These are appropriate measure to promote sleep. Choices 1, 2, and 3 are all stimulation actions that increase

arousal and wakefulness. Basic Care and Comfort

A combined low PO2 and lowSaO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not

necessarily altered in TB or pleural effusion. Depending on the degree of the pneumonia, the PO2 and PCO2

might be low because hypoxia stimulates hyperventilation. Physiological Adaptation

All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which

helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. The

body has a physiological response to stress that can decrease the immune response and increase the risk of

disease. Health Promotion and Management

Statistical patterns of health care utilization indicate that Emergency Departments and urgent care centers

provide a large portion of health care to those who live in poverty. Coordinated Care

Because Hispanic people represent a large percentage of migrant workers in the United States, many work in

agricultural settings and might be exposed to pesticides, putting them at higher risk than the other groups. Safety

and Infection Control

Vaccines provide active immunity. Passive immunity comes from antibodies produced in another human or

host. Transplacental immunity comes from passive immunity transferred from mother to infant. Health Promotion

and Maintenance

A simple cold without fever does not preclude vaccination. Choices 1 and 2 are incorrect because pregnant

women and immunocompromised individuals cannot have the MMR vaccine because the rubella component is a

live virus and might cause birth defects and/or disease. Choice 3 is incorrect because the American Academy of

Pediatrics states, “Persons who have experienced anaphylactic reactions to topically or systemically administered

neomycin should not receive measles vaccine.” Pharmacological Therapies

The greatest time-savers when planning client care are activities that facilitate focus and completion of

priority items. Time-savers include setting goals, establishing priorities, planning tasks, delegating where

appropriate, re-assessment, and ongoing evaluation of needs. Coordinated Care

The family provides sick care to its members. The other options are incorrect. Prevention and Early

Detection of Disease

The nurse needs to recognize her own beliefs and biases and learn about the client’s cultural beliefs.

Psychosocial Integrity

Tolerance is the capacity to ingest an increasing amount of a substance without effect and the experience of

decreased sensitivity to the substance. Tolerance can develop with long-term use of many drugs. Choice 1 is the

dose required to produce a defined magnitude of drug effect. Choice 3 binds to a receptor and causes an action.

Choice 4 is the maximal response produced by a drug. Pharmacological Therapies

Naloxone is an opiate antagonist. It attaches to opiate receptors and blocks or reverses the action of narcotic

analgesics. Choice 2 is incorrect because Labetalol is a beta blocker. Choice 3 is incorrect because Neostigmine is

an anticholinesterase agent. Choice 4 is incorrect because Thiothixene is an antipsychotic agent. Pharmacological

Therapies

The therapeutic index is the ratio between the median lethal dose and median effective dose of a drug. It

provides a general indication of the margin of safety of a drug. Choice 1 is incorrect because pharmacokinetics

is the process of adsorption, distribution, metabolism, and elimination. Choice 2 is incorrect because narrow

therapeutic index drugs require close monitoring since there is often little difference between the desired drug

effect and toxicity. Choice 4 is incorrect because narrow therapeutic index drugs have the potential for severe

toxic effects with only slight increases in the dose or slight decreases in elimination. Pharmacological Therapies

A dark red color is an abnormal finding when assessing the stoma. It indicates inadequate blood supply. The

other findings are normal one day postoperatively. Physiological Adaptation

Migrant workers should be provided with the medical records and immunization records for their children, including growth charts. The parents should also be encouraged to take those records with them to every health care visit, including Emergency Department visits. It is important to provide immunizations even when the child is there for an acute illness because preventive care is often not obtained. Preventive services should also be provided, not scheduled, when a child presents for an acute illness. Using a single primary care provider is not an option for most migrant families. The nurse should ask the parents about where they are going next and give them the name, address, and phone numbers of providers there. Health Promotion and Maintenance