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appraise (right supervision and evaluation). The nurse should use professional judgment and critical thinking skills when delegating. 5. A nurse is caring for an infant client with Tetralogy of Fallot... . What are cardio/pulmonary defects noted with this cardiac disorder? What are clinical manifestations associated with this cardiac disorder? - Four defects that result in mixed blood flow: pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy – cyanosis at birth: progressive cyanosis over the first year of life; systolic murmur; episodes of acute cyanosis and hypoxia (blue or “Tet” spells) - Clinical manifestations – cyanosis; shortness of breath and rapid breathing, especially during feeding or exercise; fainting; clubbing of fingers and toes; poor weight gain; tiring easily during play or exercise; irritability; prolonged crying; a heart murmur 6. Diuretics are given regularly in the acute care setting. Which of the following clients is not a good candidate for diuretics? Client with pulmonary edema Client with hypercalcemia Client with hypokalemia Client with kidney stone formation - Client with hypokalemia because diuretics can cause loss of potassium (unless a potassium- sparing diuretic) 7. A nurse is caring for a 9-year-old client who has cerebral edema status post MVA. What are seizure precautions the nurse should ensure are in place? - Pad side rails of bed, crib, and wheelchair. Keep bed free of objects that could cause injury. Have suction and oxygen equipment available. 8. A client with thyroid cancer is receiving brachytherapy. Define this therapy. - Is internal radiation that is placed close to the target tissue through placement in a body orifice (vagina) or body cavity (abdomen) or delivered via IV such as with radionuclide iodine, which is absorbed by the thyroid. Brachytherapy provides radiation to the tumor and a limited amount to surrounding normal tissues. Waste products are radioactive until the isotope has been completely eliminated from the body. Waste products should not be touched by anyone. 9. A nurse is providing education on home safety specific to the school-age client to parents. Identify four (4) examples of home safety concerns for this age group. - Firearms – be sure to keep them unloaded, locked in somewhere safe where the child cannot reach it. Teach the importance of never touching a gun. Also be sure to keep the bullets in a different location from the guns. - Play injury – do not allow the child to run with candy or anything in the mouth as it could cause choking or aspiration. Teach the child to wear protective helmets, knee and elbow pads when needed. Teach the importance of “stranger danger” and avoiding strangers, as well as keeping parents informed of strangers - Burns – the water heater setting in the home should be set to no higher than 120’F. Teach the dangers of playing with matches, fireworks, and firearms and how to properly use microwave and other cooking utensils - Poison – teach the child about the hazards and dangers of alcohol, cigarettes, and prescription, non-prescription, and illegal drugs. Also, keep any potentially dangerous substances out of reach. 10. What are guidelines when cleaning contaminated equipment a nurse should follow? - Wear gloves and protective eyewear; rinse with cold water; wash in warm water with soap [Show More]

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