RN COMPREHENSIVE ONLINE PRACTICE
EXAM QUESTIONS WITH VERIFIED
SOLUTIONS
A nurse is caring for a client who is on the spinal cord injury (SCI) unit
Nurses' Notes
Day 3, 1700
Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale,
and dry to touch. Respirations easy and unlabored. Lung sounds diminished in
lower lobes. Abdomen soft and nondistended with active bowel sounds. Client
passed a small amount of hard formed stool this AM. Indwelling urinary
catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+,
triceps 1+, pa --CORRECT ANSWER--The client is most likely experiencing
manifestations of pneumonia and autonomic dysreflexia.
The nurse should analyze cues from the client's manifestations and determine
that the client is most likely experiencing manifestations of pneumonia and
autonomic dysreflexia. A client who has a cervical SCI is at risk for respiratory
complications because spinal innervation to the respiratory muscles is disrupted.
Adventitious breath sounds in the lower lobes bilaterally and a decrease in
oxygen saturation to less than 92% can indicate pneumonia. The client's sudden
increase in blood pressure, bradycardia, flushing of the skin above the area of
Page 1 of 139
,the injury, headache, and blurred vision are manifestations of autonomic
dysreflexia, which can be a life-threatening condition.
A nurse is administering medications to a client who has a percutaneous
gastrostomy tube for enteral feedings. Which of the following actions should the
nurse take to prevent clogging of the tube?
A. Flush the client's gastrostomy tube with 30 mL of water before administering
the medication.
B. Crush the client's medications and mix them in with the tube feeding formula
prior to administration.
C. Change the client's feeding bag every 72 hr.
D. Administer multiple prescribed medications at the --CORRECT ANSWER--
A. Flush the client's gastrostomy tube with 30 mL of water before administering
the medication.
The nurse should flush the gastrotomy tube with at least 30 mL of water before
and after medication administration to clear the tube of any residuals and to
ensure patency.
Incorrect
The nurse should crush each medication and administer each separately from
the tube feeding formula to decrease the risk of residual forming, which can
clog the tube.
Page 2 of 139
,The nurse should change the feeding bag and tubing every 24 to 48 hr to
prevent clogging and to reduce the risk of infection.
The nurse should administer each prescribed medication separately to reduce
the risk of clogging of the tube.
A nurse is caring for a 5-year-old child
Physical Examination:
1510:
Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and
epiglottis is edematous and cherry red in appearance. Skin appears pale. Stridor
noted upon inspiration with diminished bilateral lung sounds.
Nurse's Notes:
1500
Child accompanied to emergency department by caregiver. Caregiver states
child has a sore throat and reports the child has "pain on swallowing" and denies
cough. Child is agitated and lean --CORRECT ANSWER--Condition: Epiglottis
Actions: Initiate droplet precautions and request a prescription for IV antibiotics
Monitors: Breath sounds and temperature
The nurse should anticipate initiating droplet precautions and requesting a
prescription for IV antibiotics. The child is most likely experiencing epiglottis
because of the clinical manifestations of a high fever, inflammation and redness
of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is
Page 3 of 139
, sitting in tripod position, and drooling. The nurse should monitor the child's
temperature and breath sounds.
A nurse is caring for a client who has abdominal pain
Nurses' Notes
0900
Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports
abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client is a perioperative
nurse, returned 1 week ago from a 2-week mission trip to an underdeveloped
country
1200
Results of antibody studies obtained. Provider prescription for antiviral
medication pending.
Physical Examination
0930
Lung sounds clear bilaterally. Skin warm to touch and jau --CORRECT
ANSWER--Hepatitis A: Client's risk from fecal-oral transmission, laboratory
results, and physical examination findings
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EXAM QUESTIONS WITH VERIFIED
SOLUTIONS
A nurse is caring for a client who is on the spinal cord injury (SCI) unit
Nurses' Notes
Day 3, 1700
Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale,
and dry to touch. Respirations easy and unlabored. Lung sounds diminished in
lower lobes. Abdomen soft and nondistended with active bowel sounds. Client
passed a small amount of hard formed stool this AM. Indwelling urinary
catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+,
triceps 1+, pa --CORRECT ANSWER--The client is most likely experiencing
manifestations of pneumonia and autonomic dysreflexia.
The nurse should analyze cues from the client's manifestations and determine
that the client is most likely experiencing manifestations of pneumonia and
autonomic dysreflexia. A client who has a cervical SCI is at risk for respiratory
complications because spinal innervation to the respiratory muscles is disrupted.
Adventitious breath sounds in the lower lobes bilaterally and a decrease in
oxygen saturation to less than 92% can indicate pneumonia. The client's sudden
increase in blood pressure, bradycardia, flushing of the skin above the area of
Page 1 of 139
,the injury, headache, and blurred vision are manifestations of autonomic
dysreflexia, which can be a life-threatening condition.
A nurse is administering medications to a client who has a percutaneous
gastrostomy tube for enteral feedings. Which of the following actions should the
nurse take to prevent clogging of the tube?
A. Flush the client's gastrostomy tube with 30 mL of water before administering
the medication.
B. Crush the client's medications and mix them in with the tube feeding formula
prior to administration.
C. Change the client's feeding bag every 72 hr.
D. Administer multiple prescribed medications at the --CORRECT ANSWER--
A. Flush the client's gastrostomy tube with 30 mL of water before administering
the medication.
The nurse should flush the gastrotomy tube with at least 30 mL of water before
and after medication administration to clear the tube of any residuals and to
ensure patency.
Incorrect
The nurse should crush each medication and administer each separately from
the tube feeding formula to decrease the risk of residual forming, which can
clog the tube.
Page 2 of 139
,The nurse should change the feeding bag and tubing every 24 to 48 hr to
prevent clogging and to reduce the risk of infection.
The nurse should administer each prescribed medication separately to reduce
the risk of clogging of the tube.
A nurse is caring for a 5-year-old child
Physical Examination:
1510:
Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and
epiglottis is edematous and cherry red in appearance. Skin appears pale. Stridor
noted upon inspiration with diminished bilateral lung sounds.
Nurse's Notes:
1500
Child accompanied to emergency department by caregiver. Caregiver states
child has a sore throat and reports the child has "pain on swallowing" and denies
cough. Child is agitated and lean --CORRECT ANSWER--Condition: Epiglottis
Actions: Initiate droplet precautions and request a prescription for IV antibiotics
Monitors: Breath sounds and temperature
The nurse should anticipate initiating droplet precautions and requesting a
prescription for IV antibiotics. The child is most likely experiencing epiglottis
because of the clinical manifestations of a high fever, inflammation and redness
of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is
Page 3 of 139
, sitting in tripod position, and drooling. The nurse should monitor the child's
temperature and breath sounds.
A nurse is caring for a client who has abdominal pain
Nurses' Notes
0900
Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports
abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client is a perioperative
nurse, returned 1 week ago from a 2-week mission trip to an underdeveloped
country
1200
Results of antibody studies obtained. Provider prescription for antiviral
medication pending.
Physical Examination
0930
Lung sounds clear bilaterally. Skin warm to touch and jau --CORRECT
ANSWER--Hepatitis A: Client's risk from fecal-oral transmission, laboratory
results, and physical examination findings
Page 4 of 139
