Nokea
The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled?
- A. Tachypnea
- B. Bradycardia
- C. Nausea
- D. Mydriasis
- E. Increased blood glucose
Correct Answer: A, C, E
Rationale: Tachypnea, nausea, and increased blood glucose are signs of uncontrolled pain.
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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 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.
When the nurse is educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following should the nurse emphasize as early signs of heart failure?
- A. Diaphoresis
- B. Sudden weight gain
- C. No wet diapers
- D. Hypoxia
- E. Increased appetite
Correct Answer: A, B, C, D
Rationale: Diaphoresis, sudden weight gain, no wet diapers, and hypoxia are early signs of heart failure in children.
The nurse is caring for a 4-year-old client who suffered second and third-degree burns to the chest, abdomen, and legs. Vital signs: P 117, RR 44, BP 90/60, pulse oximetry reading 88% on room air. The nurse should initially
- A. obtain a prescription for intravenous fluid replacement
- B. prepare the client for airway intubation
- C. perform wound care to the burned areas
- D. review the client's laboratory data
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension indicate hypovolemia from burns, requiring immediate IV fluid replacement.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a pregnant client.
Item 1 of 1
Nurses' Notes
Emergency Department
0735: Client reports sudden onset of nausea and vomiting, heavy vaginal bleeding with dark red blood, frequent low-intensity contractions, lower abdominal pain rated 9/10 on the Numerical Rating Scale for past two hours, and dull lower back pain rated 2/10 on the Numerical Rating Scale for the past 24 hours. Client is 30 weeks gestation (G=4 T=3 P=0 A=0 L=3) and is Rh-positive. Vital signs: T 99.8 ⁰ F (37.7 ⁰ C), P 99, RR 16, BP 112/76, pulse oximetry reading 94% on room air. Uterine tenderness present with gentle palpation. Client states they are a one-pack per day cigarette smoker and denies any alcohol or illicit drug use.
The nurse reviews the client's admission data to begin the plan of care. 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. initiate electronic fetal monitoring (EFM), administer Rh immune globulin, assess for signs of hyperemesis gravidarum, start peripheral access device, perform an ultrasound examination
- B. placenta previa, preterm labor, placental abruption, preeclampsia
- C. continuous electronic fetal monitoring (EFM), 24-hour urine specimen, strict intake & output, vital signs, serum creatinine levels
Correct Answer: B (placental abruption), A (initiate EFM, start peripheral access device), C (fetal heart rate pattern, vital signs)
Rationale: The client's heavy vaginal bleeding, severe abdominal pain, and frequent contractions at 30 weeks suggest placental abruption. EFM and peripheral access are critical interventions, and monitoring fetal heart rate and vital signs assesses progress.