Nokea
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower
back pain and bilateral leg weakness. The client reports that the
weakness began 3 days ago in the feet and has gradually worsened.
The client sought treatment today after becoming "so weak that I fell
while walking" and noticing new hand weakness and difficulty
swallowing. Back pain radiates down both legs and is rated as 5 on a
scale of 0-10. The client recently recovered from an illness with flu-like
symptoms. The client reports a history of hypertension and takes no
medications. Assessment of the lower extremities reveals muscle
strength of 2/5 and decreased sensation to pinprick. Achilles tendon
and patellar reflexes are decreased.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.
1030:
The client is breathless while speaking. Respirations are shallow and
labored. The client is diaphoretic. The skin is pale and cool. No
audible wheezing or stridor is present.
Which action by the nurse is appropriate?
- A. Perform oral suctioning
- B. Prepare the client for intubation
- C. Reposition the client and encourage deep breathing
- D. Request a prescription for an albuterol nebulizer treatment
Correct Answer: B
Rationale: Shallow, labored breathing and chest tightness indicate impending respiratory failure, requiring preparation for intubation.
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The nurse is caring for a 68-year-old client who is brought to the emergency department due to confusion.
History and Physical Body System Findings
General- Client's adult child reports the confusion started this morning, following 3 days of fever and productive cough; medical history includes small bowel resection 10 days ago, chronic heart failure, and coronary artery disease
Neurological- Client is drowsy and oriented to person only, but intermittently agitated Integumentary- Small abdominal surgical incision is present over lower left quadrant, edges are well approximated, and no redness or drainage is noted
Pulmonary- Vital signs are RR 24 and SpO 90% on room air; labored breathing is observed, and crackles and diminished breath sounds are auscultated over right lower chest; client is expectorating yellow sputum; history includes smoking a pack of cigarettes daily for the past 40 years
Cardiovascular- Vital signs are T 102.9 F (39.4 C), P 110, and BP 110/70; S1 and S2 are heard on auscultation; bilateral lower extremity edema is 1+; ECG shows sinus tachycardia
Gastrointestinal- Normoactive bowel sounds are auscultated; client's last bowel movement was 1 day ago
Genitourinary- Client voided concentrated yellow urine
The nurse is monitoring the client after insertion of a chest tube that is connected to a water seal chamber device. Which of the following observations are anticipated? Select all that apply
- A. Chest tube collection container positioned above the chest tube insertion site.
- B. Dependent loop in the drainage tube from the insertion site
- C. Intermittent bubbling in the water seal chamber
- D. Sterile gauze dressing taped on three sides
- E. Tidaling in water seal chamber with inspiration and expiration
Correct Answer: C,E
Rationale: Bubbling and tidaling indicate a functioning chest tube system.
The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative.
Click to highlight below the 3 findings that should concern the nurse.
- A. The client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin.
- B. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use.
- C. The client received treatment for bacterial vaginosis during the second trimester.
- D. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative.
Correct Answer: A,B,D
Rationale: Non-compliance with insulin , smoking , and excessive weight gain increase neonatal risks.
The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine
Which of the following choices would be appropriate for the client's dietary needs? Select all that apply.
- A. Chicken nuggets, ketchup, and carrot sticks
- B. Grilled ham and cheese sandwich with pretzels
- C. Plain yogurt with oats, honey, and blueberries
- D. Slice of pepperoni pizza with a side salad
- E. Wheat toast with unsalted peanut butter and banana
Correct Answer: C,E
Rationale: Low-sodium, low-protein options like yogurt with oats and toast with peanut butter are suitable for glomerulonephritis.
The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur
Which of the following statements by the nurse are appropriate to include in the teaching? Select all that apply
- A. Avoid driving after taking alprazolam.'
- B. Contact your health care provider immediately if you experience suicidal thoughts.'
- C. Do not abruptly stop taking alprazolam because you may experience withdrawal symptoms.'
- D. Limit alcoholic beverages to no more than one drink a day while taking alprazolam.'
- E. Take sertraline at the onset of a panic attack.'
Correct Answer: A,B,C
Rationale: Alprazolam requires avoiding driving , monitoring for suicidal thoughts , and gradual tapering . Alcohol limits are stricter, and sertraline is not for acute attacks.
The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur
For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.
- A. Encourage the use of positive self-talk
- B. Ask the client about any recent life stressors
- C. Assist the client to recognize physical symptoms of anxiety
- D. Encourage the client to spend time alone when feeling anxious
- E. Reinforce abdominal breathing exercises to use at the onset of anxiety
Correct Answer: A,B,C,E
Rationale: Positive self-talk , identifying stressors , recognizing symptoms , and breathing exercises manage panic disorder. Isolation may worsen anxiety.