NURSING 112023 COMPREHENSIVE
CLINICAL SKILLS REVIEW SHEET FULL
SOLUTIONS
●● A nurse is caring for a 5-year-old child
Exhibit 1: Physical Exam 15:10
Upon visual inspection, throat is inflamed, tonsils appear pink, reddened
and epiglottis is edematous and cherry red in appearance. Skin appears
pale. Stridor noted upon inspiration with diminished bilateral lung
sounds
Exhibit 2: Nurses' Notes 15:10
Child accompanied to RD by caregiver. Caregiver states child has a sore
throat and reports the child has "pain on swallowing" and denies cough.
Child is agitated and learning forward with drooling noted.
Exhibit 3: Vital Signs 15:05
Axillary Temp: 102F
HR: 130/min
Resp: 28/min
BP: 99/58 mmHg
O2: 90% on room air
,Exhibit 4: Medical History
Family history of asthma
Child seen 6 months ago for tonsillitis and treated with antibiotic
therapy.
Answer: Answer:
Condition: epiglottitis
Actions: droplet precautions and IV antibiotics
Monitor: Temp and breath sounds
●● A nurse is caring for a client who is on the spinal cord injury (SCI)
unit.
Exhibit 1: Nurses' Notes
Day 3, 1700:
Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool,
pale, and dry to touch. Respirations easy and unlabored. Lung sounds
diminished to lower lobes. Abdomen soft and nondistended with active
bowel sounds. client passed a small amount of hard formed stool this
AM. Indwelling catheter draining clean, yellow urine. DTR are biceps
1+, Triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0.
Day 4, 0600
Client reports increasing coughing and SOB. Crackles auscultated in
BLL. Face and neck flushed, skin warm and moist. Client reports
blurred vision and a headache as an 8/10 on pain scale. Abd soft and
mildly distended. hypoactive bowel sounds present. Urinary output
300mL over last 8hr
,Exhibit 2: Vital Signs
Day 3 1700:
Temp: 100.8F
HR: 74
Resp: 20
BP: 108/60 mmHg
O2: 96%
Answer: The client is most likely experiencing manifestations of
PNEUMONIA and AUTONOMIC DYSREFLEXIA.
●● A nurse is caring for a client who has abd pain
Exhibit 1: Nurses' Notes
0900:
Client reports loss of appetite, weight loss, and fatigue for 1 week.
Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client is a
perioperative nurse, returned 1 week ago from a 2-week mission trip to
an underdeveloped country.
1200:
Results of antibody studies obtained. Provider prescription for antiviral
medication pending.
Exhibit 2: Physical Exam
, 0930:
Lung sounds clear bilaterally. Skin warm to touch and jaundiced. Dry
skin noted on extremities. Sclera yellow bilaterally. Bowel sounds
normoactive in four quadrants. Client reports right upper quadrant pain
upon palpation. Urine specimen obtained for urinalysis, dark yellow in
color.
Exhibit 3: Vital Signs
0900:
Temp: 98.5F
HR: 84
Resp: 18
BP: 118/78 mmHg
O2: 98% on RA
Exhibit 4: Diagnostic Results
1100:
Aspartate aminotransferase (AST) 375 units/L (0 to 35 units/L)
A
Answer: Client's risk from bloodborne transmission: Hep B, Hep C
Physical examination findings: Hep A, Hep B, Hep C
CLINICAL SKILLS REVIEW SHEET FULL
SOLUTIONS
●● A nurse is caring for a 5-year-old child
Exhibit 1: Physical Exam 15:10
Upon visual inspection, throat is inflamed, tonsils appear pink, reddened
and epiglottis is edematous and cherry red in appearance. Skin appears
pale. Stridor noted upon inspiration with diminished bilateral lung
sounds
Exhibit 2: Nurses' Notes 15:10
Child accompanied to RD by caregiver. Caregiver states child has a sore
throat and reports the child has "pain on swallowing" and denies cough.
Child is agitated and learning forward with drooling noted.
Exhibit 3: Vital Signs 15:05
Axillary Temp: 102F
HR: 130/min
Resp: 28/min
BP: 99/58 mmHg
O2: 90% on room air
,Exhibit 4: Medical History
Family history of asthma
Child seen 6 months ago for tonsillitis and treated with antibiotic
therapy.
Answer: Answer:
Condition: epiglottitis
Actions: droplet precautions and IV antibiotics
Monitor: Temp and breath sounds
●● A nurse is caring for a client who is on the spinal cord injury (SCI)
unit.
Exhibit 1: Nurses' Notes
Day 3, 1700:
Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool,
pale, and dry to touch. Respirations easy and unlabored. Lung sounds
diminished to lower lobes. Abdomen soft and nondistended with active
bowel sounds. client passed a small amount of hard formed stool this
AM. Indwelling catheter draining clean, yellow urine. DTR are biceps
1+, Triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0.
Day 4, 0600
Client reports increasing coughing and SOB. Crackles auscultated in
BLL. Face and neck flushed, skin warm and moist. Client reports
blurred vision and a headache as an 8/10 on pain scale. Abd soft and
mildly distended. hypoactive bowel sounds present. Urinary output
300mL over last 8hr
,Exhibit 2: Vital Signs
Day 3 1700:
Temp: 100.8F
HR: 74
Resp: 20
BP: 108/60 mmHg
O2: 96%
Answer: The client is most likely experiencing manifestations of
PNEUMONIA and AUTONOMIC DYSREFLEXIA.
●● A nurse is caring for a client who has abd pain
Exhibit 1: Nurses' Notes
0900:
Client reports loss of appetite, weight loss, and fatigue for 1 week.
Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client is a
perioperative nurse, returned 1 week ago from a 2-week mission trip to
an underdeveloped country.
1200:
Results of antibody studies obtained. Provider prescription for antiviral
medication pending.
Exhibit 2: Physical Exam
, 0930:
Lung sounds clear bilaterally. Skin warm to touch and jaundiced. Dry
skin noted on extremities. Sclera yellow bilaterally. Bowel sounds
normoactive in four quadrants. Client reports right upper quadrant pain
upon palpation. Urine specimen obtained for urinalysis, dark yellow in
color.
Exhibit 3: Vital Signs
0900:
Temp: 98.5F
HR: 84
Resp: 18
BP: 118/78 mmHg
O2: 98% on RA
Exhibit 4: Diagnostic Results
1100:
Aspartate aminotransferase (AST) 375 units/L (0 to 35 units/L)
A
Answer: Client's risk from bloodborne transmission: Hep B, Hep C
Physical examination findings: Hep A, Hep B, Hep C
