RN Comp Practice A 2023 Questions and Answers.

RN Comp Practice A 2023 Questions and Answers. NGN: What assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis? Temperature (100F) Weight (-9.7 lbs) Albumin level (2.4) WBC (14) Bowel pattern (freq. loose stools) Abdominal pain location (RLQ) Heart rate (105) Temperature: Crohn's, UC & peritonitis. -Elevation can occur with all three due to inflammation and infection. Weight: Crohn's & UC. -Unintended weight loss can occur due to malabsorption in the GI tract. Bowel pattern: Crohn's. -If the patient reported there was blood in the stool, it would be UC. Crohn's doesn't cause tarry stools. WBC: Crohn's, UC & peritonitis. -Elevation can occur due to inflammation and infection. 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 generalized abd. pain that radiates to the shoulder and back. RN Comp Practice A 2023 Questions and Answers. NGN: What assessment findings can indicate a transfusion reaction in a patient receiving blood? Urine output (150mL of clear, yellow) Skin (pale, cool and dry) Anxiety Vital signs (within normal range) Headache Back pain Back pain, headache & anxiety. Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain, tachycardia, dyspnea, hypotension. NGN: Patient arrives with palpitations, difficulty breathing, and reports feeling faint. Reports constipation and joint pain for x2 days. In childhood, patient experienced physical abuse, and emotionally detached parents. Reports nervousness and only leaving home when necessary. PMH: freq. hospital visits due to headaches and GI distress. Bowtie: Condition: somatic symptom disorder -due to physical inactivity & joint pain Interventions: Monitor physical manifestations & assess for presence of 2nd gains from their illness -disorder is characterized by the presence of other real manifestations like dizziness, nausea, back pain, and joint pain. Monitor: Vital signs & pain. NGN: What actions should the nurse take when her pedi patient is exhibiting symptoms of an allergic reaction? Administer 0.9% NS IV Administer epi IM Monitor urine output q2hrs DC supplemental oxygen Monitor vital signs frequently DC IV medication Administer 0.9% NS IV Administer epi IM Monitor vital signs frequently DC IV medication -Nurse should DC the Rocephin and give IV NS to help restore fluids because fluid shifts can occur quickly during a reaction. Administering epi IM is the first line of therapy for anaphylactic reactions because it constricts blood vessels and dilates bronchioles. Monitoring vital sings frequently will allow the nurse to monitor for signs of shock. NGN: What 5 actions should the nurse plan to take with a patient experiencing hallucinations, following alcohol withdrawal? Administer thiamine Maintain a low-stimulation environment Administer chlordiazepoxide Initiate seizure precautions Perform a CIWA-Ar Administer disulfiram Administer thiamine Maintain a low-stimulation environment Administer chlordiazepoxide Initiate seizure precautions Perform a CIWA-Ar -Nurse should plan interventions that keep the patient safe and treat the physical manifestations of withdrawal. Use the CIWA-Ar to determine the severity of the withdrawal. Withdrawal seizures can occur 12-24hrs after cessation of alcohol use, therefore initiate seizure precautions to prevent injury. Administer chlordiazepoxide (a benzodiazepine) and place patient in a low-stim environment to decrease agitation and the risk for seizures. Administering thiamine can prevent Wernicke syndrome. NGN: A post-op patient is experiencing right lower extremity pain and itching, following an emergent appy. Reports right lower extremity pain that has been intermittent for x2 months.