fundmentals proctor

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Exhibit 1: Nurses' Notes 1200:Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation. 1230:Client transported for abdominal x-ray. 1245:Client returned from x-ray. Provider prescribes a hypertonic cleansing enema. 1300:Procedure explained to client who verbalized understanding. Exhibit 2: Diagnostic Results: 1245:Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed. Based on the client's clinical findings, which of the following actions should the nurse take? Select all that apply. -Assist the client to a left side-lying position with the right knee flexed. -Prepare the client for a chest x-ray. -Administer a cleansing enema. -Auscultate the client's bowel sounds. -Perform a manual digital examination of the client's rectum. -Administer oxycodone extended-release tablets. -Prepare the client for NG tube placemen

Assist the client to a left side-lying position with the right knee flexed is correct. The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure. Administer a cleansing enema is *correct*. The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray. Auscultate the client's bowel sounds is *correct*. The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract. Perform a manual digital examination of the client's rectum is *correct*. The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? Neck vein distention Urine specific gravity 1.010 Rapid heart rate Blood pressure 144/82 mm Hg

Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "I'm having mild pain." "The pain is like a dull ache in my stomach." "I notice that the pain gets worse after I eat." "The pain makes me feel nauseous."

"The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in the client's own words.

A nurse in the emergency department (ED) is caring for a client. Nurses' Notes 1100:Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile. 1110:Provider at bedside; prescriptions received. 1115:IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered. 1200:Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities. Exhibit 2 Medication Administration Record 1115:Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F)Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting Exhibit 3 Vital Signs 1100:Temperature 39.2° C (102.6° F)Pulse rate 118/minRespiratory rate 18/minBlood pressure 92/68 mm HgOxygen saturation 95%Weight 44.9 kg (99 lb)BMI 17 what indicate the client is malnourished. select all that apply -Cachectic, with flaccid muscle tone. -Skin dry and scaly with bruises on extremities. -Oriented x 3, able to move all extremities. -Pulse rate 118/min -Respiratory rate 18/min -Abdomen distended -Temperature 39.2° C (102.6° F) -BMI 17

-Cachectic, with flaccid muscle tone is *correct*. The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition. Skin dry and scaly with bruises on extremities is *correct*. The client's dry, scaly, and bruised skin can be an indication of malnutrition. Pulse rate 118/min is *correct*. The client's tachycardia can be an indication of malnutrition. Abdomen distended is *correct*. The client's abdominal distention can be an indication of malnutrition. BMI 17 is *correct*. A BMI of 17 is considered underweight and can be an indication of malnutrition.

A nurse is caring for a client. Exhibit 1 Medical History Client is receiving chemotherapy for treatment of breast cancer. Diagnostic Results Week 1: Hct 42% (37% to 47%)Hgb 15 g/dL (12 g/dL to 16 g/dL)WBC count 8,000/mm3 (5,000 to 10,000/mm3)Platelet count 350,000/mm3 (150,000 to 400,000/mm3)Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2: Hct 37% (37% to 47%)Hgb 12 g/dL (12 g/dL to 16 g/dL)WBC count 6,000/mm3 (5,000 to 10,000/mm3)Platelet count 100,000/mm3 (150,000 to 400,000/mm3)Potassium 3.6 mEq/L (3.5 to 5 mEq/L) The client is at risk for? -dysrhythmias -bleeding -infection as evidenced by the client's -platelet count -WBC count -potassium level

Bleeding is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. Platelet count is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding.

A nurse is admitting a client. Exhibit 1 Nurses' Notes 0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days.1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. A nurse is admitting a client. Exhibit 2 Vital Signs 1030:Blood pressure 110/68 mm HgHeart rate 110/min Respiratory rate 24/min Temperature 38.6° C (101.5°F) Oxygen saturation 91% on room airThe nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. -Place the client on droplet isolation precautions. -Apply oxygen at 2 L/min via nasal cannula. -Request a prescription for an antipyretic medication. -Wear an N-95 mask when providing care to the client. -Request a prescription for an antihypertensive medication. -Remain 1 m (3 feet) from the client.

Place the client on droplet isolation precautions is correct. The nurse should identify that the client has pneumonia, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should place the client on droplet isolation precautions. Apply oxygen at 2 L/min via nasal cannula is correct. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the client. Request a prescription for an antipyretic medication is correct. The nurse should identify that the client has a temperature of 36.6° C (101.5° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. Remain 1 m (3 feet) from the client is correct. The nurse should identify that the client has pneumonia. Therefore, the nurse should wear a sterile mask and remain within 1 m (3 feet) from the client.

A nurse is caring for a client who has a newly placed ileostomy. Exhibit 1 Nurses' Notes 0800:Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants. 1200:Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool. Exhibit 2 Diagnostic Results 1200:Hgb 19 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%) The nurse should first address the (pick one) -stoma color -hemoglobin level -ostomy leakage followed by the (pick one) -ostomy pouch seal -skin around the stoma -amount of stool in the pouch

Stoma color is correct. The greatest risk to the client is the necrosis of the bowel. The nurse should identify that the color of the stoma indicates the client is at greatest risk for necrosis of the bowel; therefore, the nurse should notify the provider immediately about the color of the client's stoma. Skin around the stoma is correct. The nurse should identify that the skin condition around the stoma is the next priority finding to address because it places the client at risk for infection.

A nurse is caring for a client who has a pressure injury. Exhibit 1 Nurses' Notes Day 1:Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of 0 to 10. Client repositioned every 2 hr while in bed.Day 4:Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Exhibit 2 Vital Signs Day 4:Temperature 38.3° C (101° F)Pulse rate 80/minRespiratory rate 20/minBlood pressure 128/64 mm HgOxygen saturation 93% on room air Exhibit 3 Diagnostic Results Day 4:Potassium 4.2 mEq/L (3.5 to 5 mEq/L)Hgb 13 g/dL (12 to 16 g/dL)Hct 38% (37% to 47%)WBC count 12,000/mm3 (5,000 to 10,000/mm3)Prealbumin12 mg/dL (15 to 36 mg/dL) What findings that the nurse should report to the provider? select all that apply Temperature WBC count Prealbumin level Hemoglobin level Blood pressure Pain level Odor of wound Bowel sounds

Temperature is correct. The nurse should identify that the client has a fever, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. WBC count is correct. The nurse should identify that the client has a WBC count that is greater than the expected reference range, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. Prealbumin level is correct. The nurse should identify that the client has a prealbumin level that is lower than the expected reference range. This is a manifestation of malnutrition, which contributes to delayed wound healing. Therefore, the nurse should report this finding to the provider. Pain level is correct. The nurse should identify that the client's pain level has increased over 3 days and is an indication of complications associated with wound healing. Therefore, the nurse should report this finding to the provider. Odor of wound is correct. The nurse should identify that a foul odor of a wound is a manifestation of an infection. Therefore, the nurse should report this finding to the provider.

A nurse is caring for a client who had a spinal cord injury and has paraplegia. Exhibit 1 Nurses' Notes Day 1:Client is alert and oriented.Client is repositioned every 2 hr.Passive range-of-motion exercises to lower extremities performed once each day. Day 5:Client is alert and oriented.Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day.Feet warm. Pedal pulses 2+ bilaterally.Plantar flexion contractures noted bilaterally.Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact. The nurse is reviewing the client's medical record. Select all that apply that require intervention by the nurse: -Client is repositioned every 2 hr. -Passive range-of-motion exercises to lower extremities performed once each day. -Feet warm. Pedal pulses 2+ bilaterally. -Plantar flexion contractures noted bilaterally. -Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.

-Passive range-of-motion exercises to lower extremities performed once each day is correct. The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures. -Plantar flexion contractures noted bilaterally is correct. The nurse should place a footboard at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contractures. -Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact is correct. The client has a stage 1 pressure injury on the heel. The nurse should apply foot boots to the client's feet to protect the client's heels and promote healing.

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. Exhibit 1 Nurses' Notes 1000:Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed. Exhibit 2 Vital Signs 1000:Blood pressure 132/68 mm HgHeart rate 99/min Respiratory rate 20/min Temperature 38.3° C (101° F) Oxygen saturation 96% on room air Exhibit 3 Diagnostic Results 1100:Positive throat culture for streptococci bacteria. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. -Apply a mask on the client when they leave their room. -Place the client in a negative airflow room. -Wear a mask within 1 m (3 feet) of the client. -Initiate droplet precautions. -Apply oxygen at 2 L/min via nasal cannula. -Request a prescription for an antibiotic medication.

-Request a prescription for an antibiotic medication is correct. The nurse should identify that the client has streptococcal pharyngitis due to the client's manifestations and a positive throat culture. Therefore, the nurse should request an antibiotic medication, such as penicillin, to treat the client's infection. -Initiate droplet precautions is correct. The nurse should identify that the client has streptococcal pharyngitis, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should initiate droplet precautions for the client. -Wear a mask within 1 m (3 feet) of the client is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should wear a mask when within 1 m (3 feet) of the client to prevent the spread of the infection. -Apply a mask on the client when they leave their room is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should apply a mask on the client when they leave their room to prevent transmission of the infection.

A nurse is caring for a client. Exhibit 1 Medical History Client is receiving chemotherapy for treatment of breast cancer Exhibit 2 Diagnostic Results Week 1:Hct 42% (37% to 47%)Hgb 15 g/dL (12 g/dL to 16 g/dL)WBC count 8,000/mm3 (5,000 to 10,000/mm3)Platelet count 350,000/mm3 (150,000 to 400,000/mm3)Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2:Hct 37% (37% to 47%)Hgb 12 g/dL (12 g/dL to 16 g/dL)WBC count 6,000/mm3 (5,000 to 10,000/mm3)Platelet count 100,000/mm3 (150,000 to 400,000/mm3)Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Complete the following sentence by using the lists of options. The client is at risk for ______ (selcet one) -dysrhythmias -bleeding -infection as evidenced by the client's _______________ (select one) -platelet count -WBC count -potassium level

-bleeding & Platelet count

A nurse in a medical-surgical unit is caring for six clients. Exhibit 1 Nurses' Notes​ 0800: Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis. Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed. Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed. Client 4: Client is admitted with a new diagnosis of heart failure. Client 5: Client has a stage 2 pressure injury on the left heel. Client 6: Client is admitted with a new diagnosis of diabetes mellitus. The first client the nurse should assess is client _____ (choices: 1, 2, or 3) followed by then client ______ (choices: 4,5,or 6

Client 3 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia. Client 4 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the next priority client to assess. The client has a potassium level that is less than the expected reference range, which places the client at risk for dysrhythmias.