who is unable. ● The person who serves in the role of health care surrogate to make decisions for the client should be very familiar with the client's wishes. ● Living wills can be difficult to interpret, especially in the face of unexpected circumstances. A durable power of attorney for health care, as an adjunct to a living will, can be a more effective way of ensuring that the client's decisions about health care are honored

HELLP syndrome

is a variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory tests, not clinically. ● H: Hemolysis resulting in anemia and jaundice ● EL: Elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, and nausea and vomiting ● LP: Low platelets (less than 100,000/mm3 ), resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly disseminated intravascular coagulopathy

Quality improvement

is the process used to identify and resolve performance deficiencies. Quality improvement includes measuring performance against a set of predetermined standards. In health care, these standards are set by the facility and consider accrediting and professional standards. ● Standards of care should reflect optimal goals and be based on evidence. ● The quality improvement process focuses on assessment of outcomes and determines ways to improve the delivery of quality care. All levels of employees are involved in the quality improvement process. ● The Joint Commission's accreditation standards require institutions to show evidence of quality improvement in order to attain accreditation status

prophylactic cervical cerclage

is the surgical reinforcement of the cervix with a heavy ligature that is placed submucosally around the cervix to strengthen it and prevent premature cervical dilation. Best results occur if this is done at 12 to 14 weeks of gestation. The cerclage is removed at 36 weeks of gestation or when spontaneous labor occurs.

Treatment for celiac disease

limited to avoiding gluten. However, eliminating gluten, which is found in wheat, rye and barley, is difficult because it is found in many prepared foods. Clients must read food labels carefully in order to adhere to a gluten-free diet. Some gluten-free products are unappealing to clients, and many are more expensive than other products. Prognosis is good for clients who adhere to a gluten-free die

complications of organ neoplasms

mucositis and dry mouth NURSING ACTIONS ● Provide a soft toothbrush and/or swabs. ● Lubricate the child's lips. ● Give soft, nonacidic foods. A pureed or liquid diet can be required. ● Provide analgesics. ● Avoid hydrogen peroxide and lemon glycerin swabs due to mucosal drying and irritation on eroded tissue. CLIENT EDUCATION ● Visit a dentist before therapy. ● Use chlorhexidine mouth wash or salt rinses using ½ tsp table salt mixed with 1 tsp baking soda and 1 quart wate

postpartum depression

occurs within 12 months of delivery and is characterized by persistent feelings of sadness and intense mood swings ● Feelings of guilt and inadequacies ● Irritability ● Anxiety ● Fatigue persisting beyond a reasonable amount of time ● Feeling of loss ● Lack of appetite ● Persistent feelings of sadness ● Intense mood swings ● Sleep pattern disturbances PHYSICAL ASSESSMENT FINDINGS ● Crying ● Weight loss ● Flat affect ● Irritability ● Rejection of the infant ● Severe anxiety and panic attac

A client is diagnosed with rheumatic fever. Which clinical manifestation would the nurse recognize associated with the presentation of rheumatic fever?

polyarthritis

A nurse is caring for a client taking captopril. List a lab result that shows evidence of an adverse reaction secondary to administration of captopril that needs to be reported immediately to the provider

potassium levels

respiratory distress

s can occur from compression of trachea due to hemorrhage, which is most likely to occur in the first 24 hr. Respiratory distress also can occur due to edema. Ensure that tracheostomy supplies are immediately available. Humidify air, assist to cough and deep breathe, and provide oral and tracheal suction if needed.

Iron

teeth staining (liquid form) client education: Dilute liquid iron with water or juice, drink with a straw, and rinse mouth after swallowing.

Electrolyte imbalances can depend on

the client's method of purging (laxatives, diuretics, vomiting). ● Hypokalemia ● Hyponatremia ● Hypochloremia ● Hypomagnesemia (occurs due to malnutrition) ● Hypophosphatemia (occurs due to malnutrition) ● Decreased estrogen (females who have anorexia) ● Decreased testosterone (males who have anorexia)

A new nurse is orienting to the labor and delivery unit. List three (3) potential adverse effects this new nurse should know prior to administering oxytocin

uterine rupture, uterine tachysystole, placental abruption

A nurse is caring for a client in skeletal traction. What guidelines should the nurse observe regarding traction?

· Assess neurovascular status of the affected body part every hour for 24 hr and every 4 hr after that. ● Maintain body alignment and realign if the client seems uncomfortable or reports pain. ● Avoid lifting or removing weights. ● Ensure that weights hang freely and are not resting on the floor. f the weights are accidentally displaced, replace the weights. If the problem is not corrected, notify the provider. ● Ensure that pulley ropes are free of knots, fraying, loosening, and improper positioning at least every 8 to 12 hr. ● Notify the provider if the client experiences severe pain from muscle spasms unrelieved with medications or repositioning. Routinely monitor skin integrity and document. ● Use heat/massage as prescribed to treat muscle spasms. ● Use therapeutic touch and relaxation techniques. Pin care is done frequently throughout immobilization (skeletal traction and external fixation methods) to prevent and to monitor for manifestations of infection. ◯ Drainage and redness (color, amount, odor)

A nurse reviews an order for ceftriaxone in combination with vancomycin for a client diagnosed with meningitis. Identify three (3) components of the medication prescriptions that, if missing, would require clarification with the provider

· If missing would required clarification with the provider. · Route, dosage · It has to be administered at least over 60 minutes.

A nurse cares for a client whose family member voices concern that the client may have Alzheimer's. List four (4) manifestations associated with mild Alzheimer's Disease.

· Memory lapses · Losing or misplacing items · Difficulty concentrating and organizing. · Unable to remember material just read.

Explain the steps involved in providing an intermittent enteral feeding.

■ Prepare the formula and a 60-mL syringe. ■ Remove the plunger from the syringe. ■ Hold the tubing above the instillation site. ■ Open the stopcock on the tubing, and insert the barrel of the syringe with the end up. ■ Fill the syringe with 40 to 50 mL formula. ■ If using a feeding bag, fill the bag with the total amount of formula for one feeding, and hang it to drain via gravity until empty (about 30 to 45 min). ■ If using a syringe, hold it high enough for the formula to empty gradually via gravity. ■ Continue to refill the syringe until the amount for the feeding is instilled. Follow with at least 30 mL water to flush the tube and prevent clogging.

The nurse is performing a focused gastrointestinal assessment on a client who complains of fever and abdominal pain for 2 days. What additional assessment findings alert the nurse to the possibility of appendicitis?Suggested Adult Med Surg Learning Activity: Appendicitis

● Abdominal pain in the right lower quadrant ● Rigid abdomen ● Decreased or absent bowel sounds ● Fever ● Diarrhea or constipation ● Lethargy ● Tachycardia ● Rapid, shallow breathing ● Anorexia ● Possible vomiting Computed tomography scan shows an enlarged diameter of appendix, as well as thickening of the appendiceal wall.

nursing intervention for placenta previa

● Assess for bleeding, leakage, or contractions. ● Assess fundal height. ● Refrain from performing vaginal exams (can exacerbate bleeding). ● Administer IV fluids, blood products, and medications as prescribed. Corticosteroids, such as betamethasone, promote fetal lung maturation if early delivery is anticipated (cesarean birth). ● Have oxygen equipment available in case of fetal distress.

1. List three (3) teaching points the nurse can provide a client with cholelithiasis on dietary choices for symptom management.

● Consume a low-fat diet rich in HDL sources (seafood, nuts, olive oil). ● Participate in a regular exercise program. ● Do not smoke.

An older client asks a nurse what she can do to minimize the risk of developing osteoporosis. Identify 3 (three) health promotion activities the client should implement.

● Consume adequate amounts of calcium and vitamin D, from food or supplements, especially during young adulthood. ◯ Foods rich in vitamin D are most fish, egg yolks, fortified milk, and cereal. ◯ Foods rich in calcium are milk products, green leafy vegetables, fortified orange juice and cereals, red and white beans, and figs. Some soy and rice products are fortified with vitamin D and calcium. ● Spend time outdoors to increase the body's production of vitamin D. Exposure to the sun for any length of time should include wearing sunscreen to avoid getting a sunburn. ● Engage in weight-bearing exercises (walking, lifting weights). These activities promote bone rebuilding and maintenance

hyperemesis gravidarum expected findings

● Excessive vomiting for prolonged periods ● Dehydration with possible electrolyte imbalance ● Weight loss ● Increased pulse rate ● Decreased blood pressure ● Poor skin turgor and dry mucous membranes

physical findings for gestational hypertension

● Hypertension ● Proteinuria ● Periorbital, facial, hand, and abdominal edema ● Pitting edema of lower extremities ● Vomiting ● Oliguria ● Hyperreflexia ● Scotoma ● Epigastric pain ● Right upper quadrant pain ● Dyspnea ● Diminished breath sounds ● Seizures ● Jaundice ● Manifestations of progression of hypertensive disease with indications of worsening liver involvement, kidney failure, worsening hypertension, cerebral involvement, and developing coagulopathies

nursing care for nephrotic syndrome

● Provide rest. ● Maintain strict I&O. Weigh infant diapers for recording output. ● Monitor urine for protein. ● Monitor vital signs. ● Monitor daily weights; weigh the child on the same scale with the same amount of clothing. ● Monitor edema and measure abdominal girth daily. Measure at the widest area, usually at or above the umbilicus. Assess degree of pitting, color, and texture of skin. ● Elevate legs and feet to relieve edema. ● Monitor and prevent infection (increased Risk for upper respiratory infection). ● Encourage nutritional intake within restriction guidelines. Salt can be restricted during the edematous phase. ● Cluster care to provide for rest periods. ● Assess skin for breakdown areas. ● Provide support to families and make appropriate referrals as needed. Relapses can cause physical, emotional, and financial stress for the client and family

advocacy

● The complex health care system puts clients in a vulnerable position. Nurses are clients' voice when the system is not acting in their best interest.

Strategy: Compromising/Negotiating

● This approach generally minimizes the losses for all involved while making certain each party gains something. For example, the nurse might offer to work on another medical‑surgical unit if someone from that unit feels comfortable in the pediatric environment. ● Although each party is giving up something (the manager gives in to a different solution and the nurse still has to work on another unit), this sort of compromise can result in a win‑win resolution.

lab tests for acute glomerulonephritis

● Throat culture: to identify possible streptococcus infection (usually negative by the time of diagnosis) ● Urinalysis: proteinuria, smoky or tea-colored urine, hematuria, increased speci c gravity ● Renal function: elevated BUN and creatinine ●Antistreptolysin O (ASO) titer: positive indicator for the presence of streptococcal antibodies ● Antihyaluronidase (AHase) ●Antideoxyribonuclease B (ADNase-B) ● Antistreptokinase (ASKase) ● Antideoxyribonuclease B (ADNase-B) ● Serum complement (C3): decreased initially; increases as recovery takes place; returns to normal at 8 to 10 weeks post glomerulonephritis

assessment related to possible rupture of membranes

◯ A sample of the fluid can be obtained and viewed on a slide under a microscope. Amniotic fluid will exhibit a frond-like ferning pattern. Assess the amniotic fluid for color and odor. ■ Expected findings are clear, the color of water, and free of odor. ■ Abnormal findings include the presence of meconium, abnormal color (yellow, green), and a foul odor

​A nurse is providing discharge teaching to a client following a permanent pacemaker insertion. List four (4) important teaching points that need to be included.

◯ Take pulse daily at the same time for those with pacemakers or combination devices. Notify the provider if heart rate is less than the pacemaker rate. ◯ Report dizziness, fainting, fatigue, weakness, chest pain, hiccuping, palpitations, difficulty breathing, or weight gain ◯ Never place items that generate a magnetic field directly over the pacemaker generator. These items can affect function and settings. This includes garage door openers, burglar alarms, strong magnets, generators and other power transmitters, and large stereo speakers. The use of household items is not prohibited. ◯ Inform airport security personnel about the presence of a pacemaker/ICD, because it will set off airport security detectors. The airport security device should not affect pacemaker functioning. Airport security personnel should not place wand detection devices directly over the pacemaker or ICD.