NGN-QUESTION PN ADULT
MEDICAL SURGICAL 2024
WITH NGN AND PN ADULT
MEDICAL SURGICAL 2024
EXAM PLUS PRACTICE
EXAM
A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the
following findings should the nurse identify as a risk factor for falls?
a) Instructs the client to wear their own socks to
the bathroom
b) Keeps the client's bed in the low position
c) Positions the bedside table close to the client
d) Attaches the call light to the side rail of the
client's bed A. Instructs the client to wear their own socks to the
bathroom
Rationale:
Bathroom floor can be slippery -> If wearing socks -> patient might slip (increased risk for falls)
,Option B patient will not likely be injured if fall occurs since bed is close to floor due to its low position
and patient does not have to step far off from bed to stand up -> decreasing risk for falls.
Option C patient does not need to get up to get things from bedside table, decreasing risk for falls.
Option D since call light is close to patient, little mobility is needed, decreasing risk for falls.
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is
agitated. Which of the following interventions should the nurse implement?
a) Encourage the client to ambulate with a staff member.
b) Isolate the client in their room.
c) Apply bilateral wrist restraints to the client.
d) Administer a prescribed oral dose of trazodone to the client. A. Encourage the client to ambulate
with a staff
member.
A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of
the following actions should the nurse take?
A. Alternate the client's daily routine
B. Keep the lights dimmed.
C. Raise the four side rails on the client's bed.
D. Participate in reminiscence therapy with the client. D. Participate in reminiscence therapy with the
client.
A nurse is assisting a provider with removing a client's lower-leg cast. Which of the following statements
by the nurse is appropriate?
a. "You can expect your leg muscles to look a little swollen."
b. "You should avoid elevating your leg while sitting."
,c. "You should hold still to prevent injury to your skin."
d. "You can expect to feel pressure when we cut the cast." d. "You can expect to feel pressure
when we cut the cast."
A nurse is assisting care of a client whose cardiac monitor suddenly displays ventricular tachycardia.
Which of the following is the priority nursing action?
a) Determine palpable pulse.
b) Begin chest compressions.
c) Perform immediate defibrillation.
d) Provide pulmonary ventilation. A. Determine palpable pulse.
Rationale:
Assess first to know what the cause of ventricular tachycardia was. Can't start doing intervention without
knowing the cause.
A nurse is assisting in teaching a group of nurses about pain management for older adult clients. Which
of the following information should the nurse include in the teaching?
-Use nonpharmacological measures as a substitute for pain medication.
-Withhold pain medication until the client reports a pain level of 6 or higher on a scale from 0 to 10.
-Reassess the effectiveness of the pain relief measures every 3 hr.
-Recognize that a cognitively impaired older adult client can Identify the intensity of pain. -Use
nonpharmacological measures as a substitute for pain medication.
A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following
actions should the nurse include in the plan?
A. Initiate protective isolation for the client.
B. Administer Ibuprofen for mild headache.
, C. Check the client for ecchymosis.
D. Instruct the client to shave with a disposable razor. C. Check the client for ecchymosis.
Rationale:
Thrombocytopenia is a medical condition characterized by low levels of platelets in the blood. It can
cause nosebleeds, bleeding gums, blood in urine, heavy menstrual periods, and bruising. The priority
goals of nursing care for a client with thrombocytopenia include prevention and early detection of
bleeding, as well as intervening when bleeding occurs.
Therefore, the nurse should include checking the client for ecchymosis in the plan of care. Ecchymosis is
a medical term for a bruise, which is a common symptom of thrombocytopenia. The nurse should also
instruct the client to avoid activities that may cause injury or bleeding, such as shaving with a disposable
razor. Administering Ibuprofen for mild headache is not recommended as it can thin the blood and
increase the risk of bleeding. Initiating protective isolation for the client is not necessary as
thrombocytopenia is not contagious.
A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home.
The nurse should ensure that which ofthe following equipment is available for use at home?
A. Yankauer catheter
B. Sterile gloves
C. Oropharyngeal airway
D. Water-soluble lubricant A. Yankauer catheter
A nurse is assisting with the admission assessment of a client who has late-stage emphysema. The nurse
should recognize which of the following as an expected finding?
A. Slow, deep respirations
B. Flushed facial skin
C. Elevated body mass index
D. Clubbing of the fingernails D. Clubbing of the fingernails
MEDICAL SURGICAL 2024
WITH NGN AND PN ADULT
MEDICAL SURGICAL 2024
EXAM PLUS PRACTICE
EXAM
A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the
following findings should the nurse identify as a risk factor for falls?
a) Instructs the client to wear their own socks to
the bathroom
b) Keeps the client's bed in the low position
c) Positions the bedside table close to the client
d) Attaches the call light to the side rail of the
client's bed A. Instructs the client to wear their own socks to the
bathroom
Rationale:
Bathroom floor can be slippery -> If wearing socks -> patient might slip (increased risk for falls)
,Option B patient will not likely be injured if fall occurs since bed is close to floor due to its low position
and patient does not have to step far off from bed to stand up -> decreasing risk for falls.
Option C patient does not need to get up to get things from bedside table, decreasing risk for falls.
Option D since call light is close to patient, little mobility is needed, decreasing risk for falls.
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is
agitated. Which of the following interventions should the nurse implement?
a) Encourage the client to ambulate with a staff member.
b) Isolate the client in their room.
c) Apply bilateral wrist restraints to the client.
d) Administer a prescribed oral dose of trazodone to the client. A. Encourage the client to ambulate
with a staff
member.
A nurse in a long-term care unit is assisting in the care of a client who has Alzheimer's disease. Which of
the following actions should the nurse take?
A. Alternate the client's daily routine
B. Keep the lights dimmed.
C. Raise the four side rails on the client's bed.
D. Participate in reminiscence therapy with the client. D. Participate in reminiscence therapy with the
client.
A nurse is assisting a provider with removing a client's lower-leg cast. Which of the following statements
by the nurse is appropriate?
a. "You can expect your leg muscles to look a little swollen."
b. "You should avoid elevating your leg while sitting."
,c. "You should hold still to prevent injury to your skin."
d. "You can expect to feel pressure when we cut the cast." d. "You can expect to feel pressure
when we cut the cast."
A nurse is assisting care of a client whose cardiac monitor suddenly displays ventricular tachycardia.
Which of the following is the priority nursing action?
a) Determine palpable pulse.
b) Begin chest compressions.
c) Perform immediate defibrillation.
d) Provide pulmonary ventilation. A. Determine palpable pulse.
Rationale:
Assess first to know what the cause of ventricular tachycardia was. Can't start doing intervention without
knowing the cause.
A nurse is assisting in teaching a group of nurses about pain management for older adult clients. Which
of the following information should the nurse include in the teaching?
-Use nonpharmacological measures as a substitute for pain medication.
-Withhold pain medication until the client reports a pain level of 6 or higher on a scale from 0 to 10.
-Reassess the effectiveness of the pain relief measures every 3 hr.
-Recognize that a cognitively impaired older adult client can Identify the intensity of pain. -Use
nonpharmacological measures as a substitute for pain medication.
A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following
actions should the nurse include in the plan?
A. Initiate protective isolation for the client.
B. Administer Ibuprofen for mild headache.
, C. Check the client for ecchymosis.
D. Instruct the client to shave with a disposable razor. C. Check the client for ecchymosis.
Rationale:
Thrombocytopenia is a medical condition characterized by low levels of platelets in the blood. It can
cause nosebleeds, bleeding gums, blood in urine, heavy menstrual periods, and bruising. The priority
goals of nursing care for a client with thrombocytopenia include prevention and early detection of
bleeding, as well as intervening when bleeding occurs.
Therefore, the nurse should include checking the client for ecchymosis in the plan of care. Ecchymosis is
a medical term for a bruise, which is a common symptom of thrombocytopenia. The nurse should also
instruct the client to avoid activities that may cause injury or bleeding, such as shaving with a disposable
razor. Administering Ibuprofen for mild headache is not recommended as it can thin the blood and
increase the risk of bleeding. Initiating protective isolation for the client is not necessary as
thrombocytopenia is not contagious.
A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home.
The nurse should ensure that which ofthe following equipment is available for use at home?
A. Yankauer catheter
B. Sterile gloves
C. Oropharyngeal airway
D. Water-soluble lubricant A. Yankauer catheter
A nurse is assisting with the admission assessment of a client who has late-stage emphysema. The nurse
should recognize which of the following as an expected finding?
A. Slow, deep respirations
B. Flushed facial skin
C. Elevated body mass index
D. Clubbing of the fingernails D. Clubbing of the fingernails
