PN Medical Surgical Practice 2020 Exam with 100% Correct Answers

PN Medical Surgical Practice 2020 A nurse is participating in a health fair for older adult clients. Which of the following vaccines should the nurse recommend for this age group? - Correct answer-Herpes zoster Rationale: The nurse should recommend the herpes zoster vaccine for adults who are 60 years of age and older. -------------- The nurse should recommend the meningococcal vaccine to college students and military recruits who are living in shared housing. The nurse should recommend the HPV vaccine for clients who are 9 to 26 years of age. The nurse should recommend the MMR vaccine to clients who are 62 years of age. A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedures? - Correct answer-Creatinine 1.9 mg/dL Rationale: Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy. --------------------- Expected ranges: Calcium (ca) 9 - 10.5 mg/dL Sodium (Na) 136 - 145 mEq/L Potassium (K) 3.5 - 5 mEq/L A nurse is reinforcing teaching about home care with a client who had knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? - Correct answer-The client stops the nurse and asks for pain medication Rationale: The nurse should identify that a client who is in pain will not be able to concentrate, which can interfere with their ability to learn. A nurse is caring for a client who has a acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspirations? - Correct answer-Allow for 30 min of rest before meals. Rationale: The nurse should allow the client to rest for 30 min before meals to prevent aspiration. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? - Correct answer-Encourage the client to complete ADLs. Rationale: The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning. A nurse is reinforcing about joint protection with a clietn who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? - Correct answer-Apply cold packs to the inflamed joints Rationale: The nurse should instruct the client to use both warm and cold packs on inflamed joints to decrease pain. ----------------- The nurse should instruct the client to participate in low-impact aerobic exercises, which will not inflame the client's joints. The nurse should instruct the client to carry a shoulder bag, which places the stress on larger muscles. The nurse should instruct the client to sleep on a firm mattress to support their joints. A nurse is caring for a client who is schedules for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? - Correct answer-Determine the client's understanding of the procedure. Rationale: When using the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should determine the client's understanding of the procedure to reinforce necessary teaching, which can help manage their anxiety. A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make? - Correct answer-Eat soft foods. Rationale: The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods to decrease irritation to the oral mucosa. ----------------- Instruct the client to avoid seasoning foods with salt or spices that can irritate the oral mucosa. Instruct the client to eat foods that are high in protein and calories to increase their caloric intake and nutrition. Instruct the client to choose foods that are a lukewarm or cool temperature to prevent irritation of the client's oral mucosa. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of teh following interventions should the nurse include when contributing to the plan of care? - Correct answer-Apply a mask on the client if transport is needed. Raitonale: The nurse should apply a mask to a client who has manifestations of pertussis during transport to prevent exposure to others. A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? - Correct answer-Listen to soft music before sleeping. Rationale: Listening to soft music can help the client to relax and reduces environmental stressors. A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following actions should the nurse take first? - Correct answer-Implement recommendation from the speech language pathologist. Rationale: The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first intervention the nurse should include in the plan of care is to implement recommendations from the speech language pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk for aspiration, provide teaching to the client regarding swallowing techniques, and recommend the consistency of foods and liquids for the client. A nurse is assisting in the plan of care regarding bowel retraining for a client who has acervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? - Correct answer-Determine the client's daily elimination habits. Rationale: The first action the nurse should take when using the nursing process is to collect data on the client's daily bowel elimination habits to establish a routine defecation time. A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? - Correct answerHyperactive bowel sounds. Rationale: A mechanical bowel obstruction prevents a portion or all of the bowel contents from moving forward through the bowel. The nurse should expect to auscultate high-pitched, hyperactive bowel sounds above the point of the intestinal obstruction as the intestines attempt to propel the blockage forward. A nurse is assisting with the care of a client who has a newly-inserted 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 Rationale: The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a complication and should be reported to the provider. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? - Correct answer-Keep the cleint in a side-lying position. Rationale: The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity. A nurse is contributing to the plan of care for a client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? - Correct answer-Encourage weight bearing exercises Rationale: Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis. A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching? - Correct answer-Increase fiber-rich foods. Rationale: The nurse should instruct the client to increase the amount of fiber-rich foods in their diet. Dried beans and brown rice are examples of fiber-rich foods. --------------- Instruct the client to increase their fluid intake to 2,000 mL/day to maintain soft stools. Instruct the client to increase activity to stimulate the evacuation of stool. A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? - Correct answer-Have a designated stethoscope in the client's room. Rationale: The nurse should designate equipment to leave in the client's room to avoid crosscontamination. The designated equipment should be disposed of or decontaminated before leaving the client's room. A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After stopping the infusion, which of the following actions should the nurse take next? - Correct answer-Take the client's vital signs. Rationale: The first action the nurse should take when using the nursing process is to collect data from the client to determine what actions should be taken next. A nurse is caring for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. which of the following suggestions to the client should the nurse make? - Correct answer-Eat several, small-portioned meals daily. Rationale: Clients who have difficulty eating because of pain or anorexia can usually tolerate small amounts of food at one time. Eating several small meals daily can increase the client's caloric intake. A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? - Correct answer-0.7mL 7mg/x = 10mg/1mL = x =7/10 x = 0.7 mL A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? - Correct answer-Obtain a raised toilet seat. Rationale: The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation. A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal bood test. Which of the following indtructions should the nurse include in the teaching? - Correct answer-Avoid eating red meat for 3 days prior to the test. Rationale: The nurse should instruct the client to avoid eating red meat for 3 days prior to the guaiac fecal occult blood test because this can lead to a false positive result. A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify which of the following laboratory values indicated the treatment is effective? - Correct answer-Hgb 11 g/dL Rationale: Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the epoetin alfa treatment is effective. A nurse is examining a client's IV site and notes a red line up their arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? - Correct answer-Thrombophlebitis Rationale: The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis. --------------------- swelling and cool skin at the IV site as indications of infiltration. swelling and bruising as indications of a hematoma that can develop by not holding enough pressure after discontinuing the IV. cramping at or above the insertion site and numbness as indications of venous spasms. A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all) - Correct answer--Monitor insertion site for bleeding -Maintain the pressure dressing -Check the client's peripheral pulses Rationale: Monitor the insertion site for bleeding is correct. The nurse should monitor the client's insertion site for manifestations of hemorrhaging.Position the affected extremity at a 45º angle is incorrect. The nurse should keep the client flat with the affected extremity extended, not flexed.Restrict the client's fluid intake is incorrect. The nurse should encourage fluid intake for the client following the cardiac catheterization to assist with evacuating the contrast medium from the client's system.Maintain the pressure dressing is correct. The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal.Check the client's peripheral pulses is correct. The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion. A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? - Correct answer-Loosen clothing around the client's neck. Rationale: The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration. ---------------- The nurse should leave the bed rails up to prevent the client from falling out of bed, which can cause injury. The nurse should not apply restraints that can place the client at risk for a fracture injury. The nurse should place the client in a lateral position to allow for the drainage of oral secretions and to maintain an open airway. A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration? - Correct answer-Pinch the NG tube. Rationale: The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration. ---------------------- The nurse should instill 50 mL of air through the NG tube to remove mucus and gastric secretions from the tube and to prevent aspiration of these secretions. The nurse should place the client in a sitting position to prevent the risk for aspiration. The nurse should identify that irrigating the NG tube before removal can put the client at risk for aspiration and should be avoided. A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have fecal impaction? - Correct answer-Small liquid stools Rationale: Small liquid stools can be the result of fecal material being expelled around an impaction. ------------------------ Halitosis, or bad breath, is associated with the ingestion of certain foods and medications, and it can also be an indication of infection. Hemorrhoids indicate that the client is straining when defecating. However, the presence of hemorrhoids does not indicate fecal impaction. Rebound tenderness is an indication of appendicitis. A client who has a fecal impaction can experience abdominal cramping and distention. A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? - Correct answer-Stop the medication infusion. Rationale: The greatest risk to the client is injury from an allergic response to the medication. Therefore, the first action the nurse should take is to stop the medication infusion. -------------------- The nurse should notify the charge nurse about what has occurred. However, there is another action the nurse should take first. The nurse should administer a PRN dose of diphenhydramine to keep the allergic reaction from worsening. However, there is another action the nurse should take first. The nurse should follow facility policy when reporting an adverse reaction. However, there is another action the nurse should take first. A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? - Correct answer-Combination oral contraceptives Rationale: The nurse should identify that combination oral contraceptives are contraindicated for this client because they increase estrogen levels, which can stimulate the growth of any remaining cancerous breast cells. --------------------------- The nurse should identify that the use of an intrauterine device requires the client to check the placement monthly and is not contraindicated for this client. The nurse should identify that the use of latex condoms is contraindicated for clients, or their partners, who are allergic to latex. However, it is not contraindicated for this client. The nurse should identify that prolonged use of a contraceptive sponge can increase the risk for toxic shock syndrome. However, it is not contraindicated for this client. A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? - Correct answer-Ventilate the client with 100% oxygen. Rationale: According to evidence-based practice, the first action the nurse should take is to ventilate the client with 100% oxygen before suctioning to prevent hypoxemia when removing air and debris from the upper airway. ------------------------------ The nurse should insert the catheter tip into the tracheostomy during inspiration until it meets resistance, then pull back 2.5 cm (1 in). However, evidence-based practice indicates that there is another action the nurse should take first. The nurse should rinse or flush the catheter with 0.9% sodium chloride to clear the catheter of secretions before repeating the suctioning procedure. However, evidencebased practice indicates that there is another action the nurse should take first. The nurse should occlude the vent on the catheter for 10 to 15 seconds while removing the catheter during suctioning. However, evidence-based practice indicates that there is another action the nurse should take first. A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse take? - Correct answer-"You feel like you want to discontinue treatment?" Rationale: The nurse is clarifying and acknowledging the client's feelings by establishing a trusting relationship. This question encourages the client to expand on their feelings. ------------------------- "Are you experiencing abdominal pain?