RN Adult Medical Surgical Practice 2024
A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after
hospitalization for heart failure. Based on the information in the client's chart, which of the
following findings should the nurse report to the provider? (Click on the "Exhibit" button for
additional information about the client. There are three tabs that contain separate categories of
data.) - ANS Heart rate 55/min
Rational:The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and
it can indicate the development of digoxin toxicity. The nurse should report this finding to the
provider.
Note
Here the nurse should ensure the clients SA O@ level remains at or above 90%. This finding is
within the expected range.
Nurse should report weight gain of 3lb in a day or 2.3 kg or more in a week.
A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS)
for the management of bone cancer pain. The nurse should explain that applying a TENS unit to
the painful area has which of the following effects? - ANS A tingling sensation replacing the
pain
Rational:A TENS unit applies small electric currents to the painful area, with the client
increasing the current until the "pins and needles" sensation overrides the pain.
Note: A TENS unit does not create heat when applied to a painful area. Warm compresses,
heating pads and paraffin dips are examples of modalities that apply heat to painful areas.
It does NOT use cryotherapy or cold treatment.
Acupuncture is a therapy that works via the insertion of fine needles to help unblock any
obstructed flow of energy in other parts of the body. It does not clear obstruction in energy flow.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following
findings should the nurse identify as a component of Cushing's triad? - ANS Bradycardia
Rational: A client who has increased intracranial pressure from a traumatic brain injury can
develop bradycardia, which is one component of Cushing's triad. The other components of
Cushing's triad are severe hypertension and a widened pulse pressure.
Note Increased ICP from TBI can develop HYPERtension.
TBI can develop decreased cerebral blood flow, which results in increased arterial pressure.
A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after
hospitalization for heart failure. Based on the information in the client's chart, which of the
following findings should the nurse report to the provider? (Click on the "Exhibit" button for
additional information about the client. There are three tabs that contain separate categories of
data.) - ANS Heart rate 55/min
Rational:The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and
it can indicate the development of digoxin toxicity. The nurse should report this finding to the
provider.
Note
Here the nurse should ensure the clients SA O@ level remains at or above 90%. This finding is
within the expected range.
Nurse should report weight gain of 3lb in a day or 2.3 kg or more in a week.
A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS)
for the management of bone cancer pain. The nurse should explain that applying a TENS unit to
the painful area has which of the following effects? - ANS A tingling sensation replacing the
pain
Rational:A TENS unit applies small electric currents to the painful area, with the client
increasing the current until the "pins and needles" sensation overrides the pain.
Note: A TENS unit does not create heat when applied to a painful area. Warm compresses,
heating pads and paraffin dips are examples of modalities that apply heat to painful areas.
It does NOT use cryotherapy or cold treatment.
Acupuncture is a therapy that works via the insertion of fine needles to help unblock any
obstructed flow of energy in other parts of the body. It does not clear obstruction in energy flow.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following
findings should the nurse identify as a component of Cushing's triad? - ANS Bradycardia
Rational: A client who has increased intracranial pressure from a traumatic brain injury can
develop bradycardia, which is one component of Cushing's triad. The other components of
Cushing's triad are severe hypertension and a widened pulse pressure.
Note Increased ICP from TBI can develop HYPERtension.
TBI can develop decreased cerebral blood flow, which results in increased arterial pressure.
