Learning System PN
Comprehensive Review:
Questions with Answers and
Rationales
1. The PN is collecting data on a client who is 2 days post-operative from an
abdominal hysterectomy. The client suddenly reports feeling a “pop” in her
incision. The PN observes a loop of intestine protruding from the wound. What
action should the PN take first?
A) Push the intestine back into the wound and apply a tight binder.
B) Cover the wound with sterile saline-moistened dressings, position the client with
knees bent, and notify the RN immediately.
C) Apply dry gauze over the wound and tape it securely.
D) Have the client cough and deep breathe to expand the lungs.
Correct Answer: B
Rationale: Evisceration is a surgical emergency. The protruding bowel should be
covered with sterile, saline-moistened dressings to prevent drying; the client
should be placed in low Fowler’s position with knees bent to reduce abdominal
tension, and the RN/provider notified immediately. The bowel should never be
pushed back (A). Dry gauze (C) can stick to tissue. Coughing (D) increases intra-
abdominal pressure.
,2. A client with heart failure is receiving furosemide. Which lunch selection
indicates the client understands the dietary teaching?
A) A ham and cheese sandwich with potato chips.
B) A grilled chicken salad with fresh fruit.
C) Tomato soup and a pickle spear.
D) A frozen dinner with a side of canned vegetables.
Correct Answer: B
Rationale: Furosemide is a potassium-wasting diuretic, and clients with heart
failure need a low-sodium diet. Grilled chicken salad and fresh fruit are low in
sodium and high in potassium (helpful for potassium loss). Ham, chips, tomato
soup, pickles, frozen dinners, and canned vegetables (A, C, D) are typically high in
sodium.
3. The PN is caring for a client with a new diagnosis of type 2 diabetes. Which
laboratory test provides the best indication of long-term blood glucose
control?
A) Fasting blood glucose.
B) Oral glucose tolerance test.
C) Glycosylated hemoglobin (HbA1c).
D) Postprandial glucose.
Correct Answer: C
Rationale: HbA1c reflects the average blood glucose over the past 2–3 months.
Fasting blood glucose (A) and postprandial glucose (D) provide only a single point-
in-time measurement. The oral glucose tolerance test (B) is used for diagnosis, not
routine monitoring.
,4. The PN is collecting data on a client who is 30 minutes post-operative from a
transurethral resection of the prostate (TURP). The continuous bladder
irrigation is infusing. The PN notes bright red urine with large clots. What
should the PN do first?
A) Decrease the irrigation flow rate.
B) Document the finding as normal.
C) Increase the irrigation flow rate and notify the RN.
D) Remove the indwelling catheter.
Correct Answer: C
Rationale: Bright red urine with clots indicates active bleeding. The irrigation rate
should be increased (per protocol/order) to keep urine light pink and to prevent clot
retention, and the RN/provider must be notified. Decreasing flow (A) would worsen
clotting. Documentation alone (B) delays intervention. The PN does not
independently remove the catheter (D).
5. The PN is reinforcing teaching for a client who is starting warfarin therapy.
Which statement by the client indicates a need for further teaching?
A) “I will use an electric razor for shaving.”
B) “I will keep my intake of green leafy vegetables consistent.”
C) “I can take aspirin if I have a headache.”
D) “I will report any signs of unusual bleeding to my provider.”
Correct Answer: C
Rationale: Aspirin and NSAIDs increase the risk of bleeding with warfarin;
acetaminophen is usually recommended for pain. Using an electric razor (A),
consistent vitamin K intake (B), and reporting unusual bleeding (D) indicate correct
understanding.
, 6. The PN is caring for a client with a chest tube to water-seal drainage. The PN
notes continuous bubbling in the water-seal chamber. What action should the
PN take first?
A) Clamp the chest tube near the insertion site.
B) Add sterile water to the water-seal chamber.
C) Check the system for air leaks from the client to the drainage unit.
D) Call the provider immediately.
Correct Answer: C
Rationale: Continuous bubbling indicates an air leak. The PN should first locate the
leak by checking connections and the dressing at the insertion site. Clamping the
tube indiscriminately (A) can cause tension pneumothorax. Calling the provider (D)
may be needed after assessment.
7. The PN is collecting data on a client with suspected bacterial meningitis.
Which finding is most indicative of meningeal irritation?
A) Babinski reflex.
B) Brudzinski sign (flexion of hips/knees when neck is flexed).
C) Chvostek sign.
D) Homans sign.
Correct Answer: B
Rationale: A positive Brudzinski sign (involuntary flexion of hips and knees when
the neck is flexed) indicates meningeal irritation. Chvostek sign (C) indicates
hypocalcemia. Babinski (A) is a plantar reflex. Homans sign (D) is associated with
DVT.
Comprehensive Review:
Questions with Answers and
Rationales
1. The PN is collecting data on a client who is 2 days post-operative from an
abdominal hysterectomy. The client suddenly reports feeling a “pop” in her
incision. The PN observes a loop of intestine protruding from the wound. What
action should the PN take first?
A) Push the intestine back into the wound and apply a tight binder.
B) Cover the wound with sterile saline-moistened dressings, position the client with
knees bent, and notify the RN immediately.
C) Apply dry gauze over the wound and tape it securely.
D) Have the client cough and deep breathe to expand the lungs.
Correct Answer: B
Rationale: Evisceration is a surgical emergency. The protruding bowel should be
covered with sterile, saline-moistened dressings to prevent drying; the client
should be placed in low Fowler’s position with knees bent to reduce abdominal
tension, and the RN/provider notified immediately. The bowel should never be
pushed back (A). Dry gauze (C) can stick to tissue. Coughing (D) increases intra-
abdominal pressure.
,2. A client with heart failure is receiving furosemide. Which lunch selection
indicates the client understands the dietary teaching?
A) A ham and cheese sandwich with potato chips.
B) A grilled chicken salad with fresh fruit.
C) Tomato soup and a pickle spear.
D) A frozen dinner with a side of canned vegetables.
Correct Answer: B
Rationale: Furosemide is a potassium-wasting diuretic, and clients with heart
failure need a low-sodium diet. Grilled chicken salad and fresh fruit are low in
sodium and high in potassium (helpful for potassium loss). Ham, chips, tomato
soup, pickles, frozen dinners, and canned vegetables (A, C, D) are typically high in
sodium.
3. The PN is caring for a client with a new diagnosis of type 2 diabetes. Which
laboratory test provides the best indication of long-term blood glucose
control?
A) Fasting blood glucose.
B) Oral glucose tolerance test.
C) Glycosylated hemoglobin (HbA1c).
D) Postprandial glucose.
Correct Answer: C
Rationale: HbA1c reflects the average blood glucose over the past 2–3 months.
Fasting blood glucose (A) and postprandial glucose (D) provide only a single point-
in-time measurement. The oral glucose tolerance test (B) is used for diagnosis, not
routine monitoring.
,4. The PN is collecting data on a client who is 30 minutes post-operative from a
transurethral resection of the prostate (TURP). The continuous bladder
irrigation is infusing. The PN notes bright red urine with large clots. What
should the PN do first?
A) Decrease the irrigation flow rate.
B) Document the finding as normal.
C) Increase the irrigation flow rate and notify the RN.
D) Remove the indwelling catheter.
Correct Answer: C
Rationale: Bright red urine with clots indicates active bleeding. The irrigation rate
should be increased (per protocol/order) to keep urine light pink and to prevent clot
retention, and the RN/provider must be notified. Decreasing flow (A) would worsen
clotting. Documentation alone (B) delays intervention. The PN does not
independently remove the catheter (D).
5. The PN is reinforcing teaching for a client who is starting warfarin therapy.
Which statement by the client indicates a need for further teaching?
A) “I will use an electric razor for shaving.”
B) “I will keep my intake of green leafy vegetables consistent.”
C) “I can take aspirin if I have a headache.”
D) “I will report any signs of unusual bleeding to my provider.”
Correct Answer: C
Rationale: Aspirin and NSAIDs increase the risk of bleeding with warfarin;
acetaminophen is usually recommended for pain. Using an electric razor (A),
consistent vitamin K intake (B), and reporting unusual bleeding (D) indicate correct
understanding.
, 6. The PN is caring for a client with a chest tube to water-seal drainage. The PN
notes continuous bubbling in the water-seal chamber. What action should the
PN take first?
A) Clamp the chest tube near the insertion site.
B) Add sterile water to the water-seal chamber.
C) Check the system for air leaks from the client to the drainage unit.
D) Call the provider immediately.
Correct Answer: C
Rationale: Continuous bubbling indicates an air leak. The PN should first locate the
leak by checking connections and the dressing at the insertion site. Clamping the
tube indiscriminately (A) can cause tension pneumothorax. Calling the provider (D)
may be needed after assessment.
7. The PN is collecting data on a client with suspected bacterial meningitis.
Which finding is most indicative of meningeal irritation?
A) Babinski reflex.
B) Brudzinski sign (flexion of hips/knees when neck is flexed).
C) Chvostek sign.
D) Homans sign.
Correct Answer: B
Rationale: A positive Brudzinski sign (involuntary flexion of hips and knees when
the neck is flexed) indicates meningeal irritation. Chvostek sign (C) indicates
hypocalcemia. Babinski (A) is a plantar reflex. Homans sign (D) is associated with
DVT.
