PN ADULT MEDICAL SURGICAL
ONLINE PRACTICE 2025 B
QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALES || A+
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.
The client's pulse rate is 5/min faster than the preset pacemaker rate.
There is the presence of a pacing spike before the P-wave on the ECG
rhythm strip.
The dressing over the insertion site is dry and intact. - ANSWER- The
client experiences hiccups when sitting.
,Click to highlight the findings the nurse should report to the charge
nurse immediately. To deselect a finding, click on the finding again. -
ANSWER- • 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? -
ANSWER- 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? - ANSWER-
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? - ANSWER- "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? - ANSWER- 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? - ANSWER- "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? - ANSWER- 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? - ANSWER- "Use a bronchodilator 30 minutes before
your meal."
ONLINE PRACTICE 2025 B
QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALES || A+
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.
The client's pulse rate is 5/min faster than the preset pacemaker rate.
There is the presence of a pacing spike before the P-wave on the ECG
rhythm strip.
The dressing over the insertion site is dry and intact. - ANSWER- The
client experiences hiccups when sitting.
,Click to highlight the findings the nurse should report to the charge
nurse immediately. To deselect a finding, click on the finding again. -
ANSWER- • 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? -
ANSWER- 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? - ANSWER-
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? - ANSWER- "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? - ANSWER- 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? - ANSWER- "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? - ANSWER- 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? - ANSWER- "Use a bronchodilator 30 minutes before
your meal."
