The nurse has reviewed the information from the Laboratory R...

History and Physical
Body System,Findings
General
Client has history of coronary artery disease, hypertension, hyperlipidemia, diverticulosis, and
osteoarthritis; Helicobacter pylori infection 2 years ago; client reports taking over-the-counter
ibuprofen every 8 hours for left knee pain for the past 2 weeks; daily medications include aspirin,
carvedilol, lisinopril, and atorvastatin
Neurological
Alert and oriented to person, place, time, and situation
Pulmonary
Vital signs: RR 20, SpO 96% on room air, lung sounds clear bilaterally; no shortness of breath;
client smokes 1 pack of cigarettes per day and smokes marijuana 1 or 2 times weekly
Cardiovascular
Vital signs: P 110, BP 90/62; no chest pain; S1 and S2 heard on auscultation; peripheral pulses
2+; client states feeling lightheaded and reports passing out about 1 hour ago
Gastrointestinal
Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis; two episodes of
large, black, liquid stools in the morning
Musculoskeletal
Examination of the knees shows crepitus that is worse on the left; no swelling, warmth, or
erythema; range of motion is normal
Psychosocial
Client reports drinking 1 or 2 glasses of wine per day

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.

The nurse is caring for a 16-year-old client.History and Physical
Body System, Finding
General,
Client is brought to the emergency department due to nausea, vomiting, and abdominal pain that began 24 hr
ago. Client has type 1 diabetes mellitus and usually takes insulin. Parents state that the client was at an
overnight camp for the past 4 days and are unsure of how much insulin the client has been taking.
Neurological,
Client is lethargic but arousable to voice. The pupils are equal, round, and reactive to light and accommodation.
Integumentary,
Mucous membranes are dry, skin turgor is poor.
Pulmonary,
Vital signs are RR 36 and SpOz 95% on room air. Lung sounds are clear to auscultation. Deep respirations and a
fruity odor on the breath are noted.
Cardiovascular,
Vital signs are T 98.4 F (36.9 C), P 110, and BP 98/58. Pulses are 3+ on all extremities, and capillary refill time is
4 sec.
Gastrointestinal Normoactive bowel sounds are heard in all 4 quadrants; the abdomen is nontender.
Genitourinary,
Client voided dark yellow urine.
Endocrine,
Client is prescribed levothyroxine daily for hypothyroidism and has missed one dose of levothyroxine.
Psychosocial,
Parents state that the client has been sad and slightly withdrawn for the past 2 weeks after ending a romantic relationship.
Laboratory Results
Laboratory Test and Reference Range, 1000, 1600
Blood Chemistry.
Glucose (random)
≤200 mg/dL
(≤11.1 mmol/L),
504 mg/dL
(28.0 mmol/L),
164 mg/dL
(9.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L),
133 mEq/L
(133 mmol/L),
135 mEq/L
(135 mmol/L)
Chloride
98-106 mEq/L
(98-106 mmol/L),
101 mEq/L
(101 mmol/L),
102 mEq/L
(102 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.6 mEq/L
(5.6 mmol/L),
3.2 mEq/L
(3.2 mmol/L)
Arterial Blood Gases
Arterial pH
7.35-7.45
(7.35-7.45),
7.20
(7.20),
7.31
(7.31)
HCOg
21-28 mEq/L
(21-28 mmol/L),
13 mEq/L
(13 mmol/L),
18 mEq/L
(18 mmol/L)
PaCO,
35-45 mm Hg
(4.66-5.98 kPa),
30 mm Hg
(3.99 KPa),
32 mm Hg
(4.26 kPa)
PaO,
80-100 mm Hg
(10.64-13.33 KPa),
90 mm Hg
(11.97 kPa),
90 mm Hg
(11.97 kPa)

Nurses' Notes
1600:
0.9% sodium chloride and regular insulin IV are continuously infusing. Lung sounds are clear to auscultation. Urine output
is 90 mL over the past 2 hr.
Vital signs are T 99 F (37.2 C), P 105, RR 28, BP 110/72, and SpO, 95% on room air.

The nurse has reviewed the information from the Laboratory Results and Nurses' Notes. Which of the following nursing actions are anticipated? Select all that apply

A. Adds 5% dextrose to continuous IV fluids
B. Administers potassium chloride
C. Administers sodium bicarbonate
D. Discontinues insulin infusion
E. Encourages the client to drink orange juice

Correct Answer: A,B

Rationale: The goal of treatment of diabetic ketoacidosis (DKA) is to normalize fluid volume, decrease blood glucose levels, balance electrolytes, and
correct metabolic acidosis. On administration of insulin, potassium and glucose shift from the extracellular space to the intracellular space.
Clients with DKA require potassium administration due to low intracellular potassium levels.
Insulin is administered to facilitate glucose transport into the intracellular space to resolve DKA and should be continued until the metabolic
acidosis resolves. When caring for clients with DKA, the nurse should anticipate:
• Adding 5% dextrose to continuous IV fluids when the serum blood glucose level reaches approximately 200 mg/dL (11.1 mmol/L) to
prevent hypoglycemia and cerebral edema resulting from levels decreasing too quickly (Option 1). This is done because insulin is still
required to resolve DKA. If the DKA is resolved, insulin can also be decreased instead of adding dextrose to the IV fluids.
• Administering potassium chloride for a client with hypokalemia and adequate urine output (ie, >30 mL/hr) to prevent life-threatening
arrhythmias

History and Physical
Body System
Findings
General
Client reports a 1-week history of general malaise, fever and chills, night sweats, fatigue, and
poor appetite. Client has poorly controlled hypertension, hypercholesterolemia, and mitral
valve prolapse and regurgitation.
Eye, Ear, Nose, and
Throat (EENT)
Poor dental hygiene. Client reports having 2 teeth extracted 3 weeks ago.
Pulmonary
Vital signs are RR 18 and SpO, 96% on room air. Lungs are clear to auscultation bilaterally.
Cardiovascular
Vital signs are T 100.4 F (38 C), P 105, and BP 140/82. Sinus tachycardia with occasional
premature ventricular contractions on cardiac monitor. S1 and S2 heard on auscultation with
loud systolic murmur at the apex. Peripheral pulses 2+; no edema noted.
Integumentary
Small, erythematous macular lesions on both palms. Thin, brown longitudinal lines on several
nail beds.

The nurse is preparing to administer the first dose of the prescribed IVPB antibiotic. Which 2 actions are most appropriate for the nurse to perform prior to initiating the infusion?

A. Administer a dose of PRN acetaminophen
B. Ask about the client's medication allergies
C. Ensure that prescribed blood cultures have been obtained
D. Ensure that the prescribed echocardiography has been obtained
E. Reschedule the antibiotic dose until the central venous catheter is in place

Correct Answer: B,C

Rationale: Antibiotic therapy is a critical component of treatment for clients with infective endocarditis (E). Before administering IV
antibiotics, the nurse should first obtain blood cultures to identify the infectious organism. Broad-spectrum antibiotics are
started initially. Targeted antibiotic therapy can be administered once the blood cultures identify the culprit organisms and their
antimicrobial susceptibilities. Before starting any medication, the nurse should ask about the client's medication allergies to
identify contraindications to therapy

The nurse is caring for a 24-year-old client.
Nurses' Notes
Emergency Department
1300:
The client is brought to the emergency department after a motor vehicle collision in which the driver's side airbag deployed.
The client was driving the vehicle and was not restrained by a seat belt. The client reports shortness of breath and chest
pain on inspiration and expiration.

History and Physical
Body System ,Findings
Neurological,
Awake, alert, and oriented to person; pupils equal, round, and reactive to light and accommodation; client is
agitated and moves all extremities spontaneously but does not follow commands
Integumentary, Superficial lacerations to the face; diffuse bruising noted on upper extremities and chest wall
Pulmonary,
Vital signs: RR 30, SpOz 92% via nonrebreather mask; unilateral chest wall expansion observed on inspiration;
left-sided tracheal deviation noted; breath sounds diminished throughout the right lung field
Cardiovascular,
Vital signs: P 104, BP 90/58; S1 and S2 heard on auscultation; all pulses palpable; no extremity peripheral edema
noted
Psychosocial ,Alcohol odor noted on the client's breath

Which of the following findings are consistent with a tension pneumothorax? Select all that apply.

A. Diminished breath sounds on one side
B. Dyspnea
C. Hypotension
D. Recent thoracic trauma
E. Tracheal deviation
F. Unilateral chest wall expansion

Correct Answer: A,B,C,D,E,F

Rationale: A pneumothorax is characterized by air inside the pleural space, which disrupts the negative pressure that maintains lung expansion. This
causes the lung to collapse either partially or completely, leading to unilateral, diminished breath sounds; unilateral chest wall
expansion; and dyspnea. A pneumothorax often occurs from blunt thoracic trauma (eg, during a motor vehicle collision). Air can also ent
the pleural space through the chest wall and parietal pleura (open pneumothorax) during or after an invasive procedure on or near the chest
wall (eg, thoracentesis, paracentesis, central line insertion) (Options 1, 2, 4, and 6).

Nurses' Notes
Outpatient Clinic
Initial
visit
The child recently started attending a new preschool and hit a teacher during lunch. The parent says,
"My
child has never been aggressive before but has always been particular about food."
The client was born at full term without complications and has no significant medical history. The child
started babbling at age 6 months, and the parent reports that the first words were spoken around age 12
months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color.
The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vitals signs are
normal, and the client is tracking adequately on growth curves.
During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow
the parents gaze when the parent points to toys in the office. The child begins screaming and rocking back
and forth when the health care provider comes near.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L)|
133 mEq/L (133 mmol/L)|
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%

Which of the following findings indicate that the client is improving as expected? Select all that apply.

A. Blood pressure 138/70 mm Hg
B. Clear lung sounds
C. Increased urinary output
D. SpO, 95% on room air
E. Unilateral lower extremity edema

Correct Answer: A,B,C,D

Rationale: Clinical improvement in a client with heart failure includes manifestations of reduced cardiac workload and improved fluid
volume status and gas exchange. A decrease in blood pressure from 170/100 mm Hg to 138/70 mm Hg and increased
urinary output indicate effectiveness of diuretics to reduce circulatory fluid volume and antihypertensive medications to
decrease cardiac workload . In addition, clear lung sounds and an increased capillary oxygen
saturation (SpO2) indicate a decrease in pulmonary congestion and an improvement in fluid volume status

The nurse is caring for a 68-year-old client in the emergency department.
Nurses' Notes,

Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.

Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air

Which of the following prescriptions are indicated for this client? Select all that apply.

A. 12-lead ECG
B. Chest x-ray
C. Current weight
D. Orthostatic vital signs
E. Serum electrolyte levels

Correct Answer: A,B,C,E

Rationale: This client's medical history includes hypertension, myocardial infarction, heart failure (HF), coronary artery disease, and chronic stable
angina, which place the client at high risk for several complications. When assisting in planning care for a client with a history of HF who is
experiencing dyspnea and chest discomfort, the nurse should anticipate the following prescriptions:
• A 12-lead ECG to assist in identifying acute dyshythmias and acute coronary syndromes (eg, myocardial infarction, unstable angina)
(Option 1)
• Chest x-ray to visualize pulmonary congestion, cardiomegaly, and the presence of other potential causes for the client's dyspnea (eg,
pneumonia, pleural effusion). Common causes of pleural effusions include HF (Option 2).
• The client's current weight to establish a baseline indicator of fluid volume status (Option 3)
• Serum electrolyte levels to identify fluid and electrolyte imbalances that may impair myocardial contractility (Option 5)