PN Comprehensive Online Practice
2023 A/150 Questions with solved
answers/Graded A+
A nurse is assisting in the care of a client who is 1 hr postpartum.
Exhibit 1
Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two
fingerbreadths above the umbilicus.Oxytocin 20 units being administered via
continuous IV infusion
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling
anxious. Skin cool and clammy. Provider notified.
Exhibit 2
Vital Signs
1200:
Temperature 37.5° C (99.5° F)Heart rate 92/minRespiratory - -Select the 6 actions
the nurse should take.
Weigh the perineal pads.
Insert an indwelling urinary catheter.
Administer methylergonovine.
Provide emotional support.
Administer oxygen at 12 L/min via nonrebreather face mask.
Firmly massage the uterine fundus.
When taking action for the client, the nurse should firmly massage the uterine
fundus, administer methylergonovine, weigh the perineal pads, provide emotional
support, insert an indwelling urinary catheter, and administer oxygen at 12 L/min
via nonrebreather face mask. The nurse should identify that the client is
experiencing a postpartum hemorrhage, which requires immediate intervention to
prevent hemorrhagic shock.
-A nurse is collecting data from a client who is scheduled for surgery.
Exhibit 1
Vital Signs
0630:
Temperature 36.9° C (98.5° F)Heart rate 74/minRespiratory rate 20/minBlood
pressure 122/76 mmHgOxygen saturation 96% on room air
0730:
Temperature 36.9° C (98.5° F)Heart rate 76/minRespiratory rate 20/minBlood
pressure 128/78 mmHgOxygen saturation 95% on room air
Exhibit 2
Nurses' Notes
0630:
,Client reports restlessness and inability to sleep more than 3 to 4 hr per night for
the last week. Cli - -Click to highlight the data collection findings that the nurse
should report to the provider prior to the procedure. To deselect a finding, click on
the finding again.
Hemoglobin level
Allergy
Family history
When collecting data from the client and analyzing cues, the nurse should
determine the client's hemoglobin level, latex allergy, and family history of
malignant hyperthermia should be reported to the provider. When the client's
hemoglobin level is below the expected range, the client might require blood
products during the intraoperative phase. The client's allergy to avocados and
bananas can indicate an allergy to latex products and should be reported to the
provider. The surgical team will need to remove all latex products from the
operating room. During the intraoperative phase, the nurses must be diligent in
monitoring the client's vital signs and laboratory values, especially in a client who
has a family history of malignant hyperthermia.
-A nurse is caring for a client who is recovering from a stroke and is experiencing
difficulty using eating utensils. The nurse should identify the need for a referral to
which of the following interprofessional team members? - -Occupational therapist
The nurse should identify the need for a referral to an occupational therapist to
teach the client how to use special eating utensils.
-A nurse is reviewing the electronic health records of four clients. Which of the
following client conditions should the nurse recognize as reportable to a regulatory
agency? - -A client who is newly diagnosed with tuberculosis
The nurse should identify that certain communicable diseases, such as
tuberculosis, require notification of the local and state health departments.
-A nurse is caring for a client who is being discharged home following a
cerebrovascular accident. Which of the following documents should the nurse plan
to include with the discharge report? - -List of potential complications to report
Discharge instructions are defined as any form of documentation provided to the
client, upon discharge to home, which facilitates safe and appropriate continuity of
care. The nurse should plan to include a list of potential complications that should
be reported to the provider in the client's discharge instructions.
-A nurse is reinforcing teaching with the parent of a preschooler who has lactose
intolerance. Which of the following statements by the parent indicates an
understanding of the teaching? - -"I should offer my child yogurt that has a
probiotic as a snack."
,Children who have lactose intolerance should be offered dairy products that have a
probiotic, such as lactobacillus. The probiotic promotes tolerance of lactose in the
colon.
-A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus.
Which of the following client statements indicates an understanding of the
teaching? - -"I should check my blood sugar if my appetite is decreased."
The nurse should instruct the client to monitor blood glucose levels closely.
Change in appetite can be an early sign of hyperglycemia and inadequate intake
may cause blood glucose to drop.
-A nurse is collecting data from a client who has iron deficiency anemia. Which of
the following findings should the nurse expect? - -Difficulty concentrating
In clients who have iron deficiency anemia, body cells do not receive the required
oxygen because there is less hemoglobin for binding. The nurse should recognize
that impaired oxygenation of brain tissue can lead to dizziness and difficulty
concentrating.
-A nurse is caring for a client who is immunocompromised. Which of the following
immunizations is contraindicated? - -Measles, mumps, and rubella (MMR)
The MMR vaccine consists of a live virus and is contraindicated for a client who is
immunocompromised.
-A nurse is caring for a client who has expressive aphasia following a stroke.
Which of the following methods should the nurse use when communicating with
the client? - -Provide a picture board.
A client who has expressive aphasia has difficulty expressing needs or wants
through verbalization or writing. The use of a picture board provides an alternative
means of communication that might be less frustrating for the client.
-A nurse is preparing to administer insulin to a client who has type 1 diabetes
mellitus. After drawing up the medication, the nurse accidentally brushes the
needle on the counter's surface. Which of the following actions should the nurse
take? - -Prepare a new dose of insulin for injection.
Insulin is administered using an insulin syringe with a preattached needle.
Therefore, to ensure the sterility of the needle, the nurse should prepare a new
dose of insulin for injection using a new syringe and new dose of insulin.
-A nurse is checking the reflexes of a newborn. Which of the following techniques
should the nurse use to elicit the Babinski reflex? - -Stroke the sole of the
newborn's foot upward and toward the great toe.
The nurse should stroke upward along the lateral aspect of the sole of the foot,
beginning at the heel, to elicit the Babinski reflex.
, -A nurse is administering morning medications to a client. The client questions
the nurse regarding a medication that they do not recognize. Which of the
following actions should the nurse take first? - -Verify the prescription in the
client's medical record.
The first action the nurse should take when using the nursing process is to collect
more data. By verifying the prescription in the client's medical record, the nurse
can ensure that the medication is prescribed for the client.
-A client in a mental health facility accuses a nurse of stealing money from their
room. Which of the following therapeutic responses should the nurse make? - -Tell
me how you decided who took your money."
This response by the nurse is an example of therapeutic communication, in which
the nurse validates the client's concern by encouraging them to describe their
perception
-A nurse is reinforcing teaching for a client who is preparing to return to work
after a back injury. Which of the following instructions for safe lifting technique
should the nurse include? - -"You should hold a box close to your body when lifting
it up."
The client should hold the box as close to their body as possible to maintain
balance and prevent injury.
-A nurse is instructing an assistive personnel (AP) about caring for a client who
has hepatitis A and is incontinent of stool. Which of the following infection control
precautions should the nurse instruct the AP to use? - -Contact
Hepatitis A is spread by the fecal-oral route. Standard precautions are usually
sufficient to prevent the spread of infection. However, if the client who has
hepatitis A is also incontinent of stool, then contact precautions are indicated.
-A nurse is collecting data from a client who has multiple sclerosis. Which of the
following findings should the nurse expect? - -Ataxia
The nurse should expect a client who has multiple sclerosis to manifest ataxia,
which is a lack of coordination and movement. Other manifestations include
fatigue, impaired memory, diplopia, and bowel and bladder incontinence.
-A nurse is caring for a client who is crying and states their provider informed
them that they have a tumor and will need a biopsy. Which of the following
responses should the nurse make? - -"What have you done to help yourself get
through stressful situations before?"
2023 A/150 Questions with solved
answers/Graded A+
A nurse is assisting in the care of a client who is 1 hr postpartum.
Exhibit 1
Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two
fingerbreadths above the umbilicus.Oxytocin 20 units being administered via
continuous IV infusion
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling
anxious. Skin cool and clammy. Provider notified.
Exhibit 2
Vital Signs
1200:
Temperature 37.5° C (99.5° F)Heart rate 92/minRespiratory - -Select the 6 actions
the nurse should take.
Weigh the perineal pads.
Insert an indwelling urinary catheter.
Administer methylergonovine.
Provide emotional support.
Administer oxygen at 12 L/min via nonrebreather face mask.
Firmly massage the uterine fundus.
When taking action for the client, the nurse should firmly massage the uterine
fundus, administer methylergonovine, weigh the perineal pads, provide emotional
support, insert an indwelling urinary catheter, and administer oxygen at 12 L/min
via nonrebreather face mask. The nurse should identify that the client is
experiencing a postpartum hemorrhage, which requires immediate intervention to
prevent hemorrhagic shock.
-A nurse is collecting data from a client who is scheduled for surgery.
Exhibit 1
Vital Signs
0630:
Temperature 36.9° C (98.5° F)Heart rate 74/minRespiratory rate 20/minBlood
pressure 122/76 mmHgOxygen saturation 96% on room air
0730:
Temperature 36.9° C (98.5° F)Heart rate 76/minRespiratory rate 20/minBlood
pressure 128/78 mmHgOxygen saturation 95% on room air
Exhibit 2
Nurses' Notes
0630:
,Client reports restlessness and inability to sleep more than 3 to 4 hr per night for
the last week. Cli - -Click to highlight the data collection findings that the nurse
should report to the provider prior to the procedure. To deselect a finding, click on
the finding again.
Hemoglobin level
Allergy
Family history
When collecting data from the client and analyzing cues, the nurse should
determine the client's hemoglobin level, latex allergy, and family history of
malignant hyperthermia should be reported to the provider. When the client's
hemoglobin level is below the expected range, the client might require blood
products during the intraoperative phase. The client's allergy to avocados and
bananas can indicate an allergy to latex products and should be reported to the
provider. The surgical team will need to remove all latex products from the
operating room. During the intraoperative phase, the nurses must be diligent in
monitoring the client's vital signs and laboratory values, especially in a client who
has a family history of malignant hyperthermia.
-A nurse is caring for a client who is recovering from a stroke and is experiencing
difficulty using eating utensils. The nurse should identify the need for a referral to
which of the following interprofessional team members? - -Occupational therapist
The nurse should identify the need for a referral to an occupational therapist to
teach the client how to use special eating utensils.
-A nurse is reviewing the electronic health records of four clients. Which of the
following client conditions should the nurse recognize as reportable to a regulatory
agency? - -A client who is newly diagnosed with tuberculosis
The nurse should identify that certain communicable diseases, such as
tuberculosis, require notification of the local and state health departments.
-A nurse is caring for a client who is being discharged home following a
cerebrovascular accident. Which of the following documents should the nurse plan
to include with the discharge report? - -List of potential complications to report
Discharge instructions are defined as any form of documentation provided to the
client, upon discharge to home, which facilitates safe and appropriate continuity of
care. The nurse should plan to include a list of potential complications that should
be reported to the provider in the client's discharge instructions.
-A nurse is reinforcing teaching with the parent of a preschooler who has lactose
intolerance. Which of the following statements by the parent indicates an
understanding of the teaching? - -"I should offer my child yogurt that has a
probiotic as a snack."
,Children who have lactose intolerance should be offered dairy products that have a
probiotic, such as lactobacillus. The probiotic promotes tolerance of lactose in the
colon.
-A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus.
Which of the following client statements indicates an understanding of the
teaching? - -"I should check my blood sugar if my appetite is decreased."
The nurse should instruct the client to monitor blood glucose levels closely.
Change in appetite can be an early sign of hyperglycemia and inadequate intake
may cause blood glucose to drop.
-A nurse is collecting data from a client who has iron deficiency anemia. Which of
the following findings should the nurse expect? - -Difficulty concentrating
In clients who have iron deficiency anemia, body cells do not receive the required
oxygen because there is less hemoglobin for binding. The nurse should recognize
that impaired oxygenation of brain tissue can lead to dizziness and difficulty
concentrating.
-A nurse is caring for a client who is immunocompromised. Which of the following
immunizations is contraindicated? - -Measles, mumps, and rubella (MMR)
The MMR vaccine consists of a live virus and is contraindicated for a client who is
immunocompromised.
-A nurse is caring for a client who has expressive aphasia following a stroke.
Which of the following methods should the nurse use when communicating with
the client? - -Provide a picture board.
A client who has expressive aphasia has difficulty expressing needs or wants
through verbalization or writing. The use of a picture board provides an alternative
means of communication that might be less frustrating for the client.
-A nurse is preparing to administer insulin to a client who has type 1 diabetes
mellitus. After drawing up the medication, the nurse accidentally brushes the
needle on the counter's surface. Which of the following actions should the nurse
take? - -Prepare a new dose of insulin for injection.
Insulin is administered using an insulin syringe with a preattached needle.
Therefore, to ensure the sterility of the needle, the nurse should prepare a new
dose of insulin for injection using a new syringe and new dose of insulin.
-A nurse is checking the reflexes of a newborn. Which of the following techniques
should the nurse use to elicit the Babinski reflex? - -Stroke the sole of the
newborn's foot upward and toward the great toe.
The nurse should stroke upward along the lateral aspect of the sole of the foot,
beginning at the heel, to elicit the Babinski reflex.
, -A nurse is administering morning medications to a client. The client questions
the nurse regarding a medication that they do not recognize. Which of the
following actions should the nurse take first? - -Verify the prescription in the
client's medical record.
The first action the nurse should take when using the nursing process is to collect
more data. By verifying the prescription in the client's medical record, the nurse
can ensure that the medication is prescribed for the client.
-A client in a mental health facility accuses a nurse of stealing money from their
room. Which of the following therapeutic responses should the nurse make? - -Tell
me how you decided who took your money."
This response by the nurse is an example of therapeutic communication, in which
the nurse validates the client's concern by encouraging them to describe their
perception
-A nurse is reinforcing teaching for a client who is preparing to return to work
after a back injury. Which of the following instructions for safe lifting technique
should the nurse include? - -"You should hold a box close to your body when lifting
it up."
The client should hold the box as close to their body as possible to maintain
balance and prevent injury.
-A nurse is instructing an assistive personnel (AP) about caring for a client who
has hepatitis A and is incontinent of stool. Which of the following infection control
precautions should the nurse instruct the AP to use? - -Contact
Hepatitis A is spread by the fecal-oral route. Standard precautions are usually
sufficient to prevent the spread of infection. However, if the client who has
hepatitis A is also incontinent of stool, then contact precautions are indicated.
-A nurse is collecting data from a client who has multiple sclerosis. Which of the
following findings should the nurse expect? - -Ataxia
The nurse should expect a client who has multiple sclerosis to manifest ataxia,
which is a lack of coordination and movement. Other manifestations include
fatigue, impaired memory, diplopia, and bowel and bladder incontinence.
-A nurse is caring for a client who is crying and states their provider informed
them that they have a tumor and will need a biopsy. Which of the following
responses should the nurse make? - -"What have you done to help yourself get
through stressful situations before?"
