RN COMPREHENSIVE ONLINE
PRACTICE 2023 B
A6nurse6is6caring6for6a65-year-old6child
Physical6Examination:
1510:
Upon6visual6inspection,6throat6is6inflamed,6tonsils6appear6pink,6reddened6and6epiglottis6i
s6edematous6and6cherry6red6in6appearance.6Skin6appears6pale.6Stridor6noted6upon6inspi
ration6with6diminished6bilateral6lung6sounds.
Nurse's6Notes:
1500
Child6accompanied6to6emergency6department6by6caregiver.6Caregiver6states6child6has6a
6sore6throat6and6reports6the6child6has6"pain6on6swallowing"6and6denies6cough.6Child6is6a
gitated6and6lean6-6ans--Condition:6Epiglottis
Actions:6Initiate6droplet6precautions6and6request6a6prescription6for6IV6antibiotics
Monitors:6Breath6sounds6and6temperature
The6nurse6should6anticipate6initiating6droplet6precautions6and6requesting6a6prescription6f
or6IV6antibiotics.6The6child6is6most6likely6experiencing6epiglottis6because6of6the6clinical6m
anifestations6of6a6high6fever,6inflammation6and6redness6of6the6throat,6pale6skin,6stridor6wi
th6inspiration,6painful6swallowing,6no6cough,6is6sitting6in6tripod6position,6and6drooling.6Th
e6nurse6should6monitor6the6child's6temperature6and6breath6sounds.
A6nurse6is6caring6for6a6client6who6is6on6the6spinal6cord6injury6(SCI)6unit
Nurses'6Notes
Day63,61700
Client6admitted6to6SCI6unit636days6ago6following6C76injury.6Skin6is6cool,6pale,6and6dry6to6t
ouch.6Respirations6easy6and6unlabored.6Lung6sounds6diminished6in6lower6lobes.6Abdom
en6soft6and6nondistended6with6active6bowel6sounds.6Client6passed6a6small6amount6of6ha
rd6formed6stool6this6AM.6Indwelling6urinary6catheter6draining6clear6yellow6urine.6Deep6ten
don6reflexes6(DTR)6are6biceps61+,6triceps61+,6pa6-6ans--
The6client6is6most6likely6experiencing6manifestations6of6pneumonia6and6autonomic6dysre
flexia.
The6nurse6should6analyze6cues6from6the6client's6manifestations6and6determine6that6the6c
lient6is6most6likely6experiencing6manifestations6of6pneumonia6and6autonomic6dysreflexia.
6A6client6who6has6a6cervical6SCI6is6at6risk6for6respiratory6complications6because6spinal6in
,nervation6to6the6respiratory6muscles6is6disrupted.6Adventitious6breath6sounds6in6the6lowe
r6lobes6bilaterally6and6a6decrease6in6oxygen6saturation6to6less6than692%6can6indicate6pn
eumonia.6The6client's6sudden6increase6in6blood6pressure,6bradycardia,6flushing6of6the6sk
in6above6the6area6of6the6injury,6headache,6and6blurred6vision6are6manifestations6of6auton
omic6dysreflexia,6which6can6be6a6life-threatening6condition.
A6nurse6is6caring6for6a6client6who6has6abdominal6pain
Nurses'6Notes
0900
Client6reports6loss6of6appetite,6weight6loss,6and6fatigue6for616week.6Reports6abdominal6p
ain,666on6a6scale6from606to610,6for626days.6Client6is6a6perioperative6nurse,6returned616wee
k6ago6from6a62-week6mission6trip6to6an6underdeveloped6country
1200
Results6of6antibody6studies6obtained.6Provider6prescription6for6antiviral6medication6pendi
ng.
Physical6Examination
0930
Lung6sounds6clear6bilaterally.6Skin6warm6to6touch6and6jau6-6ans--
Hepatitis6A:6Client's6risk6from6fecal-
oral6transmission,6laboratory6results,6and6physical6examination6findings
Hepatitis6B:6Antiviral6treatment,6laboratory6results,6client's6risk6from6bloodborne6transmis
sion,6physical6examination6findings
Hepatitis6C:6Antiviral6treatment,6laboratory6results,6client's6risk6from6bloodborne6transmis
sion,6and6physical6examination6findings
When6analyzing6cues,6the6nurse6should6recognize6that6manifestations6of6hepatitis6A,6he
patitis6B,6and6hepatitis6C6include6jaundice,6yellow6sclerae,6right6upper6quandrant6pain6up
on6palpation,6dark6yellow6urine,6and6elevated6AST6and6ALT6levels.6When6analyzing6cues
,6the6nurse6should6also6recognize6the6client's6risk6for6contracting6hepatitis6A6through6the6f
ecal-
oral6route6during6recent6travel6to6an6underdeveloped6country6and6the6client's6occupation
al6risk6as6a6perioperative6nurse6for6contracting6hepatitis6B6and6hepatitis6C6through6blood
borne6transmission.6The6nurse6should6recognize6that6the6current6standard6of6practice6for
A6nurse6is6caring6for6a6client6on6a6medical-surgical6unit
Vital6Signs
0700
Temperature637.66C6(99.76F)
Heart6rate6100/min
Respiratory6rate622/min
,Blood6pressure6115/706mmHg
Oxygen6saturation698%6on6room6air
Nurses'6Notes
1100
Client6alert6and6oriented6to6person,6place,6and6time.6Client6had6episode6of6diarrhea,6prov
ided6perineal6care.6Noted626cm6x626cm6(0.86in6x60.86in)6painful6edematous6area6on6sacru
m.6Client6repositioned6every646hr.6-6ans--
Click6to6highlight6the6findings6that6require6follow6up.6To6deselect6a6finding,6click6on6the6fin
ding6again.
-6Noted626cm6x626cm6(0.86in6x60.86in)6painful6edematous6area6on6sacrum
-6Client6repositioned6every646hr
When6recognizing6cues,6the6nurse6should6determine6that6the6client's6painful6edematous6
area6on6their6sacrum6and6that6the6client6has6only6been6repositioned6every646hr6requires6f
ollow6up.6The6client6has6manifestations6of6a6pressure6injury6that6need6to6be6addressed.6
The6client6should6be6repositioned6at6least6every626hr6to6prevent6worsening6of6the6pressur
e6injury6and6to6relieve6pressure6from6the6sacral6area.
A6nurse6in6an6outpatient6mental6health6clinic6is6caring6for6a6client
Vital6Signs
36months6ago
Blood6pressure6116/686mmHg
Heart6rate682/min
Respiratory6rate616/min
Temperature636.76C6(98.16F)
SaO2697%6on6room6air
Today:
Blood6pressure6128/766mmHg
Heart6rate6104/min
Respiratory6rate622/min
Temperature637.46(99.46F)
SaO2697%6on6room6air
Nurses'6Notes
36months6ago
Client6recently6admitted6with6new6diagnosis6of6schizophrenia.6Received6inpatient6treatm
ent6for6106days6and6was6discharged616week6ago.6-6ans--
Select6the636findings6that6require6immediate6follow6up:
-6Auditory6hallucinations
-6Speech
-6Restlessness
, When6recognizing6cues,6the6nurse6should6identify6that6the6findings6of6restlessness,6audit
ory6hallucinations,6and6pressured6speech6require6immediate6follow6up.6These6findings6ar
e6indications6of6psychosis.6The6nurse6should6notify6the6provider6for6additional6evaluation6
and6treatment.
A6nurse6is6caring6for6a6client6who6is6postoperative6following6coronary6artery6bypass6surg
ery6(CABG)
Laboratory6Results
0630
Sodium61456mEq/L6(1366to61456mEq/L)
Potassium63.26mEq/L6(3.56to656mEq/L)
Chloride61166mEq/L6(986to61066mEq/L)
BUN6246mg/dL6(106to6206mg/dL)
Magnesium61.56mEq/L6(1.36to62.16mEq/L)
Total6calcium696mg/dL6(96to610.56mg/dL)
Phosphate64.66mg/dL6(36to64.56mg/dL)
Glucose6956mg/dL6(746to61066mg/dL)
WBC6count69,500/mm36(5,0006to610,000/mm3)
I6&6O
0700
46hr6input64006mL
46hr6output6-6ans--
The6client6is6at6greatest6risk6for6developing6dysrhythmias,6as6evidenced6by6electrolyte6im
balance.
The6nurse6should6analyze6cues6to6determine6the6client6is6at6greatest6risk6for6developing6
dysrhythmias6related6to6hypokalemia,6as6evidenced6by6the6laboratory6report6and6the6clie
nt's6report6of6muscle6cramping.6Potassium6and6magnesium6depletion6are6common6manif
estations6in6clients6who6are6postoperative6following6CABG.6Due6to6medication6or6hemodi
lation,6it6is6important6for6the6nurse6to6closely6monitor6electrolytes.
A6nurse6is6caring6for6a6client6who6is6pregnant6in6the6acute6care6setting
Nurses'6Notes
1400
Client6reports6a6constant6low6dull6backache6and6painless6abdominal6tightening6for6the6pa
st636hr.6Denies6any6changes6in6vaginal6discharge.6External6fetal6monitor6applied.
1430
Contraction6pattern:6contractions6every646to656min,6lasting6306to6456seconds,6palpate6mil
d6in6intensity
Fetal6heart6rate:6150/min6to6155/
min,6moderate6variability,6adequate6accelerations6present,6no6decelerations6noted.6Provi
der6in6-6ans--
PRACTICE 2023 B
A6nurse6is6caring6for6a65-year-old6child
Physical6Examination:
1510:
Upon6visual6inspection,6throat6is6inflamed,6tonsils6appear6pink,6reddened6and6epiglottis6i
s6edematous6and6cherry6red6in6appearance.6Skin6appears6pale.6Stridor6noted6upon6inspi
ration6with6diminished6bilateral6lung6sounds.
Nurse's6Notes:
1500
Child6accompanied6to6emergency6department6by6caregiver.6Caregiver6states6child6has6a
6sore6throat6and6reports6the6child6has6"pain6on6swallowing"6and6denies6cough.6Child6is6a
gitated6and6lean6-6ans--Condition:6Epiglottis
Actions:6Initiate6droplet6precautions6and6request6a6prescription6for6IV6antibiotics
Monitors:6Breath6sounds6and6temperature
The6nurse6should6anticipate6initiating6droplet6precautions6and6requesting6a6prescription6f
or6IV6antibiotics.6The6child6is6most6likely6experiencing6epiglottis6because6of6the6clinical6m
anifestations6of6a6high6fever,6inflammation6and6redness6of6the6throat,6pale6skin,6stridor6wi
th6inspiration,6painful6swallowing,6no6cough,6is6sitting6in6tripod6position,6and6drooling.6Th
e6nurse6should6monitor6the6child's6temperature6and6breath6sounds.
A6nurse6is6caring6for6a6client6who6is6on6the6spinal6cord6injury6(SCI)6unit
Nurses'6Notes
Day63,61700
Client6admitted6to6SCI6unit636days6ago6following6C76injury.6Skin6is6cool,6pale,6and6dry6to6t
ouch.6Respirations6easy6and6unlabored.6Lung6sounds6diminished6in6lower6lobes.6Abdom
en6soft6and6nondistended6with6active6bowel6sounds.6Client6passed6a6small6amount6of6ha
rd6formed6stool6this6AM.6Indwelling6urinary6catheter6draining6clear6yellow6urine.6Deep6ten
don6reflexes6(DTR)6are6biceps61+,6triceps61+,6pa6-6ans--
The6client6is6most6likely6experiencing6manifestations6of6pneumonia6and6autonomic6dysre
flexia.
The6nurse6should6analyze6cues6from6the6client's6manifestations6and6determine6that6the6c
lient6is6most6likely6experiencing6manifestations6of6pneumonia6and6autonomic6dysreflexia.
6A6client6who6has6a6cervical6SCI6is6at6risk6for6respiratory6complications6because6spinal6in
,nervation6to6the6respiratory6muscles6is6disrupted.6Adventitious6breath6sounds6in6the6lowe
r6lobes6bilaterally6and6a6decrease6in6oxygen6saturation6to6less6than692%6can6indicate6pn
eumonia.6The6client's6sudden6increase6in6blood6pressure,6bradycardia,6flushing6of6the6sk
in6above6the6area6of6the6injury,6headache,6and6blurred6vision6are6manifestations6of6auton
omic6dysreflexia,6which6can6be6a6life-threatening6condition.
A6nurse6is6caring6for6a6client6who6has6abdominal6pain
Nurses'6Notes
0900
Client6reports6loss6of6appetite,6weight6loss,6and6fatigue6for616week.6Reports6abdominal6p
ain,666on6a6scale6from606to610,6for626days.6Client6is6a6perioperative6nurse,6returned616wee
k6ago6from6a62-week6mission6trip6to6an6underdeveloped6country
1200
Results6of6antibody6studies6obtained.6Provider6prescription6for6antiviral6medication6pendi
ng.
Physical6Examination
0930
Lung6sounds6clear6bilaterally.6Skin6warm6to6touch6and6jau6-6ans--
Hepatitis6A:6Client's6risk6from6fecal-
oral6transmission,6laboratory6results,6and6physical6examination6findings
Hepatitis6B:6Antiviral6treatment,6laboratory6results,6client's6risk6from6bloodborne6transmis
sion,6physical6examination6findings
Hepatitis6C:6Antiviral6treatment,6laboratory6results,6client's6risk6from6bloodborne6transmis
sion,6and6physical6examination6findings
When6analyzing6cues,6the6nurse6should6recognize6that6manifestations6of6hepatitis6A,6he
patitis6B,6and6hepatitis6C6include6jaundice,6yellow6sclerae,6right6upper6quandrant6pain6up
on6palpation,6dark6yellow6urine,6and6elevated6AST6and6ALT6levels.6When6analyzing6cues
,6the6nurse6should6also6recognize6the6client's6risk6for6contracting6hepatitis6A6through6the6f
ecal-
oral6route6during6recent6travel6to6an6underdeveloped6country6and6the6client's6occupation
al6risk6as6a6perioperative6nurse6for6contracting6hepatitis6B6and6hepatitis6C6through6blood
borne6transmission.6The6nurse6should6recognize6that6the6current6standard6of6practice6for
A6nurse6is6caring6for6a6client6on6a6medical-surgical6unit
Vital6Signs
0700
Temperature637.66C6(99.76F)
Heart6rate6100/min
Respiratory6rate622/min
,Blood6pressure6115/706mmHg
Oxygen6saturation698%6on6room6air
Nurses'6Notes
1100
Client6alert6and6oriented6to6person,6place,6and6time.6Client6had6episode6of6diarrhea,6prov
ided6perineal6care.6Noted626cm6x626cm6(0.86in6x60.86in)6painful6edematous6area6on6sacru
m.6Client6repositioned6every646hr.6-6ans--
Click6to6highlight6the6findings6that6require6follow6up.6To6deselect6a6finding,6click6on6the6fin
ding6again.
-6Noted626cm6x626cm6(0.86in6x60.86in)6painful6edematous6area6on6sacrum
-6Client6repositioned6every646hr
When6recognizing6cues,6the6nurse6should6determine6that6the6client's6painful6edematous6
area6on6their6sacrum6and6that6the6client6has6only6been6repositioned6every646hr6requires6f
ollow6up.6The6client6has6manifestations6of6a6pressure6injury6that6need6to6be6addressed.6
The6client6should6be6repositioned6at6least6every626hr6to6prevent6worsening6of6the6pressur
e6injury6and6to6relieve6pressure6from6the6sacral6area.
A6nurse6in6an6outpatient6mental6health6clinic6is6caring6for6a6client
Vital6Signs
36months6ago
Blood6pressure6116/686mmHg
Heart6rate682/min
Respiratory6rate616/min
Temperature636.76C6(98.16F)
SaO2697%6on6room6air
Today:
Blood6pressure6128/766mmHg
Heart6rate6104/min
Respiratory6rate622/min
Temperature637.46(99.46F)
SaO2697%6on6room6air
Nurses'6Notes
36months6ago
Client6recently6admitted6with6new6diagnosis6of6schizophrenia.6Received6inpatient6treatm
ent6for6106days6and6was6discharged616week6ago.6-6ans--
Select6the636findings6that6require6immediate6follow6up:
-6Auditory6hallucinations
-6Speech
-6Restlessness
, When6recognizing6cues,6the6nurse6should6identify6that6the6findings6of6restlessness,6audit
ory6hallucinations,6and6pressured6speech6require6immediate6follow6up.6These6findings6ar
e6indications6of6psychosis.6The6nurse6should6notify6the6provider6for6additional6evaluation6
and6treatment.
A6nurse6is6caring6for6a6client6who6is6postoperative6following6coronary6artery6bypass6surg
ery6(CABG)
Laboratory6Results
0630
Sodium61456mEq/L6(1366to61456mEq/L)
Potassium63.26mEq/L6(3.56to656mEq/L)
Chloride61166mEq/L6(986to61066mEq/L)
BUN6246mg/dL6(106to6206mg/dL)
Magnesium61.56mEq/L6(1.36to62.16mEq/L)
Total6calcium696mg/dL6(96to610.56mg/dL)
Phosphate64.66mg/dL6(36to64.56mg/dL)
Glucose6956mg/dL6(746to61066mg/dL)
WBC6count69,500/mm36(5,0006to610,000/mm3)
I6&6O
0700
46hr6input64006mL
46hr6output6-6ans--
The6client6is6at6greatest6risk6for6developing6dysrhythmias,6as6evidenced6by6electrolyte6im
balance.
The6nurse6should6analyze6cues6to6determine6the6client6is6at6greatest6risk6for6developing6
dysrhythmias6related6to6hypokalemia,6as6evidenced6by6the6laboratory6report6and6the6clie
nt's6report6of6muscle6cramping.6Potassium6and6magnesium6depletion6are6common6manif
estations6in6clients6who6are6postoperative6following6CABG.6Due6to6medication6or6hemodi
lation,6it6is6important6for6the6nurse6to6closely6monitor6electrolytes.
A6nurse6is6caring6for6a6client6who6is6pregnant6in6the6acute6care6setting
Nurses'6Notes
1400
Client6reports6a6constant6low6dull6backache6and6painless6abdominal6tightening6for6the6pa
st636hr.6Denies6any6changes6in6vaginal6discharge.6External6fetal6monitor6applied.
1430
Contraction6pattern:6contractions6every646to656min,6lasting6306to6456seconds,6palpate6mil
d6in6intensity
Fetal6heart6rate:6150/min6to6155/
min,6moderate6variability,6adequate6accelerations6present,6no6decelerations6noted.6Provi
der6in6-6ans--
