PN Adult Medical Surgical Online Practice 2023-2026 B verified
with correct answer
A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about
manifestations of impending death. Which of the following manifestations should the
nurse include?- correct answer>>>Incontinence of the bowel and bladder.
Rationale:The nurse should inform the caregiver that incontinence of the bowel and
bladder is a manifestation of impending death. Other manifestations include
hypotension, bradycardia, restlessness, and coolness of the skin.
A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client
indicates a therapeutic response to the medication?- correct answer>>>"I have gained 3
lbs since my last appointment"
R: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight
gain as an indication that the methimazole therapy has been effective
A nurse is contributing to the plan of care for a client who is postoperative following a
total knee arthroplasty.
The client is using a continuous passive motion (CPM) machine. Which of the following
interventions should the nurse recommend for the plan of care?- correct
answer>>>Keep a sheepskin pad between the client's extremity and the CPM machine.
R: The nurse should plan to keep a sheepskin pad between the dient's extremity and
the cOM madhune to protect the client's skin. The nurse should check the client's skin
condition frequendy wile the cient is using the CPM machine.
A nurse is reinforcing teaching with a client about testicular self-examination. Which of
the following instructions should the nurse include in the teaching?- correct
answer>>>"Perform testicular self-examination after taking a warm shower."
Rationale: The nurse should instruct the client to perform testicular self-examination
after taking a warm shower or bath. This causes relaxation of the scrotal skin, which
allows for better palpation of the testes.
A nurse is reinforcing discharge teaching for the caregivers of a client who has
Parkinson's disease. Which of the following information should the nurse include in the
teaching?- correct answer>>>Remind the client to avoid watching their feet when
walking.
R: The nurse should remind the client's caregivers to frequently remind the client to
maintain correct posture and prevent falls by not watching their feet when walking.
,A home health nurse is assisting with the care for a client who has COPD. The client
reports shortness of breath while eating, despite the use of home oxygen. Which of the
following recommendations should the nurse make?- correct answer>>>"Use a
bronchodilator 30 minutes before your meal."
R: The dient should use a bronchodilator 30 min before meals to prevent shortness of
breath while eating.
A nurse is assisting with the care of a client who has a newly inserted water-seal closed
chest tube. Which of the following findings should the nurse report to the provider?-
correct answer>>>Chest drainage is greater than 70 mL/hr.
RAT: The nurse should identify that chest drainage of greater the 70 mL/hr can indicate
a complication and should be reported to the provider. Water fluctuates in the water-
seal chamber.
Water should fluctuate in the water-seal chamber. The water rises and falls upon the
client's respiratory effort. Therefore, this finding does not need to be reported to the
provider.
A nurse is assisting with the care for a client who has a compound fracture of the femur
and was placed in balanced suspension skeletal traction 4 days ago. Which of the
following actions should the nurse take?- correct answer>>>Perform pin site care daily.
R: The nurse should perform pin site care daily with chlorhexidine solution or use a
solution according to facility protocol. The nurse should also monitor the pin sites for
manifestations of infection.
A nurse is reinforcing discharge teaching with a client who has leukemia and is
receiving chemotherapy. Which of the following statements should the nurse include in
the teaching?- correct answer>>>"You should place your toothbrush in hydrogen
peroxide."
R: Tieres who are receiving chemotherapy should clean their toothbrushes by soaking
them in a hydrogen peroxide or bleach solution. This solution rids the toothbrush of
bacteria and prevents infection.
A nurse is assisting with an educational program for clients who have been newly
diagnosed with diabetes mellitus. Which of the following instructions should the nurse
include in the program regarding insulin?- correct answer>>>Opened insulin can be
stored on a cool countertop away from light
R: The nurse should reinforce teaching with the clients that opened insulin vials do not
require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct
sunlight.
, A nurse is collecting data from a client who is receiving sumatriptan. Which of the
following is an expected outcome?- correct answer>>>Diminished headache
Rationale:
Sumatriptan is a vascular headache suppressant prescribed for relief of migraines or
cluster headaches. Therefore, the nurse should monitor the client for a diminished
headache as an expected outcome of the medication.
---------------
Nasal and throat discomfort are possible adverse effects of sumatriptan.
Muscle pain and stiffness are possible adverse effects of sumatriptan.
The nurse should not expect sumatriptan to decrease peripheral edema.
A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following
information should the nurse include?- correct answer>>>"You are at risk for infertility
with this infection, regardless of treatment."
R: The nurse should reinforce teaching with the client that there is a risk for infertility as
a result of this infection,
A nurse is changing the dressing for a client who has an abdominal incision and a
closed-suction drain. Which of the following actions should the nurse take?- correct
answer>>>Cleanse the drainage plug with alcohol swabs.
Rationale:
The nurse should cleanse the drain opening and plug with alcohol swabs to remove
excess drainage and discourage pathogens from entering the drainage system.
The nurse should secure the drainage tube to the client's gown to allow for ambulation.
Pinning the gown to the client's bedding can result in dislodgement of the drain.
The nurse should wear clean gloves to empty the drainage system because the exterior
of the drain is not sterile.
The nurse should use a precut or folded gauze dressing to fit around the drainage tube.
If the nurse cuts the gauze dressing, small threads and fibers can embed in the incision
and increase inflammation and infection.
A nurse is monitoring a client who has a history of an enlarged prostate and is
experiencing suprapubic discomfort. Which of the following actions should the nurse
take first?- correct answer>>>Palpate the abdomen.
with correct answer
A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about
manifestations of impending death. Which of the following manifestations should the
nurse include?- correct answer>>>Incontinence of the bowel and bladder.
Rationale:The nurse should inform the caregiver that incontinence of the bowel and
bladder is a manifestation of impending death. Other manifestations include
hypotension, bradycardia, restlessness, and coolness of the skin.
A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client
indicates a therapeutic response to the medication?- correct answer>>>"I have gained 3
lbs since my last appointment"
R: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight
gain as an indication that the methimazole therapy has been effective
A nurse is contributing to the plan of care for a client who is postoperative following a
total knee arthroplasty.
The client is using a continuous passive motion (CPM) machine. Which of the following
interventions should the nurse recommend for the plan of care?- correct
answer>>>Keep a sheepskin pad between the client's extremity and the CPM machine.
R: The nurse should plan to keep a sheepskin pad between the dient's extremity and
the cOM madhune to protect the client's skin. The nurse should check the client's skin
condition frequendy wile the cient is using the CPM machine.
A nurse is reinforcing teaching with a client about testicular self-examination. Which of
the following instructions should the nurse include in the teaching?- correct
answer>>>"Perform testicular self-examination after taking a warm shower."
Rationale: The nurse should instruct the client to perform testicular self-examination
after taking a warm shower or bath. This causes relaxation of the scrotal skin, which
allows for better palpation of the testes.
A nurse is reinforcing discharge teaching for the caregivers of a client who has
Parkinson's disease. Which of the following information should the nurse include in the
teaching?- correct answer>>>Remind the client to avoid watching their feet when
walking.
R: The nurse should remind the client's caregivers to frequently remind the client to
maintain correct posture and prevent falls by not watching their feet when walking.
,A home health nurse is assisting with the care for a client who has COPD. The client
reports shortness of breath while eating, despite the use of home oxygen. Which of the
following recommendations should the nurse make?- correct answer>>>"Use a
bronchodilator 30 minutes before your meal."
R: The dient should use a bronchodilator 30 min before meals to prevent shortness of
breath while eating.
A nurse is assisting with the care of a client who has a newly inserted water-seal closed
chest tube. Which of the following findings should the nurse report to the provider?-
correct answer>>>Chest drainage is greater than 70 mL/hr.
RAT: The nurse should identify that chest drainage of greater the 70 mL/hr can indicate
a complication and should be reported to the provider. Water fluctuates in the water-
seal chamber.
Water should fluctuate in the water-seal chamber. The water rises and falls upon the
client's respiratory effort. Therefore, this finding does not need to be reported to the
provider.
A nurse is assisting with the care for a client who has a compound fracture of the femur
and was placed in balanced suspension skeletal traction 4 days ago. Which of the
following actions should the nurse take?- correct answer>>>Perform pin site care daily.
R: The nurse should perform pin site care daily with chlorhexidine solution or use a
solution according to facility protocol. The nurse should also monitor the pin sites for
manifestations of infection.
A nurse is reinforcing discharge teaching with a client who has leukemia and is
receiving chemotherapy. Which of the following statements should the nurse include in
the teaching?- correct answer>>>"You should place your toothbrush in hydrogen
peroxide."
R: Tieres who are receiving chemotherapy should clean their toothbrushes by soaking
them in a hydrogen peroxide or bleach solution. This solution rids the toothbrush of
bacteria and prevents infection.
A nurse is assisting with an educational program for clients who have been newly
diagnosed with diabetes mellitus. Which of the following instructions should the nurse
include in the program regarding insulin?- correct answer>>>Opened insulin can be
stored on a cool countertop away from light
R: The nurse should reinforce teaching with the clients that opened insulin vials do not
require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct
sunlight.
, A nurse is collecting data from a client who is receiving sumatriptan. Which of the
following is an expected outcome?- correct answer>>>Diminished headache
Rationale:
Sumatriptan is a vascular headache suppressant prescribed for relief of migraines or
cluster headaches. Therefore, the nurse should monitor the client for a diminished
headache as an expected outcome of the medication.
---------------
Nasal and throat discomfort are possible adverse effects of sumatriptan.
Muscle pain and stiffness are possible adverse effects of sumatriptan.
The nurse should not expect sumatriptan to decrease peripheral edema.
A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following
information should the nurse include?- correct answer>>>"You are at risk for infertility
with this infection, regardless of treatment."
R: The nurse should reinforce teaching with the client that there is a risk for infertility as
a result of this infection,
A nurse is changing the dressing for a client who has an abdominal incision and a
closed-suction drain. Which of the following actions should the nurse take?- correct
answer>>>Cleanse the drainage plug with alcohol swabs.
Rationale:
The nurse should cleanse the drain opening and plug with alcohol swabs to remove
excess drainage and discourage pathogens from entering the drainage system.
The nurse should secure the drainage tube to the client's gown to allow for ambulation.
Pinning the gown to the client's bedding can result in dislodgement of the drain.
The nurse should wear clean gloves to empty the drainage system because the exterior
of the drain is not sterile.
The nurse should use a precut or folded gauze dressing to fit around the drainage tube.
If the nurse cuts the gauze dressing, small threads and fibers can embed in the incision
and increase inflammation and infection.
A nurse is monitoring a client who has a history of an enlarged prostate and is
experiencing suprapubic discomfort. Which of the following actions should the nurse
take first?- correct answer>>>Palpate the abdomen.
