A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. What is the primary focus of nursing care during this immediate phase?

Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic, and blood is drawn for an indirect serum bilirubin level. The test result is 12 mg/dL. The nurse explains that it is physiologic jaundice, a benign condition, which is caused by:

The parents of a newborn who is receiving phototherapy ask a nurse why their baby’s eyes are covered with eye patches. What information should the nurse consider before responding?

A nurse is teaching sterile technique to a family member of a client who is to be discharged with a large abdominal wound that requires a dressing change twice a day. What does the family member do during a return demonstration that indicates further teaching is necessary?

An infant is diagnosed with hydrocephalus. Which assessment alerts the nurse to suspect increasing intracranial pressure?

In the immediate postoperative period after a gastrectomy, the client’s nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage?

Which complication is avoided when a nurse administers a parenteral preparation of potassium slowly and cautiously?

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome?

A nurse is caring for a client in the evening after the client has had a below-the-knee amputation. What action should be implemented by the nurse?

A client with schizophrenia, paranoid type, is readmitted involuntarily to the hospital because family members state that he has threatened to harm them physically. When exploring feelings about the readmission, the client angrily shouts, “You’re one of them. Leave me alone!” How should the nurse respond?

Shortly after giving birth, a client says she feels that she is bleeding. When checking the fundus, a nurse observes a steady trickling of blood from the vagina. What is the nurse’s initial action?

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?

What is important nursing care for children with leukemia on chemotherapeutic protocols?

A client is receiving vinCRIStine. What should the nurse expect the dietary plan to include to minimize the side effects of vinCRIStine?

A nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child’s urine for the presence of which constituent?

The parents of a child with leukemia ask the nurse why irradiation of the spine and skull is necessary. What is the most accurate response by the nurse?

A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What should the nurse do?

During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect and what suggestion is made to correct it?

A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated cholesterol and triglyceride levels for a middle-age female. Which is most important for the nurse to teach the client to do when initially taking this medication?

Methylphenidate (Ritalin) has been prescribed for a 7-yearold child with attention deficit/hyperactivity disorder (ADHD) to be taken with meals. What rationale should the nurse provide for the parents about the timing of medication administration?

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator?

A client who has had thoracic surgery is admitted to the postanesthesia care unit (PACU). What should the nurse do after the chest tube is attached to a disposable plastic waterseal drainage system?

A client with schizophrenia has been experiencing hallucinations. During what client behaviors should the nurse expect the hallucinations to be more frequent?

A client who had an organ transplant is receiving cycloSPORINE (Gengraf ). For what should the nurse monitor to identify a serious adverse effect of cycloSPORINE?

During the first prenatal visit of a woman who is at 23 weeks’ gestation, the nurse discovers that the client has a history of pica. What is the most appropriate nursing action?

During the first prenatal visit of a woman who is at 23 weeks’ gestation, the nurse discovers that the client has a history of pica. What is the most appropriate nursing action?