A child has been admitted with Kawasaki disease and is started on aspirin and warfarin (Coumadin). For which nursing diagnosis does the nurse plan interventions as the priority?
A.
Acute pain related to mouth redness and cracked lips
B.
Altered body image related to peeling skin rash
C.
Altered nutrition: less than body requirements
D.
Risk for bleeding related to medication effects
ANS: D
Actual nursing diagnoses take priority over "risk for" diagnoses when the actual diagnoses exist. There is no information in the stem to show that the child has impaired mucous membranes leading to pain, an altered body image related to rash, or altered nutrition, although all of these are possible for this child. Risk for injury is the priority because the child is taking two medications that alter coagulation, and for patient safety, this is a critical diagnosis.
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A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance addiction?
1. Narcotic pain medication is contraindicated for all clients with active substance use disorders. 2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control. 3. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance. 4. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.
The nurse has taught a group of parents how to care for their children who have had tympanos-tomy tubes inserted. The nurse will know parents understand how to care for their child's tym-panostomy tubes if they: (Select all that apply.)
1. Encourage the child to drink generous amounts of fluids. 2. Administer a decongestant for 1–2 weeks following surgery. 3. Restrict the child to quiet activities after surgery. 4. Limit the child's diet to soft, bland foods. 5. Avoid getting excessive water in the ears during bath time.
Convert 1/2 ounce to an equivalent amount in teaspoons
1. 1 t 2. 3 t 3. 4 t 4. 6 t
Which of the following is a systemic complication associated with IV therapy?
A. Air embolus B. Infiltration C. Hematoma D. Phlebitis