Nokea
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
Orders
The client is a 14-year-old female who sustained facial trauma during a high school basketball game. Surgery was performed 3 days ago to repair the jaw. The client is 112.4 lb (51 kg). She has a left femoral central line for fluids.
Which prescriptions does the nurse expect the healthcare provider to write based on the information? Select all that apply.
- A. Turn off the suction on the nasogastric tube
- B. Bolus calcium
- C. Increase the intravenous fluid rate
- D. Add potassium to the intravenous fluids
- E. Administer a diuretic
- F. Flush the central line with 3% sodium chloride
- G. Decrease the percentage of sodium in the intravenous fluids
Correct Answer: A,C,D
Rationale: Discontinuing NG suction, increasing IV fluids, and adding potassium address hypovolemia and hypokalemia from fluid losses.
You may also like to solve these questions
The mother of a 4-month-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry.
- B. Awakens once for nighttime feedings.
- C. Gives up a bottle for a cup.
- D. Opens mouth when food comes her way.
Correct Answer: D
Rationale: Opening the mouth for food, along with head control and sitting support, indicates readiness for solids around 4-6 months.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols.
- B. Sign up for group therapy sessions.
- C. Start a prenatal care plan as soon as possible.
- D. Discontinue the methadone right away.
Correct Answer: C
Rationale: Early prenatal care monitors methadone effects, fetal development, and complications like neonatal abstinence syndrome, ensuring a healthy pregnancy.
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
The nurse knows that the mastitis in this scenario is most likely caused by... as evidenced by...
- A. Plugged duct
- B. Breast abscess
- C. Engorgement
- D. Nipple trauma with cracked skin
- E. Firm, red, warm area on the right breast
- F. Pus draining from the nipple
- G. Generalized swelling of the entire breast
Correct Answer: A,E
Rationale: A plugged duct, evidenced by a firm, red, warm area, is the likely cause of mastitis due to milk stasis from missed feedings. Abscess, engorgement, or nipple trauma are less likely without pus, generalized swelling, or reported cracks.
A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Establish the frequency of headaches.
- B. Ask about a history of delivering large babies.
- C. Examine the client for pedal edema.
- D. Collect a urine sample to screen for protein.
Correct Answer: D
Rationale: Severe headache and hypertension suggest preeclampsia. Screening for proteinuria is critical to confirm the diagnosis and guide urgent management.
A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?
- A. Complete the assessment while allowing the child to cry.
- B. Explain to the child the reasons an examination is needed.
- C. Talk to the mother and gradually focus on the child's toy.
- D. Request extra staff to help with the nursing assessments.
Correct Answer: C
Rationale: Engaging the mother and using the child's toy as a distraction builds trust, reducing anxiety and encouraging cooperation.