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The nurse is caring for a 6-year-old who is having chemotherapy.  When developing a teaching plan for the child and family about nutrition, what instruction would the nurse be least likely to include? 

The nurse performs an assessment of a client who is receiving magnesium sulfate for preeclampsia and is being assessed hourly.  The client has urinary output of 30 mL/hr., respiratory rate of 14 breaths per minute, and absent patellar reflexes.  What is the nurse’s next intervention?

Which of the following nursing tasks would be appropriate for the registered nurse to delegate to unlicensed assistive personnel?

Last week, a client delivered their first pregnancy at 16 weeks gestation.  During the follow-up visit in the family health clinic today, the client notices the chart states they have had a spontaneous abortion. The client is upset over the use of the word abortion.  How can the nurse best explain this terminology to the client?

A 24-year-old male client is seen at the clinic and is diagnosed with gonorrhea. Which symptom most likely prompted him to seek medical attention? 

You are administering heparin and following the protocol below for a client weighing 251 lbs. The order is to administer an initial heparin IV bolus followed by a titrated IV infusion.  Round to the tenths place. HEPARIN PROTOCOL Initial bolus- 60 units/kg Initial rate – 12 units/kg/h Obtain a PTT every 6 hours, and adjust dosage and rate as follows: If a PTT is less than 35 secs:      Repeat bolus with 40 units/kg and increase the rate by 4 units/kg/h. If a PTT is 36 to 44 seconds:       If a PTT is 36 to 44 seconds:          Repeat bolus with 20 units/kg and increase the rate by 2 units/kg/h. If a PTT is 45 to 75 seconds:       Continue current rate. If a PTT is 76 to 90 seconds:       Decrease rate by 2 units/kg/h. If a PTT is greater than 90 secs: Hold the heparin for 1 hour and decrease rate by 3 units/kg/h. Available (for bolus)  – heparin 1,000 units/mLAvailable (for infusion) –  heparin 25,000 units in 250 mL D5   6 hours later the PTT results from the lab are- PTT 80 secs.  The client is currently receiving 12units/kg/hr. What rate (mL/h) will the nurse set the pump at for the titrated heparin IV infusion in response to the PTT of 80 secs.

The mother of a 3-year-old boy recently diagnosed with hemophilia tells the nurse “I’m worried about him, I want him to be active but I don’t want him to get hurt. What’s your advice?”. Which of the following statements by the nurse is most appropriate? 

A nurse is giving discharge instructions to the parents of a newborn with congenital heart disorder.  What should the nurse instruct the parents to do in the event that the child becomes cyanotic?

The nurse is caring for an infant being treated for Acute Otitis Media (AOM). The nurse knows that complications of AOM include all of the following except:

A 6-month-old infant presents to the emergency department with poor oral intake over the last 3 days and severe diarrhea.  Which of the following would the nurse expect to assess in this infant? (Select all that apply)