RN Comprehensive Practice 2024 A
GRADED A+
RN Comprehensive Practice 2024 A
graded A+
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) - 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
,RN Comprehensive Practice 2024 A
GRADED A+
Vital signs (within normal range)
Headache
Back pain - 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: - 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 - 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?
,RN Comprehensive Practice 2024 A
GRADED A+
Administer thiamine
Maintain a low-stimulation environment
Administer chlordiazepoxide
Initiate seizure precautions
Perform a CIWA-Ar
Administer disulfiram - 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: - 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
Involuntary tongue movement and foot tremor
Increase in urination and one episode of incontinence
, RN Comprehensive Practice 2024 A
GRADED A+
Family c/o increased agitation and delusions - Involuntary tongue movement and foot
tremor
Frequent urination and incontinence
Increase in agitation
-Patient is experiencing tardive dyskinesia
A home health nurse is evaluation a school-age child who has cystic fibrosis. The nurse
should initiate a request for a high-frequency chest compression vest in response to
which of the following parent statements?
A. "My child doesn't like to sit still for nebulizer treatments."
B. "I think that my child has been running a fever over the last couple of days."
C. "My child only has a small amount of mucus after percussion therapy."
D. "I am concerned about my child's future participation in team sports." - C. "My child
has only a small amount of mucus after percussion therapy."
-The nurse should recommend a high-frequency vest for a child who has inadequate
results from other airway clearance therapy techniques. Older children often require
other techniques in addition to percussion and postural drainage to achieve adequate
mucus expectoration.
-The nurse should teach the parent techniques for administration for nebulizer
treatments to the child.
-The nurse should follow-up on reports of fever, as this could indicate a pulmonary
infection.
-The nurse should discuss participation in sports activities in relation to the child's
current physical and pulmonary health.
NGN: A patient who is x2 post-op, following a surgical repair of a left hip fracture, is c/o
of intermittent abdominal pain. Rates 5/10 on left side of abdomen. Pain began after
eating dinner. Last bowel movement was 5 days prior. Reports usual pattern is x1 daily.
Assessment: Abdomen distended, dull to percussion, firm and non-tender on palpation.
Hypoactive bowel sounds x4. Vital signs are within normal limits.
Bowtie: - Condition: Intestinal obstruction
-bowel sounds hypoactive x4, last BM was 5 days prior, intermittent to constant pain.
Interventions: Assist patient in semi-Fowler's & prepare to administer IV fluids.
-to relieve the pressure from the distention and reduce risk of developing
fluid/electrolyte imbalance.
GRADED A+
RN Comprehensive Practice 2024 A
graded A+
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) - 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
,RN Comprehensive Practice 2024 A
GRADED A+
Vital signs (within normal range)
Headache
Back pain - 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: - 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 - 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?
,RN Comprehensive Practice 2024 A
GRADED A+
Administer thiamine
Maintain a low-stimulation environment
Administer chlordiazepoxide
Initiate seizure precautions
Perform a CIWA-Ar
Administer disulfiram - 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: - 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
Involuntary tongue movement and foot tremor
Increase in urination and one episode of incontinence
, RN Comprehensive Practice 2024 A
GRADED A+
Family c/o increased agitation and delusions - Involuntary tongue movement and foot
tremor
Frequent urination and incontinence
Increase in agitation
-Patient is experiencing tardive dyskinesia
A home health nurse is evaluation a school-age child who has cystic fibrosis. The nurse
should initiate a request for a high-frequency chest compression vest in response to
which of the following parent statements?
A. "My child doesn't like to sit still for nebulizer treatments."
B. "I think that my child has been running a fever over the last couple of days."
C. "My child only has a small amount of mucus after percussion therapy."
D. "I am concerned about my child's future participation in team sports." - C. "My child
has only a small amount of mucus after percussion therapy."
-The nurse should recommend a high-frequency vest for a child who has inadequate
results from other airway clearance therapy techniques. Older children often require
other techniques in addition to percussion and postural drainage to achieve adequate
mucus expectoration.
-The nurse should teach the parent techniques for administration for nebulizer
treatments to the child.
-The nurse should follow-up on reports of fever, as this could indicate a pulmonary
infection.
-The nurse should discuss participation in sports activities in relation to the child's
current physical and pulmonary health.
NGN: A patient who is x2 post-op, following a surgical repair of a left hip fracture, is c/o
of intermittent abdominal pain. Rates 5/10 on left side of abdomen. Pain began after
eating dinner. Last bowel movement was 5 days prior. Reports usual pattern is x1 daily.
Assessment: Abdomen distended, dull to percussion, firm and non-tender on palpation.
Hypoactive bowel sounds x4. Vital signs are within normal limits.
Bowtie: - Condition: Intestinal obstruction
-bowel sounds hypoactive x4, last BM was 5 days prior, intermittent to constant pain.
Interventions: Assist patient in semi-Fowler's & prepare to administer IV fluids.
-to relieve the pressure from the distention and reduce risk of developing
fluid/electrolyte imbalance.
