Nokea
A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
- A. Acute pain related to renal calculus.
- B. Nutritional deficit related to nausea.
- C. Impaired renal function related to pain.
- D. Risk for aspiration related to vomiting.
Correct Answer: D
Rationale: Risk for aspiration related to vomiting is the highest priority because it addresses the immediate potential for airway compromise, which can be life-threatening if the client aspirates vomitus.
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Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize [condition] as the priority problem for this client, as evidenced by the client's statement, [statement].
- A. chronic bronchitis
- B. anxiety disorder
- C. exercise-induced bronchospasm
- D. impaired gas exchange
- E. cardiovascular disease
- F. respiratory infection
Correct Answer: D
Rationale: The client's difficulty breathing, need to pause to catch breath, ineffective rescue inhaler, and oxygen saturation of 88% indicate impaired gas exchange, requiring immediate intervention to improve respiratory function.
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
The nurse is caring for a client who was admitted to the hospital with reports of shortness of breath, fever, fatigue, and oral thrush three days ago. The health care provider reviews the laboratory and diagnostic tests with the client and informs of the diagnosis of Pneumocystis pneumonia. The client reports that they recently tested HIV positive. The nurse reviews the client's medical record.
HIV diagnosed 4 months ago with no medications prescribed.
Note added to H&P reporting client wishes to be confidential since family and friends are unaware of the HIV diagnosis.
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
- A. Increase IV fluids to 150 mL/hr
- B. Monitor for adverse reaction to antibiotics
- C. Repeat CD4+ T-cell count STAT
- D. Initiate airborne isolation
- E. Administer antiemetic
Correct Answer: A,B,E
Rationale: Increasing IV fluids, monitoring for antibiotic reactions, and administering an antiemetic address the client's fever, potential infection, and nausea associated with Pneumocystis pneumonia.
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Assess the pin sites for signs of infection.
- B. Administer pain medication at designated intervals around the clock.
- C. Assess the pulses proximal to the fracture site.
- D. Remove traction every shift and provide skin care.
Correct Answer: A
Rationale: Assessing pin sites for signs of infection is essential to detect early signs of complications in skeletal traction.
The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?
- A. Protect the skin of the radiation portal site from sunlight exposure.
- B. Avoid washing the skin inside the radiation portal site.
- C. Remove the ink marks of the portal after each radiation treatment.
- D. Apply moisture lotions daily to the radiation portal site.
Correct Answer: A
Rationale: Protecting the radiation portal site from sunlight exposure prevents further damage to the sensitive irradiated skin.
A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Palpitations and shortness of breath.
- B. Bradycardia and constipation.
- C. Muscle cramping and dry, flushed skin.
- D. Lethargy and lack of appetite.
Correct Answer: A
Rationale: Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine.