Exam (elaborations)
RN Comprehensive online practice 2019 A with NGN-tap 2023/2024 UPDATED
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RN Comprehensive online practice 2019 A with NGN-tap 2023/2024 UPDATED
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RN Comprehensive online practice 2019 Awith NGN-tap
A.) Ask the Caller for verification of their identity
A nurse working on a medical-surgical unit receives a telephone call requesting the status of a
client from an individual who identifies themself as the client's parent. Which of the following
actins should the nurse take?
A.)Ask the caller for verification of their identity
B.) Give the caller limited information about the client
C.) transfer the phone call to the client's room
D.) Inform the caller that they should obtain permission from the client's provider
D.) The client's heel is reddened and tender
A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder
cast for 24 hr. Which of the following assessment findings should the nurse identify as the
priority?
A.) the client reports leg itching under the cast around the mid-upper thigh area
B.) The client reports increased pain when the leg is lowered below the level of the heart
C.) The client's cast became wet during a sponge bath
D.) The client's heel is reddened and tender
B.) Complete a serum pregnancy test before taking the medication
A nurse is teaching a client who is to start taking misoprostol and currently is on long-term
therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following
information?
A.) Increase intake of fluids and fiber to prevent constipation
B.) Complete a serum pregnancy test before taking the medication
C.) This medication coats stomach ulcers so that they can heal
D.) Take a magnesium-containing antacid along with this medication
B.) Nausea
A nurse is teaching a client who has a new prescription for digoxin about manifestations of
toxicity. Which of the following findings should the nurse include in the teaching?
A.) Constipation
,B.) Nausea
C.) Wheezing
D.) Muscle rigidity
C.) Hypertension
A nurse is assessing a client who has obstructive sleep apnea. For which of the following
complications should the nurse monitor?
A.) weight loss
B.) urinary retention
C.) hypertension
D.) hypoglycemia
2.) Remove the Inner Cannula
4.) Remove soiled dressing
1.) Clean the stoma with 0.9% sodium chloride irrigation
3.) Change the tracheostomy collar
A m nurse is providing Teaching to a parent of a child who has a permanent tracheostomy tube.
Identify the sequence of steps the parent should follow to perform tracheostomy care.
Steps:
1.) clean the stoma with 0.9% sodium chloride irrigation
2.) remove the inner cannula
3.)change the tracheostomy collar
4.) remove soiled dressing
D.) Keep the head of the bed elevated to 45 degrees for 1 hour after feedings
A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube.
Which of the following actions by the newly licensed nurse indicates an understanding of the
procedure?
A.) Instill 100mL of air into the NG tube after checking for residual
B.) flushes the NG tube with 0.9% sodium chloride irrigation every 2 hours
C.) Adds 20mL of blue dye to each feeding to help detect aspiration
D.) Keep the head of the bed elevated to 45 degrees for 1 hour after feedings
D.) Mannitol
A nurse is caring for a client who has a closed-head injury and is receiving mechanical
ventilation. The nurse should expect to administer which of the following medications to reduce
intracranial pressure?
,A.) propranolol
B.) phenytoin
C.) lorazepam
D.) mannitol
C.) Places a pillow under the client's right arm
An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the
following actions by the AP requires the nurse to intervene?
A.) uses a draw sheet to move the client to the left side of the bed
B.) Raises the total height of the bed to waist level
C.) places a pillow under the client's right arm
D.) Lowers the side rails on the left side of the bed
A.) "A speech pathologist will performing a swallowing study for you"
B.) "You should rest before eating a meal"
E.) "Thicken your beverages before drinking"
A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis.
Which of the following instructions should the nurse include? (Select all that apply)
A.) "A speech pathologist will performing a swallowing study for you"
B.) "You should rest before eating a meal"
C.) "You should restrict foods that are high in Vitamin D"
D.) "reduce your intake of dietary fiber"
E.) "Thicken your beverages before drinking"
The infant is at highest risk of developing A.) dehydration As evidenced by C.) vomiting
Nurse's Notes:
1500: Infant is admitted to the pediatric unit. Parent reports infant has been irritable and has
vomited after each feeding within the last 3 days. Infant alert, not crying. S1 and S2 noted
without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored.
Abdomen firm. Bowel sounds hypoactive x4 quadrants. Small 1x1 cm2 mass palpated near
umbilicus. Skin warm and dry, turgor with tenting.
1600:
Called to room by a parent. Parent attempted breastfeeding. Infant projectile vomited No bile
noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO.
1800:
Infant crying. Soothed with Pacifier.
Diagnostic Results:
1545:
, Hgb: 20g/dL (14-24) ; Potassium: 5.8mEq/L (3.9-5.9); Na: 132mEq/L (134-150); Chloride: 110
(96-106); WBC: 16,000 (6,200-17,000); BUN: 20 (5-18); Creatinine: 0.2 (0.1-0.4)
1730:
Abdominal ultrasound: Narrowing of pyloric canal. Thickening of pylorus. Consistent with
hypertrophic pyloric stenosis.
Vital Signs:
1500:
Temp: 37.1 (98.8 F); HR: 120; RR: 30; Weight: 3.62 (8lbs)
History and Physical:
Birthweight: 3,492.7g (7.7lbs(); parent is breastfeeding. Newborn birthed vaginally at 38 weeks
of gestation.
The infant is at highest risk for_____________
A.) dehydration
B.) anemia
C.) hyperkalemia
As evidenced by the infant's __________
A.)potassium level
B.) hemoglobin
C.) vomiting
C.) massage the uterus to expel clots
A nurse is caring for a client who is 4 hours postpartum and has a boggy uterus with heavy
lochia. Which of the following actions should the nurse take first?
A.) administer oxygen
B.) initiate an infusion of oxytocin
C.) massage the uterus to expel clots
D.) obtain a CBC
A.) A client's IV pump delivers an inadequate dose of medication
A nurse is caring for a group of clients. For which of the following events should the nurse
complete an incident report?
A) A client's IV pump delivers an inadequate dose of medication
B.) A nurse follows a client's advance directives and discontinues enteral feedings
C.) A nurse discards unused, expired bags of IV fluids
D.) A client refuses an IV bolus of pain medication
A.) Flush the client's gastrostomy tube with 30mL of water before administering the medication
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