Nokea
A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
- A. Gastroccult positive emesis.
- B. Strong foul smelling flatus.
- C. Complaint of poor night vision.
- D. Loose bowel movements.
Correct Answer: A
Rationale: Gastroccult positive emesis indicates the presence of blood in the vomit, which is a sign of a serious complication such as anastomotic leak, ulcer, or bleeding. The nurse should notify the physician and monitor the client's vital signs and hemoglobin level.
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Flow sheets
1915
Arrival at emergency department
1920
Vital Signs:
- Temperature: 98.2° F (36.8° C)
- Heart rate: 92 beats/minute
- Respirations: 24 breaths/minute
- Blood pressure: 210/98 mmHg
- Oxygen saturation: 95% on room air
Imaging studies
1935
Head CT scan results:
- No evidence of intracranial hemorrhage
- No evidence of acute disease
Orders
- Obtain CT scan of the head.
- Insert a large bore peripheral IV.
- Start normal saline infusion at 50 mL/hour.
The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand. Select the interdisciplinary team members who should assist the client in recovery.
- A. Occupational Therapist
- B. Speech Therapist
- C. Case manager
- D. Physical therapist
- E. Chief Nursing Officer
- F. Pharmacy Technician
Correct Answer: A,B,C,D
Rationale: Occupational, speech, and physical therapists address stroke-related impairments in daily activities, communication, and mobility, while a case manager coordinates care and discharge planning.
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
- A. Applies prescribed lotions to the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Wears clothing to cover the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing the radiation site with antibacterial soap and water can cause dryness, inflammation, and infection, indicating a need for further teaching on using mild soap or saline.
Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?
- A. Perform a complete mental status exam.
- B. Determine if the client has had a shingles vaccination.
- C. Teach the client about phantom pain symptoms.
- D. Complete an assessment of the client's pain.
Correct Answer: D
Rationale: Completing a pain assessment is the most important action to identify the cause, severity, and impact of the pain, likely postherpetic neuralgia, to plan appropriate interventions.
A patient experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective?
- A. Headache rated at 0 on 0 to 10 scale.
- B. Oxygen saturation level of 99%.
- C. Ambulates easily without vertigo.
- D. Blood pressure of 120/80 mm Hg.
Correct Answer: C
Rationale: Ambulating easily without vertigo indicates the antihistamine is effective, as it reduces fluid buildup in the inner ear, relieving vertigo, a common symptom of Ménière's disease.
A client who received 6 units of packed red blood cells 3 days ago for a lower gastrointestinal (GI) bleed is now displaying signs of shortness of breath with occasional stridor and is reporting muscle cramping. Which serum laboratory value should the nurse immediately report to the healthcare provider?
- A. Potassium 4.7 mEq/L (4.70 mmol/L).
- B. Magnesium 2.1 mEq/L (0.86 mmol/L).
- C. Calcium 6.5 mg/dL (1.63 mmol/L).
- D. Sodium 135 mEq/L (135 mmol/L).
Correct Answer: C
Rationale: Calcium 6.5 mg/dL (1.63 mmol/L) is below the normal reference range and can cause muscle spasms, cramps, tingling, numbness, and stridor. This critical value should be immediately reported to the healthcare provider, as it can indicate a serious condition such as acute pancreatitis, sepsis, or massive blood transfusion.