RN Adult Medical Surgical Online Practice 2019 A for NGN answers

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?

Apply firm pressure to the insertion site.

A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy A nurse is providing teaching for the client. Which of the following instructions should the nurse include?

Avoid drinking fluids with meals Eat several small meals per day Consume high-protein snacks Avoid highly seasoned foods

A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection?

Avoid placing plants or flowers in the client's room.

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?

Blood pressure 170/80 mm Hg

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?

Bradycardia

A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

C

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?

Calcium

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?

Calcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.

A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer?

Calcium carbonate

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first?

Call for help.

A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take?

Check that one finger fits between the cast and the leg. To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application.

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 "I could barely breathe when I got up this morning and I had a throbbing headache Crackles heard in posterior lungs Client is diaphoretic

For each potential provider's 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. Perform neurological checks every 2 hr is nonessential. Administer oxygen at 3 L/min via nasal cannula is anticipated. Limit the client's fluid intake to 1,500 mL per day is contraindicated. Acetaminophen 500 mg PO every 6 hr as needed is anticipated. Famotidine 40 mg PO daily is nonessential.

A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

D

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?

Demonstrate ways to deep breathe and cough.

A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?

Digoxin

A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?

Dysphagia

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect?

Elevated bilirubin level

For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. Each finding can support more than one disease process.

Hand grasps is consistent with migraine, stroke, and meningitis Numbness is consistent with migraine and stroke. Aphasia is consistent with migraine and stroke Visual changes are consistent with migraine, stroke, and meningitis Family history is consistent with migraine and stroke.

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Heart rate 110/min

A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider?

Heart rate 55/min

The nurse is reviewing the client's medical record from Day 5. Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again.

Heart rate is 72/min Respiratory rate is 20/min Blood pressure is 128/56 Oxygen saturation is 96%

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment?

History of asthma

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?

Hypoactive bowel sounds

A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication?

Hypokalemia

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?

Increase fluid intake.

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority?

Increased respiratory secretions

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?

Initiate airborne precautions.

A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take?

Inject the medication into the anterolateral abdominal wall.

A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take?

Instruct the client on alternative therapies for pain reduction.

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

Instruct the client to allow the machine to breathe for them.

A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take? Select all that apply.

Instruct the client to splint the abdomen with a pillow for coughing Plan to ambulate the client as soon as possible Report urinary output to the provider Ask the client to rate their pain on a 0 to 10 pain scale

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen restrictive clothing.

A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?

Monitor the client's temperature every 4 hr.

A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew?

Naproxen

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs.

A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication?

Orthostatic hypotension

The nurse should first address the client's .. followed by the client's..

Oxygen saturation Temperature

The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse? Select all that apply.

PCO2 WBC Chest X-ray Oxygen saturation BUN

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated

Perform a 12-lead ECG is not indicated Place the client in Trendelenburg position is indicated Administer a 0.9% sodium chloride 200 mL IV bolus is indicated Apply oxygen at 2 L/min via nasal cannula is indicated Notify the provider immediately is indicated. Obtain the client's blood glucose level is not indicated

The client is experiencing manifestations of.. due to..

Peritonitis X-ray results

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

Remain with the client for the first 15 min of the infusion.

A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include?

Remind the client to scan their complete range of vision during ambulation. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls.

A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Report of a night cough

A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include?

Roll each testicle between the thumb and fingers.

A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.)

Sleepiness exhibited by the client Widening pulse pressure Decerebrate posturing

A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect?

Stone fragments in the urine

A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside?

Suction machine

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?

Suppressing gastric acid production

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority?

Tachycardia

A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching?

Take daily cranberry supplements.

The nurse is evaluating the client's understanding of discharge instructions. Which of the following client statements indicates an understanding of the teaching?

"Foods that contain tyramine might trigger my headaches" "I will keep a food and headache diary" "I will place a cool cloth on my forehead when I experience a migraine"

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?

"I am taking this medication to increase my energy level."

A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan?

Tell the client that it is possible to return to similar previous levels of activity.

The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention.

Temperature WBC Potassium

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?

The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority?

Turn the client to the side.

A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing?

Urine output 25 mL/hr

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

Urine specific gravity 1.045

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take?

Use a 30-mL syringe

Select the 4 findings that require follow-up by the nurse.

Virtual disturbances Tingling of the lips Hand grasps Expressive aphasia

A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care?

Wear a lead apron while providing care to the client.

A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?

Wear a mask.

A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include?

Wrap fingers with individual dressings.

A nurse is teaching a class about client rights. Which of the following instructions should the nurse include?

A client should sign an informed consent before receiving a placebo during a research trial.

A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first?

A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet

A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change?

A client who has multiple sclerosis and is experiencing progressive difficulty ambulating

A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients?

A client who is receiving preoperative teaching for a right knee arthroplasty

A nurse is caring for a client who was just admitted from the emergency department (ED)

Acute chest syndrome and pneumonia

A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend?

Add cabbage to the diet.

A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect?

Administer an opioid analgesic to the client.

A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change?

"I used to never worry about my feet. Now, I inspect my feet every day with a mirror."

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

"I will monitor my blood pressure while taking this medication."

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching?

"You should cut the opening of the skin barrier one-eighth inch wider than the stoma."

A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching?

"You should void every 4 hours to decrease the risk of urinary retention."

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?

Administer dextrose 10% in water until the new bag arrives.

A nurse is caring for a client in the emergency department (ED).

Administer morphine Ensure the patient is NPO Cholecystitis Monitor the color of the client's stools Monitor the client for dark urine

A nurse is caring for a client who has a migraine. Which of the following interventions should the nurse anticipate? Select all that apply.

Administer sumatriptan is correct. Dim the lights in the client's room is correct

A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

167 X mL/hr = Volume (mL)/Time (hr) X mL/hr =4000mL/24 hr X mL/hr = 166.67 Round if necessary. 166.67 = 167 mL/hr

A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?

"I am dieting to lose weight."

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?

"I should take this medication with a meal."

A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make?

"You will not be able to use sildenafil if you are taking nitroglycerin."

The nurse should identify that the client is most likely experiencing Select... and the nurse should address the client's Select...

A migraine Pain

A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid?

Aged cheese

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?

BUN 32 mg/dL

Following the administration of sumatriptan, the nurse should monitor for Select...due to the risk of Select...

Chest pain Myocardial ischemia

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider?

Hgb 8 g/dL

A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor?

Respiratory paralysis

A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?

hyperkalemia