For each event, click to specify whether the event is a sent...

For each event, click to specify whether the event is a sentinel event or a near-miss event.

A. A client fall results in a hip fracture
B. An invasive procedure is performed on the incorrect body site
C. The nurse identifies an ABO incompatibility while obtaining a blood product
D. The nurse identifies a miscalculated dose when preparing medications for a client
E. A client admitted for suicidal ideation dies of suicide in the emergency department
F. A client has an anaphylactic reaction to a medication that was documented as an allergy

Correct Answer: A,B,E,F

Rationale: Sentinel events cause harm: fall with fracture , wrong-site procedure , suicide , and anaphylaxis . Near-misses (C, D) are caught before harm.

The nurse is contacting a client at 28 weeks gestation to review laboratory results and schedule a follow-up prenatal visit. Laboratory Results Laboratory Test and Reference Range 12 Weeks Gestation 26 Weeks Gestation 28 Weeks Gestation
WBC (prostent) 5,000-1多份 (5.0-15.0 × 10°/L) 8,900/mm3 (8.9 × 10°/L) 16,500 /mm° (16.5 × 10%/L)
Hemoglobin (pregnant) 11-16 g/dL (110-160 g/L) 13 g/dL (130 g/L) 10.8 g/dL (108 g/L) Hematocrit (pregnant) 33%-47% (0.33-0.47) 39% (0.39) 32% (0.32)
Chlamydia Negative Positive Negative Hemoglobin A1c 4.0%-5.9% 5.1%
1-hour oral glucose challenge test <140 mg/dL (7.8 mmol/L) 175 mg/dL (9.7 mmol/L)
3-hour oral glucose tolerance test Fasting: <110 mg/dL (6.1 mmol/L) 1 hour: <180 mg/dL (10.0 mmol/L) 2 hour: <140 mg/dL (7.8 mmol/L 3 hour: <70-115 mg/dL (<6.4 mmol/L) Fasting: 115 mg/dL (6.4 mmol/L) 1 hour: 205 mg/dL (11.4 mmol/L) 2 hour: 162 mg/dL (9.0 mg/dL) 3 hour: 135 mg/dL (7.5 mg/dL)

The nurse should be most concerned about the client's. and anticipate the client's need for

A. Glucosuria
B. Contractions
C. Blood pressure
D. Blood glucose levels
E. Insulin
F. A urine culture
G. Antihypertensives

Correct Answer: D,E

Rationale: Blood glucose levels are critical in gestational diabetes, requiring insulin to manage hyperglycemia.

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.

The nurse is caring for a 55-year-old client in the clinic.
History and Physical
Body System
Findings: General - The client reports cramping pain in the left calf that has worsened over the past year. The pain is precipitated by walking and is partially relieved with rest. The client reports difficulty walking more than 3 blocks. Height: 72 in (182.9 cm), weight: 250 lb (113.4 kg), BMI: 33.9 kg/m?
Pulmonary- Vital signs are RR 16, SpO, 97% on room air. Client reports smoking 1 pack of cigarettes daily for the past 35 years. Breath sounds are mildly decreased throughout with mild prolonged expiration. Client has a history of chronic obstructive pulmonary disease.
Cardiovascular- Vital signs are T 98.8 F (37.1 C), P 82, BP 146/82. S1 and S2 heard on auscultation. The left lower extremity (LLE) is cooler to touch than the right and appears shiny with sparse hair. LLE pulses: femoral 2+, popliteal 1+, posterior tibia 1+, dorsalis pedis audible with Doppler. LLE capillary refill >3 sec. Client has a history of hypertension.
Gastrointestinal- Client is obese. No tenderness, guarding, masses, bruits, or hepatosplenomegaly.

Which of the following statements should the nurse include in the teaching? Select all that apply.

A. Elevate your legs several times during the day to relieve pain.'
B. Incorporate more fruits and vegetables into your diet.'
C. Inspect your feet daily for any wounds.'
D. Use a heating blanket if your legs get cold.'
E. Walk each day until you have leg pain, rest for 10 minutes, and then continue walking.'

Correct Answer: B,C,E

Rationale: Healthy diet , foot inspections , and supervised walking are appropriate. Elevation is for venous issues, and heating blankets risk burns in poor perfusion.

Nurses' Notes
Vital Signs
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.

For each intervention, click to specify if the intervention is appropriate or inappropriate for the care of the client.

A. Ensure bedside suction is set up
B. Place a bag valve mask at the bedside
C. Ensure intubation equipment is available
D. Reposition the client in the bed every 2 hours
E. Place the client on continuous cardiac monitoring
F. Apply a sequential compression device to the legs
G. Mark the appropriate surgical site for a tracheotomy

Correct Answer: A,B,C,D,E,F

Rationale: Suction , bag valve mask , intubation equipment , repositioning , cardiac monitoring , and compression devices prepare for GBS complications. Tracheotomy marking is premature.

The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine

Which of the following statements by the parent indicate a correct understanding of the teaching? Select all that apply.

A. I will contact the health care provider immediately if my child experiences any vision changes, such as blurriness.'
B. I will schedule a follow-up visit for a urinalysis and blood pressure check.'
C. My child may notice small amounts of blood in the urine for several weeks.'
D. My child should avoid exposure to friends and family who show signs of an upper respiratory infection.'
E. My child will require lifelong blood pressure medication with frequent monitoring at home.'

Correct Answer: A,B,C,D

Rationale: Monitoring vision , follow-up tests , expecting hematuria , and avoiding infections are correct. Lifelong medication is not typical.