PN ADULT MEDICAL SURGICAL NGN 2024-2025 TEST
BANK ACTUAL EXAM 250 REAL EXAM QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. Which of the following
findings should the nurse identify as an indication that the client should receive diphenhydramine? a)
Pulmonary congestion
b) Urticaria
c) Vomiting
d) Jugular vein distention - ANSWER-B. Urticaria
Rationale:
Acute hypersensitivity reaction following blood transfusion includes symptoms of localized pruritus and
urticaria unrelated to infusion site. Diphenhydramine is an antihistamine use to treat hypersensitivity or
allergic reaction.
TEST
A nurse is caring for a client who is expecting a generalized tonic-clonic seizure. Which of the following
actions should the nurse take?
a) Apply restraints to the client.
b) Insert a tongue blade into the client's mouth.
c) Administer an IV bolus of lorazepam.
d) Place the client in the prone position. - ANSWER-c) Administer an IV bolus of lorazepam
Rationale:
Administering an IV bolus of lorazepam is the appropriate action for a patient who is expecting a
generalized tonic-clonic seizure, as it can help prevent or reduce the severity of the seizure.
TEST
A nurse is prioritizing care for four clients following a change-of-shift report. Which of the following
clients should the nurse attend to first?
a) A client who has diverticulitis and a
,temperature of 38.3C (100.9F)
b) A client who has a prescription for a sputum
specimen to be obtained before breakfast
c) A client who sustained a head injury 2 days ago and
has a decreased level of consciousness
d) A client who has Alzheimer's disease and
requires assistance to the bathroom - ANSWER-C. A client who sustained a head injury 2 days ago and
has a decreased level of consciousness.
Rationale:
The decrease level of consciousness needs immediate action and monitoring. This could lead to deficit
level of brain functioning that may lead to shock thus needing intensive care. Having a febrile client as
what option 1 presents also needs attention however fever is also included in the symptoms of
infected/inflamed diverticula. Though significant but the value given is manageable range.
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. - ANSWER-D. Participate in reminiscence therapy
with the client.
TEST
A nurse is reinforcing teaching with a client who is taking oxybutynin. The nurse should tell the client that
the medication will have which of the following effects?
a) Relaxes the muscles of the bladder
b) Increases venous return to the heart
c) Relaxes the muscles of the colon
d) Increases tissue perfusion in the lungs - ANSWER-A. Relaxes the muscles of the bladder.
Rationale:
Oxybutynin relaxes the bladder muscles to decrease the urge of constant urination.
,Option B does not increase or promote venous return.
Option C the bladder is the target organ not the colon.
Option D not associated with increased blood flow and perfusion to lungs.
TEST
A nurse is reviewing the laboratory report of a client who has cancer and is experiencing anorexia. Which
of the following laboratory values should indicate to the nurse that the client is experiencing
malnutrition?
a) Prealbumin 10.5 mg/dL
b) Hematocrit 45%
c) WBC count 6,000/mm3
d) BUN 15 mg/dL - ANSWER-A. Prealbumin 10.5 mg/dL
Rationale:
Prealbumin normal range is 15-36mg/dL. Prealbumin helps in the thyroid hormone and Vitamin A
circulation in our bloodstream. It also helps in regulation of how the body uses energy. Below normal
prealbumin is indicative of malnutrition.
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 - ANSWER-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. - ANSWER-A. Encourage the client to
ambulate with a staff
member.
A nurse is reinforcing teaching with a client who is to begin taking lansoprazole. Which of the following
statements by the client indicates an understanding of the teaching?
a) "I should chew the capsule thoroughly."
b) "I should report episodes of diarrhea."
c) "I should take the medication following a meal."
d) "I should expect the medication to cause indigestion." - ANSWER-B. "I should report episodes of
diarrhea."
An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who
received the test 48 hrs ago. Which of the following clients should the nurse identify as having a positive
test result?
a) A client whose injection site has an elevated area measuring 15 mm (0.6 in)
b) A client who injection site is scabbed
c) A client whose injection site is firm and measures 3 mm (0.1 in)
d) A client whose injection site is ecchymotic - ANSWER-A. A client whose injection site has an elevated
area measuring 15 mm (0.6 in)
Rationale:
Tuberculin skin test also known as Mantoux test yields positive result if there is an induration of equal or
more than 10mm at the injection site after 48 hrs and after 72 hrs. This can interpret as the patient is
expose to Mycobacterium Tuberculosis bacteria.
BANK ACTUAL EXAM 250 REAL EXAM QUESTIONS
AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. Which of the following
findings should the nurse identify as an indication that the client should receive diphenhydramine? a)
Pulmonary congestion
b) Urticaria
c) Vomiting
d) Jugular vein distention - ANSWER-B. Urticaria
Rationale:
Acute hypersensitivity reaction following blood transfusion includes symptoms of localized pruritus and
urticaria unrelated to infusion site. Diphenhydramine is an antihistamine use to treat hypersensitivity or
allergic reaction.
TEST
A nurse is caring for a client who is expecting a generalized tonic-clonic seizure. Which of the following
actions should the nurse take?
a) Apply restraints to the client.
b) Insert a tongue blade into the client's mouth.
c) Administer an IV bolus of lorazepam.
d) Place the client in the prone position. - ANSWER-c) Administer an IV bolus of lorazepam
Rationale:
Administering an IV bolus of lorazepam is the appropriate action for a patient who is expecting a
generalized tonic-clonic seizure, as it can help prevent or reduce the severity of the seizure.
TEST
A nurse is prioritizing care for four clients following a change-of-shift report. Which of the following
clients should the nurse attend to first?
a) A client who has diverticulitis and a
,temperature of 38.3C (100.9F)
b) A client who has a prescription for a sputum
specimen to be obtained before breakfast
c) A client who sustained a head injury 2 days ago and
has a decreased level of consciousness
d) A client who has Alzheimer's disease and
requires assistance to the bathroom - ANSWER-C. A client who sustained a head injury 2 days ago and
has a decreased level of consciousness.
Rationale:
The decrease level of consciousness needs immediate action and monitoring. This could lead to deficit
level of brain functioning that may lead to shock thus needing intensive care. Having a febrile client as
what option 1 presents also needs attention however fever is also included in the symptoms of
infected/inflamed diverticula. Though significant but the value given is manageable range.
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. - ANSWER-D. Participate in reminiscence therapy
with the client.
TEST
A nurse is reinforcing teaching with a client who is taking oxybutynin. The nurse should tell the client that
the medication will have which of the following effects?
a) Relaxes the muscles of the bladder
b) Increases venous return to the heart
c) Relaxes the muscles of the colon
d) Increases tissue perfusion in the lungs - ANSWER-A. Relaxes the muscles of the bladder.
Rationale:
Oxybutynin relaxes the bladder muscles to decrease the urge of constant urination.
,Option B does not increase or promote venous return.
Option C the bladder is the target organ not the colon.
Option D not associated with increased blood flow and perfusion to lungs.
TEST
A nurse is reviewing the laboratory report of a client who has cancer and is experiencing anorexia. Which
of the following laboratory values should indicate to the nurse that the client is experiencing
malnutrition?
a) Prealbumin 10.5 mg/dL
b) Hematocrit 45%
c) WBC count 6,000/mm3
d) BUN 15 mg/dL - ANSWER-A. Prealbumin 10.5 mg/dL
Rationale:
Prealbumin normal range is 15-36mg/dL. Prealbumin helps in the thyroid hormone and Vitamin A
circulation in our bloodstream. It also helps in regulation of how the body uses energy. Below normal
prealbumin is indicative of malnutrition.
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 - ANSWER-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. - ANSWER-A. Encourage the client to
ambulate with a staff
member.
A nurse is reinforcing teaching with a client who is to begin taking lansoprazole. Which of the following
statements by the client indicates an understanding of the teaching?
a) "I should chew the capsule thoroughly."
b) "I should report episodes of diarrhea."
c) "I should take the medication following a meal."
d) "I should expect the medication to cause indigestion." - ANSWER-B. "I should report episodes of
diarrhea."
An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who
received the test 48 hrs ago. Which of the following clients should the nurse identify as having a positive
test result?
a) A client whose injection site has an elevated area measuring 15 mm (0.6 in)
b) A client who injection site is scabbed
c) A client whose injection site is firm and measures 3 mm (0.1 in)
d) A client whose injection site is ecchymotic - ANSWER-A. A client whose injection site has an elevated
area measuring 15 mm (0.6 in)
Rationale:
Tuberculin skin test also known as Mantoux test yields positive result if there is an induration of equal or
more than 10mm at the injection site after 48 hrs and after 72 hrs. This can interpret as the patient is
expose to Mycobacterium Tuberculosis bacteria.
