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 - Answers -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 - Answers -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 - Answers -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. - Answers -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
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 - Answers -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 - Answers -Which of the following findings requires immediate
follow up by the nurse?
, - Skin assessment
- Temperature
- WBC
- Casual blood glucose
- Potassium
After reviewing the information in the adolescent's EMR and recognizing cues, the nurse
should identify that the adolescent has a potential skin infection, such as cellulitis. The
skin assessment reveals that the medial lateral aspect of the left leg has a 3 x 3 cm2
area of redness with small pustules, tenderness, and warmth, which can indicate
infection. The adolescent's temperature and WBC count are above the expected
reference range, which can also indicate infection. The adolescent's casual blood
glucose and potassium are above the expected reference range, which can indicate
infection or a complication of type 1 diabetes mellitus. The nurse should immediately
follow up on these findings because they can indicate infection or other complications.
A nurse on the medical-surgical unit is caring for a client who was admitted from the
emergency department (ED)
Vital Signs
1400
Temperature 38 C (100.4 F)
Heart rate 110/min
Respiratory rate 24/min
Blood pressure 96/58 mmHg
Oxygen saturation 96% on room air
1500
Temperature 37.2 (98.9 F)
Heart rate 96/min
Respiratory rate 20/min
Blood pressure 100/70 mmHg
Oxygen saturation 97% on room air
Nurses' Notes
1500
Client admitted from the ED for dehydration. Client alert and oriented to person, pla -
Answers -The client is at risk for developing confusion due to sodium level
Upon analyzing cues, the nurse should identify that the client is at risk for confusion due
to a sodium level that is greater than the expected reference range. Hypernatremia
places the client at risk for a decreased level of consciousness, falls, and seizure
activity. Therefore, the nurse should monitor the client's level of consciousness and
place the client on fall and seizure precautions.
A nurse is caring for an adolescent in the emergency department (ED)
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 - Answers -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 - Answers -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 - Answers -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. - Answers -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
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 - Answers -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 - Answers -Which of the following findings requires immediate
follow up by the nurse?
, - Skin assessment
- Temperature
- WBC
- Casual blood glucose
- Potassium
After reviewing the information in the adolescent's EMR and recognizing cues, the nurse
should identify that the adolescent has a potential skin infection, such as cellulitis. The
skin assessment reveals that the medial lateral aspect of the left leg has a 3 x 3 cm2
area of redness with small pustules, tenderness, and warmth, which can indicate
infection. The adolescent's temperature and WBC count are above the expected
reference range, which can also indicate infection. The adolescent's casual blood
glucose and potassium are above the expected reference range, which can indicate
infection or a complication of type 1 diabetes mellitus. The nurse should immediately
follow up on these findings because they can indicate infection or other complications.
A nurse on the medical-surgical unit is caring for a client who was admitted from the
emergency department (ED)
Vital Signs
1400
Temperature 38 C (100.4 F)
Heart rate 110/min
Respiratory rate 24/min
Blood pressure 96/58 mmHg
Oxygen saturation 96% on room air
1500
Temperature 37.2 (98.9 F)
Heart rate 96/min
Respiratory rate 20/min
Blood pressure 100/70 mmHg
Oxygen saturation 97% on room air
Nurses' Notes
1500
Client admitted from the ED for dehydration. Client alert and oriented to person, pla -
Answers -The client is at risk for developing confusion due to sodium level
Upon analyzing cues, the nurse should identify that the client is at risk for confusion due
to a sodium level that is greater than the expected reference range. Hypernatremia
places the client at risk for a decreased level of consciousness, falls, and seizure
activity. Therefore, the nurse should monitor the client's level of consciousness and
place the client on fall and seizure precautions.
A nurse is caring for an adolescent in the emergency department (ED)
