PN ADULT MEDICAL SURGICAL ONLINE PRACTICE FORM B 2020 EXAM ALL 180 QUESTIONS AND
CORRECT DETAILED ANSWERS
A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes
zoster with lesions on the lower extremities. Which of the following interventions should the nurse
include in the plan of care?
Keep bed linens o of the affected areas.
Position a heat lamp over the lower extremities.
Apply warm, moist compresses to the affected areas.
Initiate droplet isolation precautions. - (answer) Keep bed linens o of the affected areas.
Rationale: Nurse should keep bed linens off of the affected areas by using a bed cradle, which will relieve
pain caused by the linens rubbing against the lesions.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the
following instructions should the nurse include to promote comfort?
Sleep on a firm mattress.
Try jogging in place when joints feel stiff.
Use a soft chair or recliner for sitting.
Apply ice packs to painful joints - (answer) Sleep on a firm mattress.
Rationale: A firm mattress or a bed board helps the client maintain joint alignment while sleeping.
A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The
client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9%
sodium chloride. Which of the following actions should the nurse take first?
Check for kinks in the NG tube.
Increase the IV uid rate.
Provide ice chips.
,PN ADULT MEDICAL SURGICAL ONLINE PRACTICE FORM B 2020 EXAM ALL 180 QUESTIONS AND
CORRECT DETAILED ANSWERS
Administer an antiemetic - (answer) Check for kinks in the NG tube.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving
antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should
indicate to the nurse that the client's therapeutic regimen is effective?
Adventitious lung sounds
Decrease in exertional dyspnea
Respiratory rate of 26/min while sitting in a chair
Elevation of the head of the bed is required to sleep - (answer) Decrease in exertional dyspnea
Rationale: A (-) in exertional dyspnea indicates the antibiotics are resolving the infection and the
albuterol treatments are facilitating effective ventilation. Therefore, the nurse should evaluate the
therapeutic regimen as effective for the client.
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased
pain at the site of the fracture. Which of the following actions should the nurse take?
Massage the area.
Remove the weights.
Loosen the ropes.
Reposition the client - (answer) Reposition the client
Rationale: When the client's body is out of alignment with the traction, muscle spasms develop, causing
increased pain. Therefore, the nurse should reposition the client, ensuring there is a straight line from
the client's hip to the traction rope and pulley, evaluate the client's response, and provide other
interventions as needed.
A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the
sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in
the order of performance. Use all the steps.)
,PN ADULT MEDICAL SURGICAL ONLINE PRACTICE FORM B 2020 EXAM ALL 180 QUESTIONS AND
CORRECT DETAILED ANSWERS
Lower the client to the floor.
Loosen the clothing around the client's neck.
Place a pad beneath the client's head.
Time the length of the client's seizure.
Reorient and reassure the client. - (answer) Lower the client to the floor.
Place a pad beneath the client's head.
Loosen the clothing around the client's neck.
Time the length of the client's seizure.
Reorient and reassure the client.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular
and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?
Withdraw both types of insulin and then add 0.2 mL of air to the syringe
Gently shake the NPH insulin prior to withdrawing the dose.
Withdraw the regular insulin before withdrawing the NPH insulin.
Inject air into the NPH vial after withdrawing regular insulin. - (answer) Withdraw the regular insulin
before withdrawing the NPH insulin.
Rationale: The nurse should instruct the client to withdraw the regular insulin before withdrawing the
NPH insulin. This will protect the regular insulin from contamination with the NPH insulin.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated
hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the
teaching?
The expected therapeutic reference range for HbA1c for a client who has diabetes mellitus is 9.5% to
10%.
, PN ADULT MEDICAL SURGICAL ONLINE PRACTICE FORM B 2020 EXAM ALL 180 QUESTIONS AND
CORRECT DETAILED ANSWERS
An HbA1c level below the expected reference range indicates ineffective glucose control
HbA1c results measure glucose control for the prior 3 months.
HbA1c testing is used to provide a diagnosis of diabetes mellitus - (answer) HbA1c results measure
glucose control for the prior 3 months.
Rationale: HbA1c testing reflects ave overall glucose control over a 3 month period. It's for long-term
glucose control.
A nurse is collecting data from a client who has 30% body surface area deep partial-thickness and full-
thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?
Granulation tissue is present.
Urine output is 50 mL/hr.
Lung sounds are clear.
Oxygen saturation level is 95%. - (answer) Urine output is 50 mL/hr.
Rationale: The nurse should closely monitor the client's urinary output as an indicator of effective fluid
resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate.
NOTE: Granulation tissue: monitor the client's wounds because infection is a complication of burns. The
presence of granulation tissue is an indicator used to monitor the effectiveness of wound therapy.
A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the
following clients should the nurse plan to see first?
A client who had a colectomy 2 days ago and has a nasogastric tube attached to low suction
A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during
the night
A client who had a right lower lobectomy 4 days ago and has 50 mL/hr of serous drainage from a chest
tube
CORRECT DETAILED ANSWERS
A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes
zoster with lesions on the lower extremities. Which of the following interventions should the nurse
include in the plan of care?
Keep bed linens o of the affected areas.
Position a heat lamp over the lower extremities.
Apply warm, moist compresses to the affected areas.
Initiate droplet isolation precautions. - (answer) Keep bed linens o of the affected areas.
Rationale: Nurse should keep bed linens off of the affected areas by using a bed cradle, which will relieve
pain caused by the linens rubbing against the lesions.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the
following instructions should the nurse include to promote comfort?
Sleep on a firm mattress.
Try jogging in place when joints feel stiff.
Use a soft chair or recliner for sitting.
Apply ice packs to painful joints - (answer) Sleep on a firm mattress.
Rationale: A firm mattress or a bed board helps the client maintain joint alignment while sleeping.
A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The
client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9%
sodium chloride. Which of the following actions should the nurse take first?
Check for kinks in the NG tube.
Increase the IV uid rate.
Provide ice chips.
,PN ADULT MEDICAL SURGICAL ONLINE PRACTICE FORM B 2020 EXAM ALL 180 QUESTIONS AND
CORRECT DETAILED ANSWERS
Administer an antiemetic - (answer) Check for kinks in the NG tube.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving
antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should
indicate to the nurse that the client's therapeutic regimen is effective?
Adventitious lung sounds
Decrease in exertional dyspnea
Respiratory rate of 26/min while sitting in a chair
Elevation of the head of the bed is required to sleep - (answer) Decrease in exertional dyspnea
Rationale: A (-) in exertional dyspnea indicates the antibiotics are resolving the infection and the
albuterol treatments are facilitating effective ventilation. Therefore, the nurse should evaluate the
therapeutic regimen as effective for the client.
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased
pain at the site of the fracture. Which of the following actions should the nurse take?
Massage the area.
Remove the weights.
Loosen the ropes.
Reposition the client - (answer) Reposition the client
Rationale: When the client's body is out of alignment with the traction, muscle spasms develop, causing
increased pain. Therefore, the nurse should reposition the client, ensuring there is a straight line from
the client's hip to the traction rope and pulley, evaluate the client's response, and provide other
interventions as needed.
A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the
sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in
the order of performance. Use all the steps.)
,PN ADULT MEDICAL SURGICAL ONLINE PRACTICE FORM B 2020 EXAM ALL 180 QUESTIONS AND
CORRECT DETAILED ANSWERS
Lower the client to the floor.
Loosen the clothing around the client's neck.
Place a pad beneath the client's head.
Time the length of the client's seizure.
Reorient and reassure the client. - (answer) Lower the client to the floor.
Place a pad beneath the client's head.
Loosen the clothing around the client's neck.
Time the length of the client's seizure.
Reorient and reassure the client.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular
and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?
Withdraw both types of insulin and then add 0.2 mL of air to the syringe
Gently shake the NPH insulin prior to withdrawing the dose.
Withdraw the regular insulin before withdrawing the NPH insulin.
Inject air into the NPH vial after withdrawing regular insulin. - (answer) Withdraw the regular insulin
before withdrawing the NPH insulin.
Rationale: The nurse should instruct the client to withdraw the regular insulin before withdrawing the
NPH insulin. This will protect the regular insulin from contamination with the NPH insulin.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated
hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the
teaching?
The expected therapeutic reference range for HbA1c for a client who has diabetes mellitus is 9.5% to
10%.
, PN ADULT MEDICAL SURGICAL ONLINE PRACTICE FORM B 2020 EXAM ALL 180 QUESTIONS AND
CORRECT DETAILED ANSWERS
An HbA1c level below the expected reference range indicates ineffective glucose control
HbA1c results measure glucose control for the prior 3 months.
HbA1c testing is used to provide a diagnosis of diabetes mellitus - (answer) HbA1c results measure
glucose control for the prior 3 months.
Rationale: HbA1c testing reflects ave overall glucose control over a 3 month period. It's for long-term
glucose control.
A nurse is collecting data from a client who has 30% body surface area deep partial-thickness and full-
thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?
Granulation tissue is present.
Urine output is 50 mL/hr.
Lung sounds are clear.
Oxygen saturation level is 95%. - (answer) Urine output is 50 mL/hr.
Rationale: The nurse should closely monitor the client's urinary output as an indicator of effective fluid
resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate.
NOTE: Granulation tissue: monitor the client's wounds because infection is a complication of burns. The
presence of granulation tissue is an indicator used to monitor the effectiveness of wound therapy.
A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the
following clients should the nurse plan to see first?
A client who had a colectomy 2 days ago and has a nasogastric tube attached to low suction
A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during
the night
A client who had a right lower lobectomy 4 days ago and has 50 mL/hr of serous drainage from a chest
tube
