PN ADULT MEDICAL SURGICAL ONLINE PRACTICE 2024 A WITH NGN(FULLY SOLVED).

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. r-Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis. A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? Avoid bending your hips more than 90 degrees. ( to prevent dislocation of the replacement hip). - Nurse should instruct client to wait 90 days before crossing legs. Crossing legs early int heh postoperative period can result in dislocation of the replacement hip. -Nurse should inform the client that she ay lie on her operative side with a pillow between her legs. This will not injure the suture site or cause dislocation of the replacement hip. - Nurse should instruct the client to sleep on a firm mattress to avoid potential dislocation of the replacement hip. 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? Remind the client to avoid watching their feet when walking. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? Initiate oxygen at 4L/min via nasal cannula. Rationale: The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect them from acquiring pneumonia. --------------------------- The nurse should collect a sputum culture to identify the organism causing the client's infection. Antimicrobial sensitivities are obtained from the sputum culture to guide the provider in prescribing antibiotics. However, there is another prescription the nurse should implement first. The nurse should administer antibiotics to treat the infection. A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is suspected because it treats both gram-positive and gram-negative bacteria. After the results of the blood and sputum cultures are obtained, the provider will often change to a more specific antibiotic. However, there is another prescription the nurse should implement first. The nurse should obtain blood cultures to identify the organism causing the client's infection. Antimicrobial sensitivities obtained from the blood cultures will guide the provider in prescribing treatment. However, there is another prescription the nurse should implement first. 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? 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 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? 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 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 procedure? Creatinine 1.9 mg/dL Normal range is 0.7 to 1.3 Therefore the it's high and should be reported the the provider A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) Ceftriaxone In exhibit 2 it says the patient is allergies: "penicillin reaction severe". A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? Visitors must don a gown and gloves before entering client's room. ( This patient will be on a client on contact isolation precautions. Contact precautions requires visitors to put on a gown and gloves prior to entering the client's room to prevent MRSA from spreading) - Nurse should identify visitors of clients who are on airborne or droplet precautions should wear a mask within 3 feet of the client. -MRSA does not spread through the respiratory tract and does not need airborne or droplet precaution. -NO FRESH FLOWERS for patient on neutropenic precaution . A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? Dysrhythmia RAT: When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia. 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? Keep a sheepskin pad between the client's extremity and the CPM machine. A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan? Encourage abdominal breathing. r- the nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes. A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching? Avoid eating red meat for 3 days prior to the test. A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? "You should have a pneumococcal immunizations every 10 years." A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an IN of 4. Available is phytonadione 10 mg/mL. How many ml should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.7 A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? "I don't cross my legs anymore." RAT: Clients who have peripheral vascular disease should not cross their legs because it can impede circulation. A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? Change the sheepskin liner weekly. Rationale: The nurse should provide instruction regarding the care and maintenance of the vest. The instruction should include changing the sheepskin liner either when soiled or at least once per week to prevent skin irritation. -------------------- The nurse should instruct the caregiver to clean the pin sites every day to decrease the risk for infection. The nurse should instruct the caregiver to never lift or reposition the client by pulling on the halo ring, which can cause further cervical injury. The nurse should instruct the caregiver to call a provider if the pins or traction bar is loose. The pin sites or traction bar supports should not be manipulated in any way because it could cause injury to the client. A nurse is caring 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? Perform pin site care daily. Rationale: 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. --------------------------- The nurse should ensure the client has an overbed trapeze to aid in lifting the upper body off the bed when necessary and to help prevent skin breakdown of the heels and elbows with client repositioning. The nurse should identify that balanced suspension skeletal traction is managed through the use of pins, pulleys, weights, and frames and that the client does not wear a boot. The nurse should ensure the weights hang freely at all times. A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? "Limit contact with large groups of people." Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people. 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. Client Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Hypovolemia Insert a large gauge IV Initiate a fluid challenge Urine output blood pressure A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? Give the client liquids with increased viscosity. *Correct: Thickened liquids are easier for the client to swallow and can prevent aspiration. Wrong: Provide small, frequent meals: Providing small, frequent meals can improve the client's nutritional intake, but it does not decrease the risk for aspiration. Wrong: Tell the client to extend his neck when swallowing. The client should tilt his neck forward while swallowing to decrease the risk for aspiration. Wrong: Provide mouth care before meals. Mouth care can enhance the client's sense of taste, but it does not decrease the risk for aspiration. 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? 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 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. r- 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 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 client in a side-lying position. RAT: 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 reinforcing teaching about joint protection with a client 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 inamed joints. A nurse is caring for a client who is scheduled 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. r-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 is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? Dyspnea r-When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is dyspnea, which is a complication of the epidural infusion. Drag words from the choices below to fill in each blank in the following sentence. Respiratory failure and hypovolemia A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? I understand that testicular cancer is painless. ( Clients should report a lump that is NOT painful bc testicular cancer is typically painless). - Perform a testicular self examination after a WARM shower - Perform testicular self exam MONTHLY - Clients should report pea- sized lump in the testes to the provider. 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. A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? Minimize the time the head of the bed is elevated. r-The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area. A nurse is reinforcing teaching about home care with a client who had a 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.