NCLEX Review

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A 10-year-old child is taking high doses of aspirin. Which of the following indicate the child is experiencing early salicylate toxicity?

dizziness

After a child returns from the postanesthesia care unit after surgery, which of the following should the nurse assess first?

After surgery, the nurse's initial assessment is the surgical site dressing to determine whether there is any bleeding or drainage. Once this assessment is completed, then the nurse would assess the other areas such as the I.V. access site, pain, and nasogastric tube function.

When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the mother to relate which of the following about the infant's crying and episodes of pain?

Intermittent with knees drawn to the chest.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and bathroom. In which order of priority from first to last should the nurse take the following actions? a) Assess the client's current condition and vital signs. b) If the client shows no signs of acute injury, get help and carefully assist the client back to bed. c) Document as required by the facility. d) Notify the client's physician and family.

a, b, d, c


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