RN Comprehensive Online Practice 2023 B
Exam Questions And Correct Answer
A nurse is caring for a client who is on the spinal cord injury
(SCI) unit
Nurses' Notes
,Day 3, 1700
Client admitted to SCI unit 3 days ago following C7 injury. Skin is
cool, pale, and dry to touch. Respirations easy and unlabored.
Lung sounds diminished in lower lobes. Abdomen soft and
nondistended with active bowel sounds. Client passed a small
amount of hard formed stool this AM. Indwelling urinary
catheter draining clear yellow urine. Deep tendon reflexes (DTR)
are biceps 1+, triceps 1+, pa - ✔✔ANSWER✔✔-The client is
most likely experiencing manifestations of pneumonia and
autonomic dysreflexia.
The nurse should analyze cues from the client's manifestations
and determine that the client is most likely experiencing
manifestations of pneumonia and autonomic dysreflexia. A
client who has a cervical SCI is at risk for respiratory
complications because spinal innervation to the respiratory
muscles is disrupted. Adventitious breath sounds in the lower
lobes bilaterally and a decrease in oxygen saturation to less
than 92% can indicate pneumonia. The client's sudden increase
in blood pressure, bradycardia, flushing of the skin above the
area of the injury, headache, and blurred vision are
manifestations of autonomic dysreflexia, which can be a life-
threatening condition.
A nurse is caring for a client who has abdominal 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 10, for 2
days. Client is a perioperative nurse, returned 1 week ago from
a 2-week mission trip to an underdeveloped country
1200
Results of antibody studies obtained. Provider prescription for
antiviral medication pending.
Physical Examination
0930
Lung sounds clear bilaterally. Skin warm to touch and jau -
✔✔ANSWER✔✔-Hepatitis A: Client's risk from fecal-oral
transmission, laboratory results, and physical examination
findings
, Hepatitis C: Antiviral treatment, laboratory results, client's risk
from bloodborne transmission, and physical examination
findings
When analyzing cues, the nurse should recognize that
manifestations of hepatitis A, hepatitis B, and hepatitis C
include jaundice, yellow sclerae, right upper quandrant pain
upon palpation, dark yellow urine, and elevated AST and ALT
levels. When analyzing cues, the nurse should also recognize
the client's risk for contracting hepatitis A through the fecal-oral
route during recent travel to an underdeveloped country and
the client's occupational risk as a perioperative nurse for
contracting hepatitis B and hepatitis C through bloodborne
transmission. The nurse should recognize that the current
standard of practice for
A nurse is caring for a client on a medical-surgical unit
Vital Signs
0700
Temperature 37.6 C (99.7 F)
Heart rate 100/min
Respiratory rate 22/min
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