NURS 493 NGN Practice 1 SP 2024 | Questions and Answers (Complete Solutions)

NURS 493 NGN Practice 1 SP 2024 | Questions and Answers (Complete Solutions) A nurse is caring for a 45-year-old client in the emergency department. Nurses' Notes Admitted to the emergency accompanied by partner. Alert and oriented x3. Skin warm and dry, no discoloration noted. Client reports substernal chest pain that radiates to the left shoulder and neck. Rates pain as 8 on a scale of 0 to 10. Pain increases with aspiration and when lying down. Client reports decreased pain when sitting upright and leaning forward. Heart sounds regular with a pericardial friction rub auscultated left lower sternal border. Lungs clear to auscultation with occasional non-productive cough. No peripheral edema noted. Vital Signs Temperature 38.3° C (101° F) Heart rate 100/min Respiration rate 20/min BP 128/82 mm Hg Oxygen saturation 98% on room air Actions to Take - obtain an echocardiogram - obtain a prescription for an NSAID such as ibuprofen Potential Condition - pericarditis Parameters to Monitor - pain level - pulsus paradoxus The nurse should obtain an echocardiogram and obtain a prescription for an NSAID such as ibuprofen because the client is most likely experiencing pericarditis due a respiratory infection. The nurse should monitor the client's pain as well as for pulsus paradoxus (a systolic blood pressure increase of 10 mm Hg during inspiration) which is a manifestation of cardiac tamponade and is a medical emergency. A nurse is reviewing the medical record of a client who has acute leukemia. Diagnostic Results Month Three: WBC count 15,500/mm3 (5,000 to 10,000/mm3) RBC count 4.0 million/mm3 (4.2 to 5.4 million/mm3) Hemoglobin 11 g/dL (12 to 16 g/dL) Hematocrit 33% (37% to 47%) Platelet count 100,000/mm3 (150,000 to 400,000/mm3) PT 13.5 seconds (11 to 12.5 seconds) INR 2.2 seconds (0.8 to 1.1 seconds) PTT 85 seconds (60 to 70 seconds) Sodium 137 mEq/L (136 to 145 mEq/L) Potassium 4.5 mEq/L (3.5 to 5 mEq/L) Glucose 98 mg/dL (74 to 106 mg/dL) BUN 15 mg/dL (10 to 20 mg/dL) Creatinine 0.8 mg/dL (0.5 to 1 mg/dL) Calcium 9.5 mg/dL (9 to 10.5 mg/dL) Vitamin D 65 ng/dL (25 to 80 ng/dL) Drag words from the choices below to fill in each blank in the following sentence. Bleeding and infection are correct. Bleeding is one of the major causes of death for clients who have acute leukemia. The nurse should note that the client's platelet count has decreased, and the PT, PTT, and INR levels have all increased, which places the client at a high risk for bleeding. Infection is also one of the major causes of death for clients who have acute leukemia. The WBC count can be low, normal, or high in leukemia, but the cells are small and nonfunctioning. The inability of the client's WBCs to mount an appropriate protection against invading micro-organisms places the client at a high risk for infection. Fracture and dysrhythmia are incorrect A nurse on a cardiac care unit is caring for a preschooler. Nurses' Notes 2015: Increase in dyspnea noted with orthopnea. Nasal flaring with respiratory rate of 36/min. Lung sounds with wheezing noted throughout. Lower extremity edema 3+ to bilateral lower extremities. Extremities cool with decreased skin pigmentation noted. Peripheral pulses weak bilateral. Jugular vein distention noted. Provider notified. Received prescription for additional dose of IV furosemide. Medication Administration Record Hospital Day 1: Furosemide 40 mg IV every 6 hr. Administered at 1755. Hospital Day 2: Give digoxin 125 mcg 12 hr after initial dose. Administered at 0608. Give digoxin 125 mcg 12 hr after second dose. Administered at 1804. Hypokalemia is correct. The client is receiving furosemide every 6 hr. Furosemide causes potassium depletion. Therefore, the client is at risk for hypokalemia. Digitalis toxicity is correct. The client is receiving digitalis every 12 hr. The margin of safety is very small, 0.8 to 2 mcg/L. Therefore, the client is at risk for digitalis toxicity. A nurse is caring for a client in the labor room. Medical History Gravida 2 Para 1 38 weeks gestation Pregnancy complicated by gestational diabetes and hydramnios. Spontaneous vaginal delivery 1 year ago. No significant past medical history. No history of surgeries. Spontaneous onset of labor Nurses Notes 1020: Client pushing effectively. Crowning. Provider present at bedside. Contraction pattern: occurring every 4- 5 min; lasting 75-90 seconds; palpate strong. Fetal heart rate 150/min. Average variability. Spontaneous accelerations noted. Variable decelerations noted when pushing. 1025: Spontaneous vaginal delivery. 2nd degree lacerations with repair. Apgar scores: 8 at 1 min and 9 at 5 min Birth weight 7 lb 8 oz (3,402 g). Box 1 Postpartum hemorrhage is correct. Overdistention of the uterus during pregnancy can impact the ability of the uterine muscles to tightly contract following delivery. This can result in excessive blood loss following delivery. Clients who have high parity, fetal macrosomia, multiple gestations, and hydramnios are more likely to experience uterine atony. Therefore, the client has the greatest risk of developing a postpartum hemorrhage due to hydramnios. Box 2 Hydramnios is correct. Hydramnios or polyhydramnios is an excessive amount of amniotic fluid that causes overdistention of the uterus. This complication can develop during the third trimester in women who have diabetes mellitus. This can impair the ability of the uterus to tightly contract. A nurse is caring for a client who is at 34 weeks of gestation. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress. Diagnostic Results Fasting blood glucose 140 mg/dL (60 to 105 mg/dL) HbA1c 10% (less than 6.5%) Urinalysis: Appearance cloudy (clear) Color amber yellow (amber yellow) pH 4.8 (4.6 to 8.0) Positive urine glucose (negative) 3+ ketones (negative) Urine specific gravity 1.010 (1.005 to 1.030) Actions to Take - obtain fasting blood glucose levels - perform a nonstress test Potential Condition - gestational diabetes mellitus Parameters to Monitor - monitor the client's hemoglobin A1c - fetal well-being The nurse should obtain fasting blood glucose levels and perform a nonstress test because the client is most likely experiencing gestational diabetes mellitus because the client has a blood glucose level above the expected reference range, glucosuria, and ketonuria. The nurse should monitor the client's hemoglobin A1c because it evaluates past glycemic control and assists the provider in evaluating how well the client is adhering to any future treatment plan. Also, fetal well-being should be monitored to determine how the client's diabetes mellitus is affecting the fetus and if additional studies or testing should be performed on the fetus in addition to nonstress testing. A nurse is caring for a client who is in the second stage of labor. Medical History 0800: 28-year-old client; G2 P1; at 39 weeks of gestation. Client has history of insulin dependent gestational diabetes mellitus with current pregnancy. Client admitted to the facility in the latent phase of labor at 4 cm, 70% effaced, and -1 station. Nurse's Notes 1300: Client reports need to have a bowel movement. Sterile vaginal examination (SVE) performed; 10 cm, 100% effaced, and +1 station. Fetal heart rate 130’s with moderate variability, occasional variable decelerations observed. Provider notified of cervical assessment. Client actively pushing with contractions. 1503: Provider at bedside. Fetal head crowning. Actions to Take - flex the client’s legs against the abdomen - apply suprapubic pressure Potential Condition - dystocia Parameters to Monitor - movement of the newborn's upper extremities - maternal perineum The nurse should flex the client’s legs against the abdomen and apply suprapubic pressure because the client is most likely experiencing shoulder dystocia. Flexing the clients legs against the abdomen straightens the maternal pelvis, helping to free the trapped anterior shoulder of the fetus. Applying suprapubic pressure also helps free the anterior shoulder, allowing for birth of the newborn's body. The nurse should monitor the movement of the newborn's upper extremities because newborns who experience a shoulder dystocia are at a greater risk for brachial plexus injuries. The nurse should also monitor the maternal perineum because mothers who experience shoulder dystocia are at a greater risk for trauma to the vagina, perineum, and rectum. A nurse is caring for a school-age child who was involved in a motor-vehicle crash. Nurses' Notes 1845: Client is awake, alert, oriented to person, place, and time. Skin warm and dry. Capillary refill less than 2 seconds. Heart rate regular. Scattered rhonchi bilateral bases. Respirations even and non-labored. Bowel sounds hypoactive in all four quadrants... 2125: Skin warm and dry. Respirations even and slightly labored. Nonproductive cough noted. Bowel sounds hypoactive in all four quadrants. Last bowel movement two days ago soft, formed. Pedal pulse +2 bilateral. +2 edema noted to right lower extremity. Rates pain as 5 on pain scale from 0 to 10. Capillary refill to lower extremities less than 2 seconds. Voided 200 mL clear, yellow urine. 2125: Temperature: 37.1°C (98.8°F) Pulse rate: 94/min Respiratory rate: 23/min Blood pressure: 110/64 mm Hg Oxygen saturation: 93% room air Dropdown 1 Pulmonary embolism is correct. Immobility from traction decreases venous return and causes pooling of blood, which increases the risk of clot formation. The child is receiving traction therapy for management of femur fracture and is experiencing a change in respiratory status with their respirations being slightly labored. These findings put the child at great risk for developing an embolus. Dropdown 2 Oxygen saturation level is correct. The child's oxygen saturation level has decreased, which indicates hypoxia. This finding can be related to pulmonary embolism. A nurse is caring for a client who reports fatigue, unexplained bruising, and headaches. Diagnostic Results CBC: RBC 4.0 million/mm3 (4.7 to 6.1 million/mm3) WBC 4.0 x 106/mm3 (4.7 to 6.1 x 106/mm3) Hemoglobin 10,500 mm3 (5,000 to 10,000 mm3) Hematocrit 10 g/dL (14 to 18 g/dL) Platelets 60,000/mm3 (150,000 to 40,000/mm3) Basic Metabolic Profile: BUN 18 mg/dL (10 to 20 mg/dL) Creatinine 1.0 mg/dL (0.6 to 1.3 mg/dL) Total calcium 9.5 mg/dL (9.0 to 10.5 mg/dL) Carbon dioxide 27 mEq/L (23 to 30 mEq/L) Chloride 101 mEq/L (98 to 106 mEq/L) Glucose 80 mg/dL (74 to 106 mEq/L) Potassium 4.2 mEq/L (3.5 to 5 mEq/L) Sodium 104 mEq/L (136 to 145 mEq/L) The client is at risk for developing ____________________ due to their ____________________ When analyzing cues, the nurse should identify that the client findings of fatigue, headache, bruising, and decreased platelet count are related to thrombocytopenia. Clients who have this condition are at risk for disseminated intravascular coagulation which is condition that causes spontaneous excessive bleeding due to decreased clotting ability of the blood. The client’s current platelet count is below the expected reference range, therefore, the client is as risk for bleeding and the nurse should monitor the client for the development of DIC. A nurse is caring for a client who has pneumonia on a medical-surgical unit. Nurse's Notes Client admitted to the unit 12 hr ago with pneumonia, over the last 1 hr the client has exhibited dyspnea and restlessness. Respiratory rate is currently 32/min with deep breaths, BP 198/78 mm Hg. Oxygen has been increased from 2 L nasal cannula to 50% face mask with little improvement of oxygen saturation. Current oxygen saturation is 91% on 50% facemask. Arterial blood gases drawn and sent to lab. Diagnostic Results ABGs: pH 7.25 (7.35 to 7.45) pCO2 62 mm Hg (35 to 45 mm Hg) HCO3- 22 mEq/L (22 to 26 mEq/L) Actions to Take - administer a bronchodilator - prepare the client for intubation Potential Condition - respiratory acidosis and respiratory distress Parameters to Monitor - correct placement of the ETT following intubation - arterial blood gases The nurse should administer a bronchodilator and prepare the client for intubation because the client is likely experiencing respiratory acidosis and respiratory distress. The nurse should then monitor for the correct placement of the ETT following intubation as well as the client's arterial blood gases to normalize. A nurse is caring for a newborn who is 64 hr old. Medical History A newborn who was born at 37 weeks of gestation was admitted to the newborn nursery following a cesarean birth. Maternal history of methadone use during pregnancy and no prenatal care. Maternal positive drug screen for methadone. Actions to Take - administer oxygen as prescribed because the newborn has tachypnea with retractions - administer morphine Potential Condition - neonatal abstinence syndrome Parameters to Monitor - monitor the newborn's oral intake and output - monitor the newborn for overstimulation The nurse should administer oxygen as prescribed because the newborn has tachypnea with retractions and is experiencing neonatal abstinence syndrome. The nurse should monitor the newborn's oral intake and output to evaluate nutrition status and potential dehydration related to diarrhea. The nurse should administer morphine as prescribed because the newborn is experiencing neonatal abstinence syndrome. The nurse should monitor the newborn for overstimulation because decreasing stimulation will help with easing withdrawal. A nurse is caring for a client who reports fatigue and had a syncopal episode at home. Medical History 30-year-old female admitted with reports of increased fatigue x 6 months. States they needs to rest frequently and is unable to participate in many activities due to reduced energy level. Reports dyspnea on exertion. Experienced syncopal episode at home without injuries. Vital Signs 0800: Temperature 37.1°C (98.8° F) Apical Pulse 100/min Respiratory rate 22/min Blood pressure 102/76 mm Hg Oxygen saturation 90% on room air Vital Signs 0800: Temperature 37.1°C (98.8° F) Apical Pulse 100/min Respiratory rate 22/min Blood pressure 102/76 mm Hg Oxygen saturation 90% on room air The nurse should first address the client’s ________________________ followed by the ________________________ Dropdown 1 Oxygen saturation is correct. The first action the nurse should take when using the airway, breathing, circulation approach to client care is client’s oxygen saturation. Anemia is a reduction in the number of RBCs and the amount of hemoglobin or hematocrit. Hemoglobin carries oxygen to the tissues. When a client's hemoglobin level is low, the delivery of oxygen is decreased, which results in hypoxia. Dropdown 2 Hypotension is correct. After the nurse had addressed the client’s oxygen saturation level, the nurse should address the client’s hypotension. Anemia reduces oxygen delivery causing the heart to work harder to maintain tissue perfusion. Pulses become weak and thready and blood pressure decreases. A nurse is caring for a newborn who is 30 min old. Medical History Spontaneous vaginal birth with dark brown-greenish amniotic fluid noted during labor 42 weeks gestation Nurses' Notes 1100: Newborn is alert and active. Respirations rapid and shallow with occasional expiratory grunting. Fine crackles auscultated throughout lung fields. Small amount of green-stained vernix present in skin folds. Fingernails stained green. Molding of skull and generalized soft occipital swelling noted. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the greatest risk to the newborn is _______________________ due to _______________________ Meconium aspiration syndrome is correct. The nurse should identify that meconium aspiration syndrome is the complication that poses the greatest risk to the newborn because this can result in both a mechanical obstruction in the airways and a chemical pneumonitis. The presence of meconium-stained amniotic fluid at birth increases the risk that the fetus could inhale the meconium into their lungs while in utero or during the birth process. The nurse should monitor the newborn for signs of respiratory distress frequently and intervene if there are any unexpected findings. Color of amniotic fluid is correct. The presence of meconium in the amniotic fluid at delivery increases the risk for meconium aspiration syndrome and meconium ileus. A nurse is caring for a client who has received a terminal diagnosis. Day 1 0930: Client is sitting on side of bed with daughter at bedside. Client is tearful and states that they believe the diagnosis they received is incorrect and that lab results sent to their provider were not theirs. Day 3 1130: Client is in bed and struggling to prepare their breakfast tray. Client asks the nurse, "Why is this happening to me? I have always been healthy." The client refuses all medications and care. Provider notified. The nurse identifies that the client is currently in Kübler-Ross's _______________________ stage of grief as evidenced by _______________________ Condition: Anger is correct. By day 3, the client is exhibiting manifestations that typically occur in the anger stage of Kübler-Ross's stages of grief. In this stage, the client is prepared to acknowledge their illness, becomes sad, blames others, and has a decreased ability to function. Finding: Acknowledgement of illness is correct. The client is exhibiting manifestations that typically occur in the anger stage of Kübler-Ross's stages of grief. In this stage, the client is prepared to acknowledge their illness, becomes sad, blames others, and has a decreased ability to function. A nurse is caring for a 36-hr-old newborn in the neonatal intensive care unit (NICU) born at 34 weeks of gestation. Physical Examination • Color pink, warm, and dry • In flexed position, moves extremities symmetrical • Airway patent, no retractions or nasal flaring noted • Respiratory rate 72/min, lungs clear bilaterally • Murmur noted • Cord clamped and drying; no drainage noted at umbilicus • Peripheral pulses bounding Nurses Notes 0800: Assessment reveals skin tone consistent with genetic background, no cyanosis. Skin is warm and dry to touch. Lungs sounds clear bilateral, but an extra heart sound that was not present at birth. Tachycardia and tachypnea noted that was not present at last assessment. Newborn fed by parent and consumed 20 mL of breast milk via bottle. Apgar at birth 36 hr ago was 7 at 1 minute and 8 at 5 minutes. Newborn was admitted to the NICU following a vaginal delivery. Maternal history incl Actions to Take - administer oxygen as prescribed - restrict fluids Potential Condition - patent ductus arteriosus Parameters to Monitor - monitor arterial blood gases - Intake and output The nurse should administer oxygen as prescribed because the newborn might be experiencing patent ductus arteriosus. Respiratory support is needed because the ductus arteriosus might have re-opened due to low oxygen levels; therefore, the newborn requires oxygen. The nurse should restrict fluids to decrease cardiovascular volume overload. The nurse should monitor arterial blood gases because the amount of respiratory support needed will be based on the blood gases. The blood gases are also significant because they might show metabolic acidosis. The nurse should monitor fluid balance to ensure fluid overload does not occur. A nurse is caring for a client on the medical-surgical unit. Day 2 0700: The client requests medication “to help with diarrhea.” Client states they have not had any nausea or vomiting since yesterday, but states “I have had four loose stools in the last few hours." They rate abdominal pain 2 on 0-10 pain scale. No abdominal guarding. Chvostek sign present and positive Trousseau sign. Provider notified. Laboratory Results Day 1: 1200: Serum amylase 680 units/L (60 to 120 units/L) Serum lipase 300 units/L (0 to 160 units/L) Calcium 9.0 mg/dL (9 to 10.5 mg/dL) Magnesium 1.8 mEq/L (1.3 to 2.1 mEq/L) Potassium 5.0 mEq/L (3.5 to 5 mEq/L) Sodium 144 mEq/L (136 to 145 mEq/L) Actions to Take - prepare to check a serum albumin - initiate seizure precautions Potential Condition - hypocalcemia Parameters to Monitor - bowel sounds - signs of impaired memory Upon recognizing and analyzing the client cues of acute pancreatitis and a history of end-stage renal disease with new-onset diarrhea and positive Chvostek and Trousseau signs, the nurse’s priority hypotheses is that the potential condition this client can be experiencing is hypocalcemia. It is important to generate solutions and take actions that will ensure client safety and further evaluate the validity and cause of the hypocalcemia. Therefore, the nurse should prepare to check a serum albumin and (initiate seizure precautions because hypocalcemia can increase irritability of the central and peripheral nervous systems and cause seizure activity. To evaluate these interventions the nurse should monitor the client’s bowel sounds and any signs of impaired memory. Hypocalcemia can cause impaired memory, confusion, and delirium as well as hyperactive bowel sounds. A nurse is caring for a school-aged child following surgery for a right upper arm fracture. Diagnostic Results 0600: Radiology: Right humorous spiral fracture. Also noted an old, healed hairline fracture to same arm. CT scan: Thymus gland appears normal size Nurses Notes 0900: Client returned from surgery for open reduction and internal fixation at 0840 oriented to place, person, and time. Reports a pain level of 0 on a pain scale from 0 to 10. When asked how the client broke their arm, the client paused, looked at both parents and stated, "I tripped over my dog. My parents say I am clumsy a lot." Client does not wear glasses. Last eye exam unknown. 1200: Parent returned to client's room after lunch slurring words, stumbling, yelling, smelling of alcohol and demanding to discharge child. Provider notified and security called for standby. Actions to Take - interview the child separately from the parents - ask the parents about the scars and the old fracture noted Potential Condition - physical maltreatment Parameters to Monitor - signs from the child of fear or apprehension around either parent - negative comments about the child The nurse should interview the child separately from the parents and ask the parents about the scars and the old fracture noted because the child is most likely experiencing physical maltreatment due to injuries that are typical of maltreatment along with a history of injuries that do not all have explanations that make sense. A parent who abuses substances is also a risk factor for child maltreatment. The nurse should monitor for signs from the child of fear or apprehension around either parent and note if either parent makes negative comments about the child, because these are also signs of child maltreatment and should be documented in the medical record. Medical History 1600: Client brought to facility by adult grandchild who found the client on the floor of their living room "passed out from drinking." Client has 5.1-cm (2-in) laceration on forehead with dried blood present. Grandchild states client "has been drinking my entire life. I don't know how they are still alive." Plan: Admit for alcohol use disorder, observe for alcohol withdrawal. Diagnostic Results 1800: Blood alcohol 360 mg/dL (0 to 50 mg/dL) CBC: WBC count 6,500/mm3 (5,000 to 10,000/mm3) RBC count 4.0 (4.2 to 5.4) Hemoglobin 11 g/dL (12 to 16 g/dL) Hematocrit 33% (37% to 47%) Platelet count 35,000/mm3 (150,000 to 400,000/mm3) Albumin 3.5 g/dL (3.5 to 5 g/dL) Ammonia 79 mcg/dL (10 to 80 mcg/dL) The client is at highest risk for developing _______________________ as evidenced by the client's _______________________ Drop down 1 Bleeding is correct. The client is at highest risk for bleeding due to a platelet count that is less than the expected reference range. Alcohol toxicity impairs platelet production, causing thrombocytopenia and an increased risk for hemorrhage. Drop down 2 Platelet count is correct. The client is at highest risk for bleeding due to a platelet count that is less than the expected reference range. Alcohol toxicity impairs platelet production, causing thrombocytopenia and an increased risk for hemorrhage. A nurse is caring for a client who is dehydrated. Medication Administration Record 1045 Initiate peripheral IV sitePotassium chloride 20 mEq in 0.9% sodium chloride 125 mL/hr by continuous IV infusion Nurses' Notes 1100: Peripheral IV site in left forearm with potassium chloride 20 mEq in 0.9% sodium chloride 125 mL/hr by continuous infusion 1300: Client is reporting IV site is painful. IV site is red, swollen, warm to touch. IV site has palpable cord along vein. Client is oriented to person, place, and time. Lungs clear to auscultation and respirations are regular. Vital signs obtained along with oxygen saturation. Complete the following sentence by using the list of options. The client is at highest risk for developing _______________________ as evidenced by the client's _______________________ Dropdown 1: Phlebitis is correct. The nurse should identify the client is at greatest risk for developing phlebitis as evidenced by the IV site is painful, red, swollen, and warm to touch. The IV site has also palpable cord along the vein which can indicate inflammation of the inner layer of the vein. The nurse should stop the infusion, discontinue the IV, and notify the client’s provider. Dropdown 2: Inflammation is correct. The nurse should identify the client has inflammation of the inner layer of the vein, which is the cause of the phlebitis. Phlebitis can cause the IV site to be painful, red, swollen, and warm to touch. Physical Examination 1000: Height 165.1 cm (65 in) Weight 89 lb BMI 14.8 Client oriented to person, place, time; appears lethargic. S1 and S2 heard on auscultation; peripheral pulses weak; extremities pale and cold. Respiratory rate elevated; breath sounds clear on auscultation, diminished in bases. Bowel sounds hypoactive x 4 quadrants. Client reports no difficulty with urination, voiding dark, concentrated urine. Diagnostic Results 1200: ECG shows sinus bradycardia 1300: Laboratory results: Complete blood count: Hemoglobin 10 g/dL (12 to 16 g/dL) Hematocrit 30% (37% to 47%) Total WBC count 4,000/mm3 (5,000 to 10,000/mm3) Platelet count 100,000 mm3 (150,000 to 400,000/mm3) Creatinine 1.2 mg/dL (0.5 to 1.0 mg/dL) BUN 30 mg/dL (10 to 20 mg/dL) Potassium 2.9 mEq/L (3.5 to 5 mEq/L) The nurse should first address the client's _______________________ followed by the client’s _______________________ Drop Down 1 Potassium level is correct. The greatest risk to the client is cardiac dysrhythmias brought on by their potassium level, which is in the critical range. Therefore, the nurse should address this finding first. Drop Down 2 BUN level is correct. The next greatest risk to the client is the potential for dehydration, which can occur from decreased fluid intake, as indicated by the BUN level. The client is experiencing hypotension and concentrated urine, which indicates dehydration. Therefore, this is the next finding the nurse should address. A nurse is caring for a client who has severe right wrist pain. Diagnostic Results 1230: Right wrist x-ray indicates non-displaced distal radius fracture 1315: Client requested pain medication. Rates pain as 8 on a scale of 0 to 10. Client given 4 mg of IV morphine per provider's prescription Following administration, the client became lethargic and respirations decreased to 6/min. Naloxone IV was administered per provider's prescription. Client is still lethargic at this time, but respirations have increased. Provider notified. 1315: Temperature 37.2° C (99° F) Apical pulse 76/min Respiratory rate 10/min and shallow Blood pressure 110/70 mm Hg Pulse oximetry 91% on room air Respiratory acidosis is correct. An adverse reaction to morphine sulfate is respiratory depression. The client's respiratory rate has decreased from 20/min to 10/min and is now shallow. Respiratory acidosis occurs when there is impaired respiratory function, causing reduced oxygen and carbon dioxide exchange, which leads to carbon dioxide retention. Hypervolemia is correct. The client is at risk for hypervolemia because of their history of congestive heart failure and the rate at which the IV solution is running. A nurse is caring for a client who is receiving hemodialysis. Nurses Notes 0600: Client transferred to hemodialysis room. Client is alert oriented to person, place, and time. Denies discomfort. 1030: Client returns to client room from hemodialysis room. Alert and oriented to person and place, but client has episodes of confusion. Client reports nausea and headache. Restless along with fatigue. 1100: Client ambulates to bathroom with the assist of one, gait unsteady. Vomits 300 mL of undigested food. Returns to bed Medical History Chronic kidney disease; hemodialysis three times per week Type 1 diabetes mellitus Actions to Take - implement seizure precautions - obtain an electrolyte panel to be drawn Potential Condition - disequilibrium syndrome Parameters to Monitor - neurological status - nausea and vomiting The nurse should implement seizure precautions and obtain an electrolyte panel to be drawn because the client is most likely experiencing disequilibrium syndrome. Disequilibrium syndrome can occur during or after hemodialysis has been completed as a result of the rapid decrease in electrolytes and other particles. Disequilibrium syndrome is caused by cerebral fluid shifts. The nurse should monitor the client's neurological status along with the presence of nausea and vomiting. Manifestations for disequilibrium syndrome include headache, nausea, vomiting, fatigue, restlessness, seizures, and coma. A nurse is caring for a newborn who was born at 37 weeks of gestation and is 12 hr old. Nurse's Notes Newborn is experiencing tachypnea, grunting, nasal flaring, and substernal retractions. Acrocyanosis noted on extremities bilaterally. Diagnostic Results Blood glucose level: 40 mg/dL (30 to 60 mg/dL) Bilirubin level: 4 mg/dL (1.0 to 12.0 mg/dL) pH: 7.30 (7.32-7.45) PaO2: 60 mm Hg (60 to 80 mm Hg) PaCO2: 32 mm Hg (40 to 50 mm Hg) HCO-3 17 mEq/L (16 to 24 mEq/L) Vital Signs Respirations: 90/min Heart rate: 162 /min BP: 70/45 mm Hg Temperature: 37.5° C (99.5° F) Oxygen saturation: 92% Actions to Take - administer oxygen per facility protocol - administer surfactant as prescribed Potential Condition - respiratory distress syndrome Parameters to Monitor - oxygen saturation - arterial blood gases The nurse should administer oxygen per facility protocol and administer surfactant as prescribed because the newborn is most likely experiencing respiratory distress syndrome. The nurse should monitor oxygen saturation and arterial blood gases to note trends and details of the newborn’s oxygenation status to discern if appropriate oxygenation is occurring. A nurse is caring for a 64-year-old client in an emergency department. Nurses Notes Client presents with report of sudden onset of dyspnea and sharp chest pain. Respirations labored with crackles auscultated throughout lung fields. Dry cough present. Skin is cool and moist. Heart sounds are moderate and regular. Jugular vein distention noted. Abdomen is soft, nondistended with active bowel sounds in all four quadrants. 1+ peripheral edema noted. Peripheral pulses are moderate. Client is restless and anxious. Medical History Client states that they just returned from trip to Hawaii with family. Client reports experiencing gastrointestinal influenza-like symptoms for 1 day on the trip. Vital Signs Temperature 38° C (100.4° F) Apical pulse rate 116/min Respiratory rate 26/min Blood pressure 100/64 mm Hg Oxygen saturation 90% on room air Actions to Take - request a D-dimer - apply oxygen Potential Condition - pulmonary embolism Parameters to Monitor - client's pulse oximetry - partial thromboplastin time The nurse should request a D-dimer and apply oxygen because the client is most likely experiencing a pulmonary embolism because the client has had a sudden onset of dyspnea with pleuritic (sharp) chest pain along with hypotension after returning from a trip. Due to a decreased gas exchange, the client needs oxygen applied. A D-dimer needs to be drawn to assist with diagnosing a pulmonary embolism. The nurse should monitor the client's pulse oximetry and partial thromboplastin time because a client who has a pulmonary embolism display manifestations of decreased gas exchange and decreased tissue perfusion. Treatment for a pulmonary embolism includes drug therapy with an anticoagulant, such as unfractionated heparin, low-molecular-weight heparin, or fondaparinux. The client's partial thromboplastin time is drawn before anticoagulant therapy is started and throughout therapy per facility policy. A nurse is assisting in the care of a 6-year-old child. Nurses' Notes Admission note: Child presents with caregiver to the emergency department. Left knee is warm to touch, swollen, and reddened. Skin is intact. Child rates pain as a 9 on the Faces Pain Scale of 0 to 10. Child is guarding left leg and has limited movement. Caregiver reports child was limping last night on the way to bed. Caregiver thought child was trying to avoid going to bed, but this morning child was in pain and refusing to walk, so caregiver brought child to the emergency department. Diagnostic Results Hgb: 12.5 g/dL (10 to 15.5 g/dL) Hct: 38% (32% to 44%) Platelets: 280,100/mm3 (150,000 to 400,000/mm3) PT: 11.7 seconds (11 to 12.5 seconds) PTT: 118 seconds (60 to 70 seconds) WBC count: 7600/mm3 (5000 to 10,000/mm3) Factor VIII assay: 28% (55% to 145%) C-reactive protein: 0.75 mg/dL (less than 1.0 mg/dL) X-ray of left leg: No fractures are obs Actions to Take - apply ice (RICE: Rest, ice, compression, elevation) to the child's left knee - give factor replacement via IV Potential Condition - episode of hemarthrosis Parameters to Monitor - anti-hemophiliac factor - urine dipstick, which will show if blood is present in the urine The nurse should apply ice (RICE: Rest, ice, compression, elevation) to the child's left knee and give factor replacement via IV because this child has hemophilia and is most likely experiencing an episode of hemarthrosis based on the manifestations, the prolonged PTT, and the decreased Factor VIII assay. The nurse should monitor for other spontaneous bleeding episodes such as hematuria that may occur, the urine dipstick, which will show if blood is present in the urine, and the nurse should also continue to monitor the anti-hemophiliac factor (Factor VIII) results. The child may require another dose of the factor replacement to avoid further spontaneous bleeding episodes. A nurse is caring for a client who was recently admitted and has symptomatic bradycardia. 1300: Returns to room after insertion of permanent pacemaker Alert and oriented to person, needs cues for time and place Skin cool and dry Heart sounds regular, heart rate 72/min Lung sounds are coarse bilaterally Hyperresonance noted upon percussion of chest wall Respiratory rate 24/min and slightly labored Oxygen saturation 2 L/min per nasal cannula 98% Reports slight incisional pain left upper chest area Small amount red drainage present on dressing over incisional site Vital Signs Temperature 36.6° C (97.8° F) Apical pulse 42/min Respiratory rate 26/min Blood pressure 104/68 mm Hg Oxygen saturation 94% on room air The nurse should monitor the client for and following permanent pacemaker placement. Dropdown 1: Incisional site bleeding is correct. The incisional site should be monitored for bleeding and hematoma post implantation. The dressing over the site should remain clean and dry. Dropdown 2: Bradycardia is correct. The nurse should closely monitor the client's ECG rhythm following permanent pacemaker insertion to ensure that the pacemaker is preventing bradycardia. A nurse is caring for a client who has HIV. Physical Examination 1000: Reports flu-like symptoms of headache, body aches, sore throat, low-grade fever, shortness of breath, productive cough. Swollen lymph nodes. Dry skin with rash. Weight loss of 15 lb over last 3 months with report of diarrhea and anorexia, difficulty eating due to oral ulcers. Diagnostic Results 1200: Chest x-ray: Areas of increased density and white infiltrates to lower right lobe indicative of pneumonia. 1600: Hemoglobin 11 g/dL (12 g/dL to 16 g/dL) Hematocrit 36% (37% to 47%) Platelet count 155,000/mm3 (150,000 to 400,000/mm3)