NGN

76

NEW GENERATION NCLEX

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NGN Case Study - Part 1 of 6
The nurse in the emergency department (ED) is caring for a 68-year-old male client.

Day 1

Nurses Notes

0800:

Client was brought to the ED by his wife due to left sided chest pain, diaphoresis, and dyspnea. The client describes the chest pain as “crushing”, starting three hours ago. The client states, “it feels as if someone is hitting me across the chest with a baseball bat repeatedly”. History of hypertension and smoking one pack of cigarettes a day for 10 years. Vital signs: T 96.8° F (36.0°C), P 73, RR 23, BP 144/97, pulse oximetry reading 93% on oxygen at 2L/min via nasal cannula. On assessment, client is sitting on stretcher bent over with right hand over the left side of his chest, breathing appears slightly labored. Lung sounds are clear bilaterally. S1 and S2 detected on auscultation, no jugular venous distension, thrills, or heaves noted. Skin cool and clammy to touch, diaphoresis noted on forehead; pulses 2+ bilaterally and regular. Capillary refill is 4 seconds. Client rates pain at a 9/10 on left side of chest and states it is radiating down the left arm. Client is alert and oriented to person, place, and time. Peripheral venous access device (PVAD) placed in left antecubital fossa.

Which of the following actions should the nurse do immediately?

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NGN Case Study - Part 2 of 6
The nurse in the emergency department (ED) is caring for a 68-year old male client.
Nurses Notes
Day 1
0800:
Client was brought to the ED by his wife due to left sided chest pain, diaphoresis, and dyspnea. The client describes the chest pain as “crushing”, starting three hours ago. The client states, “it feels as if someone is hitting me across the chest with a baseball bat repeatedly”. History of hypertension and smoking one pack of cigarettes a day for 10 years. Vital signs: T 96.8° F (36.0°C), P 73, RR 23, BP 144/97, pulse oximetry reading 93% on oxygen at 2L/min via nasal cannula. On assessment, client is sitting on stretcher bent over with right hand over the left side of his chest, breathing appears slightly labored. Lung sounds are clear bilaterally. S1 and S2 detected on auscultation, no jugular venous distension, thrills, or heaves noted. Skin cool and clammy to touch, diaphoresis noted on forehead; pulses 2+ bilaterally and regular. Capillary refill is 4 seconds. Client rates pain at a 9/10 on left side of chest and states it is radiating down the left arm. Client is alert and oriented to person, place, and time. Peripheral venous access device (PVAD) placed in left antecubital fossa.
0830:
Administered 1 tablet of nitroglycerin sublingually to client. Vital signs: T 96.8° F (36.0°C), P 75, RR 20, BP: 144/97, pulse oximetry reading 95% on oxygen at 5L/min via nasal cannula.
0900:
Client states chest pain is unchanged and rates 9/10 with facial grimacing.
Which of the following orders should the nurse consider a priority? (Select all that apply)

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NGN Case Study - Part 3 of 6
The nurse in the emergency department (ED) is caring for a 68-year old male client.
Nurses Notes
Day 1
0800:
Client was brought to the ED by his wife due to left sided chest pain, diaphoresis, and dyspnea. The client describes the chest pain as “crushing”, starting three hours ago. The client states, “it feels as if someone is hitting me across the chest with a baseball bat repeatedly”. History of hypertension and smoking one pack of cigarettes a day for 10 years. Vital signs: T 96.8° F (36.0°C), P 73, RR 23, BP 144/97, pulse oximetry reading 93% on oxygen at 2L/min via nasal cannula. On assessment, client is sitting on stretcher bent over with right hand over the left side of his chest, breathing appears slightly labored. Lung sounds are clear bilaterally. S1 and S2 detected on auscultation, no jugular venous distension, thrills, or heaves noted. Skin cool and clammy to touch, diaphoresis noted on forehead; pulses 2+ bilaterally and regular. Capillary refill is 4 seconds. Client rates pain at a 9/10 on left side of chest and states it is radiating down the left arm. Client is alert and oriented to person, place, and time. Peripheral venous access device (PVAD) placed in left antecubital fossa.
0830:
Administered 1 tablet of nitroglycerin sublingually to client. Vital signs: T 96.8° F (36.0°C), P 75, RR 20, BP: 144/97, pulse oximetry reading 95% on oxygen at 5L/min via nasal cannula.
0900:
Client states chest pain is unchanged and rates 9/10 with facial grimacing.
The nurse should prepare the client for which of the following?

Diagnostic Results

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NGN Case Study - Part 4 of 6
The nurse in the emergency department (ED) is caring for a 68-year old male client.

Nurses Notes

Day 1
0800:
Client was brought to the ED by his wife due to left sided chest pain, diaphoresis, and dyspnea. The client describes the chest pain as “crushing”, starting three hours ago. The client states, “it feels as if someone is hitting me across the chest with a baseball bat repeatedly”. History of hypertension and smoking one pack of cigarettes a day for 10 years. Vital signs: T 96.8° F (36.0°C), P 73, RR 23, BP 144/97, pulse oximetry reading 93% on oxygen at 2L/min via nasal cannula. On assessment, client is sitting on stretcher bent over with right hand over the left side of his chest, breathing appears slightly labored. Lung sounds are clear bilaterally. S1 and S2 detected on auscultation, no jugular venous distension, thrills, or heaves noted. Skin cool and clammy to touch, diaphoresis noted on forehead; pulses 2+ bilaterally and regular. Capillary refill is 4 seconds. Client rates pain at a 9/10 on left side of chest and states it is radiating down the left arm. Client is alert and oriented to person, place, and time. Peripheral venous access device (PVAD) placed in left antecubital fossa.
0830:
Administered 1 tablet of nitroglycerin sublingually to client. Vital signs: T 96.8° F (36.0°C), P 75, RR 20, BP: 144/97, pulse oximetry reading 95% on oxygen at 5L/min via nasal cannula.
0900:
Client states chest pain is unchanged and rates 9/10 with facial grimacing.

Coronary Care Unit

Day 2
0800:
Client returned from cardiac catheterization lab following percutaneous transluminal coronary angioplasty (PTCA) in stable condition. Received transfer of accountability from catheterization laboratory RN. No concerns during PTCA noted. Client alert and oriented to person, place, and time but closing eyes attempting to sleep when writer is not directly speaking to client. Client is aroused by voice. Vital signs: T: 96.8° F (35.0°C), P 60, RR 14, BP: 150/90, pulse oximetry reading 97% on oxygen at 5L/min via nasal cannula.
1000:
Client alert and oriented to person, place, and time. Client remained upright and awake in bed for continued assessments. No concerns of sedation noted. Vital signs: T: 96.8° F (35.0°C), P 75, RR 16, BP: 145/88, pulse oximetry reading 99% on oxygen at 5L/min via nasal cannula. Titrated oxygen down to 2L/min via nasal cannula, pulse oximetry remained at 99%.
Which of the following nursing interventions are indicated for the postoperative care of the client? (Select all that apply)

Diagnostic Results

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NGN Case Study - Part 5 of 6
The nurse in the emergency department (ED) is caring for a 68-year old male client.

Nurses Notes

Day 1
0800:
Client was brought to the ED by his wife due to left sided chest pain, diaphoresis, and dyspnea. The client describes the chest pain as “crushing”, starting three hours ago. The client states, “it feels as if someone is hitting me across the chest with a baseball bat repeatedly”. History of hypertension and smoking one pack of cigarettes a day for 10 years. Vital signs: T 96.8° F (36.0°C), P 73, RR 23, BP 144/97, pulse oximetry reading 93% on oxygen at 2L/min via nasal cannula. On assessment, client is sitting on stretcher bent over with right hand over the left side of his chest, breathing appears slightly labored. Lung sounds are clear bilaterally. S1 and S2 detected on auscultation, no jugular venous distension, thrills, or heaves noted. Skin cool and clammy to touch, diaphoresis noted on forehead; pulses 2+ bilaterally and regular. Capillary refill is 4 seconds. Client rates pain at a 9/10 on left side of chest and states it is radiating down the left arm. Client is alert and oriented to person, place, and time. Peripheral venous access device (PVAD) placed in left antecubital fossa.
0830:
Administered 1 tablet of nitroglycerin sublingually to client. Vital signs: T 96.8° F (36.0°C), P 75, RR 20, BP: 144/97, pulse oximetry reading 95% on oxygen at 5L/min via nasal cannula.
0900:
Client states chest pain is unchanged and rates 9/10 with facial grimacing.

Coronary Care Unit

Day 2
0800:
Client returned from cardiac catheterization lab following percutaneous transluminal coronary angioplasty (PTCA) in stable condition. Received transfer of accountability from catheterization laboratory RN. No concerns during PTCA noted. Client alert and oriented to person, place, and time but closing eyes attempting to sleep when writer is not directly speaking to client. Client is aroused by voice. Vital signs: T: 96.8° F (35.0°C), P 60, RR 14, BP: 150/90, pulse oximetry reading 97% on oxygen at 5L/min via nasal cannula.
1000:
Client alert and oriented to person, place, and time. Client remained upright and awake in bed for continued assessments. No concerns of sedation noted. Vital signs: T: 96.8° F (35.0°C), P 75, RR 16, BP: 145/88, pulse oximetry reading 99% on oxygen at 5L/min via nasal cannula. Titrated oxygen down to 2L/min via nasal cannula, pulse oximetry remained at 99%.
Which of the following meals should the nurse recommend this client choose?

Diagnostic Results

6 / 6

NGN Case Study - Part 6 of 6
The nurse in the emergency department (ED) is caring for a 68-year old male client.

Nurses Notes

Day 1
0800:
Client was brought to the ED by his wife due to left sided chest pain, diaphoresis, and dyspnea. The client describes the chest pain as “crushing”, starting three hours ago. The client states, “it feels as if someone is hitting me across the chest with a baseball bat repeatedly”. History of hypertension and smoking one pack of cigarettes a day for 10 years. Vital signs: T 96.8° F (36.0°C), P 73, RR 23, BP 144/97, pulse oximetry reading 93% on oxygen at 2L/min via nasal cannula. On assessment, client is sitting on stretcher bent over with right hand over the left side of his chest, breathing appears slightly labored. Lung sounds are clear bilaterally. S1 and S2 detected on auscultation, no jugular venous distension, thrills, or heaves noted. Skin cool and clammy to touch, diaphoresis noted on forehead; pulses 2+ bilaterally and regular. Capillary refill is 4 seconds. Client rates pain at a 9/10 on left side of chest and states it is radiating down the left arm. Client is alert and oriented to person, place, and time. Peripheral venous access device (PVAD) placed in left antecubital fossa.
0830:
Administered 1 tablet of nitroglycerin sublingually to client. Vital signs: T 96.8° F (36.0°C), P 75, RR 20, BP: 144/97, pulse oximetry reading 95% on oxygen at 5L/min via nasal cannula.
0900:
Client states chest pain is unchanged and rates 9/10 with facial grimacing.

Coronary Care Unit

Day 2
0800:
Client returned from cardiac catheterization lab following percutaneous transluminal coronary angioplasty (PTCA) in stable condition. Received transfer of accountability from catheterization laboratory RN. No concerns during PTCA noted. Client alert and oriented to person, place, and time but closing eyes attempting to sleep when writer is not directly speaking to client. Client is aroused by voice. Vital signs: T: 96.8° F (35.0°C), P 60, RR 14, BP: 150/90, pulse oximetry reading 97% on oxygen at 5L/min via nasal cannula.
1000:
Client alert and oriented to person, place, and time. Client remained upright and awake in bed for continued assessments. No concerns of sedation noted. Vital signs: T: 96.8° F (35.0°C), P 75, RR 16, BP: 145/88, pulse oximetry reading 99% on oxygen at 5L/min via nasal cannula. Titrated oxygen down to 2L/min via nasal cannula, pulse oximetry remained at 99%.

Orders

  • 80 units/kg heparin sodium intravenous (IV) bolus
Which of the following findings would require prompt follow-up?

Diagnostic Results

 

 

 

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