Provider Prescriptions Day 1, 1730:CT scan of head STATNPOSeizure precautionsElevate head of bed 15° to 30°. Nurses’ Notes Day 2, 1745:Called to room by parent. Adolescent is having jerking movements of all extremities, is unresponsive, eyes are rolled upwards, mucous membranes are blue, and copious amounts of clear mucus is noted at the corners of the mouth. Vital Signs Day 2, 1745:Pulse rate 132/min Oxygen saturation 88% on room air   Which of the following actions should the nurse take? (Select all that apply).

Which of the following findings require immediate follow-up? (Select all that apply).

Provider order: Acetaminophen 200 mg PO nowSafe dose range: 10–15 mg/kg/dose every 4–6 hoursChild’s weight: 12.5 kg Is this dose safe, below safe range, or above safe range?

The client is placed on NPO status and fluids are started as the client may need surgery. Select the priority order from each category that the nurse anticipates including in the plan of care at this time. Nursing Diagnostics Medication  

A nurse is caring for a preterm infant who has developed increasing abdominal distention, abdominal tenderness, bilious gastric residuals, and bloody stools. The infant has also become lethargic and has an increased frequency of apnea. Which action should the nurse take first?

A teenager has been diagnosed with bipolar disorder and is having manic symptoms. What are appropriate nursing responses? (Select all that apply.)

A nurse is caring for a pediatric client with leukemia who is due for a varicella vaccine booster. Which nursing action is most appropriate?

The nurse is caring for a 3-day-old infant and the physician suspects some type of congenital cardiac defect. The caregivers ask what’s going to happen next. Which statement below should the nurse include in the response?

A position in which the patient is lying flat on his or her stomach is termed

Which of the following observations should cause you to suspect child abuse? Cigarette burn marks. Bruises shaped like hands, fingers, or objects, such as a belt. Failure to seek prompt treatment for a serious injury. Fracture of the radius