RN Adult Medical Surgical Online Practice 2023 A NGN
1.The client is experiencing manifestations of
peritonitis
due to
x-ray results
.: NGN
1000:
Client is alert and oriented and reports not feeling well for a few days. Client is on
continuous ambulatory peritoneal dialysis (CAPD) and reports dialysate appeared cloudy
this morning.
Reports abdominal pain as 4 on a scale of 0 to 10. Bowel
sounds active in all quadrants.
Peritoneal dialysis access site red, warm to touch, with a small amount of purulent drainage
noted on dressing.1300:
Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly
distended, hypoactive bowel sounds. Client reports nausea. Reports pain as 6 on a scale of
0 to 10. Provider notified and updated with client condition and diagnostic results.
2.Insert a large-gauge IV.
Initiate a fluid challenge.
Hypovolemia Urine
output
Blood pressure: NGN
Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2 on
a scale of 0 to 10. Client appears restless and frequently asks for water. Bilateral lower
extremities cool with +1 pedal pulses. Urine output is 40 mL for the past 2 hr. Moderate
amount of bright red drainage noted on surgical incision dressing.
3.Hypoactive Bowel Sounds: A nurse is caring for a client who has a potassium level of
3 mEq/L. Which of the following assessment findings should the nurse expect?
4.The client is experiencing manifestations of
pancreatitis
as evidenced by the amylase
and lipase
.: NGN
0900:
Client presents with abdominal pain in the upper left quadrant for the past 2 days. States
pain became worse this morning and is radiating to the back. Rates pain as
, RN Adult Medical Surgical Online Practice 2023 A NGN
8 on a scale of 0 to 10.
Hypoactive bowel sounds; reports nausea, no vomiting; client is passing flatus. Febrile,
oriented to person, place, and time.
Tachypnea with diminished breath sounds. Sinus
tachycardia.
Client voids 300 mL of clear, amber urine. 0930:
Client vomited 100 mL brown liquid.
5.Perform a 12-lead ECG is not indicated.
Place the client in Trendelenburg position is indicated. Administer a
0.9% sodium chloride 200 mL IV bolus is indicated. Apply oxygen at 2
L/min via nasal cannula is indicated
Notify the provider immediately is indicated
Obtain the client's blood glucose level is not indicated.: 0530: Client is
awake and alert.
Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit.
Lung sounds clear upon auscultation; client denies shortness of breath. No peripheral
edema noted; capillary refill is less than 3 seconds; +2 bilateral pedal and radial pulses.
AVF access prepared and cannulated twice with no difficulty. Lines are taped and secured;
treatment is initiated.0600:
Client is reading a book. Access is visible, and lines are secure. Client reports no discomfor
or pain.0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly
confused.
6.During the emergent phase of burn care, the client is at risk for developing
hypovolemia
and
respiratory failure
.: 1800:
Emergency medical team removed client's shirt at the scene and initiated 18-gauge IV
therapy in the right antecubital space.
Client has full-thickness burns over the upper half of the chest and both forearms; partial-
thickness burns are present on the client's face and neck.
1.The client is experiencing manifestations of
peritonitis
due to
x-ray results
.: NGN
1000:
Client is alert and oriented and reports not feeling well for a few days. Client is on
continuous ambulatory peritoneal dialysis (CAPD) and reports dialysate appeared cloudy
this morning.
Reports abdominal pain as 4 on a scale of 0 to 10. Bowel
sounds active in all quadrants.
Peritoneal dialysis access site red, warm to touch, with a small amount of purulent drainage
noted on dressing.1300:
Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly
distended, hypoactive bowel sounds. Client reports nausea. Reports pain as 6 on a scale of
0 to 10. Provider notified and updated with client condition and diagnostic results.
2.Insert a large-gauge IV.
Initiate a fluid challenge.
Hypovolemia Urine
output
Blood pressure: NGN
Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2 on
a scale of 0 to 10. Client appears restless and frequently asks for water. Bilateral lower
extremities cool with +1 pedal pulses. Urine output is 40 mL for the past 2 hr. Moderate
amount of bright red drainage noted on surgical incision dressing.
3.Hypoactive Bowel Sounds: A nurse is caring for a client who has a potassium level of
3 mEq/L. Which of the following assessment findings should the nurse expect?
4.The client is experiencing manifestations of
pancreatitis
as evidenced by the amylase
and lipase
.: NGN
0900:
Client presents with abdominal pain in the upper left quadrant for the past 2 days. States
pain became worse this morning and is radiating to the back. Rates pain as
, RN Adult Medical Surgical Online Practice 2023 A NGN
8 on a scale of 0 to 10.
Hypoactive bowel sounds; reports nausea, no vomiting; client is passing flatus. Febrile,
oriented to person, place, and time.
Tachypnea with diminished breath sounds. Sinus
tachycardia.
Client voids 300 mL of clear, amber urine. 0930:
Client vomited 100 mL brown liquid.
5.Perform a 12-lead ECG is not indicated.
Place the client in Trendelenburg position is indicated. Administer a
0.9% sodium chloride 200 mL IV bolus is indicated. Apply oxygen at 2
L/min via nasal cannula is indicated
Notify the provider immediately is indicated
Obtain the client's blood glucose level is not indicated.: 0530: Client is
awake and alert.
Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit.
Lung sounds clear upon auscultation; client denies shortness of breath. No peripheral
edema noted; capillary refill is less than 3 seconds; +2 bilateral pedal and radial pulses.
AVF access prepared and cannulated twice with no difficulty. Lines are taped and secured;
treatment is initiated.0600:
Client is reading a book. Access is visible, and lines are secure. Client reports no discomfor
or pain.0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly
confused.
6.During the emergent phase of burn care, the client is at risk for developing
hypovolemia
and
respiratory failure
.: 1800:
Emergency medical team removed client's shirt at the scene and initiated 18-gauge IV
therapy in the right antecubital space.
Client has full-thickness burns over the upper half of the chest and both forearms; partial-
thickness burns are present on the client's face and neck.
