Nokea
A home care nurse is caring for a client who has advancing multiple sclerosis.
Nurses' Notes
2 weeks ago:
Client reports depression is increasing as they are unable to participate in activities they once
enjoyed because of the advancing multiple sclerosis. Even getting up to the wheelchair is "just
too much" for them.
Today:
Home health aide reported client will not permit turning or position changes. Client states, "I can
only get comfortable curled on my left side, I'm not moving."
Select the 5 complications the client is at risk for.
- A. Hypertension
- B. Hypocalcemia
- C. Calcium resorption
- D. Urinary stasis
- E. Contractures
- F. Atelectasis
- G. Diarrhea
Correct Answer: C,D,E,F,H
Rationale: Immobility increases risks of urinary stasis, contractures, atelectasis, and pressure injuries.
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A nurse in an acute care mental health facility is placing a client in seclusion and restraints.
Which of the following actions should the nurse plan to take?
- A. Document the client's behavior every 15 minutes.
- B. Obtain a prescription for restraints within 4 hours.
- C. Release the restraints every 2 hours to assess circulation.
- D. Discontinue restraints only when the provider removes the order.
Correct Answer: C
Rationale: The correct answer is C: Release the restraints every 2 hours to assess circulation. This action is essential to prevent complications related to impaired circulation and tissue damage. Releasing the restraints allows the nurse to assess the client's circulation, skin integrity, and comfort. It promotes safety and prevents potential harm.
Choice A (Document the client's behavior every 15 minutes) is not the best action as it focuses on behavior rather than safety and circulation. Choice B (Obtain a prescription for restraints within 4 hours) is not necessary as restraints should only be used if all other options have been exhausted. Choice D (Discontinue restraints only when the provider removes the order) is incorrect as the nurse should assess the client's condition independently and not solely rely on provider orders.
A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color," Client also reports contractions began about 4 hr. ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
2020:
Contractions occurring every 4 to 5 min, lasting 40 to 60 seconds. Small amount of bloody show
noted when changing disposable pad on bed. Client rates contraction pain as a 5 on a scale of 0
to 10, breathing well through contractions., FHR 168/min, minimal variability. Client denies
epigastric pain or visual disturbances. Trace of edema noted to bilateral lower extremities
The nurse should first notify the provider about------- followed by the-----------
- A. the fetal station and presentation
- B. frequency of uterine contractions
- C. green color of amniotic fluid
- D. history of gestational diabetes
- E. cervical dilation of 4 cm
Correct Answer: C
Rationale: The green color of amniotic fluid indicates meconium-stained fluid which can be a sign of fetal distress.
A nurse is caring for a client in an outpatient clinic.
Laboratory Results
First office visit:
Erythrocyte sedimentation rate (ESR) 21 mm/hr (up to 20 mm/hr)
Hct 36% (37 to 47%6)
Hgb 12 g/dL (12 to 16 g/dL)
WBC count 6000/mm³ (5,000 to 10,000/mm³)
Uric acid 6.1 mg/dL (2.7 to 7.3 mg/dL)
6-month follow-up:
Erythrocyte sedimentation rate (ESR) 22 mm/hr (up to 20 mm/hr)
Antinuclear antibodies (ANA) positive
Hct 35% (37 to 47%)
Hgb 11 g/dL (12 to 16 g/dL)
WBC 4000/mm³ (5,000 to 10,000/mm³)
Uric acid 6,3 mg/dL (2.7 to 7.3 mg/dL)
The client is at highest risk for developing--------- evidenced by the client's--------
- A. Rheumatoid arthritis
- B. decreased Hct and Hgb levels
- C. ESR level
- D. Systemic lupus erythematosus
- E. Anemia evidenced by the client's
- F. Gout evidenced
- G. decreased WBC count
Correct Answer: D,G
Rationale: Decreased WBC count and elevated ESR suggest systemic lupus erythematosus.
A nurse is assessing a client who has type one diabetes myelitis and was administered insulin lispro 1 hour ago.
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
- A. Confusion
- B. Increased thirst
- C. Frequent urination
- D. Flushed skin
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is a condition characterized by low blood sugar levels, leading to symptoms like confusion due to the brain not receiving enough glucose for energy. Increased thirst and frequent urination are more indicative of hyperglycemia (high blood sugar levels). Flushed skin is not a common manifestation of hypoglycemia.
A nurse is caring for a client in the emergency department. Nurses' Notes
1100:
The client reports shortness of breath and difficulty sleeping. The client feels tired very quickly
and occasionally feels nauseous. The client reports experiencing intermittent chest tightness and
a cough that is aggravated by exercise. The client has a productive cough and irregular breathing
pattern. Crackles and wheezing present on auscultation. The client has a history of smoking a
pack of cigarettes per day for the past 35 years. There is no clubbing of the fingers. The client
appears anxious.
1130:
Administered albuterol and oxygen per provider's prescription. The client is instructed to perform
pursed-lip breathing.
1230:
The client is breathing with minimal effort and coughing has decreased
Vital Signs 1100:
Temperature 36.8°C (98.2° F) Heart
rate 92/min Respiratory rate 28/min
BP 145/90 mm Hg
Oxygen saturation 87% on room air
1145:
Temperature 36.2° C (97.2" F) Heart
rate 88/min
Respiratory rate 22/min BP
140/90 mm Hg
Oxygen saturation 92% on room air
Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Increase oxygen flow rate to 4 L/min.
- B. Assess the client's breath sounds
- C. Perform chest percussion and vibration.
- D. Place the client in a supine position.
- E. Restrict the client's fluid intake.
- F. Instruct the client to perform diaphragmatic breathing
Correct Answer: A,B,F
Rationale: The correct interventions are A, B, and F.
A: Increasing oxygen flow rate to 4 L/min ensures adequate oxygenation for the client.
B: Assessing breath sounds helps monitor respiratory status and detect any abnormalities.
F: Instructing the client to perform diaphragmatic breathing promotes effective use of respiratory muscles.
Incorrect choices:
C: Chest percussion and vibration are not typically indicated for all clients and may not be appropriate in this case.
D: Placing the client in a supine position can worsen respiratory function, especially in certain conditions.
E: Restricting fluid intake may not be necessary unless specifically ordered by a healthcare provider and could potentially lead to dehydration.