For each potential intervention, click to specify if the int...

The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn

For each potential intervention, click to specify if the intervention is indicated or not indicated for the care the client.

A. Cleanse the client's body thoroughly
B. Remove the client's abdominal staples
C. Remove identifying name tags from the client
D. Notify the organ and tissue donation organization
E. Allow the family to be present during postmortem care
F. Remove the drains, urinary catheter, and peripheral IV catheters

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

Rationale: Cleansing the body , removing identifiers , notifying donation organizations , allowing family presence , and removing invasive devices are standard postmortem care. Staples should remain for autopsy or funeral preparation.

The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur

Which of the following statements by the nurse are appropriate to include in the teaching? Select all that apply

A. Avoid driving after taking alprazolam.'
B. Contact your health care provider immediately if you experience suicidal thoughts.'
C. Do not abruptly stop taking alprazolam because you may experience withdrawal symptoms.'
D. Limit alcoholic beverages to no more than one drink a day while taking alprazolam.'
E. Take sertraline at the onset of a panic attack.'

Correct Answer: A,B,C

Rationale: Alprazolam requires avoiding driving , monitoring for suicidal thoughts , and gradual tapering . Alcohol limits are stricter, and sertraline is not for acute attacks.

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. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.

For each nursing action, click to specify if the action is indicated or not indicated for the care of the newborn during a heel stick.

A. Warm the heel prior to initiating the procedure
B. Collect the first drop of blood for blood glucose testing
C. Draw blood by pricking the skin with a small-gauge needle
D. Obtain the blood specimen from the lateral aspect of the heel
E. Clean the heel with an alcohol pad prior to obtaining the blood specimen

Correct Answer: A,C,D,E

Rationale: Warming the heel , using a needle , lateral heel site , and cleaning are standard. The first drop is discarded to avoid contamination.

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

The nurse should notify the health care provider about which client data?

A. Miosis of bilateral pupils
B. Most recent reticulocyte count
C. No bowel movement in 2 days
D. Pain rated as 2 on a scale of 0-10

Correct Answer: A

Rationale: Miosis suggests opioid overdose, requiring immediate provider notification.

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 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"

For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client.

A. Administer antibiotics
B. Administer a bronchodilator
C. Perform chest physiotherapy
D. Administer nebulized hypertonic saline
E. Place the client on airborne isolation precautions

Correct Answer: A,B,C,D

Rationale: Antibiotics treat bacterial pneumonia, bronchodilators relieve wheezing, chest physiotherapy aids mucus clearance, and hypertonic saline thins mucus. Airborne isolation is not indicated for bacterial pneumonia.