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Infant postop pyloric stenosis repair. RN action:

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Monitor infant following feedings for vomiting (Evaluates success of surgery)

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Monthly assessment for methylphenidate (Ritalin). ADRs

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Weight loss

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Adolescent managing tinea pedis. understands teaching

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I should wear sandals as much as possible. (Allow air circulation, promoting healing of fungal infection)

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7-mo-old. Report what to PCP

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Inability to babble one-syllable sounds (babbling one-syllable sounds is appropriate for a 6-months old infant)

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Hospice RN 1yr anniv of death (leukemia). Reaction indicating need for bereavement counseling referral

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The parent has not returned to work. (complicated grief reaction)

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Toddler w/ diarrhea. Alert for worsening diarrhea

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Decreased tear production (decrease in tear production indicates worsening dehydration)

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Education for juvenile idiopathic arthritis.

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Encourage the child to perform independent self-care (self-care minimize pain while maximizing mobility)

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Child maltreatment class for new RNs. sxs of physical abuse

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Symmetric burns of the lower extremities

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Low leg cast education. Report what?

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Inability to move the toes (a sign of neurovascular damage; requires immediate attention)

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School aged child dx w/ asthma, reports chest pain. RN action

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Auscultate breath sounds (1st action of nursing process)

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Pediculosis. Understands teaching

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"I'll need to remove the nits after treatment." (Treatment are not 100% effective in killing nits, removal of nits is recommended)

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School aged w/ poorly controlled seizure disorder. plan of care

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Have oxygen available (may requires supplemental oxygen follwing a sezuire)

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Mom argues w/ adolescent about playing music & studying. appropriate RN response

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Consider letting her make her own choice about listening to music while studying

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Eepiglottitis. RN action

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Monitor oxygen saturation

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Food choices for celiac disease.

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Rice pudding

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Cerebral palsy, trouble w/ verbal comm.

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Use pictures and objects when talking to the child; encourage the child to move his lips and tongue when eating; allow the child time to articulate at his own pace

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Partial thickness burns on >40% body. give ____ in first 24hr

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Lactated ringer's

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School age room assignment, important consideration

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Disease process

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Preschooler, acute lymphocytic leukemia, severe stomatitis. plan of care

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Help the child brush her teeth gently with a soft sponge toothbrush

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Serum lead 4mcg/dl. appropriate RN action

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Schedule the toddler for a yearly rescreening

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Postop care 13mo post cleft palate repair. RN intervention

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Prevent the client from using a pacifier

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Newly Rx methotrexate (MTX). pre-first dose RN action

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Liver function test

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Plan of care juvenile idiopathic arthritis

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Monitoring students for presence of communicable diseases

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Bryant traction. RN action

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Maintain the hips at a 90 degree angle to the body

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Nephrotic syndrome. RN assessment to confirm peripheral edema

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Palpating dorsum of feet

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Impetigo. teaching

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Remove crust after soaking with 1:20 Burow's solution

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6 yo chemotherapy. report lab value to PCP

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Hemoglobin 9.0 g/dL

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18mo dehydration. understands teaching

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"I will monitor my child's number of wet diapers"

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IV famotidine (pepcid). ADR

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Bruising

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Halo brace plan of care

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Provide pin site care

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4yo assessment. expect developmental milestone?

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Cuts a shape using scissors (should be able to use scissors to cute out a shape)

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Early manifestation of pertussis

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Dry, hacking cough

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IV fluids in periph IV cath. upon removal, what should RN do

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Turn off the pump

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Large sacral myelomenin. pre-op, RN prevents complications by

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Keeping the newborn's leg abducted with a pad between the knees (risk of hip subluxation due to paralysis of LE)

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Physical neglect finding

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Poor personal hygiene

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3yo well visit. Report to PCP

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Respirations 30/min

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Pulm stenosis. ID area of ejection murmur heard loudest

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Baby's 2nd internal costal left sternal boarder

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Respiratory syncytial virus (RSV) in a mist tent. RN implementation for infection control

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Have a designated stethoscope in the room

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3yo given pain med. appropriate pain scale

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Oucher

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Postop tonsillectomy. Sxs of hemorrhage

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Frequent swallowing

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New dx of lyme disease. manifestation of stage 1 of dz

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Skin rash

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4mo heart failure. highest priority finding

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Three episodes of vomiting (vomiting may indicate digoxin toxicity)

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Discharge teaching car seat 6mo. Mother needs more teaching

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Using a blanket as padding underneath the infant while traveling

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Treated streptococcal throat infection but admitted w/ dx acute rheumatic fever. appropriate RN intervention

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Maintain bed rest

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Ancef med

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1.9 mL

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Glomerulonephritis & is edematous. plan of care

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Restrict sodium intake

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Appendicitis, possible perforation. manifestations of peritonitis

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Abdominal distention

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6mo at well infant visit. RN report to PCP

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Presence of strabismus

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Adolescent w/ infectious mononucleosis. understands teaching

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"I should take ibuprofen for my headaches"

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Diaper dermatitis. apply ____ to affected area

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Zinc oxide

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Infant w/ heart failure. RN expectation

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Peripheral edema (systemic venous congestion)

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Pneumonia

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Crackles

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Toddler w/ foreign body aspiration. RN action

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Prepare for an endoscopy

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Growth hormone injections to mother of child w/ growth hormone deficiency. teaching

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Have serum calcium levels drawn periodically

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Heart dz w/ HF. plan of care

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Provide small, frequent meals (poor cardiac function; to conserve energy)

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Adolescent lumbar puncture. confirmation of bacterial meningitis dx

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Increased protein (confirms the dx of BM dx)

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Acute perforated appendix. expected immediately postop

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Absence of peristalsis (Expected finding until bowel resumes functioning)

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Nephrotic syndrome sxs

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Hyperalbuminuria (manifestation of nephrotic syndrome)

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Child begins to stare into space & grunt. extremities extend stiffly

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Lower the child to the floor; place pillow under the child's head; loosen restrictive clothing; assess the child's mouth for injuries

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Urine dipstick test w/ nephrotic syndrome. Rn expects

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4+protein (glomerular membrane to become permeable to protein)

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