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 -correct answers The client is most likely experiencing manifestations of
pneumonia and autonomic dysreflexia.
The nurse should analyze cues from the client's manifestations and determine that the client is
most likely experiencing manifestations of pneumonia and autonomic dysreflexia. A client who
has a cervical SCI is at risk for respiratory complications because spinal innervation to the
respiratory muscles is disrupted. Adventitious breath sounds in the lower lobes bilaterally and a
decrease in oxygen saturation to less than 92% can indicate pneumonia. The client's sudden
increase in blood pressure, bradycardia, flushing of the skin above the area of the injury,
headache, and blurred vision are manifestations of autonomic dysreflexia, which can be a life-
threatening condition.
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 -correct answers The client is at greatest risk for developing dysrhythmias, as
evidenced by electrolyte imbalance.
The nurse should analyze cues to determine the client is at greatest risk for developing
dysrhythmias related to hypokalemia, as evidenced by the laboratory report and the client's
report of muscle cramping. Potassium and magnesium depletion are common manifestations in
clients who are postoperative following CABG. Due to medication or hemodilation, it is
important for the nurse to closely monitor electrolytes.
A nurse is caring for a client who is pregnant in the acute care setting
Nurses' Notes
1400
Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr.
Denies any changes in vaginal discharge. External fetal monitor applied.
, 1430
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 -correct answers 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 assessing a newborn who is 3 days old
History and Physical
Newborn was delivered at 37 weeks of gestation via cesarean section for fetal distress. Apgar
scores: 8 at 1 min and 9 at 5 min. Birth weight: 2.9 kg (6 lb 6 oz) The client who gave birth plans
to breastfeed.
Flow Sheet
Day 2 of Life, 0900:
Temperature 36.7° C (98.1° F) Heart rate 140/min Respiratory rate 48/min Weight 2.7 kg (6 lb);
6% weight loss Day 3 of Life, 0800:
Temperature 36.4° C (97.5° F) Heart rate 140/min Res -correct answers Click to highlight the
findings that require follow up. To deselect a finding, click on the finding again.
- Temperature 36.4 C (97.5 F)
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 -correct answers The client is most likely experiencing manifestations of
pneumonia and autonomic dysreflexia.
The nurse should analyze cues from the client's manifestations and determine that the client is
most likely experiencing manifestations of pneumonia and autonomic dysreflexia. A client who
has a cervical SCI is at risk for respiratory complications because spinal innervation to the
respiratory muscles is disrupted. Adventitious breath sounds in the lower lobes bilaterally and a
decrease in oxygen saturation to less than 92% can indicate pneumonia. The client's sudden
increase in blood pressure, bradycardia, flushing of the skin above the area of the injury,
headache, and blurred vision are manifestations of autonomic dysreflexia, which can be a life-
threatening condition.
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 -correct answers The client is at greatest risk for developing dysrhythmias, as
evidenced by electrolyte imbalance.
The nurse should analyze cues to determine the client is at greatest risk for developing
dysrhythmias related to hypokalemia, as evidenced by the laboratory report and the client's
report of muscle cramping. Potassium and magnesium depletion are common manifestations in
clients who are postoperative following CABG. Due to medication or hemodilation, it is
important for the nurse to closely monitor electrolytes.
A nurse is caring for a client who is pregnant in the acute care setting
Nurses' Notes
1400
Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr.
Denies any changes in vaginal discharge. External fetal monitor applied.
, 1430
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 -correct answers 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 assessing a newborn who is 3 days old
History and Physical
Newborn was delivered at 37 weeks of gestation via cesarean section for fetal distress. Apgar
scores: 8 at 1 min and 9 at 5 min. Birth weight: 2.9 kg (6 lb 6 oz) The client who gave birth plans
to breastfeed.
Flow Sheet
Day 2 of Life, 0900:
Temperature 36.7° C (98.1° F) Heart rate 140/min Respiratory rate 48/min Weight 2.7 kg (6 lb);
6% weight loss Day 3 of Life, 0800:
Temperature 36.4° C (97.5° F) Heart rate 140/min Res -correct answers Click to highlight the
findings that require follow up. To deselect a finding, click on the finding again.
- Temperature 36.4 C (97.5 F)
