A nurse on a medical-surgical unit is caring for a client who is postoperative
following an emergency appendectomy.
Vital Signs
- Temperature 37.7° C (99.8° F)• Heart rate 82/min• Respiratory rate 16/min•
Blood pressure 127/80 mm Hg• Oxygen saturation 99% on room air
Assessment
Height 157.5 cm (62 in)Weight 90 kg (198 lb)Bilateral lower extremities warm to
touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower
extremities. Distended veins noted on right lower extremity.
Nurses’ Notes
Client reports pain at abdominal incision site as 4 on a 0 to 10 scale.Client also
reports right lower extremity pain as 5 on a 0 to 10 scale, and itching.Reports that
right lower extremity pain has been intermittent for about the last 2
months.Denies current left lower extremity pain. – ~ ANSWER
Potential condition: varicose veins
Actions to take: apply compression stockings and elevate extremity
Parameters to monitor: Edema and pruritis of right lower extremity
A nurse is caring for a preschooler on the pediatric unit.
Provider Prescriptions
Day 1, 2350:Admit for observation.Obtain vital signs every 4 hr and
PRN.Administer oxygen 2 L/min via nasal cannula to maintain oxygen saturation
above 95%.Initiate saline lock.Administer ceftriaxone 250 mg IV every 12
hr.Administer acetaminophen oral suspension 240 mg every 4 hr PRN for
temperature greater than 38° C (100.4° F).Place on regular diet and encourage
oral fluids of preschooler’s choice.Monitor intake and output every 8 hr.
Assessment
Day 2, 0030:Preschooler lying on bed, awake and alert. Breath sounds with
wheezing auscultated on expiration on the right side. Nonproductive cough with
no retractions or nasal flaring observed. Abdomen soft and nondistended, bowel
sounds active in all four quadrants. Preschooler reports headache and pain in
abdomen. Rates pain in abdomen as a 2 on a 0 to 10 FACES pain scale.
Vital Signs
Day 2, 0030:Temperature 38.1° C (100.6° F)Heart rate 122/minRespiratory rate
25/minOxygen saturation 98% on oxygen at 2 L/min via nasal cannulaWeight 17.3
kg (38 lb)Height 102.3 cm (40.3 in)
Nurses’ Notes
Day 2, 0100:Saline lock inserted on first attempt. Assisted preschooler to right
side-lying position for splinting. Administered ceftriaxone IV. Caregiver at
bedside.Day 2, 0130:Preschooler sitting up in bed, appearing anxious and flushed.
Lips swollen. Preschooler scratching hives that have appeared on both upper
extremities.
History and Physical
2250:Admitted from the emergency department with a diagnosis of pneumonia
on the right side with mild pleural effusion
Medical history: Preschooler has a history of asthma
Allergies: No known allergies – ~ ANSWER Administer epinephrine
IM.
Administer 0.9% sodium chloride IV.
Monitor vital signs frequently.
Discontinue the IV medication.
A nurse is caring for a client who is 24 hr postoperative following a cesarean birth.
History and Physical
Client is G2P2 at 38 weeks of gestation
Diagnosed with preeclampsia at 32 weeks of gestation
Scheduled repeat cesarean birth
Diagnosed with gestational diabetes mellitus at 29 weeks of gestation
Nurses’ Notes
1500:
Dressing dry and intact. Fundus firm midline at umbilicus. Scant lochia rubra.
Client rates incisional pain as a 3 on a scale of 0 to 10, denies need for analgesia.
Indwelling urinary catheter removed.1700:
Client reports headache with pain rated at 4 on a scale of 0 to 10. Analgesic
administered.1800:
Client reports blurred vision and nausea. Rates pain from headache as a 6 on a
scale of 0 to 10. Deep tendon reflexes 4+, clonus positive.
Vital Signs
1500:
Temperature 36.6° C (97.9° F)Heart rate 86/minRespiratory rate 18/minBlood
pressure 155/90 mm HgOxygen saturation 98% on room air1800:
Heart rate 96/minRespiratory rate 22/minBlood pressure 185/115 mm HgOxygen
saturation 96% on room air
Laboratory Results
1700:
Capillary blood glucose (casual) 120 mg/dL (less than 200 mg/dL)
WBC 22,000/mm3 (5,000 to 10,000/mm3)
Hct 37% (greater than 33%)
Hgb 12 g/dL (greater than 11 g/dL)
Platelets 160,000/mm3 (150,000 to 400,000/mm3) – ~ ANSWER
The client is at risk for developing
seizures as evidenced by blood pressure.
A nurse is caring for a client who has schizophrenia in an inpatient facility.
Medication Administration Recor
0730:Clozapine 100 mg PO daily
Aripiprazole 5 mg PO daily
Multivitamin PO daily
Laboratory Results
0730:Sodium 125 mEq/L (136 to 145 mEq/L)
Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L)
Chloride 90 mEq/L (98 to 106 mEq/L)
BUN 8 mg/dL (10 to 20 mg/dL)
Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L)
Vital Signs
1230:
Temperature 37.6° C (99.7° F)Heart rate 98/min
Respiratory rate 20/min
Blood pressure 142/92 mm Hg
Oxygen saturation 100% on room air
1500:
Temperature 37.1° C (98.8° F)
Heart rate 104/min
Respiratory rate 24/min
Blood pressure 150/90 mm Hg
Oxygen saturation 100% on room air