RN Comprehensive Online Practice 2024
B
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 - ANSCondition: 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 - ANSThe 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 - ANSHepatitis 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. - ANSClick 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. - ANSSelect 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 - ANSThe 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 - ANSThe nurse should first address the client's respiratory
rate, followed by the client's level of consciousness
B
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 - ANSCondition: 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 - ANSThe 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 - ANSHepatitis 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. - ANSClick 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. - ANSSelect 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 - ANSThe 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 - ANSThe nurse should first address the client's respiratory
rate, followed by the client's level of consciousness
