R N
C o m p r e h e n s i v e
O n l i n e
P r a c t i c e
2 0 1 9
B
w i t h
N G N
A
nurse
has
just
received
a
change-of-shift
report
on
four
clients.
Which
of
the
following
clients
should
the
nurse
assess
first?
A
client
who
is
postoperative
with
abdominal
distention
and
no
bowel
sounds
A
client
who
has
diabetes
mellitus
and
a
blood
glucose
level
of
105
mg/dL
A
client
who
has
heart
failure
and
2+
pitting
edema
A
client
who
is
receiving
maintenance
IV
fluids
and
needs
a
new
IV
catheter
-
ANS
A
client
who
is
postoperative
with
abdominal
distention
and
no
bowel
sounds
Using
the
acute
vs.
chronic
approach
to
client
care,
the
nurse
should
first
assess
the
client
who
is
postoperative
with
abdominal
distention
and
no
bowel
sounds
because
these
manifestations
are
indications
of
a
paralytic
ileus.
For
each
assessment
finding,
click
to
specify
if
the
finding
is
consistent
with
attention
deficit
hyperactivity
disorder
(ADHD)
or
intellectual
disability
(ID).
Each
finding
may
support
more
than
1
disease
process.
Assessment
Findings
Intellectual
impairment
Interrupting
others
Impaired
language
skills
Hyperreactivity
to
sensory
input
Losing
necessary
things
A
nurse
is
caring
for
a
school-age
child.
Nurses'
Notes
First
visit:
A
child
is
brought
to
the
clinic
accompanied
by
guardians.
The
guardians
have
received
feedback
from
the
child's
teacher
that
the
child
has
become
disinterested
in
schoolwork and
has
difficulty
paying
attention
during
class.
The
child
often
loses
their
school
supplies.
The
guardians
report
that
the
child
demonstrates
these
behaviors
at
home
as
well.
The
child
refuses
to
participate
in
household
chores,
keeps
their
room
untidy ,
does
not
clean
up
when
told
to,
and
is
generally
careless
and
disinterested.
On
assessing,
the
child
is
found
to
be
talkative,
restless,
and
easily
distracted.
2
weeks
later:
The
child's
guardians
report
that
the
child
seems
to
be
doing
better
at
school.
The
child
is
improving
at
paying
attention
during
class
and
completing
assignments
on
time.
Vital
Signs
First
visit:
Blood
pressure
94/56
mm
Hg
Heart
rate
90/min
Respiratory
rate
24/min
Temperature
37.2°
C
(99°
F)
SaO2
99%
on
room
air
2
weeks
later:
Blood
pressure
98/60
mm
Hg
Heart
rate
88/min
Respiratory
rate
22/min
Temperature
37°
C
(98.6°
F)
SaO2
99%
on
room
air
Provider
Prescriptions
Atomoxetine
10
mg
PO
daily
with
breakfast
for
5
days,
then
increase
dose
to
18
mg
PO
daily
with
breakfast
-
ANS
ADHD
Hyperreactivity
to
sensory
input
Losing
necessary
things
Interrupting
others
Intellectual
impairment
ID
Intellectual
impairment
Hyperreactivity
to
sensory
input When
analyzing
cues,
the
nurse
should
identify
that
manifestations
of
ADHD
include
losing
necessary
things,
interrupting
others,
intellectual
impairment,
and
hyper
reactivity
to
sensory
input.
In
ADHD,
the
client
often
loses
necessary
things
in
daily
life,
such
as
pencils,
erasers,
and
books.
The
client
often
interrupts
others
and
has
difficulty
waiting
for
their
turn
in
conversation.
The
client
might
have
an
intellectual
impairment,
which
can
lead
to
poor
academic
performance
and
difficulties
with
socialization.
The
client
might
exhibit
hyperreactivity
or
hyporeactivity
to
stimuli.
A
charge
nurse
is
providing
an
educational
session
about
infection
control
for
a
group
of
staff
nurses.
Which
of
the
following
statements
by
one
of
the
staff
nurses
indicates
an
understanding
of
isolation
precautions?
"Droplet
precautions
should
be
initiated
for
a
client
who
tests
positive
for
measles."
"A
client
who
requires
airborne
precautions
should
be
placed
in
a
negative-pressure
airflow
room."
"Airborne
precautions
should
be
initiated
for
a
client
who
has
Clostridium
difficile."
"A
client
who
is
immunocompromised
should
be
placed
in
a
negative-pressure
airflow
room."
-
ANS
A
client
who
requires
airborne
precautions
should
be
placed
in
a
negative-pressure
airflow
room."
Airborne
precautions
require
a
negative-pressure
airflow
room
that
has
at
least
six
to
12
air
exchanges
each
hour
using
a
HEPA
filtration
system.
A
nurse
is
admitting
a
client
who
has
pneumonia.
The
nurse
should
initiate
which
of
the
following
isolation
precautions
for
the
client?
Droplet
Airborne
Contact
Protective
environment
-
ANS
Droplet The
nurse
should
initiate
droplet
precautions
for
this
client
by
placing
the
client
in
a
private
room
and
wearing
a
surgical
mask
when
caring
for
the
client.
Pneumonia
is
transmitted
by
droplet
particles.
A
nurse
in
a
community
center
is
providing
an
educational
session
to
a
group
of
clients
about
ovarian
cancer .
Which
of
the
following
manifestations
of
ovarian
cancer
should
the
nurse
include
in
the
teaching?
Diarrhea
Urinary
retention
Purulent
discharge
Abdominal
bloating
-
ANS
Abdominal
bloating
The
nurse
should
include
the
presence
of
abdominal
bloating
as
an
early
manifestation
of
ovarian
cancer .
Other
manifestations
include
an
increase
in
abdominal
girth,
pelvic
or
abdominal
pain,
early
satiety ,
and
urinary
frequency
or
urgency .
A
nurse
is
reviewing
the
ABG
values
of
a
client.
The
client
has
a
pH
of
7.2,
PaCO2
of
60
mm
Hg,
and
HCO3-
of
25
mEq/L.
The
nurse
should
identify
that
the
client
has
which
of
the
following
acid-base
imbalances?
Respiratory
alkalosis
Metabolic
alkalosis
Respiratory
acidosis
Metabolic
acidosis
-
ANS
Respiratory
acidosis
A
client
who
has
respiratory
acidosis
will
have
a
decreased
pH
below
the
expected
reference
range
of
7.35
to
7.45,
an
increased
PaCO2
above
the
expected
reference
range
of
35
to
45
mm
Hg,
and
an
HCO3-
within
the
expected
reference
range
of
22
to
26
mEq/L.
C o m p r e h e n s i v e
O n l i n e
P r a c t i c e
2 0 1 9
B
w i t h
N G N
A
nurse
has
just
received
a
change-of-shift
report
on
four
clients.
Which
of
the
following
clients
should
the
nurse
assess
first?
A
client
who
is
postoperative
with
abdominal
distention
and
no
bowel
sounds
A
client
who
has
diabetes
mellitus
and
a
blood
glucose
level
of
105
mg/dL
A
client
who
has
heart
failure
and
2+
pitting
edema
A
client
who
is
receiving
maintenance
IV
fluids
and
needs
a
new
IV
catheter
-
ANS
A
client
who
is
postoperative
with
abdominal
distention
and
no
bowel
sounds
Using
the
acute
vs.
chronic
approach
to
client
care,
the
nurse
should
first
assess
the
client
who
is
postoperative
with
abdominal
distention
and
no
bowel
sounds
because
these
manifestations
are
indications
of
a
paralytic
ileus.
For
each
assessment
finding,
click
to
specify
if
the
finding
is
consistent
with
attention
deficit
hyperactivity
disorder
(ADHD)
or
intellectual
disability
(ID).
Each
finding
may
support
more
than
1
disease
process.
Assessment
Findings
Intellectual
impairment
Interrupting
others
Impaired
language
skills
Hyperreactivity
to
sensory
input
Losing
necessary
things
A
nurse
is
caring
for
a
school-age
child.
Nurses'
Notes
First
visit:
A
child
is
brought
to
the
clinic
accompanied
by
guardians.
The
guardians
have
received
feedback
from
the
child's
teacher
that
the
child
has
become
disinterested
in
schoolwork and
has
difficulty
paying
attention
during
class.
The
child
often
loses
their
school
supplies.
The
guardians
report
that
the
child
demonstrates
these
behaviors
at
home
as
well.
The
child
refuses
to
participate
in
household
chores,
keeps
their
room
untidy ,
does
not
clean
up
when
told
to,
and
is
generally
careless
and
disinterested.
On
assessing,
the
child
is
found
to
be
talkative,
restless,
and
easily
distracted.
2
weeks
later:
The
child's
guardians
report
that
the
child
seems
to
be
doing
better
at
school.
The
child
is
improving
at
paying
attention
during
class
and
completing
assignments
on
time.
Vital
Signs
First
visit:
Blood
pressure
94/56
mm
Hg
Heart
rate
90/min
Respiratory
rate
24/min
Temperature
37.2°
C
(99°
F)
SaO2
99%
on
room
air
2
weeks
later:
Blood
pressure
98/60
mm
Hg
Heart
rate
88/min
Respiratory
rate
22/min
Temperature
37°
C
(98.6°
F)
SaO2
99%
on
room
air
Provider
Prescriptions
Atomoxetine
10
mg
PO
daily
with
breakfast
for
5
days,
then
increase
dose
to
18
mg
PO
daily
with
breakfast
-
ANS
ADHD
Hyperreactivity
to
sensory
input
Losing
necessary
things
Interrupting
others
Intellectual
impairment
ID
Intellectual
impairment
Hyperreactivity
to
sensory
input When
analyzing
cues,
the
nurse
should
identify
that
manifestations
of
ADHD
include
losing
necessary
things,
interrupting
others,
intellectual
impairment,
and
hyper
reactivity
to
sensory
input.
In
ADHD,
the
client
often
loses
necessary
things
in
daily
life,
such
as
pencils,
erasers,
and
books.
The
client
often
interrupts
others
and
has
difficulty
waiting
for
their
turn
in
conversation.
The
client
might
have
an
intellectual
impairment,
which
can
lead
to
poor
academic
performance
and
difficulties
with
socialization.
The
client
might
exhibit
hyperreactivity
or
hyporeactivity
to
stimuli.
A
charge
nurse
is
providing
an
educational
session
about
infection
control
for
a
group
of
staff
nurses.
Which
of
the
following
statements
by
one
of
the
staff
nurses
indicates
an
understanding
of
isolation
precautions?
"Droplet
precautions
should
be
initiated
for
a
client
who
tests
positive
for
measles."
"A
client
who
requires
airborne
precautions
should
be
placed
in
a
negative-pressure
airflow
room."
"Airborne
precautions
should
be
initiated
for
a
client
who
has
Clostridium
difficile."
"A
client
who
is
immunocompromised
should
be
placed
in
a
negative-pressure
airflow
room."
-
ANS
A
client
who
requires
airborne
precautions
should
be
placed
in
a
negative-pressure
airflow
room."
Airborne
precautions
require
a
negative-pressure
airflow
room
that
has
at
least
six
to
12
air
exchanges
each
hour
using
a
HEPA
filtration
system.
A
nurse
is
admitting
a
client
who
has
pneumonia.
The
nurse
should
initiate
which
of
the
following
isolation
precautions
for
the
client?
Droplet
Airborne
Contact
Protective
environment
-
ANS
Droplet The
nurse
should
initiate
droplet
precautions
for
this
client
by
placing
the
client
in
a
private
room
and
wearing
a
surgical
mask
when
caring
for
the
client.
Pneumonia
is
transmitted
by
droplet
particles.
A
nurse
in
a
community
center
is
providing
an
educational
session
to
a
group
of
clients
about
ovarian
cancer .
Which
of
the
following
manifestations
of
ovarian
cancer
should
the
nurse
include
in
the
teaching?
Diarrhea
Urinary
retention
Purulent
discharge
Abdominal
bloating
-
ANS
Abdominal
bloating
The
nurse
should
include
the
presence
of
abdominal
bloating
as
an
early
manifestation
of
ovarian
cancer .
Other
manifestations
include
an
increase
in
abdominal
girth,
pelvic
or
abdominal
pain,
early
satiety ,
and
urinary
frequency
or
urgency .
A
nurse
is
reviewing
the
ABG
values
of
a
client.
The
client
has
a
pH
of
7.2,
PaCO2
of
60
mm
Hg,
and
HCO3-
of
25
mEq/L.
The
nurse
should
identify
that
the
client
has
which
of
the
following
acid-base
imbalances?
Respiratory
alkalosis
Metabolic
alkalosis
Respiratory
acidosis
Metabolic
acidosis
-
ANS
Respiratory
acidosis
A
client
who
has
respiratory
acidosis
will
have
a
decreased
pH
below
the
expected
reference
range
of
7.35
to
7.45,
an
increased
PaCO2
above
the
expected
reference
range
of
35
to
45
mm
Hg,
and
an
HCO3-
within
the
expected
reference
range
of
22
to
26
mEq/L.
