XNACE PN TO RN COMPLETE SOLUTION
100% VERIFIED ANSWERS A+ GRADED
FREE
To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep
palpation is to assess which of the following? - Correct Answer: Organs
The purpose of deep palpation, in which the nurse indents the client's skin approximately 1-1/2", is to
assess underlying organs and structures such as the kidneys and spleen. Skin turgor, hydration, and
temperature can be assessed using light touch or light palpation.
A client is brought to the emergency department and the physician determines he has gastrointestinal
(GI) bleeding. In planning for his care, which of the following would be first priority? - The Correct
answer is: assessment of vital signs Vital sign assessment would be the priority nursing intervention. This
would provide an indication of the amount of blood loss that has occurred and also provide a baseline by
which to monitor the progress of treatment. The other answers (b, c, and d) are important but not
priority actions.
When providing instructions to the adolescent regarding physical development of her body, the RN
should do all of the following EXCEPT - Correct Answer: Discuss the importance of avoiding social events
in order to stay out of trouble.
Socialization is very important to teenagers and is a normal part of their development. The other
answers (b, c, and d) are all accurate instructions and discussions for the adolescent regarding
development.
The nurse is developing discharge plans for a 65-year-old client. The discharge plans indicate the client
will be discharged home with home health nursing care. The nurse provides the home health agency
with details regarding the needs of the patient. The nurse made which of the following to the home
health agency? - Correct answer: A referral. A referral is recommending home care services or giving
information to an home care service regarding the client and the client's needs. Typically the sources of
referral to a home care agency are family members, nurses, physicians, social workers, discharge
planners or therapists.
Which of the following is the normal serum electrolyte level for magnesium? - Correct answer: 1.6 to 2.4
mEq/L
,The school nurse is approached by a mother who explains that her kindergarten child is constantly
scratching the perianal area and that the area is irritated. The RN understands that she should instruct
the mother to obtain a rectal specimen by a tape test and that the mother should obtain the specimen
when? - The Correct answer is: in the morning, when the child awakens Visualization of pinworms by
means of a tape test is necessary for the diagnosis. Transparent tape is lightly touched to the anus and
then applied to a slide for microscopic examination. The best specimen is obtained as the child awakens,
before toileting or bathing.
A 20-year-old patient is admitted to the hospital with respiratory failure. He's intubated, given oxygen,
and is coughing with copious secretions in his lungs. What should be done first? - Correct Answer:
Suction the lungs
The first priority is to make sure the client's airways are clear and that he can breathe. The other choices
can be addressed after ensuring the client can breathe.
A high school student is referred to the school nurse for suspected substance abuse. Following the
nurse's assessment and intervention, what would be the MOST desirable outcome? - Correct Answer:
The student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable;
however, the best outcome is that the student would agree to seek the assistance of a professional
substance abuse counselor.
The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the
client with seizures. Which of the following solutions will the nurse use to dilute this medication? -
Normal saline (0.9%) solution. Phenytoin (Dilantin) should be administered by injection into a large vein
by intermittent intravenous infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose
should be avoided because of medication precipitation.
Which of the following terms corresponds with the phrase: a woman that is pregnant? - Gravida
Gravida is another word for pregnancy. Spermatogonia refers to male sperm cells. Placenta previa is
when the placenta is too close to the cervix.
A healthy first time pregnant client asks the nurse, "How long will I stay in the hospital after my baby is
born." The client is scheduled for a Caesarean section. The nurse understands the average timeframe for
the hospital stay for a Caesarean section is what? - Correct Answer: 72 hours. The hospital stay for a
healthy mother who has delivered an infant varies depending on the type of delivery. The length of stay
in the hospital for a vaginal birth is typically 24 to 48 hours. The length of stay in the hospital for a
Caesarean section that does not have any complications is 72 hours.
, The community nurse is planning a smoking cessation program. What would be the first step in
developing a health promotion program? - Correct Answer: Conducting health risk surveys
First conduct initial assessments to determine if there is a health risk. Then follow the course of action in
place in this event.
A woman is two months pregnant when her five-year-old child develops rubella. What is most likely to
be given to the mother? - Correct Answer: Immune serum globulin
Immune serum globulin gives her a passive immunity and helps keep her from developing rubella, which
can have devastating effect on her unborn child. MMR is a live virus and is not given to pregnant women.
RhoGam prevents anti Rh antibody development. There is no such thing as rubella antitoxin.
What is the normal value of urine potassium? - 25-120 mEq/24 hr
The normal value for urine potassium is 25-120 mEq/24 hr
Before applying a cord clamp, the nurse assesses the umbilical cord for the presence of vessels. The
findings that are often associated with genitourinary abnormalities are what? - Correct Answer: one
artery, one vein. Two arteries and one vein are present in a normal umbilical cord. The presence of one
artery in the umbilical cord is associated with genitourinary abnormalities.
You are assigned to educate the nursing assistants regarding caring for the older adult. It is important
that the assistants understand that which of the following situations portrays ageism? - The Correct
answer is: Advising older adults to forgo aggressive treatment. Ageism is a form of prejudice in which
older adults are stereotyped by characteristics found in only a few members of their group. Fundamental
to ageism is the view that older persons are different from "me" and will remain different from "me."
Advising older adults to forgo (go without) aggressive treatment, when such a treatment would be
offered as a possibility to the general population, displays ageism by treating the older adults as
fundamentally different from the general population. The other answers identify supporting roles of the
nurse for the older person.
When taking a dietary history from a newly admitted client, the nurse should remember that which of
the following foods is a common allergen? - The correct answer is strawberries. Common food allergens
include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots and oranges rarely
cause allergic reactions.
100% VERIFIED ANSWERS A+ GRADED
FREE
To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep
palpation is to assess which of the following? - Correct Answer: Organs
The purpose of deep palpation, in which the nurse indents the client's skin approximately 1-1/2", is to
assess underlying organs and structures such as the kidneys and spleen. Skin turgor, hydration, and
temperature can be assessed using light touch or light palpation.
A client is brought to the emergency department and the physician determines he has gastrointestinal
(GI) bleeding. In planning for his care, which of the following would be first priority? - The Correct
answer is: assessment of vital signs Vital sign assessment would be the priority nursing intervention. This
would provide an indication of the amount of blood loss that has occurred and also provide a baseline by
which to monitor the progress of treatment. The other answers (b, c, and d) are important but not
priority actions.
When providing instructions to the adolescent regarding physical development of her body, the RN
should do all of the following EXCEPT - Correct Answer: Discuss the importance of avoiding social events
in order to stay out of trouble.
Socialization is very important to teenagers and is a normal part of their development. The other
answers (b, c, and d) are all accurate instructions and discussions for the adolescent regarding
development.
The nurse is developing discharge plans for a 65-year-old client. The discharge plans indicate the client
will be discharged home with home health nursing care. The nurse provides the home health agency
with details regarding the needs of the patient. The nurse made which of the following to the home
health agency? - Correct answer: A referral. A referral is recommending home care services or giving
information to an home care service regarding the client and the client's needs. Typically the sources of
referral to a home care agency are family members, nurses, physicians, social workers, discharge
planners or therapists.
Which of the following is the normal serum electrolyte level for magnesium? - Correct answer: 1.6 to 2.4
mEq/L
,The school nurse is approached by a mother who explains that her kindergarten child is constantly
scratching the perianal area and that the area is irritated. The RN understands that she should instruct
the mother to obtain a rectal specimen by a tape test and that the mother should obtain the specimen
when? - The Correct answer is: in the morning, when the child awakens Visualization of pinworms by
means of a tape test is necessary for the diagnosis. Transparent tape is lightly touched to the anus and
then applied to a slide for microscopic examination. The best specimen is obtained as the child awakens,
before toileting or bathing.
A 20-year-old patient is admitted to the hospital with respiratory failure. He's intubated, given oxygen,
and is coughing with copious secretions in his lungs. What should be done first? - Correct Answer:
Suction the lungs
The first priority is to make sure the client's airways are clear and that he can breathe. The other choices
can be addressed after ensuring the client can breathe.
A high school student is referred to the school nurse for suspected substance abuse. Following the
nurse's assessment and intervention, what would be the MOST desirable outcome? - Correct Answer:
The student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable;
however, the best outcome is that the student would agree to seek the assistance of a professional
substance abuse counselor.
The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the
client with seizures. Which of the following solutions will the nurse use to dilute this medication? -
Normal saline (0.9%) solution. Phenytoin (Dilantin) should be administered by injection into a large vein
by intermittent intravenous infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose
should be avoided because of medication precipitation.
Which of the following terms corresponds with the phrase: a woman that is pregnant? - Gravida
Gravida is another word for pregnancy. Spermatogonia refers to male sperm cells. Placenta previa is
when the placenta is too close to the cervix.
A healthy first time pregnant client asks the nurse, "How long will I stay in the hospital after my baby is
born." The client is scheduled for a Caesarean section. The nurse understands the average timeframe for
the hospital stay for a Caesarean section is what? - Correct Answer: 72 hours. The hospital stay for a
healthy mother who has delivered an infant varies depending on the type of delivery. The length of stay
in the hospital for a vaginal birth is typically 24 to 48 hours. The length of stay in the hospital for a
Caesarean section that does not have any complications is 72 hours.
, The community nurse is planning a smoking cessation program. What would be the first step in
developing a health promotion program? - Correct Answer: Conducting health risk surveys
First conduct initial assessments to determine if there is a health risk. Then follow the course of action in
place in this event.
A woman is two months pregnant when her five-year-old child develops rubella. What is most likely to
be given to the mother? - Correct Answer: Immune serum globulin
Immune serum globulin gives her a passive immunity and helps keep her from developing rubella, which
can have devastating effect on her unborn child. MMR is a live virus and is not given to pregnant women.
RhoGam prevents anti Rh antibody development. There is no such thing as rubella antitoxin.
What is the normal value of urine potassium? - 25-120 mEq/24 hr
The normal value for urine potassium is 25-120 mEq/24 hr
Before applying a cord clamp, the nurse assesses the umbilical cord for the presence of vessels. The
findings that are often associated with genitourinary abnormalities are what? - Correct Answer: one
artery, one vein. Two arteries and one vein are present in a normal umbilical cord. The presence of one
artery in the umbilical cord is associated with genitourinary abnormalities.
You are assigned to educate the nursing assistants regarding caring for the older adult. It is important
that the assistants understand that which of the following situations portrays ageism? - The Correct
answer is: Advising older adults to forgo aggressive treatment. Ageism is a form of prejudice in which
older adults are stereotyped by characteristics found in only a few members of their group. Fundamental
to ageism is the view that older persons are different from "me" and will remain different from "me."
Advising older adults to forgo (go without) aggressive treatment, when such a treatment would be
offered as a possibility to the general population, displays ageism by treating the older adults as
fundamentally different from the general population. The other answers identify supporting roles of the
nurse for the older person.
When taking a dietary history from a newly admitted client, the nurse should remember that which of
the following foods is a common allergen? - The correct answer is strawberries. Common food allergens
include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots and oranges rarely
cause allergic reactions.
