PN Medical Surgical Practice 2020 Questions With Well Explained Rationale 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? - 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? - 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? - 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? - 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? - 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? - 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? - 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? - 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? - 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? - 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? - 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? - 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? - Hyperactive 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? - 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? - 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? - 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? - 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? - Have a designated stethoscope in the client's room. Rationale: The nurse should designate equipment to leave in the client's room to avoid cross-contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room.