Fluid and electrolytes

The nurse is providing developmentally appropriate care for a toddler hospitalized for observation following a fall down the steps. Which measures might the nurse consider when caring for this child? Select all that apply. Use the en face position when holding the toddler. Explain activities in concrete, simple terms. Avoid leaving small objects that can be swallowed in the bed. Encourage parents to stay to prevent separation anxiety. Allow the child to select meals and activities.

Avoid leaving small objects that can be swallowed in the bed. Encourage parents to stay to prevent separation anxiety.

The nurse is working on a burns unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of what imbalance? Metabolic alkalosis Hypermagnesemia Hypercalcemia Hypovolemia

Hypovolemia Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply. Absence of pain Stable blood pressure Ability to tolerate oral fluids Sufficient oxygen saturation Adequate respiratory function

Stable blood pressure Sufficient oxygen saturation Adequate respiratory function A client remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Clients can be released from PACU before resuming oral intake. Pain is often present at discharge from the PACU and can be addressed in other inpatient settings.

The PACU nurse is caring for a male client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? Dysrhythmias, blood loss, and hyperthermia Electrolytes imbalances and neurologic changes A parasympathetic reaction and low blood volumes Pain, hypoxia, or bladder distention

Pain, hypoxia, or bladder distention

The OR nurse is providing care for a 25-year-old major trauma client who has been involved in a motorcycle accident. What intraoperative change may suggest the presence of anesthesia awareness? Respiratory depression Sudden hypothermia and diaphoresis Vital sign changes and client movement Bleeding that is beyond what is anticipated

Vital sign changes and client movement Indications of the occurrence of anesthesia awareness include an increase in the blood pressure, rapid heart rate, and client movement. Respiratory depression, hypothermia and bleeding are not associated with this complication.

The nurse is determining the amount of IV fluids to administer in a 24-hour period to a child who weighs 40 kg. How many milliliters should the nurse administer? 1,000 mL 1,500 mL 1,750 mL 1,900 mL

1,900 mL

The nurse is administering a liquid medication to a 3-year-old using an oral syringe. Which action would be most appropriate? Direct the liquid toward the anterior side of the mouth. Keep the child's hand away from the oral syringe when squirting the medication. Give all of the drug in the syringe at one time with one squirt. Allow the child time to swallow the medication in between amounts.

Allow the child time to swallow the medication in between amounts. When using an oral syringe to administer liquid medications, give the drug slowly in small amounts and allow the child to swallow before placing more medication in the mouth. The syringe is directed toward the posterior side of the mouth. The toddler or young preschooler may enjoy helping by squirting the medication into his or her mouth.

The nurse is consulting with a child life specialist (CLS) to help minimize the stress of hospitalization for a child. Which services would the CLS provide? Select all that apply. Medical preparation for tests, surgeries, and other medical procedures Support before and after, but not during, medical procedures Activities to support normal growth and development Grief and bereavement support Emergency room interventions for children and families Only inpatient consultations with families

Activities to support normal growth and development Grief and bereavement support Emergency room interventions for children and families The CLS would provide activities to support normal growth and development, grief and bereavement support, and emergency room interventions for children and families. The CLS would also provide nonmedical preparation for tests, surgeries, and other medical procedures; support during medical procedures; and outpatient consultation with families.

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? Heart rate and rhythm Skin integrity Core body temperature Airway patenc

Airway patency The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

The nurse is planning client teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? Upon the client's admission to the postanesthesia care unit (PACU) When the client returns from the PACU During the intraoperative period As soon as possible before the surgical procedure

As soon as possible before the surgical procedure Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the physician's office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the client is usually drowsy, making this an inopportune time for teaching. Upon the client's return from the PACU, the client may remain drowsy. During the intraoperative period, anesthesia alters the client's mental status, rendering teaching ineffective.

A 7-year-old boy has reentered the hospital for the second time in a month. Which intervention is particularly important at this time? Assessing his parents' coping abilities Seeking his parents' input about their child's needs Educating his family about the procedure Notifying the care team about his hospitalization

Assessing his parents' coping abilities Transition times, such as when the child reenters the hospital, create additional stress on the parents and child. Assessing the parents' coping abilities is particularly important at this time. Seeking parental input, educating about a procedure, and notifying the care team are basic activities of family-centered care and care coordination.

The nurse is providing atraumatic care to children in a hospital setting. What are principles of this philosophy of care? Select all that apply. Avoid or reduce painful procedures Avoid or reduce physical distress Minimize parent child interactions Provide child-centered care Minimize child control Use core primary nursing

Avoid or reduce painful procedures Avoid or reduce physical distress Use core primary nursing When using atraumatic care, the nurse would avoid or reduce painful procedures, avoid or reduce physical distress, use core primary nursing, maximize parent child interactions, provide family-centered care, and provide opportunities for control, such as participating in care, attempting to normalize daily schedule, and providing direct suggestions.

A 77-year-old client with a diagnosis of congestive heart failure has experienced a downward trend in their hemoglobin levels in recent days, and the care team ordered the administration of two unit of packed red blood cells. In the hours following the blood transfusion, the client complained of increasing shortness of breath, and chest auscultation revealed diffuse crackles. The nurse also noted an increase in the client's peripheral edema, and fluid volume excess (FVE) is suspected. What assessment should the nurse prioritize in the care of this client? Close monitoring of the client's intake and output Assessment of the client's hemoglobin, hematocrit and red blood cells Neurovital signs every hour Assessment of the client's electrolyte levels

Close monitoring of the client's intake and output

The nurse is teaching the student nurse how to communicate effectively with children. Which method would the nurse recommend? Position self above the child's level to denote authority. If possible, communicate with the child apart from the parent. Direct questions and explanations to the child. Use the medical terms for body parts and medical care.

Direct questions and explanations to the child. To communicate effectively with children, the nurse should direct questions and explanations to the child; position self at the child's level; allow the child to remain near the parent if needed, so the child can remain comfortable and relaxed; and use the child's or family's terms for body parts and medical care when possible.

The OR nurse is participating in the appendectomy of a 20 year-old female client who has a dangerously low body mass index. What action should the nurse implement to prevent the development of hypothermia? Ensure that IV fluids are warmed to the client's body temperature. Transfuse packed red blood cells to increase oxygen carrying capacity. Place warmed bags of normal saline at strategic points around the client's body. Monitor the client's blood pressure and heart rate vigilantly.

Ensure that IV fluids are warmed to the client's body temperature. Warmed IV fluids can prevent the development of hypothermia. Applying warmed bags of saline around the client is not common practice. The client is not transfused to prevent hypothermia. Blood pressure and heart rate monitoring are important, but do not relate directly to the risk for hypothermia.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? Maintain a low sodium diet Encourage the use of over-the-counter calcium supplements Ensure the client has sufficient potassium intake Encourage fluid intake

Ensure the client has sufficient potassium intake Diuretics cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake and increased fluid intake does not reduce the client's risk for electrolyte disturbances.

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). The plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the client's health? Nutritional status Potassium balance Calcium balance Fluid volume status

Fluid volume status A specific gravity will detect if the client has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

When providing care to a dying child and his family, which would be most important? Focusing on the family as the unit of care Teaching the family appropriate care measures Offering the child support and encouragement Assisting the parents in decision making

Focusing on the family as the unit of care When caring for a dying child and his family, the most important aspect of care is focusing on the family as the unit of care. Teaching, offering support, and assisting in decision making are important, but these actions must be implemented while focusing on the family as the unit of care.

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? Active transport of hydrogen ions across the capillary walls Pressure of the blood in the renal capillaries Action of the dissolved particles contained in a unit of blood Hydrostatic pressure resulting from the pumping action of the heart

Hydrostatic pressure resulting from the pumping action of the heart An example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure results from the pumping action of the heart. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration.

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing what electrolyte imbalance? Hypernatremia Hypomagnesemia Hypophosphatemia Hypercalcemia

Hypercalcemia

The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate? Hypermagnesemia Hyponatremia Hypocalcemia Hyperkalemia

Hypocalcemia You can induce Chvostek sign by tapping the client's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek sign.

The PACU nurse is caring for an adult client who had a left lobectomy. The nurse is assessing the client frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. Hypotension Heart murmurs Hypervolemia Dysrhythmias Hypertension

Hypotension Dysrhythmias Hypertension The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery. Hypervolemia is not a common cardiovascular complication seen in the PACU, though fluid balance must be vigilantly monitored.

The intraoperative nurse is implementing a care plan that addresses the surgical client's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? Impaired skin integrity Hypoxia Malignant hyperthermia Hypothermia

Hypoxia

The nurse is performing a cultural assessment of an Asian family that has a child hospitalized for leukemia. What is the best technique for providing culturally competent care for this family? Research the culture and base care on findings. Ask other Asians to explain their culture. Just ask the family about their culture and listen. Hire an interpreter to explain the family culture

Just ask the family about their culture and listen. Understanding and respecting the family's culture helps foster good communication and improves child and family education about health care. The best way to assess the family's cultural practices is to ask and then listen. Determine the language spoken at home and observe the use of eye contact and other physical contact. Demonstrate a caring, nonjudgmental attitude and sensitivity to the child's and family's cultural diversity. An interpreter should be hired for a family who does not speak English.

The nurse is caring for a hospitalized 13-year-old girl, who is questioning everything the medical staff is doing and is resistant to treatment. How should the nurse respond? Let's work together to plan your day along with your treatments. The sooner you cooperate, the sooner you are going to leave. If you are more cooperative, perhaps we can arrange a visit from friends. Please don't make me call your parents about this

Let's work together to plan your day along with your treatments. Collaborating with the adolescent will provide the teen with increased control. The nurse should work with the teen to provide a mutually agreeable schedule that allows for the teen's preferences while incorporating the required nursing care. Threatening to call the parents will most likely promote further resistance. The nurse should try to immediately engage the girl, rather than making the nurse's cooperation conditional upon the girl's cooperation. Telling the girl that the sooner she cooperates, the sooner she will leave is inappropriate. The nurse is incorrectly implying that her behavior, rather than her medical needs, is going to determine when she will be discharged from the hospital.

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance? Hypercalcemia Metabolic acidosis Metabolic alkalosis Respiratory acidosis

Metabolic alkalosis Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.

A priority nursing intervention for a client with hypervolemia involves which of the following? Establishing IV access with a large-bore catheter. Drawing a blood sample for typing and crossmatching. Monitoring respiratory status for signs and symptoms of pulmonary complications. Encouraging the client to consume sodium-free fluids.

Monitoring respiratory status for signs and symptoms of pulmonary complications. Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The highest or most important intervention on the list involves monitoring respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.

An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? Providing emotional support to the family Monitoring the client's physiologic status Maintaining the client's cognitive status Maintaining a clean environment

Monitoring the client's physiologic status During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the client's cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.

A client has questioned the nurse's administration of IV normal saline, asking, Wouldn't sterile water would be a more appropriate choice than saltwater? Under what circumstances would the nurse administer electrolyte-free water intravenously? Never, because it rapidly enters red blood cells, causing them to rupture. When the client is severely dehydrated resulting in neurologic signs and symptoms When the client is in excess of calcium and/or magnesium ions When a client's fluid volume deficit is due to acute or chronic kidney disease

Never, because it rapidly enters red blood cells, causing them to rupture. IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture.

The nurse is caring for an 82-year-old female client in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurse's subsequent assessment? Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. Confusion, restlessness, and agitation are expected postoperative findings in older adults and they will diminish in time. Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss. Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia

Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss.

The nurse is providing palliative care for a 9-year-old boy in hospice. Which is unique to hospice care for children? Encouraging visits from friends and family Educating parents about terminal dehydration Prolonging treatment that might possibly help Treating constipation to relieve abdominal pain

Prolonging treatment that might possibly help Hospice for children allows for continuation of hopeful treatment so long as certain criteria are met. This is different from adult hospice. Encouraging visits from friends and family, educating parents about terminal dehydration, and treating constipation are common to family-centered care.

The nurse is caring for a 10-year-old girl who is in an isolation room. Which intervention would be a priority intervention for this child? Reduce noise as much as possible. Provide age-appropriate toys and games. Discourage visits from family members. Put on mask prior to entering the room.

Provide age-appropriate toys and games. Children in this setting may experience sensory deprivation due to the limited contact with others and the use of personal protective equipment such as gloves, masks, and gowns. The nurse should stimulate the child by playing with her with age-appropriate toys/games. Reducing noise would be appropriate for sensory overload. The nurse should encourage the family to visit often, introduce himself or herself before entering the room, and allow the child to view his or her face before applying a mask.

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action? Leave and promptly notify the physician Quickly attempt to determine the cause of hemorrhage Begin resuscitation Put the client in the Trendelenberg position

Quickly attempt to determine the cause of hemorrhage Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Resuscitation is not necessarily required and the nurse must not leave the client. The Trendelenberg position would be contraindicated.

The nurse is researching behavioral-cognitive pain relief strategies to use on a 5-year-old child with unrelieved pain. Which methods might the nurse choose? Select all that apply. Relaxation Distraction Thought stopping Massage Sucking

Relaxation Distraction Thought stopping Common behavioral-cognitive strategies include relaxation, distraction, imagery, thought stopping, and positive self-talk. Sucking and massage are examples of biophysical interventions.

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis

Respiratory acidosis The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

The perioperative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia? Increased Temperature Oliguria Tachycardia Hypotension

Tachycardia

During the health history, the mother of a 4-month-old child tells the nurse she is concerned that her baby is not doing what he should be at this age. What is the nurse's best response? I'll be able to tell you more after I do his physical. Fill out the questionnaire and then I can let you know. Tell me what concerns you. All mothers worry about their babies. I'm sure he's doing wel

Tell me what concerns you. Asking about the mother's concerns is assessment and is the first thing the nurse should do. The mother has intimate knowledge of the infant and can provide invaluable information that can help structure the nurse's assessment. Relying on the physical assessment ignores the value of the mother's input. A screening questionnaire is no substitute for a developmental assessment. Minimizing the mother's concerns reduces communication between the mother and the nurse.

The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? The client may be experiencing presurgical anxiety. The client may be at risk for malignant hyperthermia. The grandmother's surgery has minimal relevance to the client's surgery. The client may be at risk for a sudden onset of postsurgical infection

The client may be at risk for malignant hyperthermia. Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the mortality rate is 50%. The client's anxiety is not relevant, the grandmother's surgery is very relevant, and all clients are at risk for hypothermia.

A nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The kidneys react rapidly to compensate for imbalances in the body. The kidneys regulate the bicarbonate level in the intracellular fluid.

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by kidney disease. Renal compensation for imbalances is relatively slow (a matter of hours or days).

The nurse admitting a client who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this client's diagnosis of type 1 diabetes affect the care that the nurse plans? The nurse should administer a bolus of dextrose IV solution preoperatively. The nurse should keep the client NPO for at least 8 hours preoperatively. The nurse should initiate a subcutaneous infusion of long-acting insulin. The nurse should assess the client's blood glucose levels vigilantly

The nurse should assess the client's blood glucose levels vigilantly. The client with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Close glycemic monitoring is necessary. Dextrose infusion and prolonged NPO status are contraindicated. There is no specific need for an insulin infusion preoperatively.

The nurse is performing an admission of a 10-year-old boy. Which actions will help the nurse establish a trusting and caring relationship with the child and his family? Select all that apply. The nurse should not minimize the child's fears by smiling. The nurse should initiate introductions. The nurse should not use formal titles at the introduction. The nurse should maintain eye contact at the appropriate level. The nurse should start communication with the child first and then move on to the family. The nurse should use age-appropriate communication with the child.

The nurse should use age-appropriate communication with the child. The nurse should initiate introductions. The nurse should maintain eye contact at the appropriate level

The mother of a 15-month-old child is questioning the nurse about the need for the hepatitis B vaccination. Which comment provides the most compelling reason for the vaccine? The most common side effect is injection site soreness. This is a recombinant or genetically engineered vaccine. Immunizations are needed to protect the general population. This protects your child from infection that can cause liver disease

This protects your child from infection that can cause liver disease. Up to 90% of neonates infected with hepatitis B develop chronic carrier status and will be predisposed to cirrhosis and hepatic cancer. The mother is not questioning side effects, safety, or disease prevention in general. Therefore, it is best to speak to her concerns.

An adult client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to retch. What should the nurse do next? Administer a dose of IV analgesic Apply a cool cloth to the client's forehead Offer the client a small amount of ice chips Turn the client completely to one side

Turn the client completely to one side Turning the client completely to one side allows collected fluid to escape from the side of the mouth if the client vomits. After turning the client to the side, the nurse can offer a cool cloth to the client's forehead. Ice chips can increase feelings of nausea. An analgesic is not given for nausea and vomiting.

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen? The client's calcium will rise dramatically due to pituitary stimulation. Oxygen will increase the client's intracranial pressure and create confusion. Oxygen may cause the client to hyperventilate and become acidotic. Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia.

Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia.

The nurse is preparing to administer an intramuscular injection to an 8-month-old infant. The preferred appropriate site would be ? Rectus femoris Vastus lateralis Dorsogluteal muscle Deltoid

Vastus lateralis The preferred injection site in infants is the vastus lateralis muscle. An alternative site is the rectus femoris. The dorsogluteal site is not used in children until the child has been walking for at least 1 year. The deltoid muscle is used as a site in children after the age of 4 or 5 years.

After teaching the mother about follow-up immunizations for her daughter, who received the varicella vaccine at age 14 months, the nurse determines that the teaching was successful when the mother states that a follow-up dose should be given at which time? When the child is 20 to 36 months of age When the child is 4 to 6 years of age When the child is 11 to 12 years of age When the child is 13 to 15 years of age

When the child is 4 to 6 years of age A second dose of varicella vaccine should be given when the child is 4 to 6 years of age. Hepatitis A vaccine should be given to infants at age 12 months, with a repeat dose given in 6 to 12 months. The human papillomavirus (HPV) vaccine should be given to children beginning at age 11 to 12 years, with catch-up doses to begin at 13 to 14 years of age.

Emergency services brings a 2 month old into the pediatric emergency department. The mother reports that the child has had vomiting and watery diarrhea for the last 24 hours. The nurse assesses the child and finds her very lethargic with a sunken fontanel and dry mouth. The nurse should prioritize the following interventions in what order? a- Start an IV and begin giving fluids b- Draw blood for lab tests c- Apply a urine bag to collect urine d- Obtain vital signs including weight

d,a,c,b The most important intervention is to ensure that the child's vital signs are stable and to get a baseline weight. IV fluids will be the only way to replace the child's fluids since the child is vomiting and will not be able to keep oral fluids in. Urine output is good to measure, but not a first priority. Lab tests will be a late indicator of the child's condition, but it is important to get baseline data.