RN Comprehensive Online Practice 2025 B with Questions and Verified Detailed Answers,
100% Guarantee Pass ||Complete A+ Guide
A nurse is caring for a 5-year-old child
Physical Examination:
1510:
Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epiglottis is edematous
and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished
bilateral lung sounds.
Nurse's Notes:
1500
Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and
reports the child has "pain on swallowing" and denies cough. Child is agitated and lean -
(answer)Condition: Epiglottis
Actions: Initiate droplet precautions and request a prescription for IV antibiotics
Monitors: Breath sounds and temperature
The nurse should anticipate initiating droplet precautions and requesting a prescription for IV
antibiotics. The child is most likely experiencing epiglottis because of the clinical manifestations of a high
fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no
cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and
breath sounds.
A nurse is caring for a client who is on the spinal cord injury (SCI) unit
Nurses' Notes
Day 3, 1700
Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch.
Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and
,RN Comprehensive Online Practice 2025 B with Questions and Verified Detailed Answers,
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nondistended with active bowel sounds. Client passed a small amount of hard formed stool this AM.
Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps
1+, pa - (answer)The client is most likely experiencing manifestations of pneumonia and autonomic
dysreflexia.
The nurse should analyze cues from the client's manifestations and determine that the client is most
likely experiencing manifestations of pneumonia and autonomic dysreflexia. A client who has a cervical
SCI is at risk for respiratory complications because spinal innervation to the respiratory muscles is
disrupted. Adventitious breath sounds in the lower lobes bilaterally and a decrease in oxygen saturation
to less than 92% can indicate pneumonia. The client's sudden increase in blood pressure, bradycardia,
flushing of the skin above the area of the injury, headache, and blurred vision are manifestations of
autonomic dysreflexia, which can be a life-threatening condition.
A nurse is caring for a client who has abdominal pain
Nurses' Notes
0900
Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports abdominal pain, 6 on a scale
from 0 to 10, for 2 days. Client is a perioperative nurse, returned 1 week ago from a 2-week mission trip
to an underdeveloped country
1200
Results of antibody studies obtained. Provider prescription for antiviral medication pending.
Physical Examination
0930
Lung sounds clear bilaterally. Skin warm to touch and jau - (answer)Hepatitis A: Client's risk from fecal-
oral transmission, laboratory results, and physical examination findings
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Hepatitis B: Antiviral treatment, laboratory results, client's risk from bloodborne transmission, physical
examination findings
Hepatitis C: Antiviral treatment, laboratory results, client's risk from bloodborne transmission, and
physical examination findings
When analyzing cues, the nurse should recognize that manifestations of hepatitis A, hepatitis B, and
hepatitis C include jaundice, yellow sclerae, right upper quandrant pain upon palpation, dark yellow
urine, and elevated AST and ALT levels. When analyzing cues, the nurse should also recognize the
client's risk for contracting hepatitis A through the fecal-oral route during recent travel to an
underdeveloped country and the client's occupational risk as a perioperative nurse for contracting
hepatitis B and hepatitis C through bloodborne transmission. The nurse should recognize that the
current standard of practice for
A nurse is caring for a client on a medical-surgical unit
Vital Signs
0700
Temperature 37.6 C (99.7 F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 115/70 mmHg
Oxygen saturation 98% on room air
Nurses' Notes
1100
Client alert and oriented to person, place, and time. Client had episode of diarrhea, provided perineal
care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4
, RN Comprehensive Online Practice 2025 B with Questions and Verified Detailed Answers,
100% Guarantee Pass ||Complete A+ Guide
hr. - (answer)Click to highlight the findings that require follow up. To deselect a finding, click on the
finding again.
- Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum
- Client repositioned every 4 hr
When recognizing cues, the nurse should determine that the client's painful edematous area on their
sacrum and that the client has only been repositioned every 4 hr requires follow up. The client has
manifestations of a pressure injury that need to be addressed. The client should be repositioned at least
every 2 hr to prevent worsening of the pressure injury and to relieve pressure from the sacral area.
A nurse in an outpatient mental health clinic is caring for a client
Vital Signs
3 months ago
Blood pressure 116/68 mmHg
Heart rate 82/min
Respiratory rate 16/min
Temperature 36.7 C (98.1 F)
SaO2 97% on room air
Today:
Blood pressure 128/76 mmHg
Heart rate 104/min
Respiratory rate 22/min
Temperature 37.4 (99.4 F)
SaO2 97% on room air
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A nurse is caring for a 5-year-old child
Physical Examination:
1510:
Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epiglottis is edematous
and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished
bilateral lung sounds.
Nurse's Notes:
1500
Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and
reports the child has "pain on swallowing" and denies cough. Child is agitated and lean -
(answer)Condition: Epiglottis
Actions: Initiate droplet precautions and request a prescription for IV antibiotics
Monitors: Breath sounds and temperature
The nurse should anticipate initiating droplet precautions and requesting a prescription for IV
antibiotics. The child is most likely experiencing epiglottis because of the clinical manifestations of a high
fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no
cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and
breath sounds.
A nurse is caring for a client who is on the spinal cord injury (SCI) unit
Nurses' Notes
Day 3, 1700
Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch.
Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and
,RN Comprehensive Online Practice 2025 B with Questions and Verified Detailed Answers,
100% Guarantee Pass ||Complete A+ Guide
nondistended with active bowel sounds. Client passed a small amount of hard formed stool this AM.
Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps
1+, pa - (answer)The client is most likely experiencing manifestations of pneumonia and autonomic
dysreflexia.
The nurse should analyze cues from the client's manifestations and determine that the client is most
likely experiencing manifestations of pneumonia and autonomic dysreflexia. A client who has a cervical
SCI is at risk for respiratory complications because spinal innervation to the respiratory muscles is
disrupted. Adventitious breath sounds in the lower lobes bilaterally and a decrease in oxygen saturation
to less than 92% can indicate pneumonia. The client's sudden increase in blood pressure, bradycardia,
flushing of the skin above the area of the injury, headache, and blurred vision are manifestations of
autonomic dysreflexia, which can be a life-threatening condition.
A nurse is caring for a client who has abdominal pain
Nurses' Notes
0900
Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports abdominal pain, 6 on a scale
from 0 to 10, for 2 days. Client is a perioperative nurse, returned 1 week ago from a 2-week mission trip
to an underdeveloped country
1200
Results of antibody studies obtained. Provider prescription for antiviral medication pending.
Physical Examination
0930
Lung sounds clear bilaterally. Skin warm to touch and jau - (answer)Hepatitis A: Client's risk from fecal-
oral transmission, laboratory results, and physical examination findings
,RN Comprehensive Online Practice 2025 B with Questions and Verified Detailed Answers,
100% Guarantee Pass ||Complete A+ Guide
Hepatitis B: Antiviral treatment, laboratory results, client's risk from bloodborne transmission, physical
examination findings
Hepatitis C: Antiviral treatment, laboratory results, client's risk from bloodborne transmission, and
physical examination findings
When analyzing cues, the nurse should recognize that manifestations of hepatitis A, hepatitis B, and
hepatitis C include jaundice, yellow sclerae, right upper quandrant pain upon palpation, dark yellow
urine, and elevated AST and ALT levels. When analyzing cues, the nurse should also recognize the
client's risk for contracting hepatitis A through the fecal-oral route during recent travel to an
underdeveloped country and the client's occupational risk as a perioperative nurse for contracting
hepatitis B and hepatitis C through bloodborne transmission. The nurse should recognize that the
current standard of practice for
A nurse is caring for a client on a medical-surgical unit
Vital Signs
0700
Temperature 37.6 C (99.7 F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 115/70 mmHg
Oxygen saturation 98% on room air
Nurses' Notes
1100
Client alert and oriented to person, place, and time. Client had episode of diarrhea, provided perineal
care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4
, RN Comprehensive Online Practice 2025 B with Questions and Verified Detailed Answers,
100% Guarantee Pass ||Complete A+ Guide
hr. - (answer)Click to highlight the findings that require follow up. To deselect a finding, click on the
finding again.
- Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum
- Client repositioned every 4 hr
When recognizing cues, the nurse should determine that the client's painful edematous area on their
sacrum and that the client has only been repositioned every 4 hr requires follow up. The client has
manifestations of a pressure injury that need to be addressed. The client should be repositioned at least
every 2 hr to prevent worsening of the pressure injury and to relieve pressure from the sacral area.
A nurse in an outpatient mental health clinic is caring for a client
Vital Signs
3 months ago
Blood pressure 116/68 mmHg
Heart rate 82/min
Respiratory rate 16/min
Temperature 36.7 C (98.1 F)
SaO2 97% on room air
Today:
Blood pressure 128/76 mmHg
Heart rate 104/min
Respiratory rate 22/min
Temperature 37.4 (99.4 F)
SaO2 97% on room air
