Saunders NCLEX-PN: Data Collection

A woman arrives at the emergency department complaining of abdominal pain of 4 on a scale of 1 to 10. She states that she thinks she is about 10 weeks pregnant. Her vital signs are pulse, 86 beats per minute; respirations,16 breaths per minute; and blood pressure,112/78 mm Hg. Which signs/symptoms should the nurse report to the health care provider immediately?

1. Pulse, 112 beats per minute 4. Pain rating of 8 on a scale of 1 to 10 5. States "I feel like I am about to faint."

During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?

150 beats per minute

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload?

4. Dry cough 5. Distended neck veins

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide (Lasix), penicillin (Nafcillin) and ibuprofen (Motrin). He has received ibuprofen (Motrin) twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool?

9 total points (moderate risk)

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse should become concerned with which fibrinogen level?

90 mg/dL

The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown?

A client with a lowered mental awareness status

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a PCo2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?

A potassium level of 3.2 mEq/L

The nurse is monitoring a client receiving spironolactone (Aldactone) by mouth daily. Which data would indicate to the nurse that the client is experiencing a side effect related to the medication?

A potassium level of 5.2 mEq/L

An older postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. The nurse collects data regarding which important item before advancing the diet to solids?

Ability to chew

The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure?

Allergy to iodine or shellfish

A tuberculin skin test is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse checks the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which findings did the nurse identify to make this interpretation?

An area of induration at the test site measuring 7 mm

A preliminary diagnosis is made for a child with acute lymphoblastic leukemia (ALL). In reviewing the complete blood cell count (CBC) of the child, the nurse should expect to find which?

An erythrocyte (red blood cell) count of 2 cells in 1 mL of peripheral blood

The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position?

At the midclavicular line at the fifth left intercostal space

A 15-year-old child is scheduled to receive a series of the hepatitis B vaccine. The child arrives at the clinic for the first dose. The nurse collects data on the child before administering the vaccine and asks the child about a history of an allergy to which product?

Baker's yeast

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the nurse should check which priority item?

Blood pressure

A new mother attempting breast-feeding for the first time has developed mastitis. She states, "My breasts look terrible and I think that I will stop breast-feeding." The nurse plans care knowing that the client is concerned about which problem?

Body image

The nurse is collecting data from a client with hypertension being treated with diuretic therapy. The nurse should monitor the client for hypokalemia if the client is receiving which diuretic?

Bumetanide

The nurse determines that which client is most likely to be a candidate for cardioversion?

Client with unstable rapid atrial fibrillation

A clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse assesses for an early manifestation of Pneumocystis jiroveci infection by monitoring for which sign/symptom at each client visit?

Cough

An older client is taking multiple medications for a variety of health problems. The nurse should monitor the results of which most important laboratory test(s) when evaluating adverse effects of medication therapy in the older adult?

Creatinine

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse should suspect that which finding will be reported from this blood test?

Decrease of all cell types

An older client has been prescribed digoxin (Lanoxin). The nurse understands that which age-related change would place the client at risk for digoxin toxicity?

Decreased lean body mass and glomerular filtration rate

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder should the nurse suspect that this client may have based on the use of this medication?

Dementia

The nurse is reviewing the record of a pregnant client and notes that the health care provider has documented the presence of Chadwick's sign. The nurse understands that the hormone responsible for the development of this sign is which?

Estrogen

The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which data obtained by the nurse could place the client at increased risk for disturbed thought processes?

Eyeglasses left at home

An adolescent client with type 1 diabetes is experiencing high glucose levels upon awakening in the morning. After reviewing the client's chart, the nurse determines that the elevated glucose level in the morning is due to the Somogyi effect. Which finding should lead the nurse to this conclusion?

Glucose level at 2 am of 65 mg/dL

The nurse is admitting a client with chronic kidney disease (CKD) to the nursing unit. The nurse monitors the client for which frequent cardiovascular sign that occurs in CKD?

Hypertension

The nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status. For which complication is the nurse collecting data?

Increase in circulating volume

The nurse is preparing to admit a client diagnosed with obsessive-compulsive disorder (OCD) to the mental health unit. The nurse should observe this client for which behavioral characteristic(s)?

Inflexibility and rigidity

The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?

Metabolic alkalosis

A client and her husband are being discharged from the hospital after delivering a stillborn infant. They ask about the possibility of attending a bereavement support group in the community. Which response should this request indicate to the nurse?

Normal grieving

A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has experienced which precipitating factor?

Omitted doses of medication

A client receiving total parenteral nutrition (PN) has a history of heart failure. The health care provider has prescribed furosemide (Lasix) 40 mg orally daily to prevent fluid overload. The nurse should monitor which laboratory value to identify an adverse effect from this medication?

Potassium

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?

Red

The nurse is reviewing the record of a client with mastoiditis. The nurse should expect to note which documented characteristic regarding the results of the otoscopic examination?

Red, dull, thick, and immobile tympanic membrane

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?

Respiratory distress

A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease?

Reticulocyte count

The nurse is reviewing the health record of a client who is suspected of having mittelschmerz. Which should the nurse expect to note documented in the client's record?

Sharp pain located on the right side of the pelvis

The nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing which problem?

Social phobia

The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicate poor absorption of dietary fats?

Steatorrhea

A postoperative client has received a dose of naloxone (Narcan) for respiratory depression. The nurse anticipates that the client will have which additional effect from the administration of this medication?

Sudden increase in pain

The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?

Syphilis

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned client is at risk for excess fluid volume?

The client with renal failure

A 2-year-old child is diagnosed with constipation due to encopresis. Which description is a characteristic of this disorder?

The infrequent and difficult passage of dry stools

The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan?

The presence of food allergies

The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which?

The presence of infection

In caring for a preterm newborn's skin, which special characteristics should the nurse expect to note?

Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture

A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which is the most common client complaint associated with a disorder involving the inner ear?

Tinnitus

The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in which area?

Vulva

The nurse is preparing to monitor a fetal heart rate. The nurse knows that the fetal heart rate can first be heard with a fetoscope at which gestational week?

Week 20