2025 A
Following an emergency appendectomy, a client who is post-op is being cared for by a nurse on
a med surge unit. 1st Exhibit: VS Temp 37.7, HR 82, RR 16, BP 127/80, and O2 99 percent on
RA Exhibit 2: Evaluation Ht 157.7cm
Wt 90kg
BLE is warm to the touch, the pedal pulses 2+ b/l, and there are spider veins on BLE and
distended veins on RLE. 3rd Exhibit: RN Notes Client reports pain at abd incision site as 4/10;
reports RLE pain as 5/10 and itchy; reports RLE pain has been intermittent for ~2 mo; denies
current LLE pain
Describe the probable condition that the client is experiencing, two steps that the nurse should
take, and two parameters that the nurse should keep an eye on to evaluate the client's
progress. Varicose veins are the condition I'm experiencing. Steps to take include elevating the
affected limb and using graduated compression stockings. Monitoring parameters include RLE
edema and pruritis. A preschooler is being cared for by a nurse on a pediatric unit. Which of the
following actions should the nurse take after looking over the results of the assessment? Select
4 actions the nurse should take.
Discontinue IV Medication
Apply 0.9% NaCl intravenously. Administer epinephrine IM
Check VS frequently. A nurse is caring for a client who is 24 hr postop following a c-section.
Drag one condition and one client finding to each empty space: The client is at risk for
developing __A__ as evidenced by __B__.
A: Sicknesses B - BP
A nurse is caring for a client who has schizophrenia in an inpatient facility. Click to highlight the
findings that require immediate follow up.
Unidentified Response A nurse is caring for a client who is in the spinal cord injury unit.
Exhibit 1 - RN Notes
Day 1; 1700: Client admitted to SCI 3 ays ago following C7 injury. Over the past 12 hours, the
indwelling urinary catheter has produced 800 mL of urine. Day 2; 0600: Client has
nonproductive cough. Over the past six hours, the indwelling urinary catheter produced 100 mL
of urine. Exhibit 2 - VS
Day 1, 2200: Temp 37.2, HR 74, RR 20, BP 110/60, O2 95% on RA
Day 2, 0600: Temp 37.8, HR 54, RR 26, BP 96/60, O2 90% on RA
Exhibit 3 - PE
Day 1, 1700: Lower lobe lung sounds lessen. Deep tendon reflexes (DTR) are biceps 1+,
triceps 1+, patella 0, and ankle 0 b/l. Skin is cool, pale, and dry to touch.
Day 2, 0600: Adventitious lung sounds auscultated in lower lobes b/l. Abdomen distended w/
hypoactive bowel sounds.