Nokea
The nurse has reviewed the information from the Laboratory Results. The health care provider suspects the client is experiencing upper gastrointestinal bleeding. For each potential prescription, click to specify whether the prescription is anticipated or unanticipated for the care of the client.
- A. Place the client on NPO status
- B. Administer isotonic IV fluid bolus
- C. Administer proton pump inhibitor IV
- D. Collect blood samples for type and crossmatch
- E. Administer heparin for deep venous thrombosis prophylaxis
Correct Answer:
Rationale: Anticipated prescriptions for a client with upper gastrointestinal (GI) bleeding include:
• Placing the client on NPO status to reduce the risk of continued bleeding and vomiting. NPO status is important to
initiate prior to esophagogastroduodenoscopy to reduce aspiration risk.
• Administering an isotonic IV fluid bolus to restore circulating fluid volume and maintain perfusion of vital organs.
• Administering a proton pump inhibitor IV (eg, pantoprazole) to reduce gastric acid secretion and prevent further
irritation and breakdown of suspected peptic ulcers.
• Collecting blood samples for type and crossmatch to ensure blood type compatibility before initiating a blood
transfusion. This client's hemoglobin and hematocrit levels are low, and the client continues to have active bleeding.
Therefore, a blood transfusion should be anticipated to increase blood volume and improve oxygenation and perfusion.
Administering heparin for deep venous thrombosis prophylaxis is not anticipated. Anticoagulation will prolong bleeding
and increase risk for hemorrhagic shock. Anticoagulation is contraindicated for clients with active GI bleeding.
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Select 5 findings that require further investigation.
- A. unable to lie flat and sleeps in a chair at night
- B. 6-1b (2.7-kg) weight
gain in 1 week - C. increased urinary hesitancy and urgency
- D. SpO2 88% on room air
- E. crackles in bilateral lung
bases;
Correct Answer: A,B,D,E
Rationale: A client with chronic heart failure (HF) who reports worsening fatigue, dyspnea, orthopnea, and peripheral edema is likely
experiencing declining oxygenation due to fluid volume overload. Assessment findings that require further investigation
include:
• Orthopnea: Labored breathing in the supine position is a common manifestation in clients with HF due to pulmonary
edema. Clients with orthopnea often sleep on a chair or on propped-up pillows to decrease work of breathing.
Paroxysmal nocturnal dyspnea, which is waking up in the middle of the night with suffocation due to dyspnea, is another
characteristic finding in HF.
• Crackles on auscultation: Crackles are a manifestation of pulmonary edema caused by fluid in the alveoli. Pulmonary
edema is concerning for worsening HF and impaired gas exchange.
• Peripheral edema and rapid weight gain (ie, >5 Ib/week [2.3 kg/week]): These symptoms are concerning for fluid
volume overload
• Hypoxemia: Decreased capillary oxygen saturation (SpO, <95%) is a sign of inadequate gas exchange. This is most
likely related to pulmonary edema from HF exacerbation.
The nurse has implemented the prescribed therapies and is now assisting the client to fill out the lunch menu. Which meal choice is best for this client?
- A. Black beans and rice, sliced tomatoes, and a banana
- B. Grilled chicken sandwich, corn on the cob, and applesauce
- C. Hamburger patty on a whole wheat bun with avocado
- D. Salmon, green peas, baked potato, and strawberries
Correct Answer: B
Rationale: This client is experiencing hyperkalemia and should reduce dietary intake of potassium. The preferred meal choice for this client would
include lean meat, such as chicken, that is grilled rather than cooked in oil, and side dishes consisting of fruits and vegetables low in
potassium, such as corn and applesauce (Option 2).
(Options 1, 3, and 4) Beans (a legume), salmon, tomatoes, bananas, potatoes, strawberries, whole wheat products, and avocados are all
high-potassium foods that the client should avoid at this time. Clients with cardiovascular disease should not consume red meat (eg,
hamburger patty) except in limited quantity because it is high in saturated fat.
Complete the following sentence/sentences by choosing from the list/lists of options. he nurse should prioritize interventions for------- due to the client's -----
- A. Malnutrion
- B. Suicidal Behavior
- C. Substance withdrawal
- D. Recent weight loss
- E. Thoughts of self harm
- F. History of cocaine and marijuana use
Correct Answer: B,E
Rationale: The nurse should prioritize interventions for suicidal behavior due to the client's thoughts of self-harm.
This client has several predisposing factors that increase the risk of suicide, including a psychiatric disorder, previous suicide
attempt, stressful life events (eg, divorce), and substance use. However, the strongest single factor predictive of suicide is the
history of a prior suicide attempt (eg, jumping off a building). The nurse should anticipate implementation of suicide
precautions (eg, 1-to-1 observation).
For each finding below, click to specify if the finding is consistent with the disease process of autism spectrum disorder, obsessive-compulsive disorder, or separation anxiety disorder. Each finding may support more than one disease process.
- A. Ritualized pattern of behavior
- B. Disinterest in social interaction
- C. Lack of spontaneous eye contact
- D. Restricted, fixated thoughts or interests
Correct Answer:
Rationale: Symptoms of autism spectrum disorder (ASD) range in severity from one individual to another. Clients often demonstrate a
ritualized pattern of behavior, resulting in distress and self-harm (eg, hitting the head) in response to changes in routine or
environment. Other manifestations include disinterest in social interaction, deficiency in verbal and nonverbal
communication (eg, lack of spontaneous eye contact or facial expressions), and restricted, fixated thoughts or interests
(eg, attached to unusual objects).
Obsessive-compulsive disorder (OCD) is characterized by obsessions (ie, restricted, fixated thoughts, impulses, or
images) and compulsions (ie, ritualistic, repetitive behaviors performed to reduce anxiety or prevent an adverse event).
These compulsions are time consuming and cause significant distress. In contrast to those with OCD, clients with ASD are not
bothered about their preoccupations or mannerisms and do not desire to change. Clients with OCD do not have issues with
social interaction or social-emotional reciprocity (eg, poor eye contact).
The nurse has reviewed the information from the Nurses' Notes, Vital Signs, and Laboratory Results.The nurse is reviewing the client's response to potassium-lowering therapies. Which finding is unexpected and requires follow-up by the
nurse?
- A. Blood glucose level and diaphoresis
- B. Blood pressure and heart rate
- C. Crackles and peripheral edema
- D. Serum potassium level
Correct Answer: A
Rationale: Treatment for hyperkalemia includes administration of calcium gluconate, furosemide, albuterol nebulizer, and insulin with dextrose. These
therapies may cause rapid shifts in fluid volume, blood glucose, and serum electrolytes. Insulin shifts available glucose and potassium into
the cell, lowering serum potassium levels; however, too much insulin and not enough dextrose cause hypoglycemia (eg, blood glucose 50
mg/dL [2.7 mmol/L]). Clients with kidney disease have an increased risk of hypoglycemia because insulin may accumulate.
The nurse should understand that a low blood glucose level and symptoms suspicious for hypoglycemia (eg, diaphoresis) require follow-u
to prevent seizures, coma, and death due to lack of circulating glucose (Option 1). This client requires an additional dose of dextrose.
(Option 2) This client's blood pressure is 146/88 mm Hg and heart rate is within normal limits. This is an improvement from the initial blood
pressure and represents a therapeutic response to furosemide administration. Blood pressure should be lowered slowly to avoid hypotensior