PN ADULT MEDICAL SURGICAL REVIEW TIPS
ANSWERS AND QUESTIONS SET A+
✔✔A nurse is contributing to the plan of care for a client who has a head injury and is at
risk for increased intracranial pressure (ICP). Which of the following actions should the
nurse include in the plan?
Measure rectal temperature every 4 hr.
Remind the client to cough as needed.
Use a turn sheet to reposition the client.
Apply wrist restraints. - ✔✔Use a turn sheet to reposition the client.
✔✔A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of
the following instructions should the nurse include?
"You can take acetaminophen for pain."|
"Consume a diet that is high in animal protein."
"Sleep lying flat on your back."
"Consume foods that are low in sodium." - ✔✔"Consume foods that are low in sodium."
✔✔A nurse is reinforcing teaching with 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 in the teaching?
Weekly sputum cultures will be needed.
Household family members should be tested for TB.
TB is no longer contagious after 2 to 3 days of medication therapy.
Family members should wear N95 masks when in contact with the client. -
✔✔Household family members should be tested for TB.
✔✔A nurse is preparing to remove a client's NG tube. Which of the following
interventions should the nurse take to decrease the risk for aspiration?
Instill 10 mL of air through the NG tube.
Place the client in the supine position.
Irrigate the NG tube.
Pinch the NG tube. - ✔✔Pinch the NG tube.
, ✔✔A nurse is reviewing the laboratory reports of a client who reports chest pain. Which
of the following laboratory results indicates the client is experiencing a myocardial
infarction?
Decreased lipase
Decreased erythrocyte sedimentation rate (ESR)
Elevated creatinine.
Elevated troponin. - ✔✔Elevated troponin
✔✔A nurse is assisting with the care of client.
Exhibit 1
Nurses' Notes
1000:Client is alert and oriented and reports not feeling well for a few days.Client is on
continuous ambulatory peritoneal dialysis (CAPD) and reports that dialysate appeared
cloudy this morning.Client reports abdominal pain as a 4 on a scale of 0 to 10. Bowel
sounds are active in all quadrants.Peritoneal dialysis access site is red and warm to the
touch, with a small amount of purulent drainage noted on the dressing.1300:Client is
lying in bed with their knees flexed, guarding their abdomen. Abdomen is slightly
distended; hypoactive bowel sounds are present. Client reports nausea and pain as a 6
on a scale of 0 to 10. Provider notified and updated with client condition and diagnostic
results.
Exhibit 2
Vital Signs
1000:Blood pressure 142/90 mm HgRespiratory rate 18/minTemperature 38.3° C (101°
F)Heart rate 90/minOxygen saturation 96% on room air - ✔✔The client is experiencing
manifestations of
peritonitis
due to the client's
abdominal x-ray results
✔✔A nurse is assisting with the care of a client who was admitted from the emergency
department with a burn injury.
Exhibit 1
Nurses' Notes
1800:
Client has full thickness burns over both forearms; partial thickness burns are present
on the client's neck.Sinus tachycardia noted. Pulses to extremities are palpable. 1+
edema to upper extremities noted.Respirations are even and labored with scattered
rhonchi.Hypoactive bowel sounds are present.16 French indwelling urinary catheter was
inserted with return of 250 mL of yellow urine.Lactated Ringer's is infusing to the right
antecubital.1830:
Client's voice is becoming hoarse, and client reports difficulty swallowing. Wheezes are
present in upper lobes bilaterally. Charge nurse was notified. Client is positioned
upright, and oxygen 40% is being delivered via face tent. Blood collected for ABGs.
Exhibit 2
Vital Signs
1800:
ANSWERS AND QUESTIONS SET A+
✔✔A nurse is contributing to the plan of care for a client who has a head injury and is at
risk for increased intracranial pressure (ICP). Which of the following actions should the
nurse include in the plan?
Measure rectal temperature every 4 hr.
Remind the client to cough as needed.
Use a turn sheet to reposition the client.
Apply wrist restraints. - ✔✔Use a turn sheet to reposition the client.
✔✔A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of
the following instructions should the nurse include?
"You can take acetaminophen for pain."|
"Consume a diet that is high in animal protein."
"Sleep lying flat on your back."
"Consume foods that are low in sodium." - ✔✔"Consume foods that are low in sodium."
✔✔A nurse is reinforcing teaching with 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 in the teaching?
Weekly sputum cultures will be needed.
Household family members should be tested for TB.
TB is no longer contagious after 2 to 3 days of medication therapy.
Family members should wear N95 masks when in contact with the client. -
✔✔Household family members should be tested for TB.
✔✔A nurse is preparing to remove a client's NG tube. Which of the following
interventions should the nurse take to decrease the risk for aspiration?
Instill 10 mL of air through the NG tube.
Place the client in the supine position.
Irrigate the NG tube.
Pinch the NG tube. - ✔✔Pinch the NG tube.
, ✔✔A nurse is reviewing the laboratory reports of a client who reports chest pain. Which
of the following laboratory results indicates the client is experiencing a myocardial
infarction?
Decreased lipase
Decreased erythrocyte sedimentation rate (ESR)
Elevated creatinine.
Elevated troponin. - ✔✔Elevated troponin
✔✔A nurse is assisting with the care of client.
Exhibit 1
Nurses' Notes
1000:Client is alert and oriented and reports not feeling well for a few days.Client is on
continuous ambulatory peritoneal dialysis (CAPD) and reports that dialysate appeared
cloudy this morning.Client reports abdominal pain as a 4 on a scale of 0 to 10. Bowel
sounds are active in all quadrants.Peritoneal dialysis access site is red and warm to the
touch, with a small amount of purulent drainage noted on the dressing.1300:Client is
lying in bed with their knees flexed, guarding their abdomen. Abdomen is slightly
distended; hypoactive bowel sounds are present. Client reports nausea and pain as a 6
on a scale of 0 to 10. Provider notified and updated with client condition and diagnostic
results.
Exhibit 2
Vital Signs
1000:Blood pressure 142/90 mm HgRespiratory rate 18/minTemperature 38.3° C (101°
F)Heart rate 90/minOxygen saturation 96% on room air - ✔✔The client is experiencing
manifestations of
peritonitis
due to the client's
abdominal x-ray results
✔✔A nurse is assisting with the care of a client who was admitted from the emergency
department with a burn injury.
Exhibit 1
Nurses' Notes
1800:
Client has full thickness burns over both forearms; partial thickness burns are present
on the client's neck.Sinus tachycardia noted. Pulses to extremities are palpable. 1+
edema to upper extremities noted.Respirations are even and labored with scattered
rhonchi.Hypoactive bowel sounds are present.16 French indwelling urinary catheter was
inserted with return of 250 mL of yellow urine.Lactated Ringer's is infusing to the right
antecubital.1830:
Client's voice is becoming hoarse, and client reports difficulty swallowing. Wheezes are
present in upper lobes bilaterally. Charge nurse was notified. Client is positioned
upright, and oxygen 40% is being delivered via face tent. Blood collected for ABGs.
Exhibit 2
Vital Signs
1800:
