RN Comprehensive Online Practice 2025
B
A nurse is worrying for a 5-year-old child
Physical Examination:
1510:
Upon visual inspection, throat is infected, tonsils appear crimson, reddened and epiglottis is
edematous and cherry crimson in appearance. Skin seems light. Stridor referred to upon notion
with dwindled bilateral lung sounds.
Nurse's Notes:
1500
Child accompanied to emergency department by using caregiver. Caregiver states infant has a
sore throat and reviews the kid has "pain on swallowing" and denies cough. Child is agitated
and lean - ANSCondition: Epiglottis
Actions: Initiate droplet precautions and request a prescription for IV antibiotics
Monitors: Breath sounds and temperature
The nurse must count on initiating droplet precautions and requesting a prescription for IV
antibiotics. The baby is most likely experiencing epiglottis because of the clinical manifestations
of a excessive fever, irritation and redness of the throat, pale pores and skin, stridor with idea,
painful swallowing, no cough, is sitting in tripod role, and drooling. The nurse must display the
kid's temperature and breath sounds.
A nurse is being concerned for a customer who is at the spinal cord harm (SCI) unit
Nurses' Notes
Day three, 1700
Client admitted to SCI unit 3 days in the past following C7 damage. Skin is cool, pale, and dry to
touch. Respirations clean and unlabored. Lung sounds faded in lower lobes. Abdomen smooth
and nondistended with energetic bowel sounds. Client exceeded a small amount of hard
fashioned stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon
reflexes (DTR) are biceps 1+, triceps 1+, pa - ANSThe client is most in all likelihood
experiencing manifestations of pneumonia and autonomic dysreflexia.
The nurse ought to analyze cues from the consumer's manifestations and determine that the
consumer is most likely experiencing manifestations of pneumonia and autonomic dysreflexia. A
consumer who has a cervical SCI is at chance for respiratory complications due to the fact
,spinal innervation to the respiration muscles is disrupted. Adventitious breath sounds in the
decrease lobes bilaterally and a decrease in oxygen saturation to much less than ninety two%
can suggest pneumonia. The purchaser's sudden increase in blood stress, bradycardia, flushing
of the skin above the place of the injury, headache, and blurred vision are manifestations of
autonomic dysreflexia, which may be a existence-threatening condition.
A nurse is being concerned for a customer who has belly pain
Nurses' Notes
0900
Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports abdominal pain, 6 on
a scale from 0 to ten, for two days. Client is a perioperative nurse, lower back 1 week in the past
from a 2-week mission ride to an underdeveloped united states of america
1200
Results of antibody studies acquired. Provider prescription for antiviral medicine pending.
Physical Examination
0930
Lung sounds clear bilaterally. Skin warm to the touch and jau - ANSHepatitis A: Client's hazard
from fecal-oral transmission, laboratory outcomes, and bodily examination findings
Hepatitis B: Antiviral remedy, laboratory results, purchaser's chance from bloodborne
transmission, physical exam findings
Hepatitis C: Antiviral remedy, laboratory results, consumer's hazard from bloodborne
transmission, and physical exam findings
When analyzing cues, the nurse should understand that manifestations of hepatitis A, hepatitis
B, and hepatitis C include jaundice, yellow sclerae, proper higher quandrant pain upon
palpation, dark yellow urine, and extended AST and ALT stages. When reading cues, the nurse
need to also recognize the patron's chance for contracting hepatitis A thru the fecal-oral course
for the duration of current travel to an underdeveloped u . S . And the customer's occupational
danger as a perioperative nurse for contracting hepatitis B and hepatitis C thru bloodborne
transmission. The nurse should recognize that the modern-day preferred of practice for
A nurse is being concerned for a customer on a scientific-surgical unit
Vital Signs
0700
Temperature 37.6 C (99.7 F)
Heart fee a hundred/min
Respiratory rate 22/min
Blood pressure 115/70 mmHg
,Oxygen saturation ninety eight% on room air
Nurses' Notes
1100
Client alert and oriented to individual, vicinity, and time. Client had episode of diarrhea,
furnished perineal care. Noted 2 cm x 2 cm (zero.Eight in x 0.Eight in) painful edematous region
on sacrum. Client repositioned each four hr. - ANSClick to focus on the findings that require
follow up. To deselect a locating, click at the finding again.
- Noted 2 cm x 2 cm (zero.8 in x 0.Eight in) painful edematous vicinity on sacrum
- Client repositioned every 4 hr
When spotting cues, the nurse ought to decide that the purchaser's painful edematous area on
their sacrum and that the consumer has only been repositioned every 4 hr calls for observe up.
The client has manifestations of a strain injury that need to be addressed. The client must be
repositioned at the least every 2 hr to save you worsening of the strain injury and to alleviate
pressure from the sacral area.
A nurse in an outpatient intellectual fitness clinic is being concerned for a client
Vital Signs
3 months in the past
Blood strain 116/68 mmHg
Heart charge 82/min
Respiratory price sixteen/min
Temperature 36.7 C (98.1 F)
SaO2 97% on room air
Today:
Blood pressure 128/seventy six mmHg
Heart rate 104/min
Respiratory fee 22/min
Temperature 37.4 (99.Four F)
SaO2 97% on room air
Nurses' Notes
three months ago
Client lately admitted with new prognosis of schizophrenia. Received inpatient remedy for 10
days and changed into discharged 1 week ago. - ANSSelect the three findings that require
instantaneous observe up:
- Auditory hallucinations
- Speech
- Restlessness
, When spotting cues, the nurse must pick out that the findings of restlessness, auditory
hallucinations, and pressured speech require on the spot observe up. These findings are
symptoms of psychosis. The nurse ought to notify the provider for additional evaluation and
treatment.
A nurse is being concerned for a consumer who's postoperative following coronary artery skip
surgical procedure (CABG)
Laboratory Results
0630
Sodium a hundred forty five mEq/L (136 to one hundred forty five mEq/L)
Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
Chloride 116 mEq/L (98 to 106 mEq/L)
BUN 24 mg/dL (10 to 20 mg/dL)
Magnesium 1.5 mEq/L (1.Three to 2.1 mEq/L)
Total calcium nine mg/dL (9 to ten.5 mg/dL)
Phosphate 4.6 mg/dL (three to 4.Five mg/dL)
Glucose 95 mg/dL (74 to 106 mg/dL)
WBC be counted nine,500/mm3 (5,000 to 10,000/mm3)
I&O
0700
4 hr input 400 mL
4 hr output - ANSThe client is at finest threat for developing dysrhythmias, as evidenced by
electrolyte imbalance.
The nurse have to analyze cues to decide the consumer is at best danger for developing
dysrhythmias associated with hypokalemia, as evidenced through the laboratory document and
the customer's record of muscle cramping. Potassium and magnesium depletion are not
unusual manifestations in clients who're postoperative following CABG. Due to medication or
hemodilation, it is vital for the nurse to carefully screen electrolytes.
A nurse is being concerned for a consumer who is pregnant in the extreme care putting
Nurses' Notes
1400
Client reviews a constant low stupid backache and painless abdominal tightening for the past
three hr. Denies any modifications in vaginal discharge. External fetal screen carried out.
1430
Contraction sample: contractions each 4 to 5 min, lasting 30 to 45 seconds, palpate mild in
intensity
Fetal coronary heart fee: one hundred fifty/min to 155/min, slight variability, good enough
accelerations present, no decelerations stated. Provider in - ANSThe nurse ought to first