Nokea
A client admitted with thyrotoxicosis is reporting a 'pounding heart in the chest.' Which assessment finding warrants immediate intervention by the nurse?
- A. Anxiety
- B. Hyperglycemia
- C. Fever
- D. Dyspnea.
Correct Answer: D
Rationale: Dyspnea may indicate severe complications like heart failure or thyroid storm, requiring immediate intervention due to potential life-threatening respiratory distress.
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The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?
- A. Weight gain.
- B. Hypoventilation.
- C. Cold intolerance.
- D. Lethargy
Correct Answer: B
Rationale: Hypoventilation can lead to hypoxemia and hypercapnia, requiring immediate intervention to prevent respiratory crisis. Other symptoms are common but not immediately life-threatening.
A client recovering from cardiac surgery experiences a dysrhythmia, noted on the telemetry monitor. Which assessment finding is most likely to have contributed to the development of the dysrhythmia?
- A. Calcium level 7.2 mg/dL (1.8 mmol/L).
- B. Potassium level 3.8 mg/dl. (3.8 mmol)
- C. Sodium level 140 mEq/L (140mmol/L).
- D. Oxygen saturation level 97%.
Correct Answer: A
Rationale: Hypocalcemia (low calcium) can cause cardiac dysrhythmias, such as prolonged QT intervals, unlike normal potassium, sodium, or oxygen levels.
Nurses votes
Skin assessment reveals a stage 2 pressure injury on the right trochanter. Measures 0.79" x 1.57" x 0.39 (2 cm X 4 cm X 1 cm). Minimal drainage noted. Painful to touch. The Braden Scale was utilized during the skin assessment. The score is two for sensory, three for moisture, two for activity, two for mobility, two for nutrition and one for friction and shear.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Actions to Take
A. Begin enteral feedings
B. Insert Indwelling urinary catheter
C. Ambulate every four
D. Apply pressure reduction mattress to bed
E. Request service of wound care nurse
- B. Potential Conditions
Choices
A. Immobility
B. Dehydration
C. Malnutrition
D. Poor healing of stage 2 pressure injury
- C. Parameters to monitor
Choices
A. Sterile dressing changes
B. Adherence to repositioning schedule hours
C. Temperature
D. Laboratory studies for malnutrition status
E. Progression of wound
Correct Answer: D
Rationale: Poor healing of a pressure injury requires a pressure reduction mattress and wound care nurse consultation, monitoring wound progression and repositioning adherence.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?
- A. Place pillows around the bed rails to provide padding.
- B. Watch the seizure activity and document the time and client movement.
- C. Manually ventilate the client with a bag-valve mask (BVM).
- D. Stop the IV fluids.
- E. Increase the supplemental oxygen to 10 L/minute via nasal cannula.
- F. Begin chest compressions.
Correct Answer: B,C,E
Rationale: Ventilation, oxygen increase, and seizure monitoring address hypoxia and safety during a tonic-clonic seizure.
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention?
- A. Place an indwelling urinary catheter and measure strict Intake and output.
- B. Initiate bilateral intermittent sequential pneumatic compression devices.
- C. Administer aspirin to prevent further det formation and platelet dumping.
- D. Obtain a focused history to determine recent bleeding and use of anticoagulants.
Correct Answer: D
Rationale: A focused history assesses for stroke risk factors like anticoagulant use, critical for managing neurological symptoms.