RN Adult Medical Surgical Online
Practice 2023 B
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.) - ANS 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.
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? - ANS 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.
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? - ANS 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.
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? - ANS 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.
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? - ANS 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.
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? - ANS Increase fiber intake to at least 30 g per day.
Rational:
Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse
expect? - ANS 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.
,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.) - ANS 167 mL/hr
Rational:
mL/hr =
4000/24 = 166.6 = 167
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. - ANS Perineal pad saturated
with blood, large clots present
Change of blood pressure, heart rate of 102/min
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.
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? - ANS 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.
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?
- ANS "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.
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? - ANS 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.
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? - ANS Avocados
Rational:
Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to
certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the
nurse plan to administer? - ANS Regular insulin 20 units IV bolus
Rational:
DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and
elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base
imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be
effective within 10 min when administered intravenously.
Practice 2023 B
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.) - ANS 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.
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? - ANS 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.
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? - ANS 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.
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? - ANS 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.
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? - ANS 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.
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? - ANS Increase fiber intake to at least 30 g per day.
Rational:
Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse
expect? - ANS 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.
,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.) - ANS 167 mL/hr
Rational:
mL/hr =
4000/24 = 166.6 = 167
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. - ANS Perineal pad saturated
with blood, large clots present
Change of blood pressure, heart rate of 102/min
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.
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? - ANS 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.
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?
- ANS "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.
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? - ANS 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.
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? - ANS Avocados
Rational:
Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to
certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the
nurse plan to administer? - ANS Regular insulin 20 units IV bolus
Rational:
DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and
elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base
imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be
effective within 10 min when administered intravenously.
