NACE PN TO RN EXAM WITH COMPLETE SOLUTIONS

To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following? - ANSWER Correct Answer: Organs The purpose of deep palpation, in which the nurse indents the client's skin approximately 1-1/2", is to assess underlying organs and structures such as the kidneys and spleen. Skin turgor, hydration, and temperature can be assessed using light touch or light palpation. A client is brought to the emergency department and the physician determines he has gastrointestinal (GI) bleeding. In planning for his care, which of the following would be first priority? - ANSWER The Correct answer is: assessment of vital signs Vital sign assessment would be the priority nursing intervention. This would provide an indication of the amount of blood loss that has occurred and also provide a baseline by which to monitor the progress of treatment. The other answers (b, c, and d) are important but not priority actions. When providing instructions to the adolescent regarding physical development of her body, the RN should do all of the following EXCEPT - ANSWER Correct Answer: Discuss the importance of avoiding social events in order to stay out of trouble. Socialization is very important to teenagers and is a normal part of their development. The other answers (b, c, and d) are all accurate instructions and discussions for the adolescent regarding development. The nurse is developing discharge plans for a 65-year-old client. The discharge plans indicate the client will be discharged home with home health nursing care. The nurse provides the home health agency with details regarding the needs of the patient. The nurse made which of the following to the home health agency? - ANSWER Correct answer: A referral. A referral is recommending home care services or giving information to an home care service regarding the client and the client's needs. Typically the sources of referral to a home care agency are family members, nurses, physicians, social workers, discharge planners or therapists. Which of the following is the normal serum electrolyte level for magnesium? - ANSWER Correct answer: 1.6 to 2.4 mEq/L The school nurse is approached by a mother who explains that her kindergarten child is constantly scratching the perianal area and that the area is irritated. The RN understands that she should instruct the mother to obtain a rectal specimen by a tape test and that the mother should obtain the specimen when? - ANSWER The Correct answer is: in the morning, when the child awakens Visualization of pinworms by means of a tape test is necessary for the diagnosis. Transparent tape is lightly touched to the anus and then applied to a slide for microscopic examination. The best specimen is obtained as the child awakens, before toileting or bathing.