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RN Comp Practice 2023 A 2024/2025 latest update guaranteed pass
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RN Comp Practice 2023 A 2024/2025 latest update guaranteed pass
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RN Comp Practice 2023 ANGN: 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) - ANSTemperature: 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
Vital signs (within normal range)
Headache
,Back pain - ANSBack 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: - ANSCondition: 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 - ANSAdminister 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?
Administer thiamine
Maintain a low-stimulation environment
Administer chlordiazepoxide
,Initiate seizure precautions
Perform a CIWA-Ar
Administer disulfiram - ANSAdminister 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: - ANSCondition: 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
Family c/o increased agitation and delusions - ANSInvoluntary 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." - ANSC. "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: - ANSCondition: 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.
Monitor: Bowel sounds & urine output.
A nurse is caring for a patient who has a new prescription for clonidine. The nurse should inform
the patient that which of the following findings is an adverse effect of this medication?
A. Diarrhea
B. Dry mouth
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