Nokea
A nurse is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?
- A. You will need to fast for 2 hours before the procedure.
- B. You will have the bone marrow taken from your femur.
- C. You will not receive a local anesthetic agent for this procedure.
- D. I will hold pressure on the site after the procedure.
Correct Answer: D
Rationale: Holding pressure on the site post-procedure prevents bleeding, a standard part of bone marrow aspiration care.
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Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
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.
Day 1, 1100:
Morphine administered as prescribed. IV fluids with potassium supplements initiated. Nasogastric tube inserted into left nare and set to low wall suction.
Day 4, 1000:
Client reports that abdominal pain has decreased to 3 on a scale of 0 to 10. Client states, "I feel less nauseous today and haven't vomited since yesterday." Client reports having a small bowel movement early this morning.
Physical exam:
General: Appears more comfortable, not grimacing.
HEENT: Mucous membranes moist.
Cardiovascular: S1, S2, no murmur.
Respiratory: Bilateral breath sounds clear.
Gastrointestinal:
Mild tenderness to palpation.
Bowel sounds present and more regular, less high-pitched.
Skin: No jaundice noted, skin warm and dry.
The nurse continues to assist with the care of the client.
The nurse continues to assist with the care of the client. Which of the following findings indicates that the client's condition has improved?
- A. Fluid intake
- B. Temperature
- C. Wound findings
- D. Pain level
- E. Report of nausea
- F. Bowel sounds
Correct Answer: D,E,F
Rationale: Decreased pain (from 7 to 3), reduced nausea, and more regular bowel sounds indicate improvement in the client's condition, likely due to resolution of obstruction.
A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter.
- A. Apply pressure to the venipuncture site with sterile gauze.
- B. Perform hand hygiene.
- C. Clamp the IV tubing.
- D. Withdraw the catheter from the client's vein.
- E. Remove the dressing and tape from the venipuncture site.
Correct Answer: B,E,C,A,D
Rationale: The sequence is: hand hygiene, remove dressing/tape, clamp tubing, apply pressure, withdraw catheter-ensuring safety and preventing bleeding.
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.
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 the right leg upon falling. Right leg was immobilized at the scene and the 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 1+, foot cool to palpation with minimal movement and reduced.
A nurse is assisting in the care of a client who The first action the nurse should take is to followed by. is postoperative following an open reduction internal fixation of the right tibia. Complete the following sentence by using the lists of options. The first action the nurse should take is to..... followed by.....
- A. Assess neurovascular status.
- B. Elevate the leg.
- C. Administer prescribed pain medication
- D. Monitor vital signs
- E. Apply a sterile dressing to the wound
- F. Notify the provider
Correct Answer: A,F
Rationale: Assessing neurovascular status first identifies complications like compartment syndrome, followed by notifying the provider for urgent intervention.
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.