Question

The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on botom.)

Answer 1

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

🔷 A (Asthma with wheezing): Indicates compromised airway and breathing, which must be addressed first.

🔷 B (Hypoglycemia symptoms): Urgent but less critical than airway; untreated low glucose can lead to seizures.

🔷 C (Bleeding lacerations): Needs wound care but is not immediately life-threatening.

🔷 D (Crying from incontinence): Stable with no urgent physical needs, lowest priority.

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Answer 2

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

🔶 E (Apical HR): Required before giving digoxin due to risk of bradycardia.

🔶 A (Remove medication): Ensures medication is ready and accessible.

🔶 B (Compare ID): Verifies correct patient identity, prevents errors.

🔶 D (Open package): Done after confirming all checks.

🔶 C (Document): Final and necessary legal step.

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Answer 3

Correct Highlights :

The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
he noticed that his inhaler was expired and was worried the medication was not working.

Rationale :

💠 A (Inhaler not working): Shows treatment ineffectiveness, needs medical intervention.

💠 E (Expired inhaler): Client is using a potentially ineffective or unsafe medication.

💠 Both indicate poor asthma control and urgent need for updated treatment.

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Answer 4

Correct Answers:

Administer medications as ordered.
Provide client teaching.
Apply oxygen via nasal cannula

Rationale :

💎 Administer meds: Bronchodilators and steroids relieve bronchospasm and inflammation.

💎 Apply oxygen: Corrects hypoxemia (SpO₂ at 88%).

💎 Ask for med list: Ensures accurate medication history.

💎 Provide teaching: Helps client manage triggers and long-term care.

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Answer 5

Correct Answers

Blood pressure 130/86 mmHg [ Neither disease process nor medication use ]
Respirations 28 breaths/minute [ Disease process ]
Temperature 98.9" F (37.1°C) [ Neither disease process nor medication use ]
Heart rate 112 beats/minute [ Medication use ]
Oxygen saturation 88% on room air [ Disease process ]

Rationale :

🔷 Oxygen saturation 88% is below normal and reflects hypoxemia, directly caused by the impaired gas exchange in asthma—another disease-related abnormality.

🔷 Heart rate 112 bpm reflects tachycardia, likely due to albuterol or beta-agonist use, a known medication side effect.

🔷 Blood pressure 130/86 mmHg is within normal range for many adults and doesn’t indicate a pathological or pharmacological cause—classified as neither.

🔷 Temperature 98.9°F is a normal reading, showing no evidence of infection or fever, and isn’t influenced by medication—also neither.

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Answer 6

Correct Answers

Lung sounds clear [ Indicates the Interventions Were Successful ]
Client can now speak in full sentences without pausing successful [ Indicates the Interventions Were Successful ]
Respirations 16 breaths/minute [ Indicates the Interventions Were Successful ]
Client reports, "It's a lot easier to breathe now.": [ Indicates the Interventions Were Successful ]
Blood Pressure 122/84 mmHg [ No Indication that the Interventions Were Successful ]

Rationale :

🔶 Lung sounds clear reflects resolution of bronchospasm and effective air movement, showing a positive response to nebulizer treatment.

🔶 Speaking in full sentences without pausing shows that oxygenation and ventilation have improved, confirming that respiratory distress has resolved.

🔶 Respirations of 16/min indicate that the client's breathing rate has normalized, reducing the risk of fatigue or respiratory failure.

🔶 The client stating it's easier to breathe is a subjective indicator of relief from symptoms and improved comfort level.

🔶 BP 122/84 mmHg, although within normal limits, does not specifically reflect improvement in respiratory status—hence not a valid marker of intervention success.

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Answer 7

Correct Answers:

Assess the pin sites for signs of infection.

Rationale :

♦ Skeletal traction involves invasive pins or wires, which carry a high risk of infection at the insertion sites.

♦ Monitoring for redness, swelling, drainage, or other signs of local infection is essential for early detection and prevention of complications such as osteomyelitis.

♦ Including pin site assessment in the care plan ensures the nurse is proactively reducing risks associated with orthopedic hardware and immobilization.

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Answer 8

Correct Answers

Colchicine [ Decreases Pain ; Reduces Inflammation ; Minimize Alcohol Consumption ; Avoid Grapefruit Juice ]
Naproxen [ Decreases Pain ; Manages Pain ; Reduces Inflammation ; Minimize Alcohol Consumption ]
Predinosone [ Manages Pain ; Reduces Inflammation ]
Allopurinol [ Low Uric Acid Levels ; Minimize Alcohol Consumption ]

Rationale :

🔷Allopurinol

✅It used for long-term gout management and works by inhibiting xanthine oxidase, an enzyme involved in uric acid production. ✅It is not for acute pain relief but is essential in preventing recurrent attacks by lowering serum uric acid.

Alcohol intake should be limited because it increases uric acid levels and reduces medication effectiveness

🔷 Colchicine

✅ is effective in acute gout flare-ups due to its ability to interrupt the inflammatory cycle of urate crystal deposition. ✅It doesn't relieve pain directly but reduces inflammation that contributes to pain.

✅Patients should avoid grapefruit juice, which can interfere with drug metabolism and increase toxicity.

🔷 Naproxen

✅A nonsteroidal anti-inflammatory drug (NSAID), is appropriate for acute pain and inflammation management.

✅ It should be used cautiously with alcohol due to the risk of gastrointestinal bleeding.

🔷 Prednisone,

✅ A corticosteroid, is indicated in acute flares when NSAIDs or colchicine are contraindicated, and it provides both pain and inflammation relief through immunosuppressive effects.

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Answer 9

Correct Answers

Blank 1 Correct Option: Inflammation
Blank 2 Correct Option: Erythema

Rationale :

◈ The client’s uric acid level of 9.1 mg/dL confirms hyperuricemia, a diagnostic feature of gout.

◈ The joint symptoms described—persistent pain and swelling—are typical of acute inflammatory response due to urate crystal deposition.

◈ Erythema is a visible indicator of localized inflammation and vasodilation at the joint.

◈ These features signify a classic gout flare, distinguishing it from joint conditions like osteoarthritis or trauma.

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Answer 10

Correct Answers:

Liver
Shrimp
Sardine

Rationale :

◆ These foods are high in purines, which metabolize into uric acid, the main substance accumulating in gout.

◆ Liver and sardines, in particular, have a high purine concentration and are known to provoke flares.

◆ Dietary modification is a critical aspect of managing chronic gout and reducing attack frequency.

◆ Limiting purine-rich foods helps lower serum urate and reduces dependency on medication.

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RN-Hesi Medical Surgical II

No.

2 :
A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

3 : A patient's presents as follows

Correct Highlights :

4 :
The nurse has identified the priority problem for the client and now must determine proper care interventions

Answer Options

5 :
A client in the Emergency Department

Correct Answers

6 :
A patient in the ED

Correct Answers

7 :
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

8 :
A male client presents to the clinic

Correct Answers

🔷Allopurinol

9 :
A healthcare provider is attending to a client who presents to the clinic. The healthcare provider places orders to determine the extent of the client condition.

Correct Answers

10 :
The nurse is reviewing the client's dietary choices for opportunities to pro better outcomes by limiting gout attacks.

Answer Options

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Options	Neither disease process nor medication use	Disease process	Medication use
Blood pressure 130/86 mmHg
Respirations 28 breaths/minute
Temperature 98.9" F (37.1°C)
Heart rate 112 beats/minute
Oxygen saturation 88% on room air

Options	No Indication that the Interventions Were Successful	Indicates the Interventions Were Successful
Lung sounds clear
Client can now speak in full sentences without pausing successful
Respirations 16 breaths/minute
Client reports, "It's a lot easier to breathe now.":
Blood Pressure 122/84 mmHg

Options	Decreases Pain	Manages Pain	Reduces Inflammation	Low Uric Acid Levels	Minimize Alcohol Consumption	Avoid Grapefruit Juice
Colchicine
Naproxen
Predinosone
Allopurinol

RN-Hesi Medical Surgical II

No.

2 : A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

3 : A patient's presents as follows

Correct Highlights :

4 : The nurse has identified the priority problem for the client and now must determine proper care interventions

Answer Options

5 : A client in the Emergency Department

Correct Answers

6 : A patient in the ED

Correct Answers

7 : A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

8 : A male client presents to the clinic

Correct Answers

🔷Allopurinol

9 : A healthcare provider is attending to a client who presents to the clinic. The healthcare provider places orders to determine the extent of the client condition.

Correct Answers

10 : The nurse is reviewing the client's dietary choices for opportunities to pro better outcomes by limiting gout attacks.

Answer Options

2 :
A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

4 :
The nurse has identified the priority problem for the client and now must determine proper care interventions

5 :
A client in the Emergency Department

6 :
A patient in the ED

7 :
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

8 :
A male client presents to the clinic

9 :
A healthcare provider is attending to a client who presents to the clinic. The healthcare provider places orders to determine the extent of the client condition.

10 :
The nurse is reviewing the client's dietary choices for opportunities to pro better outcomes by limiting gout attacks.