A nurse is caring for a toddler admitted to the hospital.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

A nurse is planning care for a client who is scheduled to receive a transfusion of packed RBCs. Which of the following actions should the nurse plan to take?

A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

A nurse is caring for a neonate in the neonatal intensive care unit.

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the neonate. There must be at least 1 selection in every row. There does not need to be a selection in n in every column.

A nurse is caring for a client.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia. Which of the following actions should the nurse take?

A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?

A nurse is caring for a client.

Complete the following sentence by using the lists of options.

The client is at risk of developing

A nurse is caring for a 6-year-old child in an emergency department.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

A nurse is caring for a 9-year-old child at a clinic.

The nurse reviews the assessment findings.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Assessment

Respirations easy and unlabored. Abdomen non-distended. Right forearm and fingers are edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child verbalizes a pain level of 4 on a scale of 0 to 10. Multiple areas of bruising are noted on lower extremities in various stages of healing.

Vital Signs

Temperature 36.8° C (98.2° F)

Heart rate 102/min Respiratory rate 22/min

BP 100/60 mm Hg

Oxygen saturation 98% on room air