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Patient Data

The emergency department nurse conducted an initial assessment.

Click to highlight the findings from the nurse's assessment that warrant follow-up.

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Client is alert and oriented to person, place, time, and situation. Client states, "It's been hard to catch my breath." Crackles are heard in the bases of bilateral lungs. S1 and S2 heart sounds noted. Heart rate is 118 beats/minute with a regular rhythm. Bilateral peripheral pitting edema of 2+ is present in both legs. Client denies pain. Reports voiding prior to coming to hospital.

Client is alert and oriented to person, place, time, and situation.

Client states, "It's been hard to catch my breath."

Crackles are heard in the bases of bilateral lungs.

S1 and S2 heart sounds noted.

Heart rate is 118 beats/minute with a regular rhythm.

Bilateral peripheral pitting edema of 2+ is present in both legs.

Client denies pain.

Reports voiding prior to coming to hospital.

Answer and Explanation

The Correct Answer is ["B","C","E","F"]

Rationale for correct answers:

Client states, "It's been hard to catch my breath.": This subjective report of dyspnea (shortness of breath) is a significant indicator of respiratory distress or cardiovascular compromise, especially given her oxygen saturation was only 83% on room air.
Crackles are heard in the bases of bilateral lungs: Crackles (rales) typically indicate fluid in the alveolar spaces. In a patient with a history of MI and hypertension, this is a classic sign of pulmonary edema related to left-sided heart failure.
Heart rate is 118 beats/minute with a regular rhythm: This is tachycardia (a heart rate over 100 bpm). The heart is likely overcompensating for low oxygen levels or decreased cardiac output.
Bilateral peripheral pitting edema of 2+ is present in both legs: Pitting edema indicates systemic fluid volume overload, commonly associated with right-sided heart failure or the heart's inability to pump effectively.

Rationale for incorrect choices:

Client is alert and oriented to person, place, time, and situation: This is a normal neurological finding (A&O x4), indicating that brain perfusion is currently adequate.
S1 and S2 heart sounds noted: These are the "lub-dub" sounds of normal heart valve closure. Their presence is a baseline normal finding.
Client denies pain: At 0125, the absence of pain is a stable finding (though follow-up became necessary at 0135 when she began reporting "heavy" chest pain).
Reports voiding prior to coming to hospital: This indicates recent renal perfusion and bladder function, which is a normal historical detail.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Rolling both gloves off at the same time is not recommended, as it increases the risk of contamination. Proper glove removal involves peeling off one glove at a time, turning it inside out to avoid contact with contaminated surfaces.

B. Using two pairs of gloves (double-gloving) may be necessary for certain high-risk procedures, but it is not required for routine bedpan handling. The focus should be on proper technique rather than adding extra gloves unnecessarily.

C. Advising the UAP that the technique being used will result in hand contamination is correct. Sliding fingers inside the contaminated glove and rolling it off inappropriately can transfer pathogens to the skin. The nurse should correct the technique by teaching the proper method: grasp the outside of one glove at the wrist, peel it off inside out, then tuck it into the remaining glove and peel off the second glove inside out. This minimizes the risk of self-contamination and infection transmission.

D. Discarding gloves in the appropriate container is important, but the primary concern here is the incorrect removal technique, which poses an immediate contamination risk. Teaching correct removal takes priority over simply reminding where to discard gloves.

A. Ventricular arrhythmias. B. Profound weight gain. C. Decreased urinary output. D. Low blood glucose levels.

Correct Answer is A

Explanation

A. Ventricular arrhythmias warrant immediate intervention because they indicate a life-threatening cardiac complication. Clients with a history of bilateral adrenalectomy are at risk for adrenal crisis, which can cause electrolyte imbalances such as hyperkalemia. Hyperkalemia can precipitate ventricular arrhythmias, making this a critical, time-sensitive finding requiring urgent treatment.

B. Profound weight gain may indicate fluid retention, which is important to monitor but is not immediately life-threatening. It requires assessment and intervention over time but does not take priority over a potentially fatal arrhythmia.

C. Decreased urinary output is a sign of compromised renal perfusion or fluid imbalance. While concerning, it is not as immediately life-threatening as ventricular arrhythmias and typically follows assessment and stabilization of cardiovascular status.

D. Low blood glucose levels (hypoglycemia) are important to identify and treat promptly in clients without adrenal function, but the immediate threat to life from ventricular arrhythmias takes precedence. Hypoglycemia should be treated after ensuring cardiac stability.

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Medication	Drug classification	Medication action
Amlodipine	_____1_____	_____5_____
Aspirin	_____2_____	_____6_____
Lisinopril	_____3_____	_____7_____
Nitroglycerin	_____4_____	_____8_____

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) begin to remove exam gloves after emptying a bedpan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off. Which action should the nurse implement?

Correct Answer is C

Explanation

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?

Patient Data For each medication, choose the drug classification and medication action. Medication Drug classification Medication action Amlodipine _____1_____ _____5_____ Aspirin _____2_____ _____6_____ Lisinopril _____3_____ _____7_____ Nitroglycerin _____4_____ _____8_____

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. Which action should the nurse take?

A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication?