RN Comprehensive Online Practice 2019 B with NGN Latest Update 2024/2025

A nurse has just received change-of-shift report on four clients. Which of the following clients should the nurse assess first?

A client who is postoperative with abdominal distention and no bowel sounds

A client who has diabetes mellitus and a blood glucose level of 105 mg/dL

A client who has heart failure and 2+ pitting edema

A client who is receiving maintenance IV fluids and needs a new IV catheter - ANSWER--A client who is postoperative with abdominal distention and no bowel sounds

Using the acute vs. chronic approach to client care, the nurse should first assess the client who is postoperative with abdominal distention and no bowel sounds because these manifestations are indications of a paralytic ileus.
A nurse is caring for a school-age child.

Nurses' Notes
First visit:
A child is brought to the clinic accompanied by guardians. The guardians have received feedback from the child's teacher that the child has become disinterested in schoolwork and has difficulty paying attention during class. The child often loses their school supplies.
The guardians report that the child demonstrates these behaviors at home as well. The child refuses to participate in household chores, keeps their room untidy, does not clean up when told to, and is generally careless and disi - ANSWER--ADHD
Hyperreactivity to sensory input
Losing necessary things
Interrupting others
Intellectual impairment

ID
Intellectual impairment
Hyperreactivity to sensory input

When analyzing cues, the nurse should identify that manifestations of ADHD include losing necessary things, interrupting others, intellectual impairment, and hyper reactivity to sensory input.

In ADHD, the client often loses necessary things in daily life, such as pencils, erasers, and books. The client often interrupts others and has difficulty waiting for their turn in conversation.

The client might have an intellectual impairment, which can lead to poor academic performance and difficulties with socialization. The client might exhibit hyperreactivity or hyporeactivity to stimuli.

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?

"Droplet precautions should be initiated for a client who tests positive for measles."

"A client who requires airborne precautions should be placed in a negative-pressure airflow room."

"Airborne precautions should be initiated for a client who has Clostridium difficile."

"A client who is immunocompromised should be placed in a negative-pressure airflow room." - ANSWER--A client who requires airborne precautions should be placed in a negative-pressure airflow room."

Airborne precautions require a negative-pressure airflow room that has at least six to 12 air exchanges each hour using a HEPA filtration system.

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

Droplet

Airborne

Contact

Protective environment - ANSWER--Droplet

The nurse should initiate droplet precautions for this client by placing the client in a private room and wearing a surgical mask when caring for the client. Pneumonia is transmitted by droplet particles.

A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?

Diarrhea

Urinary retention

Purulent discharge

Abdominal bloating - ANSWER--Abdominal bloating

The nurse should include the presence of abdominal bloating as an early manifestation of ovarian cancer. Other manifestations include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency.

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

Respiratory alkalosis

Metabolic alkalosis