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RN Comp Practice 2023 A WITH 100- SURE ANSWERS
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RN Comp Practice 2023 A WITH 100- SURE ANSWERS
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EUNICERN Comp Practice 2023 A WITH 100% SURE ANSWERS
Terms in this set (148)
Temperature: 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.
NGN: What assessment findings are
-If the patient reported there was blood in the stool, it would be UC. Crohn's doesn't
consistent with Crohn's disease, ulcerative
cause tarry stools.
colitis, or peritonitis?
WBC: Crohn's, UC & peritonitis.
Temperature (100F)
-Elevation can occur due to inflammation and infection.
Weight (-9.7 lbs)
Albumin level (2.4)
Heart rate: peritonitis.
WBC (14)
-Tachycardia can occur due to inflammation, infection, and dehydration.
Bowel pattern (freq. loose stools)
Abdominal pain location (RLQ)
Albumin level: Crohn's & UC.
Heart rate (105)
-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.
1/25
,NGN: What assessment findings can Back pain, headache & anxiety.
indicate a transfusion reaction in a patient
receiving blood? Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain,
tachycardia, dyspnea, hypotension.
Urine output (150mL of clear, yellow)
Skin (pale, cool and dry)
Anxiety
Vital signs (within normal range)
Headache
Back pain
NGN: Patient arrives with palpitations, Condition: somatic symptom disorder
difficulty breathing, and reports feeling -due to physical inactivity & joint pain
faint. Reports constipation and joint pain
for x2 days. In childhood, patient Interventions: Monitor physical manifestations & assess for presence of 2nd gains
experienced physical abuse, and from their illness
emotionally detached parents. Reports -disorder is characterized by the presence of other real manifestations like dizziness,
nervousness and only leaving home when nausea, back pain, and joint pain.
necessary.
PMH: freq. hospital visits due to headaches Monitor: Vital signs & pain.
and GI distress.
Bowtie:
NGN: What actions should the nurse take Administer 0.9% NS IV
when her pedi patient is exhibiting Administer epi IM
symptoms of an allergic reaction? Monitor vital signs frequently
DC IV medication
Administer 0.9% NS IV
Administer epi IM -Nurse should DC the Rocephin and give IV NS to help restore fluids because fluid
Monitor urine output q2hrs shifts can occur quickly during a reaction. Administering epi IM is the first line of
DC supplemental oxygen therapy for anaphylactic reactions because it constricts blood vessels and dilates
Monitor vital signs frequently bronchioles. Monitoring vital sings frequently will allow the nurse to monitor for signs
DC IV medication of shock.
Administer thiamine
NGN: What 5 actions should the nurse plan Maintain a low-stimulation environment
to take with a patient experiencing Administer chlordiazepoxide
hallucinations, following alcohol Initiate seizure precautions
withdrawal? Perform a CIWA-Ar
Administer thiamine -Nurse should plan interventions that keep the patient safe and treat the physical
Maintain a low-stimulation environment manifestations of withdrawal. Use the CIWA-Ar to determine the severity of the
Administer chlordiazepoxide withdrawal. Withdrawal seizures can occur 12-24hrs after cessation of alcohol use,
Initiate seizure precautions therefore initiate seizure precautions to prevent injury. Administer chlordiazepoxide
Perform a CIWA-Ar (a benzodiazepine) and place patient in a low-stim environment to decrease
Administer disulfiram agitation and the risk for seizures. Administering thiamine can prevent Wernicke
syndrome.
2/25
, NGN: A post-op patient is experiencing Condition: Varicose veins.
right lower extremity pain and itching, -due to edema & pruritis
following an emergent appy. Reports right
lower extremity pain that has been Interventions: Elevate extremity & apply compression stockings
intermittent for x2 months. -to promote venous return & circulation
Assessment: Bilat lower extremities warm to Monitor: Pruritis & edema
touch, pedal pulses 2+ bilat. Spider veins
noted. Distended veins noted on right
lower extremity. Vital signs are within
normal limits.
Bowtie:
NGN: Which assessment findings require an Involuntary tongue movement and foot tremor
immediate follow-up in a schizophrenic Frequent urination and incontinence
patient? Increase in agitation
Hyperactive bowel sounds x4 -Patient is experiencing tardive dyskinesia
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
A home health nurse is evaluation a school- C. "My child has only a small amount of mucus after percussion therapy."
age child who has cystic fibrosis. The nurse
should initiate a request for a high- -The nurse should recommend a high-frequency vest for a child who has inadequate
frequency chest compression vest in results from other airway clearance therapy techniques. Older children often require
response to which of the following parent other techniques in addition to percussion and postural drainage to achieve
statements? adequate mucus expectoration.
A. "My child doesn't like to sit still for -The nurse should teach the parent techniques for administration for nebulizer
nebulizer treatments." treatments to the child.
B. "I think that my child has been running a
fever over the last couple of days." -The nurse should follow-up on reports of fever, as this could indicate a pulmonary
C. "My child only has a small amount of infection.
mucus after percussion therapy."
D. "I am concerned about my child's future -The nurse should discuss participation in sports activities in relation to the child's
participation in team sports." current physical and pulmonary health.
3/25
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