RN Comprehensive online practice 2023 A with NGN-tap ALL SOLUTION LATEST EDITION GUARANTEED GRADE A+

A.) Ask the Caller for verification of their identity A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actins should the nurse take? A.)Ask the caller for verification of their identity B.) Give the caller limited information about the client C.) transfer the phone call to the client's room D.) Inform the caller that they should obtain permission from the client's provider D.) The client's heel is reddened and tender A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority? A.) the client reports leg itching under the cast around the mid-upper thigh area B.) The client reports increased pain when the leg is lowered below the level of the heart C.) The client's cast became wet during a sponge bath D.) The client's heel is reddened and tender B.) Complete a serum pregnancy test before taking the medication A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information? A.) Increase intake of fluids and fiber to prevent constipation B.) Complete a serum pregnancy test before taking the medication C.) This medication coats stomach ulcers so that they can heal D.) Take a magnesium-containing antacid along with this medication B.) Nausea A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? A.) Constipation B.) Nausea C.) Wheezing D.) Muscle rigidity C.) Hypertension A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor? A.) weight loss B.) urinary retention C.) hypertension D.) hypoglycemia 2.) Remove the Inner Cannula 4.) Remove soiled dressing 1.) Clean the stoma with 0.9% sodium chloride irrigation 3.) Change the tracheostomy collar A m nurse is providing Teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. Steps: 1.) clean the stoma with 0.9% sodium chloride irrigation 2.) remove the inner cannula 3.)change the tracheostomy collar 4.) remove soiled dressing D.) Keep the head of the bed elevated to 45 degrees for 1 hour after feedings A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A.) Instill 100mL of air into the NG tube after checking for residual B.) flushes the NG tube with 0.9% sodium chloride irrigation every 2 hours C.) Adds 20mL of blue dye to each feeding to help detect aspiration D.) Keep the head of the bed elevated to 45 degrees for 1 hour after feedings D.) Mannitol A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure? A.) propranolol B.) phenytoin C.) lorazepam D.) mannitol C.) Places a pillow under the client's right arm An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? A.) uses a draw sheet to move the client to the left side of the bed B.) Raises the total height of the bed to waist level C.) places a pillow under the client's right arm D.) Lowers the side rails on the left side of the bed A.) "A speech pathologist will performing a swallowing study for you" B.) "You should rest before eating a meal" E.) "Thicken your beverages before drinking" A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? (Select all that apply) A.) "A speech pathologist will performing a swallowing study for you" B.) "You should rest before eating a meal" C.) "You should restrict foods that are high in Vitamin D" D.) "reduce your intake of dietary fiber" E.) "Thicken your beverages before drinking" The infant is at highest risk of developing A.) dehydration As evidenced by C.) vomiting Nurse's Notes: 1500: Infant is admitted to the pediatric unit. Parent reports infant has been irritable and has vomited after each feeding within the last 3 days. Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive x4 quadrants. Small 1x1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor with tenting. 1600: Called to room by a parent. Parent attempted breastfeeding. Infant projectile vomited No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO. 1800: Infant crying. Soothed with Pacifier. Diagnostic Results: 1545: Hgb: 20g/dL (14-24) ; Potassium: 5.8mEq/L (3.9-5.9); Na: 132mEq/L (134-150); Chloride: 110 (96-106); WBC: 16,000 (6,200-17,000); BUN: 20 (5-18); Creatinine: 0.2 (0.1-0.4) 1730: Abdominal ultrasound: Narrowing of pyloric canal. Thickening of pylorus. Consistent with hypertrophic pyloric stenosis. Vital Signs: 1500: Temp: 37.1 (98.8 F); HR: 120; RR: 30; Weight: 3.62 (8lbs) History and Physical: Birthweight: 3,492.7g (7.7lbs(); parent is breastfeeding. Newborn birthed vaginally at 38 weeks of gestation. The infant is at highest risk for_____________ A.) dehydration B.) anemia C.) hyperkalemia As evidenced by the infant's __________ A.)potassium level B.) hemoglobin C.) vomiting C.) massage the uterus to expel clots A nurse is caring for a client who is 4 hours postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? A.) administer oxygen B.) initiate an infusion of oxytocin C.) massage the uterus to expel clots D.) obtain a CBC A.) A client's IV pump delivers an inadequate dose of medication A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? A) A client's IV pump delivers an inadequate dose of medication B.) A nurse follows a client's advance directives and discontinues enteral feedings C.) A nurse discards unused, expired bags of IV fluids D.) A client refuses an IV bolus of pain medication A.) Flush the client's gastrostomy tube with 30mL of water before administering the medication A nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? A.) Flush the client's gastrostomy tube with 30mL of water before administering the medication B.) Crush the client's medications and mix them in with the tube feeding formula prior to administration C.) Change the client's feeding bag every 72 hours D.) Administer multiple prescribed medications at the same time A.) Obtain the client's blood pressure before the nurse administers medication A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A.) Obtain the client's blood pressure before the nurse administers medication B.) Initiate a referral with a dietician for the client C.) Inform the client about adverse effects of the medication D.) Recommend a salt substitute to the client The client is most likely experience manifestations of _B.) Autonomic dysreflexia ______ and ____E.) Pneumonia _____ The nurse is caring for a client who is on the spinal cord injury (SCI) unit. Nurse's Notes: Day 3: 1700: Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and non-distended with active bowel sounds. Client passed a small amount of hard formed stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0 on a 0 to 10 scale. Day 4: 0600: Client reports increased coughing and shortness of breath. Crackles auscultated in lower lobes bilaterally. Face and neck flushed. Skin warm and moist. Client reports blurred vision and a headache as an 8 on a 0 to 10 pain scale. Abdomen soft and mildly distended. Hypoactive bowel sounds present. Urinary output 300mL over last 8 hours. Vital Signs Day 3: 1700: Temp 38.2 C (100.8 F) HR: 74 RR: 20 BP: 108/60 and O2 sat: 96 on room air Day 4: 0600: temp: 38.4 (101.2 F) HR: 54; RR: 26; BP: 142/90; O2 sat: 91 on room air The client is most likely experience manifestations of _______ and _________ Choose words from these words: A.) Paralytic ileus B.) Autonomic dysreflexia C.) peritonitis D.) urinary tract infection E.) Pneumonia B.) Facial Flushing D.) Nasal Congestion e.) Headache A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (Select all that apply) A.) Nystagmus B.) facial flushing C.) diplopia D.) Nasal congestion E.) Headache D.) Provide a staff member to stay with the client continuously A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? A.)Remove the client's restraints while sleeping B.) Document the client's status every 60 minutes C.) Check for a new prescription every 6 hours D.) Provide a staff member to stay with the client continuously C.) Blowing bubbles with liquid soap to "blow the hurt away" When caring for a child, a nurse plans to use non-pharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? A.) Coloring with crayons in a coloring book B.) Deep breathing and "going limp as a rag doll" C.) Blowing bubbles with liquid soap to "blow the hurt away" D.) Taking a warm bath and playing with a bath toy C.) Pulsus paradoxus A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? A.) Carotid bruit B.) tracheal deviation C.) Pulsus paradoxus D.) Heart murmur A.) Back pain B.) headache C.) anxiety A nurse is caring for a client who is receiving a transfusion of packed red blood cells (RBCs) Vital Signs: 0900: Temp 36.9 C (98.5 F) HR: 74; RR: 16; BP: 112/68; Pulse ox: 98 0915: Temp: 36.9 C (98.5 F); HR: 76; RR: 16; BP: 120/68; Pulse Ox: 98 0930: Temp: 36.9 C (98.5 F); HR: 90; RR: 18; BP: 116/70; Pulse Ox: 98 Diagnostic Results: 0800: Hgb 5.6 (12-16); Platelets: 18000 (150,000-400,000) Nurse's Notes: 0900: platelet count and hgb unchanged from post-transfusion results yesterday. Infusion of 1 unit of packed RBCs started as ordered. Client alert and oriented to person, place, and time. 0930: Client requests pain medication for headache and reports level of 5 on a scale of 0-10. Client reports "arthritis must be acting up because my back and knees and ankles hurt" Asked if nurse can assist in placing pillows behind back for low back pain. Reports back and joint pain as a 4 on a scale of 0 to 10. States they did not have any concerns yesterday during transfusions but "starting to feel a little anxious about it now. I'm not really sure why I need this". Alert and oriented to person and place. Skin pale, cool, and dry to touch. Mucous membranes pink and moist. Urine output 150mL of clear, yellow urine in urinal. The nurse should suspect a transfusion reaction based on which of the following assessment findings? Select all that apply: A.) Back pain B.) headache C.) anxiety D.) urine output E.) skin F.) vital signs medication B.) Check the insulin dose with another licensed nurse A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? A.) Teach the client reportable adverse effects from the medication B.) Check the insulin dose with another licensed nurse C.) Administer the insulin at a 90 degree angel D.) Clean the insertion site. C.) Upper chest petechia * sign of a fat embolism; fat enters the blood stream and obstructs blood vessels; petechia on upper torso is a common sign* A nurse is assessing a client who has a skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? A.) muscle spasms of the affected extremity B.) A pain rating of 6 on a scale from 0 to 10 C.) Upper chest petechia D.) Ecchymosis over the fractured area D.) guided imagery a nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSD) and asks the nurse to recommend a non-pharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? A.) spinal manipulation B.) acupuncture C.) therapeutic touch D.) guided imagery D.) Elevate the affected leg A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? A.) Maintain the client on bed rest B.) restrict the client to 1L of fluid per day C.) Place cool compress on the edematous area D.) Elevate the affected leg The client is at risk for _____C.) Thrombocytopenia ________ Due to ____C.) Petechiae _______ A nurse is caring for a client who is on 24-hour observation. Laboratory Results: Day 1 0600: Sodium 150 (136-145); Potassium: 5.5 (3.5-5); Chloride: 105 ( 98-106); BUN: 17 (7-30); Magnesium: 1.2 (1.3-2.1); Total Calcium: 10 (9-10.5); Phosphate: 4 (3-4.5); Glucose: 135 (74-106); Platelet: 99,500 (150,000-400,000); WBC: 9500 (5,000-10,000); total protein: 4 (6.4 to 8.3); Albumin: 1.5 (3.5-5); blood alcohol content: 200 (0-50) History and Physical: 0600: Client admitted for 24 hour observation for alcohol intoxication. History of alcohol use disorder per family. Client alert and oriented to person. Client appears lethargic. Diminished lung sounds auscultated in bilateral lower lobes. Heart is tachycardic. Nausea and vomiting for last 2 days. Bowel sounds hypoactive in all 4 quadrants. Abdomen is distended and nontender. Client unable to verbalize last alcohol ingestion. Petechiae noted on forearms bilaterally. Client is diaphoretic. Medication Administration Record: Day 1 0700: 0.9% sodium chloride IV fluids at 150mL/hr Vital Signs: Day 1: 0600: Temp 38.4 C (101.1 F) HR: 84; RR: 18; BP: 132/68; O2Sat: 98 0645: Temp: 37.7 (99.9 F); HR: 90; RR: 20; BP: 142/58; O2 Sat: 95 0800: Temp: 35.9 C (96.6 F); HR: 110; RR: 20; BP: 110/76; O2 Sat: 92 0910: Temp: 37.6 C (99.7 F); HR: 116; RR: 22; BP: 105/62; O2: 90 on room air Nurse's Notes: Day 1: 0700: Client is sleeping. No change in previous condition. 0810: Client awake. Lethargic. Bleeding noted from left nostril. Applied pressure to left nostril with cotton gauze. Provider notified. 0903: Client alert to person and place. Verbalized last drink was "last night". Does not recall events from previous night. Bleeding increased. Provider notified The client is at risk for _____________ A.) Dehydration B.) Malnutrition C.) Thrombocytopenia Due to _________ A.) Fever B.) Decreased bowel sounds C.) Petechiae B.) Confusion *early sign of lithium toxicity* A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following findings should the nurse identify as the priority? A.) Lethargy B.) Confusion C.) Polyuria D.) Fine hand tremors D.) An assistive personnel (AP) who is assisting a client to return to bed. A nurse is caring for a client who is 12 hours postoperative is receiving PCA for pain control, and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information? A.) An RN who is monitoring a client who started receiving a blood transfusion 5 min ago B.) An assistive personnel (AP) who just began performing a bed bath. C.) a Licensed practical nurse (LPN) who is reinforcing discharge instructions with a client D.) An assistive personnel (AP) who is assisting a client to return to bed. The nurse should first address the client's __A.) Respiratory Rate______ Followed by the client's __C.) Level of consciousness ___ A nurse is caring for a client who is pregnant in the acute care setting. Nurse's Notes: 1400: Client reports a constant low dull backache and painless abdominal tightening for the past 3 hours. Denies any changes in vaginal discharge. External fetal monitor applied. 1430: Contraction pattern: contractions every 4 to 5 min , lasting 30 to 45 seconds, palpate mild in intensity. Fetal HR: 150-155 bpm, moderate variability, adequate accelerations present, no decelerations noted. Provider in to see client. Specimen obtained for fetal fibronectin. 1800: Client sleepy. Difficult to arouse. Respirations slow and shallow, Contraction pattern: Contractions every 10 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal HR: 140 bpm, moderate variability, no accelerations noted, no decelerations noted. Vital Signs: 1400: Temp: 37 C (98.6 F); HR: 72; RR: 20; BP: 115/75; O2 Sat: 98 on room air 1800: HR: 65; RR: 10; BP: 100/60; O2 sat: 88 on room air Medication Administration Record: 1445: Administered magnesium sulfate 4g IV bolus over 20min. Initiated lactated Ringer's continuous infusion at 75mL/hr. 1450: Administered betamethasone 12mg IM. 1505: Initiated magnesium sulfate continuous infusion at 2g/hr History and Physical: Gravida 2 Para 1; 30 weeks gestation. Previously uncomplicated pregnancy. Reported the onset of back pain and contractions 3 hr ago. Vaginal examination: 3cm dilated and 50% effaced. Amniotic membranes intact. Diagnosis: Preterm labor Plan: Administer tocolytics and glucocorticoids The nurse reviews the assessment data at 1800. Which of the following actions should the nurse plan to take? The nurse should first address the client's ________ A.) Respiratory Rate B.) Contraction Pattern C.) Fetal heart rate variability Followed by the client's _____ A.) Blood pressure B.) absent accelerations C.) Level of consciousness C.) boggy uterus A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? A.) intermittent cramping B.) moderate lochia rubra C.) boggy uterus D.) perineal edema D.) sublimation A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out". The nurse should recognize the client is demonstrating which of the following defense mechanisms? A.) Displacement B.) Regression C.) Suppression D.) sublimation A.) Temp 39.4 C (102.9 F) A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report to the provider? A.) Temp 39.4 C (102.9 F) B.) headache C.) constipation D.) Dry mouth B.) WBC: 2,800 A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? A.) BP: 150/87 B.) WBC: 2,800 c.) auditory hallucinations D.) nausea A.) identify health-related issues within the community A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? A.) identify health-related issues within the community B.) develop measurable health goals for community residents C.) Create safety education classes for the program D.) Enlist volunteers from the rural community to promote the program D.) "I will walk for short distances throughout the day" A home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? A.) "I will leave my drinking water out of my refrigerator for at least 1 hour so it will be room temperature" B.) "I will clean my toothbrush in my dishwasher once each month" C.) "I will take my temperature once each week and let my doctor know if it is high" D.) "I will walk for short distances throughout the day" D.) Notify the incident commander 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 client tracking system C.) Ask the communications officer to release a press statement D.) Notify the incident commander B.) Discontinue the IV medication C.) monitor vital signs frequently D.) Administer epinephrine IM E.) administer 0.9% sodium chloride IV A nurse is caring for a preschooler on the pediatric unit. History and Physical: 2250: Admitted from the emergency department with a diagnosis of pneumonia on the right side with mild pleural effusion. Medical history: Preschooler has a history of asthma. Allergies: No known allergies Provider Prescriptions: Day 1: 2350: Admit for observation. Obtain vital signs every 4 hours and PRN. Administer oxygen 2L/min via nasal cannula to maintain an oxygen saturation above 95. Initiate saline lock. Administer ceftriaxone 250mg IV q12h. Administer acetaminophen oral suspension 240 mg q4h prn for temperature greater than 38 C (100.4 F). Place on regular diet and encourage oral fluids of preschooler's choice. Monitor intake and output every 8 hours. Assessment: Day 2: 0030: Preschooler lying on bed, awake and alert. Breath sounds with wheezing auscultated on expiration on CONTINUED..