The nurse observes a toddler-age client, admitted with possible respiratory syncytial virus (RSV) bronchiolitis, grunting with expiration. Which action by the nurse is appropriate?
A) Assist the child to clear the nasal passages.
B) Limit fluids.
C) Suction the airway to relieve the obstruction.
D) Lay the child on his back.
Answer: C
Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on his back will not improve the child's ability to breathe. Fluids should be increased to thin secretions. Assisting the child to clear the nasal passages would be applicable if the child were experiencing rhinorrhea.
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A nurse cares for a client who has a specific mutation in the a1AT (alpha1-antitrypsin) gene. Which action should the nurse take?
a. Teach the client to perform monthly breast self-examinations and schedule an annual mammogram. b. Support the client when she shares test results and encourages family members to be screened for cancer. c. Advise the client to limit exposure to secondhand smoke and other respiratory irritants. d. Obtain a complete health history to identify other genetic problems associated with this gene mutation.
In planning the nursing care of a client with anorexia nervosa, which nursing goal is the highest priority in the initial phase of treatment?
A) Regain lost weight. B) Restore electrolyte imbalances. C) Support healthy coping mechanisms. D) Improve self-esteem and body image.
An elderly patient has hypertension and renal insufficiency secondary to nephrosclerosis. Which combination of medications would be the best?
a. An ACE inhibitor and a loop diuretic b. A beta blocker and an ACE inhibitor c. A thiazide diuretic and a loop diuretic d. An alpha blocker and a beta blocker
Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes?
A) The nurse expresses the client outcome as a nursing intervention. B) The nurse develops measurable outcomes using verbs that are observable. C) The nurse develops a target time when the client is expected to achieve that outcome. D) The outcome should include a subject, verb, conditions, performance criteria, and target time.