Over the course of an eight-hour shift caring for a child
recovering from ventriculoatrial shunt placement, the nurse notes that the child's cry has become increasingly shrill and the child has projectile vomiting. For which reason should the nurse immediately notify the health care provider?
A) Infection at the surgical site
B) Rejection of the shunt
C) A sudden increase in pain
D) Increased intracranial pressure
Ans: D
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A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the client's nose and around the intravenous catheter. What action by the nurse is the priority?
a. Hold pressure over the client's nose for 10 minutes. b. Take the client's pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.
A patient asks the nurse why an anticoagulant has been prescribed. What is the nurse's best response?
a. "It will dissolve any clots in your blood vessels." b. "It will prevent any new clots from forming." c. "It will prevent a clot from migrating." d. "It will thin your blood."
A 25-year-old client who has given birth is apprehensive about the use of certain drugs when breastfeeding. Which of the following drugs should the nurse ask the client to avoid during breastfeeding?
A) Acetaminophen B) Amphetamines C) Codeine D) Pseudoephedrine
Which of the following items are considered biohazardous waste?
A) A disposable incontinent pad soiled with urine and feces B) The package a disposable enema kit came in C) Disposable dishes with partially eaten food D) A used water pitcher and cup