The health care provider suspects that the client is experie...

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.

The health care provider suspects that the client is experiencing postoperative ileus. The nurse should prepare the client for and provide.

A. A digital rectal examination
B. Abdominal and pelvic x-rays
C. An emergency small bowel resection
D. Enteral tube feedings
E. Total parenteral nutrition
F. Small sips of clear liquids

Correct Answer: B

Rationale: Postoperative ileus is characterized by absent bowel sounds, abdominal distension, and lack of flatus, as noted in the client. Abdominal and pelvic x-rays are used to confirm the diagnosis by identifying air-fluid levels or dilated bowel loops. A digital rectal examination is not diagnostic for ileus. Emergency surgery is not indicated without evidence of obstruction or perforation. Enteral feedings or clear liquids are contraindicated until ileus resolves, and total parenteral nutrition is typically reserved for prolonged cases.

Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO, 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.
1 Hour Later
After attempting a bottle feed with 10 mL of formula, the client has a coughing episode, and there is formula mixed with saliva in the mouth. Coarse breath sounds are noted bilaterally with intercostal retractions. S1 and S2 are present with no murmurs. Neurologic examination shows normal neuromuscular findings.
A nasogastric tube insertion is attempted per prescription by the health care provider, and resistance is met at 10 cm of insertion.

During a diaper change, the client becomes cyanotic with frothy secretions from the mouth and nose. What action should nurse perform first?

A. Activate the rapid response team
B. Initiate rescue breathing with a bag valve mask
C. Perform nasal and oropharyngeal suction
D. Prepare the newborn for intubation

Correct Answer: C

Rationale: Suctioning clears the airway of frothy secretions, addressing the immediate cause of cyanosis. This is the first priority before other interventions.

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.

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 topics should the nurse reinforce during the initial prenatal visit? Select all that apply.

A. Commitment to pain management preferences during labor
B. Expected discomforts of pregnancy
C. Foods to avoid
D. Herbal supplements and over-the-counter medications to avoid
E. Method of delivery
F. Symptoms of potential pregnancy complications

Correct Answer: B,C,D,F

Rationale: The initial prenatal visit should focus on educating about expected discomforts (e.g., nausea), foods to avoid (e.g., raw fish), medications/supplements to avoid, and symptoms of complications. Pain management and delivery method are discussed later.

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.

Which 3 additional findings or diagnostic results are most important to plan care for this client?

A. Blood alcohol level
B. Capillary blood glucose level
C. CT scan of the head
D. Electroencephalography
E. Standardized stroke assessment

Correct Answer: B, C, E

Rationale: A CT scan (C) is critical to diagnose stroke type. A standardized stroke assessment (E) evaluates severity and guides treatment. Capillary glucose (B) ensures hypoglycemia is not contributing to symptoms. Blood alcohol level (A) is less relevant with minimal alcohol history. EEG (D) is not urgent for suspected stroke.