PN ADULT MEDICAL SURGICAL ONLINE PRACTICE 2023 B 2026/2027
ACTUAL QUESTIONS WITH VERIFIED ANSWERS.
A nurse in a telemetry unit is collecting data from a client who has a newly-inserted permanent
pacemaker. Which of the following findings should the nurse report to the provider?
The client experiences hiccups when sitting.
The client's pulse rate is 5/min faster than the preset pacemaker rate.
There is the presence of a pacing spike before the P-wave on the ECG rhythm strip.
The dressing over the insertion site is dry and intact. - (ANSWER)The client experiences hiccups when
sitting.
Click to highlight the findings the nurse should report to the charge nurse immediately. To deselect a
finding, click on the finding again. - (ANSWER)• Perineal pad is saturated with blood, and large clots are
present is correct. The presence of vaginal bleeding and blood clots is a manifestation of vaginal
hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
• Blood pressure 98/56 mm Hg is correct. Decreased
blood pressure is a manifestation of vaginal hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
• Heart rate 102/min is correct, Tachycardia is a manifestation of vaginal hemorrhage. Therefore, the
nurse should report this finding to the charge nurse.
A nurse is assisting with the care for a client who reports shortness of breath and has an oxygen
saturation
90%. Which of the following actions should the nurse take? - (ANSWER)Administer oxygen via nasal
cannula
R: The nurse should administer oxygen via nasal cannula to a client who reports shortness of breath and
has an oxygen saturation below the expected reference range. The nurse should continue to monitor the
client and adjust the oxygen flow rate as needed.
,PN ADULT MEDICAL SURGICAL ONLINE PRACTICE 2023 B 2026/2027
ACTUAL QUESTIONS WITH VERIFIED ANSWERS.
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? -
(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? - (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? - (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? - (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.
, PN ADULT MEDICAL SURGICAL ONLINE PRACTICE 2023 B 2026/2027
ACTUAL QUESTIONS WITH VERIFIED ANSWERS.
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? - (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? - (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? - (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? - (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.
ACTUAL QUESTIONS WITH VERIFIED ANSWERS.
A nurse in a telemetry unit is collecting data from a client who has a newly-inserted permanent
pacemaker. Which of the following findings should the nurse report to the provider?
The client experiences hiccups when sitting.
The client's pulse rate is 5/min faster than the preset pacemaker rate.
There is the presence of a pacing spike before the P-wave on the ECG rhythm strip.
The dressing over the insertion site is dry and intact. - (ANSWER)The client experiences hiccups when
sitting.
Click to highlight the findings the nurse should report to the charge nurse immediately. To deselect a
finding, click on the finding again. - (ANSWER)• Perineal pad is saturated with blood, and large clots are
present is correct. The presence of vaginal bleeding and blood clots is a manifestation of vaginal
hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
• Blood pressure 98/56 mm Hg is correct. Decreased
blood pressure is a manifestation of vaginal hemorrhage.
Therefore, the nurse should report this finding to the charge nurse.
• Heart rate 102/min is correct, Tachycardia is a manifestation of vaginal hemorrhage. Therefore, the
nurse should report this finding to the charge nurse.
A nurse is assisting with the care for a client who reports shortness of breath and has an oxygen
saturation
90%. Which of the following actions should the nurse take? - (ANSWER)Administer oxygen via nasal
cannula
R: The nurse should administer oxygen via nasal cannula to a client who reports shortness of breath and
has an oxygen saturation below the expected reference range. The nurse should continue to monitor the
client and adjust the oxygen flow rate as needed.
,PN ADULT MEDICAL SURGICAL ONLINE PRACTICE 2023 B 2026/2027
ACTUAL QUESTIONS WITH VERIFIED ANSWERS.
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? -
(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? - (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? - (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? - (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.
, PN ADULT MEDICAL SURGICAL ONLINE PRACTICE 2023 B 2026/2027
ACTUAL QUESTIONS WITH VERIFIED ANSWERS.
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? - (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? - (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? - (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? - (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.
