RN Comprehensive Online Practice 2023 B
RN Comprehensive Online Practice
2023 B: Complete Review & Mastery
Guide
A nurse is caring for a 5-year-old Condition: Epiglottis
child Actions: Initiate droplet precautions and request a
prescription for IV antibiotics
Physical Examination: Monitors: Breath sounds and temperature
1510:
Upon visual inspection, throat is The nurse should anticipate initiating droplet
inflamed, tonsils appear pink, precautions and requesting a prescription for IV
reddened and epiglottis is antibiotics. The child is most likely experiencing
edematous and cherry red in epiglottis because of the clinical manifestations of
appearance. Skin appears pale. a high fever, inflammation and redness of the
Stridor noted upon inspiration with throat, pale skin, stridor with inspiration, painful
diminished bilateral lung sounds. swallowing, no cough, is sitting in tripod position,
and drooling. The nurse should monitor the child's
Nurse's Notes: temperature and breath sounds.
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
,A nurse is caring for a client who is The client is most likely experiencing
on the spinal cord injury (SCI) unit manifestations of pneumonia and autonomic
dysreflexia.
Nurses' Notes
Day 3, 1700 The nurse should analyze cues from the client's
Client admitted to SCI unit 3 days manifestations and determine that the client is most
ago following C7 injury. Skin is cool, likely experiencing manifestations of pneumonia
pale, and dry to touch. Respirations and autonomic dysreflexia. A client who has a
easy and unlabored. Lung sounds cervical SCI is at risk for respiratory complications
diminished in lower lobes. Abdomen because spinal innervation to the respiratory
soft and nondistended with active muscles is disrupted. Adventitious breath sounds in
bowel sounds. Client passed a small the lower lobes bilaterally and a decrease in
amount of hard formed stool this oxygen saturation to less than 92% can indicate
AM. Indwelling urinary catheter pneumonia. The client's sudden increase in blood
draining clear yellow urine. Deep pressure, bradycardia, flushing of the skin above
tendon reflexes (DTR) are biceps 1+, the area of the injury, headache, and blurred vision
triceps 1+, pa are manifestations of autonomic dysreflexia, which
can be a life-threatening condition.
,A nurse is caring for a client who has Hepatitis A: Client's risk from fecal-oral
abdominal pain transmission, laboratory results, and physical
examination findings
Nurses' Notes
0900 Hepatitis B: Antiviral treatment, laboratory results,
Client reports loss of appetite, client's risk from bloodborne transmission, physical
weight loss, and fatigue for 1 week. examination findings
Reports abdominal pain, 6 on a scale
from 0 to 10, for 2 days. Client is a Hepatitis C: Antiviral treatment, laboratory results,
perioperative nurse, returned 1 week client's risk from bloodborne transmission, and
ago from a 2-week mission trip to an physical examination findings
underdeveloped country
When analyzing cues, the nurse should recognize
1200 that manifestations of hepatitis A, hepatitis B, and
Results of antibody studies obtained. hepatitis C include jaundice, yellow sclerae, right
Provider prescription for antiviral upper quandrant pain upon palpation, dark yellow
medication pending. urine, and elevated AST and ALT levels. When
analyzing cues, the nurse should also recognize
Physical Examination the client's risk for contracting hepatitis A through
0930 the fecal-oral route during recent travel to an
Lung sounds clear bilaterally. Skin underdeveloped country and the client's
warm to touch and jau occupational risk as a perioperative nurse for
contracting hepatitis B and hepatitis C through
bloodborne transmission. The nurse should
recognize that the current standard of practice for
, A nurse is caring for a client on a Click to highlight the findings that require follow
medical-surgical unit up. To deselect a finding, click on the finding again.
- Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful
Vital Signs edematous area on sacrum
0700 - Client repositioned every 4 hr
Temperature 37.6 C (99.7 F)
Heart rate 100/min When recognizing cues, the nurse should
Respiratory rate 22/min determine that the client's painful edematous area
Blood pressure 115/70 mmHg on their sacrum and that the client has only been
Oxygen saturation 98% on room air repositioned every 4 hr requires follow up. The
client has manifestations of a pressure injury that
Nurses' Notes need to be addressed. The client should be
1100 repositioned at least every 2 hr to prevent
Client alert and oriented to person, worsening of the pressure injury and to relieve
place, and time. Client had episode pressure from the sacral area.
of diarrhea, provided perineal care.
Noted 2 cm x 2 cm (0.8 in x 0.8 in)
painful edematous area on sacrum.
Client repositioned every 4 hr.
RN Comprehensive Online Practice
2023 B: Complete Review & Mastery
Guide
A nurse is caring for a 5-year-old Condition: Epiglottis
child Actions: Initiate droplet precautions and request a
prescription for IV antibiotics
Physical Examination: Monitors: Breath sounds and temperature
1510:
Upon visual inspection, throat is The nurse should anticipate initiating droplet
inflamed, tonsils appear pink, precautions and requesting a prescription for IV
reddened and epiglottis is antibiotics. The child is most likely experiencing
edematous and cherry red in epiglottis because of the clinical manifestations of
appearance. Skin appears pale. a high fever, inflammation and redness of the
Stridor noted upon inspiration with throat, pale skin, stridor with inspiration, painful
diminished bilateral lung sounds. swallowing, no cough, is sitting in tripod position,
and drooling. The nurse should monitor the child's
Nurse's Notes: temperature and breath sounds.
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
,A nurse is caring for a client who is The client is most likely experiencing
on the spinal cord injury (SCI) unit manifestations of pneumonia and autonomic
dysreflexia.
Nurses' Notes
Day 3, 1700 The nurse should analyze cues from the client's
Client admitted to SCI unit 3 days manifestations and determine that the client is most
ago following C7 injury. Skin is cool, likely experiencing manifestations of pneumonia
pale, and dry to touch. Respirations and autonomic dysreflexia. A client who has a
easy and unlabored. Lung sounds cervical SCI is at risk for respiratory complications
diminished in lower lobes. Abdomen because spinal innervation to the respiratory
soft and nondistended with active muscles is disrupted. Adventitious breath sounds in
bowel sounds. Client passed a small the lower lobes bilaterally and a decrease in
amount of hard formed stool this oxygen saturation to less than 92% can indicate
AM. Indwelling urinary catheter pneumonia. The client's sudden increase in blood
draining clear yellow urine. Deep pressure, bradycardia, flushing of the skin above
tendon reflexes (DTR) are biceps 1+, the area of the injury, headache, and blurred vision
triceps 1+, pa are manifestations of autonomic dysreflexia, which
can be a life-threatening condition.
,A nurse is caring for a client who has Hepatitis A: Client's risk from fecal-oral
abdominal pain transmission, laboratory results, and physical
examination findings
Nurses' Notes
0900 Hepatitis B: Antiviral treatment, laboratory results,
Client reports loss of appetite, client's risk from bloodborne transmission, physical
weight loss, and fatigue for 1 week. examination findings
Reports abdominal pain, 6 on a scale
from 0 to 10, for 2 days. Client is a Hepatitis C: Antiviral treatment, laboratory results,
perioperative nurse, returned 1 week client's risk from bloodborne transmission, and
ago from a 2-week mission trip to an physical examination findings
underdeveloped country
When analyzing cues, the nurse should recognize
1200 that manifestations of hepatitis A, hepatitis B, and
Results of antibody studies obtained. hepatitis C include jaundice, yellow sclerae, right
Provider prescription for antiviral upper quandrant pain upon palpation, dark yellow
medication pending. urine, and elevated AST and ALT levels. When
analyzing cues, the nurse should also recognize
Physical Examination the client's risk for contracting hepatitis A through
0930 the fecal-oral route during recent travel to an
Lung sounds clear bilaterally. Skin underdeveloped country and the client's
warm to touch and jau occupational risk as a perioperative nurse for
contracting hepatitis B and hepatitis C through
bloodborne transmission. The nurse should
recognize that the current standard of practice for
, A nurse is caring for a client on a Click to highlight the findings that require follow
medical-surgical unit up. To deselect a finding, click on the finding again.
- Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful
Vital Signs edematous area on sacrum
0700 - Client repositioned every 4 hr
Temperature 37.6 C (99.7 F)
Heart rate 100/min When recognizing cues, the nurse should
Respiratory rate 22/min determine that the client's painful edematous area
Blood pressure 115/70 mmHg on their sacrum and that the client has only been
Oxygen saturation 98% on room air repositioned every 4 hr requires follow up. The
client has manifestations of a pressure injury that
Nurses' Notes need to be addressed. The client should be
1100 repositioned at least every 2 hr to prevent
Client alert and oriented to person, worsening of the pressure injury and to relieve
place, and time. Client had episode pressure from the sacral area.
of diarrhea, provided perineal care.
Noted 2 cm x 2 cm (0.8 in x 0.8 in)
painful edematous area on sacrum.
Client repositioned every 4 hr.
