Comp Practice B 2023
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 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 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 this desired effect?
"I have not vomited as much recently."
A nurse is providing discharge instructions to the 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 has breast cancer. The nurse should recognize which of the following statements by the client as an example of altruism?
"I told my doctor that I would like to start a support group for the other people who has sick in my community."
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 with 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 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 to a client who is at 24 weeks of gestation and is scheduled for a 3hr 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 is an outpatient mental health clinic is caring for a client Exhibit 1: 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 Exhibit 2: 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. Exhibit 3: Graphic Record 3 mont
3 immediate follow ups 1. Speech 2. Restlessness 3. Auditory hallucinations
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? (SATA)
-A client who has gestational hypertension -A client who reports decreased fetal movement -A client who has premature rupture of membranes
A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Exhibit 1: 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 O2 95% on 2 L/min via NC Exhibit 2: MAR 1110: Morphine 4 mg IV bolus Exhibit 3: 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
4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm. 1. HR 2. Mental Status 3. Temperature 4. BP
A nurse in a provider's office is caring for a client. Exhibit 1: 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. Exhibit 2: 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
4 prescriptions the nurse should anticipate 1. Collect urine specimen for culture 2. Educate client on new prescription of sulfamethoxazole/trimethoprim 3. Educate client on new prescription for phenazopyridine 4. Collect urine specimen for urinalysis
A nurse is planning morning care for a client who has heart disease and type 2 DM. Exhibit 1: MAR Digoxin 0.25 mg PO daily Potassium chloride 20 mEq/L PO daily Metformin 500 mg PO daily Furosemide 20 mg PO daily Exhibit 2: 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) Exhibit 3: Lab Results Digoxin 0.78 ng/mL Potassium 3.7 mEq/L Glucose 85 mg/dL
Administer daily medications
A nurse is caring for an older adult 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
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 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 caring for a 5-year-old child Exhibit 1: Physical Exam 15:10 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 Exhibit 2: Nurses' Notes 15:10 Child accompanied to RD by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and learning forward with drooling noted. Exhibit 3: Vital Signs 15:05 Axillary Temp: 102F HR: 130/min Resp: 28/min BP: 99/58 mmHg O2: 90% on room air Exhibit 4: Medical History Family history of asthma Child seen 6 months ago for tonsillitis and treated with antibiotic therapy.
Answer: Condition: epiglottitis Actions: droplet precautions and IV antibiotics Monitor: Temp and breath sounds
A nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a toddler who weighs 10 kg (22 lbs) and is experiencing a grand mal seizure. Available is diazepam solution for injection 5mg/mL. How many mL should the nurse administer? (round to nearest tenth)
Answer=0.6mL 0.3mg * 10kg = 3mg 3mg/5mg = 0.6mL
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 for at least 1 minute.
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 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.
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 assessing a client who has major depressive disorder and is take 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 is caring for an adolescent in the ED Exhibit 1: Lab Results Sodium 140 mEq/L Potassium 3.6 mEq/L Chloride 103 mEq/L BUN 15 mg/dL Magnesium 1.5 mEq/L Total calcium 9.5 mg/dL Phosphate 3.7 mg/dL Glucose 80 mg/dL Total protein 7 g/dL Albumin 4.5 g/dL WBC count 19,500/mm3 + Aspartate aminotransferase (AST) 30 units/L Alanine transaminase (ALT) 20 units/L Exhibit 2: Diagnostic Results Cerebrospinal fluid examination: Pressure: 35 cm H2O Color: Cloudy Blood: None RBC: 0 WBC total: 120 cells/µL Protein: 90 mg/dL Glucose: 20 mg/dL Exhibit 3: MAR Day 1, 0830:Acetaminophen 325 mg PO 0930: Midazolam 2.5 mg IV Cefotaxime 2 g IV Exhibit 4: Vital Signs 0830: Temperature 39.2° C (102.6° F) Weight 51.4 kg (113.3 lb) Exhibit 5: 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 p
Bacterial Meningitis: fever, photophobia, nuchal rigidity, petechial rash, and impaired consciousness Encephalitis: fever, nuchal rigidity, and AMS Reye Syndrome: AMS, and impaired hepatic function
A nurse is caring for a client following laparoscopic cholecystectomy. Exhibit 1: 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. Exhibit 2: 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
Anticipated vs Contraindicated Change dressing when soiled ANTICIPATED Ondansetron 4 mg PO for nausea CONTRAINDICATED Encourage deep breathing exercises Q1hr ANTICIPATED Apply heat for abd pain as needed ANTICIPATED
A nurse on an antopartum unit is caring for a client who is at 33 weeks of gestation. Exhibit 1: Diagnostics Results WBC count 9,800/mm3 Hgb 13 g/dL Hct 41% Platelet count 170,000/mm3 BUN 20 mg/dL Lactate dehydrogenase (LDH) 80 units/L Aspartate aminotransferase (AST) 18 units/L Alanine aminotransferase (ALT) 19 units/L Uric acid (serum) 5.4 mg/dL Kleihauer-Betke (fetal hemoglobin test) 3% Blood type: A Rh: positive Urine reagent strip Glucose: none pH: 6 Specific gravity: 1.020 Ketones: none Nitrates: none Leukocyte esterase: negative Protein: negative Nitrites: none Exhibit 2: 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 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 mo
Condition: Abruptio Placentae Actions: Avoid cervical exam Insert large-bore IV Monitor: Monitor BP Monitor Platelet
A nurse is caring for a client who is postoperative following administration of general anesthesia. Exhibit 1: 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 Exhibit 2: Nurses' Notes 0830: Client is postoperative following an inguinal hernia repair. Apical pulse 134/min and irregular Client reports dyspnea. Exhibit 3: Diagnostic Results 0835: Arterial blood gases (ABGs) pH 7.30 PCO2 64 mm Hg HCO3- 26 mEq/L PO2 80 mm Hg
Condition: Malignant Hyperthermia Actions: Administer Dantrolene Administer O2 Monitor: Hypercapnia Muscle Rigidity
A nurse in an ED is assessing a client. Exhibit 1: 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 Exhibit 2: 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 Exhibit 3: 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 auscultatio
Condition: Neuroleptic Malignant Syndrome Actions: Hold all antipsychotic medications Apply cooling blanket Monitor: Temperature Hydration status
A nurse in an ED 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
A nurse is caring for a client who has abd pain Exhibit 1: 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. Exhibit 2: Physical Exam 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. Exhibit 3: Vital Signs 0900: Temp: 98.5F HR: 84 Resp: 18 BP: 118/78 mmHg O2: 98% on RA Exhibit 4: Diagnostic Results 1100: Aspartate aminotransferase (AST) 375 units/L (0 to 35 units/L) A
Client's risk from bloodborne transmission: Hep B, Hep C Physical examination findings: Hep A, Hep B, Hep C Client's risk from fecal-oral transmission: Hep A Antiviral treatment: Hep B, Hep C Laboratory results: Hep A, Hep B, Hep C
A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the just 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 client is receiving IV fluids at 150mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?
Dyspnea
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 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 275mL/24hr
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 3-5 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 manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use of evaluate the nurse's time management skills?
Maintain regular notes about the nurse's time management skills.
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 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 dificit?
Orthostatic hypotension
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 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 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 performing an admission assessment on a client who has 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 Naegele's rule Add 7 days to 1st day of menstrual period, Subtract 3 months
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 30mL of water before administering the medication.
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 is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
Pink, frothy sputum
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 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 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 in a provider's office is caring for a client. Exhibit 1: 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. Exhibit 2: 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 Exhibit 3: Provider Prescriptions Day 1, 0930: Collect urine specimen for urinalysis and urine culture and sensitivity. Trimethoprim/sulfamethoxazole 160/800
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 active 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 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 administered 1 unit of packed RBCs to a client. The client becomes anxious and reports SOB 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 ED 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 manager is planning to make changes to the current scheduling system on the unit. To facility 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 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 wt loss
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiated the IV for this client?
Radial vein of the inner arm
A nurse is caring for a client who is pregnant. Exhibit 1: 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. Exhibit 2: 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 Res
Recommended vs Contraindicated Eat Q2-3hrs RECOMMENDED Increase intake of high-fat foods. CONTRAINDICATED Drink warm ginger ale when nauseated. RECOMMENDED Alternated eating solid foods and liquids RECOMMENDED
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 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?
Secondary lifestyle
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 preparing a sterile field in order to insert a 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 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 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 in a provider's office is caring for a client. Exhibit 1: 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 Exhibit 2: Lab 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 Exhibit 3: 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
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 has a new diagnosis of anorexia nervosa. Exhibit 1: 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 Exhibit 2: 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 Exhibit 3: Lab results Day 1, 2030: Sodium 146 mEq/L Potassium 3.3 mEq/L Chloride 110 mEq/L BUN 21 mg/dL Magnesium 1.2 mEq/L Phosphate 2.8 mg/dL Glucose (casual) 75 mg/dL Total protein 5.8 g/dL Albumin 3 g/dL Day 2, 0530: Sodium 150 mEq/L Potassium 3.1 mEq/L Chloride 110 mEq/L BUN 25 mg/dL Magnesium 1 mEq/L Phosphate 2.8 mg/dL Fasting blood glucose 65 mg/dL Total protein 5.5 g
The nurse should first address the client's ELECTROLYTE IMBALANCE followed by the client's FEAR OF WEIGHT GAIN
A nurse is caring for a client who is pregnant in the acute care setting. Exhibit 1: 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. Exhibit 2: Vital Signs 1400: Temperature 37° C (98.6° F) Heart rate 72/min Respirato
The nurse should first address the client's RESPIRATORY RATE, followed by the client's LOC.
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 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 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.
The client returns to the provider's office 3 days later. Exhibit 1: 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 x 3. 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." Exhibit 2: Vital Signs: Day 1, 0900: Temperature 37.2° C (99° F) Heart rate 88/m
UTI is improving... Specific Gravity pH WBC
A nurse is reviewing the ABG results of a client who has COPD. The results include: pH 7.3 PaCO2 54 mmHg HCO3 26 mEq/L PaO2 56 mmHg SaO2 87% Which of the following is the correct interpretation of these values?
Uncompensated Respiratory Acidosis
A nurse is caring for a client who is postoperative following an appendectomy. Exhibit 1: 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. Exhibit 2: Vital Sign 1800: Temperature 36.8° C (98.4° F) Heart rate 104/min Respiratory rate 22/min Blood pressure 142/80 mm Hg O2 saturation 97% on room air 2000: Temperature 36.8° C (98.4° F) Heart rate 110/min Respiratory rate 24/min
Which of the following 4 client findings should the nurse report to the provider? 1. Pain 2. Nausea 3. HR 4. O2
A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24hr. Which of the following assessment findings should the nurse identify as the priority?
the client's heel is reddened and tender.
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 mediation?
"Have you had any stomach pain or bloody stools?"
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 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 wt daily."
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 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 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 DM and has had repeated hospitalizations for DKA
A nurse must recommend clients for discharge to 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 Q8hr
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
An antepartum nurse is caring for 4 clients. For which of the following clients should the nurse initiate seizure precautions?
A client who is a 33 weeks of gestation and has severe gestational hypertension
A nurse is caring for 4 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
A nurse has received change-of-shift report on 4 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 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 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 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. Exhibit 1: 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. Exhibit 2: 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 saturatio
Anticipated vs Contraindicated Cluster nursing care CONTRAINDICATED Keep the lights in the client's room dim ANTICIPATED Administer O2 therapy to keep O2 sat above 95% ANTICIPATED Maintain the client's hips in flexion CONTRAINDICATED Monitor BG Q4hrs ANTICIPATED Keep the client supine. CONTRAINDICATED
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 working on a med-surge unit receives a telephone call requesting the status of a client for 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 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.
The client returns to the provider's office 3 days later. Exhibit 1: 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 x 3. 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." Exhibit 2: Vital Signs: Day 1, 0900: Temperature 37.2° C (99° F) Heart rate 88/m
Assessment Finding Urine Color: E Skin: U Voiding Pattern: E Blood Pressure: E Temperature: U Bowel Elimination: U O2 Sat: E
A nurse is caring for a client who had abd surgery 24hr 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 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 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 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 is an ED 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 ED is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect?
Diaphoresis
A nurse on a Med-Surge 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 caring for a client on a Med-Surge unit. Exhibit 1: Vital Signs 0700: Temp: 99.7F HR: 100 Resp: 22 BP: 115/70 mmHg O2: 98% on RA Exhibit 2: 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.
Highlight the findings that need follow up 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.*
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 charge nurse is preparing to administer 0900 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 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 a client.
A nurse in an ED 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 make?
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 wo 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 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 providing teaching to a client who has a new diagnosis of type 1 DM. 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 is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?
Jaundice
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 indicated an understanding of the procedure?
Keeps the head of the bed elevated to 45* for 1hr after feedings
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 is receiving a blood transfusion. Which of the following findings should indicate to the nurse that this client is having a hemolytic transfusion reaction?
Low back pain
A nurse on the Med-Surge 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 to social services
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?
Measure the client's daily wt.
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 creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan?
Withhold administering the varicella vaccine to the child.
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 minutes
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 on a med-surge 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 1 day postoperative following a total thyroidectomy. Exhibit 1: Lab results 0700: Sodium 143 mEq/L Potassium 3.5 mEq/L Chloride 104 mEq/L BUN 15 mg/dl Magnesium 1.5 mEq/L Total calcium 8 mg/dL Phosphate 4.6 mg/dL Glucose 95 mg/dL WBC 9,500/mm3 Exhibit 2: 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
The client is at rightest risk for developing HYPOCALCEMIA as evidenced by the REPORT OF NUMBNESS AROUND LIPS
A nurse on the Meg-Surge unit is caring for a client who was admitted from the ED Exhibit 1: 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 Exhibit 2: 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 (D5W) infusing at 100 mL/hr. Exhibit 3: lab results 1400: Calcium 10.2 mg/dL Magnesium 1.5 mEq/L Potassium 4.7 mEq/L Sodium 150 mEq/L 1700: Calcium 9.5 mg/dL Magnesium 1.5 mEq/L Potassium 4.1 mEq/L Sodium 164 mEq/L
The client is at risk for developing CONFUSION due to SODIUM LEVEL. 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. Hypernatremia places the client at risk for a decreased LOC, falls, and seizure activity. Therefore, the nurse should monitor the client's level of consciousness and place the client on fall and seizure precautions.
A nurse is caring for a client who is on the spinal cord injury (SCI) unit. Exhibit 1: 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 to lower lobes. Abdomen soft and nondistended with active bowel sounds. client passed a small amount of hard formed stool this AM. Indwelling catheter draining clean, yellow urine. DTR are biceps 1+, Triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0. Day 4, 0600 Client reports increasing coughing and SOB. Crackles auscultated in BLL. Face and neck flushed, skin warm and moist. Client reports blurred vision and a headache as an 8/10 on pain scale. Abd soft and mildly distended. hypoactive bowel sounds present. Urinary output 300mL over last 8hr Exhibit 2: Vital Signs Day 3 1700: Temp: 100.8F HR: 74 Resp: 20 BP: 108/60 mmHg O2: 96%
The client is most likely experiencing manifestations of PNEUMONIA and AUTONOMIC DYSREFLEXIA.
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 1-month0old infant. Exhibit 1: 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. Exhibit 2: Diagnostic Results 1545: Hgb 20 g/dL Hct 60% Potassium 5.8 mEq/L Sodium 132 mEq/L Chloride 110 mEq/L WBC count 16,000/mm3 BUN 20 mg/dL Creatinine 0.2 mg/dL 1730: Abdomin
The infant is at highest risk for developing DEHYDRATION, as evidence by the infant's VOMITING
A nurse is caring for an adolescent in the ED Exhibit 1: 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. Exhibit 2: Vital Signs 0700: Temp: 101.7F HR: 100 Resp: 18 BP: 1
The nurse is reviewing the adolescent's EMR. Which of the following findings requires immediate follow up by the nurse? SKIN TEMP WBC BG POTASSIUM
A nurse is caring for a client at a provider's office. Exhibit 1: H&P 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. Exhibit 2: 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 pre
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 CABG Exhibit 1: Lab results 0630: Sodium 145 mEq/L Potassium 3.2 mEq/L Chloride 116 mEq/L BUN 24 mg/dL Magnesium 1.5 mEq/L Total calcium 9 mg/dL Phosphate 4.6 mg/dL Glucose 95 mg/dL WBC count 9,500/mm3 Exhibit 2: I&O 0700: 4 hr input 400 mL 4 hr output 350 mL 1100: 4 hr input 475 mL 4 hr output 360 mL 1500: 4 hr input 350 mL 4 hr output 375 mL Exhibit 3: Vital Signs 0700: Temperature 37.6° C (99.6° F) Heart rate 86/min Respiratory rate 20/min Blood pressure 115/70 mm Hg O2 100% on 2 L via NC 1100: Temperature 37.2° C (99° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 110/72 mm Hg O2 100% on 2 L via NC 1500: Temperature 37.7° C (99.8° F) Heart rate 80/min Respiratory rate 20/min Blood pressure 108/70 mm Hg O2 100% on 2 L via NC Exhibit 4: Nurses' Notes 0700: Client alert and oriented to person, place, time. Reports pain as 6 on a s
The nurse should analyze cues to determine the client is at greatest risk for developing dysrhythmias related to hypokalemia, as evidenced by electrolyte imbalances. The laboratory report and the client's report of muscle cramping. Potassium and magnesium depletion are common manifestations in clients who are postoperative following CABG. Due to medication or hemodilution, it is important for the nurse to closely monitor electrolytes.
A nurse in an ED 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
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 3-point gait.
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 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 assessing a newborn who is 3 days old. Exhibit 1: H&P 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. Exhibit 2: 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 Exhibit 3: 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.
What requires follow up? Flow sheet *Temp 97.5F* HR 140 Resp: 48 *Wt 5 lbs 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.*
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.
When teaching the parent to provide tracheostomy care, the nurse should instruct the parent to first remove the inner cannula. Next, the nurse should instruct the parent to remove the soiled dressing and then clean the stoma with 0.9% sodium chloride irrigation. Finally, the nurse should instruct the parent to change the tracheostomy collar.
A nurse in a provider's office is caring for a client. Exhibit 1: 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. Exhibit 2: 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 assessment findings to report to provider... Frequency Urgency Dysuria
A nurse is caring for a client in the ED. Exhibit 1: 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. Exhibit 2: Vital Signs 0600: Temperature 37.8° C (100° F) Heart rate 104/min Respiratory rate 26/min Blood pressure 88/56 mm Hg O2 90% on 2 L via NC Exhibit 3: Diagnostic Results 0645: Hematocrit 25% Hemoglobin 8.3 g/dL WBC count 18,000/mm3 Reticulocytes 8% Total bilirubin 1.9 mg/dL
Which of the following interventions should the nurse implement? SATA *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.
