Question: Exit A_Alt Calculator Time Remaining: 01:30:41 24 Of 100 An Infant Falls From The Bed To The Floor And Sustains A Head Injury. The Nurse Finds No Apparent Changes In Airway, Breathing, Or Circulation. The Infant Is Sent Home With The Parent. Which Instructions Does The Nurse Give The Parent? 1. Check Vital Signs Every 4 Hours When Awake For 3 Days. …

Exit A_Alt Calculator Time Remaining: 01:30:41 24 of 100 An infant falls from the bed to the floor and sustains a head injury. The nurse finds no apparent changes in airway, breathing, or circulation. The infant is sent home with the parent. Which instructions does the nurse give the parent? 1. Check vital signs every 4 hours when awake for 3 days. O2. Observe for changes in speech patterns over 48 hours O3 Watch for vomiting that starts after 24 hours and does not stop for 2 days O4 Assess pupillary response every 4 hours, day and night, for 2 days Time Remaining: 01:24:42 28 of 100 Exit A_Alt Calculator The nurse prepares to insert an indwelling urinary catheter for a client diagnosed with urinary retention which is the most important principle for the nurse to follow when inserting the catheter? 01. Inflate balloon before inserting the catheter O 2 Wear stenle gloves during the entire procedure 3. Identity urinary meatus before cleansing O4 Maintain catheter sterility at all times Time Remaining 01:37:56 17 of 100 Exit A_Alt Calculator A chent is to receive 2 units of blood. The client has an IV in the right forearm with DW in normal saline that is used to administer an antibiotic every 4 hours Which does the nurse do first? 1. Start a second IV with isotonic saline O2 Receive the first unit of blood from the blood bank. 3. Use a filtered tubing to administer the blood O4 Insert a microdrip chamber into the IV. Exit A_Alt Calculator Time Remaining 01:26.3 27 of 10 A client has a chest tube in the right chest that is connected to wall suction. Which nursing action is most important for this client? 1. Help client with range of motion for the right shoulder O2 Assess blood pressure every hour for the first 24 hours O3. Change connector tubing every 24 hours 4. Have client use incentive spirometer every 4 hours Calculator 33 of 100 The nurse evaluates the fontanels of a newborn immediately after birth. Two days later, the nurse determines that the fontanels are larger than they were after birth. Which does the nurse know about this change? 1. Indicates increased intracranial pressure. O2. Fontanels are growing as the head grows. O3. Caused by a deformity of the head. O 4. Molding of the head has decreased Calculator 33 of 100 The nurse evaluates the fontanels of a newborn immediately after birth. Two days later, the nurse determines that the fontanels are larger than they were after birth. Which does the nurse know about this change? 01. Indicates increased intracranial pressure O2. Fontanels are growing as the head grows. O3. Caused by a deformity of the head. O 4. Molding of the head has decreased EXIT A_Alt Calculator Which action by the nurse is contraindicated when monitoring a client’s vital signs? 1. Measuring a rectal temperature on a client diagnosed with myocardial infarction O 2. Measuring a client’s respirations by holding the client’s wrist that is lying on the chest. O 3. Assessing a blood pressure on the right arm of a client with a left mastectomy O 4. Using a pediatric blood pressure cuff on a client diagnosed with anorexia nervosa.