Final Exam

The nurse is caring for a 9-month-old child who was admitted with severe dehydration after several days of diarrhea. The child has completed initial rehydration therapy. The nurse is instructing the parents on the best way to maintain adequate fluids. Which course of treatment should the nurse recommend?

Continue with breast milk or lactose-free formula.

The nurse on a surgical unit has been assigned five clients. Place the clients in order of priority of care. All options must be used.

client rating pain as 9 out of 10 client 1-day postoperative transurethral resection of the prostate (TURP) client with a postoperative infection due to receive oral antibiotics client being discharged to home in 2 hours client with a fever documented at 99°F (37.2°C)

A nurse working in a public health department is educating a nursing student about administering an intradermal allergen injection. What statements made by the nursing student would indicate further teaching is required? Select all that apply.

"A 2 mL sterile syringe is one piece of equipment I need to have." "When injecting the intradermal allergen, I need to inject 0.01 to 0.02 mL." "It does not matter where I give it in the arm, as long as it is somewhere in the arm

The nurse is caring for a client who has been prescribed a benzodiazepine medication for acute anxiety. What information is most important for the nurse to include when teaching the client about the medication?

"Take the medication as prescribed as there is risk for addiction."

The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"?

"You're very concerned when you think about how this will change your life."

Two days after a client undergoes repair of a ruptured cerebral aneurysm, a physician orders mannitol, 0.5 g/kg to be infused over 60 minutes. The client weighs 175 lb. The nurse should administer how many grams of mannitol? Record your answer using a whole number.

40

The nurse is caring for a 5-year-old child in pain. What is the best method to assess the child's pain?

Ask the child to point to a face drawing that indicates pain intensity.

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. When teaching the client about the diet, the nurse should take which action first?

Assess the client's and family's typical food preferences.

The nurse is planning care for a 4-day-old breastfed infant receiving phototherapy. What interventions and outcomes support a decrease in the serum bilirubin levels? Select all that apply.

Infant breastfeeds every 2 to 3 hours. Urine output is 3 mL/kg/hr. Infant has 3 to 4 seedy, yellow stools per day.

The nurse is caring for a 5-year-old child with a skin rash. Which of these instructions should the nurse give to the parent to help prevent skin breakdown? Select all that apply.

Keep the child's fingernails short. Provide a coloring book and crayons. Use prescribed antihistamines as needed. Apply gloves to the child's hands.

The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. Which choice will best meet the client's nutritional needs at this time?

a peanut butter sandwich

There has been a large disaster, and nurses from various units have been assigned to help with the large influx of clients. To which client would it be most appropriate to assign an obstetric-postpartum nurse?

female in pelvic traction who is three months pregnant

A school-age client is experiencing severe itching in both hands that is worse at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. Which nursing diagnosis should the nurse use to plan care for this client?

impaired skin integrity

A nurse is working with an unlicensed assistive personnel (UAP). Which client(s) should the nurse assign to the UAP? Select all that apply.

older adult client who had hip replacement surgery and needs to walk in the hall with a walker adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours

A parent brings a child to the clinic with symptoms of weight loss, paleness, fatigue, and not growing. What question about the child's environment should the nurse ask the parent based on these symptoms?

"How old is the house that you live in?"