RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
1. NGN: What assessment findings are consistent with Crohn's disease, ulcer-
ative colitis, or peritonitis?
Temperature (100F)
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.
2. 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
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
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.
3. NGN: Patient arrives with palpitations, difficulty breathing, and reports feel-
ing faint. Reports constipation and joint pain for x2 days. In childhood, patient
experienced physical abuse, and emotionally detached parents. Reports ner-
vousness 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.
4. 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.
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
5. NGN: What 5 actions should the nurse plan to take with a patient experienc-
ing 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 chlordiazepox-
ide (a benzodiazepine) and place patient in a low-stim environment to decrease
agitation and the risk for seizures. Administering thiamine can prevent Wernicke
syndrome.
6. NGN: A post-op patient is experiencing right lower extremity pain and
itching, following an emergent appy. 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
7. NGN: Which assessment findings require an immediate follow-up in a schiz-
ophrenic patient?
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
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
8. A home health nurse is evaluation a school-age child who has cystic fibro-
sis. The nurse should initiate a request for a high-frequency chest compres-
sion 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.": C.
"My child has only a small amount of mucus after percussion therapy."
-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 ade-
quate 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.
9. 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
Study online at https://quizlet.com/_e4dkcc
1. NGN: What assessment findings are consistent with Crohn's disease, ulcer-
ative colitis, or peritonitis?
Temperature (100F)
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.
2. 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
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
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.
3. NGN: Patient arrives with palpitations, difficulty breathing, and reports feel-
ing faint. Reports constipation and joint pain for x2 days. In childhood, patient
experienced physical abuse, and emotionally detached parents. Reports ner-
vousness 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.
4. 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.
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
5. NGN: What 5 actions should the nurse plan to take with a patient experienc-
ing 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 chlordiazepox-
ide (a benzodiazepine) and place patient in a low-stim environment to decrease
agitation and the risk for seizures. Administering thiamine can prevent Wernicke
syndrome.
6. NGN: A post-op patient is experiencing right lower extremity pain and
itching, following an emergent appy. 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
7. NGN: Which assessment findings require an immediate follow-up in a schiz-
ophrenic patient?
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
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
8. A home health nurse is evaluation a school-age child who has cystic fibro-
sis. The nurse should initiate a request for a high-frequency chest compres-
sion 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.": C.
"My child has only a small amount of mucus after percussion therapy."
-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 ade-
quate 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.
9. 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
