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A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Current medication prescriptions
- B. Primary health problem
- C. Number of family members who have visited
- D. Admission vital signs from 1 week ago
- E. Scheduled times for dressing changes
Correct Answer: A,B,E
Rationale: Medications, primary problem, and dressing schedules are critical for continuity of care in the ICU; family visits and old vital signs are less relevant.
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A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure?
- A. Soreness at the incision site
- B. Serosanguineous drainage on the dressing
- C. Report of sore throat
- D. Tingling of the fingers
Correct Answer: D
Rationale: Tingling of the fingers suggests hypocalcemia due to parathyroid gland damage during thyroidectomy, a potential complication.
A nurse is reinforcing teaching with a client who is to take a fecal occult blood test at home. Which of the following instructions should the nurse include in the teaching?
- A. Apply five drops of developer to each smear.
- B. Use the same part of stool for each sample.
- C. Ensure the sample contains no urine.
- D. Wait 10 min before applying the developing solution.
Correct Answer: C
Rationale: Ensuring the sample is free of urine prevents contamination, which could lead to inaccurate fecal occult blood test results.
A nurse is reinforcing teaching with a client who has herpes simplex virus type 2. Which of the following statements by the client indicates an understanding of the teaching?
- A. I am only contagious while the lesions are present.
- B. The virus cannot spread to areas other than the genital area.
- C. I can have unprotected sex as long as I am taking acyclovir.
- D. The lesions may reoccur in times of stress.
Correct Answer: D
Rationale: Herpes simplex virus type 2 can recur during stress due to immune suppression, indicating client understanding.
Nurses' Notes
Vital Signs
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days. The client states, “I also have vomited, once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
The nurse is assisting with the care of a client. The nurse is collecting data on the client. Which of the following findings require follow-up?
- A. Blood pressure
- B. BUN level
- C. Potassium level Abdominal findings
- D. WBC count
- E. Breath sounds
Correct Answer: A,B,C,D
Rationale: Blood pressure, BUN, potassium, and abdominal findings (pain, constipation, vomiting, high-pitched bowel sounds) require follow-up due to potential dehydration or obstruction; breath sounds are normal and do not need follow-up.
A nurse is preparing to administer enoxaparin 1.5 mg/kg subcutaneously to a client who weighs 175 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 119
Rationale: The client's weight is 175 lb = 79.5 kg (175 ÷ 2.2). Dose = 1.5 mg/kg × 79.5 kg = 119.25 mg, rounded to 119 mg.