RN Comprehensive Online Practice 2023 B

Study online at https://quizlet.com/_eegol7

"I should watch for common reactions

A nurse is providing discharge instruc- like dry mouth and constipation."
tions to a client who has a new prescrip-
tion for amitriptyline to treat depression. The nurse should reinforce that increas-
The nurse should identify that which of ing dietary fiber, fluid intake, and chew-
the following client statements indicates ing sugar-free gum can alleviate the anti-
an understanding of the teaching? cholinergic effects of dry mouth and con-
stipation.
A nurse is caring for an adolescent in the
emergency department (ED).

Laboratory Results
Sodium 140 mEq/L (136 to 145 mEq/L)
Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
Chloride 103 mEq/L (98 to 106 mEq/L)
BUN 15 mg/dL (10 to 20 mg/dL) Mag-
nesium 1.5 mEq/L (1.3 to 2.1 mEq/L)
Total calcium 9.5 mg/dL (9 to 10.5
When recognizing cues, the nurse
mg/dL) Phosphate 3.7 mg/dL (3 to 4.5
should recognize that manifestations of
mg/dL) Glucose 80 mg/dL (74 to 106
bacterial meningitis can include fever,
mg/dL) Total protein 7 g/dL (6.4 to
photophobia, nuchal rigidity, petechial
8.3 g/dL) Albumin 4.5 g/dL (3.5 to 5
rash, and impaired consciousness. The
g/dL) WBC count 19,500/mm3 (5,000
adolescent is experiencing these symp-
to 10,000/mm3) Aspartate aminotrans-
toms. Encephalitis is characterized by
ferase (AST) 30 units/L (10 to 40 units/L)
fever, nuchal rigidity, and altered mental
Alanine transaminase (ALT) 20 units/L (4
status. Reye syndrome is characterized
to 36 units/L)
primarily by altered mental status and
impaired hepatic function.
Diagnostic Results
Cerebrospinal fluid examinationPres-
sure: 35 cm H2O (less than 20 cm
H2O) Color: Cloudy (clear and colorless)
Blood: None RBC: 0 (0 cells) WBC total:
120 cells/µL (0 to 10 cells/µL) Protein:
90 mg/dL (15 to 45 mg/dL) Glucose: 20
mg/dL (50 to 75 mg/dL)

Medication Administration Record

1 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
History and Physical
2 months ago:
Client presented to clinic for routine visit.
Client reported feeling tired at times but
getting through the workday and walking
after work. Reported chronic nonproduc-
tive cough. Smokes 1.5 packs of ciga-
rettes per day.
Today, 1030:
Client reports fatigue over the past For each assessment finding noted
several days, spending more time in above, click to specify if the finding is
bed. Reports chronic productive cough expected of pneumonia, COPD, or heart
with blood-tinged sputum this morning. failure.
Smokes 1 pack of cigarettes per day.
Client takes lisinopril 20 mg PO daily, Pneumonia = tobacco use, elevated
atorvastatin 20 mg PO daily. WBC, productive cough w/ sputum, inc
temp, dec O2, resp acidosis
Assessment
2 months ago: COPD = tobacco use, dec O2 sat
Client states, "I sleep in my recliner
and that works great." Skin is warm, HF = tobacco use, BNP level, dec O2 sat
dry. Lungs clear to auscultation. Chron-
ic nonproductive cough. Abdomen soft,
nondistended. Bowel sounds present.
Slight edema in feet bilaterally.
Today, 1030:
Client states, "I can't catch my breath."
Skin pale. Respirations labored. Crack-
les present in left-lower lobe. Coughing
during assessment. Blood
A nurse is caring for a client who is 1 day
postoperative following a total thyroidec-
tomy.

Laboratory Results
0700:
Sodium 143 mEq/L (136 to 145 mEq/L)
Potassium 3.5 mEq/L (3.5 to 5 mEq/L)
Chloride 104 mEq/L (98 to 106 mEq/L )
2 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
BUN 15 mg/dl (10 to 20 mg/dl)
Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L
)
Total calcium 8 mg/dL (9 to 10.5 mg/dL) the client is at highest risk for devel-
Phosphate 4.6 mg/dL (3 to 4.5 mg/dL) oping hypocalcemia as evidenced by
Glucose 95 mg/dL (74 to 106 mg/dL) client's report of muscle spasms, numb-
WBC 9,500/mm3 (5,000 to 10,000/mm3) ness around lips, and dec calcium level.

Nurses' Notes Hypocalcemia is more likely to occur

0700: in clients who have experienced a thy-
Client alert and oriented to person, roidectomy, due to accidental damage
place, and time. Respirations even and to the parathyroid. Numbness around
unlabored with no adventitious sounds. the lips is a clinical manifestation spe-
Bowel sounds active in all 4 quadrants. cific to hypocalcemia. Hypocalcemia pre-
Surgical dressing dry, slight edema at sents as muscle spasms and can lead to
incision site noted. Client rates dull pain cardiac dysrhythmias. Hypocalcemia is
in neck of 2 on a 0 to 10 scale. Declines the highest priority, as it requires imme-
pain medication. diate treatment with calcium gluconate to
1100: avoid dysrhythmias and other complica-
Client alert and oriented to person, tions.
place, and time. Respirations even and
unlabored with no adventitious sounds.
Bowel sounds active in all 4 quadrant
A nurse is caring for a client who has
abdominal pain.

Nurses' Notes
0900:
For each condition, click to specify if the
Client reports loss of appetite, weight
characteristic is consistent with an acute
loss, and fatigue for 1 week. Reports ab-
infection of hepatitis A, hepatitis B, or
dominal pain, 6 on a scale from 0 to 10,
hepatitis C. Each characteristic may sup-
for 2 days. Client is a perioperative nurse,
port more than one disease process.
returned 1 week ago from a 2-week mis-
sion trip to an underdeveloped country.
Manifestations of Hep A, Hep B, & Hep C
1200:
Results of antibody studies obtained.
Provider prescription for antiviral med-
ication pending.

3 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
Physical Examination
0930:
Lung sounds clear bilaterally. Skin warm
to touch and jaundiced. Dry skin noted
on extremities. Sclera yellow bilaterally. = jaundice, yellow sclera, RUQ pain on
Bowel sounds normoactive in four quad- palpation, dark yellow urine, inc AST &
rants. Client reports right upper quadrant ALT levels
pain upon palpation. Urine specimen ob-
tained for urinalysis, dark yellow in color. Hep A = risk from fecal-oral transmission
(recent travel to underdeveloped country
Vital Signs & occupational risk)
0900:
Temperature 36.9° C (98.5° F) Heart rate Hep B & Hep C = bloodborne transmis-
84/min Respiratory rate 18/min Blood sion
pressure 118/78 mm Hg Oxygen satura-
tion 98% on room air Hep B, & C = antiviral medication

Diagnostic Results
1100:
Aspartate aminot
A nurse is caring for a client on a med-
ical-surgical unit.
Click to highlight the findings that require
follow up. To deselect a finding, click on
Vital Signs
the finding again.
0700:
Temperature 37.6° C (99.7° F)
When recognizing cues, the nurse
Heart rate 100/min
should determine that the client's painful
Respiratory rate 22/min
edematous area on their sacrum and
Blood pressure 115/70 mm Hg
that the client has only been repositioned
Oxygen saturation 98% on room air
every 4 hr requires follow up.
Nurses' Notes
The client has manifestations of a pres-
1100:
sure injury that need to be addressed.
Client alert and oriented to person,
The client should be repositioned at least
place, and time. Client had episode of
every 2 hr to prevent worsening of the
diarrhea, provided perineal care. Noted 2
pressure injury and to relieve pressure
cm x 2 cm (0.8 in x 0.8 in) painful edema-
from the sacral area.
tous area on sacrum. Client repositioned
every 4 hr.
4 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7

A nurse is caring for a client who is on

the spinal cord injury (SCI) unit.

Nurses' Notes
Day 3, 1700: The nurse should analyze cues from
Client admitted to SCI unit 3 days ago the client's manifestations and determine
following C7 injury. Skin is cool, pale, and that the client is most likely experiencing
dry to touch. Respirations easy and unla- manifestations of pneumonia and auto-
bored. Lung sounds diminished in lower nomic dysreflexia.
lobes. Abdomen soft and nondistended
with active bowel sounds. Client passed A client who has a cervical SCI is at risk
a small amount of hard formed stool this for respiratory complications because
AM. Indwelling urinary catheter draining spinal innervation to the respiratory mus-
clear yellow urine. Deep tendon reflexes cles is disrupted. Adventitious breath
(DTR) are biceps 1+, triceps 1+, patella sounds in the lower lobes bilaterally and
0, and ankle 0 bilaterally. Client reports a decrease in oxygen saturation to less
pain of 0 on a 0 to 10 scale. than 92% can indicate pneumonia. The
Day 4, 0600: client's sudden increase in blood pres-
Client reports increased coughing and sure, bradycardia, flushing of the skin
shortness of breath. Crackles auscultat- above the area of the injury, headache,
ed in lower lobes bilaterally. Face and and blurred vision are manifestations of
neck flushed. Skin warm and moist. autonomic dysreflexia, which can be a
Client reports blurred vision and a life-threatening condition.
headache as an 8 on a 0 to 10 pain scale.
Abdomen soft and mildly distended. Hy-
poactive bowel sounds present. Urinary
output 300 mL over last 8 hr.
A nurse is caring for a client who is preg-
nant in the acute care setting.

Nurses' Notes
1400:
Client reports a constant low dull back- When prioritizing hypotheses, the nurse
ache and painless abdominal tightening should recognize that magnesium sul-
for the past 3 hr. Denies any changes in
vaginal discharge. External fetal monitor
applied.
1430:
Contraction pattern: contractions every
5 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
4 to 5 min, lasting 30 to 45 seconds,
palpate mild in intensity. Fetal heart rate:
150/min to 155/min, moderate variabil-
ity, adequate accelerations present, no
decelerations noted. Provider in to see
client. Specimen obtained for fetal fi- fate is a central nervous system de-
bronectin. pressant that can affect respirations,
1800: consciousness, and reflexes when tox-
Client sleepy. Difficult to arouse. Respira- ic blood levels occur. Using the airway,
tions slow and shallow. Contraction pat- breathing, circulation priority framework,
tern: contractions every 10 min, lasting the nurse should plan to first take action
30 to 45 seconds, palpate mild in inten- to support respirations, followed by ac-
sity. Fetal heart rate: 140/min, moderate tion to increase the client's level of con-
variability, no accelerations present, no sciousness. The nurse should plan to dis-
decelerations noted. continue the magnesium sulfate infusion
and administer calcium gluconate as an
Vital Signs antidote.
1400:
Temperature 37° C (98.6° F)
Heart rate 72/min
Respiratory rate 20/min
Blood
A nurse is caring for a client who is imme-
diately postoperative following a subtotal
thyroidectomy.

Vital Signs
1100:
Temperature 37.4° C (99.4° F)
Select the 4 client findings that lead the
Heart rate 98/min
nurse to suspect that the client is experi-
Respiratory rate 18/min
encing thyroid storm.
Blood pressure 128/68 mm Hg
Oxygen saturation 97% on room air
1115:
Temperature 37.8° C (100.1° F)
Heart rate 110/min
Respiratory rate 16/min
Blood pressure 138/74 mm Hg
Pulse oximetry 95% on room air
6 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
1130:
Temperature 38.6° C (101.5° F)
Heart rate 136/min
Respiratory rate 16/min
Blood pressure 154/86 mm Hg
Oxygen saturation 95% on 2 L/min via
nasal cannula When analyzing cues, the nurse should
identify that thyroid storm can be caused
Medication Administration Record by trauma to the thyroid gland, such as
1110: surgery, and excessive release of thyroid
Morphine 4 mg IV bolus hormone greatly increases the metabolic
rate. Fever greater than 38.5° C (101.3°
Nurses' Notes F), heart rate greater than 130/min, sys-
1100: tolic hypertension, and mental status
The client is asleep, easily aroused. changes, such as confusion, restless-
Rates pain at incision site as 8 on a scale ness, and sleepiness, are characteristic
of 0 to 10. Portable wound bulb suc- of thyroid storm.
tion device in place with scant serosan-
guinous drainage present. Dressing to
neck dry and intact.
1115:
Client asleep. Arousable with name
called loudly multiple times. Cl
A charge nurse is preparing to admin-
ister 0900 medications and is told by
the pharmacy staff that the medications
D. Inform the nurse manager of the issue
are not available. Medication availability
has been an ongoing problem, and the
The greatest risk to clients is injury
charge nurse has previously discussed
from not receiving medications on time
this issue with the pharmacy staff. which
and developing a medical complication.
of the following actions should they take
Therefore, the priority intervention the
first?
charge nurse should take is to follow the
chain of command and contact the nurse
A. document actual time of med admin
manager.
B. notify risk manager
C. complete incident report
D. Inform the nurse manager of the issue

7 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
0.6 mL
Nurse preparing to admin diazepam 0.3
mg/kg IV bolus to a toddler who weighs Determine whether the amount to admin-
10 kg (22lb) and is experiencing grand ister makes sense. If there are 5 mg/mL,
mal seizure. avail is diazepam solution the prescription reads 0.3 mg/kg, and
for injection 5mg/mL. how many mL the toddler weighs 22 lb, it makes sense
should nurse administer? to administer 0.6 mL. The nurse should
administer diazepam 0.6 mL IV bolus.
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 mm Hg the client is at risk for developing confu-
Oxygen saturation 96% on room air sion due to sodium level
1500:
Temperature 37.2° C (98.9° F) Upon analyzing cues, the nurse should
Heart rate 96/min identify that the client is at risk for confu-
Respiratory rate 20/min sion due to a sodium level that is greater
Blood pressure 100/70 mm Hg than the expected reference range. Hy-
Oxygen saturation 97% on room air pernatremia places the client at risk for a
decreased level of consciousness, falls,
Nurses' Notes and seizure activity. Therefore, the nurse
1500: should monitor the client's level of con-
Client admitted from the ED for dehydra- sciousness and place the client on fall
tion. Client alert and oriented to person, and seizure precautions.
place, and time. Client reports they are
feeling "weak." IV dextrose 5% in water
(D5W) infusing at 100 mL/hr.

Laboratory Results
1400:
Calcium 10.2 mg/dL (9 to 10.5 mg/dL)
Magnesium 1.5 mEq/L (1.3 to 2.1
mEq/L)
8 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
Potassium 4.7 mEq/L (3.5 to 5 mEq/L)
Sodium 150 mEq/L (136 to 145 mEq/L)
1700:
Calcium 9.5 mg/dL (9 to 10.5 mg/dL)
Magnesium 1.5 mEq/L (1.3 to 2.1
mEq/L)
Potassium 4.1 mEq/L (3.5 to 5 mEq/L)
Sodium 16
A nurse is caring for a client who has a
new diagnosis of anorexia nervosa.

Vital Signs
Day 1, 2005:
Temperature 35.3° C (95.5° F)
Heart rate 60/min
Respiratory rate 23/min
Blood pressure 90/55 mm Hg
Oxygen saturation 98% on room air The nurse should first address the
Day 2, 0800: client's electrolyte imbalance, followed
Temperature 36.1° C (97° F) by the client's fear of weight gain.
Heart rate 65/min
Respiratory rate 20/min When analyzing cues, the nurse should
Blood pressure 88/57 mm Hg first address the client's electrolyte im-
Oxygen saturation 98% on room air balance. The client has hypokalemia,
which increases the risk for cardiac ar-
Graphic Record rhythmias. Once the client's medical con-
Day 1, 2005: cerns are addressed, the nurse should
Weight 37.5 kg (82.7 lb) then focus on the underlying psycholog-
Height 162.56 cm (64 in) ical issues behind the eating disorder,
BMI 14.2 such as the client's fear of weight gain.
Day 2, 0800:
Weight 37.4 kg (82.5 lb)
BMI 14.1

Laboratory Results
Day 1, 2030:
Sodium 146 mEq/L (136 to 145 mEq/L)
Potassium 3.3 mEq/L (3.5 to 5 mEq/L)
Chloride 110 mEq/L (98 to 106 mEq/L)
9 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
BUN 21 mg/dL (10 to 20 mg/dL )
Magnesium 1.2 mEq/L (1.3 to 2.1
mEq/L)
Phosphate 2.8 mg/dL (3 to 4.5 mg/dL)
Glucose (casual) 75 mg/dL (74 to 106
mg/dL)
Total protein 5.8 g/dL (6.4 to 8.3 g/dL)
Albumin 3 g/dL (3.5 to 5 g/dL)
Day 2, 0530:
Sodium 150 mEq/L (136 to
Nurses' Notes
Day 1, 1000:
Client presents to the emergency depart-
ment (ED) with right-sided hemiparesis,
lethargy, and aphasia. The client's symp- For each potential provider's prescrip-
toms started 1 hr prior to arrival at the tion, click to specify if the potential pre-
ED. Client received fibrinolytic therapy scription is anticipated or contraindicated
and was transferred to the ICU. for the client.
Day 2, 0800:
Client is awake and alert to per- When generating solutions, the nurse
son, place, and time. Client has weak should identify that oxygen therapy, mon-
right-side hand grasp. However, this is itoring blood glucose, and keeping lights
improved from admission. Client to be in the client's room dim are anticipat-
evaluated by speech therapy due to ed prescriptions. The client is exhibit-
aphasia. ing manifestations of increased intracra-
Day 2, 1930: nial pressure (ICP). Therefore, the nurse
Called to the client's room by a family should titrate oxygen therapy to maintain
member. Client is lethargic and restless, the oxygen saturation level above 95%
oriented to person and place. Client re- and avoid hypoxia. The nurse should fre-
ports headache. The client's family mem- quently monitor the client's vital signs
ber also reports that the client just vom- and blood glucose to avoid secondary
ited in an emesis basin. Client's speech brain injury. The nurse should also dim
is slurred. the lights in the client's room, because
many clients who have increased ICP
Vital Signs experience photophobia.
Day 1,1000:
Temperature 37.2° C (99° F)
Heart rate 114/min
Blood pressure 184/88 mm Hg
10 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
Respiratory rate 24/min
Oxygen saturation 97% on 2 L via nasal
cannula
Day 2, 0800:
Temperature
A nurse is caring for an adolescent in the
emergency department (ED).
The nurse is reviewing the adolescent's
Nurses' Notes electronic medical record (EMR). Which
0700: of the following findings requires immedi-
Adolescent admitted to ED. Adolescent's ate follow up by the nurse?
parents are concerned about left leg in-
jury that appears to be getting worse. the nurse should identify that the ado-
Parents report adolescent has had fever, lescent has a potential skin infection,
decreased appetite, and decreased en- such as cellulitis. The skin assessment
ergy within the past 2 days. Adolescent reveals that the medial lateral aspect of
reports leg injury occurred while playing the left leg has a 3 x 3 cm2 area of
soccer. redness with small pustules, tenderness,
0715: and warmth, which can indicate infection.
Adolescent is alert and oriented to per- The adolescent's temperature and WBC
son, place, time, and situation. Adoles- count are above the expected reference
cent reports left lower leg pain as 4 on a range, which can also indicate infection.
scale of 0 to 10.Heart rate regular. Capil- The adolescent's casual blood glucose
lary refill less than 3 seconds. Respira- and potassium are above the expected
tions even, unlabored. Lungs clear an- reference range, which can indicate in-
terior/posterior. Abdomen soft, nondis- fection or a complication of type 1 dia-
tended. Bowel sounds hyperactive in all betes mellitus. The nurse should immedi-
4 quadrants. Pedal pulses +2 bilaterally. ately follow up on these findings because
Medial lateral aspect of left lower leg: 3 they can indicate infection or other com-
x 3 cm2 area of redness with small pus- plications.medial-lateral
tules present. Tenderness and warmth
noted to the area.

A nurse is caring for a client who is

postoperative following coronary artery
bypass surgery (CABG).

Laboratory Results
0630:
11 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
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)
The nurse should analyze cues to de-
I&O termine the client is at greatest risk for
0700: developing dysrhythmias related to hy-
4 hr input 400 mL4 hr output 350 pokalemia, as evidenced by the labo-
mL1100: ratory report and the client's report of
4 hr input 475 mL4 hr output 360 muscle cramping. Potassium and mag-
mL1500: nesium depletion are common manifes-
4 hr input 350 mL4 hr output 375 mL tations in clients who are postoperative
following CABG. Due to medication or
Vital Signs hemodilution, it is important for the nurse
0700: to closely monitor electrolytes.
Temperature 37.6° C (99.6° F)Heart
rate 86/minRespiratory rate 20/minBlood
pressure 115/70 mm HgOxygen satura-
tion 100% on 2 L via nasal cannula
1100:
Temperature 37.2° C (99° F)Heart
rate 88/minRespiratory rate 18/minBlood
pressure 110/72 mm HgOxygen satura-
tion 100% on 2 L via nasal cannula1500:
Temperature 37.7° C (99
A nurse is caring for a client who is preg-
For each discharge instruction, click to
nant.
specify if each action is recommended or
contraindicated for the client.
Nurses' Notes
1000:
When taking action and providing dis-
The client reports repeated episodes of
charge teaching for a client who has hy-
vomiting and two episodes of diarrhea
peremesis gravidarum, the nurse should
in past 24 hr. Client is at 18 weeks of
12 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
gestation and reports a history of nausea recommend the client should eat every 2
and vomiting for the past 12 weeks.1015: to 3 hr to avoid having an empty stom-
IV fluids initiated. Prochlorperazine ach, which can increase nausea. The
administered via intermittent IV bo- client should separate liquids from solids
lus.1100: every 2 to 3 hr to help minimize nausea.
Client reports improvement in nausea. The client should eat foods high in pro-
Ice chips provided. Client voided 50 mL tein that are low in fat. Warm ginger ale
of dark yellow urine.1500: or ginger tea can also decrease nausea.
Client tolerating fluids well. Ate four gra-
ham crackers without emesis. Has void- contraindicated = increase intake of high
ed 300 mL of amber-colored urine. fat foods
I will make sure my child receives a year-
ly influenza immunization
the nurse is providing edu to the parent
of a school age child with asthma. which
Children who have asthma should be im-
of the following statements by the parent
munized and protected from infections.
indicates an understanding of the teach-
Therefore, the nurse should educate the
ing?
parent to ensure the child receives a
yearly influenza immunization.
the new nurse writes detailed notes while
a charge nurse is observing a newly li- performing the HTTA
censed nurse performing a physical as-
sessment on a client. which of the follow- The newly licensed nurse should record
ing actions by the nurse indicates that brief notes during the assessment to
the charge should intervene? avoid delays and write more detailed
notes after completing the assessment.
Upper chest petechiae
-The nurse should reposition the client or
check the weights to relieve the client's
muscle spasms. However, another find-
ing is the priority.

-The nurse should provide analgesia to

relieve the client's moderate pain level.
However, another finding is the priority.

-The greatest risk to this client is organ

damage from fat embolism syndrome, a
13 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
life-threatening complication of fractures.
In fat embolism syndrome, a fat embolus
enters the blood stream and can obstruct
blood vessels of a major organ, such
as the lung, kidney, or brain. Manifesta-
tions include petechiae on the upper tor-
a nurse is assessing a client who has
so, dyspnea, hypoxia, headache, lethar-
a skeletal traction for a femur fracture.
gy, and confusion. Therefore, the nurse
which of the following findings should the
should identify this as the priority finding.
nurse identify as the priority?
-The nurse should identify ecchymosis
over the fractured area as an expected
finding due to localized trauma and pro-
vide comfort measures. However, anoth-
er finding is the priority.
When taking actions for a client who
is postoperative following a laparoscopic
A nurse is caring for a client following a
cholecystectomy, the nurse should antic-
laparoscopic cholecystectomy.
ipate prescriptions for the client to ap-
ply heat for abdominal pain as need-
Nurses' Notes
ed, to encourage deep breathing, and to
1030:
change the dressing when soiled. The
33-year-old client is 1 hr postoperative
client can use heat for abdominal pain re-
following a laparoscopic cholecystecto-
lated to carbon dioxide retention. During
my. Alert and oriented to person, place,
the procedure, carbon dioxide is inflated
and time. Skin warm and dry. Lungs clear
into the abdominal cavity for visualiza-
auscultated throughout all lung fields.
tion for the provider. The client's dress-
Normal sinus rhythm. Client denies nau-
ing should be changed when soiled as
sea and vomiting, bowel sounds hypoac-
needed. The dressing should be clean,
tive in all four quadrants. Peripheral puls-
dry, and intact to prevent infection. The
es +2 bilaterally. Incision dressing clean
nurse should identify that medication for
and dry, incision intact upon inspection,
nausea should be provided as needed
no redness, swelling, or drainage noted.
and is contraindicated for scheduled ad-
ministration.

A nurse is assessing a newborn who is

3 days old.
History and Physical
Newborn was delivered at 37 weeks of
14 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
gestation via cesarean section for fetal
distress.Apgar scores: 8 at 1 min and 9 at
5 min.Birth weight: 2.9 kg (6 lb 6 oz)The
client who gave birth plans to breastfeed.
Flow Sheet
Day 2 of Life, 0900:
When recognizing cues, the nurse
Temperature 36.7° C (98.1° F)Heart rate
should identify that a temperature of
140/minRespiratory rate 48/minWeight
36.4° C (97.5° F) is below the expect-
2.7 kg (6 lb); 6% weight lossDay 3 of Life,
ed reference range. Hypothermia can
0800:
lead to the occurrence of hypoglycemia
Temperature 36.4° C (97.5° F)Heart rate
and respiratory distress. The newborn
140/minRespiratory rate 48/min Weight
breastfeeding for short intervals, nipple
2.5 kg (5 lb 9 oz); 12% weight loss
discomfort, and a weight loss of greater
Nurses' Notes
than 10% of birth weight can indicate
Day 3 of Life, 0800:
inadequate transfer of breastmilk, which
Skin color consistent with newborn's
can result in hypoglycemia. The pres-
genetic background. Respirations easy
ence of mild tremors can be a manifes-
and unlabored. Abdomen soft with active
tation of hypoglycemia.
bowel sounds. Mild tremors noted when
awake. Anterior fontanel level and soft.
Large ecchymotic caput succedaneum
noted on posterior scalp. Small amount
of bloody mucus discharge noted from
vagina. Breastfeeding every 3 to 5 h
actions:
avoid cervical exam & insert large bore
IV catheter
experiencing:
abruptio placentae
A nurse on an antepartum unit is caring
parameters to monitor:
for a client who is at 33 weeks of gesta-
BP & Platelet count
tion.
The nurse should avoid cervical exami-
Diagnostic Results
nation and insert a large-bore IV catheter
WBC count 9,800/mm3 (5,000 to
because the client is most likely experi-
encing abruptio placentae indicated by
the sudden onset of abdominal pain,
contractions, and dark red vaginal bleed-
ing. Cervical examination can cause fur-
15 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
ther damage to the placenta and in-
crease bleeding. The nurse should im-
mediately establish IV access with a
large-bore catheter to administer IV flu-
10,000/mm3)Hgb 13 g/dL (greater ids and blood products if bleeding in-
than 11 g/dL)Hct 41% (greater creases or if manifestations of fetal dis-
than 33%)Platelet count 170,000/mm3 tress occur.
(150,000 to 400,000/mm3)BUN 20 The nurse should monitor the client's
mg/dL (10 to 20 mg/dL)Lactate dehy- blood pressure and platelet count be-
drogenase (LDH) 80 units/L (100 to cause of the risk of significant blood loss
190 units/L)Aspartate aminotransferase due to the abruption. Hemorrhage might
(AST) 18 units/L (0 to 35 units/L) Ala- not be visible as vaginal bleeding if it
nine aminotransferase (ALT) 19 units/L is concealed between the placenta and
(4 to 36 units/L)Uric acid (serum) uterine wall. Therefore, manifestations
5.4 mg/dL (2.7 to 7.3 mg/dL)Klei- of hypovolemic shock (decreasing blood
hauer-Betke (fetal hemoglobin test) 3% pressure, increasing heart rate) can pro-
(less than 1%)Blood type: ARh: posi- vide indications that internal placental
tiveUrine reagent stripGlucose: nonepH: bleeding is worsening. Abruptio placen-
6Specific gravity: 1.020Ketones: noneN- tae can also lead to alterations in coag-
itrates: noneLeukocyte esterase: nega- ulation, such as disseminated intravas-
tiveProtein: negativeNitrites: none cular coagulation, further increasing the
client's risk for hemorrhage. Therefore,
the nurse should monitor the client's
platelet count to identify if the client is at
an increased risk for bleeding.
Blowing bubbles with liquid soap to "blow
the hurt away"
when caring for a child, a nurse plans to
use nonpharmacological interventions to
Having the child blow bubbles is a visu-
enhance the effectiveness of pain meds.
alization technique that can help to de-
which of the following strategies incor-
crease the child's discomfort. The child
porates visualization techniques to help
can visualize the pain as the bubble that
dec the child's discomfort?
they blow away from themself and into
the air.

When taking actions, the nurse should

A nurse is caring for a client in the emer-
administer IV fluids, use humidification
gency department (ED).
with oxygen therapy, and assess the
client's mouth every 8 hr and peripheral
16 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
circulation hourly. Hydration is a priority
Nurses' Notes when caring for a client in sickle cell crisis
0600: because it decreases the rate of cell sick-
Client admitted to the ED with fatigue, ling and can reduce pain. Hypotonic flu-
shortness of breath, and weakness for ids are typically infused at 250 mL/hr for 4
the last 2 days. Client states that they hr. Oxygen administered without humidi-
have a history of sickle cell disease fication can cause drying of the mucous
(SCD). Client is alert and orientated to membranes, especially in clients who are
person, place, and time. Restless. Client already fluid-depleted. Placing humidifi-
rates generalized pain as a 9 on a scale cation on the oxygen therapy promotes
of 0 to 10. Vital signs taken and blood comfort and reduces the risk of sores
drawn for laboratory tests. Oxygen 2 L and lesions of the mucous membranes.
via nasal cannula applied. Awaiting pre- The nurse should assess the client's pe-
scription for pain management. ripheral circulation because of the risk of
0615: venous occlusion caused by the sickling
Client still rates pain as a 9 on a scale of and clumping of the red blood cells and
0 to 10. Hydromorphone 4 mg IV admin- assess the client's mouth at least every
istered. 8 hr for the presence of sores or lesions
and any other signs of infection.
A nurse in an outpatient mental health
clinic is caring for a client.

Nurses' Notes
3 months ago:
Client recently admitted with new diag- When recognizing cues, the nurse
nosis of schizophrenia. Received inpa- should identify that the findings of rest-
tient treatment for 10 days and was dis- lessness, auditory hallucinations, and
charged 1 week ago. Client is alert and pressured speech require immediate fol-
oriented to person, place, time, and sit- low up. These findings are indications
uation. Responds appropriately to ques- of psychosis. The nurse should notify
tions. Client reports sleeping well and the provider for additional evaluation and
working at a local retail store.Today: treatment.
Client presents for follow-up visit. Pres-
sured speech noted. Appears to be lis-
tening to unseen others. Client is rest-
less. Frequently getting out of chair. Ap-
pears tired and disheveled.

17 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
A nurse is caring for a 1-month-old infant.

Nurses' Notes
1500:
Infant admitted to the pediatric unit. Par-
ent reports infant has been irritable and
has vomited after each feeding within the
When prioritizing hypotheses and using
last 3 days.Infant alert, not crying. S1
the urgent vs. nonurgent priority frame-
and S2 noted without murmurs. Lungs
work, the nurse should identify that the
clear to auscultation anterior/posterior.
infant is at the greatest risk for devel-
Respirations even, unlabored. Abdomen
oping dehydration due to a loss of gas-
firm. Bowel sounds hypoactive in all 4
tric content from vomiting. An infant with
quadrants. Small 1 x 1 cm2 mass palpat-
pyloric stenosis presents with projec-
ed near umbilicus. Skin warm and dry,
tile vomiting after feeding, distended ab-
turgor with tenting.
domen, and olive-shaped mass in the
1600:
epigastrium.
Called to room by parent. The client who
gave birth attempted breastfeeding. In-
fant projectile vomited. No bile noted in
vomit. Some blood-tinged vomitus noted.
Instructed parent to keep child NPO.
1800:
Infant crying. Soothed with pacifier.
A nurse is caring for a client who is post-
operative following an appendectomy.

Nurses' Notes
1800:
When recognizing cues, the nurse
Client alert and oriented to person,
should identify that the findings of pain,
place, time, and situation.Skin warm
nausea, heart rate, and oxygen satura-
and dry.Lungs clear on auscultationBow-
tion are unexpected findings for a client
el sounds hypoactive in all four quad-
who is postoperative following an appen-
rants.Urine clear yellowIncisional dress-
dectomy. These findings should be re-
ing clean and dry.Client reports pain as
ported to the provider.
6 on a scale of 0 to 10.
1815:
Morphine administered as prescribed.
2000:
Client reports abdominal pain as 10 on a
18 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
scale of 0 to 10.Client reports nausea, no
vomiting.Incisional dressing is dry and
intact with no breakthrough bleeding not-
ed.Lung sounds are clear to ausculta-
tion.Hypoactive bowel sounds present in
all four quadrants.
A nurse is caring for a 5-year-old child.

Physical Examination
1510:
Upon visual inspection, throat is in-
flamed, tonsils appear pink, reddened
The nurse should anticipate initiating
and epiglottis is edematous and cherry
droplet precautions and requesting a
red in appearance. Skin appears pale.
prescription for IV antibiotics. The child
Stridor noted upon inspiration with dimin-
is most likely experiencing epiglottitis be-
ished bilateral lung sounds.
cause of the clinical manifestations of
1500:
a high fever, inflammation and redness
Child accompanied to emergency de-
of the throat, pale skin, stridor with in-
partment by caregiver. Caregiver states
spiration, painful swallowing, no cough,
child has a sore throat and reports the
is sitting in tripod position, and drooling.
child has "pain on swallowing" and de-
The nurse should monitor the child's tem-
nies cough. Child is agitated and leaning
perature and breath sounds.
forward with drooling noted.
1505:
Axillary temperature 38.8° C (102°
F)Heart rate 130/minRespiratory rate
28/minBlood pressure 99/58 mm
HgOxygen saturation 90% on room air

Upon recognizing and analyzing the

A nurse is caring for a client who is
client cues of tachycardia, tachypnea,
postoperative following administration of
hypotension, and irregular heart rhythm,
general anesthesia.
the nurse's priority hypothesis should be
that this client is most likely experienc-
Vital Signs
ing malignant hyperthermia and that it is
0830:
important to generate solutions and take
Temperature 36.9° C (98.5° F)Heart
actions that will correct dysrhythmias,
rate 134/minRespiratory rate 28/min-
provide oxygen to tissues, correct elec-
Blood pressure 92/52 mm HgOxygen
trolyte imbalances, and reverse meta-
19 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
bolic and respiratory acidosis. Therefore,
saturation 89% on room air
the nurse should prepare to administer
Nurses' Notes
dantrolene and administer oxygen. The
0830:
nurse should monitor the PCO2 level on
Client is postoperative following an in-
the client's ABGs for hypercapnia and
guinal hernia repair.Apical pulse 134/min
observe the client for muscle rigidity of
and irregularClient reports dyspnea.
the jaw and chest muscles.
Upon recognizing and analyzing the
client cues of decreased responsive-
ness, muscle rigidity, posturing, di-
aphoresis, and vital signs that are out-
side the expected reference ranges, the
nurse's priority hypotheses should be
that this client is most likely experiencing
A nurse in an emergency department
neuroleptic malignant syndrome, which
(ED) is assessing a client.
is related to the client's haloperidol ther-
apy. It is important to generate solu-
Medical History
tions and take actions that will decrease
1030:
the client's temperature, blood pressure,
Diagnosed with schizophrenia 2 years
heart rate, and respiratory status, which
ago Migraine headaches Unrespon-
will improve the client's neurological sta-
sive to second-generation medications
tus. The nurse should hold the client's an-
(clozapine and risperidone), changed
tipsychotic medications and apply a cool-
to first-generation medication 6 months
ing blanket to reduce the client's temper-
agoCurrent medications:
ature. Neuroleptic malignant syndrome
Haloperidol 5 mg PO TIDSumatriptan 50
is a life-threatening condition. Therefore,
mg PO every 2 hr PRN headache
the nurse should monitor the client's lab-
oratory and arterial blood gas values as
multiorgan failure can occur. To evaluate
interventions and track the client's condi-
tion, the nurse should monitor the client's
temperature, hydration status, and pro-
vide for early detection of complications.

a nurse is caring for a newborn immedi-

ately after delivery. which of the follow- C
ing interventions should the nurse imple- Heat loss by conduction is a loss of
ment to prevent heat loss by conduction? heat between the newborn's skin and the
A. dry immediately after birth
20 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
B. maintain ambient room temp of 24
degrees cooler surfaces beneath it. Using a pro-
C. use protective cover on the scale tective cover prevents contact with the
when weighing scale, which prevents the loss of heat
D. place bassinet away from outside win- through conduction.
dows
a home health nurse is caring for a group
of older adults. the nurse should initiate a
referral to a program of all-inclusive care
for the elderly (PACE) for which client? D
A. client whose family requests hospi- The nurse should initiate a referral for
tal-based hospice care PACE for this client because PACE pro-
B. client who requires transfer to a skilled vides adult day care services along with
care facility in-home assessments and supportive
C. client who qualifies for telehealth for services.
pacemaker diagnostics
D. client whose caregiver requests adults
day care services
a nurse is assessing a client following a
vaginal delivery and notes heavy lochia
and boggy fundus. which of the following C. oxytocin
meds should the nurse expect to admin-
ister? The nurse should administer oxytocin, a
A. Nalbuphine hormone that stimulates uterine contrac-
B. terbutaline tions, to decrease vaginal bleeding.
C. oxytocin
D. mag sulfate

A nurse is planning to delegate client

care tasks to assistive personnel. which
C
of the following tasks should the nurse
plan to delegate?
The nurse should delegate providing
A. provide instructions about client care
gastrostomy feedings through the client's
to a family member over the phone.
established gastrostomy tube to an AP
B. determine if the PRN pain med admin-
because this task is within the AP's range
istered 30 mins ago has helped
of function.
C. perform gastrostomy feedings through
a clients gastrostomy tube.
21 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
D. teach a client how to measure their
own BP
a charge nurse is observing a new nurse
adminstering enteral feedings via NG
tube. which of the following actions by the
new nurse indicates an understanding of
D
the procedure?
A. Instills 100 mL of air into the NG tube
The nurse should keep the client's head
after checking for residual
elevated to 30° to 45° for 1 to 2 hr after
B Flushes the NG tube with 0.9% sodium
feedings to decrease the risk for aspira-
chloride irrigation every 2 hr
tion.
c. Adds 20 mL of blue dye to each feed-
ing to help detect aspiration
D. Keeps the head of the bed elevated to
45° for 1 hr after feedings
A nurse is teaching a pt who has opioid
use disorder about methadone. which
of the following information should the
nurse include in the teaching? C
A. "If you suspect you are pregnant, stop
taking this medication." Sedation and drowsiness are common
B. "You cannot become physically de- adverse effects of methadone. Sedation
pendent on this medication." most frequently occurs at the beginning
C. "Sedation is a common adverse effect of treatment or during dosage increases.
of this medication."
D. "If you forget a dose, you can double
your next dose."
A nurse is interviewing a pt who is now
without a home due to a natural disaster.
After ensuring the client's safety, which D
of the following actions should the nurse The first action the nurse should take
take first? using the nursing process is to assess
A. Assist the client with contacting indi- the client. Therefore, the nurse should
viduals from the client's support system. first determine the client's feelings and
B. Give the client information about avail- understanding of the natural disaster and
able community resources for shelter. its personal impact.
C. Suggest the client obtain mental
health counseling.
22 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
D. Determine the client's perception of
the personal impact of the crisis.
A mental health nurse is conducting the
first of several meetings with a client
whose partner recently died. The nurse
should perform which of the following ac-
tions to establish trust during the orien-
tation phase of the nurse-client relation- D. Establish the termination date of ther-
ship? apy.

A. Encourage the client's problem-solv- This task occurs in the orientation phase
ing abilities. of a therapeutic relationship.
B. Discuss the client's previous experi-
ence with loss.
C. Promote the client's self-esteem.
D. Establish the termination date of ther-
apy.
B
A nurse is reviewing the ABG results of
a client who has COPD. The results in-
A pH of 7.3 is below the expected refer-
clude a pH of 7.3 (7.35 to 7.45), PaO2
ence range and indicates the client has
56 mm Hg (80 to 100 mm Hg), PaCO2
acidosis. A PaCO2 of 54 mm Hg is above
54 mm Hg (35 to 45 mm Hg), HCO3-
the expected reference range, which in-
26 mEq/L (21 to 28 mEq/L), and SaO2
dicates the acidosis has a respiratory ori-
87%. Which of the following is the correct
gin when combined with the low pH. The
interpretation of these values?
HCO3- of 26 mEq/L is within the expect-
A. Uncompensated metabolic acidosis
ed reference range, indicating that the
B. Uncompensated respiratory acidosis
acidosis is not metabolic in origin and the
C. Compensated respiratory acidosis
body has not yet corrected the imbalance
D. Compensated metabolic acidosis
through compensation.
A nurse is providing teaching to a client
who has a new diagnosis of type 1 dia-
A
betes mellitus. The nurse should instruct
the client to monitor for which of the
The nurse should instruct the client to
following findings as a manifestation of
monitor for irritability, which can indicate
hypoglycemia?
decreased blood glucose levels.
A. Irritability
B. Increased urination
23 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
C. Vomiting
D. Facial warmth
C. Place the skin barrier over the stoma
and hold it for 30 seconds.

The nurse should activate the adhesive

A nurse is providing colostomy care
in the skin barrier by holding it in place
for a client using a two-piece pouching
over the stoma for 30 seconds.
system. Which of the following actions
should the nurse take?
INCORRECT:
A. Cleanse the skin at the stoma site with
The nurse should cleanse the skin at the
povidone-iodine for 15 seconds.
stoma site using a washcloth and warm
B. Dampen the skin before applying the
water to reduce the risk of skin irritation.
skin barrier and ostomy pouch.
The nurse should thoroughly dry the skin
C. Place the skin barrier over the stoma
around the stoma using a patting motion
and hold it for 30 seconds.
before applying the skin barrier to ensure
D. Cut the skin barrier opening 0.6 cm
the pouch adheres to the client's skin.
(0.24 in) larger than the stoma.
The nurse should cut the skin barrier
opening no more than 0.3 cm (0.12 in)
larger than the stoma to reduce the risk
of skin irritation.
A nurse in a provider's office is assess-
ing an adolescent who has been taking
ibuprofen for 6 months to treat juvenile
idiopathic arthritis. Which of the following
B
questions should the nurse ask to as-
sess for an adverse effect of this medica-
The nurse should ask the client about
tion?
the presence of stomach pain or bloody
A. "Have you experienced muscle stiff-
stools, which is an indication of gastroin-
ness?"
testinal bleeding, an adverse effect of
B. "Have you had any stomach pain or
ibuprofen.
bloody stools?"
C. "Have you experienced a dry cough?"
D. "Have you noticed an increase in urine
output?"
A nurse is developing a client educa- D
tion program about osteoporosis for old-
er adult clients. The nurse should include A sedentary lifestyle is a risk factor for
24 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
which of the following variables as a risk
osteoporosis. The nurse should encour-
factor for osteoporosis?
age older adult clients to engage in
A. obesity
weight-bearing exercises because they
B. acromegaly
will promote bone health by increasing
C. estrogen dominance
calcium and phosphorus levels.
D. sedentary lifestyle
A nurse is caring for a toddler who is
admitted to the pediatric unit for surgery.
Which of the following should the nurse
include in the toddler's plan of care? A
A. Encourage the parents to bring toys
from home. To help decrease the toddler's anxiety,
B. Use a visual analog scale to rate the the nurse should encourage the family to
toddler's pain. bring familiar objects from home, such as
C. Inform the toddler about the proce- toys, blankets, and feeding utensils.
dure 1 week before hospitalization.
D. Stress to the parents the need for
maintaining the hospital's daily routine.
A nurse is administering 1 unit of packed
RBCs to a client. The client becomes
anxious and reports shortness of breath
A
and urticaria 15 min after initiation of
the transfusion. Which of the following
The nurse should recognize that the
actions should the nurse take?
client is experiencing an anaphylactic re-
A. Prepare to administer epinephrine to
action to the blood transfusion. There-
the client.
fore, the nurse should prepare to admin-
B. Decrease the rate of the client's trans-
ister epinephrine to the client to alleviate
fusion.
manifestations of anaphylaxis.
C. Obtain a culture of the client's blood.
D. Anticipate administering diuretics to
the client.
A nurse is providing discharge instruc-
tions to a client following a total hip C
arthroplasty. Which of the following in-
structions should the nurse include? The client should use a raised toilet seat
A. Minimize the use of a walker. at home to minimize hip flexion and pre-
B. Maintain the hip at an angle greater vent hip dislocation.
than 90°.
25 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
C. Install a raised toilet seat at home.
D. Place a pillow under the knees when
lying down.
Place the BP cuff in a labeled bag to send
it for decontamination.
A nurse is caring for a client who vomits
on a reusable BP cuff. Which of the fol- The nurse should place the BP cuff in a
lowing actions should the nurse take? labeled bag before removing it from the
client's room and sending it to the proper
facility location for decontamination.
A nurse is assessing a school-age child
who has bacterial meningitis. Which of
Nuchal rigidity
the following findings should the nurse
expect?
A nurse at an urgent care clinic is as-
sessing a client who reports impaired
vision in one eye. Which of the following
Floating dark spots
reports by the client should indicate to
the nurse that the client has a detached
retina?
"The enlarged uterus compresses the in-
testines and causes constipation."
A nurse is caring for a client who is at
28 weeks of gestation. The client asks During the second and third trimesters,
the nurse to explain what is causing the the size and weight of the growing uterus
constipation. Which of the following re- cause both displacement and compres-
sponses should the nurse make? sion of the intestines. These changes
cause a decrease in motility, leading to
constipation.
Performing a rapid needs assessment

A community health nurse is assisting Disaster management includes preven-

with the development of a disaster man- tion, preparedness, response, and re-
agement plan. The nurse should include covery stages. The nurse should perform
which of the following nursing responsi- a rapid needs assessment during the
response phase of the disaster cycle.
A rapid needs assessment allows the
26 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
nurse to identify the severity of the inci-
bilities in the disaster response stage of dent, the health needs of the community,
the plan? and the priority actions needed during
the response stage.
Dyspnea

A client is receiving IV fluids at 150 The nurse should recognize that dysp-
mL/hr. Which of the following findings nea indicates the client could be experi-
indicates that the client is experiencing encing fluid overload. Fluid overload can
fluid overload? lead to the backup of fluid in the pul-
monary system, resulting in shortness of
breath.
"I have not vomited as much recently."
A clinic nurse is caring for a client who
is in the first trimester of pregnancy. The
Using an acupressure band on the wrists
client reports using acupressure bands
is a type of complementary and alterna-
on both wrists. Which of the following
tive therapy that applies pressure to a
statements by the client indicates that
specific part of the body and can be used
this therapy is having the desired effect?
to alleviate nausea and vomiting.
Occlusive dressing on the insertion site
A nurse is assessing a client who has a
chest tube. Which of the following find- An occlusive dressing on the insertion
ings should the nurse expect? site prevents air from leaking and is an
expected finding.
Ask the client to point to items on a pic-
A nurse is caring for a client who has ture menu.
sensorineural hearing loss and is helping
them choose items for their meal tray. The nurse should recognize that using
Which of the following techniques should visual aids can help the client communi-
the nurse use to help the client commu- cate their meal choices. The use of a vi-
nicate their choices? sual aid, like a picture menu, can ensure
the client understands the meal choices.
A nurse is providing teaching to a par- When teaching the parent to provide tra-
ent of a child who has a permanent tra- cheostomy care, the nurse should in-
cheostomy tube. Identify the sequence of struct the parent to first
steps the parent should follow to perform
tracheostomy care. (Move the steps into 1. remove the inner cannula.
27 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
2. remove the soiled dressing.
the box on the right, placing them in the
3. clean the stoma with 0.9% sodium
selected order of performance. Use all
chloride irrigation.
the steps.)
4. change the tracheostomy collar.
A client who is confused and has been
attempting to get out of bed
A nurse is caring for four clients at
the beginning of a shift. After receiving
The nurse should recognize that a client
change-of-shift report, which of the fol-
who is confused and has been attempt-
lowing clients should the nurse attend to
ing to get out of bed is at greatest risk
first?
for injury from a fall. Therefore, the nurse
should attend to this client first.
"I would like to talk to you about the unit
policies regarding break time."
A charge nurse notices that one of
the nurses on the shift frequently vio-
The charge nurse is dealing with the con-
lates unit policies by taking an extended
flict in a cooperative, positive manner by
amount of time for break. Which of the
using this statement to open the conver-
following statements should the charge
sation in a nonthreatening way. The focus
nurse make to address this conflict?
is on the length of the break time and is
not a personal affront.
Verify the client and blood product infor-
mation with another licensed nurse.
A nurse is preparing to administer a
blood transfusion to a client. Which of the The nurse should compare the blood
following procedures should the nurse product label against the medical record
follow to ensure proper client identifica- and the client's identification number
tion? with another nurse to ensure the correct
blood product is administered to the cor-
rect client.
Difficulty performing ADLs
A nurse on a medical-surgical unit is as-
sessing a client who has had a stroke. The nurse should initiate a referral for oc-
For which of the following findings should cupational therapy to teach the client the
the nurse initiate a referral for occupa- skills necessary to become independent
tional therapy? in performing ADLs such as bathing,
dressing, or eating.

28 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7

Instruct the client to void.

A nurse is preparing a client for a para- The nurse should instruct the client to
centesis. Which of the following actions void prior to the procedure because an
should the nurse take? empty bladder decreases the risk of
a bladder puncture and minimizes the
client's discomfort during the procedure.
A nurse is planning care for a client who Auscultate the affected extremity for a
is receiving hemodialysis via an estab- bruit.
lished arteriovenous (AV) fistula in the
right arm. Which of the following inter- The nurse should auscultate the AV fistu-
ventions should the nurse include in the la every 4 hr to ensure a bruit is present,
client's plan of care? which indicates patency.
Allow the client time for reflection and
decision making.

A nurse is caring for a client who has be- The nurse should allow the client silence
come aggressive and potentially violent. and time to reflect on what is occurring as
Which of the following actions should the well as what decision they would like to
nurse take? make moving forward. Clients might feel
more stressed if they feel they are being
rushed, which can increase the chance
of violent behavior.
Lack of remorse
A nurse is assessing a client who has
antisocial personality disorder. Which of
A client who has antisocial personality
the following manifestations should the
disorder is more likely to show a lack of
nurse expect?
remorse.
A nurse is teaching a client who has a
new prescription for total parenteral nu-
trition through a central line. Which of the "I will need to measure your weight daily."
following information should the nurse
include in the teaching?
Avoid including raw fruits in the client's
A nurse is planning care for a client
diet.
who is receiving chemotherapy and has
neutropenia. Which of the following inter-
The nurse should exclude raw fruits and
29 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
ventions should the nurse include in the vegetables from the client's diet to re-
plan? duce the risk of bacterial infections.
Report of chest pain
A nurse is assessing a client after admin-
The nurse should identify that a report
istering epinephrine for an anaphylactic
of chest pain by the client can indi-
reaction. Which of the following findings
cate an adverse effect of the medication.
should the nurse identify as an adverse
Epinephrine increases cardiac workload
effect of this medication?
and oxygen demand, which can result in
angina.
Acute confusion
A nurse is assessing an older adult client
who has pneumonia. Which of the follow- An older adult client who has pneumonia
ing findings should the nurse expect? will also typically have acute confusion,
fatigue, lethargy, and anorexia.
Observe the client every 15 min.
A nurse working on an inpatient mental
health unit is caring for a client who has
The nurse should observe the client who
bipolar disorder and is experiencing ma-
is experiencing mania every 15 minutes.
nia. Which of the following interventions
Frequent observation allows the nurse to
should the nurse recommend including
identify behaviors that need redirection
in the plan of care to ensure a safe client
and to protect the safety of the client and
care environment?
others.
Survey the scene for potential hazards to
staff and children.

A school nurse is notified of an emer- The first action the nurse should take
gency in which several children were when using the nursing process is to
injured following the collapse of play- assess the situation. By surveying the
ground equipment. Upon arrival at the scene, the nurse can identify potential
playground, which of the following ac- hazards to staff and children. These find-
tions should the nurse take first? ings allow the nurse and staff to enter the
scene and safely provide care to injured
children and help decrease the risk for
further injury.
A nurse is preparing a sterile field in
order to insert an indwelling urinary
30 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
catheter for a male client. Which of the
following techniques should the nurse Set the catheter tray on the overbed table
use to maintain surgical aseptic tech- at waist height.
nique?
A nurse is providing teaching for a client
who has a fracture of the right fibula Use a three-point gait.
with a short-leg cast in place and a new
prescription for crutches. The client is A three-point crutch gait allows the client
non-weight-bearing for 6 weeks. Which to be mobile without bearing weight on
of the following instructions should the the affected extremity.
nurse include in the teaching?
Inject 20 units of air into the NPH insulin
vial.
A nurse is preparing to administer 15
units of regular insulin along with 20 units The nurse should inject 20 units of air
of NPH insulin. Which of the following into the NPH insulin vial and withdraw the
actions should the nurse plan to take? needle without touching the insulin, then
proceed to inject 15 units of air into the
regular insulin vial.
Provide information about scheduling is-
sues to the staff.
A nurse manager is planning to make
changes to the current scheduling sys-
The first stage of the change process
tem on the unit. To facilitate the staff's
is the unfreezing stage, when the nurse
acceptance of this change, which of the
should inform the staff about the current
following actions should the nurse man-
staffing issues. This can increase their
ager take first?
understanding of why changes are nec-
essary.
Auscultate the apical pulse at least 1 min.

The nurse should auscultate the apical

A nurse is assessing a newborn's heart
pulse to obtain an accurate assessment
rate. Which of the following actions
of heart rate and rhythm. Auscultation of
should the nurse take?
a newborn's heart sounds can be difficult
because of the rapid rate and the trans-
mission of respiratory sounds.

31 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7

A client who is at 33 weeks of gestation

and has severe gestational hypertension

The nurse should initiate seizure precau-

tions for a client who has severe gesta-
An antepartum nurse is caring for four
tional hypertension because an extreme-
clients. For which of the following clients
ly elevated blood pressure in an antepar-
should the nurse initiate seizure precau-
tum client can trigger seizure activity. The
tions?
nurse should provide the client with a
quiet, darkened environment, place suc-
tion equipment and oxygen at the bed-
side, and position the call light within the
client's reach.
A client who has diabetes mellitus and
has had repeated hospitalizations for di-
abetic ketoacidosis
A case manager is reviewing the med-
ical records of several clients. For which
A client who is having repeated episodes
of the following clients should the nurse
of a life-threatening complication re-
request an interprofessional care confer-
quires an interprofessional care confer-
ence?
ence so team members can address the
client's needs to provide care and sup-
port.
Flush the client's gastrostomy tube with
30 mL of water before administering the
A nurse is administering medications to medication.
a client who has a percutaneous gas-
trostomy tube for enteral feedings. Which The nurse should flush the gastrotomy
of the following actions should the nurse tube with at least 30 mL of water be-
take to prevent clogging of the tube? fore and after medication administration
to clear the tube of any residuals and to
ensure patency.
Persistent uterine contractions
A nurse is caring for a client who is at 37
weeks of gestation and is experiencing The nurse should expect a client who has
abruptio placentae. Which of the follow- abruptio placentae to experience persis-
ing findings should the nurse expect? tent uterine contractions, board-like ab-
domen, and dark red vaginal bleeding.
32 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7

A nurse in a provider's office is caring for

a client.

Nurses' Notes
Day 1, 0900:
Client is 65-year-old who reports pain
and burning on urination.Client states, "I When recognizing cues, the nurse
am having trouble making it to the bath- should identify that the client's report
room on time and I'm up throughout the of frequency, dysuria, and urgency are
night needing to urinate." manifestations of a UTI and should be
Client alert and oriented to person, reported to the provider. These manifes-
place, and time.Bilateral breath sounds tations occur due to bacteria invading the
clear. Respirations even and unla- urinary tract through the urethra.
bored.S3 auscultated. Lower extremi-
ty edema +1. Radial and pedal pulses
+2.Bowel sounds normoactive. Client re-
ports no nausea or vomiting. Client has
a history of type 2 diabetes mellitus, hy-
pertension, and COPD.
A nurse in a provider's office is caring for
a client.

Nurses' Notes When analyzing cues, the nurse should

Day 1, 0900: anticipate provider prescriptions to col-
Client is 65-year-old who reports pain lect urine specimens for urinalysis and
and burning on urination.Client states, "I urine culture and to educate the client
am having trouble making it to the bath- on new prescriptions for sulfamethoxa-
room on time and I'm up throughout the zole/trimethoprim and phenazopyridine.
night needing to urinate." The nurse should identify that the client
Client alert and oriented to person, is most likely experiencing a urinary
place, and time.Bilateral breath sounds tract infection (UTI). UTIs are diagnosed
clear. Respirations even and unla- through urinalysis and urine culture.
bored.S3 auscultated. Lower extremi- Clients experiencing a UTI should be
ty edema +1. Radial and pedal pulses prescribed an antibiotic and an analgesic
+2.Bowel sounds normoactive. Client re- for urinary pain relief and frequency.
ports no nausea or vomiting.Client has
a history of type 2 diabetes mellitus, hy-
pertension, and COPD.

33 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
The nurse should determine that the pri-
A nurse in a provider's office is caring for
ority hypothesis is the client is at the
a client.
highest risk for developing pyelonephri-
tis as evidenced by the client's urinaly-
Provider Prescriptions
sis results. The urinalysis indicates dark
Day 1, 0930:
cloudy urine, increased specific grav-
Collect urine specimen for urinalysis and
ity, increased pH, increased red and
urine culture and sensitivity. Trimetho-
white blood cells, positive nitrites, pos-
prim/sulfamethoxazole 160/800 mg PO
itive leukocytes, and trace amounts of
twice daily for 10 days
blood, which indicate a urinary tract in-
Phenazopyridine 200 mg PO every 6 hr
fection (UTI). If left untreated, a UTI can
for 2 days
lead to pyelonephritis.
A nurse in a provider's office is caring for
a client.

Nurses' Notes
Day 1, 0900:
Client is 65-year-old who reports pain
and burning on urination.Client states, "I
am having trouble making it to the bath-
room on time and I'm up throughout the
night needing to urinate." Gently cleanse the perineum before in-
Client alert and oriented to person, tercourse.
place, and time.Bilateral breath sounds
clear. Respirations even and unla- When generating solutions, the nurse
bored.S3 auscultated. Lower extremi- should educate the client on how to pre-
ty edema +1. Radial and pedal pulses vent future UTIs by cleansing the per-
+2.Bowel sounds normoactive. Client re- ineum prior to intercourse. During inter-
ports no nausea or vomiting.Client has course, bacteria from the skin can enter
a history of type 2 diabetes mellitus, hy- the urinary tract, causing infection.
pertension, and COPD.

The nurse is planning to teach the client

how to prevent further UTIs from occur-
ring. Which of the following instructions
should the nurse plan to include?

Drink approximately 4 L of fluids daily.

Void every 4 to 6 hr during the day.
34 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
Drink orange juice daily.
Gently cleanse the perineum before in-
tercourse.
When taking action, the nurse should
The client returns to the provider's office
identify that the client's urine color, void-
3 days later.
ing pattern, oxygen saturation, and blood
pressure are expected findings and do
Nurses' Notes
not need to be reported to the provider.
Day 1, 0900:
The client's report of orange urine is an
Client is 65-year-old who reports pain
expected finding due to the prescribed
and burning on urination.Client states, "I
medication phenazopyridine, which can
am having trouble making it to the bath-
cause reddish-orange discoloration of
room on time and I'm up throughout the
urine. The client's voiding pattern is an
night needing to urinate."
expected finding due to increased fluid
Client alert and oriented x 3.Bilateral
intake of 3 L daily. The client's oxygen
breath sounds clear. Respirations even
saturation is an expected finding due to
and unlabored.S3 auscultated. Lower
the client's history of COPD. The client's
extremity edema +1. Radial and ped-
blood pressure is an expected finding
al pulses +2.Bowel sounds normoac-
due to the client's history of hyperten-
tive. Client reports no nausea or vomit-
sion.
ing.Client has a history of type 2 diabetes
The nurse should identify that the client's
mellitus, hypertension, and COPD.
temperature, skin, and bowel elimination
3 days later, 0900:
are unexpected findings and should be
Client returns to office due to orange-col-
reported to the provider. The client's tem-
ored urine and diarrhea.Client reports
perature is above the expected reference
drinking a minimum of 3 L of fluids daily
range, which can be an indication of
as instructed and states, "I'm still going
Clostridium difficile. The client's diarrhea
to the bathroom a lot, and I noticed that
can also be an indication of C. difficile.
I am bruising more easily."
The client's unexpected bruising can be
an indication of Stevens-Johnson syn-
Which of the following assessment find-
drome. C. difficile and Stevens-Johnson
ings should the nurse report to the
syndrome are potential side effects of
provider as unexpected?
trimethoprim/sulfamethoxazole.

Nurses' Notes
Day 1, 0900:
Client is a 65-year-old who reports pain
and burning on urination.Client states, "I
am having trouble making it to the bath-
35 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
room on time and I'm up throughout the
night needing to urinate."
Client alert and oriented to person,
place, and time.Bilateral breath sounds
clear. Respirations even and unla- When evaluating outcomes, the nurse
bored.S3 auscultated. Lower extremi- should identify that the client's urinary
ty edema +1. Radial and pedal pulses tract infection (UTI) is improving as evi-
+2.Bowel sounds normoactive. Client re- denced by the client's urine specific grav-
ports no nausea or vomiting.Client has a ity, pH, and WBC results. These find-
history of type 2 diabetes mellitus, hyper- ings are within the expected reference
tension, and COPD.3 days later, 0900: ranges and indicate that the medication
has been effective in treating the UTI.
Click to highlight the findings that indi-
cate the client's urinary tract infection is
improving. To deselect a finding, click on
the finding again.
Initiate transmission-based precautions.

When using the urgent vs. nonurgent ap-

A nurse in an emergency department is
proach to client care, the nurse should
caring for a child who has a fever and flu-
determine that the priority action is to ini-
id-filled vesicles on the trunk and extrem-
tiate transmission-based precautions for
ities. Which of the following interventions
the child. The child most likely has vari-
should the nurse identify as the priority?
cella. Therefore, the nurse should isolate
the child to prevent the spread of the
infection.
The client is able to accurately describe
A nurse on a medical-surgical unit is car- the upcoming procedure.
ing for a client prior to a surgical pro-
cedure. Which of the following findings The ability of the client to accurately de-
should indicate to the nurse that the scribe the upcoming procedure indicates
client has the ability to sign the informed that the provider adequately informed the
consent? client and that the client is able to sign
the informed consent form.
Confusion
A nurse is assessing a client who has
been taking lithium carbonate for the When using the urgent vs. nonurgent ap-
proach to client care, the nurse should
36 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
determine that the priority finding is
confusion because it is an early man-
past month to treat bipolar disorder.
ifestation of lithium toxicity. The nurse
Which of the following assessment find-
should monitor the client for addition-
ings should the nurse identify as the pri-
al indications of lithium toxicity, includ-
ority?
ing coarse hand tremors, incoordination,
ECG changes, and sedation.
The nurse should recognize the client's
urine specific gravity is significantly el-
A nurse in an emergency department is
evated above the expected reference
caring for a client who is at 9 weeks of
range of 1.005 to 1.03 if a client at
gestation and reports nausea and vom-
9 weeks gestation reports nausea and
iting for the past 2 days. Which of the fol-
vomiting for the past 2 days. An in-
lowing findings should the nurse expect?
creased urine specific gravity indicates
dehydration from vomiting.
"I will be checking you once with your
eyes open and once with them closed."
A nurse is providing information to a
client immediately before their sched- The nurse should inform the client that
uled Romberg test. Which of the follow- the Romberg test will be performed once
ing statements should the nurse make? with eyes open and once with eyes
closed. A Romberg test is performed to
assess balance and motor function.
A nurse is planning teaching about allow-
oranges
able foods for a client who has a history
of uric acid-based urinary calculi forma-
A client who is prone to uric acid calculi
tion. Which of the following foods should
formation can eat citrus fruits.
the nurse include in the teaching?
"Notify your provider if you experience
increased thirst."
A nurse is providing teaching about lithi-
um to a client who has bipolar disorder. The nurse should recognize that an in-
Which of the following statements should crease in thirst is a manifestation of lithi-
the nurse include in the teaching? um toxicity. The nurse should instruct the
client to report increased thirst, vomiting,
diarrhea, or tremors to the provider.

37 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
A nurse is preparing to transfer a client
who has had a stroke to a rehabilitation
facility. The client's family tells the nurse Facilitate an interdisciplinary conference
they are concerned about the level of at the new facility for the family.
care the client will receive. Which of the
following actions should the nurse take?
Measure the client's daily weight.
A nurse is caring for a client who has fluid
volume overload. Which of the following
tasks should the nurse delegate to an It is within the AP's range of function to
assistive personnel (AP)? measure a client's daily weight, so the
nurse should delegate this task to the AP.
Initiate fall precautions for the client.

A nurse is caring for a client who has The nurse should initiate fall precautions
generalized anxiety disorder and is to for a client who has a new prescription for
begin taking alprazolam. Which of the alprazolam because common adverse
following actions should the nurse take? effects associated with this medication
are orthostatic hypotension, dizziness,
confusion, and lethargy.
Withhold administering the varicella vac-
A nurse is creating a plan of care for a cine to the child.
child who has acute lymphoid leukemia
and an absolute neutrophil count of A child who has severe immunodeficien-
400/mm3 (2500 to 8000/mm3). Which cy should not receive a live vaccine due
of the following interventions should the to the risk of developing the disease. In-
nurse include in the plan? activated vaccines can be administered
to children who are immunosuppressed.
Ask the caller for verification of their iden-
tity.
A nurse working on a medical-surgical
unit receives a telephone call requesting According to HIPAA, if someone re-
the status of a client from an individual quests information about a client, it is
who identifies themselves as the client's the nurse's duty to protect that informa-
guardian. Which of the following actions tion. Therefore, the nurse should inform
should the nurse take? the caller that nurses cannot release any
client information over the phone without
the permission of the client. The nurse
38 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
should ask for verification of the caller's
identity to determine if they have been
authorized by the client to receive infor-
mation.
Use the ventrogluteal site.
A nurse is preparing to administer an IM
injection to a client who is obese. Which The nurse should use the ventrogluteal
of the following actions should the nurse site because it has a thick area of muscle
plan to take? and contains no large nerves or blood
vessels.
Grandiose delusions

A nurse is caring for a client who is in the Clients who are in the manic phase of
manic phase of bipolar disorder. Which bipolar disorder typically exhibit behav-
of the following manifestations should iors that appear to be euphoric. Clients
the nurse expect? can also have abrupt mood changes, ex-
pansiveness, unlimited energy, poor im-
pulse control, and grandiose delusions.
Instruct the client to avoid coughing dur-
ing the procedure.
A nurse is preparing to assist with a tho-
racentesis for a client who has pleurisy.
It is important for the nurse to remind the
The nurse should plan to perform which
client to avoid coughing and to lie still
of the following actions?
during a thoracentesis to avoid punctur-
ing the pleura.
A nurse is caring for an older adult client Albumin 2.8 g/dL (3.5 to 5 g/dL)
who is experiencing chronic anorexia
and is receiving enteral tube feedings. The nurse should recognize that an albu-
Which of the following laboratory values min level of less than 3.5 g/dL indicates
indicates the client needs additional nu- malnutrition and a need for additional nu-
trients added to the feeding? tritional supplementation.
A nurse is caring for a client who states,
Sublimation
"My boss accused me of stealing yester-
day. I was so angry I went to the gym and
The client is exhibiting behaviors consis-
worked out." The nurse should recognize
tent with sublimation, which is displayed
the client is demonstrating which of the
when a client substitutes socially unac-
following defense mechanisms?
39 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
ceptable behavior for acceptable behav-
ior.
"I will not allow anyone to smoke near my
A nurse is providing teaching to the baby."
guardians of a newborn about mea-
sures to prevent sudden unexpected in- This statement by the guardian indicates
fant death (SUID). Which of the following an understanding of the nurse's instruc-
guardian statements indicates an under- tions. Research indicates a strong cor-
standing of the teaching? relation between exposure to cigarette
smoke and the occurrence of SUID.
Hypertension
A nurse is assessing a client who has
The nurse should assess the client for
obstructive sleep apnea. For which of the
hypertension, a complication of obstruc-
following complications should the nurse
tive sleep apnea from hypoxia. Other
monitor?
complications include heart failure and
cardiac dysrhythmias.
Hemoptysis 275 mL/24 hr
A nurse is assessing a school-age child
who has cystic fibrosis. Which of the Hemoptysis greater than 250 mL/24 hr
following findings is the priority for the indicates that this child is at greatest risk
nurse to report to the provider? for hemorrhage. Therefore, this is the pri-
ority finding for the nurse to report.
A nurse must recommend clients for dis-
charge in order to make room for sev-
eral critically injured clients from a local A client who has cellulitis and is receiving
disaster. Which of the following clients oral antibiotics every 8 hr
should the nurse recommend for dis-
charge?
A nurse is performing tracheostomy care
Apply suction for 10 seconds.
for a client who is postoperative following
a laryngectomy. Which of the following
The nurse should apply suction for only
actions should the nurse take when suc-
5 to 15 seconds to minimize oxygen loss.
tioning the client's airway?
Turn off the CPM machine during meal-
A nurse is caring for a client who has
time.
a prescription for a continuous passive
40 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
motion (CPM) machine following a total The nurse should turn off the CPM ma-
knee arthroplasty. Which of the following chine during meals to promote client
actions should the nurse take? comfort and dietary intake.
A nurse is assessing a client who is re-
ceiving a blood transfusion. Which of the
following findings should indicate to the Low back pain
nurse that the client is having a hemolytic
transfusion reaction?
Recent weight loss
A nurse working in a long-term care fa-
Weight loss can increase the client's risk
cility is assessing an adult client. Which
for developing a pressure injury. Inade-
of the following findings places the client
quate nutrition will cause decreased nu-
at risk for the development of a pressure
trients for the skin and tissues and an
injury?
increased chance for shearing against
bony prominences.
A nurse manager is preparing an educa-
tional session about advocacy to a group
Advocacy is a leadership role that helps
of nurses. The nurse manager should in-
others to self-actualize.
clude which of the following information
in the teaching?
A nurse is admitting a client to the men-
tal health unit after an attempted sui-
cide. The client states, "My family does
"How does this make you feel?"
not care whether I live or die." Which of
the following responses should the nurse
make?
Orthostatic hypotension
A nurse is caring for a client who has
had nausea and vomiting for the past
Clients who have a fluid volume deficit
2 days. The nurse should identify which
can experience orthostatic hypotension,
of the following findings as an indication
which is a result of the body's inability
the client is experiencing fluid volume
to maintain adequate blood pressure fol-
deficit?
lowing position changes.
Diaphoresis

Diaphoresis is an expected finding of

41 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
A nurse in an emergency depart- MDMA use. Additionally, the client might
ment is assessing a client who re- experience increased tactile sensitivity,
ports taking methylenedioxymetham- lowered inhibition, chills, muscle cramp-
phetamine (MDMA). Which of the follow- ing, teeth clenching, and mild hallucino-
ing findings should the nurse expect? genic effects.
The client's heel is reddened and tender.
A nurse is caring for a client who has a
fractured femur and has had a fiberglass The greatest risk to this client is in-
leg cylinder cast for 24 hr. Which of the jury from a pressure ulcer. Therefore,
following assessment findings should the priority assessment finding the nurse
the nurse identify as the priority? should identify is a reddened and tender
heel.
A nurse is performing an admission as-
February 15
sessment on a client who had a re-
cent positive pregnancy test. The first
Using Naegele's rule, the nurse should
day of their last menstrual period (LMP)
add 7 days to the first day of the client's
was May 8. According to Naegele's rule,
LMP (8 + 7 = 15) and then subtract 3
which of the following dates should the
months. Therefore, the nurse should doc-
nurse document as the client's estimated
ument the client's EDB as February 15th.
date of birth (EDB)?
A client who has premature rupture of
membranes is correct. Clients who have
premature rupture of membranes require
fetal monitoring to assess and evaluate
fetal well-being.
A nurse is caring for multiple clients in A client who reports decreased fetal
an antepartum clinic. For which of the movement is correct. Clients who report
following clients should the nurse plan to decreased fetal movement require fetal
perform fetal heart monitoring? (Select monitoring to assess and evaluate fetal
all that apply.) well-being.
A client who has gestational hyperten-
sion is correct. Clients who have gesta-
tional hypertension require fetal monitor-
ing to assess and evaluate fetal well-be-
ing.
"I told my doctor that I would like to start
A nurse is conducting group therapy
a support group for other people who are
with clients who have breast cancer. The
sick in my community."
42 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7

nurse should recognize which of the fol-

This statement indicates that the client is
lowing statements by a client as an ex-
demonstrating altruism by reaching out
ample of altruism?
and helping others.
A nurse is teaching about adverse ef- Cough
fects with a client who is starting to take
captopril. Which of the following findings The client can develop a cough due to
should the nurse identify as an adverse a buildup of bradykinin in the lungs. The
effect of the medication to report to the client should report this finding to the
provider? provider.
A nurse is providing teaching to a client "You will need to fast the night before the
who is at 24 weeks of gestation and is test."
scheduled for a 3-hr oral glucose tol-
erance test. Which of the following in- The nurse should instruct the client that
structions should the nurse include in the they will need to fast the night before the
teaching? test to prevent inaccurate test results.
A nurse is assessing a client who has
pulmonary edema. Which of the follow- Pink, frothy sputum
ing findings should the nurse expect?
A nurse is providing teaching to a client
who has a prescription for levothyroxine
Take the medication on an empty stom-
25 mcg PO daily. Which of the following
ach 30 min before breakfast.
instructions should the nurse include in
the teaching?
Autonomy
A nurse manager is reviewing clients'
rights with the nurses on the unit. The Autonomy refers to a client's ability to
nurse manager should tell the nurses make their own decisions about treat-
that informed consent promotes which of ment. Informed consent promotes auton-
the following ethical principles? omy by providing clients with complete
information about treatment.

A nurse is providing teaching about ad- "I can designate my partner as my health
vance directives to a middle adult client. care surrogate."
Which of the following client responses
indicates an understanding of the teach- This statement indicates that the client
ing? recognizes that designating a health
43 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
care surrogate is part of advance direc-
tives.
Assist with deep breathing and cough-
ing.

A nurse is caring for a client who had ab- The priority action the nurse should take
dominal surgery 24 hr ago. Which of the when using the airway, breathing, circu-
following actions is the nurse's priority? lation approach to client care is to assist
the client with deep breathing and cough-
ing, which reduces the risk for postoper-
ative pneumonia.
Introduce new foods one at a time over 3
A nurse is providing dietary teaching to 5 days.
to the parents of a 6-month-old in-
fant. Which of the following instructions The parents should introduce new foods
should the nurse include? one at a time over 3 to 5 days to identify
potential food allergies.
Supervise the client during and after eat-
A nurse in an acute mental health facil-
ing.
ity is planning care for a client who has
anorexia nervosa. Which of the following
The nurse should monitor the client dur-
interventions should the nurse include in
ing and for 1 hr after meals to prevent the
the client's plan of care?
client from hiding food or purging.
Delegate non-nursing tasks to ancillary
staff.
A nurse manager is preparing an educa-
tional session for nursing staff about how
Delegating non-nursing tasks to ancillary
to provide cost-effective care. Which of
staff is an effective method of providing
the following methods should the nurse
high-quality, cost-effective care because
include in the teaching?
this will allow additional time for nurses
to focus on skilled tasks.
A nurse is assessing a client who has Blurred vision
major depressive disorder and is taking
amitriptyline. Which of the following find- The nurse should identify blurred vision
ings should the nurse identify as an ad- as an adverse effect of amitriptyline and
verse effect of the medication? notify the provider.

44 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
"Maybe this is better for our child
A nurse is caring for an adolescent because we don't want any suffering
client who has a new diagnosis of termi- through chemotherapy treatments."
nal cancer. When discussing the client's
prognosis with the parents, the nurse By justifying the adolescent's prognosis
should recognize which of the following by searching for a more personally ac-
responses by the parents as an example ceptable explanation for the impending
of rationalization? loss, the parent is using the defense
mechanism of rationalization.
Make a referral for social services.
A nurse on a medical-surgical unit is car-
ing for a client who has a new diagnosis As a client advocate, the nurse should
of terminal cancer. The client tells the support the client's decisions and obtain
nurse that they would like to go home a referral for social services to ensure
to be with family and loved ones. Which that the client's needs at home are met.
of the following actions should the nurse Social services can set up home care
take? or hospice care services for the client if
needed.
A client who is receiving an MAOI and is
requesting a cheeseburger for dinner
A nurse has received change-of-shift re-
port on four assigned clients. For which
This client's food selection contains tyra-
of the following clients should the nurse
mine. Clients prescribed an MAOI must
intervene to prevent a potential food and
restrict intake of foods that contain tyra-
medication interaction?
mine due to adverse effects, such as hy-
pertension.
A nurse is caring for a client who has
active tuberculosis (TB). Which of the fol- Have the client wear a surgical mask
lowing actions should the nurse plan to while being transported outside the
take to prevent the transmission of the room.
disease?
Radial vein of the inner arm
A nurse is preparing to initiate IV access
for an older adult client. Which of the The nurse should select the radial vein of
following sites should the nurse select the inner arm when initiating IV access
when initiating the IV for this client? for an older adult client because this site
will have adequate subcutaneous tissue.

45 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
A nurse in an emergency department is
assessing a school-age child who was Contact Child Protective Services.
brought in by their parents and has scald
burns to both hands and wrists. The The nurse has a legal responsibility to
nurse suspects physical abuse. Which of report suspected physical abuse to Child
the following actions should the nurse Protective Services.
take?
Involve the client in selection of a physi-
A nurse is caring for a client who re- cal therapy provider.
quires physical therapy following dis-
charge. Which of the following actions The nurse should involve the client in
should the nurse take? the referral process, including selection
of the physical therapist and the location.
Audible stridor

A nurse is caring for an older adult client Audible stridor, or a high-pitched sound
in the PACU following general anes- heard in the client's airway, indicates
thesia. Which of the following findings edema, laryngeal spasm, secretions, or
should the nurse report to the provider? some type of airway obstruction that
could become life-threatening. The nurse
should report this finding to the provider.
Maintain regular notes about the nurse's
time management skills.
A nurse manager is preparing a newly
licensed nurse's performance appraisal.
Maintaining notes over a period of time
Which of the following methods should
provides a comprehensive view of the
the nurse manager use to evaluate the
nurse's abilities, so the manager can
nurse's time management skills?
identify trends in the nurse's overall per-
formance.
"A client who requires airborne pre-
A charge nurse is providing an educa- cautions should be placed in a nega-
tional session about infection control for tive-pressure airflow room."
a group of staff nurses. Which of the
following statements by one of the staff Airborne precautions require a nega-
nurses indicates an understanding of tive-pressure airflow room that has at
isolation precautions? least six to 12 air exchanges each hour
using a HEPA filtration system.

46 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
A nurse in an emergency department is Proceed with provision of medical care.
caring for a client who is unconscious
and requires emergency medical pro- When a client is unable to give informed
cedures. The nurse is unable to locate consent in an emergency, health care
members of the client's family to obtain personnel can proceed with necessary
consent. Which of the following actions life-saving care because the law consid-
should the nurse take? ers this implied consent.
Ideas of self-harm
A nurse on a mental health unit is
conducting a mental status examination The greatest risk to this client is in-
(MSE) on a newly admitted client. Which jury from ideas of self-harm. Therefore,
of the following components of the MSE the priority assessment the nurse should
is the priority for the nurse to assess? make is to determine whether the client
has had suicidal or homicidal ideas.
Determine the client's reading skills.

The first action the nurse should take

A nurse is updating the plan of care
when using the nursing process is to
for a client who is 48 hr postoperative
assess the client. By determining the
following a laryngectomy and is unable
client's level of reading skills and cogni-
to speak. Which of the following actions
tion, the nurse can best provide the client
should the nurse plan to take first?
with a variety of customized techniques
to practice and use after verbal skills are
lost.
Instruct the client to elevate the affected
extremity when sitting.
A nurse is caring for a client who has
a deep vein thrombosis. Which of the
The nurse should instruct the client to
following actions should the nurse take?
elevate the affected extremity when in
the bed or chair.
Serum sodium 138 mEq/L
A nurse is caring for a school-age child
who has dehydration and is receiving an A serum sodium level of 138 mEq/L is
oral rehydration solution. Which of the within the expected reference range of
following laboratory results indicates that 136 mEq/L to 145 mEq/L and is an indi-
the treatment regimen is effective? cation that the child is responding to the
oral rehydration solution.

47 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
A nurse in a mental health clinic is as- Borderline
sessing a client who has a history of
seeking counseling for relationship prob- The nurse should identify that clients
lems. The client shows the nurse mul- who have borderline personality disorder
tiple superficial self-inflicted lacerations tend to be emotionally unstable, have
on their forearms. The nurse should iden- troubled interpersonal relationships, and
tify these behaviors as characteristics of often engage in harmful behaviors such
which of the following personality disor- as cutting, substance use, and suicidal
ders? ideation.
Jaundice
A nurse is caring for a client who is tak-
The nurse should monitor the client for
ing valproic acid for seizure control. For
jaundice and report any indication to the
which of the following adverse effects
provider. Clients who take valproic acid
should the nurse monitor and report?
are at risk for liver damage, which can
lead to jaundice.
A client who has significant head trauma
and agonal respirations
A community health nurse is performing
triage tagging following a mass casualty The nurse should place a black tag on
incident. On which of the following clients a client who has significant head trau-
should the nurse place a black tag? ma and agonal respirations because this
client is not likely to recover or will require
extensive resources for care.
Develop a safety plan with the client.
A nurse in an emergency department is
preparing to discharge a client who has
The greatest risk to this client is injury
experienced intimate partner violence.
from violence. Therefore, the first action
Which of the following actions should the
the nurse should take is to develop a
nurse take first?
safety plan with the client.
Medication Record
Digoxin 0.25 mg PO daily
Potassium chloride 20 mEq/L PO daily
Metformin 500 mg PO daily
Furosemide 20 mg PO daily
Vital Signs
Blood pressure 116/62 mm Hg
Respiratory rate 18/min
48 / 49
 RN Comprehensive Online Practice 2023 B
Study online at https://quizlet.com/_eegol7
Temperature 37.3° C (99.1° F)Apical
heart rate 62/min
Daily weight 84.82 kg (187 lb) (gain of
0.6 lb in 24 hr)
Administer daily medications.
Laboratory Results
Digoxin 0.78 ng/mL
The client's vital signs and laboratory
Potassium 3.7 mEq/L
data are within the expected reference
Glucose 85 mg/dL
range. Therefore, the nurse should ad-
A nurse is planning morning care for a
minister the client's daily medications.
client who has heart disease and type
2 diabetes mellitus. Upon review of the
client's medical record, which of the fol-
lowing actions should the nurse take?

49 / 49