PN Adult Med-Surg
1. A nurse is collecting data from a client who has hyperkalemia. Which of the following findings should the nurse expect?
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Bradycardia
2. A nurse is reinforcing teaching about safety with a client who has fallen. Which of the following statements by the client indicates a need for further teaching?
I understand all four side rails will be up while I’m in bed
3. A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions is the priority?
Determine the client’s understanding of the procedure
4. A nurse is assisting with the care of a client who was in a motor-vehicle crash 4 hr. ago and has a head injury. The nurse should place the client in which of the following positions?
Low-fowlers
5. 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 is an appropriate nursing action? Offer a small snack at bedtime
6. A nurse working in a long-term care facility is reviewing the care of clients who have stage II pressure ulcer with the assistive personnel. Which of the following actions should the nursing staff implement as best practice for prevention of pressure ulcer? Reposition clients on bed rest every 2 Hrs.
7. A nurse is reinforcing discharge teaching with a client who has esophageal varices. Which of the following instructions should the nurse include?
Consume foods high in fiber
8. A nurse working in a health clinic is collecting data from four clients. Which of the following clients should the nurse recommend that the provider examine first?
A client who reports double vision and weakness of the left arm.
9. A nurse is reviewing ABG results for a client who was admitted with acute exacerbation of COPD. Which of the following results should the nurse expect?
PaCo2 56 mmHG
10. A nurse id caring for a client who is 5 days postoperative following abdominal surgery. The client coughs and then reports to the nurse. I feel as if I just split open. The nurse sees a protrusion of internal organs. After calling for help, which of the following actions is the priority intervention?
Apply a sterile, saline-soaked dressing over the wound.
11. A nurse is caring for a client who was admitted with neutropenia. Which of the following nursing interventions is appropriate for this client?
Limit visitors to healthy adults
12. A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching?
Report purulent drainage to the provider.
13. 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 painless
14. A nurse is preparing to administer dextrose 5% in 0.9% sodium chloride 1,200 ml IV to infuse over 10 hr. The drop factor of the manual IV tubing is 15 gtt/ml. The nurse should set the manual IV infusion to deliver how many ggt/min?
30 ggt/min
15. A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the following instructions should the nurse include in the teaching?
Take calcium supplements 30 min before meals
16. A client who has AIDS is admitted with Pneumocystis jirovecil (carinii) pneumonia. The client is receiving pentamidine isethionate 268 mg IV daily, nebulizer treatments with albuterol four times a day, and IV fluids at 125 ml/hr. Which of the following client findings indicates that the therapeutic regimen is effective?
Decrease in exertional dyspnea
17. A nurse is preparing to auscultate the bowel sounds of a client who has abdominal adhesions in the upper gastrointestinal tract. When listening in the left upper quadrant, the nurse should identify the sound as which of the following?
Hyperactive bowel sounds
18. A client who has a new diagnosis of osteoporosis states to a nurse. I am lactose intolerant, so I cannot eat any dairy products. Which of the following responses by the nurse is appropriate?
Green leafy vegetables such as spinach, are high in calcium
19. A nurse is caring for a client who is 8 hr. postoperative from abdominal surgery and has Jackson-Pratt suction device. Which of the following actions should the nurse plan to take?
Maintain compression of the bulb
20. A nurse is caring for a client who is postoperative following an amputation of the left lower extremity. Which of the following actions should the nurse take?
Rewrap the compression dressing three times daily
21. A nurse is caring for a client who is experiencing an adrenal crisis. The crisis was precipitated by the client not taking her medication for several days. Withdrawal from which of the following medications is responsible for the client’s condition?
Prednisone
22. A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?
I should call my doctor if my ankles swell.
23. A nurse is assisting with the care of a client who had a total thyroidectomy 8 hr. ago and is demonstrating manifestations of a thyroid storm. Which of the following findings should the nurse expect?
Hypertension
24. A nurse is collecting data from an older adult client and notices several skin lesions. The nurse should report the lesions to the provider if which of the following characteristics are noted?
Variegated color and irregular borders
25. A nurse is caring for a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure?
Creatinine 1.9 mg/dl
26. A nurse is caring for a client who has receiving continuous enteral feedings. Which of the following actions should the nurse take?
Elevate the head of the client’s bed to a 30 angle, auscultate for bowel sounds, Change the tubing and feeding bag every 24 hr.
27. A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease?
Diabetes mellitus
28. A nurse is contributing to the plan of care for a client following an above-the- knee amputation, which of the following interventions should the nurse include?
Place the client in prone position for 30 min three times per day.
29. A nurse is caring for a client who developed dumping syndrome following an abdominal surgery. Which of the following interventions should the nurse implement?
Provide a low-fiber diet.
30. A nurse is assisting with the plan of care for a client who had a cerebrovascular accident. Before initiating oral intake, the nurse should receive a report from which of the following members of the health care team?
Speech-language pathologist
31. A nurse is caring for a client who is in skeletal traction and is delegating the task of repositioning the client to an assistive personnel. Which of the following instructions should the nurse give the AP?
Allow the weights to hang freely.
32. A nurse is reinforcing discharge teaching with a client who has multiple sclerosis. Which of the following instructions should the nurse include?
Plan to exercise daily.
33. A nurse is preparing to suction the airway of a client who has a tracheostomy. Which of the following actions should the nurse take?
Hyperoxygenate the client
34. A nurse is contributing to the plan of care for a client who has a hearing impairment of the right ear. Which of the following instructions should the nurse include in the plan of care?
Face the client while speaking
35. A nurse is caring for a client who has an NG tube. When administering a PO medication, which of the following actions should the nurse take first?
Verify tube placement
36. A nurse is examining a client’s IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site, these findings indicate which of the following complications of IV therapy? Thrombophlebitis
37. A nurse is caring for a client who has type 2 diabetes mellitus. Which of the following laboratory values indicates the client is a t risk for delayed wound healing?
Prealbumin 12 mg/dl
38. A nurse observes a client who is lying in bed experiencing a tonic-clinic seizure, which of the following actions should the nurse take?
Loosen clothing around the client’s neck.
39. A nurse is caring for 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.
40. A nurse is caring for a client who has Parkinson’s disease and is taking carbidopa levodopa. The client reports she can move well some days and other days has difficulty with ambulation, the nurse should suspect the client.
41. A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration?
Give the client liquid with increased viscosity.
42. A nurse is reinforcing teaching with a client who is receiving radiation therapy. Which of the following statements by the client indicates the teaching was effective?
I will cover the radiation site when in sunlight.
43. A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include?
Dangle the extremities off the side of the bed.
44. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include when reinforcing teaching?
Household family members should be tested for TB.
45. A nurse is reinforcing teaching with a client who becomes easily fatigued and dyspneic. Which of the following statements by the client indicates a need for further teaching?
I will complete personnel hygiene care activities early in the morning.
46. A nurse is collecting data on a client who is scheduled for a cardiac catherization. Which of the following laboratory levels should the nurse review prior to the procudre?
BUN
47. A nurse in a clinic is caring for a client who has chronic kidney failure and is receiving epoetin alfa. Which of the following laboratory values indicates the treatment is effective?
Hgb 11g/Dl
48. A nurse is collecting data from a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
Periorbital edema
49. At the start of the evening shift, a nurse collects data on a client admitted the previous evening for treatment of facial fractures and multiple lacerations. The nurse obtains vital signs and notes that the client is agitated, diaphoretic, and reports nausea. However, the client responds to questions appropriately. At this time, it is important for the nurse to do which of the following first?
Ask the client how much alcohol he drinks on a typical day
50. A nurse is reinforcing teaching with a client who has a left arm cast. Which of the following instruction should the nurse include in the teaching to help promote mobility? Lift the left arm over the head.
Determine when the last dose was administered
51. A nurse is caring for a client who has a prescription for acetaminophen 650 mg PO every 6 hr PRN headache. Which of the following actions should the nurse take first? Determine when the last dose was administered
52. A nurse is caring for a client following a gastrectomy. Which if the following actions should the nurse take to decrease episodes of dumping syndrome?
Place the client in the supine position after meals
53. A nurse is reinforcing teaching with a newly licensed nurse on how to check a client for orthostatic hypotension. Which of the following instructions should the nurse include?
Wait at least 3 min to measure blood pressure after position changes.
54. A nurse is caring for a client who is scheduled for a blood transfusion. The client is currently receiving IV fluids through an 18-guage needle. Which of the following actions should the nurse plan to take when assisting with this procedure?
Take the clients vital signs immediately before the transfusion
55. A nurse is reviewing the medical record of a client following a myocardial infarction. Which of the following laboratory values should the nurse monitor? Serum troponin
56. A nurse is preparing to administer phytonadione 7mg subcutaneously to a client who has an INR of 4. Available it phytonadione 10mg/ML. How many Ml should the nurse administer?
0.7 ml
57. A nurse is caring for a client who is receiving intermittent enternal feedings through an NG tube. Which of the following actions should the nurse take?
Test the Ph of the gastric contents to verify tube placement
58. A nurse is assisting with the admission of a client who has Clostridium difficile. An assistive personnel asks the nurse about transmission-based precautions when caring for the client. Which of the following statements by the nurse are approaptiate responses?
Provide the client with disposable utensils and dishes for meals, leave blood pressure equipment in the client’s room, and clean contaminated surfaces with a bleach solution
59. A nurse is collecting data from a client who reports having nausea, vomiting, and constipation for the last 48hr. Which of the following questions should the nurse ask to help determine if the client is experiencing a bowel obstruction?
Can you describe the odor of your vomit?
60. A nurse is preparing to remove an indwelling urinary catheter. Which of the following actions should the nurse take prior to removing the catheter?
Withdraw the solution in the balloon
61. A nurse is reinforcing teaching with a client who has a new diagnosis of hepatitis A about preventing the spread of the disease to others. Which of the following statements by the client demonstrates an understanding of the teaching?
Washing my hand before handling food can prevent the spread of the virus
62. A client who has a diagnosis of genital herpes asks for information about the virus. Which of the following is an appropriate statement by the nurse?
The virus can be transmitted without lesions present
63. An older adult client is moving to an assisted-living facility. The client’s medical record indicates that she recievedc the hepatitis B vaccine series 10 years ago, the tetanus vaccine 3 years ago, and the influenza and pneumococcal vaccines 1 year ago. The nurse recognizes that the client should have which of the following vaccinations re-administered?
Influenza
64. A nurse is caring for a clent who has a prescription for pneumonic compression devices for the lower extremities. Which of the following actions should the nurse take to ensure maximum benefit and proper management of the devices?
Measure the circumference of the thighs [Show Less]