Nokea
Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
Nurses' Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Which of the following 3 statements indicate the client understands the instructions? (Iron deficiency anemia)
- A. I should increase green leafy vegetables in my diet
- B. The iron supplement might cause my stools to be black.
- C. I should expect to have swelling in my feet.
- D. I will take my iron supplement 1 hour before a meal.
- E. The iron supplement might cause ringing in my ears.
- F. I'll take it with milk for better absorption.
- G. I should avoid citrus fruits.
Correct Answer: A,B,D
Rationale: Green leafy vegetables provide iron, black stools are a side effect, and taking it before meals enhances absorption.
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Exhibit 1 Exhibit 2 Exhibit 3
Graphic Record
Heart rate 112/min
Blood pressure 122/60 mm Hg
Temperature 38.6° C (101.5° F)
Respiratory rate 24/min
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse to report to the provider?
- A. Sputum results
- B. Creatinine level
- C. Temperature
- D. WBC count
Correct Answer: C
Rationale: Pneumonia, an acute respiratory infection, requires monitoring for signs of worsening condition or treatment response. The exhibit shows heart rate 112/min, blood pressure 122/60 mm Hg, temperature 38.6°C (101.5°F), and respiratory rate 24/min. Option C, temperature, is the priority 38.6°C indicates fever, a key sign of active infection or potential sepsis, especially with tachycardia (112/min) and tachypnea (24/min). This triad suggests systemic inflammatory response, needing urgent provider attention to adjust antibiotics or assess deterioration. Option A, sputum results, guides therapy but isn't immediately actionable without context. Option B, creatinine, monitors kidney function but isn't the acute priority here. Option D, WBC count, reflects infection severity but fever drives immediate concern. Elevated temperature, per triage protocols, signals potential escalation, making it the most critical to report for timely intervention.
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Administer an antiemetic after each meal.
- C. Season foods with spices.
- D. Provide a high-calorie diet.
Correct Answer: D
Rationale: A high-calorie diet addresses malnutrition in AIDS by meeting increased metabolic needs. Large meals may be overwhelming, antiemetics are given before meals if needed, and spices may not be tolerated.
A nurse is reinforcing dietary teaching with an older adult client who has an increased LDL level. Which of the following foods should the nurse encourage the client to limit?
- A. Canola oil
- B. Swiss cheese
- C. Avocados
- D. Walnuts
- E. Olive oil
- F. Fatty fish
- G. Whole grains
Correct Answer: B
Rationale: Swiss cheese is high in saturated fat, raising LDL; canola oil, avocados, and walnuts are heart-healthy.
A nurse is contributing to the plan of care for a client who is postoperative following a fasciotomy. Which of the following interventions should the nurse plan to include?
- A. Provide a diet of pureed foods.
- B. Assist the client to the restroom 30 min after meals.
- C. Offer small, frequent meals.
- D. Instruct the client to avoid sexual intercourse until the cervix is healed.
Correct Answer: C
Rationale: Post-fasciotomy care focuses on pain management, wound healing, and monitoring for complications like infection or compartment syndrome recurrence, not dietary or reproductive restrictions. Offering small, frequent meals supports nutritional needs without overloading the stomach, aiding recovery by maintaining energy for tissue repair, especially if appetite is reduced from pain or medications. A pureed diet is unnecessary unless swallowing is impaired, which isn't indicated here fasciotomy addresses limb pressure, not GI issues. Assisting to the restroom post-meals relates to bowel training, irrelevant to this surgical context. Avoiding sexual intercourse applies to pelvic procedures like colposcopy, not a limb fasciotomy. Small, frequent meals align with postoperative principles, promoting healing and comfort, making it the most relevant intervention for this client's plan of care, enhancing overall recovery without complicating the surgical focus.
A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?
- A. Absence of Chvostek's sign
- B. Presence of Kussmaul respirations
- C. Presence of diaphoresis
- D. Absence of urinary ketones
Correct Answer: B
Rationale: Kussmaul respirations indicate hyperglycemia-induced metabolic acidosis as the body compensates for high glucose. Chvostek's is unrelated, diaphoresis suggests hypoglycemia, and ketones may be present but aren't definitive here.