RN Comprehensive Practice 2023 A
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) - Correct answer 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 - Correct answer 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: - Correct answer 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 - Correct answer 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 - Correct answer 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: - Correct answer Condition: Varicose veins.
-due to edema & pruritis
Interventions: Elevate extremity & apply compression stockings
-to promote venous return & circulation
Monitor: Pruritis & edema
NGN: Which assessment findings require an immediate follow-up
in a schizophrenic patient?
Hyperactive bowel sounds x4
Last HCP appointment was 6 months ago
Client AO x2
Agitated
Speech disorganized
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) - Correct answer 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 - Correct answer 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: - Correct answer 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 - Correct answer 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 - Correct answer 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: - Correct answer Condition: Varicose veins.
-due to edema & pruritis
Interventions: Elevate extremity & apply compression stockings
-to promote venous return & circulation
Monitor: Pruritis & edema
NGN: Which assessment findings require an immediate follow-up
in a schizophrenic patient?
Hyperactive bowel sounds x4
Last HCP appointment was 6 months ago
Client AO x2
Agitated
Speech disorganized
