RN Comp Practice 2023 A | Latest Update, Complete Solutions (Verified Answers)

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RN Comp Practice 2023 A | Latest Update, Complete Solutions (Verified Answers) NGN: What assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis? Temperature (1 ... 00F) Weight (-9.7 lbs) Albumin level (2.4) WBC (14) Bowel pattern (freq. loose stools) Abdominal pain location (RLQ) Heart rate (105) Temperature: Crohn's, UC & peritonitis. -Elevation can occur with all three due to inflammation and infection. Weight: Crohn's & UC. -Unintended weight loss can occur due to malabsorption in the GI tract. Bowel pattern: Crohn's. -If the patient reported there was blood in the stool, it would be UC. Crohn's doesn't cause tarry stools. WBC: Crohn's, UC & peritonitis. -Elevation can occur due to inflammation and infection. Heart rate: peritonitis. -Tachycardia can occur due to inflammation, infection, and dehydration. Albumin level: Crohn's & UC. -Because of the malabsorption in the GI tract, the body isn't receiving enough protein. Abdominal pain location: Crohn's. -Because it is in the RLQ, it is more consistent with Crohn's. With patients that have peritonitis, they experience generalized abd. pain that radiates to the shoulder and back. NGN: What assessment findings can indicate a transfusion reaction in a patient receiving blood? Urine output (150mL of clear, yellow) Skin (pale, cool and dry) Anxiety Vital signs (within normal range) Headache Back pain Back pain, headache & anxiety. Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain, tachycardia, dyspnea, hypotension. NGN: Patient arrives with palpitations, difficulty breathing, and reports feeling faint. Reports constipation and joint pain for x2 days. In childhood, patient experienced physical abuse, and emotionally detached parents. Reports nervousness and only leaving home when necessary. PMH: freq. hospital visits due to headaches and GI distress. Bowtie: Condition: somatic symptom disorder -due to physical inactivity & joint pain Interventions: Monitor physical manifestations & assess for presence of 2nd gains from their illness -disorder is characterized by the presence of other real manifestations like dizziness, nausea, back pain, and joint pain. Monitor: Vital signs & pain. NGN: What actions should the nurse take when her pedi patient is exhibiting symptoms of an allergic reaction? Administer 0.9% NS IV Administer epi IM Monitor urine output q2hrs DC supplemental oxygen Monitor vital signs frequently DC IV medication Administer 0.9% NS IV Administer epi IM Monitor vital signs frequently DC IV medication -Nurse should DC the Rocephin and give IV NS to help restore fluids because fluid shifts can occur quickly during a reaction. Administering epi IM is the first line of therapy for anaphylactic reactions because it constricts blood vessels and dilates bronchioles. Monitoring vital sings frequently will allow the nurse to monitor for signs of shock. NGN: What 5 actions should the nurse plan to take with a patient experiencing hallucinations, following alcohol withdrawal? Administer thiamine Maintain a low-stimulation environment Administer chlordiazepoxide Initiate seizure precautions Perform a CIWA-Ar Administer disulfiram Administer thiamine Maintain a low-stimulation environment Administer chlordiazepoxide Initiate seizure precautions Perform a CIWA-Ar -Nurse should plan interventions that keep the patient safe and treat the physical manifestations of withdrawal. Use the CIWA-Ar to determine the severity of the withdrawal. Withdrawal seizures can occur 12-24hrs after cessation of alcohol use, therefore initiate seizure precautions to prevent injury. Administer chlordiazepoxide (a benzodiazepine) and place patient in a low-stim environment to decrease agitation and the risk for seizures. Administering thiamine can prevent Wernicke syndrome. NGN: A post-op patient is experiencing right lower extremity pain and itching, following an emergent apply. Reports right lower extremity pain that has been intermittent for x2 months. Assessment: Bilat lower extremities warm to touch, pedal pulses 2+ bilat. Spider veins noted. Distended veins noted on right lower extremity. Vital signs are within normal limits. Bowtie: Condition: Varicose veins. -due to edema & pruritis Interventions: Elevate extremity & apply compression stockings -to promote venous return & circulation Monitor: Pruritis & edema NGN: Which assessment findings require an immediate follow-up in a schizophrenic patient? Hyperactive bowel sounds x4 Last HCP appointment was 6 months ago Client AO x2 Agitated Speech disorganized Involuntary tongue movement and foot tremor Increase in urination and one episode of incontinence Family c/o increased agitation and delusions Involuntary tongue movement and foot tremor Frequent urination and incontinence Increase in agitation -Patient is experiencing tardive dyskinesia A home health nurse is evaluation a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? A. "My child doesn't like to sit still for nebulizer treatments." B. "I think that my child has been running a fever over the last couple of days." C. "My child only has a small amount of mucus after percussion therapy." D. "I am concerned about my child's future participation in team sports." -The nurse should recommend a high-frequency vest for a child who has inadequate results from other airway clearance therapy techniques. Older children often require other techniques in addition to percussion and postural drainage to achieve adequate mucus expectoration. -The nurse should teach the parent techniques for administration for nebulizer treatments to the child. -The nurse should follow-up on reports of fever, as this could indicate a pulmonary infection. -The nurse should discuss participation in sports activities in relation to the child's current physical and pulmonary health. NGN: A patient who is x2 post-op, following a surgical repair of a left hip fracture, is c/o of intermittent abdominal pain. Rates 5/10 on left side of abdomen. Pain began after eating dinner. Last bowel movement was 5 days prior. Reports usual pattern is x1 daily. Assessment: Abdomen distended, dull to percussion, firm and non-tender on palpation. Hypoactive bowel sounds x4. Vital signs are within normal limits. Bowtie: Condition: Intestinal obstruction -bowel sounds hypoactive x4, last BM was 5 days prior, intermittent to constant pain. Interventions: Assist patient in semi-Fowler's & prepare to administer IV fluids. -to relieve the pressure from the distention and reduce risk of developing fluid/electrolyte imbalance. Monitor: Bowel sounds & urine output. A nurse is caring for a patient who has a new prescription for clonidine. The nurse should inform the patient that which of the following findings is an adverse effect of this medication? A. Diarrhea B. Dry mouth C. Photophobia D. Bruising -Clonidine is an indirect-acting anti-adrenergic agent used for HTN, severe pain, and ADD. Dry mouth (or xerostomia) is common. -Constipation, dry eyes, and rashes are common adverse effects. A nurse caring for a patient who had a recent stroke. Prior to transferring the patient to the bedside commode, which of the following actions should the nurse take first? A. Ask for help with a two-person assist transfer. B. Assess the patient for functional limitations. C. Request a mechanical lift device. D. Medicate the patient for pain. -When using the nursing process, the first action the nurse should take is to assess the patient's functional limitations to determine how much the patient can assist with the transfer. A charge nurse is planning an educational session for staff nurses about working with parents whose children have a terminal illness and are candidates for donating their organs. Which of the following information should the nurse plan to include? A. Choosing to donate organs can delay the timing of the child's funeral. B. The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body. C. The family should understand that an autopsy is mandatory prior to organ donation. D. The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death. -Removal of organs does not damage or violate the child's body in a way that would prevent an open casket funeral. -Donation does not affect or delay funeral time/expenses. -A pathologist will perform an autopsy following an unattended death or at the request of the family. -Discussion about donation should take place separately from discussion of child's prognosis. A community health nurse is reviewing the medical records of four newly diagnoses patients. The nurse should identify which of the following patients as having a nationally notifiable infectious condition? A. A patient who is pregnant and has CMV B. An adolescent patient who has foodborne botulism C. A child who has erythema infectiosum D. A young adult who has HSV-1 -The nurse should report botulism to the CDC because this information is necessary for the prevention and control of this disease. Patients who ingest the toxin can develop dysphagia, drooping eyelids, and vision changes. In 12-36hrs can develop neurologic symptoms such as symmetric, flaccid paralysis and cranial nerve impairment. A nurse is planning care for a patient who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? A. Perform ADLs for the patient to promote rest. B. Allow for freq. rest periods throughout the day. C. Use heat to reduce joint inflammation. D. Develop a daily schedule for acetaminophen up to 6g/day that covers peak periods of pain. -The nurse should encourage patients who have RA to balance rest with exercise to maintain muscle strength, joint function, and ROM. -The nurse should allow patients to perform their own ADLs to promote joint mobility and independence. -The nurse should use ice to reduce joint inflammation and heat to alleviate joint discomfort. -The nurse should not administer >3g of acetaminophen to reducer the risk of injury to the patient. A nurse is assessing a patient who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the vision loss? A. An increase in the intraocular pressure B. Deterioration of the macula C. Increased opacity of the lens D. Vitreous hemorrhage -A cataract is a cloudy or opaque area of the lens of the eye that inhibits light penetration. -Glaucoma leads to an increase in intraocular pressure, causing mild headaches and foggy vision. -Macular degeneration is caused by deterioration of the macula, resulting in decreased central vision. -Vitreous hemorrhage is bleeding following damage of retinal blood vessels, which can occur due to elevated BP or uncontrolled diabetes. A nurse is assessing a patient following a colonoscopy. Which of the following findings should indicate to the nurse that the patient is hemorrhaging? A. Sudden drop in heart rate B. Rapid decrease in blood pressure C. Patient reports feeling of fullness D. Patient reports pain 8/10 -An increased heart rate and rapid decrease in BP indicates hemorrhage. -A feeling of fullness is an expected finding following a colonoscopy. -Pain could indicate bowel perforation. A nurse is assessing a 2mo-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex? A. Stroke the infant's cheek B. Depress the infant's tongue C. Turn the infant's head to one side D. Tap on the bridge of the infant's nose -Rooting reflex includes stroking infant's cheek which should cause the infant to turn towards that side and suck. -The nurse should depress the infant' tongue to assess the extrusion reflex, which should cause the infant to stick out the tongue. -The nurse should turn the infant's head to one side to assess the asymmetric tonic neck reflex, which should cause the infant to extend their arm and leg on that side and flex their arm and leg on the other side. -The nurse should tap on the bridge of the infant's nose to assess the glabellar reflex, which should cause the infant to close their eyes tightly. A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36hrs. Which of the following findings should the nurse identify is an indication that the patient has developed oxygen toxicity? A. Wheezes B. Tachycardia C. Restlessness D. Substernal pain -The nurse should identify substernal pain as a manifestation of oxygen toxicity due to the increased WOB. Another manifestation is crackles. -Tachycardia and restlessness indicate hypoxemia and requires oxygen therapy. A patient is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/in and a BP of 90/44. Which of the following medications should the nurse anticipate administering? A. Naloxone B. Flumazenil C. Acetylcysteine D. Atropine -Flumazenil is a competitive benzo receptor antagonist. It reverses the sedative effects of lorazepam. In addition, the nurse should continue to support the patient's respirations with a bag-valve mask. -Naloxone is the antidote for opiate overdose. -Acetylcysteine is the antidote for acetaminophen overdose. -Atropine is the antidote for cholinesterase inhibitor overdose. A nurse is assessing a patient whose partner recently died. The patient states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? A. "It's natural for you to feel this way now, but things will get better with time." B. "You seem to be having a difficult time right now." C. "Why do you feel like your life isn't worth living?" D. "You'd be surprised how many people experience these feelings." -This statement makes an observation, which is a therapeutic response by the nurse. It encourages the patient to express their thoughts and feelings. -Offering false reassurance and minimizing the patient's feelings is not therapeutic. -Asking the patient a "why" questions implies criticism and can make the patient feel defensive. A nurse is teaching a patient who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the patient to monitor and report to the provider? A. Hypotension B. Headaches C. Bruising D. Oliguria -The nurse should instruct the patient to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events. -Other symptoms to report include HTN, swelling/tenderness of an extremity, fluid retention, or genitourinary candidiasis. A nurse is caring for a patient who has bipolar disorder. The nurse observes that the patient is becoming increasingly restless. The patient is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? A. Provide an opportunity for the patient to express their feelings. B. Move the patient to a quiet place away from others. C. State expectations that set limits on the patient's behavior. D. Administer a PRN dose of haloperidol to calm the patient. -The patient's behavior indicates the greatest risk is injury to others. Therefore, the first action the nurse should take is to prevent harm to other patients by moving this patient to a quiet place away from others. A nurse is caring for a patient who is in labor at 39wks of gestation. During the second stage of labor, the nurse observes early decels on the monitor tracing. Which of the following actions should the nurse take? A. Continue observing the FHR. B. Assist the patient to a knee-chest position. C. Prepare the patient for continuous internal monitoring. D. Prepare for an emergency C-sect -Early decels indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the FHR and tracing. -Assist the patient into a knee-chest position if the umbilical cord prolapses. -No indication for internal monitoring. -Prepare for an emergency c-sect if the monitor indicates late/variable decels, despite interventions. A nurse is creating a plan of care for a patient who has a left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? A. Massage bony prominences on the patient's left side. B. Support the patient's left arm on a pillow while sitting. C. Position the bedside table on the patient's left side. D. Place the patient's cane on their left side while ambulating. -Support the affected arm to prevent the extremity from hanging freely because this can cause shoulder subluxation. -Avoid massaging bony prominences because it can cause deep tissue trauma. -Position the table on the patient's unaffected side so items are within reach. -Teach patient to hold the cane on the stronger side of their body. A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? A. Maintain a flexible daily schedule for the child. B. Use a reward system to modify the child's behavior. C. Provide a variety of family member to care for the child. D. Administer alprazolam PRN to reduce the child's anxiety. -Children who have autism spectrum disorder respond well to a reward system, which can provide structure and expectations for behavior. -Children with autism respond better to a familiar daily schedule and having familiar caregivers. Usually are prescribed SSRIs to improve mood and reduce anxiety. A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical sterile technique? A. Hold hands folded below the waist after donning sterile gloves. B. Pick up and pour solutions with the palm of the hand covering bottle labels. C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. D. Maintain sterile objects within the line of vision. -Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep sterile objects in direct sight to maintain surgical asepsis. -Sterile technique includes holding hands away from body and above waist level. Items should be kept at least 2.5 cm (1 in) away from the border. -The nurse should use this technique to prevent the solution from running down the label and obscuring the writing, but this action does not maintain sterile technique. A nurse is reviewing the lab results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect? (Normal: 30-40 sec) A. 11 seconds B. 22 seconds C. 30 seconds D. 45 seconds -A manifestation of hemophilia A is a longer clotting time. A nurse manager in a LTC facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first? A. Form a committee of staff members to investigate current staffing issues. B. Provide support to staff members who are resistant to staffing changes. C. Schedule a staff meeting to present the different options to staff members. D. Give the staff members advance written notice of staffing changes. -The first action the nurse should take when using the nursing process is to assess the current staffing issue. The first stage pf change is the "unfreezing stage", which is gathering information about the problem. A nurse is planning care for a patient who has thrombocytopenia. Which of the following instructions should the nurse include in the plan of care? A. Avoid venipunctures when possible. B. Restrict visitors to family members. C. Limit oral fluid intake in between meals. D. Prohibit fresh flowers in the patient's room. -Patients who have thrombocytopenia have a decreased PLT count and are at risk for bleeding. -Neutropenic precautions are for patients with a decreased level of WBC, putting them at risk for infection. Precautions include restricting visitors to healthy individuals and prohibiting fresh flowers in their room. A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? A. Contact the triage officer. B. Implement the patient tracking system. C. Ask the communications officer to release a press statement. D. Notify the incident commander. -The first action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy and maintain order. NGN: What should be included in the plan of care for a 8yr old patient with cystic fibrosis? Admission: SOB, wheezes x5 lobes, prod. cough with thick sputum. Vitals: HR 108, R 26, T 98.9F, BP 100/62, O2 92%. Sputum culture (+) B. cepacia A. Initiate droplet precautions. B. Keep the child NPO x12hrs. C. Maintain the child on bed rest x24hrs. D. Administer high-dose antibiotic therapy. -Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections. -Initiate contact precautions, high-calorie/high-protein diet with unlimited fat, and include ADLs in plan of care. Exercise facilitates mucus excretions and can increase the child's self-esteem. A nurse is caring for school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests? A. Chest x-ray B. Serum liver enzyme levels C. ABGs D. Urine culture and sensitivity -Valproic acid can cause hepatic toxicity. Assess liver function prior to and periodically during therapy. A nurse receives a request from a patient to review information in his medical record. Which of the following responses should the nurse give? A. "There's a protocol for reviewing your medical record, and I can initiate the process." B. "The medical record has a lot of medical terminology, and it might be difficult for you to understand." C. "You should really talk to your provider if you have any questions about your treatment." D. "Some parts of your medical record are restricted, but I can show you the parts that you are allowed to see." -The patient's record is the legal property of the facility, but the patient has a right to access the record, obtain a copy of the record, and request corrections to the document if there are discrepancies. According to HIPAA, the nurse is responsible for following the facility's policy when providing the patient with access to the medical record. A nurse is reviewing the lab results of a patient who has ESRD and received HD 24hrs ago. Which of the following labs should the nurse report to the HCP? A. PLT 268 B. Calcium 9.2 C. WBC 5,200 D. Sodium 148 -Elevation indicated hypernatremia. Patients with renal disease often retain sodium and require sodium-restricted diets. A nurse is caring for a patient who is in the fourth stage of labor and is receiving continuous oxytocin IV. Which of following assessments is the nurse's priority? A. Amount of vaginal bleeding B. Amount of urinary output C. Pain level D. Fundal height -The first action the nurse should take using the nursing process is to assess the amount of vaginal bleeding. A patient who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount the amount vaginal bleeding is the nurse's priority. A charge nurse is planning care for a patient who has mechanical restraints in place. Which of the following interventions should the nurse include the plan? A. Remove the patient's restraints while sleeping B. Document the patient's status q60 min. C. Check for a new prescription q6hrs. D. Provide a staff member to stay with the patient -A staff member must remain continuously with a patient who is in restraints or view the patient via audiovisual equipment, if necessary, due to risk of injury. -The nurse should not remove restraints until the patient is calm, in control, and able to follow simple commands. -Assess the patient for physical needs, safety, and comfort q15-30 min and document the findings. -HCP must renew a prescription for restraints q4hrs for patients 18yrs<, q2hrs for children 9-17yrs, and q1hr for children <9yrs. A nurse administers an incorrect dose of medication to a patient. The nurse recognize the error immediately and completes an incident report. Which of following facts related to the incident should the nurse document in the patient's medical record? A. Completion of the incident report B. Time the medication was given C. Reason for the medication error D. Notification of the pharmacist -Document the time, the name of the medication, the dose, and the route in which the medication was given on the med administration record. Document the time that the incorrect medication was administered to the patient in the incident report, as this is a fact directly related to the occurrence. A nurse on an inpatient unit is caring for a patient who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take? A. Implement fall precautions for the patient. B. Monitor the patient's thyroid function. C. Place the patient on a fluid restriction. D. Discontinue the medication if hallucinations occur. -Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. -Monitor the patient's CBC for anemia, thrombocytopenia, leukocytosis, leukopenia, and elevated AST/ALTs. -Can cause constipation, diarrhea, or dry mouth. Nurse should encourage increased intake of fluids. A nurse is providing discharge teaching about disease management for a patient who has a new diagnosis of DM1. Which of the following is the nurse's priority? A. Instruct the patient about the importance of regular medical appointments. B. Encourage the patient to participate in daily exercise. C. Explain proper foot care techniques to the patient. D. Ensure that the patient understands the medication regimen. -The priority action the nurse should take when using the safety vs. risk reduction approach to patient care is to ensure the patient understands the medication regimen. The greatest risk to the patient is the potential to develop hypoglycemia/hyperglycemia, which can be life-threatening if treated incorrectly. A patient who is 24hrs post-op following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? A. Ask the patient to rate their pain level. B. Assist the patient in changing positions. C. Administer a PRN analgesic medication. D. Explain the importance of early ambulation. -Using the nursing process, the first action the nurse should take is to assess the patient's level of pain. If indicated, the nurse should administer an analgesic, then wait 30-45 min to allow the analgesic to take effect before encouraging the patient to ambulate. Management of the patient's pain is a priority for encouraging post-op activity. A nurse is caring for a patient who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? A. Assess the patient's IV site q8hrs. B. Check the WBC count q48hrs. C. Monitor the patient's mouth q8hrs. D. Change the IV tubing q48hrs. -Monitor mouth at least q8hrs for manifestations of an infection (like sores or lesions). -Check IV site q4hrs for REEDA. -Monitor WBC count q24hrs. -Change IV tubing q24hrs. A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? A. Popcorn [Show More]

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