RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
1. NGN: What assessment find- Temperature: Crohn's, UC & peritonitis.
ings are consistent with -Elevation can occur with all three due to inflammation and
Crohn's disease, ulcerative col- infection.
itis, or peritonitis?
Weight: Crohn's & UC.
Temperature (100F) -Unintended weight loss can occur due to malabsorption in
Weight (-9.7 lbs) the GI tract.
Albumin level (2.4)
WBC (14) Bowel pattern: Crohn's.
Bowel pattern (freq. loose -If the patient reported there was blood in the stool, it would
stools) be UC. Crohn's doesn't cause tarry stools.
Abdominal pain location
WBC: Crohn's, UC & peritonitis.
(RLQ)
-Elevation can occur due to inflammation and infection.
Heart rate (105)
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 general-
ized abd. pain that radiates to the shoulder and back.
2. NGN: What assessment find- Back pain, headache & anxiety.
ings can indicate a transfusion
reaction in a patient receiving Hemolytic reaction S/S: back pain, headache, anxiety, fever,
blood? chills, chest pain, tachycardia, dyspnea, hypotension.
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
Urine output (150mL of clear,
yellow)
Skin (pale, cool and dry)
Anxiety
Vital signs (within normal
range)
Headache
Back pain
3. NGN: Patient arrives with pal- Condition: somatic symptom disorder
pitations, difficulty breathing, -due to physical inactivity & joint pain
and reports feeling faint. Re-
ports constipation and joint Interventions: Monitor physical manifestations & assess for
pain for x2 days. In childhood, presence of 2nd gains from their illness
patient experienced physical -disorder is characterized by the presence of other real man-
abuse, and emotionally de- ifestations like dizziness, nausea, back pain, and joint pain.
tached parents. Reports ner-
Monitor: Vital signs & pain.
vousness and only leaving
home when necessary.
PMH: freq. hospital visits due
to headaches and GI distress.
Bowtie:
4. NGN: What actions should the Administer 0.9% NS IV
nurse take when her pedi pa- Administer epi IM
tient is exhibiting symptoms of Monitor vital signs frequently
an allergic reaction? DC IV medication
Administer 0.9% NS IV -Nurse should DC the Rocephin and give IV NS to help restore
Administer epi IM fluids because fluid shifts can occur quickly during a reaction.
Monitor urine output q2hrs Administering epi IM is the first line of therapy for anaphy-
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
DC supplemental oxygen lactic reactions because it constricts blood vessels and dilates
Monitor vital signs frequently bronchioles. Monitoring vital sings frequently will allow the
DC IV medication nurse to monitor for signs of shock.
5. NGN: What 5 actions should Administer thiamine
the nurse plan to take with Maintain a low-stimulation environment
a patient experiencing hal- Administer chlordiazepoxide
lucinations, following alcohol Initiate seizure precautions
withdrawal? Perform a CIWA-Ar
Administer thiamine -Nurse should plan interventions that keep the patient safe
Maintain a low-stimulation en- and treat the physical manifestations of withdrawal. Use the
vironment CIWA-Ar to determine the severity of the withdrawal. With-
Administer chlordiazepoxide drawal seizures can occur 12-24hrs after cessation of alcohol
Initiate seizure precautions use, therefore initiate seizure precautions to prevent injury.
Perform a CIWA-Ar Administer chlordiazepoxide (a benzodiazepine) and place
Administer disulfiram patient in a low-stim environment to decrease agitation and
the risk for seizures. Administering thiamine can prevent Wer-
nicke syndrome.
6. NGN: A post-op patient is ex- Condition: Varicose veins.
periencing right lower extrem- -due to edema & pruritis
ity pain and itching, follow-
ing an emergent appy. Reports Interventions: Elevate extremity & apply compression stock-
right lower extremity pain that ings
has been intermittent for x2 -to promote venous return & circulation
months.
Monitor: Pruritis & edema
Assessment: Bilat lower ex-
tremities warm to touch, ped-
al pulses 2+ bilat. Spider veins
noted. Distended veins noted
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
on right lower extremity. Vital
signs are within normal limits.
Bowtie:
7. NGN: Which assessment find- Involuntary tongue movement and foot tremor
ings require an immediate fol- Frequent urination and incontinence
low-up in a schizophrenic pa- Increase in agitation
tient?
-Patient is experiencing tardive dyskinesia
Hyperactive bowel sounds x4
Last HCP appointment was 6
months ago
Client AO x2
Agitated
Speech disorganized
Involuntary tongue move-
ment and foot tremor
Increase in urination and one
episode of incontinence
Family c/o increased agitation
and delusions
8. A home health nurse is eval- C. "My child has only a small amount of mucus after percus-
uation a school-age child who sion therapy."
has cystic fibrosis. The nurse
should initiate a request for -The nurse should recommend a high-frequency vest for a
a high-frequency chest com- child who has inadequate results from other airway clearance
pression vest in response to therapy techniques. Older children often require other tech-
which of the following parent niques in addition to percussion and postural drainage to
statements? achieve adequate mucus expectoration.
A. "My child doesn't like to sit -The nurse should teach the parent techniques for adminis-
Study online at https://quizlet.com/_e4dkcc
1. NGN: What assessment find- Temperature: Crohn's, UC & peritonitis.
ings are consistent with -Elevation can occur with all three due to inflammation and
Crohn's disease, ulcerative col- infection.
itis, or peritonitis?
Weight: Crohn's & UC.
Temperature (100F) -Unintended weight loss can occur due to malabsorption in
Weight (-9.7 lbs) the GI tract.
Albumin level (2.4)
WBC (14) Bowel pattern: Crohn's.
Bowel pattern (freq. loose -If the patient reported there was blood in the stool, it would
stools) be UC. Crohn's doesn't cause tarry stools.
Abdominal pain location
WBC: Crohn's, UC & peritonitis.
(RLQ)
-Elevation can occur due to inflammation and infection.
Heart rate (105)
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 general-
ized abd. pain that radiates to the shoulder and back.
2. NGN: What assessment find- Back pain, headache & anxiety.
ings can indicate a transfusion
reaction in a patient receiving Hemolytic reaction S/S: back pain, headache, anxiety, fever,
blood? chills, chest pain, tachycardia, dyspnea, hypotension.
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
Urine output (150mL of clear,
yellow)
Skin (pale, cool and dry)
Anxiety
Vital signs (within normal
range)
Headache
Back pain
3. NGN: Patient arrives with pal- Condition: somatic symptom disorder
pitations, difficulty breathing, -due to physical inactivity & joint pain
and reports feeling faint. Re-
ports constipation and joint Interventions: Monitor physical manifestations & assess for
pain for x2 days. In childhood, presence of 2nd gains from their illness
patient experienced physical -disorder is characterized by the presence of other real man-
abuse, and emotionally de- ifestations like dizziness, nausea, back pain, and joint pain.
tached parents. Reports ner-
Monitor: Vital signs & pain.
vousness and only leaving
home when necessary.
PMH: freq. hospital visits due
to headaches and GI distress.
Bowtie:
4. NGN: What actions should the Administer 0.9% NS IV
nurse take when her pedi pa- Administer epi IM
tient is exhibiting symptoms of Monitor vital signs frequently
an allergic reaction? DC IV medication
Administer 0.9% NS IV -Nurse should DC the Rocephin and give IV NS to help restore
Administer epi IM fluids because fluid shifts can occur quickly during a reaction.
Monitor urine output q2hrs Administering epi IM is the first line of therapy for anaphy-
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
DC supplemental oxygen lactic reactions because it constricts blood vessels and dilates
Monitor vital signs frequently bronchioles. Monitoring vital sings frequently will allow the
DC IV medication nurse to monitor for signs of shock.
5. NGN: What 5 actions should Administer thiamine
the nurse plan to take with Maintain a low-stimulation environment
a patient experiencing hal- Administer chlordiazepoxide
lucinations, following alcohol Initiate seizure precautions
withdrawal? Perform a CIWA-Ar
Administer thiamine -Nurse should plan interventions that keep the patient safe
Maintain a low-stimulation en- and treat the physical manifestations of withdrawal. Use the
vironment CIWA-Ar to determine the severity of the withdrawal. With-
Administer chlordiazepoxide drawal seizures can occur 12-24hrs after cessation of alcohol
Initiate seizure precautions use, therefore initiate seizure precautions to prevent injury.
Perform a CIWA-Ar Administer chlordiazepoxide (a benzodiazepine) and place
Administer disulfiram patient in a low-stim environment to decrease agitation and
the risk for seizures. Administering thiamine can prevent Wer-
nicke syndrome.
6. NGN: A post-op patient is ex- Condition: Varicose veins.
periencing right lower extrem- -due to edema & pruritis
ity pain and itching, follow-
ing an emergent appy. Reports Interventions: Elevate extremity & apply compression stock-
right lower extremity pain that ings
has been intermittent for x2 -to promote venous return & circulation
months.
Monitor: Pruritis & edema
Assessment: Bilat lower ex-
tremities warm to touch, ped-
al pulses 2+ bilat. Spider veins
noted. Distended veins noted
, RN Comp Practice 2023 A
Study online at https://quizlet.com/_e4dkcc
on right lower extremity. Vital
signs are within normal limits.
Bowtie:
7. NGN: Which assessment find- Involuntary tongue movement and foot tremor
ings require an immediate fol- Frequent urination and incontinence
low-up in a schizophrenic pa- Increase in agitation
tient?
-Patient is experiencing tardive dyskinesia
Hyperactive bowel sounds x4
Last HCP appointment was 6
months ago
Client AO x2
Agitated
Speech disorganized
Involuntary tongue move-
ment and foot tremor
Increase in urination and one
episode of incontinence
Family c/o increased agitation
and delusions
8. A home health nurse is eval- C. "My child has only a small amount of mucus after percus-
uation a school-age child who sion therapy."
has cystic fibrosis. The nurse
should initiate a request for -The nurse should recommend a high-frequency vest for a
a high-frequency chest com- child who has inadequate results from other airway clearance
pression vest in response to therapy techniques. Older children often require other tech-
which of the following parent niques in addition to percussion and postural drainage to
statements? achieve adequate mucus expectoration.
A. "My child doesn't like to sit -The nurse should teach the parent techniques for adminis-
