NGN
Allergic Reaction - ANSWER Indicated by joint pain as a response to medication
Auditory Hallucinations - ANSWER Schizophrenic client hearing voices telling them
to harm others
Electroconvulsive Therapy - ANSWER Treatment for depression with increased risk
due to hyperthyroidism
Rheumatoid Arthritis - ANSWER Nurse should report ESR of 75 mm/hr in a client's
lab results
Mechanical Ventilation - ANSWER Effective suctioning indicated by decreased peak
inspiratory pressure
Seclusion Room - ANSWER Client with violent behavior should be managed
assertively by the nurse
Adrenalectomy - ANSWER Priority postoperative action is monitoring fluid and
electrolyte status
Surgical Procedure - ANSWER Nurse should respect client's decision to refuse
surgery
Borderline Personality Disorder - ANSWER Improved condition indicated by
decreased clinging behavior
Healthy Snack Options - ANSWER Nurse should recommend air-popped popcorn
for school-age children
Enoxaparin - ANSWER Nurse should teach client to take acetaminophen for pain
relief concurrently
Fibromyalgia - ANSWER Nurse should administer pregabalin for pain in a client with
fibromyalgia
Digoxin Toxicity - ANSWER Risk indicated by potassium level of 3.1 mEq/L in a
client with CHF
Alteplase - ANSWER Contraindicated in a client with a history of hip arthroplasty 1
week ago
Implantable Cardioverter Defibrillator - ANSWER Client understands teaching if they
avoid microwave oven use
, Indwelling Urinary Catheter - ANSWER Dark yellow urine drainage at 25ml/hr
requires obtaining a urine specimen
Stillbirth - ANSWER Nurse should offer to take pictures of the newborn for the
grieving client
Burn Injury - ANSWER Priority action to prevent wound infection is using sterile
dressings
Alzheimer's Disease - ANSWER Nurse should assist caregiver in arranging a
daycare program for the client
Postpartum Urinary Retention - ANSWER Nurse should perform a fundal massage
for a client unable to urinate
Medication Reconciliation - ANSWER Nurse should compare home medications to
admission prescriptions
Betamethasone - ANSWER Adverse effect is hypotension in a client with preterm
labor at 25 weeks gestation
Central Venous Catheter Blood Sample - ANSWER Actions include aspirating for
blood return and flushing with sodium chloride
Preschooler Dressing Change - ANSWER Prepare child by explaining the
procedure in simple terms
Deep-breathing methods - ANSWER Techniques taught to a child before a medical
procedure.
Abdominal incision wound care - ANSWER Process including irrigating with a 10-mL
syringe and using low-pressure flow.
Client prioritization - ANSWER Determining which client to see first based on
conditions like gestation week and symptoms.
Amputation recovery report - ANSWER Information to share with an occupational
therapist, e.g., living situation and allergies.
Supporting a depressed client - ANSWER Appropriate responses to a client
expressing loneliness and lack of care.
Head trauma action priority - ANSWER Immediate action for a client with severe
head trauma and nose bleeding.
Sinus arrhythmia expectation - ANSWER Anticipated findings in the rhythm strip of a
client with sinus arrhythmia.
Dementia symptom documentation - ANSWER Identifying a client's false belief as
confabulation.