NUR283 Transition to Registered Nursing -
Practical Scenarios Revised Exam
What should the nurse do when a client with pericarditis has a WBC count of 13,000 mm3 and a
fever of 100.8 F?
Update the nursing interventions as needed.
What is the significance of a PTT of 76 seconds in a client with cirrhosis?
It indicates a prolonged clotting time, which may increase the risk of bleeding.
What is the normal range for blood glucose levels in a client receiving NPH insulin?
Typically, a capillary blood glucose level should be between 70-130 mg/dL.
What should a nurse do if a client refuses medication?
Respect the client's autonomy and document the refusal.
What is a common symptom of pancreatitis that a nurse should monitor?
Mid-epigastric discomfort.
What is a potential complication following a transesophageal echocardiogram (TEE)?
Sore throat due to irritation from the procedure.
What is a common postoperative complaint after laparoscopic cholecystectomy?
Bilateral shoulder pain due to referred pain from diaphragmatic irritation.
What is the priority assessment for a child with Kawasaki disease starting immunoglobulin
therapy?
Monitor for signs of adverse reactions to the therapy.
What is the expected change in wound drainage from sanguineous to serosanguineous?
It indicates normal healing progression post-surgery.
,What nursing action should be taken for a client with multiple sclerosis (MS) experiencing
diplopia?
Assess the client's neurological status and provide safety measures.
What is the importance of monitoring a client who is receiving hydrocortisone?
To assess potential hyperglycemia.
What is the significance of a blood pressure reading of 106/61 mm Hg in a postoperative client?
It may indicate hypotension and requires further assessment.
What should a nurse do if a client on a low-sodium diet is found eating salted potato chips?
Educate the client on dietary restrictions and encourage adherence.
What is a key indicator of effective pain management in postoperative clients?
A reported pain level of less than 4 on a scale of 0 to 10.
What should a nurse monitor for in a child with cystic fibrosis who has frequent hospitalizations?
Signs of respiratory distress and nutritional status.
What is the role of the nurse when a client is alert and oriented but wants to leave against
medical advice (AMA)?
Inform the client of the risks and document their decision.
What indicates correct documentation by a staff nurse regarding a dressing change?
'Dressing change performed to coccyx wound with no adverse effects noted by the client. Client
transferred to chair.'
What should a nurse do when a client brings their own CPAP machine to the hospital?
Have the machine inspected by the facility's engineering department.
Which client should be recommended for discharge during an emergency response plan
activation?
,The client who has suspected appendicitis, intense pain at McBurney's point, and now reports
cessation
of pain.
What indicates correct client care by newly hired UAP when caring for a client with herpes
zoster?
Placing dedicated equipment in the room of a client who has herpes zoster.
What statement by a parent indicates a need for further teaching on child car passenger safety?
'Car seats should be rear-facing in the back seat around ages 2 to 4 years.' (They should be
rear-facing until at least age 2.)
What requires follow-up by the nurse regarding a 10-year-old with adrenocortical insufficiency?
Discontinuation of hydrocortisone IV.
What order should the nurse clarify for a client with an ischemic stroke?
Receiving IV alteplase if the stroke symptoms started 2 hours ago.
What assessment finding should lead to discontinuation of oxytocin IV during labor?
Dark, red streaks in her bloody show.
What is the appropriate action if a client has a DVT and is receiving warfarin with a PT of 28
seconds?
Monitor the client closely as the PT indicates a risk for bleeding.
What should the nurse observe when a UAP is caring for a client with influenza?
Wearing a gown when entering the room.
What is the correct placement of a car seat harness chest clip for an infant?
At the level of the infant's armpits.
What is an appropriate fluid bolus for a 12-year-old child with sickle cell crisis?
A fluid bolus of 500 mL over 1 hour.
, What dietary restriction is appropriate for a client diagnosed with acute kidney injury?
A low-sodium, low-potassium diet.
What indicates incorrect care by a newly hired UAP when emptying a urinary drainage device?
Donning sterile gloves to empty a urinary drainage device.
What should a nurse do if a client is positive for HIV with a nonproductive cough and a Mantoux
test reading of 6 mm?
Monitor for further respiratory symptoms as the Mantoux test indicates possible exposure.
What is the significance of a 24-hour Mantoux test reading of 6 mm induration?
It may indicate a previous exposure to tuberculosis but is not definitive.
What is the appropriate action if a client with COPD has an oxygen saturation level of 86% on
room air?
Assess the need for supplemental oxygen.
What should the nurse do if a client has a diagnosis of polycythemia vera and is to receive
packed red blood cells?
Clarify the order as it may not be appropriate for this condition.
What is the expected nursing action when a client reports pain in the abdomen with vomiting?
Assess the client further and document the findings.
What should the nurse do if a client is found sitting on the floor with no pain or abrasions?
Notify the primary health care provider and complete an incident report.
What is the correct action regarding a client who has a deep vein thrombosis and is on
warfarin?
Monitor the prothrombin time and assess for signs of bleeding.
What are the signs of fetal distress indicated by a fetal heart rate (FHR) of 68 for 90 seconds?
This indicates potential fetal distress, as a normal FHR typically ranges from 110 to 160 beats
per minute.
Practical Scenarios Revised Exam
What should the nurse do when a client with pericarditis has a WBC count of 13,000 mm3 and a
fever of 100.8 F?
Update the nursing interventions as needed.
What is the significance of a PTT of 76 seconds in a client with cirrhosis?
It indicates a prolonged clotting time, which may increase the risk of bleeding.
What is the normal range for blood glucose levels in a client receiving NPH insulin?
Typically, a capillary blood glucose level should be between 70-130 mg/dL.
What should a nurse do if a client refuses medication?
Respect the client's autonomy and document the refusal.
What is a common symptom of pancreatitis that a nurse should monitor?
Mid-epigastric discomfort.
What is a potential complication following a transesophageal echocardiogram (TEE)?
Sore throat due to irritation from the procedure.
What is a common postoperative complaint after laparoscopic cholecystectomy?
Bilateral shoulder pain due to referred pain from diaphragmatic irritation.
What is the priority assessment for a child with Kawasaki disease starting immunoglobulin
therapy?
Monitor for signs of adverse reactions to the therapy.
What is the expected change in wound drainage from sanguineous to serosanguineous?
It indicates normal healing progression post-surgery.
,What nursing action should be taken for a client with multiple sclerosis (MS) experiencing
diplopia?
Assess the client's neurological status and provide safety measures.
What is the importance of monitoring a client who is receiving hydrocortisone?
To assess potential hyperglycemia.
What is the significance of a blood pressure reading of 106/61 mm Hg in a postoperative client?
It may indicate hypotension and requires further assessment.
What should a nurse do if a client on a low-sodium diet is found eating salted potato chips?
Educate the client on dietary restrictions and encourage adherence.
What is a key indicator of effective pain management in postoperative clients?
A reported pain level of less than 4 on a scale of 0 to 10.
What should a nurse monitor for in a child with cystic fibrosis who has frequent hospitalizations?
Signs of respiratory distress and nutritional status.
What is the role of the nurse when a client is alert and oriented but wants to leave against
medical advice (AMA)?
Inform the client of the risks and document their decision.
What indicates correct documentation by a staff nurse regarding a dressing change?
'Dressing change performed to coccyx wound with no adverse effects noted by the client. Client
transferred to chair.'
What should a nurse do when a client brings their own CPAP machine to the hospital?
Have the machine inspected by the facility's engineering department.
Which client should be recommended for discharge during an emergency response plan
activation?
,The client who has suspected appendicitis, intense pain at McBurney's point, and now reports
cessation
of pain.
What indicates correct client care by newly hired UAP when caring for a client with herpes
zoster?
Placing dedicated equipment in the room of a client who has herpes zoster.
What statement by a parent indicates a need for further teaching on child car passenger safety?
'Car seats should be rear-facing in the back seat around ages 2 to 4 years.' (They should be
rear-facing until at least age 2.)
What requires follow-up by the nurse regarding a 10-year-old with adrenocortical insufficiency?
Discontinuation of hydrocortisone IV.
What order should the nurse clarify for a client with an ischemic stroke?
Receiving IV alteplase if the stroke symptoms started 2 hours ago.
What assessment finding should lead to discontinuation of oxytocin IV during labor?
Dark, red streaks in her bloody show.
What is the appropriate action if a client has a DVT and is receiving warfarin with a PT of 28
seconds?
Monitor the client closely as the PT indicates a risk for bleeding.
What should the nurse observe when a UAP is caring for a client with influenza?
Wearing a gown when entering the room.
What is the correct placement of a car seat harness chest clip for an infant?
At the level of the infant's armpits.
What is an appropriate fluid bolus for a 12-year-old child with sickle cell crisis?
A fluid bolus of 500 mL over 1 hour.
, What dietary restriction is appropriate for a client diagnosed with acute kidney injury?
A low-sodium, low-potassium diet.
What indicates incorrect care by a newly hired UAP when emptying a urinary drainage device?
Donning sterile gloves to empty a urinary drainage device.
What should a nurse do if a client is positive for HIV with a nonproductive cough and a Mantoux
test reading of 6 mm?
Monitor for further respiratory symptoms as the Mantoux test indicates possible exposure.
What is the significance of a 24-hour Mantoux test reading of 6 mm induration?
It may indicate a previous exposure to tuberculosis but is not definitive.
What is the appropriate action if a client with COPD has an oxygen saturation level of 86% on
room air?
Assess the need for supplemental oxygen.
What should the nurse do if a client has a diagnosis of polycythemia vera and is to receive
packed red blood cells?
Clarify the order as it may not be appropriate for this condition.
What is the expected nursing action when a client reports pain in the abdomen with vomiting?
Assess the client further and document the findings.
What should the nurse do if a client is found sitting on the floor with no pain or abrasions?
Notify the primary health care provider and complete an incident report.
What is the correct action regarding a client who has a deep vein thrombosis and is on
warfarin?
Monitor the prothrombin time and assess for signs of bleeding.
What are the signs of fetal distress indicated by a fetal heart rate (FHR) of 68 for 90 seconds?
This indicates potential fetal distress, as a normal FHR typically ranges from 110 to 160 beats
per minute.
