Nokea
The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?
- A. Assess the client for pain
- B. Assess the client's oxygen saturation
- C. Assess the client with the Glasgow Coma Scale (GCS)
- D. Assess the client's lung sounds
Correct Answer: B
Rationale: Restlessness and irritability post-sedation may indicate hypoxia. Assessing oxygen saturation is the priority to ensure airway and breathing stability.
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The nurse is reviewing a client's list of medications who has cystic fibrosis. The nurse anticipates a prescription for which medication?
- A. Multivitamin
- B. Aspirin
- C. Warfarin
- D. Simvastatin
- E. Salmeterol
Correct Answer: A, E
Rationale: Multivitamins address malabsorption, and salmeterol helps manage airway obstruction in cystic fibrosis.
The following scenario applies to the next 1 items
The nurse in the obstetrics department is caring for a 29-year-old primigravida client.
Item 1 of 1
History and Physical
2300: Client is a primigravida at 33 weeks gestation, who awoke to moderate bright red vaginal bleeding. She reports noticing light spotting earlier in the day, which she dismissed as benign. She denies abdominal pain, cramping, or contractions. Her pregnancy has been uncomplicated until recently. She reports increased fetal movement over the last 48 hours. One week ago, she presented to the ED with fever, fatigue, and body aches, and was diagnosed with influenza A. She was treated supportively and discharged home with hydration instructions. Over the past 24 hours, she has experienced nasal congestion and fatigue.
Four days ago, a transabdominal ultrasound showed:
• Fetus in cephalic position
• Normal amniotic fluid volume
Exam findings
• Abdomen: Soft, non-tender
• No uterine contractions noted on palpation
• Moderate amount of dried bright red blood was seen on the undergarments
• 1+ pedal edema
• Peripheral pulses 2+
•
Diagnostics
2342: Fetal Heart Rate (FHR): 144 bpm, moderate variability, no decelerations
Vital Signs
• Temperature: 99.5°F (37.5°C)
• HR 88 bpm
• BP 137/78 mmHg
• RR 18/min
• Pulse oximetry 98% on room air
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. Request a prescription for indomethacin, Prepare the client for a transvaginal ultrasound, Place the client in the lithotomy position for a manual cervical exam, Establish a peripheral vascular access device, Place the client in a room with monitored negative airflow
- B. Placental abruption, Preeclampsia, Placenta previa, Influenza recurrence
- C. Fetal heart rate pattern, Pedal edema, Amount and color of vaginal bleeding, Temperature, Nasal congestion and fatigue level
Correct Answer: C (placenta previa), A (prepare for transvaginal ultrasound, establish peripheral vascular access device), C (fetal heart rate pattern, amount and color of vaginal bleeding)
Rationale: Moderate bright red vaginal bleeding without pain at 33 weeks suggests placenta previa. Transvaginal ultrasound confirms the diagnosis, peripheral access prepares for potential intervention, and monitoring fetal heart rate and bleeding assesses progress.
The following scenario applies to the next 1 items
The case manager is reviewing the medical record of a client with schizophrenia
Item 1 of 1
Progress Notes
Discharge Summary
0900: Third involuntary admission in the past six months. The client was admitted four days ago because of florid psychosis. During the stay, the client was stabilized with their prescribed aripiprazole. Once stabilized, the client reported nonadherence to aripiprazole because they 'forget.' It is documented that the client also missed two follow-up appointments for some unknown reason. The client was prescribed aripiprazole oral disintegrating tablet (ODT) to optimize adherence versus tablets. Provided two refills and a follow-up appointment at discharge. Thorough counseling was provided regarding the dosing schedule. Considering the client's repeated nonadherence, there is a high probability of readmission. Will consult case management for follow-up.
Orders
0815:
• discharge client home
• case management consultation for repeated readmissions
• arrange outpatient follow-up appointment prior to discharge
• give morning dose of aripiprazole prior to discharge
• discharge with a prescription for aripiprazole 15 mg ODT daily
The case manager reviews the physician's progress notes and orders. Select the actions the case manager should take to reduce the client's risk of readmission.
- A. perform a post discharge follow-up phone call
- B. recommend the client be prescribed a long acting injectable antipsychotic
- C. review the client's advanced directives
- D. assess the client's social determinants of health
- E. arrange for more frequent follow-up appointments
Correct Answer: A, B, D, E
Rationale: Follow-up calls, long-acting injectable antipsychotics, assessing social determinants, and frequent appointments address nonadherence and reduce readmission risk.
The nurse is teaching a group of students about incident reports. Which of the following statements made by the student would require further teaching?
- A. Reporting can only be completed if it is within one hour after the event.
- B. Witnesses to an incident should be mentioned in the report.
- C. A client eloping does not require an incident report.
- D. A slip and fall by a client should be reported.
- E. Incidents involving visitors do not have to be reported.
Correct Answer: A, C, E
Rationale: Incident reports can be filed anytime, elopement requires reporting, and visitor incidents should be reported.
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
- A. captopril for a client with congestive heart failure
- B. metoprolol for a client with multiple premature ventricular contractions (PVCs)
- C. verapamil for a client with atrial fibrillation
- D. spironolactone for a client with end-stage renal disease
Correct Answer: D
Rationale: Spironolactone can cause hyperkalemia, which is dangerous in end-stage renal disease, and should be questioned.