Nokea
The nurse is caring for a 6-year-old client accompanied by the parents.
History and Physical
Body System
Findings
General
Client is brought to the emergency department due to
shortness of breath; medical history includes cystic fibrosis
and many previous hospital admissions for pneumonia; in the
3rd percentile for height and weight
Neurological
Alert and oriented to person, place, and time; no neurologic
deficits
Pulmonary
Vital signs: RR 30, SpO, 87% on room air; moderate
subcostal retractions; bilateral wheezing and coarse crackles
throughout lung fields with fine inspiratory crackles at left lung
base; paroxysmal coughing that produces thick, yellow,
blood-tinged sputum; parents report that the client has begun
to become "winded" after showering and other activities Cardiovascular
Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm
and dry; peripheral pulses palpable 2+; capillary refill 3
econds; mild finger clubbing noted
Gastrointestinal
Abdomen soft with normoactive bowel sounds; parent states,
"Swallowing the enzyme capsules is very difficult for my child,
and I have noticed an increase in greasy, bulky stools"
Which prescription should the nurse implement first?
- A. Administer albuterol via a metered-dose inhaler
- B. Administer hypertonic saline via a nebulizer
- C. Contact respiratory therapy to initiate chest physiotherapy
- D. Reinforce teaching on how to use a positive expiratory pressure device
Correct Answer: A
Rationale: Albuterol is prioritized to relieve acute bronchospasm and improve airflow in respiratory distress.
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The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn
Which finding is a priority for the nurse?
- A. Blood pressure
- B. Cervical examination
- C. Deep tendon reflexes
- D. Gestational age of fetus Body
Correct Answer: A
Rationale: Elevated blood pressure is a critical finding in suspected preeclampsia, indicating a risk for severe complications.
The nurse is caring for a 69-year-old client.
Progress Notes Emergency Department
1100: The client is unconscious following a suicide attempt. The paramedics immediately initiate CPR.
1115: The nurse reviews the client's chart and is unable to find documentation of a durable power of attorney for health care.
For each rationale, click to specify if the rationale is applicable or not applicable regarding the need to continue cardiopulmonary resuscitation.
- A. The client is unconscious
- B. The client is under the age of 70
- C. The client's toxicology report reveals no illegal substances
- D. The client does not have a living will documented in the medical record
Correct Answer: A,D
Rationale: Unconsciousness and no living will support continuing CPR unless a DNR exists. Age and toxicology are irrelevant.
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 finding below, click to specify if the finding is consistent with the disease process of hyperthyroidism, myocardial infarction, or panic disorder.
- A. Diaphoresis
- B. Trembling hands
- C. Heart palpitations
- D. Shortness of breath
Correct Answer: A,B,C,D
Rationale: Diaphoresis , palpitations , and shortness of breath occur in all three. Trembling hands are specific to hyperthyroidism and panic disorder.
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
For each potential prescription, click to specify if the prescription is anticipated or unanticipated for the care of the client.
- A. Obtain daily weights
- B. Maintain fluid restrictions
- C. Administer loop diuretics
- D. Maintain client on strict bed rest
- E. Administer ibuprofen as needed for headache
Correct Answer: A,B,C
Rationale: Daily weights , fluid restrictions , and diuretics manage fluid overload. Bed rest is unnecessary, and ibuprofen risks renal damage.
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.