Nokea
The nurse cares for a client four days postoperative following an open splenectomy. The client's vital signs are T 101.1°F (38.4°C), P 92, RR 17, BP 152/86, and pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. The surgical wound is assessed to have erythema and purulent drainage. The nurse should take which actions? Select all that apply.
- A. Request an order for an antibiotic
- B. Notify the physician
- C. Ambulate the client to the bedside chair
- D. Obtain an order for blood cultures
- E. Increase the nasal cannula oxygen to 4 L/minute
Correct Answer: A,B,D
Rationale: Fever, erythema, and purulent drainage suggest infection, requiring notifying the physician (B), requesting antibiotics (A), and obtaining blood cultures (D). Ambulation (C) and increasing oxygen (E) are not indicated.
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The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Notes
0555: Client presents with abdominal pain, nausea, and some vomiting. The client's parents report that his symptoms started two nights ago and originated in the right lower quadrant. Overnight, his symptoms significantly intensified, and he developed a fever and chills. On assessment, the client's skin is hot and pale. Lung sounds are clear, and apical pulse is regular. Bowel sounds are absent in all quadrants. Abdomen is distended and rigid with guarding. Generalized abdominal pain was reported and rated 8/10 on the Numerical Rating Scale. He states that his abdominal pain increases with cough or movement and is relieved by bending the right hip. Vital signs: T 104°F (40°C), P 116, RR 21, BP 110/76, pulse oximetry reading 96% on room air. He has a medical history of iron deficiency anemia.
Laboratory Results
white blood cell (WBC) count: 21,000 mm3 [5,000–10,000/mm3]
hemoglobin: 13.9 g/dL [14–18 g/dL]
hematocrit: 41.7% [42%–52%]
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Insert a peripheral venous access device (VAD), obtain a stool specimen for culture and sensitivity (C & S), prepare the client for surgery, request an order for a clear liquid diet.
- B. Peritonitis, diverticulitis, appendicitis, gastroenteritis.
- C. Lung sounds, pulse, temperature, hemoglobin and hematocrit.
Correct Answer: B: Appendicitis; A: Insert a peripheral VAD, prepare the client for surgery; C: Temperature, pulse
Rationale: The clinical presentation (right lower quadrant pain, fever, leukocytosis, rigid abdomen) strongly suggests appendicitis (B). Inserting a VAD and preparing for surgery (A) are critical for anticipated appendectomy. Monitoring temperature and pulse (C) tracks infection and hemodynamic status.
The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a client with liver cirrhosis
Item 1 of 1
Nurses' Note
57-year-old male reporting increasing dyspnea and abdominal pressure after missing his previously scheduled paracentesis. The client reports he feels 'uncomfortable.' He is alert and oriented x 4; sclera is yellow along with jaundice skin appearance. Respirations were labored, tachypnea, and clear breath sounds. Abdominal distention noted, hypoactive bowel sounds in all four quadrants. Ascites and dependent edema were noted. Peripheral pulses were intact.
Vital Signs
• Oral Temperature 101 o F (38.3o C)
• Heart rate 94/minute
• Respirations 24/minute
• Blood pressure 104/68 mm Hg
• Oxygen saturation 95% on room air
Medical History
• Hepatitis C
• Liver cirrhosis
• Substance use disorder
• Hyperlipidemia
Which assessment findings require follow-up? Select all that apply.
- A. Jaundice
- B. Labored breathing
- C. Hypoactive bowel sounds
- D. Respiratory rate
- E. Oral temperature
- F. Yellow sclera
Correct Answer: B,D,E
Rationale: Labored breathing (B), elevated respiratory rate (D), and fever (E) indicate potential complications like infection or respiratory compromise in liver cirrhosis, requiring urgent follow-up. Jaundice and yellow sclera (A, F) are expected, and hypoactive bowel sounds (C) are less urgent.
The nurse is caring for a postoperative client who underwent abdominal surgery and is receiving patient-controlled analgesia (PCA) with morphine for pain management. The nurse notes that the client is sedated but still complaining of severe pain. What is the most appropriate action for the nurse to take?
- A. Increase the PCA dosage
- B. Administer a non-opioid analgesic
- C. Discontinue PCA and Administer Intramuscular (IM) Morphine
- D. Notify the healthcare provider
Correct Answer: D
Rationale: Notifying the provider (D) is appropriate when the client is sedated yet in severe pain, indicating potential PCA inadequacy or complications requiring reassessment.
The nurse is caring for a client who is newly prescribed cimetidine. The nurse understands that this medication is prescribed to treat which condition?
- A. Cystic fibrosis
- B. Clostridium difficile
- C. H. pylori infection
- D. Crohn’s disease
Correct Answer: C
Rationale: Cimetidine, an H2 receptor blocker, is used in H. pylori infection to reduce gastric acid, aiding in ulcer healing alongside antibiotics. It is not indicated for cystic fibrosis, C. difficile, or Crohn’s disease.
The nurse is assessing a client with suspected acute cholecystitis. Which of the following findings would support a diagnosis of acute cholecystitis?
- A. Decreased serum bilirubin
- B. Increased high density lipoprotein cholesterol (HDL-C)
- C. Decreased serum aminotransferases
- D. Increased white blood cell count (WBC)
Correct Answer: D
Rationale: An increased WBC count (D) indicates inflammation or infection, supporting a diagnosis of acute cholecystitis. Bilirubin (A) and aminotransferases (C) may rise, and HDL-C (B) is unrelated.