34 NURS 493 NGN Practice 1 SP 2024 (234)

A nurse is caring for a client who is 1 day postoperative following a right-sided thoracotomy with a chest tube insertion. Nurses Notes 0800: Chest tube is patent to client's right side, dressing is dry and intact, connected to a disposable three-chamber drainage system. Suction at prescribed -20 cm H2O. Tidaling noted in the water seal chamber along with continuous bubbling. Client reports pain as 3 on a scale of 0 to 10. 50 mL of sanguineous drainage noted in the collection chamber since 0700. Productive cough with clear sputum.

Actions to Take - assess for subcutaneous emphysema - check the drainage system and tubing Potential Condition - air leak Parameters to Monitor - client for their ability to perform lung expansion exercises - respiratory status The nurse should identify that the client is potentially experiencing an air leak because there is continuous bubbling in the water seal chamber of the chest drainage system. The nurse should assess for subcutaneous emphysema by palpating around the dressing site. If subcutaneous emphysema is present, the nurse will hear a cracking sound with palpation, and the provider should be notified. The nurse should also check the drainage system and tubing for the source of the air leak. If a leak is found in the drainage system, the unit should be replaced. If the nurse cannot find the source of the air leak within the drainage unit, the provider should be notified. The nurse should monitor the client for their ability to perform lung expansion exercises, such as deep breathing, the use of an incentive spirometer, and coughing. These activities will help to maximize the client's lung inflation, open closed airways, and remove secretions. The nurse should also monitor the client's respiratory status. If the client is experiencing an air leak, a pneumothorax is possible. The client will exhibit tachycardia, tachypnea, and increasing shortness of breath. A pneumothorax is a medical emergency, and the provider should be notified immediately.

Nurses' Notes Guardians brought the child to the primary care office for evaluation. Child is pale and irritable, afebrile. Guardians report decreased urine output and oral intake with two episodes of emesis and diarrhea in the past 48 hours. Child recovered from varicella infection 1 week ago. Petechiae to bilateral upper and lower extremities. No dyspnea, no murmurs. Vital Signs: Temperature 36.7°C (98.1°F) oral Blood pressure 122/76 mm Hg Heart rate 110/min Respiratory rate: 22/min Diagnostic Results WBC count 12,000/mm3 Hgb 9.2 g/dl Hct 27.6% Platelets 120,000/mm3 Reticulocyte count 3% BUN 23 mg/dL Creatinine 1.1 mg/dL Sodium 141 mEq/L

Actions to Take - initiate IV hydration - prepare the child for hemodialysis Potential Condition - hemolytic uremic syndrome Parameters to Monitor - patient's blood pressure - weight should be monitored The nurse should initiate IV hydration and prepare the child for hemodialysis because they are most likely experiencing hemolytic uremic syndrome. The patient's blood pressure and weight should be monitored because weight is the best indicator of fluid balance and hemolytic uremic syndrome can cause hypertension.

A nurse in the emergency department is caring for a preschool-age child. Nurses Notes Guardians brought child to the emergency department for evaluation of changes in balance. Guardians report noticing child with intermittent unsteady gait for the past week. Child has appeared to be more tired and has had two incidents of emesis in the morning just after waking up for the day. Guardians report child has had a decrease in appetite for the past 3 to 4 days and has been irritable. Child reports pain in head and right ear. Child is clinging to guardians and tearful during exam. Heart rate is regular with no murmur, lungs are clear bilaterally, bowel sounds are active in all quadrants. Skin is warm and dry with no bruising or rashes. Strength to all extremities is 2 out of 5. Child has a positive Romberg test and misses touching nose with finger when tested. Gait is steady, and deep tendon reflexes easily elicited.

Actions to Take - place the child in a quiet, softly lit room - prepare the child for an MRI. Potential Condition - CNS tumor Parameters to Monitor - neurologic status - paint rating The nurse should place the child in a quiet, softly lit room, and prepare the child for an MRI. The child is most likely experiencing a CNS tumor because of the history of irritability, emesis upon waking, positive Romberg and finger/nose test, and unsteady gait. The nurse should monitor the child's neurologic status and paint rating because they will determine any worsening intracranial pressure or growth of the tumor.

A nurse is caring for a client who was recently admitted and has symptomatic bradycardia. 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 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 The nurse should monitor the client for and following permanent pacemaker placement.

Dropdown 1: Incisional site bleeding is correct. The incisional site should be monitored for bleeding and hematoma post implantation. The dressing over the site should remain clean and dry. Dropdown 2: Bradycardia is correct. The nurse should closely monitor the client's ECG rhythm following permanent pacemaker insertion to ensure that the pacemaker is preventing bradycardia.

A nurse is caring for a client who has pneumonia on a medical-surgical unit. Nurse's Notes Client admitted to the unit 12 hr ago with pneumonia, over the last 1 hr the client has exhibited dyspnea and restlessness. Respiratory rate is currently 32/min with deep breaths, BP 198/78 mm Hg. Oxygen has been increased from 2 L nasal cannula to 50% face mask with little improvement of oxygen saturation. Current oxygen saturation is 91% on 50% facemask. Arterial blood gases drawn and sent to lab. Diagnostic Results ABGs: pH 7.25 (7.35 to 7.45) pCO2 62 mm Hg (35 to 45 mm Hg) HCO3- 22 mEq/L (22 to 26 mEq/L)

Actions to Take - administer a bronchodilator - prepare the client for intubation Potential Condition - respiratory acidosis and respiratory distress Parameters to Monitor - correct placement of the ETT following intubation - arterial blood gases The nurse should administer a bronchodilator and prepare the client for intubation because the client is likely experiencing respiratory acidosis and respiratory distress. The nurse should then monitor for the correct placement of the ETT following intubation as well as the client's arterial blood gases to normalize.

A nurse is caring for a newborn who is 64 hr old. Medical History A newborn who was born at 37 weeks of gestation was admitted to the newborn nursery following a cesarean birth. Maternal history of methadone use during pregnancy and no prenatal care. Maternal positive drug screen for methadone.

Actions to Take - administer oxygen as prescribed because the newborn has tachypnea with retractions - administer morphine Potential Condition - neonatal abstinence syndrome Parameters to Monitor - monitor the newborn's oral intake and output - monitor the newborn for overstimulation The nurse should administer oxygen as prescribed because the newborn has tachypnea with retractions and is experiencing neonatal abstinence syndrome. The nurse should monitor the newborn's oral intake and output to evaluate nutrition status and potential dehydration related to diarrhea. The nurse should administer morphine as prescribed because the newborn is experiencing neonatal abstinence syndrome. The nurse should monitor the newborn for overstimulation because decreasing stimulation will help with easing withdrawal.

Nurse's Notes 1100: Child seen today for well child visit. Child is in 98th percentile for height and weight. Child appears tired, skin is warm and pale, and clinging to guardian throughout the exam. No rashes noted, and moves all extremities without difficulty. Lungs clear, heart rate regular, and peripheral pulses strong in all extremities. Immunizations are up to date. Provider prescribed lab work at outpatient center. Guardians will bring child this afternoon.

Actions to Take - educate the guardians about the need for iron supplementation - provide foods rich in ascorbic acid (vitamin C) Potential Condition - iron deficiency anemia Parameters to Monitor - iron ferritin - hemoglobin levels The nurse should educate the guardians about the need for iron supplementation and provide foods rich in ascorbic acid (vitamin C), which can aid in the absorption of iron , because the child is most likely experiencing iron deficiency anemia. The nurse should monitor the child's iron ferritin and hemoglobin levels to assess the response to treatment.

28-year-old female client presents for a routine check-up. Client was diagnosed with schizophrenia 9 years ago while in college and was hospitalized for 2 weeks at time of diagnosis for treatment of psychosis. Schizophrenia is managed with medications and outpatient treatment. Client noted to have a weight increase of 6.8 kg (15 lb) in past 6 months.

Actions to Take - instruct the client on the use of a glucometer - encourage the client to engage in daily physical activity Potential Condition - metabolic syndrome Parameters to Monitor - weight - HgbA1c The nurse should instruct the client on the use of a glucometer and encourage the client to engage in daily physical activity because the client is likely experiencing metabolic syndrome as a result of the client's medication. This is evidences by the client's weight gain and having glucose, LDL, and HDL results outside of the expected reference ranges. The nurse should monitor the client's weight and HgbA1c because an increase in weight and glucose levels indicate metabolic syndrome. Metabolic syndrome can increase the risk for hypertension and cardiovascular disease.

A nurse is caring for a client who is at 34 weeks of gestation. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Diagnostic Results Fasting blood glucose 140 mg/dL (60 to 105 mg/dL) HbA1c 10% (less than 6.5%) Urinalysis: Appearance cloudy (clear) Color amber yellow (amber yellow) pH 4.8 (4.6 to 8.0) Positive urine glucose (negative) 3+ ketones (negative) Urine specific gravity 1.010 (1.005 to 1.030)

Actions to Take - obtain fasting blood glucose levels - perform a nonstress test Potential Condition - gestational diabetes mellitus Parameters to Monitor - monitor the client's hemoglobin A1c - fetal well-being The nurse should obtain fasting blood glucose levels and perform a nonstress test because the client is most likely experiencing gestational diabetes mellitus because the client has a blood glucose level above the expected reference range, glucosuria, and ketonuria. The nurse should monitor the client's hemoglobin A1c because it evaluates past glycemic control and assists the provider in evaluating how well the client is adhering to any future treatment plan. Also, fetal well-being should be monitored to determine how the client's diabetes mellitus is affecting the fetus and if additional studies or testing should be performed on the fetus in addition to nonstress testing.

A nurse is caring for a client who is receiving hemodialysis. Nurses Notes 0600: Client transferred to hemodialysis room. Client is alert oriented to person, place, and time. Denies discomfort. 1030: Client returns to client room from hemodialysis room. Alert and oriented to person and place, but client has episodes of confusion. Client reports nausea and headache. Restless along with fatigue. 1100: Client ambulates to bathroom with the assist of one, gait unsteady. Vomits 300 mL of undigested food. Returns to bed Medical History Chronic kidney disease; hemodialysis three times per week Type 1 diabetes mellitus

Actions to Take - implement seizure precautions - obtain an electrolyte panel to be drawn Potential Condition - disequilibrium syndrome Parameters to Monitor - neurological status - nausea and vomiting The nurse should implement seizure precautions and obtain an electrolyte panel to be drawn because the client is most likely experiencing disequilibrium syndrome. Disequilibrium syndrome can occur during or after hemodialysis has been completed as a result of the rapid decrease in electrolytes and other particles. Disequilibrium syndrome is caused by cerebral fluid shifts. The nurse should monitor the client's neurological status along with the presence of nausea and vomiting. Manifestations for disequilibrium syndrome include headache, nausea, vomiting, fatigue, restlessness, seizures, and coma.

Nurses' Notes Client is admitted to the emergency department with periodic episodes of wheezing and shortness of breath. Client reports wheezing, chest tightness, and persistent dry cough that increases at night. Bilateral breath sounds with inspiratory and expiratory wheezing. Color pale, skin warm and dry. Medical History Client is a nonsmoker and has a history of GERD. Vital Signs Temperature 37.1º C (98.8º F)Blood pressure 108/60 mm HgPulse 96/minRespiratory rate 28/minPulse oximetry 90% on room air

Actions to Take - plan to administer a bronchodilator - measure the client's peak airflow Potential Condition - asthma Parameters to Monitor - pulmonary function tests - oxygen saturation The nurse should plan to administer a bronchodilator and measure the client's peak airflow because the client is most likely experiencing asthma. The nurse should monitor the client's pulmonary function tests and oxygen saturation to assess the client's progress and determine the need for supplemental oxygen.

Nurses Notes 1130: Breasts soft, warm, and tender to touch. Client denies nipple or breast discomfort. Fundus boggy, located 1 cm above umbilicus, and deviated to the right. Fundus firm with massage. Client reports abdominal cramping and rates pain as 4 on a scale of 0 to 10. Perineal pad with moderate amount of lochia rubra. Assisted client to bathroom. Voided 250 mL yellow urine. Fundus midline, 1 cm above umbilicus. Fundus firm with massage. Client given prescribed analgesic. 1230: Client continues to report cramping and rates pain as 4 on a scale of 0 to 10. Fundus boggy, midline above the umbilicus. Fundus firms with fundal massage. Perineal pad saturated with lochia rubra and small clots expressed. Provider notified. The complication that poses the greatest risk for the client is as evidenced by their

Hemorrhage is correct. The nurse should identify that the client is at great risk of hemorrhaging as evidenced by their boggy uterus, moderate amount of lochia rubra, and saturation of the perineal pads. The nurse should continue to monitor the client's vital signs and fundus, and report unexpected findings to the provider. Amount of lochia is correct. The client is experiencing a moderate amount of lochia rubra with some small clots and a boggy uterus. This is an unexpected finding that can indicate uterine atony, which results in hemorrhage.

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

Actions to Take - obtain a 12-lead ECG - administer an anticoagulant Potential Condition - atrial fibrillation Parameters to Monitor - PTT and INR - manifestations of stroke The nurse should obtain a 12-lead ECG and administer an anticoagulant as prescribed because the client is most likely experiencing atrial fibrillation. Atrial fibrillation is characterized by manifestations of a fast, irregular heart rate that appears as a chaotic rhythm with unclear P waves. The nurse should monitor for manifestations of stroke as well as the client's PTT and INR because clients who have atrial fibrillation are at risk for the formation of clots.

A nurse is caring for a newborn who is 30 min old. Medical History Spontaneous vaginal birth with dark brown-greenish amniotic fluid noted during labor 42 weeks gestation Nurses' Notes 1100: Newborn is alert and active. Respirations rapid and shallow with occasional expiratory grunting. Fine crackles auscultated throughout lung fields. Small amount of green-stained vernix present in skin folds. Fingernails stained green. Molding of skull and generalized soft occipital swelling noted. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the greatest risk to the newborn is _______________________ due to _______________________

Meconium aspiration syndrome is correct. The nurse should identify that meconium aspiration syndrome is the complication that poses the greatest risk to the newborn because this can result in both a mechanical obstruction in the airways and a chemical pneumonitis. The presence of meconium-stained amniotic fluid at birth increases the risk that the fetus could inhale the meconium into their lungs while in utero or during the birth process. The nurse should monitor the newborn for signs of respiratory distress frequently and intervene if there are any unexpected findings. Color of amniotic fluid is correct. The presence of meconium in the amniotic fluid at delivery increases the risk for meconium aspiration syndrome and meconium ileus.

A nurse is caring for a newborn who was born at 37 weeks of gestation and is 12 hr old. Nurse's Notes Newborn is experiencing tachypnea, grunting, nasal flaring, and substernal retractions. Acrocyanosis noted on extremities bilaterally. Diagnostic Results Blood glucose level: 40 mg/dL (30 to 60 mg/dL) Bilirubin level: 4 mg/dL (1.0 to 12.0 mg/dL) pH: 7.30 (7.32-7.45) PaO2: 60 mm Hg (60 to 80 mm Hg) PaCO2: 32 mm Hg (40 to 50 mm Hg) HCO-3 17 mEq/L (16 to 24 mEq/L) Vital Signs Respirations: 90/min Heart rate: 162 /min BP: 70/45 mm Hg Temperature: 37.5° C (99.5° F) Oxygen saturation: 92%

Actions to Take - administer oxygen per facility protocol - administer surfactant as prescribed Potential Condition - respiratory distress syndrome Parameters to Monitor - oxygen saturation - arterial blood gases The nurse should administer oxygen per facility protocol and administer surfactant as prescribed because the newborn is most likely experiencing respiratory distress syndrome. The nurse should monitor oxygen saturation and arterial blood gases to note trends and details of the newborn's oxygenation status to discern if appropriate oxygenation is occurring.

A nurse is caring for a young adult. Vital Signs BP: 92/50 mm Hg Heart rate: 56/min Respiratory rate: 14/min Temperature: 36.2° C (97.2° F) tympanic SpO2: 96% room air Height: 165.1 cm (65 in) Weight: 45.4 kg (100 lb) BMI: 16.6 Nurses Notes Client presents with a report of anxiety and obsessive thoughts. Client has a flat affect and avoids eye contact. Client noted to have lanugo and skin is cool to palpation. Client reports constipation and hair loss. Client works full-time at an insurance office and attends college part-time. Client also reports smoking "a few" cigarettes and drinking alcohol 2 or 3 weekends a month. Client denies history of mental illness, medical history unremarkable except for recurrent otitis media as a child.

Actions to Take - observe the client for 1 hr after meals - check the client's vital signs three times per day Potential Condition - anorexia nervosa Parameters to Monitor - client's daily morning weight - potassium level The nurse should observe the client for 1 hr after meals and check the client's vital signs three times per day because the client is most likely experiencing anorexia nervosa as evidenced by the client's preoccupation with food, abnormal laboratory values, and low BMI. The nurse should monitor the client's daily morning weight and potassium level because being significantly underweight can cause electrolyte imbalances, which can lead to cardiovascular collapse.

Nurses' Notes Day of Admission 0700: 3-year-old admitted for fever of unknown origin. Has had a fever for 4 days and a non-productive cough. Child has not been eating or drinking for 24 hr per guardian. Child has received no immunizations per guardian. Child has a non-productive harsh cough, copious clear nasal secretions, and right eye is red, swollen, and tearing. Koplik spots are present on the buccal mucosa Breath sounds are clear and equal bilaterally. Mucous membranes are dry and capillary refill is 3 sec. Skin turgor is decreased. Guardian does not recall last time child voided. 1600: Flat rash present on face, neck and arms. Non-productive, dry cough present. The nurse is planning care for a child who has rubeola.The nurse should initiate Select... followed by Select...

Airborne precautions is correct. The nurse should recognize that children who have rubeola should be in isolation with airborne precautions. Providing a cool-mist vaporizer is correct. The nurse should recognize that children who have rubeola develop coryza and a cough. The child should be provided a cool-mist vaporizer to keep the mucous membranes moist and decrease coughing.

A nurse is reviewing the medical record of a client who has acute leukemia. Diagnostic Results 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) Drag words from the choices below to fill in each blank in the following sentence.

Bleeding and infection are correct. Bleeding is one of the major causes of death for clients who have acute leukemia. The nurse should note that the client's platelet count has decreased, and the PT, PTT, and INR levels have all increased, which places the client at a high risk for bleeding. Infection is also one of the major causes of death for clients who have acute leukemia. The WBC count can be low, normal, or high in leukemia, but the cells are small and nonfunctioning. The inability of the client's WBCs to mount an appropriate protection against invading micro-organisms places the client at a high risk for infection. Fracture and dysrhythmia are incorr

A nurse is caring for a client in the labor room. Medical History Gravida 2 Para 1 38 weeks gestation Pregnancy complicated by gestational diabetes and hydramnios. Spontaneous vaginal delivery 1 year ago. No significant past medical history. No history of surgeries. Spontaneous onset of labor Nurses Notes 1020: Client pushing effectively. Crowning. Provider present at bedside. Contraction pattern: occurring every 4- 5 min; lasting 75-90 seconds; palpate strong. Fetal heart rate 150/min. Average variability. Spontaneous accelerations noted. Variable decelerations noted when pushing. 1025: Spontaneous vaginal delivery. 2nd degree lacerations with repair. Apgar scores: 8 at 1 min and 9 at 5 min Birth weight 7 lb 8 oz (3,402 g).

Box 1 Postpartum hemorrhage is correct. Overdistention of the uterus during pregnancy can impact the ability of the uterine muscles to tightly contract following delivery. This can result in excessive blood loss following delivery. Clients who have high parity, fetal macrosomia, multiple gestations, and hydramnios are more likely to experience uterine atony. Therefore, the client has the greatest risk of developing a postpartum hemorrhage due to hydramnios. Box 2 Hydramnios is correct. Hydramnios or polyhydramnios is an excessive amount of amniotic fluid that causes overdistention of the uterus. This complication can develop during the third trimester in women who have diabetes mellitus. This can impair the ability of the uterus to tightly contract.

A nurse is caring for a client on an acute care mental health unit. Nurses' Notes Day 1 0900: Client alert and oriented x 4. Appears anxious and sensitive to light and sound. Pupils dilated. Client has a decreased appetite. Day 2 0700: Client exhibits anxiety, paranoia, agitation, and irritability. Client states, "I can't live without the drug." Reports insomnia. Day 2 0730: Temperature 37° C (98.6° F) Heart rate 125/min Respiratory rate 12/min Blood pressure 156/92 mm Hg Oxygen saturation 96% on room air The nurse should plan to administer Followed by once the client has been withdrawn from the amphetamine.

Diazepam is correct. The nurse should recognize that diazepam is a benzodiazepine that is used to treat agitation in clients who are experiencing amphetamine withdrawal. The nurse should administer diazepam to the client. Bupropion is correct. The nurse should recognize that antidepressants, such as bupropion, are effective in treating the manifestations of depression that can be experienced by clients who have been withdrawn from amphetamines. The nurse should administer bupropion to the client after administering diazepam.

A nurse is caring for a preschool-age child in the emergency department. Nurses' Notes 1800: Parents report a 2-day history of nausea, vomiting and diarrhea. Child reports an intermittent "belly ache" and states "I don't feel good". Parents state the child has been having frequent emesis and "can't keep anything down". Child irritable and frequently requesting a drink. Lips and mucus membranes dry. Capillary refill 3 seconds. Sluggish skin recoil noted. 1830: Child vomited small amount of clear-colored mucoid fluid. Voided a small amount of dark concentrated urine. Passed a moderate amount of liquid brown stool. No blood noted in stool. Urine and blood specimens collected. Which of the following prescriptions should the nurse anticipate from the provider?The nurse should anticipate a provider prescription for an and

Drop Down 1 Antitoxin is incorrect. An antitoxin is a solution of antibodies administered to provide temporary immunity to a specific type of bacteria which produces a toxin. Examples of toxin producing bacteria include diphtheria and botulism. There is no indication for the child to be prescribed this type of medication. Drop Down 2 Oral rehydration therapy is correct. The child has moderate dehydration, probably from a gastrointestinal infection, as evidenced by clinical manifestations, laboratory results and a 6% weight loss. Oral rehydration therapy is usually the first line of treatment for children who have mild to moderate dehydration and are alert and active. It is cost effective and has a lower risk of complications.

Nurses' Notes 1200:Client has a history of cirrhosis of the liver for the past 5 years. Client admitted to the medical-surgical unit for weight gain, vomiting, and worsening ascites. Client is lethargic and orientated only to self and place. Client has profound abdominal distention including a protruding umbilicus and taut skin. Client is jaundice throughout. The client nods 'yes' when asked if they are in pain but cannot give a pain level. +1 pitting edema noted in bilateral lower extremities. Bilateral pedal pulses are +2. Client is dyspneic, bilateral crackles auscultated in bilateral lower bases. The nurse should first address the client's followed by the client's

Fluid volume status is correct. The client has manifestations of fluid volume overload as evidenced by ascites, crackles, edema, and dyspnea. Using the urgent versus non-urgent priority setting framework, the nurse should address this first because the increased fluid volume is causing the client to have difficulty breathing. Neurological status is correct. Using the urgent versus non-urgent priority setting framework, the nurse should next address the client's neurological status. The client is lethargic and only orientated to person and place. The client's ammonia level is also elevated, which can affect neurological status. If the client's neurological status is not addressed and becomes worse, the client may be at risk for respiratory complications, such as pneumonia and atelectasis.

A nurse is caring for a client in the emergency department (ED). 1500: Client was brought to ED by a coworker. The coworker states that the client had been working outside all day in the sun and 36.7°C (98° F) heat. Approximately 1 hr prior to arrival the client complained of dizziness and fainted, staying on the ground for several minutes prior to being able to get up.

Hypernatremia and confusion are correct. Extreme temperature heat can cause clients to lose body water through insensible loss resulting in hypernatremia. Manifestations of hypernatremia include hypotension, weakness, tachycardia with weak pulses, tachypnea, dry mucous membranes, and oliguria. If fluids are not restored confusion and disorientation can occur.

A nurse is caring for a client who has a urinary tract infection. Day 3: Client reports frequent watery diarrhea. Day 1: Hypertension The client is at an increased risk for developing and

Hypokalemia is correct. Furosemide, a loop diuretic, can result in potassium loss in the urine. The client also has diarrhea, which can result in potassium loss in the stool. Therefore, the client is at an increased risk for hypokalemia. Fluid volume deficit is correct. Furosemide, a loop diuretic, promotes urine excretion and fluid loss. Diarrhea can cause fluid loss. Therefore, the client is at an increased risk for fluid volume deficit.

Medical History Gravida 2 Para 1 at 38 weeks of gestation with spontaneous rupture of membranes 8 hr ago, fluid clear. Previous cesarean birth 5 years ago at 41 weeks of gestation due to breech presentation and failed external version; no complications. Client requested a vaginal birth after cesarean (VBAC). Diagnostic Results Blood type: A Rh: Positive WBC count: 9,500/mm3 (5000 to 10,000/mm³) Hgb: 12 mg/dL (12 to 18 g/dL) Hct: 35% (37% to 52%) Platelet count: 180,000/mm3 (150,000 to 400,000/mm³)

Actions to Take - prepare the client for immediate surgery - discontinue the infusion of oxytocin Potential Condition - uterine rupture Parameters to Monitor - signs of hypovolemic shock - for vaginal bleeding The nurse should prepare the client for immediate surgery and discontinue the infusion of oxytocin. The nurse should identify that the client is most likely experiencing uterine rupture as evidenced by the client experiencing a sudden severe pelvic pain, contractions no longer appearing on the monitor, the FHR being bradycardic and having absent variability, and the client being hypotensive, tachycardic, and tachypneic. The nurse should monitor the client for signs of hypovolemic shock and for vaginal bleeding because the client's uterus may have ruptured, completely or incompletely. Incomplete uterine rupture might not be evident until later. Either type of rupture may requires an emergency cesarean birth, blood transfusion, or resuscitation.

1400: Client experiencing Tonic-clonic seizure noted for approximately 1 minute. Airway maintained throughout. Client denies a history of seizures. Provider notified and at the bedside. Glasgow Coma Scale 14. Client is not oriented to time. 1430: The client states "I'm scared I'm going to die! My head really hurts." Client is agitated and restless. Lungs sounds are clear to auscultation; however, their heart rate is irregular. Client is bradycardic. The client is experiencing weakness on the right side of their body. Their right eye pupil is dilated, and their left eye pupil is reactive to light. Oriented to person and place. Glasgow coma scale 13. They are confused and unable to follow commands. The client is at highest risk for developing as evidenced by the client's

- Intracranial hemorrhage - Glasgow Coma Scale The nurse should determine that the priority hypothesis the client is experiencing intracranial hemorrhage as evidenced by the client's Glasgow coma scale following the client's fall. Intracranial hemorrhage is a hematoma or clot in the brain often caused by injury. The nurse should monitor the client's neurological status and vital signs, along with seizure activity which can increase ICP and be life threatening.

Medical History Cirrhosis Type 2 diabetes mellitus Hypertension Partner reports client drinks 12 cans of beer daily Diagnostic Results 0700: Hemoglobin 11 g/dL (12 to 16 g/dL) Hematocrit 34% (37% to 47%) Aspartate aminotransferase (AST) 135 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 150 units/L (4 to 36 units/L) Alkaline phosphatase (ALP) 301 units/L (30 to 120 units/L) Ammonia 236 mcg/dL (10 to 80 mcg/dL) Total bilirubin 9.7 mg/dL (0.3 to 1.0 mg/dL) Albumin 2.5 g/dL (3.5 to 5 g/dL) Total protein 5.0 g/dL (6.4 to 8.3 g/dL) Prothrombin time 12.4 seconds (11.0 to 12.5 seconds) Glucose 180 mg/dL (74 to 106 mg/dL) Physical Examination 0800: Client is difficult to arouse and is disoriented to person, place, and time Lung sounds clear, no shortness of breath noted Bowel sounds active in all 4 quadrants, abdomen soft and slightly distended Skin intact, no petechiae or bruising noted. 2+ edema to legs bilater

Actions to Take - Administer Lactulose is given to decrease ammonia - assess for asterixis Potential Condition - Encephalopathy Parameters to Monitor - neurological status - safety measures The nurse should identify that the client is most likely experiencing encephalopathy related to cirrhosis. Encephalopathy can lead to seizures and coma and is life-threatening if not treated. Increased ammonia levels lead to encephalopathy, which can cause alterations in mental status and motor disturbances, including asterixis, an involuntary flapping of hands. Lactulose is given to decrease ammonia by expelling it in the stool. The nurse should expect two to three soft stools per day from the lactulose and should notify the provider if liquid stools develop. The nurse should frequently monitor the client's neurological status to promptly recognize any further progression of confusion. The nurse should also ensure appropriate safety measures are in place to keep the client safe from injury.

Today: 0815: A client states they have developed shortness of breath at rest and with activity over the last two months. They deny chest pain but expresses feeling dizzy and states, "I just feel like I can't catch my breath well." The client also admits they must use two pillows to sleep at night. Breath sounds with faint crackles bilaterally. Dyspnea observed while walking in room and with activity. An S4 heart sound heard on auscultation. A murmur is also heard over the second intercostal space. The client also has slight peripheral cyanosis to all extremities.

Actions to Take - Inform client they will require ECG every 6 to 12 months - Educate the client on risk factors to decrease inflammatory response Potential Condition - aortic stenosis Parameters to Monitor - heart rate and rhythm - pulse pressure Upon recognizing and analyzing the cues of increased heart rate, new murmur, ECG indicating left ventricular hypertrophy, drop in BP, and client reports and observed manifestations, the nurse's priority hypotheses is that this client is most likely experiencing aortic stenosis. It is important to generate solutions and take actions that will reduce the risk of further development and the need for aggressive treatment. Therefore, the nurse should Educate the client on risk factors to decrease inflammatory response and Inform client they will require ECG every 6 to 12 months. To evaluate these interventions, the nurse should monitor the clients heart rate and rhythm, as well as their pulse pressure.

Nurse's Notes The client presents to the ED stating that they had a sudden onset of dyspnea while taking a shower. The client appears restless, pale and diaphoretic, and keeps stating "I think I'm going to die." Client is alert and orientated x 4. Heart sounds are clear, pulse is tachycardic. Crackles in bilateral lower bases are auscultated as well as a pleural friction rub. Bowel sounds are normoactive in all 4 quadrants. Bilateral pedal pulses are +2.

Actions to Take - Placing the client in high-Fowler's promotes optimal gas exchange - obtaining venous access Potential Condition - pulmonary embolism (PE) Parameters to Monitor - aPTT valvues - cardiac dysrhythmias The nurse should place the client in high-Fowler's position and obtain venous access because the client is most likely experiencing a pulmonary embolism (PE). Placing the client in high-Fowler's promotes optimal gas exchange and obtaining venous access allows for medications to treat the PE or complications to be administered. The nurse should monitor for petechiae on the chest and cardiac dysrhythmias, which can occur with a PE and can be life threatening. The nurse should also monitor the client's aPTT prior to the administration of anticoagulants and also while the client is receiving treatment, as prescribed.

A nurse is planning care for an adolescent who was admitted from the emergency department. Nurses' Notes 0600: Client admitted for unstable respiratory status. Alert and oriented. Caregiver reports child having a fever as high as 39.88° C (103.8° F) for past 3 days with severe fatigue, chills, productive, harsh cough, and dyspnea with exertion. No nausea/vomiting or diarrhea. Reports no weight loss, night sweats, or recent travel. Breath sounds diminished bilateral lower lobes with crackles in the upper lobes. Vital Signs 0600: Temperature 39.05° C (102.3° F) Heart rate 101/min Respiratory rate 23/min Blood pressure 98/57 mm Hg Oxygen saturation 92% room air

Actions to Take - administer a prescribed antipyretic - try to cluster care to allow for rest Potential Condition - viral pneumonia Parameters to Monitor - levels of fatigue - oxygen saturation levels The nurse should administer a prescribed antipyretic and try to cluster care to allow for rest because the client is most likely experiencing viral pneumonia. Symptoms of pneumonia include high fever, fatigue, chills, productive cough, rales and diminished breath sounds, consolidation in the lungs on X-ray, increased WBC, and decreased oxygen saturation levels. The nurse should monitor levels of fatigue and oxygen saturation levels because these could indicate worsening respiratory status or complications of pneumonia.

Nurses' Notes Client comes to the ED with nausea, vomiting, confusion, and tremors. Client is agitated and irritable. Orientated only to self. The client states, "I'm tired of all these people in my house; visiting is over, my mom is dead, and I need to rest before the funeral." The client's partner states the client's mother died 6 years ago. The client's partner states that the client has been drinking "a lot" for the past 6 months. The client agreed to stop drinking 2 days ago. The partner believes that the client's last drink was roughly 36 hr ago.

Actions to Take - administer lorazepam - pad the client's bedrails Potential Condition - alcohol withdrawal syndrome Parameters to Monitor - fluid and electrolyte status - seizure activity This client is most likely experiencing alcohol withdrawal syndrome. Therefore, the nurse should administer lorazepam as prescribed for sedation to allow the client to rest and reduce the risk of injury. The nurse should then pad the client's bedrails to prevent injury from potential seizure activity. The nurse should monitor the client for seizure activity because seizures are a potential manifestation of alcohol withdrawal syndrome. The nurse should also monitor the client's fluid and electrolyte status because the client might have fluid and electrolyte disturbances caused using alcohol or as a result of vomiting.

A nurse is caring for a client who is 2 days postpartum. Medical History Client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. Second degree mediolateral perineal laceration with repair. Placenta manually extracted. Estimated blood loss 600 mL. Physical Examination Client awake and alert after eating 25% of breakfast. Face flushed, skin hot to palpation. Heart rate regular. Lung sounds clear bilaterally. Breasts soft and nontender without redness. Abdomen soft and distended, bowel sounds active in all four quadrants. Fundus boggy, 1 cm above umbilicus. Large amount of malodorous lochia rubra noted on perineal pad. Fundal massage performed, expressed two golf ball size clots. Client reports constant lower abdominal pain; rates a 6 on 0 to 10 pain scale. Grimacing noted during abdominal palpation and fundal massage. Perineal laceration with scant edema, sut

Actions to Take - administer methylergonovine - initiate an infusion of oxytocin Potential Condition - subinvolution of the uterus Parameters to Monitor - number of saturated perineal pads - hemoglobin and hematocrit levels The nurse should administer methylergonovine and initiate an infusion of oxytocin because the client is most likely experiencing subinvolution of the uterus as evidenced by the client's report of abdominal pain, fundal height, and large amount of vaginal bleeding. Both methylergonovine and oxytocin are uterotonic medications, which cause the uterine muscle to contract, decreasing bleeding. The nurse should monitor the number of saturated perineal pads and the client's hemoglobin and hematocrit levels because the client is experiencing a large amount of vaginal bleeding, an alteration in vital signs, and abdominal pain. These findings indicate postpartum hemorrhage due to uterine subinvolution.

A nurse is caring for a 36-hr-old newborn in the neonatal intensive care unit (NICU) born at 34 weeks of gestation. Physical Examination • Color pink, warm, and dry • In flexed position, moves extremities symmetrical • Airway patent, no retractions or nasal flaring noted • Respiratory rate 72/min, lungs clear bilaterally • Murmur noted • Cord clamped and drying; no drainage noted at umbilicus • Peripheral pulses bounding Nurses Notes 0800: Assessment reveals skin tone consistent with genetic background, no cyanosis. Skin is warm and dry to touch. Lungs sounds clear bilateral, but an extra heart sound that was not present at birth. Tachycardia and tachypnea noted that was not present at last assessment. Newborn fed by parent and consumed 20 mL of breast milk via bottle. Apgar at birth 36 hr ago was 7 at 1 minute and 8 at 5 minutes. Newborn was admitted to the NICU following a vaginal delivery. Maternal history incl

Actions to Take - administer oxygen as prescribed - restrict fluids Potential Condition - patent ductus arteriosus Parameters to Monitor - monitor arterial blood gases - Intake and output The nurse should administer oxygen as prescribed because the newborn might be experiencing patent ductus arteriosus. Respiratory support is needed because the ductus arteriosus might have re-opened due to low oxygen levels; therefore, the newborn requires oxygen. The nurse should restrict fluids to decrease cardiovascular volume overload. The nurse should monitor arterial blood gases because the amount of respiratory support needed will be based on the blood gases. The blood gases are also significant because they might show metabolic acidosis. The nurse should monitor fluid balance to ensure fluid overload does not occur.

Medical History Guardians state child has had an upper respiratory infection for 3 days. Child woke up with a harsh barky-like nonproductive cough that did not resolve. Guardians transported the toddler to the ED. Physical Examination Child is in moderate distress but appears well, clinging to guardian during exam, has a hoarse cry. Demonstrates mild work of breathing, no retractions or grunting noted. Mild nasal flaring, audible stridor. Afebrile. Heart rate 110/min Respiratory rate 34/min

Actions to Take - administer steroids - racemic epinephrine Potential Condition - acute laryngeotracheobronchitis Parameters to Monitor - oxygen saturation - respiratory status The nurse should administer steroids and racemic epinephrine because the child is most likely experiencing acute laryngeotracheobronchitis. The nurse should monitor the child's oxygen saturation and respiratory status in order to measure the child's response to treatment.

1200: The client was admitted to the medical-surgical unit for COPD exacerbation. The client states they have become progressively short of breath over the last week and says, "I wasn't able to breathe, and I was so tired." The client is short of breath, chest is barreled, and they are wheezing in lungs bilaterally. They deny sputum production. S1, S2 heart sounds heard with no murmur. Their skin is dry, clubbing of fingernails. The client denies fever. Past Medical History: COPD, hypertension Social History: Smokes 1ppd for 40 years, denies alcohol use

Actions to Take - administering IV antibiotics - request a prescription for a bronchodilator Potential Condition - respiratory acidosis Parameters to Monitor - PaCO2 - papilledema Upon recognizing and analyzing the client cues of a low arterial PH and high arterial CO2, with a history of COPD a new-onset pneumonia, the nurse's priority hypotheses is that this client is most likely experiencing respiratory acidosis. It is important to generate solutions and take actions that will improve ventilation and treat the underlying cause of inadequate ventilation. Therefore, the nurse should anticipate administering IV antibiotics and request a prescription for a bronchodilator. To evaluate these interventions, the nurse should monitor the client's PaCO2 and the development of papilledema which can indicate a worsening in the client's condition. If respiratory acidosis is severe, intracranial pressure can increase resulting in papilledema.

Nurses' Notes Infant is afebrile, moving all extremities well. Bounding pulses in bilateral upper extremities, weak femoral pulses bilaterally. Brisk capillary refill. No work of breathing, abdomen soft, bowel sounds present in all quadrants. Skin clear. Vital Signs Temperature 37.5⁰ C (99.5⁰ F) Heart rate186/min Respiratory rate 30/min Blood pressure 100/44 mm Hg

Actions to Take - anticipate the provider to prescribe inotropic medications - prepare the infant for mechanical ventilation Potential Condition - coarctation of the aorta Parameters to Monitor - systemic hypertension - heart failure The nurse should anticipate the provider to prescribe inotropic medications and prepare the infant for mechanical ventilation as a part of preoperative preparation. The infant is most likely experiencing coarctation of the aorta according to the physical assessment findings of bounding pulses in bilateral upper extremities and weak femoral pulses bilaterally. The nurse should monitor the infant for systemic hypertension and heart failure because of potential complications related to the corrective surgical procedure.

A nurse is assisting in the care of a 6-year-old child. Nurses' Notes Admission note: Child presents with caregiver to the emergency department. Left knee is warm to touch, swollen, and reddened. Skin is intact. Child rates pain as a 9 on the Faces Pain Scale of 0 to 10. Child is guarding left leg and has limited movement. Caregiver reports child was limping last night on the way to bed. Caregiver thought child was trying to avoid going to bed, but this morning child was in pain and refusing to walk, so caregiver brought child to the emergency department. Diagnostic Results Hgb: 12.5 g/dL (10 to 15.5 g/dL) Hct: 38% (32% to 44%) Platelets: 280,100/mm3 (150,000 to 400,000/mm3) PT: 11.7 seconds (11 to 12.5 seconds) PTT: 118 seconds (60 to 70 seconds) WBC count: 7600/mm3 (5000 to 10,000/mm3) Factor VIII assay: 28% (55% to 145%) C-reactive protein: 0.75 mg/dL (less than 1.0 mg/dL) X-ray of left leg: No fractures are obs

Actions to Take - apply ice (RICE: Rest, ice, compression, elevation) to the child's left knee - give factor replacement via IV Potential Condition - episode of hemarthrosis Parameters to Monitor - anti-hemophiliac factor - urine dipstick, which will show if blood is present in the urine The nurse should apply ice (RICE: Rest, ice, compression, elevation) to the child's left knee and give factor replacement via IV because this child has hemophilia and is most likely experiencing an episode of hemarthrosis based on the manifestations, the prolonged PTT, and the decreased Factor VIII assay. The nurse should monitor for other spontaneous bleeding episodes such as hematuria that may occur, the urine dipstick, which will show if blood is present in the urine, and the nurse should also continue to monitor the anti-hemophiliac factor (Factor VIII) results. The child may require another dose of the factor replacement to avoid further spontaneous bleeding episodes.

Medical History 7-year-old client with increasing anxiety. Caregiver notes child has regressed in school related work and is unable to complete homework assignments. Recent IQ test revealed IQ level of 80. Noted to exhibit repetitive behaviors, such as lining up all toys in a line across room and repeating phrases heard over and over, according to caregiver. Has a new fascination with flashing lights and insists on touching everything. Not interested in attending play dates with peers. Becomes very annoyed when routine activities are altered. Wants to wear same clothes each morning. Nurses Notes Caregiver in room. Small-framed, thin child sitting in chair while rocking body and swinging legs. Child looking down at floor and will not look at nurse's face. Hesitant to answer questions and is staring at fan in room. Withdraws from physical touch but does want to touch stethoscope.

Actions to Take - assess for history of impaired social interactions - anticipate a prescription for escitalopram Potential Condition - autism spectrum disorder (ASD) Parameters to Monitor - achievement of realistic educational goals - level of anxiety

Nurses' Notes Parent reports the child had expected development until 3 years of age, when they began speaking less, avoiding physical touch, and showing less emotion. Parent reports the child is now withdrawn and does not want to play with other children; repeatedly places toys and shoes in rows; eats only 3 foods (bananas, peanut butter sandwiches, green beans). Child's last physical exam was 3 years ago, at age 2 years. Parent states child does not attend school because they are "not ready." Child is awake and alert but does not respond when spoken to and avoids eye contact with nurse. Child noted to persistently shake both hands and rock back and forth frequently when sitting still. Medical History Child was born at 39 weeks of gestation, vaginal birth without complications. Met all expected growth and developmental milestones during infancy and at last visit at age 2 years, 1 month. Child has received all recom

Actions to Take - assess for manifestations of maltreatment - administer risperidone Potential Condition - Autism spectrum disorder (ASD) Parameters to Monitor - improvement in communication skills - management of aggressive behaviors The nurse should assess for manifestations of maltreatment and administer risperidone because the client is most likely experiencing as evidenced by the client's lack of eye contact, withdrawal from socialization, shaking hands, decreased speech, and avoidance of physical contact. The nurse should monitor the child for improvement in communication skills and management of aggressive behaviors because these findings are goals for treatment.

Medical History Client is a 41-year-old Gravida 4 Para 3 .History of gestational diabetes mellitus, preeclampsia with previous pregnancy, and chronic hypertension for 5 years. Admitted to antepartum unit from provider's office with elevated blood pressure, 3 + edema in lower extremities, 3+ proteinuria. Physical Examination Awake, alert, and oriented to person, place, and time Respirations even and unlabored Pedal pulse strong and regular bilaterally 3+ edema in lower extremities Deep tendon reflexes (DTRs) TR's 3+ with positive clonus Client reports headache, dizziness, and blurred vision for 1 week FHR 140 with minimal variability Diagnostic Results Magnesium level: 8 mg/dL (5 to 8 mg/dL) Hemoglobin: 15 g/dL (12 to 18 g/dL) Hematocrit: 47% (37 to 52%) WBC count: 9, 000/ mm3 (5000 to 10,000/ mm3) Platelet count: 140,000 mm3 (150,000 to 400,000 mm3) Creatinine: 1.3 mg/dL (0.5 to 1.2 mg/dL) BUN: 25 mg/dL (10 to 20 m

Actions to Take - check deep tendon reflexes (DTRs) every hour - implement seizure precautions Potential Condition - preeclampsia Parameters to Monitor - liver function studies - neurological status The nurse should check deep tendon reflexes (DTRs) every hour because the client is most likely experiencing preeclampsia. DTRs reflect the balance between the cerebral cortex and spinal cord. The client's hyperactive DTRs and the nurse should monitor frequently for increase in severity. An increase in severity of DTRs may be an indication of the client progressing to preeclampsia. The nurse should implement seizure precautions because the client has reported headaches, dizziness, and blurred vision for 1 week, which indicates preeclampsia. The nurse should monitor liver function studies and neurological status because these are indications that the client's condition is worsening.

A nurse in a medical clinic is caring for a client. Vital Signs BP: 118/68 mm Hg Heart rate: 74/min Respiratory rate: 16/min Temperature: 37.1° C (98.8° F) tympanic Nurses Notes Client presents for follow-up appointment after an emergency department (ED) visit 1 week ago due to experiencing suicidal thoughts. Client's spouse states that the client has been drinking a bottle of wine each evening for the past few days, which is a new behavior. Clients states they have little energy, decreased appetite, and feel sad. Client and spouse report that about 3 weeks ago the client experienced a period of several days of increased energy, decreased sleep, inability to concentrate, decreased appetite, and spending several hundred dollars shopping. Client states they did not experience hallucinations, delusions, or alterations in speech during this episode. Client's medical history is unremarkable other than laparoscopic chole

Actions to Take - determine if the client has thoughts of harming themselves or others - administer lithium carbonate Potential Condition - bipolar II disorder Parameters to Monitor - weight - sodium intake The nurse should determine if the client has thoughts of harming themselves or others and administer lithium carbonate because the client is most likely experiencing bipolar II disorder. This is evidenced by the client's recently exhibited suicidal ideation, decreased energy and appetite, increased alcohol intake, and recently exhibited manifestations of hypomania. The nurse should monitor the client's weight and sodium intake because hypomania and depression can lead to decreased food intake, which can result in decreased sodium intake. Changes in sodium intake can cause fluctuations in lithium levels, which increases the risk for lithium toxicity.

Nurses Notes Client states, "My anxiety is so bad. I need a pill or something to help me." Client appears disheveled, clothes unwashed, body odor present. Client states they eat about once per day, have no desire to prepare food or perform self-care. Reports they have not been to work for a week and states, "I just don't feel like going." Client also reports they have not left home for the past week because they "just want to be alone." Client says that they hear voices occasionally. Frequent grimacing and blinking noted throughout conversation. Client denies pain or other recent changes in health status. Weight today is 79.8 kg (176 lb) and client states this is 4.5 kg (10 lb) less than their usual weight.

Actions to Take - determine if the client is experiencing command hallucinations - clearly explain expectations for daily hygiene Potential Condition - schizophrenia Parameters to Monitor - daily weight - indications of suicidal ideation The nurse should determine if the client is experiencing command hallucinations and clearly explain expectations for daily hygiene because the client is most likely experiencing schizophrenia as evidenced by auditory hallucinations, poor nutritional intake, poor hygiene, anxiety, social isolation, and grimacing/blinking frequently. The nurse should monitor the client's daily weight and for indications of suicidal ideation because command hallucinations can direct the client to harm themselves or others and because recent weight loss indicates a nutritional deficiency and possible malnutrition.

A nurse is caring for a client who is in the second stage of labor. Medical History 0800: 28-year-old client; G2 P1; at 39 weeks of gestation. Client has history of insulin dependent gestational diabetes mellitus with current pregnancy. Client admitted to the facility in the latent phase of labor at 4 cm, 70% effaced, and -1 station. Nurse's Notes 1300: Client reports need to have a bowel movement. Sterile vaginal examination (SVE) performed; 10 cm, 100% effaced, and +1 station. Fetal heart rate 130's with moderate variability, occasional variable decelerations observed. Provider notified of cervical assessment. Client actively pushing with contractions. 1503: Provider at bedside. Fetal head crowning.

Actions to Take - flex the client's legs against the abdomen - apply suprapubic pressure Potential Condition - dystocia Parameters to Monitor - movement of the newborn's upper extremities - maternal perineum The nurse should flex the client's legs against the abdomen and apply suprapubic pressure because the client is most likely experiencing shoulder dystocia. Flexing the clients legs against the abdomen straightens the maternal pelvis, helping to free the trapped anterior shoulder of the fetus. Applying suprapubic pressure also helps free the anterior shoulder, allowing for birth of the newborn's body. The nurse should monitor the movement of the newborn's upper extremities because newborns who experience a shoulder dystocia are at a greater risk for brachial plexus injuries. The nurse should also monitor the maternal perineum because mothers who experience shoulder dystocia are at a greater risk for trauma to the vagina, perineum, and rectum.

Medical History Client is a 19-year-old primigravida who is at 28 weeks of gestation. Urine reagent strip: 3+ protein Casual blood glucose: 122 mg/dL (74 to -106 mg/dL) Hgb: 15 g/dL (>11 g/dL) Hct: 44% (>33%) Platelet count: 99,000/mm3 (150,000 to -400,00/mm3) BUN: 38 mg/dL (10 to -20 mg/dL) Uric acid: 7.9 mg/dL (2.7 to -7.3 mg/dL) 24 hr urine protein: Pending collection Vital Signs Temperature: 37.1° C (98.8° F) Heart rate: 82/min Respiratory rate: 18/min BP: 164/112 mm Hg Oxygen saturation: 100% on room air Physical Examination Client reports constant headache and vision changes. Rates headache pain a 6 on a 0 to 10 scale, describes as throbbing and unrelieved by acetaminophen and rest. Client has 3+ pitting edema noted in lower extremities. Client reports occasional urinary frequency, denies contractions or backache. Deep tendon reflexes 3+. Client reports a 2.7 kg (6 lb) weight gain in past week. FHR

Actions to Take - initiate an infusion of magnesium sulfate - administer an antihypertensive medication Potential Condition - preeclampsia with severe features Parameters to Monitor - serum magnesium level - check the blood pressure every 15 to 30 min The nurse should initiate an infusion of magnesium sulfate and administer an antihypertensive medication because the client is most likely experiencing preeclampsia with severe features as evidenced by increased blood pressure, vision changes, headache, and proteinuria. The nurse should monitor the serum magnesium level to monitor for magnesium toxicity and check the blood pressure every 15 to 30 min to closely monitor for changes in the client's condition.

A nurse is caring for a school-aged child following surgery for a right upper arm fracture. Diagnostic Results 0600: Radiology: Right humorous spiral fracture. Also noted an old, healed hairline fracture to same arm. CT scan: Thymus gland appears normal size Nurses Notes 0900: Client returned from surgery for open reduction and internal fixation at 0840 oriented to place, person, and time. Reports a pain level of 0 on a pain scale from 0 to 10. When asked how the client broke their arm, the client paused, looked at both parents and stated, "I tripped over my dog. My parents say I am clumsy a lot." Client does not wear glasses. Last eye exam unknown. 1200: Parent returned to client's room after lunch slurring words, stumbling, yelling, smelling of alcohol and demanding to discharge child. Provider notified and security called for standby.

Actions to Take - interview the child separately from the parents - ask the parents about the scars and the old fracture noted Potential Condition - physical maltreatment Parameters to Monitor - signs from the child of fear or apprehension around either parent - negative comments about the child The nurse should interview the child separately from the parents and ask the parents about the scars and the old fracture noted because the child is most likely experiencing physical maltreatment due to injuries that are typical of maltreatment along with a history of injuries that do not all have explanations that make sense. A parent who abuses substances is also a risk factor for child maltreatment. The nurse should monitor for signs from the child of fear or apprehension around either parent and note if either parent makes negative comments about the child, because these are also signs of child maltreatment and should be documented in the medical record.

A nurse is caring for a 40-year-old client in a transplant unit. Nurses' Notes 40-year-old client is 2 days post-op following a renal transplant. Client alert and oriented x3. Sitting in high Fowler's. Skin warm and dry. Client reports pain at incision site as 5 on a scale of 0 to 10. Incision approximated, sutures intact. No drainage noted. Heart sounds regular. Lung sounds diminished throughout. Instructed to use incentive spirometer. Abdomen soft and non-distended. Bowel sounds hypoactive x4. 1+ peripheral edema noted bilaterally. Foley catheter patent, urine pink tinged. Urine output in last hour 1500mL. Vital Signs Temperature 37.7° C (99.8° F) Heart rate 110/min Respiration rate 24/min BP 94/56 mm Hg Oxygen saturation 96% on room air

Actions to Take - lower the head of the client's bed - obtain a prescription to administer an IV bolus Potential Condition - hypovolemia Parameters to Monitor - urinary output - blood pressure The nurse should lower the head of the client's bed and obtain a prescription to administer an IV bolus because the client is most likely hypovolemic due to their excessive urinary output. Clients may have diuresis following their transplant. Manifestations of hypovolemia include increased heart rate, decreased blood pressure, weak peripheral pulses, increased respiratory rate, dry mucous membranes, changes in cognition, and concentrated urine. The nurse should monitor the client's urinary output and blood pressure along with their heart rate. A client who is experiencing hypovolemia can experience dysrhythmias, along with orthostatic hypotension. The nurse should monitor the client's urinary output because decreased fluid volume leads to decreased perfusion.

Nurses Notes 1200: Client is 2 hr postoperative transurethral resection of prostate (TURP). Drowsy but responds to verbal stimuli. Reports having the urge to urinate. Abdomen distended, slightly firm to palpitation. Continuous bladder irrigation is patent and infusing slowly. Indwelling urinary catheter is patent with a small amount of dark burgundy urine with small clots present. Continuous bladder infusion rate increased. Lungs clear upon auscultation. Heart sounds are regular. No peripheral edema noted. In the last 2 hr, total intake is 1,200 mL and total output is 1,050 mL. 1300: Client is awake and restless. Continues to report the urge to urinate. Reporting spasmodic pain to lower abdomen. Abdomen is distended and firm to palpation. Continuous bladder irrigation continues at an increased rate. Urinary output is 45 mL in the last hour; color of urine is burgundy with several moderate-size clots.

Actions to Take - medicate the client for bladder spasms - irrigate the urinary catheter Potential Condition - obstructed urinary catheter Parameters to Monitor - urine output - hemoglobin and hematocrit The nurse should medicate the client for bladder spasms and irrigate the urinary catheter because the client is most likely experiencing an obstructed urinary catheter. Clots and tissue debris can pass through and block the flow of urine through the catheter. If the urinary catheter becomes obstructed, the nurse should irrigate the indwelling catheter to maintain the flow of irrigation and urine. The nurse should also medicate the client for bladder spasms that can occur as a result of obstruction of the catheter. The nurse should closely monitor the client's urine output to ensure that further obstruction to the catheter does not occur. The nurse should also frequently monitor the client's blood pressure and pulse to detect if bleeding is occurring because this is a risk factor of a TURP procedure. The nurse should monitor the client's hemoglobin and hematocrit levels and urine output because a complication of a transurethral resection of the prostate is bleeding from bladder spasms or movement. Also, the nurse should monitor the color, consistency, and amount of the client's output to detect any further obstruction and bleeding.

A nurse is caring for a 45-year-old client in the emergency department. Nurses' Notes Admitted to the emergency accompanied by partner. Alert and oriented x3. Skin warm and dry, no discoloration noted. Client reports substernal chest pain that radiates to the left shoulder and neck. Rates pain as 8 on a scale of 0 to 10. Pain increases with aspiration and when lying down. Client reports decreased pain when sitting upright and leaning forward. Heart sounds regular with a pericardial friction rub auscultated left lower sternal border. Lungs clear to auscultation with occasional non-productive cough. No peripheral edema noted. Vital Signs Temperature 38.3° C (101° F) Heart rate 100/min Respiration rate 20/min BP 128/82 mm Hg Oxygen saturation 98% on room air

Actions to Take - obtain an echocardiogram - obtain a prescription for an NSAID such as ibuprofen Potential Condition - pericarditis Parameters to Monitor - pain level - pulsus paradoxus The nurse should obtain an echocardiogram and obtain a prescription for an NSAID such as ibuprofen because the client is most likely experiencing pericarditis due a respiratory infection. The nurse should monitor the client's pain as well as for pulsus paradoxus (a systolic blood pressure increase of > 10 mm Hg during inspiration) which is a manifestation of cardiac tamponade and is a medical emergency.

Medical History Client states that they began having shortness of breath while walking their dog this morning. Client then attempted to lay down to rest but was unable to breathe in the recumbent position. Client later reported dizziness when standing, fatigue, and had difficulty ambulating. Past medical history: Coronary artery disease; myocardial infarction 2 years ago with stent placement Hypertension Type 2 diabetes mellitus Former smoker, quit 2 years ago Sleep apnea

Actions to Take - obtain the client's weight as a baseline - prepare to administer a diuretic medication Potential Condition - heart failure Parameters to Monitor - client's BNP level - pulmonary edema The nurse should obtain the client's weight as a baseline and prepare to administer a diuretic medication because the client is most likely experiencing heart failure. Weight is the most sensitive indicator of fluid loss or gain and should be monitored daily for a client who has heart failure and is receiving a diuretic medication. The nurse should monitor the client's BNP level as this is a definitive diagnosis for heart failure and the levels will direct treatment. The nurse should also monitor the client for complications of heart failure, such as pulmonary edema, which can be life threatening.

A nurse is caring for a client who is 31 weeks of gestation. Medical History Client is 31 weeks of gestation, gravida 1. Admitted from the provider's office with a history of a low-lying placenta and active vaginal bleeding for 1 hr. There was a history of spotting at 12 weeks of gestation. Client was placed on bed rest for 2 months with pelvic rest. Nurses Notes 0830: Client is admitted from provider's office. Client is at 31 weeks of gestation and reports active vaginal bleeding for the last hour. The client is admitted to the labor and birth unit. Abdomen is soft and nontender. The client denies abdominal pain. Perineal pad is saturated with bright red vaginal bleeding. Fetal heart tones 180/min (110 to 160 beats/min) with minimal variability and occasional late decelerations noted. Fundal height is 30 cm. Blood drawn for type and cross match.

Actions to Take - perform continuous fetal and contraction monitoring - prepare the client for a cesarean birth Potential Condition - placenta previa Parameters to Monitor - uterine activity (contraction) - for postpartum hemorrhage with a firm fundus The nurse should perform continuous fetal and contraction monitoring and prepare the client for a cesarean birth because the client is most likely experiencing placenta previa. The client is at risk for hypovolemic shock because of significant blood loss, and the well-being of the fetus is at risk. The nurse should monitor the client's uterine activity and for postpartum hemorrhage with a firm fundus because increased uterine activity places the fetus at risk for hypoxia. After surgery, the client's fundus might be firm, but because decreased muscle bundles in the lower uterus are absent, the client might still experience postpartum hemorrhage.

Laboratory Results 1030: Sodium 129 mEq/L (child: 136 to 145 mEq/L) Potassium 3.7 mEq/L (child: 3.4 to 4.7 mEq/L) CO2 17mEq/L (child: 20 to 28 mEq/L Chloride 84 mEq/L (child: 90 to 110 mEq/L) Vital Sign 1000: Weight 20 kg (44 lb) Temperature 37.1°C (98.8 °F) Heart rate 128/min Respiratory rate 36/min Blood pressure 72/52 mm Hg (left arm) 1040: Heart rate 120/min Respiratory rate 32/min Nurses' Notes 1000: The caregiver reports 6-year-old child has been vomiting for two days and has abdominal pain. This morning the child reported feeling very weak and a headache which they rated a 4 on the FACES pain rating scale. Upon physical examination, child is sleepy but arousable, reports feeling tired. Respirations rapid and deep, unlabored. Heart rate regular without murmur. Skin turgor non-elastic, capillary refill 5 seconds.

Actions to Take - place the child on a cardiac monitor - determine urine output Potential Condition - diabetic ketoacidosis (DKA) Parameters to Monitor - cardiac arrhythmia - urinary output Upon recognizing and analyzing the child cues of vomiting without diarrhea, hyponatremia, acidosis, dehydration, and deep, rapid respirations, the nurse's priority hypothesis is that this child is most likely experiencing diabetic ketoacidosis (DKA). It is important for the nurse to generate solutions and take actions that will improve electrolyte imbalance and hydration and will prevent complications from further electrolyte imbalance (particularly potassium). Therefore, the nurse should place the child on a cardiac monitor and determine urine output as polyuria often occurs with initial diagnosis of type 1 diabetes mellitus as is DKA. With rehydration hypokalemia may occur resulting in critical cardiac. To evaluate these interventions the nurse should monitor the client's electrolytes and urinary output. The nurse monitors the child's urinary output to determine kidney function because the urinary output should be at least 25 mL/hr. Additionally, the nurse should also monitor for cardiac arrhythmia occurring with possible hypokalemia during the rehydration phase.

A nurse is caring for a newborn who was born 6 hr ago. Maternal: Age: 30 Gravida 2, Para 2 Primary elective cesarean birth at 36 4/7 weeks of gestation α-fetoprotein: Positive Medical History: Unremarkable Surgical history: None Group B Streptococcus ß-hemolytic: Positive Newborn: APGAR scores: 6 and 7 (at 1 min and 5 min) Weight: 2495 grams (5 lb 8 oz) Length: 48 cm (18.9 in) Physical Examination Skin warm, dry. Color consistent with genetic background. Mild amount of lanugo noted. Head circumference 34 cm (13.4 inches). Sutures palpable and separated. Anterior and posterior fontanel flat and soft. Eyes evenly spaced with pupils that are equal, round, reactive to light and accommodation. Chest barrel shaped with symmetric respiratory movements. No retractions noted. Abdomen soft, rounded, nondistended. Umbilical cord clamped, no herniations noted. Extremities symmetrical with full range of motion. Spine even. 2 c

Actions to Take - place the newborn in a prone position - apply a non-adhering saline moist compress Potential Condition - meningocele Parameters to Monitor - newborn's head circumference - manifestations of cerebrospinal fluid leakage

0700 Received client awake, alert, and oriented x 3. Respiration even and unlabored. Breath sounds clear. Bowel sounds absent in all quadrants. Upper abdominal distention with visible peristaltic waves observed in center of abdomen. Client states, "that pain that started yesterday keeps getting worse; it's not the same pain from the surgery." Client reports the pain is constant and is 8 on a 0 to 10 pain scale in their abdomen described as dull, cramping, and achy. Client states surgical wound is causing no pain. "I'm not passing gas, and I'm very bloated." Client reports mild nausea and poor appetite. Provider notified of findings. 0800: Hemoglobin: 18.5 g/dL (14-18 g/dL) Hematocrit: 55% (40%-52%) Creatinine: 1.4 mg/dL (0.5-1.1 mg/dL) Sodium: 134 mEq/L (136-145 mEq/L) Potassium: 3.4 mEq/L (3.5-5 mEq/L)

Actions to Take - placing the client on NPO status - have a nasogastric tube (NGT) inserted Potential Condition - paralytic ileus Parameters to Monitor - serum sodium - potassium Upon recognizing and analyzing the client cues of post hernia repair, signs of dehydration, decreased bowel sounds, and CT scan results, the priority hypotheses is that this client is most likely experiencing a paralytic ileus. It is important to generate solutions and take actions that will reduce the risk of life-threatening complications. In addition to placing the client on NPO status, the provider will prescribe for the client to have a nasogastric tube (NGT) inserted to decompress the bowel by draining fluid and air. The NG tube is attached to suction. To evaluate outcomes, the nurse should monitor the client's serum sodium and potassium which may be imbalanced because of the client's NPO status and possible paralytic ileus. The nurse should also monitor the client for a change in the type of pain the client may experience. A change from intermittent to constant pain should be reported to the provider immediately as this could be indicative of intestinal perforation or peritonitis.

Nurses' Notes 1100 : Child seen today for 24-month well child visit. Guardians report that child has been listless the past few weeks. Takes 1-2 naps per day Child has had low-grade fever intermittently for the past 4 days. Child has had decreased PO intake last bowel movement this morning. Child appears tired, skin warm to touch and pallor noted, clinging to guardian throughout exam. No rashes noted, moves all extremities without difficulty. Lungs clear, heart rate regular, peripheral pulses strong in all extremities. Immunizations are up to date Provider ordered lab work at outpatient center. Guardians will bring child this afternoon. Diagnostic Results 1400 : Hgb 10.6 g/dl Hct 31% RBC count 3.5 million/mm³ Platelet count 300,000/mm3 WBC count 10.8 million/mm³ (expected reference range 150,000-400,000/mm3)

Actions to Take - prepare the child for an MRI - prepare the child for a transfusion of packed red blood cells. (or need chelation therapy to remove excess iron from their blood) Potential Condition - beta thalassemia Parameters to Monitor - Height and weight - (can't find the answer) The child has beta thalassemia. The nurse should prepare the child for a transfusion of packed red blood cells. This is the main treatment for this condition. Due to chronic red blood cell transfusions, the child will need chelation therapy to remove excess iron from their blood. The nurse should prepare the child for an MRI to evaluate the iron content of the liver, heart. Due to the chronic hypoxemia that beta thalassemia causes, growth retardation and delayed sexual maturity are common. Sexual maturity and height should be monitored to promote healthy growth and development.

A nurse in an outpatient clinic is assessing a 4-year-old child. Nurses' Notes Guardians report within the last 2 weeks, child has had three episodes of acute onset of abdominal pain. During the episodes, child brings knees to chest and cries in pain. Episodes resolve on their own. Child has had 2 bowel movements that are dark red with mucus. Physical Examination Child is apprehensive but cooperative. Rates pain as 4 on faces pain scale. Lungs are clear bilateral. Heart rate regular. Abdomen distended and tender to touch. Bowel sounds active in all 4 quadrants. Sausage shaped mass noted in RUQ of abdomen. Full range of motion to all extremities. Vital Signs Axillary Temperature: 37.1°C (98.8°F) Heart rate: 110/min Respiratory rate: 22/min

Actions to Take - prepare the child for ultrasound - educate the guardians about hydrostatic enema Potential Condition - intussusception Parameters to Monitor - bowels sounds - bowel movements (stool color, pattern, and consistency) The nurse should prepare the child for ultrasound and educate the guardians about hydrostatic enema because the child is most likely experiencing intussusception because of the abdominal pain and tenderness and a sausage shaped mass in the RUQ. The nurse should monitor the child's bowels sounds and bowel movements after the procedure to ensure that therapy has been effective.

A nurse is caring for a client on the medical-surgical floor. Medical history Hypertension, atrial fibrillation Current Medications lisinopril 40mg PO daily, warfarin 2.5 mg PO daily The client is in no acute distress. Oropharynx clear, mucous membranes moist, breath sounds clear bilaterally. Heart rate with regular rhythm and no murmur. CN II-XII intact, no weakness. WBC 11,000 mm3 (5,000 to 10,00mm3) Urinalysis Appearance clear Color dark amber pH 6 (4.6 to 8) Protein 2 mg/dL (0 to 8 mg/dL) Leukocyte esterase positive Nitrites positive Ketones none Bilirubin none Blood positive INR: 4.9 (0.8 to 1.1) 0930: Temperature 37.2˚C (98.9˚F) Heart Rate 62/min Respiratory Rate 19/min Blood Pressure 159/83 mmHg SaO2 93% on room air

Actions to Take - prepare the client for a STAT CT brain - place the client on seizure precautions Potential Condition - hemorrhagic stroke Parameters to Monitor - blood pressure - PT/INR Upon recognizing and analyzing the cues of the client stating, "You've got to help, something is wrong; this is the worst headache of my life," ringing in the ears, photophobia, and left-sided weakness. They deny facial pain. Followed by nursing observations of client crying with aphasia and left-sided upper and lower extremity weakness, the nurse's priority hypotheses is that this client is most likely experiencing a hemorrhagic stroke. It is important to generate solutions and take actions to care for the client's emergent needs. Therefore, the nurse should prepare the client for a STAT CT brain and place the client on seizure precautions. To evaluate these interventions, the nurse should monitor the client's blood pressure and PT/INR.

A nurse in a provider's office is caring for a 34-year-old client. Medical History 34-year-old for follow-up appointment after bariatric surgery one week ago. Client states they have been "vomiting after eating" for 3 days. States they have developed back and abdominal pain that has been worsening since the vomiting started. Client has a history of hypertension and cholecystitis Vital Signs Temperature 37.8° C (101.8° F) Heart rate 128/min Respiration rate 20/min BP 114/72 mm Hg Oxygen saturation 98% on room air Nurses' Notes Alert and oriented x3. Skin warm. Mucous membranes dry. Pallor noted in nails and mucous membranes. Heart sounds moderate and regular. Lung sounds clear to auscultation but diminished throughout. Abdomen rigid with hypoactive bowel sounds present. Client reports abdominal pain upon palpation and nausea along with back pain. Rates pain as 8 on a scale of 0 to 10. States urine output has decr

Actions to Take - prepare the client for laboratory tests, including a WBC count, - abdominal x-ray Potential Condition - anastomotic leak Parameters to Monitor - heart rate - urine output The nurse should prepare the client for laboratory tests, including a WBC count, and an abdominal x-ray because the client is most likely experiencing an anastomotic leak causing peritonitis. An anastomotic leak is a leak of digestive juices and partially digested food through the anastomosis causing the client pain. This can be detected on an abdominal x-ray and infection is indicated by an elevated WBC. Manifestations include increasing back, shoulder, or abdominal pain; restlessness; unexplained tachycardia; and oliguria. The nurse should monitor the client's heart rate and urine output because, due to anastomotic leak and resulting peritonitis, the client can develop manifestations of sepsis and septic shock, which can lead to death.

Admission Assessment Day 1 0900: A client was admitted to the medical-surgical floor for treatment of a urinary tract infection. They reported urinary frequency, urgency, and burning for the last week. S1, S2 heart sounds heard. Lung sounds clear to auscultation bilaterally. Skin is warm and dry. Medications were prescribed and administered. Client has a history of hypertension and diabetes. 1230: A nurse returns to check on the client. They state, "things are getting worse." The client appears uncomfortable and anxious. Mucous membranes are tender. Skin has generalized erythema, a few large flaccid bullae noted to the upper extremities, skin very tender to palpation. Nurse notified provider with update on client's condition. Temperature 101.1˚F (38.4˚C) Heart Rate 92/min Respiratory Rate 22/min Blood Pressure 142/89 mm Hg

Actions to Take - prepare to administer IV fluids - discontinue the offending agent (trimethoprim/sulfamethoxazole) Potential Condition - Steven-Johnson Syndrome Parameters to Monitor - serum electrolytes - temperature Upon recognizing and analyzing the cues of a client who is receiving a sulfa-based medication with an onset of painful mucous membranes, diffuse erythema, tender skin, flaccid bullae, and fever, the nurse's priority hypotheses is that this client is most likely experiencing Steven-Johnson Syndrome. It is important to generate solutions and take actions that maintain fluid and electrolyte balance. Therefore, the nurse should immediately discontinue the offending agent (trimethoprim/sulfamethoxazole) and prepare to administer IV fluids. To evaluate these interventions the nurse should monitor the client's serum electrolytes and body temperature. The client may lose significant areas of the skin which can affect electrolyte levels as well as, thermoregulation' therefore body temperature should also be monitored.

History and Physical 0800: Past Medical History: Hypertension, obstructive sleep apnea Social History: Smoked for 1ppd for 30 years; however, stopped smoking 3 years ago. Denies use or alcohol. 1000: Blood Pressure: 165/91 mmHg Heart Rate: 118/min Respiratory Rate: 20/min Temperature: 98.6 °F (37 °C)

Actions to Take - prepare to administer IV heparin - send the client promptly for a lower extremity doppler to confirm the diagnosis Potential Condition - arterial thrombosis Parameters to Monitor - aPTT - platelet count Upon recognizing and analyzing the client clues of acute pain, pallor, paresthesia, and decreased pulses, the nurse's priority hypotheses is that the client is most likely experiencing an arterial thrombosis brought on by a new-onset atrial fibrillation and that it is important to generate solutions and take actions that will restore blood flow. The nurse should prepare to administer IV heparin and to send the client promptly for a lower extremity doppler to confirm the diagnosis. To evaluate these interventions, the nurse should monitor the aPTT and platelet count. The aPTT will need to be monitored during heparin administration as well as platelet counts to monitor for bleeding.

A nurse is caring for a client on the medical-surgical unit. Day 2 0700: The client requests medication "to help with diarrhea." Client states they have not had any nausea or vomiting since yesterday, but states "I have had four loose stools in the last few hours." They rate abdominal pain 2 on 0-10 pain scale. No abdominal guarding. Chvostek sign present and positive Trousseau sign. Provider notified. Laboratory Results Day 1: 1200: Serum amylase 680 units/L (60 to 120 units/L) Serum lipase 300 units/L (0 to 160 units/L) Calcium 9.0 mg/dL (9 to 10.5 mg/dL) Magnesium 1.8 mEq/L (1.3 to 2.1 mEq/L) Potassium 5.0 mEq/L (3.5 to 5 mEq/L) Sodium 144 mEq/L (136 to 145 mEq/L)

Actions to Take - prepare to check a serum albumin - initiate seizure precautions Potential Condition - hypocalcemia Parameters to Monitor - bowel sounds - signs of impaired memory Upon recognizing and analyzing the client cues of acute pancreatitis and a history of end-stage renal disease with new-onset diarrhea and positive Chvostek and Trousseau signs, the nurse's priority hypotheses is that the potential condition this client can be experiencing is hypocalcemia. It is important to generate solutions and take actions that will ensure client safety and further evaluate the validity and cause of the hypocalcemia. Therefore, the nurse should prepare to check a serum albumin and (initiate seizure precautions because hypocalcemia can increase irritability of the central and peripheral nervous systems and cause seizure activity. To evaluate these interventions the nurse should monitor the client's bowel sounds and any signs of impaired memory. Hypocalcemia can cause impaired memory, confusion, and delirium as well as hyperactive bowel sounds.

Oropharynx clear, mucous membranes dry. No tenderness noted to McBurney's point, no rebound or guarding. Hyperactive bowel sounds noted. Right lower extremity minimally red with no tenderness or warmth to palpation. Client states that abdominal cramping and pain started yesterday evening. Client states that they have "been up pooping and haven't been able to stop having bowel movements since. I have been going about every thirty minutes, all night. Can you give me something to slow it down? I've never had diarrhea like this before." 0800 Blood Pressure 105/68 mm Hg Heart Rate 82/min Respiratory Rate 18/min Temperature 100.9 °F (38.3 °C) Weight 199 pounds (90.5 kg) Height 71 inches (180.3 cm) BMI 27.75 kg/m2

Actions to Take - prepare to start IV fluids - place the client on contact precautions Potential Condition - C. difficile colitis Parameters to Monitor - serum potassium - HYPOTENSION (for signs of volume depletion (hypotension)) Upon recognizing and analyzing the client cues of abdominal pain and acute onset of diarrhea after the administration of a high dose IV antibiotics, the nurse's priority hypotheses is that this client is most likely experiencing C. difficile colitis. It is important to generate solutions and take actions that will protect others from infection and treat the symptoms of volume depletion caused by diarrhea. Therefore, the nurse should prepare to start IV fluids and place the client on contact precautions. To evaluate therapy, the nurse should monitor the client's serum potassium and for signs of volume depletion (hypotension) as these can be a consequence of severe diarrhea.

A nurse in the emergency department is caring for a client. Medical History Client works for an international relief agency, reports returning from a month-long assignment in Central America 2 weeks ago. While in Central America, the client participated in recovery of an area recently devasted by a hurricane. No significant health history. Takes no medications. Reports no alcohol or substance use. Runs 5 miles "most days of the week." Follows a vegan diet. Family history significant for arthritis and hypertension Physical Examination Client is brought to the ED with report of headache, abdominal pain, myalgia, and nausea and vomiting for the past 3 days. States they are experiencing indigestion even though they have not felt like eating in days. Reports dark urine. Skin and sclera appear mildly jaundiced and abdomen appears enlarged and is tender to palpation. Client has mild fever, tachycardia, tachypnea, and hypo

Actions to Take - provide the client with a high-calorie/high-carbohydrate diet - promote rest with a gradual increase of activity Potential Condition - hepatitis A. Parameters to Monitor - liver enzymes - bilirubin (Amylase and lipase level) The nurse should provide the client with a high-calorie/high-carbohydrate diet and promote rest with a gradual increase of activity because the client is most likely experiencing hepatitis A. The client's history indicates travel outside of the United States and hepatitis A is more prevalent in countries with overcrowding and poor sanitation. Rest will allow the liver to heal and restore proper metabolism. Small, frequent feedings of a high-calorie/high-carbohydrate diet will sustain the client's nutritional needs. Moderate amounts of protein and fat should be added to the diet after the client's nausea and vomiting have subsided. The nurse should monitor the client's liver enzymes and bilirubin because the client has signs of jaundice, which could lead to liver damage. The nurse should also monitor for manifestations of fluid volume deficit because the client has been experiencing vomiting and diarrhea for several days.

A nurse is caring for a 64-year-old client in an emergency department. Nurses Notes Client presents with report of sudden onset of dyspnea and sharp chest pain. Respirations labored with crackles auscultated throughout lung fields. Dry cough present. Skin is cool and moist. Heart sounds are moderate and regular. Jugular vein distention noted. Abdomen is soft, nondistended with active bowel sounds in all four quadrants. 1+ peripheral edema noted. Peripheral pulses are moderate. Client is restless and anxious. Medical History Client states that they just returned from trip to Hawaii with family. Client reports experiencing gastrointestinal influenza-like symptoms for 1 day on the trip. Vital Signs Temperature 38° C (100.4° F) Apical pulse rate 116/min Respiratory rate 26/min Blood pressure 100/64 mm Hg Oxygen saturation 90% on room air

Actions to Take - request a D-dimer - apply oxygen Potential Condition - pulmonary embolism Parameters to Monitor - client's pulse oximetry - partial thromboplastin time The nurse should request a D-dimer and apply oxygen because the client is most likely experiencing a pulmonary embolism because the client has had a sudden onset of dyspnea with pleuritic (sharp) chest pain along with hypotension after returning from a trip. Due to a decreased gas exchange, the client needs oxygen applied. A D-dimer needs to be drawn to assist with diagnosing a pulmonary embolism. The nurse should monitor the client's pulse oximetry and partial thromboplastin time because a client who has a pulmonary embolism display manifestations of decreased gas exchange and decreased tissue perfusion. Treatment for a pulmonary embolism includes drug therapy with an anticoagulant, such as unfractionated heparin, low-molecular-weight heparin, or fondaparinux. The client's partial thromboplastin time is drawn before anticoagulant therapy is started and throughout therapy per facility policy.

A nurse in an outpatient clinic is caring for a client who has major depressive disorder. Medical History Client presents with continued feelings of depression and anxiety that have been nonresponsive to psychotherapy. Admits to feelings of helplessness and powerlessness. Lacks energy and has trouble sleeping at night but does doze off during the day. New onset of heartburn. Recently started on amitriptyline 75 mg twice daily. Will evaluate for potential change in dosage.

Actions to Take - should assess BP lying, sitting, and standing - educate client to take medication at bedtime Potential Condition - anticholinergic adverse effects Parameters to Monitor - fall risks - suicidal thoughts to ensure client safety The nurse should assess BP lying, sitting, and standing and educate client to take medication at bedtime because the client is most likely experiencing anticholinergic adverse effects from the medication amitriptyline, a tricyclic antidepressant (TCA). TCAs can cause orthostatic hypotension and tachycardia, which could lead to dizziness and falls. Educating the client to take the medication at bedtime, especially when dosages are increased, can assist with sleeping as well as minimizing adverse effects, such as dizziness and sedation, during waking hours, thereby minimizing risks to the client. The nurse should monitor the client's fall risks and suicidal thoughts to ensure client safety. Evaluating the client for orthostatic hypotension and educating the client to rise from a sitting or lying position slowly will help to avoid falls. Clients should be evaluated for suicidal thoughts during the initial period of therapy and amount of medication restricted to prevent a potential overdose.

Nurses' Notes Client received to emergency department from home via private vehicle. Reports fatigue, blurred vision, dizziness, and headache x 2 days. Reports running out of blood glucose strips and Humulin regular insulin due to lack of financial means. States that they are afraid of possible falls from fatigue and dizziness. Lives at home alone. Orders received; will increase glargine from 20 units to 25 units at bedtime. Other meds taken at home remain the same at this time. Diagnostic Results HbA1c 8.4% (less than 7% for diabetics) Blood glucose 235 mg/dL (74 to 106 mg/dL) Hemoglobin 14.2 g/dL (12 to 18 g/dL) Hematocrit 42.6% (37 to 52%) Total WBC count 6000/mm3 (5000 to 10,000/mm3) HDL 75 mg/dL (greater than 55 mg/dL) LDL 124 mg/dL (less than 130 mg/dL) BNP 52 pg/ml (less than 100 pg/mL) Chest x-ray: Clear. No evidence of infiltrates.

Actions to Take - teach the client signs of hyperglycemia - assess their feet for sensation Potential Condition - type 1 diabetes mellitus Parameters to Monitor - urinary output - fingerstick blood glucose The nurse should teach the client signs of hyperglycemia and assess their feet for sensation because the client is most likely experience type 1 diabetes mellitus because the HgA1c is elevated to a level indicating only fair diabetic control and the fingerstick blood glucose level is high, which is indicative of diabetes. The nurse will need to assess for the potential diabetic complication of peripheral neuropathy in the feet. The nurse should monitor urinary output and fingerstick blood glucose. This will allow the nurse to determine whether the medication and diet are effective in controlling the client's glucose levels.

Nurses' Notes 1015:Client presents to clinic and reports flu-like symptoms of fatigue, fever, chills, and sore throat.Client reports they have been compliant with clozapine therapy. Diagnostic Results Casual blood glucose 115 mg/dL (less than 200 mg/dL) WBC count 3,000/mm3 (5,000 to 10,000/mm3)ANC count 1,500/mm3 (2,500 to 8,000/mm3) Medical History Client diagnosed with schizophrenia 3 years ago, began clozapine 150 mg PO BID 6 months ago Baseline findings prior to initiation of clozapine therapy: Weight 83.9 kg (185 lb) BMI 27.3 Casual blood glucose 138 mg/dL (less than 200 mg/dL) WBC count 7,000/mm3 (5,000 to 10,000/mm3) Absolute neutrophil count (ANC) 5,000/mm3 (2,500 to 8,000/mm3) The client is at risk for developing as evidenced by the client's

Agranulocytosis is correct. Agranulocytosis is a potential adverse effect of antipsychotic medications, such as clozapine. Manifestations include flu-like symptoms and a reduced neutrophil count. Mild neutropenia occurs at an ANC level of 1,000 to 1,499/mm3. The client has manifestations of infection and has a reduced ANC level, placing them at risk for agranulocytosis. ANC count is correct. Mild neutropenia occurs at an ANC level of 1,000 to 1,499/mm3. The client is experiencing manifestations of infection and has a reduced ANC level, placing them at risk for agranulocytosis.

Medical History 4 days after 2-week wellness visit: Ultrasound confirms developmental dysplasia of the hip (DDH). Parent is notified and is to return to office with infant to learn the use of a Pavlik harness. Harness should be worn as much as possible but may be removed for baths. Harness has been ordered from manufacturer. Upon arrival of harness, arrange for parent to come to office for teaching. Which of the following instructions should the nurse plan to include when teaching the parents about the Pavlik harness?The nurse should include and in the teaching plan for the parents.

Always place the diaper under the straps is correct. Placing the diaper under the straps prevent the straps from becoming wet or soiled which would increase the risk of skin irritation. Gently massage intact skin under the straps once a day is correct. The parent should be instructed to massage intact skin under the straps once a day to promote circulation to the area and prevent skin breakdown.

Diagnostic Results 2145: β-hCG: 2,000 IU/L (< 25 IU/L) Hemoglobin: 8 mg/dL (expected value 12-16 g/dL; pregnant females >11 g/dL) Hematocrit: 24 % (37-47%) WBC: 9,000/mm3 (expected value 5,000-10,000 mm3) Platelets: 200,000/mm3 (150,000-400,000/mm3) Blood Type A negative 2200: Temperature 36.9° C (99.2° F) Heart rate 120/min Respirations 24/min Blood Pressure 100/62 mm Hg Pulse oximeter 92% Physical Examination 2200: Client pale, clammy, and restless. Large amount of vaginal bleeding observed with clots present. Peripheral pulses weak. The priority prescription for the nurse to implement is followed by

Apply oxygen per nonrebreather mask at 10 L/min to maintain oxygen saturation ≥ 95% is correct. This client's oxygen saturation has decreased from 98% to 92% in one hour. The client is pale, clammy, restless, and has had an increase in their respiratory rate. All of these are manifestations of hypoxia; therefore, using the ABC priority-setting framework, the nurse should apply oxygen per nonrebreather mask at 10 L/min. Bolus 1,000 mL lactated Ringer's is correct. The client has experienced a significant amount of blood loss as indicated by the client's physical assessment findings, changes in vital signs, and diagnostic results. Therefore, using the ABC-priority setting framework, the next step the nurse should take is bolus 1,000 mL of lactated Ringer's to increase the client's fluid volume status and promote adequate cardiac output.

A nurse is caring for a client who has a central venous access device (CVAD). Nurses' Notes 0900:Client returned from interventional radiology (IR) following peripherally inserted central catheter (PICC) line placement in the right arm. Placement confirmed in IR. PICC line is secured with a securement device. Site is covered with transparent dressing, no catheter visible. Dressing dry and intact. 0.9% sodium chloride infusion initiated at 150 mL/hr. 1200:Client is sitting in chair following a session with physical therapy. Transparent dressing over PICC line noted to be partially off. Approximately 2 cm of catheter noted from insertion site to hub. Small amount of serosanguinous drainage noted at insertion site. The client is most likely experiencing The nurse should

Catheter dislodgement is correct. The client has just had physical therapy and might have been moving the limb during therapy. The dressing over the PICC line has been disturbed and there is catheter visible, indicating that the catheter has been dislodged. Stop the infusion is correct. The nurse should stop the infusion until placement of the PICC line can be confirmed. Due to the dislodgement, the catheter might be in the wrong location, which could lead to complications of IV infusion therapy.

A nurse is caring for a 22-year-old female client who reports lower abdominal and pelvic pain. 1000: Provider at bedside. Pelvic examination performed, cervical cultures obtained and sent to the laboratory. Scheduled client to return to clinic in 1 week for results. Instructed not to have any type of sexual contact until result are received. Client verbalized understanding and consent. 1 Week After Initial Visit, 1100: Client returned to clinic for test results and was notified that both gonorrhea and chlamydia cultures are positive. Antibiotics administered. See medication administration record (MAR).

Condition Pelvic inflammatory disease (PID) is correct. Several factors increase a client's risk for developing PID. These factors include being female and less than 25 years of age, having multiple sexual partners, having a history of sexually transmitted infections and PID, and never having been pregnant. The nurse should recognize that the client is at risk for developing PID and should counsel the client about the potential adverse effects of PID including infertility and ectopic pregnancy. Finding Recurring STI's is correct. Several factors increase a client's risk for developing PID. These factors include being female and less than 25 years of age, having multiple sexual partners, a history of sexually transmitted infections and PID, and never having been pregnant. The nurse should recognize that the client is a risk for developing PID and should counsel the client about the potential adverse effects consequences of PID including infertility and ectopic pregnancy.

A nurse is caring for a client who has received a terminal diagnosis. Day 1 0930: Client is sitting on side of bed with daughter at bedside. Client is tearful and states that they believe the diagnosis they received is incorrect and that lab results sent to their provider were not theirs. Day 3 1130: Client is in bed and struggling to prepare their breakfast tray. Client asks the nurse, "Why is this happening to me? I have always been healthy." The client refuses all medications and care. Provider notified. The nurse identifies that the client is currently in Kübler-Ross's _______________________ stage of grief as evidenced by _______________________

Condition: Anger is correct. By day 3, the client is exhibiting manifestations that typically occur in the anger stage of Kübler-Ross's stages of grief. In this stage, the client is prepared to acknowledge their illness, becomes sad, blames others, and has a decreased ability to function. Finding: Acknowledgement of illness is correct. The client is exhibiting manifestations that typically occur in the anger stage of Kübler-Ross's stages of grief. In this stage, the client is prepared to acknowledge their illness, becomes sad, blames others, and has a decreased ability to function.

Vital Signs 1200: Temperature 34.7° C (94.5° F) Heart rate 35/min Respiratory rate irregular Blood pressure 52 mm Hg palpated 1230: Client with no pulse or respirations, pronounced dead by the provider. Family notified of death, informed they will be allowed to see the client following postmortem care. The nurse should first and then

Confirm the time of death was certified is correct. Using the nursing process, the first step the nurse should take when providing postmortem care is to ensure the provider has certified and confirmed the time of the client's death. Identify the client using two identifiers is correct. Using the nursing process, the first step the nurse should take in providing postmortem care is to confirm the identity of the client is accurate.

Physical Examination 1000: Height 165.1 cm (65 in) Weight 89 lb BMI 14.8 Client oriented to person, place, time; appears lethargic. S1 and S2 heard on auscultation; peripheral pulses weak; extremities pale and cold. Respiratory rate elevated; breath sounds clear on auscultation, diminished in bases. Bowel sounds hypoactive x 4 quadrants. Client reports no difficulty with urination, voiding dark, concentrated urine. Diagnostic Results 1200: ECG shows sinus bradycardia 1300: Laboratory results: Complete blood count: Hemoglobin 10 g/dL (12 to 16 g/dL) Hematocrit 30% (37% to 47%) Total WBC count 4,000/mm3 (5,000 to 10,000/mm3) Platelet count 100,000 mm3 (150,000 to 400,000/mm3) Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL) BUN 30 mg/dL (10 to 20 mg/dL) Potassium 2.9 mEq/L (3.5 to 5 mEq/L) The nurse should first address the client's _______________________ followed by the client's _______________________

Drop Down 1 Potassium level is correct. The greatest risk to the client is cardiac dysrhythmias brought on by their potassium level, which is in the critical range. Therefore, the nurse should address this finding first. Drop Down 2 BUN level is correct. The next greatest risk to the client is the potential for dehydration, which can occur from decreased fluid intake, as indicated by the BUN level. The client is experiencing hypotension and concentrated urine, which indicates dehydration. Therefore, this is the next finding the nurse should address.

Medical History 1600: Client brought to facility by adult grandchild who found the client on the floor of their living room "passed out from drinking." Client has 5.1-cm (2-in) laceration on forehead with dried blood present. Grandchild states client "has been drinking my entire life. I don't know how they are still alive." Plan: Admit for alcohol use disorder, observe for alcohol withdrawal. Diagnostic Results 1800: Blood alcohol 360 mg/dL (0 to 50 mg/dL) CBC: WBC count 6,500/mm3 (5,000 to 10,000/mm3) RBC count 4.0 (4.2 to 5.4) Hemoglobin 11 g/dL (12 to 16 g/dL) Hematocrit 33% (37% to 47%) Platelet count 35,000/mm3 (150,000 to 400,000/mm3) Albumin 3.5 g/dL (3.5 to 5 g/dL) Ammonia 79 mcg/dL (10 to 80 mcg/dL) The client is at highest risk for developing _______________________ as evidenced by the client's _______________________

Drop down 1 Bleeding is correct. The client is at highest risk for bleeding due to a platelet count that is less than the expected reference range. Alcohol toxicity impairs platelet production, causing thrombocytopenia and an increased risk for hemorrhage. Drop down 2 Platelet count is correct. The client is at highest risk for bleeding due to a platelet count that is less than the expected reference range. Alcohol toxicity impairs platelet production, causing thrombocytopenia and an increased risk for hemorrhage.

Nurses' Notes 0835 : Infant is being admitted with intussusception and perforation with peritonitis. The infant's guardians report increasing lethargy between periods of acute abdominal pain and vomiting. Lately their infant has been crying and drawing knees up to their chest. During diaper changes noticed red "jelly-looking" stools. Provider is planning surgical intervention. 1105: 20 mL of yellowish emesis noted. Infant pain is at 4 using the FLACC pain scale. Provider notified. After reviewing the information in the infant's chart, the nurse should anticipate a provider prescription for and

Dropdown 1 Intravenous antibiotics are correct. An infant who has intussusception and a perforation requires IV fluids and IV antibiotic therapy prior to surgery. The infant's physical exam indicates findings associated with peritonitis, which requires management with IV antibiotics. Dropdown 2 Nasogastric tube insertion is correct. An infant who has intussusception with a perforation requires decompression of the bowel prior to surgery. Therefore, the nurse should prepare to insert a nasogastric tube.

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 x 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. 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 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 The nurse should first address the client's ________________________ followed by the ________________________

Dropdown 1 Oxygen saturation is correct. The first action the nurse should take when using the airway, breathing, circulation approach to client care is client's oxygen saturation. Anemia is a reduction in the number of RBCs and the amount of hemoglobin or hematocrit. Hemoglobin carries oxygen to the tissues. When a client's hemoglobin level is low, the delivery of oxygen is decreased, which results in hypoxia. Dropdown 2 Hypotension is correct. After the nurse had addressed the client's oxygen saturation level, the nurse should address the client's hypotension. Anemia reduces oxygen delivery causing the heart to work harder to maintain tissue perfusion. Pulses become weak and thready and blood pressure decreases.

A nurse is caring for a school-age child who was involved in a motor-vehicle crash. Nurses' Notes 1845: Client is awake, alert, oriented to person, place, and time. Skin warm and dry. Capillary refill less than 2 seconds. Heart rate regular. Scattered rhonchi bilateral bases. Respirations even and non-labored. Bowel sounds hypoactive in all four quadrants... 2125: Skin warm and dry. Respirations even and slightly labored. Nonproductive cough noted. Bowel sounds hypoactive in all four quadrants. Last bowel movement two days ago soft, formed. Pedal pulse +2 bilateral. +2 edema noted to right lower extremity. Rates pain as 5 on pain scale from 0 to 10. Capillary refill to lower extremities less than 2 seconds. Voided 200 mL clear, yellow urine. 2125: Temperature: 37.1°C (98.8°F) Pulse rate: 94/min Respiratory rate: 23/min Blood pressure: 110/64 mm Hg Oxygen saturation: 93% room air

Dropdown 1 Pulmonary embolism is correct. Immobility from traction decreases venous return and causes pooling of blood, which increases the risk of clot formation. The child is receiving traction therapy for management of femur fracture and is experiencing a change in respiratory status with their respirations being slightly labored. These findings put the child at great risk for developing an embolus. Dropdown 2 Oxygen saturation level is correct. The child's oxygen saturation level has decreased, which indicates hypoxia. This finding can be related to pulmonary embolism.

Nurses' Notes Guardians report child has had a decrease in activity for 2 weeks. Child has been complaining of pain in the legs. Guardians state that their child has been napping longer than usual and appears tired throughout the day. Child has had cold symptoms that have been persistent with a fever and congestion for the past 10 days. Guardians have been administering acetaminophen for fever with moderate relief. Diagnostic Results White blood cell count: 12,000/mm³ (5,000 to 10,000/mm³) Hemoglobin: 7.6 g/dL (9.5 to 14 g/dL) Hematocrit: 21% (30 to 40%) Platelets: 110,000/mm³ (150,000 to 400,000/mm³) The nurse should first address the child's followed by the child's

Dropdown 1: By using the urgent and non-urgent approach to care the nurse should address the child's temperature first. The child has a temperature that is above the expected reference range and should be addressed to prevent further complications. Although the child's heart rate is above the expected reference range, there is no clinical indication that the child has an underlying cardiac condition. Bruising should be addressed; however, this could be result of thrombocytopenia. The child's pain should be monitored and addressed. Currently the child is experiencing mild pain, which may require intervention; however, there is another action the nurse should address first. Dropdown 2: By using the urgent and non-urgent approach to care the nurse should next address the child's laboratory values. This child has laboratory values suggestive of Acute Lymphoblastic Leukemia (ALL). Anemia and thrombocytopenia need to be addressed to avoid bleeding and adverse cardiac and systemic effects of anemia. The high white count may be indicative of an infection on top of the leukemia and needs to be addressed. The nurse should address petechiae and nasal stuffiness which could indicate other conditions; however, it is not priority. The respiratory rate is above the expected reference range; however, this is not a priority for the nurse to address.

A nurse is caring for a client who is dehydrated. Medication Administration Record 1045 Initiate peripheral IV sitePotassium chloride 20 mEq in 0.9% sodium chloride 125 mL/hr by continuous IV infusion Nurses' Notes 1100: Peripheral IV site in left forearm with potassium chloride 20 mEq in 0.9% sodium chloride 125 mL/hr by continuous infusion 1300: Client is reporting IV site is painful. IV site is red, swollen, warm to touch. IV site has palpable cord along vein. Client is oriented to person, place, and time. Lungs clear to auscultation and respirations are regular. Vital signs obtained along with oxygen saturation. Complete the following sentence by using the list of options. The client is at highest risk for developing _______________________ as evidenced by the client's _______________________

Dropdown 1: Phlebitis is correct. The nurse should identify the client is at greatest risk for developing phlebitis as evidenced by the IV site is painful, red, swollen, and warm to touch. The IV site has also palpable cord along the vein which can indicate inflammation of the inner layer of the vein. The nurse should stop the infusion, discontinue the IV, and notify the client's provider. Dropdown 2: Inflammation is correct. The nurse should identify the client has inflammation of the inner layer of the vein, which is the cause of the phlebitis. Phlebitis can cause the IV site to be painful, red, swollen, and warm to touch.

A nurse is caring for a 24-year-old client who reports a recent fall, hitting their head and right shoulder. Medical History Client reports falling and hitting their head and right shoulder after slipping on a wet floor yesterday. Denies loss of consciousness. Complains of pain in right shoulder. Has taken both acetaminophen and ibuprofen for pain with minimal relief obtained. Stayed up entire night playing video games yesterday to distract self from pain. Reports intermittent nausea and vomiting. The nurse should first address the client's followed by the client's Nurses' Notes 0900: Reports pain in right shoulder. Limited range of motion noted. Rates pain as 7 on a scale of 0 to 10. Denies numbness and tingling in arm. No swelling or bruising over the shoulder. Fingers warm with capillary refill time less than 3 seconds, sensation intact. Drowsy. Oriented to person, place, and time. Irritable and restless at ti

Drowsiness is correct. Loss of consciousness is the most important variable to assess with head injuries. A decrease or a change in loss of consciousness is often the first sign of deterioration and can indicate increased intracranial pressure. This should be reported to the provider immediately. Right shoulder pain is correct. The nurse should address the client's right shoulder pain after addressing the client's drowsiness. A client's recovery can be affected by pain by inhibiting their ability to become active and involved in self-care. The goal is to provide pain relief so that the client is able to participate in their recovery and to improve the client's functional status. Assessment of pain should include intensity, quality, duration, and location.

A nurse is caring for a client who was admitted 48 hr ago with a burn injury. Medical History Client admitted through emergency department after experiencing full thickness burns to hands and face and partial thickness burns to chest. The client is at risk for developing and

Fluid overload and infection are correct. During the emergent/resuscitative phase of a burn injury, hypovolemia can occur as fluid is lost due to capillary leakage. The acute/intermediate phase begins 48 to 72 hr after the burn injury. During this time, fluid shifts are occurring within the vascular compartment and fluid overload becomes a risk. Indications of fluid overload include increased pulse rate, elevated blood pressure, weight gain, and decreasing levels of sodium, BUN, hematocrit, and hemoglobin. Clients who experience a burn injury are also at high risk for infection as the protective skin barrier is lost, allowing micro-organisms to invade the tissue.

Nurses' Notes Client admitted to medical-surgical floor from the emergency department (ED). Client has a history of HIV, first diagnosed 15 years ago, that has recently progressed to AIDS. Client presents with headache, diarrhea, night sweats, and weight loss for approximately 1 week. Day 2: WBC count 3,100/mm3 (5,000 to 10,000 mm3)Hemoglobin 17 g/dL (12 to 18 g/dL)Hematocrit 51% (37% to 52%)Potassium 3.9 mEq/L (3.5 to 5 mEq/L)Sodium 140 mEq/L (136 to 145 mEq/L)CD4-T-cell count 198 mm3 (800 to 1000 mm3) The client is at highest risk for developing due to their

Infection is correct. When using the urgent vs non-urgent approach to client care, the nurse should determine that the client is at greatest risk for infection. This client has a CD4-T-cell count of 198 - 200 mm3, indicating that the client has decreased immune function. CD4-T-cell count is correct. This client has a CD4-T-cell count of 198 - 200 mm3, indicating that the client's has decreased immune function. This decrease in the function of the client's immune system places the client at greatest risk for opportunistic infections.

Diagnostic Results 0900: ABO/Rh: A positive Coombs test, indirect: positive (negative) Total bilirubin 6.2 mg/dL (1.0 to 12.0 mg/dL) Urine toxicology screen: positive for cocaine and marijuana (negative) Nurses Notes 0800: Newborn is alert and active with a strong cry. Skin color is consistent with the newborn's genetic background. Respirations are easy and unlabored. Anterior fontanel even and soft. Molding of skull noted. Generalized edematous area noted on occiput. Newborn is breastfeeding vigorously every 2 to 4 hr. No void or stool noted since birth. The nurse should recognize the newborn is at risk for developing and

Jaundice is correct. A positive Coombs test indicates the presence of anti-A and anti-B maternal antibodies within the newborn's blood. These antibodies will result in an accelerated destruction of the newborn's type A blood cells. The by-product of red blood cell hemolysis is bilirubin. The accelerated breakdown of the red blood cells can lead to excess bilirubin accumulating within the newborn's skin, mucus membranes, and sclera, resulting in a yellow discoloration known as jaundice. The nurse should continue to monitor the newborn's bilirubin levels. Anemia is correct. A positive Coombs test indicates the presence of anti-A and anti-B maternal antibodies within the newborn's blood. These antibodies will cause an accelerated destruction of the newborn's type A blood cells. The accelerated hemolysis can result in anemia.

A nurse is caring for a client who has severe right wrist pain. Diagnostic Results 1230: Right wrist x-ray indicates non-displaced distal radius fracture 1315: Client requested pain medication. Rates pain as 8 on a scale of 0 to 10. Client given 4 mg of IV morphine per provider's prescription Following administration, the client became lethargic and respirations decreased to 6/min. Naloxone IV was administered per provider's prescription. Client is still lethargic at this time, but respirations have increased. Provider notified. 1315: Temperature 37.2° C (99° F) Apical pulse 76/min Respiratory rate 10/min and shallow Blood pressure 110/70 mm Hg Pulse oximetry 91% on room air

Respiratory acidosis is correct. An adverse reaction to morphine sulfate is respiratory depression. The client's respiratory rate has decreased from 20/min to 10/min and is now shallow. Respiratory acidosis occurs when there is impaired respiratory function, causing reduced oxygen and carbon dioxide exchange, which leads to carbon dioxide retention. Hypervolemia is correct. The client is at risk for hypervolemia because of their history of congestive heart failure and the rate at which the IV solution is running.

A nurse is caring for a client who has HIV. Physical Examination 1000: Reports flu-like symptoms of headache, body aches, sore throat, low-grade fever, shortness of breath, productive cough. Swollen lymph nodes. Dry skin with rash. Weight loss of 15 lb over last 3 months with report of diarrhea and anorexia, difficulty eating due to oral ulcers. Diagnostic Results 1200: Chest x-ray: Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia. 1600: Hemoglobin 11 g/dL (12 g/dL to 16 g/dL) Hematocrit 36% (37% to 47%) Platelet count 155,000/mm3 (150,000 to 400,000/mm3) WBC count 4,500/mm3 (5,000 to 10,000/mm3) CD4-T-Cell count 400 cells/mm3 (600 to 1,500 cells/mm3) Sputum culture Pneumocystis jirovecii The client is at risk for developing and

Sepsis and malnutrition are correct. The client's sputum culture along with chest x-ray both indicate the client is experiencing pneumonia and the CD4-T-cell count is low, all of which places the client at risk for developing sepsis. The client is experiencing malnutrition as evidenced by weight loss, diarrhea, and oral ulcers, which places the client at risk for developing sepsis.

A nurse is caring for a client who is receiving a blood transfusion. 0800: Client is 1-day postoperative following abdominal surgery. Moderate amount of bloody drainage on surgical dressing. Provider notified of drainage and of 0730 hemoglobin and hematocrit levels. Prescription provided to transfuse 1 unit of packed RBCs. 0900: Packed RBCs arrived from blood bank. Transfusion started. 1030: Client reports feeling short of breath. Vital signs obtained. Client has a new cough. Lungs auscultated, crackles in bilateral lobes. Jugular distension noted. Urine output 150 mL in the last hr. The client is likely experiencing as evidenced by the clien'ts

Transfusion-associated circulatory overload is correct. The client is experiencing manifestations of transfusion-associated circulatory overload (TACO) including dyspnea, crackles, and distended jugular veins. The client also has an elevated blood pressure, which is an indication of hypervolemia. Respiratory assessment is correct. The client is experiencing TACO. Manifestation of TACO include dyspnea and crackles in the lungs.

A nurse is caring for a client who is 2 days postoperative following a small bowel resection. Medical History The client has a history of Crohn's disease. The client presented to the emergency department 2 days ago with bowel incontinence accompanied by an abdominal pain rating of 10 on a scale of 0 to 10. It was determined that the client needed to undergo an emergent bowel resection. The client has no other significant medical history. Diagnostic Results Albumin 3.7 g/dL (3.5 to 5 g/dL) WBC count 18/mm3 (5,000 to 10,000/mm3) RBC count 4.0 µL (4.2 to 6.1 µL) Hgb 10 g/dL (12 to 18 g/dL) Hct 39% (37% to 52%) When prioritizing client needs, the nurse should first address the client's followed by notifying the provider of the client's

WBC count is correct. The client's WBC count is above the expected reference range and is an indication of infection. The nurse should notify the provider immediately. Incisional pain is correct. It is important that the nurse address the client's incisional pain to aid in the client's recovery.

A nurse is caring for a client who reports fatigue, unexplained bruising, and headaches. Diagnostic Results CBC: RBC 4.0 million/mm3 (4.7 to 6.1 million/mm3) WBC 4.0 x 106/mm3 (4.7 to 6.1 x 106/mm3) Hemoglobin 10,500 mm3 (5,000 to 10,000 mm3) Hematocrit 10 g/dL (14 to 18 g/dL) Platelets 60,000/mm3 (150,000 to 40,000/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 mEq/L) Potassium 4.2 mEq/L (3.5 to 5 mEq/L) Sodium 104 mEq/L (136 to 145 mEq/L) The client is at risk for developing ____________________ due to their ____________________

When analyzing cues, the nurse should identify that the client findings of fatigue, headache, bruising, and decreased platelet count are related to thrombocytopenia. Clients who have this condition are at risk for disseminated intravascular coagulation which is condition that causes spontaneous excessive bleeding due to decreased clotting ability of the blood. The client's current platelet count is below the expected reference range, therefore, the client is as risk for bleeding and the nurse should monitor the client for the development of DIC.

Day 1,1000: 2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf. Calf circumference: Left: 40 cm (15.8 in) Right: 38.1 cm (15 in) Day 2 0800: 3.8 cm x 3.8 cm (1.5 in x 1.5 in) reddened area noted on client's left calf. Calf circumference: Left: 42 cm (16.5 in) Right: 38.4 cm (15.1 in) The client is at risk for developing due to

When analyzing cues, the nurse should note that the client is at risk for developing a pulmonary embolism due to possible deep vein thrombosis. The client reports they just returned from an 8-hr car trip. Extended periods of immobility place the client at an increased risk for a deep vein thrombosis which can lead to a pulmonary embolism. Manifestations of a deep vein thrombosis include unilateral edema, pain, and redness, which often develops in the lower extremities.

A nurse is caring for a client who is postoperative following repair of a right femur fracture. Nurses' Notes 1200: Client reports pain as 7 on a scale of 0 to 10. Administered oxycodone as prescribed. Peripheral IV of dextrose 5% in 0.45% sodium chloride infusing at 75 mL/hr into left hand. Femur dressing dry and intact. Toes are warm, movement and sensation intact, pedal pulses 2+ bilaterally. 1300: Client reports pain as 2 on a scale of 0 to 10. Femur dressing has small amount of serosanguinous drainage. Toes are warm, movement and sensation intact, pedal pulses 2+ bilaterally. The client is at risk for developing due to their

When analyzing cues, the nurse should recognize the client is at risk for constipation due to their oxycodone prescription. Narcotic analgesics slow intestinal motility, which can cause constipation. The nurse should promote fluid intake to soften stools, provide the client with a high-fiber diet, and encourage the client to ambulate as soon as possible. The client might require a prescription for a stool softener to loosen the stool to promote defecation.

1000: Client out of bed to chair with the assist of 1. Medicated with hydromorphone 1 tablet PO prior to abdominal dressing change. 1100: Client up walking in room, assisted back to bed. Abdominal dressing changed. Incision with top edges slightly separated; lower edges approximated. Lower staples intact, upper staples appear stretched out. Incision with redness and purulent drainage present. Type 2 diabetes mellitus Obesity (BMI 32) Peripheral vascular disease (PVD) Heart failure Hypertension The client is at risk for developing and

Wound infection is correct. The client's history indicates risk factors associated with poor wound healing, such as diabetes, obesity, and PVD. The client currently has a fever, and their surgical incision is red with purulent drainage. These are indications that an infection may be developing. Dehiscence is correct. The client's history indicates risk factors associated with poor wound healing. The assessment of the wound shows edges slightly separated and staples stretched out. These are indications that the client is at risk for developing dehiscence.

09/13/xx 0800: Client states they are feeling better "now that my fever has come down." Client denies abdominal pain and states appetite has improved slightly from yesterday. Reports headache as 3 on a pain scale of 0 to 10 as dull. Labs drawn as prescribed. 0845: Client reports feeling dizzy and nauseated when they got up to go to the bathroom. The client also reported hearing ringing in their ears while they were feeling dizzy, but it has since gone away. The client was instructed to request assistance to the bathroom and to remain in bed. 09/13/xx 0900: WBC count 13,200 mm3 (5000-10,00mm3) Gentamicin peak 20 mcg/mL (<10mcg/mL) ALT (Alanine Aminotransferase) 37 U/L (4-36 U/L) AST (Aspartate Aminotransferase: 36 U/L (0-35 U/L) BUN 23 mg/dL (10-20 mg/dL) Creatinine 1.4 mg/dL (0.5-1.1 mg/dL) The client is at greatest risk for developing due to

hearing loss due to antibiotics The nurse should identify that the priority hypothesis is that the greatest risk for the client is developing hearing loss due to antibiotics. The client was admitted with a possible diagnosis of infective endocarditis and prescribed gentamicin which is an aminoglycoside. The client is exhibiting signs of headache, dizziness, nausea, and tinnitus. Ototoxicity may occur in clients who are receiving aminoglycosides. The client's diagnostic lab results also indicate an increase in BUN, creatinine, gentamicin peak level, ALT, and AST all which place the client at risk for ototoxicity and hearing loss. Hearing loss is generally in the high frequency range and is associated with peak aminoglycoside levels that continue to remain elevated.

A nurse is reviewing laboratory data on a client who is recovering from surgery. Postoperative: WBC 7,000/mm3 (5,000 to 10,000/mm3) Potassium 3.0 mEq/L (3.5 to 5 mEq/L) Prealbumin 15 mg/dL (15 to 36 mg/dL) Platelets 160,000/mm3 (150,000 to 400,000/mm3) BUN 19 mg/dL (10 to 20 mg/dL) The client is at risk for developing due to

Dysrhythmias is correct. The client's potassium level is below the expected reference range, which places them at risk for dysrhythmias. Potassium level is correct. The client's potassium level is below the expected reference range, which places them at risk for dysrhythmias.

A nurse in a rehabilitation facility is caring for a client. Day 1, 1230: Alert and oriented to person, place, and time. Weakness to right upper and lower extremities. Urine output 240 mL/8 hr. Client had one small hard bowel movement. Bowel sounds hypoactive in 4 quadrants. Day 6, 0800: Bowel sounds hypoactive in 4 quadrants. Abdomen with left lower quadrant firm. Client reports unable to have a bowel movement since admission to the rehabilitation facility. Urine output 200 mL/8 hr. Day 6, 0730: Urine specific gravity 1035 (1.005 to 1.030) The client is at an increased risk for developing and

Fecal impaction and postural hypotension are correct. The client is at risk for fecal impaction and postural hypotension. The client has manifestations of constipation, such as infrequent, hard, dry stools, and hypoactive bowel sounds, which places the client at risk for fecal impaction. The client has manifestations of dehydration, such as reduced urine output and a specific gravity that is greater than the expected reference range, which places the client at risk for postural hypotension.

A nurse is caring for a client in the emergency department (ED). Medical History Client reports a 3-day history of nausea, vomiting, and diarrhea. The client states that they have been unable to "keep water down" for the last 24 hr. Provider Prescriptions Supplemental oxygen for oxygen saturation less than 95% Start a peripheral IV Administer 500 mL 0.9% sodium chloride IV bolus then infuse at 125 mL/hr Obtain a serum potassium level Obtain daily weights Strict intake and output Administer acetaminophen 650 mg PO q6h for temp greater than 38.6°C (101.5 °F) Vital Signs 1000: Temperature 38.7° C (101.7° F) Blood pressure 88/50 mm Hg Heart rate 112/min Respirations 24/min Pulse oximetry 94% on room air The nurse should first followed by

Initiate oxygen is correct. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to initiate oxygen. The client's oxygen saturation has decreased and the client is at risk for hypoxia. Administer a fluid bolus is correct. The action the nurse should take after initiating oxygen to address the hypoxia when using the airway, breathing, circulation approach to client care is to administer a fluid bolus. The client's blood pressure has decreased, and the client requires IV fluids to increase circulatory volume.

A nurse is caring for a client who has impaired mobility. Medical History Client is admitted to the rehabilitation unit following a hip arthroplasty. Client has limited mobility and requires assistance to turn and transfer out of bed. Nurses Notes Day 1: Client is alert and oriented. Client voided 400 mL of clear yellow urine into a bed pan. Hip dressing is dry and intact. Abdomen soft, nondistended, bowel sounds hypoactive. Nurses Notes Day 2: Client is oriented to person but disoriented to time and place. Client is incontinent of a large amount of urine x 2. The client is at highest risk for developing as evidenced by the client's

Pressure injury is correct. The greatest risk to this client is a pressure injury from immobility. Therefore, the priority intervention the nurse should take is to implement interventions to reduce the risk for a pressure injury, such as frequent repositioning and skin assessment. Urinary incontinence is correct. The greatest risk to this client is developing a pressure injury from urinary incontinence and impaired mobility. Therefore, the priority intervention the nurse should take is to implement interventions to reduce the risk for a pressure injury, such as applying a moisture barrier to protect the skin, frequent repositioning, and frequent skin assessment.

A nurse is caring for a client who is receiving a blood transfusion. 0800: Client is 1-day postoperative following abdominal surgery. Moderate amount of bloody drainage on surgical dressing. Provider notified of drainage and of 0730 hemoglobin and hematocrit levels. Prescription provided to transfuse 1 unit of packed RBCs. 0900: Packed RBCs arrived from blood bank. Transfusion started. 1030: Client reports feeling short of breath. Vital signs obtained. Client has a new cough. Lungs auscultated, crackles in bilateral lobes. Jugular distension noted. Urine output 150 mL in the last hr. 1030: Temperature 36.7° C (98.5° F) Heart rate 105/min Respiratory rate 34/min Blood pressure 188/82 mm Hg Oxygen saturation 92% on room air The client is likely experiencing as evidenced by the client's

Transfusion-associated circulatory overload is correct. The client is experiencing manifestations of transfusion-associated circulatory overload (TACO) including dyspnea, crackles, and distended jugular veins. The client also has an elevated blood pressure, which is an indication of hypervolemia. Respiratory assessment is correct. The client is experiencing TACO. Manifestation of TACO include dyspnea and crackles in the lungs.

0800: Client is alert and oriented. Breath sounds are clear and present throughout. Denies tobacco use. Client lives in a one-story house with their child. Client reports they just returned from an 8-hr car trip. Client eats a high fiber diet and drinks 1,800 mL of fluid/day. 1000: 2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf. 0800: Temperature 38° C (100.4° F) Blood pressure 114/50 mm Hg Heart rate 96/min Respiratory rate 20/min SaO2 95% on room air The client is at an increased risk for developing due to

Deep vein thrombosis is correct. The client reports they just returned from an 8-hr car trip. Extended periods of immobility place the client at an increased risk for a deep vein thrombosis. Recent car ride is correct. The client reports they just returned from an 8-hr car trip. Extended periods of immobility place the client at an increased risk for a deep vein thrombosis.

A nurse on a cardiac care unit is caring for a preschooler. Nurses' Notes 2015: Increase in dyspnea noted with orthopnea. Nasal flaring with respiratory rate of 36/min. Lung sounds with wheezing noted throughout. Lower extremity edema 3+ to bilateral lower extremities. Extremities cool with decreased skin pigmentation noted. Peripheral pulses weak bilateral. Jugular vein distention noted. Provider notified. Received prescription for additional dose of IV furosemide. Medication Administration Record Hospital Day 1: Furosemide 40 mg IV every 6 hr. Administered at 1755. Hospital Day 2: Give digoxin 125 mcg 12 hr after initial dose. Administered at 0608. Give digoxin 125 mcg 12 hr after second dose. Administered at 1804.

Hypokalemia is correct. The client is receiving furosemide every 6 hr. Furosemide causes potassium depletion. Therefore, the client is at risk for hypokalemia . Digitalis toxicity is correct. The client is receiving digitalis every 12 hr. The margin of safety is very small, 0.8 to 2 mcg/L. Therefore, the client is at risk for digitalis toxicity .