A nurse is assessing an infant. The assessment that might indicate the infant's respiratory status is worsening is:
1. Acrocyanosis.
2. An arterial CO2 of 40.
3. Periorbital edema.
4. Grunting respirations with nasal flaring.
4
Rationale:
1. Acrocyanosis (cyanosis of the extremities) is a normal finding in an infant.
2. A CO2 of 40 is within a normal range.
3. Periorbital edema does not necessarily mean deterioration in respiratory status.
4. Grunting respirations with nasal flaring indicate that respiratory status is becoming worse.
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The nurse instructs the client to prevent air embolism with total parenteral nutrition (TPN) by performing the Valsalva's maneuver. The nurse instruct the client to take a breath, then:
a. breathe rapidly. b. hold it, and bear down. c. exhale and bear down. d. exhale and hold it.
A client tells the nurse that the health care provider has prescribed a new medication that "has just come on the market."
The nurse has not heard of this particular medication but is able to give the client important information based on its prototype drug because of which principles? 1. Knowing the prototype drug allows the nurse to predict the mechanism of action of the new medication. 2. The information regarding the prototype drug can be extended to any drug in the same class. 3. The prototype drug is the drug to which all drugs in a class are compared. 4. Knowing the prototype drug's therapeutic or pharmacologic classification can reveal important information about other drugs in the same class. 5. This is a new drug on the market. It may not have a prototype drug yet and its properties cannot be predicted.
A client arrives in the emergency department with complaints of intermittent nosebleeds over the past two days. Which are priority assessments for the nurse to implement when providing care to this client? Select all that apply.
A. Request information from the client regarding increased propensity for bruising or bleeding. B. Obtain a blood pressure. C. Check for deviated septum. D. Assess the tonsils for redness or swelling. E. Request information from the client to determine if there was any recent thin, watery drainage from the nose.