It is important to examine the infant's anterior fontanel when the child is:
A. Lying supine
B. Relaxed and sitting up
C. Lying prone
D. Standing with assistance
ANS: B
When assessing pediatric patients, remember to ask about head trauma, head growth, and the history of headaches. The head circumference should be measured at all well visits up to 2 years of age to assess for macro- or microcephaly. Assess the head symmetry and look for plagiocephaly. For the fontanel to be accurately assessed, the child should be sitting upright and not crying.
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An older adult client presents to the emergency room with a severe acid-base imbalance after taking "cold medicine" for a week. The client has a history of arthritis and reports daily use of aspirin. Which late effect acid-base imbalance does the nurse suspect the client is experiencing?
A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis
What term is used to describe the metabolic mechanism whereby complex molecules are manufactured from simpler molecules?
What will be an ideal response?
A patient with epistaxis and a history of hemophilia A is admitted to the unit and is scheduled for replacement therapy. The nurse should prepare to administer
a. tranexamic acid (Cyklokapron). b. aminocaproic acid (Amicar). c. desmopressin (Stimate). d. factor VIII.
The following questions refer to your patient who is on IV heparin therapy according to the "Standard Weight-Based Heparin Protocol" noted below. The patient weighs 144 pounds. On admission, the patient's APTT is 30 seconds. You initiate IV heparin therapy at 1130 on 06/06/XX. Record your answers in the spaces below unless provided with the "Standard Weight Based Heparin Protocol Worksheet" by
your instructor. Standard Weight-Based Heparin Protocol For all patients on heparin drips: 1. Weight in KILOGRAMS required for order to be processed: ______ kg. 2. Heparin 25,000 units in 250 mL of 1/2 NS. Boluses to be given as 1,000 units/mL. 3. APTT q.6h or 6 hours after rate change; daily after two consecutive therapeutic APTTs. 4. CBC initially and repeat every ____ day(s). 5. Obtain APTT and PT/INR on day one prior to initiation of therapy. 6. Guaiac stool initially, then every __ day(s) until heparin discontinued. Notify if positive. 7. Neuro checks every ____ hours while on heparin. Notify physician of any changes. 8. D/C APTT and CBC once heparin drip is discontinued unless otherwise ordered. 9. Notify physician of any bleeding problems. 10. Bolus with 80 units/kg. Start drip at 18 units/kg/h. 11. If APTT is < 35 secs: Rebolus with 80 units/kg and increase rate by 4 units/kg/h. 12. If APTT is 36-44 secs: Rebolus with 40 units/kg and increase rate by 2 units/kg/h. 13. If APTT is 45-75 secs: Continue current rate. 14. If APTT is 76-90 secs: Decrease rate by 2 units/kg/h. 15. If APTT is > 90 secs: Hold heparin for 1 hour and decrease rate by 3 units/kg/h. At 0600, on 06/07/XX, the patient's APTT is 50 seconds. What should you do now? When should the APTT be checked again? __________ (hours) on __________ (date) Fill in the blank(s) with correct word