NCLEX-style case study · Free sample
NCLEX-RN Adult Health Case Study 2
Client record
Item 1 of 6
A nurse in the emergency department is caring for a 64-year-old client.
Initial assessment
Emergency department admission note
- 0715:
Triage assessment
The client arrives by wheelchair and is alert and oriented to person, place, time and situation. He reports two episodes of coffee-ground emesis and three black, tarry stools since the previous evening. He reports burning epigastric pain rated 4 out of 10, generalized weakness and dizziness when standing. The skin is pale, cool and diaphoretic. Radial pulses are weak and thready at 1+. Capillary refill is 4 seconds. The abdomen is soft with mild epigastric tenderness and no rigidity. Lung sounds are clear bilaterally. Urine output during the previous hour was approximately 20 mL of dark amber urine.
Initial assessment
0715 vital signs
| Item | 0715 |
|---|---|
| Temperature | 98.2 F (36.8 C) |
| Heart rate | 118/min |
| Respiratory rate | 22/min |
| Blood pressure | 96/58 mmHg |
| Oxygen saturation | 97% on room air |
Item 1 of 6
Review the client’s initial assessment in the electronic health record. Which findings are priority cues that require immediate follow-up? Select all that apply.
Select all findings that require immediate follow-up.