Select the findings that require immediate follow up.

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.

A. Total abdominal hysterectomy with bilateral oophorectomy and tumor debulking
B. She has had four episodes of vomiting with bilious emesis over the past 12 hours,
C. The client has been receiving broad-spectrum antibiotics since the procedure.
D. The client reports incontinence with coughing or during episodes of vomiting.
E. The abdomen is markedly distended and tenderagogue palpation.

Correct Answer: B,E

Rationale: B: Requires follow-up - Persistent vomiting despite antiemetics suggests a postoperative complication like ileus or obstruction. E: Requires follow-up - Abdominal distension and tenderness indicate potential ileus or obstruction, requiring urgent evaluation. A, C, D: Do not require immediate follow-up as they are expected or less urgent.

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.

Select findings that require immediate follow-up.

A. The client is alert and oriented to time, place, person, and situation.
B. The client reports sudden-onset right-sided facial drooping.
C. Bilateral pupils are equal, round, and reactive to light and accommodation
D. Vital signs: RR 16
E. The client has a history of hypertension
F. The client has diabetes mellitus
G. Right-sided lower extremity weakness is seen

Correct Answer: B, G

Rationale: Sudden-onset right-sided facial drooping (B) and lower extremity weakness (G) are signs of a possible stroke, requiring urgent evaluation. Being alert (A), normal pupils (C), and normal respiratory rate (D) are stable findings. Hypertension (E) and diabetes (F) are chronic and less urgent in this context.

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.

Which of the following laboratory tests should the nurse anticipate during the first prenatal visit? Select all that apply.

A. 1-hour glucose tolerance test
B. Group B Streptococcus rectovaginal culture
C. Maternal blood type and screen
D. Sexually transmitted infection screen
E. Urinalysis

Correct Answer: C,D,E

Rationale: First prenatal visit tests include maternal blood type and screen, STI screen, and urinalysis. Glucose tolerance and Group B Streptococcus tests are performed later in pregnancy.

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, SpO2 94% on room air.
1800:
The client is awake, alert, and oriented to person, place, time, and situation. The client is experiencing severe withdrawal symptoms and is admitted for supervised detoxification.

Laboratory Results
Urine Drug Screen
On admission
Cocaine- Negative
Opioids- Positive
Amphetamines- Negative
Marijuana- Positive
Phencyclidine-Negative
Benzodiazepines- Negative
Barbiturates- Negative
Laboratory Test and Reference Range
Cocaine- Negative
Opioids- Negative
Amphetamines- Negative
Marijuana- Negative
Phencyclidine- Negative
Benzodiazepines- Negative
Barbiturates- Negative

The nurse has reviewed the information from the Progress Notes and Laboratory Results. For each potential intervention, click to specify if the intervention is expected or unexpected for the care of the client.

A. Initiate seizure precautions
B. Monitor the client for suicidal ideation
C. Administer antidiarrheal and antiemetic medications as needed
D. Use a standardized scoring scale to assess for withdrawal symptoms

Correct Answer: B,C,D

Rationale: B: Expected - Depression history increases suicide risk during withdrawal. C: Expected - Antidiarrheals and antiemetics manage withdrawal symptoms like nausea. D: Expected - Standardized scales (e.g., COWS) assess opioid withdrawal severity. A: Unexpected - Seizures are more associated with alcohol or benzodiazepine withdrawal, not opioids.

The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92

The client is most likely experiencing.......... and requires intervention to prevent............

A. Hypothyroidism
B. Hyperthyroidism
C. Addison disease
D. Addisonian crisis
E. Myxedema
F. Acute thyrotoxicosis

Correct Answer: B,F

Rationale: The client's symptoms (tachycardia, weight loss, exophthalmos, etc.) indicate hyperthyroidism, and intervention is needed to prevent acute thyrotoxicosis, a life-threatening complication.

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.