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

History,

Labor and Delivery Unit
Admission: The client, gravida 1 para 0, at 16 weeks gestation with a twin pregnancy reports nausea and vomiting for the past
several weeks. The client also reports dry heaving, increasing weakness, light-headedness, and an inability to tolerate
oral intake for the past 24 hours. In addition, the client has had occasional right-sided, shooting pain from the abdomen
to the groin that occurs with sudden position changes. The pain quickly resolves without intervention per the client's
report. She has had no contractions or vaginal bleeding and has felt no fetal movement during this pregnancy. The
client has a history of childhood asthma and is currently taking no asthma medications. The client reports no other
pregnancy complications.

Physical,
Prepregnancy,12 Weeks Gestation 16 Weeks Gestation(Prenatal Visit),(Labor and Delivery Admission)
Height ,5 ft 5 in (165.1 cm),5 ft 5 in (165.1 cm)|, 5 ft 5 in (165.1 cm)
Weight, 145 lb (65.8 kg),148 lb (67.1 kg),138 lb (62.6 kg)
BMI, 24.1 kg/m2, 24.6 kg/m2,23.0 kg/m2

Vital Signs,
12 Weeks Gestation(Prenatal Visit),16 Weeks Gestation(Labor and Delivery Admission)
T,98.7 F (37.1 C),99.8 F (37.7 C)
P,70,101
RR,14,18
BP,122/78,90/55
SpO2,99% on room air,96% on room air

Laboratory Results,
Laboratory Test and Reference Range, 16 Weeks Gestation
Blood Chemistry.
Sodium
136-145 mEq/L
(136-145 mmol/L)|,
136 mEq/L
(136 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
2.7 mEq/L
(2.7 mmol/L)
TSH
0.3-5.0 uU/mL
(0.3-5.0 mU/L),
0.4 pu/mL
(0.4 mU/L)
Hematology.
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
16 g/dL
(160 g/L)
Hematocrit (pregnant)
>33%
(>0.33),
49%
(0.49)
Urinalysis
Specific gravity
1.005-1.030
1.030,
Ketones
Not present,
Present
Giucose
Not present,
Not present
Nitrites
Not present,
Not present

Prescriptions,
10 mEq/hr potassium chloride in dextrose 5% and sodium chloride 0.45% IV continuously
• 1000 mg calcium carbonate q6h
• 10 mL multivitamin and 0.6 mg folic acid once daily
• 12.5 mg promethazine q6h

The nurse has reviewed the information from the Prescriptions. The client received 2 L of lactated Ringer solution IV, 100 mg thiamine IV, and vitamin B, plus doxylamine IV shortly after arrival due to reports of severe nausea and vomiting. Click to highlight below the prescription that the nurse should anticipate completing next when planning care with the registered nurse.

A. 10 mEq/hr potassium chloride in dextrose 5% and sodium chloride 0.45% IV continuously
B. 1000 mg calcium carbonate q6h
C. 10 mL multivitamin and 0.6 mg folic acid once daily
D. 12.5 mg promethazine q6h

Correct Answer: A

Rationale: Clients with hyperemesis gravidarum (HG) may require hospitalization if experiencing hypovolemia and electrolyte abnormalities. On
admission, clients with HG usually receive fluid replacement (eg, lactated Ringer solution) and antiemetics (eg, doxylamine and vitamin Bg).
Thiamine (vitamin B,) is often administered in initial fluids to prevent Wernicke encephalopathy.
For clients with HG experiencing hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) due to vomiting, it is critical to administer potassium
chloride promptly. Hypokalemia can have multiple potentially serious effects that, without intervention, put the client at immediate risk for
death; such effects include cardiac dyshythmia, respiratory muscle weakness causing respiratory failure, and impaired gastrointestinal
motility causing constipation and ileus

The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).
Laboratory Results
Laboratory Test and Reference Range, 0900
Glucose, serum (random)
≤200 mg/dL
(<11.1 mmol/L),
573 mg/dL
(31.8 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.7 mEq/L
(5.7 mmol/L)

The nurse reinforces teaching about managing diabetes mellitus during an acute illness. For each of the statements made by the client,click to specify whether the statement indicates correct understanding or incorrect understanding

A. I should not take insulin if I cannot eat due to nausea.
B. I should drink extra fluids to stay hydrated when I am experiencing an illness.
C. I will check my blood glucose levels more frequently if I am experiencing an illness
D. I need to check my urine for ketones if my blood glucose levels are persistently elevated
E. I will reduce my carbohydrate intake if I experience high blood glucose levels during an
illness.

Correct Answer:

Rationale: When a client with diabetes mellitus experiences an infection or another illness, the release of stress hormones can cause increased insulin
resistance, which increases the blood glucose level and leads the body to break down fats for energy (ketosis). This can precipitate diabeti
ketoacidosis (DKA) as break down of fatty acids produces ketones. Interventions for managing diabetes mellitus and preventing DKA durin
an illness include:
• Increasing fluid intake to help clear ketones from the system and prevent dehydration during illness
• Checking blood glucose levels more frequently (eg, every 4 hr) to monitor for hyperglycemia
• Monitoring the urine for ketones if blood glucose levels are persistently elevated (>240 mg/dL [13.3 mmol/L]) for early detection of
impending DKA
• Consuming beverages that contain glucose and replacing electrolytes if nausea and vomiting are present
• Notifying the health care provider of persistently elevated blood glucose levels, ketones in the urine, high fever, nausea, vomiting, or
diarrhea

The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).

Select 5 findings that require immediate follow-up.

A. sore throat and nasal congestion for the past week
B. Pregnancy status is
unknown.
C. The abdomen is soft without rigidity or
rebound tenderness,
D. appears drowsy and is oriented to person and time on
E. Vital signs are T 98.8 F (37.1 C), V P 128, V RR 30, and BP 88/60 mm Hg
F. Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L) .

Correct Answer: B,D,E,F

Rationale: This client has findings of chronic hyperglycemia, including polydipsia (increased thirst) and polyuria (increased urination) which may indicate
untreated diabetes mellitus. Recent findings also indicate potential upper respiratory infection, hypovolemia, and an acute abdominal
condition. For this client, the following findings are the priority for follow-up:
• Delayed menstruation (time since last menstruation exceeds typical cycle length) could indicate that the client is pregnant, which
presents a risk for pregnancy-related complications (eg, ruptured ectopic pregnancy) and affects care provided to the client (eg, avoid x-
rays and teratogenic medications).
• Decreased level of consciousness (eg, drowsiness, disorientation) places the client at increased risk for injury and aspiration and
may indicate impaired brain perfusion. This may be due to hypotension or hyperglycemia-induced cerebral edema.
• Hypotension causes impaired organ perfusion that could be life threatening without immediate intervention.
• Tachycardia occurs to compensate for hypotension or can be the cause of hypotension and requires prompt attention to prevent
cardiovascular collapse.
• Tachypnea is concerning, particularly when associated with rapid, deep respirations (ie, Kussmaul breathing), because it may indicate a
compensatory response to an underlying metabolic acidosis (eg, ketoacidosis, hypotension-induced lactic acidosis).
• Severe hyperglycemia may indicate diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus. In addition,
hyperglycemia has a diuretic effect leading to fluid loss that worsens cardiovascular compromise.

The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).
Laboratory Results
Laboratory Test and Reference Range, 0900
Glucose, serum (random)
≤200 mg/dL
(<11.1 mmol/L),
573 mg/dL
(31.8 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.7 mEq/L
(5.7 mmol/L)

Drag words from the choices below to fill in the blanks. The nurse gathers supplies for medication administration. The nurse recognizes that the priority prescriptions are -------and ----------

A. 50% dextrose IV PRN
B. 0.9% sodium chloride IV bolus
C. Potassium chloride IV PRN|
D. Regular insulin continuous IV infusion
E. 5% dextrose in 0.45% sodium chloride IV infusion

Correct Answer: E,B

Rationale: The priority intervention for management of diabetic ketoacidosis is fluid resuscitation with isotonic IV fluid, typically starting with large-voli
0.9% sodium chloride IV boluses (eg, 1 L/hr) to prevent life-threatening hypovolemic shock. Fluid resuscitation also helps normalize
glucose and electrolyte levels via hemodilution. After initial large-volume boluses are complete, either hypotonic or isotonic IV fluids are
administered at continuous rate. Administration of regular insulin continuous IV infusion is also essential to correct hyperglycemia.

History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Laboratory Results
Laboratory Test and Reference Range,Admission
Urine drug screen
Cocaine
Negative
Positive,
Opioid
Negative
Negative,
Amphetamines
Negative
Negative,
Marijuana
Negative
Positive,
Phencyclidine
Negative
Negative,
Benzodiazepines
Negative
Negative,
Barbiturates
Negative
Negative,
Breathalyzer
No alcoho detected
0.00
Nurses' Notes
Inpatient: Mental Health Unit
0900:
1200:
1500:
2000:
The client is inattentive, withdrawn, and depressed with low energy. The client's appearance is disheveled
with noted body odor. The client is declining breakfast and does not participate in group therapy. Education
was provided about the importance of participating in the treatment plan, and the client was encouraged to
shower.
The client is observed pacing back and forth in the room. The client is visibly upset and tearful and states, "I
can't live like this anymore. Everything in my life is going wrong." The client is encouraged to use deep
breathing and relaxation techniques to ease anxiety.
The client remains isolated to the room, pacing back and forth. The client rates depression as 6 on a scale of
0-10 and anxiety as 5 on a scale of 0-10.
The client was observed collecting blankets and storing them in the room behind the bed. When
approached, the client became defensive.

The nurse is caring for the client 4 days after admission. For each finding below, click to specify if the finding indicates that the client's status is improving or concerning.

A. Client ate 80% of the meals and took a shower today.
B. Client is seen joining group activities in the day room.
C. Client states, "I feel more energetic today than I have in many months."
D. Client is seen handing a personal watch and photo album to another client.
E. Client reports depression 0/10 and states, "I feel a lot better. I think I know what I need to do now."

Correct Answer:

Rationale: Participation in group activities, increased appetite, and performing self-hygiene (eg, showering) indicate an
improvement in the client's status because the client was previously withdrawn with little interest in interacting with others or
performing self-care (eg, declining breakfast tray, body odor).
During the early phase of therapy with antidepressants (eg, selective serotonin reuptake inhibitors [escitalopram]), the risk of
suicide may increase because clients can become more energized as the depression lifts, enabling them to carry out previous
suicide plans. The nurse should find concerning the client's statements about feeling more energized and "knowing what to
do now," which can indicate that the client has determined a plan for suicide and is at peace knowing the plan.
Giving away meaningful possessions (eg, watch, photo album) is concerning for an impending suicide attempt. The nurse
should ask directly about thoughts of suicide.

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Correct Answer: A,B,D,E

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