Nokea
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. Changed mental status
- B. Temperature 37.3°C (99.1°F)
- C. WBC count 9,000/mm3 (5000 to 10,000/mm3)
- D. Diminished reflexes
Correct Answer: A
Rationale: Changed mental status is a common sign of a bladder infection (UTI) in older adults, often presenting as confusion rather than typical urinary symptoms.
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A nurse is assisting in the care of the client who is postoperative following a fasciotomy.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses.
Day 3, 2300:
Client is alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Right leg with splint in place. Incisional dressing dry and intact. Wound drain to negative-pressure vacuum, draining small amounts of serosanguinous fluid. Bilateral pedal pulses 3+. feet warm with intact movement and sensation. Client reports pain as a 4 on a scale of 0 to 10.
The nurse is reviewing the client's electronic medical record (EMR). Select statements in the EMR that indicate the client's condition is improving since implementing interventions.
- A. Temperature 37.8°C (100°F)
- B. Client is alert and oriented to person, place, and time
- C. Bilateral breath sounds clear and present throughout
- D. Feet warm with intact movement and sensation
- E. Heart rate 98/min
- F. Bilateral pedal pulses 3+
- G. Respiratory rate 20/min
Correct Answer: B,C,D
Rationale: Alertness, clear breath sounds, and warm feet with intact sensation indicate recovery from the initial injury and fasciotomy.
A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?
- A. There is no cure for MRSA.
- B. We will need to wear masks when we are in the hospital room.
- C. MRSA only occurs in health care facilities.
- D. We should remove gloves before leaving the hospital room.
Correct Answer: D
Rationale: Removing gloves before leaving prevents the spread of MRSA, consistent with contact precautions.
Nurses' Notes
Vital Signs
Laboratory Results
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. For each finding, click to specify if the finding is consistent with small bowel obstruction or acute pancreatitis. Each finding may support more than 1 disease process.
- A. Pain level
- B. Social history
- C. Skin findings
- D. Lipase level
- E. WBC count
- F. Abdominal findings
Correct Answer: A (small bowel obstruction, acute pancreatitis), B (acute pancreatitis), C (neither), D (acute pancreatitis), E (small bowel obstruction, acute pancreatitis), F (small bowel obstruction)
Rationale: Pain level and abdominal findings (tenderness, high-pitched bowel sounds) support small bowel obstruction and acute pancreatitis; social history (alcohol use) and lipase support pancreatitis; WBC count supports both; skin findings (no jaundice) support neither.
A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?
- A. The client has inspiratory stridor
- B. The client reports a sore throat.
- C. The client's sputum has streaks of blood.
- D. The client's temperature is 38.6°C / 101.4°F
Correct Answer: A
Rationale: Inspiratory stridor indicates possible airway obstruction or swelling post-bronchoscopy, a serious complication requiring immediate reporting.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Clamp the tube for 30 min every 8 hr.
- B. Pin the tubing to the client's bed sheets.
- C. Monitor for at least 150 mL of drainage every hour.
- D. Replace the unit when the drainage chamber is full.
Correct Answer: D
Rationale: Replacing the unit when the drainage chamber is full ensures proper function and prevents complications, such as obstruction or infection, in a closed-chest tube system.