Nokea
The nurse is caring for a child immediately following a nephrectomy in the postanesthesia care unit (PACU). Which assessment should the nurse initially perform?
- A. pain level
- B. peripheral vascular access device
- C. surgical incision
- D. vital signs
Correct Answer: D
Rationale: Vital signs are the initial priority in the PACU to assess stability post-nephrectomy.
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The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 5 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Orders
• insert peripheral vascular access device
• serum type and screen
• transfuse two units of fresh frozen plasma
• perform a bedside swallow evaluation
• apply sequential compression devices
• obtain a complete metabolic panel (CMP)
The nurse has received orders from the physician. Select three (3) orders that the nurse should consider a priority.
- A. insert peripheral vascular access device
- B. serum type and screen
- C. transfuse two units of fresh frozen plasma
- D. perform a bedside swallow evaluation
- E. apply sequential compression devices
- F. obtain a complete metabolic panel
Correct Answer: A, B, C
Rationale: Peripheral access, serum type and screen, and FFP transfusion are priorities to manage bleeding risk from subarachnoid hemorrhage and elevated INR.
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
- A. Levothyroxine for a client with a myxedema coma
- B. Hydrochlorothiazide for a client with hyperparathyroidism
- C. Hydrocortisone for a client with adrenal insufficiency
- D. Regular insulin for a client with diabetic ketoacidosis
Correct Answer: B
Rationale: Hydrochlorothiazide can worsen hypercalcemia in hyperparathyroidism and should be questioned.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 1 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Which of the following assessment findings require immediate follow-up?
- A. lung sounds
- B. pupil assessment
- C. abdominal assessment findings
- D. pulse, respirations, and blood pressure
- E. Glasgow coma scale
- F. speech characteristics
- G. home medications
Correct Answer: B, E, G
Rationale: Pupil sluggishness, Glasgow Coma Scale of 14, and warfarin use (increasing bleeding risk) require immediate follow-up due to potential traumatic brain injury.
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 caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first?
- A. Instruct the client to restrict activity
- B. Establish a vascular access device
- C. Review the client's current medications
- D. Educate the client about topical eye ointments
Correct Answer: A
Rationale: Restricting activity is the first priority to prevent further retinal damage.