A critically ill child who is experiencing internal bleeding from a motor vehicle accident demonstrates a sudden significant drop in blood pressure. What intervention should the nurse implement first?
A) Administer 20 mL/kg intravenous crystalloid fluid.
B) Assess for oversedation with benzodiazepines or narcotics.
C) Increase frequency of vital sign assessment to every 15 minutes.
D) Reassess mental status and level of consciousness.
A
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According to the recommendations of the American Academy of Pediatrics on infant nu-trition:
a. Infants should be given only human milk for the first 6 months of life. b. Infants fed on formula should be started on solid food sooner than breastfed in-fants. c. If infants are weaned from breast milk before 12 months, they should receive cow's milk, not formula. d. After 6 months, mothers should shift from breast milk to cow's milk.
A nurse is caring for a client in the intensive care unit who underwent a CABG earlier this morning. Which nursing diagnosis takes priority?
a. Decreased Cardiac Output b. Impaired Gas Exchange c. Pain d. Risk for Hemorrhage
The nurse is reviewing the steps of the nursing process with a student. The nurse knows that the student understands the teaching when the student correctly lists which of the following as the correct order of the nursing process?
A. Establish nursing diagnosis, assessment, intervene, collaborate, evaluation B. Establish goals, assessment, intervention, planning, communication C. Assessment, establish nursing diagnosis, planning, interventions, evaluation D. Assessment, planning, establish objectives, communication, evaluation
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order?
a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b. Furosemide (Lasix) 20 mg PO now c. Oxygen via face mask at 8 L/min d. KCl 20 mEq PO two times per day