RN Adult Medical Surgical Online Practice
202 A NGN
Client admitted to medical-surgical unit from PACU.
• Client reports incisional pain as 2/10
• Specify what condition pt is most likely experiencing,
• Select two actions nurse should take to address that condition,
• Two parameters the nurse should monitor to assess the client's progress.
Potential Condition: Hypovolemia
Actions to take:
• Insert a large-gauge IV.
• Initiate a fluid challenge.
Parameters to Monitor
• Urine output
• Blood pressure
Because the client is most likely experiencing hypovolemia as evidenced by the client's
restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased
urine output.
The nurse should monitor the client's urine output and blood pressure to evaluate the
effectiveness of treatment.
Pt A&O, reports not feeling well for a few days. On continuous ambulatory peritoneal dialysis
(CAPD). Reports dialysate cloudy this morning.
Abd pain 4/10. Bowel sounds active x4. Peritoneal dialysis access site red, warm to touch, w/
small amount of purulent drainage noted on dressing.
1300: Client lying in bed w/ knees flexed, guarding abd.
Abd slightly distended, hypoactive bowel sounds. Pt reports nausea, pain as 6/10. Provider
notified and updated with client condition and diagnostic results.
,Select the condition and confirmation
The client is experiencing manifestations of Peritonitis.
such as abdominal pain, cloudy dialysate, and an elevated white blood cell count.
X-ray results : The client’s abdominal x-ray shows fluid in the abdomen along with inflammation,
both of which are indications of peritonitis.
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A nurse is caring for a client who has a potassium level of 3 mEq/L.
(3.5-5 mEq/L) Which of the following assessment findings should the nurse expect?
Hypoactive Bowel Sounds Hypokalemia decreases smooth muscle contraction in the
gastrointestinal tract leading to decreased peristal
0900: Pt presents w/ LUQ abd pain for past 2 days. States pain became worse this AM,
radiating to back. Pain rated 8/10.
Hypoactive bowel sounds; nausea, no vomiting; passing flatus.
Febrile, A&Ox3. Tachypnea w/ diminished breath sounds. Sinus tachycardia.
Client voids 300 mL of clear, amber urine.
0930: Client vomited 100 mL brown liquid.
Select condition and confirmation
, Pt experiencing manifestations of pancreatitis
as evidenced by the amylase and lipase.
Lab results and physical assessment indicate the client is experiencing manifestations of
pancreatitis. Pts w/ pancreatitis experience an increase in pancreatic enzymes, amylase, and
lipase.
0530: Pt awake & alert.
Arteriovenous fistula (AVF) to R FA w/ thrill palpated, auscultated for bruit. Lung sounds clear
upon auscultation; client denies SOB. No peripheral edema noted; capillary refill < 3 sec; +2
bilateral pedal, radial pulses.
AVF access prepared and cannulated twice w/ no difficulty.
Lines taped and secured; treatment initiated.
0600: Client reading a book. Access visible, lines are secure. Reports no discomfort or pain.
0630: Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly
confused.
Select if the interventions are indicated/not indicated
• Trendelenburg Position
• 0.9 NaCl 200 mL IV bolus
• Notify Provider immediately
• Perform a 12-lead ECG
• Obtain BGM
Place the client in Trendelenburg position is indicated. The client should be placed in the
Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ
perfusion.
202 A NGN
Client admitted to medical-surgical unit from PACU.
• Client reports incisional pain as 2/10
• Specify what condition pt is most likely experiencing,
• Select two actions nurse should take to address that condition,
• Two parameters the nurse should monitor to assess the client's progress.
Potential Condition: Hypovolemia
Actions to take:
• Insert a large-gauge IV.
• Initiate a fluid challenge.
Parameters to Monitor
• Urine output
• Blood pressure
Because the client is most likely experiencing hypovolemia as evidenced by the client's
restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased
urine output.
The nurse should monitor the client's urine output and blood pressure to evaluate the
effectiveness of treatment.
Pt A&O, reports not feeling well for a few days. On continuous ambulatory peritoneal dialysis
(CAPD). Reports dialysate cloudy this morning.
Abd pain 4/10. Bowel sounds active x4. Peritoneal dialysis access site red, warm to touch, w/
small amount of purulent drainage noted on dressing.
1300: Client lying in bed w/ knees flexed, guarding abd.
Abd slightly distended, hypoactive bowel sounds. Pt reports nausea, pain as 6/10. Provider
notified and updated with client condition and diagnostic results.
,Select the condition and confirmation
The client is experiencing manifestations of Peritonitis.
such as abdominal pain, cloudy dialysate, and an elevated white blood cell count.
X-ray results : The client’s abdominal x-ray shows fluid in the abdomen along with inflammation,
both of which are indications of peritonitis.
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:15
Full screen
Brainpower
Read More
A nurse is caring for a client who has a potassium level of 3 mEq/L.
(3.5-5 mEq/L) Which of the following assessment findings should the nurse expect?
Hypoactive Bowel Sounds Hypokalemia decreases smooth muscle contraction in the
gastrointestinal tract leading to decreased peristal
0900: Pt presents w/ LUQ abd pain for past 2 days. States pain became worse this AM,
radiating to back. Pain rated 8/10.
Hypoactive bowel sounds; nausea, no vomiting; passing flatus.
Febrile, A&Ox3. Tachypnea w/ diminished breath sounds. Sinus tachycardia.
Client voids 300 mL of clear, amber urine.
0930: Client vomited 100 mL brown liquid.
Select condition and confirmation
, Pt experiencing manifestations of pancreatitis
as evidenced by the amylase and lipase.
Lab results and physical assessment indicate the client is experiencing manifestations of
pancreatitis. Pts w/ pancreatitis experience an increase in pancreatic enzymes, amylase, and
lipase.
0530: Pt awake & alert.
Arteriovenous fistula (AVF) to R FA w/ thrill palpated, auscultated for bruit. Lung sounds clear
upon auscultation; client denies SOB. No peripheral edema noted; capillary refill < 3 sec; +2
bilateral pedal, radial pulses.
AVF access prepared and cannulated twice w/ no difficulty.
Lines taped and secured; treatment initiated.
0600: Client reading a book. Access visible, lines are secure. Reports no discomfort or pain.
0630: Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly
confused.
Select if the interventions are indicated/not indicated
• Trendelenburg Position
• 0.9 NaCl 200 mL IV bolus
• Notify Provider immediately
• Perform a 12-lead ECG
• Obtain BGM
Place the client in Trendelenburg position is indicated. The client should be placed in the
Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ
perfusion.
