PN Comprehensive Practice A [2024]
1. A nurse is reinforcing teaching
with a client who is to self-admin-
ister epoetin alfa. Which of the
following
instructions should the nurse in-
clude?
2. A nurse enters the room of
an adolescent client and finds
them on the floor experiencing
a tonic...
PN Comprehensive Practice A [2024]
1. A nurse is reinforcing teaching administer the medication subcuta-
with a client who is to self-admin- neously.
ister epoetin alfa. Which of the
following
instructions should the nurse in-
clude?
2. A nurse enters the room of keep the client in a side-lying position.
an adolescent client and finds
them on the floor experiencing rationale: the nurse should keep the
a tonic-clonic seizure. Which of client in a side-lying position to facilitate
the following actions should the drainage of any secretion and prevent
nurse take when the seizure sub- aspiration
sides?
3. A nurse is caring for a client who the client asks the nurse to help them die
is in the final stages of cancer. peacefully in their sleep.
Which of the following client sit-
uations should the nurse identify rationale: the situation presents and ethi-
as an ethical dilemma? cal issue for the nurse because the client
is asking for a variation of active eu-
thanasia, also known as assisted suicid-
ed, which is in violation of the code of
ethics for nurses. The nurse is legally
and ethically unable to support this de-
cision by the client and should ask for
assistance with this dilemma.
4. A nurse is caring fur a client who the client remains relaxed when thinking
has a phobia elevators, Which of about the phobia.
the following should me nurse
recognize as an indication of a rationale: The purpose of desensitiza-
positive client response to sys- tion therapy is to teach the client to use
tematic: desensitization? relaxation techniques to overcome the
anxiety caused by the phobia The nurse
should recognize the clients lack of anx-
iety when thinking about the phobia as a
positive response to
the therapy.
, PN Comprehensive Practice A [2024]
5. A nurse is checking the reflex- Stroke the sole of the newborn's foot
es of a newborn. Which of the upward and toward the great toe.
following techniques should the
nurse use to elicit the Babinski
reflex?
6. A nurse is reviewing the lab- WBC 25, 000 mm
oratory report of a client who
is 2 days postoperative follow- rationale: The nurse should identify a
ing thoracic surgery. Which of WBC count of 25,000/mm3 is above the
the following laboratory results expected reference range and is an indi-
should the nurse report to the cation that the client might have a post-
provider? operative infection; therefore, the nurse
should report this finding to the provider.
7. A nurse in an urgent care clinic wheeze
is completing a client examina-
tion. After listening to the client's [audio]
lungs, which of the following
adventitious sounds should the rationale: the nurse should document
nurse document? (Click on the this sound as a wheeze. A wheeze is a
audio button to listen to the clip.) high pitched musical sound that is heard
when air moved through narrowed air-
way during either inspiration or expira-
tion.`
8. A nurse is preparing to admin- lets give the medication to your doll first.
ister an 1M immunization to a
preschooler. Which of the follow-
ing statements should the nurse
plan to make prior to performing
the injection?
9. A nurse is reviewing the medical INR 5.0
record of a client who is receiv-
ing warfarin and has atrial fibril- rationale: The international normalized
lation. Which of the following lab- ratio (INR) is a measurement of the
oratory values should the nurse body's blood clotting ability. A client re-
report to the provider? ceiving warfarin to prevent clot formation
, PN Comprehensive Practice A [2024]
related to atrial fibrillation should have
an INR of 2.0 to 3.0. An INR of 5.0 or
greater indicates that the client is at risk
for bleeding. Therefore, the nurse should
notify the provider about this laboratory
value.
Why PT of 18 is wrong: rationale The
prothrombin time (PT) is a measurement
of the body's blood clotting ability. A pro-
longed PT is an indication of prolonged
bleeding. A client receiving warfarin to
prevent clot formation related to atrial
fibrillation should have a PT of 1.3 to 1.5
times the control of 11.0 to 12.5 sec-
onds. The client's PT is 1.4 times the
control value of 12.5 seconds. There-
fore, the nurse does not need to report
this value to the provider.
10. A nurse is caring for a client who ensure the dialysate solution is at room
is scheduled for peritoneal dial- temperature,
ysis. Which Of the following ac-
tions should the nurse take first? rationale: Evidence-based practice indi-
cates the nurse should administer the
dialysate solution at a temperature of
37' C (98.6' F); therefore, the first action
the nurse should take is to warm the
prescribed solution.
11. A nurse is reviewing the critical document the finding as a variance.
pathway of a client who is 4 days
postoperative following a total rationale: Whenever a client does not
knee arthroplasty. The client's vi- meet the goals or outcomes in the crit-
tal signs are oral temperature ical pathway due to unexpected findings
39.10 C (102.40 F), heart rate or a need for additional interventions.
116/min, respiratory rate 24/min, the nurse should document the details
and blood pressure 152/92 mm as a variance in the critical pathway. In
this case. it is a negative variance. If the
, PN Comprehensive Practice A [2024]
Hg. Which of the following ac- client progresses faster than the path-
tions should the nurse take? way specifies, it is a positive variance.
12. A nurse is performing a dressing Yellow green drainage at the incision
change for a client who is 3 days line.
postoperative. Which of the fol-
lowing findings should the nurse rationale: Yellow green purulent or odor-
report to the provider? ous drainage indicates the wound is in-
fected. the nurse should report this find-
ing.
rationale 2: pink incision line with slight
crusting, serosanguineous drainage on
the old dressing, slight swelling around
staples- are all expected finding for the
client
13. A nurse is inspecting the skin of Generalized petechiae
a newborn. Which of the follow-
ing findings should the nurse re- rationale: Petechiae are an expected
port to the provider? finding over the presenting part of the
newborn, such as on the forehead in a
brow presentation, and also anywhere
on the head of newborns who had a
nuchal cord, which is an umbilical cord
around the neck. However, petechiae all
over the newborn's body can indicate
infection or a decreased platelet count
and should be reported to the provider.
14. A nurse is caring for a client who Occupational therapist.
is recovering from a stroke and
is experiencing difficulty using rationale: to teach client how to use spe-
eating utensils. The nurse should cial eating utensils.
identify the need for a referral to
which of the following interpro-
fessional team members?
15. A nurse is assisting with a dis- an infection with gonorrhea can result in
cussion about STIs with a group infertility.
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