PN ADULT MEDICAL SURGICAL standard exams
ANSWERS AND QUESTIONS SET A+
✔For each potential provider prescription, click to specify if the potential prescription is
anticipated or contraindicated for the client. - ✔✔Transfuse packed RBCs - anticipated
Place the client in Trendelenburg position - contraindicated
Prepare the client for chest tube insertion - anticipated
Cover the client with a cooling blanket - contraindicated
Initiate NPO status - anticipated
✔✔The nurse is assisting with the care of the client following the placement of a chest
tube for a hemothorax. Which of the following actions should the nurse take?
Select all that apply.
Ensure that all chest tube connections are securely attached.
Palpate the chest tube insertion site for subcutaneous emphysema.
Place two rubber-tipped hemostats in the client's room.
Place the client in high-Fowler's position.
Monitor drainage every 30 min for the first hour.
Strip the drainage tubing to ensure it is patent.
Ensure there is continuous bubbling in the water seal chamber. - ✔✔Ensure that all
chest tube connections are securely attached.
Palpate the chest tube insertion site for subcutaneous emphysema.
Place two rubber-tipped hemostats in the client's room.
Place the client in high-Fowler's position.
✔✔The nurse is assisting with the care of the client 1 hr following chest tube insertion.
Click to highlight the findings that indicate the client's condition is improving. To deselect
a finding, click on the finding again. - ✔✔Client reports pain as a 3 on a scale of 0 to 10.
Client reports shortness of breath has decreased.
Wound dressing is dry and intact.
Respiratory rate 24/min
Blood pressure 108/74 mm Hg
Oxygen saturation 95% on oxygen 2 L/min via nasal cannula
,✔✔A nurse is preparing to suction a client who has a tracheostomy. Which of the
following actions should the nurse take first?
Insert the suction catheter into the tracheostomy.
Rinse the catheter with sterile 0.9% sodium chloride.
Ventilate the client with 100% oxygen.
Occlude the vent on the catheter for 10 seconds. - ✔✔Ventilate the client with 100%
oxygen.
✔✔A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB).
Which of the following client statements indicates an understanding of the teaching?
"I can develop TB by breathing in the infection."|
"After exposure, I could develop TB within 5 days."
"A positive reaction to a TB test means I'm currently infected."
"I need to wear a mask in my house if I become infected." - ✔✔"I can develop TB by
breathing in the infection."
✔✔A nurse is assisting with the care for a client who begins to have a seizure while
ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move
the steps into the box on the right, placing them in the order of performance. Use all the
steps.) - ✔✔Lower client to the floor.
Place a pad beneath the client's head.
Loosen the clothing around the client's neck.
Time the length of the client's seizure.
Reorient and reassure the client.
✔✔A nurse is examining a client's IV site and notes a hardened vein above their IV site.
The client reports a throbbing, burning pain at the IV site. The nurse should identify that
the client's manifestations indicate which of the following complications of IV therapy?
Thrombophlebitis
Infiltration
Hematomal
Venous spasms - ✔✔Thrombophlebitis
✔✔A nurse is planning care for a group of clients after receiving change-of-shift report.
Which of the following clients should the nurse plan to see first?
A client who had a colectomy 2 days ago and has a nasogastric tube attached to low
suction
A client who is dehydrated, has mental confusion, and has tried to get out of bed
several times during the night.
A client who had a right lower lobectomy 4 days ago and has 50 mL/hr of serous
drainage from a chest tube.
A client who has pneumonia; has an elevated oral temperature, and is requesting
medication for a cough. - ✔✔A client who is dehydrated, has mental confusion, and has
tried to get out of bed several times during the night
, ✔✔A nurse is reinforcing teaching regarding the use of a continuous passive motion
(CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the
following information should the nurse include in the teaching? (Select all that apply.)
"Your knee is flexed and extended as prescribed by your provider."
"The machine is padded with sheep skin."!
"You might have the head of the bed elevated to 45 degrees while using this machine."
"To use the machine, you must pedal as if you are riding a bike."
"We will store the CPM machine on the floor under the bed when not in use." - ✔✔"Your
knee is flexed and extended as prescribed by your provider."
"The machine is padded with sheep skin."
✔✔A nurse is assisting with the care for a client who has difficulty swallowing. Which of
the following actions should the nurse implement to prevent aspiration?
Provide small, frequent meals.
Tell the client to extend their neck when swallowing.
Provide mouth care before meals.
Give the client liquids with increased viscosity. - ✔✔Give the client liquids with
increased viscosity.
✔✔A nurse is contributing to the plan of care for a client who has Ménière's disease.
Which of the following interventions should the nurse include in the plan of care?
Increase the client's fluid intake.
Assist the client with changing positions often.
Encourage the client to rest in a well-lit room.
Administer an antiemetic to the client. - ✔✔Administer an antiemetic to the client.
✔✔A nurse is reinforcing teaching with a client who has chronic kidney disease about
disease management. Which of the following statements by the client indicates an
understanding of the teaching?
"I will add a banana to my morning cereal.".
"I will decrease my intake of carbohydrates."
"I will limit my daily intake of protein."
"I will season my foods wit - ✔✔"I will limit my daily intake of protein."
✔✔A nurse is assisting with the discharge planning for a client who is postoperative
following a total hip arthroplasty. Which of the following instructions should the nurse
include in the discharge plan?
Expect decreased sensation for the first postoperative week.
Avoid lying on the operative side.
Obtain a raised toilet seat.
Cross legs at the ankles. - ✔✔Obtain a raised toilet seat.
✔✔A nurse is assisting with the care for a client who is suspected of having a
myocardial infarction. Which of the following actions should the nurse take to prepare
the client for an ECG?
ANSWERS AND QUESTIONS SET A+
✔For each potential provider prescription, click to specify if the potential prescription is
anticipated or contraindicated for the client. - ✔✔Transfuse packed RBCs - anticipated
Place the client in Trendelenburg position - contraindicated
Prepare the client for chest tube insertion - anticipated
Cover the client with a cooling blanket - contraindicated
Initiate NPO status - anticipated
✔✔The nurse is assisting with the care of the client following the placement of a chest
tube for a hemothorax. Which of the following actions should the nurse take?
Select all that apply.
Ensure that all chest tube connections are securely attached.
Palpate the chest tube insertion site for subcutaneous emphysema.
Place two rubber-tipped hemostats in the client's room.
Place the client in high-Fowler's position.
Monitor drainage every 30 min for the first hour.
Strip the drainage tubing to ensure it is patent.
Ensure there is continuous bubbling in the water seal chamber. - ✔✔Ensure that all
chest tube connections are securely attached.
Palpate the chest tube insertion site for subcutaneous emphysema.
Place two rubber-tipped hemostats in the client's room.
Place the client in high-Fowler's position.
✔✔The nurse is assisting with the care of the client 1 hr following chest tube insertion.
Click to highlight the findings that indicate the client's condition is improving. To deselect
a finding, click on the finding again. - ✔✔Client reports pain as a 3 on a scale of 0 to 10.
Client reports shortness of breath has decreased.
Wound dressing is dry and intact.
Respiratory rate 24/min
Blood pressure 108/74 mm Hg
Oxygen saturation 95% on oxygen 2 L/min via nasal cannula
,✔✔A nurse is preparing to suction a client who has a tracheostomy. Which of the
following actions should the nurse take first?
Insert the suction catheter into the tracheostomy.
Rinse the catheter with sterile 0.9% sodium chloride.
Ventilate the client with 100% oxygen.
Occlude the vent on the catheter for 10 seconds. - ✔✔Ventilate the client with 100%
oxygen.
✔✔A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB).
Which of the following client statements indicates an understanding of the teaching?
"I can develop TB by breathing in the infection."|
"After exposure, I could develop TB within 5 days."
"A positive reaction to a TB test means I'm currently infected."
"I need to wear a mask in my house if I become infected." - ✔✔"I can develop TB by
breathing in the infection."
✔✔A nurse is assisting with the care for a client who begins to have a seizure while
ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move
the steps into the box on the right, placing them in the order of performance. Use all the
steps.) - ✔✔Lower client to the floor.
Place a pad beneath the client's head.
Loosen the clothing around the client's neck.
Time the length of the client's seizure.
Reorient and reassure the client.
✔✔A nurse is examining a client's IV site and notes a hardened vein above their IV site.
The client reports a throbbing, burning pain at the IV site. The nurse should identify that
the client's manifestations indicate which of the following complications of IV therapy?
Thrombophlebitis
Infiltration
Hematomal
Venous spasms - ✔✔Thrombophlebitis
✔✔A nurse is planning care for a group of clients after receiving change-of-shift report.
Which of the following clients should the nurse plan to see first?
A client who had a colectomy 2 days ago and has a nasogastric tube attached to low
suction
A client who is dehydrated, has mental confusion, and has tried to get out of bed
several times during the night.
A client who had a right lower lobectomy 4 days ago and has 50 mL/hr of serous
drainage from a chest tube.
A client who has pneumonia; has an elevated oral temperature, and is requesting
medication for a cough. - ✔✔A client who is dehydrated, has mental confusion, and has
tried to get out of bed several times during the night
, ✔✔A nurse is reinforcing teaching regarding the use of a continuous passive motion
(CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the
following information should the nurse include in the teaching? (Select all that apply.)
"Your knee is flexed and extended as prescribed by your provider."
"The machine is padded with sheep skin."!
"You might have the head of the bed elevated to 45 degrees while using this machine."
"To use the machine, you must pedal as if you are riding a bike."
"We will store the CPM machine on the floor under the bed when not in use." - ✔✔"Your
knee is flexed and extended as prescribed by your provider."
"The machine is padded with sheep skin."
✔✔A nurse is assisting with the care for a client who has difficulty swallowing. Which of
the following actions should the nurse implement to prevent aspiration?
Provide small, frequent meals.
Tell the client to extend their neck when swallowing.
Provide mouth care before meals.
Give the client liquids with increased viscosity. - ✔✔Give the client liquids with
increased viscosity.
✔✔A nurse is contributing to the plan of care for a client who has Ménière's disease.
Which of the following interventions should the nurse include in the plan of care?
Increase the client's fluid intake.
Assist the client with changing positions often.
Encourage the client to rest in a well-lit room.
Administer an antiemetic to the client. - ✔✔Administer an antiemetic to the client.
✔✔A nurse is reinforcing teaching with a client who has chronic kidney disease about
disease management. Which of the following statements by the client indicates an
understanding of the teaching?
"I will add a banana to my morning cereal.".
"I will decrease my intake of carbohydrates."
"I will limit my daily intake of protein."
"I will season my foods wit - ✔✔"I will limit my daily intake of protein."
✔✔A nurse is assisting with the discharge planning for a client who is postoperative
following a total hip arthroplasty. Which of the following instructions should the nurse
include in the discharge plan?
Expect decreased sensation for the first postoperative week.
Avoid lying on the operative side.
Obtain a raised toilet seat.
Cross legs at the ankles. - ✔✔Obtain a raised toilet seat.
✔✔A nurse is assisting with the care for a client who is suspected of having a
myocardial infarction. Which of the following actions should the nurse take to prepare
the client for an ECG?
