ATI Comp Practice B W/NGN

A nurse is caring for a client who has abdominal pain. Nurses' Notes 0900: Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client is a perioperative nurse, returned 1 week ago from a 2-week mission trip to an underdeveloped country. 1200: Results of antibody studies obtained. Provider prescription for antiviral medication pending. Physical Examination 0930: Lung sounds clear bilaterally. Skin warm to touch and jaundiced. Dry skin noted on extremities. Sclera yellow bilaterally. Bowel sounds normoactive in four quadrants. Client reports right upper quadrant pain upon palpation. Urine specimen obtained for urinalysis, dark yellow in color. Vital Signs 0900: Temperature 36.9° C (98.5° F) Heart rate 84/min Respiratory rate 18/min Blood pressure 118/78 mm Hg Oxygen saturation 98% on room air Diagnostic Results 1100: Aspartate aminotransferase (AST) 375 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 100 international units/L (4 to 36 international units/L) Alkaline phosphatase (ALP) 60 units/L (30 to 120 units/L) For each condition, click to specify if the characteristic is consistent with an acute infection of hepatitis A, hepatitis B, or hepatitis C. Each characteristic may support more than one disease process.

Characteristic Hepatitis A: Laboratory results Physical examination findings Client's risk from fecal-oral transmission Hepatitis B: Laboratory results Antiviral treatment Client's risk from bloodborne transmission Physical examination findings Hepatitis C: Laboratory results Antiviral treatment Client's risk from bloodborne transmission Physical examination findings

A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care?

Encourage the parents to bring toys from home.

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?

Facilitate an interdisciplinary conference at the new facility for the family.

A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?

Floating dark spots

A nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube?

Flush the client's gastrostomy tube with 30 mL of water before administering the medication.

A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first?

Inform the nurse manager of the issue.

A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Keeps the head of the bed elevated to 45° for 1 hr after feedings

A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching?

Oranges

A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which of the following medications should the nurse expect to administer?

Oxytocin

A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan?

Performing a rapid needs assessment

A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect?

Persistent uterine contractions

A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first?

Provide information about scheduling issues to the staff.

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?

Sedentary lifestyle

A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique?

Set the catheter tray on the overbed table at waist height.

A nurse is assessing a newborn who is 3 days old. History and Physical Newborn was delivered at 37 weeks of gestation via cesarean section for fetal distress. Apgar scores: 8 at 1 min and 9 at 5 min. Birth weight: 2.9 kg (6 lb 6 oz) The client who gave birth plans to breastfeed. Flow Sheet Day 2 of Life, 0900: Temperature 36.7° C (98.1° F) Heart rate 140/min Respiratory rate 48/min Weight 2.7 kg (6 lb); 6% weight loss Day 3 of Life, 0800: Temperature 36.4° C (97.5° F) Heart rate 140/min Respiratory rate 48/min Weight 2.5 kg (5 lb 9 oz); 12% weight loss Nurses' Notes Day 3 of Life, 0800: Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted when awake. Anterior fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Small amount of bloody mucus discharge noted from vagina. Breastfeeding every 3 to 5 hr for 5 to 10 min. Client reports nipple discomfort throughout the feeding. Click to highlight the findings that require follow up. To deselect a finding, click on the finding again.

Temperature 36.4° C (97.5° F) Weight 2.5 kg (5 lb 9 oz); 12% weight loss Mild tremors noted when awake. Breastfeeding every 3 to 5 hr for 5 to 10 min. Client reports nipple discomfort throughout the feeding.

A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take?

Place the skin barrier over the stoma and hold it for 30 seconds.

A nurse is administering 1 unit of packed RBCs to a client. The client becomes anxious and reports shortness of breath and urticaria 15 min after initiation of the transfusion. Which of the following actions should the nurse take?

Prepare to administer epinephrine to the client.

A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?

Urine specific gravity 1.052 (1.005 to 1.03)

A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?

Use a protective cover on the scale when weighing the infant.

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?

"A client who requires airborne precautions should be placed in a negative-pressure airflow room."

A nurse is admitting a client to the mental health unit after an attempted suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

"How does this make you feel?"

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?

"I can designate my partner as my health care surrogate."

A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching?

"I should watch for common reactions like dry mouth and constipation."

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?

"I told my doctor that I would like to start a support group for other people who are sick in my community."

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden unexpected infant death (SUID). Which of the following guardian statements indicates an understanding of the teaching?

"I will not allow anyone to smoke near my baby."

A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization?

"Maybe this is better for our child because we don't want any suffering through chemotherapy treatments."

A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?

"You will need to fast the night before the test."

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

A client who has cellulitis and is receiving oral antibiotics every 8 hr

A nurse is caring for multiple clients in an antepartum clinic. For which of the following clients should the nurse plan to perform fetal heart monitoring? (Select all that apply.)

A client who has premature rupture of membranes A client who reports decreased fetal movement A client who has gestational hypertension

A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag?

A client who has significant head trauma and agonal respirations

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

A client who is receiving an MAOI and is requesting a cheeseburger for dinner

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?

Advocacy is a leadership role that helps others to self-actualize.

A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates the client needs additional nutrients added to the feeding?

Albumin 2.8 g/dL (3.5 to 5 g/dL)

A nurse is caring for a client. Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU. Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right-side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia. Day 2, 1930: Called to the client's room by a family member. Client is lethargic and restless, oriented to person and place. Client reports headache. The client's family member also reports that the client just vomited in an emesis basin. Client's speech is slurred. Vital Signs Day 1,1000: Temperature 37.2° C (99° F) Heart rate 114/min Blood pressure 184/88 mm Hg Respiratory rate 24/min Oxygen saturation 97% on 2 L via nasal cannula Day 2, 0800: Temperature 36.7° C (98.1° F) Heart rate 81/min Blood pressure 140/72 mm Hg Respiratory rate 18/min Oxygen saturation 99% on 1 L via nasal cannula Day 2, 1930: Temperature 36.8° C (98.3° F) Heart rate 106/min Blood pressure 188/92 mm Hg Respiratory rate 26/min Oxygen saturation 94% on 2 L via nasal cannula

Anticipated: Keep the lights in the client's room dim. Monitor blood glucose every 4 hr. Administer oxygen therapy to keep oxygen saturation above 95%. Contraindicated: Keep the client supine. Cluster nursing care. Maintain the client's hips in flexion.

A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

Apply suction for 10 seconds.

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Assist with deep breathing and coughing.

A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?

Audible stridor

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

Autonomy

A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Vital Signs 1100: Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min Blood pressure 128/68 mm Hg Oxygen saturation 97% on room air 1115: Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min Blood pressure 138/74 mm Hg Pulse oximetry 95% on room air 1130: Temperature 38.6° C (101.5° F) Heart rate 136/min Respiratory rate 16/min Blood pressure 154/86 mm Hg Oxygen saturation 95% on 2 L/min via nasal cannula Medication Administration Record 1110: Morphine 4 mg IV bolus Nurses' Notes 1100: The client is asleep, easily aroused. Rates pain at incision site as 8 on a scale of 0 to 10. Portable wound bulb suction device in place with scant serosanguinous drainage present. Dressing to neck dry and intact. 1115: Client asleep. Arousable with name called loudly multiple times. Client rates pain as 7 on a scale of 0 to 10. Reports having a hard time staying awake. 1130: Client asleep. Arousable with name called loudly several times. Client rates pain as 5 on a scale of 0 to 10. Restless upon awakening, oriented to person. Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm.

Blood pressure Temperature Mental status Heart rate

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?

Blurred vision

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

Borderline

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

Contact Child Protective Services.

Medication Record Digoxin 0.25 mg PO daily Potassium chloride 20 mEq/L PO daily Metformin 500 mg PO daily Furosemide 20 mg PO daily Vital Signs Blood pressure 116/62 mm Hg Respiratory rate 18/min Temperature 37.3° C (99.1° F) Apical heart rate 62/min Daily weight 84.82 kg (187 lb) (gain of 0.6 lb in 24 hr) Laboratory Results Digoxin 0.78 ng/mL Potassium 3.7 mEq/L Glucose 85 mg/dL A nurse is planning morning care for a client who has heart disease and type 2 diabetes mellitus. Upon review of the client's medical record, which of the following actions should the nurse take?

Contact the provider.

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

Cough

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching?

Delegate non-nursing tasks to ancillary staff.

A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?

Determine the client's reading skills.

A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first?

Develop a safety plan with the client.

A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect?

Diaphoresis

A nurse is caring for a client at a provider's office. History and Physical 2 months ago: Client presented to clinic for routine visit. Client reported feeling tired at times but getting through the workday and walking after work. Reported chronic nonproductive cough. Smokes 1.5 packs of cigarettes per day. Today, 1030: Client reports fatigue over the past several days, spending more time in bed. Reports chronic productive cough with blood-tinged sputum this morning. Smokes 1 pack of cigarettes per day. Client takes lisinopril 20 mg PO daily, atorvastatin 20 mg PO daily. Assessment 2 months ago: Client states, "I sleep in my recliner and that works great." Skin is warm, dry. Lungs clear to auscultation. Chronic nonproductive cough. Abdomen soft, nondistended. Bowel sounds present. Slight edema in feet bilaterally. Today, 1030: Client states, "I can't catch my breath." Skin pale. Respirations labored. Crackles present in left-lower lobe. Coughing during assessment. Blood-tinged sputum. Abdomen soft, nondistended. Bowel sounds present. +1 edema in feet and ankles bilaterally. Vital Signs 2 months ago: Temperature 37° C (98.6° F) Heart rate 86/min Respiratory rate 18/min Blood pressure 136/84 mm Hg Oxygen saturation 96% on room air Weight 81 kg (178.6 lb) Today, 1030: Temperature 39.2° C (102.6° F) Heart rate 118/min Respiratory rate 22/min Blood pressure 152/80 mm Hg Oxygen saturation 89% on room air Weight 78 kg (172 lb) Diagnostic Results Today, 1030: WBC count 12,000/mm3 (5,000 to 10,000/mm3) B-type natriuretic peptide (BNP) 68 pg/mL (less than 100 pg/mL) ABGs: pH 7.25 (7.35 to 7.45) PaCO2 48 mm Hg (35 to 45 mm Hg) HCO3- 24 mEq/L (21 to 28 mEq/L) PaO2 70 mm Hg (80 to 100 mm Hg) For each assessment finding noted above, click to specify if the finding is expected of pneumonia, COPD, or heart failure.

ENTER ANSWER

A nurse is caring for a client following a laparoscopic cholecystectomy. Nurses' Notes 1030: 33-year-old client is 1 hr postoperative following a laparoscopic cholecystectomy. Alert and oriented to person, place, and time. Skin warm and dry. Lungs clear auscultated throughout all lung fields. Normal sinus rhythm. Client denies nausea and vomiting, bowel sounds hypoactive in all four quadrants. Peripheral pulses +2 bilaterally. Incision dressing clean and dry, incision intact upon inspection, no redness, swelling, or drainage noted. Client Education 1230: Discharge instructions given to client. Instructions on incision/wound care and proper hand washing. Client to report swelling, redness, drainage, bleeding, or warmth at operative site to surgeon. Client expected to experience carbon dioxide retention in the abdomen. Instructed the client to rest for 24 hr following surgery. Client can bathe or shower the day after surgery. Instructed the client to avoid lifting 2.3 kg (5 lb) or more for 1 week. Diet as tolerated. Provider Prescriptions 1030: Acetaminophen 500 mg PO every 4 hr PRN pain Cefaclor 250 mg PO every 8 hr Vital Signs 1030: Temperature 36.0° C (96.8° F) Heart rate 82/min Respiratory rate 16/min Blood pressure 122/64 mm Hg Oxygen saturation 96% on room air

ENTER ANSWER

A nurse in a provider's office is caring for a client. Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time.Bilateral breath sounds clear. Respirations even and unlabored.S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs 0900: Temperature 37.2° C (99° F) Heart rate 88/min Blood pressure 142/88 mm Hg Respiratory rate 20/min Oxygen saturation 92% on room air Which of the following provider prescriptions should the nurse anticipate for this client? Select the 4 prescriptions the nurse should anticipate.

Educate the client on new prescription for sulfamethoxazole/trimethoprim Collect urine specimen for urine culture Educate client on new prescription for phenazopyradine Collect urine specimen for urinalysis

A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship?

Establish the termination date of therapy.

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of their last menstrual period (LMP) was May 8. According to Naegele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

February 15

A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?

Have the client wear a surgical mask while being transported outside the room.

A nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider?

Hemoptysis 275 mL/24 hr

A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor?

Hypertension

A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess?

Ideas of self-harm

A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?

Instruct the client to elevate the affected extremity when sitting.

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

Instruct the client to void.

A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include?

Introduce new foods one at a time over 3 to 5 days.

A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take?

Involve the client in selection of a physical therapy provider.

A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?

Jaundice

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?

Low back pain

A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills?

Maintain regular notes about the nurse's time management skills.

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

Make a referral for social services.

A nurse working on an inpatient mental health unit is caring for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse recommend including in the plan of care to ensure a safe client care environment?

Observe the client every 15 min.

A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fluid volume deficit?

Orthostatic hypotension

A nurse is caring for a client who is postoperative following an appendectomy. Nurses' Notes 1800: Client alert and oriented to person, place, time, and situation. Skin warm and dry. Lungs clear on auscultation Bowel sounds hypoactive in all four quadrants. Urine clear yellow Incisional dressing clean and dry. Client reports pain as 6 on a scale of 0 to 10. 1815: Morphine administered as prescribed. 2000: Client reports abdominal pain as 10 on a scale of 0 to 10. Client reports nausea, no vomiting. Incisional dressing is dry and intact with no breakthrough bleeding noted. Lung sounds are clear to auscultation. Hypoactive bowel sounds present in all four quadrants. Vital Signs 1800: Temperature 36.8° C (98.4° F) Heart rate 104/min Respiratory rate 22/min Blood pressure 142/80 mm Hg O​2 saturation 97% on room air 2000: Temperature 36.8° C (98.4° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 158/88 mm Hg O2 saturation 93% on room air Medication Administration Record Morphine 4 mg IV bolus every 4 hr PRN pain Which of the following 4 client findings should the nurse report to the provider?

Pain level Heart rate o2 sat Nausea

A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Perform gastrostomy feedings through a client's established gastrostomy tube.

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

Pink, frothy sputum

A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take?

Place the BP cuff in a labeled bag to send it for decontamination.

A nurse on an antepartum unit is caring for a client who is at 33 weeks of gestation. Diagnostic Results WBC count 9,800/mm3 (5,000 to 10,000/mm3) Hgb 13 g/dL (greater than 11 g/dL) Hct 41% (greater than 33%) Platelet count 170,000/mm3 (150,000 to 400,000/mm3) BUN 20 mg/dL (10 to 20 mg/dL) Lactate dehydrogenase (LDH) 80 units/L (100 to 190 units/L) Aspartate aminotransferase (AST) 18 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 19 units/L (4 to 36 units/L) Uric acid (serum) 5.4 mg/dL (2.7 to 7.3 mg/dL) Kleihauer-Betke (fetal hemoglobin test) 3% (less than 1%) Blood type: ARh: positive Urine reagent strip Glucose: nonepH: 6 Specific gravity: 1.020 Ketones: none Nitrates: none Leukocyte esterase: negative Protein: negative Nitrites: none Vital Signs Blood pressure 130/84 mm Hg Heart rate 104/min Respiratory rate 22/min Temperature 37.3° C (99.2° F) Oxygen saturation 97% on room air Nurses' Notes Client is a primigravida who presents with report of decreased fetal movement and new onset of a small amount of dark red vaginal bleeding. External fetal monitor applied; FHR 116/min. Scant amount of dark red blood noted on perineal pad. Client reports sudden onset of pain above umbilicus and occasional uterine tightening over past hour. +1 nonpitting edema noted to feet and ankles. Denies visual changes, heartburn.

Potential condition: Abruptio placentae Actions to take: Insert a large bore IV catheter Avoid cervical exam Parameters to monitor: Platelet count blood pressure

A nurse is caring for a 5-year-old child. Physical Examination 1510: Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epiglottis is edematous and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished bilateral lung sounds. Nurses' Notes 1500: Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and leaning forward with drooling noted. Vital Signs 1505: Axillary temperature 38.8° C (102° F) Heart rate 130/min Respiratory rate 28/min Blood pressure 99/58 mm Hg Oxygen saturation 90% on room air Medical History ​Family history of asthma Child seen 6 months ago for tonsillitis and treated with antibiotic therapy

Potential condition: Epiglottitis Actions to take: IV antibiotics Droplet precautions Parameters to monitor: Temp Breath sounds

A nurse is caring for a client who is postoperative following administration of general anesthesia. Vital Signs 0830: Temperature 36.9° C (98.5° F) Heart rate 134/min Respiratory rate 28/min Blood pressure 92/52 mm Hg Oxygen saturation 89% on room air Nurses' Notes 0830: Client is postoperative following an inguinal hernia repair. Apical pulse 134/min and irregular Client reports dyspnea. Diagnostic Results 0835: Arterial blood gases (ABGs) pH 7.30 (7.35 to 7.45) PCO2 64 mm Hg (35 to 45 mm Hg) HCO3​- 26 mEq/L (21 to 28 mEq/L) PO2 80 mm Hg (80 to 100 mm Hg)

Potential condition: Malignant hyperthermia Actions to take: admin oxygen admin dantrolene Parameters to monitor: hypercapnia muscle rigidity

A nurse in an emergency department (ED) is assessing a client. Medical History 1030: Diagnosed with schizophrenia 2 years ago Migraine headaches Unresponsive to second-generation medications (clozapine and risperidone), changed to first-generation medication 6 months ago Current medications: Haloperidol 5 mg PO TID Sumatriptan 50 mg PO every 2 hr PRN headache Vital Signs 1030: Heart rate 122/min Respiratory rate 28/min Blood pressure 182/85 mm Hg Temperature 39.7° C (103.5° F) Oxygen saturation 90% on room air Nurses' Notes 1030: Client arrived at ED via ambulance. Emergency medical technicians (EMTs) report being called to client's home by the client's partner. According to EMTs, partner stated they found the client with decreased responsiveness, muscle rigidity, posturing, and diaphoresis. 1045: Client unresponsive to questions, does not follow simple commands. Sinus tachycardia; S1S2 on auscultation; peripheral pulses +4. Respirations rapid and labored at 28/min, chest clear on auscultation. Bowel sounds active x 4 quadrants; incontinent of urine. Febrile, diaphoretic. Muscle rigidity with extensor posturing of arms. 1100: Assessment reported to ED provider, prescription for transfer to intensive care unit received.

Potential condition: Neuroleptic malignant syndrome Actions to take: provide cooling blanket Hold all antipsychotic meds Parameters to monitor: Temp Hydration status

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?

Proceed with provision of medical care.

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

Radial vein of the inner arm

A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for the development of a pressure injury?

Recent weight loss

A nurse is caring for a school-age child who has dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?

Serum sodium 138 mEq/L

A nurse is caring for an adolescent in the emergency department (ED). Nurses' Notes 0700: Adolescent admitted to ED. Adolescent's parents are concerned about left leg injury that appears to be getting worse. Parents report adolescent has had fever, decreased appetite, and decreased energy within the past 2 days. Adolescent reports leg injury occurred while playing soccer. 0715: Adolescent is alert and oriented to person, place, time, and situation. Adolescent reports left lower leg pain as 4 on a scale of 0 to 10. Heart rate regular. Capillary refill less than 3 seconds. Respirations even, unlabored. Lungs clear anterior/posterior. Abdomen soft, nondistended. Bowel sounds hyperactive in all 4 quadrants. Pedal pulses +2 bilaterally. Medial lateral aspect of left lower leg: 3 x 3 cm2 area of redness with small pustules present. Tenderness and warmth noted to the area. Vital Signs 0700: Temperature 38.7° C (101.7° F) Heart rate 100/min Respiratory rate 18/min Blood pressure 110/60 mm Hg Laboratory Results 0730: Sodium 132 mEq/L (136 to 145 mEq/L) Potassium 5 mEq/L (3.4 to 4.7 mEq/L) BUN 16 mg/dL (5 to 18 mg/dL) WBC count 13,000/mm3 (5,000 to 10,000/mm3) Hgb 9.5 g/dL (10 to 15.5 g/dL) Hct 30% (32% to 44%) Casual blood glucose 250 mg/dL (less than 200 mg/dL) History and Physical Type 1 diabetes mellitus The nurse is reviewing the adolescent's electronic medical record (EMR). Which of the following findings requires immediate follow up by the nurse? Click to highlight the findings that require immediate follow up. To deselect a finding, click on the finding again.

Skin assessment Temperature WBC count Casual blood glucose Potassium

A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms?

Sublimation

A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

Supervise the client during and after eating.

A nurse is providing teaching to a client who has a prescription for levothyroxine 25 mcg PO daily. Which of the following instructions should the nurse include in the teaching?

Take the medication on an empty stomach 30 min before breakfast.

A nurse in a provider's office is caring for a client. Provider Prescriptions Day 1, 0930: Collect urine specimen for urinalysis and urine culture and sensitivity Trimethoprim/sulfamethoxazole 160/800 mg PO twice daily for 10 days Phenazopyridine 200 mg PO every 6 hr for 2 days Laboratory Results Day 1, 1100: Urinalysis Color: Amber (Amber yellow) Appearance: Cloudy (Clear) Specific gravity: 1.04 (1.005 to 1.03) pH: 9 (4.6 to 8) Glucose: None (None) Ketones: None (None) Bilirubin: None (None) Blood: Trace (None) Nitrite: Positive (negative) Leukocyte esterase: Positive (Negative) RBC: 18 (less than 2)WBC: 30 (0 to 4) Urine culture: pending Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time.Bilateral breath sounds clear. Respirations even and unlabored.S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs 0900: Temperature 37.2° C (99° F) Heart rate 88/min Blood pressure 142/88 mm Hg Respiratory rate 20/min Oxygen saturation 92% on room air

The client is at highest risk for developing pyelonephritis, as evidenced by the client's urinalysis results.

A nurse is caring for a client who is on the spinal cord injury (SCI) unit. Nurses' Notes Day 3, 1700: Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and nondistended with active bowel sounds. Client passed a small amount of hard formed stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0 on a 0 to 10 scale. Day 4, 0600: Client reports increased coughing and shortness of breath. Crackles auscultated in lower lobes bilaterally. Face and neck flushed. Skin warm and moist. Client reports blurred vision and a headache as an 8 on a 0 to 10 pain scale. Abdomen soft and mildly distended. Hypoactive bowel sounds present. Urinary output 300 mL over last 8 hr. Vital Signs Day 3, 1700: Temperature 38.2° C (100.8° F) Heart rate 74/min Respiratory rate 20/min Blood pressure 108/60 mm Hg Oxygen saturation 96% on room air Day 4, 0600: Temperature 38.4° C (101.2° F)Heart rate 54/min Respiratory rate 26/min Blood pressure 142/90 mm Hg Oxygen saturation 91% on room air

The client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia.

A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority?

The client's heel is reddened and tender.

A nurse is caring for a client who is pregnant in the acute care setting. Nurses' Notes 1400: Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr. Denies any changes in vaginal discharge. External fetal monitor applied. 1430: Contraction pattern: contractions every 4 to 5 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 150/min to 155/min, moderate variability, adequate accelerations present, no decelerations noted. Provider in to see client. Specimen obtained for fetal fibronectin. 1800: Client sleepy. Difficult to arouse. Respirations slow and shallow. Contraction pattern: contractions every 10 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 140/min, moderate variability, no accelerations present, no decelerations noted. Vital Signs 1400: Temperature 37° C (98.6° F) Heart rate 72/min Respiratory rate 20/min Blood pressure 115/75 mm Hg Oxygen saturation 98% on room air 1800: Heart rate 65/min Respiratory rate 10/min Blood pressure 100/60 mm Hg Oxygen saturation 88% on room air Medication Administration Record 1445: Administered magnesium sulfate 4 g IV bolus over 20 min Initiated lactated Ringer's continuous infusion at 75 mL/hr 1450: Administered betamethasone 12 mg IM 1505: Initiated magnesium sulfate continuous infusion at 2 g/hr History and Physical Gravida 2 para 1 30 weeks of gestation Previously uncomplicated pregnancy Reported the onset of back pain and contractions 3 hr ago Vaginal examination: 3 cm dilated and 50% effaced. Amniotic membranes intact. Diagnosis: Preterm labor Plan: Administer tocolytics and glucocorticoids. Laboratory Results 1445: Fetal fibronectin: positive (negative)

The nurse should first address the client's respiratory rate, followed by the client's level of consciousness.

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?

Turn off the CPM machine during mealtime.

A nurse in a provider's office is caring for a client. Provider Prescriptions Day 1, 0930: Collect urine specimen for urinalysis and urine culture and sensitivity Trimethoprim/sulfamethoxazole 160/800 mg PO twice daily for 10 days Phenazopyridine 200 mg PO every 6 hr for 2 days Laboratory Results Day 1, 1100: Urinalysis Color: Amber (Amber yellow) Appearance: Cloudy (Clear) Specific gravity: 1.04 (1.005 to 1.03) pH: 9 (4.6 to 8) Glucose: None (None) Ketones: None (None) Bilirubin: None (None) Blood: Trace (None) Nitrite: Positive (negative) Leukocyte esterase: Positive (Negative) RBC: 18 (less than 2)WBC: 30 (0 to 4) Urine culture: pending Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time. Bilateral breath sounds clear. Respirations even and unlabored.S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. 3 days later, 0900: Client returns to office due to orange-colored urine and diarrhea. Client reports drinking a minimum of 3 L of fluids daily as instructed and states, "I'm still going to the bathroom a lot, and I noticed that I am bruising more easily." Vital Signs 0900: Temperature 37.2° C (99° F) Heart rate 88/min Blood pressure 142/88 mm Hg Respiratory rate 20/min Oxygen saturation 92% on room air 3 days later, 0900: Temperature 37.7° C (100.9° F) Heart rate 87/min Blood pressure 144/90 mm Hg Respiratory rate 22/min Oxygen saturation 93% on room air Which of the following assessment findings should the nurse report to the provider as unexpected? For each assessment finding, click to specify if the finding is expected or unexpected.

Voiding pattern- expected Temp- unexpected Urine color- expected O2 sat- expected Bowel elimination- unexpected BP- expected Skin- unexpected

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?

A client whose caregiver requests adult day care services

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

Difficulty performing ADLs

A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?

Lack of remorse

A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority?

Upper chest petechiae

A nurse in a provider's office is caring for a client. Provider Prescriptions Day 1, 0930: Collect urine specimen for urinalysis and urine culture and sensitivity Trimethoprim/sulfamethoxazole 160/800 mg PO twice daily for 10 days Phenazopyridine 200 mg PO every 6 hr for 2 days Laboratory Results Day 1, 1100: Urinalysis Color: Amber (Amber yellow) Appearance: Cloudy (Clear) Specific gravity: 1.04 (1.005 to 1.03) pH: 9 (4.6 to 8) Glucose: None (None) Ketones: None (None) Bilirubin: None (None) Blood: Trace (None) Nitrite: Positive (negative) Leukocyte esterase: Positive (Negative) RBC: 18 (less than 2)WBC: 30 (0 to 4) Urine culture: pending 3 days later, 1100: Urinalysis Color: Orange (Amber yellow) Appearance: Clear (Clear) Specific gravity: 1.005 (1.005 to 1.03) pH: 4.6 (4.6 to 8) Glucose: Trace (None) Ketones: None (None) Bilirubin: None (None) Blood: None (None) Nitrite: Negative (negative) Leukocyte esterase: Negative (Negative) RBC: 0 (less than 2) WBC: 0 (0 to 4) Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time. Bilateral breath sounds clear. Respirations even and unlabored.S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. 3 days later, 0900: Client returns to office due to orange-colored urine and diarrhea. Client reports drinking a minimum of 3 L of fluids daily as instructed and states, "I'm still going to the bathroom a lot, and I noticed that I am bruising more easily." Vital Signs 0900: Temperature 37.2° C (99° F) Heart rate 88/min Blood pressure 142/88 mm Hg Respiratory rate 20/min Oxygen saturation 92% on room air 3 days later, 0900: Temperature 37.7° C (100.9° F) Heart rate 87/min Blood pressure 144/90 mm Hg Respiratory rate 22/min Oxygen saturation 93% on room air Click to highlight the findings that indicate the client's urinary tract infection is improving. To deselect a finding, click on the finding again.

specific gravity pH WBC

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

Dyspnea

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Use the ventrogluteal site.

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?

Irritability

A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?

Ask the client to point to items on a picture menu.

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

Verify the client and blood product information with another licensed nurse.

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?

"Have you had any stomach pain or bloody stools?"

A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect?

"I have not vomited as much recently."

A nurse is providing information to a client immediately before their scheduled Romberg test. Which of the following statements should the nurse make?

"I will be checking you once with your eyes open and once with them closed."

A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?

"I will make sure my child receives a yearly influenza immunization."

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

"I will need to measure your weight daily."

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

"I would like to talk to you about the unit policies regarding break time."

A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience increased thirst."

A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching?

"Sedation is a common adverse effect of this medication."

A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what is causing the constipation. Which of the following responses should the nurse make?

"The enlarged uterus compresses the intestines and causes constipation."

A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 10 kg (22 lb) and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.6

A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference?

A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis

An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?

A client who is at 33 weeks of gestation and has severe gestational hypertension

A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first?

A client who is confused and has been attempting to get out of bed ********** MIGHT BE WRONG

A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?

Acute confusion

A nurse is caring for a client in the emergency department (ED). Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Vital Signs 0600: Temperature 37.8° C (100° F) Heart rate 104/min Respiratory rate 26/min Blood pressure 88/56 mm Hg Oxygen saturation 90% on 2 L via nasal cannula Diagnostic Results 0645: Hematocrit 25% (37% to 52%) Hemoglobin 8.3 g/dL (12 to 16 g/dL) WBC count 18,000/mm3 (5,000 to 10,000/mm3) Reticulocytes 8% (0.5% to 2%) Total bilirubin 1.9 mg/dL (0.3 to 1 mg/dL) Which of the following interventions should the nurse implement?

Administer IV fluids Use humidification with oxygen therapy in correct Assess peripheral circulation hourly is correct Assess the client's mouth every 8 hr is correct

A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themselves as the client's guardian. Which of the following actions should the nurse take?

Ask the caller for verification of their identity.

A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care?

Auscultate the affected extremity for a bruit.

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Auscultate the apical pulse at least 1 min.

When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort?

Blowing bubbles with liquid soap to "blow the hurt away"

A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?

Determine the client's perception of the personal impact of the crisis.

A nurse in a provider's office is caring for a client. Provider Prescriptions Day 1, 0930: Collect urine specimen for urinalysis and urine culture and sensitivity Trimethoprim/sulfamethoxazole 160/800 mg PO twice daily for 10 days Phenazopyridine 200 mg PO every 6 hr for 2 days Laboratory Results Day 1, 1100: Urinalysis Color: Amber (Amber yellow) Appearance: Cloudy (Clear) Specific gravity: 1.04 (1.005 to 1.03) pH: 9 (4.6 to 8) Glucose: None (None) Ketones: None (None) Bilirubin: None (None) Blood: Trace (None) Nitrite: Positive (negative) Leukocyte esterase: Positive (Negative) RBC: 18 (less than 2)WBC: 30 (0 to 4) Urine culture: pending Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time.Bilateral breath sounds clear. Respirations even and unlabored.S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs 0900: Temperature 37.2° C (99° F) Heart rate 88/min Blood pressure 142/88 mm Hg Respiratory rate 20/min Oxygen saturation 92% on room air The nurse is planning to teach the client how to prevent further UTIs from occurring. Which of the following instructions should the nurse plan to include?

Gently cleanse the perineum before intercourse.

A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect?

Grandiose delusions

A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take?

Initiate fall precautions for the client.

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

Initiate transmission-based precautions.

A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take?

Inject 20 units of air into the NPH insulin vial.

A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?

Install a raised toilet seat at home.

A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?

Instruct the client to avoid coughing during the procedure.

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measure the client's daily weight.

A nurse is caring for a client on a medical-surgical unit. Vital Signs 0700: Temperature 37.6° C (99.7° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 115/70 mm Hg Oxygen saturation 98% on room air Nurses' Notes 1100: Client alert and oriented to person, place, and time. Client had episode of diarrhea, provided perineal care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4 hr.

Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4 hr.

A nurse is assessing a school-age child who has bacterial meningitis. Which of the following findings should the nurse expect?

Nuchal rigidity

A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect?

Occlusive dressing on the insertion site

A nurse is caring for a client who is pregnant. Nurses' Notes 1000: The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks. 1015: IV fluids initiated. Prochlorperazine administered via intermittent IV bolus. 1100: Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine. 1500: Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine. Vital Signs 1000: Temperature 36.8° C (98.2° F) Heart rate 112/min Respiratory rate 20/min Blood pressure 100/65 mm Hg SaO2​ 97% on room air 1200: Temperature 37° C (98.6° F) Heart rate 102/min Respiratory rate 20/min Blood pressure 104/70 mm Hg SaO2 98% on room air 1500: Temperature 36.8° C (98.2° F) Heart rate 90/min Respiratory rate 18/min Blood pressure 110/72 mm Hg SaO2​ 97% on room air

Recommended: Eat every 2 to 3 hr. Alternate eating solid foods and liquids. Drink warm ginger ale when nauseated. Contraindicated: Increase intake of high-fat foods.

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

Report of chest pain

A nurse in an outpatient mental health clinic is caring for a client Vital Signs 3 months ago: Blood pressure 116/68 mm Hg Heart rate 82/min Respiratory rate 16/min Temperature 36.7° C (98.1° F) SaO2 97% on room air Today: Blood pressure 128/76 mm Hg Heart rate 104/min Respiratory rate 22/min Temperature 37.4° C (99.4° F) SaO2 97% on room air Nurses' Notes 3 months ago: Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. Client is alert and oriented to person, place, time, and situation. Responds appropriately to questions. Client reports sleeping well and working at a local retail store. Today: Client presents for follow-up visit. Pressured speech noted. Appears to be listening to unseen others. Client is restless. Frequently getting out of chair. Appears tired and disheveled. Graphic Record 3 months ago: 83.9 kg (185 lb)Today: 83 kg (183 lb) Select the 3 findings that require immediate follow up.

Speech Auditory hallucinations Restlessness

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

Survey the scene for potential hazards to staff and children.

A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent?

The client is able to accurately describe the upcoming procedure.

A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG). Laboratory Results 0630: Sodium 145 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5 mEq/L) Chloride 116 mEq/L (98 to 106 mEq/L) BUN 24 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9 mg/dL (9 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC count 9,500/mm3 (5,000 to 10,000/mm3​) I&O 0700: 4 hr input 400 mL4 hr output 350 mL 1100: 4 hr input 475 mL4 hr output 360 mL 1500: 4 hr input 350 mL4 hr output 375 mL Vital Signs 0700: Temperature 37.6° C (99.6° F) Heart rate 86/min Respiratory rate 20/min Blood pressure 115/70 mm Hg Oxygen saturation 100% on 2 L via nasal cannula 1100: Temperature 37.2° C (99° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 110/72 mm Hg Oxygen saturation 100% on 2 L via nasal cannula 1500: Temperature 37.7° C (99.8° F) Heart rate 80/min Respiratory rate 20/min Blood pressure 108/70 mm Hg Oxygen saturation 100% on 2 L via nasal cannula Nurses' Notes 0700: Client alert and oriented to person, place, time. Reports pain as 6 on a scale of 0 to 10. Administered morphine 5 mg IV. Incisional dressing intact. No redness or excessive drainage noted. Urinary catheter patent, draining clear yellow urine. Chest tube patent. No redness or edema noted at chest tube site. 1100: Client alert and oriented to person, place, and time. Reports pain as 1 on a scale of 0 to 10. Incisional dressing intact. No redness or excessive drainage noted. Urinary catheter patent, draining clear yellow urine. Chest tube patent. No redness or edema noted at chest tube site. Client states their leg muscles are cramping. Assisted the client with range-of-motion exercises to lower extremities. Client tolerated activity. 1500: Client alert and oriented to person, place, and time. Reports pain as 2 on a scale of 0 to 10. Incisional dressing intact. No redness or excessive drainage noted. Urinary catheter patent, draining clear yellow urine. Chest tube patent. No redness or edema noted at chest tube site. Client continues to report leg muscle cramps. Medication Administration Record 0700: 0.9% sodium chloride at 150 mL/hr via continuous infusion Enoxaparin 40 mg subcutaneously daily Morphine 5 mg IV every 4 hr PRN incisional pain

The client is at greatest risk for developing dysrhythmias as evidenced by electrolyte imbalance.

A nurse on the medical-surgical unit is caring for a client who was admitted from the emergency department (ED). Vital Signs 1400: Temperature 38° C (100.4° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 96/58 mm Hg Oxygen saturation 96% on room air 1500: Temperature 37.2° C (98.9° F) Heart rate 96/min Respiratory rate 20/min Blood pressure 100/70 mm Hg Oxygen saturation 97% on room air Nurses' Notes 1500: Client admitted from the ED for dehydration. Client alert and oriented to person, place, and time. Client reports they are feeling "weak." IV dextrose 5% in water (D5​​W) infusing at 100 mL/hr. Laboratory Results 1400: Calcium 10.2 mg/dL (9 to 10.5 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Potassium 4.7 mEq/L (3.5 to 5 mEq/L) Sodium 150 mEq/L (136 to 145 mEq/L) 1700: Calcium 9.5 mg/dL (9 to 10.5 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Potassium 4.1 mEq/L (3.5 to 5 mEq/L) Sodium 164 mEq/L (136 to 145 mEq/L)

The client is at risk for developing confusion due to sodium level.

A nurse is caring for a 1-month-old infant. Nurses' Notes 1500: Infant admitted to the pediatric unit. Parent reports infant has been irritable and has vomited after each feeding within the last 3 days. Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive in all 4 quadrants. Small 1 x 1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor with tenting. 1600: Called to room by parent. The client who gave birth attempted breastfeeding. Infant projectile vomited. No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO. 1800: Infant crying. Soothed with pacifier. Diagnostic Results 1545: Hgb 20 g/dL (14 to 24 g/dL) Hct 60% (44% to 64%) Potassium 5.8 mEq/L (3.9 to 5.9 mEq/L) Sodium 132 mEq/L (134 to 150 mEq/L) Chloride 110 mEq/L (96 to 106 mEq/L) WBC count 16,000/mm3 (6,200 to 17,000/mm3) BUN 20 mg/dL (5 to 18 mg/dL) Creatinine 0.2 mg/dL (0.1 to 0.4 mg/dL) 1730: Abdominal ultrasound: Narrowing of pyloric canal. Thickening of pylorus. Consistent with hypertrophic pyloric stenosis. Vital Signs 1500: Temperature 37.1° C (98.8° F) Heart rate 120/min Respiratory rate 30/min Weight 3.62 kg (8 lb) History and Physical Birth weight 3.5 kg (7.7 lb) The client who gave birth is breastfeeding. Newborn birthed vaginally at 38 weeks of gestation.

The infant is at highest risk for developing dehydration, as evidenced by the infant's vomiting.

A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene?

The newly licensed nurse writes detailed notes while performing the head-to-toe assessment.

A nurse is caring for a client who has a new diagnosis of anorexia nervosa. Vital Signs Day 1, 2005: Temperature 35.3° C (95.5° F) Heart rate 60/min Respiratory rate 23/min Blood pressure 90/55 mm Hg Oxygen saturation 98% on room air Day 2, 0800: Temperature 36.1° C (97° F) Heart rate 65/min Respiratory rate 20/min Blood pressure 88/57 mm Hg Oxygen saturation 98% on room air Graphic Record Day 1, 2005: Weight 37.5 kg (82.7 lb) Height 162.56 cm (64 in) BMI 14.2 Day 2, 0800: Weight 37.4 kg (82.5 lb) BMI 14.1 Laboratory Results Day 1, 2030: Sodium 146 mEq/L (136 to 145 mEq/L) Potassium 3.3 mEq/L (3.5 to 5 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 21 mg/dL (10 to 20 mg/dL ) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Phosphate 2.8 mg/dL (3 to 4.5 mg/dL) Glucose (casual) 75 mg/dL (74 to 106 mg/dL) Total protein 5.8 g/dL (6.4 to 8.3 g/dL) Albumin 3 g/dL (3.5 to 5 g/dL) Day 2, 0530: Sodium 150 mEq/L (136 to 145 mEq/L) Potassium 3.1 mEq/L (3.5 to 5 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 25 mg/dL (10 to 20 mg/dL) Magnesium 1 mEq/L (1.3 to 2.1 mEq/L) Phosphate 2.8 mg/dL (3 to 4.5 mg/dL) Fasting blood glucose 65 mg/dL (74 to 106 mg/dL) Total protein 5.5 g/dL (6.4 to 8.3 g/dL) Albumin 2.7 g/dL (3.5 to 5.0 g/dL) Nurses' Notes Day 1, 2005: Client alert and oriented with flat affect. Client states, "I cannot gain any more weight. My legs are already too big." Lanugo noted over face, skin cool to touch. 2+ nonpitting edema to lower extremities. Client reports last bowel movement was 4 days ago. Bowel sounds hypoactive.

The nurse should first address the client's electrolyte imbalance, followed by the client's fear of weight gain.

A nurse in a provider's office is caring for a client. Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination.Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented to person, place, and time.Bilateral breath sounds clear. Respirations even and unlabored.S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2.Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs 0900: Temperature 37.2° C (99° F) Heart rate 88/min Blood pressure 142/88 mm Hg Respiratory rate 20/min Oxygen saturation 92% on room air The nurse is assessing the client. Which of the following assessment findings should the nurse report to the provider?

Urgency Frequency Dysuria

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3 (2500 to 8000/mm3). Which of the following interventions should the nurse include in the plan?

Withhold administering the varicella vaccine to the child.

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?

confusion

A nurse is caring for an adolescent in the emergency department (ED). Laboratory Results Sodium 140 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Chloride 103 mEq/L (98 to 106 mEq/L) BUN 15 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9.5 mg/dL (9 to 10.5 mg/dL) Phosphate 3.7 mg/dL (3 to 4.5 mg/dL) Glucose 80 mg/dL (74 to 106 mg/dL) Total protein 7 g/dL (6.4 to 8.3 g/dL) Albumin 4.5 g/dL (3.5 to 5 g/dL) WBC count 19,500/mm3 (5,000 to 10,000/mm​3) Aspartate aminotransferase (AST) 30 units/L (10 to 40 units/L) Alanine transaminase (ALT) 20 units/L (4 to 36 units/L) Diagnostic Results Cerebrospinal fluid examination Pressure: 35 cm H2​O (less than 20 cm H2O) Color: Cloudy (clear and colorless) Blood: None RBC: 0 (0 cells) WBC total: 120 cells/µL (0 to 10 cells/µL) Protein: 90 mg/dL (15 to 45 mg/dL) Glucose: 20 mg/dL (50 to 75 mg/dL) Medication Administration Record Day 1, 0830: Acetaminophen 325 mg PO 0930: Midazolam 2.5 mg IVCefotaxime 2 g IV Vital Signs 0830: Temperature 39.2° C (102.6° F) Weight 51.4 kg (113.3 lb) Nurses' Notes Day 1, 0830: Adolescent presents to the ED with vomiting and irritability. Adolescent reports neck pain and headache as 6 on a 0 to 10 scale. 0930: Adolescent prepped for CSF biopsy and examination. Tolerated procedure well. No redness, excessive bleeding, or drainage noted from site. Resting in bed with lights off. 1000: Called to bedside by parent. Petechial rash noted on adolescent's arms bilaterally. Provider notified. For each assessment finding, click to specify if the assessment finding is consistent with bacterial meningitis, encephalitis, or Reye syndrome. Each finding may support more than 1 disease process.

Bacterial Meningitis: fever photophobia nuchal rigidity petechial rash impaired consciousness Encephalitis: fever nuchal rigidity altered mental status Reye Syndrome: altered mental status impaired hepatic function.

A nurse is caring for a client who has become aggressive and potentially violent. Which of the following actions should the nurse take?

Allow the client time for reflection and decision making.

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

Avoid including raw fruits in the client's diet.

A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Remove inner cannula Remove soiled dressing Clean stoma with 0.9% sodium chloride irrigation change the trach collar

A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Laboratory Results 0700: Sodium 143 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5 mEq/L) Chloride 104 mEq/L (98 to 106 mEq/L ) BUN 15 mg/dl (10 to 20 mg/dl) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L ) Total calcium 8 mg/dL (9 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC 9,500/mm3 (5,000 to 10,000/mm3) Nurses' Notes 0700: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client rates dull pain in neck of 2 on a 0 to 10 scale. Declines pain medication. 1100: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client reports muscle cramps in legs as a pain level of 5 on a 0 to 10 scale. Morphine 5 mg IV administered. Encouraged client to ambulate with assistance. 1200: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client ambulated down the hall with assistance. Client reports numbness around lips. Vital Signs 0700: Temperature 37.6° C (99.6° F) Heart rate 65/min Respiratory rate 16/min Blood pressure 115/70 mm Hg Oxygen saturation 98% on room air 0900: Temperature 37.2° C (99° F) Heart rate 72/min Respiratory rate 18/min Blood pressure 110/72 mm Hg Oxygen saturation 100% on room air 1100: Temperature 37.7° C (99.9° F) Heart rate 76/min Respiratory rate 16/min Blood pressure 108/70 mm Hg Oxygen saturation 100% on room air Medication Administration Record 1100: 0.9% Sodium chloride at 150 mL/hr Morphine sulfate 5 mg IV

The client is at highest risk for developing hypocalcemia as evidenced by the report of numbness around lips.

A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3 (7.35 to 7.45), PaO2 56 mm Hg (80 to 100 mm Hg), PaCO2 54 mm Hg (35 to 45 mm Hg), HCO3- 26 mEq/L (21 to 28 mEq/L), and SaO2 87%. Which of the following is the correct interpretation of these values?

Uncompensated respiratory acidosis

A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?

Use a three-point gait.