NCLEX new generation case study

A 12-year-old client visits the health care clinic for a follow-up visit after laboratory and other testing. The client is accompa-nied by a parent. The client tells the nurse about an increase in appetite lately and about urinating more frequently than usual. The nurse reviews the client's test results and collects data from the client prior to the client being seen by the physician. The following is documented in the medical record. Health History Nurses' Notes Diagnostic Tests Lab Results VS: T = 98.2°F (36.6°C); HR = 78 BPM; BP = 118/70 mm Hg; RR = 16 bpm; SpO2 = 96% on RA; denies pain. Skin: Warm, dry, intact. Respiratory: Dry cough. Reports sputum expectoration of white thick mucus following respiratory treatments. Lung sounds clear to auscultation in all lung fields. GI: Increased appetite. Reports taking pancreatic enzymes with all meals and snacks. Bowel sounds active × 4 quadrants. Regular bowel movements that are brown and fatty. Weight: 91.5 lb (41.5 kg) Height: 59.0 inches (149.8 cm) Parent states that client was diagnosed at 3 years of age with cystic fibrosis (CF). Health History Nurses' Notes Diagnostic Tests Lab Results Chest x-ray: Mild lung hyperinflation; no chest infiltrates, atelectasis, or bronchiectasis Oral glucose tolerance test (OGTT): glucose 240 mg/dL (13.37 mmol/L) 2 hours after administration of the glucose liquid For each body system, click to select the priority client need to pre-vent a complication of the client's health problem. Each body sys-tem supports one priority client need.

Body System Priority Client Need Respiratory X☐ Oscillatory positive expiratory therapy (PEP) ☐ Oxygen administration GI X☐ Pancreatic enzyme therapy ☐ Low-fat diet IMMUNE ☐ Prophylactic antibiotic therapy X☐ Contact precautions with separation from others with CF by at least 6 feet Endocrine X☐ Insulin administration ☐ Recombinant human growth hormone administration Integumentary X☐ High-sodium foods ☐ Oatmeal baths

Not Likely to Result in Fetal Harm

Breech baby Strong uterine contractions

Rationale for the Previous Question

CF is a condition characterized by exocrine (mucus-producing) gland dys-function and leads to multisystem involvement. CF is inherited as an autosomal reces-sive trait. CF leads to decreased pancreatic secretion of bicarbonate and chloride and an increase of sodium and chloride in both sweat and saliva. The primary factor respon-sible for many manifestations of the health problem is mechanical obstruction caused by the increased viscosity of mucous gland secretions. The mucous glands produce a think, heavy mucoprotein that accumulates and dilates them. Then small passages in organs

A 45-year-old client is admitted to the ED because of frequent ep-isodes of chest pain unrelieved by sublingual nitroglycerin. The ECG shows ST segment elevation. Troponin levels are elevated. While awaiting results of diagnostic studies and transfer to the cardiac unit, the nurse monitors the client. Vital signs reveal the following: Health History Nurses' Notes Vital Signs Laboratory Results 1200: HR = 88 BPM; RR = 22 bpm; BP = 142/86 mm Hg 1215: HR = 92 BPM; RR = 24 bpm; BP = 120/82 mm Hg 1230: HR = 106 BPM and weak; RR = 28 bpm; BP = 100/62 mm Hg 1245: HR = 120 BPM and weak; RR = 32 bpm; BP = 90/58 mm Hg The nurse determines that these vital sign findings most likely indi-cate which complication(s)? Select all that apply. ☐ Dysrhythmias ☐ Pulmonary edema ☐ Cardiogenic shock ☐ Cardiac tamponade ☐ Pulmonary embolism ☐ Dissecting aortic aneurysm

Cardiogenic shock

Rationale for the Previous Question

Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension; a rapid heart rate that becomes weaker; decreased urine output; and cool, clammy skin. RR increases as the body develops meta-bolic acidosis from shock. Dysrhythmias would be detected by changes in the rate and rhythm of the pulse and would be evidenced on the cardiac monitor and ECG. Although ST segment elevation is noted, there is no evidence of dysrhythmias. Pulmonary edema is evidenced by severe dyspnea and breathlessness and adventitious breath sounds. Car-diac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain.

Causes Early Decelerations

Causes Breech baby Strong uterine contractions

Rationale for the Previous Question

Dehydration is a condition in which the body has a lower than needed amount of body fluid. At admission this client showed signs of dehydration and reported weakness. The client's skin and mucous membranes were very dry, and the client was sleepy. In addition, the BUN, creatinine, sodium, and potassium are elevated, also noted in dehydration and due to the loss of fluid affecting cellular regulation. The dehydration is likely a result of the client not being able to eat or drink for the last 3 days. Circulatory overload occurs when the volume of fluid in the body is greater than the body needs and fluid accumulates faster than the circulatory system can compensate for the large volume of fluid. Fluid exists in greater amounts than needed in the extracellular compartments. An elderly client is at risk because of changes in the circulatory system due to the aging process. In addition, those with compromised cardiac function, such as a cli-ent with heart failure, are at greatest risk. In this client, 400 mL of fluid is infused into the client during a 1-hour period (inadvertently, because the prescribed rate was 100 mL/hr), and this is the likely cause of the circulatory overload. Some of the signs and symptoms of circulatory overload include headache, dyspnea, orthopnea, wheezing, tightness in the chest, cough, cyanosis, tachypnea, a rapid increase in BP, and distended neck veins. A client taking digoxin is at risk for digoxin toxicity. The therapeutic digoxin level ranges from 0.5 ng/mL (0.66 nmol/L) to 2.0 ng/mL (2.6 nmol/L). A digoxin level of 2.2 ng/mL (2.8 nmol/L) is above the therapeutic level. Early signs of digoxin toxicity are mental status changes and GI alterations that include anorexia, nausea, vomiting, and diarrhea. Brady-cardia or tachycardia can occur and the client develops visual disturbances such as blurred vision and changes in colors.

Digoxin Toxicity

Digoxin Toxicity Anorexia, blurred vision, mental status changes, dysrhythmias, nausea, vomiting, and diarrhea Anorexia RELATED Dry mucous membranes NON REALTED BUN and creatinine levels NON RELATED Sodium and potassium levels NON RELATED Digoxin level RELATED Elevation in BP and RR NON RELATED

Assessment Finding Dehydration

Dry mucous membranes, mental status changes, weakness, low-grade fever, decreased and concentrated urine, hemoconcentration, elevated BUN and creatinine levels, hypotension Anorexia NON RELATE Dry mucous membranes RELATE BUN and creatinine levels REALTE Sodium and potassium levels RELATE Digoxin level NON RELATED Elevation in BP and RR NON RELATED Wheezing and congestion NON RELATED bilaterally in lungs Neck vein distention Not related (opposite)

Client Finding Otitis Media

Ear pain No fever Attends full school days Swimming daily for the past week

Client Finding Otitis Externa

Ear pain No fever No sick contacts Swimming daily for the past week Tenderness noted on palpation and manipulation of the auricle Erythema in the ear canal

Late Decelerations

Fetal hypoxemia Metabolic fetal acidemia Uteroplacental insufficiency

Potential to Result in Fetal Harm

Fetal hypoxemia Metabolic fetal acidemia Uteroplacental insufficiency

Every 30 minutes the nurse is monitoring a 28-year-old client who was admitted 3 hours ago to the labor and delivery unit in the first stage of labor. The nurse suddenly notes late decelerations and frequent episodes of fetal tachycardia in response to FHR decel-erations on the monitor The nurse determines that these findings indicate which ofthe follow-ing conditions? Select all that apply. ☐ Breech baby ☐ Fetal hypoxemia ☐ Metabolic fetal acidemia ☐ Strong uterine contractions ☐ Uteroplacental insufficiency

Fetal hypoxemia ☐ Metabolic fetal acidemia Uteroplacental insufficiency

Circulatory Overload

Headache, shortness of breath, cough, elevated BP, puffiness around the eyes, dependent edema, neck vein distention, congestion in the lungs Anorexia NON RELATED Dry mucous membranes NON RELATED BUN and creatinine levels NON RELATED Sodium and potassium levels NON RELATED Digoxin level NON RELATED Elevation in BP and RR REALTED

86-year-old client with altered mental status who is accompanied by their child is admitted to the medical-surgical unit, and the nurse is performing an assessment. The client has an IV solution of a 1000-mL bag of 0.9% sodium chloride hung at 1200 in the ED that is infusing at 100 mL/hr. One hour after admission the client's child calls the nurse and reports that the client has a pounding headache, is having trouble breathing, and seems scared. Health History Nurses' Notes Vital Signs Laboratory Results 1300: Client is weak and reports has not been able to eat or drink in the past 3 days because of anorexia. Skin is very dry, dry mucous membranes, sleepy. The child reports that the client has a H/O heart failure, hypertension, and hyperlipidemia. Breath sounds clear bilaterally. Medications include lisinopril, carvedilol, and digoxin. 1400: Client is dyspneic and complaining of chest tightness, coughing and is pale, neck vein distention is seen. Breath sounds wheezing and congestion remaining in the IV bag Nurses' Notes Result Blood urea nitrogen (BUN) 24 mg/dL (8.64 mmol/L) Creatinine1 .8 mg/dL (159.4 mcmol/L) Digoxin level2.2 ng/mL (2.8 nmol/L) Sodiun 148 mEq/L (148 mmol/L) Potasium 5.2 mEq/L (5.2 mmol/L) Medical History T = 100.2°F (36.8°C); apical HR = 72 BPM and regular; BP = 100/68 mm Hg; RR = 24 bpm; SpO2 = 90% on RA 1400: T = 100.2°F (36.8°C); apical HR = 110 BPM and regular; BP = 152/98 mm Hg; RR = 28 bpm; SpO2 = 89% on RA For each assessment finding below, click to specify if the finding is most likely consistent with dehydration, circulatory overload, or di-goxin toxicity.

Normal Reference Range Blood Urea nitrogen 10-20 mg/dL (3.6-7.1 mmol/L) Creatinine 0.5-1.2 mg/dL (44-106 mcmol/L) Digoxin level 0.5-2.0 ng/mL (0.64-2.56 nmol/L) Sodium 135-145 mEq/L (135-145 mmol/L) Potasium p3.5-5.0 mEq/L (3.5-5.0 mmol/L) Assessment Finding Dehydration Dry mucous membranes BUN and creatinine levels Sodium and potassium levels Circulatory Overload Elevation in BP and RR Wheezing and congestion bilaterally Neck vein distention Digoxin Toxicity Anorexia Digoxin level

A 45-year-old client diagnosed with CKD requires dialysis. As a candidate for both hemodialysis and peritoneal dialysis, the cli-ent decides that peritoneal dialysis is the better option for their lifestyle. The client is hospitalized and undergoes insertion of the peritoneal dialysis catheter, and the first dialysis procedure is ordered. The nurse documents predialysis assessment data and reviews laboratory results. Health History Nurses' Notes Vital Signs Laboratory Results 1100: T = 98.2°F (36.8°C); apical HR = 90 BPM and regular; BP = 146/98 mm Hg; RR = 16 bpm; breath sounds clear bilaterally. Weight = 160 lb (72.57 kg) Nurses' Notes Result nitrogen (BUN) =30 mg/dL (10.8 mmol/L) H creatinine =6.0 mg/dL (528 mcmol/L) H Glucose 110 mg/dL (6.1 mmol/L) H Sodium 150 mEq/L (150 mmol/L) H Potasium 5.5 mEq/L (5.5 mmol/L) H During dialysis infusion, the nurse notes a slow inflow ofthe dialysate and the client complains ofpain. On assessment ofthe catheter, the nurse notes some fibrin clot formation in the dialysis tubing. Com-plete the following sentences by choosing from the list ofoptions. The nurse recognizes that the slow inflow , presence of fibrin clots, and complaints of pain are most likely the result of the -------------- due to the-----------------

Options for 1 Peritonitis Initial dialysis treatment Bowel perforation Abdominal pressure Options for 2 Catheter slippage x Surgical procedure Lack of aseptic technique Elevated BP and laboratory results

The nurse working at the outpatient pediatric clinic is perform-ing an admission assessment for a 7-year-old child who is ac-companied by their parent. The child reports right ear pain for 3 days. The nurse documents the following assessment findings. Health History Nurses' Notes Vital Signs Diagnostic Results Reports right ear pain × 3 days described as constant, aching, nonradiating; denies dry mucous membranes, eye drainage, nasal drainage, or throat pain; oropharynx pink, moist, with no redness, swelling, exudate Reports no sick contacts and has been attending full days of school; reports swimming daily for the past week Denies neck stiffness; no swelling of the neck, or swollen lymph nodes Denies cough, wheezing, difficulty breathing; lung sounds clear Tenderness noted on palpation and manipulation of right auricle with ear canal erythema; no discharge; left auricle nontender Immunizations up-to-date Allergies: No known allergies Health History Nurses' Notes Vital Signs Weight: 55 lb (59th percentile) Height: 49.25 inches (55th percentile) BMI: 15.94 (58th percentile) T: 97.9°F (36.6°C) temporal HR: 98 BPM RRs: 18 bpm BP: 108/70 mm Hg Clinical findings noted in the assessment that point to otitis externa include

Options for 1 No sick contacts Ear pain without fever Attends full school days Left auricle is nontender to manipulation Options for 2 Denies neck stiffness Immunizations up-to-date Swimming daily for the past week Lack of nasal drainage or throat pain Options for 3 Denies cough No lymphoadenop-athy Tenderness on manipulation of right auricle Lung sounds clear to auscultation bilaterally

Rationale for the Previous Question

Otitis externa is also known as swimmer's ear and is associated with inflam-mation and possibly exudate in the external auditory canal. Otitis externa is confirmed when there are no other disorders such as otitis media or mastoiditis. Fever is usually absent, and hearing is unaffected. Often there is tenderness on palpation of the tragus and manipulation of the auricle. The lining of the canal is erythematous and edematous, and discharge may be seen. Another factor that suggests otitis externa is that the child has been swimming daily for the past week. The other findings noted are not risk factors for this problem. Attending full school days heightens the risk for otitis media, which can occur secondary to an upper respiratory infection.

Rationale for the Previous Question

Pain during the inflow of dialysate is common when a client is initially started on peritoneal dialysis therapy following the surgical procedure and catheter placement. Usually, this pain no longer occurs 1 to 2 weeks after receiving these treat-ments. Warming the dialysate bags before instillation by using a heating pad to wrap the bag or by using the warming chamber of the automated cycling machine will assist in preventing pain. Slow inflow of the dialysate is not uncommon initially but should always be assessed because it could be due to a kink in the tubing or fibrin clots. Fibrin clot formation is not uncommon after catheter placement, although it is also important to know that it can occur with peritonitis. In this client situation fibrin clot formation is most likely an expected finding because the client recently had the catheter placed and because there are no associated findings of peritonitis such as fever. In addition, it is not likely that signs of peritonitis would show just after catheter placement. Milking the tubing may dislodge the fibrin clot and improve flow. Bowel perforation would be exhibited by a brown-colored outflow. Abdominal pressure may occur on inflow and may cause minimal discomfort, but this is an unlikely occurrence in this client situation; also, fibrin clots are not associated with abdominal pressure.

A 68-year-old client complaining of chest pain is admitted to the medical-surgical nursing unit for acute coronary syndrome. The cardiologist prescribes a continuous IV heparin infusion per protocol. The client weighs 165 lb (74.8 kg), and baseline partial thromboplastin time (PTT) is 32 seconds. A bolus is administered as prescribed and a continuous infusion is initiated based on the protocol noted in the Medication Administration Record Health History Nurses' Notes Vital Signs Med Admn Record Baseline PTT and every 6 or 12 hours after start of continuous infusion based on protocol Heparin 80 units/kg IV bolus prior to start of continuous infusion Start heparin 25,000 units in 250 mL D5W (concentration 100 units/mL) continuous infusion 18 units/kg/hr Adjust continuous infusion based on the following: • PTT less than 35 seconds: IV bolus 80 units/kg, in-crease rate by 4 units/kg/hr, PTT in 6 hours • PTT 35-45 seconds: IV bolus 40 units/kg, increase rate by 2 units/kg/hr, PTT in 6 hours • PTT 46-70 seconds (goal): No bolus, no rate change, PTT in 12 hours • PTT 71-90 seconds: No bolus, decrease rate by 2 units/kg/hr, PTT in 12 hours • PTT above 90 seconds: No bolus, stop infusion The next day, the oncoming nurse assigned to monitor the cli-ent assesses the client and checks laboratory results. The client states, "I feel OK, I just have a hard time sleeping since I've been in the hospital. My chest pain is better. I had a nosebleed this morning but it stopped. I'm ready for breakfast; it should be here soon." The most recent PTT from 1 hour ago was 92 seconds. The heparin infusion is running at 13.5 mL/hr.

Select the three priority needs that are of immediate concern. ☐ Appetite ☐ Chest pain ☐ Nosebleed ☐ PTT results ☐ Heparin infusion ☐ Difficulty sleeping

Rationale for the Previous Question

The major adverse effects of heparin therapy include heparin-induced thrombocytopenia (HIT) and/or hemorrhage. Other adverse effects include hypersen-sitivity, local irritation and hematoma, and allergic responses. The priority needs in this scenario that are of immediate concern are the client report of a nosebleed, the PTT results, and the heparin infusion. Nosebleeds can be associated with an adverse effect of HIT or hemorrhage. The PTT results are above the therapeutic range and could also lead to bleeding. The heparin infusion is still running and therefore is of immediate concern. The cardiologist needs to be notified of the nosebleed and supratherapeutic PTT level, and the heparin infusion needs to be stopped. The client is reporting look-ing forward to having breakfast; this is not a concerning finding related to appetite. The client reports that the chest pain has improved, and therefore this is not an immediate concern. The client's difficulty sleeping since being in the hospital is most likely due to the disruption in routine and is not specifically related to the treatment; therefore this is not of immediate concern.

Rationale for the Previous Question

There are certain FHR patterns associated with physiologic processes for both the birth parent and the fetus. A deceleration can be benign or abnormal. Early decelerations, considered a normal finding, are caused by fundal pressure; breech posi-tions; strong uterine contractions; vaginal examination; and placement of internal monitoring equipment. Late decelerations are caused by fetal hypoxemia due to utero-placental insufficiency and therefore are considered an abnormal and concerning find-ing. Metabolic fetal acidemia is characterized by fetal tachycardia in response to FHR decelerations and is a possible condition. In cases of fetal hypoxia, the nurse would observe progressively more frequent episodes of tachycardia after decelerations that are initially transient and later become more consistent. This is because in response to repetitive hypoxic stress from uterine contractions, the fetus initially compensates by increasing its HR, as its ability to increase stroke volume is not very efficient.

Select the three priority needs that are of immediate concern.

☐ Nosebleed ☐ PTT results ☐ Heparin infusion