HEC Unit 2 Example Review

A pediatric client weighing 22 lbs is diagnosed with an acute ear infection accompnanied by a fever of 38.8C. The heatlhcare provider orders Acetaminophen 15 mg/kg per dose oral suspension for fever management. ​The medication on hand is acetaminophen 160 mg/ 5 ml. How many mL will the nurse administer per dose? ​ (a) _ _ _ _ _ _ _ _ _ _

4.7mL

A nurse is caring for a client with a casted tibia fracture. Initially the clien’ts pain improved. The client is now complaining of increased pain with passive motion and numbness in the toes. The nurse observes decreased movement of the toes and pale extremity. Which of the following is the priority intervention?

Remove the case

The nurse is caring for a pediatric client who came in with a fever of 103F. There are no other signs or symptoms of illness. Which of the following diagnostic tests should the nurse anticipate completing?

Urine Specimen, Throat Swab & Blood Culture

A nurse is teaching nursery staff about nonshivering thermogenesis and cold stress in neonates. Which statement by a staff member indicates a correct understanding of how brown adipose tissue (brown fat) metabolism affects the infant?

"Increased breakdown of brown fat increases glucose demands, placing the infant at risk for hypoglycemia."

The nurse is caring for an adult client admitted with an ankle fracture. Which finding is of greatest concern?

Diminished pedal pulse

The nurse is caring for an older adult client who was found outside in cold weather wearing only a light shirt and pants. The client is shivering, pale. and cold to the touch. Which action should the nurse take first?

Place the client on a cardiac monitor

A nurse is caring for a 4 month old with acute otitis media. Which of the following is an appropriate supportive care measure for a mild case of acute otitis media?

Education family about risk factors

A 3 year old child is brought in by her parents for a concern of having an ear infection. The nurse identifies which of the following as increasing the risk for developing ear infections?

Attending Daycare

A nurse is educating a client about appropriate use of pain medication after surgery. The nurse knows the teaching was effective when the client states which of the following?

“I should take my oxycodone as prescribed to reduce my risk of overdose and addiction.”

A nurse is assessing a newborn in the nursery 30 minutes post-delivery. Which findings indicate the infant is experiencing cold stress? Select 4 that apply

Acrocyanosis and pale, mottled skin, Axillary temperature of 35.8C, Weak cry and poor feeding attempts, Signs of respiratory distress

Which of the following clients is at highest risk for experiencing impaired thermoregulation?

An 86 year old client with cognitive impairment living in a cold climate

A pediatric nurse is providing discharge instructions to parents of a 4 year old child who has an acute viral infection with a fevers of 38.9C. Which instruction should the nurse emphasize?

"Use acetaminophen according to the child's weight"

A nurse is bathing a full-term newborn under a radiant warmer. After the bath, the nurse leaves the newborn undressed on the metal scale to obtain a weight. By which mechanism is the newborn most at risk for heat loss in this situation?

Conduction

The nurse is caring for a client with a closed fracture of the left femur. The client has significant pain that has been making daily activities difficult. The client’s pain is being managed with oxycodone (opioid). Which adverse effect would the nurse be most concerned with?

Respiratory Depression

The nurse is caring for a client with pain of 8/10. The nurse administers medication for pain management. Which of the following is the most reliable reassessment of the client’s pain?

Asking the client to rate their pain

A client comes in complaining of chronic back pain. The client reports the pain radiates down their legs with occasional numbness and tingling. There has been no recent injury to the back. Which type of the pain does the nurse most suspect is occurring?

Neuropathic

The nurse receives reports for 4 post-operative clients. Which client should the nurse assess first?

A 54 year old female with a repaired fracture post op day 1 taking oxycodone with pain level of 2/10 and respiratory rate of 10

The nurse is assessing a client presenting to the clinic with suspected heat stroke (hyperthermia). Which clinical manifestation should the nurse expect to observe?

Warm, flushed, and diaphoretic

A nurse is caring for an adult client with hyperthermia. Which nursing interventions are appropriate for managing hyperthermia? (Select 3 that apply)

Remove excess clothing and blankets, Provide external cool packs and a cooling blankets, Hydrate with cool oral or intravenous fluids

A school nurse is caring for a fourth grade student who sprained their ankle during gym class and is experiencing pain of 5/10. Which of the following nonpharmacologic interventions are appropriate? Select 3 that apply

Perform breathing exercises, Immobilize the ankle, Elevate the extremity