Nokea
History and Physical
Nurses' Notes
Laboratory Results
The client is a 38-year-old male with a history of type 1 diabetes mellitus. The client was diagnosed at the age of 8. The client reports that he has stopped testing his blood glucose regularly since losing his insurance 4 years ago and has been in the hospital 2 times for diabetic ketoacidosis
A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding(s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.
- A. Serum potassium of 4.2 mEq/L.
- B. Hemoglobin A1C 7%.
- C. Total cholesterol 180 mg/dL.
- D. Hematocrit 45%.
- E. Random plasma glucose level 200 mg/dl.
Correct Answer: B,E
Rationale: Hemoglobin A1C of 7% and random plasma glucose of 200 mg/dL indicate poor glycemic control, suggestive of diabetes, requiring immediate reporting.
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A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
- A. Auscultate the abdomen for bowel sound activity.
- B. Bring additional sterile dressing supplies to the room.
- C. Obtain a sample of the drainage to send to the laboratory.
- D. Prepare the client to return to the operating room.
Correct Answer: D
Rationale: Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.
A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
- A. Palpate the right flank for tenderness.
- B. Test the urine for the presence of hematuria.
- C. Evaluate the urine for a strong odor.
- D. Measure the temperature and pulse rate.
Correct Answer: D
Rationale: Measuring temperature and pulse rate is important to identify signs of systemic infection or inflammation contributing to the client's symptoms.
A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump?
- A. 125
Correct Answer: A
Rationale: To calculate: 3000 mL / 24 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
- A. Eating patterns of dietary intake.
- B. Activity level of bowel sounds.
- C. Level and amount of physical activity.
- D. Color and consistency of feces.
Correct Answer: A
Rationale: Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.
After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Right foot pale with sluggish capillary refill.
- B. Circumferential edema of right foot.
- C. Reports throbbing right leg pain.
- D. Increased temperature to lower extremity.
Correct Answer: A
Rationale: A pale right foot with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, requiring immediate intervention to prevent tissue damage.