swift river (Arthur Thomason, Charlie Raymond,Dotty Hamilton,Hildegard Lowe,Wight Goodman,Ramona Stukes)

Arthur Thomason

Arthur Thomason is a 56-year-old client who was involved in a motor vehicle crash (MVC). The client is four days post-operative for splenectomy and femur repair. Arthur is experiencing new onset of shortness of breath and is on oxygen at 2 L/min via nasal cannula with SpO2 at 89%. The client is restless with slight confusion but easily orientated x 3. Temperature spiked during the night to 39.1° C (102.4° F) and last temperature check was 38° C (101° F); BP now 146/94 mm Hg, which is slightly elevated from the client's baseline; respirations at 30/min and slightly labored; heart rate 102/min versus 84/min from last night's shift. Skin cool to touch and appears pale. Unproductive coughing to clear their airway. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (hypercapnia). The client appears anx

Maslow's Hierarchy of Needs

Your response: High Priority

Airway, Breathing, Circulation

Your response: High Priority

Safety and Risk Reduction

Your response: High Priority

Urgent vs Nonurgent; high

Chronic vs Acute/Stable vs Unstable- high

Initial Nursing Assessment

Arthur Thomason is a 56-year-old client who was involved in a motor vehicle accident (MVA). The client is four days post-operative for splenectomy and femur repair. Arthur is experiencing new onset of shortness of breath and is on oxygen at 2 L/min via nasal cannula with SpO2 at 89%. The client is restless with slight confusion but easily orientated x 3. Temperature spiked during the night to 39.1° C (102.4° F) and last temperature check was 38° C (101°F); BP now 146/94 mm Hg, which is slightly elevated from the client's baseline; respirations at 30/min and slightly labored; heart rate 102/min versus 84/min from last night's shift. Skin cool to touch and appears pale. Unproductive coughing to clear their airway. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (hypercapnia). The clie

Physiological: Gas Exchang,

Physiological: Acid Base

Physiological: Thermoregulation

Psychosocial: Cognition

Physiological: Comfort

Psychosocial: Stress and Coping

Physiological: Perfusion

Arthur Thomason

After receiving hand-off report, the nurse enters the client's room and observes the client talking to self. The nurse greets the client and introduces self but notices the client appears confused. The nurse provides reorientation to the client who is lying in supine position with their nasal cannula not on properly. The client is dyspneic at rest and appears restless.

Which of the following actions should the nurse take? (Select all that apply.)

Check the client's oxygen saturation level.

Place the nasal cannula on the client properly.

Assist client to high-Fowler's position

Arthur Thomason

The nursing assessment reveals lungs sounds with crackles auscultated bilaterally; respirations 29/min on oxygen at 4 L/min. IV of D5LR infusing to left hand at 75 mL/hr without signs of infiltration. Oral mucosa moist, skin pale and cool to touch. Indwelling urinary catheter draining yellow urine with 70 mL collected in two hours. Vital signs temperature 38.5°C (101.3° F); blood pressure 148/92 mm Hg; heart rate 105/min; respirations 30/min and slightly labored; SpO2 89% on 4 L/min of oxygen. The client reports "feeling funny" with some discomfort and appears anxious. Denies pain.

Which of the following provider's prescriptions should the nurse anticipate? (Select all that apply.)

Obtain arterial blood gases stat.

Maintain strict intake and output.

Administer morphine 4 mg IV every

4 hours as needed for anxiety or pain.

Administer furosemide 40 mg IV push twice daily.

Arthur Thomason

The nurse administered morphine 4 mg IV for anxiety to the client. Respiratory therapist placed the client on oxygen 7 L/min via simple face mask and SpO2 is now 94%. The client is alert and oriented x 3 and appears calm. The client has prescriptions for acetaminophen 650 mg PO every 4 hours PRN temperature greater than 38° C (100.4° F) and furosemide (Lasix) 40 mg BID as diuretic. The nurse has administered acetaminophen 650 mg PO for the client's fever and is preparing to administer furosemide 40 mg IV to the client.

Which of the following nursing actions should the nurse take for the administration of furosemide? (Select all that apply.)

Assess client's blood pressure before administration of furosemide

Ask client if they have allergies to sulfonamides.

Instruct client to change positions slowly.

Arthur Thomason

The nurse returns to the client's room one hour later to assess the client's status. When the nurse walks in the client's room, the client is sitting up in bed with simple face mask hanging off their face and reports sharp chest pain on inspiration rated as 10 on a scale of 0 to 10. The nurse observes the client sweating, several tissues with blood-tinged sputum, and the client appears apprehensive and states "feels like I am not going to make it". Lung sounds with crackles, increased respirations at 34/min, heart rate 112/min with S4 heart sounds auscultated.

The nurse suspects the client is experiencing a pulmonary embolism. Which of the following actions should the nurse take? (Select all that apply.)

Place the simple face mask back on the client.

Prepare the client for transfer to the intensive care unit (ICU).

Remain with client and reassure them.

Assess capillary refill

Arthur Thomason

The nurse preparing a plan of care for the client who has just returned from the intensive care unit (ICU) after six days following a pulmonary embolism. The client is awake, alert, and oriented x 3. Breath sounds clear, respirations even and unlabored. Abdomen soft with active bowel sounds x 4 quadrants. Active range of motion to all extremities. No swelling or edema in lower extremities. The client reports they feel so much better and cannot wait to be discharged home. The client's prescription for heparin has been discontinued, but the prescription for warfarin (Coumadin) 5 mg PO daily remains active.

Which of the following nursing interventions should the nurse include in the plan of care for the client recovering from a pulmonary embolism? (Select all that apply.)

Monitor the client's PTT.

Inform the client to report bleeding mouth or gums.

Assess vital signs frequently.

Monitor the client's platelet count.

Charlie Raymond, a 65-year-old client, was admitted to a negative pressure room on COVID-19 precautions. Charlie is a retired postal worker who lives at home with their partner. Charlie has a history of COPD, hypertension, type II diabetes, smoking, and a recent myocardial infarction. Wheezing auscultated in bilateral lower lobes. Current prescriptions include cefotaxime 2 g IV every 4 hours and insulin glargine 24 units at bedtime. The client reports no pain but states they have some shortness of breath on exertion. Vital Signs are blood pressure 145/78 mmHg, heart rate 89/min, respirations 24/min and slightly labored, temperature 100.2°F (37.9°C), and oxygen saturation 94% on 2L nasal cannula. The client reports feeling very anxious about their diagnosis.

After receiving handoff report, the nurse should determine the client's priority needs. Indicate if the client is a high priority or low priority using each of t

Maslow's Hierarchy of Needs- high

Airway, Breathing, Circulation- high

Safety and Risk Reduction- high

Urgent vs Nonurgent- high

Chronic vs Acute/Stable vs Unstable- low

Charlie Raymond

Initial Nursing Assessment

The nurse reviews the information received in the report and enters the client's room to perform a physical assessment. Upon assessment, the client is alert and oriented to person, place, time, and event. Pupils are equal, round, reactive to light, and accommodation. IV to left hand is heparin locked. Lung sounds reveal crackles and wheezes in bilateral lower lobes. Shortness of breath on exertion noted with dry non-productive cough. ABG results are pending. Client reports fatigue, headache rated as a 6 on a 0 to 10 pain scale, and loss of taste and smell. S1S2 heart tones noted. All pulses palpable. Abdomen is soft and non-tender. Bowel sounds active in all 4 quadrants. Client is lying in semi-Fowler's position. Call light is within reach.

Which of the following concerns should the nurse address while providing client care? (Select all that apply.)

Physiological: Comfort

Physiological: Gas Exchange

Physiological: Perfusion

Physiological: Infection

Health Promotion: Client Education

Charlie Raymond

The assistive personnel (AP) informs the nurse that the client's current vital signs are blood pressure 125/78 mmHg, heart rate 102/min, respirations 30/min and labored, temperature 101.3°F (38.5°C), and oxygen saturation 91% on 2L via nasal cannula. When reviewing the client's recent ABG results, the nurse identifies these findings to be consistent with respiratory distress and is preparing to enter the client's room.

Which of the following actions should the nurse take? (Select all that apply.)

Review the client's chest x-ray results.

Assess the client for bronchial breath sounds.

Reposition the client every 2 hours.

Charlie Raymond

The nurse is reviewing the client's electronic medical record (EMR) and identifies a new provider prescription for the client to receive furosemide 20 mg IV push twice daily. Upon entering the client's room to administer the furosemide, the nurse finds the client confused, combative and has pulled out their IV, and attempting to remove their oxygen. The client has a hematoma in the right hand from the IV removal.

When planning client care, which of the following actions should the nurse plan to take? (Select all that apply.)

Contact the client's provider for a prescription for restraints

Reinsert the client's IV into the right basilic vein.

Weigh the client daily.

Charlie Raymond

The nurse continues to review the client's EMR and identifies a prescription for the client to have an indwelling catheter. When entering the client's room, the client continues to demonstrate confusion. After reviewing the providers prescription and assessing the client, the nurse is preparing to insert an indwelling catheter.

Which of the following actions should the nurse take? (Select all that apply.)

Advance the client's catheter to the bifurcation during insertion.

Charlie Raymond

After inserting the urinary catheter, the nurse identifies that the client's urinary output over the past 3 hours is 50 mL. Current vital signs are blood pressure 92/58 mmHg, heart rate 102/min, respirations 32/min and labored, temperature 102.3° F (39.1° C), and oxygen saturation 90% on 2L/min via nasal cannula. Blood glucose is 112 mg/dL. A focused respiratory assessment reveals bilateral atelectasis in the lower lung bases. Client is expectorating frothy white sputum. Peripheral edema +3 noted in bilateral ankles and JVD.

Which of the following actions should the nurse take? (Select all that apply.)

Check the client's catheter for obstructions.

Notify the rapid response team of the client's condition.

Administer lactated Ringer's IV fluid.

Increase the client's oxygen to 3L/min.

Charlie Raymond

The rapid response team stabilizes the client. The nurse is planning client care and reviewing outcomes for the client.

Which of the following should the nurse identify as an indication of improvement in the client's condition? (Select all that apply.)

The client's blood glucose level is 109 mg/dL.

The client has a Modified Early Warning System (MEWS) score of 2.

Dotty Hamilton is 52-year-old client who came in at 0600 this morning as a preoperative client. They are scheduled for a laparoscopic Roux-en-Y gastric bypass at 0900.

Dotty has a history of obesity, with a BMI of 51.9, type II diabetes mellitus which they take metformin for, sleep apnea that they use a CPAP machine for at night, and hypertension. Recently they were diagnosed with nonalcoholic fatty liver disease. Dotty has difficulty ambulating and normally uses a cane.

The client states they have not had anything to eat or drink since 2000 last evening and have not taken any of their home medications this morning. They are very anxious about the procedure, especially because the OR nurse came to tell Dotty that they are running about an hour behind.

A 20 g left AC PIV was placed and capped.

Preop labs were drawn on admission and results just returned. The results are as follows: HgbA1c 9.5%, AST 52 units/L, ALT 4

Maslow's Hierarchy of Needs- high

Airway, Breathing, Circulation- low

Safety and Risk Reduction- high

Urgent vs Nonurgent-low

Chronic vs Acute/Stable vs Unstable- low

Dotty Hamilton

Initial Nursing Assessment

The client has just returned from the OR following a laparoscopic Roux-en-Y gastric bypass. The provider reports that the surgery went as planned and that there were no complications. The client is lethargic from the effects of anesthesia but arouses to their name and follows commands. They state that they are having pain and rates it at a 5 on a 0 to 10 scale. The client also reports nausea. Lungs sounds are decreased in bilateral bases, heart sounds are clear and bowel sounds are absent in all four quadrants. The client is on a 40% non-rebreather mask. The client appears pale. Bilateral radial pulses are 2+ and bilateral pedal pulses are 1+. Vital signs are temperature 37.3° C (99.1° F), pulse 96/min, respiratory rate 22/min, blood pressure 176/94 mm Hg, and oxygen saturation 96% on 40% non-rebreather mask.

Which of the following concerns should the nurse address while pr

Safety: Injury prevention

Physiological: Nutrition

Physiological: Perfusion

Physiological: Fluid and Electrolyte

Physiological: Pain

I

Dotty Hamilton

Two hours later, the nurse enters the client's room. The client is still lethargic but awakes spontaneously or to verbal stimuli. The client states that their pain is at a 3 on a 0 to 10 scale and denies needing intervention for pain. The client does report they are having nausea and feels dizzy. The client has a 0.9% sodium chloride IV drip running at 30 mL/hr through the peripheral IV. Lungs sounds are diminished bilaterally in the bases, heart sounds are clear. The client reports being thirsty and is asking for water. Bowel sounds in all four quadrants are absent. Bilateral radial pulses are 1+, and bilateral dorsalis pedis pulses 1+. Urine output via foley catheter is 60 cc in the last hour. Vital signs are temp 37.3° C (99.1° F), pulse 116/min, respiratory rate 28/min, blood pressure 110/88 mm Hg, and oxygen saturation 96% on 6L NC. The skin is clammy and cool to the touch.

The nurse calls the pr

Push ondansetron 4 mg IV.

Obtain a CBC stat.

Perform 500cc 0.9% sodium chloride IV bolus one time.

Dotty Hamilton

The nurse has implemented the provider's prescriptions and the client is now stable and resting comfortably. The nurse is creating a plan of care for the client.

Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Place the client in a semi-Fowler's position.

Place absorbent dressings between the client's skin folds

Apply bilateral sequential compression stockings.

Dotty Hamilton

The client is one day postoperative; nausea has resolved, and vital signs have remained stable overnight. Physical therapy has just finished assisting the client with ambulation and Dotty is now sitting in a chair in their room. The nurse is assisting the client with ordering a meal tray.

Which of the following items should the nurse encourage the client to order on their meal tray? (Select all that apply.)

Room temperature tea

Chicken broth

Warm milk

Dotty Hamilton

The client is 2 days postoperative, and the nurse enters the room to perform their beginning of shift assessment. The client is sitting up in bed, alert and orientated x4. The client states they finished their breakfast tray about 15 min ago. The client appears pale and slightly diaphoretic and states they want to lay down. Lungs sounds are diminished in the bases, and heart sounds are clear. Bowel sounds are hyperactive in all four quadrants. Bilateral radial and dorsalis pedal pulses are 1+. Vital signs are temp 36.8° C (98.2° F), pulse 104/min, respiratory rate 22/min, blood pressure 142/71 mm Hg, and oxygen saturation 98% on RA. Labs from this morning are: WBC 9000/mm³, Hct 48%,Hgb 16 g/dL, Plt 275,000/mm³, K⁺ 4.3 mEq/L, and Na 141 mEq/L.

Which of the following post operative complications does the nurse anticipate that the client is experiencing? (Select all that apply.)

Dumping syndrome

Dotty Hamilton

The client is 3 days postoperative and has a prescription to be discharged home later today. The nurse is completing the discharge teaching with the client and their partner.

Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply

will need to take iron supplements has prescribed."

During meals I will eat the foods with protein first."

I may experience changes in my bowel patterns such as diarrhea."

Hildegard Lowe is a 68-year-old female, admitted through the emergency department (ED) for a persistent cough. The client is alert and cooperative, receiving oxygen at 2 L/min via nasal canula. IV 0.9% normal saline infusing at 125 mL/hr. Chest x-ray upon admission indicates right middle lobe pneumonia. Vital signs are blood pressure 128/86 mmHg, pulse 105/min, respirations 32/min, temperature 37.7° C (99.8° F), and oxygen saturation 93% on 2 L/min via nasal canula. Laboratory results from the ED are pending. Plan of care is antibiotic therapy and supplemental oxygen therapy. Client had fall that resulted in an open reduction internal fixation of the right ulna 3 months ago. The client has a history of age-related macular degeneration and osteoporosis. The client takes alendronate for osteoporosis. The client is widowed and has one child who is on their way from out of state who will be arriving sometime today. The c

Maslow's Hierarchy of Needs- high

Airway, Breathing, Circulation- high

Safety and Risk Reduction- high

Urgent vs Nonurgent- high

Chronic vs Acute/Stable vs Unstable- low

Hildegard Lowe

Initial Nursing Assessment

The nurse reviews the information received in the report and enters the client's room to perform a physical assessment. Upon assessment, the client is alert and oriented to person, place, time, and event. Pupils are equal, round, reactive to light, and accommodation. IV to left forearm is infusing 0.9% normal saline at 125 mL/hr. Crackles auscultated bilaterally with lung sounds diminished in the right middle lobe. Dulled percussion is noted over right middle lung base. The client is tachypneic and is receiving oxygen at 2 L/min via nasal canula. Client has a productive cough and is expectorating green-yellow sputum. The client rates pain as a 4 on a 0 to 10 pain scale during coughing episodes. S1S2 heart tones are noted. All pulses palpable. The abdomen is soft and nontender upon palpation. Bowel sounds are active in all four quadrants. The client is lying in semi-Fowler's

Physiological: Comfort

Physiological: Gas Exchange

Physiological: Infection

Physiological: Inflammation

Physiological: Perfusion

Hildegard Lowe

The assistive personnel reports current vital signs to the nurse. Blood pressure is 140/92 mmHg, heart rate 110/min, respirations 36/min, temperature 37.7° C (99.8° F), and oxygen saturation 88% on 2 L/min via nasal canula. When the nurse enters the client's room, the client is pleasant and cooperative but appears anxious.

Which of the following actions should the nurse take? (Select all that apply.)

Teach the client how to use an incentive spirometer.

Instruct the client to cough and deep breathe every 2 hr.

Increase the client's supplemental oxygen from 2 L/min to 4 L/min.

Hildegard Lowe

The nurse is reviewing the client's electronic medical record (EMR) and notices that laboratory results have returned.

Which of the following lab values should the nurse report to the client's provider? (Select all that apply.)

Hemoglobin 10.9 g/dL

Hematocrit 34.3%

BUN 6 mg/dL

RBC 3.5 x 10⁶/µl

WBC 15,600 mm³

Hildegard Lowe

The client calls the nurses' station to report their IV pump is beeping. Upon entering the client's room, the nurse assesses the infusion site and notices the site is soft and raised. IV to left forearm is infusing 0.9% normal saline at 125 mL/hr. The client reports discomfort and burning at the site.

Which of the following actions should the nurse take?

Stop the client's IV infusion.

Hildegard Lowe

The nurse removes the client's IV due to infiltration and is preparing for reinsertion. When reviewing the client's electronic medical record and current provider prescriptions, the nurse notices that the client has new prescriptions, including fluticasone 100 mcg inhaled twice daily, methylprednisolone 40 mg IM weekly, and azithromycin 500 mg IV every 24 hr.

Which of the following nursing actions should the nurse include in the client's plan of care? (Select all that apply.)

Teach the client how to use a metered-dose inhaler.

Monitor the client's blood glucose level.

Hildegard Lowe

The nurse is evaluating the client's treatment outcomes in the electronic medical record (EMR). Recent vital signs are blood pressure 124/82 mmHg, heart rate 91/min, respirations 20/min, temperature 37.1° C (98.8° F), and oxygen saturation 96% on room air.

Which of the following indicates the client is progressing toward discharge? (Select all that apply.)

The client's oxygen saturation on 96%.

The client has a mild productive cough with clear sputum

John Davis was admitted to the hospital for biopsy and surgical resection of multiple pigmented macular and papular lesions on the shoulders, arms, and back. The client has a history of cancerous and precancerous lesions throughout the upper body and face and has a scar over the left eyebrow from the removal of a basal carcinoma 4 years ago. The client is 54 years old and works for a landscaping business. The client also has a cabin on a lake and spends weekends boating with family and friends.

Client is fair skinned, of slight build weighing 150 lb (68 kg) with a recent weight loss of 8 lb (3.63 kg). There is a 3.5 cm by 3.0 cm scar over the client's left eyebrow and concern has been verbalized about additional scarring from the upcoming procedures. The possibility of a biopsy and removing lymph nodes has also been discussed with the provider if any of the lesions are melanoma. Mole mapping was done by the dermat

Maslow's Hierarchy of Needs- low

Airway, Breathing, Circulation- low

Safety and Risk Reduction- low

Urgent vs Nonurgent- low

Chronic vs Acute/Stable vs Unstable- low

John Davis

Initial Nursing Assessment

Client is awake, alert, and able to answer all questions without difficulty. 3.5 cm by 3.0 cm scar over left eyebrow from the removal of a basal cell carcinoma 4 years ago. Family history of several family members who had skin cancer and paternal grandfather who died from a melanoma that originated from their shoulder. The client admits to not taking enough preventive measures to prevent skin exposure daily. "It's just part of my job to be outside, and to be honest, I love being outside whether working or boating on a lake." The nurse asked about their level of exercise, and they reported that their work and recreation provide plenty of exercise. The client shows the nurse a watch that monitors exercise, nutrition, and sleep. Breath sounds clear; respiration even and unlabored. Abdomen flat, without any pulsations or masses with bowel sounds present in all four quadrants. Full r

Physiological: Tissue Integrity

Health Promotion: Client Education

Physiological: Cellular regulation

Psychosocial: Stress and Coping

Health Promotion: Self Care

John Davis

The time for the client's surgery has changed, and the client has 4 hr before going to surgery. The nurse takes this opportunity to educate the client about skin cancer and lifestyle choices with the client.

Which of the following information should the nurse include in the client teaching about skin cancer, risk factors, and health promotion? (Select all that apply.)

Light-skinned people are at greater risk of skin cancer.

Wear opaque clothing when in the sun.

John Davis

The PACU nurse calls to give report on the client. The surgeon treated a total of 21 actinic keratoses scattered across the client's arms, shoulders, and upper back using cryotherapy. A combination of 8 squamous and basal cell carcinomas were removed by curettage and electrodessication; the latter being an electric probe that destroyed any remaining cancerous tissue. Three melanomas were identified via microscopic analysis and removed using a full thickness wide excision technique. The excised tissue was sent to the laboratory for analysis of the margins along with lymph nodes located close to each melanoma. One melanoma was located on the right forearm, one on the left shoulder, and a third located just over the right scapula. A new mole map was developed and is in the EHR. The provider has prescribed the client lie in the prone position for 4 hr for better observation of the three full thickness surgical

Assess the client's airway.

John Davis

The nurse is reviewing the client's postoperative prescriptions and surgical notes in the client's medical record. It has been an hour since the client has returned from surgery. The client's IV of LR at 125 mL is infusing to the client's left hand, patent. Vital signs blood pressure 128/70 mm Hg; pulse 70/min; respirations 16/min; temperature 98.6° F (37° C); SpO₂ 98% on room air. The client reports pain of 0 on a pain scale of 0 to 10. Two of the pressure dressings on the client's back have moderate amounts of slight red drainage on them.

Which of the following actions should the nurse take while caring for the client? (Select all that apply.)

Mark and date the outer perimeter of the drainage.

Reinforce the dressing with gauze.

Document the amount, color, and consistency of the drainage.

John Davis

The surgeon and the nurse walk into John Davis' room the morning following surgery to discuss the results of the pathology report on the melanomas. The melanomas on the shoulder and scapula had clear margins, and the sentinel lymph nodes did not have any cancer cells in them. The melanoma on the arm, which was the largest, also had clear margins but there were cancer cells in its sentinel lymph node. A positron emission tomography (PET) scan has been scheduled to determine if there are metastases to any part of the body. After the surgeon leaves the room, the client asks the nurse more information about the PET scan and if it is painful.

Which of the following statements should the nurse include in teaching the client about PET scans? (Select all that apply.)

The scan uses a glucose-based tracer that lights up cancer cells brighter than healthy cells; may experience some discomfort.

John Davis

The nurse enters the client's room and introduces the oncologist who will be establishing the client's therapeutic protocol and following the client during treatment. The oncologist explains that the test results are back from the PET scan performed yesterday. There were two small tumors in the left lung. The client asks if there could be a mistake, but the oncologist informed the client that they reviewed the results and agrees with the diagnosis of stage 4 melanoma. The client appears shocked and scared when informed about the diagnosis and asks what comes next. The oncologist recommends immunotherapy, and the client agrees to undergo the treatment. The oncologist informs the client that an infusion specialist will be by before discharge to make arrangements for the treatments. The nurse stays with the client after the oncologist leaves and sits down next to the client.

The client has just received

Give support

Education

Resources

Wight Goodman is a 22-year-old who experienced a concussion 2 days ago. He is brought to the Emergency Department by a roommate who states that the client has been reporting worsening headaches since the concussion. The roommate states that over the last 24 hours, the client has become confused, unable to sleep, vomited several times, and recently started reporting extreme pain from the headaches.

The client is lethargic and moaning in pain. Vital signs are temperature 38.0°C (100.4° F), pulse 98/min, respirations 32/ min, blood pressure 138/85 mmHg and SpO2 92%. Glasgow coma scale (GCS) score is 13.

After receiving handoff report, the nurse should determine the client's priority needs. Indicate if the client is a high priority or low priority using each of the priority frameworks below.

Maslow's Hierarchy of Needs- high

Airway, Breathing, Circulation- high

Safety and Risk Reduction- high

Urgent vs Nonurgent- high

Chronic vs Acute/Stable vs Unstable- high

Wight Goodman

Initial Nursing Assessment

The client has just returned from a STAT CT scan. The nurse reassesses the client and finds that he is now obtunded and confused and he localizes to pain. The client opens eyes to painful stimuli. GCS is 11. Vital signs are T 38.5°C (101.3° F), P 66/min, R 12/ min, BP 155/75 mmHg, and SpO2 88% on 2L NC. The client's pupils are round. The right pupil is 3mm in diameter and reacts to light while the left pupil is 5mm in diameter and is sluggish to light. Results of CT the scan reveals a subdural hematoma that overlays the posterior frontal lobe and part of the temporal lobe. A midline shift of 5mm is present. The provider determines that emergency surgery is indicated.

Safety: Injury prevention

Psychosocial: Cognition

Physiological: Gas Exchange

Physiological: Intracranial regulation

Physiological: Perfusion

Physiological: Pain

Physiological: Thermoregulation

Wight Goodman

The client is admitted to the ICU following emergency evacuation of a subdural hematoma via burr hole and placement of a subarachnoid bolt to monitor ICP. The client was extubated in the OR and is sleepy but answers questions appropriately and is orientated x 3. Glasgow Coma Scale score is 13. Client can move all extremities when asked to do so. Pupils are equal and reactive; however, the left pupil is more sluggish. Vital signs are T 37.5°C (99.5° F), P 68/min, R 16/ min, BP 100/60 mmHg, and SpO2 97% on 4L NC. The client rates head pain as a 5 on a scale of 0 to 10.

Which of the following assessment findings in the nurse most concerned about? (Select all that apply.)

Pupils

Blood pressure

ICP

Wight Goodman

During the hour after admission the nurse checks the client's ICP every 15 minutes and notes that the client's ICP has increased consistently and is now registering 22 mmHg. The nurse notifies the provider and receives a prescription for mannitol 20 % 1 gram IV STAT. The nurse quickly obtains the medication from the pharmacy and prepares to administer the medication.

What actions should the nurse implement regarding safe administration of this drug? (Select all that apply.)

Maintain strict intake and output.

Monitor serum osmolality every 6 hrs.

Administer over 30 minutes.

Wight Goodman

The nurse reviews the client's plan of care for interventions that will help to decrease the client's ICP.

Which of the following actions should the nurse take? (Select all that apply.)

Keep the head and neck midline.

Cluster tasks to minimize interruptions.

Administer oxygen to maintain PaO2 between 80-100 mmHg.

Wight Goodman

3 hours later the nurse enters the client's room and finds the client hard to arouse. The client's vital signs are T 39.2°C (102.5° F), P 56/min, R 12/ min and irregular, BP 172/70 mmHg ICP is now 25 mmHg, Glasgow Coma Scale score is 5, and left pupil is fixed and 8 mmHg.

Which of the following complications does the nurse anticipate the client is experiencing?

Cushing's response

Wight Goodman

The nurse notifies the provider of the client's current condition.

Which of the following prescriptions does the nurse anticipate? (Select all that apply.)

Begin therapeutic hypothermia.

Prepare the client for intubation.

Administration of an antipyretic.

Start a propofol drip.

Ramona Stukes, 69-years-old, third day post-operative cholecystectomy. No significant past medical history and no known allergies. Last vital signs were temperature 37° C (98.6° F), Heart rate 100/min, Respirations 20/min, Blood pressure 114/62 mm Hg, SpO2 is 95% on room air. Client is alert and cooperative. Daily dressing changes; Nasogastric tube in place but will possibly be discontinued today after Dr. Levine rounds. Today's incentive spirometry tidal volume is 1250 mL, an improvement over yesterday's 900 mL. NPO with small amounts of ice chips only. Hypoactive bowel sounds in all 4 quadrants, has not passed flatus. Weight this morning 226 lbs (102.5 kg). IV of D51/2NS with 20KCL@ 125mL/hr in left forearm. Last pain medication 4 hours ago at 1100 with morphine 4 mg IV push. Client ambulates with assistance because they are afraid to move. Significant other at bedside.

After receiving handoff report, the nurse

Maslow's Hierarchy of Needs- high

Airway, Breathing, Circulation- low

Safety and Risk Reduction- high

Urgent vs Nonurgent- low

Chronic vs Acute/Stable vs Unstable- low

Ramona Stukes

Initial Nursing Assessment

1500: Received awake, alert, and oriented to person, place, and time. PERRLA. Breath sounds clear in bilateral lungs; respirations even and unlabored. Nasogastric tube to right nare to low intermittent suction with no drainage in tubing and small amount of tan drainage in canister. No skin breakdown observed around nares or under tape. IV of Dextrose 5% in 0.45% sodium chloride with 20mEq Potassium Chloride infusing at 125 mL/hr in left forearm without redness or swelling observed. Capillary refill less than 3 seconds in bilateral upper and bilateral lower extremities. Abdomen soft, nondistended, hypoactive bowel sounds active in all quadrants. Abdominal incision midline and intact with sutures. Skin warm and dry; color appropriate for genetic background. Reports pain a 5 on a scale of 0 to 10 in their abdomen as burning. Encouraged client not to wait until pain gets too seve

Physiological: Mobility

Safety: Injury prevention

Physiological: Nutrition

Physiological: Pain

Physiological: Tissue Integrit

Physiological: Elimination

Ramona Stukes

1510: The nurse has just administered morphine 4 mg IV push to the client. The client rated pain 5 on a scale of 0 to 10 in the abdomen as burning. The nurse observes the client appears to be upset and crying. The client states, "I came in for a simple procedure and was supposed to go home the next day; it is four days later and now I have this thing sticking out of my nose." The client reports that they feel awkward with their stomach contents visible in the tube and they do not want to have visitors for that reason.

After listening to the client's concerns, which of the following actions should the nurse take? (Select all that apply.)

Acknowledge that the client may be experiencing the stages of grief.

Discuss measures that can be taken to cover up the drainage collection container.

Encourage the client to continue to express their feelings.

Ramona Stukes

1800: The client's partner comes to the nurses' station and requests the nurse come to the client's room. They report the client was eating ice chips and began coughing as if they were choking and could not stop. After a few minutes of coughing, their incision began bleeding and then it "opened up." After entering the client's room, the nurse observes the client sitting on the side of the bed and observed that wound dehiscence has occurred.

Which of the following actions should the nurse take? (Select all that apply.)

Call for another nurse to contact the surgeon.

Document the incident in the client's electronic medical record

Apply a sterile saline dressing to the wound.

Place client in low Fowler's position with knees and hips bent.

Ensure the client has patent IV access

Ramona Stukes

The surgeon finds that the client does not require an incision and drainage (I&D) and closes the wound to heal. The wound is sutured, re-dressed, and covered with an abdominal binder to provide additional support to the wound. The surgeon has stepped away to complete their documentation. The client reports not feeling well. The nurse performs an assessment on the client. The client's lung sounds reveal wheezes in right lower lobe; hypoactive bowel sounds; IV of Dextrose 5% in 0.45% sodium chloride with 20 mEQ Potassium chloride @ 125mL/hr in left forearm without redness, swelling, or pain at insertion site. The nurse observes light yellow sputum on a napkin the client coughed up. The client's vital signs are temperature = 100.9° F (38.3° C), Heart Rate 101/min, Respirations = 21/min, BP = 120/74 mm Hg, SpO2 is 96%. Incentive spirometry tidal volume is 1000 mL.

Based on the assessment, which of the fol

Lung sounds

Temperature

Sputum

Ramona Stukes

The provider suspects the client may have hospital-acquired pneumonia and prescribes a chest x-ray and IV antibiotics.

Which of the following statements should the nurse include in the client teaching about pulmonary hygiene? (Select all that apply.)

Use the incentive spirometer at least once every hour while you are awake."

You should change positions or go for a walk about every 2 hours."

Ramona Stukes

It has been 4 days since the client was diagnosed with pneumonia and dehiscence. The client reports they are feeling better and ready to go home. The provider has since written discharge prescriptions and home health consultation for the client who will be discharged post-cholecystectomy.

Which of the following statements made by the client indicates an understanding of the discharge teaching regarding post-cholecystectomy? (Select all that apply.)

"I should consume a diet that includes lots of carbohydrates and protein."

I should contact the provider's office if the color of my stool changes."