RN Comprehensive (150 Questions and Answers)., Exams of Nursing

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RN Comprehensive (150 Questions and

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The client returns to the provider's office 3 days later. Exhibit 1: Nurses' Notes Day 1, 0900: Client is 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x 3. Bilateral breath sounds clear. Respirations even and unlabored. S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2. Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. 3 days later, 0900: Client returns to office due to orange-colored urine and diarrhea. Client reports drinking a minimum of 3 L of fluids daily as instructed and states, "I'm still going to the bathroom a lot, and I noticed that I am bruising more easily." Exhibit 2: Vital Signs: Day 1, 0900: Temperature 37.2° C (99° F) Heart rate 88/min B - Correct Answer Assessment Finding Urine Color: E Skin: U Voiding Pattern: E Blood Pressure: E Temperature: U Bowel Elimination: U O2 Sat: E A nurse is caring for a 5-year-old child Exhibit 1: Physical Exam 15:

Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epiglottis is edematous and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished bilateral lung sounds Exhibit 2: Nurses' Notes 15: Child accompanied to RD by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and learning forward with drooling noted. Exhibit 3: Vital Signs 15: Axillary Temp: 102F HR: 130/min Resp: 28/min BP: 99/58 mmHg O2: 90% on room air Exhibit 4: Medical History Family history of asthma Child seen 6 months ago for tonsillitis and treated with antibiotic therapy. - Correct Answer Answer: Condition: epiglottitis Actions: droplet precautions and IV antibiotics Monitor: Temp and breath sounds A nurse is caring for a client who is on the spinal cord injury (SCI) unit. Exhibit 1: Nurses' Notes Day 3, 1700: Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations easy and unlabored. Lung sounds diminished to lower lobes. Abdomen soft and nondistended with active bowel sounds. client passed a small amount of hard formed stool this AM. Indwelling catheter draining clean, yellow urine. DTR are biceps 1+, Triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0. Day 4, 0600 Client reports increasing coughing and SOB. Crackles auscultated in BLL. Face and neck flushed, skin warm and moist. Client reports blurred vision and a headache as an 8/10 on pain scale. Abd soft and mildly distended. hypoactive bowel sounds present. Urinary output 300mL over last 8hr Exhibit 2: Vital Signs

Day 3 1700: Temp: 100.8F HR: 74 Resp: 20 BP: 108/60 mmHg O2: 96% - Correct Answer The client is most likely experiencing manifestations of PNEUMONIA and AUTONOMIC DYSREFLEXIA. A nurse is caring for a client who has abd pain Exhibit 1: Nurses' Notes 0900: Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client is a perioperative nurse, returned 1 week ago from a 2-week mission trip to an underdeveloped country. 1200: Results of antibody studies obtained. Provider prescription for antiviral medication pending. Exhibit 2: Physical Exam 0930: Lung sounds clear bilaterally. Skin warm to touch and jaundiced. Dry skin noted on extremities. Sclera yellow bilaterally. Bowel sounds normoactive in four quadrants. Client reports right upper quadrant pain upon palpation. Urine specimen obtained for urinalysis, dark yellow in color. Exhibit 3: Vital Signs 0900: Temp: 98.5F HR: 84 Resp: 18 BP: 118/78 mmHg O2: 98% on RA Exhibit 4: Diagnostic Results 1100: Aspartate aminotransferase (AST) 375 units/L (0 to 35 units/L) A - Correct Answer Client's risk from bloodborne transmission: Hep B, Hep C

Physical examination findings: Hep A, Hep B, Hep C Client's risk from fecal-oral transmission: Hep A Antiviral treatment: Hep B, Hep C Laboratory results: Hep A, Hep B, Hep C A nurse is caring for a client on a Med-Surge unit. Exhibit 1: Vital Signs 0700: Temp: 99.7F HR: 100 Resp: 22 BP: 115/70 mmHg O2: 98% on RA Exhibit 2: Nurses' Notes 1100: Client alert and oriented to person, place, and time. Client had episode of diarrhea, provided perineal care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4 hr. - Correct Answer Highlight the findings that need follow up Client alert and oriented to person, place, and time. Client had episode of diarrhea, provided perineal care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4 hr. A nurse is an outpatient mental health clinic is caring for a client Exhibit 1: Vital Signs 3 months ago Blood pressure 116/68 mm Hg Heart rate 82/min Respiratory rate 16/min Temperature 36.7° C (98.1° F) SaO2 97% on room air Today: Blood pressure 128/76 mm Hg Heart rate 104/min Respiratory rate 22/min Temperature 37.4° C (99.4° F)

SaO2 97% on room air Exhibit 2: Nurses' Notes 3 months ago: Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. Client is alert and oriented to person, place, time, and situation. Responds appropriately to questions. Client reports sleeping well and working at a local retail store. Today: Client presents for follow-up visit. Pressured speech noted. Appears to be listening to unseen others. Client is restless. Frequently getting out of chair. Appears tired and disheveled. Exhibit 3: Graphic Record 3 months a - Correct Answer 3 immediate follow ups

1. Speech
2. Restlessness
3. Auditory hallucinations A nurse is caring for a client who is postoperative following CABG Exhibit 1: Lab results 0630: Sodium 145 mEq/L Potassium 3.2 mEq/L Chloride 116 mEq/L BUN 24 mg/dL Magnesium 1.5 mEq/L Total calcium 9 mg/dL Phosphate 4.6 mg/dL Glucose 95 mg/dL WBC count 9,500/mm Exhibit 2: I&O 0700: 4 hr input 400 mL 4 hr output 350 mL 1100: 4 hr input 475 mL 4 hr output 360 mL

1500:

4 hr input 350 mL 4 hr output 375 mL Exhibit 3: Vital Signs 0700: Temperature 37.6° C (99.6° F) Heart rate 86/min Respiratory rate 20/min Blood pressure 115/70 mm Hg O2 100% on 2 L via NC 1100: Temperature 37.2° C (99° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 110/72 mm Hg O2 100% on 2 L via NC 1500: Temperature 37.7° C (99.8° F) Heart rate 80/min Respiratory rate 20/min Blood pressure 108/70 mm Hg O2 100% on 2 L via NC Exhibit 4: Nurses' Notes 0700: Client alert and oriented to person, place, time. Reports pain as 6 on a scale o - Correct Answer The nurse should analyze cues to determine the client is at greatest risk for developing dysrhythmias related to hypokalemia, as evidenced by electrolyte imbalances. The laboratory report and the client's report of muscle cramping. Potassium and magnesium depletion are common manifestations in clients who are postoperative following CABG. Due to medication or hemodilution, it is important for the nurse to closely monitor electrolytes. A nurse is caring for a client who is pregnant in the acute care setting. Exhibit 1: Nurses' Notes 1400:

Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr. Denies any changes in vaginal discharge. External fetal monitor applied. 1430: Contraction pattern: contractions every 4 to 5 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 150/min to 155/min, moderate variability, adequate accelerations present, no decelerations noted. Provider in to see client. Specimen obtained for fetal fibronectin. 1800: Client sleepy. Difficult to arouse. Respirations slow and shallow. Contraction pattern: contractions every 10 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 140/min, moderate variability, no accelerations present, no decelerations noted. Exhibit 2: Vital Signs 1400: Temperature 37° C (98.6° F) Heart rate 72/min Respiratory - Correct Answer The nurse should first address the client's RESPIRATORY RATE, followed by the client's LOC. A nurse is caring for an adolescent in the ED Exhibit 1: Nurses' Notes 0700: Adolescent admitted to ED. Adolescent's parents are concerned about left leg injury that appears to be getting worse. Parents report adolescent has had fever, decreased appetite, and decreased energy within the past 2 days. Adolescent reports leg injury occurred while playing soccer. 0715: Adolescent is alert and oriented to person, place, time, and situation. Adolescent reports left lower leg pain as 4 on a scale of 0 to 10.Heart rate regular. Capillary refill less than 3 seconds. Respirations even, unlabored. Lungs clear anterior/posterior. Abdomen soft, nondistended. Bowel sounds hyperactive in all 4 quadrants. Pedal pulses +2 bilaterally. Medial lateral aspect of left lower leg: 3 x 3 cm2 area of redness with small pustules present. Tenderness and warmth noted to the area. Exhibit 2: Vital Signs 0700: Temp: 101.7F

HR: 100

Resp: 18 BP: 1 - Correct Answer The nurse is reviewing the adolescent's EMR. Which of the following findings requires immediate follow up by the nurse? SKIN TEMP WBC BG POTASSIUM A nurse on the Meg-Surge unit is caring for a client who was admitted from the ED Exhibit 1: Vital Signs 1400: Temperature 38° C (100.4° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 96/58 mm Hg Oxygen saturation 96% on room air 1500: Temperature 37.2° C (98.9° F) Heart rate 96/min Respiratory rate 20/min Blood pressure 100/70 mm Hg Oxygen saturation 97% on room air Exhibit 2: Nurses' Notes 1500: Client admitted from the ED for dehydration. Client alert and oriented to person, place, and time. Client reports they are feeling "weak." IV dextrose 5% in water (D5W) infusing at 100 mL/hr. Exhibit 3: lab results 1400: Calcium 10.2 mg/dL Magnesium 1.5 mEq/L Potassium 4.7 mEq/L Sodium 150 mEq/L 1700: Calcium 9.5 mg/dL

Magnesium 1.5 mEq/L Potassium 4.1 mEq/L Sodium 164 mEq/L - Correct Answer The client is at risk for developing CONFUSION due to SODIUM LEVEL. Upon analyzing cues, the nurse should identify that the client is at risk for confusion due to a sodium level that is greater than the expected reference range. Hypernatremia places the client at risk for a decreased LOC, falls, and seizure activity. Therefore, the nurse should monitor the client's level of consciousness and place the client on fall and seizure precautions. A nurse is caring for an adolescent in the ED Exhibit 1: Lab Results Sodium 140 mEq/L Potassium 3.6 mEq/L Chloride 103 mEq/L BUN 15 mg/dL Magnesium 1.5 mEq/L Total calcium 9.5 mg/dL Phosphate 3.7 mg/dL Glucose 80 mg/dL Total protein 7 g/dL Albumin 4.5 g/dL WBC count 19,500/mm3 + Aspartate aminotransferase (AST) 30 units/L Alanine transaminase (ALT) 20 units/L Exhibit 2: Diagnostic Results Cerebrospinal fluid examination: Pressure: 35 cm H2O Color: Cloudy Blood: None RBC: 0 WBC total: 120 cells/μL Protein: 90 mg/dL Glucose: 20 mg/dL Exhibit 3: MAR Day 1, 0830:Acetaminophen 325 mg PO 0930: Midazolam 2.5 mg IV Cefotaxime 2 g IV

Exhibit 4: Vital Signs 0830: Temperature 39.2° C (102.6° F) Weight 51.4 kg (113.3 lb) Exhibit 5: Nurses' Notes Day 1, 0830: Adolescent presents to the ED with vomiting and irritability. Adolescent reports neck pain and headache as 6 on a 0 to 10 scale. 0930: Adolescent preppe - Correct Answer Bacterial Meningitis: fever, photophobia, nuchal rigidity, petechial rash, and impaired consciousness Encephalitis: fever, nuchal rigidity, and AMS Reye Syndrome: AMS, and impaired hepatic function A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Exhibit 1: Lab results 0700: Sodium 143 mEq/L Potassium 3.5 mEq/L Chloride 104 mEq/L BUN 15 mg/dl Magnesium 1.5 mEq/L Total calcium 8 mg/dL Phosphate 4.6 mg/dL Glucose 95 mg/dL WBC 9,500/mm Exhibit 2: Nurses' Notes 0700: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client rates dull pain in neck of 2 on a 0 to 10 scale. Declines pain medication.

1100:

Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client reports muscle cramps in legs as a pain level of 5 on a 0 to 10 scale. Morphine 5 - Correct Answer The client is at rightest risk for developing HYPOCALCEMIA as evidenced by the REPORT OF NUMBNESS AROUND LIPS A nurse on the Med-Surge unit is caring for a client who has a new diagnosis of terminal cancer. the client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take? - Correct Answer Make a referral to social services A nurse is assessing a newborn who is 3 days old. Exhibit 1: H&P Newborn was delivered at 37 weeks of gestation via cesarean section for fetal distress. Apgar scores: 8 at 1 min and 9 at 5 min. Birth weight: 2.9 kg (6 lb 6 oz) The client who gave birth plans to breastfeed. Exhibit 2: Flow Sheet Day 2 of Life, 0900: Temperature 36.7° C (98.1° F) Heart rate 140/min Respiratory rate 48/min Weight 2.7 kg (6 lb); 6% weight loss Day 3 of Life, 0800: Temperature 36.4° C (97.5° F) Heart rate 140/min Respiratory rate 48/min Weight 2.5 kg (5 lb 9 oz); 12% weight loss Exhibit 3: Nurses' Notes Day 3 of Life, 0800: Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted when awake. Anterior fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Small amount of bloody

mucus discharge noted from vagina. Bre - Correct Answer What requires follow up? Flow sheet Temp 97.5F HR 140 Resp: 48 Wt 5 lbs 9 oz (12% weight loss) Nurses' Notes Day 3 of Life, 0800: Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted when awake. Anterior fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Small amount of bloody mucus discharge noted from vagina. Breastfeeding every 3 to 5 hr for 5 to 10 min. Client reports nipple discomfort throughout the feeding. A nurse is caring for a client who is postoperative following administration of general anesthesia. Exhibit 1: Vital Signs 0830: Temperature 36.9° C (98.5° F) Heart rate 134/min Respiratory rate 28/min Blood pressure 92/52 mm Hg Oxygen saturation 89% on room air Exhibit 2: Nurses' Notes 0830: Client is postoperative following an inguinal hernia repair. Apical pulse 134/min and irregular Client reports dyspnea. Exhibit 3: Diagnostic Results 0835: Arterial blood gases (ABGs) pH 7. PCO2 64 mm Hg HCO3- 26 mEq/L PO2 80 mm Hg - Correct Answer Condition:

Malignant Hyperthermia Actions: Administer Dantrolene Administer O Monitor: Hypercapnia Muscle Rigidity A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden unexpected infant death (SUID). Which of the following guardian statements indicates an understanding of the teaching?

• Correct Answer "I will not allow anyone to smoke near my baby." A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. which of the following actions should the nurse plan to take first? - Correct Answer Determine the client's reading skills. A nurse is caring for a client who is postoperative following an appendectomy. Exhibit 1: Nurses' Notes 1800: Client alert and oriented to person, place, time, and situation. Skin warm and dry. Lungs clear on auscultation Bowel sounds hypoactive in all four quadrants. Urine clear yellow Incisional dressing clean and dry. Client reports pain as 6 on a scale of 0 to 10. 1815: Morphine administered as prescribed. 2000: Client reports abdominal pain as 10 on a scale of 0 to 10. Client reports nausea, no vomiting. Incisional dressing is dry and intact with no breakthrough bleeding noted. Lung sounds are clear to auscultation. Hypoactive bowel sounds present in all four quadrants. Exhibit 2: Vital Sign 1800:

Temperature 36.8° C (98.4° F) Heart rate 104/min Respiratory rate 22/min Blood pressure 142/80 mm Hg O2 saturation 97% on room air 2000: Temperature 36.8° C (98.4° F) Heart rate 110/min Respiratory rate 24/min Blood - Correct Answer Which of the following 4 client findings should the nurse report to the provider?

1. Pain
2. Nausea
3. HR
4. O A nurse in an ED is assessing a client. Exhibit 1: Medical History 1030: Diagnosed with schizophrenia 2 years ago Migraine headaches Unresponsive to second-generation medications (clozapine and risperidone), changed to first-generation medication 6 months ago Current medications: Haloperidol 5 mg PO TID Sumatriptan 50 mg PO every 2 hr PRN headache Exhibit 2: Vital Signs 1030: Heart rate 122/min Respiratory rate 28/min Blood pressure 182/85 mm Hg Temperature 39.7° C (103.5° F) Oxygen saturation 90% on room air Exhibit 3: Nurses' Notes 1030: Client arrived at ED via ambulance. Emergency medical technicians (EMTs) report being called to client's home by the client's partner. According to EMTs, partner stated they found the client with decreased responsiveness, muscle rigidity, posturing, and diaphoresis. 1045:

Client unresponsive to questions, does not follow simple commands. Sinus tachycardia; S1S2 on auscultation; - Correct Answer Condition: Neuroleptic Malignant Syndrome Actions: Hold all antipsychotic medications Apply cooling blanket Monitor: Temperature Hydration status A nurse is caring for a client following laparoscopic cholecystectomy. Exhibit 1: Nurses' Notes 1030: 33-year-old client is 1 hr postoperative following a laparoscopic cholecystectomy. Alert and oriented to person, place, and time. Skin warm and dry. Lungs clear auscultated throughout all lung fields. Normal sinus rhythm. Client denies nausea and vomiting, bowel sounds hypoactive in all four quadrants. Peripheral pulses +2 bilaterally. Incision dressing clean and dry, incision intact upon inspection, no redness, swelling, or drainage noted. Exhibit 2: Client Education 1230: Discharge instructions given to client. Instructions on incision/wound care and proper hand washing. Client to report swelling, redness, drainage, bleeding, or warmth at operative site to surgeon. Client expected to experience carbon dioxide retention in the abdomen. Instructed the client to rest for 24 hr following surgery. Client can bathe or - Correct Answer Anticipated vs Contraindicated Change dressing when soiled ANTICIPATED Ondansetron 4 mg PO for nausea CONTRAINDICATED Encourage deep breathing exercises Q1hr ANTICIPATED Apply heat for abd pain as needed ANTICIPATED A nurse is caring for a client who is pregnant. Exhibit 1: Nurses' Notes

1000:

The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks. 1015: IV fluids initiated. Prochlorperazine administered via intermittent IV bolus. 1100: Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine. 1500: Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine. Exhibit 2: Vital Signs 1000: Temperature 36.8° C (98.2° F) Heart rate 112/min Respiratory rate 20/min Blood pressure 100/65 mm Hg SaO2 97% on room air 1200: Temperature 37° C (98.6° F) Heart rate 102/min Respiratory rate 20/min Blood pressure 104/70 mm Hg SaO2 98% on room air 1500: Temperature 36.8° C (98.2° F) Heart rate 90/min Respiratory - Correct Answer Recommended vs Contraindicated Eat Q2-3hrs RECOMMENDED Increase intake of high-fat foods. CONTRAINDICATED Drink warm ginger ale when nauseated. RECOMMENDED Alternated eating solid foods and liquids RECOMMENDED A nurse is caring for a client who has a new diagnosis of anorexia nervosa.

Exhibit 1: Vital Signs Day 1, 2005: Temperature 35.3° C (95.5° F) Heart rate 60/min Respiratory rate 23/min Blood pressure 90/55 mm Hg Oxygen saturation 98% on room air Day 2, 0800: Temperature 36.1° C (97° F) Heart rate 65/min Respiratory rate 20/min Blood pressure 88/57 mm Hg Oxygen saturation 98% on room air Exhibit 2: Graphic Record Day 1, 2005: Weight 37.5 kg (82.7 lb) Height 162.56 cm (64 in)BMI 14. Day 2, 0800: Weight 37.4 kg (82.5 lb)BMI 14. Exhibit 3: Lab results Day 1, 2030: Sodium 146 mEq/L Potassium 3.3 mEq/L Chloride 110 mEq/L BUN 21 mg/dL Magnesium 1.2 mEq/L Phosphate 2.8 mg/dL Glucose (casual) 75 mg/dL Total protein 5.8 g/dL Albumin 3 g/dL Day 2, 0530: Sodium 150 mEq/L Potassium 3.1 mEq/L Chloride 110 mEq/L BUN 25 mg/dL Magnesium 1 mEq/L Phosphate 2.8 mg/dL Fasting blood glucose 65 mg/dL

Total protein 5.5 g/dL - Correct Answer The nurse should first address the client's ELECTROLYTE IMBALANCE followed by the client's FEAR OF WEIGHT GAIN A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Exhibit 1: Vital Signs 1100: Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min Blood pressure 128/68 mm Hg Oxygen saturation 97% on room air 1115: Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min Blood pressure 138/74 mm Hg Pulse oximetry 95% on room air 1130: Temperature 38.6° C (101.5° F) Heart rate 136/min Respiratory rate 16/min Blood pressure 154/86 mm Hg O2 95% on 2 L/min via NC Exhibit 2: MAR 1110: Morphine 4 mg IV bolus Exhibit 3: Nurses' Notes 1100: The client is asleep, easily aroused. Rates pain at incision site as 8 on a scale of 0 to 10. Portable wound bulb suction device in place with scant serosanguinous drainage present. Dressing to neck dry and intact. 1115: Client asleep. Arousable with name called loudly multiple times. Client rates pain as 7 on a sca - Correct Answer 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm.

1. HR

2. Mental Status
3. Temperature
4. BP A nurse is caring for a 1-month0old infant. Exhibit 1: Nurses' Notes 1500: Infant admitted to the pediatric unit. Parent reports infant has been irritable and has vomited after each feeding within the last 3 days.Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive in all 4 quadrants. Small 1 x 1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor with tenting. 1600: Called to room by parent. The client who gave birth attempted breastfeeding. Infant projectile vomited. No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO. 1800: Infant crying. Soothed with pacifier. Exhibit 2: Diagnostic Results 1545: Hgb 20 g/dL Hct 60% Potassium 5.8 mEq/L Sodium 132 mEq/L Chloride 110 mEq/L WBC count 16,000/mm BUN 20 mg/dL Creatinine 0.2 mg/dL 1730: Abdomin - Correct Answer The infant is at highest risk for developing DEHYDRATION, as evidence by the infant's VOMITING A nurse is caring for a client. Exhibit 1: Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr

prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU. Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right- side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia. Day 2, 1930: Called to the client's room by a family member. Client is lethargic and restless, oriented to person and place. Client reports headache. The client's family member also reports that the client just vomited in an emesis basin. Client's speech is slurred. Exhibit 2: Vital Signs Day 1,1000: Temperature 37.2° C (99° F) Heart rate 114/min Blood pressure 184/88 mm Hg Respiratory rate 24/min Oxygen saturation - Correct Answer Anticipated vs Contraindicated Cluster nursing care CONTRAINDICATED Keep the lights in the client's room dim ANTICIPATED Administer O2 therapy to keep O2 sat above 95% ANTICIPATED Maintain the client's hips in flexion CONTRAINDICATED Monitor BG Q4hrs ANTICIPATED Keep the client supine. CONTRAINDICATED A nurse is caring for an older adult who is experiencing chronic anorexia and is receiving enteral tube feedings. which of the following laboratory values indicates the client needs additional nutrients added to the feeding?

• Correct Answer Albumin 2.8 g/dL A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. which of the following findings should the nurse

identify as an adverse effect of this medication? - Correct Answer Report of chest pain A nurse is assessing a client who has skeletal traction for a femur fracture. which of the following findings should the nurse identify as the priority? - Correct Answer Upper Chest Petechiae A nurse is caring for a client in the ED. Exhibit 1: Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Exhibit 2: Vital Signs 0600: Temperature 37.8° C (100° F) Heart rate 104/min Respiratory rate 26/min Blood pressure 88/56 mm Hg O2 90% on 2 L via NC Exhibit 3: Diagnostic Results 0645: Hematocrit 25% Hemoglobin 8.3 g/dL WBC count 18,000/mm3 Reticulocytes 8% Total bilirubin 1.9 mg/dL - Correct Answer Which of the following interventions should the nurse implement? SATA When taking actions, the nurse should administer IV fluids, use humidification with oxygen therapy, and assess the client's mouth every 8 hr and peripheral circulation hourly. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and

can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling and clumping of the red blood cells and assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection. A nurse is caring for a client at a provider's office. Exhibit 1: H&P 2 months ago: Client presented to clinic for routine visit. Client reported feeling tired at times but getting through the workday and walking after work. Reported chronic nonproductive cough. Smokes 1.5 packs of cigarettes per day. Today, 1030: Client reports fatigue over the past several days, spending more time in bed. Reports chronic productive cough with blood-tinged sputum this morning.Smokes 1 pack of cigarettes per day.Client takes lisinopril 20 mg PO daily, atorvastatin 20 mg PO daily. Exhibit 2: Assessment 2 months ago: Client states, "I sleep in my recliner and that works great." Skin is warm, dry. Lungs clear to auscultation. Chronic nonproductive cough. Abdomen soft, nondistended. Bowel sounds present. Slight edema in feet bilaterally. Today, 1030: Client states, "I can't catch my breath." Skin pale. Respirations labored. Crackles pre - Correct Answer The nurse should analyze cues of pneumonia that include tobacco use, elevated WBC count, a productive cough with blood-tinged sputum, elevated temperature, a decreased oxygen saturation level, and an ABG level indicating respiratory acidosis. The nurse should also analyze cues of COPD that include tobacco use and a decreased oxygen saturation. The nurse should also analyze cues of heart failure that include tobacco use, BNP level, and a decreased oxygen saturation.

A nurse on an antopartum unit is caring for a client who is at 33 weeks of gestation. Exhibit 1: Diagnostics Results WBC count 9,800/mm3 Hgb 13 g/dL Hct 41% Platelet count 170,000/mm3 BUN 20 mg/dL Lactate dehydrogenase (LDH) 80 units/L Aspartate aminotransferase (AST) 18 units/L Alanine aminotransferase (ALT) 19 units/L Uric acid (serum) 5.4 mg/dL Kleihauer-Betke (fetal hemoglobin test) 3% Blood type: A Rh: positive Urine reagent strip Glucose: none pH: 6 Specific gravity: 1.020 Ketones: none Nitrates: none Leukocyte esterase: negative Protein: negative Nitrites: none Exhibit 2: Vital Signs Blood pressure 130/84 mm Hg Heart rate 104/min Respiratory rate 22/min Temperature 37.3° C (99.2° F) Oxygen saturation 97% on room air Exhibit 3: Nurses' Notes Client is a primigravida who presents with report of decreased fetal movement and new onset of a small amount of dark red vaginal bleeding. External fetal moni - Correct Answer Condition: Abruptio Placentae Actions: Avoid cervical exam

Insert large-bore IV Monitor: Monitor BP Monitor Platelet A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider? - Correct Answer Audible Stridor A nurse is admitting a client to the mental health unit after an attempted suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make? - Correct Answer "How does this make you feel?" A nurse is providing teaching to a client who has a prescription for levothyroxine 25 mcg PO daily. Which of the following instructions should the nurse include in the teaching? - Correct Answer Take the medication on an empty stomach 30 min before breakfast A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use of evaluate the nurse's time management skills? - Correct Answer Maintain regular notes about the nurse's time management skills. A nurse is caring for a client who has become aggressive and potentially violent. Which of the following actions should the nurse take? - Correct Answer Allow the client time for reflection and decision making A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices? - Correct Answer Ask the client to point to items on a picture menu. A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? - Correct Answer Place the skin barrier over the stoma and hold it for 30 seconds. A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse

take when suctioning the client's airway? - Correct Answer Apply suction for 10 seconds. A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship? - Correct Answer Establish the termination date of therapy A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take? - Correct Answer Instruct the client to elevate the affected extremity when sitting A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this mediation? - Correct Answer "Have you had any stomach pain or bloody stools?" A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? - Correct Answer "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? - Correct Answer Withhold administering the varicella vaccine to the child. A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care? - Correct Answer Supervise the client during and after eating. A charge nurse is preparing to administer 0900 medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff.