Exam (elaborations)
RN ADULT MEDICAL SURGICAL ONLINE PRACTICE 2023 A NGN
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RN ADULT MEDICAL SURGICAL ONLINE PRACTICE 2023 A NGN
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RN ADULT MEDICALSURGICAL ONLINE
PRACTICE 2023 A
NGN
NGN
1000:
Client is alert and oriented and reports not feeling well for a few days. Client is on
continuous ambulatory peritoneal dialysis (CAPD) and reports dialysate appeared
cloudy this morning.
Reports abdominal pain as 4 on a scale of 0 to 10.
Bowel sounds active in all quadrants.
Peritoneal dialysis access site red, warm to touch, with a small amount of purulent
drainage noted on dressing.1300:
Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly
distended, hypoactive bowel sounds. Client reports nausea. Reports pain as 6 on a
scale of 0 to 10. Provider notified and updated with client condition and diagnostic
results. - Answers-The client is experiencing manifestations of
peritonitis
due to
x-ray results
.
0530:
Client is awake and alert.
Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit.
Lung sounds clear upon auscultation; client denies shortness of breath. No peripheral
edema noted; capillary refill is less than 3 seconds; +2 bilateral pedal and radial pulses.
AVF access prepared and cannulated twice with no difficulty. Lines are taped and
secured; treatment is initiated.0600:
, Client is reading a book. Access is visible, and lines are secure. Client reports no
discomfort or pain.0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly
confused. - Answers-Perform a 12-lead ECG is not indicated.
Place the client in Trendelenburg position is indicated.
Administer a 0.9% sodium chloride 200 mL IV bolus is indicated.
Apply oxygen at 2 L/min via nasal cannula is indicated
Notify the provider immediately is indicated
Obtain the client's blood glucose level is not indicated.
NGN
Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2
on a scale of 0 to 10. Client appears restless and frequently asks for water. Bilateral
lower extremities cool with +1 pedal pulses. Urine output is 40 mL for the past 2 hr.
Moderate amount of bright red drainage noted on surgical incision dressing. - Answers-
Insert a large-gauge IV.
Initiate a fluid challenge.
Hypovolemia
Urine output
Blood pressure
A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the
following assessment findings should the nurse expect? - Answers-Hypoactive Bowel
Sounds
NGN
0900:
Client presents with abdominal pain in the upper left quadrant for the past 2 days.
States pain became worse this morning and is radiating to the back. Rates pain as 8 on
a scale of 0 to 10.
Hypoactive bowel sounds; reports nausea, no vomiting; client is passing flatus.
Febrile, oriented to person, place, and time.
Tachypnea with diminished breath sounds.
Sinus tachycardia.
Client voids 300 mL of clear, amber urine.
0930:
Client vomited 100 mL brown liquid. - Answers-The client is experiencing manifestations
of
pancreatitis
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