PN Adult Medical Surgical Online Practice 2023 B| Questions and Answers, 100% Correct| W, Exams of Nursing

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PN Adult Medical Surgical Online Practice

2023 B| Questions and Answers, 100%

Correct| With Rationales

A nurse in a telemetry unit is collecting data from a client who has a newly inserted permanent pacemaker. Which of the following findings should the nurse report to the provider? The client experiences hiccups when sitting. A nurse is reinforcing preoperative teaching with a client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. " I will need to do the breathing exercises every 1 to 2 hrs after surgery." "I will use my PCA medication before my knee starts to hurt too bad." "I will probably be going home with a walker." Click to highlight the findings the nurse should report to the charge nurse immediately. To deselect a finding, click on the finding again.

• Perineal pad is saturated with blood, and large clots are present is correct. The presence of vaginal bleeding and blood clots is a manifestation of vaginal hemorrhage. Therefore, the nurse should report this finding to the charge nurse.

• Blood pressure 98/56 mm Hg is correct. Decreased blood pressure is a manifestation of vaginal hemorrhage. Therefore, the nurse should report this finding to the charge nurse.
• Heart rate 102/min is correct, Tachycardia is a manifestation of vaginal hemorrhage. Therefore, the nurse should report this finding to the charge nurse. A nurse is assisting with the care for a client who reports shortness of breath and has an oxygen saturation 90%. Which of the following actions should the nurse take? Administer oxygen via nasal cannula R: The nurse should administer oxygen via nasal cannula to a client who reports shortness of breath and has an oxygen saturation below the expected reference range. The nurse should continue to monitor the client and adjust the oxygen flow rate as needed. A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include? Incontinence of the bowel and bladder.

Rationale:The nurse should inform the caregiver that incontinence of the bowel and bladder is a manifestation of impending death. Other manifestations include hypotension, bradycardia, restlessness, and coolness of the skin. A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response to the medication? "I have gained 3 lbs since my last appointment" R: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as an indication that the methimazole therapy has been effective A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? Keep a sheepskin pad between the client's extremity and the CPM machine. R: The nurse should plan to keep a sheepskin pad between the dient's extremity and the cOM madhune to protect the client's skin. The nurse should check the client's skin condition frequendy wile the cient is using the CPM machine.

A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching? "Perform testicular self-examination after taking a warm shower." Rationale: The nurse should instruct the client to perform testicular self- examination after taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for better palpation of the testes. A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? Remind the client to avoid watching their feet when walking. R: The nurse should remind the client's caregivers to frequently remind the client to maintain correct posture and prevent falls by not watching their feet when walking. A home health nurse is assisting with the care for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make? "Use a bronchodilator 30 minutes before your meal."

R: The dient should use a bronchodilator 30 min before meals to prevent shortness of breath while eating. A nurse is assisting with the care of a client who has a newly inserted water-seal closed chest tube. Which of the following findings should the nurse report to the provider? Chest drainage is greater than 70 mL/hr. RAT: The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a complication and should be reported to the provider. Water fluctuates in the water-seal chamber. Water should fluctuate in the water-seal chamber. The water rises and falls upon the client's respiratory effort. Therefore, this finding does not need to be reported to the provider. A nurse is assisting with the care for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? Perform pin site care daily. R: The nurse should perform pin site care daily with chlorhexidine solution or use

a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection. A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching? "You should place your toothbrush in hydrogen peroxide." R: Tieres who are receiving chemotherapy should clean their toothbrushes by soaking them in a hydrogen peroxide or bleach solution. This solution rids the toothbrush of bacteria and prevents infection. A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin? Opened insulin can be stored on a cool countertop away from light R: The nurse should reinforce teaching with the clients that opened insulin vials do not require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct sunlight. A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome?

Diminished headache Rationale: Sumatriptan is a vascular headache suppressant prescribed for relief of migraines or cluster headaches. Therefore, the nurse should monitor the client for a diminished headache as an expected outcome of the medication.

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Nasal and throat discomfort are possible adverse effects of sumatriptan. Muscle pain and stiffness are possible adverse effects of sumatriptan. The nurse should not expect sumatriptan to decrease peripheral edema. A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? "You are at risk for infertility with this infection, regardless of treatment." R: The nurse should reinforce teaching with the client that there is a risk for infertility as a result of this infection,

A nurse is changing the dressing for a client who has an abdominal incision and a closed-suction drain. Which of the following actions should the nurse take? Cleanse the drainage plug with alcohol swabs. Rationale: The nurse should cleanse the drain opening and plug with alcohol swabs to remove excess drainage and discourage pathogens from entering the drainage system. The nurse should secure the drainage tube to the client's gown to allow for ambulation. Pinning the gown to the client's bedding can result in dislodgement of the drain. The nurse should wear clean gloves to empty the drainage system because the exterior of the drain is not sterile. The nurse should use a precut or folded gauze dressing to fit around the drainage tube. If the nurse cuts the gauze dressing, small threads and fibers can embed in the incision and increase inflammation and infection.

A nurse is monitoring a client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? Palpate the abdomen. RAT: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? Encourage the client to complete ADLs. R: The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning. A nurse is assisting with the care for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect?

Irrigate the urethral catheter with 0.9% sodium chloride. R: The nurse should expect a prescription to irrigate the urethral catheter because this will clear the tubing of any blood clots or tissue pieces and allow for a better flow. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? Initiate oxygen at 4L/min via nasal cannula. Rationale: The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect them from acquiring pneumonia.

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The nurse should collect a sputum culture to identify the organism causing the client's infection. Antimicrobial sensitivities are obtained from the sputum culture to guide the provider in prescribing antibiotics. However, there is another prescription the nurse should implement first. The nurse should administer antibiotics to treat the infection. A broad spectrum

antibiotic, such as ceftriaxone, is administered when sepsis is suspected because it treats both gram-positive and gram-negative bacteria. After the results of the blood and sputum cultures are obtained, the provider will often change to a more specific antibiotic. However, there is another prescription the nurse should implement first. The nurse should obtain blood cultures to identify the organism causing the client's infection. Antimicrobial sensitivities obtained from the blood cultures will guide the provider in prescribing treatment. However, there is another prescription the nurse should implement first. A nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should the nurse include? Dangle the extremities o the side of the bed. R: The nurse should include in the plan of care to have the client dangle their lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow. A nurse is assisting with the care for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make?

Eat soft foods R: The nurse should remind a client who has stomatitis to eat soft, nonirritating foods to decrease irritation to the oral mucosa. A nurse is reviewing the medical record for a client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) Notify the charge nurse of the client's BUN R: The client's BUN level is above the expected reference range of 10 to 20 mg/dL, which can indicate impaired renal function. The nurse should anticipate interventions to restore the client's fluid volume. A nurse is assisting with the care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) nfection in a surgical wound. Which of the following information should the nurse plan to share with visitors? Visitors must don a gown and gloves prior to entering the client's room. R: The nurse should provide teaching to the visitors regarding the infection control measures for a client who is on contact isolation precautions. Contact precautions

require visitors to put on a gown and gloves prior to entering the room of a client who has MRS4 to prevent the spread of infection A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber? 1/2 cup cooked kidney beans R: The nurse should recommend kidney beans as the best source of fiber because 1/2 cup contains 6.5 g of fiber Complete the following sentence by using the lists of options. After reviewing the findings in the client's medical record, the nurse should first address the client's abdominal distention , followed by the client's Acute pain R:

• Abdominal distention is correct. When using the greatest risk framework, the nurse should identify that a manifestation of an inflammatory intestinal disorder is abdominal distention. The nurse should address this finding to reduce the risk for life-threatening

• Acute pain is correct. When using the greatest risk framework, the nurse should identify that a manifestation of an inflammatory intestinal disorder is acute abdominal pain. The nurse should address this finding to reduce the risk for life- threatening complications, such as obstruction or infection. The nurse is collecting data on the client. For each client finding, click to specify if the finding is consistent with Appendicitis, Diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process. Blood in the stool is consistent with diverticular disease and Crohn's disease. Clients who have diverticular disease can have a decreased hemoglobin and hematocrit level from chronic or severe bleeding, and their stools should be checked for occult or frank bleeding. Anemia relating to Crohn's disease is common because of slow bleeding, and the stools of client's who have Crohn's disease might contain bright red blood. Pain in the right lower quadrant is consistent with appendicitis and Crohn's disease. Pain in the right lower quadrant is a manifestation of appendicitis. Clients who have inflammation from Crohn's disease usually have constant pain located in the right lower quadrant. Clients who have diverticular disease might experience pain in the left lower quadrant. Mucus in the stool is consistent with Crohn's disease.

Clients who have Crohn's disease usually have mucus and fat in their stools. Nausea is consistent with appendicitis, diverticular disease, and Crohn's disease. Clients who have appendicitis, diverticular disease, or Crohn's disease might experience nausea. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The nurse is caring for the client who has manifestations of peritonitis therefore, the priority finding for the nurse to report is laboratory values The nurse is contributing to the plan of care for the client who has peritonitis and Crohn's disease. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the client. Obtain blood cultures - indicated obtain the client's vital signs every 15 min - indicated Administer a hypotonic IV solution - contraindicated insert a nasogastric tube - indicated The nurse is assisting with the care of the client who is preoperative for an exploratory laparotomy. Select the 4 actions the nurse should take.

Administer phenytoin with a sip of water on the day of surgery. Assist with the administration of gentamicin 100 mg IV. Assist with the administration of dextrose 5% in lactated Ringer's. Contact the wound, ostomy, and continence nurse. The nurse is reinforcing discharge teaching with the client. Which of the following client statements indicates an understanding of the teaching? Select all that apply. "I should schedule several rest periods throughout the day" "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit". A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? Rephrase client instructions when not understood. Rationale: When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood.

When communicating with a client who has hearing loss, the nurse should keep their hands away from their mouth to promote lip reading. When communicating with a client who has hearing loss, the nurse should speak in a normal tone of voice. Higher pitched sounds can impede hearing by accentuating vowel sounds and concealing consonants. When communicating with a client who has hearing loss, the nurse should sit or stand facing the client on the same level so that the nurse's mouth and lips can be seen for lip reading. A nurse is assisting with the care of a client who has hearing loss. Which of the following actions should the nurse take? Lower voice pitch when speaking R: The nurse should lower their voice pitch when speaking to a client who has hearing loss. Clients who have hearing loss have difficulty hearing high-pitched sounds. A nurse is assisting with the care of a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures?

Escharotomy R: The nurse should anticipate a prescription for an escharotomy to relieve constriction of the client's chest due to a burn injury. Following removal of the eschar, chest wall movement will be possible, and the client's oxygenation should improve. A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? Avoid stopping this medication suddenly. r-The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations. A nurse is assisting with the care for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? Minimize the time the head of the bed is elevated. R: The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area.

A nurse in a long-term care facility is collecting data from a client who reports ful 1088 in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction? Small liquid stools R: Small liquid stools can be the result of fecal material being expelled around an impaction. A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? "I drink bottled water." Rationale: To avoid exposure to bacteria, clients who have cancer and are receiving chemotherapy should be sure that drinking water is safe. Drinking fresh, bottled water limits exposure to bacteria.

A nurse is assisting with the care for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? Decreases pain during urination R: Phenazopyridine reduces pain and burning during urination by exerting an anesthetic effect on the mucosa of the urinary tract. A nurse is assisting with the care of a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? Administer epinephrine. R: The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema. A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an IN of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is assisting with the care of a client who is at risk for developing pressure injuries. Which of the following actions should the nurse take? Position pillows between the bony prominences. R: The nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure injury development. A nurse is contributing to planning care for a client who overdosed on oxycodone. Which of the following medications should the nurse recommend for the client? Naloxone R: Naloxone is an opioid antagonist used to prevent respiratory depression as a result of opioid overdose. The nurse should recommend this medication for the client. A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all that apply.) Monitor the insertion site for bleeding is correct. The nurse should monitor the client's insertion site for manifestations of hemorrhaging.

Position the affected extremity at a 45º angle is incorrect. The nurse should keep the client flat with the affected extremity extended, not flexed. Restrict the client's fluid intake is incorrect. The nurse should encourage fluid intake for the client following the cardiac catheterization to assist with evacuating the contrast medium from the client's system. Maintain the pressure dressing is correct. The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal. Check the client's peripheral pulses is correct. The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion. The nurse is reviewing the client's diagnostic results. Which of the following findings require follow up? Select all that apply. PaCO2 WBC count Chest x-ray

Oxygen saturation BUN The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. Client is short of breath and has a productive cough with yellow mucus States, "I could barely breathe when I got up this morning and I had a throbbing headache" Client is diaphoretic Crackles heard in posterior lung A nurse is prioritizing care for the client. Complete the following sentence by using the lists of options. At 1000, the nurse should first address the client's Oxygen saturation followed by the client's Heart rate The nurse is assisting with the plan of care for the client. For each potential provider prescription, click to specify if the potential

prescription is anticipated, nonessential, or contraindicated for the client. Cough and deep breathe every 2 hr is anticipated Obtain a sputum culture and sensitivity is anticipated Titrate oxygen to keep oxygen saturation greater than 90% is anticipated. Place client on a 1,500 mL fluid restriction is contraindicated Administer acetaminophen 500 mg PO every 6 hr PRN is anticipated. Administer famotidine 40 mg PO daily is nonessential. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention. Temperature WBC Potassium Click to highlight the findings that indicate the client is improving. To deselect a finding, click on the finding again. A nurse is preparing to perform intermittent urinary catheterization for a female client who has been unable to void following surgery 6 hr ago. Which of the following catheters should the nurse use to perform this procedure? B- clear plastic with blue cap

A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? Keep the cleint in a side-lying position. Rationale: The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity. A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A (red) is correct. FRONTAL LOBE Injury to the frontal lobe can result in alterations to motor function or voluntary movement. This involves the ability to speak and the ability to move purposefully.

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