Answer to Question 1
Correct Answer: 2
Rationale: In near-drowning cases, the nurse should be nonjudgmental and provide a forum for parents to express guilt. Telling the parents to watch the child more closely or asking them why they let the child almost drown is judgmental. Saying the child will be fine may not be true. The nurse should reassure the parents that the child is receiving all possible medical treatment.
Answer to Question 2
Correct Answer: 1
Rationale: Cerebral spinal fluid leakage could be present from the nose or ears and, if it persists, may indicate that surgical repair will be needed. Headache, transient confusion, and periorbital ecchymosis are findings that commonly present with a basilar skull fracture but do not indicate that surgical repair will be needed.
Client on IV patient-controlled analgesia (PCA).
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
Client receiving hemodialysis.
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Client positioned and draped