RN Comp Practice 2023 A/ Actual Exam Questions with
Complete Definitive Answers & Rationales/ Updated 2025
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Terms in this set (148)
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.
NGN: What assessment findings are consistent -If the patient reported there was blood in the stool, it would be UC. Crohn's doesn't cause
with Crohn's disease, ulcerative colitis, or tarry stools.
peritonitis?
WBC: Crohn's, UC & peritonitis.
Temperature (100F) -Elevation can occur due to inflammation and infection.
Weight (-9.7 lbs)
Albumin level (2.4) Heart rate: peritonitis.
WBC (14) -Tachycardia can occur due to inflammation, infection, and dehydration.
Bowel pattern (freq. loose stools)
Abdominal pain location (RLQ) Albumin level: Crohn's & UC.
Heart rate (105) -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 Back pain, headache & anxiety.
transfusion reaction in a patient receiving
blood? Hemolytic reaction S/S: back pain, headache, anxiety, fever, chills, chest pain, tachycardia, dyspnea,
hypotension.
Urine output (150mL of clear, yellow)
Skin (pale, cool and dry)
Anxiety
Vital signs (within normal range)
Headache
Back pain
NGN: Patient arrives with palpitations, Condition: somatic symptom disorder -due to
difficulty breathing, and reports feeling faint. physical inactivity & joint pain
Reports constipation and joint pain for x2
days. In childhood, patient experienced Interventions: Monitor physical manifestations & assess for presence of 2nd gains from their
physical abuse, and emotionally detached illness
parents. Reports nervousness and only leaving -disorder is characterized by the presence of other real manifestations like dizziness, nausea,
home when necessary. back pain, and joint pain.
PMH: freq. hospital visits due to headaches
and GI distress. Monitor: Vital signs & pain.
Bowtie:
NGN: What actions should the nurse take Administer 0.9% NS IV
when her pedi patient is exhibiting symptoms Administer epi IM
of an allergic reaction? Monitor vital signs frequently DC IV
medication
Administer 0.9% NS IV
Administer epi IM -Nurse should DC the Rocephin and give IV NS to help restore fluids because fluid shifts can
Monitor urine output q2hrs 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.
DC supplemental oxygen
Monitoring vital sings frequently will allow the nurse to monitor for signs of shock.
Monitor vital signs frequently
DC IV medication
Administer thiamine
Maintain a low-stimulation environment
NGN: What 5 actions should the nurse plan to Administer chlordiazepoxide
take with a patient experiencing Initiate seizure precautions Perform a
hallucinations, following alcohol withdrawal? CIWA-Ar
Administer thiamine -Nurse should plan interventions that keep the patient safe and treat the physical
Maintain a low-stimulation environment 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
Administer chlordiazepoxide
seizure precautions to prevent injury. Administer chlordiazepoxide (a benzodiazepine) and
Initiate seizure precautions place patient in a low-stim environment to decrease agitation and the risk for seizures.
Perform a CIWA-Ar Administering thiamine can prevent Wernicke syndrome.
Administer disulfiram
,NGN: A post-op patient is experiencing right Condition: Varicose veins.
lower extremity pain and itching, following an -due to edema & pruritis
emergent appy. Reports right lower extremity
pain that has been intermittent for x2 months. Interventions: Elevate extremity & apply compression stockings
-to promote venous return & circulation
Assessment: Bilat lower extremities warm to
touch, pedal pulses 2+ bilat. Spider veins Monitor: Pruritis & edema
noted. Distended veins noted on right lower
extremity. Vital signs are within normal limits.
Bowtie:
NGN: Which assessment findings require an Involuntary tongue movement and foot tremor
immediate follow-up in a schizophrenic Frequent urination and incontinence
patient? Increase in agitation
Hyperactive bowel sounds x4 -Patient is experiencing tardive dyskinesia
Last HCP appointment was 6 months ago
Client AO x2
Agitated
Speech disorganized
Involuntary tongue movement and foot tremor
Increase in urination and one episode of
incontinence
Family c/o increased agitation and delusions
A home health nurse is evaluation a school- C. "My child has only a small amount of mucus after percussion therapy."
age child who has cystic fibrosis. The nurse
should initiate a request for a high-frequency -The nurse should recommend a high-frequency vest for a child who has inadequate results
chest compression vest in response to which from other airway clearance therapy techniques. Older children often require other
of the following parent statements? techniques in addition to percussion and postural drainage to achieve adequate mucus
expectoration.
A. "My child doesn't like to
sit still fornebulizer -The nurse should teach the parent techniques for administration for nebulizer treatments to the
treatments." child.
B. "I think that my child
has been running afever -The nurse should follow-up on reports of fever, as this could indicate a pulmonary
over the last couple of
infection.
days." C. "My child only has
a small amount of mucus
after percussion therapy." D. -The nurse should discuss participation in sports activities in relation to the child's current physical
"I am concerned about my and pulmonary health.
child's future participation
in team sports."
, NGN: A patient who is x2 post-op, following a Condition: Intestinal obstruction
surgical repair of a left hip fracture, is c/o of -bowel sounds hypoactive x4, last BM was 5 days prior, intermittent to constant pain.
intermittent abdominal pain. Rates 5/10 on
left side of abdomen. Pain began after eating Interventions: Assist patient in semi-Fowler's & prepare to administer IV fluids. -to
dinner. Last bowel movement was 5 days prior. relieve the pressure from the distention and reduce risk of developing
Reports usual pattern is x1 daily. fluid/electrolyte imbalance.
Assessment: Abdomen distended, dull to Monitor: Bowel sounds & urine output.
percussion, firm and non-tender on
palpation. Hypoactive bowel sounds x4.
Vital signs are within normal limits.
Bowtie:
A nurse is caring for a patient who has a new B. Dry mouth
prescription for clonidine. The nurse should
inform the patient that which of the following -Clonidine is an indirect-acting anti-adrenergic agent used for HTN, severe pain, and ADD. Dry
findings is an adverse effect of this mouth (or xerostomia) is common.
medication?
-Constipation, dry eyes, and rashes are common adverse effects.
A. Diarrhea
B. Dry mouth
C. Photophobia
D. Bruising
A nurse caring for a patient who had a recent B. Assess the patient for functional limitations.
stroke. Prior to transferring the patient to the
bedside commode, which of the following -When using the nursing process, the first action the nurse should take is to assess the
actions should the nurse take first? patient's functional limitations to determine how much the patient can assist with the
transfer.
A. Ask for help with a two-person
assisttransfer.
B. Assess the patient for
functionallimitations.
C. Request a mechanical lift device.
D. Medicate the patient for pain.
