RN Comprehensive Online Practice 2023 B| Complete Questions and Answers, 100% Correct With Rationales

RN Comprehensive Online Practice 2023 B| Complete Questions and Answers, 100% Correct With Rationales 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 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 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 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 Hepatitis A: Client's risk from fecal-oral transmission, laboratory results, and physical examination findings 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 hr. 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 Nurses' Notes 3 months ago Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. Select the 3 findings that require immediate follow up: - Auditory hallucinations - Speech - Restlessness When recognizing cues, the nurse should identify that the findings of restlessness, auditory hallucinations, and pressured speech require immediate follow up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment. A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG) Laboratory Results 0630 Sodium 145 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5 mEq/L) Chloride 116 mEq/L (98 to 106 mEq/L) BUN 24 mg/dL (10 to 20 mg/dL) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 9 mg/dL (9 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC count 9,500/mm3 (5,000 to 10,000/mm3) I & O 0700 4 hr input 400 mL 4 hr output The client is at greatest risk for developing dysrhythmias, as evidenced by electrolyte imbalance. The nurse should analyze cues to determine the client is at greatest risk for developing dysrhythmias related to hypokalemia, as evidenced by the laboratory report and the client's report of muscle cramping. Potassium and magnesium depletion are common manifestations in clients who are postoperative following CABG. Due to medication or hemodilation, it is important for the nurse to closely monitor electrolytes. A nurse is caring for a client who is pregnant in the acute care setting Nurses' Notes 1400 Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr. Denies any changes in vaginal discharge. External fetal monitor applied. 1430 Contraction pattern: contractions every 4 to 5 min, lasting 30 to 45 seconds, palpate mild in intensity Fetal heart rate: 150/min to 155/min, moderate variability, adequate accelerations present, no decelerations noted. Provider in The nurse should first address the client's respiratory rate, followed by the client's level of consciousness When prioritizing hypotheses, the nurse should recognize that magnesium sulfate is a central nervous system depressant that can affect respirations, consciousness, and reflexes when toxic blood levels occur. Using the airway, breathing, circulation priority framework, the nurse should plan to first take action to support respirations, followed by action to increase the client's level of consciousness. The nurse should plan to discontinue the magnesium sulfate infusion and administer calcium gluconate as an antidote. A nurse is caring for an adolescent in the emergency department (ED) Nurses' Notes 0700 Adolescent admitted to ED. Adolescent's parents are concerned about left leg injury that appears to be getting worse. Parents report adolescent has had fever, decreased appetite, and decreased energy within the past 2 days. Adolescent reports leg injury occurred while playing soccer. 0715 Adolescent is alert and oriented to person, place, time, and situation. Adolescent reports left lower leg pain as 4 on Which of the following findings requires immediate follow up by the nurse?