PN Adult Medical Surgical Online Practice 2023 B

A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen clothing around the client's neck.

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

A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

Maintain hip flexion at 90° or less when sitting.

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

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.

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. Maintain the pressure dressing is correct. Check the client's peripheral pulses is correct.

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

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

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.

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.

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

PaCO2 WBC Chest X-ray O2 sats BUN

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.

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

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?

Straight catheter

A nurse in a long-term care facility is collecting data from a client who reports fullness 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

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

Temperature WBC Potassium

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.

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.

The client is most likely experiencing hypovolemia as evidenced by their restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. Therefore, the nurse should insert a large gauge IV and initiate a fluid challenge. The nurse should also monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment.

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.

The nurse should reduce the temperature in the client's room and limit visitors because the client has manifestations of hyperthyroidism. Clients who have hyperthyroidism have heat intolerance and require an environment with decreased stimuli. The nurse should monitor the client for an increased temperature which can indicate a thyroid storm, as well as the client's weight daily, to monitor for weight loss.

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 pounds since my last appointment."

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" is correct. "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit" is correct.

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 hours after surgery" is correct. "I will use my PCA medication before my knee starts to hurt too bad" is correct. "I will probably be going home with a walker" is correct.

A nurse is reinforcing discharge teaching with a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my dentist about this procedure."

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."

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."

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."

A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR 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 mL

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

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 is correct.

After reviewing the findings in the client's medical record, the nurse should first address the client's ________, followed by the client's _______.

Abdominal distention is correct. Acute pain is correct.

A nurse is reinforcing teaching with the client. Which of the following instructions should the nurse include? Select all that apply.

Avoid drinking fluids with meals is correct. Eat several small meals per day is correct. Consume high-protein snacks is correct.

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 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.

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. Pain in the right lower quadrant is consistent with appendicitis and Crohn's disease. Mucus in the stool is consistent with Crohn's disease. Nausea is consistent with appendicitis, diverticular disease, and Crohn's disease.

A nurse is monitoring a client who has a cast and reports intense itching underneath the cast. Which of the following actions should the nurse take?

Blow cool air into the cast using a blow dryer on a cool setting.

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 V1 electrode? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

C is correct

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.

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.

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 lungs

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

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. Perform neurologic checks every 2 hr is nonessential. 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.

A nurse is assisting in the care of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory test does the nurse anticipate that the provider will prescribe?

Creatinine

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 off the side of the bed.

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

A nurse is reviewing the laboratory results of a client. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing?

Decreased iron

A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include?

Dispose of radiation implants in a lead container.

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.

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

A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider?

Heart rate 120/min

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

Heart rate 72/min, regular; Respiratory rate 20/min; Blood pressure 128/56 mm Hg is correct. Oxygen saturation is 95% on room air is correct.

A nurse is participating in a health fair for older adult clients. Which of the following vaccines should the nurse recommend for this age group?

Herpes zoster

A nurse is reviewing the laboratory results of a female client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective?

Hgb 11 g/dL (12 to 16 g/dL)

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

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 4 L/min via nasal cannula.

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

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.

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.

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.

A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care?

Keep bed linens off of the affected areas.

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 client in a side-lying position.

A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

"The medication should be taken before I eat breakfast every morning."

A nurse is reinforcing teaching about hospice care with a client who has terminal cancer. Which of the following statements should the nurse make?

"Hospice care will provide support for you and your loved ones during the dying process."

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."

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."

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."

A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching?

"I understand that testicular cancer is typically painless."

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."

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."

FLAG A nurse is assisting with the care for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make?

"Select foods that are low in protein."

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.

A nurse is assisting with the care for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take?

Administer oxygen via nasal cannula.

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 is correct. Assist with the administration of gentamicin 100 mg IV is correct. Assist with the administration of dextrose 5% in lactated Ringer's is correct. Contact the wound, ostomy, and continence nurse is correct.

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

A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first?

Determine the client's daily elimination habits.

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.

A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome?

Diminished headache

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

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 blood pressure.

At 1000, the nurse should first address the client's _______, followed by the client's _______.

O2 Heart rate

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 is indicated. Obtain the client's vital signs every 15 min is indicated. Administer a hypotonic IV solution is contraindicated. Insert a nasogastric tube is indicated.

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.

The client is experiencing manifestations of ________ as evidenced by ________.

Pancreatitis is correct. Amylase and lipase is correct.

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.

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 Blood pressure 98/56 mm Hg is correct. Heart rate 102/min is correct.

Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client has manifestations of _______; therefore, the priority finding for the nurse to report is the _______.

Peritonitis is correct. Laboratory values is correct.

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.

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.

A nurse is assisting with the care for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder?

Truncal obesity

A nurse is assisting with the care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection 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.

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.