PN Adult Medical Surgical Online Practice 2023 B 100% VERIFIED ANSWERS GUARANTEED PASS, Exams of Nursing

Download PN Adult Medical Surgical Online Practice 2023 B 100% VERIFIED ANSWERS GUARANTEED PASS and more Exams Nursing in PDF only on Docsity! PN Adult Medical Surgical Online Practice 2023 B 100% VERIFIED ANSWERS GUARANTEED PASS 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? 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. --------------- 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. --------------------------- 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 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. 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.) 0.7 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. also known as "buffalo hump". The nurse should use therapeutic communication techniques to investigate the client's body image concerns. A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity? Furosemide The nurse should identify that loop diuretics, such as furosemide, increase the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk for the development of digoxin toxicity. A nurse is assisting with the care for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? Determine the client's understanding of the procedure. R: When using the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should determine the client's understanding of the procedure to reinforce necessary teaching, which can help manage their anxiety. A nurse is reviewing the plan of care for a client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care? Keep an abduction pillow between the client's legs. Rationale: The nurse should keep an abduction pillow or a splint between the client's legs to prevent hip dislocation after surgery. ----- The nurse should encourage and assist the client to get out of bed as soon as possible after the surgery. The nurse should have the client perform incentive spirometry every 2 hr as well as deep breathing and coughing every 2 hr to prevent atelectasis. The nurse should check the neurovascular status on the extremity every 2 to 4 hr. A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? Avoid bending your hips more than 90 degrees. ( to prevent dislocation of the replacement hip). - Nurse should instruct client to wait 90 days before crossing legs. Crossing legs early int heh postoperative period can result in dislocation of the replacement hip. -Nurse should inform the client that she ay lie on her operative side with a pillow between her legs. This will not injure the suture site or cause dislocation of the replacement hip. - Nurse should instruct the client to sleep on a firm mattress to avoid potential dislocation of the replacement hip. A nurse is assisting with the care for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? Mask R: The nurse should identify that a client who has meningococcal pneumonia requires droplet precautions, which include wearing a mask when providing care within 1 m (3 feet) of the client. A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the followi is statements by the client indicates an understanding of the teaching? "The medication should be taken before I eat breakfast every morning." R: The nurse should remind the client to take levothyroxine at the same time each day, preferably 1 hr before breakfast. A nurse is assisting with the care for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury? Muscle twitching R: A common complication of a thyroidectomy is parathyroid gland injury, leading to hypocalcemia. Clients experiencing hypocalcemia can have twitching, numbness, and tingling of fingers, toes, and around the mouth. A nurse is assisting with the care for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? Pulmonary embolism R: Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea. A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? "Limit contact with large groups of people." Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people. A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test, Which of the following instructions should the nurse include in the teaching? Avoid eating red meat for 3 days prior to the test. A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine? "I had a low fever this morning." Rationale:Clients who have a febrile illness should not receive the influenza vaccine. ----- Clients who recently received a tuberculosis skin test can receive the influenza vaccine. Clients who have an allergy to latex can receive the influenza vaccine. Clients who have an allergy to shrimp or shellfish can receive the influenza vaccine. A nurse is assisting with the care for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure? Decreased blood pressure R: Following an abdominal paracentesis, the nurse should monitor the client for a decrease in blood pressure. This finding indicates hypovolemia as a result of excess fluid withdrawal. Depending on the amount of fluid withdrawn, hypovolemia can lead to shock. A nurse is collecting data from a client who has 30% body surface area deep partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate? Urine output is 50 mL/hr. R: The nurse should closely monitor the client's urinary output as an indicator of effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Hypovolemia Insert a large gauge IV Initiate a fluid challenge blood pressure Urine output A nurse is assisting with the care for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? Compartment syndrome R: Compartment syndrome is a complication that involves increased pressure within a compartment (an area that supports blood vessels, bones, and nerves) leading to circulatory compromise to the limb. The pressure can be caused externally by a cast that is too tight or internally by the inflammation or edema from the injury. Circulatory impairment causes pallor and paresthesia of the extremities, a delay in capillary refill, and, without immediate treatment, can cause nerve damage and necrosis. A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? Offer a small snack at bedtime. Rationale: The nurse should offer the client a small snack of carbohydrates or a glass of milk as part of the bedtime routine, which can help the client relax and prepare for sleep. A nurse is assisting with the care for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? Intra-abdominal bleeding R: Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis. A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the Folliowing instractions should the nurse include in the teaching? Avoid eating red meat for 3 days prior to the test. R: The nurse should remind the client to avoid eating red meat for 3 days prior to the guaiac fecal occult blood test because this can lead to a false positive result.