NEWEST VERSION WITH COMPLETE QESTIONS AND
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A+ \ACTUAL EXAM 209
Ineffective airway clearance related to retained secretions as evidenced
by abnormal breath sounds. What's outcome?
Pt. Will exhibit clear breath sounds in bilateral lower lobes after
nebulizer and chest physiotherapy (PT)
Ineffective airway clearance related to retained secretions as evidenced
by abnormal breath sounds. What's interventions?
-Provide nebulizer treatment and chest and chest
physiotherapy/postural drainage as prescribed
-Administer IV antibiotics on time
Caregiver role strain related to perceived lack of support as evidenced
by lack of compliance to prescribed treatment regimen. What is the
outcome?
Grandmother will identify resources to assist with caring for the child
with chronic illness by discharge.
,Caregiver role strain related to perceived lack of support as evidenced
by lack of compliance to prescribed treatment regimen. What is the
interventions?
-Provide grandmother with contact information for the American Lung
Association and Cystic Fibrosis Foundation
-Refer the pt.'s family to a hospital social worker.
Imbalanced nutrition: less than body requirements related to
inadequate absorption of calories as evidenced by height and weight
below 3rd percentile. What is the outcome?
The child will gain 2 pounds within one month
Impaired Gas Exchange related to poor perfusion as evidenced by
cyanosis and clubbing of fingers. What is the outcome?
The child will maintain oxygen saturation above 92% on room air by
discharge.
Imbalanced nutrition: less than body requirements related to
inadequate absorption of calories as evidenced by height and weight
below 3rd percentile. What is the interventions?
-Elicit the patient's food preferences when completing the menu
-Provide pancrelipase with meals and snack
,Impaired Gas Exchange related to poor perfusion as evidenced by cyanosis
and clubbing of fingers. What is the interventions?
-Limit feeding times to 20 minutes
-Place child in knee-chest position during that spells
The registered nurse is getting ready to administer the ophthalmic
(erythromycin) preparation to the newborn. Which is true regarding the
medication? Select all
that apply.
Silbert-Flagg & Pillitteri 8th edition, p. 431
Which newborn assessment finding would require the RN to report to the
health care provider?
Silbert-Flagg & Pillitteri 8th edition, pp433-443
The RN assesses that the 2-hour-old infant's axillary temperature is 97F
(36.1C). which intervention should the nurse implement first?
Silbert-Flagg & Pillitteri 8th edition, p. 430
A parent is questioning why their newborn needs a Hepatitis B vaccine
so soon after birth. Which explanation is the most appropriate to offer
the parent?
Silbert-Flagg and Pillitteri, 8th ed, pp 1270-1271
, The grandmother of a newborn comes to the nursery and tells the RN
she wants to bring the baby back to the mother. The grandmother is
not wearing an
identification bracelet. Which response is most appropriate by the RN?
Silbert-Flagg and Pillitteri, 8th ed, pp. 451-452
Which newborn assessment finding would require the RN to report to the
health care provider?
The newborn whose toes curl when the lateral heel is stroked. : Please
review normal newborn characteristics Reference: Silbert-Flagg &
Pillitteri 8th edition, pp433-443
The registered nurse is caring for an infant with the nursing diagnosis of
Ineffective thermoregulation. Which is a realistic, measurable patient
outcome for this infant?
The patient will maintain a body temperature of 97.8° to 98.6° F by
discharge.
Reference: Silbert-Flagg & Pillitteri 8th edition, p 689 Review the
NANDA-I nursing diagnosis of Ineffective thermoregulation