Complete the following sentence by choosing from the lists o...

The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).

Complete the following sentence by choosing from the lists of options. Based on the clinical findings, the client is most at risk for--------------------- as evidenced by the client's------------------------

A. vital signs
B. peritonitis and sepsis
C. fluid volume deficit and hypovolemic shock
D. abdominal pain
E. date of last menstrual period
F. intraabdominal hemorrhage and hypovolemic shock

Correct Answer: C,A

Rationale: The client's findings are most aligned with diabetic ketoacidosis (DKA). When there is a lack of insulin to transport glucose into cells, glucose
accumulates, creating an osmotic gradient that leads to diuresis (polyuria) and fluid loss. If the hyperglycemia persists, the process continues
and the fluid volume deficit decreases cardiac output and perfusion to vital organs (hypotension). The heart rate increases (tachycardia)
to compensate for the decrease in cardiac output. Without immediate treatment, compensatory mechanisms eventually fail, and the client is
at risk for developing life-threatening hypovolemic shock

History

Labor and Delivery Unit
Admission: The client, gravida 1 para 0, at 16 weeks gestation with a twin pregnancy reports nausea and vomiting for the past
several weeks. The client also reports dry heaving, increasing weakness, light-headedness, and an inability to tolerate
oral intake for the past 24 hours. In addition, the client has had occasional right-sided, shooting pain from the abdomen
to the groin that occurs with sudden position changes. The pain quickly resolves without intervention per the client's
report. She has had no contractions or vaginal bleeding and has felt no fetal movement during this pregnancy. The
client has a history of childhood asthma and is currently taking no asthma medications. The client reports no other
pregnancy complications.

Physical
Prepregnancy,12 Weeks Gestation 16 Weeks Gestation(Prenatal Visit),(Labor and Delivery Admission)
Height ,5 ft 5 in (165.1 cm),5 ft 5 in (165.1 cm)|, 5 ft 5 in (165.1 cm)
Weight, 145 lb (65.8 kg),148 lb (67.1 kg),138 lb (62.6 kg)
BMI, 24.1 kg/m2, 24.6 kg/m2,23.0 kg/m2

Vital Signs
12 Weeks Gestation(Prenatal Visit),16 Weeks Gestation(Labor and Delivery Admission)
T,98.7 F (37.1 C),99.8 F (37.7 C)
P,70,101
RR,14,18
BP,122/78,90/55
SpO2,99% on room air,96% on room air

Laboratory Results
Laboratory Test and Reference Range, 16 Weeks Gestation
Blood Chemistry.
Sodium
136-145 mEq/L
(136-145 mmol/L)|,
136 mEq/L
(136 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
2.7 mEq/L
(2.7 mmol/L)
TSH
0.3-5.0 uU/mL
(0.3-5.0 mU/L),
0.4 pu/mL
(0.4 mU/L)
Hematology.
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
16 g/dL
(160 g/L)
Hematocrit (pregnant)
>33%
(>0.33),
49%
(0.49)
Urinalysis
Specific gravity
1.005-1.030
1.030,
Ketones
Not present,
Present
Giucose
Not present,
Not present
Nitrites
Not present,
Not present

The client is diagnosed with hyperemesis gravidarum and is planning care with the registered nurse. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.

A. Give clear liquids
B. Weigh the client daily
C. Obtain a 12-lead ECG
D. Administer enteral nutrition
E. Initiate a large-bore peripheral IV
F. Document strict intake and output
G. Auscultate the fetal heart rate intermittently

Correct Answer:

Rationale: When caring for clients with hyperemesis gravidarum (HG), the primary goal is to alleviate vomiting, replenish fluids, and correct electrolyte
and nutritional imbalances. Once completed, resumption of oral intake can be attempted. Interventions that are indicated at this time
include:
• Weighing the client daily to monitor for additional weight loss
• Obtaining a 12-lead ECG to monitor for cardiac changes related to electrolyte imbalances (eg, hypokalemia)
• Initiating a large-bore peripheral IV (eg, 18-gauge) to allow for administration of fluids and medications
• Documenting strict intake and output (eg, emesis, urinary output) to monitor hydration status and kidney function
• Auscultating the fetal heart rate intermittently (eg, twice daily, once per shift) to verify fetal status. (Continuous fetal heart rate
monitoring is not indicated at this gestational age.)
Many clients with HG cannot tolerate anything by mouth and are typically placed on a short period of gut rest (ie, NPO status), if hospitalized.
Therefore, giving clear liquids is contraindicated during the initial treatment phase of HG but should be offered once nausea and vomiting
have stopped. For the same reasons, administering enteral nutrition (eg, tube feeding) is contraindicated initially for this client and is not
anticipated unless feedings by mouth and other treatment measures fail.

The nurse is caring for a 20-year-old client.
Progress Notes

Clinic Visit
For the past week, the client has experienced flu-like symptoms, including low-grade fevers, headaches, nausea, vomiting, and, today,
diarrhea and dark urine. The client reports widespread itching but has no rash. Skin and scleras are jaundiced. No lymphadenopathy
is present, and the abdomen is nondistended with a palpable liver edge. The client returned from an international mission trip a few
weeks ago.
Vital signs are T 99.9 F (37.7 C), P 88, RR 18, BP 128/80, and SpOz 98% on room air.

Laboratory Results
Laboratory Test and Reference Range ,Current
Liver Function Tests
Total bilirubin, Increased
Alkaline phosphatase, Increased
Aspartate aminotransferase (AST), Increased
Alanine aminotransferase (ALT) ,Increased

Complete the following sentence by choosing from the lists of options. The nurse suspects the client has ----------- and should implement ----------- precautions.

A. Influenza
B. Droplet
C. Contact
D. Standard
E. Hepatitis A

Correct Answer: D,E

Rationale: Hepatitis A is an infection that leads to widespread inflammation of the liver. Transmission occurs through the fecal-oral route and is commo
in areas with overcrowding and poor sanitation. Outbreaks frequently result from contaminated water or food, and the condition is seen
primarily in resource-limited countries. Symptoms develop abruptly, initially including nausea, vomiting, anorexia, fever, and right upper
quadrant pain. A few days later, dark urine (bilirubinuria) and/or pale stools (lacking bilirubin pigment) may be seen. These are usually
followed by jaundice and pruritus. In addition, laboratory results show elevated liver function tests.
Hand hygiene, especially after toileting and before meals, is the most important intervention for reducing the risk of hepatitis A infection.
Therefore, for a client hospitalized with hepatitis A, standard precautions (ie, hand hygiene, disinfection of equipment and surfaces) must be
implemented to prevent transmission. Additional precautions (eg, disposable gown, gloves) should be used as needed (eg, during procedure

The nurse has reviewed the information from the Laboratory Results. The client is transferred to an inpatient care facility. Which of the following orders should the nurse expect for the client? Select all that apply

A. insulin IV infusion
B. continuous cardiac monitoring
C. hourly finger-stick blood glucose level
D. 5% dextrose in 0.9% sodium chloride IV infusion
E. rectal sodium polystyrene sulfonate
F. strict intake and output monitoring

Correct Answer: A,B,C,G

Rationale: Management of diabetic ketoacidosis (DKA) initially focuses on IV fluid resuscitation to reverse hypovolemia and then correction of
hyperglycemia, electrolyte abnormalities, and acid-base imbalance. Appropriate interventions include:
• Continuous insulin IV infusion to correct hyperglycemia. IV insulin has a more rapid onset of action than subcutaneous insulin, whic
allows faster and more precise management of the blood glucose level (Option 1).
• Continuous cardiac monitoring to detect dyshythmias related to metabolic acidosis or electrolyte abnormalities (Option 2).
• Hourly finger-stick blood glucose level checks to monitor for treatment effectiveness and detect any hypoglycemia related to the
insulin infusion (Option 3).
• Isotonic IV fluid (eg, 0.9% sodium chloride) to replace fluid losses and strict intake and output monitoring to evaluate the
effectiveness of fluid resuscitation and monitor for signs of acute kidney injury (Option 6).
• Frequent monitoring of arterial blood gas levels and electrolyte levels.

The nurse is performing a home health visit for an 84-year-old male.
History and Physical
Body System, Findings
General,
Client reports a 1-month-long history of fatigue and dyspnea that has worsened; he is unable to lie
flat and sleeps in a chair at night, medical history includes myocardial infarction, chronic heart
failure, chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus; client
was diagnosed with benign prostatic hyperplasia 8 months ago; client is adherent with prescribed
medications; client reports frequent consumption of donuts, hamburgers, steak, and fried chicken;
BMI is 34 kg/m?; client reports 6-Ib (2.7-kg) weight gain in 1 week
Neurological,
Alert and oriented to person, place, time, and situation
Pulmonary,
Vital signs: RR 24, SpOz 88% on room air; labored breathing, crackles in bilateral lung bases; client
expectorates frothy, pink-tinged sputum; client has a 40-year history of smoking 1 pack of cigarettes
per day
Cardiovascular,
Vital signs: T 98.8 F (37.1 C), P 98, BP 113/92; S1, S2, and S3 present; 3+ bilateral lower extremity
edema
Genitourinary, Concentrated yellow urine; client reports increased urinary hesitancy and urgency
Psychosocial,
Client reports being lonely and has depressed mental status

The health care provider has confirmed that the client is experiencing an exacerbation of heart failure. For each potential prescription, click to specify if the prescription is expected or unexpected for the care of the client.

A. Potential Prescription, Expected, Unexpected
B. Perform daily weights
C. Administer furosemide
D. Apply compression stockings
E. Encourage the client to limit mobility
F. Encourage increased oral fluid intake

Correct Answer:

Rationale: Heart failure (F) exacerbation management focuses on improving oxygenation and reducing fluid overload. Expected
prescriptions include:
• Performing daily weights to monitor fluid volume status and guide treatment. Ideally, daily weights should be performed
at the same time of day, on the same scale, and with the client wearing the same amount/type of clothes. Rapid weight
gain (ie, >5 lb/week [(2.3 kg/week]) should be communicated to the health care provider immediately.
• Administering loop diuretics (eg, furosemide, torsemide, bumetanide) to prevent reabsorption of sodium and chloride in
the kidneys, which increases fluid excretion and urine output. This provides symptom relief by reducing pulmonary
congestion and peripheral edema.
• Applying compression stockings, a common nopharmacological intervention, to promote venous blood return and
reduce peripheral edema.
Limiting mobility is unexpected for a client with increased fluid volume. The client should be encouraged to ambulate
frequently to promote venous return, exercise cardiac muscle, and reduce risk of deep venous thrombosis.
Increasing oral fluid intake is unexpected for a client with hypervolemia (ie, heart failure exacerbation) because it
exacerbates existing symptoms (eg, edema, pulmonary congestion).

The nurse is caring for a 58-year-old client.
Admission Note
Emergency Department
A client with colorectal cancer reports intractable bilious vomiting for the past day; it is accompanied by severe, colicky
abdominal pain. The client cannot tolerate oral intake and has not passed gas or had a bowel movement since the
symptoms began. The abdomen is distended, and bowel sounds are hyperactive.
Vital Signs
Emergency Department
T, 97.3 F (36.3 C)
P, 98
RR, 18
BP, 110/70
SpO2, 98% on room air

The nurse is contributing to the client's plan of care. For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client.

A. Administer antiemetic
B. Insert a nasogastric tube
C. Place the client on a soft diet
D. Obtain an abdominal CT scan
E. Administer a stimulant laxative

Correct Answer:

Rationale: Small bowel obstruction (SBO) is an intestinal blockage that obstructs the flow of intestinal contents (eg, fluid, gas, fecal
material). The blockage may be due to mechanical (eg, surgical adhesions, hernias, tumors) or nonmechanical/functional (eg,
paralytic ileus) causes. As intestinal contents accumulate, clients develop abdominal distension, colicky abdominal pain,
bilious vomiting, and inability to pass flatus or stool.
Clients with SBO are at risk for fluid, electrolyte, and nutritional imbalances due to decreased intestinal absorption. Clients may
develop bowel necrosis and perforation due to impaired intestinal blood flow, which can lead to peritonitis and sepsis.
The practical nurse should anticipate assisting the registered nurse with the following interventions for a client with SBO:
• Inserting a nasogastric tube for gastrointestinal decompression to reduce abdominal distension and improve intestinal
blood flow
• Administering antiemetics (eg, ondansetron) to prevent further fluid and electrolyte imbalance from vomiting
• Preparing the client for abdominal CT scan to determine the size and location of intestinal obstruction
• Administering IV fluids to improve fluid volume status
In clients with SBO, bowel rest (ie, NPO status) with gastric decompression is prescribed; therefore, a soft diet is not
indicated. Stimulant laxatives increase intestinal motility and are not indicated for clients with intestinal obstruction due to
the risk for bowel perforation.

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