2020 PN Clinical Analysis Comprehensive Practice Exam With Answers (150 Solved Questions)

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1/ 24PN Comprehensive Practice(Verified Answers by Expert)1.Anurseisreinforcingteachingwithaclientwhoistoself-administerepoetinalfa.Which of thefollowinginstructionsshouldthenurseinclude>>>>>administerthemedicationsubcuta-neously.2.Anurseenterstheroomofanadolescentclientandfindsthemonthefloorexperiencing a tonic-clonicseizure. Which of the following actionsshouldthe nurse take when the seizure subsides>>>>>keep the client in a side-lyingposition.rationale:thenurseshouldkeeptheclientinaside-lyingpositiontofacilitatedrainageofany secretionandprevent aspiration3.Anurseiscaringforaclientwhoisinthefinalstagesofcancer.Whichof the following client situations should the nurse identify as an ethicaldilemma>>>>>theclientasksthenursetohelpthemdiepeacefullyintheirsleep.rationale:thesituationpresentsandethicalissueforthenursebecausetheclientis

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2/ 24askingforavariationofactiveeuthanasia,alsoknownasassistedsuicided,whichis in violation of the code ofethics for nurses. The nurse is legally and ethicallyunable to support this decision by the clientand should ask for assistance withthis dilemma.4.A nurse is caring fur a client who has a phobiaelevators, Which of thefollowingshouldmenurserecognizeasanindicationofapositiveclientresponse to systematic: desensitization>>>>>the client remains relaxedwhenthinking about the phobia.rationale:The purpose of desensitization therapy is to teach the client to userelaxation techniques to overcome the anxiety caused by the phobia The nurseshouldrecognizetheclientslackofanxietywhenthinkingaboutthephobiaasapositiveresponse tothetherapy.5.A nurse is checking the reflexes of a newborn. Which of the followingtechniquesshouldthenurseusetoelicittheBabinskireflex>>>>>Strokethesoleofthenewborn's footupwardandtowardthegreat toe.6.A nurse is reviewing the laboratory report of a client who is 2 dayspostoperativefollowingthoracicsurgery.Whichofthefollowinglaboratoryresultsshouldthe nursereportto theprovider>>>>>WBC25,000 mm

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3/ 24rationale: The nurse shouldidentify a WBC count of 25,000/mm3 is above theexpected reference range and is an indication that the client might have a post-operativeinfection;therefore,thenurseshouldreportthisfindingtotheprovider.7.Anurseinanurgentcarecliniciscompletingaclientexamination.Afterlistening to the client's lungs, which of the following adventitious soundsshould the nurse document?(Click on the audio button to listen to theclip.):wheeze[audio]rationale:thenurseshoulddocumentthissoundasawheeze.Awheezeisahighpitched musical sound that is heard when air moved through narrowed airwayduringeither inspiration orexpiration.`8.Anurseispreparingtoadministeran1Mimmunizationtoapreschooler.Which of the following statements should the nurse plan to make prior toperformingtheinjection>>>>>letsgive themedicationtoyour dollfirst.9.A nurse is reviewingthe medical record of a client who is receivingwarfarinandhasatrialfibrillation.Whichofthe followinglaboratory valuesshouldthe nurse reportto the provider>>>>>INR 5.0rationale:Theinternationalnormalizedratio(INR)isameasurementofthebody'sblood clottingability.Aclient receivingwarfarin toprevent clotformation relatedto

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4/ 24atrialfibrillationshouldhaveanINRof2.0to3.0.AnINRof5.0orgreaterindicatesthattheclientisatriskforbleeding.Therefore,thenurseshouldnotifytheprovideraboutthis laboratory value.Why PT of 18 is wrong: rationale The prothrombin time (PT) is a measurementofthebody'sbloodclottingability.AprolongedPTisanindicationofprolongedbleeding.AclientreceivingwarfarintopreventclotformationrelatedtoatrialfibrillationshouldhaveaPTof1.3to1.5timesthecontrolof11.0to12.5seconds.Theclient'sPTis1.4timesthecontrolvalueof12.5seconds.Therefore,thenursedoesnot need toreport this value totheprovider.10.Anurseiscaringforaclientwhoisscheduledforperitonealdialysis.Which Of the following actions should the nurse take first>>>>>ensurethedialysatesolution is at room temperature,rationale:Evidence-basedpracticeindicatesthenurseshouldadministerthe

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5/ 24dialysatesolutionatatemperatureof37'C(98.6'F);therefore,thefirstactionthenurseshould take is to warm the prescribed solution.11.A nurse is reviewing the critical pathway of a client who is 4 days post-operativefollowingatotalkneearthroplasty.Theclient'svital signsare oraltemperature 39.10 C (102.40 F), heart rate 116/min, respiratory rate 24/min,andbloodpressure152/92mmHg.Whichofthefollowingactionsshouldthenursetake>>>>>documentthefinding as avariance.rationale: Whenever aclient does not meet the goals or outcomes in the criticalpathway due to unexpected findings or a need for additional interventions. thenurseshoulddocumentthedetailsasavarianceinthecriticalpathway.Inthiscase.itisanegativevariance.Iftheclientprogressesfasterthanthepathwayspecifies,itis a positive variance.12.A nurse is performing a dressing change for a client who is 3 dayspostoperative.Whichofthefollowingfindingsshouldthenursereporttotheprovider>>>>>Yellowgreendrainageattheincisionline.rationale:Yellowgreenpurulentorodorousdrainageindicatesthewoundisinfect-ed.the nurse should report this finding.rationale2:pinkincisionlinewithslightcrusting,serosanguineousdrainageontheolddressing,slightswellingaroundstaples-areallexpectedfindingfortheclient

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6/ 2413.A nurse is inspecting the skin of a newborn.Which of the followingfindingsshouldthenursereporttotheprovider>>>>>Generalizedpetechiaerationale:Petechiaeareanexpectedfindingoverthepresentingpartofthenew-born, such as on the forehead in a brow presentation, and also anywhere on thehead of newborns who had a nuchal cord, which is an umbilical cordaround theneck. However, petechiae all over the newborn's body can indicateinfection or adecreasedplatelet count andshould be reported tothe provider.14.A nurse is caring for a client who is recovering from a stroke and isexperiencingdifficultyusingeatingutensils.The nurseshould identify theneed for a referral to which of the following interprofessional team mem-bers>>>>>Occupational therapist.rationale:toteachclienthowtousespecialeatingutensils.15.AnurseisassistingwithadiscussionaboutSTIswithagroupofadoles-centsatahealthfair.Whichofthefollowingstatementsshouldthe nurse

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7/ 24make>>>>>aninfectionwithgonorrheacanresultininfertility.rationale:gonorrheacanleadtoPIDandtubalscarringwhichcanresultininfertilityinfemale clients.16.Anurseinanoutpatientsurgerycenterisreinforcingdischargeteachingwithaclientfollowingalithotripsyforuricacidstones.Whichofthefollowinginstructionsshouldthenurseplantoincludeintheteaching>>>>>straintheurinetocollect stone fragments.rationale: The client shouldverify passage of the stones by straining their urine.Laboratoryanalysisofthestonescanprovideinformationtohelppreventfuturestoneformation.17.Anurseisassistingwiththetransferofaclienttoalong-termcarefacility.The nurse should review which of the following sections of the electronichealth record to locate informationabout the client's personal health insur-ance>>>>>admissionsheet18.A nurse is preparing to perform a bladder scan for a client.Which ofthefollowingactionsshouldthenursetake>>>>>Telltheclienttheyshouldnotexperienceany discomfort.rationale:thenurseappliesthehandheldscannerovertheareaofthebalderand

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8/ 24thisisa noninvasiveprocedureso itdoesnot requirewrittenconsent.19.Anurseiscollectingdatafromaclientwhohasschizophrenia.Whichof the following statements by the clientshould the nurse identify as adelusion>>>>>Mydoctorsglasseshavelasersthatwillburnholesinmybrainifilookat them.rationale:The client's statement demonstrates a belief that is contrary to realitythatsomeoneintendstocausethemharmusingunrealisticmeans.Therefore,thenurseshould identify this statement as a delusion ofpersecution.20.A nurse in a provider's office is reinforcing teaching with a client who istofollowa2,000mgsodium-restricteddiet.Whichofthefollowingclientfoodselectionsindicatesanunderstandingoftheteaching>>>>>cannedpeaches.rationale:cannedpeacheshavealowsodiumcontent.whynot;cottagecheese,leanhamandwheatcrackers,allhavehighsodiumcontent.,

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9/ 2421.Anurseisreinforcingteachingwithafemaleclientwhohastuberculosisand a new prescription for rifampin. Whichof the following statements bythe client indicates an understanding of the teaching>>>>>i will usecondoms inaddition to birth pillsto decrease myrisk of becoming pregnant.rationale: Rifampin can interact with and reduce the effectiveness of oral contra-ceptives.Therefore,thenurseshouldinstructtheclienttouseasecondarymethodtopreventpregnancy.22.A nurse is participating in a quality improvement study about the effec-tivenessofclientpainmanagementontheunit.Whichofthefollowingstrate-gies should the nurse use to collect data>>>>>review clients chart for theirratingofpainbeforepainmedicationwasadministeredand1hrafteradministration.23.Anurseiscaringforaclientwhoiscryingandstatesthattheirproviderinformed them that they have a tumor and will need a biopsy.Which of thefollowing responses should thenurse make>>>>>what have you done tohelpyourselfget though stressfulsituation before?24.Anurseiscontributingtotheplanofcareforaclientwhohasacontinenturinary diversion. Which of thefollowing interventions should the nurseplantoimplementtofacilitateurinaryelimination>>>>>useintermittenturinarycatheterizationfor the client regular intervals.rationale: A continent urinary diversion contains valves that prevent urine from

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10/24exitingthepouch;therefore,thenurseshouldplantoinsertaurinarycatheteratregular intervals to drain urine from the client's pouch.25.Anurseiscaringforanewbornwhois12hrold.Thenurseshouldexpectthenewborn'sstooltohavewhichofthefollowingcharacteristicswithinthefirst24hrfollowingbirth>>>>>Darkgreenishblackand viscous.rationale:Thefirststoolpassedbyanewbornisthemeconium that develops inutero. It is dark greenish-blackand viscous, containing components of amnioticfluid,cells, intestinal secretions,andblood.whynotrationales;goldenbrown-breastfednewborns,appearson4thdaygreenishbrown-transitional stoolpaleyellowandsoft-formulafednewborns

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11/2426.Anurseiscaringforanewbornwhois1hrold.The mother receivedfentanyl 30 min before birth. For which of the following adverse effectsshouldthe nursemonitor the newborn>>>>>respiratory depression27.A nurse ispreparing toperform tracheostomycare for aclient.WhichOfthefollowingactionsshouldthenursetakefirst>>>>>opensterilepackagesrationale: When preparingto perform tracheostomy care, the greatest risk to theclient is the transmissionofmicro-organisms. Therefore, the priority action is toopensterilepackages.Thenurseshouldhaveasterilebowl inwhich to pourthesterilesolutiontopreventthecontamination ofthesterilegloves.28.Anurseisreinforcingteachingaboutadvancewithaclient.Whichofthefollowing statements by the client indicates an understanding of the teach-ing>>>>>icanchangemyhealthcaredecisionsevenifihaveadvanceddirectives.29.A licensed practical nurse (LPN) is reviewing client assignments for theupcomingshift.WhichofthefollowingclientsshouldtheLPNaskthechargenursetoreassigntoaregisterednurse(RN)>>>>>aclientwhohasanewcolostomyandrequires the developmentof a teachingplan.rationale:LPnDONTdelegateassessmentsandteachings.30.A nurse iscollecting datafrom aclient who hasa gastriculcer.Whichofthe following findings should the nurse identify as a complication to reporttothe provider>>>>>Hematemesisrationale;bloodinvomitingisanindicationofgastrointestinalhemorrhagewhich

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12/24can lead to hemorrhagic shock and should be reported.31.A nurse is reinforcing teaching with a client who is scheduled for an ex-erciseelectrocardiography(ECG)stresstest.whichofthefollowingactionsshould the nursetake>>>>>recommend the client wear comfortable shoesduringthe test.32.Anurseiscollectingdatafromaclientwhohaschronicpancreatitisandis receiving pancrelipase.Which of the following client findings indicates atherapeuticeffectofthismedication>>>>>reportsadecreasedinnumberofstools.rationale:Pancrelipaseisadministeredasreplacementtherapyforadeficiencyinpancreaticenzymes,whichresultsinsteatorrhea,orfattystools.Thenurseshouldmonitorforimprovednutritionandadecreaseinthenumberofbowelmovements,whichwould indicate a therapeuticresponse to the medication.

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13/2433.A nurse is reinforcing teaching with a client who is receiving radiationtherapyforcancerofthelarynx.Whichofthefollowingstatementsmadebythe client indicates an understanding of the teaching>>>>>i should wearasoftscarfaround my neck wheni am outside.rationale:toprotecttheskinformsunexposure,nosoap-use plain wateruseelectricrazorinsteadofstraightrazoravoidusingaheatsourceontheradioationsite.34.Anurseisreviewingthetechniquesfortransferringaclientfromabedto a chair with a group of assistive personnel(AP). Which of the followinginstructionsshouldthenurseinclude>>>>>uselowerbodystrength.rationale;uselowerbodystrengthtoreducestressontheback.35.Anurseiscaringforaclientwhois12hrpostoperativefollowingatotalhiparthroplasty.Whichofthefollowingactionsshouldthenursetake>>>>>placeanabduction wedge between the client'slegs when in bed.rationale: The nurseshould place an abductionwedge between the client's legswhileinbedtopreventadductionofthelegsandhipdislocationfollowingatotalhiparthroplasty.36.A nurse is collecting data from a 5-year-oldChild at a well-child Visit.The parentreports that the Child is havingfrequent nightmares. Which ofthe following statements by the parent indicates to the nurse that the childisexperiencingsleepterrorsratherthannightmares>>>>>Mychildgoesbacktosleepright away.

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14/24rationale:Thenurseshouldrealizethatgoingbacktosleepquicklyisanindicationof sleep terrors, rather than nightmares. A child who is experiencing nightmareshasdifficulty returningto sleepbecause ofcontinued fear.37.A client is requesting information from a nurse about creating a healthcareproxy.Whichofthefollowingstatementsshouldthenursemake>>>>>theperson you appoint will make health care decisions for you ifyou cannot do soyourself.38.A client in a mental health facility unjustly accuses a nurse of stealingmoneyfromtheirroom.Whichofthefollowingtherapeuticresponsesshouldthenursemake>>>>>tellmehowyoudecidedwhotookyourmoney.

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