RN Comp Practice 2023 A
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.
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.
Brainpower
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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.
Assessment: Bilat lower extremities warm to touch, pedal pulses 2+ bilat. Spider veins noted. Distended
veins noted on right lower extremity. Vital signs are within normal limits.
Bowtie:
Condition: Varicose veins.
-due to edema & pruritis
Interventions: Elevate extremity & apply compression stockings
-to promote venous return & circulation
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.
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.
Brainpower
Read More
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.
Assessment: Bilat lower extremities warm to touch, pedal pulses 2+ bilat. Spider veins noted. Distended
veins noted on right lower extremity. Vital signs are within normal limits.
Bowtie:
Condition: Varicose veins.
-due to edema & pruritis
Interventions: Elevate extremity & apply compression stockings
-to promote venous return & circulation
