A 10-month-old girl with bronchitis is taken out of the 30% oxygen tent for breakfast because she refuses to eat unless in a high chair. During the feeding, the nurse notes that the child’s respiratory rate has increased, she is becoming more irritable, and she is using accessory muscles to breathe. Which of the following should be the nurse’s first action
A. Perform postural drainage then complete the feeding.
B. Suction the child’s nose with a bulb syringe.
C. Discontinue the feeding and place the child back in the tent.
D. Assess the pulse rate and respirations and notify the physician.
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An unconscious client has been admitted with a head injury. Which of the following nursing diagnoses would receive the greatest priority in the plan of care
A. Disturbed sensory perception related to decreased level of consciousness.
B. Ineffective airway clearance related to inability to remove respiratory secretions.
C. Impaired gas exchange related to shallow irregular breathing.
D. Risk for injury related to disorientation and decreased level of consciousness.
A mother is discussing with the nurse her 4-year-old boy’s strange eating habits including not finishing meals and eating the same food for several days in a row. She would like to develop a plan to correct this situation. When developing such a plan, which of the following should the nurse and mother consider
A. Deciding on a good reward for finishing the meal.
B. Allowing him to make some decisions about the foods he eats.
C. Restricting the availability of foods to those served at meal times.
D. Not allowing him to leave the table until he has eaten the foo
Which of the following nursing measures would the nurse institute to help reduce eyelid edema in a child with nephrotic syndrome
A. Instill eye drops every 8 hours.
B. Limit the child’s television watching.
C. Apply cool compresses to the child’s eyes.
D. Elevate the head of the child’s be
During a conversation with the client, the nurse observes the client shaking his leg and tapping his fingers on the table next to him. The nurse’s best statement is.
A. "I’ll get you something to help you feel less anxious. "
B. "I know that you feel anxious. Let’s discuss something more pleasant. "
C. "I see that you’re anxious. I’ll be back later when you’re calmer. "
D. "I noticed that your leg is shaking and you’re tapping your fingers on the table. How are you feeling now"
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