Reduction of Risk Potential

The 20-year-old student went on a mission trip to Ghana to help at a local hospital. She presented to the clinic 12 days after her return; she began to experience anorexia, flu-like symptoms, and fatigue. Ten days later, she noticed her eyes and skin looked yellow. Her history, assessment, and vitals are within normal limits except her yellow sclera and jaundiced skin. Initial lab studies reveal a total bilirubin of 16, indirect bilirubin of 8, AST of 1320 and ALT of 1400. The nurse prepares the patient for which test next? 

The 4-week-old neonate in the neonatal intensive care unit was born at 29 weeks gestation. The patient is stable on room air and has been tolerating nasogastric feedings of expressed breast milk. Generally an active and responsive patient, the nurse notes the patient is lethargic and does not react to his diaper change. Additionally, the patient’s heart rate is 194 bpm, respiratory rate is 82 breaths per minute, and the blood pressure is 54/21 mm Hg. The patient’s abdomen is distended and discolored; dark green emesis is noted as well. An abdominal x-ray is ordered and performed. Which x-ray findings are consistent with the patient’s clinical picture? Select all that apply.  

The 23-year-old patient is brought to the emergency department after contacting emergency services to report profound weakness that started in his feet and worsened and spread cranially over the past few days. He reports severe diarrhea after a camping trip a week ago. Upon assessment, strength, sensation, and deep tendon reflexes are significantly reduced, with the lower extremities more severely affected than his upper extremities. Vital signs are normal and the patient seems to be breathing well. The nurse anticipates which finding on the lumbar puncture result?  

The 50-year-old previously healthy patient complains of shortness of breath, especially on exertion or when laying down to sleep. She takes over-the-counter allergy medicine for seasonal allergies and melatonin to help her sleep sometimes. Her vital signs are heart rate of 64 bpm, respirations 22, oxygen saturation 99%, and blood pressure 114/68 mmHg. Her assessment is notable for crackles over the bilateral lung bases and a moderate diastolic apical murmur. The nurse prepares the patient for which initial tests? Select all that apply. 

The 38-year-old patient who strictly adheres to a vegan diet complains of weakness and tingling in her lower extremities. She retains the strength in her lower extremities but proprioception is decreased.  Her complete blood count revealed a hemoglobin of 10.2 mg/dL, white blood cell count of 9 x 10³ cells/µL, and a mean corpuscular volume of 110. Which information does the nurse provide to the patient?  

The 20-year-old patient with asthma presents to the emergency department with increased work of breathing and severe wheezing after exposure to household dust and mold. The patient used the albuterol inhaler 6 times in the previous 4 hours with minimal relief. Upon inspection, the nurse notes extensive accessory respiratory muscle use with moderate supraclavicular retractions and nasal flaring. The nurse auscultates expiratory wheezing in all lung fields. The patient is afebrile, normotensive, significantly tachypneic, and mildly tachycardic. The nurse anticipates which findings on a chest x-ray?

The patient with human immunodeficiency virus and a CD4 count of 158 has a purified protein derivative (PPD) skin test performed and is found to have a 7-mm induration with circumferential erythema. Which statement does the nurse make to the patient?  

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mmHg. Which lab studies does the nurse obtain? Select all that apply.  

The nurse witnesses a healthy 19-year-old collapse while playing football. The individual is arousable but confused and irritable. The skin is warm, dry, and flushed. The nurse instructs a teammate to bring the water cooler and pours it over the victim. The teammate shouts, “Why did you do that?! Won’t he go into shock?”  The nurse bases the response on the need for rapid cooling to prevent which conditions? Select all that apply.  

The 49-year-old patient presented with a breast lump found during her monthly breast self-exam. This is confirmed on mammogram; the lump was biopsied and found to be an adenocarcinoma that is HER2/neu negative. The patient requests that interventions conserve as much of her breast tissue as possible. The nurse prepares the patient for which next step in management?  

The nurse is providing education to the parents of a child who was admitted with abdominal pain, fatigue, and yellow-tinged skin and sclera that was determined to be due to hemolysis. The liver dysfunction has resolved and the child is ready to be discharged, but the cause of the child’s hemolysis is still unknown at this time. Out of an abundance of caution, the nurse instructs on the list of medications/food the child must not receive to prevent possible recurrence. Which items are included on the list? Select all that apply.

The nurse is attempting to perform an electrocardiogram on a patient. The machine alerts the nurse that the V1, V4, and V5 electrodes are not picking up correctly. The nurse adjusts the leads in which locations? Select all that apply.  

The nurse is preparing to insert an intravenous catheter into the patient with a BMI of 39. Which angle of insertion does the nurse utilize in order to most likely maximize the chance of successfully entering the vessel? 

The nurse performs an electrocardiogram on a patient and notes right axis deviation. The nurse suspects the patient has which undiagnosed condition? 

The nurse is supervising the student nurse in the insertion of a peripheral intravenous catheter. The nurse observes the student nurse apply a tourniquet, clean the insertion site, and insert the needle into the skin and get a flash of blood in the chamber. The nurse continues to quietly observe if the student nurse performs which action? 

Upon insertion of an intravenous catheter, bright red blood is noted prior to attaching the tubing. Which initial action is appropriate?

The nurse is observing the student nurse preparing a 6-year-old for the insertion of an intravenous catheter. Which statement by the student nurse prompts the nurse to intervene? 

The nurse is caring for the patient with prostate cancer that has metastasized to the bone. The physician has prescribed extended-release oxycodone to treat severe bone pain. The patient expresses to the nurse he is concerned he will become addicted to the opioid pain medication given what you see on television. Which response from the nurse is most appropriate?

The baby born at 40 weeks gestation requires substantial resuscitation at birth and remains a critically ill neonate. Initial testing reveals a diagnosis of E. coli sepsis. Until further testing is completed, the nurse avoids administering which substance?

The patient experiencing an oversecretion of vasopressin presents with a decrease in which laboratory value?