Nokea
The nurse is caring for an 82-year-old client in the emergency department.
Nurses' Notes
0930:
The client reports shortness of breath and left-sided chest pain for 2 days. The client fractured the right femoral neck a month ago after a fall and decided against operative management. Since then, the client has been wheelchair dependent and takes acetaminophen for fracture pain management. The client was placed on continuous cardiac monitoring.
History and physical
Body System
Neurological
The client is awake, alert, and oriented to person, place, time, and situation; the client appears anxious
Pulmonary
Vital signs are RR 22, SpOz 89% on room air; bilateral breath sounds are clear; pain increases with inhalation; the client reports shortness of breath for the past 2 days; the client smoked 1 pack of cigarettes per day for 10 years.
Cardiovascular
Vital signs are T 99.8 F (37.7 C), P 110, BP 110/60; S1 and S2 are present; there are no murmurs, redness and edema of the right lower extremity are noted; sinus tachycardia is seen on the monitor, chest pain is reported as 7 on a scale of 0-10
Musculoskeletal
The client has osteoporosis, is wheelchair dependent, and is unable to bear weight on the right leg
Diagnostic Results
CT pulmonary angiography
1030: Pulmonary embolism is confirmed
Lower extremity doppler ultrasound
1100: Deep venous thrombosis is noted in the right lower extremity.
For each potential prescription, click to specify if the prescription is anticipated or contraindicated for the care of the client.
- A. Heparin infusion
- B. Acetaminophen PRN for pain
- C. Physical therapy for mobility exercises
- D. Supplemental oxygen to maintain SpO2 ≥ 90%
- E. Sequential compression devices to bilateral lower extremities
Correct Answer: A,B,D
Rationale: A: Heparin infusion is anticipated to treat pulmonary embolism and DVT by preventing further clot formation. B: Acetaminophen is anticipated for pain management, as it is safe for this client. C: Physical therapy is contraindicated due to the acute PE and DVT, as mobilization could dislodge clots. D: Supplemental oxygen is anticipated to correct hypoxemia (SpO2 89%). E: Sequential compression devices are contraindicated, as DVT is already present, and they could dislodge the clot.
You may also like to solve these questions
Nurses' Notes
0930:
The client reports shortness of breath and left-sided chest pain for 2 days. The client fractured the right femoral neck a month ago after a fall and decided against operative management. Since then, the client has been wheelchair dependent and takes acetaminophen for fracture pain management. The client was placed on continuous cardiac monitoring.
History and physical
Body System
Neurological
The client is awake, alert, and oriented to person, place, time, and situation; the client appears anxious
Pulmonary
Vital signs are RR 22, SpOz 89% on room air; bilateral breath sounds are clear; pain increases with inhalation; the client reports shortness of breath for the past 2 days; the client smoked 1 pack of cigarettes per day for 10 years.
Cardiovascular
Vital signs are T 99.8 F (37.7 C), P 110, BP 110/60; S1 and S2 are present; there are no murmurs, redness and edema of the right lower extremity are noted; sinus tachycardia is seen on the monitor, chest pain is reported as 7 on a scale of 0-10
Musculoskeletal
The client has osteoporosis, is wheelchair dependent, and is unable to bear weight on the right leg
For each finding below, click to specify if the finding is consistent with the disease process of myocardial infarction, pneumonia, or pulmonary embolism.
- A. Dyspnea
- B. Chest pain
- C. Hypoxemia
- D. Sinus tachycardia
- E. Right lower extremity redness and edema
Correct Answer: A: Myocardial infarction, Pneumonia, Pulmonary embolism; B: Myocardial infarction, Pneumonia, Pulmonary embolism; C: Pneumonia, Pulmonary embolism; D: Myocardial infarction, Pulmonary embolism; E: Pulmonary embolism
Rationale: A: Dyspnea is common in all three due to impaired oxygenation or cardiac output. B: Chest pain occurs in all three, though the nature varies (e.g., pleuritic in pneumonia/PE, crushing in MI). C: Hypoxemia is typical in pneumonia (due to alveolar impairment) and PE (due to ventilation-perfusion mismatch). D: Sinus tachycardia is seen in MI (due to cardiac stress) and PE (due to hypoxia and embolism). E: Right lower extremity redness and edema suggest DVT, which is strongly associated with PE.
The nurse is caring for a client at a women’s health clinic.
History & Physical
Labor and delivery unit
0800:
A 28-year-old nulliparous female comes to the clinic for confirmation of suspected pregnancy due to amenorrhea and a positive home pregnancy test. The client's current exercise regimen includes indoor cycling and outdoor running. The client reports nausea, vomiting, and breast tenderness. She has a 28-day menstrual cycle, and her last menstrual period was March 10- 17. The health care provider notes a bluish-purple vaginal mucosa and cervix during pelvic examination and confirms a 12-week intrauterine pregnancy by sonography. A fetal heart rate of 155/min is detected with handheld Doppler.
Progress Notes
Trending Maternal Weight
Prepregnancy
Height: 5 ft 5 in (165.1 cm)
Weight: 140 lb (63.5 kg)
BMI: 23.3 kg/m
12 weeks gestation
Weight: 150 lb (68 kg)
16 weeks gestation
Weight: 160 lb (72.6 kg)
Nurses’ notes
0800
Client comes to the clinic for a 20-week gestation prenatal visit. Client reports no bleeding or cramping. Vital signs and physical examination are normal. Current weight is 157 lb (71.2 kg). Client states that she is feeling well overall.
What client statement requires additional teaching reinforcement?
- A. I added gymnastics into my exercise routine.
- B. I eat carbohydrates that are high in fiber.
- C. I eat salmon once per week.
- D. I go to an indoor cycling class 3 times per week.
Correct Answer: A
Rationale: Gymnastics poses a risk of falls and injury during pregnancy, requiring reinforcement about safe exercises like walking or prenatal yoga.
The nurse is caring for a 52-year-old client on the orthopedic unit.
Nurses' Notes
Postoperative Day 1
0900:
The client's left leg was placed in balanced suspension skeletal traction for a fractured femur 12 hours ago. The client is positioned supine in the center of the bed with the foot of the bed elevated 15 degrees. Traction ropes are free of frays, centered in the pulleys, and moving freely with attached weights resting on the bed frame.
Serous drainage noted around the pin sites. Left foot slightly cool to the touch with posterior tibial and dorsalis pedis pulses palpable at 2+ and capillary refill <2 seconds in the toes. Client has normal sensation and movement of the left toes. Client rates left leg pain as 8 on a scale of 0-10.
Vital signs are T 100.4 F (38 C), P 110, RR 18, and BP 132/68. Weight is 173 lb (78.5 kg).
For each potential prescription, click to specify if the prescription is expected or not expected for the care of the client.
- A. Restrict fluid intake
- B. Offer a low-fiber diet
- C. Use incentive spirometer
- D. Administer stool softener
- E. Administer anticoagulant
Correct Answer: C,D,E
Rationale: Expected prescriptions include using an incentive spirometer (C) to prevent atelectasis, administering a stool softener (D) for constipation, and an anticoagulant (E) for DVT prevention. Fluid restriction (A) and low-fiber diet (B) are not indicated.
The nurse is caring for a 58-year-old client on a medical-surgical unit.
History and Physical
General
The client is vomiting bright red blood; medical history includes alcohol use disorder, liver cirrhosis, and hypertension; the client was admitted a year ago for alcohol-induced acute pancreatitis
Neurological
The client is oriented to person and place; the pupils are equal, round, and reactive to light and accommodation
Eye, Ear, Nose, and Throat (EENT)
Yellow scleras are noted
Pulmonary
Vital signs are RR 18, SpO 94% on room air
Cardiovascular
Vital signs are T 99 F (37.2 C), P 102, BP 90/40; S1 and S2 are heard on auscultation; peripheral pulses are 2+ in all extremities; 1+ edema is noted at the bilateral lower extremities
Gastrointestinal
The abdomen is distended and nontender to palpation; the flanks are dull to percussion; bowel sounds are hypoactive; distended veins are present around the umbilicus
Genitourinary
Client is voiding amber-colored urine
The health care provider confirms that the client is experiencing bleeding from esophageal varices secondary to complications from liver cirrhosis. For each potential prescription, specify if the prescription is anticipated or unanticipated for the care of this client.
- A. Maintain NPO status
- B. Start octreotide infusion
- C. Administer IV fluid bolus
- D. Transfuse packed RBCs
- E. Gather supplies for paracentesis
- F. Prepare client for esophagogastroduodenoscopy
Correct Answer: A: Anticipated, B: Anticipated, C: Anticipated, D: Anticipated, E: Unanticipated, F: Anticipated
Rationale: A) Anticipated: NPO prevents aspiration and supports esophageal varices management. B) Anticipated: Octreotide reduces portal pressure to control variceal bleeding. C) Anticipated: IV fluids address hypovolemia (BP 90/40). D) Anticipated: PRBCs treat blood loss from variceal bleeding. E) Unanticipated: Paracentesis is for ascites, not urgent here. F) Anticipated: EGD is standard to visualize and treat varices.
The nurse in the emergency department is caring for a 62-year-old client.
History and Physical
Neurological
The client is alert and oriented to time, place, person, and situation; the client reports sudden-onset right-sided facial drooping, speech is slurred; positive right-sided arm drift is seen
Eye, Ear, Nose, and Throat (EENT)
Bilateral pupils are equal, round, and reactive to light and accommodation
Pulmonary
Vital signs: RR 16, SpO, 95% on room air, lung sounds are clear bilaterally
Cardiovascular
Vital signs: T 99 F (37.2 C), P 86, BP 166/90; S1 and S2 are heard on auscultation; no murmurs are noted; the client has a history of hypertension
Musculoskeletal
Right-sided lower extremity weakness is seen
Endocrine
The client has diabetes mellitus
Psychosocial
The client reports drinking one glass of wine each evening with dinner, no tobacco use, and a history of major depression; the client takes sertraline.
Laboratory Results
During Admission
Blood Chemistry.
Glucose: 72 mg/dL (4.0 mmol/L)
Sodium: 133 mEq/L (133 mEq/L)
Chloride: 101 mEq/L (101 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)
Laboratory Test and Reference Range
Blood Chemistry.
Glucose 74-106 mg/dL (4.1-5.9 mmol/L)
Sodium 136-145 mEq/L (136-145 mmol/L)
Chloride 98-106 mEq/L(98-106 mmol/L)
Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L
Diagnostic Results
Admission
CT scan of the head without contrast
1830:
No areas of hemorrhage are noted
Based on the clinical data, which condition should the nurse suspect?
- A. Bell palsy
- B. Guillain-Barré syndrome
- C. Ischemic stroke
- D. Seizure disorder
Correct Answer: C
Rationale: Sudden-onset right-sided facial drooping, slurred speech, arm drift, and leg weakness, with a non-hemorrhagic CT scan, strongly suggest ischemic stroke (C). Bell palsy (A) typically involves only facial weakness. Guillain-Barré (B) presents with ascending paralysis. Seizure disorder (D) lacks seizure activity in the history.