The nurse recognizes that the client is most likely experien...

The nurse is caring for a 6-hour-old newborn.
Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO, 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.
1 Hour Later
After attempting a bottle feed with 10 mL of formula, the client has a coughing episode, and there is formula mixed with saliva in the mouth. Coarse breath sounds are noted bilaterally with intercostal retractions. S1 and S2 are present with no murmurs. Neurologic examination shows normal neuromuscular findings.
A nasogastric tube insertion is attempted per prescription by the health care provider, and resistance is met at 10 cm of insertion.

The nurse recognizes that the client is most likely experiencing a tracheoesophageal fistula with esophageal atresia and will require interventions to prevent ___ and ___

A. Hernia
B. Dehydration
C. Aspiration pneumonia
D. Necrotizing enterocolitis

Correct Answer: B,C

Rationale: Tracheoesophageal fistula can lead to aspiration pneumonia due to food entering the lungs and dehydration from inability to feed properly. These are the most immediate risks requiring intervention.

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.

For each finding, click to specify whether the finding indicates that the client's status has improved or declined.

A. HR 90
B. RR 18
C. SpO2 92% on room air
D. Decreased platelet count
E. Pain rated as 3 on a scale of 0-10

Correct Answer: A: Improved; B: Improved; C: Improved; D: Declined; E: Improved

Rationale: A: HR 90 (down from 110) indicates improved cardiovascular stability. B: RR 18 (down from 22) suggests improved respiratory status. C: SpO2 92% (up from 89%) indicates improved oxygenation. D: Decreased platelet count suggests a decline, possibly due to heparin-induced thrombocytopenia. E: Pain rated 3 (down from 7) indicates improved pain control.

The nurse is caring for an 8-year-old client who was brought to the emergency department after
becoming short of breath at school.
Nurses' Notes
0920:
Nebulized administration of albuterol (salbutamol) and ipratropium bromide completed. Client continues to have a dry cough. Breath sounds are clear to auscultation; no intercostal retractions are visible.
Vital signs: RR 24, SpO2 96% on 6 L humidified oxygen via nasal cannula.

Select the findings that indicate the client is progressing as expected.

A. Nebulized administration of albuterol (salbutamol) and ipratropium bromide completed
B. Client continues to have a dry cough
C. Breath sounds are clear to auscultation
D. no intercostal retractions are visible
E. Vital signs: RR 24, SpO2 96% on 6 L humidified oxygen via nasal cannula

Correct Answer: C,D,E

Rationale: C: Clear breath sounds indicate improved airflow. D: Absence of intercostal retractions suggests reduced respiratory effort. E: RR 24 and SpO2 96% reflect improved oxygenation and respiratory status post-treatment.

The nurse is caring for an 84-year-old client with dementia.
Nurses' Notes
Medical-Surgical Unit
Day 1: The left antecubital peripheral IV insertion site has no erythema or edema, and the catheter flushes easily. The dressing is clean, dry, and intact. Potassium chloride infusion is initiated.
Day 3: Potassium chloride is infusing. The area surrounding the IV site is taut, edematous, blanched, and cool to the touch. Small, fluid-filled vesicles are noted around the IV site. Capillary refill distal to the IV site is >3 seconds. The client is grimacing and unable to verbally report pain.

For each potential intervention, click to specify if the potential intervention is appropriate or not appropriate for the care of client.

A. Elevate the affected extremity
B. Apply pressure to the affected area
C. Discontinue the potassium chloride infusion
D. Aspirate the potassium chloride from the IV catheter
E. Leave the IV catheter in place for potential antidote administration

Correct Answer: A: Appropriate, B: Not Appropriate, C: Appropriate, D: Not Appropriate, E: Appropriate

Rationale: The symptoms suggest IV infiltration with potassium chloride, which is caustic. Elevating the extremity (A) reduces swelling. Discontinuing the infusion (C) prevents further damage. Leaving the catheter in place (E) allows for potential antidote administration. Applying pressure (B) may worsen tissue damage, and aspirating (D) is not standard for infiltration.

The nurse is caring for a client on the medical-surgical unit.
History
Admission
0500: The client is admitted with an abscess and cellulitis of the right leg. The abscess is noted on the lateral aspect of the right calf, with redness, swelling, and warmth extending from the knee to the ankle. The abscess was incised in the emergency department, and a moderate amount of purulent, yellowish-green drainage was noted. The leg was wrapped with gauze, and the client received the first dose of IV antibiotics and opioids for pain control.
The client reports chronic lower back pain and gastrosophageal reflux disease, and he was admitted to the hospital once last year for gastrointestinal bleeding. He is currently prescribed daily pantoprazole but takes it only a few times a week.
Vital signs: T 100.9 F (38.3 C), P 82, RR 14, BP 130/80, SpO, 95% on room air

Progress Notes
Medical-Surgical Unit
2300:
The client reports nausea, headache, and insomnia. The client is trembling, diaphoretic, and restless.
The client states, "I would sleep better if those mice and cats would stop climbing up and down the walls."
The upper portion of the clients dressing is saturated with yellowish-green drainage. The peripheral V was removed by the client, and dried blood is noted at the IV site. The IV catheter is on the floor. The client yelled and pushed the nurse's hands away during inspection of the IV site.
Vital signs: T 99 F (37.2 C), P 102, RR 18, BP 170/96, SpO≥ 95% on room air

The nurse should contact the health care provider and anticipate prescriptions for.....and.....

A. Naloxone
B. Thiamine
C. Haloperidol
D. Lorazepam

Correct Answer: B,D

Rationale: B: Thiamine is given to prevent Wernicke encephalopathy in alcohol withdrawal. D: Lorazepam manages withdrawal symptoms and prevents seizures. Naloxone is for opioid overdose, and haloperidol is not first-line for withdrawal.

The nurse is caring for a 66-year-old client in the emergency department.
Nurses' Notes
Emergency Department
1930:
The client is admitted for cellulitis of the right arm due to V drug use. The client was diagnosed with HIV 25 years ago and is taking antiretroviral therapy but reports frequently skipping doses. This is the client's third admission to the hospital within the past 6 months for complications due to IV drug use.
2015:
While assisting with an IV catheter placement, the nurse accidentally sustains a needlestick injury.

For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client.

A. Wash the injury with soap and water
B. Screen the client for hepatitis C virus
C. Squeeze tissue to let the wound bleed
D. Anticipate initiating antiretrovirals for the nurse
E. Anticipate initiating oral antibiotics for the nurse
F. Replace the cap on the needle prior to disposal

Correct Answer: A,B,C,D

Rationale: A: Indicated - Washing with soap and water is a standard first step to clean a needlestick injury and reduce infection risk. B: Indicated - Screening the client for hepatitis C is necessary due to the risk of bloodborne pathogen transmission, especially given the client's IV drug use history. C: Indicated - Allowing the wound to bleed can help flush out potential contaminants. D: Indicated - Post-exposure prophylaxis with antiretrovirals may be needed due to the client's HIV status and non-compliance with therapy. E: Not indicated - Antibiotics are not routinely given for needlestick injuries unless infection is evident. F: Not indicated - Recapping needles increases the risk of injury and is against safety protocols.