1. A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take
... [Show More] first?
Administer oxygen.
The nurse should administer oxygen to improve gas exchange. However, there is another action the nurse should take first.
Initiate an infusion of oxytocin.
The nurse should initiate an infusion of oxytocin to promote uterine contractions. However, there is another action the nurse should take first.
Massage the uterus to expel clots.
MY ANSWER
Using the airway, breathing, circulation approach to client care, the nurse should place the priority on massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding.
Obtain a CBC.
The nurse should obtain a CBC to monitor the status of the client. However, there is another action the nurse should take first.
• 2.
RN Comprehensive Online Practice 2016 A
CLOSE
Question 2 loaded rationals provided
Question: 2 of 150
CORRECT
• Time Elapsed: 00:02:14
• Pause Remaining: 08:20:00
PAUSE
FLAG
A nurse is caring for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan?
Keep the client resting in bed.
A client who has a CN II deficit does not require bed rest.
Ask the client to restate directions.
The nurse should plan to ask clients who have a CN VIII deficit, which causes hearing loss, to restate directions.
Clear objects from the client's walking area.
MY ANSWER
The nurse should plan to clear objects from the client's walking area because a CN II deficit can result in visual impairment and lead to falls.
Evaluate the client's ability to swallow.
The nurse should plan to evaluate the swallowing ability of clients who have a CN IX deficit because it can impair swallowing.
• 3.
RN Comprehensive Online Practice 2016 A
CLOSE
Question 3 loaded rationals provided
Question: 3 of 150
CORRECT
• Time Elapsed: 00:04:01
FLAG
• Pause Remaining: 08:20:00
PAUSE
A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of
labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?
Continue observing the fetal heart rate.
MY ANSWER
Early decelerations indicate the progression of labor and are a benign finding. The nurse should continue to observe the fetal heart rate.
Assist the client to a knee-chest position.
The nurse should assist the client into a knee-chest position if she notes a prolapsed cord.
Prepare the client for continuous internal monitoring.
There is no indication for the client to have internal monitoring.
Prepare for an emergency cesarean birth.
The nurse should prepare for an emergency cesarean birth if the monitor indicates late or variable decelerations despite interventions.
•
RN Comprehensive Online Practice 2016 A
CLOSE
Question 4 loaded rationals provided
Question: 4 of 150
INCORRECT
• Time Elapsed: 00:05:19
FLAG
• Pause Remaining: 08:20:00
PAUSE
A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.30, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCO3- 26 mEq/L, SaO2 87%. Which of the following is the correct interpretation of these values?
Uncompensated metabolic acidosis
An HCO3- of 26 mEq/L is within the expected reference range. Therefore, these laboratory values do not indicate metabolic acidosis. Uncompensated respiratory acidosis
A pH of 7.30 is below the expected reference range and indicates the client has acidosis. The PaCO2 of 54 mm Hg is above the expected reference range, which, with the low pH indicates that the acidosis has a respiratory origin.
The HCO3- of 26 mEq/L is within the expected reference range, indicating that the acidosis is not metabolic in origin and the body has not yet corrected the imbalance through compensation.
Compensated respiratory acidosis
MY ANSWER
The laboratory values do not indicate compensation has occurred.
Compensated metabolic acidosis
An HCO3- of 26 mEq/L is within the expected reference range. Therefore, these laboratory values do not indicate metabolic acidosis.
•
RN Comprehensive Online Practice 2016 A
CLOSE
Question 5 loaded rationals provided
Question: 5 of 150
CORRECT
• Time Elapsed: 00:06:32
• Pause Remaining: 08:20:00
PAUSE
FLAG
A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?
Maintain the client on bed rest.
The nurse should encourage the client to ambulate, as walking does not increase the risk for pulmonary emboli nor does it worsen the deep-vein thrombosis once an anticoagulant is initiated.
Restrict the client to 1 L of fluid per day.
The nurse should encourage the client to drink 2 to 3 L of fluid daily to decrease platelet aggregation and prevent dehydration.
Place cool compresses on the edematous area.
The nurse should place warm compresses on the affected area to reduce swelling and promote comfort.
Elevate the affected leg.
MY ANSWER
The nurse should elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency.
•
RN Comprehensive Online Practice 2016 A
CLOSE
Question 6 loaded rationals provided
Question: 6 of 150
INCORRECT
• Time Elapsed: 00:07:32
• Pause Remaining: 08:20:00
PAUSE
FLAG
A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent?
The client's partner tells the nurse that the client understands the procedure.
MY ANSWER
The client can tell his partner that he understands the procedure, but the nurse must speak directly to the client to ensure that the client understands what the provider has told him before being certain that the client has the ability to sign the form.
The nurse locates the provider's prescription for the surgical procedure.
A written prescription for a surgical procedure does not ensure that the provider has explained the procedure to the client or that the client has the knowledge to give informed consent.
The nurse witnesses the provider's explanation of the procedure.
Even though the provider has explained the procedure to the client, the nurse cannot assume that the client understands the information the provider gave.
The client is able to accurately describe the upcoming procedure.
The ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client, and that the client has the ability to sign the informed consent.
•
RN Comprehensive Online Practice 2016 A
CLOSE
Question 7 loaded rationals provided
Question: 7 of 150
INCORRECT
• Time Elapsed: 00:08:13
• Pause Remaining: 08:20:00
PAUSE [Show Less]