Nokea
The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900: The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO, 94% on room air.
1800:
The client is awake, alert, and oriented to person, place, time, and situation. The client is experiencing severe withdrawal symptoms and is admitted for supervised detoxification.
Laboratory Results
Urine Drug Screen
On admission
Cocaine- Negative
Opioids- Positive
Amphetamines- Negative
Marijuana- Positive
Phencyclidine-Negative
Benzodiazepines- Negative
Barbiturates- Negative
Laboratory Test and Reference Range
Cocaine- Negative
Opioids- Negative
Amphetamines- Negative
Marijuana- Negative
Phencyclidine- Negative
Benzodiazepines- Negative
Barbiturates- Negative
The nurse is helping the client prepare for discharge after 3 days of inpatient detoxification. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to identify maladaptive behaviors
- B. Encourage participation in an opioid recovery support group
- C. Ensure that the client and family members are trained in the use of naloxone
- D. Obtain referrals for rehabilitation programs
- E. Reinforce education regarding prescribed opioid agonist medications
Correct Answer: A,B,C,D,E
Rationale: All are appropriate: A: Identifying maladaptive behaviors supports recovery. B: Support groups aid long-term sobriety. C: Naloxone training prevents overdose deaths. D: Referrals ensure continued care. E: Education on medications (e.g., methadone) ensures adherence.
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The nurse is caring for a 58-year-old client on a medical-surgical unit.
History and Physical
General
The client is vomiting bright red blood; medical history includes alcohol use disorder, liver cirrhosis, and hypertension; the client was admitted a year ago for alcohol-induced acute pancreatitis
Neurological
The client is oriented to person and place; the pupils are equal, round, and reactive to light and accommodation
Eye, Ear, Nose, and Throat (EENT)
Yellow scleras are noted
Pulmonary
Vital signs are RR 18, SpO 94% on room air
Cardiovascular
Vital signs are T 99 F (37.2 C), P 102, BP 90/40; S1 and S2 are heard on auscultation; peripheral pulses are 2+ in all extremities; 1+ edema is noted at the bilateral lower extremities
Gastrointestinal
The abdomen is distended and nontender to palpation; the flanks are dull to percussion; bowel sounds are hypoactive; distended veins are present around the umbilicus
Genitourinary
Client is voiding amber-colored urine
Nurses’ notes.
Postoperative Day 1
1000:
The client underwent banding of esophageal varices 1 day ago. Today, the client is somnolent and oriented to person only. Speech is slurred. Flapping tremors are present in the clients arms and hands. The abdomen is soft and distended; bowel sounds are present. Dark-colored stool is noted. Amber-colored urine is noted. Vital signs are T 98.2 F (36.8 C), P 85, RR 24, BP 132/76, SpOz 94% on room air.
For each finding, specify if the finding is expected or unexpected for this client.
- A. Respiratory
- B. Neurological
- C. Genitourinary
- D. Cardiovascular
- E. Gastrointestinal
- F. Musculoskeletal
Correct Answer: A: Expected, B: Expected, C: Expected, D: Expected, E: Expected, F: Unexpected
Rationale: A) Expected: RR 24 is slightly elevated but consistent with cirrhosis and post-op status. B) Expected: Somnolence, disorientation, slurred speech, and flapping tremors indicate hepatic encephalopathy, common in cirrhosis. C) Expected: Amber urine is typical in cirrhosis due to dehydration or bilirubin. D) Expected: Stabilized vitals (BP 132/76, P 85) are post-treatment improvements. E) Expected: Dark stool is from variceal bleeding or banding, and distended abdomen is from ascites. F) Unexpected: No musculoskeletal issues (e.g., tremors are neurological) are noted.
The nurse is caring for an 82-year-old client in the emergency department.
Nurses' Notes
0930:
The client reports shortness of breath and left-sided chest pain for 2 days. The client fractured the right femoral neck a month ago after a fall and decided against operative management. Since then, the client has been wheelchair dependent and takes acetaminophen for fracture pain management. The client was placed on continuous cardiac monitoring.
History and physical
Body System
Neurological
The client is awake, alert, and oriented to person, place, time, and situation; the client appears anxious
Pulmonary
Vital signs are RR 22, SpOz 89% on room air; bilateral breath sounds are clear; pain increases with inhalation; the client reports shortness of breath for the past 2 days; the client smoked 1 pack of cigarettes per day for 10 years.
Cardiovascular
Vital signs are T 99.8 F (37.7 C), P 110, BP 110/60; S1 and S2 are present; there are no murmurs, redness and edema of the right lower extremity are noted; sinus tachycardia is seen on the monitor, chest pain is reported as 7 on a scale of 0-10
Musculoskeletal
The client has osteoporosis, is wheelchair dependent, and is unable to bear weight on the right leg
Diagnostic Results
CT pulmonary angiography
1030: Pulmonary embolism is confirmed
Lower extremity doppler ultrasound
1100: Deep venous thrombosis is noted in the right lower extremity.
Which of the following statements by the nurse indicate a correct understanding of heparin therapy? Select all that apply.
- A. Clients who have had recent surgeries or have a history of hemorrhagic stroke should not receive heparin.
- B. Heparin is administered via IV infusion pump.
- C. Heparin requires two licensed health care personnel to verify the infusion rate.
- D. Heparin should be discontinued if platelets decrease significantly.
- E. I will collect a blood specimen for a complete blood count and coagulation panel before heparin is initiated.
- F. The heparin dose is adjusted based on frequently checked PT/INR results.
Correct Answer: A,B,C,D,E
Rationale: A: Correct, as recent surgery or hemorrhagic stroke are contraindications due to bleeding risk. B: Correct, as heparin is typically administered via IV infusion pump for precise dosing. C: Correct, as high-risk medications like heparin often require dual verification. D: Correct, as significant platelet decrease may indicate heparin-induced thrombocytopenia, requiring discontinuation. E: Correct, as baseline CBC and coagulation panels are needed before starting heparin. F: Incorrect, as heparin dosing is adjusted based on aPTT, not PT/INR, which is used for warfarin.
The nurse is caring for an 8-year-old client who was brought to the emergency department after
becoming short of breath at school.
History and Physical
General
Well-nourished child; currently sitting in the tripod position; patches of dry, scaly, reddened skin are present in the creases of bilateral elbows and behind both knees; client reports that these areas itch
Neurological
Alert and oriented to person, place, and time
Eye, Ear, Nose, andThroat (EENT)
Pupils equal, round, and reactive to light and accommodation; client reports no nasal congestion
Pulmonary
Vital signs: RR 34, SpO 92% on room air, airway patent, intercostal retractions noted during inspiration; expiratory wheezes auscultated bilaterally; dry, spasmodic cough is noted; no stridor; difficulty speaking in complete sentences
Cardiovascular
Vital signs: T 98.8 F (37.1 C), P 110, BP 94/60; S1 and S2 heard on auscultation; nom murmurs noted; peripheral pulses 2+; capillary refill 3 seconds; no edema
Gastrointestinal
Abdomen soft; bowel sounds normal
Psychosocial
Client appears anxious and is crying, client speaks in short phrases, stating, "left my medicine at a friend's house" and "feels like I can't breathe"; client cannot remember the name of the prescribed home medication; client's parents were notified and are en route to hospital
Select the findings that require immediate follow up.
- A. Well-nourished child; currently sitting in the tripod position; patches of dry, scaly, reddened skin are present in the creases of bilateral elbows and behind both knees
- B. Vital signs: RR 34, SpO 92% on room air
- C. airway patent, intercostal retractions noted during inspiration; expiratory wheezes auscultated bilaterally
- D. difficulty speaking in complete sentences
- E. Vital signs: T 98.8 F (37.1 C), P 110, BP 94/60; S1 and S2 heard on auscultation
- F. capillary refill 3 seconds; no edema
- G. Client appears anxious and is crying
Correct Answer: B,C,D,G
Rationale: B: RR 34 and SpO2 92% indicate respiratory distress and hypoxia, requiring immediate intervention. C: Intercostal retractions and wheezes suggest severe airway obstruction. D: Difficulty speaking in complete sentences indicates significant respiratory compromise. G: Anxiety and crying reflect distress and may exacerbate respiratory issues.
The nurse is caring for a 52-year-old client on the orthopedic unit.
Nurses' Notes
Postoperative Day 1
0900:
The client's left leg was placed in balanced suspension skeletal traction for a fractured femur 12 hours ago. The client is positioned supine in the center of the bed with the foot of the bed elevated 15 degrees. Traction ropes are free of frays, centered in the pulleys, and moving freely with attached weights resting on the bed frame.
Serous drainage noted around the pin sites. Left foot slightly cool to the touch with posterior tibial and dorsalis pedis pulses palpable at 2+ and capillary refill <2 seconds in the toes. Client has normal sensation and movement of the left toes. Client rates left leg pain as 8 on a scale of 0-10.
Vital signs are T 100.4 F (38 C), P 110, RR 18, and BP 132/68. Weight is 173 lb (78.5 kg).
Select the 2 findings that require immediate follow-up.
- A. The client's left leg was placed in balanced suspension skeletal traction for a fractured femur 12 hours ago.
- B. The client is positioned supine in the center of the bed with the foot of the bed elevated 15 degrees.
- C. Traction ropes are free of frays, centered in the pulleys, and moving freely with attached weights resting on the bed frame.
- D. Serous drainage noted around the pin sites.
- E. Left foot slightly cool to the touch with posterior tibial and dorsalis pedis pulses palpable at 2+ and capillary refill <2 seconds in the toes.
Correct Answer: G,E
Rationale: Serous drainage (G) and a slightly cool foot (E) require immediate follow-up due to potential infection or compromised circulation.
The nurse in the emergency department is caring for a 62-year-old client.
History and Physical
Neurological
The client is alert and oriented to time, place, person, and situation; the client reports sudden-onset right-sided facial drooping, speech is slurred; positive right-sided arm drift is seen
Eye, Ear, Nose, and Throat (EENT)
Bilateral pupils are equal, round, and reactive to light and accommodation
Pulmonary
Vital signs: RR 16, SpO, 95% on room air, lung sounds are clear bilaterally
Cardiovascular
Vital signs: T 99 F (37.2 C), P 86, BP 166/90; S1 and S2 are heard on auscultation; no murmurs are noted; the client has a history of hypertension
Musculoskeletal
Right-sided lower extremity weakness is seen
Endocrine
The client has diabetes mellitus
Psychosocial
The client reports drinking one glass of wine each evening with dinner, no tobacco use, and a history of major depression; the client takes sertraline.
Laboratory Results
During Admission
Blood Chemistry.
Glucose: 72 mg/dL (4.0 mmol/L)
Sodium: 133 mEq/L (133 mEq/L)
Chloride: 101 mEq/L (101 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)
Laboratory Test and Reference Range
Blood Chemistry.
Glucose 74-106 mg/dL (4.1-5.9 mmol/L)
Sodium 136-145 mEq/L (136-145 mmol/L)
Chloride 98-106 mEq/L(98-106 mmol/L)
Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L
Diagnostic Results
Admission
CT scan of the head without contrast
1830:
No areas of hemorrhage are noted
The nurse is assisting the registered nurse in planning care for a client prescribed tissue plasminogen activator (tPA) therapy. Which of the following actions are appropriate prior to administration? Select all that apply.
- A. Ask the client's caretaker about a history of recent surgery or trauma
- B. Maintain BP ≤ 185/110
- C. Plan to initiate subcutaneous heparin immediately after tPA infusion is complete
- D. Review the client's current home medication list
- E. Verify the exact time the stroke symptoms started
Correct Answer: A, B, D, E
Rationale: Recent surgery/trauma (A) is a contraindication for tPA. BP ≤ 185/110 (B) is required to reduce bleeding risk. Reviewing medications (D) identifies anticoagulants that contraindicate tPA. Verifying symptom onset time (E) ensures tPA is within the therapeutic window. Heparin post-tPA (C) increases bleeding risk and is not immediate.