Med Surg II: ATI NGN Questions for Hematology (100/100)

13a) A nurse is caring for a client in the emergency department. Nurses' Notes 1300: A 26-year-old client presents to the emergency department. Client reported they went to their provider for a "routine physical" for their employment and "they told me to come here because my labs were abnormal." Client is alert and oriented x 3. Jaundice observed to both sclera. Respirations even and unlabored; bilateral breath sounds clear. Heart sound with S3 auscultated. Capillary refill in 4 seconds in bilateral upper and lower extremities Abdomen soft, nondistended and nontender with active bowel sounds in all quadrants. Pulses in bilateral upper extremities at +2; pulses in bilateral lower extremities +1 and cool to touch. Active ROM to all extremities but reports some stiffness and pain in both their knees. Rates pain at 3 or 4 on a 0 to 10 pain scale and states "I just live with it."

1400: Nurse called to the client's room with client reporting sudden onset of pain in their hands, legs, chest, and back. Rates pain as 7 on a pain scale of 0 to 10 as dull and achy. "This happens from time to time, but it typically goes away after a while, but it's very painful." Upon further questioning, the client states "this happens about once a month, mostly after strenuous exercise, playing a game or two of basketball, or if I have had a hard day at work." Client states "I also have priapism sometimes."

1a) A nurse is caring for a client in the emergency department (ED). Nurses' Notes 1500: Client presents to the ED and reports dyspnea, chest pain, and tachycardia. Client returned home from a vacation out of the country 24 hr ago. 1515: The client has become diaphoretic, increasingly dyspneic, and states that their chest pain is sharp and increasing. The client states, "I feel like I'm going to die." Crackles auscultated in bilateral lower lobes, S3 and 54 heart sounds noted. Petechiae noted on the client's chest. Pulmonary embolism protocol initiated. Vital Signs 1500: Temperature: 38.1° C (100.6° F) Heart rate: 110/min Respiratory rate: 24/min BP: 138/52 mm Hg Oxygen saturation: 92% oxygen at 2 L/min via nasal cannula 1515: Temperature: 38.1° C (100.6° F) Heart rate: 135/min Respiratory rate: 32/min BP: 120/50 mm Hg Oxygen saturation: 90% on 4 L/min via nasal cannula

1b) The nurse should first __________ followed by ______________ First: place the client in high-Fowler's position obtain a doppler ultrasound administer an anticoagulant obtain ABGS Followed by: placing the client on telemetry initiating bleeding precautions obtaining IV access obtaining vital signs

2b) The nurse should monitor the client for __________ and _____________ following permanent pacemaker placement. 1st choice: Stroke Pulmonary edema Incisional site bleeding Decreased urine output 2nd choice: Bradycardia Hypokalemia Acute kidney injury

1st choice: Incisional site bleeding 2nd choice: Bradycardia

12a) A nurse is assessing a postpartum client. History and Physical 1300: 36-year-old postpartum client who delivered twins via cesarean birth 3 weeks ago. Reports throbbing pain as 7 on a scale of 0 to 10, swelling, discoloration, and warmth in left calf for two days. Also reports shortness of breath for the last 8 hours. Vital Sign 1303: Temperature 37.2° C (99° F) Heart rate 101/min Respiration rate 21/min BP 128/84 mm Hg Oxygen saturation 94% on room air

Answer in the picture! Admission Assessment 1307: Lungs clear to auscultation bilaterally, no wheezes or crackles. S1, S2 auscultated, no extra heart sounds noted. Client's left calf is erythematous, warm, edematous (pitting edema +2), swollen, and tender upon palpation. Laboratory Results 1530: D-dimer 1.0 mcg/mL (Less than 0.4 mcg/mL)

4a) A nurse is providing care for a client in the intensive care unit (ICU). Nurses' Notes 1600: Client admitted to ICU after undergoing tricuspid valve replacement surgery. Physical Exam: General: Client responds to name and follows commands; reports pain as 10 on a scale of 0 to10. Cardiovascular: Heart rate 82/min and regular, peripheral pulses +2 Respiratory: Respiratory rate 22/min, lungs clear to auscultation GU: Voiding clear yellow urine via indwelling catheter 1700: RN at bedside to assess client. Client not responding to name. Physical Exam: General: Unresponsive Vital Signs 1600: Blood pressure 122/66 mm Hg Pulse 82/min Respirations 22/min Temperature 37° C (98.6° F) 1715: No BP, pulse, or respirations Laboratory Results 1600: Potassium 2.8 mEq/L (3.5 to 5.0 mEq/L) Medications Morphine sulphate 10 mg IV for pain

Answer in the picture! After assessing the client, the nurse should first __________ and then _____________ 1st choice: obtain the crash cart anticipate provider order for naloxone (Narcan) STAT confirm the client is in cardiac arrest and call for help assist in immediately placing an advanced airway 2nd choice: begin CPR at rate of 30:2 compression to ventilation ratio insert venous access to administer IV fluids instruct assistive personnel to obtain crash cart prepare to defibrillate

11b) Nurses' Notes January: Client reports fatigue and nausea following chemotherapy treatments. States, "It just makes me not want to eat. When I do eat, the food taste funny." Client teaching: Instructed client to attempt to eat small meals several times daily, to eat food cold or at room temperature, to avoid fried foods. Encourage client to rest before eating meals. Oral mucosa is inflamed. Client teaching: Instructed client to avoid mouthwashes that contain alcohol, to increase water intake to 2 or more liters daily, and to avoid hot foods. Reviewed laboratory findings and stressed the need to protect self from illness due to immunosuppression. Client teaching: Instructed client to not eat raw or undercooked meat, to drink only pasteurized milk, and to boil water before drinking it; take temperature daily and report fever, avoid crowds, wash hands frequently with antimicrobial soap.

Answer in the picture! February: Client has experienced weight loss of 1.5 kg (3 lb), has experienced decrease in hct and hgb, WBC, and platelet count. Client reports still not able to consume much food; has increased intake of water. Oral mucosa with less inflammation. Client reports no bleeding episodes.

7a) A nurse is assessing a 24-year-old female client. History and Physical 1800: A 24-year-old female client reports throbbing pain, swelling, discoloration, and warmth in right calf for three days. Also reports shortness of breath for one day. Denies anything that makes it better or worse and denies any other symptoms. Client reports pain as 7 on a scale of 0 to 10. Reports that only medication is a combined hormonal oral contraceptive every day, started four months ago. Labs were drawn and the client is scheduled for venous duplex Admission Assessment 1807: Lungs clear to auscultation bilaterally, no wheezes or crackles. S1, 52 normal, no extra heart sounds noted. Warm, discoloration, and pitting edema 1+ noted on right calf. Right calf swollen and tender upon palpation.

Answer in the picture! Vital Sign 1803: Temperature 37.2° C (99° F) Heart rate 98/min Respiration rate 18/min Blood pressure 118/78 mm Hg Oxygen saturation 94% on room air Laboratory Results 2030: D-dimer 1.0 mcg/mL (Less than 0.4 mcg/mL)

8a) A nurse is caring for a client who reports fatigue and had a syncopal episode at home. Medical History. 30-year-old female admitted with reports of increased fatigue × 6 months. States they needs to rest frequently and is unable to participate in many activities due to reduced energy level. Reports dyspnea on exertion. Experienced syncopal episode at home without injuries. BMI: 21 Height: 62 inches Weight: 128.5 lb Denies recent weight loss. Denies anorexia. Past medical history: Has routine well health check-ups. Regular menses cycles, with heavy menstrual bleeding over the last year. Placed on ethinyl estradiol/drospirenone, one tablet PO daily 1 month ago. Denies sexual activity. No other health issues. Family history: Mother has hypertension, father has diabetes mellitus, no siblings.

Answer in the picture! Vital Signs 0800: Temperature 37.1°C (98.8° F) Apical Pulse 100/min Respiratory rate 22/min Blood pressure 102/76 mm Hg Oxygen saturation 90% on room air Diagnostic Results Hemoglobin 10.2 g/dL (Male: 14 to 18 g/dL; Female: 12 to 16 g/dL) Hematocrit 35% (Male: 42% to 52%; Females: 37% to 47%) Ferritin 9 ng/mL (Male: 12 to 300 ng/mL; Female: 10 to 150 ng/mL) Iron 54 mcg/dL (Male: 80 to 180 mcg/dL; Female: 60 to 160 mcg/dL) TIBC 464 mcg/dL (250 to 460 mcg/dL)

11a) A nurse is caring for a client who has cancer and is undergoing chemotherapy. Physical Examination January: Weight 70.5 kg (155 lb)BMI 24 February: Weight 69 kg (152 lb)BMI 23 Diagnostic Results January: Complete Blood Count:WBC count 5,500/mm³ (5,000 to 10,000/mm³)RBC count 4.2 (4.2 to 5.4)Hgb 12 g/dL (12 g/dL to 16 g/dL)Hct 37% (37% to 47%)Platelet count: 150,000/mm³ (150,000 to 400,000/mm³) February: Complete Blood Count:WBC count: 4,500/mm³ (5,000 to 10,000/mm³)RBC count 4 (4.2 to 5.4)Hgb: 14 g/dL (15 g/dL to 16 g/dL)Hct: 36% (37% to 47%)Platelet count: 140,000/mm³ (150,000 to 400,000/mm³)

Answer in the picture! Which of the following assessments indicates an improvement in the client's condition? (Select all that apply.) Platelet count Weight change Oral health Bleeding episodes WBC count

8b) Nurses' Notes 0800: Resting in bed. Alert and oriented × 4. Skin is cool, dry, and pale. Mucous membranes pale and moist. Small fissures noted at corners of mouth. Heart sounds moderate and regular, soft murmur noted. Capillary refill 4 seconds. Lungs clear to auscultation. Abdomen soft with active bowel sounds × 4. No peripheral edema noted. Small 1 cm open area on right heel. Slight redness noted, no drainage noted. Client states wound is from a blister after wearing a new pair of shoes. Reports fatigue and lack of energy. Denies pain or vertigo at this time. Takes 100% of diet. No nausea.

Answer in the picture! 1200: Up to bathroom with assistance of one. Reports dizziness. Lowered to sitting position on floor. Helped into bed with assistance of two. Temperature 37° C (98.6° F) Heart rate 104/min Respiratory rate 26/min Blood pressure 94/59 mm Hg Oxygen saturation 88% on room air

6a) A nurse is caring for a client in the medical surgical unit of a hospital. Nurses' Notes 1 week ago: Client presents to the emergency department with manifestations of increased fatigue for 2 days prior with a new appearance of black stools on the morning of admission. Client states they are also having a "dull pain" in their stomach over the past week. Rates pain as 4 to 5 on a scale of 0 to 10. Alert and oriented ×3. Appears anxious. Skin dry and pale. Abdomen mildly distended and soft, tender of the left upper quadrant on palpation. Bowel sounds are hypoactive in all 4 quadrants. Normal S1, 52, no murmurs, pedal edema absent. History of hypothyroidism and a serious car accident 6 yr ago with fracture of right hip with open reduction/internal fixation (ORIF) repair. Home medications: Naproxen EC 500 mg PO twice daily Levothyroxine sodium 125 mcg PO daily

Answer in the picture! 3 days ago: Client stable following 4 days in the intensive care unit. Transferred from intensive care unit to medical surgical unit. Today, 0830: Client alert and oriented x3. Client reports no nausea or vomiting. Rates pain as 0 on a scale of 0 to 10. Client reports bowel movement this morning that was light brown and soft. Abdomen soft, non-distended; bowel sounds active in all 4 quadrants. Client up ad lib. Discharge orders obtained. Provider Prescriptions Today, 0830: Esomeprazole 40 mg PO twice daily for 6 weeks Discontinue NSAIDs at home. Follow-up with Gl in 2 weeks. Follow-up with pain management. Diagnostic Results 1 week ago: Emergency endoscopy performed: peptic ulcer 1st choice: - increased thyroid-stimulating hormone (TSH) - weight loss - hypomagnesemia - hyperlipidemia 2nd choice: - history of hip fracture - hypothyroidism - history of Gl bleed - prescription for esomeprazole

3a) A nurse is reviewing the medical record of a client who has acute leukemia. Diagnostic Results Month One: WBC count 15,500/mm3 (5,000 to 10,000/mm3) RBC count 4.3 million/mm3 (4.2 to 5.4 million/mm3) Hemoglobin 15 g/dL (12 to 16 g/dL) Hematocrit 45% (37% to 47%) Platelet count 160,000/mm3 (150,000 to 400,000/mm3) PT 11.5 seconds (11 to 12.5 seconds) INR 1 second (0.8 to 1.1 seconds) PTT 65 seconds (60 to 70 seconds) Sodium 139 mEq/L (136 to 145 mEq/L) Potassium 4.2 mEq/L (3.5 to 5 mEq/L) Glucose 100 mg/dL (74 to 106 mg/dL) BUN 16 mg/dL (10 to 20 mg/dL) Creatinine 0.8 mg/dL (0.5 to 1 mg/dL) Calcium 9.5 mg/dL (9 to 10.5 mg/dL) Vitamin D 65 ng/dL (25 to 80 ng/dL)

Answer in the picture! Month Three: WBC count 15,500/mm3 (5,000 to 10,000/mm3) RBC count 4.0 million/mm3 (4.2 to 5.4 million/mm3) Hemoglobin 11 g/dL (12 to 16 g/dL) Hematocrit 33% (37% to 47%) Platelet count 100,000/mm3 (150,000 to 400,000/mm3) PT 13.5 seconds (11 to 12.5 seconds) INR 2.2 seconds (0.8 to 1.1 seconds) PTT 85 seconds (60 to 70 seconds) Sodium 137 mEq/L (136 to 145 mEq/L) Potassium 4.5 mEq/L (3.5 to 5 mEq/L) Glucose 98 mg/dL (74 to 106 mg/dL) BUN 15 mg/dL (10 to 20 mg/dL) Creatinine 0.8 mg/dL (0.5 to 1 mg/dL) Calcium 9.5 mg/dL (9 to 10.5 mg/dL) Vitamin D 65 ng/dL (25 to 80 ng/dL)

10a) A nurse is caring for a client who was involved in a motor-vehicle crash. Medical History Client admitted following a head-on motor vehicle crash with a tree. The client was found unconscious in the vehicle. Emergency services were called and the client was brought into the emergency department. Nurses' Notes Client arrived in the emergency department via ambulance. No family or significant other present. Cervical collar in place. Police working to notify next of kin. Airway intact. Oxygen applied at 2 L/min via nasal cannula. IV inserted into left antecubital with normal saline infusing at 100 mL/hr. Glasgow coma scale score is 7.

Answer in the picture! The nurse should first address the client's________followed by the client's__________ 1st choice: circulatory status sensory perception mobility perceptions upper body findings 2nd choice: level of consciousness temperature WBC count oxygen saturation Nurses' Notes Motor response withdraws with pain, verbal response is incomprehensible sounds, and is unable to open eyes. Contusions and lacerations noted to the face, chest, and extremities. Peripheral pulses faint. Skin is clammy and moist to touch. Foley catheter inserted and draining pink-tinged urine. Urinary output 25 mL/hr. Vital Signs Blood pressure 102/60 mm Hg Respiratory rate 24/min Pulse rate 118/min Temperature 37.2 º C (99.0° F) Pulse oximetry 94% Diagnostic Results RBC count: 4.0/mm3 (4.2 to 6.1/mm3) WBC count: 7,000/mm3 ( 5,000 to 10,000/mm3) Hgb: 9 g/dL (12 to 18 g/dL) Hct: 20% (37% to 52%)

9a) A nurse is caring for a client on a medical-surgical unit. Nurse's Notes Client admitted to the unit for a lower Gl bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes, oxygen saturation 92% on 2L nasal cannula, and jugular vein distension noted.

Answer in the picture! Vital Signs Temperature 37.3° (99.1° F) Blood pressure 189/90 mm Hg Pulse rate 100/min Respiratory rate 28/min

13b) Laboratory Results 1300: Hemoglobin 7.2 g/dL (14-18 g/dL) Hematocrit 22% (40%-52%) Ferritin 150 ng/mL (12-300 ng/mL) Transferrin Saturation 35% (20-50%) Total bilirubin 2.1 mg/dL

Vital Signs 1300: Temperature 37.7 °C (99.9 °F) Respirations 20/min Apical pulse 88/min Blood pressure 128/64 mm Hg SaO2 94% 1400: Temperature 37.7 °C (99.9 °F) Respirations 22/min Apical pulse 94/min Blood pressure 136/72 mm Hg SaO2 92%

2a) A nurse is caring for a client who was recently admitted and has symptomatic bradycardia. Vital Signs Temperature 36.6° C (97.8° F) Apical pulse 42/min Respiratory rate 26/min Blood pressure 104/68 mm Hg Oxygen saturation 94% on room air Diagnostic Results CBC: RBC count 5.2 million/mm? (4.7 to 6.1 million/mm3) WBC count 7,000 mm3 (5,000 to 10,000 mm3) Hemoglobin 15.4 g/dL (14 to 18 g/dL) Hematocrit 48% (42% - 52%) Platelets 250,000/mm3 (150,000 to 400,000/mm3) Basic Metabolic Profile: BUN 18 mg/dL (10 to 20 mg/dL) Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL) Total Calcium 9.5 mg/dL (9.0 to 10.5 mg/dL) Carbon Dioxide 27 mEq/L (23 to 30 mEq/L) Chloride 101 mEq/L (98 to 106 mEq/L) Glucose 80 mg/dL (74 to 106 mg/dL) Potassium 5.1 mEq/L (3.5 to 5 mEq/L) Sodium 140 mE/L (136 to 145 mEq/L)

Physical Examination 0800: Alert and oriented to person and place Skin pale and dry Pupils equal, round, and reactive to light and accommodation Mucous membranes moist and pink Heart sounds regular and moderate Peripheral pulses moderate Capillary refill 3 seconds Lungs sounds clear to auscultation bilaterally Respirations labored at rest Abdomen soft and nontender, active bowel sounds × 4 quadrants No peripheral edema Reports slight midsternal chest pain, rates pain as a 2 on a 0 to 10 pain scale States they have been weak for the past 4 months with dizziness. Denies dizziness at this time. 1300: Returns to room after insertion of permanent pacemaker Alert and oriented to person, needs cues for time and place Skin cool and dry Heart sounds regular, heart rate 72/min Lung sounds are coarse bilaterally Hyperresonance noted upon percussion of chest wall Respiratory rate 24/min and slightly labored Oxygen saturation 2 L/min per nasal cannula 98% Reports slight incisional pain left upper chest area Small amount red drainage present on dressing over incisional site

5a) A nurse is caring for a client in the emergency department (ED). Nurse's Notes The client arrives to the ED and reports a "fluttering" and "racing" heartbeat. The client also reports dizziness and shortness of breath. Client placed on telemetry, cardiac rhythm is irregular, tachycardic and has unclear P waves. Vital Signs Blood pressure 165/88 mm Hg Pulse rate126/min Respiratory rate 22/min Oxygen Saturation 94% on room air

Potential Condition: Atrial fibrillation Actions to Take: - Administer an anticoagulant - Obtain a 12-lead electrocardiogra m (ECG) Parameters to Monitor: - Manifestations of stroke - PTT/INR