What client statement requires additional teaching reinforce...

The nurse is caring for a client at a women’s health clinic.
History & Physical
Labor and delivery unit
0800:
A 28-year-old nulliparous female comes to the clinic for confirmation of suspected pregnancy due to amenorrhea and a positive home pregnancy test. The client's current exercise regimen includes indoor cycling and outdoor running. The client reports nausea, vomiting, and breast tenderness. She has a 28-day menstrual cycle, and her last menstrual period was March 10- 17. The health care provider notes a bluish-purple vaginal mucosa and cervix during pelvic examination and confirms a 12-week intrauterine pregnancy by sonography. A fetal heart rate of 155/min is detected with handheld Doppler.

Progress Notes
Trending Maternal Weight
Prepregnancy
Height: 5 ft 5 in (165.1 cm)
Weight: 140 lb (63.5 kg)
BMI: 23.3 kg/m
12 weeks gestation
Weight: 150 lb (68 kg)
16 weeks gestation
Weight: 160 lb (72.6 kg)

Nurses’ notes
0800
Client comes to the clinic for a 20-week gestation prenatal visit. Client reports no bleeding or cramping. Vital signs and physical examination are normal. Current weight is 157 lb (71.2 kg). Client states that she is feeling well overall.

What client statement requires additional teaching reinforcement?

A. I added gymnastics into my exercise routine.
B. I eat carbohydrates that are high in fiber.
C. I eat salmon once per week.
D. I go to an indoor cycling class 3 times per week.

Correct Answer: A

Rationale: Gymnastics poses a risk of falls and injury during pregnancy, requiring reinforcement about safe exercises like walking or prenatal yoga.

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

For each finding below, click to specify if the finding is consistent with the disease process of myocardial infarction, pneumonia, or pulmonary embolism.

A. Dyspnea
B. Chest pain
C. Hypoxemia
D. Sinus tachycardia
E. Right lower extremity redness and edema

Correct Answer: A: Myocardial infarction, Pneumonia, Pulmonary embolism; B: Myocardial infarction, Pneumonia, Pulmonary embolism; C: Pneumonia, Pulmonary embolism; D: Myocardial infarction, Pulmonary embolism; E: Pulmonary embolism

Rationale: A: Dyspnea is common in all three due to impaired oxygenation or cardiac output. B: Chest pain occurs in all three, though the nature varies (e.g., pleuritic in pneumonia/PE, crushing in MI). C: Hypoxemia is typical in pneumonia (due to alveolar impairment) and PE (due to ventilation-perfusion mismatch). D: Sinus tachycardia is seen in MI (due to cardiac stress) and PE (due to hypoxia and embolism). E: Right lower extremity redness and edema suggest DVT, which is strongly associated with PE.

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).

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

A. Restrict fluid intake
B. Offer a low-fiber diet
C. Use incentive spirometer
D. Administer stool softener
E. Administer anticoagulant

Correct Answer: C,D,E

Rationale: Expected prescriptions include using an incentive spirometer (C) to prevent atelectasis, administering a stool softener (D) for constipation, and an anticoagulant (E) for DVT prevention. Fluid restriction (A) and low-fiber diet (B) are not indicated.

The practical nurse is assisting the registered nurse with the care of a 58-year-old client in the emergency department.
Nurses' Notes
Initial Clinic Visit
The client monitors blood pressure (BP) at home and reports that it has been elevated for the past month. BP is 157/92 mm Hg. Physical examination is normal. The client is prescribed a thiazide diuretic for hypertension.

Emergency Department 4 Weeks Later
The client reports muscle weakness and severe cramping in the lower extremities with increased lethargy over the past 3 days. BP is 123/75 mm Hg. Physical examination findings include 1+ deep tendon reflexes bilaterally.

The nurse recognizes that the client is most likely experiencing.......... and, without prompt intervention, is at risk for...........

A. Hypokalemia
B. Hypoglycemia
C. Hypermagnesemia
D. Seizures
E. Hypotension
F. Cardiac dysrhythmias

Correct Answer: A,F

Rationale: The client is most likely experiencing hypokalemia and, without prompt intervention, is at risk for cardiac dysrhythmias. Thiazide diuretics can cause potassium loss, leading to muscle weakness, cramping, and lethargy. Low potassium levels can disrupt cardiac electrical activity, risking dysrhythmias.

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

The nurse is monitoring the transfusion of prescribed packed RBCs (PRBCs) initiated by the registered nurse. Which of the following actions are appropriate? Select all that apply.

A. The blood transfusion rate is set to infuse over 6 hours
B. The blood transfusion tubing is primed with lactated Ringer solution
C. The nurse stays with the client for the first 15 minutes of the transfusion
D. The PRBCs are administered through Y-type tubing with an in-line filter
E. The registered nurse verifies client and blood product identifiers with the licensed practical nurse

Correct Answer: C,D

Rationale: C) Appropriate: Staying for the first 15 minutes monitors for transfusion reactions. D) Appropriate: Y-type tubing with an in-line filter is standard for PRBCs to prevent complications. A) Inappropriate: PRBCs typically infuse over 2-4 hours, not 6, to avoid fluid overload. B) Inappropriate: Tubing is primed with normal saline, not lactated Ringer's, to prevent hemolysis. E) Inappropriate: Verification requires two registered nurses, not an LPN.

The nurse is assisting with a staff in-service regarding safe handling of controlled substances. For each behavior or finding, click to specify whether the behavior/finding is concerning or not concerning for possible drug diversion.

A. Excessively wastes controlled substances
B. Friends with many other nurses on the unit
C. Causes inventory discrepancies in the medication-dispensing machine
D. Frequently volunteers to administer medications for other nurses' clients
E. Asks for another nurse's password to the medication-dispensing system

Correct Answer: A,C,D,E

Rationale: A: Excessive wasting of controlled substances is concerning as it may indicate diversion for personal use or distribution. C: Inventory discrepancies suggest possible theft or misuse. D: Frequently volunteering to administer medications may provide opportunities for diversion. E: Requesting another nurse's password is a security breach and highly concerning for diversion.