QUESTIONS AND WELL VERIFIED ANSWERS
[ALREADY GRADED A+} REAL EXAM!!! REAL
EXAM!!!
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
Client alert and oriented to person, place, and time. Client had episode of diarrhea,
provided perineal care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on
sacrum. Client repositioned every 4 hr. - ANS✔✔---Click to highlight the findings that
require follow up. To deselect a finding, click on the finding again.
- Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum
- Client repositioned every 4 hr
When recognizing cues, the nurse should determine that the client's painful edematous
area on their sacrum and that the client has only been repositioned every 4 hr requires
follow up. The client has manifestations of a pressure injury that need to be addressed.
The client should be repositioned at least every 2 hr to prevent worsening of the
pressure injury and to relieve pressure from the sacral area.
A nurse in an outpatient mental health clinic is caring for a client
Vital Signs
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
4 hr output - ANS✔✔---The client is at greatest risk for developing dysrhythmias, as
evidenced by electrolyte imbalance
.
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.