VATI Greenlight Exam with complete solutions

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2 hrs post-op following an ileal conduit procedure bladder cancer - ANSWER Dusky-colored stoma Administering an INJ to a client even after the client states, "I don't want that injection. The last ... time I got that I was sore for a week." - ANSWER Battery Admitting a client to the medical-surgical unit. Which of the following actions should the nurse first take? - ANSWER Observe the client's level of mobility Adolescent client who has no previous history of a seizure disorder and is admitted after having a 3-min tonic-clonic seizure 2 wks after sustaining a mild concussion. EEG - ANSWER Explain that the client may not have coffee prior to the EEG Adolescent who has cystic fibrosis and has a prescription for pancrelipase - ANSWER Take w/ meals After evaluating the morning lab results on several clients, the provider writes prescriptions for 4 clients assigned to the nurses care? - ANSWER Infuse 10 meQ/l potassium chloride IV over 1 hr to a client who has potassium of 3.2 After making morning round, the charge nurse on a surgical unit delegates the follow tasks to the AP. - ANSWER Set up a room for an expected postoperative admission AP reports to the nurse that another ap has spent the entire morning on the phone and has not completed the morning assignment - ANSWER Redirect the AP to discuss the issue with the other AP Assessing client who systemic lupus erythematous SLE which of the following is an expected findings - ANSWER Dry, raised facial rash At the start of an evening shift on a cardiac unit, a LPN brings the nurse a list of client reports - ANSWER Indigestion Benefit from a three-way indwelling catheter - ANSWER Prone to development of blood clots un the urine Caring for a client who has a new prescription for chlorpromazine by IM injection - ANSWER Check orthostatic BP 1 hr after admin Caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse "Am I dying?" - ANSWER Admin pain meds Charge nurse creating assignments for next shift for several nurses and one of the nurses is pregnant - which pt the nurse should NOT be assigned to? - ANSWER 60 yr old who is recovering from shingles Charge nurse on pediatric unit is making assignments for a float nurse from the medical unit. Pt to see first? - ANSWER 10 yr old who has pneumonia & is receiving respiratory txs Child who has pediculosis capitis - ANSWER store non-washable items in plastic bags for 14 days Child who is unresponsive has ICP - ANSWER Pad the side of the bed A client ask the nurse if it is safe for him to take glucosamine supplement? - ANSWER Shellfish allergy Client following an open colectomy - ANSWER Uncontrolled pain A client has just returned to the nursing unit following cardiac catheterization. In the immediate postoperative post procedure period which of the following is the priority nursing actions? - ANSWER Immobilizing the affect extremity A client hopitialized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The clients sibling comes to visit but has obvious manifestations of an upper respiratory infection. - ANSWER Allow the sibling to visit after donning a sterile gown, mask, gloves but prohibits physical contact Client recovering from closed head injury assumes a decerbrate posture in response to stimuli - ANSWER D lying flat ?? (Extentend extremities) The client rigidly extends his arm Client reports chest pain. Which of the following lab findings indicates myocardial damage - ANSWER Troponin 1.8 Client who has a left femur fracture and is skeletal traction. The clients reports pain due to muscle spasms in affected leg - ANSWER Realign the extremity in traction Client who has given birth to a stillborn - ANSWER Acknowledging the reality of the newborn's death Client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea - ANSWER Admin an antiemetic (Aprepitant for nausea) Client who is 8hr postoperative following a right-modified radical mastectomy - which findings to report to provider? (SATA) - ANSWER Coughing Frothy, pink secretions Client who is receiving a controlled epidural analgesia infusion - ANSWER Covering the insertion site with a transparent dressing Client who reports the use of chondroitin and glucosamine - ANSWER Improve joint functioning Community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house - ANSWER Review the effects of secondhand smoke w/ family members A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic - ANSWER Determine the client living situation A community health nurse is planning to make home visits to several clients who all live within a few miles radius of the office - Who to see first? - ANSWER An infant who has failure-to-thrive and was discharged from a facility yesterday to a foster home on daily weights Creating and activity plan for a home bound older adult client. In the planning, the nurse considers the physiologic changes that may affect pulmonary function r/t the normal aging process - ANSWER Decreased blood oxygenation Delegates the following tasks to the AP bathe four clients, distribute fresh water, obtain morning vital signs - ANSWER Set a clear time frame for the completion of each task DI w/ severe head injury - ANSWER Urine output 250 Diagnosis of antisocial personality disorder - ANSWER Poor impulse control Diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36wks gestation w/ contractions 5 min in frequency and 1 min in duration - ANSWER Prepare the client for c-section Dietary intervention for a client who is immobile due to pelvic and femur fractures - ANSWER Provide a high-protein diet Difficulty falling asleep at night - ANSWER Eat a bedtime snack (containing carbohydrates??) Disaster triage following a natural disaster - ANSWER Amputation Discharge teaching about disease prevention to a client who has active Tb - ANSWER Educating the client how to cover nose and mouth with tissues when coughing Discussing a living will with a client - ANSWER It communicates my wishes for end of life care Discussing care w/ newly licensed nurse for a client who practices orthodox Judaism - which food not given? - ANSWER Roast beef and ice cream Education about ECT major depressive disorder - ANSWER General anesthetic admin prior ECT treatments(This treatment are for pts who aren't responding to their pharmaceutical meds) Education to the mother of a toddler who has pertussis - ANSWER Pertussis booster An emergency department nurse triages a group of school children injured in a school bus crash - ANSWER A child who reports diplopia and nausea and was unconscious at the scene but is now awake Experiencing acute mania ... - ANSWER Provide high-calorie nutritional supplements (provide pt with portable nutritious food because pt may not be able to sit down) Gravida 2, para 1. The client is at 41 wks gestation and is receiving oxytocin for the augmentation of labor - ANSWER Contractions occur every 90 sec Haloperidol for the tx of schizophrenia - ANSWER Screen the client for Tardive Dyskinesia (inform pt to lower doses to decrease the chances of TD) health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field - rx? - ANSWER Closes eyes Hearing impairment - incorporate which communication methods? - ANSWER Rephrase sentences the client doesn't understand Home health nurse is admitting a client who is prescribed peritoneal dialysis - ANSWER Clarify the clients actual and perceived health needs A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client who has 2 minor children and a limited support system - ANSWER Ask the client about her understanding of the diagnosis A home-health nurse is providing teaching about self-administration of insulin to client who is newly diagnosed w/ diabetes mellitus - ANSWER I can use the same area as long as I rotate injection sites Home health nurse is reviewing treatment goals w/ a client who has diabetes mellitus evaluate lab tests to determine effective long-term management of blood glucose levels - ANSWER HbA1C Hyperthyroidism - which of the following rooms is appropriate for the nurse to assign this client? - ANSWER Cool room (reduced room temp) If something happens to me from which I cannot recover, I don't want to go on a ventilator: - ANSWER You're concerned that something may go wrong? Ileal conduit due to treatment for bladder cancer - ANSWER Cleanse w/ moisturizing soap Immediate postoperative period following thorac surgery, a nurse medicates a client for pain on a schedule - ANSWER Reduces the RR Infection control nurse is reviewing care procedures for four clients - ANSWER A client who has varicella zoster is placed in a negative pressure room In-home assessment for an older adult client who is at risk for falls. Which of the following assessment findings should the nurse identify as a potential hazard? - ANSWER A comp. chair wheels In patient psychiatric unit is setting short-term goals for an adolescent who was admitted for tx of anorexia nervosa - ANSWER The client will develop personalized meal plan Involuntarily admitted to psychiatric unit following a failed suicide attempt - experimental tx - ANSWER Witness consent before medication administration Lab data on client who has dehydration - ANSWER Elevated BUN Lab values on a client who has taken an overdose of acetaminophen - organ damage - ANSWER ALT Mastitis of left breast - does this mean that i must stop nursing my baby? - ANSWER No, you can continue to nurse from both your breasts medical unit received change-of-shift report ... - ANSWER 68 yr old Morning lab values to several clients ... - ANSWER Client who is prescribed digoxin and furosemide Pt w/ Neutropenia (MS pg. 543) - ANSWER Remove fresh flowers from a client's room Newborn nursery is performing assessments on four neonates that are all less than 24 hr old - which pt is priority? - ANSWER Pinna below the outer canthus of the eye (The eye should be even with the upper tip of the pinna of the newborn's ear; MN p. 158) Pt is Nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement w/ 5cm of dilation. At the end of last contraction, the nurse observes a large gush of fluid coming out of clients perineal area. What should nurse do first? - ANSWER Check FHR!! A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable dx to the CDC? - ANSWER Hepatitis A A nurse at the family planning clinic triages several clients over the phone - (PRIORITY)? - ANSWER Sharp pain in RIGHT shoulder A nurse delegates tasks to a LPN and an AP. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube - which of the following tasks is most appropriate to delegate to the LPN? - ANSWER Insert an indwelling catheter if the client has not voided in 3 hr A nurse educator is discussing modes of transmission w/ nursing students. Which of the following should the nurse educator include as an example of vector-borne transmission? - ANSWER West Nile virus from mosquito bite A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk w/ an adolescent client who was admitted w/ clinical depression. After a few minutes of convo, the adolescent ask the nurse "why did you choose to talk to me out of this room full of kids?" - ANSWER You're curious why I am interested in you and not the others? A nurse in a mental health clinic is reviewing the hx and physical for a 17-yr old client who has a new dx of social phobia: - ANSWER Client reports minimal alteration in performance at a part-time job Nurse in an emergency department is assessing a client who has a nasal fracture. - ANSWER Clear fluid drainage from the nares A nurse in a pedi unit is caring for a group of clients. Which of the following diseases should the nurse implement droplet precautions? - ANSWER Pertussis A nurse in a provider's office is caring for a client who has Parkinson's Disease and has been taking levodopa for the past 5 wks. The client reports a new onset of muscle twitching - best response? - ANSWER This is a manifestation of drug toxicity & may require a dosage reduction A nurse in the emergency department is caring for a client following a motor vehicle crash - PRIORITY? - ANSWER Stabilize the cervical spine A nurse in the emergency department is caring for a client who has abdominal pain. Which of the following actions by the nurse demonstrates VERACITY? - ANSWER A nurse explains the potential risks of tx. (Veracity = truth/not withhold all info; Fidelity = keeping promises) A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the first 24hr following sx, the nurse should instruct the client to do which of the following? - ANSWER Intermittently place ice on the ankle (30 mins - 1 hr??) A nurse in the PACU is caring for four post-op clients. The nurse realizes that coughing poses a risk to which of the following clients? - ANSWER Thyroidectomy (Coughing can cause incision to reopen & bleeding can occur) A nurse is admitting a client who has chronic gout - What med should the nurse admin? - ANSWER Allopurinol A nurse is admitting an infant who has bacterial meningitis. Nursing intervention? - ANSWER Minimize environmental stimuli A nurse is admitting an unidentified female who was brought to the emergency department: - ANSWER 3 months A nurse is analyzing cardiac rhythms of four telemetry clients in the coronary care unit: - ANSWER C looks normal but lots of artifact or Fibs in between QRS's A nurse is assessing a client 1 wk after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? - ANSWER Graft vs host disease A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr - ANSWER Blood is backing up in the IV tubing A nurse is assessing a client who is 2 hrs post-op following insertion of a chest tube connected to chest drainage system as depicted in the diagram above: - ANSWER Fluctuation of the fluid level chamber b (middle) A nurse is assessing a client who is post-op following abdominal sx. States "I feel like my incision ripped open." - ANSWER Place client in Low-Fowler's position A nurse is assessing a client w/ schizophrenia - what is a manifestation? - ANSWER Auditory hallucinations A nurse is caring for a client following insertion of a subclavian non-tunneled percutaneous central venous catheter - What should nurse do? - ANSWER Review the chest x-ray A nurse is caring for a client who has a partial laryngectomy and is receiving continuous enteral feedings at 65ml.hr through a gastrostomy tube (intervene??) - ANSWER The client is lying in a supine position A nurse is caring for a client who has newly implanted sealed internal radiation device to treat cervical cancer. - ANSWER Keep a 3 ft distance from the radiation implant A nurse is caring for a client who has a new prescription for lithium carbonate. PRIOR TO ADMINISTERING THE FIRST DOSE, WHICH OF THE following lab values should the nurse evaluate? - ANSWER Sodium A nurse is caring for a client who has a typical depression and is taking phenelzine - What can you eat? - ANSWER Low-fat yogurt A nurse is caring for a client who has cirrhosis of the liver: - ANSWER Monitor for abdominal ascites Nurse is caring for a client who has end stage liver disease. The daughter of the clients ask about her father's DNR request. - ANSWER Tell me your feelings bout your father's prognosis. A nurse is caring for a client who has heart failure and has started taking a loop diuretic: - ANSWER Decreased reflexes A nurse is caring for a client who has just returned to the unit following a bronchoscopy: - ANSWER Offer oral fluids to the client A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest? - ANSWER Taking walks (physical activity) A nurse is caring for a client who is postoperative and at risk for development of DVT - Risk factor? - ANSWER Prolonged bed rest A nurse is caring for a client who is receiving enteral nutrition. What lab level should be reported? - ANSWER Serum sodium of 128 A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity? - ANSWER Tinnitus P-pee (furosemide) A-abx & aspirin C-cancer (tamoxifen) T-tinnitus A nurse is caring for a client who is receiving IV antibiotics and tests positive for C. diff - PRIORITY? - ANSWER Place client on contact precautions A nurse is caring for a client who will be receiving a transfusion of platelets - Effectiveness? - ANSWER Decrease in bleeding from puncture sites A nurse is caring for a client with fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an aPTT of 100 seconds - What nurse do next?? - ANSWER Turn off heparin drip A nurse is caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? (SATA) - ANSWER -Transfer a client from bed to chair w/ mechanical lift -Provide postmortem care on a client who experienced cardiac arrest A nurse is caring for a mother who was prescribed methadone during pregnancy (MN p. 183): - ANSWER -Tachypnea -Irritability -Tremors or -Increased seizures, sleep pattern disturbance, higher birth wt A nurse is caring for an infant who is being treated for dehydration - indication for further education? - ANSWER -Flat anterior fontanel (Reason: Fontanels should be soft & flat; No tears = dehydration) A nurse is caring for a post-op client. Which of the following interventions will reduce the risk of DVT? - ANSWER Apply venous plexus foot pumps A nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1 hr ago. - ANSWER Support the affected leg on a pillow A nurse is discussing the z-track method to admin hydroxyzine hydrochloride w/ a newly licensed nurse - Understanding of teaching? - ANSWER This technique decreases the risk of subcutaneous infiltration A nurse is electronically documenting assessment findings for a client - How should document/assess pain? - ANSWER The client reports a pain level of 6 on a scale of 0-10 A nurse is giving change-of-shift report about a client who is 36-hr post-op to another nurse: - ANSWER Pain relieved by changing position A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say? - ANSWER "Let's talk about what happened to you" A nurse is planning care for a client who has a new diagnosis of HIV. - ANSWER I cant seem to gain any weight A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx - What should nurse do? - ANSWER Provide the client with an alternating pressure mattress A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? - ANSWER Remind the client to place the cane on the unaffected side. Rationale: Keep the cane on the stronger side of the body 1- Move cane forward 15cm 2- Then, move weaker cane forward 3- Advance stronger cane A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy: - ANSWER Place the newborn 45cm or 18 in from the light source A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections UTI: - ANSWER Empty bladder before & after sexy time A nurse is planning to change the dressings on a school-age child who has sustained multiple burns: - ANSWER Apply the dressings in a proximal to distal pattern A nurse is planning to provide community education about viral hepatitis - What info should include? - ANSWER Clients who have a hx of viral hepatitis are unable to donate blood A nurse is preparing the auscultate a client's apical pulse at the point of maximal impulse (PMI): - ANSWER 5th intercostal space at the left midclavicular line A nurse is preparing to administer potassium chloride intravenously to a client who has hypokalemia. The client is receiving a current infusion of 0.9% sodium chloride at 125ml/hr. Which of the following actions should the nurse plan to take? - ANSWER Dilute the solution prior to the infusion. Rationale: Dilute K+ and give no more than 40mEq/L of IV solution to prevent vein irritation A nurse is providing teaching for a client who has a new prescription for lithium carbonate - (Need for further education???) - ANSWER Take medication w/ milk. Rationale: Taking lithium with food would help with decreasing GI distress A nurse is providing teaching to the parent of a preschooler who was newly diagnosed with a latex allergy - What foods to avoid? - ANSWER Bananas A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all the new employees to screen for the presence of tuberculosis? - ANSWER Mantoux test A nurse is reviewing medical records for four clients - Which of the following represents appropriate documentation? - ANSWER Carafate 1g PO 1hr AC A nurse is reviewing the hx and physical of a client who has right ventricular heart failure: - ANSWER Hepatomegaly (liver enlargement) A nurse is teaching a client who has a new dx of GERD - Include in teaching? - ANSWER Sleep w/ HOB elevated A nurse is teaching a client who has a new prescription for digoxin. Which of the following should the nurse include in the teaching? - ANSWER Notify your provider if you experience muscle weakness! A nurse is teaching a client who has left-leg weakness how to use a standard walker (further education?) - ANSWER Moves the left leg and walker ahead together A nurse is teaching a client who has a low literacy level about home management of diabetes mellitus: - ANSWER Show the client an educational video A nurse is teaching a family about home hospice care: - ANSWER Hospice care improves the quality of life through palliative care A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents - What include in teaching? (SATA) - ANSWER -Swallowing sounds are audible -Stools are yellow and seedy after 7 days -Maternal breasts become soft following feedings A nurse is writing a plan of care for a client who is home bound and has stage 2 Alzheimer's Disease. Which of the following should the nurse include in the plan of care? - ANSWER Assist with money management A nurse manager is making staffing assignments for the med surg unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit? - ANSWER A client who is 2 days posto-op following a colon resection A nurse manager is presenting an in-service for newly licensed nurses about advance directives: - ANSWER Advanced directives must benotarized to be legally implemented A nurse manager is presenting info to the nursing staff regarding the appropriate use of client restraints - What should be included? (SATA) - ANSWER -Nurse should pad the bony prominences. -Providers prescription should include the type of restraint to use. -Remove or replace restraints frequently to ensure good circulation to the area A nurse notices smoke coming from aclients room and discovers a fire in the wastebasket. After moving the client to safety what nurse do next? - ANSWER Co said: Notify the facility operator I found: Activate fire alarm A nurse plans to ambulate a client on the third day after cardiac sx. - ANSWER Premedicate the client w/ the prescribed analgesic A nurse supervisor receives notification of a disaster in the community and the possibility for multiple admissions to the facility - Which ppl can be discharged? (SATA) - ANSWER - 1 day post op -laparoscopic -cholecystectomy -temp 98 A client who has an abdominal wound and is receiving negative pressure wound therapy - ANSWER Report to the nurse manager Rationale: negative pressure wound therapy is used to reduce edema A nurse volunteers to assist after witnessing a mass casualty incident involving a train derailment. Which of the following clients should the nurse immediately and completely immobilize? - ANSWER Pt w/ Glasgow coma???? A nurse who typically works on the postpartum unit is assigned to float to the maternal newborn unit. The nurse is very anxious about floating and uncomfortable with the assignment the charge nurse has selected - What should nurse do? - ANSWER Ask the charge nurse to assign an experienced nurse to act as a resource A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room - What should do? - ANSWER Accompany the client awayfrom the common area Nutritional assessment on a client who has a calcium deficiency - ANSWER Osteogenesis OCD - Further education?? - ANSWER Teach the client to meditate about obsessive thoughts An older adult client tells the nurse, "I thought immunizations were for kids." The nurse informs the client that older adults should receive which of the following immunizations? - ANSWER Herpes zoster vaccine Orthopedic floor is completing the morning assessments on several clients - PRIORITY client? - ANSWER 24-year old male who has a casted femur fracture Performing postmorten care on an older adult client - ANSWER Place absorbent pads under the buttocks area Rationale: Apply fresh linens w/ aborbent pads on bed and a gown Perform wound irrigation for a client who has an open secondary wound when creating a sterile field - ANSWER Hold bottle w/ the palm over .... while pouring Postpartum unit is caring for several clients (which pt do you see first?) - ANSWER 1 day postpartum has not voiding in 8hrs Preparing a client for sx and nursejust administered the preoperative injection (what is the next step or first step?) *safety question - ANSWER Raise the side rails on the bed Preparing to administer eye drops to a client: - ANSWER Use aseptic technique and drop the medication into the conjunctival sac Preparing to obtain informed consent for a colonoscopy from a client who does not speak english: - ANSWER Provide a consent form in the client's spoken language Prescribed furosemide - indication of fluid overload??? - ANSWER Rales in lower lobes of lungs Primagravida client in the emergency department at 12 weeks of gestation hyperemesis gravidarum: - ANSWER 1,000 mL/hr Providing dietary teaching for a client who has a hx of nephrolithiasis - Which of the following is appropriate to include in the teaching? - ANSWER Avoid foods that have high levels of oxalates Rationale: avoid foods high in oxalate sources such as spinach, black tea, cocoa, beets, pecans, peanuts, okra etc. Providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in her diet during lactation? - ANSWER Calcium Providing postoperative teaching to a client who has a newly inserted pacemaker (if for further education this maybe the answer because this is not in the education) - ANSWER I will use my cellphone on the earopposite of my pacemaker Recognizes that the teen pregnancy rate in the community has increased: - ANSWER Arrange a meeting with teenage mothers who are high school students in the community Rationale: Provide pregnancy counseling, including alternative course of actions, instructions and encourgament in parenting role in home and peer group settings. Recovering from an acute myocardial infarction - left sided heart failure: - ANSWER Bilateral lung crackles Recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling - What could be problem? - ANSWER The tubing may be kinked Rationale: Tidaling is expected. Cessation of tidaling in water seal chamber signals lungs re-expansion or obstruction. Continuous bubbling indicates an air leak. Referral for a speech language pathologist: - ANSWER Client who has difficulty swallowing Reviewing data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibility of child abuse? - ANSWER A 3-month old infant who has a skull fracture from reportedly rolling off the changing table "Reviewing" medications for a group of clients labor and delivery (which would you NOT give?) - ANSWER Phenytoin for seizure disorder Rising number of sexually transmitted infections in the community???? - ANSWER ????? School nurse scabies - ANSWER Red itchy papules on child's groin area Several client measurements were obtained with morning vital signs - pt priority*?? - ANSWER A 4-year old who has closed head injury and heart rate of 60 Tetralogy of Fallot: - ANSWER Pulse oximeter Urinalysis done for a preschool age child: - ANSWER Pyelonephritis ???? PRIORITY action for post-op ileus? - ANSWER Monitor bowel sounds Idenfy risks for fat embolism syndrome (FES): - ANSWER Older adults (70 or older) and hip/pelvis fractures are common causes (turn upside down)? Disorder of eye post-op risk? - ANSWER Bleeding and infection [Show More]

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