C
Terms in this set (450)
RN Comprehensive Online
Practice exam
QUESTIONS AND VERIFIED
ANSWERS WELL GRADED,
BEST ATI
COMPREHENSIVE (NEW
UPDATE)
QUESTIONS WITH
VERIFIED ANSWERS |
100% CORRECT | A+
GRADE.
,A nurse is caring for a client who is on the The client is most likely experiencing manifestations
of spinal cord injury (SCI) unit pneumonia and autonomic dysreflexia.
Nurses' Notes The nurse should analyze cues from the client's manifestations
Day 3, 1700 and determine that the client is most likely experiencing
Client admitted to SCI unit 3 days ago manifestations of pneumonia and autonomic dysreflexia.
A following C7 injury. Skin is cool, pale, and client who has a cervical SCI is at risk for respiratory
dry to touch. Respirations easy and complications because spinal innervation to the respiratory
unlabored. Lung sounds diminished in lowermuscles is disrupted. Adventitious breath sounds in the
lower lobes. Abdomen soft and nondistended lobes bilaterally and a decrease in oxygen
saturation to less with active bowel sounds. Client passed a than 92% can indicate pneumonia. The
client's sudden
small amount of hard formed stool this AM. increase in blood pressure, bradycardia, flushing of the skin
Indwelling urinary catheter draining clear above the area of the injury, headache, and blurred vision
are yellow urine. Deep tendon reflexes (DTR) manifestations of autonomic dysreflexia, which can
be a life-are biceps 1+, triceps 1+, pa threatening condition.
A nurse is caring for a client who has Hepatitis A: Client's risk from fecal-oral transmission,
abdominal pain laboratory results, and physical examination findings
Nurses' Notes Hepatitis B: Antiviral treatment, laboratory results, client's risk
0900 from bloodborne transmission, physical examination
findings Client reports loss of appetite, weight loss,
and fatigue for 1 week. Reports abdominal Hepatitis C: Antiviral treatment, laboratory results, client's risk
pain, 6 on a scale from 0 to 10, for 2 days. from bloodborne transmission, and physical examination
Client is a perioperative nurse, returned 1 findings
week ago from a 2-week mission trip to an
underdeveloped country When analyzing cues, the nurse should recognize that
manifestations of hepatitis A, hepatitis B, and hepatitis C
1200 include jaundice, yellow sclerae, right upper quandrant pain
Results of antibody studies obtained. upon palpation, dark yellow urine, and elevated AST and ALT
Provider prescription for antiviral levels. When analyzing cues, the nurse should also
recognize medication pending. the client's risk for contracting hepatitis A through the fecal-
oral route during recent travel to an underdeveloped country
Physical Examination and the client's occupational risk as a perioperative nurse for
0930 contracting hepatitis B and hepatitis C through bloodborne
Lung sounds clear bilaterally. Skin warm to transmission. The nurse should recognize that the current
touch and jau standard of practice for
,A nurse is caring for a client on a Click to highlight the findings that require follow up. To
medical-surgical unit deselect a finding, click on the finding again.
- Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area
Vital Signs on sacrum
0700 - Client repositioned every 4 hr
Temperature 37.6 C (99.7 F)
Heart rate 100/min When recognizing cues, the nurse should determine that the
Respiratory rate 22/min client's painful edematous area on their sacrum and that the
Blood pressure 115/70 mmHg client has only been repositioned every 4 hr requires
Oxygen saturation 98% on room air follow
up. The client has manifestations of a pressure injury that need
Nurses' Notes to be addressed. The client should be repositioned at
1100 least every 2 hr to prevent worsening of the pressure injury
Client alert and oriented to person, place, and to relieve pressure from the sacral area.
and time. Client had episode of diarrhea,
provided perineal care. Noted 2 cm x 2 cm
(0.8 in x 0.8 in) painful edematous area on
sacrum. Client repositioned every 4 hr.
A nurse in an outpatient mental health clinic Select the 3 findings that require immediate follow up:
is caring for a client - Auditory hallucinations
- Speech
Vital Signs - Restlessness
3 months ago
Blood pressure 116/68 mmHg When recognizing cues, the nurse should identify that the
Heart rate 82/min findings of restlessness, auditory hallucinations, and pressured
Respiratory rate 16/min speech require immediate follow up. These findings are
Temperature 36.7 C (98.1 F) indications of psychosis. The nurse should notify the provider
SaO2 97% on room air for additional evaluation and treatment.
Today:
Blood pressure 128/76 mmHg
Heart rate 104/min
Respiratory rate 22/min
Temperature 37.4 (99.4 F)
SaO2 97% on room air
Nurses' Notes
3 months ago
Client recently admitted with new diagnosis
of schizophrenia. Received inpatient
treatment for 10 days and was discharged 1
week ago.
, A nurse is caring for a client who is The client is at greatest risk for developing dysrhythmias,
as postoperative following coronary artery evidenced by electrolyte imbalance.
bypass surgery (CABG)
The nurse should analyze cues to determine the client is at
Laboratory Results greatest risk for developing dysrhythmias related to
0630 hypokalemia, as evidenced by the laboratory report and the
Sodium 145 mEq/L (136 to 145 mEq/L) client's report of muscle cramping. Potassium and magnesium
Potassium 3.2 mEq/L (3.5 to 5 mEq/L) depletion are common manifestations in clients who are
Chloride 116 mEq/L (98 to 106 mEq/L) postoperative following CABG. Due to medication or
BUN 24 mg/dL (10 to 20 mg/dL) hemodilation, it is important for the nurse to closely
monitor Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) electrolytes.
Total calcium 9 mg/dL (9 to 10.5 mg/dL)
Phosphate 4.6 mg/dL (3 to 4.5 mg/dL)
Glucose 95 mg/dL (74 to 106 mg/dL)
WBC count 9,500/mm3 (5,000 to
10,000/mm3)
I&
O
0700
4 hr input 400 mL
4 hr output
A nurse is caring for a client who is pregnant The nurse should first address the client's
respiratory rate, in the acute care setting followed by the client's level of consciousness
Nurses' Notes When prioritizing hypotheses, the nurse should recognize that
1400 magnesium sulfate is a central nervous system depressant that
Client reports a constant low dull backache can affect respirations, consciousness, and reflexes when
toxic and painless abdominal tightening for the blood levels occur. Using the airway, breathing,
circulation past 3 hr. Denies any changes in vaginal priority framework, the nurse should plan to first take
action to discharge. External fetal monitor applied. support respirations, followed by action to
increase the
client's level of consciousness. The nurse should plan to
1430 discontinue the magnesium sulfate infusion and administer
Contraction pattern: contractions every 4 tocalcium gluconate as an antidote.
5 min, lasting 30 to 45 seconds, palpate
mild in intensity
Fetal heart rate: 150/min to 155/min,
moderate variability, adequate
accelerations present, no decelerations
noted. Provider in
Terms in this set (450)
RN Comprehensive Online
Practice exam
QUESTIONS AND VERIFIED
ANSWERS WELL GRADED,
BEST ATI
COMPREHENSIVE (NEW
UPDATE)
QUESTIONS WITH
VERIFIED ANSWERS |
100% CORRECT | A+
GRADE.
,A nurse is caring for a client who is on the The client is most likely experiencing manifestations
of spinal cord injury (SCI) unit pneumonia and autonomic dysreflexia.
Nurses' Notes The nurse should analyze cues from the client's manifestations
Day 3, 1700 and determine that the client is most likely experiencing
Client admitted to SCI unit 3 days ago manifestations of pneumonia and autonomic dysreflexia.
A following C7 injury. Skin is cool, pale, and client who has a cervical SCI is at risk for respiratory
dry to touch. Respirations easy and complications because spinal innervation to the respiratory
unlabored. Lung sounds diminished in lowermuscles is disrupted. Adventitious breath sounds in the
lower lobes. Abdomen soft and nondistended lobes bilaterally and a decrease in oxygen
saturation to less with active bowel sounds. Client passed a than 92% can indicate pneumonia. The
client's sudden
small amount of hard formed stool this AM. increase in blood pressure, bradycardia, flushing of the skin
Indwelling urinary catheter draining clear above the area of the injury, headache, and blurred vision
are yellow urine. Deep tendon reflexes (DTR) manifestations of autonomic dysreflexia, which can
be a life-are biceps 1+, triceps 1+, pa threatening condition.
A nurse is caring for a client who has Hepatitis A: Client's risk from fecal-oral transmission,
abdominal pain laboratory results, and physical examination findings
Nurses' Notes Hepatitis B: Antiviral treatment, laboratory results, client's risk
0900 from bloodborne transmission, physical examination
findings Client reports loss of appetite, weight loss,
and fatigue for 1 week. Reports abdominal Hepatitis C: Antiviral treatment, laboratory results, client's risk
pain, 6 on a scale from 0 to 10, for 2 days. from bloodborne transmission, and physical examination
Client is a perioperative nurse, returned 1 findings
week ago from a 2-week mission trip to an
underdeveloped country When analyzing cues, the nurse should recognize that
manifestations of hepatitis A, hepatitis B, and hepatitis C
1200 include jaundice, yellow sclerae, right upper quandrant pain
Results of antibody studies obtained. upon palpation, dark yellow urine, and elevated AST and ALT
Provider prescription for antiviral levels. When analyzing cues, the nurse should also
recognize medication pending. the client's risk for contracting hepatitis A through the fecal-
oral route during recent travel to an underdeveloped country
Physical Examination and the client's occupational risk as a perioperative nurse for
0930 contracting hepatitis B and hepatitis C through bloodborne
Lung sounds clear bilaterally. Skin warm to transmission. The nurse should recognize that the current
touch and jau standard of practice for
,A nurse is caring for a client on a Click to highlight the findings that require follow up. To
medical-surgical unit deselect a finding, click on the finding again.
- Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area
Vital Signs on sacrum
0700 - Client repositioned every 4 hr
Temperature 37.6 C (99.7 F)
Heart rate 100/min When recognizing cues, the nurse should determine that the
Respiratory rate 22/min client's painful edematous area on their sacrum and that the
Blood pressure 115/70 mmHg client has only been repositioned every 4 hr requires
Oxygen saturation 98% on room air follow
up. The client has manifestations of a pressure injury that need
Nurses' Notes to be addressed. The client should be repositioned at
1100 least every 2 hr to prevent worsening of the pressure injury
Client alert and oriented to person, place, and to relieve pressure from the sacral area.
and time. Client had episode of diarrhea,
provided perineal care. Noted 2 cm x 2 cm
(0.8 in x 0.8 in) painful edematous area on
sacrum. Client repositioned every 4 hr.
A nurse in an outpatient mental health clinic Select the 3 findings that require immediate follow up:
is caring for a client - Auditory hallucinations
- Speech
Vital Signs - Restlessness
3 months ago
Blood pressure 116/68 mmHg When recognizing cues, the nurse should identify that the
Heart rate 82/min findings of restlessness, auditory hallucinations, and pressured
Respiratory rate 16/min speech require immediate follow up. These findings are
Temperature 36.7 C (98.1 F) indications of psychosis. The nurse should notify the provider
SaO2 97% on room air for additional evaluation and treatment.
Today:
Blood pressure 128/76 mmHg
Heart rate 104/min
Respiratory rate 22/min
Temperature 37.4 (99.4 F)
SaO2 97% on room air
Nurses' Notes
3 months ago
Client recently admitted with new diagnosis
of schizophrenia. Received inpatient
treatment for 10 days and was discharged 1
week ago.
, A nurse is caring for a client who is The client is at greatest risk for developing dysrhythmias,
as postoperative following coronary artery evidenced by electrolyte imbalance.
bypass surgery (CABG)
The nurse should analyze cues to determine the client is at
Laboratory Results greatest risk for developing dysrhythmias related to
0630 hypokalemia, as evidenced by the laboratory report and the
Sodium 145 mEq/L (136 to 145 mEq/L) client's report of muscle cramping. Potassium and magnesium
Potassium 3.2 mEq/L (3.5 to 5 mEq/L) depletion are common manifestations in clients who are
Chloride 116 mEq/L (98 to 106 mEq/L) postoperative following CABG. Due to medication or
BUN 24 mg/dL (10 to 20 mg/dL) hemodilation, it is important for the nurse to closely
monitor Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) electrolytes.
Total calcium 9 mg/dL (9 to 10.5 mg/dL)
Phosphate 4.6 mg/dL (3 to 4.5 mg/dL)
Glucose 95 mg/dL (74 to 106 mg/dL)
WBC count 9,500/mm3 (5,000 to
10,000/mm3)
I&
O
0700
4 hr input 400 mL
4 hr output
A nurse is caring for a client who is pregnant The nurse should first address the client's
respiratory rate, in the acute care setting followed by the client's level of consciousness
Nurses' Notes When prioritizing hypotheses, the nurse should recognize that
1400 magnesium sulfate is a central nervous system depressant that
Client reports a constant low dull backache can affect respirations, consciousness, and reflexes when
toxic and painless abdominal tightening for the blood levels occur. Using the airway, breathing,
circulation past 3 hr. Denies any changes in vaginal priority framework, the nurse should plan to first take
action to discharge. External fetal monitor applied. support respirations, followed by action to
increase the
client's level of consciousness. The nurse should plan to
1430 discontinue the magnesium sulfate infusion and administer
Contraction pattern: contractions every 4 tocalcium gluconate as an antidote.
5 min, lasting 30 to 45 seconds, palpate
mild in intensity
Fetal heart rate: 150/min to 155/min,
moderate variability, adequate
accelerations present, no decelerations
noted. Provider in
