Nokea
Click to highlight below the findings indicating that the client is improving.
- A. Abdominal dressing removed. Wound is clean, dry, and intact with no bleeding or foul-smelling drainage.
- B. Fundus is firm, midline, and at the umbilicus. Urine output was $500 \mathrm{~mL}$ over the past 4 hours.
- C. Client states that she is too tired and sore to ambulate in room with nursing assistance.
- D. Client states that she cannot properly latch the newborn during breastfeeding.
- E. Tolerating oral labetalol; systolic BP has been 110-130 mm Hg and diastolic BP has been 70-80 mm Hg over the past 12 hours.
- F. Client reports no headaches and remains free of seizures.
Correct Answer: A,B,E,F
Rationale: Clean wound , normal fundus and urine output , stable blood pressure , and absence of headaches/seizures indicate improvement.
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The nurse is caring for a 68-year-old client who is brought to the emergency department due to confusion.
History and Physical Body System Findings
General- Client's adult child reports the confusion started this morning, following 3 days of fever and productive cough; medical history includes small bowel resection 10 days ago, chronic heart failure, and coronary artery disease
Neurological- Client is drowsy and oriented to person only, but intermittently agitated Integumentary- Small abdominal surgical incision is present over lower left quadrant, edges are well approximated, and no redness or drainage is noted
Pulmonary- Vital signs are RR 24 and SpO 90% on room air; labored breathing is observed, and crackles and diminished breath sounds are auscultated over right lower chest; client is expectorating yellow sputum; history includes smoking a pack of cigarettes daily for the past 40 years
Cardiovascular- Vital signs are T 102.9 F (39.4 C), P 110, and BP 110/70; S1 and S2 are heard on auscultation; bilateral lower extremity edema is 1+; ECG shows sinus tachycardia
Gastrointestinal- Normoactive bowel sounds are auscultated; client's last bowel movement was 1 day ago
Genitourinary- Client voided concentrated yellow urine
Which action should the nurse take?
- A. Place the client in Trendelenburg position
- B. Prepare the client for chest tube insertion
- C. Prepare the client for intubation
- D. Remove the thoracentesis dressing
Correct Answer: B
Rationale: Pneumothorax requires chest tube insertion to re-expand the lung.
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 3 findings require immediate follow-up?
- A. Cardiovascular findings
- B. Genitourinary symptoms
- C. Musculoskeletal symptoms
- D. Neurologic symptoms
- E. Vital signs
Correct Answer: B,C,D
Rationale: Urinary retention , trouble walking , and decreased sensation suggest spinal cord compression, requiring urgent intervention.
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower
back pain and bilateral leg weakness. The client reports that the
weakness began 3 days ago in the feet and has gradually worsened.
The client sought treatment today after becoming "so weak that I fell
while walking" and noticing new hand weakness and difficulty
swallowing. Back pain radiates down both legs and is rated as 5 on a
scale of 0-10. The client recently recovered from an illness with flu-like
symptoms. The client reports a history of hypertension and takes no
medications. Assessment of the lower extremities reveals muscle
strength of 2/5 and decreased sensation to pinprick. Achilles tendon
and patellar reflexes are decreased.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.
1030:
The client is breathless while speaking. Respirations are shallow and
labored. The client is diaphoretic. The skin is pale and cool. No
audible wheezing or stridor is present.
Which of the following statements by the client's spouse indicate that the teaching has been effective? Select all that apply.
- A. My children and I need to get tested because we could become paralyzed, too.'
- B. My spouse may have neurologic deficits for several months.'
- C. My spouse may need a temporary feeding tube for nutrition while on the ventilator.'
- D. Our children should refrain from getting a yearly flu vaccine.'
- E. This was most likely triggered by the recent flu-like illness.'
Correct Answer: B,C,E
Rationale: Prolonged deficits , feeding tube need , and viral trigger are accurate. GBS is not contagious , and flu vaccines are recommended.
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"
Click to highlight below the assessment findings that require immediate follow-up?
- A. 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
- B. Alert and oriented to person, place, and time; no neurologic deficits
- C. Vital signs: RR 30, SpO2 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
- D. 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 seconds; mild finger clubbing noted
- E. 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'
Correct Answer: A,C,D,E
Rationale: Findings A, C, D, and E indicate urgent issues: shortness of breath with a history of cystic fibrosis , low oxygen saturation and respiratory distress , fever and tachycardia , and malabsorption symptoms require immediate intervention.
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower
back pain and bilateral leg weakness. The client reports that the
weakness began 3 days ago in the feet and has gradually worsened.
The client sought treatment today after becoming "so weak that I fell
while walking" and noticing new hand weakness and difficulty
swallowing. Back pain radiates down both legs and is rated as 5 on a
scale of 0-10. The client recently recovered from an illness with flu-like
symptoms. The client reports a history of hypertension and takes no
medications. Assessment of the lower extremities reveals muscle
strength of 2/5 and decreased sensation to pinprick. Achilles tendon
and patellar reflexes are decreased.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.
1030:
The client is breathless while speaking. Respirations are shallow and
labored. The client is diaphoretic. The skin is pale and cool. No
audible wheezing or stridor is present.
Which action by the nurse is appropriate?
- A. Perform oral suctioning
- B. Prepare the client for intubation
- C. Reposition the client and encourage deep breathing
- D. Request a prescription for an albuterol nebulizer treatment
Correct Answer: B
Rationale: Shallow, labored breathing and chest tightness indicate impending respiratory failure, requiring preparation for intubation.