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If a child is leaning forward with the chin thrust out, this is an indication that the airway may be obstructed.
Other indications might include nasal flaring, tachycardia, high fever and sore throat. To prevent spasm of the epiglottitis and airway obstruction, no attempt should be made to visualize the pharynx.

The primary reason for administering charcoal is to prevent absorption of toxins into the system. Charcoal is not used to induce vomiting or diarrhea. It does not reduce current drug levels, but it may reduce future drug levels.

Liquefaction necrosis is an indication that the chemical is still burning the patient. Exposure to acids or heat causes thick, leathery eschars to form. Thermal injury can lead to cherry red, firm tissue. Partial-thickness thermal injury leads to intact blisters.

The pediatric nurse should be able to complete care on a 32-year-old diabetic patient. The other patients on the list all have illnesses that are mainly adult illnesses, and the pediatric nurse may not know how to complete the care on those patients.

The nurse should call the family and get consent for the procedure. The nurse will need to have two witnesses available to sign. In emergency cases the physician is allowed to take a patient to surgery without consent if every effort has been made to contact the family.

New standards in CPR emphasize chest compressions over airway, so the next step after calling for help is to check the pulse and begin chest compressions. Chest compressions should be given immediately (30 for an adult patient), and then followed by opening the airway and beginning respirations. Ventilation is only initiated when the airway is open or patent, as oxygen is not needed until the patient is breathing.

The nurse would prepare 15 ml of potassium chloride.
Desired dose: 30 mEq
Available concentration: 40 mEq (Units) per 20 mL (Volume)

Tinnitus is the most common complaint of patients with disorders of the inner ear. Tinnitus is a ringing in the ear that can be loud intolerable ringing or mild ringing that can be unnoticed during the day.

The patient who is having Kussmaul respirations would have abnormally deep, regular and increased respirations. Bradypnea would produce regular, slow respirations. Hyperpnea is labored, increased respirations, and apnea is when a patient stops breathing for short periods of time.

No charges will be filed against the nurse, because the actions of the nurse are reasonable. False imprisonment is an act with intent to confine a person to a specific area. This could be charged against the nurse if the patient had been voluntarily admitted to the hospital.

The nurse would want to investigate possible sexual abuse. This diagnosis in a child who is not sexually active should trigger suspicions in the nurse. Allergy, trauma and infection can all cause conjunctivitis, but chlamydia is a sexually transmitted disease.

A pH level of 7.30 would indicate an acid base imbalance. The normal pH is 7.35 and 7.45. Anything less than 7.35 would indicate acidosis, and anything greater than 7.45 would indicate an alkaline state. The normal PCO2 is 35 to 45 mm Hg. Bicarbonate is usually associated with a metabolic state.

You would not want to suction a patient who just had a tonsillectomy. Suction equipment should be available at bedside in case of airway obstruction. Otherwise, a patient would not be suctioned due to the risk of trauma to the oropharynx. All other orders listed are appropriate for this patient.

The nurse would want to notify the physician of the change. This is a sign of decreased circulation to the extremity. The physician will need to intervene to prevent the patient from having further adverse affects.

The nurse should give the older patient time to process the information. The other options are not appropriate for this patient because the patient should be allowed to make their own decisions if able, not be rushed and provided written instructions in addition to time to process.

The patient will be able to deny suicidal ideations and identify options for dealing with stressors at the completion of care. The patient has developed a plan for his suicidal ideations and this should be directed as the priority for care. The patient will need to learn to identify other options for dealing with his stress rather than suicide.

You as the nurse can be charged with assault for threatening to restrain the patient. You as the nurse have put the patient in fear of harmful or offensive contact. In order for this to be a chargeable offense, the patient must be aware of the threat.

The nurse needs to monitor the cardiac output to determine if treatment is effective. The cardiac output monitors the left ventricular function of the heart. The peripheral pulses and respiratory rate may remain within normal, so they are not the best indicators of treatment effectiveness.

The physician will need to be notified if the patient develops stridor. Stridor is a high-pitched, coarse sound heard over the trachea. This is an indication of airway edema, which puts the patient at risk for airway blockage.

Weight is a good indication of this patient's fluid loss or gain. One kilogram of weight represents one liter of fluid loss or gain, which makes this a very reliable source for dehydration.

In stage I Lyme disease a three-week course of oral antibiotics is begun. In later stages the patient may require intravenous antibiotics. Both A and D are inappropriate responses for patients with Lyme disease.
Prevention, education and early diagnoses are important in controlling Lyme disease.

The most appropriate assignment for the nursing assistant would be a urine culture collection for the laboratory. The nurse must choose the most appropriate assignment for each staff member on the unit. In this case the nursing assistant should have the appropriate skills to collect urine and send it to the laboratory.

The patient would exhibit a low arterial PAO2. Increased respiratory rate would be the earliest sign that the nurse would see. Then the patient will begin to display air hunger, labored breathing, retractions and cyanosis.
Hypoxia is evidenced by the arterial blood gas.

You should call the nursing supervisor and report the nurse for taking medications from the unit. The nurse practice act requires that all impaired nurses be reported. The nursing supervisor should then report to the board of nursing who will develop a plan for treatment and supervision for the nurse.

A CO 3 L/min and PCWP that is high would indicate that the patient in cardiogenic shock is unstable.
Normal cardiac output is 4 to 8 L/min. The heart fails to pump, which leads to the cardiac output falling and PCWP rising.

You would want to perform visual acuity tests on the affected eye first. This allows the nurse to assess any damage to the vision. Any foreign objects in the eye should only be removed by an ophthalmologist. Do not cover or rinse eye because it may dislodge foreign objects and cause further damage to the eye.

The nurse should stand in front of the patient with hearing loss while trying to communicate with them. By standing in front of the patient and providing adequate lighting, the nurse insures that the patient can see the nurse clearly. If there is still difficulty communicating, then notes and pantomime can be used.

The patient receiving a platelet transfusion should begin to have a decrease in blood oozing from puncture sites and gums. Platelets are necessary for proper clotting. Granulocytes would be given to decrease fever, and red blood cells would be given to raise hemoglobin and hematocrit.

The patient is displaying all the symptoms of fluid overload. If the patient were experiencing a transfusion reaction, there would also be itching and a rash. Bacteremia would lead to the patient having a fever. Fluid overload is the best answer due to the crackles in the lungs indicating fluid has become a problem.

The physician would order for the affected extremity to be immobilized. The autograft being placed over the joint will require the patient to keep it immobilized for three to seven days while the graft adheres.