RN ADULT MEDICAL SURGICAL ONLINE
PRACTICE 2023 A NGN LATEST UPDATE
h NGN
1000:
Client is alert and oriented and reports not feeling well for a few days. Client is on continuous
ambulatory peritoneal dialysis (CAPD) and reports dialysate appeared cloudy this morning.
Reports abdominal pain as 4 on a scale of 0 to 10.
Bowel sounds active in all quadrants.
Peritoneal dialysis access site red, warm to touch, with a small amount of purulent drainage noted on
dressing.1300:
Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly distended,
hypoactive bowel sounds. Client reports nausea. Reports pain as 6 on a scale of 0 to 10. Provider notified
and updated with client condition and diagnostic results. - The client is experiencing manifestations of
peritonitis
due to
x-ray results
.
NGN
Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2 on a scale of 0 to
10. Client appears restless and frequently asks for water. Bilateral lower extremities cool with +1 pedal
pulses. Urine output is 40 mL for the past 2 hr. Moderate amount of bright red drainage noted on
surgical incision dressing. - Insert a large-gauge IV.
Initiate a fluid challenge.
Hypovolemia
Urine output
Blood pressure
, A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment
findings should the nurse expect? - Hypoactive Bowel Sounds
NGN
0900:
Client presents with abdominal pain in the upper left quadrant for the past 2 days. States pain became
worse this morning and is radiating to the back. Rates pain as 8 on a scale of 0 to 10.
Hypoactive bowel sounds; reports nausea, no vomiting; client is passing flatus.
Febrile, oriented to person, place, and time.
Tachypnea with diminished breath sounds.
Sinus tachycardia.
Client voids 300 mL of clear, amber urine.
0930:
Client vomited 100 mL brown liquid. - The client is experiencing manifestations of
pancreatitis
as evidenced by the
amylase and lipase
.
0530:
Client is awake and alert.
Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit. Lung sounds
clear upon auscultation; client denies shortness of breath. No peripheral edema noted; capillary refill is
less than 3 seconds; +2 bilateral pedal and radial pulses.
AVF access prepared and cannulated twice with no difficulty. Lines are taped and secured; treatment is
initiated.0600:
Client is reading a book. Access is visible, and lines are secure. Client reports no discomfort or pain.0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly confused. -
Perform a 12-lead ECG is not indicated.
Place the client in Trendelenburg position is indicated.
, Administer a 0.9% sodium chloride 200 mL IV bolus is indicated.
Apply oxygen at 2 L/min via nasal cannula is indicated
Notify the provider immediately is indicated
Obtain the client's blood glucose level is not indicated.
1800:
Emergency medical team removed client's shirt at the scene and initiated 18-gauge IV therapy in the
right antecubital space.
Client has full-thickness burns over the upper half of the chest and both forearms; partial-thickness
burns are present on the client's face and neck.
Sinus tachycardia, pulses to brachial extremities palpable. 1+ edema to upper extremities.
Respirations even, labored with scattered rhonchi. Soot noted to the client's mouth and nose. Oxygen
40% via face tent applied.
Hypoactive bowel sounds.
16 French indwelling urinary catheter inserted with return of 250 mL of yellow urine.
Lactated Ringer's infusing to right antecubital. Provider preparing to insert right femoral central line
catheter.
1830:
Client's voice is becoming hoarse and reports difficulty swallowing. Wheezes present to upper lobes
bilaterally. Provider notified. Client positioned upright, oxygen via face tent. Blood collected - During the
emergent phase of burn care, the client is at risk for developing
hypovolemia
and
respiratory failure
.
PRACTICE 2023 A NGN LATEST UPDATE
h NGN
1000:
Client is alert and oriented and reports not feeling well for a few days. Client is on continuous
ambulatory peritoneal dialysis (CAPD) and reports dialysate appeared cloudy this morning.
Reports abdominal pain as 4 on a scale of 0 to 10.
Bowel sounds active in all quadrants.
Peritoneal dialysis access site red, warm to touch, with a small amount of purulent drainage noted on
dressing.1300:
Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly distended,
hypoactive bowel sounds. Client reports nausea. Reports pain as 6 on a scale of 0 to 10. Provider notified
and updated with client condition and diagnostic results. - The client is experiencing manifestations of
peritonitis
due to
x-ray results
.
NGN
Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2 on a scale of 0 to
10. Client appears restless and frequently asks for water. Bilateral lower extremities cool with +1 pedal
pulses. Urine output is 40 mL for the past 2 hr. Moderate amount of bright red drainage noted on
surgical incision dressing. - Insert a large-gauge IV.
Initiate a fluid challenge.
Hypovolemia
Urine output
Blood pressure
, A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment
findings should the nurse expect? - Hypoactive Bowel Sounds
NGN
0900:
Client presents with abdominal pain in the upper left quadrant for the past 2 days. States pain became
worse this morning and is radiating to the back. Rates pain as 8 on a scale of 0 to 10.
Hypoactive bowel sounds; reports nausea, no vomiting; client is passing flatus.
Febrile, oriented to person, place, and time.
Tachypnea with diminished breath sounds.
Sinus tachycardia.
Client voids 300 mL of clear, amber urine.
0930:
Client vomited 100 mL brown liquid. - The client is experiencing manifestations of
pancreatitis
as evidenced by the
amylase and lipase
.
0530:
Client is awake and alert.
Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit. Lung sounds
clear upon auscultation; client denies shortness of breath. No peripheral edema noted; capillary refill is
less than 3 seconds; +2 bilateral pedal and radial pulses.
AVF access prepared and cannulated twice with no difficulty. Lines are taped and secured; treatment is
initiated.0600:
Client is reading a book. Access is visible, and lines are secure. Client reports no discomfort or pain.0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly confused. -
Perform a 12-lead ECG is not indicated.
Place the client in Trendelenburg position is indicated.
, Administer a 0.9% sodium chloride 200 mL IV bolus is indicated.
Apply oxygen at 2 L/min via nasal cannula is indicated
Notify the provider immediately is indicated
Obtain the client's blood glucose level is not indicated.
1800:
Emergency medical team removed client's shirt at the scene and initiated 18-gauge IV therapy in the
right antecubital space.
Client has full-thickness burns over the upper half of the chest and both forearms; partial-thickness
burns are present on the client's face and neck.
Sinus tachycardia, pulses to brachial extremities palpable. 1+ edema to upper extremities.
Respirations even, labored with scattered rhonchi. Soot noted to the client's mouth and nose. Oxygen
40% via face tent applied.
Hypoactive bowel sounds.
16 French indwelling urinary catheter inserted with return of 250 mL of yellow urine.
Lactated Ringer's infusing to right antecubital. Provider preparing to insert right femoral central line
catheter.
1830:
Client's voice is becoming hoarse and reports difficulty swallowing. Wheezes present to upper lobes
bilaterally. Provider notified. Client positioned upright, oxygen via face tent. Blood collected - During the
emergent phase of burn care, the client is at risk for developing
hypovolemia
and
respiratory failure
.
