Administering a measles, mumps, and rubella immunization to an infant
RATIONALE: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a ...
Diarrhea.RATIONALE: Oral acyclovir may cause such adverse GI effects as diarrhea, nausea, and vomiting. It isnt associated with palpitations, dizziness, or a metallic taste.
CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge
REFERENCE: Karch, A.M. 2007 Lippincotts Nursing Drug Guide. Philadelphia: ...
Talk with the mother about the concept of protected health information under the Health Insurance Portability and Accountability Act (HIPAA).RATIONALE: The Center for Adolescent Health Policy and the Law has determined that its appropriate for a minor to exercise privacy rights under the HIPAA regulation, whether or not the minor is emancipated. Therefore, it isnt appropriate for the nurse to ...
A disease process is present.RATIONALE: This X-ray suggests tuberculosis. An ET tube thats 3/4 above the carina is at an adequate level in the trachea. Theres no need to advance it or pull it back.
CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis
REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarths Textbook of Medical ...
Apply a dressing over the wound and tape it on three sides.RATIONALE: The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube ...
21The correct answer is 21.
RATIONALE: The basal dosage for this client is 5 units of regular insulin and 10 units of NPH insulin. Using the medium-dose sliding scale and the clients blood glucose reading of 264 mg/dl, the nurse should determine that an additional 6 units of regular insulin are required, totalling 21 units (5 units + 10 units + 6 units = 21 units).
CLIENT NEEDS CATEGORY: ...