RN Adult Medical Surgical Proctored Assessment Q&A

1 latex allergy: A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? Avocados. Rationale: Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity. shellfish allergy = allergic reaction to povidone-iodine. peanut allergy = allergic reaction to propofol. egg allergy = allergic reaction to propofol. A nurse is performing a preoperative assessment of a client about to undergo a cholecystectomy. the nurse should identify a risk for a latex allergy when the client reports an allergy to? Bananas #2 Cancer treatment options: safety precautions for a client who has a sealed radiation implant A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care? wear a lead apron while providing care to the client. The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure. A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? Keep a lead-lined container in the client's room. #3: A nurse is caring for a client who will receive brachytherapy to treat uterine cancer. The nurse should ensure the client understands that she will receive which of the following interventions? A. Radioactive infusion or insertions into or near the tumor ANS: brachytherapy is a type of radiation therapy during which the radiation source, either an implant of via infusion, is in direct contact with the clients tumor continuously for a specific duration A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include? You will need to stay still in bed during each treatment session." Rationale: The nurse should instruct the client that they will need to remain on bed rest with very limited movement because excessive movement can cause the radioactive source to become dislodged. The nurse should instruct the client that there is not excreted radiation between treatments. The nurse should instruct the client that there will likely be between two and five treatments, once or twice each week. The nurse should instruct the client that blood in the urine is an adverse effect of brachytherapy and is not an expected finding. #4 Infection control: precautions for a client who has positive culture for an infection A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? Bathe the client using chlorhexidine solution. # 5 Verapamil drug: A nurse is providing teaching for the Drug Verapamil. Which of the following information should the nurse include in the teaching? Increase fiber intake to avoid constipation A nurse is providing discharge teaching to a client who has angina pectoris and a new prescription for verapamil. The client tells the nurse, "my brother takes verapamil for high blood pressure. Do you think the provider made a mistake?" Which of the following responses should the nurse make? A. Verapamil is used to treat both high blood pressure and angina." ANS: A: Verapamil is a calcium channel blocker that is used for both hypertension and anginal pain because of its ability to dilate arteries and decrease afterload #5 Mannitol 1. A nurse is assessing a client who has increased intracranial pressure and has received IV Mannitol. Which of the following findings indicates a therapeutic effect of this medication? A. Increased urine output. ANS: Increased urine output. Mannitol is an osmotic diuretic used to reduce intracranial pressure by mobilizing fluids 2. A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure. Which of the following findings indicates that the medication is having a therapeutic effect? A. the client's serum osmolarity is 310 mOsm/L Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. This serum osmolarity is desired 3. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? Crackles heard on auscultation #6: interventions for a transfusion reaction: 1. a nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of RBCs. Which of the following interventions should the nurse use to prevent these manifestations with the clients next transfusion? Use a transfusion pump to regulate and maintain the transfusion at a slower rate ANS Rational: These are the manifestations of a hypervolemic reaction due to circulatory overload. To prevent this problem with future transfusions, the nurse should use a transfusion pump to regulate the transfusion 2. a nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is 0-negative. Which of the following actions should the nurse take? B. remove the unit of plasma immediately and start an IV infusion of NS ANS Rational: a client who receives FFP that is not compatible can experience a hemolytic transfusion reaction 3. A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? Slow the infusion rate Rationale: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload. #8: Steps for administering a blood product: 1. A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed RBCs, which of the following actions should the nurse take? SATA