Nokea
The nurse is evaluating the client's use of hearing aids. Nurses' Notes
The client reports keeping hearing aids in a box in the bedside table when asleep. The client demonstrates pulling the top of the ear down and back to insert the hearing aid. When the device makes a whistling sound, the client reports turning the volume up. Every few days, when the aids are dirty, the client washes them gently with a wet washcloth. Before taking a break from the hearing aids over the weekend, the client removes the battery
Select 3 findings that require follow-up.
- A. The client reports keeping hearing aids in a box in the bedside table when asleep.
- B. The client demonstrates pulling the top of the ear down and back to insert the hearing aid.
- C. When the device makes a whistling sound, the client reports turning the volume up.
- D. Every few days, when the aids are dirty, the client washes them gently with a wet washcloth.
- E. Before taking a break from the hearing aids over the weekend, the client removes the battery.
Correct Answer: C,D,E
Rationale: Turning up the volume for whistling (feedback) may indicate improper fit. Washing hearing aids with water can damage them. Removing batteries for storage is correct, but follow-up ensures proper technique.
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The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900: The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO, 94% on room air.
The nurse should prioritize administration of........... to...........
- A. Thiamine
- B. Naloxone
- C. Oral activated charcoal
- D. Prevent respiratory failure
Correct Answer: B,D
Rationale: B to D: Naloxone reverses opioid intoxication to prevent respiratory failure. The client's obtundation, shallow breathing, and pinpoint pupils indicate opioid overdose, requiring urgent reversal to restore breathing. Thiamine is for alcohol-related conditions, and charcoal is for recent ingestions, not specified here.
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.
The client's last menstrual period was March 10-17. Unprotected intercourse occurred on March 24. The client's menstrual cycles are regular and occur every 28 days. Based on the Naegele rule, what is the estimated date of birth?
- A. 3-Dec
- B. 17-Dec
- C. 24-Dec
- D. 31-Dec
Correct Answer: B
Rationale: Using Naegele's rule (first day of LMP + 1 year - 3 months + 7 days), March 10, 2025 + 1 year = March 10, 2026 - 3 months = December 10, 2025 + 7 days = December 17, 2025.
The nurse is caring for an 84-year-old client with dementia.
Nurses' Notes
Medical-Surgical Unit
Day 1: The left antecubital peripheral IV insertion site has no erythema or edema, and the catheter flushes easily. The dressing is clean, dry, and intact. Potassium chloride infusion is initiated.
Day 3: Potassium chloride is infusing. The area surrounding the IV site is taut, edematous, blanched, and cool to the touch. Small, fluid-filled vesicles are noted around the IV site. Capillary refill distal to the IV site is >3 seconds. The client is grimacing and unable to verbally report pain.
For each potential intervention, click to specify if the potential intervention is appropriate or not appropriate for the care of client.
- A. Elevate the affected extremity
- B. Apply pressure to the affected area
- C. Discontinue the potassium chloride infusion
- D. Aspirate the potassium chloride from the IV catheter
- E. Leave the IV catheter in place for potential antidote administration
Correct Answer: A: Appropriate, B: Not Appropriate, C: Appropriate, D: Not Appropriate, E: Appropriate
Rationale: The symptoms suggest IV infiltration with potassium chloride, which is caustic. Elevating the extremity (A) reduces swelling. Discontinuing the infusion (C) prevents further damage. Leaving the catheter in place (E) allows for potential antidote administration. Applying pressure (B) may worsen tissue damage, and aspirating (D) is not standard for infiltration.
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
The client is diagnosed with ischemic stroke. For each potential intervention, click to specify if the intervention is indicated, not indicated for the care of the client.
- A. Obtain a 12-lead ECG
- B. Implement fall risk precautions
- C. Offer the client small sips of water
- D. Perform frequent neurologic assessments
- E. Ensure tissue plasminogen activator is available
- F. Apply sequential compression device to bilateral lower extremities
Correct Answer: A: Indicated, B: Indicated, C: Not Indicated, D: Indicated, E: Indicated, F: Indicated
Rationale: An ECG (A) monitors for cardiac causes of stroke. Fall precautions (B) address weakness-related risks. Frequent neurologic assessments (D) track stroke progression. tPA availability (E) is crucial for potential thrombolytic therapy. Sequential compression devices (F) prevent DVT in immobile patients. Oral intake (C) is contraindicated due to aspiration risk from dysphagia.
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
The nurse is assisting the registered nurse in planning care for a client prescribed tissue plasminogen activator (tPA) therapy. Which of the following actions are appropriate prior to administration? Select all that apply.
- A. Ask the client's caretaker about a history of recent surgery or trauma
- B. Maintain BP ≤ 185/110
- C. Plan to initiate subcutaneous heparin immediately after tPA infusion is complete
- D. Review the client's current home medication list
- E. Verify the exact time the stroke symptoms started
Correct Answer: A, B, D, E
Rationale: Recent surgery/trauma (A) is a contraindication for tPA. BP ≤ 185/110 (B) is required to reduce bleeding risk. Reviewing medications (D) identifies anticoagulants that contraindicate tPA. Verifying symptom onset time (E) ensures tPA is within the therapeutic window. Heparin post-tPA (C) increases bleeding risk and is not immediate.