NCLEX New Generation Case Study

NCLEX new generation case study

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110 terms kandykat1012Preview NCLEX NGN Pre-Test Questions 73 terms CamadarPreview LPN NCLEX Case Study Questions 491 terms wlb1688Preview NCLEX 116 terms Sun The nurse working at the outpatient pediatric clinic is perform-ing an admission assessment for a 7-year-old child who is ac-companied by their parent. The child reports right ear pain for 3 days. The nurse documents the following assessment findings.Health History Nurses' Notes Vital Signs Diagnostic Results Reports right ear pain × 3 days described as constant, aching, nonradiating; denies dry mucous membranes, eye drainage, nasal drainage, or throat pain; oropharynx pink, moist, with no redness, swelling, exudate Reports no sick contacts and has been attending full days of school; reports swimming daily for the past week Denies neck stiffness; no swelling of the neck, or swollen lymph nodes Denies cough, wheezing, difficulty breathing; lung sounds clear Tenderness noted on palpation and manipulation of right auricle with ear canal erythema; no discharge; left auricle nontender

Immunizations up-to-date Allergies: No known allergies

Health History Nurses' Notes Vital Signs Weight: 55 lb (59th percentile) Height: 49.25 inches (55th percentile) BMI: 15.94 (58th percentile) T: 97.9°F (36.6°C) temporal HR: 98 BPM RRs: 18 bpm

BP: 108/70 mm Hg

Clinical findings noted in the assessment that point to otitis externa include Options for 1 No sick contacts Ear pain without fever Attends full school days Left auricle is nontender to manipulation Options for 2 Denies neck stiffness Immunizations up-to-date Swimming daily for the past week Lack of nasal drainage or throat pain Options for 3 Denies cough No lymphoadenop-athy Tenderness on manipulation of right auricle Lung sounds clear to auscultation bilaterally

Rationale for the Previous QuestionOtitis externa is also known as swimmer's ear and is associated with inflam-mation and possibly exudate in the external auditory canal. Otitis externa is confirmed when there are no other disorders such as otitis media or mastoiditis. Fever is usually absent, and hearing is unaffected. Often there is tenderness on palpation of the tragus and manipulation of the auricle. The lining of the canal is erythematous and edematous, and discharge may be seen. Another factor that suggests otitis externa is that the child has been swimming daily for the past week.The other findings noted are not risk factors for this problem. Attending full school days heightens the risk for otitis media, which can occur secondary to an upper respiratory infection.Client Finding Otitis ExternaEar pain No fever No sick contacts Swimming daily for the past week Tenderness noted on palpation and manipulation of the auricle Erythema in the ear canal Client Finding Otitis MediaEar pain No fever Attends full school days Swimming daily for the past week A 45-year-old client diagnosed with CKD requires dialysis. As a candidate for both hemodialysis and peritoneal dialysis, the cli-ent decides that peritoneal dialysis is the better option for their lifestyle. The client is hospitalized and undergoes insertion of the peritoneal dialysis catheter, and the first dialysis procedure is ordered. The nurse documents predialysis assessment data and reviews laboratory results.Health History Nurses' Notes Vital Signs Laboratory Results

1100: T = 98.2°F (36.8°C); apical HR = 90 BPM and regular;

BP = 146/98 mm Hg; RR = 16 bpm; breath sounds clear bilaterally. Weight = 160 lb (72.57 kg) Nurses' Notes Result nitrogen (BUN) =30 mg/dL (10.8 mmol/L) H creatinine =6.0 mg/dL (528 mcmol/L) H Glucose 110 mg/dL (6.1 mmol/L) H Sodium 150 mEq/L (150 mmol/L) H Potasium 5.5 mEq/L (5.5 mmol/L) H During dialysis infusion, the nurse notes a slow inflow ofthe dialysate and the client complains ofpain. On assessment ofthe catheter, the nurse notes some fibrin clot formation in the dialysis tubing. Com-plete the following sentences by choosing from the list ofoptions.The nurse recognizes that the slow inflow , presence of fibrin clots, and complaints of pain are most likely the result of the -------------- due to the----------------- Options for 1 Peritonitis Initial dialysis treatment Bowel perforation Abdominal pressure Options for 2 Catheter slippage x Surgical procedure Lack of aseptic technique Elevated BP and laboratory results

Rationale for the Previous QuestionPain during the inflow of dialysate is common when a client is initially started on peritoneal dialysis therapy following the surgical procedure and catheter placement. Usually, this pain no longer occurs 1 to 2 weeks after receiving these treat-ments. Warming the dialysate bags before instillation by using a heating pad to wrap the bag or by using the warming chamber of the automated cycling machine will assist in preventing pain. Slow inflow of the dialysate is not uncommon initially but should always be assessed because it could be due to a kink in the tubing or fibrin clots. Fibrin clot formation is not uncommon after catheter placement, although it is also important to know that it can occur with peritonitis. In this client situation fibrin clot formation is most likely an expected finding because the client recently had the catheter placed and because there are no associated findings of peritonitis such as fever. In addition, it is not likely that signs of peritonitis would show just after catheter placement. Milking the tubing may dislodge the fibrin clot and improve flow. Bowel perforation would be exhibited by a brown-colored outflow. Abdominal pressure may occur on inflow and may cause minimal discomfort, but this is an unlikely occurrence in this client situation; also, fibrin clots are not associated with abdominal pressure.Every 30 minutes the nurse is monitoring a 28-year-old client who was admitted 3 hours ago to the labor and delivery unit in the first stage of labor. The nurse suddenly notes late decelerations and frequent episodes of fetal tachycardia in response to FHR decel-erations on the monitor The nurse determines that these findings indicate which ofthe follow-ing conditions? Select all that apply.☐ Breech baby ☐ Fetal hypoxemia ☐ Metabolic fetal acidemia ☐ Strong uterine contractions ☐ Uteroplacental insufficiency Fetal hypoxemia ☐ Metabolic fetal acidemia Uteroplacental insufficiency Rationale for the Previous QuestionThere are certain FHR patterns associated with physiologic processes for both the birth parent and the fetus. A deceleration can be benign or abnormal. Early decelerations, considered a normal finding, are caused by fundal pressure; breech posi-tions; strong uterine contractions; vaginal examination; and placement of internal monitoring equipment. Late decelerations are caused by fetal hypoxemia due to utero-placental insufficiency and therefore are considered an abnormal and concerning find-ing. Metabolic fetal acidemia is characterized by fetal tachycardia in response to FHR decelerations and is a possible condition.In cases of fetal hypoxia, the nurse would observe progressively more frequent episodes of tachycardia after decelerations that are initially transient and later become more consistent. This is because in response to repetitive hypoxic stress from uterine contractions, the fetus initially compensates by increasing its HR, as its ability to increase stroke volume is not very efficient.Causes Early DecelerationsCauses Breech baby Strong uterine contractions Late Decelerations Fetal hypoxemia Metabolic fetal acidemia Uteroplacental insufficiency

Potential to Result in Fetal HarmFetal hypoxemia Metabolic fetal acidemia Uteroplacental insufficiency Not Likely to Result in Fetal HarmBreech baby Strong uterine contractions A 45-year-old client is admitted to the ED because of frequent ep-isodes of chest pain unrelieved by sublingual nitroglycerin. The ECG shows ST segment elevation.Troponin levels are elevated. While awaiting results of diagnostic studies and transfer to the cardiac unit, the nurse monitors the client.

Vital signs reveal the following:

Health History Nurses' Notes Vital Signs Laboratory Results 1200: HR = 88 BPM; RR = 22 bpm; BP = 142/86 mm Hg 1215:

HR = 92 BPM; RR = 24 bpm; BP = 120/82 mm Hg 1230: HR =

106 BPM and weak; RR = 28 bpm; BP = 100/62 mm Hg

1245: HR = 120 BPM and weak; RR = 32 bpm; BP = 90/58

mm Hg The nurse determines that these vital sign findings most likely indi-cate which complication(s)?Select all that apply.☐ Dysrhythmias ☐ Pulmonary edema ☐ Cardiogenic shock ☐ Cardiac tamponade ☐ Pulmonary embolism ☐ Dissecting aortic aneurysm Cardiogenic shock Rationale for the Previous QuestionCardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension; a rapid heart rate that becomes weaker; decreased urine output; and cool, clammy skin. RR increases as the body develops meta-bolic acidosis from shock. Dysrhythmias would be detected by changes in the rate and rhythm of the pulse and would be evidenced on the cardiac monitor and ECG. Although ST segment elevation is noted, there is no evidence of dysrhythmias. Pulmonary edema is evidenced by severe dyspnea and breathlessness and adventitious breath sounds. Car-diac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels.Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain.