NSG 4060 RN COMPREHENSIVE ONLINE PRACTICE B
1. Patient refused a newly open fentanyl patch. Which of the following
actions should the nurse take?
Ask another nurse to witness the disposal of the new patch.
2. Client receiving heparin continuous IV infusion and warfarin 5 mg PO
daily. Lab values are a PTT 98 seconds and INR 1.8
Withhold the heparin infusion
3. A nurse at an urgent care clinic is assessing a client who reports
impaired vision in one eye . Which indicates the client has a detached
retina
Floating dark spots
4. infant with hydrocephalus 6 hr post op following ventriculoperitoneal
shunt placement . finding to report to provider
Irritability when being held. signifies increased ICP
5. Assessing a newborn heart rate follow actions the nurse should take
Auscultate the apical pulse and count beats for at least 1 min.
6. Caring for a client who has a fecal impaction actions to be taken when
digitally evacuating the stool
Insert a lubricated gloved finger and advance along the rectal wall.
7. Dietary teaching for a new prescription of phenelzine
,Broccoli, Yogurt, Cream Cheese
8. Nurse administers incorrect dose of medication. Which facts related to
incident report should the nurse document in the client's medical
record?
Time the medication was given
9. Nurse on pediatric unit received shift report on 4 children. Which
should the nurse assess first?
A 10-year old child who is awaiting surgery for an appendectomy and experienced
sudden relief of pain. Can indicate peritonitis from a ruptured appendix.
10.Community health nurse providing teaching on home safety for older
adults
Have grab bars installed around your bathtub and toilet.
11.School age child with scald burns on both hands and wrists suspected
abuse
Contact child protective services.
12.Client who has acute blood loss following trauma refuses potentially life
saving blood transfusion
Explore the client's reasons fro refusing the treatment
13.Discussing common prenatal discomfort 20 weeks gestational
I will wear a supportive bra overnight
, 14.Discharge instructions to client to received home oxygen therapy
Wear clothing made with cotton fabrics while oxygen is in use.
15.Preparing an educational session about advocacy to a group of nurses
Advocacy is a leadership role that helps others to self actualize
16.Continuous bladder irrigation following transurethral resection of
prostate. Bladder spasms and decreased urinary output
Irrigate the catheter with 0.9% sodium chloride irrigation
17.Child with sickle cell anemia and is having a vaso-occlusive crisis
Infuse IV fluids
18.Client teaching about the basal body temp method for birth control
Your body temperature might decrease slightly just prior to ovulation
19.Caring for a client who is unconscious and requires emergency medical
procedures. Unable to locate family to obtain consent
Proceed with provision of medical care
20.Client who has fluid volume overload. Which tasks can nurse delegate
to UAP
Measure the client's daily weight
21.Checking for Chvostek's sign
1. Patient refused a newly open fentanyl patch. Which of the following
actions should the nurse take?
Ask another nurse to witness the disposal of the new patch.
2. Client receiving heparin continuous IV infusion and warfarin 5 mg PO
daily. Lab values are a PTT 98 seconds and INR 1.8
Withhold the heparin infusion
3. A nurse at an urgent care clinic is assessing a client who reports
impaired vision in one eye . Which indicates the client has a detached
retina
Floating dark spots
4. infant with hydrocephalus 6 hr post op following ventriculoperitoneal
shunt placement . finding to report to provider
Irritability when being held. signifies increased ICP
5. Assessing a newborn heart rate follow actions the nurse should take
Auscultate the apical pulse and count beats for at least 1 min.
6. Caring for a client who has a fecal impaction actions to be taken when
digitally evacuating the stool
Insert a lubricated gloved finger and advance along the rectal wall.
7. Dietary teaching for a new prescription of phenelzine
,Broccoli, Yogurt, Cream Cheese
8. Nurse administers incorrect dose of medication. Which facts related to
incident report should the nurse document in the client's medical
record?
Time the medication was given
9. Nurse on pediatric unit received shift report on 4 children. Which
should the nurse assess first?
A 10-year old child who is awaiting surgery for an appendectomy and experienced
sudden relief of pain. Can indicate peritonitis from a ruptured appendix.
10.Community health nurse providing teaching on home safety for older
adults
Have grab bars installed around your bathtub and toilet.
11.School age child with scald burns on both hands and wrists suspected
abuse
Contact child protective services.
12.Client who has acute blood loss following trauma refuses potentially life
saving blood transfusion
Explore the client's reasons fro refusing the treatment
13.Discussing common prenatal discomfort 20 weeks gestational
I will wear a supportive bra overnight
, 14.Discharge instructions to client to received home oxygen therapy
Wear clothing made with cotton fabrics while oxygen is in use.
15.Preparing an educational session about advocacy to a group of nurses
Advocacy is a leadership role that helps others to self actualize
16.Continuous bladder irrigation following transurethral resection of
prostate. Bladder spasms and decreased urinary output
Irrigate the catheter with 0.9% sodium chloride irrigation
17.Child with sickle cell anemia and is having a vaso-occlusive crisis
Infuse IV fluids
18.Client teaching about the basal body temp method for birth control
Your body temperature might decrease slightly just prior to ovulation
19.Caring for a client who is unconscious and requires emergency medical
procedures. Unable to locate family to obtain consent
Proceed with provision of medical care
20.Client who has fluid volume overload. Which tasks can nurse delegate
to UAP
Measure the client's daily weight
21.Checking for Chvostek's sign
