Exam (elaborations)
RN Comp Practice 2023 A with latest solution
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- ATI comprehensive predictor
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- ATI Comprehensive Predictor
RN Comp Practice 2023 A with latest solution
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RN Comp Practice 2023 A with latestsolution
NGN: What assessment findings are consistent with Crohn's disease, ulcerative
colitis, or peritonitis?
Temperature (100F)
Weight (-9.7 lbs)
Albumin level (2.4)
WBC (14)
Bowel pattern (freq. loose stools)
Abdominal pain location (RLQ)
Heart rate (105)
Temperature: Crohn's, UC & peritonitis.
-Elevation can occur with all three due to inflammation and infection.
Weight: Crohn's & UC.
-Unintended weight loss can occur due to malabsorption in the GI tract.
Bowel pattern: Crohn's.
-If the patient reported there was blood in the stool, it would be UC. Crohn's
doesn't cause tarry stools.
WBC: Crohn's, UC & peritonitis.
-Elevation can occur due to inflammation and infection.
Heart rate: peritonitis.
-Tachycardia can occur due to inflammation, infection, and dehydration.
Albumin level: Crohn's & UC.
-Because of the malabsorption in the GI tract, the body isn't receiving enough
protein.
,Abdominal pain location: Crohn's.
-Because it is in the RLQ, it is more consistent with Crohn's. With patients that
have peritonitis, they experience generalized abd. pain that radiates to the
shoulder and back.
NGN: What assessment findings can indicate a transfusion reaction in a patient
receiving blood?
Urine output (150mL of clear, yellow)
Skin (pale, cool and dry)
Anxiety
Vital signs (within normal range)
Headache
Back pain
Back pain, headache & anxiety.
Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain,
tachycardia, dyspnea, hypotension.
NGN: Patient arrives with palpitations, difficulty breathing, and reports feeling
faint. Reports constipation and joint pain for x2 days. In childhood, patient
experienced physical abuse, and emotionally detached parents. Reports
nervousness and only leaving home when necessary.
PMH: freq. hospital visits due to headaches and GI distress.
Bowtie:
Condition: somatic symptom disorder
-due to physical inactivity & joint pain
Interventions: Monitor physical manifestations & assess for presence of 2nd
gains from their illness
-disorder is characterized by the presence of other real manifestations like
dizziness, nausea, back pain, and joint pain.
,Monitor: Vital signs & pain.
NGN: What actions should the nurse take when her pedi patient is exhibiting
symptoms of an allergic reaction?
Administer 0.9% NS IV
Administer epi IM
Monitor urine output q2hrs
DC supplemental oxygen
Monitor vital signs frequently
DC IV medication
Administer 0.9% NS IV
Administer epi IM
Monitor vital signs frequently
DC IV medication
-Nurse should DC the Rocephin and give IV NS to help restore fluids because
fluid shifts can occur quickly during a reaction. Administering epi IM is the first
line of therapy for anaphylactic reactions because it constricts blood vessels and
dilates bronchioles. Monitoring vital sings frequently will allow the nurse to
monitor for signs of shock.
NGN: What 5 actions should the nurse plan to take with a patient experiencing
hallucinations, following alcohol withdrawal?
Administer thiamine
Maintain a low-stimulation environment
Administer chlordiazepoxide
Initiate seizure precautions
Perform a CIWA-Ar
Administer disulfiram
Administer thiamine
Maintain a low-stimulation environment
Administer chlordiazepoxide
Initiate seizure precautions
, Perform a CIWA-Ar
-Nurse should plan interventions that keep the patient safe and treat the physical
manifestations of withdrawal. Use the CIWA-Ar to determine the severity of the
withdrawal. Withdrawal seizures can occur 12-24hrs after cessation of alcohol
use, therefore initiate seizure precautions to prevent injury. Administer
chlordiazepoxide (a benzodiazepine) and place patient in a low-stim environment
to decrease agitation and the risk for seizures. Administering thiamine can
prevent Wernicke syndrome.
NGN: A post-op patient is experiencing right lower extremity pain and itching,
following an emergent appy. Reports right lower extremity pain that has been
intermittent for x2 months.
Assessment: Bilat lower extremities warm to touch, pedal pulses 2+ bilat. Spider
veins noted. Distended veins noted on right lower extremity. Vital signs are within
normal limits.
Bowtie:
Condition: Varicose veins.
-due to edema & pruritis
Interventions: Elevate extremity & apply compression stockings
-to promote venous return & circulation
Monitor: Pruritis & edema
NGN: Which assessment findings require an immediate follow-up in a
schizophrenic patient?
Hyperactive bowel sounds x4
Last HCP appointment was 6 months ago
Client AO x2
Agitated
Speech disorganized
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