RN Comprehensive Online Practice 2025 B Questions and
Answers
A nurse is caring for a 5-year-old child biceps 1+, triceps 1+, pa - - The client is
most likely experiencing manifestations of
Physical Examination: pneumonia and autonomic dysreflexia.
1510:
Upon visual inspection, throat is inflamed, tonsils
The nurse should analyze cues from the client's
appear pink, reddened and epiglottis is manifestations and determine that the client is
edematous and cherry red in appearance. Skin most likely experiencing manifestations of
appears pale. Stridor noted upon inspiration with pneumonia and autonomic dysreflexia. A client
diminished bilateral lung sounds. who has a cervical SCI is at risk for respiratory
complications because spinal innervation to the
Nurse's Notes: respiratory muscles is disrupted. Adventitious
1500 breath sounds in the lower lobes bilaterally and a
Child accompanied to emergency department by decrease in oxygen saturation to less than 92%
caregiver. Caregiver states child has a sore can indicate pneumonia. The client's sudden
throat and reports the child has "pain on increase in blood pressure, bradycardia, flushing
swallowing" and denies cough. Child is agitated of the skin above the area of the injury,
and lean - - Condition: Epiglottis headache, and blurred vision are manifestations
Actions: Initiate droplet precautions and request of autonomic dysreflexia, which can be a life-
a prescription for IV antibiotics threatening condition.
Monitors: Breath sounds and temperature
The nurse should anticipate initiating droplet A nurse is caring for a client who has abdominal
precautions and requesting a prescription for IV pain
antibiotics. The child is most likely experiencing
epiglottis because of the clinical manifestations Nurses' Notes
of a high fever, inflammation and redness of the 0900
throat, pale skin, stridor with inspiration, painful Client reports loss of appetite, weight loss, and
swallowing, no cough, is sitting in tripod position, fatigue for 1 week. Reports abdominal pain, 6 on
and drooling. The nurse should monitor the a scale from 0 to 10, for 2 days. Client is a
child's temperature and breath sounds. perioperative nurse, returned 1 week ago from a
2-week mission trip to an underdeveloped
country
A nurse is caring for a client who is on the spinal
cord injury (SCI) unit 1200
Results of antibody studies obtained. Provider
Nurses' Notes prescription for antiviral medication pending.
Day 3, 1700
Client admitted to SCI unit 3 days ago following Physical Examination
C7 injury. Skin is cool, pale, and dry to touch. 0930
Respirations easy and unlabored. Lung sounds Lung sounds clear bilaterally. Skin warm to touch
diminished in lower lobes. Abdomen soft and and jau - - Hepatitis A: Client's risk from
nondistended with active bowel sounds. Client fecal-oral transmission, laboratory results, and
passed a small amount of hard formed stool this physical examination findings
AM. Indwelling urinary catheter draining clear
yellow urine. Deep tendon reflexes (DTR) are Hepatitis B: Antiviral treatment, laboratory results,
,RN Comprehensive Online Practice 2025 B Questions and
Answers
client's risk from bloodborne transmission, - Client repositioned every 4 hr
physical examination findings
When recognizing cues, the nurse should
Hepatitis C: Antiviral treatment, laboratory determine that the client's painful edematous
results, client's risk from bloodborne area on their sacrum and that the client has only
transmission, and physical examination findings been repositioned every 4 hr requires follow up.
The client has manifestations of a pressure injury
When analyzing cues, the nurse should that need to be addressed. The client should be
recognize that manifestations of hepatitis A, repositioned at least every 2 hr to prevent
hepatitis B, and hepatitis C include jaundice, worsening of the pressure injury and to relieve
yellow sclerae, right upper quandrant pain upon pressure from the sacral area.
palpation, dark yellow urine, and elevated AST
and ALT levels. When analyzing cues, the nurse
should also recognize the client's risk for A nurse in an outpatient mental health clinic is
contracting hepatitis A through the fecal-oral caring for a client
route during recent travel to an underdeveloped
country and the client's occupational risk as a Vital Signs
perioperative nurse for contracting hepatitis B 3 months ago
and hepatitis C through bloodborne transmission. Blood pressure 116/68 mmHg
The nurse should recognize that the current Heart rate 82/min
standard of practice for Respiratory rate 16/min
Temperature 36.7 C (98.1 F)
SaO2 97% on room air
A nurse is caring for a client on a medical-
surgical unit Today:
Blood pressure 128/76 mmHg
Vital Signs Heart rate 104/min
0700 Respiratory rate 22/min
Temperature 37.6 C (99.7 F) Temperature 37.4 (99.4 F)
Heart rate 100/min SaO2 97% on room air
Respiratory rate 22/min
Blood pressure 115/70 mmHg Nurses' Notes
Oxygen saturation 98% on room air 3 months ago
Client recently admitted with new diagnosis of
Nurses' Notes schizophrenia. Received inpatient treatment for
1100 10 days and was discharged 1 week ago. -
Client alert and oriented to person, place, and - Select the 3 findings that require
time. Client had episode of diarrhea, provided immediate follow up:
perineal care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) - Auditory hallucinations
painful edematous area on sacrum. Client - Speech
repositioned every 4 hr. - - Click to - Restlessness
highlight the findings that require follow up. To
deselect a finding, click on the finding again. When recognizing cues, the nurse should identify
- Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful that the findings of restlessness, auditory
edematous area on sacrum hallucinations, and pressured speech require
,RN Comprehensive Online Practice 2025 B Questions and
Answers
immediate follow up. These findings are Client reports a constant low dull backache and
indications of psychosis. The nurse should notify painless abdominal tightening for the past 3 hr.
the provider for additional evaluation and Denies any changes in vaginal discharge.
treatment. External fetal monitor applied.
1430
A nurse is caring for a client who is postoperative Contraction pattern: contractions every 4 to 5
following coronary artery bypass surgery (CABG) min, lasting 30 to 45 seconds, palpate mild in
intensity
Laboratory Results Fetal heart rate: 150/min to 155/min, moderate
0630 variability, adequate accelerations present, no
Sodium 145 mEq/L (136 to 145 mEq/L) decelerations noted. Provider in - - The
Potassium 3.2 mEq/L (3.5 to 5 mEq/L) nurse should first address the client's respiratory
Chloride 116 mEq/L (98 to 106 mEq/L) rate, followed by the client's level of
BUN 24 mg/dL (10 to 20 mg/dL) consciousness
Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)
Total calcium 9 mg/dL (9 to 10.5 mg/dL) When prioritizing hypotheses, the nurse should
Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) recognize that magnesium sulfate is a central
Glucose 95 mg/dL (74 to 106 mg/dL) nervous system depressant that can affect
WBC count 9,500/mm3 (5,000 to 10,000/mm3) respirations, consciousness, and reflexes when
toxic blood levels occur. Using the airway,
I&O breathing, circulation priority framework, the
0700 nurse should plan to first take action to support
4 hr input 400 mL respirations, followed by action to increase the
4 hr output - - The client is at greatest risk client's level of consciousness. The nurse should
for developing dysrhythmias, as evidenced by plan to discontinue the magnesium sulfate
electrolyte imbalance. infusion and administer calcium gluconate as an
antidote.
The nurse should analyze cues to determine the
client is at greatest risk for developing
dysrhythmias related to hypokalemia, as A nurse is caring for an adolescent in the
evidenced by the laboratory report and the emergency department (ED)
client's report of muscle cramping. Potassium
and magnesium depletion are common Nurses' Notes
manifestations in clients who are postoperative 0700
following CABG. Due to medication or Adolescent admitted to ED. Adolescent's parents
hemodilation, it is important for the nurse to are concerned about left leg injury that appears
closely monitor electrolytes. to be getting worse. Parents report adolescent
has had fever, decreased appetite, and
decreased energy within the past 2 days.
A nurse is caring for a client who is pregnant in Adolescent reports leg injury occurred while
the acute care setting playing soccer.
Nurses' Notes 0715
1400 Adolescent is alert and oriented to person, place,
, RN Comprehensive Online Practice 2025 B Questions and
Answers
time, and situation. Adolescent reports left lower Blood pressure 100/70 mmHg
leg pain as 4 on - - Which of the following Oxygen saturation 97% on room air
findings requires immediate follow up by the
nurse? Nurses' Notes
- Skin assessment 1500
- Temperature Client admitted from the ED for dehydration.
- WBC Client alert and oriented to person, pla - -
- Casual blood glucose The client is at risk for developing confusion due
- Potassium to sodium level
After reviewing the information in the Upon analyzing cues, the nurse should identify
adolescent's EMR and recognizing cues, the that the client is at risk for confusion due to a
nurse should identify that the adolescent has a sodium level that is greater than the expected
potential skin infection, such as cellulitis. The reference range. Hypernatremia places the client
skin assessment reveals that the medial lateral at risk for a decreased level of consciousness,
aspect of the left leg has a 3 x 3 cm2 area of falls, and seizure activity. Therefore, the nurse
redness with small pustules, tenderness, and should monitor the client's level of consciousness
warmth, which can indicate infection. The and place the client on fall and seizure
adolescent's temperature and WBC count are precautions.
above the expected reference range, which can
also indicate infection. The adolescent's casual
blood glucose and potassium are above the A nurse is caring for an adolescent in the
expected reference range, which can indicate emergency department (ED)
infection or a complication of type 1 diabetes
mellitus. The nurse should immediately follow up Laboratory Results
on these findings because they can indicate Sodium 140 mEq/L (136 to 145 mEq/L)
infection or other complications. Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
Chloride 103 mEq/L (98 to 106 mEq/L)
BUN 15 mg/dL (10 to 20 mg/dL)
A nurse on the medical-surgical unit is caring for Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)
a client who was admitted from the emergency Total calcium 9.5 mg/dL (9 to 10.5 mg/dL)
department (ED) Phosphate 3.7 mg/dL (3 to 4.5 mg/dL)
Glucose 80 mg/dL (74 to 106 mg/dL)
Vital Signs Total protein 7 g/dL (6.4 to 8.3 g/dL)
1400 Albumin 4.5 g/dL (3.5 to 5 g/dL)
Temperature 38 C (100.4 F) WBC count 19,500/mm3 (5,000 to 10,000/mm3)
Heart rate 110/min Asp - - Bacterial Meningitis: Temperature,
Respiratory rate 24/min photophobia, rash, mental status, and pain
Blood pressure 96/58 mmHg Encephalitis: Temperature, pain, and mental
Oxygen saturation 96% on room air status
Reye Syndrome: mental status and hepatic
1500 function
Temperature 37.2 (98.9 F)
Heart rate 96/min When recognizing cues, the nurse should
Respiratory rate 20/min recognize that manifestations of bacterial
Answers
A nurse is caring for a 5-year-old child biceps 1+, triceps 1+, pa - - The client is
most likely experiencing manifestations of
Physical Examination: pneumonia and autonomic dysreflexia.
1510:
Upon visual inspection, throat is inflamed, tonsils
The nurse should analyze cues from the client's
appear pink, reddened and epiglottis is manifestations and determine that the client is
edematous and cherry red in appearance. Skin most likely experiencing manifestations of
appears pale. Stridor noted upon inspiration with pneumonia and autonomic dysreflexia. A client
diminished bilateral lung sounds. who has a cervical SCI is at risk for respiratory
complications because spinal innervation to the
Nurse's Notes: respiratory muscles is disrupted. Adventitious
1500 breath sounds in the lower lobes bilaterally and a
Child accompanied to emergency department by decrease in oxygen saturation to less than 92%
caregiver. Caregiver states child has a sore can indicate pneumonia. The client's sudden
throat and reports the child has "pain on increase in blood pressure, bradycardia, flushing
swallowing" and denies cough. Child is agitated of the skin above the area of the injury,
and lean - - Condition: Epiglottis headache, and blurred vision are manifestations
Actions: Initiate droplet precautions and request of autonomic dysreflexia, which can be a life-
a prescription for IV antibiotics threatening condition.
Monitors: Breath sounds and temperature
The nurse should anticipate initiating droplet A nurse is caring for a client who has abdominal
precautions and requesting a prescription for IV pain
antibiotics. The child is most likely experiencing
epiglottis because of the clinical manifestations Nurses' Notes
of a high fever, inflammation and redness of the 0900
throat, pale skin, stridor with inspiration, painful Client reports loss of appetite, weight loss, and
swallowing, no cough, is sitting in tripod position, fatigue for 1 week. Reports abdominal pain, 6 on
and drooling. The nurse should monitor the a scale from 0 to 10, for 2 days. Client is a
child's temperature and breath sounds. perioperative nurse, returned 1 week ago from a
2-week mission trip to an underdeveloped
country
A nurse is caring for a client who is on the spinal
cord injury (SCI) unit 1200
Results of antibody studies obtained. Provider
Nurses' Notes prescription for antiviral medication pending.
Day 3, 1700
Client admitted to SCI unit 3 days ago following Physical Examination
C7 injury. Skin is cool, pale, and dry to touch. 0930
Respirations easy and unlabored. Lung sounds Lung sounds clear bilaterally. Skin warm to touch
diminished in lower lobes. Abdomen soft and and jau - - Hepatitis A: Client's risk from
nondistended with active bowel sounds. Client fecal-oral transmission, laboratory results, and
passed a small amount of hard formed stool this physical examination findings
AM. Indwelling urinary catheter draining clear
yellow urine. Deep tendon reflexes (DTR) are Hepatitis B: Antiviral treatment, laboratory results,
,RN Comprehensive Online Practice 2025 B Questions and
Answers
client's risk from bloodborne transmission, - Client repositioned every 4 hr
physical examination findings
When recognizing cues, the nurse should
Hepatitis C: Antiviral treatment, laboratory determine that the client's painful edematous
results, client's risk from bloodborne area on their sacrum and that the client has only
transmission, and physical examination findings been repositioned every 4 hr requires follow up.
The client has manifestations of a pressure injury
When analyzing cues, the nurse should that need to be addressed. The client should be
recognize that manifestations of hepatitis A, repositioned at least every 2 hr to prevent
hepatitis B, and hepatitis C include jaundice, worsening of the pressure injury and to relieve
yellow sclerae, right upper quandrant pain upon pressure from the sacral area.
palpation, dark yellow urine, and elevated AST
and ALT levels. When analyzing cues, the nurse
should also recognize the client's risk for A nurse in an outpatient mental health clinic is
contracting hepatitis A through the fecal-oral caring for a client
route during recent travel to an underdeveloped
country and the client's occupational risk as a Vital Signs
perioperative nurse for contracting hepatitis B 3 months ago
and hepatitis C through bloodborne transmission. Blood pressure 116/68 mmHg
The nurse should recognize that the current Heart rate 82/min
standard of practice for Respiratory rate 16/min
Temperature 36.7 C (98.1 F)
SaO2 97% on room air
A nurse is caring for a client on a medical-
surgical unit Today:
Blood pressure 128/76 mmHg
Vital Signs Heart rate 104/min
0700 Respiratory rate 22/min
Temperature 37.6 C (99.7 F) Temperature 37.4 (99.4 F)
Heart rate 100/min SaO2 97% on room air
Respiratory rate 22/min
Blood pressure 115/70 mmHg Nurses' Notes
Oxygen saturation 98% on room air 3 months ago
Client recently admitted with new diagnosis of
Nurses' Notes schizophrenia. Received inpatient treatment for
1100 10 days and was discharged 1 week ago. -
Client alert and oriented to person, place, and - Select the 3 findings that require
time. Client had episode of diarrhea, provided immediate follow up:
perineal care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) - Auditory hallucinations
painful edematous area on sacrum. Client - Speech
repositioned every 4 hr. - - Click to - Restlessness
highlight the findings that require follow up. To
deselect a finding, click on the finding again. When recognizing cues, the nurse should identify
- Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful that the findings of restlessness, auditory
edematous area on sacrum hallucinations, and pressured speech require
,RN Comprehensive Online Practice 2025 B Questions and
Answers
immediate follow up. These findings are Client reports a constant low dull backache and
indications of psychosis. The nurse should notify painless abdominal tightening for the past 3 hr.
the provider for additional evaluation and Denies any changes in vaginal discharge.
treatment. External fetal monitor applied.
1430
A nurse is caring for a client who is postoperative Contraction pattern: contractions every 4 to 5
following coronary artery bypass surgery (CABG) min, lasting 30 to 45 seconds, palpate mild in
intensity
Laboratory Results Fetal heart rate: 150/min to 155/min, moderate
0630 variability, adequate accelerations present, no
Sodium 145 mEq/L (136 to 145 mEq/L) decelerations noted. Provider in - - The
Potassium 3.2 mEq/L (3.5 to 5 mEq/L) nurse should first address the client's respiratory
Chloride 116 mEq/L (98 to 106 mEq/L) rate, followed by the client's level of
BUN 24 mg/dL (10 to 20 mg/dL) consciousness
Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)
Total calcium 9 mg/dL (9 to 10.5 mg/dL) When prioritizing hypotheses, the nurse should
Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) recognize that magnesium sulfate is a central
Glucose 95 mg/dL (74 to 106 mg/dL) nervous system depressant that can affect
WBC count 9,500/mm3 (5,000 to 10,000/mm3) respirations, consciousness, and reflexes when
toxic blood levels occur. Using the airway,
I&O breathing, circulation priority framework, the
0700 nurse should plan to first take action to support
4 hr input 400 mL respirations, followed by action to increase the
4 hr output - - The client is at greatest risk client's level of consciousness. The nurse should
for developing dysrhythmias, as evidenced by plan to discontinue the magnesium sulfate
electrolyte imbalance. infusion and administer calcium gluconate as an
antidote.
The nurse should analyze cues to determine the
client is at greatest risk for developing
dysrhythmias related to hypokalemia, as A nurse is caring for an adolescent in the
evidenced by the laboratory report and the emergency department (ED)
client's report of muscle cramping. Potassium
and magnesium depletion are common Nurses' Notes
manifestations in clients who are postoperative 0700
following CABG. Due to medication or Adolescent admitted to ED. Adolescent's parents
hemodilation, it is important for the nurse to are concerned about left leg injury that appears
closely monitor electrolytes. to be getting worse. Parents report adolescent
has had fever, decreased appetite, and
decreased energy within the past 2 days.
A nurse is caring for a client who is pregnant in Adolescent reports leg injury occurred while
the acute care setting playing soccer.
Nurses' Notes 0715
1400 Adolescent is alert and oriented to person, place,
, RN Comprehensive Online Practice 2025 B Questions and
Answers
time, and situation. Adolescent reports left lower Blood pressure 100/70 mmHg
leg pain as 4 on - - Which of the following Oxygen saturation 97% on room air
findings requires immediate follow up by the
nurse? Nurses' Notes
- Skin assessment 1500
- Temperature Client admitted from the ED for dehydration.
- WBC Client alert and oriented to person, pla - -
- Casual blood glucose The client is at risk for developing confusion due
- Potassium to sodium level
After reviewing the information in the Upon analyzing cues, the nurse should identify
adolescent's EMR and recognizing cues, the that the client is at risk for confusion due to a
nurse should identify that the adolescent has a sodium level that is greater than the expected
potential skin infection, such as cellulitis. The reference range. Hypernatremia places the client
skin assessment reveals that the medial lateral at risk for a decreased level of consciousness,
aspect of the left leg has a 3 x 3 cm2 area of falls, and seizure activity. Therefore, the nurse
redness with small pustules, tenderness, and should monitor the client's level of consciousness
warmth, which can indicate infection. The and place the client on fall and seizure
adolescent's temperature and WBC count are precautions.
above the expected reference range, which can
also indicate infection. The adolescent's casual
blood glucose and potassium are above the A nurse is caring for an adolescent in the
expected reference range, which can indicate emergency department (ED)
infection or a complication of type 1 diabetes
mellitus. The nurse should immediately follow up Laboratory Results
on these findings because they can indicate Sodium 140 mEq/L (136 to 145 mEq/L)
infection or other complications. Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
Chloride 103 mEq/L (98 to 106 mEq/L)
BUN 15 mg/dL (10 to 20 mg/dL)
A nurse on the medical-surgical unit is caring for Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)
a client who was admitted from the emergency Total calcium 9.5 mg/dL (9 to 10.5 mg/dL)
department (ED) Phosphate 3.7 mg/dL (3 to 4.5 mg/dL)
Glucose 80 mg/dL (74 to 106 mg/dL)
Vital Signs Total protein 7 g/dL (6.4 to 8.3 g/dL)
1400 Albumin 4.5 g/dL (3.5 to 5 g/dL)
Temperature 38 C (100.4 F) WBC count 19,500/mm3 (5,000 to 10,000/mm3)
Heart rate 110/min Asp - - Bacterial Meningitis: Temperature,
Respiratory rate 24/min photophobia, rash, mental status, and pain
Blood pressure 96/58 mmHg Encephalitis: Temperature, pain, and mental
Oxygen saturation 96% on room air status
Reye Syndrome: mental status and hepatic
1500 function
Temperature 37.2 (98.9 F)
Heart rate 96/min When recognizing cues, the nurse should
Respiratory rate 20/min recognize that manifestations of bacterial
