Select client findings that are most concerning to the nurse...

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.

Select client findings that are most concerning to the nurse.

A. The client is brought to the emergency department by a family member after being found confused and lethargic.
B. The client is obtunded and does not respond to verbal stimuli.
C. Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago.
D. Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds.
E. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L).
F. Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO2 94% on room air.

Correct Answer: B,C,E,G

Rationale: B: Obtundation indicates severe CNS depression. C: Though listed as a choice, it repeats B and is likely a typo; assuming it refers to the same finding, it's concerning. E: Pinpoint pupils, shallow breathing, and reduced bowel sounds suggest opioid intoxication. G: Low BP and slow respiratory rate are life-threatening. A is less urgent, D is historical, and F is normal.

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 sensationand 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).
Postoperative Day 15
0800:
The client is increasingly tearful and states, "Life is going on without me while I am lying in this bed. I miss my friends." Left leg is in balanced suspension traction. Weights are hanging freely from the traction device. A 1-inch area of purple discoloration is noted on the right heel. Pin sites are free of erythema, swelling, and purulent drainage. Perineum is reddened with areas of excoriation and erythematous papules. External urinary catheter is in place. Scapula and sacrum are free of erythema.
Vital signs are T 98.8 F (37.1 C), P 100, RR 16, and BP 122/72. Weight is 164 lb (74. 4 kg).

The nurse has reviewed the information from the Nurses' Notes. The nurse reinforces client teaching. Which statement by the client indicates a need for further teaching?

A. I should request a protein shake with my meals.
B. I will contact the staff right away if my external catheter is leaking.
C. Resting my heel on a rolled towel will reduce pressure on my wound.
D. The trapeze can be used to help me shift my weight around in the bed.

Correct Answer: C

Rationale: Resting the heel on a rolled towel may increase pressure on the wound, worsening the purple discoloration noted on the right heel. The other statements reflect appropriate understanding of nutritional needs, catheter care, and mobility assistance.

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 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.

Which statement by the client is the most concerning?

A. I feel pain and tightness in my right calf.
B. I stay in the same position in bed until physical therapy when I do my exercises.
C. Sitting in this bed all day makes me feel so depressed.
D. The drainage from the surgical site is cloudy today.

Correct Answer: A

Rationale: Pain and tightness in the calf (A) is concerning for deep venous thrombosis, a potentially life-threatening complication requiring immediate attention.

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

Which of the following complications are related to liver cirrhosis? Select all that apply.

A. Abdominal ascites
B. Coagulopathies
C. Esophageal varices
D. Hepatic encephalopathy
E. Malnutrition

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

Rationale: Liver cirrhosis leads to portal hypertension and impaired liver function, causing: A) Abdominal ascites due to fluid accumulation from portal hypertension and hypoalbuminemia; B) Coagulopathies from decreased synthesis of clotting factors; C) Esophageal varices from portal hypertension causing collateral vein formation; D) Hepatic encephalopathy from ammonia buildup due to impaired liver detoxification; E) Malnutrition from impaired nutrient metabolism and absorption.