RN Adult Medical Surgical Online Practice
2023 A
A nurse is caring for a client who is receiving dialysis treatment.
For each potential nursing intervention, click to specify if the intervention is indicated or not
indicated. - ANS Perform a 12-lead ECG is not indicated. The client is not reporting chest pain;
therefore, a 12-lead ECG is not indicated at this time.
Place the client in the Trendelenburg position is indicated. The client should be placed in the
Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ
perfusion.
Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should administer
200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's blood
pressure.
Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should administer oxygen at
2 L/min via nasal cannula to increase the amount of oxygen carried in the blood.
Notify the provider immediately is indicated. The nurse should notify the provider immediately as
part of the nurse's role to provide an update on the client's condition.
Obtain the client's blood glucose level is not indicated. There is no indication that the client is
experiencing hypoglycemia; therefore, obtaining a blood glucose level is not indicated.
A nurse is caring for a client who is postoperative following abdominal surgery.
A nurse is caring for a client who is postoperative. Which of the following actions should the
nurse take? - ANS Apply oxygen via a face mask is incorrect. It is not necessary to place a face
mask on the client because their SaO2 is within the expected reference range of 95% to 100%.
Instruct the client to splint the abdomen with a pillow for coughing is correct. It is important for
the client to turn, cough, and deep breathe to reduce the risk for respiratory complications. The
nurse should instruct the client to splint the incision while performing these actions to reduce the
risk of complications to the surgical incision.
Plan to ambulate the client as soon as possible is correct. The nurse should plan to ambulate
the client as soon as possible to promote ventilation and decrease the risk of thrombosis.
Report urinary output to the provider is correct. The client should produce at least 30 mL of
urine per hour. Therefore, the nurse should report this finding to the provider.
, Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse should have the
client rate their pain prior to and following the administration of pain medication to evaluate its
effectiveness.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not
available when the current infusion is nearly completed. which actions should the nurse take? -
ANS Administer dextrose 10% in water until the new bag arrives
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the
following findings should the nurse report to the provider? - ANS The client reports back pain
A nurse is caring for a client who is having a seizure. Which of the following interventions is the
nurse's priority? - ANS Turn the client to the side.
A nurse in a provider's office is assessing a client who has hypertension and takes propranolol.
Which of the following findings should indicate to the nurse that the client is experiencing an
adverse reaction to this medication? - ANS Report of a night cough.
(the nurse should recognize that this is an early indication of heart failure and report this
adverse reaction to the provider)
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a
pressure injury. Which of the following actions should the nurse take? - ANS Use a 30-mL
syringe.
(Nurse should use a 30-60 mL syringe with an 18 or 19-gauge catheter to deliver the ideal
pressure of 8 pounds per square inch (psi) when irrigating a wound.)
A nurse is assessing a client who has Graves' disease. Which of the following images should
indicate to the nurse that the client has exophthalmos? - ANS Last picture or the picture with
wide-opened, bulging eyes.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to the
nurse that the client's condition is improving? - ANS glucose 272 mg/dL
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations
should the nurse expect? - ANS Constipation
(due to client's decrease in metabolism, resulting in slow motility of the gastrointestinal tract.)
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the
following actions should the nurse take first? - ANS Check for the type and number of units of
blood to administer.
2023 A
A nurse is caring for a client who is receiving dialysis treatment.
For each potential nursing intervention, click to specify if the intervention is indicated or not
indicated. - ANS Perform a 12-lead ECG is not indicated. The client is not reporting chest pain;
therefore, a 12-lead ECG is not indicated at this time.
Place the client in the Trendelenburg position is indicated. The client should be placed in the
Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ
perfusion.
Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should administer
200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's blood
pressure.
Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should administer oxygen at
2 L/min via nasal cannula to increase the amount of oxygen carried in the blood.
Notify the provider immediately is indicated. The nurse should notify the provider immediately as
part of the nurse's role to provide an update on the client's condition.
Obtain the client's blood glucose level is not indicated. There is no indication that the client is
experiencing hypoglycemia; therefore, obtaining a blood glucose level is not indicated.
A nurse is caring for a client who is postoperative following abdominal surgery.
A nurse is caring for a client who is postoperative. Which of the following actions should the
nurse take? - ANS Apply oxygen via a face mask is incorrect. It is not necessary to place a face
mask on the client because their SaO2 is within the expected reference range of 95% to 100%.
Instruct the client to splint the abdomen with a pillow for coughing is correct. It is important for
the client to turn, cough, and deep breathe to reduce the risk for respiratory complications. The
nurse should instruct the client to splint the incision while performing these actions to reduce the
risk of complications to the surgical incision.
Plan to ambulate the client as soon as possible is correct. The nurse should plan to ambulate
the client as soon as possible to promote ventilation and decrease the risk of thrombosis.
Report urinary output to the provider is correct. The client should produce at least 30 mL of
urine per hour. Therefore, the nurse should report this finding to the provider.
, Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse should have the
client rate their pain prior to and following the administration of pain medication to evaluate its
effectiveness.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not
available when the current infusion is nearly completed. which actions should the nurse take? -
ANS Administer dextrose 10% in water until the new bag arrives
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the
following findings should the nurse report to the provider? - ANS The client reports back pain
A nurse is caring for a client who is having a seizure. Which of the following interventions is the
nurse's priority? - ANS Turn the client to the side.
A nurse in a provider's office is assessing a client who has hypertension and takes propranolol.
Which of the following findings should indicate to the nurse that the client is experiencing an
adverse reaction to this medication? - ANS Report of a night cough.
(the nurse should recognize that this is an early indication of heart failure and report this
adverse reaction to the provider)
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a
pressure injury. Which of the following actions should the nurse take? - ANS Use a 30-mL
syringe.
(Nurse should use a 30-60 mL syringe with an 18 or 19-gauge catheter to deliver the ideal
pressure of 8 pounds per square inch (psi) when irrigating a wound.)
A nurse is assessing a client who has Graves' disease. Which of the following images should
indicate to the nurse that the client has exophthalmos? - ANS Last picture or the picture with
wide-opened, bulging eyes.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to the
nurse that the client's condition is improving? - ANS glucose 272 mg/dL
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations
should the nurse expect? - ANS Constipation
(due to client's decrease in metabolism, resulting in slow motility of the gastrointestinal tract.)
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the
following actions should the nurse take first? - ANS Check for the type and number of units of
blood to administer.
