RN MEDSURG RETAKE 2 PROCTORED EXAM-LATEST GUIDE
1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed.
Which of the following findings indicates that the client is experiencing increased ICP? SATA.
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins are incorrect. With increased ICP, the jugular veins are typically
distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye-opening,
motor, and verbal response.
The sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the
client from sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic
with aconcurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the clients to withhold
for 48hr prior to cardioversion?
a. Enoxaparin
b. Metformin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their ability to
prevent blood clots that can be released into the client's circulatory system
after cardioversion. This medication should not be withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac
catheterization or other procedures involving contrast dye to prevent
damage to the kidneys. However, metformin should not be withheld prior to
cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients before cardioversion to reduce
anxiety and minimize the discomfort associated with the procedure. This
, medication should not be withheld.
j. Digoxin: ANSWER
k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion.
These medications can increase ventricular irritability and put the client
at risk for ventricular fibrillation after the synchronized countershock of
cardioversion.
3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s
priority?
a. Anorexia
b. Abdominal pain radiating to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a client
who has acute cholecystitis. Therefore, there is another finding that is
the nurse's priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent because it
is an expected finding for a client who has acute cholecystitis.
Therefore, there is another finding that is the nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is tachycardia.
Tachycardia is a manifestation of biliary colic, which can lead to
shock. The nurse should position the head of the client's bed flat and
report this finding immediately to the provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an
expected finding for a client who has acute cholecystitis. Therefore,
there is another finding that is the nurse's priority.
4. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the
following items at the client’s bedside?
a. Suction machine
b. Wire cutters
c. Padded clamp
, d. Communication board
e. Suction machine: ANSWER The nurse should ensure that a suction machine
is at the bedside of a client who has dysphagia to clear the client's airway
as needed and reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a
client who has an inner maxillary fixation to cut the wires in case the client
vomits. This enables the client to clear their airway and reduce the risk for
aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at the bedside
of a client who has a chest tube to clamp the tube and prevent air from
entering the client's chest if there is an interruption in the sealed drainage
system.
h. Communication board: The nurse should ensure a communication board is at
the bedside of a client who has aphasia to assist the client with
communicating.
5. A nurse is caring for a client who is having a seizure. Which of the following intervention is the nurse’s
priority?
a. Loosen the clothing around the client’s neck
b. Check the client’s pupillary response
c. Turn the client to the side.
d. Move furniture away from the client
i. Loosen the clothing around the client's neck: The nurse should
loosen any restrictive clothing the client is wearing to prevent
injury to the client. However, another action is the priority.
ii. Check the client's pupillary response: The nurse should perform
neurologic checks after the seizure to monitor the client's recovery.
However, another action is the priority.
iii. Turn the client to the side.: The greatest risk to this client is hypoxia from
an impaired airway. Therefore, the priority intervention the nurse
should take is to place the client in a side-lying position to prevent
aspiration.
iv. Move furniture away from the client.: AThe nurse should move furniture
away from the client to prevent self-injury. However, another action is
the priority.
6. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The
nurse should instruct the client that which of the following supplements can interfere with the
effectiveness of the medication?
a. Ginkgo biloba
, b. Glucosamine
c. Calcium
d. Vitamin C
i.
Ginkgo biloba
ii. Ginkgo biloba reduces the pain associated with peripheral vascular
disease by promoting vasodilation. It can interact with medications
that have anticoagulant properties, but it is not known to interfere
with the absorption of levothyroxine.
iii. Glucosamine: Glucosamine treats osteoarthritis by decreasing
inflammation and stimulating the body's production of synovial fluid and
cartilage. It can interact with medications that have antiplatelet or
anticoagulant properties, but it is not known to interfere with the
absorption of levothyroxine.
iv. Calcium:NSWER
v. Calcium limits the development of osteoporosis in clients who are
postmenopausal and works as an antacid. Calcium supplements can
interfere
with the metabolism of a number of medications, including
levothyroxine. The nurse should instruct the client to avoid taking
calcium within 4 hr of levothyroxine administration.
vi. Vitamin C: Vitamin C promotes wound healing. It can cause a false
negative in fecal occult blood tests, but it is not known to interfere with
the absorption
of levothyroxine.
7. A nurse is planning to irrigate and dress a clean, granulation wound for a client who has a pressure
injury. Which of the following actions should the nurse take?
a. Apply a wet-to-dry gauze dressing
b. Irrigate with hydrogen peroxide solution
c. Use a 30-ml syringe
d. Attach a 24-gauge angiocatheter to the syringe.
a. Apply a wet-to-dry gauze dressing.: The nurse should not apply wet-to-dry
dressings to clean, granulating wounds as they interrupt viable, healing
tissues when they are removed. Appropriate dressings for a wound that is
developing granulation tissue include a hydrocolloid dressing and a
transparent film dressing.
1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed.
Which of the following findings indicates that the client is experiencing increased ICP? SATA.
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins are incorrect. With increased ICP, the jugular veins are typically
distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye-opening,
motor, and verbal response.
The sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the
client from sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic
with aconcurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the clients to withhold
for 48hr prior to cardioversion?
a. Enoxaparin
b. Metformin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their ability to
prevent blood clots that can be released into the client's circulatory system
after cardioversion. This medication should not be withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac
catheterization or other procedures involving contrast dye to prevent
damage to the kidneys. However, metformin should not be withheld prior to
cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients before cardioversion to reduce
anxiety and minimize the discomfort associated with the procedure. This
, medication should not be withheld.
j. Digoxin: ANSWER
k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion.
These medications can increase ventricular irritability and put the client
at risk for ventricular fibrillation after the synchronized countershock of
cardioversion.
3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s
priority?
a. Anorexia
b. Abdominal pain radiating to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a client
who has acute cholecystitis. Therefore, there is another finding that is
the nurse's priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent because it
is an expected finding for a client who has acute cholecystitis.
Therefore, there is another finding that is the nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is tachycardia.
Tachycardia is a manifestation of biliary colic, which can lead to
shock. The nurse should position the head of the client's bed flat and
report this finding immediately to the provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an
expected finding for a client who has acute cholecystitis. Therefore,
there is another finding that is the nurse's priority.
4. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the
following items at the client’s bedside?
a. Suction machine
b. Wire cutters
c. Padded clamp
, d. Communication board
e. Suction machine: ANSWER The nurse should ensure that a suction machine
is at the bedside of a client who has dysphagia to clear the client's airway
as needed and reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a
client who has an inner maxillary fixation to cut the wires in case the client
vomits. This enables the client to clear their airway and reduce the risk for
aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at the bedside
of a client who has a chest tube to clamp the tube and prevent air from
entering the client's chest if there is an interruption in the sealed drainage
system.
h. Communication board: The nurse should ensure a communication board is at
the bedside of a client who has aphasia to assist the client with
communicating.
5. A nurse is caring for a client who is having a seizure. Which of the following intervention is the nurse’s
priority?
a. Loosen the clothing around the client’s neck
b. Check the client’s pupillary response
c. Turn the client to the side.
d. Move furniture away from the client
i. Loosen the clothing around the client's neck: The nurse should
loosen any restrictive clothing the client is wearing to prevent
injury to the client. However, another action is the priority.
ii. Check the client's pupillary response: The nurse should perform
neurologic checks after the seizure to monitor the client's recovery.
However, another action is the priority.
iii. Turn the client to the side.: The greatest risk to this client is hypoxia from
an impaired airway. Therefore, the priority intervention the nurse
should take is to place the client in a side-lying position to prevent
aspiration.
iv. Move furniture away from the client.: AThe nurse should move furniture
away from the client to prevent self-injury. However, another action is
the priority.
6. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The
nurse should instruct the client that which of the following supplements can interfere with the
effectiveness of the medication?
a. Ginkgo biloba
, b. Glucosamine
c. Calcium
d. Vitamin C
i.
Ginkgo biloba
ii. Ginkgo biloba reduces the pain associated with peripheral vascular
disease by promoting vasodilation. It can interact with medications
that have anticoagulant properties, but it is not known to interfere
with the absorption of levothyroxine.
iii. Glucosamine: Glucosamine treats osteoarthritis by decreasing
inflammation and stimulating the body's production of synovial fluid and
cartilage. It can interact with medications that have antiplatelet or
anticoagulant properties, but it is not known to interfere with the
absorption of levothyroxine.
iv. Calcium:NSWER
v. Calcium limits the development of osteoporosis in clients who are
postmenopausal and works as an antacid. Calcium supplements can
interfere
with the metabolism of a number of medications, including
levothyroxine. The nurse should instruct the client to avoid taking
calcium within 4 hr of levothyroxine administration.
vi. Vitamin C: Vitamin C promotes wound healing. It can cause a false
negative in fecal occult blood tests, but it is not known to interfere with
the absorption
of levothyroxine.
7. A nurse is planning to irrigate and dress a clean, granulation wound for a client who has a pressure
injury. Which of the following actions should the nurse take?
a. Apply a wet-to-dry gauze dressing
b. Irrigate with hydrogen peroxide solution
c. Use a 30-ml syringe
d. Attach a 24-gauge angiocatheter to the syringe.
a. Apply a wet-to-dry gauze dressing.: The nurse should not apply wet-to-dry
dressings to clean, granulating wounds as they interrupt viable, healing
tissues when they are removed. Appropriate dressings for a wound that is
developing granulation tissue include a hydrocolloid dressing and a
transparent film dressing.
