PN Adult Medical Surgical Online
Practice 2025 B Exam-Graded A
A nurse is assisting with the development of a plan of care to manage pain for a client
who has herpes zoster with lesions on the lower extremities. Which of the following
interventions should the nurse include in the plan of care?
Keep bed linens o of the affected areas.
Position a heat lamp over the lower extremities.
Apply warm, moist compresses to the affected areas.
Initiate droplet isolation precautions. - correct Answer-Keep bed linens o of the affected
areas.
Rationale: Nurse should keep bed linens off of the affected areas by using a bed cradle,
which will relieve pain caused by the linens rubbing against the lesions.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. Which of the following instructions should the nurse include to promote
comfort?
Sleep on a firm mattress.
Try jogging in place when joints feel stiff.
Use a soft chair or recliner for sitting.
Apply ice packs to painful joints - correct Answer-Sleep on a firm mattress.
Rationale: A firm mattress or a bed board helps the client maintain joint alignment while
sleeping.
A nurse is caring for a client who has an intestinal obstruction and reports a new onset
of nausea. The client has an NG tube set at low intermittent suction and is receiving
continuous IV infusion of 0.9% sodium chloride. Which of the following actions should
the nurse take first?
Check for kinks in the NG tube.
Increase the IV uid rate.
Provide ice chips.
Administer an antiemetic - correct Answer-Check for kinks in the NG tube.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client
is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the
following findings should indicate to the nurse that the client's therapeutic regimen is
effective?
,Adventitious lung sounds
Decrease in exertional dyspnea
Respiratory rate of 26/min while sitting in a chair
Elevation of the head of the bed is required to sleep - correct Answer-Decrease in
exertional dyspnea
Rationale: A (-) in exertional dyspnea indicates the antibiotics are resolving the infection
and the albuterol treatments are facilitating effective ventilation. Therefore, the nurse
should evaluate the therapeutic regimen as effective for the client.
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client
reports increased pain at the site of the fracture. Which of the following actions should
the nurse take?
Massage the area.
Remove the weights.
Loosen the ropes.
Reposition the client - correct Answer-Reposition the client
Rationale: When the client's body is out of alignment with the traction, muscle spasms
develop, causing increased pain. Therefore, the nurse should reposition the client,
ensuring there is a straight line from the client's hip to the traction rope and pulley,
evaluate the client's response, and provide other interventions as needed.
A nurse is caring for a client who begins to have a seizure while ambulating in the hall.
Identify the sequence of actions the nurse should follow. (Move the steps into the box
on the right, placing them in the order of performance. Use all the steps.)
Lower the client to the floor.
Loosen the clothing around the client's neck.
Place a pad beneath the client's head.
Time the length of the client's seizure.
Reorient and reassure the client. - correct Answer-Lower the client to the floor.
Place a pad beneath the client's head.
Loosen the clothing around the client's neck.
Time the length of the client's seizure.
Reorient and reassure the client.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new
prescription for regular and NPH insulin. Which of the following instructions on preparing
the insulins should the nurse include?
Withdraw both types of insulin and then add 0.2 mL of air to the syringe
Gently shake the NPH insulin prior to withdrawing the dose.
Withdraw the regular insulin before withdrawing the NPH insulin.
, Inject air into the NPH vial after withdrawing regular insulin. - correct Answer-Withdraw
the regular insulin before withdrawing the NPH insulin.
Rationale: The nurse should instruct the client to withdraw the regular insulin before
withdrawing the NPH insulin. This will protect the regular insulin from contamination with
the NPH insulin.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about
glycosylated hemoglobin (HbA1c) testing. Which of the following information should the
nurse include in the teaching?
The expected therapeutic reference range for HbA1c for a client who has diabetes
mellitus is 9.5% to 10%.
An HbA1c level below the expected reference range indicates ineffective glucose
control
HbA1c results measure glucose control for the prior 3 months.
HbA1c testing is used to provide a diagnosis of diabetes mellitus - correct Answer-
HbA1c results measure glucose control for the prior 3 months.
Rationale: HbA1c testing reflects ave overall glucose control over a 3 month period. It's
for long-term glucose control.
A nurse is collecting data from a client who has 30% body surface area deep partial-
thickness and full-thickness burns. Which of the following findings indicates that fluid
resuscitation is adequate?
Granulation tissue is present.
Urine output is 50 mL/hr.
Lung sounds are clear.
Oxygen saturation level is 95%. - correct Answer-Urine output is 50 mL/hr.
Rationale: The nurse should closely monitor the client's urinary output as an indicator of
effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that
fluid resuscitation is adequate.
NOTE: Granulation tissue: monitor the client's wounds because infection is a
complication of burns. The presence of granulation tissue is an indicator used to monitor
the effectiveness of wound therapy.
A nurse is planning care for a group of clients after receiving change-of-shift report.
Which of the following clients should the nurse plan to see first?
A client who had a colectomy 2 days ago and has a nasogastric tube attached to low
suction
A client who is dehydrated, has mental confusion, and has tried to get out of bed
several times during the night
Practice 2025 B Exam-Graded A
A nurse is assisting with the development of a plan of care to manage pain for a client
who has herpes zoster with lesions on the lower extremities. Which of the following
interventions should the nurse include in the plan of care?
Keep bed linens o of the affected areas.
Position a heat lamp over the lower extremities.
Apply warm, moist compresses to the affected areas.
Initiate droplet isolation precautions. - correct Answer-Keep bed linens o of the affected
areas.
Rationale: Nurse should keep bed linens off of the affected areas by using a bed cradle,
which will relieve pain caused by the linens rubbing against the lesions.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has
osteoarthritis. Which of the following instructions should the nurse include to promote
comfort?
Sleep on a firm mattress.
Try jogging in place when joints feel stiff.
Use a soft chair or recliner for sitting.
Apply ice packs to painful joints - correct Answer-Sleep on a firm mattress.
Rationale: A firm mattress or a bed board helps the client maintain joint alignment while
sleeping.
A nurse is caring for a client who has an intestinal obstruction and reports a new onset
of nausea. The client has an NG tube set at low intermittent suction and is receiving
continuous IV infusion of 0.9% sodium chloride. Which of the following actions should
the nurse take first?
Check for kinks in the NG tube.
Increase the IV uid rate.
Provide ice chips.
Administer an antiemetic - correct Answer-Check for kinks in the NG tube.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client
is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the
following findings should indicate to the nurse that the client's therapeutic regimen is
effective?
,Adventitious lung sounds
Decrease in exertional dyspnea
Respiratory rate of 26/min while sitting in a chair
Elevation of the head of the bed is required to sleep - correct Answer-Decrease in
exertional dyspnea
Rationale: A (-) in exertional dyspnea indicates the antibiotics are resolving the infection
and the albuterol treatments are facilitating effective ventilation. Therefore, the nurse
should evaluate the therapeutic regimen as effective for the client.
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client
reports increased pain at the site of the fracture. Which of the following actions should
the nurse take?
Massage the area.
Remove the weights.
Loosen the ropes.
Reposition the client - correct Answer-Reposition the client
Rationale: When the client's body is out of alignment with the traction, muscle spasms
develop, causing increased pain. Therefore, the nurse should reposition the client,
ensuring there is a straight line from the client's hip to the traction rope and pulley,
evaluate the client's response, and provide other interventions as needed.
A nurse is caring for a client who begins to have a seizure while ambulating in the hall.
Identify the sequence of actions the nurse should follow. (Move the steps into the box
on the right, placing them in the order of performance. Use all the steps.)
Lower the client to the floor.
Loosen the clothing around the client's neck.
Place a pad beneath the client's head.
Time the length of the client's seizure.
Reorient and reassure the client. - correct Answer-Lower the client to the floor.
Place a pad beneath the client's head.
Loosen the clothing around the client's neck.
Time the length of the client's seizure.
Reorient and reassure the client.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new
prescription for regular and NPH insulin. Which of the following instructions on preparing
the insulins should the nurse include?
Withdraw both types of insulin and then add 0.2 mL of air to the syringe
Gently shake the NPH insulin prior to withdrawing the dose.
Withdraw the regular insulin before withdrawing the NPH insulin.
, Inject air into the NPH vial after withdrawing regular insulin. - correct Answer-Withdraw
the regular insulin before withdrawing the NPH insulin.
Rationale: The nurse should instruct the client to withdraw the regular insulin before
withdrawing the NPH insulin. This will protect the regular insulin from contamination with
the NPH insulin.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about
glycosylated hemoglobin (HbA1c) testing. Which of the following information should the
nurse include in the teaching?
The expected therapeutic reference range for HbA1c for a client who has diabetes
mellitus is 9.5% to 10%.
An HbA1c level below the expected reference range indicates ineffective glucose
control
HbA1c results measure glucose control for the prior 3 months.
HbA1c testing is used to provide a diagnosis of diabetes mellitus - correct Answer-
HbA1c results measure glucose control for the prior 3 months.
Rationale: HbA1c testing reflects ave overall glucose control over a 3 month period. It's
for long-term glucose control.
A nurse is collecting data from a client who has 30% body surface area deep partial-
thickness and full-thickness burns. Which of the following findings indicates that fluid
resuscitation is adequate?
Granulation tissue is present.
Urine output is 50 mL/hr.
Lung sounds are clear.
Oxygen saturation level is 95%. - correct Answer-Urine output is 50 mL/hr.
Rationale: The nurse should closely monitor the client's urinary output as an indicator of
effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that
fluid resuscitation is adequate.
NOTE: Granulation tissue: monitor the client's wounds because infection is a
complication of burns. The presence of granulation tissue is an indicator used to monitor
the effectiveness of wound therapy.
A nurse is planning care for a group of clients after receiving change-of-shift report.
Which of the following clients should the nurse plan to see first?
A client who had a colectomy 2 days ago and has a nasogastric tube attached to low
suction
A client who is dehydrated, has mental confusion, and has tried to get out of bed
several times during the night
