RN MEDSURG RETAKE 2 PROCTORED EXAM-LATEST GUIDE
1. 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 ICP? SATA.
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins are incorrect. With increased ICP, the jugular veins are
typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of
15 indicates neurological functioning within the expected reference range for
eye-opening, motor, and verbal response.
The sleepiness exhibited by the client is correct. Sleepiness or difficulty
arousing the client from sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in
systolic with a concurrent decrease in diastolic blood pressure) is an
indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing
indicate increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the clients to withhold
for 48hr prior to cardioversion?
a. Enoxaparin
b. Metformin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their
ability to prevent blood clots that can be released into the client's
circulatory system after cardioversion. This medication should not be
withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac
catheterization or other procedures involving contrast dye to
prevent damage to the kidneys. However, metformin should not be
withheld prior to cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients before cardioversion
to reduce anxiety and minimize the discomfort associated with the
, procedure. This medication should not be withheld.
j. Digoxin: ANSWER
k. Cardiac glycosides, such as digoxin, are withheld prior to
cardioversion. These medications can increase ventricular
irritability and put the client at risk for ventricular fibrillation
after the synchronized countershock of cardioversion.
3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s
priority?
a. Anorexia
b. Abdominal pain radiating to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a
client who has acute cholecystitis. Therefore, there is another
finding that is the nurse's priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent
because it is an expected finding for a client who has acute
cholecystitis. Therefore, there is another finding that is the
nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care,
the nurse should determine that the priority finding is
tachycardia. Tachycardia is a manifestation of biliary colic,
which can lead to shock. The nurse should position the head of
the client's bed flat and report this finding immediately to the
provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an
expected finding for a client who has acute cholecystitis.
Therefore, there is another finding that is the nurse's priority.
4. 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?
a. Suction machine
, b. Wire cutters
c. Padded clamp
d. Communication board
e. Suction machine: ANSWER The nurse should ensure that a suction
machine is at the bedside of a client who has dysphagia to clear
the client's airway as needed and reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the
bedside of a client who has an inner maxillary fixation to cut the
wires in case the client vomits. This enables the client to clear their
airway and reduce the risk for aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at
the bedside of a client who has a chest tube to clamp the tube
and prevent air from entering the client's chest if there is an
interruption in the sealed drainage system.
h. Communication board: The nurse should ensure a communication
board is at the bedside of a client who has aphasia to assist the
client with communicating.
5. A nurse is caring for a client who is having a seizure. Which of the following intervention is the nurse’s
priority?
a. Loosen the clothing around the client’s neck
b. Check the client’s pupillary response
c. Turn the client to the side.
d. Move furniture away from the client
i. Loosen the clothing around the client's neck: The nurse
should loosen any restrictive clothing the client is wearing
to prevent injury to the client. However, another action is
the priority.
ii. Check the client's pupillary response: The nurse should perform
neurologic checks after the seizure to monitor the client's
recovery. However, another action is the priority.
iii. Turn the client to the side.: The greatest risk to this client is
hypoxia from an impaired airway. Therefore, the priority
intervention the nurse should take is to place the client in a
side-lying position to prevent aspiration.
iv. Move furniture away from the client.: AThe nurse should move
furniture away from the client to prevent self-injury. However,
another action is the priority.
6. 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?
a. Ginkgo biloba
b. Glucosamine
c. Calcium
d. Vitamin C
i.
Ginkgo biloba
ii. Ginkgo biloba reduces the pain associated with peripheral
vascular disease by promoting vasodilation. It can interact
with medications that have anticoagulant properties, but it is
not known to interfere with the absorption of levothyroxine.
iii. Glucosamine: Glucosamine treats osteoarthritis by
decreasing inflammation and stimulating the body's production
of synovial fluid and cartilage. It can interact with medications
that have antiplatelet or anticoagulant properties, but it is not
known to interfere with the absorption of levothyroxine.
iv. Calcium:NSWER
v. Calcium limits the development of osteoporosis in clients
who are postmenopausal and works as an antacid. Calcium
supplements can interfere
with the metabolism of a number of medications, including
levothyroxine. The nurse should instruct the client to avoid
taking calcium within 4 hr of levothyroxine administration.
vi. Vitamin C: Vitamin C promotes wound healing. It can cause a
false negative in fecal occult blood tests, but it is not known to
interfere with the absorption
of levothyroxine.
7. A nurse is planning to irrigate and dress a clean, granulation wound for a client who has a pressure
injury. Which of the following actions should the nurse take?
a. Apply a wet-to-dry gauze dressing
b. Irrigate with hydrogen peroxide solution
c. Use a 30-ml syringe
d. Attach a 24-gauge angiocatheter to the syringe.
a. Apply a wet-to-dry gauze dressing.: The nurse should not apply wet-
to-dry dressings to clean, granulating wounds as they interrupt
viable, healing tissues when they are removed. Appropriate
dressings for a wound that is developing granulation tissue include a
1. 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 ICP? SATA.
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins are incorrect. With increased ICP, the jugular veins are
typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of
15 indicates neurological functioning within the expected reference range for
eye-opening, motor, and verbal response.
The sleepiness exhibited by the client is correct. Sleepiness or difficulty
arousing the client from sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in
systolic with a concurrent decrease in diastolic blood pressure) is an
indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing
indicate increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the clients to withhold
for 48hr prior to cardioversion?
a. Enoxaparin
b. Metformin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their
ability to prevent blood clots that can be released into the client's
circulatory system after cardioversion. This medication should not be
withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac
catheterization or other procedures involving contrast dye to
prevent damage to the kidneys. However, metformin should not be
withheld prior to cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients before cardioversion
to reduce anxiety and minimize the discomfort associated with the
, procedure. This medication should not be withheld.
j. Digoxin: ANSWER
k. Cardiac glycosides, such as digoxin, are withheld prior to
cardioversion. These medications can increase ventricular
irritability and put the client at risk for ventricular fibrillation
after the synchronized countershock of cardioversion.
3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s
priority?
a. Anorexia
b. Abdominal pain radiating to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a
client who has acute cholecystitis. Therefore, there is another
finding that is the nurse's priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent
because it is an expected finding for a client who has acute
cholecystitis. Therefore, there is another finding that is the
nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care,
the nurse should determine that the priority finding is
tachycardia. Tachycardia is a manifestation of biliary colic,
which can lead to shock. The nurse should position the head of
the client's bed flat and report this finding immediately to the
provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an
expected finding for a client who has acute cholecystitis.
Therefore, there is another finding that is the nurse's priority.
4. 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?
a. Suction machine
, b. Wire cutters
c. Padded clamp
d. Communication board
e. Suction machine: ANSWER The nurse should ensure that a suction
machine is at the bedside of a client who has dysphagia to clear
the client's airway as needed and reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the
bedside of a client who has an inner maxillary fixation to cut the
wires in case the client vomits. This enables the client to clear their
airway and reduce the risk for aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at
the bedside of a client who has a chest tube to clamp the tube
and prevent air from entering the client's chest if there is an
interruption in the sealed drainage system.
h. Communication board: The nurse should ensure a communication
board is at the bedside of a client who has aphasia to assist the
client with communicating.
5. A nurse is caring for a client who is having a seizure. Which of the following intervention is the nurse’s
priority?
a. Loosen the clothing around the client’s neck
b. Check the client’s pupillary response
c. Turn the client to the side.
d. Move furniture away from the client
i. Loosen the clothing around the client's neck: The nurse
should loosen any restrictive clothing the client is wearing
to prevent injury to the client. However, another action is
the priority.
ii. Check the client's pupillary response: The nurse should perform
neurologic checks after the seizure to monitor the client's
recovery. However, another action is the priority.
iii. Turn the client to the side.: The greatest risk to this client is
hypoxia from an impaired airway. Therefore, the priority
intervention the nurse should take is to place the client in a
side-lying position to prevent aspiration.
iv. Move furniture away from the client.: AThe nurse should move
furniture away from the client to prevent self-injury. However,
another action is the priority.
6. 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?
a. Ginkgo biloba
b. Glucosamine
c. Calcium
d. Vitamin C
i.
Ginkgo biloba
ii. Ginkgo biloba reduces the pain associated with peripheral
vascular disease by promoting vasodilation. It can interact
with medications that have anticoagulant properties, but it is
not known to interfere with the absorption of levothyroxine.
iii. Glucosamine: Glucosamine treats osteoarthritis by
decreasing inflammation and stimulating the body's production
of synovial fluid and cartilage. It can interact with medications
that have antiplatelet or anticoagulant properties, but it is not
known to interfere with the absorption of levothyroxine.
iv. Calcium:NSWER
v. Calcium limits the development of osteoporosis in clients
who are postmenopausal and works as an antacid. Calcium
supplements can interfere
with the metabolism of a number of medications, including
levothyroxine. The nurse should instruct the client to avoid
taking calcium within 4 hr of levothyroxine administration.
vi. Vitamin C: Vitamin C promotes wound healing. It can cause a
false negative in fecal occult blood tests, but it is not known to
interfere with the absorption
of levothyroxine.
7. A nurse is planning to irrigate and dress a clean, granulation wound for a client who has a pressure
injury. Which of the following actions should the nurse take?
a. Apply a wet-to-dry gauze dressing
b. Irrigate with hydrogen peroxide solution
c. Use a 30-ml syringe
d. Attach a 24-gauge angiocatheter to the syringe.
a. Apply a wet-to-dry gauze dressing.: The nurse should not apply wet-
to-dry dressings to clean, granulating wounds as they interrupt
viable, healing tissues when they are removed. Appropriate
dressings for a wound that is developing granulation tissue include a
