PN ADULT MEDICAL SURGICAL LATEST UPDATED
ANSWERS AND QUESTIONS SET A+
✔✔A nurse is caring for a client who has a prescription for enalapril 10 mg PO daily and
reports dizziness and weakness. Which of the following actions should the nurse take
first? - ✔✔Check the client's blood pressure.
✔✔A nurse is monitoring a client who is receiving a unit of packed RBCs. Which of the
following statements by the client should alert the nurse that the client might be
experiencing a transfusion reaction related to an incompatibility with the blood product?
- ✔✔"I have pain in my lower back."
✔✔A nurse is collecting data from a client 2 months following the initiation of
levothyroxine therapy. Which of the following findings should the nurse identify as an
indication that the client might require a reduction in their dosage? - ✔✔Difficulty
sleeping
✔✔A nurse is reinforcing teaching with a client who has pernicious anemia and is
receiving cyanocobalamin. Which of the following statements by the client indicates an
understanding of the teaching? - ✔✔"I will be able to switch to a nasal form of
cyanocobalamin when my levels stabilize."
✔✔A nurse is collecting data from a client who is postoperative following permanent
pacemaker placement. Which of the following data should the nurse plan to collect? -
✔✔Status of the insertion site
✔✔The client must have both feet or one foot and the quad cane on the floor at all times
to keep an equal balance and avoid being off balance, which can lead to a fall. -
✔✔Turn the client on their side.
✔✔A nurse is caring for a client who has acute glomerulonephritis. Which of the
following findings should the nurse expect? - ✔✔Periorbital edema
, ✔✔A home care nurse finds a client who has just sustained partial-thickness burns to
their face and arms. After removing the client from danger and securing their airway,
which of the following interventions is the nurse's priority? - ✔✔Remove smoldering
clothes.
✔✔A nurse is caring for a client who reports excessive perspiration and frequent
urination. Which of the following manifestations is an indication of a low sodium level? -
✔✔Dry tongue
✔✔A nurse is caring for a client who is postoperative following abdominal surgery. The
nurse begins to change the client's abdominal dressing and observes that the wound
has eviscerated. Which of the following actions should the nurse take? - ✔✔Position the
client supine with their knees bent..
✔✔A nurse is caring for a client who had a sigmoid colon resection 2 days ago. Which
of the following findings should the nurse report to the provider? - ✔✔Oral temperature
of 38.5° C (101.3° F)
✔✔A nurse is collecting data from a client who underwent an open reduction and
internal fixation for fractures of the tibia and fibula 24 hr ago. Following ambulation using
crutches with minimal assistance, the client reports shortness of breath. Which of the
following actions should the nurse take? - ✔✔Auscultate the client's lung sounds.
✔✔A nurse is caring for a client who has a tracheostomy tube. Which of the following
actions should the nurse take? - ✔✔Leave old tracheostomy ties in place while applying
new ties.
✔✔A nurse is caring for a client who is in skeletal traction. Which of the following
actions should the nurse take? - ✔✔Cleanse the pin sites with sterile water daily.
✔✔A nurse is caring for a client who underwent a percutaneous transluminal coronary
angioplasty (PTCA) and had a stent placed through the right femoral artery. The nurse
should recognize that which of the following findings is the priority? - ✔✔Diminished
right dorsalis pedis pulse
✔✔A nurse is preparing a client for a lumbar puncture. In which of the following
positions should the nurse place the client? - ✔✔Side-lying with their head bent forward
and their knees pulled up to the trunk.
✔✔A nurse is caring for a client who has undergone a below-the-knee amputation.
Which of the following actions should the nurse take to help prevent hip flexion
contractures? - ✔✔Place the client in a prone position periodically throughout the day.
ANSWERS AND QUESTIONS SET A+
✔✔A nurse is caring for a client who has a prescription for enalapril 10 mg PO daily and
reports dizziness and weakness. Which of the following actions should the nurse take
first? - ✔✔Check the client's blood pressure.
✔✔A nurse is monitoring a client who is receiving a unit of packed RBCs. Which of the
following statements by the client should alert the nurse that the client might be
experiencing a transfusion reaction related to an incompatibility with the blood product?
- ✔✔"I have pain in my lower back."
✔✔A nurse is collecting data from a client 2 months following the initiation of
levothyroxine therapy. Which of the following findings should the nurse identify as an
indication that the client might require a reduction in their dosage? - ✔✔Difficulty
sleeping
✔✔A nurse is reinforcing teaching with a client who has pernicious anemia and is
receiving cyanocobalamin. Which of the following statements by the client indicates an
understanding of the teaching? - ✔✔"I will be able to switch to a nasal form of
cyanocobalamin when my levels stabilize."
✔✔A nurse is collecting data from a client who is postoperative following permanent
pacemaker placement. Which of the following data should the nurse plan to collect? -
✔✔Status of the insertion site
✔✔The client must have both feet or one foot and the quad cane on the floor at all times
to keep an equal balance and avoid being off balance, which can lead to a fall. -
✔✔Turn the client on their side.
✔✔A nurse is caring for a client who has acute glomerulonephritis. Which of the
following findings should the nurse expect? - ✔✔Periorbital edema
, ✔✔A home care nurse finds a client who has just sustained partial-thickness burns to
their face and arms. After removing the client from danger and securing their airway,
which of the following interventions is the nurse's priority? - ✔✔Remove smoldering
clothes.
✔✔A nurse is caring for a client who reports excessive perspiration and frequent
urination. Which of the following manifestations is an indication of a low sodium level? -
✔✔Dry tongue
✔✔A nurse is caring for a client who is postoperative following abdominal surgery. The
nurse begins to change the client's abdominal dressing and observes that the wound
has eviscerated. Which of the following actions should the nurse take? - ✔✔Position the
client supine with their knees bent..
✔✔A nurse is caring for a client who had a sigmoid colon resection 2 days ago. Which
of the following findings should the nurse report to the provider? - ✔✔Oral temperature
of 38.5° C (101.3° F)
✔✔A nurse is collecting data from a client who underwent an open reduction and
internal fixation for fractures of the tibia and fibula 24 hr ago. Following ambulation using
crutches with minimal assistance, the client reports shortness of breath. Which of the
following actions should the nurse take? - ✔✔Auscultate the client's lung sounds.
✔✔A nurse is caring for a client who has a tracheostomy tube. Which of the following
actions should the nurse take? - ✔✔Leave old tracheostomy ties in place while applying
new ties.
✔✔A nurse is caring for a client who is in skeletal traction. Which of the following
actions should the nurse take? - ✔✔Cleanse the pin sites with sterile water daily.
✔✔A nurse is caring for a client who underwent a percutaneous transluminal coronary
angioplasty (PTCA) and had a stent placed through the right femoral artery. The nurse
should recognize that which of the following findings is the priority? - ✔✔Diminished
right dorsalis pedis pulse
✔✔A nurse is preparing a client for a lumbar puncture. In which of the following
positions should the nurse place the client? - ✔✔Side-lying with their head bent forward
and their knees pulled up to the trunk.
✔✔A nurse is caring for a client who has undergone a below-the-knee amputation.
Which of the following actions should the nurse take to help prevent hip flexion
contractures? - ✔✔Place the client in a prone position periodically throughout the day.
