RN Comp Practice 2023 A

A nurse is caring for a patient who is in labor at 39wks of gestation. During the second stage of labor, the nurse observes early decels on the monitor tracing. Which of the following actions should the nurse take? A. Continue observing the FHR. B. Assist the patient to a knee-chest position. C. Prepare the patient for continuous internal monitoring. D. Prepare for an emergency C-sect

A. Continue observing the FHR -Early decels indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the FHR and tracing. -Assist the patient into a knee-chest position if the umbilical cord prolapses. -No indication for internal monitoring. -Prepare for an emergency c-sect if the monitor indicates late/variable decels, despite interventions.

A nurse in the ER is assessing a preschooler with facial lacerations. Which is an indication of potential child sexual maltreatment? A. Exhibits discomfort while walking B. Thin extremities C. Bruises on the upper back D. Wearing a stained shirt

A. Exhibits discomfort while walking -Neglect: wearing stained shirt and having thin extremities -Maltreatment: Bruises on upper back

A nurse is caring for a patient who is hard of hearing. What can the nurse do to improve communication? A. Reduce environmental stimuli B. Provide written material at an 8th grade reading level C. Provide interpretation services over the phone D. Use exaggerated lip movements when speaking

A. Reduce environmental stimuli -Excessive stimuli in the environment can increase sensory alterations. -Provide written materials that are a 5th grade reading level -Provide face-to-face communication to improve understanding -Avoid using exaggerated lip movements

A nurse working on an impatient mental heath unit is caring for a patient who is experiencing active suicidal ideations. What should the nurse do to ensure a safe patient care environment? A. Serve meals with plastic utensils B. Monitor patient for 30 min following meals C. Observe patient q15 min D. Provide patient with brightly lit environment

A. Serve meals with plastic utensils -Better alternative to metal utensils -Observe patient continuously

A nurse is assessing a newborn who is 2hrs-old. What finding should be reported to HCP? A. Slightly blue hands and feet B. Respiratory rate 40 C. Ax. temp 97.2F D. Apical pulse 136

C. Ax. temp 97.2F -Expected range is 97.7-99.5F. Below the range indicated cold stress and should be reported.

A nurse is planning care for a patient with cranial nerve II deficit. What should be included in the plan? A. Keep the patient resting in bed B. Ask the patient to restate directions C. Clear object from patient's walking area D. Evaluate the patient's ability to swallow

C. Clear the object from the patient's walking area -CN II deficit results in visual impairment.

A nurse is caring for a patient who has MRSA in an abdominal wound. Which precautions are appropriate? A. Airborne B. Droplet C. Contact D. Protective environment

C. Contact -MRSA spreads by direct contact

NGN: A nurse is caring for a patient with bulimia. Reports feeling excessively tired and light-headed. What is the patient at risk for developing?

Hyponatremia & cardiovascular abnormalities. -Due to chronic vomiting.

NGN: Performing an abdominal assessment

1. Inspection 2. Auscultation 3. Percussion 4. Palpation

A nurse is caring for a newborn whose parents asks why the baby is receiving vitamin K. The nurse should explain to the parents that the newborn is receiving vitamin K to prevent what? A. Bleeding B. Potassium deficiency C. Infection D. Hyperbilirubinemia

A. Bleeding -Vitamin K helps clotting factors.

A nurse is reviewing the lab results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect? (Normal: 30-40 sec) A. 11 seconds B. 22 seconds C. 30 seconds D. 45 seconds

D. 45 seconds -A manifestation of hemophilia A is a longer clotting time.

A nurse is caring for an older patient. Which is a normal physiological change associated with aging? A. Decreased blood pressure B. Increased cardiac output C. Increased oral temp D. Decreased lung expansion

D. Decreased lung expansion -Due to decreased mobility of the ribs. -Other normal changes: increased SBP but regular DBP, decreased cardiac output and decreased oral temp.

A nurse is caring for a patient who is becoming agitated. Which attempting to deescalate, what should the nurse do first? A. Observe the patient and the situation B. Respect the patient's personal space C. Give the patient several clear options D. Select a quiet location to talk to the patient while remaining visible to staff members

A. Observe the patient and the situation -When using the nursing process priority framework, the first action the nurse should take is to assess and observe the patient and situation. This action affords the nurse the opportunity to implement the best deescalation techniques and practice principles.

A night shift nurse is giving change-of-report to the day shift nurse on a patient who is ready for discharge. What should the nurse prioritize communicating to the oncoming nurse? A. Patient needs assistance when transferring from bed to wheelchair B. Patient will have a visit by a home health nurse tomorrow C. Patient's partner will bring clothes prior to discharge D. Patient needs encouragement to engage in personal hygiene activities

A. Patient needs assistance when transferring from bed to wheelchair -The greatest risk to this patient is injury due to a fall.

A nurse is caring for a patient following a vacuum-assisted birth. What complications should the nurse monitor for related to vacuum-assisted births? A. Constipation B. Urinary urgency C. Cervical laceration D. Retained placenta

C. Cervical laceration -Complications include perineal, vaginal and cervical lacerations.

A nurse is teaching about TPN and IV lipid emulsions with a patient who has extensive burns. What should be included? A. "This type of nutrition is more effective than eating by mouth." B. "You will receive fingersticks for blood glucose testing." C. "TPN is a way to provide vitamins and minerals without increased calories." D. "Taking TPN can increase the risk of developing a latex allergy."

B. "You will receive fingersticks for blood glucose testing." -Patient is at risk for hyperglycemia due to dextrose in TPN solution.

A nurse is assessing a newborn following a vaginal delivery. What findings should be reported to HCP? A. Heart rate 136 B. Nasal flaring C. Transient strabismus D. Overlapping of sutures

B. Nasal flaring -Indication of respiratory distress, as well as retractions or grunting.

A nurse is teaching a patient who has a prescription for digoxin about manifestations of toxicity. What findings should be included in the teaching? A. Constipation B. Nausea C. Wheezing D. Muscle rigidity

B. Nausea -Manifestations include nausea, anorexia, abdominal pain, bradycardia and visual changes.

A nurse is caring for a patient who has DM1 and reports severe ankle pain after falling off a step stool at home. Which prescriptions need clarification with HCP? A. Obtain capillary blood glucose q2hrs B. Check neuromuscular status of the lower extremities qhr C. Apply cold pack to the patient's ankle for 30min qhr D. Maintain the affected ankle elevates and immobilized

C. Apply cold pack to the patient's ankle for 30min qhr -DM1 is a contraindication for receiving cold therapy. Because they have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. Ice can further impair circulation.

A nurse is providing teaching to a school-aged child who has asthma about using an albuterol metered-dose inhaler. What should be included? A. Clean mouthpiece with warm water q2wks B. Wait 10 sec between inhalations C. Take a quick inhalation when pressing the dispenser D. Take the medication 15 min before playing sports

D. Take the medication 15 min before playing sports -Take medication 5-20 min prior to exercise to promote bronchodilator. Effects begin immediately, peak in 30-60 min, and lasts for 5-6hrs. -Clean mouthpiece qd with warm water and soap, drying it before attaching it back to the inhaler. -Take long, slow inhalations while activating the dispenser to facilitate delivery of medication.

NGN: A nurse in a HCP's office is caring for a patient who has new diagnosis of DM2. The patient has a vascular ulcer noted on right ankle. Capillary refill is treated then 5 sec bilaterally. Pedal pulses are 1+ bilaterally. What is the patient at risk for developing? Labs: Glucose 175 HbA1c 9% WBC 9,500 Hct 44% Hgb 15 K 3.6

Delayed wound healing due to glucose level. -The nurse should educate the patient on wound care and proper nutrition to control their glucose levels.

NGN: A nurse is caring for a patient who is 3 days post-op, following a T4 SCI. What is the patient at risk for developing?

Developing a hemorrhagic stroke due to autonomic dysreflexia.

A nurse is assessing a patient with multiple sclerosis. Which manifestation is expected? A. Abdominal striae B. Masklike face C. Nystagmus D. Ptosis

C. Nystagmus -Involuntary eye movements and muscle spasticity is expected in MS. -Abdominal striae is with Cushing's syndrome. -Masklike face is caused by rigidity of the facial muscles and is associated with Parkinson's. -Drooping of the upper eyelids is due to a decreased level of acetylcholine and is associated with myasthenia gravis.

A RN is observing a LVN and an AP move a patient up in the bed. When should the RN intervene? A. Team lowers the side rails before lifting patient up in bed B. Prior to lifting the patent, the team raise the bed to waist level C. The team grasp the patient under their arms to lift him up in bed D. The team ask the patient to flex his knees and push his heels into the bed as they lift.

C. The team grasp the patient under their arms to lift him up in bed -Can result in a shoulder disclocation or other injury to the patient. -Instruct team to use draw sheets or a friction-reducing device

A nurse is performing a gastric lavage for a patient who has GI bleeding and a NGT in place. What should the nurse do? A. Instill chilled lavage solution in the NGT B. Attach the NGT to low-intermittent suction C. Use 0.9% NS for irrigation of the NGT D. Instill the lavage solution into the NGT in volumes of 500 mL at a time

C. Use 0.9% NS for irrigation of the NGT -Use 0.9% NS, sterile water or tap water for irrigation of NGT. -Use room temp solution to reduce the risk of injury to the patient -After instilling the solution, the nurse should manually withdraw the solution and blood from the patient's NGT -Instill solution in volumes of 200-300 mL at a time to reduce the risk of injury to the patient

A nurse in a community center is providing an education session to a group of patients about ovarian cancer. Which manifestation should be included in the teaching? A. Diarrhea B. Urinary retention C. Purulent discharge D. Abdominal bloating

D. Abdominal bloating -Manifestations include: abdominal bloating, pelvic/abdominal pain, early satiety, and urinary frequency/urgency

A nurse is preparing to teach about dietary management to a patient who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the patient to decrease in their diet? A. Calories B. Protein C. Potassium D. Fiber

D. Fiber -Consume a low-fiber diet to reduce diarrhea and inflammation. -Increase protein, potassium and caloric intake to at least 3,000 kcal/day.

NGN: A nurse is assessing a patient who is scheduled for surgery. Which findings should the nurse notify the HCP prior to procedure for? H&P: 68yr-old. Diagnosed with cholelithiasis 2wks ago. C/o RUQ pain, rated 8/10 after meals. Family history of CAD and malignant hyperthermia. Allergic to avocados and bananas. NKDA. Vital signs are within normal range. Labs: Cr 0.9. Hct 43%. Hgb 12.

Hemoglobin, allergies, and family history. -Patient might require blood products during the intraoperative phase. -The allergy to avocados and bananas can indicate an allergy to latex products and should be reported to the HCP. The surgical team will need to remove all latex products from the OR. -During the surgery, the nurses must be diligent in monitoring the patient's vital signs and labs, especially in a patient who has a familial history of malignant hyperthermia.

A nurse is caring for a patient who is in the fourth stage of labor and is receiving continuous oxytocin IV. Which of following assessments is the nurse's priority? A. Amount of vaginal bleeding B. Amount of urinary output C. Pain level D. Fundal height

A. Amount of vaginal bleeding. -The first action the nurse should take using the nursing process is to assess the amount of vaginal bleeding. A patient who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount the amount vaginal bleeding is the nurse's priority.

A nurse is caring for four patients. What task can be delegated to an AP? A. Arrange the lunch tray for a patient who has a hip fracture B. Measure the vital signs of a patient who just returned from the PACU C. Evaluate dietary intake for a patient who has anorexia D. Assess I&O for a patient who is receiving dialysis

A. Arrange the lunch tray for a patient who has a hip fracture -Post op patients are not considered medically stable so it not within the range of an AP -Assessing and evaluating is the nurse's responsibility

NGN: What should the nurse do after the adolescent returns from surgery, following an open reduction internal fixation of the right tibia? SATA: A. Perform neurovascular assessments qhr. B. Remove indwelling urinary catheter when no longer indicated. C. Elevate the affected limb at chest level. D. Apply warm packs to right extremity for the first 24hrs. E. Assist the adolescent with ambulation from bed to chair.

A. Perform neurovascular assessments qhr. B. Remove indwelling urinary catheter when no longer indicated. C. Elevate the affected limb at chest level. -Elevate the affected limb at chest level to reduce edema. -Neurovascular assessments should be performed qhr for the first 24hrs for immediate recognition of neurovascular compromise. -Catheters should be removed ASAP or within 24hrs if no longer necessary.

An AP and a nurse are turning a patient onto their right side. Which actions by the AP cause the nurse to intervene? A. Places a pillow under the patient's right arm. B. Raises the total height of the bed to waist level. C. Uses a draw sheet to move the patient to the left side of the bed. D. Lowers the side rails on the left side of the bed.

A. Places a pillow under the patient's right arm. -The AP should place the pillow under the patient's left arm to prevent internal rotation of the left shoulder.

A nurse manager is reviewing unit records and discovers that patient falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? A. Investigate environmental factors that might be contributing to patient injury during these hours. B. Review the performance evaluations of nurses who work during these hours. C. Implement a plan to transition from team nursing to primary care nursing during these hours. D. Discuss a plan with the HCPs to reduce the use of barbiturate sedatives prior to these hours.

A. Investigate environmental factors that might be contributing to patient injury during these hours. -When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the patients' falls, including environmental factors that might be causing the problem.

A nurse is teaching a group of guardians about child safety measures. Which statements indicate understanding? A. "I will make sure my 4yr-old child wears a helmet when using a skateboard." B. "I should have my child avoid sun exposure between 10am and 2pm." C. "I can give my 2yr-old child a whole hotdog on a bun." D. "When my infant is in the carrier, I will place it on a raised, flat surface whenever possible."

B. "I should have my child avoid sun exposure between 10am and 2pm." -Sunburn prevention: apply sunscreen, wear protective clothing, and avoid the sun between 10am and 2pm.

A nurse is teaching the parent of a school-age child about administering ear drops. Which response indicates understanding? A. "I should administer the ear drops as soon as I remove them from the refrigerator." B. "I should pull the top of the ear upward and back while instilling the medication." C. "I should massage behind the ear after I instill the drops." D. "I should have my child lie on the affected side for a few min after I put the drops in my ear."

B. "I should pull the top of the ear upward and back while instilling the medication." -Allows medication to reach the entire ear canal

A nurse is caring for a patient who has cancer and is deciding between two treatment plans. Patient asks nurse for assistance in making a decision. What should the nurse say? A. "I understand this is a difficult decision." B. "Tell me more about your understanding of the options." C. "You will make the right choice." D. "I will ask your provider to talk with you further."

B. "Tell me more about your understanding of the options." -Offers a general lead that facilitates communication between the nurse and patient, and will help the nurse explore the patient's feelings about the treatment options.

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 should be included in the plan of care for a 8yr old patient with cystic fibrosis? Admission: SOB, wheezes x5 lobes, prod. cough with thick sputum. Vitals: HR 108, R 26, T 98.9F, BP 100/62, O2 92%. Sputum culture (+) B. cepacia A. Initiate droplet precautions. B. Keep the child NPO x12hrs. C. Maintain the child on bed rest x24hrs. D. Administer high-dose antibiotic therapy.

D. Administer high-dose antibiotic therapy. -Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections. -Initiate contact precautions, high-calorie/high-protein diet with unlimited fat, and include ADLs in plan of care. Exercise facilitates mucus excretions and can increase the child's self-esteem.

A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? A. Contact the triage officer. B. Implement the patient tracking system. C. Ask the communications officer to release a press statement. D. Notify the incident commander.

D. Notify the incident commander. -The first action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy and maintain order.

A charge nurse is planning care for a patient who has mechanical restraints in place. Which of the following interventions should the nurse include the plan? A. Remove the patient's restraints while sleeping B. Document the patient's status q60 min. C. Check for a new prescription q6hrs. D. Provide a staff member to stay with the patient

D. Provide a staff member to stay with the patient continuously. -A staff member must remain continuously with a patient who is in restraints or view the patient via audiovisual equipment, if necessary, due to risk of injury. -The nurse should not remove restraints until the patient is calm, in control, and able to follow simple commands. -Assess the patient for physical needs, safety, and comfort q15-30 min and document the findings. -HCP must renew a prescription for restraints q4hrs for patients 18yrs<, q2hrs for children 9-17yrs, and q1hr for children <9yrs.

A nurse is reviewing the lab results of a patient who has ESRD and received HD 24hrs ago. Which of the following labs should the nurse report to the HCP? A. PLT 268 B. Calcium 9.2 C. WBC 5,200 D. Sodium 148

D. Sodium 148 -Elevation indicated hypernatremia. Patients with renal disease often retain sodium and require sodium-restricted diets.

A patient who has high blood pressure is having difficulty following their treatment plan. Which of the following is the greatest barrier to the patient's ability to be compliant? A. A detailed plan of care B. Absence of symptoms C. Dietary salt restrictions D. Addition of a new medication

B. Absence of symptoms -Asymptomatic patients may not understand the need for treatment.

A community health nurse is reviewing the medical records of four newly diagnoses patients. The nurse should identify which of the following patients as having a nationally notifiable infectious condition? A. A patient who is pregnant and has CMV B. An adolescent patient who has foodborne botulism C. A child who has erythema infectiosum D. A young adult who has HSV-1

B. An adolescent patient who has foodborne botulism -The nurse should report botulism to the CDC because this information is necessary for the prevention and control of this disease. Patients who ingest the toxin can develop dysphagia, drooping eyelids, and vision changes. In 12-36hrs can develop neurologic symptoms such as symmetric, flaccid paralysis and cranial nerve impairment.

A nurse is preparing to replace a patient's transdermal fentanyl patch after 72hrs of use. After the nurse opens the packet of the new batch, the patient denies it. What should the nurse do? A. Withhold pain medications for 24hrs after the old patch is removed. B. Ask another nurse to witness the disposal of the new patch. C. Seal the patches in the plastic bag and place in the patient's trashcan. D. Stick the two patches to each other and place them in the sharps bin.

B. Ask another nurse to witness the disposal of the new patch. -The nurse should have another nurse witness the waste of the fentanyl patch. The nurse should then waste the medication in a secure receptacle, according to facility's policy, when disposing unused portions of controlled substances. -The nurse should request a prescription for an alternative pain medication. To maintain pain control, another analgesic should be given within 12-18hrs. -The nurse should fold the patch in half, with the medication side touching, and waste medication in a secure receptacle, according to facility's policy.

A nurse is assessing correct placement of a patient's NG feeding tube prior to administering a bolus feeding. What should the nurse do? A. Insert air in the tube and listen for gurgling sounds in the epigastric area B. Aspirate contents and verify pH level C. Review the medical record for previous x-ray verification D. Auscultate the lungs for adventitious breath sounds

B. Aspirate contents and verify pH level -pH level should be less than 5 -Other methods are unreliable

A nurse caring for a patient who had a recent stroke. Prior to transferring the patient to the bedside commode, which of the following actions should the nurse take first? A. Ask for help with a two-person assist transfer. B. Assess the patient for functional limitations. C. Request a mechanical lift device. D. Medicate the patient for pain.

B. Assess the patient for functional limitations. -When using the nursing process, the first action the nurse should take is to assess the patient's functional limitations to determine how much the patient can assist with the transfer.

A nurse is preparing to administer a long-acting insulin to a patient with DM. What should the nurse do first? A. Teach the patient reportable adverse effects from the medication. B. Check the insulin dose with another licensed nurse. C. Administer the insulin at a 90 deg. angle. D. Clean the insertion site.

B. Check the insulin dose with another licensed nurse. -The greatest risk to the patient is injury due to a medication error. Therefore, the priority action is for the nurse to validate the correct dose of insulin with another licensed nurse prior to administration.

A patient is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/in and a BP of 90/44. Which of the following medications should the nurse anticipate administering? A. Naloxone B. Flumazenil C. Acetylcysteine D. Atropine

B. Flumazenil -Flumazenil is a competitive benzo receptor antagonist. It reverses the sedative effects of lorazepam. In addition, the nurse should continue to support the patient's respirations with a bag-valve mask. -Naloxone is the antidote for opiate overdose. -Acetylcysteine is the antidote for acetaminophen overdose. -Atropine is the antidote for cholinesterase inhibitor overdose.

A nurse is assessing a patient following a colonoscopy. Which of the following findings should indicate to the nurse that the patient is hemorrhaging? A. Sudden drop in heart rate B. Rapid decrease in blood pressure C. Patient reports feeling of fullness D. Patient reports pain 8/10

B. Rapid decrease in blood pressure. -An increased heart rate and rapid decrease in BP indicates hemorrhage. -A feeling of fullness is an expected finding following a colonoscopy. -Pain could indicate bowel perforation.

A nurse is caring for school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests? A. Chest x-ray B. Serum liver enzyme levels C. ABGs D. Urine culture and sensitivity

B. Serum liver enzyme levels -Valproic acid can cause hepatic toxicity. Assess liver function prior to and periodically during therapy.

NGN: A nurse is caring for a young adult patient that was brought in by their parents. The parents expresses concern about patient's recent weight loss. Parents report patient states that they are overweight and limiting how much they eat. What is the patient exhibiting signs of? Assessment: yellow sclera, lanugo, +2 edema, skin cool and dry. Labs: Potassium 3.3. Sodium 133. Magnesium 1.1.

Anorexia and is at risk for arrhythmias. -Manifestations: low BMI, weight loss, food restriction, lanugo, edema, cold extremities. -Complications: arrhythmias, decreased bone density, muscle weakening, and HF.

A nurse is providing teach to a patient who is scheduled to for electroconvulsive therapy (ECT). Which of the following is an adverse effect? A. Agitation B. Short-term memory loss C. Post-treatment seizures D. Incontinence of bowel/bladder

B. Short-term memory loss

A nurse is reviewing the medical record of a patient who has schizophrenia and is scheduled to begin a new prescription for clozapine. Which of the following is a contraindication for clozapine? A. BP 150/87 B. WBC 2,800 C. Auditory hallucinations D. Nausea

B. WBC 2,800 -Clozapine can cause agranulocytosis. Therefore, a WBC <3,000 is a contraindication. Hold medication and notify HCP.

NGN: Which of the following findings indicate the adolescent's conditions is improving, following a fasciotomy for compartment syndrome? -Drowsy and reports nausea. -Respirations shallow. -Unproductive cough present. -Abdomen soft and contender with hypoactive bowel sounds x4. -Extremity pulse +3. -Capillary refill 2 sec. -Right extremity warm to touch. -Reports no numbness or tingling. -Reports pain 2/10.

-Extremity pulse +3. -Capillary refill 2 sec. -Right extremity warm to touch. -Reports no numbness or tingling. -Reports pain 2/10. -Indicates fasciotomy was effective. -The relief of pressure restores perfusion to the area and reduces pain.

NGN: A nurse is caring for a patient in the inpatient psychiatric unit. The patient tells the nurse "I just can't do it anymore. I am going to end my life." Based on this, what should the nurse do? SATA: -Provide one-on-one observation. -Ensure the patient does not have access to sharp objects. -Ensure the patient is assigned to a private room. -Discuss with them things aren't as bad as they seem. -Assess the patient's method of lethality. -Remind them everything is going to be fine. -Observe the patient swallow all prescribed medications.

-Provide one-on-one observation. -Ensure the patient does not have access to sharp objects. -Assess the patient's method of lethality. -Observe the patient swallow all prescribed medications. -Primary concern is the patient's safety.

NGN: What 6 actions should the nurse take while caring for a mom who is 1hr postpartum, who is experiencing large amounts of loch rubra with several large clots? -Weigh the perineal pads. -Administer methylergonovine. -Provide emotional support. -Insert indwelling urinary catheter. -Firmly massage the uterine fundus. -Administer terbutaline. -Administer oxygen.

-Weigh the perineal pads. -Administer methylergonovine. -Provide emotional support. -Insert indwelling urinary catheter. -Firmly massage the uterine fundus. -Administer oxygen. -The nurse should identify that the patient is experiencing a postpartum hemorrhage, which requires immediate intervention to prevent hemorrhagic shock.

A nurse receives a request from a patient to review information in his medical record. Which of the following responses should the nurse give? A. "There's a protocol for reviewing your medical record, and I can initiate the process." B. "The medical record has a lot of medical terminology, and it might be difficult for you to understand." C. "You should really talk to your provider if you have any questions about your treatment." D. "Some parts of your medical record are restricted, but I can show you the parts that you are allowed to see."

A. "There's a protocol for reviewing your medical record, and I can initiate the process." -The patient's record is the legal property of the facility, but the patient has a right to access the record, obtain a copy of the record, and request corrections to the document if there are discrepancies. According to HIPAA, the nurse is responsible for following the facility's policy when providing the patient with access to the medical record.

A nurse is providing teaching about improving nutrition for a patient who has multiple sclerosis. What should the nurse include in the teachings? SATA: A. "You should rest before eating a meal." B. "Reduce your intake of dietary fiber." C. "A speech pathologist will be performing a swallow study for you." D. "Thicken your beverages before drinking." E. "You should restrict foods that are high in vitamin D."

A. "You should rest before eating a meal." C. "A speech pathologist will be performing a swallow study for you." D. "Thicken your beverages before drinking." -The swallowing study will be performed to determine the risk for aspiration due to difficulty swallowing, which is a symptom of MS. -Encourage the patient to rest before each meal. In MS, the patients report feeling weak and easily fatigued. -Instruct the patient to maintain adequate vitamin D because deficiency is a risk factor for MS. -Instruct the patient to increase dietary fiber and fluids to decrease the risk for constipation, which is a symptom for MS. -Liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, a symptom of MS.

A rural community health nurse is developing plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? A. Agency for Healthcare Research and Quality B. National Institutes of Health C. Department of Agriculture D. World Health Organization

A. Agency for Healthcare Research and Quality -The goal of AHRQ is to improve the quality of healthcare services for all populations, including low-income groups and minorities. -NIH focuses on biomedical research to improve the prevention, diagnosis, and treatment of specific diseases. -DA focuses on the availability of food and nutrition services for US citizens. -WHO focuses on improving the health of the world's global population by developing initiatives and conducting research that benefit all countries.

A nurse is caring for a newborn who has HSV. Which isolation precaution should the nurse initiate? A. Contact B. Droplet C. Airborne D. Protective environment

A. Contact -HSV is transmissible by direct and indirect contact with others and the environment. -Droplet: infections transmitted via droplets larger than 5 microns. Pertussis, rubella, and streptococcal pharyngitis. -Airborne: infections transmissible via droplets smaller than 5 microns. Varicella, rubeola, and tuberculosis. -Protective: for patients with a severely compromised immune system. Stem-cell transplants.

A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following should the nurse expect? A. Fever unresponsive to antipyretics B. Pain in weight-bearing joints C. Decreased heart rate D. Peeling of the soles of feet

A. Fever unresponsive to antipyretics -Acute phase: high fever unresponsive to treatment and tachycardia. -Subacute phase: pain in weight-bearing joints and peeling of the soles of their feet.

A nurse is assessing a 2mo-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex? A. Stroke the infant's cheek B. Depress the infant's tongue C. Turn the infant's head to one side D. Tap on the bridge of the infant's nose

A. Stroke the infant's cheek -Rooting reflex includes stroking infant's cheek which should cause the infant to turn towards that side and suck. -The nurse should depress the infant' tongue to assess the extrusion reflex, which should cause the infant to stick out the tongue. -The nurse should turn the infant's head to one side to assess the asymmetric tonic neck reflex, which should cause the infant to extend their arm and leg on that side and flex their arm and leg on the other side. -The nurse should tap on the bridge of the infant's nose to assess the glabellar reflex, which should cause the infant to close their eyes tightly.

NGN: The nurse is preparing the adolescent for the fasciotomy for compartment syndrome. Which finding should the nurse report to HCP prior to surgery? A. The adolescent's parents have concerns regarding the surgery. B. The adolescent has not voided in 4hrs. C. The adolescent's BP is 131/89. D. The adolescent reports severe pain.

A. The adolescent's parents have concerns regarding the surgery. -The nurse should notify the HCP if the parents of the adolescent have questions/concerns regarding the procedure, which could indicate lack of understanding about the informed consent.

A nurse is preparing to transfer a patient from the ICU to the medical floor. The patient was recently weaned from mechanical ventilation, following a pneumonectomy. What should be included in the change-of-shift report? A. Time of the patient's last dose of pain medication B. Most recent ventilator settings C. Last time the HCP evaluated the patient D. The frequency the patient presses the call button

A. Time of the patient's last dose of pain medication -An effective change-of-shift report provides a baseline of the patent's status for comparison and should include any recent changes or priority situations affecting the patient's conditions. Therefore, the time of the last given pain medication is important to include the oncoming nurse can anticipate what time the next dose can be given.

A nurse is caring for a patient who is receiving a cont. heparin infusion. What lab report does the nurse need to assess for titration of heparin? A. aPTT B. PT C. INR D. WBC

A. aPTT -Review the activated partial thromboplastin time (aPTT) and increase/decrease heparin dose accordingly. Expected range for aPTT is 30-40 sec. For patients receiving heparin, the therapeutic range is 60-80 sec (1.5-2 times normal range). -PT & INR are for warfarin therapy. -WBC is for monitoring infections, fever or if the patient is immunocompromised.

NGN: Which findings are consistent with ADHD or ID? -Intellectual impairment -Losing necessary things -Interrupting others -Hyperreactivity to sensory input -Impaired language skills

ADHD: losing necessary things, interrupting others, intellectual impairment & hyperreactivity to sensory input. ID: intellectual impairment & hyperreactivity to sensory input.

NGN: A nurse is caring for a patient who is in the SCI unit. Admitted 3 days prior, following a C7 injury. On day 2, the patient has a nonproductive cough and output is 100 mL over the last 6hrs. Vital signs: T 100F. HR 54. R 26. BP 96/60. O2 90% RA.

Address the patient's O2 sat first, followed by the output. -Using the ABC framework, the priority finding the nurse should address is the O2 at 90%. Impaired functioning of the intercostal muscles and nerves of the diaphragm increases the risk of atelectasis and pneumonia for the patient who has a SCI. -Using the greatest risk framework, the nurse should identify the decreased urine output should be addressed next. Recognize the risk of autonomic dysreflexia from urinary retention and observe the patient's abdominal distention, assess for bladder distention, and check the catheter tubing for obstruction.

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: Which of the potential prescriptions are anticipated and contraindicated in a patient, admitted following a suicide attempt? Assessment: Allergic to SSRIs and penicillin. Sleeping since admission, flat affect noted. Vital signs within normal range. Medications: Lithium 300mg PO tid. Acetaminophen 325mg 1-2 tabs PO q6hrs PRN. Labs: Sodium 140. Potassium 3.2. Chloride 110. BUN 11. Magnesium 1.3. -Potassium 40 mEq PO qd -Initiate suicide precautions -Fluoxetine 20 mg PO qd -Low sodium diet

Anticipated: potassium 40 mEq PO qd & initiate suicide precautions. Contraindicated: Fluoxetine 20 mg PO qd & low sodium diet. -The patient has hypokalemia, which is treated with a potassium supplement. Patient had a recent suicide attempt so precautions should be implemented. -A low sodium diet increases their risk for lithium toxicity. Patient is allergic to SSRIs, so fluoxetine should not be administered.

NGN: Which interventions are anticipated and contraindicated in the adolescent experiencing compartment syndrome, following an open reduction internal fixation of the right tibia? -Remove the splint. -Prepare the adolescent for surgery. -Elevate the right leg above heart level. -Apply ice to the affect extremity.

Anticipated: remove the splint & prepare the adolescent for surgery. Contraindicated: elevate the right leg above heart level & apply ice to the affected extremity. -The adolescent will need a fasciotomy to decrease atrial spasms and increase perfusion within the muscle compartments. -Elevating the right leg above heart level and applying ice to the affected extremity will further compromise blood flow.

NGN: A nurse is caring for a newborn delivered at 41wks gestation. What should the nurse plan to assess first and second? H&P: spontaneous vaginal delivery with meconium-stained amniotic fluid. Mom (+) for marijuana use during pregnancy. Mom's blood type is A(-). GBS is (+). Assessment: Expiratory grunting and nasal flaring present. Skin loose and dry. Scant amount of green stained vernix caseosa noted in skin folds.

Assess the respiratory rate first, followed by the newborn's heart rate. -Indicate respiratory distress. The presence of meconium-stained amniotic fluid increases the risk that the newborn will develop meconium aspiration syndrome.

A nurse is caring for a patient who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? A. Decreased blood pressure B. Decreased hallucinations C. Decreased cholesterol D. Decreased esophageal reflux

B. Decreased hallucinations -Chlorpromazine is an anti-psychotic medication administered to decreased manifestations of schizophrenia.

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? A. Popcorn B. Diced steamed carrots C. Whole celery sticks D. Marshmallows

B. Diced steamed carrots -Choose foods that are soft and do not present as a choking hazard.

A nurse is caring for a patient who has a new prescription for clonidine. The nurse should inform the patient that which of the following findings is an adverse effect of this medication? A. Diarrhea B. Dry mouth C. Photophobia D. Bruising

B. Dry mouth -Clonidine is an indirect-acting anti-adrenergic agent used for HTN, severe pain, and ADD. Dry mouth (or xerostomia) is common. -Constipation, dry eyes, and rashes are common adverse effects.

A nurse is teaching a patient who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the patient to monitor and report to the provider? A. Hypotension B. Headaches C. Bruising D. Oliguria

B. Headaches -The nurse should instruct the patient to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events. -Other symptoms to report include HTN, swelling/tenderness of an extremity, fluid retention, or genitourinary candidiasis.

A nurse is assessing a patient who has sickle cell anemia. Which is a manifestation of a vaso-occlusive crisis? A. Diminished reflexes B. Hematuria C. Hyperglycemia D. Hearing loss

B. Hematuria -Results from ischemia of the kidneys -Other manifestations: painful swelling of hands/feet and visual disturbances.

A nurse is assessing an infant with hydrocephalus and is 6hrs post-op following a ventriculoperitoneal shunt. What finding should be reported to the HCP? A. Heart rate 122 B. Irritability when being held C. Hypoactive bowel sounds D. Urine specific gravity 1.018

B. Irritability when being held -Manifestation of increased ICP, indicating the VP shunt is malfunctioning. Report to HCP immediately.

A nurse is caring for a patient who has bipolar disorder. The nurse observes that the patient is becoming increasingly restless. The patient is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? A. Provide an opportunity for the patient to express their feelings. B. Move the patient to a quiet place away from others. C. State expectations that set limits on the patient's behavior. D. Administer a PRN dose of haloperidol to calm the patient.

B. Move the patient to a quiet place way from others. -The patient's behavior indicates the greatest risk is injury to others. Therefore, the first action the nurse should take is to prevent harm to other patients by moving this patient to a quiet place away from others.

A nurse is assessing a patient who has a stage 2 pressure injury. Which is an expected wound characteristic? A. Muscle damage B. Partial-thickness skin loss C. Visible subcutaneous tissue D. Tendon exposure

B. Partial-thickness skin loss

A nurse is caring for a patient who is receiving PEEP via mechanical ventilation. The nurse should monitor the patient for which adverse effect? A. Hypoxemia B. Tension pneumothorax C. Malignant HTN D. Atelectasis

B. Tension pneumothorax -Monitor qtr for indications of a tension pneumothorax (tracheal deviation, absent breath sounds, and distended neck veins). -Another adverse effect is hypotension from the increased chest pressure and decreased blood return to the heart.

A charge nurse is planning an educational session for staff nurses about working with parents whose children have a terminal illness and are candidates for donating their organs. Which of the following information should the nurse plan to include? A. Choosing to donate organs can delay the timing of the child's funeral. B. The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body. C. The family should understand that an autopsy is mandatory prior to organ donation. D. The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death.

B. The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body. -Removal of organs does not damage or violate the child's body in a way that would prevent an open casket funeral. -Donation does not affect or delay funeral time/expenses. -A pathologist will perform an autopsy following an unattended death or at the request of the family. -Discussion about donation should take place separately from discussion of child's prognosis.

A nurse administers an incorrect dose of medication to a patient. The nurse recognize the error immediately and completes an incident report. Which of following facts related to the incident should the nurse document in the patient's medical record? A. Completion of the incident report B. Time the medication was given C. Reason for the medication error D. Notification of the pharmacist

B. Time the medication was given -Document the time, the name of the medication, the dose, and the route in which the medication was given on the med administration record. Document the time that the incorrect medication was administered to the patient in the incident report, as this is a fact directly related to the occurrence.

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? A. Maintain a flexible daily schedule for the child. B. Use a reward system to modify the child's behavior. C. Provide a variety of family member to care for the child. D. Administer alprazolam PRN to reduce the child's anxiety.

B. Use a reward system to modify the child's behavior. -Children who have autism spectrum disorder respond well to a reward system, which can provide structure and expectations for behavior. -Children with autism respond better to a familiar daily schedule and having familiar caregivers. Usually are prescribed SSRIs to improve mood and reduce anxiety.

A nurse is assessing a patient taking propranolol. Which is an adverse reaction to this medication? A. Weight loss B. Wheezing C. BP 146/92 D. Heart rate 110

B. Wheezing

A home health nurse is evaluation a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? A. "My child doesn't like to sit still for nebulizer treatments." B. "I think that my child has been running a fever over the last couple of days." C. "My child only has a small amount of mucus after percussion therapy." D. "I am concerned about my child's future participation in team sports."

C. "My child has only a small amount of mucus after percussion therapy." -The nurse should recommend a high-frequency vest for a child who has inadequate results from other airway clearance therapy techniques. Older children often require other techniques in addition to percussion and postural drainage to achieve adequate mucus expectoration. -The nurse should teach the parent techniques for administration for nebulizer treatments to the child. -The nurse should follow-up on reports of fever, as this could indicate a pulmonary infection. -The nurse should discuss participation in sports activities in relation to the child's current physical and pulmonary health.

A nurse in a clinic receives a call from a guardian whose child has varicella, and asks when the child can return to school. What should the nurse say? A. "When the lesions no longer itch." B. "Three days after the lesions appear." C. "When crusts have formed on every lesion." D. "When the lesions disappear."

C. "When crusts have formed on every lesion." -When crusts form over the lesions, the child is no longer contagious.

A nurse is teaching a patient about the basal body temp method to prevent conception. What should be included in the teaching? A. "Your body temp will drop approximately 1 deg. one week after ovulation." B. "You should take your body temp each evening prior to going to sleep." C. "Your body temp might decrease slightly just prior to ovulation." D. "Your body temp is at its highest during menstruation."

C. "Your body temp might decrease slightly just prior to ovulation." -Body temp rises about 0.7-1.4F after ovulation. Elevation remains until 2-4 days prior to the start of menstruation. -Measure body temp upon waking up every morning before getting out of bed.

A nurse is assessing a patient who has macular degeneration. Which is an expected finding? A. Increased intraocular pressure B. Floating dark spots C. Decreased central vision D. Double vision

C. Decreased central vision -The nurse should expect a patient who has macular degeneration to have a decrease or loss of central vision due to bleeding into the macula or yellow spots under the retina. -An increase in intraocular pressure is a manifestation of glaucoma. -Floating dark spots are a manifestation of retinal detachment. -Double vision is a manifestation of cataracts.

A nurse is caring for a patient who has a potassium level of 3. What should the nurse monitor for? A. Increased bowel sounds B. Dry, sticky mucous membranes C. Decreased deep tendon reflexes D. Numbness and tingling of the extremities

C. Decreased deep tendon reflexes -Hypokalemia: muscle weakness, decreased DTRs and hypoactive bowel sounds -Hypernatremia: dry, sticky mucous membranes -Hypocalcemia: numbness and tingling of the extremities and around the mouth

A nurse is assessing a patient for compartment syndrome. Which of the following should the nurse expect? A. Fever B. Shortened femoral neck C. Edema D. Dark brown urine

C. Edema -Compartment syndrome S/S: increased pain, pallor, paresthesia from the increased edema.

A home health nurse is teaching a patient who has a new ileostomy. What should be included? A. Limit intake of fluids to 1000 mL/day B. Take a laxative if no stool has passed after 12hrs. C. Empty the appliance when it is one-third to one-half full. D. Change entire pouch system q1-2 days

C. Empty the appliance when it is one-third to one-half full. -Prevents stool leakage and skin irritation -Recommend fluid intake of at least 1,920 mL -If no stool has passed after 6-12hrs, contact HCP -Change system q3-7 days to prevent skin irritation

A nurse is preparing to administer 2 units of fresh frozen plasma to a patient. What should the nurse do? A. Allow the plasma to warm for 30 min before transfusion. B. Conform the patient's identification by check the room number. C. Enter the plasma product number into the patient's medical record. D. Administer each unit of plasma over 4hrs.

C. Enter the plasma product number into the patient's medical record. -The nurse should complete documentation follow blood product therapy, which includes recording the type of product, amount administered, product number, infusion time, and patient's response. -The nurse should transfuse the plasma immediately after obtaining it from the blood bank to maintain integrity of the clotting factors. -The nurse should confirm the patient's identification by verifying that the patient's name and facility-assigned number on the identification bracelet match the information provided on the units of plasma. -The nurse should administer each unit of plasma over 30-60 min. Slow the infusion rate if the patients shows indications of fluid overload.

A nurse is planning care for a patient who has rheumatoid arthritis. Which interventions should be included? A. Encourage the patient to take a cool sponge bath every morning. B. Administer opioid analgesia. C. Increase the patient's dietary iron intake D. Restrict the patient's intake of foods high in purines.

C. Increase the patient's dietary iron intake -Patients with RA require foods high in protein, vitamins, and iron to promote tissue repair. -Encourage hot showers to help relieve morning stiffness. -NSAIDS are used to relieve pain and inflammation associated with RA. -Patients who have gout should avoid foods high in purines.

A nurse is assessing a patient who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the vision loss? A. An increase in the intraocular pressure B. Deterioration of the macula C. Increased opacity of the lens D. Vitreous hemorrhage

C. Increased opacity of the lens -A cataract is a cloudy or opaque area of the lens of the eye that inhibits light penetration. -Glaucoma leads to an increase in intraocular pressure, causing mild headaches and foggy vision. -Macular degeneration is caused by deterioration of the macula, resulting in decreased central vision. -Vitreous hemorrhage is bleeding following damage of retinal blood vessels, which can occur due to elevated BP or uncontrolled diabetes.

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? A. Include chicken broth in diet. B. Feed the toddler the BRAT diet. C. Initiate oral rehydration therapy. D. Offer flavored gelatin.

C. Initiate oral rehydration therapy. -Infectious gastroenteritis leads to dehydration. Treat with oral rehydration therapy to replace fluids lost by diarrhea, along with soft/pureed foods. After adequate rehydration has occurred, a regular diet can be resumed. -Chicken and beef broths contain excessive amounts of sodium and very few carbs. -BRAT diet is bananas, rice, applesauce and toast. Contains little nutritional value, low amounts of protein and electrolytes, and high in simple carbs. Contraindicated for a child experiencing acute diarrhea. -Gelatin is high in carbs, low in electrolytes, and high in osmolality, which prolongs diarrhea and electrolyte imbalance.

A nurse is preparing to insert an indwelling urinary catheter for a patient. What should the nurse assess for prior to starting the procedure? A. Ketonuria B. Fecal impaction C. Latex allergy D. Tachycardia

C. Latex allergy -Risk of an allergic reaction.

A nurse is administering cyclophosphamide PO to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? A. Give an antiemetic 30 min after administering. B. Monitor blood glucose levels. C. Maintain hydration with liberal fluid intake. D. Monitor for tumor lysis syndrome.

C. Maintain hydration with liberal fluid intake. -Offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this medication. Administer an antiemetic 30 min before administering to decrease GI effects.

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which is the priority step in the time management process? A. Organizing the work environment B. Delegating assigned tasks appropriately C. Making a list of activities to complete D. Rewarding oneself for accomplishing goals

C. Making a list of activities to complete -Planning is the most important step in managing time effectively. Other activities include setting goals, establishing priorities, and scheduling activities.

A nurse is providing teaching to a postpartum patient who has decided to bottle feed the newborn. Which instructions should be included to help prevent the discomfort of engorgement? A. Allow the newborn to breastfeed temporarily. B. Relieve pressure by expressing milk daily. C. Place ice packs on the breasts for 15 min. several times per day. D. Sleep with a loose-fitting bra to prevent nipple stimulation.

C. Place ice packs on the breasts for 15 min. several times per day. -Reduces swelling and relieves pain caused by engorgement. -Avoid nipple stimulation because it increases milk production, leading to engorgement. -Wear a tight-fitting, supportive bra or breast binder to decrease discomfort.

A nurse is assessing a patient with delirium. Which manifestation is expected? A. Projecting blame B. Excessive clinging C. Rapid speech D. Social awkwardness

C. Rapid speech -Projecting blame is associated with paranoid personality disorder. -Excessing clinging is associated with dependent personality disorder. -Social awkwardness is associated with schizotypal personality disorder.

A charge nurse overhears two staff nurses in the hall discussing the nutritional status of a patient with anorexia. What should the charge nurse do? A. Apologize to the patient for the nurses' actions. B. Advise the nurses they are being insubordinate. C. Tell the nurses to stop the discussion. D. Document the incident in the medical record.

C. Tell the nurses to stop the discussion. -Prevents any further breach of confidentiality

A nurse is caring for a patient who has a pulmonary embolism. The patient is receiving heparin via cont. IV infusion at 1,200 u/hr and warfarin 5 mg PO daily. The morning labs for the patient are aPTT 98 sec and INR 1.8. What should the nurse do? A. Plan to administer vitamin K1. B. Prepare to administer alteplase. C. Withhold the heparin infusion. D. Withhold the next dose of warfarin.

C. Withhold the heparin infusion. -Expected value for aPTT is 30-40 sec. A therapeutic level of heparin increases the aPTT by 1.5-2, making the aPTT 60-80 sec. Since the patient's aPTT is 98 sec, the dose should be reduces or the infusion stopped, until the aPTT returns to the therapeutic range. -The nurse should administer vitamin K1 for excessive warfarin levels but the INR is below the therapeutic range for a patient on warfarin (2-3). -Alteplase is a thrombolytic, and the patient is already on anticoags. -The INR is below the expected range for a patient on warfarin (2-3).

NGN: What are four findings that require follow-up in the adolescent with an open wound and displaced bone in the right lower extremity? BP 124/82 Capillary refill (4 sec) Heart rate 89 Pain 10/10 Pedal pulse (+1) Skin temp (cool to touch)

Capillary refill (4 sec) Pain 10/10 Pedal pulse (+1) Skin temp (cool to touch) -These findings are indicative of decreased perfusion to the extremity and require follow-up by the nurse.

NGN: What is the adolescent with an internal fixation of the right tibia most at risk for developing? Assessment: reports pain 10/10, right foot is cool and pale. Unable to palpate pedal pulse. Reports tingling and numbness in right foot.

Compartment syndrome AEB the patient's paresthesia. -Using the urgent vs. non urgent approach, the priority finding is the paresthesia. Indicative of compartment syndrome, which requires immediate intervention.

A nurse is caring for a patient who has a terminal illness and request no lifesaving measures. What should the nurse say? A. "You will need to draft a healthcare surrogate so a designee can make this decision for you." B. "I will make sure that no one performs any lifesaving measures if your heart stops." C. "Your HCP determines if you should have lifesaving measures if your heart stops." D. "I will provide you with information about medical treatment to include in your living will."

D. "I will provide you with information about medical treatment to include in your living will." -The nurse's responsibility is to provide the patient with information about specific instructions for addressing medical treatment in a living will.

A nurse on a pedi unit has received change-of-shift report for four children. Which of the following patients should the nurse assess first? A. 6mo-old infant who has croup and an O2 sat of 92% RA. B. 15yr-old who is 2hrs post-op following an open education and internal fixation of the left ankle and is requesting pain medication C. 3yr-old toddler who has gastroenteritis, moderate dehydration and had x2 loose BM in the past 24hrs. D. 10yr-old who is awaiting surgery for an appy and experienced sudden relief from pain

D. 10yr-old who is awaiting surgery for an appy and experienced sudden relief from pain -Use the urgent vs. non-urgent approach. Findings indicate peritonitis from a ruptured appendix. Notify HCP immediately.

A nurse is caring for a patient who is post-op after receiving moderate (conscious) sedation. The patient suddenly becomes restless and reports feeling lightheaded. What should the nurse do? A. Check the patient's temp. B. Prepare to administer acetylcysteine. C. Place the patient in Trendelenberg position. D. Check the patient's O2 sat.

D. Check the patient's O2 sat. -Restlessness and lightheadedness are indications of hypoxia. -Malignant hyperthermia is a complication of general anesthesia, not conscious sedation. -Acetylcysteine is an antidote for acetaminophen. -Trendelenberg position is used to promote venous circulation. A patient who is hypoxic should be places with the HOB elevated.

A nurse is teaching home wound care to the family of a child who has a large wound. Which intervention should the nurse recommend? A. Apply an OTC cream if the wound becomes infected. B. Clean the wound x2 daily with povidone-iodine. C. Apply heat to the wound for 10 min x4 daily. D. Double-bag soil dressings in plastic bags for disposal.

D. Double-bag soil dressings in plastic bags for disposal. -To prevent the spread of micro-organisms to other household members. -Do not use OTC products without consulting with HCP first. -Do not use PVI to clean the wound due to its toxicity. PVI is used for cleaning equipment and intact skin. -Heat is contraindicated in wound therapy.

A nurse is planning care for a patient who is receiving heparin to treat a DVT of the lower left leg. Which intervention should be included? A. Maintain the patient on bed rest B. Restrict the patient to 1L of fluid/day C. Place cool compresses on edematous area D. Elevate the affected leg

D. Elevate the affected leg -To reduce edema and decrease the risk of chronic venous insufficiency -Encourage ambulation once anticoagulant is initiated -Encourage fluid intake 2-3L/day to decrease platelet aggregation and prevent dehydration -Place warm compresses on affected area to reduce swelling and provide comfort

A nurse is working with a patient who has PTSD. Patient asks the nurse to recommend a nonpharmalogical therapy to use to provide relief of the manifestations. Which complementary therapies should the nurse recommend to help alleviate the distress? A. Spinal manipulation B. Acupuncture C. Therapeutic touch D. Guided imagery

D. Guided imagery -Helping patients imagine themselves as strong and capable and in settings that are positive and therapeutic can assist patients who have PTSD by relieving anxiety and pain. -Spinal manipulation is not a therapy the patient can do themselves. Involves adjusting and aligning the spine, which helps with back pain, asthma and allergies. -Acupuncture requires special training. Improves immune, neurologic, cardiac and endocrine function. Helps relieve pain and assist with substance withdrawal. -Touch therapy is not a therapy a patient can do themselves. Helps alleviate pain, depression, healing of body tissues, and physiological needs (reducing blood pressure, fever and nausea).

A nurse is caring for a patient who has a fecal impaction. What should the nurse do when digitally evacuating the stool? A. Place the patient in the lithotomy position B. Elicit a vagal response by performing gentle rectal stimulation C. Administer oral bisacodyl 30 min prior to the procedure D. Insert a lubricated gloved finger and advance along the rectal wall.

D. Insert a lubricated gloved finger and advance along the rectal wall.

A RN is planning care for a group of patients and is working with a LVN and an AP. Which tasks can be delegated to the LVN? A. Collection of a stool specimen B. Preparation of a patient's post-op bed C. Preparation of a teaching plan about pneumonia D. Insertion of a NG tube

D. Insertion of a NG tube

A nurse is caring for a patient who has a closed-head injury and is receiving mechanical ventilation. Which medication should the nurse give to reduce intracranial pressure? A. Propranolol B. Phenytoin C. Lorazepam D. Mannitol

D. Mannitol -Mannitol is an osmotic diuretic, that reduces ICP caused by cerebral edema

A nurse on an inpatient mental health unit is monitoring a visit between a patient who has a history of aggressive behavior and the patient's partner. Which observation indicates a potential for violence? A. The patient is taking numerous deep, measured breaths. B. The patient is calm telling their partner that "the staff here is so controlling". C. The patient is sitting with their head in their hands and appears to be crying. D. The patient is pacing around the chair the partner is sitting in.

D. The patient is pacing around the chair the partner is sitting in -Hyperactivity and pacing indicated the patient is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the patient in a low, calm voice using short sentences.

NGN: A nurse is caring for a patient who is on 24hr observation. Patient was admitted for alcohol intoxication. What is the patient at risk for? Assessment: AO x1, lethargic. Diminished lung sounds auscultated in lower lobes, bilaterally. Tachycardic. N/V x2 days. Bowel sounds hypoactive x4. Abdomen is distended and contender. Petechiae noted on forearms, bilaterally. Diaphoretic. PLT 99.5.

Hemorrhage due to thrombocytopenia. -Chronic alcohol use disorder increases the risk for hemorrhaging due to the inability of the liver to assist with platelet formation.

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 Involuntary tongue movement and foot tremor Increase in urination and one episode of incontinence Family c/o increased agitation and delusions

Involuntary tongue movement and foot tremor Frequent urination and incontinence Increase in agitation -Patient is experiencing tardive dyskinesia

NGN: A nurse is caring for a 3yr-old child who has a G tube. The nurse notices redness and clear drainage from G tube site. Temp is 100.6F. What is the child risk for developing? -Infection -Skin breakdown -Delayed bowel training -Dehydration -Aspiration

Risk for developing an infection and skin breakdown. -The G tube site is red and there is drainage from the site, which could lead to skin breakdown. The child also developed a fever, which could indicate infection.

NGN: A nurse is providing phone advice for a patient who is pregnant. What is the patient at risk for? Week 6 gest: reports nausea and vomiting with weight loss of 2lbs. Week 10 gest: weight loss of 15lbs. Nausea continues, making it harder to eat.

Risk for metabolic acidosis AEB weight loss. -The intake and retention of food is not meeting the patient's nutritional requirements. Undernutrition can lead to the breakdown of fatty tissue which increases the release of nonvolatile acids into the blood stream.

NGN: A nurse is caring for a patient who is 24hrs post-op, following a c-sect. The patient reports blurred vision and nausea. Rates headache 6/10. DTRs 4+, clonus positive. What is the patient at risk for developing? Vital signs: HR 96. R 22. BP 185/115. O2 96% RA. Labs: Blood glucose 120 WBC 22,000 Hct 37% Hgb 12 PLT 160

Seizures AEB patient's BP. -The report of a new onset of headache, blurred vision, and nausea. Assessment findings are elevated BP, hyperreflexia, and clonus. Which are all indicative of CNS irritability, which increases the risk for seizures or eclampsia.

A hospice nurse is consulting with a patient and family about receiving home services. Which statements indicate understanding of hospice care? A. "We can expect the hospice nurse to provide support for us after our mother's death." B. "A hospice nurse will come the house each time our mother needs pain medication." C. "Now that my mother is receiving hospice services, we will not be able to get respite care." D. "Hospice care focuses on arranging treatment that will prolong our mother's life."

A. "We can expect the hospice nurse to provide support for us after our mother's death." -Hospice includes: bereavement services and respite care. -Nurse will teach family how to administer pain medications but is also available on call 24hrs/day. -Hospice focuses on providing palliative, psychosocial, and spiritual care without the intent of prolonging life.

A patient who is 24hrs post-op following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? A. Ask the patient to rate their pain level. B. Assist the patient in changing positions. C. Administer a PRN analgesic medication. D. Explain the importance of early ambulation.

A. Ask the patient to rate their pain level. -Using the nursing process, the first action the nurse should take is to assess the patient's level of pain. If indicated, the nurse should administer an analgesic, then wait 30-45 min to allow the analgesic to take effect before encouraging the patient to ambulate. Management of the patient's pain is a priority for encouraging post-op activity.

A nurse is planning care for a patient who has thrombocytopenia. Which of the following instructions should the nurse include in the plan of care? A. Avoid venipunctures when possible. B. Restrict visitors to family members. C. Limit oral fluid intake in between meals. D. Prohibit fresh flowers in the patient's room.

A. Avoid venipunctures when possible. -Patients who have thrombocytopenia have a decreased PLT count and are at risk for bleeding. -Neutropenic precautions are for patients with a decreased level of WBC, putting them at risk for infection. Precautions include restricting visitors to healthy individuals and prohibiting fresh flowers in their room.

A nurse manager in a LTC facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first? A. Form a committee of staff members to investigate current staffing issues. B. Provide support to staff members who are resistant to staffing changes. C. Schedule a staff meeting to present the different options to staff members. D. Give the staff members advance written notice of staffing changes.

A. Form a committee of staff members to investigate current staffing issues. -The first action the nurse should take when using the nursing process is to assess the current staffing issue. The first stage pf change is the "unfreezing stage", which is gathering information about the problem.

A nurse on an inpatient unit is caring for a patient who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take? A. Implement fall precautions for the patient. B. Monitor the patient's thyroid function. C. Place the patient on a fluid restriction. D. Discontinue the medication if hallucinations occur.

A. Implement fall precautions for the patient. -Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. -Monitor the patient's CBC for anemia, thrombocytopenia, leukocytosis, leukopenia, and elevated AST/ALTs. -Can cause constipation, diarrhea, or dry mouth. Nurse should encourage increased intake of fluids.

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following should the nurse expect? A. Strict adherence to routines B. Difficulty paying attention to tasks C. Disobedience to authority figures D. Excessive anxiety when separated from parents

A. Strict adherence to routines -Children with autism will exhibit strict adherence to routines/rituals, a fixation to specific objects, and a resistance to change.

A nurse is assessing a patient whose partner recently died. The patient states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? A. "It's natural for you to feel this way now, but things will get better with time." B. "You seem to be having a difficult time right now." C. "Why do you feel like your life isn't worth living?" D. "You'd be surprised how many people experience these feelings."

B. "You seem to be having a difficult time right now." -This statement makes an observation, which is a therapeutic response by the nurse. It encourages the patient to express their thoughts and feelings. -Offering false reassurance and minimizing the patient's feelings is not therapeutic. -Asking the patient a "why" questions implies criticism and can make the patient feel defensive.

A nurse is planning care for a patient who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? A. Perform ADLs for the patient to promote rest. B. Allow for freq. rest periods throughout the day. C. Use heat to reduce joint inflammation. D. Develop a daily schedule for acetaminophen up to 6g/day that covers peak periods of pain.

B. Allow for freq. rest periods throughout the day. -The nurse should encourage patients who have RA to balance rest with exercise to maintain muscle strength, joint function, and ROM. -The nurse should allow patients to perform their own ADLs to promote joint mobility and independence. -The nurse should use ice to reduce joint inflammation and heat to alleviate joint discomfort. -The nurse should not administer >3g of acetaminophen to reducer the risk of injury to the patient.

A nurse is creating a plan of care for a patient who has a left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? A. Massage bony prominences on the patient's left side. B. Support the patient's left arm on a pillow while sitting. C. Position the bedside table on the patient's left side. D. Place the patient's cane on their left side while ambulating.

B. Support the patient's left arm on a pillow while sitting. -Support the affected arm to prevent the extremity from hanging freely because this can cause shoulder subluxation. -Avoid massaging bony prominences because it can cause deep tissue trauma. -Position the table on the patient's unaffected side so items are within reach. -Teach patient to hold the cane on the stronger side of their body.

A nurse is providing discharge teaching to a patient following a cataract extraction. Which statement indicates understanding? A. "I can resume my daily aspirin therapy." B. "I will contact my HCP if my eye feels itchy." C. "I will bend at my knees when picking an object up off the floor." D. "It's okay for me to pick up my grandchild, who weighs 20lbs."

C. "I will bend at my knees when picking an object up off the floor." -Avoid bending at the waist because this increases intraocular pressure, as well as lifting anything that weighs more than 10lbs. -Avoid taking aspirin because of its anti-coag effect. -Use cool compress to ease the discomfort of itching

A nurse is caring for a patient who has end-stage Alzheimer's. The patient's child says "I don't know why I bother to visit my mother anymore." What should the nurse say? A. "Your mother might still know you are here." B. "Why do you feel that way?" C. "It seems like you feel your visits are a waste of time." D. "Are you sure you would not want to see your mother again?"

C. "It seems like you feel your visits are a waste of time." -Clarifying technique facilitates the nurse's understanding of the child's feelings

A nurse is caring for a patient who is 4hrs postpartum and has a boggy uterus with heavy loch. What should the nurse do first? A. Administer oxygen B. Initiate an infusion of oxytocin C. Massage the uterus to expel clots D. Obtain CBC

C. Massage the uterus to expel clots -Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding.

A nurse is caring for a patient who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? A. Assess the patient's IV site q8hrs. B. Check the WBC count q48hrs. C. Monitor the patient's mouth q8hrs. D. Change the IV tubing q48hrs.

C. Monitor the patient's mouth q8hrs. -Monitor mouth at least q8hrs for manifestations of an infection (like sores or lesions). -Check IV site q4hrs for REEDA. -Monitor WBC count q24hrs. -Change IV tubing q24hrs.

A nurse in a mental facility is caring for four patients. Which is an example of sublimation, used as a defense mechanism? A. Patient transfers their anger about their job onto their family and then apologizes B. Patient misses provider appointments because they are "too busy" C. Patient channels their energy into a new hobby following the loss of their job D. Patient's partner died 4yrs ago and they still set a place for them at dinner every night

C. Patient channels their energy into a new hobby following the loss of their job -Sublimation: channeling negative feelings from a loss into something new -Displacement: transferring anger to a less threatening source -Rationalization: justifies actions -Denial: avoiding feelings of loss

NGN: A patient who is x2 post-op, following a surgical repair of a left hip fracture, is c/o of intermittent abdominal pain. Rates 5/10 on left side of abdomen. Pain began after eating dinner. Last bowel movement was 5 days prior. Reports usual pattern is x1 daily. Assessment: Abdomen distended, dull to percussion, firm and non-tender on palpation. Hypoactive bowel sounds x4. Vital signs are within normal limits. Bowtie:

Condition: Intestinal obstruction -bowel sounds hypoactive x4, last BM was 5 days prior, intermittent to constant pain. Interventions: Assist patient in semi-Fowler's & prepare to administer IV fluids. -to relieve the pressure from the distention and reduce risk of developing fluid/electrolyte imbalance. Monitor: Bowel sounds & urine output.

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

A home health nurse is providing teaching about infection prevention to a patient that has cancer and is receiving chemo. Which statements indicate understanding? A. "I will leave my drinking water out of my refrigerator for at least 1hr so it will be room temp." B. "I will clean my toothbrush in my dishwasher once a month. C. "I will take my temp once a week and let my HCP know if it's high." D. "I will walk for short distances throughout the day."

D. "I will walk for short distances throughout the day." -The patient should ambulate short distances as tolerated throughout the day. Helps reduce pulmonary stasis and prevent the development of respiratory infections. -Consuming liquids that have been standing at room temp for longer than 1hr increases the risk for infection. -Clean toothbrushes in dishwasher once per week to reduce the risk for transmission of bacteria. -Take temp once a day to monitor for infections.

A nurse is teaching a patient who is 20wks gestation about common discomforts associated with pregnancy. Which statement indicates understanding? A. "I will decrease my intake of high-fiber foods." B. "I will apply hydrocortisone cream if I develop a rash on my face." C. "I will sleep flat on my back if I develop back pain." D. "I will wear a supportive bra overnight."

D. "I will wear a supportive bra overnight." -Promotes comfort by providing support to enlarged breasts during pregnancy

A charge nurse assigns a newly licensed nurse to care for a patient who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following should the charge nurse take first to provide teaching? A. Refer the nurse to the procedure manual B. Use a diagram to explain the procedure C. Demonstrate the procedure D. Ask the nurse about their knowledge of the procedure

D. Ask the nurse about their knowledge of the procedure -The first action the charge nurse should take using the nursing process is to assess the nurse's knowledge about the procedure. By assessing, the charge nurse can identify the nurse's learning needs.

A charge nurse is speaking with the partner of a patient. The partner states the patient is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation? A. Evaluate the changes the partner requests. B. Review the patient's plan of care. C. Analyze other reports of poor care to look for trends. D. Ask the partner to list specific concerns.

D. Ask the partner to list specific concerns. -The first action the nurse should take, using the nursing process, is to assess the situation by asking the partner to list specific concerns.

A nurse is providing discharge teaching about disease management for a patient who has a new diagnosis of DM1. Which of the following is the nurse's priority? A. Instruct the patient about the importance of regular medical appointments. B. Encourage the patient to participate in daily exercise. C. Explain proper foot care techniques to the patient. D. Ensure that the patient understands the medication regimen.

D. Ensure the patient understands the medication regimen. -The priority action the nurse should take when using the safety vs. risk reduction approach to patient care is to ensure the patient understands the medication regimen. The greatest risk to the patient is the potential to develop hypoglycemia/hyperglycemia, which can be life-threatening if treated incorrectly.

A charge nurse observes a staff nurse document a dressing change in the patient's chart that was not performed. What should the charge nurse do first? A. Ensure the staff nurse changes the dressing B. Notify the nurse manager C. Complete an incident report D. Gather more information about the staff nurse's actions

D. Gather more information about the staff nurse's actions -First step is to assess the reasons for the staff nurse's negligent actions. After discussing actions, then the charge nurse should decide the next course of action.

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical sterile technique? A. Hold hands folded below the waist after donning sterile gloves. B. Pick up and pour solutions with the palm of the hand covering bottle labels. C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. D. Maintain sterile objects within the line of vision.

D. Maintain sterile objects within the line of vision. -Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep sterile objects in direct sight to maintain surgical asepsis. -Sterile technique includes holding hands away from body and above waist level. Items should be kept at least 2.5 cm (1 in) away from the border. -The nurse should use this technique to prevent the solution from running down the label and obscuring the writing, but this action does not maintain sterile technique.

A nurse is providing discharge teaching to a new parent about car seat safety. What should be included? A. Place baby's car seat at a 30 deg. angle B. Car seat should be rear-facing until he is 6mo-old. C. Swaddle the baby in a light blanket before placing him in car seat D. Secure the retainer clip at the level of baby's armpits

D. Secure the retainer clip at the level of baby's armpits -The bones of the rib cage and sternum provide protection to underlying organs in the event of a collision -Place car seat at a 45 deg. angle -Should be rear-facing until 2yrs-old or per recommendations

A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36hrs. Which of the following findings should the nurse identify is an indication that the patient has developed oxygen toxicity? A. Wheezes B. Tachycardia C. Restlessness D. Substernal pain

D. Substernal pain -The nurse should identify substernal pain as a manifestation of oxygen toxicity due to the increased WOB. Another manifestation is crackles. -Tachycardia and restlessness indicate hypoxemia and requires oxygen therapy.

A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the new nurse's actions require the nurse manager to intervene? A. Informs the HCP about a patient's suicide plan B. Notifies the health dept. of a patient's diagnosis of chlamydia C. Reports suspected child maltreatment to social services D. Tells the hospital chaplain a patient's diagnosis

D. Tells the hospital chaplain a patient's diagnosis

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.