Nokea
The charge nurse has received a change-of-shift report on the following clients in the maternity unit. The nurse should first assess the client who
- A. delivered a term newborn 2 days ago and reports sweating and increased urinary frequency
- B. is 15 weeks pregnant and is being treated for hyperemesis gravidarum and reports increased nausea following a meal
- C. is 32 weeks pregnant and admitted 2 hours ago with placenta previa, who reports increased lower back pain
- D. is in the first stage of labor, and the most recent fetal heart rate pattern showed early decelerations
Correct Answer: C
Rationale: Increased lower back pain in a client with placenta previa at 32 weeks suggests possible complications like bleeding, requiring immediate assessment.
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Relaxin is a hormone that is released throughout a woman's pregnancy to help prepare her uterine ligaments for the growth of her fetus and uterus. A downside to relaxin is that it may:
- A. Cause high blood pressure in some women
- B. Lead to musculoskeletal injury due to loose ligaments
- C. Make urinating more difficult than normal
- D. Increase bowel motility
Correct Answer: B
Rationale: Relaxin loosens ligaments, increasing the risk of musculoskeletal injuries during pregnancy.
The nurse is screening clients at risk of sudden infant death syndrome (SIDS). The nurse correctly identifies which client is at the greatest risk for SIDS? An infant who is
- A. a preterm 4-month-old female who sleeps supine and is formula fed
- B. a preterm 12-month-old male who sleeps prone and is formula fed
- C. a term 6-month-old male who sleeps supine and is formula fed
- D. a preterm 3-month-old male who sleeps lateral and is breastfed
Correct Answer: A
Rationale: Preterm infants who are formula-fed and within the peak SIDS risk age (2-4 months) have higher risk, even if sleeping supine.
The following scenario applies to the next 1 items
The nurse is caring for a 72-year-old client in the emergency department (ED)
Item 1 of 1
Nurses' Notes
1430: 72-year-old male was brought to the ED with reports of dyspnea, chest pain, diaphoresis, and restlessness. The client's daughter reports that he recently took a long drive across several states and that the symptoms started abruptly. The client's oxygen saturation was 80% on room air and improved to 86% on 100% FiO2 via a nonrebreather mask. The physician was immediately notified at this time of the client's condition and came to the bedside for evaluation.
1442: The physician ordered rapid sequence intubation medications for immediate endotracheal intubation (ETT). The physician intubated the client using a #8 ETT and connected the client to mechanical ventilation using assist-control at a tidal volume of 500 mL, rate of 12/minute, 100% FiO2, PEEP 5 cm H2O. Post-intubation vital signs: T 99° F (37° C), P110, RR 12, BP 90/62, pulse oximetry reading 98%.
The nurse has reviewed both of the Nurses' Note entries and is planning care for the client. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client.
- A. Request an order for a chest radiograph (x-ray)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Collaborate with respiratory therapy to assist in the client's care
- D. Place the client in low-Fowler's position
- E. Request an order to administer an 0.45% saline intravenous fluid bolus
- F. Turn the client every four hours
- G. Suction the endotracheal tube (ETT) every two hours
Correct Answer: A, B, C, F (indicated); D, E, G (contraindicated)
Rationale: Indicated: Chest x-ray confirms tube placement, ABG assesses ventilation, respiratory therapy collaboration optimizes care, and turning prevents complications. Contraindicated: Low-Fowler€™s position worsens respiratory distress, 0.45% saline is inadequate for hypovolemia, and routine ETT suctioning is unnecessary.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 4 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
The nurse reviews the diagnostic and laboratory results. For each potential nursing intervention, click to specify whether the Nurses' Notes intervention is indicated or not indicated for the care of the client.
- A. obtain an order for serum type and screen
- B. obtain a prescription for protamine sulfate
- C. perform neurological assessments every 15 minutes
- D. obtain a prescription for andexanet
- E. obtain a prescription to transfuse platelets
- F. obtain a prescription for ketorolac
- G. monitor the client for signs and symptoms of increased intracranial pressure
Correct Answer: A, C, D, G (indicated); B, E, F (not indicated)
Rationale: Indicated: Serum type and screen for potential transfusion, frequent neurological assessments, andexanet for warfarin reversal, and monitoring for increased intracranial pressure due to subarachnoid hemorrhage. Not indicated: Protamine sulfate (for heparin, not warfarin), platelet transfusion (platelets mildly low), ketorolac (contraindicated due to bleeding risk).
The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions?
- A. Major Depressive Disorder
- B. Attention Deficit Hyperactivity Disorder
- C. Obsessive-Compulsive Disorder
- D. Generalized Anxiety Disorder
- E. Bipolar Disorder
Correct Answer: A, C, D
Rationale: Sertraline, an SSRI, is indicated for Major Depressive Disorder, Obsessive-Compulsive Disorder, and Generalized Anxiety Disorder, but not for ADHD or Bipolar Disorder.