PN ADULT MEDICAL SURGICAL ONLINE
PRACTICE A 2023 ACTUAL QUESTIONS AND
ANSWERS GRADED A+
A nurse is assisting with the care of a client who is postoperative following
abdominal surgery.
Which of the following actions should the nurse take? (Select all that apply.)
a. Apply oxygen to the client via a face mask.
b. Instruct the client to splint their abdomen with a pillow when coughing.
c. Plan to ambulate the client as soon as possible.
d. Report the client's urinary output to the charge nurse.
e. Monitor the client's pain level.
b. Instruct the client to splint their abdomen with a pillow when coughing.
c. Plan to ambulate the client as soon as possible.
d. Report the client's urinary output to the charge nurse.
e. Monitor the client's pain level.
,Apply oxygen to the client via a face mask is incorrect. It is not necessary to place
a face mask on the client because their oxygen saturation level is within the
expected reference range of 95% to 100%.
Instruct the client to splint their abdomen with a pillow when coughing is correct.
It is important for the client to turn, cough, and deep breathe to reduce the risk for
respiratory complications. The client should be instructed to splint the incision
while performing these actions to reduce the risk for 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
for thrombosis.
Report the client's urinary output to the charge nurse is correct. The client should
produce at least 30 mL/hr of urine. Therefore, the nurse should report this finding
to the charge nurse.
Monitor the client's pain level is correct. The nurse should monitor the client's pain
prior to and following the administration of pain medication to monitor the
effectiveness of the medication.
A nurse is reviewing the laboratory results of a client who reports chest pain.
Which of the following laboratory results indicates the client is experiencing a
myocardial infarction?
,a. Decreased lipase
b. Decreased erythrocyte sedimentation rate (ESR)
c. Elevated creatinine
d. Elevated troponin
d. Elevated troponin
Laboratory evaluation of troponin is used specifically to detect cardiac muscle
injury. Therefore, the nurse should identify an elevated troponin level as an
indication that the client is experiencing a myocardial infarction.
A nurse is assisting with the care of a client.
Nurses' Notes
1200:
Client was admitted to the unit with shortness of breath, a nonproductive cough,
chest discomfort, and myalgia. Prefers orthopneic position. Client reports that
manifestations began about 2 days ago.
1215:
, Oxygen applied at 2 L/min via nasal cannula. Wheezes noted bilaterally. Use of
accessory muscles noted. Client speaks in short phrases, with increased shortness
of breath. Oral mucosa is pink; capillary refill is 4 seconds.
Vital Signs
1200:
Temperature 38.7° C (101.6° F)
Blood pressure 104/64 mm Hg
Heart rate 100/min
Respiratory rate 26/min
Oxygen saturation 88% on room air
1215:
Temperature 38.7° C (101.6° F)
Blood pressure 106/64 mm Hg
PRACTICE A 2023 ACTUAL QUESTIONS AND
ANSWERS GRADED A+
A nurse is assisting with the care of a client who is postoperative following
abdominal surgery.
Which of the following actions should the nurse take? (Select all that apply.)
a. Apply oxygen to the client via a face mask.
b. Instruct the client to splint their abdomen with a pillow when coughing.
c. Plan to ambulate the client as soon as possible.
d. Report the client's urinary output to the charge nurse.
e. Monitor the client's pain level.
b. Instruct the client to splint their abdomen with a pillow when coughing.
c. Plan to ambulate the client as soon as possible.
d. Report the client's urinary output to the charge nurse.
e. Monitor the client's pain level.
,Apply oxygen to the client via a face mask is incorrect. It is not necessary to place
a face mask on the client because their oxygen saturation level is within the
expected reference range of 95% to 100%.
Instruct the client to splint their abdomen with a pillow when coughing is correct.
It is important for the client to turn, cough, and deep breathe to reduce the risk for
respiratory complications. The client should be instructed to splint the incision
while performing these actions to reduce the risk for 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
for thrombosis.
Report the client's urinary output to the charge nurse is correct. The client should
produce at least 30 mL/hr of urine. Therefore, the nurse should report this finding
to the charge nurse.
Monitor the client's pain level is correct. The nurse should monitor the client's pain
prior to and following the administration of pain medication to monitor the
effectiveness of the medication.
A nurse is reviewing the laboratory results of a client who reports chest pain.
Which of the following laboratory results indicates the client is experiencing a
myocardial infarction?
,a. Decreased lipase
b. Decreased erythrocyte sedimentation rate (ESR)
c. Elevated creatinine
d. Elevated troponin
d. Elevated troponin
Laboratory evaluation of troponin is used specifically to detect cardiac muscle
injury. Therefore, the nurse should identify an elevated troponin level as an
indication that the client is experiencing a myocardial infarction.
A nurse is assisting with the care of a client.
Nurses' Notes
1200:
Client was admitted to the unit with shortness of breath, a nonproductive cough,
chest discomfort, and myalgia. Prefers orthopneic position. Client reports that
manifestations began about 2 days ago.
1215:
, Oxygen applied at 2 L/min via nasal cannula. Wheezes noted bilaterally. Use of
accessory muscles noted. Client speaks in short phrases, with increased shortness
of breath. Oral mucosa is pink; capillary refill is 4 seconds.
Vital Signs
1200:
Temperature 38.7° C (101.6° F)
Blood pressure 104/64 mm Hg
Heart rate 100/min
Respiratory rate 26/min
Oxygen saturation 88% on room air
1215:
Temperature 38.7° C (101.6° F)
Blood pressure 106/64 mm Hg
