Edapt - Pediatric Nursing - NR328 - Tonsillitis Case Study solutions

Edapt - Pediatric Nursing - NR328 - Tonsillitis Case Study solutions After the nurse's initial assessment, the client is at highest risk for developing ---- as evidenced by the client's --- Ineffective airway clearance.....inflammation and secretions For each potential nursing intervention, click to specify whether the intervention is indicated, nonessential, or contraindicated. Mark only one response per intervention. Indicated Place client in high Fowler's position. Suction secretions. Nonessential Request an order to insert an additional peripheral venous access device (VAD). Contraindicated Give 3 mg of IV morphine. Prepare the client for defibrillation. Select the 3 orders that the nurse should perform right away. *Acetaminophen-hydrocodone 33.3 mg-0.5 mg every 4 hours as needed (PRN) for severe pain *Laboratory test: complete blood count (CBC), basic metabolic panel (BMP), arterial blood gas (ABGs) *Oxygen via nasal cannula to maintain pulse oximetry at 94% or greater For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined. Improved Pulse 88 Pain level Pulse oximetry 100% No Change Breath sounds RR 24 Declined - NONE Select the 4 findings that require immediate attention. Compromised airway Weight down from admission weight History of increasing difficulty eating Morphine several times during the night