RN Adult Medical Surgical Online Practice 2023 B
Study online at https://quizlet.com/_f0etpy
1. ***A nurse is caring for a client who presents to a clinic for a 1-week
follow-up visit after hospitalization for heart failure.
Prescriptions:
Digoxin 0.25 mg PO daily
Furosemide 40 mg PO daily
Potassium chloride 20 mEq/L PO daily
History and Physical
Discharge: Weight 66.7 kg (147 lb)
SaO2 94%
2+ pedal edema
Heart rate 74/min
Current:Weight 67.1 kg (148 lb)
SaO2 92%
1+ pedal edema
Heart rate 55/min
Laboratory Results
Discharge:Sodium 137 mEq/L (136 to 145 mEq/L)Potassium 4.2 mEq/L (3.5 to
5 mEq/L)Digoxin 1.2 ng/dL (0.8 to 2 ng/dL)
Current:Sodium 135 mEq/L (136 to 145 mEq/L)Potassium 4.1 mEq/L (3.5 to 5
mEq/L)Digoxin 1.8 ng/dL (0.8 to 2 ng/dL)
Based on the information in the client's chart, which of the following findings
should the nurse report to the provider?
-Potassium 4.1
-HR 55
-SaO2 92
-Wt 67.1. kg: Heart rate 55/min
Rational:
The client's heart rate of 55/min is a decrease from the client's baseline of 74/min,
and it can indicate the development of digoxin toxicity. The nurse should report this
finding to the provider.
2. ***A nurse is teaching a client about the use of transcutaneous electrical
nerve stimulation (TENS) for the management of bone cancer pain. The nurse
should explain that applying a TENS unit to the painful area has which of the
following effects?
-Electrically generated feelings of heat
-Cryotherapy for painful areas
, RN Adult Medical Surgical Online Practice 2023 B
Study online at https://quizlet.com/_f0etpy
-Realignment of energy flow through meridians
-A tingling sensation replacing the pain: A tingling sensation replacing the pain
Rational:
A TENS unit applies small electric currents to the painful area, with the client
increasing the current until the "pins and needles" sensation overrides the pain.
A TENS unit does not create heat when applied to a painful area. Warm compresses,
heating pads, and paraffin dips are examples of modalities that apply heat to painful
areas.
Many over-the-counter gels and creams work by creating a sense of cold to help
relieve muscles aches and pain. A TENS unit does not work by cryotherapy, or cold
treatment.
Acupuncture is a therapy that works via the insertion of fine needles to help unblock
any obstructed flow of energy in other parts of the body. A TENS unit does not clear
obstructions in energy flow.
3. ***A nurse in an ICU is assessing a client who has a traumatic brain injury.
Which of the following findings should the nurse identify as a component of
Cushing's triad?
-Hypotension
-Tachypnea
-Nuchal rigidity
-Bradycardia: *Bradycardia*
Rational:
A client who has increased intracranial pressure from a traumatic brain injury
can develop bradycardia, which is one component of Cushing's triad. The other
components of Cushing's triad are
severe hypertension and a widened pulse pressure.
A client who has increased intracranial pressure from a traumatic brain injury can
develop hypertension, which is one component of Cushing's triad.
A client who has a traumatic brain injury can develop decreased cerebral blood flow,
which results in increased arterial pressure. The changes to arterial pressure cause
changes in blood pressure. However, respirations are not affected.
Nuchal rigidity, or neck stiffness, is an indication of meningitis.
4. **A nurse is teaching a family about the care of a parent who has a new
diagnosis of Alzheimer's disease. Which of the following information should
, RN Adult Medical Surgical Online Practice 2023 B
Study online at https://quizlet.com/_f0etpy
the nurse include in the teaching?
-Position tabletop clocks with multi-colored backgrounds throughout the
home.
-Explain how to complete a task while having the client do the task.
-Place a calendar on the wall with days and weeks included.
-Create complete outfits and allow the client to select one each day.: -Create
complete outfits and allow the client to select one each day.
Rational:
The family should place completed outfits on hangers and allow the client to select
which one to wear each day.
5. **A nurse is planning care for a client who has extensive burn injuries and
is immunocompromised. Which of the following precautions should the nurse
include in the plan of care to prevent a Pseudomonas aeruginosa infection?
-Encourage the client to eat raw fruits and vegetables.
-Avoid placing plants or flowers in the client's room.
-Limit visitors to members of the client's immediate family.
-Wear an N95 respirator mask when providing care to the client.: Avoid placing
plants or flowers in the client's room.
Rational:
Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds
and cause life-threatening complications. The nurse should ensure no one brings
live plants or flowers into the client's room.
The nurse should identify that P. aeruginosa can be found in raw fruits and vegeta-
bles.
The nurse does NOT need to limit visits to family members. However, the nurse
should prohibit visits from those at risk for P. aeruginosa infection, such as anyone
who is ill, other hospitalized clients, and small children.
P. aeruginosa spreads by contact, either on health care workers' hands or contami-
nated equipment. It is not airborne, so respirator masks are unnecessary.
6. ***A nurse is providing teaching to a client who has irritable bowel syndrome
(IBS). Which of the following instructions should the nurse include in the
teaching?
-Take an antacid before meals and at bedtime.
, RN Adult Medical Surgical Online Practice 2023 B
Study online at https://quizlet.com/_f0etpy
-Increase fiber intake to at least 30 g per day.
-Drink ginger tea daily.
-Consume no more than 1 L of water per day.: Increase fiber intake to at least 30
g per day.
Rational:
Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
7. A nurse is assessing a client who has diabetes insipidus. Which of the
following findings should the nurse expect?
-Low urine specific gravity
-Hypertension
-Bounding peripheral pulses
-Hyperglycemia: Low urine specific gravity
Rational:
An expected finding for a client who has diabetes insipidus is a urine specific gravity
between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is
caused by an alteration in antidiuretic hormone release or the kidneys' responsive-
ness to the hormone.
8. A nurse is caring for a client who has a new prescription for total parenteral
nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution
has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the
answer to the nearest whole number. Use a leading zero if it applies. Do not
use a trailing zero.): 167 mL/hr
Rational:
mL/hr =
4000/24 = 166.6 = 167
9. A nurse is caring for a client who is 4 hr postoperative following a total
vaginal hysterectomy. Click to highlight the findings the nurse should report
to the provider immediately.
-Client sleeping, arouses to verbal stimuli
-Respiratory rate 14/min
-Oxygen saturation 95% on room air, breath sounds clear
-Reports pain as 2 on scale of 0 to 10
-Perineal pad saturated with blood, large clots present
-Change of blood pressure, heart rate of 102/min: Perineal pad saturated with
Study online at https://quizlet.com/_f0etpy
1. ***A nurse is caring for a client who presents to a clinic for a 1-week
follow-up visit after hospitalization for heart failure.
Prescriptions:
Digoxin 0.25 mg PO daily
Furosemide 40 mg PO daily
Potassium chloride 20 mEq/L PO daily
History and Physical
Discharge: Weight 66.7 kg (147 lb)
SaO2 94%
2+ pedal edema
Heart rate 74/min
Current:Weight 67.1 kg (148 lb)
SaO2 92%
1+ pedal edema
Heart rate 55/min
Laboratory Results
Discharge:Sodium 137 mEq/L (136 to 145 mEq/L)Potassium 4.2 mEq/L (3.5 to
5 mEq/L)Digoxin 1.2 ng/dL (0.8 to 2 ng/dL)
Current:Sodium 135 mEq/L (136 to 145 mEq/L)Potassium 4.1 mEq/L (3.5 to 5
mEq/L)Digoxin 1.8 ng/dL (0.8 to 2 ng/dL)
Based on the information in the client's chart, which of the following findings
should the nurse report to the provider?
-Potassium 4.1
-HR 55
-SaO2 92
-Wt 67.1. kg: Heart rate 55/min
Rational:
The client's heart rate of 55/min is a decrease from the client's baseline of 74/min,
and it can indicate the development of digoxin toxicity. The nurse should report this
finding to the provider.
2. ***A nurse is teaching a client about the use of transcutaneous electrical
nerve stimulation (TENS) for the management of bone cancer pain. The nurse
should explain that applying a TENS unit to the painful area has which of the
following effects?
-Electrically generated feelings of heat
-Cryotherapy for painful areas
, RN Adult Medical Surgical Online Practice 2023 B
Study online at https://quizlet.com/_f0etpy
-Realignment of energy flow through meridians
-A tingling sensation replacing the pain: A tingling sensation replacing the pain
Rational:
A TENS unit applies small electric currents to the painful area, with the client
increasing the current until the "pins and needles" sensation overrides the pain.
A TENS unit does not create heat when applied to a painful area. Warm compresses,
heating pads, and paraffin dips are examples of modalities that apply heat to painful
areas.
Many over-the-counter gels and creams work by creating a sense of cold to help
relieve muscles aches and pain. A TENS unit does not work by cryotherapy, or cold
treatment.
Acupuncture is a therapy that works via the insertion of fine needles to help unblock
any obstructed flow of energy in other parts of the body. A TENS unit does not clear
obstructions in energy flow.
3. ***A nurse in an ICU is assessing a client who has a traumatic brain injury.
Which of the following findings should the nurse identify as a component of
Cushing's triad?
-Hypotension
-Tachypnea
-Nuchal rigidity
-Bradycardia: *Bradycardia*
Rational:
A client who has increased intracranial pressure from a traumatic brain injury
can develop bradycardia, which is one component of Cushing's triad. The other
components of Cushing's triad are
severe hypertension and a widened pulse pressure.
A client who has increased intracranial pressure from a traumatic brain injury can
develop hypertension, which is one component of Cushing's triad.
A client who has a traumatic brain injury can develop decreased cerebral blood flow,
which results in increased arterial pressure. The changes to arterial pressure cause
changes in blood pressure. However, respirations are not affected.
Nuchal rigidity, or neck stiffness, is an indication of meningitis.
4. **A nurse is teaching a family about the care of a parent who has a new
diagnosis of Alzheimer's disease. Which of the following information should
, RN Adult Medical Surgical Online Practice 2023 B
Study online at https://quizlet.com/_f0etpy
the nurse include in the teaching?
-Position tabletop clocks with multi-colored backgrounds throughout the
home.
-Explain how to complete a task while having the client do the task.
-Place a calendar on the wall with days and weeks included.
-Create complete outfits and allow the client to select one each day.: -Create
complete outfits and allow the client to select one each day.
Rational:
The family should place completed outfits on hangers and allow the client to select
which one to wear each day.
5. **A nurse is planning care for a client who has extensive burn injuries and
is immunocompromised. Which of the following precautions should the nurse
include in the plan of care to prevent a Pseudomonas aeruginosa infection?
-Encourage the client to eat raw fruits and vegetables.
-Avoid placing plants or flowers in the client's room.
-Limit visitors to members of the client's immediate family.
-Wear an N95 respirator mask when providing care to the client.: Avoid placing
plants or flowers in the client's room.
Rational:
Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds
and cause life-threatening complications. The nurse should ensure no one brings
live plants or flowers into the client's room.
The nurse should identify that P. aeruginosa can be found in raw fruits and vegeta-
bles.
The nurse does NOT need to limit visits to family members. However, the nurse
should prohibit visits from those at risk for P. aeruginosa infection, such as anyone
who is ill, other hospitalized clients, and small children.
P. aeruginosa spreads by contact, either on health care workers' hands or contami-
nated equipment. It is not airborne, so respirator masks are unnecessary.
6. ***A nurse is providing teaching to a client who has irritable bowel syndrome
(IBS). Which of the following instructions should the nurse include in the
teaching?
-Take an antacid before meals and at bedtime.
, RN Adult Medical Surgical Online Practice 2023 B
Study online at https://quizlet.com/_f0etpy
-Increase fiber intake to at least 30 g per day.
-Drink ginger tea daily.
-Consume no more than 1 L of water per day.: Increase fiber intake to at least 30
g per day.
Rational:
Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
7. A nurse is assessing a client who has diabetes insipidus. Which of the
following findings should the nurse expect?
-Low urine specific gravity
-Hypertension
-Bounding peripheral pulses
-Hyperglycemia: Low urine specific gravity
Rational:
An expected finding for a client who has diabetes insipidus is a urine specific gravity
between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is
caused by an alteration in antidiuretic hormone release or the kidneys' responsive-
ness to the hormone.
8. A nurse is caring for a client who has a new prescription for total parenteral
nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution
has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the
answer to the nearest whole number. Use a leading zero if it applies. Do not
use a trailing zero.): 167 mL/hr
Rational:
mL/hr =
4000/24 = 166.6 = 167
9. A nurse is caring for a client who is 4 hr postoperative following a total
vaginal hysterectomy. Click to highlight the findings the nurse should report
to the provider immediately.
-Client sleeping, arouses to verbal stimuli
-Respiratory rate 14/min
-Oxygen saturation 95% on room air, breath sounds clear
-Reports pain as 2 on scale of 0 to 10
-Perineal pad saturated with blood, large clots present
-Change of blood pressure, heart rate of 102/min: Perineal pad saturated with
