The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client's
__
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Lung sounds: The client is exhibiting slight inspiratory wheezes, suggesting airway narrowing that could worsen quickly, particularly with a history of asthma. Following the ABC priority framework (Airway, Breathing, Circulation), any compromise in breathing must be assessed and managed first to prevent respiratory decline.
Bowel sounds: Although bowel sounds are hyperactive, they do not immediately threaten life or stability. They are typically monitored rather than prioritized unless accompanied by severe gastrointestinal symptoms like obstruction.
Heart rate: Tachycardia is present but mild at 104/min and not currently associated with hypotension or hypoxia. While important to monitor, it is a secondary concern after ensuring airway patency and addressing breathing issues.
Anxiety: Anxiety may be contributing to elevated heart rate and hyperactive bowel sounds but does not represent an immediate physiological risk. Emotional support is important but should be provided after stabilizing airway and circulation.
Vaginal spotting: Vaginal spotting, especially in early pregnancy with abdominal tenderness, raises concern for ectopic pregnancy. After securing the airway, the next concern would be assessing for ongoing or worsening vaginal bleeding, which could signify internal hemorrhage.
Hemoglobin: The client's hemoglobin is low-normal (11 g/dL), suggesting mild anemia, possibly from chronic or early bleeding. However, there are no signs of active major blood loss requiring emergent correction, so it would not take immediate precedence over bleeding evaluation.

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Correct Answer is ["C","D","E"]

Explanation

A. "The client in room 204 received some pain medicine earlier today": This statement is vague and nonspecific, lacking essential information such as the type of pain medication, dose, timing, and client response. Change-of-shift reports require clear, detailed, and actionable information to ensure continuity of care.

B. "The client in room 205 has had several visitors today": Information about visitors is generally not relevant to clinical care unless it impacts the client's condition. Reporting should focus on clinical updates, treatments, medications, or changes in the client’s status that require attention from the incoming nurse.

C. "The client in room 204 has a new prescription for gentamicin": This statement provides important clinical information regarding a change in the medication regimen. It alerts the next nurse to monitor for potential side effects, such as nephrotoxicity or ototoxicity, associated with gentamicin use.

D. "The client in room 203 will undergo surgery at 0900 tomorrow": Communicating scheduled surgeries is critical for planning preoperative care, ensuring that preoperative checklists are completed, and managing fasting requirements. It allows the next shift to prepare the client properly and coordinate care.

E. "The client in room 205 is scheduled for a dressing change at 1800": Including scheduled treatments like dressing changes ensures that important interventions are completed on time. It also helps the incoming nurse prioritize tasks and manage the shift effectively to meet the client’s care needs.

A. Repeat quantitative B-hCG level B. Methotrexate IM C. Blood typing D. Cervical cerclage E. Transvaginal ultrasound

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

• Repeat quantitative B-hCG level: Monitoring the trend of quantitative beta-hCG levels is crucial in suspected ectopic pregnancy. Falling or plateauing hCG levels confirm the diagnosis and guide the management plan, especially if methotrexate is administered or surgical intervention is considered.

• Methotrexate IM: Methotrexate is an anticipated prescription for the medical management of a stable ectopic pregnancy. It works by stopping the growth of rapidly dividing cells and is appropriate when the client is hemodynamically stable and the ectopic pregnancy is unruptured.

• Blood typing: Blood typing is essential to determine Rh factor status. If the client is Rh-negative, Rh immune globulin should be administered to prevent isoimmunization, which could impact future pregnancies. This is a standard part of the care plan for any pregnancy loss or threatened pregnancy complication.

• Transvaginal ultrasound: A transvaginal ultrasound is needed to confirm the location of the pregnancy. In ectopic pregnancies, it helps visualize the presence or absence of an intrauterine gestational sac and may directly identify ectopic implantation, such as in the fallopian tube.

• Cervical cerclage: Cervical cerclage is contraindicated in this case. It is used to prevent preterm birth in clients with cervical insufficiency but is not appropriate in a non-viable pregnancy or suspected ectopic pregnancy. Placing a cerclage could worsen the clinical situation and delay necessary treatment.

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The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. Complete the following sentence by using the lists of options. The nurse should first address the client's _____ followed by the client's ______.

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Naxlex Comprehensive Predictor Exams

A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's
_
followed by the client's
__
.