43. While the nurse is taking routine vital signs, she notices that the infant is having a hypercyanotic episode.  What should the nurse do first?  

49. The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected pulmonary stenosis.  The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?

20. What concerns should the nurse anticipate for a patient who had a right hemisphere stroke? (Select all that apply)

55. A 6-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis.  What are the priority nursing concerns? (Select all that apply)

57. A 9-month-old infant has been prescribed iron supplements. During follow-up visits, the nurse observes that the infant’s iron-deficiency anemia has not improved despite treatment. Which action taken by the parents does the nurse recognize as the reason for the lack of improvement?

13. The nurse performed a routine physical assessment of a client admitted with back pain. Which assessment finding should immediately be reported to the primary health care provider?

23. Diltiazem is prescribed for a patient newly diagnosed Printzmetal’s angina. Which action of diltiazem is accurate for the nurse to include in the teaching plan?

31. Which measures would the nurse implement in the postoperative period to prevent pulmonary embolus in a patient? (Select all that apply)

22. A 62-year-old woman who is usually independent has been feeling heart palpitations and shortness of breath for a few weeks. To date, she has not sought treatment. Today, her husband noticed that she was having slurred speech and difficulty walking, so he brought her to the Emergency Department. She was able to walk in but needed assistance. Nursing assessment reveals the following: radial pulse too rapid to count, apical pulse 160 beats per minute and irregular, blood pressure 168/98, respirations 24, and oral temperature 99.4°F (37.4°C). SpO2 was 95% on room air. EKG shows atrial fibrillation with rapid ventricular response of 164. Skin is warm, flushed, and dry. She reports a headache, and falls asleep during the interview, with a decreased level of consciousness. When she tries to answer questions, her speech is slurred. Right hand grip is weaker than left hand. Lower legs have 1+ edema bilaterally. States her last bowel movement was 2 days ago; the abdomen is slightly distended. Which assessment findings require immediate follow-up by the nurse? (Select all that apply)

46. Which assessment finding would lead the nurse to suspect that a newborn infant has a ventricular septal defect?