For each potential prescription, click to specify if the pre...

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 6-hour-old newborn.
Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpOz 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.

Select 2 findings that require immediate feedback?

A. A newborn is brought to the emergency department due to coughing and difficulty feeding.
B. The client was born at home 6 hours ago via spontaneous vaginal birth.
C. With each attempt to breastfeed, the client coughs, vomits, and 'turns blue.'
D. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
E. Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO2 95% on room air.
F. Ballard scoring estimates the client at 37 weeks gestation.
G. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.

Correct Answer: C,E

Rationale: Coughing, vomiting, and cyanosis during feeding indicate potential airway or gastrointestinal issues, such as tracheoesophageal fistula. The elevated respiratory rate (RR 50) suggests respiratory distress, requiring immediate attention.

The nurse is caring for a 12-month-old male client.
History and Physical
Body System
General
The client is brought to the emergency department by the parents due to increased leg bruising and left knee swelling for 1 day; the parents report that the client seems more tired and less playful; both parents and the sister are healthy, but a maternal uncle died at age 7 after mild head trauma.

Integumentary
Good hygiene; no abrasions; no burns; bilateral scattered lower extremity bruising

Eye, Ear, Nose, and Throat (EENT)
The parents report that the client's gums have been bleeding when chewing on crackers

Pulmonary
Vital signs: RR 38, SpO 100% on room air, upper respiratory infection 3 weeks ago that completely resolved after 4 days.

Cardiovascular
Vital signs: T 98.7 F (37.1 C), P 136

Musculoskeletal
Left knee redness and swelling with limited range of motion; the client can bear weight on both lower extremities; the parents state the child has recently started learning to walk by holding onto furniture and sometimes falls

Genitourinary
The parents state that urine output has been normal; urine is clear and pale yellow; the penis is uncircumcised

Psychosocial
The client is cooperative during examination; the client appears appropriately dressed for the season and weather; the mother says the child has no interest in toilet-training

Select the findings that require follow-up.

A. The client is brought to the emergency department by the parents due to increased leg bruising and left knee swelling for 1 day;
B. Good hygiene; no abrasions; no burns; bilateral scattered lower extremity bruising
C. The parents report that the client's gums have been bleeding when chewing on crackers
D. Vital signs: RR 38, SpO2 100% on room air,
E. Vital signs: T 98.7 F (37.1 C), P 136
F. Left knee redness and swelling with limited range of motion; the client can bear weight on both lower extremities;
G. The parents state that urine output has been normal;

Correct Answer: A,B,C,F

Rationale: A: Requires follow-up - Increased bruising and knee swelling suggest a potential bleeding disorder. B: Requires follow-up - Bilateral bruising is abnormal and may indicate a hematologic issue. C: Requires follow-up - Bleeding gums are concerning for a coagulation disorder. F: Requires follow-up - Knee swelling and limited motion could indicate hemarthrosis, common in bleeding disorders. D, E, G: Normal findings that do not require immediate follow-up.

The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.

Nurses' Notes
Inpatient - Mental Health Unit
2100:
Client appears anxious and withdrawn, and states, "I am afraid to sleep at night because I get nightmares about my sibling." The client would not elaborate on the content of the nightmares.

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

A. Provide the client privacy during flashbacks
B. Help the client identify available support systems
C. Directly ask if the client is having thoughts of self-harm
D. Determine the client's ability to perform activities of daily living
E. Reinforce the use of progressive muscle relaxation for anxiety
F. Avoid discussion of the traumatic event when speaking to the client

Correct Answer: B,C,E

Rationale: Appropriate interventions include identifying support systems (B), directly assessing for self-harm (C), and using relaxation techniques (E). Providing privacy during flashbacks (A) may increase distress, assessing ADLs (D) is less urgent, and avoiding discussion of the trauma (F) may hinder therapeutic progress.

The nurse in the surgical unit is caring for a 57-year-old client who underwent an abdominal hysterectomy.
Progress Notes
1 Day Postoperative
0800:
The client underwent total abdominal hysterectomy with bilateral oophorectomy and tumor debulking 1 day ago for treatment of ovarian cancer. She has had four episodes of vomiting with bilious emesis over the past 12 hours, which have continued despite V antiemetic administration. The client has been receiving V broad-spectrum antibiotics since the procedure. The skin is warm. A low transverse abdominal incision is present; staples are clean and dry. Chest expansion is symmetric; respirations are unlabored: diminished breath sounds are auscultated in bilateral lower lobes. Radial pulses 2+ bilaterally, capillary refill <3 seconds in all four extremities; no peripheral edema is noted. The client reports frequent hot flashes occurring roughly every hour, starting last night. The abdomen is markedly distended and tender to palpation. Bowel sounds are absent in all four quadrants; the client reports no flatus. Urine is clear yellow with moderate output. The client reports incontinence with coughing or during episodes of vomiting.

The health care provider suspects that the client is experiencing postoperative ileus. The nurse should prepare the client for and provide.

A. A digital rectal examination
B. Abdominal and pelvic x-rays
C. An emergency small bowel resection
D. Enteral tube feedings
E. Total parenteral nutrition
F. Small sips of clear liquids

Correct Answer: B

Rationale: Postoperative ileus is characterized by absent bowel sounds, abdominal distension, and lack of flatus, as noted in the client. Abdominal and pelvic x-rays are used to confirm the diagnosis by identifying air-fluid levels or dilated bowel loops. A digital rectal examination is not diagnostic for ileus. Emergency surgery is not indicated without evidence of obstruction or perforation. Enteral feedings or clear liquids are contraindicated until ileus resolves, and total parenteral nutrition is typically reserved for prolonged cases.

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.