Nokea
The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative.
Click to highlight below the 3 findings that should concern the nurse.
- A. The client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin.
- B. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use.
- C. The client received treatment for bacterial vaginosis during the second trimester.
- D. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative.
Correct Answer: A,B,D
Rationale: Non-compliance with insulin , smoking , and excessive weight gain increase neonatal risks.
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The nurse is caring for a 6-year-old client accompanied by the parents.
History and Physical
Body System
Findings
General
Client is brought to the emergency department due to
shortness of breath; medical history includes cystic fibrosis
and many previous hospital admissions for pneumonia; in the
3rd percentile for height and weight
Neurological
Alert and oriented to person, place, and time; no neurologic
deficits
Pulmonary
Vital signs: RR 30, SpO, 87% on room air; moderate
subcostal retractions; bilateral wheezing and coarse crackles
throughout lung fields with fine inspiratory crackles at left lung
base; paroxysmal coughing that produces thick, yellow,
blood-tinged sputum; parents report that the client has begun
to become "winded" after showering and other activities Cardiovascular
Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm
and dry; peripheral pulses palpable 2+; capillary refill 3
econds; mild finger clubbing noted
Gastrointestinal
Abdomen soft with normoactive bowel sounds; parent states,
"Swallowing the enzyme capsules is very difficult for my child,
and I have noticed an increase in greasy, bulky stools"
Which of the following client findings are consistent with a cystic fibrosis exacerbation? Select all that apply.
- A. Blood-tinged sputum
- B. Greasy, bulky stools
- C. Paroxysmal coughing
- D. SpO2 of 87% on room air
- E. Temperature of 101.7 F (38.7 C)
Correct Answer: A,B,C,D,E
Rationale: Cystic fibrosis exacerbations often present with increased respiratory symptoms (A, C, D), fever , and malabsorption issues due to pancreatic insufficiency.
The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days
Which client statement requires immediate follow-up with the health care provider?
- A. Are my feet covered? I cannot feel them anymore.'
- B. I cannot finish my lunch today; my abdomen feels so distended.'
- C. I have been so exhausted since my last chemotherapy treatment.'
- D. When is my next dose of pain medicine? My pain is a 10 out of 10 .'
Correct Answer: A
Rationale: Loss of sensation in the feet suggests worsening spinal cord compression, requiring urgent provider notification.
The nurse is caring for a 16-year-old client.
History and Physical Laboratory Results
Body System- Findings
General- The client comes to the emergency department with pain in the upper back, both knees, and the lower legs that is rated as 9 on a scale of 0-10; medical history includes sickle cell disease; the client reports attending an outdoor sports camp for the past 4 days; the client appears restless with frequent position changes and facial grimacing
Neurological- The client is alert and oriented to person, place, and time
Pulmonary- Vital signs: RR 24, SpOz 95% on room air, breath sounds are clear bilaterally Cardiovascular- Vital signs: T 98.4 F (36.9 C), P 120, BP 130/78; S1 and S2 are auscultated with no murmurs, continuous cardiac monitor shows sinus tachycardia
Gastrointestinal- The abdomen is soft and nontender with normal bowel sounds; the client vomited 30 mL of clear liquid
Musculoskeletal- The client has multiple, tender, bony points
Genitourinary- The client voided 50 mL of clear, amber-colored urine
Click to highlight below the 2 prescriptions the nurse should implement first.
- A. Administer morphine
- B. Administer hydroxyurea PO
- C. Apply moist heat to knees
- D. Encourage incentive spirometer
- E. Continuous IV fluids
- F. Record strict intake and output
Correct Answer: A,E
Rationale: Morphine and IV fluids are prioritized to relieve pain and improve hydration in a sickle cell crisis.
The nurse is caring for a 6-year-old client accompanied by the parents.
History and Physical
Body System
Findings
General
Client is brought to the emergency department due to
shortness of breath; medical history includes cystic fibrosis
and many previous hospital admissions for pneumonia; in the
3rd percentile for height and weight
Neurological
Alert and oriented to person, place, and time; no neurologic
deficits
Pulmonary
Vital signs: RR 30, SpO, 87% on room air; moderate
subcostal retractions; bilateral wheezing and coarse crackles
throughout lung fields with fine inspiratory crackles at left lung
base; paroxysmal coughing that produces thick, yellow,
blood-tinged sputum; parents report that the client has begun
to become "winded" after showering and other activities Cardiovascular
Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm
and dry; peripheral pulses palpable 2+; capillary refill 3
econds; mild finger clubbing noted
Gastrointestinal
Abdomen soft with normoactive bowel sounds; parent states,
"Swallowing the enzyme capsules is very difficult for my child,
and I have noticed an increase in greasy, bulky stools"
Which of the following parent statements indicate a correct understanding? Select all that apply.
- A. A low-fat diet will help normalize my child's stool.'
- B. I will encourage my child to get regular exercise.'
- C. I will make sure that my child receives the flu vaccine each year.'
- D. My child should perform daily breathing exercises, even if there are no symptoms.'
- E. My child will require lifelong vitamin supplementation.'
- F. The pancre-lipase capsules can be opened and sprinkled on food.'
Correct Answer: B,C,D,E,F
Rationale: Exercise , flu vaccine , daily breathing exercises , vitamin supplementation , and sprinkling pancre-lipase are correct. A low-fat diet is incorrect; a high-calorie, high-fat diet is needed for cystic fibrosis.
The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days
For each finding, click to specify whether the finding indicates that the client's condition has improved or not improved.
- A. Muscle strength is rated 4/5
- B. Deep tendon reflexes are rated 2+
- C. Client is experiencing constipation
- D. The client rates pain as 4 on a scale of 0 to 10
- E. Reports feeling sensation with touch to the lower extremities
- F. Bladder scan immediately after voiding indicates residual urine
Correct Answer: A,B,E
Rationale: Improved strength , normal reflexes , and sensation indicate recovery. Constipation , pain , and residual urine suggest ongoing issues.