Adult Medical Surgical Practice A
Questions and Correct Answers
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus.
Which of the following findings should the nurse expect? - <CORRECT ANSWER >>Facial
butterfly rash.
R: A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks
and nose and can disappear during times of remission.
A nurse is caring for a client who is receiving plasmapheresis through a venous access site.
Which of the following actions should the nurse take? - <CORRECT ANSWER >>Check electrolyte
levels before and after therapy.
R: Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should monitor
the clients electrolyte levels before and after therapy.
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? - <CORRECT ANSWER >>The nurse
should identify an outward protrusion of the eyes is exophthalmos a common finding of graves
disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle
and increases fatty tissue behind the eye which results in the eyes protruding outward.
Exophthalmos can cause the client to experience problems with vision including focusing on
objects as well as pressure on the optic nerve.
A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days
ago. Which of the following actions should the nurse take first after hearing the following
sound? - <CORRECT ANSWER >>Listen with the client on his left side. When providing nursing
care the nurse should first use the least invasive intervention. Therefore after auscultating a
murmur the first action the nurse should take is to place the client on his left side and listen to
his heart again.
,A nurse is providing teaching to an older adult female client who has stress incontinence and a
BMI of 32. Which of the following statements by the client indicates an understanding of the
teaching question mark - <CORRECT ANSWER >>I am dieting to lose weight. Excess weight cut
creates increased abdominal pressure that can result in stress incontinence.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following
results should the nurse expect? - <CORRECT ANSWER >>Paco2 of 56. A client who has COPD
retains paco2 due to the weakening and the collapse of the alveolar sacs which decreases the
area and lungs for gas exchange and causes the paco2 to increase above the expected
reference range.
A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the client to notify the provider? Select all that apply. - <CORRECT ANSWER >>Calf pain,
numbness in the arms and intense headache. Calf pain is an indication of DVT and the client
should report this finding to the provider immediately. Numbness in the arms can indicate
cerebrovascular accident which is an adverse effect of hormone replacement therapy and an
intense headache can indicate a cerebrovascular accident.
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription
for erythropoietin. Which of the following statements by the client indicates an understanding
of the teaching? - <CORRECT ANSWER >>I am taking this medication to increase my energy
level. The goal of erythropoietin therapy is to increase the level of hematocrit and clients who
have anemia. When the medication is effective the client should have a decreasing fatigue and
an improvement and activity tolerance.
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following
statements should the nurse identify as an indication that the client understands teaching? -
<CORRECT ANSWER >>I will wear clean graduated compression stockings everyday. The client
should apply a clean pair of graduated compression stockings each day and clean soiled
stockings with mild detergent and warm water by hand.
A nurse is preparing to present a program about atherosclerosis at a health fair. Which of the
following recommendations should the nurse plan to include? Select all that apply. - <CORRECT
ANSWER >>Follow a smoking cessation program maintain an appropriate weight eat a low-fat
diet and increase fluid intake. Smoking cessation is an important lifestyle modification to
, prevent Arthur sclerosis and preventing obesity through diet and exercise can help prevent
atherosclerosis. Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis.
A nurse is caring for a client who is 12 hours post-operative following a total hip arthroplasty.
Which of the following actions should the nurse take? - <CORRECT ANSWER >>Place a pillow
between the clients legs. The nurse should place a pillow between the clients legs to prevent
hip dislocation.
A nurse is reviewing the medication history of a client who is to undergo allergy testing. The
nurse should instruct the client to discontinue which of the following medications before the
testing? - <CORRECT ANSWER >>...
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? - <CORRECT ANSWER >>Check for the type and
number of units of blood to administer. According to evidence based practice the nurse should
first confirm that the type and number of units of blood to administer matches what is
indicated in the clients medication administration record.
A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron
supplement. Which of the following statements by the client indicates an understanding of the
teaching? - <CORRECT ANSWER >>I will eat more high-fiber foods. The client should eat high-
fiber foods to help prevent constipation which is a common adverse effect of oral iron
supplements.
A nurse is caring for a client who is post-operative following a total hip arthroplasty. Which of
the following laboratory values should the nurse report to the provider? - <CORRECT ANSWER
>>HGB of 8. The nursery report and HGB level of 8 which is below the expected reference range
and as an indicator of postoperative hemorrhage or anemia.
A nurse is caring for a client who has a leg cast and is returning demonstration on the proper
use of crutches while climbing stairs. Identify the sequence the client should follow when
demonstrating crutch use. - <CORRECT ANSWER >>Place body weight on the crutches Advance
the unaffected leg onto the stair shift weight from the crutches to the unaffected leg and then
bring the crutches and the affected leg up to the stair
Questions and Correct Answers
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus.
Which of the following findings should the nurse expect? - <CORRECT ANSWER >>Facial
butterfly rash.
R: A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks
and nose and can disappear during times of remission.
A nurse is caring for a client who is receiving plasmapheresis through a venous access site.
Which of the following actions should the nurse take? - <CORRECT ANSWER >>Check electrolyte
levels before and after therapy.
R: Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should monitor
the clients electrolyte levels before and after therapy.
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? - <CORRECT ANSWER >>The nurse
should identify an outward protrusion of the eyes is exophthalmos a common finding of graves
disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle
and increases fatty tissue behind the eye which results in the eyes protruding outward.
Exophthalmos can cause the client to experience problems with vision including focusing on
objects as well as pressure on the optic nerve.
A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days
ago. Which of the following actions should the nurse take first after hearing the following
sound? - <CORRECT ANSWER >>Listen with the client on his left side. When providing nursing
care the nurse should first use the least invasive intervention. Therefore after auscultating a
murmur the first action the nurse should take is to place the client on his left side and listen to
his heart again.
,A nurse is providing teaching to an older adult female client who has stress incontinence and a
BMI of 32. Which of the following statements by the client indicates an understanding of the
teaching question mark - <CORRECT ANSWER >>I am dieting to lose weight. Excess weight cut
creates increased abdominal pressure that can result in stress incontinence.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following
results should the nurse expect? - <CORRECT ANSWER >>Paco2 of 56. A client who has COPD
retains paco2 due to the weakening and the collapse of the alveolar sacs which decreases the
area and lungs for gas exchange and causes the paco2 to increase above the expected
reference range.
A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the client to notify the provider? Select all that apply. - <CORRECT ANSWER >>Calf pain,
numbness in the arms and intense headache. Calf pain is an indication of DVT and the client
should report this finding to the provider immediately. Numbness in the arms can indicate
cerebrovascular accident which is an adverse effect of hormone replacement therapy and an
intense headache can indicate a cerebrovascular accident.
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription
for erythropoietin. Which of the following statements by the client indicates an understanding
of the teaching? - <CORRECT ANSWER >>I am taking this medication to increase my energy
level. The goal of erythropoietin therapy is to increase the level of hematocrit and clients who
have anemia. When the medication is effective the client should have a decreasing fatigue and
an improvement and activity tolerance.
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following
statements should the nurse identify as an indication that the client understands teaching? -
<CORRECT ANSWER >>I will wear clean graduated compression stockings everyday. The client
should apply a clean pair of graduated compression stockings each day and clean soiled
stockings with mild detergent and warm water by hand.
A nurse is preparing to present a program about atherosclerosis at a health fair. Which of the
following recommendations should the nurse plan to include? Select all that apply. - <CORRECT
ANSWER >>Follow a smoking cessation program maintain an appropriate weight eat a low-fat
diet and increase fluid intake. Smoking cessation is an important lifestyle modification to
, prevent Arthur sclerosis and preventing obesity through diet and exercise can help prevent
atherosclerosis. Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis.
A nurse is caring for a client who is 12 hours post-operative following a total hip arthroplasty.
Which of the following actions should the nurse take? - <CORRECT ANSWER >>Place a pillow
between the clients legs. The nurse should place a pillow between the clients legs to prevent
hip dislocation.
A nurse is reviewing the medication history of a client who is to undergo allergy testing. The
nurse should instruct the client to discontinue which of the following medications before the
testing? - <CORRECT ANSWER >>...
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? - <CORRECT ANSWER >>Check for the type and
number of units of blood to administer. According to evidence based practice the nurse should
first confirm that the type and number of units of blood to administer matches what is
indicated in the clients medication administration record.
A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron
supplement. Which of the following statements by the client indicates an understanding of the
teaching? - <CORRECT ANSWER >>I will eat more high-fiber foods. The client should eat high-
fiber foods to help prevent constipation which is a common adverse effect of oral iron
supplements.
A nurse is caring for a client who is post-operative following a total hip arthroplasty. Which of
the following laboratory values should the nurse report to the provider? - <CORRECT ANSWER
>>HGB of 8. The nursery report and HGB level of 8 which is below the expected reference range
and as an indicator of postoperative hemorrhage or anemia.
A nurse is caring for a client who has a leg cast and is returning demonstration on the proper
use of crutches while climbing stairs. Identify the sequence the client should follow when
demonstrating crutch use. - <CORRECT ANSWER >>Place body weight on the crutches Advance
the unaffected leg onto the stair shift weight from the crutches to the unaffected leg and then
bring the crutches and the affected leg up to the stair
