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A nurse is caring for a 5-year-old child Physical Examination: 1510: 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. Nurse's Notes: 1500 Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and lean - Ans>> Condition: Epiglottis Actions: Initiate droplet precautions and request a prescription for IV antibiotics Monitors: Breath sounds and temperature
The nurse should anticipate initiating droplet precautions and requesting a prescription for IV antibiotics. The child is most likely experiencing epiglottis because of the clinical manifestations of a high fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and breath sounds. A nurse is caring for a client who is on the spinal cord injury (SCI) unit 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 in lower lobes. Abdomen soft and nondistended with active bowel sounds. Client passed a small amount of hard formed stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, pa - Ans>> The client is most
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. Physical Examination 0930 Lung sounds clear bilaterally. Skin warm to touch and jau - Ans>> Hepatitis A: Client's risk from fecal-oral transmission, laboratory results, and physical examination findings Hepatitis B: Antiviral treatment, laboratory results, client's risk from bloodborne transmission, physical examination findings Hepatitis C: Antiviral treatment, laboratory results, client's risk from bloodborne transmission, and physical examination findings When analyzing cues, the nurse should recognize that manifestations of hepatitis A,
hepatitis B, and hepatitis C include jaundice, yellow sclerae, right upper quandrant pain upon palpation, dark yellow urine, and elevated AST and ALT levels. When analyzing cues, the nurse should also recognize the client's risk for contracting hepatitis A through the fecal-oral route during recent travel to an underdeveloped country and the client's occupational risk as a perioperative nurse for contracting hepatitis B and hepatitis C through bloodborne transmission. The nurse should recognize that the current standard of practice for A nurse is caring for a client on a medical- surgical unit Vital Signs 0700 Temperature 37.6 C (99.7 F) Heart rate 100/min Respiratory rate 22/min Blood pressure 115/70 mmHg Oxygen saturation 98% on room air Nurses' Notes 1100
3 months ago Blood pressure 116/68 mmHg 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 mmHg Heart rate 104/min Respiratory rate 22/min Temperature 37.4 (99.4 F) SaO2 97% on room air 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. - Ans>> Select the 3 findings that require immediate follow up:
- Auditory hallucinations
- Speech
- Restlessness When recognizing cues, the nurse should identify that the findings of restlessness,
auditory hallucinations, and pressured speech require immediate follow up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment. A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG) Laboratory Results 0630 Sodium 145 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5 mEq/L) Chloride 116 mEq/L (98 to 106 mEq/L) BUN 24 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9 mg/dL (9 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC count 9,500/mm3 (5,000 to 10,000/mm3) I & O 0700 4 hr input 400 mL
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 - Ans>> The nurse should first address the client's respiratory rate, followed by the client's level of consciousness When prioritizing hypotheses, the nurse should recognize that magnesium sulfate is a central nervous system depressant that can affect respirations, consciousness, and reflexes when toxic blood levels occur. Using the airway, breathing, circulation priority framework, the nurse should plan to first take action to support respirations, followed by action to increase the client's level of consciousness. The nurse should plan to discontinue the magnesium sulfate infusion and administer calcium gluconate as an antidote. A nurse is caring for an adolescent in the emergency department (ED)
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 - Ans>> Which of the following findings requires immediate follow up by the nurse?
- Skin assessment
- Temperature
- WBC
- Casual blood glucose
- Potassium After reviewing the information in the adolescent's EMR and recognizing cues, the nurse should identify that the adolescent has a potential skin infection, such as cellulitis. The skin assessment reveals that the medial
Temperature 37.2 (98.9 F) Heart rate 96/min Respiratory rate 20/min Blood pressure 100/70 mmHg Oxygen saturation 97% on room air Nurses' Notes 1500 Client admitted from the ED for dehydration. Client alert and oriented to person, pla - Ans>> 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 level of consciousness, 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 emergency department (ED) Laboratory Results
Sodium 140 mEq/L (136 to 145 mEq/L) Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Chloride 103 mEq/L (98 to 106 mEq/L) BUN 15 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9.5 mg/dL (9 to 10.5 mg/dL) Phosphate 3.7 mg/dL (3 to 4.5 mg/dL) Glucose 80 mg/dL (74 to 106 mg/dL) Total protein 7 g/dL (6.4 to 8.3 g/dL) Albumin 4.5 g/dL (3.5 to 5 g/dL) WBC count 19,500/mm3 (5,000 to 10,000/mm3) Asp - Ans>> Bacterial Meningitis: Temperature, photophobia, rash, mental status, and pain Encephalitis: Temperature, pain, and mental status Reye Syndrome: mental status and hepatic function When recognizing cues, the nurse should recognize that manifestations of bacterial meningitis can include fever, photophobia, nuchal rigidity, petechial rash, and impaired consciousness. The adolescent is experiencing these symptoms. Encephalitis is characterized by fever, nuchal rigidity, and altered mental
developing hypocalcemia as evidenced by the client's report of muscle spasms, numbness around lips, and decreased calcium level. Hypocalcemia is more likely to occur in clients who have experienced a thyroidectomy, due to accidental damage to the parathyroid. Numbness around the lips is a clinical manifestation specific to hypocalcemia. Hypocalcemia presents as muscle spasms and can lead to cardiac dysrhythmias. Hypocalcemia is the highest priority, as it requires immediate treatment with calcium gluconate to avoid dysrhythmias and other complications. A nurse on a medical-surgical 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? A. Contact the facility chaplain to visit with the client. B. Explain the process of leaving the facility against medical advice. C. Make a referral for social services.
D. Encourage the client to continue with inpatient care. - Ans>> C. Make a referral for social services. As a client advocate, the nurse should support the client's decisions and obtain a referral for social services to ensure that the client's needs at home are met. Social services can set up home care or hospice care services for the client if needed. Incorrect: The nurse should ask the client's permission before contacting the facility chaplain to visit. The nurse should identify that the client is not leaving the facility against medical advice. Therefore, the nurse should notify the provider of the client's wishes. The nurse should recognize the client's autonomy and support the client's wishes to go home. A nurse is assessing a newborn who is 3 days old History and Physical
Hypothermia can lead to the occurrence of hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia. A nurse is caring for a client who is postoperative following administration of general anesthesia. 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 Nurses' Notes 0830: Client is postoperative following an inguinal hernia repair.Apical pulse 134/min and irregular Client reports dyspnea.
Diagnostic Results 0835: Arterial blood gases (ABGs) pH 7.30 (7.35 to 7.45) PCO2 64 mm Hg (35 to 45 mm - Ans>> Condition: Malignant hyperthermia Actions: administer dantrolene and administer oxygen Parameters to monitor: Hypercapnia and muscle rigidity Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.
