The nurse cares for a toddler diagnosed with immune thrombocytopenia purport. The child’s platelet count is 52,000/mm (52 x 10). The nurse prepares a care plan for the child. Which nursing diagnosis is most appropriate for this child? Fatigue related to elevated platelet count. Risk for injury related to low platelet count. Risk for activity intolerance related to need for rest. Impaired Physical mobility related to need for physical therapy. 2. The client takes heparin 12, 000 units daily by subcutaneous injection. Today’s aPTT level is 45 seconds. Which action does the nurse take first? Nothing as this is a normal a PTT level Notifies the health care provider to decrease the dosage. Changes the route from subcutaneous to intramuscular. Notifies the health care provider to increase the dosage. 3. The client is the single parent of the 2 week old baby, the firstborn child. The client had considered terminating the pregnancy but continued the pregnancy. There is little client family support. The client has a history of an editing disorder. The nurse knows which nursing diagnosis is most important for the client? Risk for impaired attachment related to lack of knowledge of child care. Situational Low Self-Esteem related to body changes of childbirth. Risk for ineffective coping related to postpartum depression. Disturbed sleep Pattern related to care of infant at night. 4.A nurse provides care for the newborn in the delivery area. The baby is breathing and crying well with good color. The nurse knows which priority is next? Prevent cold stress. Record Apgar. Initiate physical assessment. Begin bonding with parents. 5. The nurse care for the adolescent diagnosed with acquired aplastic anemia. The diagnosis is related to the practice of huffing substances with benzene. Which goal is the most important for this client during immunosuppression? Will have increased production of red blood cells. Will manage pain related to growth factor injections. Will cope with probability of death from disease. Will verbalize feelings about lack of bone marrow donor. 6. The nurse is preparing to insert an indwelling urinary catheter. Prioritize the order of steps.. From start to finish. All options must be used. Unordered options Lubricate tip of the catheter. Drape the client Insert the catheter Put on sterile gloves Cleanse the meatus 7.The nurse assesses the position of the fetus at the beginning of labor. The nurse feels the fetal occiput toward the left side of the pregnant clients sacrum. How does the nurse interpret thus finding? Right occiput anterior (ROA); fetus is currently in correct position for birth. Left sacrum anterior (LSA); fetus will need to flip end to end prior to birth. Left occiput transverse (LOT); fetus will turn head slightly prior to birth. Left occiput posterior (LOP); fetus will need to burn head prior to birth. 8. A client diagnosed with infective endocarditis is discharged home on IV antibiotic therapy. The nurse knows the client understands the discharge treatment plan when the client makes which statement? “when I get home, I can take of these compression stockings when I am walking.” “I can help care for my grandchildren when they are sick and stay home from school” “I can go back to my job next week and start back traveling” “I will tell my dentist about this illness before having my teeth cleaned.” 9. The client sustained a right hip fracture. The client had surgery to repair the hip. The nurse prepares for the client to return from surgery to the surgical unit. Which equipment is out important for the nurse to have available? Sandbags and pillows Walker and wheelchair Elevated toilet seat Continuous passive motion machine. 10. The nurse care for the 4 year old child. The parents report the child is irritable and has lost weight. The nurse assesses the child and discovers an irregular heart rate at 18- beats per minute and rest at 24 per min. Which does the nurse do first? Assesses the Childs temp…
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