Comprehensive B
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
Actions to take: request IV antibiotics, initiate droplet precautions Condition: Epiglottis Parameters to monitor: temp, breathe sounds
A nurse is caring for an adolescent in the emergency department (ED). Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 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.
After reviewing the information in the adolescent's EMR and recognizing cues, the nurse should identify that the adolescent has a potential skin infection, such as cellulitis. The skin assessment reveals that the medial lateral aspect of the left leg has a 3 x 3 cm2 area of redness with small pustules, tenderness, and warmth, which can indicate infection. The adolescent's temperature and WBC count are above the expected reference range, which can also indicate infection. The adolescent's casual blood glucose and potassium are above the expected reference range, which can indicate infection or a complication of type 1 diabetes mellitus. The nurse should immediately follow up on these findings because they can indicate infection or other complications.
The nurse should recognize cues and determine that the client is at highest risk for developing hypocalcemia as evidenced by the client's report of muscle spasms, numbness around lips, and decreased calcium level.
As a client advocate, the nurse should support the client's decisions and obtain a referral for social services to ensure that the client's needs at home are met. Social services can set up home care or hospice care services for the client if needed.
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
Pneumonia and autonomic dysreflexia
0700: Temperature 37.6° C (99.7° F)Heart rate 100/minRespiratory rate 22/min Blood pressure 115/70 mm Hg Oxygen saturation 98% on room air
When recognizing cues, the nurse should determine that the client's painful edematous area on their sacrum and that the client has only been repositioned every 4 hr requires follow up. The client has manifestations of a pressure injury that need to be addressed. The client should be repositioned at least every 2 hr to prevent worsening of the pressure injury and to relieve pressure from the sacral area.
This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarette smoke and the occurrence of SUID
The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost.
A nurse is assessing a newborn who is 3 days old. Exhibit 1 Exhibit 2 Exhibit 3 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
When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia.
A nurse is caring for a client at a provider's office. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 History and Physical2 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.
The nurse should analyze cues of pneumonia that include tobacco use, elevated WBC count, a productive cough with blood-tinged sputum, elevated temperature, a decreased oxygen saturation level, and an ABG level indicating respiratory acidosis. The nurse should also analyze cues of COPD that include tobacco use and a decreased oxygen saturation. The nurse should also analyze cues of heart failure that include tobacco use, BNP level, and a decreased oxygen saturation.
A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG). Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5 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)
The nurse should analyze cues to determine the client is at greatest risk for developing dysrhythmias related to hypokalemia, as evidenced by the laboratory report and the client's report of muscle cramping.
A nurse on an antepartum unit is caring for a client who is at 33 weeks of gestation. Exhibit 1 Exhibit 2 Exhibit 3 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
The nurse should avoid cervical examination and insert a large-bore IV catheter because the client is most likely experiencing abruptio placentae indicated by the sudden onset of abdominal pain, contractions, and dark red vaginal bleeding. Cervical examination can cause further damage to the placenta and increase bleeding. The nurse should immediately establish IV access with a large-bore catheter to administer IV fluids and blood products if bleeding increases or if manifestations of fetal distress occur. The nurse should monitor the client's blood pressure and platelet count because of the risk of significant blood loss due to the abruption. Hemorrhage might not be visible as vaginal bleeding if it is concealed between the placenta and uterine wall. Therefore, manifestations of hypovolemic shock (decreasing blood pressure, increasing heart rate) can provide indications that internal placental bleeding is worsening. Abruptio placentae can also lead to alterations in coagulation, such as disseminated intravascular coagulation, further increasing the client's risk for hemorrhage. Therefore, the nurse should monitor the client's platelet count to identify if the client is at an increased risk for bleeding.
A nurse on the medical-surgical unit is caring for a client who was admitted from the emergency department (ED). Exhibit 1 Exhibit 2 Exhibit 3 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
Upon analyzing cues, the nurse should identify that the client is at risk for confusion due to a sodium level that is greater than the expected reference range
A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 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 adventi
The nurse should recognize cues and determine that the client is at highest risk for developing hypocalcemia as evidenced by the client's report of muscle spasms, numbness around lips, and decreased calcium level.
Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.
This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarette smoke and the occurrence of SUID
A nurse in an emergency department (ED) is assessing a client. Exhibit 1 Exhibit 2 Exhibit 3 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 agoCurrent medications: Haloperidol 5 mg PO TIDSumatriptan 50 mg PO every 2 hr PRN headache
Upon recognizing and analyzing the client cues of decreased responsiveness, muscle rigidity, posturing, diaphoresis, and vital signs that are outside the expected reference ranges, the nurse's priority hypotheses should be that this client is most likely experiencing neuroleptic malignant syndrome, which is related to the client's haloperidol therapy. It is important to generate solutions and take actions that will decrease the client's temperature, blood pressure, heart rate, and respiratory status, which will improve the client's neurological status. The nurse should hold the client's antipsychotic medications and apply a cooling blanket to reduce the client's temperature. Neuroleptic malignant syndrome is a life-threatening condition. Therefore, the nurse should monitor the client's laboratory and arterial blood gas values as multiorgan failure can occur. To evaluate interventions and track the client's condition, the nurse should monitor the client's temperature, hydration status, and provide for early detection of complications.
A nurse is caring for a client who is postoperative following administration of general anesthesia. Exhibit 1 Exhibit 2 Exhibit 3 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
Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.
A nurse is caring for a client who has a new diagnosis of anorexia nervosa. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Vital Signs Day 1, 2005: Temperature 35.3° C (95.5° F)Heart rate 60/minRespiratory rate 23/minBlood pressure 90/55 mm HgOxygen saturation 98% on room airDay 2, 0800: Temperature 36.1° C (97° F)Heart rate 65/minRespiratory rate 20/minBlood pressure 88/57 mm HgOxygen saturation 98% on room air
When analyzing cues, the nurse should first address the client's electrolyte imbalance. The client has hypokalemia, which increases the risk for cardiac arrhythmias. Once the client's medical concerns are addressed, the nurse should then focus on the underlying psychological issues behind the eating disorder, such as the client's fear of weight gain.
A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Exhibit 1 Exhibit 2 Exhibit 3 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
When analyzing cues, the nurse should identify that thyroid storm can be caused by trauma to the thyroid gland, such as surgery, and excessive release of thyroid hormone greatly increases the metabolic rate. Fever greater than 38.5° C (101.3° F), heart rate greater than 130/min, systolic hypertension, and mental status changes, such as confusion, restlessness, and sleepiness, are characteristic of thyroid storm
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.
When analyzing cues, the nurse should recognize that manifestations of hepatitis A, hepatitis B, and hepatitis C include jaundice, yellow sclerae, right upper quadrant pain upon palpation, dark yellow urine, and elevated AST and ALT levels. When analyzing cues, the nurse should also recognize the client's risk for contracting hepatitis A through the fecal-oral route during recent travel to an underdeveloped country and the client's occupational risk as a perioperative nurse for contracting hepatitis B and hepatitis C through bloodborne transmission. The nurse should recognize that the current standard of practice for treating hepatitis B and hepatitis C infections is with antiviral medication
A nurse is caring for a client. Exhibit 1 Exhibit 2 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.
When generating solutions, the nurse should identify that oxygen therapy, monitoring blood glucose, and keeping lights in the client's room dim are anticipated prescriptions. The client is exhibiting manifestations of increased intracranial pressure (ICP). Therefore, the nurse should titrate oxygen therapy to maintain the oxygen saturation level above 95% and avoid hypoxia. The nurse should frequently monitor the client's vital signs and blood glucose to avoid secondary brain injury. The nurse should also dim the lights in the client's room, because many clients who have increased ICP experience photophobia
A nurse is caring for a client who is postoperative following an appendectomy. Exhibit 1 Exhibit 2 Exhibit 3 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.
When recognizing cues, the nurse should identify that the findings of pain, nausea, heart rate, and oxygen saturation are unexpected findings for a client who is postoperative following an appendectomy. These findings should be reported to the provider
A nurse in an outpatient mental health clinic is caring for a client. Exhibit 1 Exhibit 2 Exhibit 3 Vital Signs 3 months ago: Blood pressure 116/68 mm HgHeart rate 82/minRespiratory rate 16/minTemperature 36.7° C (98.1° F)SaO2 97% on room airToday: Blood pressure 128/76 mm HgHeart rate 104/minRespiratory rate 22/minTemperature 37.4° C (99.4° F)SaO2 97% on room air
When recognizing cues, the nurse should identify that the findings of restlessness, auditory hallucinations, and pressured speech require immediate follow up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment.
A nurse is caring for an adolescent in the emergency department (ED). Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5 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/mm3) Aspartate aminotransferase (AST) 30 units/L (10 to 40 units/L) Alanine transaminase (ALT) 20 units/L (4 to 36 units/L)
When recognizing cues, the nurse should recognize that manifestations of bacterial meningitis can include fever, photophobia, nuchal rigidity, petechial rash, and impaired consciousness. The adolescent is experiencing these symptoms. Encephalitis is characterized by fever, nuchal rigidity, and altered mental status. Reye syndrome is characterized primarily by altered mental status and impaired hepatic function.
A nurse is caring for a client who is pregnant. Exhibit 1 Exhibit 2 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.
When taking action and providing discharge teaching for a client who has hyperemesis gravidarum, the nurse should recommend the client should eat every 2 to 3 hr to avoid having an empty stomach, which can increase nausea. The client should separate liquids from solids every 2 to 3 hr to help minimize nausea. The client should eat foods high in protein that are low in fat. Warm ginger ale or ginger tea can also decrease nausea.
A nurse is caring for a client following a laparoscopic cholecystectomy. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 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.
When taking actions for a client who is postoperative following a laparoscopic cholecystectomy, the nurse should anticipate prescriptions for the client to apply heat for abdominal pain as needed, to encourage deep breathing, and to change the dressing when soiled. The client can use heat for abdominal pain related to carbon dioxide retention. During the procedure, carbon dioxide is inflated into the abdominal cavity for visualization for the provider. The client's dressing should be changed when soiled as needed. The dressing should be clean, dry, and intact to prevent infection. The nurse should identify that medication for nausea should be provided as needed and is contraindicated for scheduled administration
A nurse is caring for a client in the emergency department (ED). Exhibit 1 Exhibit 2 Exhibit 3 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.
When taking actions, the nurse should administer IV fluids, use humidification with oxygen therapy, and assess the client's mouth every 8 hr and peripheral circulation hourly. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling and clumping of the red blood cells and assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection.
A nurse is caring for a 1-month-old infant. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 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.
the nurse should identify that the infant is at the greatest risk for developing dehydration due to a loss of gastric content from vomiting
A nurse is caring for a client who is pregnant in the acute care setting. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5 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.
the nurse should plan to first take action to support respirations, followed by action to increase the client's level of consciousness
