RN Comprehensive online practice
A.) Ask the Caller for verification of their identity
A nurse working on a medical-surgical unit receives a telephone call requesting the
status of a client from an individual who identifies themself as the client's parent. Which
of the following actins should the nurse take?
A.)Ask the caller for verification of their identity
B.) Give the caller limited information about the client
C.) transfer the phone call to the client's room
D.) Inform the caller that they should obtain permission from the client's provider
D.) The client's heel is reddened and tender
A nurse is caring for a client who has a fractured femur and has had a fiberglass leg
cylinder cast for 24 hr. Which of the following assessment findings should the nurse
identify as the priority?
A.) the client reports leg itching under the cast around the mid-upper thigh area B.)
The client reports increased pain when the leg is lowered below the level of the
heart
C.) The client's cast became wet during a sponge bath
D.) The client's heel is reddened and tender
B.) Complete a serum pregnancy test before taking the medication
A nurse is teaching a client who is to start taking misoprostol and currently is on
long-term therapy with NSAIDs for arthritis. The nurse should provide the client with
which of the following information?
A.) Increase intake of fluids and fiber to prevent constipation
B.) Complete a serum pregnancy test before taking the medication
C.) This medication coats stomach ulcers so that they can heal
D.) Take a magnesium-containing antacid along with this medication
B.) Nausea
A nurse is teaching a client who has a new prescription for digoxin about manifestations
of toxicity. Which of the following findings should the nurse include in the teaching?
A.) Constipation
B.) Nausea
,C.) Wheezing
D.) Muscle rigidity
C.) Hypertension
A nurse is assessing a client who has obstructive sleep apnea. For which of the
following complications should the nurse monitor?
A.) weight loss
B.) urinary retention
C.) hypertension
D.) hypoglycemia
2.) Remove the Inner Cannula
4.) Remove soiled dressing
1.) Clean the stoma with 0.9% sodium chloride irrigation
3.) Change the tracheostomy collar
A m nurse is providing Teaching to a parent of a child who has a permanent
tracheostomy tube. Identify the sequence of steps the parent should follow to perform
tracheostomy care.
Steps:
1.) clean the stoma with 0.9% sodium chloride irrigation
2.) remove the inner cannula
3.)change the tracheostomy collar
4.) remove soiled dressing
D.) Keep the head of the bed elevated to 45 degrees for 1 hour after feedings A charge
nurse is observing a newly licensed nurse administer enteral feedings via NG tube.
Which of the following actions by the newly licensed nurse indicates an understanding
of the procedure?
A.) Instill 100mL of air into the NG tube after checking for residual B.) flushes
the NG tube with 0.9% sodium chloride irrigation every 2 hours C.) Adds
20mL of blue dye to each feeding to help detect aspiration D.) Keep the head
of the bed elevated to 45 degrees for 1 hour after feedings D.) Mannitol
A nurse is caring for a client who has a closed-head injury and is receiving mechanical
ventilation. The nurse should expect to administer which of the following medications to
reduce intracranial pressure?
A.) propranolol
B.) phenytoin
C.) lorazepam
,D.) mannitol
C.) Places a pillow under the client's right arm
An assistive personnel (AP) and a nurse are turning a client onto the right side. Which
of the following actions by the AP requires the nurse to intervene?
A.) uses a draw sheet to move the client to the left side of the bed
B.) Raises the total height of the bed to waist level
C.) places a pillow under the client's right arm
D.) Lowers the side rails on the left side of the bed
A.) "A speech pathologist will performing a swallowing study for you"
B.) "You should rest before eating a meal"
E.) "Thicken your beverages before drinking"
A nurse is providing teaching about improving nutrition for a client who has multiple
sclerosis. Which of the following instructions should the nurse include? (Select all that
apply)
A.) "A speech pathologist will performing a swallowing study for you"
B.) "You should rest before eating a meal"
C.) "You should restrict foods that are high in Vitamin D"
D.) "reduce your intake of dietary fiber"
E.) "Thicken your beverages before drinking"
The infant is at highest risk of developing A.) dehydration As evidenced by C.) vomiting
Nurse's Notes:
1500: Infant is admitted to the pediatric unit. Parent reports infant has been irritable and
has vomited after each feeding within the last 3 days. Infant alert, not crying. S1 and S2
noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations
even, unlabored. Abdomen firm. Bowel sounds hypoactive x4 quadrants. Small 1x1 cm2
mass palpated near umbilicus. Skin warm and dry, turgor with tenting. 1600:
Called to room by a parent. Parent attempted breastfeeding. Infant projectile vomited
No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep
child NPO.
1800:
Infant crying. Soothed with Pacifier.
Diagnostic Results:
1545:
Hgb: 20g/dL (14-24) ; Potassium: 5.8mEq/L (3.9-5.9); Na: 132mEq/L (134-150);
Chloride: 110 (96-106); WBC: 16,000 (6,200-17,000); BUN: 20 (5-18); Creatinine: 0.2
(0.1-0.4)
1730:
, Abdominal ultrasound: Narrowing of pyloric canal. Thickening of pylorus. Consistent
with hypertrophic pyloric stenosis.
Vital Signs:
1500:
Temp: 37.1 (98.8 F); HR: 120; RR: 30; Weight: 3.62 (8lbs)
History and Physical:
Birthweight: 3,492.7g (7.7lbs(); parent is breastfeeding. Newborn birthed vaginally at 38
weeks of gestation.
The infant is at highest risk for_____________
A.) dehydration
B.) anemia
C.) hyperkalemia
As evidenced by the infant's __________
A.)potassium level
B.) hemoglobin
C.) vomiting
C.) massage the uterus to expel clots
A nurse is caring for a client who is 4 hours postpartum and has a boggy uterus with
heavy lochia. Which of the following actions should the nurse take first?
A.) administer oxygen
B.) initiate an infusion of oxytocin
C.) massage the uterus to expel clots
D.) obtain a CBC
A.) A client's IV pump delivers an inadequate dose of medication
A nurse is caring for a group of clients. For which of the following events should the
nurse complete an incident report?
A) A client's IV pump delivers an inadequate dose of medication
B.) A nurse follows a client's advance directives and discontinues enteral feedings
C.) A nurse discards unused, expired bags of IV fluids
D.) A client refuses an IV bolus of pain medication
A.) Flush the client's gastrostomy tube with 30mL of water before administering the
medication
A nurse is administering medications to a client who has a percutaneous gastrostomy
tube for enteral feedings. Which of the following actions should the nurse take to
prevent clogging of the tube?
A.) Ask the Caller for verification of their identity
A nurse working on a medical-surgical unit receives a telephone call requesting the
status of a client from an individual who identifies themself as the client's parent. Which
of the following actins should the nurse take?
A.)Ask the caller for verification of their identity
B.) Give the caller limited information about the client
C.) transfer the phone call to the client's room
D.) Inform the caller that they should obtain permission from the client's provider
D.) The client's heel is reddened and tender
A nurse is caring for a client who has a fractured femur and has had a fiberglass leg
cylinder cast for 24 hr. Which of the following assessment findings should the nurse
identify as the priority?
A.) the client reports leg itching under the cast around the mid-upper thigh area B.)
The client reports increased pain when the leg is lowered below the level of the
heart
C.) The client's cast became wet during a sponge bath
D.) The client's heel is reddened and tender
B.) Complete a serum pregnancy test before taking the medication
A nurse is teaching a client who is to start taking misoprostol and currently is on
long-term therapy with NSAIDs for arthritis. The nurse should provide the client with
which of the following information?
A.) Increase intake of fluids and fiber to prevent constipation
B.) Complete a serum pregnancy test before taking the medication
C.) This medication coats stomach ulcers so that they can heal
D.) Take a magnesium-containing antacid along with this medication
B.) Nausea
A nurse is teaching a client who has a new prescription for digoxin about manifestations
of toxicity. Which of the following findings should the nurse include in the teaching?
A.) Constipation
B.) Nausea
,C.) Wheezing
D.) Muscle rigidity
C.) Hypertension
A nurse is assessing a client who has obstructive sleep apnea. For which of the
following complications should the nurse monitor?
A.) weight loss
B.) urinary retention
C.) hypertension
D.) hypoglycemia
2.) Remove the Inner Cannula
4.) Remove soiled dressing
1.) Clean the stoma with 0.9% sodium chloride irrigation
3.) Change the tracheostomy collar
A m nurse is providing Teaching to a parent of a child who has a permanent
tracheostomy tube. Identify the sequence of steps the parent should follow to perform
tracheostomy care.
Steps:
1.) clean the stoma with 0.9% sodium chloride irrigation
2.) remove the inner cannula
3.)change the tracheostomy collar
4.) remove soiled dressing
D.) Keep the head of the bed elevated to 45 degrees for 1 hour after feedings A charge
nurse is observing a newly licensed nurse administer enteral feedings via NG tube.
Which of the following actions by the newly licensed nurse indicates an understanding
of the procedure?
A.) Instill 100mL of air into the NG tube after checking for residual B.) flushes
the NG tube with 0.9% sodium chloride irrigation every 2 hours C.) Adds
20mL of blue dye to each feeding to help detect aspiration D.) Keep the head
of the bed elevated to 45 degrees for 1 hour after feedings D.) Mannitol
A nurse is caring for a client who has a closed-head injury and is receiving mechanical
ventilation. The nurse should expect to administer which of the following medications to
reduce intracranial pressure?
A.) propranolol
B.) phenytoin
C.) lorazepam
,D.) mannitol
C.) Places a pillow under the client's right arm
An assistive personnel (AP) and a nurse are turning a client onto the right side. Which
of the following actions by the AP requires the nurse to intervene?
A.) uses a draw sheet to move the client to the left side of the bed
B.) Raises the total height of the bed to waist level
C.) places a pillow under the client's right arm
D.) Lowers the side rails on the left side of the bed
A.) "A speech pathologist will performing a swallowing study for you"
B.) "You should rest before eating a meal"
E.) "Thicken your beverages before drinking"
A nurse is providing teaching about improving nutrition for a client who has multiple
sclerosis. Which of the following instructions should the nurse include? (Select all that
apply)
A.) "A speech pathologist will performing a swallowing study for you"
B.) "You should rest before eating a meal"
C.) "You should restrict foods that are high in Vitamin D"
D.) "reduce your intake of dietary fiber"
E.) "Thicken your beverages before drinking"
The infant is at highest risk of developing A.) dehydration As evidenced by C.) vomiting
Nurse's Notes:
1500: Infant is admitted to the pediatric unit. Parent reports infant has been irritable and
has vomited after each feeding within the last 3 days. Infant alert, not crying. S1 and S2
noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations
even, unlabored. Abdomen firm. Bowel sounds hypoactive x4 quadrants. Small 1x1 cm2
mass palpated near umbilicus. Skin warm and dry, turgor with tenting. 1600:
Called to room by a parent. Parent attempted breastfeeding. Infant projectile vomited
No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep
child NPO.
1800:
Infant crying. Soothed with Pacifier.
Diagnostic Results:
1545:
Hgb: 20g/dL (14-24) ; Potassium: 5.8mEq/L (3.9-5.9); Na: 132mEq/L (134-150);
Chloride: 110 (96-106); WBC: 16,000 (6,200-17,000); BUN: 20 (5-18); Creatinine: 0.2
(0.1-0.4)
1730:
, Abdominal ultrasound: Narrowing of pyloric canal. Thickening of pylorus. Consistent
with hypertrophic pyloric stenosis.
Vital Signs:
1500:
Temp: 37.1 (98.8 F); HR: 120; RR: 30; Weight: 3.62 (8lbs)
History and Physical:
Birthweight: 3,492.7g (7.7lbs(); parent is breastfeeding. Newborn birthed vaginally at 38
weeks of gestation.
The infant is at highest risk for_____________
A.) dehydration
B.) anemia
C.) hyperkalemia
As evidenced by the infant's __________
A.)potassium level
B.) hemoglobin
C.) vomiting
C.) massage the uterus to expel clots
A nurse is caring for a client who is 4 hours postpartum and has a boggy uterus with
heavy lochia. Which of the following actions should the nurse take first?
A.) administer oxygen
B.) initiate an infusion of oxytocin
C.) massage the uterus to expel clots
D.) obtain a CBC
A.) A client's IV pump delivers an inadequate dose of medication
A nurse is caring for a group of clients. For which of the following events should the
nurse complete an incident report?
A) A client's IV pump delivers an inadequate dose of medication
B.) A nurse follows a client's advance directives and discontinues enteral feedings
C.) A nurse discards unused, expired bags of IV fluids
D.) A client refuses an IV bolus of pain medication
A.) Flush the client's gastrostomy tube with 30mL of water before administering the
medication
A nurse is administering medications to a client who has a percutaneous gastrostomy
tube for enteral feedings. Which of the following actions should the nurse take to
prevent clogging of the tube?
