PN COMPREHENSIVE ONLINE PRACTICE 2020 FORM A,
B AND C ACTUAL EXAM COMPLETE 450 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY 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 - ANSWER: 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 - ANSWER: 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? - ANSWER: 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? - ANSWER: 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? - ANSWER: 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? - ANSWER: "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? -
ANSWER: "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? - ANSWER: 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? - ANSWER: 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? -
ANSWER: 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? -
ANSWER: 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? - ANSWER: 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? - ANSWER: 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? -
ANSWER: 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? - ANSWER: "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? - ANSWER: Contact
B AND C ACTUAL EXAM COMPLETE 450 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY 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 - ANSWER: 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 - ANSWER: 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? - ANSWER: 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? - ANSWER: 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? - ANSWER: 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? - ANSWER: "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? -
ANSWER: "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? - ANSWER: 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? - ANSWER: 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? -
ANSWER: 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? -
ANSWER: 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? - ANSWER: 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? - ANSWER: 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? -
ANSWER: 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? - ANSWER: "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? - ANSWER: Contact
