The client is a 12-year-old male who sustained a gunshot wound to his abdomen. He had a surgical repair of a perforated small intestine 4 days ago. The client is 112.4 Ib. (51 kg). He has a nasogastric tube, a left femoral central line for fluids, and a right hand peripheral intravenous line.

Review H and P, laboratory results, flow sheet, and orders.

The nurse receives the report from the lab and documents the intake and output for 1600.

Based on the client's information at 1600, what symptoms should the nurse look for? Select all that apply.

1030: The child has an audible murmur. Lung sounds are clear and equal. Pedal pulses present and marked. The parents state that the child has no known allergies. His last meal was approximately 3 hours ago. The child's parents are extremely concerned about the cardiac catheterization.

Vital signs:

Heart rate 108 beats/minute

Blood pressure 92/56 mm Hg

Respiratory rate 22 breaths/minute

Ovvoen saturation 96%

What can the nurse do to help the parents to decrease their anxiety? Select all that apply

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

Parents of an infant with an inguinal hernia bring their child to the emergency department reporting that the hernia has changed in color to dark purple and child has not had a bowel movement in 24 hours. The nurse obtains a Face, Legs, Activity, Cry, Consolability (FLACC) scale score of 8 on initial assessment. Which action should the nurse prioritize?

The nurse is assessing a child with acute glomerulonephritis who presents to the clinic with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?

A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol. The child's mother tells the nurse that she uses this medication to open her son's airway when he is having trouble breathing. What is the nurse's best response?

An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

This is a 3-year-old with a history of ventricular septal defect. He was born vaginally at 35 weeks and was in the neonatal intensive care unit (NICU) for 3 weeks due to poor feeding. He lives with his parents and an older sibling, who has no medical conditions. The client is here for a follow-up visit. The nurse educates the parents on post-discharge care for the child.

What should the nurse include in post-discharge care education? Select all that apply.

An infant who has a Wilms' tumor is admitted for surgery. Which intervention should the nurse implement during the preoperative period?

During a follow-up clinic visit, a mother tells the nurse that her 5-month-old son who had surgical correction for tetralogy of Fallot (TOF) has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse Implement to ensure the child's cooperation?