The nurse is caring for a client who has been prescribed prednisone. Which of the following statements, if made by the nurse, would be correct?
Rationale:
A: This medication may make you gain weight.
Prednisone can lead to increased appetite and fat redistribution, commonly resulting in weight gain. This side effect is well-documented and important for clients to understand while on the medication.
B: It is best to take this medication in the morning with food.
Taking prednisone in the morning helps mimic the body's natural cortisol rhythm, while food can minimize gastrointestinal irritation. This guidance ensures optimal absorption and reduces side effects.
C: If you have pain, it is okay to take ibuprofen.
Concurrent use of ibuprofen with prednisone can increase the risk of gastrointestinal bleeding, particularly in patients with pre-existing risk factors, necessitating caution and professional guidance before combining these medications.
D: Your blood pressure may decrease while taking this medication.
Prednisone typically causes fluid retention and can lead to increased blood pressure rather than a decrease. Clients should be monitored for hypertension while on this corticosteroid treatment.
E: You may experience mood changes while on this medicine.
Prednisone can affect mood and behavior, leading to anxiety, irritability, or mood swings. This psychological side effect is significant and should be discussed with clients to ensure awareness and management.
The nurse is performing a physical assessment on a newborn. The nurse assessed 3+ brachial pulses, cold and pale feet, decreased capillary refill time in the feet, and warm and pink hands. Which cardiac disease process do these assessment findings support?
Rationale:
Coarctation of the aorta (COA) is indicated by the assessed findings of diminished brachial pulses and cold, pale feet, suggesting compromised circulation due to a narrowed aorta.
A: Tetralogy of Fallot (TOF) Involves structural heart defects that typically present with cyanosis and varying pulse strength, which do not align with the observed pulse and temperature differences in this scenario.
B: Hypoplastic left heart syndrome Primarily affects the left side of the heart, leading to systemic circulation failure, yet the findings indicate differential perfusion, not typical of this condition.
D: Transposition of the great arteries Typically results in severe cyanosis and equal pulse strength in all extremities, contrasting sharply with the differential findings of warm hands and cold feet in this assessment.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 70-year-old client.
Item 1 of 1
Nurses' Notes
1100: Client was brought into the ED via emergency medical services (EMS) after he was found wandering the streets and completely disoriented. He was carrying a wallet and identification. His previous medical history was obtained from medical records—history of atrial fibrillation and diabetes mellitus (type two). On assessment, the client is lethargic, disoriented, and mumbling incoherent words. Breathing appears slightly labored, and wheezes with scattered rhonchi are noted in the bilateral lung fields—productive cough with a large amount of mucous. Skin is hot to touch, pale in tone; pulses 2+ and irregular. The client has an unkempt appearance and is malodorous. Peripheral venous access device (VAD) placed in right forearm. Vital signs: T 102° F (38.9° C), P 92, RR 24, BP 144/89, pulse oximetry reading 91% on room air. Orders received from the physician.
The nurse reviews the physician's orders and plans implementation. For each potential nursing action, click to specify whether the action is a high priority or a low priority.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Educate the client on using the incentive spirometer
B
Perform a head-to-toe skin assessment
C
Notify radiology to obtain the portable chest radiograph (x-ray)
D
Administer albuterol via nebulizer
E
Apply supplemental oxygen via nasal cannula
F
Collect ordered laboratory work (CBC, CMP, blood cultures)
G
Perform admission medication reconciliation
Rationale:
C: Notifying radiology to obtain the portable chest radiograph (x-ray) is crucial for diagnosing the client’s respiratory issues. Given the signs of respiratory distress, imaging will guide further treatment decisions and interventions promptly.
A: Educating the client on using the incentive spirometer does not address the immediate critical respiratory concerns and is less urgent than ensuring proper diagnostics and interventions.
B: Performing a head-to-toe skin assessment, while important, does not take precedence over addressing respiratory distress and potential underlying conditions indicated by the client’s current symptoms.
G: Conducting admission medication reconciliation is essential but can be postponed in favor of more urgent interventions that directly impact the client's immediate health status and stabilization.
The nurse is caring for a client with suspected placenta previa. The nurse anticipates an order for which diagnostic test to confirm this finding?
Rationale:
Transvaginal ultrasound. This imaging technique provides a clear view of the placenta's position relative to the cervix, allowing for accurate diagnosis of placenta previa, which is essential for appropriate management.
A: Manual cervical exam. This method poses risks, such as causing bleeding, and does not offer the visual clarity needed to assess placental positioning effectively.
C: Contraction stress test. This test evaluates fetal response to uterine contractions and does not assess placental location, making it unsuitable for diagnosing placenta previa.
D: Nonstress test. Focused on fetal heart rate patterns, this test does not provide information regarding placental placement, thus lacking relevance for confirming suspected placenta previa.
The nurse has attended a continuing education presentation about acid-base imbalances. It would indicate a correct understanding of the conference if the nurse identifies which of the following conditions may cause the ABG in the exhibit.
Rationale:
A: A five-day history of severe diarrhea can lead to metabolic acidosis due to significant loss of bicarbonate and electrolytes, impacting the acid-base balance reflected in arterial blood gases (ABGs).
B: Hyperemesis gravidarum typically involves excessive vomiting, potentially causing metabolic alkalosis rather than directly influencing ABG results related to diarrhea or other gastrointestinal losses.
C: End-stage renal disease (ESRD) primarily leads to metabolic acidosis due to impaired kidney function but is not directly caused by the scenario presented about diarrhea.
E: Chronic obstructive pulmonary disease (COPD) contributes to respiratory acidosis due to impaired gas exchange but does not relate to the gastrointestinal causes of acid-base imbalance due to diarrhea.
F: Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) results in hyperglycemia and dehydration, affecting osmotic balance rather than directly causing the acid-base abnormalities seen with severe diarrhea.
The nurse is caring for a child immediately following a nephrectomy in the postanesthesia care unit (PACU). Which assessment should the nurse initially perform?
Rationale:
Vital signs. Monitoring vital signs is critical immediately after nephrectomy to assess the child’s hemodynamic stability and detect potential complications such as bleeding or shock, which require prompt intervention.
A: pain level. Evaluating pain level is important but secondary to assessing vital signs, as the child’s stability takes precedence in the immediate postoperative period.
B: peripheral vascular access device. While checking the vascular access device is necessary, ensuring vital signs first addresses any immediate physiological concerns that could compromise the child's recovery.
C: surgical incision. Inspecting the surgical incision is essential later on; however, vital signs provide the most crucial information about the child's overall condition right after surgery.
The nurse assists a client with cystic fibrosis in picking out items on a menu. It will indicate effective teaching if the client selects meals that are
Rationale:
High in fat. Individuals with cystic fibrosis require a diet rich in calories and fat to meet their increased energy needs and to help with nutrient absorption due to pancreatic insufficiency.
B: low in sodium. Clients with cystic fibrosis typically need a higher sodium intake to replace losses from excessive sweating, making low sodium options inappropriate for their dietary requirements.
C: low in calories. A low-calorie diet fails to meet the heightened energy demands of clients with cystic fibrosis, potentially leading to malnutrition and inadequate growth.
D: low in protein. Protein is essential for tissue repair and growth in cystic fibrosis patients, so selecting low-protein meals would not support their nutritional needs effectively.
The nurse is screening clients at risk of sudden infant death syndrome (SIDS). The nurse correctly identifies which client is at the greatest risk for SIDS? An infant who is
Rationale:
A: A preterm 4-month-old female who sleeps supine and is formula fed. This infant is at heightened risk for SIDS due to being preterm, which is a significant risk factor for this condition.
B: A preterm 12-month-old male who sleeps prone and is formula fed. Although preterm infants are at risk, sleeping prone at this age greatly increases the likelihood of SIDS.
C: A term 6-month-old male who sleeps supine and is formula fed. Term infants typically have lower risk factors, and sleeping supine reduces the chance of SIDS significantly.
D: A preterm 3-month-old male who sleeps lateral and is breastfed. While preterm infants are at risk, lateral sleeping positions are not recommended and increase the risk compared to supine sleeping.
•
The nurse transfused the prescribed fresh frozen plasma. Click to specify which assessment data is necessary after the transfusion of FFP.
Rationale:
Assessment of international normalized ratio (INR) is essential post-transfusion of fresh frozen plasma (FFP) to evaluate the effectiveness of clotting factors and ensure coagulation parameters are normalized.
B: Activated thromboplastin time (aPTT) measures clotting ability but is not the primary focus for assessing FFP's effectiveness immediately after transfusion, where INR is more relevant.
C: Hematocrit levels indicate red blood cell concentration but do not directly assess the function of coagulation factors provided by FFP, making it less critical in this context.
D: Vital signs are important to monitor for transfusion reactions but do not specifically evaluate the success of the FFP in correcting coagulation abnormalities, unlike INR assessment.
The nurse is discussing infection control with a group of nursing students. Which conditions require contact precautions?
Rationale:
Contact precautions are required for pediculosis, scabies, and Clostridium difficile. These conditions involve direct skin contact or infectious materials that can easily spread, necessitating specific measures to prevent transmission.
A: Rubeola This viral infection requires airborne precautions due to its high contagion potential through respiratory droplets, not contact precautions.
B: Psoriasis This skin condition is non-infectious and does not require any special precautions, making contact precautions unnecessary.
D: Rubella Although contagious, rubella requires airborne precautions, as it spreads through respiratory droplets rather than direct contact.
The nurse is caring for a child diagnosed with Tetralogy of Fallot. The client has had multiple hypercyanotic episodes (tet spells). The nurse anticipates that the physician will prescribe
Rationale:
Morphine sulfate. This medication is commonly administered during hypercyanotic episodes in children with Tetralogy of Fallot to alleviate anxiety, reduce metabolic demand, and improve oxygenation while stabilizing the patient.
B: adenosine. This drug is primarily used for its antiarrhythmic properties in cases of supraventricular tachycardia, not for managing cyanotic spells or improving oxygen delivery in Tetralogy of Fallot.
C: diltiazem. While diltiazem is a calcium channel blocker used for hypertension and arrhythmias, it does not address the immediate needs of a child experiencing hypercyanotic episodes in Tetralogy of Fallot.
D: atropine sulfate. This anticholinergic medication is typically utilized to increase heart rate and treat bradycardia, which does not directly help in managing hypercyanotic episodes related to Tetralogy of Fallot.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 4 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child's sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
Progress Notes
1401: The client was evaluated. The rash is localized, raised, and appears like a bullseye. The client has inguinal lymphadenopathy. The client's recent camping trip supports the probability of a vector-borne illness—specifically, Lyme disease.
The nurse reviews the physician's progress note and plans care for this client. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Obtain confirmatory testing via urine specimen
B
Notify the local health department if confirmation testing comes back positive
C
Request an order for antiviral medication
D
Prepare the client for lumbar puncture
Rationale:
B: Notify the local health department if confirmation testing comes back positive. Reporting Lyme disease is crucial for public health tracking and intervention, especially after a potential vector-borne illness exposure during the client's recent camping trip.
A: Obtain confirmatory testing via urine specimen. Lyme disease diagnosis typically relies on serological tests rather than urine specimens, making this intervention not suitable for accurate confirmation.
C: Request an order for antiviral medication. Lyme disease is caused by a bacterial infection, thus requiring antibiotics instead of antiviral medications, which target viral infections, not bacterial ones.
D: Prepare the client for lumbar puncture. A lumbar puncture is unnecessary in this scenario as Lyme disease is diagnosed through clinical evaluation and serology, not by analyzing cerebrospinal fluid.
The nurse has attended a staff education program about the signs of pregnancy. Which of the following is considered a positive sign of pregnancy?
Rationale:
A: Amenorrhea This symptom indicates a missed period but does not provide definitive proof of pregnancy, as it can occur due to various other health conditions or factors.
B: Uterine soufflé This refers to a sound produced by blood flow, which may suggest pregnancy, yet it lacks the definitive confirmation needed to be classified as a positive sign.
C: Positive pregnancy test A positive result indicates pregnancy but is based on hormonal levels rather than direct evidence, making it less definitive than observing a fetal heartbeat.
A nurse is taking care of a client with acute peritonitis. The nurse should do which of the following to meet the client's nutritional needs?
Rationale:
D: Administer parenteral nutrition. Parenteral nutrition delivers essential nutrients directly into the bloodstream, bypassing the gastrointestinal tract, which is crucial for clients with acute peritonitis who cannot tolerate oral or enteral feedings.
A: Administer feedings via nasogastric (NG) tube. NG tube feedings might irritate the gastrointestinal tract, which is compromised in acute peritonitis, thereby failing to meet nutritional needs safely.
B: Administer gastric enteral feedings. Enteral feedings require a functional gastrointestinal tract, which is obstructed in acute peritonitis, making this option unsuitable for meeting the client’s nutritional requirements.
C: Feed the client orally. Oral feeding is not feasible for patients with acute peritonitis due to potential gastrointestinal distress, which could worsen their condition and impede recovery.
The nurse is caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first?
Rationale:
Instruct the client to restrict activity. Limiting physical movement is crucial in managing retinal detachment, as it helps prevent further damage to the retina and mitigates the risk of complications during treatment.
B: Establish a vascular access device. This action is not immediately necessary for retinal detachment and does not address the urgent need to minimize physical activity to protect the retina.
C: Review the client's current medications. While medication assessment is important, it does not directly impact the immediate care required for a client experiencing retinal detachment.
D: Educate the client about topical eye ointments. Providing education on eye ointments is irrelevant at this stage, as the priority is to restrict activity to prevent worsening retinal conditions.
The nurse is admitting a new client and begins to review information regarding advanced directives. The client becomes agitated and refuses to discuss the issue or accept a handout about the topic. Which is the appropriate nursing action?
Rationale:
Document the client's refusal, using the client's own words, in quotes. This action respects the client's autonomy and right to make informed choices, while also ensuring that the refusal is accurately recorded in the medical record for future reference.
A: Leave the handout on the client's bedside table instructing him that he must review the content. This approach disregards the client's expressed agitation and refusal, potentially escalating discomfort and non-compliance.
C: Explain to the client that he must make decisions about accepting or refusing treatment while in the hospital. This statement may come across as coercive, undermining the client's autonomy and ignoring their current emotional state.
D: Request an assessment of the client's competency related to making decisions about advanced directives. This step might be premature, as the client’s agitation could stem from emotional distress rather than cognitive incapacity.
The nurse is caring for a client in the second stage of labor. The fetal heart monitor shows late decelerations. The nurse should initially
Rationale:
C: Reposition the client to a left side-lying position. This action increases uterine perfusion and alleviates pressure on the umbilical cord, which can help resolve late decelerations observed on the fetal heart monitor.
A: notify the physician. While informing the physician is important, immediate intervention to address the fetal heart rate pattern is more critical for the well-being of the fetus.
B: encourage the client deep-breathe slowly. Although slow breathing may help the client relax, it does not address the underlying cause of late decelerations, which requires more proactive management.
D: obtain a prescription for intravenous isotonic fluids. Administering fluids may be beneficial later, but repositioning the client is the first priority to improve fetal heart rate patterns effectively.
When assessing a postpartum client, a nurse notes that the client has soaked three perineal pads in the three hours since delivery. The nurse also notes a soft fundus. The initial action for the nurse would be which of the following?
Rationale:
B: Massage the client's fundus.
Massaging the fundus stimulates uterine contraction, which can help reduce bleeding. A soft fundus indicates potential uterine atony, making fundal massage an immediate and effective intervention to control excessive postpartum hemorrhage.
A: Insert vaginal packing.
This action is typically a later intervention and not the first step. It does not address the underlying cause of bleeding, which is often related to uterine tone.
C: Apply an ice pack over the client's perineal area.
While ice can help with swelling and discomfort, it does not directly address the issue of excessive bleeding or the condition of the fundus.
D: Administer packed red blood cells.
Transfusion is a response to significant blood loss but is not an initial action. First, the nurse must assess and manage the cause of the bleeding.
The nurse has taught a client who has been ordered a high in phosphorus diet about appropriate food choices. Which of the following food choices by the client would indicate a correct understanding of the teaching?
Rationale:
C, E
Nuts and turkey are high in phosphorus, making them appropriate choices for a client on a high-phosphorus diet. These foods provide essential nutrients while meeting the dietary requirements outlined by the nurse's teaching.
A: Leafy greens High in calcium and fiber, leafy greens do not significantly contribute to phosphorus levels, thus not aligning with a high-phosphorus dietary requirement.
B: Garlic Although garlic offers flavor and health benefits, it does not contain a substantial amount of phosphorus and does not fulfill the dietary needs specified for the client.
D: Butter While butter is high in fat, it lacks phosphorus content and therefore does not meet the criteria for a high-phosphorus diet as instructed by the nurse.
The nurse is caring for assigned clients and is reviewing laboratory data. Which laboratory data requires follow-up? A client with a
Rationale:
A: serum total cholesterol 180 mg/dl (4.65 mmol/L) This value is within the normal range, indicating no immediate concern regarding cholesterol levels for the client.
B: glycosylated hemoglobin (A1C) 7.5% This level indicates poor long-term glucose control and necessitates follow-up to manage potential complications related to diabetes effectively.
C: serum calcium 9.2 mg/dl (2.30 mmol/L) This calcium level falls within the normal range, suggesting no abnormalities that would require further investigation for this client.
D: serum creatinine 1.0 mg/dL (88.4 µmol/L) This creatinine level is considered normal, indicating proper kidney function and no need for additional follow-up in this regard.
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
Rationale:
D: spironolactone for a client with end-stage renal disease. Spironolactone is a potassium-sparing diuretic, and in end-stage renal disease, potassium levels can become dangerously high, leading to serious complications such as hyperkalemia.
A: captopril for a client with congestive heart failure. Captopril is an ACE inhibitor that effectively manages heart failure by reducing blood pressure and decreasing fluid overload, making it a suitable choice.
B: metoprolol for a client with multiple premature ventricular contractions (PVCs). Metoprolol is a beta-blocker that can help control heart rate and reduce the frequency of PVCs, thus benefiting the client.
C: verapamil for a client with atrial fibrillation. Verapamil, a calcium channel blocker, is often used to control ventricular rate in atrial fibrillation, making it appropriate for this condition.
The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?
Rationale:
B: Assess the client's oxygen saturation. Restlessness and irritability following sedation can indicate respiratory distress or hypoxia. Monitoring oxygen saturation is crucial to ensure adequate oxygenation and prompt intervention if necessary.
A: Assess the client for pain. While pain management is important, the immediate concern in a sedated client exhibiting restlessness is potential respiratory issues rather than pain levels.
C: Assess the client with the Glasgow Coma Scale (GCS). Evaluating consciousness is relevant, yet the primary issue indicated by restlessness and irritability is likely related to oxygenation rather than neurological status.
D: Assess the client's lung sounds. Although lung sounds can provide valuable information, they do not directly address the urgent need to assess oxygen saturation in a sedated patient showing signs of distress.
The emergency department (ED) nurse cares for a child with epistaxis. Place the following actions in the order in which they need to be performed, starting from first to last.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Apply ice or a cold cloth to the bridge of the nose if the bleeding persists.
B
Apply continuous pressure to the tip of the nose with thumb and forefinger for at least 10 minutes.
C
Provide the child with a drink to wash away the taste of blood.
D
Have the child sit up with the neck forward or erect.
E
Evaluate the bleeding to determine the effectiveness of the interventions.
Rationale:
Have the child sit up with the neck forward or erect. This position minimizes the risk of blood flowing down the throat, reduces anxiety, and allows for better access to control the bleeding effectively.
A: Apply ice or a cold cloth to the bridge of the nose if the bleeding persists. This action is secondary and should follow initial pressure application for optimal bleeding control.
C: Provide the child with a drink to wash away the taste of blood. This step is not a priority in managing epistaxis and can distract from necessary interventions.
E: Evaluate the bleeding to determine the effectiveness of the interventions. Assessment should occur after initial actions to manage the bleeding, not before or concurrently.
A client is receiving allopurinol and asks what they should know about taking this medicine. The nurse would be most correct in stating which of the following?
Rationale:
B: Drink at least 3000 mL of water per day. Adequate hydration is essential while taking allopurinol as it helps prevent the formation of kidney stones and promotes the excretion of uric acid, enhancing the medication’s effectiveness and reducing potential side effects.
A: Facial swelling is expected in the first few days of therapy. While some side effects may occur, facial swelling is not a typical or expected reaction to allopurinol therapy.
C: Do not eat while taking this medication. Allopurinol can be taken with or without food, and there are no dietary restrictions that necessitate avoiding eating while on this medication.
D: This medication begins working immediately. Allopurinol requires time to effectively lower uric acid levels, and its therapeutic effects may not be apparent right away after administration.
The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate?
Rationale:
May I help you? We must be careful with the baby's intestines since we do not want the swaddle to push them back inside.
This response acknowledges the parent's effort while addressing the critical need for careful handling of the infant's condition. It emphasizes the importance of preventing any pressure on the omphalocele, ensuring the baby's safety and comfort during swaddling.
A: Stop! You will kill your baby. This alarming response is overly dramatic and fails to provide constructive guidance or support, potentially increasing parental anxiety rather than fostering a collaborative approach to care.
B: That is a nice, tight swaddle. It will help soothe your new baby. Complimenting the swaddle ignores the medical implications of an unrepaired omphalocele and may lead to unsafe practices that compromise the infant's health.
D: Swaddling is not allowed for these babies; please stop. This statement is overly prohibitive and lacks the nuance needed in addressing the situation, missing an opportunity to educate the parent on safe practices.
The following scenario applies to the next 1 items
The nurse in the obstetrics department is caring for a 29-year-old primigravida client.
Item 1 of 1
History and Physical
2300: Client is a primigravida at 33 weeks gestation, who awoke to moderate bright red vaginal bleeding. She reports noticing light spotting earlier in the day, which she dismissed as benign. She denies abdominal pain, cramping, or contractions. Her pregnancy has been uncomplicated until recently. She reports increased fetal movement over the last 48 hours. One week ago, she presented to the ED with fever, fatigue, and body aches, and was diagnosed with influenza A. She was treated supportively and discharged home with hydration instructions. Over the past 24 hours, she has experienced nasal congestion and fatigue.
Four days ago, a transabdominal ultrasound showed:
• Fetus in cephalic position
• Normal amniotic fluid volume
Exam findings
• Abdomen: Soft, non-tender
• No uterine contractions noted on palpation
• Moderate amount of dried bright red blood was seen on the undergarments
• 1+ pedal edema
• Peripheral pulses 2+
•
Diagnostics
2342: Fetal Heart Rate (FHR): 144 bpm, moderate variability, no decelerations
Vital Signs
• Temperature: 99.5°F (37.5°C)
• HR 88 bpm
• BP 137/78 mmHg
• RR 18/min
• Pulse oximetry 98% on room air
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Request a prescription for indomethacin, Prepare the client for a transvaginal ultrasound, Place the client in the lithotomy position for a manual cervical exam, Establish a peripheral vascular access device, Place the client in a room with monitored negative airflow
B
Placental abruption, Preeclampsia, Placenta previa, Influenza recurrence
C
Fetal heart rate pattern, Pedal edema, Amount and color of vaginal bleeding, Temperature, Nasal congestion and fatigue level
Rationale:
Placenta previa. This condition is indicated by the client’s bright red vaginal bleeding at 33 weeks gestation, often associated with the placenta's abnormal placement, creating risks for both mother and fetus.
A: Request a prescription for indomethacin. This medication is typically used for preterm labor, not appropriate for managing a client with placenta previa.
B: Preeclampsia. The absence of hypertension and other symptoms makes this diagnosis unlikely in the context of the client’s current presentation.
D: Influenza recurrence. The client’s symptoms suggest viral illness, but they do not correlate with vaginal bleeding, thus not relevant to the current obstetric concern.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 1 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.†Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Which of the following assessment findings require immediate follow-up?
Rationale:
Pupil assessment requires immediate follow-up. The client's pupils are sluggishly reactive, which could indicate a serious neurological issue following his head injury, necessitating further evaluation to rule out complications such as increased intracranial pressure.
A: Lung sounds are clear bilaterally, indicating no immediate respiratory distress or complications that require urgent attention.
C: Abdominal assessment findings show no distention or pain, suggesting there are no urgent gastrointestinal issues present.
D: Vital signs are stable with a normoactive pulse and blood pressure, indicating no immediate cardiovascular crisis that needs urgent follow-up.
E: Glasgow coma scale of 14 indicates only mild impairment; therefore, it doesn't necessitate immediate intervention despite the head injury.
F: Speech characteristics are clear and articulate, which suggests that cognitive function is intact, reducing the urgency for follow-up.
G: Home medications do not present immediate concerns that require urgent assessment or intervention in the context of the current medical situation.
The following scenario applies to the next 1 items
The case manager is reviewing the medical record of a client with schizophrenia
Item 1 of 1
Progress Notes
Discharge Summary
0900: Third involuntary admission in the past six months. The client was admitted four days ago because of florid psychosis. During the stay, the client was stabilized with their prescribed aripiprazole. Once stabilized, the client reported nonadherence to aripiprazole because they 'forget.' It is documented that the client also missed two follow-up appointments for some unknown reason. The client was prescribed aripiprazole oral disintegrating tablet (ODT) to optimize adherence versus tablets. Provided two refills and a follow-up appointment at discharge. Thorough counseling was provided regarding the dosing schedule. Considering the client's repeated nonadherence, there is a high probability of readmission. Will consult case management for follow-up.
Orders
0815:
• discharge client home
• case management consultation for repeated readmissions
• arrange outpatient follow-up appointment prior to discharge
• give morning dose of aripiprazole prior to discharge
• discharge with a prescription for aripiprazole 15 mg ODT daily
The case manager reviews the physician's progress notes and orders. Select the actions the case manager should take to reduce the client's risk of readmission.
Rationale:
The case manager should perform a post discharge follow-up phone call. This action directly addresses the client’s history of nonadherence and missed appointments, ensuring ongoing support and engagement to potentially mitigate the risk of readmission.
B: Recommend the client be prescribed a long acting injectable antipsychotic. While this may enhance adherence, the case notes do not indicate a need for medication adjustment at this time.
C: Review the client's advanced directives. This does not directly contribute to reducing readmission risk; the focus should be on medication adherence and follow-up care instead.
D: Assess the client's social determinants of health. While important for overall care, this action does not immediately address the client's adherence issues or recent missed appointments.
E: Arrange for more frequent follow-up appointments. While beneficial, the effectiveness depends on the client’s willingness to attend, which has been inconsistent as noted in their record.
The nurse is caring for a client seven hours postoperative following a subtotal thyroidectomy. The client reports peripheral numbness and tingling, muscle twitching, and spasms. The nurse anticipates a prescription for
Rationale:
Calcium gluconate. The client's symptoms indicate potential hypoparathyroidism due to decreased calcium levels following thyroid surgery, leading to neuromuscular irritability. Calcium gluconate is essential for correcting this electrolyte imbalance and alleviating symptoms.
A: levothyroxine. This medication is typically used for thyroid hormone replacement, not to address acute symptoms of hypocalcemia or neuromuscular irritability seen in this patient.
B: hydrocortisone. This corticosteroid primarily addresses inflammation and adrenal insufficiency, unrelated to the specific symptoms of numbness, tingling, and muscle spasms following a subtotal thyroidectomy.
C: thiamine. Thiamine is a vitamin used for conditions like Wernicke's encephalopathy; it does not address calcium levels or neuromuscular issues arising from thyroid surgery.
The following scenario applies to the next 1 items
The emergency department nurse is caring for a 22-year-old with altered mental status
Item 1 of 1
Admission Notes
2330 - 22-year-old male client arrived at the emergency department (ED) with friends who were at a party and was observed snorting a white powder and started acting erratically.
The client is hyper-alert, agitated, and only oriented to place on assessment. The client started shouting at staff during the assessment and struck a nurse with his fist. The primary healthcare provider (PHCP) was immediately notified of this incident.
Vital Signs
• Temperature 98.0o F (37o C)
• Pulse 110/minute
• Respirations 16/minute
• Blood Pressure 155/96 mm Hg
• O2 saturation 96% on room air
Complete the following sentences from the list of options.. Based on the client assessment, the client is likely intoxicated with ___ the nurse should immediately ___ based on the client's ___
Rationale:
The client is likely intoxicated with cocaine; the nurse should immediately restrain the client based on the client's physical violence.
Cocaine often induces hyper-alertness and agitation, which aligns with the client’s erratic behavior and aggression. Restraining the client is necessary to ensure safety for both the patient and the staff, especially given the violent outburst observed during assessment.
A: heroin The client's symptoms, including agitation and hyper-alertness, are more indicative of cocaine use rather than heroin, which typically causes sedation and respiratory depression.
D: obtain a urine drug screen While obtaining a urine drug screen is essential, immediate restraint is critical for safety due to the client's aggressive actions rather than solely focusing on diagnostics.
E: blood pressure Blood pressure readings, although elevated, do not directly address the immediate need to manage the client's violent behavior, which requires urgent intervention to protect staff and the patient.
The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted?
Rationale:
B: Concave and bowl-shaped. A retracted stoma appears sunken and bowl-shaped due to the surrounding tissue being higher than the stoma itself, indicating a potential complication requiring further assessment and intervention.
A: Narrowed and flattened. This description suggests an abnormal stoma shape, often associated with complications, but does not specifically indicate retraction, which is characterized by a concave appearance.
C: Dry and reddish-purple. While dryness and discoloration can indicate issues with the stoma, they do not specifically reflect retraction, which is more about the stoma's overall shape and position.
D: Pinkish-red and moist. A healthy stoma typically appears pinkish-red and moist; this finding does not suggest retraction, as a retracted stoma would not maintain this appearance.
The following scenario applies to the next 5 items
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 1 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child's sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
Which of the following would require immediate follow-up?
Rationale:
The integumentary assessment findings require immediate follow-up. The raised lesion's characteristics, along with the increased size and associated symptoms, suggest potential infection or other serious conditions that necessitate prompt evaluation.
A: temperature and pulse oximetry reading Neither of these vital signs indicates immediate concern; the child's temperature is normal, and oxygen saturation is within acceptable limits, requiring no urgent follow-up.
B: pulse, respirations, and blood pressure These vital signs are stable and within normal ranges, indicating no pressing issues that warrant immediate intervention or follow-up in the current clinical scenario.
C: medical and surgical history While relevant, this information does not indicate an acute need for follow-up, as it does not directly relate to the current presenting symptoms or condition.
E: lymph node assessment The lymph node findings are critical, as the firmness in the groin and the lesion's characteristics warrant immediate investigation to rule out possible infections or malignancies.
F: recent camping trip The camping trip provides context but does not necessitate immediate follow-up, as it’s not directly linked to the acute symptoms observed in the client.
G: immunization status The lack of the seasonal influenza vaccine is important, yet it does not pose an immediate threat requiring urgent follow-up in light of the current clinical picture.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 4 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.†Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
The nurse reviews the diagnostic and laboratory results. For each potential nursing intervention, click to specify whether the Nurses' Notes intervention is indicated or not indicated for the care of the client.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
obtain an order for serum type and screen
B
obtain a prescription for protamine sulfate
C
perform neurological assessments every 15 minutes
D
obtain a prescription for andexanet
E
obtain a prescription to transfuse platelets
F
obtain a prescription for ketorolac
G
monitor the client for signs and symptoms of increased intracranial pressure
Rationale:
Obtaining an order for serum type and screen is indicated as the client has a significant subarachnoid hemorrhage, which may require a blood transfusion if surgical intervention or further treatment is necessary.
B: obtain a prescription for protamine sulfate. Protamine sulfate is an antidote for heparin, not relevant here as the client is on warfarin, not heparin.
E: obtain a prescription to transfuse platelets. The client's platelet count is only slightly below normal and does not indicate the immediate need for transfusion given the current clinical context.
F: obtain a prescription for ketorolac. Ketorolac is a nonsteroidal anti-inflammatory drug that could increase bleeding risk, making it an inappropriate choice for this client with a subarachnoid hemorrhage.
When educating an adolescent diagnosed with bacterial conjunctivitis about how to prevent the spread of their infection, which of the following points should you include?
Rationale:
Do not share towels or washcloths with family members. This measure effectively prevents the transmission of bacteria that cause conjunctivitis, limiting the risk of spreading the infection to others in close contact.
B: Stay home from school until they have taken antibiotics for 48 hours. This advice focuses on treatment initiation rather than immediate prevention of spreading the infection.
C: Apply a warm compress to lessen any irritation. While soothing, this action does not directly prevent the transmission of the infection to others.
D: Throw out the contact lenses and get new ones. Although this may seem prudent, it does not address the key preventative measures to stop the spread of infection.
E: Perform hand hygiene, especially prior to touching face or eyes. This practice is crucial to minimizing the risk of transferring bacteria from hands to the eyes, thereby preventing the spread of the infection.
The nurse reviews a client's medical record taking prescribed isoniazid for pulmonary tuberculosis. Which laboratory data is most important to monitor?
Rationale:
Liver enzymes. Isoniazid is known to potentially cause hepatotoxicity, making it essential to monitor liver enzymes to detect any signs of liver damage early in clients receiving this medication.
A: PT and PTT. These tests assess coagulation factors, which are not directly affected by isoniazid therapy and do not provide relevant information regarding the drug's potential hepatic side effects.
B: CBC. A complete blood count monitors overall health and detects anemia or infection, but it does not specifically address the liver toxicity risks associated with isoniazid treatment.
C: BUN. Blood urea nitrogen levels evaluate kidney function rather than liver health, making them less relevant for monitoring the adverse effects of isoniazid on the liver.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 3 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.†Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Complete the following sentence by choosing from the list of options. The nurse should prioritize obtaining an order for a ___ and ___ to better determine the extent of the client's injuries.
Rationale:
Obtaining a computed tomography scan of the head and international normalized ratio is essential to assess possible intracranial injuries and evaluate the client’s anticoagulation status due to warfarin use.
A: radiograph (x-ray) of the head and neck. An x-ray may not provide adequate information regarding potential brain injuries, which is critical given the client's symptoms and mechanism of injury.
B: electrocardiogram. While an ECG can assess heart rhythm, it does not evaluate head injuries or provide insight into the client's neurological status post-crash.
C: electroencephalogram. An EEG monitors electrical activity in the brain but is not the initial choice for assessing acute head trauma or injury extent in this scenario.
E: hematocrit. Hematocrit levels are important for assessing blood volume but do not directly inform about potential brain injuries following the client’s fall while skiing.
F: platelet count. A platelet count alone does not provide relevant information about head trauma effects or the need for immediate imaging in this acute situation.
G: international normalized ratio. This measure is critical for evaluating the client's anticoagulation status, particularly given his warfarin use, making it essential for assessing potential bleeding risks.
The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled?
Rationale:
Tachypnea suggests that the client's pain is not well controlled, as it often occurs in response to discomfort or stress, indicating that the patient may be experiencing significant pain after surgery.
B: Bradycardia does not typically indicate uncontrolled pain; rather, it may reflect a physiological response unrelated to pain management, often influenced by medications or underlying medical conditions.
C: Nausea can occur due to various factors, including medication side effects or anxiety, and does not specifically point to inadequate pain control after surgery in this context.
D: Mydriasis, or dilated pupils, may result from various causes, including neurological factors or medication effects, rather than being a direct indicator of pain management inadequacy.
E: Increased blood glucose levels can arise from stress or hormonal responses unrelated to pain levels, thus not serving as a reliable indicator of pain control after surgical procedures.
When the nurse is educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following should the nurse emphasize as early signs of heart failure?
Rationale:
Diaphoresis, sudden weight gain, no wet diapers, and hypoxia should be emphasized as early signs of heart failure. These symptoms indicate the body's struggle to maintain adequate circulation and oxygenation, crucial for detecting potential heart failure in young children promptly. Educating parents on these signs allows for timely intervention and improved outcomes for their children.
B: Sudden weight gain Excessive weight gain can indicate fluid retention associated with heart failure, but it may not be as immediate or observable as other symptoms.
C: No wet diapers A lack of wet diapers suggests dehydration or other issues, which may not directly correlate with heart failure signs and can be influenced by various factors.
D: Hypoxia While hypoxia indicates low oxygen levels, it is often a later manifestation of heart failure rather than an early sign and may not be easily recognized by parents.
E: Increased appetite An increased appetite does not typically signify heart failure; in fact, many children with heart conditions may exhibit decreased appetite instead, making this option misleading.
The following scenario applies to the next 1 items
The nurse cares for a primigravida in labor.
Item 1 of 1
Nurses' Note
1940: The client is alert and fully oriented. The client is talkative and has an anxious affect. Cervical dilation of 6 cm with 100% effacement. No vaginal discharge was noted. Contractions are noted every 2-3 minutes, lasting 40-60 seconds with moderate intensity.
Fetal Heart Rate
Continuous fetal heart monitoring (FHR): 130-145/minute with normal variability.
Vital Signs
• Oral Temperature 98o F (37o C)
• Heart rate 84/minute
• Respirations 20/minute
• Blood pressure 131/72 mm Hg
• Oxygen saturation 95% on room air
The nurse reviews the client's clinical data. Drag a word from the choices below to complete the sentence. Based on the clinical data, the client is in the ___ stage of labor. Specifically, the ___ phase.
Rationale:
The client is in the first stage of labor, specifically the active phase. This stage is characterized by cervical dilation from 6 cm to 10 cm, which aligns with the client's current dilation and contraction pattern. Additionally, the client's anxiety and talkativeness indicate engagement in the active labor process.
B: second This phase typically follows the active phase and involves more intense pushing efforts, which are not yet indicated by the client's current status.
C: third This stage occurs after the baby is delivered, indicating that labor is complete, which contradicts the client's ongoing contractions and dilation.
D: fourth This stage refers to the recovery period post-delivery, making it irrelevant to the client's current labor status and ongoing contractions.
E: latent This phase precedes the active phase, where cervical dilation is minimal; the client's dilation of 6 cm indicates she has progressed beyond this initial stage.
G: transition This phase represents the final part of the first stage of labor and is characterized by intense contractions and emotional changes, which are not evident in the client's presentation.
The nurse in the outpatient clinic is caring for a 33-year-old female.
Item 1 of 1
Nurses' Note
1435: Client reports vaginal discharge that is malodorous x 3 days. The client reports that the discharge is thin, green, and yellow. She reports being sexually active with multiple partners without any protection. She denies any dysuria, dyspareunia, fevers, chills, or fatigue. The client is alert and oriented to person, place, and time. Reports no pain. Lung sounds are clear, with a regular breathing pattern. Active bowel sounds in all quadrants. Peripheral pulses were 2+ and regular—no peripheral edema. Skin is warm and moist. Vital signs: T 98° F (36.7° C), P 72, RR 18, BP 132/76, pulse oximetry reading 98% on room air.
Complete the following sentences by choosing from the lists of options. The client is demonstrating signs and symptoms of ___ To confirm this diagnosis, the nurse anticipates a physician's order for...........
Rationale:
The client is demonstrating signs and symptoms of trichomoniasis. To confirm this diagnosis, the nurse anticipates a physician's order for wet mount microscopy.
A: syphilis. The symptoms described do not align with syphilis, which typically presents differently, such as with sores or rashes, rather than malodorous vaginal discharge.
C: urolithiasis. Urolithiasis involves kidney stones, which would likely present with severe pain and urinary symptoms, neither of which are reported by the client.
D: human immunodeficiency virus (HIV). HIV symptoms are often systemic and do not specifically include the distinctive malodorous discharge described, which is characteristic of other infections.
F: RPR (rapid plasma reagin). RPR is a test for syphilis, not relevant here since the client's symptoms suggest a different infectious process.
G: HIV p24 antigen. This test is not indicated given the client's specific symptoms of vaginal discharge, which are unrelated to HIV confirmation.
The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include?
Rationale:
Daily use of soap and water should be used around the urinary meatus. This practice helps to maintain hygiene, reduces the risk of infection, and is essential for the proper care of patients with indwelling catheters.
A: Sterile gloves should be used to perform urinary catheter care. While sterile gloves are important during initial catheter insertion, routine care can often be performed with clean gloves.
B: Urinary specimens may be collected from a catheter bag. Collecting specimens from the bag poses contamination risks, leading to inaccurate results; specimens should be taken from the sampling port instead.
C: You may irrigate a catheter with warm water for poor outflow. Irrigation is typically not recommended unless ordered, as it can introduce infection and does not address underlying issues of obstruction.