RN Adult Medical Surgical Online Practice 2023 B
1200: Client is sitting up in high-Fowler's position and appears anxious. Client reports shortness of breath
and severe chest pain as 9 on a scale of 0 to 10. Client states that they have started coughing and are
expectorating pink-tinged mucus.
Lung sounds with increased wheezing in left lung and clear on the right side. Equal chest expansion
noted. Neck veins flat. No peripheral edema observed.
Blood pressure 136/90 mm Hg
Respiratory rate 32/min
Temperature 38.7° C (101.6° F)
Heart rate 110/min
SaO2 90% on 3 L/min via nasal cannula
The client is most likely experiencing _________ and__________.
A. Pnuemonia
B. Pneumothorax
C. Fluid Volume Overload
D. Acute Chest Syndrome - (correct Answer) - Answer: The client is most likely experiencing PNEUMONIA
and ACUTE CHEST SYNDROME
D - The client is most likely experiencing acute chest syndrome, which can be caused by respiratory
infections and debris from sickled cells. The client is displaying manifestations of acute chest syndrome,
which include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain.
A - The client is most likely experiencing pneumonia as evidenced by the manifestations of cough,
shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain.
Rationale:
C - While the client is experiencing an increased respiratory rate and shortness of breath, fluid volume
overload typically includes moist crackles on auscultation, pitting edema in dependent areas, neck vein
distension, and hypertension.
,B - While the client is experiencing increased respiratory distress, a pneumothorax typically presents
with reduced or absent breath sounds and unequal chest expansion.
A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse
should give the AP which of the following instructions?
A. Wear a mask.
B. Wear a gown.
C. Keep the client's room well-lit.
D. Maintain the head of the bed at a 45° elevation. - (correct Answer) - Answer: A. Wear a mask
- Bacterial meningitis requires droplet precautions. Therefore, the AP and the nurse should wear a mask
when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic
therapy.
Rationale:
B - A gown is necessary when caring for clients who require contact precautions. Bacterial meningitis
does not spread via direct contact.
C - Staff caring for this client should keep the illumination in the room dim and avoid bright light from
windows to promote comfort and rest and avoid photophobia.
D - Staff caring for this client should keep the head of the bed at a 30° elevation
A nurse is providing discharge teaching about infection prevention to a client who is receiving
chemotherapy. Which of the following statements by the client indicates understanding of the teaching?
A. "I will avoid eating raw fruits and vegetables."
B. "I can ask a friend to change my cats litter box."
C. "I will use a mild soap when washing my genital area."
D. "I can sip on a glass of juice for at least 2 hours before I should discard it." - (correct Answer) - Answer:
B. "I can ask a friend to change my cats litter box."
- Changing a pet's litter box increases the client's risk of being exposed to toxoplasmosis. Therefore, the
client should wear gloves or avoid changing the pet's litter box.
Rationale:
,A - The nurse should instruct the client to wash raw fruits and vegetables thoroughly prior to eating
them, because uncleaned fruits and vegetables can contain micro-organisms and place the client at risk
for an infection.
C - The nurse should instruct the client to wash genital area twice a day with anti-microbial soap to
prevent bacterial and fungal infections.
D - The nurse should instruct the client to avoid drinking any liquids that have been out for more than 1
hr. Beverages left out for extended periods of time could expose the client to micro-organisms and place
them at risk for an infection.
A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the
priority assessment finding that the nurse should report to the provider?
A.Restlessness
B. T3 level 215 ng/dL (40 to 180 ng/dL)
C. Blood pressure 170/80 mm Hg
D. Decreased weight - (correct Answer) - Answer: C. Blood pressure 170/80 mm Hg
- Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority
finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid
storm.
Rationale:
A - Restlessness is nonurgent because it is an expected finding for a client who has hyperthyroidism.
Therefore, there is another finding that is the priority to report.
B - An elevated T3 level is nonurgent because it is an expected finding for a client who has
hyperthyroidism. Therefore, there is another finding that is the priority to report.
D - Decreased weight is nonurgent because it is an expected finding for a client who has
hyperthyroidism. Therefore, there is another finding that is the priority to report.
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the
following findings should the nurse identify as a manifestation of this condition?
A. Bounding pedal pulse
B. Capillary refill less than 2 seconds
C. Pain that increases with passive movement
, D. Areas of warmth on the cast - (correct Answer) - Answer: C. Pain that increases with passive
movement
- The nurse should identify that a client who has compartment syndrome experiences pain that increases
with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity
caused by a decrease in the muscle compartment size due to a cast that is too tight.
Rationale:
A - The nurse should expect a client who has compartment syndrome to have a diminished pulse or
pulselessness in the affected extremity due to lack of distal perfusion caused by a decrease in the muscle
compartment size.
B - The nurse should expect a client who has compartment syndrome to have capillary refill greater than
2 seconds in the affected extremity due to a lack of distal perfusion and venous congestion caused by a
decrease in the muscle compartment size.
D - A client who has a short leg cast can exhibit areas of warmth on the cast, which can indicate an
infection of the underlying tissue, not compartment syndrome.
Client presents with upper abdominal pain that radiates to the right shoulder. Client rates pain as 7/ 10.
Client also reports N/V and dyspepsia.
Client is A&O x3. Lung sounds clear B/L S1 and S2.
Aspartate aminotransferase (AST) 45 units/L (0 to 35 units/L)
ALT 39 international units/L (4 to 36 international units/L)
LDH 200 units/L (100 to 190 units/L)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
Potential Conditions:
- Cholecystitis
- Appendicitis
- Ulcerative colitis
- Peritonitis
Actions to Take:
- Maintain the client in semi-Fowler's position.
1200: Client is sitting up in high-Fowler's position and appears anxious. Client reports shortness of breath
and severe chest pain as 9 on a scale of 0 to 10. Client states that they have started coughing and are
expectorating pink-tinged mucus.
Lung sounds with increased wheezing in left lung and clear on the right side. Equal chest expansion
noted. Neck veins flat. No peripheral edema observed.
Blood pressure 136/90 mm Hg
Respiratory rate 32/min
Temperature 38.7° C (101.6° F)
Heart rate 110/min
SaO2 90% on 3 L/min via nasal cannula
The client is most likely experiencing _________ and__________.
A. Pnuemonia
B. Pneumothorax
C. Fluid Volume Overload
D. Acute Chest Syndrome - (correct Answer) - Answer: The client is most likely experiencing PNEUMONIA
and ACUTE CHEST SYNDROME
D - The client is most likely experiencing acute chest syndrome, which can be caused by respiratory
infections and debris from sickled cells. The client is displaying manifestations of acute chest syndrome,
which include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain.
A - The client is most likely experiencing pneumonia as evidenced by the manifestations of cough,
shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain.
Rationale:
C - While the client is experiencing an increased respiratory rate and shortness of breath, fluid volume
overload typically includes moist crackles on auscultation, pitting edema in dependent areas, neck vein
distension, and hypertension.
,B - While the client is experiencing increased respiratory distress, a pneumothorax typically presents
with reduced or absent breath sounds and unequal chest expansion.
A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse
should give the AP which of the following instructions?
A. Wear a mask.
B. Wear a gown.
C. Keep the client's room well-lit.
D. Maintain the head of the bed at a 45° elevation. - (correct Answer) - Answer: A. Wear a mask
- Bacterial meningitis requires droplet precautions. Therefore, the AP and the nurse should wear a mask
when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic
therapy.
Rationale:
B - A gown is necessary when caring for clients who require contact precautions. Bacterial meningitis
does not spread via direct contact.
C - Staff caring for this client should keep the illumination in the room dim and avoid bright light from
windows to promote comfort and rest and avoid photophobia.
D - Staff caring for this client should keep the head of the bed at a 30° elevation
A nurse is providing discharge teaching about infection prevention to a client who is receiving
chemotherapy. Which of the following statements by the client indicates understanding of the teaching?
A. "I will avoid eating raw fruits and vegetables."
B. "I can ask a friend to change my cats litter box."
C. "I will use a mild soap when washing my genital area."
D. "I can sip on a glass of juice for at least 2 hours before I should discard it." - (correct Answer) - Answer:
B. "I can ask a friend to change my cats litter box."
- Changing a pet's litter box increases the client's risk of being exposed to toxoplasmosis. Therefore, the
client should wear gloves or avoid changing the pet's litter box.
Rationale:
,A - The nurse should instruct the client to wash raw fruits and vegetables thoroughly prior to eating
them, because uncleaned fruits and vegetables can contain micro-organisms and place the client at risk
for an infection.
C - The nurse should instruct the client to wash genital area twice a day with anti-microbial soap to
prevent bacterial and fungal infections.
D - The nurse should instruct the client to avoid drinking any liquids that have been out for more than 1
hr. Beverages left out for extended periods of time could expose the client to micro-organisms and place
them at risk for an infection.
A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the
priority assessment finding that the nurse should report to the provider?
A.Restlessness
B. T3 level 215 ng/dL (40 to 180 ng/dL)
C. Blood pressure 170/80 mm Hg
D. Decreased weight - (correct Answer) - Answer: C. Blood pressure 170/80 mm Hg
- Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority
finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid
storm.
Rationale:
A - Restlessness is nonurgent because it is an expected finding for a client who has hyperthyroidism.
Therefore, there is another finding that is the priority to report.
B - An elevated T3 level is nonurgent because it is an expected finding for a client who has
hyperthyroidism. Therefore, there is another finding that is the priority to report.
D - Decreased weight is nonurgent because it is an expected finding for a client who has
hyperthyroidism. Therefore, there is another finding that is the priority to report.
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the
following findings should the nurse identify as a manifestation of this condition?
A. Bounding pedal pulse
B. Capillary refill less than 2 seconds
C. Pain that increases with passive movement
, D. Areas of warmth on the cast - (correct Answer) - Answer: C. Pain that increases with passive
movement
- The nurse should identify that a client who has compartment syndrome experiences pain that increases
with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity
caused by a decrease in the muscle compartment size due to a cast that is too tight.
Rationale:
A - The nurse should expect a client who has compartment syndrome to have a diminished pulse or
pulselessness in the affected extremity due to lack of distal perfusion caused by a decrease in the muscle
compartment size.
B - The nurse should expect a client who has compartment syndrome to have capillary refill greater than
2 seconds in the affected extremity due to a lack of distal perfusion and venous congestion caused by a
decrease in the muscle compartment size.
D - A client who has a short leg cast can exhibit areas of warmth on the cast, which can indicate an
infection of the underlying tissue, not compartment syndrome.
Client presents with upper abdominal pain that radiates to the right shoulder. Client rates pain as 7/ 10.
Client also reports N/V and dyspepsia.
Client is A&O x3. Lung sounds clear B/L S1 and S2.
Aspartate aminotransferase (AST) 45 units/L (0 to 35 units/L)
ALT 39 international units/L (4 to 36 international units/L)
LDH 200 units/L (100 to 190 units/L)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
Potential Conditions:
- Cholecystitis
- Appendicitis
- Ulcerative colitis
- Peritonitis
Actions to Take:
- Maintain the client in semi-Fowler's position.
