RN Adult Medical Surgical Online Practice 2023 B
1. A nurse is caring for a client who presents to a clinic for a 1-week
follow-up visit after hospitalization for heart failure. Based on the
information in the client's chart, which of the following findings should the
nurse report to the provider? (Click on the "Exhibit" button for additional
information about the client. There are three tabs that contain separate
categories of data.): Heart rate 55/min
Rational:
The client's heart rate of 55/min is a decrease from the client's baseline of 74/min,
and it can indicate the development of digoxin toxicity. The nurse should report
this finding to the provider.
2. A nurse is teaching a client about the use of transcutaneous electrical
nerve stimulation (TENS) for the management of bone cancer pain.
Thenurse should explain that applying a TENS unit to the painful area has
which of the following effects?: A tingling sensation replacing the pain
Rational:
A TENS unit applies small electric currents to the painful area, with the client
increasing the current until the "pins and needles" sensation overrides the pain.
3. A nurse in an ICU is assessing a client who has a traumatic brain injury.
Which of the following findings should the nurse identify as a componentof
Cushing's triad?: Bradycardia
Rational:
A client who has increased intracranial pressure from a traumatic brain injury can
develop bradycardia, which is one component of Cushing's triad. The other
components of Cushing's triad are severe hypertension and a widened pulse
pressure.
4. A nurse is teaching a family about the care of a parent who has a new
diagnosis of Alzheimer's disease. Which of the following information
shouldthe nurse include in the teaching?: Create complete outfits and allow
the client to select one each day.
Rational:
The family should place completed outfits on hangers and allow the client to select
which one to wear each day.
, RN Adult Medical Surgical Online Practice 2023 B
5. A nurse is planning care for a client who has extensive burn injuries
and is immunocompromised. Which of the following precautions should
thenurse include in the plan of care to prevent a Pseudomonas aeruginosa
infection?: Avoid placing plants or flowers in the client's room.
Rational:
Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds
and cause life-threatening complications. The nurse should ensure no one brings
live plants or flowers into the client's room.
6. A nurse is providing teaching to a client who has irritable bowel
syndrome (IBS). Which of the following instructions should the nurse
include in the teaching?: Increase fiber intake to at least 30 g per day.
Rational:
Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
7. A nurse is assessing a client who has diabetes insipidus. Which of the
following findings should the nurse expect?: Low urine specific gravity
Rational:
An expected finding for a client who has diabetes insipidus is a urine specific gravity
between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is
caused by an alteration in antidiuretic hormone release or the kidneys'
responsiveness to the hormone.
8. A nurse is caring for a client who has a new prescription for total
parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN
solution has 500 kcal/L. The IV pump should be set at how many mL/hr?
(Round the answer to the nearest whole number. Use a leading zero if it
applies. Do not use a trailing zero.): 167 mL/hr
Rational:
mL/hr =
4000/24 = 166.6 = 167
9. A nurse is caring for a client who is 4 hr postoperative following a
totalvaginal hysterectomy.Click to highlight the findings the nurse should
report to the provider immediately.: Perineal pad saturated with blood, large clots
present Change of blood pressure, heart rate of 102/min
, RN Adult Medical Surgical Online Practice 2023 B
Rational:
Perineal pad saturated with blood, large clots present, blood pressure trend, and
heart rate of 102/min are correct. The client has manifestations of vaginal
hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and
tachycardia. The nurse should report these findings to the provider.
10. 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?:
Suction machine
Rational:
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.
11. A nurse is providing discharge teaching about infection prevention to a
client who is receiving chemotherapy. Which of the following statements by
the client indicates understanding of the teaching?: "I can ask a friend to
change my cats litter box."
Rational:
Changing a pet's litter box increases the client's risk of being exposed to
toxoplasmosis. Therefore, the client should wear gloves or avoid changing the pet's
litter box.
12. A nurse is assessing a client who has had a plaster cast applied to their
left leg 2 hr ago. Which of the following actions should the nurse take?: Check
that one finger fits between the cast and the leg.
Rational:
To make sure the cast is not too tight, the nurse should be able to slide one finger
under the cast. It is not uncommon for casts to loosen as swelling subsides, but that
should not be an issue 2 hr after application.
13. A nurse is performing a preoperative assessment for a client. The nurse
should identify that an allergy to which of the following foods can indicate a
latex allergy?: Avocados
1. A nurse is caring for a client who presents to a clinic for a 1-week
follow-up visit after hospitalization for heart failure. Based on the
information in the client's chart, which of the following findings should the
nurse report to the provider? (Click on the "Exhibit" button for additional
information about the client. There are three tabs that contain separate
categories of data.): Heart rate 55/min
Rational:
The client's heart rate of 55/min is a decrease from the client's baseline of 74/min,
and it can indicate the development of digoxin toxicity. The nurse should report
this finding to the provider.
2. A nurse is teaching a client about the use of transcutaneous electrical
nerve stimulation (TENS) for the management of bone cancer pain.
Thenurse should explain that applying a TENS unit to the painful area has
which of the following effects?: A tingling sensation replacing the pain
Rational:
A TENS unit applies small electric currents to the painful area, with the client
increasing the current until the "pins and needles" sensation overrides the pain.
3. A nurse in an ICU is assessing a client who has a traumatic brain injury.
Which of the following findings should the nurse identify as a componentof
Cushing's triad?: Bradycardia
Rational:
A client who has increased intracranial pressure from a traumatic brain injury can
develop bradycardia, which is one component of Cushing's triad. The other
components of Cushing's triad are severe hypertension and a widened pulse
pressure.
4. A nurse is teaching a family about the care of a parent who has a new
diagnosis of Alzheimer's disease. Which of the following information
shouldthe nurse include in the teaching?: Create complete outfits and allow
the client to select one each day.
Rational:
The family should place completed outfits on hangers and allow the client to select
which one to wear each day.
, RN Adult Medical Surgical Online Practice 2023 B
5. A nurse is planning care for a client who has extensive burn injuries
and is immunocompromised. Which of the following precautions should
thenurse include in the plan of care to prevent a Pseudomonas aeruginosa
infection?: Avoid placing plants or flowers in the client's room.
Rational:
Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds
and cause life-threatening complications. The nurse should ensure no one brings
live plants or flowers into the client's room.
6. A nurse is providing teaching to a client who has irritable bowel
syndrome (IBS). Which of the following instructions should the nurse
include in the teaching?: Increase fiber intake to at least 30 g per day.
Rational:
Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
7. A nurse is assessing a client who has diabetes insipidus. Which of the
following findings should the nurse expect?: Low urine specific gravity
Rational:
An expected finding for a client who has diabetes insipidus is a urine specific gravity
between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is
caused by an alteration in antidiuretic hormone release or the kidneys'
responsiveness to the hormone.
8. A nurse is caring for a client who has a new prescription for total
parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN
solution has 500 kcal/L. The IV pump should be set at how many mL/hr?
(Round the answer to the nearest whole number. Use a leading zero if it
applies. Do not use a trailing zero.): 167 mL/hr
Rational:
mL/hr =
4000/24 = 166.6 = 167
9. A nurse is caring for a client who is 4 hr postoperative following a
totalvaginal hysterectomy.Click to highlight the findings the nurse should
report to the provider immediately.: Perineal pad saturated with blood, large clots
present Change of blood pressure, heart rate of 102/min
, RN Adult Medical Surgical Online Practice 2023 B
Rational:
Perineal pad saturated with blood, large clots present, blood pressure trend, and
heart rate of 102/min are correct. The client has manifestations of vaginal
hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and
tachycardia. The nurse should report these findings to the provider.
10. 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?:
Suction machine
Rational:
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.
11. A nurse is providing discharge teaching about infection prevention to a
client who is receiving chemotherapy. Which of the following statements by
the client indicates understanding of the teaching?: "I can ask a friend to
change my cats litter box."
Rational:
Changing a pet's litter box increases the client's risk of being exposed to
toxoplasmosis. Therefore, the client should wear gloves or avoid changing the pet's
litter box.
12. A nurse is assessing a client who has had a plaster cast applied to their
left leg 2 hr ago. Which of the following actions should the nurse take?: Check
that one finger fits between the cast and the leg.
Rational:
To make sure the cast is not too tight, the nurse should be able to slide one finger
under the cast. It is not uncommon for casts to loosen as swelling subsides, but that
should not be an issue 2 hr after application.
13. A nurse is performing a preoperative assessment for a client. The nurse
should identify that an allergy to which of the following foods can indicate a
latex allergy?: Avocados
