Nokea
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
- A. Heart rate.
- B. Blood pressure.
- C. Temperature.
- D. Respiratory rate.
Correct Answer: D
Rationale: Respiratory rate assesses hypoxia.
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History and Physical
A 75-year-old male presents to the emergency department (ED) with poorly controlled diabetes. He had been experiencing polyuria, nausea and vomiting, confusion, and unstable blood sugars. The client was stabilized in the ED and transferred to the medical unit for continued stabilization and management. The client has a history of smoking and has smoked one pack per day for the past 40 years. There is a history of moderate obesity, insulin-dependent diabetes, and mobility issues. He requires the use of a walker for mobility..
Nurse’s Notes
17:35
The client is moved from the gurney to the medical bed and requires two people to assist. The nurse performs a functional assessment. The client reports neuropathy in bilateral hands and lower legs. His skin is moist. He reports the need to wear an incontinence brief due to occasional accidents of both urine and stool. He explains that it is difficult for him to move quickly enough when he feels the urge to use the bathroom. At home, where he lives alone, he reports spending most of his time in his recliner, though he can ambulate within the home and does so if needed. He feels like he slides in bed to move because repositioning is difficult. He is currently using a front-wheeled walker. He reports difficulty eating a full meal and has less than optimal PO intake. Contracting sounds are noted.
17:35
The perineal area is noted to have redness with no open sores. The client has blanchable redness noted on both heels bilaterally and on the coccyx
Lab Results
Laboratory Test
Result
Reference Range
Glucose 180 mg/dl (10 mmol/L) 74 to 106 mg/dl (4.1 to 5.9 mmol/L)
Flow Sheet
17:15
Vital Signs and Assessments:
• Temperature: 98.7°F (37°C)
• Heart rate: 94 beats/minute
• Respiratory rate: 18 breaths/minute
• Blood pressure: 138/88 mmHg
• Oxygen saturation: 95% on room air
• Pain: 3 on a 0 to 10 pain scale, baseline numbness and tingling in bilateral upper and lower extremities
• Braden score: 13
Orders
17:15
• Capillary blood glucose before meals and bedtime
The nurse reviews the client’s data.Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
- A. Cleanse and dress wound, Ofload coccyx and other bony prominences, Contact adult protective services, Immediately begin a bowel training program
- B. Pressure Injury, Elder abuse, Altered nutrition, Bowel obstruction
- C. Wound status, Documentation of skin prevention measures, Incontinence episodes, Vital signs
Correct Answer:
Rationale: Choice A reason:
There is no mention of an open wound that requires cleansing and dressing, so this action is not applicable based on the provided patient data.
Choice B reason:
The patient has blanchable redness on both heels and the coccyx, which are signs of pressure injury risk. Ofloading these areas is essential to prevent the development of pressure ulcers.
Choice C reason:
There is no indication of elder abuse in the provided scenario, so contacting adult protective services would not be appropriate.
Choice D reason:
Given the patient's difficulty with mobility and the reported occasional accidents, a bowel training program could help manage his bowel incontinence and improve his quality of life.
Choice E reason:
An enema is not indicated as there is no evidence of constipation or bowel obstruction in the patient's history or nurse's notes.
Condition F reason:
The patient is most likely experiencing pressure injuries, as indicated by the redness on his heels and coccyx, which are common sites for pressure ulcers due to immobility.
Condition G reason:
There is no evidence of elder abuse in the patient's history or nurse's notes. Condition H reason:
Altered nutrition may be a concern due to the patient's reported difficulty eating full meals and less than optimal intake, but it is not the primary condition indicated by the nurse's assessment.
Condition I reason:
There is no evidence of bowel obstruction; the patient's main issue seems to be related to pressure injury and incontinence.
Parameter J reason:
Monitoring wound status is crucial for managing and tracking the healing process of any existing or potential pressure injuries.
Parameter K reason:
While documentation of skin prevention measures is important, it is not as immediate as monitoring wound status and incontinence episodes.
Parameter L reason:
Monitoring incontinence episodes will help evaluate the effectiveness of the bowel training program and any other interventions put in place to manage the patient's incontinence.
Parameter M reason:
Vital signs should always be monitored, but they are not specific to assessing the progress of pressure injury management or bowel training program effectiveness.
Parameter N reason:
Family dynamics are not relevant in this case as the patient lives alone and there is no indication of family involvement in his care.
While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?
- A. Unpleasant odor of the breath
- B. White patches on the mucosa.
- C. Gumline that has visibly receded.
- D. Discoloration of several teeth.
Correct Answer: B
Rationale: White patches suggest thrush requiring treatment.
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Stethoscope.
- B. Bed linens.
- C. Sputum specimen.
- D. Paper mask and gown.
Correct Answer: D
Rationale: Disposable PPE prevents contamination.
The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
- A. Explain that since the medication is a controlled substance, it must be taken.
- B. Credit the medication back and put it in the client's medication box.
- C. Keep the medication and see if the client will want to take it later.
- D. Have another nurse witness the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal prevents misuse of controlled substances.
The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?
- A. Complete an admission assessment.
- B. Access a central venous line.
- C. Reinforce discharge teaching.
- D. Initiate blood product infusions.
Correct Answer: C
Rationale: PNs can reinforce teaching within scope.