RN Adult Medical Surgical Online Practice 2023 A NGN
04 September 2024RN Adult Medical Surgical Online Practice 2023 A NGN
1. The client is experiencing manifestations of peritonitis due to X-ray results.
ANSWER: The client has cloudy dialysate, abdominal pain, and guarding, which are signs of peritonitis.
2. Insert a large-gauge IV. Initiate a fluid challenge.
ANSWER: The client is likely experiencing hypovolemia based on low urine output and restlessness.
3. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?
ANSWER: Hypoactive bowel sounds. Rationale: Low potassium levels can lead to decreased bowel motility.
4. The client is experiencing manifestations of pancreatitis as evidenced by the amylase and lipase levels.
ANSWER: The client reports upper left quadrant pain, nausea, and fever, indicating pancreatitis.
5. A client with an arteriovenous fistula reports feeling warm, nauseated, and lightheaded.
ANSWER: Administer 0.9% sodium chloride 200 mL IV bolus and apply oxygen at 2 L/min are indicated.
6. During the emergent phase of burn care, the client is at risk for hypovolemia and respiratory failure.
ANSWER: Full-thickness burns and soot in the mouth indicate risk for respiratory complications and fluid loss.
7. A client should sign an informed consent before receiving a placebo during a research trial.
ANSWER: Informed consent is essential for ethical participation in trials.
8. A nurse is caring for a client with vomiting and diarrhea for 3 days. Which finding indicates fluid volume deficit?
ANSWER: Heart rate 110/min. Rationale: Tachycardia is a common sign of fluid volume deficit.
9. A nurse is creating a care plan for a client with neutropenia due to chemotherapy.
ANSWER: Monitor the client’s temperature every 4 hours. Rationale: Neutropenic clients are at risk for infections, so frequent temperature monitoring is necessary.
10. A nurse in the emergency department is caring for a client with full-thickness burns.
ANSWER: IV fluids should be administered first to prevent hypovolemic shock.
11. A nurse is caring for a client 4 hours postoperative following open reduction internal fixation of the right ankle.
ANSWER: Extremity cool upon palpation. Rationale: This indicates compromised circulation and should be reported.
12. A nurse is caring for a client 12 hours postoperative following a total hip arthroplasty.
ANSWER: Place a pillow between the client’s legs. Rationale: This prevents dislocation of the hip joint.
13. A nurse is assessing a client with Graves’ disease. Which image indicates exophthalmos?
ANSWER: The image of the client with bulging eyes. Rationale: Exophthalmos is a characteristic finding in Graves’ disease.
14. A nurse is providing teaching to a female client with recurrent UTIs.
ANSWER: Void before and after intercourse. Rationale: This helps prevent bacteria from entering the urinary tract.
15. A nurse is providing postoperative teaching following a total knee arthroplasty.
ANSWER: Flex the foot every hour when awake. Rationale: This helps prevent blood clots and promotes circulation.
16. A nurse is assessing a client with a suspected stroke. What is the priority finding?
ANSWER: Dysphagia. Rationale: Difficulty swallowing increases the risk of aspiration.
17. A nurse is administering packed RBCs. Which finding indicates a hemolytic transfusion reaction?
ANSWER: Low back pain and apprehension. Rationale: These are early signs of a hemolytic reaction.
18. A nurse in the emergency department is assessing an older adult client with a history of blurry vision and a recent fall.
ANSWER: Check the client’s neurologic status. Rationale: Sudden vision changes and a fall may indicate a neurological issue.
19. A nurse is evaluating the care plan for four clients. Which client needs a plan revision?
ANSWER: A client who is postoperative following abdominal surgery and reports a “popping” sensation. Rationale: This could indicate wound dehiscence or hernia.
20. A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hours ago.
ANSWER: Stone fragments in the urine. Rationale: The procedure breaks up stones, which are then passed in the urine.
21. A nurse is providing teaching to a client with stage II cervical cancer scheduled for brachytherapy.
ANSWER: “You will need to stay still in the bed during each treatment session.” Rationale: Movement could dislodge the radiation implant.
22. A nurse is caring for a client with chronic glomerulonephritis and oliguria. Which finding indicates a complication?
ANSWER: Hyperkalemia. Rationale: Oliguria can lead to potassium retention.
23. A nurse is admitting a client with active tuberculosis.
ANSWER: Airborne precautions. Rationale: Tuberculosis is spread via airborne droplets.
24. A nurse is providing teaching to a client receiving epoetin alfa for chemotherapy-induced anemia.
ANSWER: “I will monitor my blood pressure while taking this medication.” Rationale: Epoetin alfa can cause hypertension.
25. A nurse is caring for a terminally ill client who expresses a desire to stop treatments.
ANSWER: “Discontinuing treatments is your choice if it is your wish.” Rationale: The nurse should support the client’s autonomy in making end-of-life decisions.
26. A nurse is caring for a client with anorexia, low-grade fever, and a productive cough.
ANSWER: Initiate airborne precautions. Rationale: These are symptoms of tuberculosis, requiring airborne precautions.
27. A nurse is reviewing the laboratory results of a client with aplastic anemia.
ANSWER: WBC count 2,000/mm³. Rationale: A low WBC count increases the risk of infection.
28. A nurse is assessing a client with a penetrating chest wound and diminished lung sounds.
ANSWER: The client is most likely experiencing a hemothorax as evidenced by respiratory findings. Rationale: Diminished breath sounds and a penetrating wound suggest a hemothorax.
29. A nurse is caring for a client with a chest tube after a penetrating chest wound.
ANSWER: Place the client in high-Fowler’s position. Rationale: This position facilitates lung expansion and drainage.
30. A nurse is planning care for a client with a penetrating chest wound.
ANSWER: Transfuse packed RBCs and prepare the client for chest tube insertion. Rationale: These interventions address blood loss and lung drainage.
31. A nurse is assessing a client with a penetrating chest wound.
ANSWER: The nurse should first address the client’s oxygenation, followed by the client’s blood pressure. Rationale: Maintaining oxygenation is the priority in managing a client with a chest injury.
32. A nurse is assessing a client with a penetrating chest wound.
ANSWER: The client is most likely experiencing a hemothorax as evidenced by the client’s respiratory findings. Rationale: Hemothorax is suggested by diminished breath sounds and a penetrating wound.
33. A nurse is assessing a client with a penetrating chest wound.
ANSWER: Oxygen saturation is correct. Pain level is correct. Rationale: These findings are critical in evaluating the client’s respiratory and pain status after a chest injury.
34. A nurse is caring for a client with a closed-suction drain following a laparotomy.
ANSWER: Compress the drain reservoir after emptying. Rationale: Compressing the drain reservoir helps maintain negative pressure to facilitate wound drainage.
35. A nurse is caring for a client who is starting dialysis treatments.
ANSWER: Tell the client that it is possible to return to similar previous levels of activity. Rationale: Offering reassurance about activity levels can help decrease psychosocial health issues.
36. A nurse is caring for a client undergoing brachytherapy via a sealed vaginal implant.
ANSWER: Wear a lead apron while providing care to the client. Rationale: Radiation safety precautions are required when caring for clients undergoing brachytherapy.
37. A nurse is planning care for a client scheduled for a thoracentesis.
ANSWER: Encourage the client to take deep breaths after the procedure. Rationale: Deep breathing helps expand the lung after fluid removal during a thoracentesis.
38. A nurse is caring for a client at risk for seizures.
ANSWER: Ensure that the client has a patent IV. Rationale: A patent IV is important for administering medications if a seizure occurs.
39. A nurse is providing preoperative teaching for a client scheduled for an open cholecystectomy.
ANSWER: Demonstrate ways to deep breathe and cough. Rationale: Proper breathing and coughing techniques help prevent respiratory complications after surgery.
40. A nurse is caring for a client with homonymous hemianopsia due to a stroke.
ANSWER: “Scan the environment by turning your head from side to side.” Rationale: Scanning helps compensate for the visual deficit caused by homonymous hemianopsia.
41. A nurse is assessing a client with advanced lung cancer who just underwent thoracentesis.
ANSWER: Dyspnea. Rationale: Thoracentesis helps relieve dyspnea by removing pleural fluid.
42. A nurse is caring for a client receiving total parenteral nutrition (TPN).
ANSWER: Administer dextrose 10% in water until the new bag arrives. Rationale: Dextrose 10% prevents hypoglycemia when TPN is not available.
43. A nurse is providing teaching to a client with a gastric ulcer and a new prescription for omeprazole.
ANSWER: Suppressing gastric acid production. Rationale: Omeprazole reduces gastric acid production, promoting ulcer healing.
44. A nurse is planning to irrigate and dress a clean, granulating wound.
ANSWER: Use a 30-mL syringe. Rationale: A 30-mL syringe is appropriate for wound irrigation to clean and promote healing.
45. A nurse is providing teaching to a client with cancer prescribed an opioid analgesic.
ANSWER: “You should void every 4 hours to decrease the risk of urinary retention.” Rationale: Opioids can cause urinary retention, so regular voiding is important.
46. A nurse is assessing a client with hypertension taking propranolol. Which finding indicates an adverse reaction?
ANSWER: Report of a night cough. Rationale: A night cough can indicate heart failure, a potential adverse effect of propranolol.
47. A nurse is teaching newly licensed nurses about pain management for older adults.
ANSWER: “Ibuprofen can cause gastrointestinal bleeding in older adult clients.” Rationale: Ibuprofen increases the risk of gastrointestinal bleeding, especially in older adults.
48. A nurse is assessing a client following hemodialysis. What is the nurse’s priority?
ANSWER: Restlessness. Rationale: Restlessness can indicate fluid imbalance or other complications requiring immediate attention.
49. A nurse is assessing a client post-thyroidectomy. What is the priority finding?
ANSWER: Temperature 38.9°C (102°F). Rationale: Fever post-thyroidectomy could indicate infection or thyroid storm, requiring prompt intervention.
50. A nurse is providing education to a client with tuberculosis (TB) and their family.
ANSWER: Family members in the household should undergo TB testing. Rationale: TB is contagious, so household contacts should be tested for exposure.
51. A nurse is providing discharge instructions to a client following an upper GI series with barium contrast.
ANSWER: Increase fluid intake. Rationale: Fluids help flush the barium from the system and prevent constipation.
52. A nurse is assessing a client with visual disturbances and tingling of the lips. What action should the nurse take next?
ANSWER: Monitor for chest pain due to the risk of myocardial ischemia. Rationale: Sumatriptan can cause chest pain as a side effect, so monitoring is essential.
53. A nurse is assessing a client with visual disturbances, tingling of the lips, and photophobia.
ANSWER: Administer sumatriptan is correct. Dim the lights in the client’s room is correct. Rationale: These interventions are appropriate for managing migraines.
54. A nurse is providing care for a client with a migraine.
ANSWER: The nurse should address the client’s pain. Rationale: Pain management is the priority intervention for clients with migraines.
55. A nurse is providing teaching to a client regarding sumatriptan and migraine triggers.
ANSWER: “Foods that contain tyramine might trigger my headaches” is correct. Rationale: Tyramine is a known trigger for migraines.
56. A nurse is reviewing the ABG results of a client with advanced COPD.
ANSWER: PaCO₂ 56 mm Hg. Rationale: Clients with COPD often have elevated PaCO₂ due to chronic respiratory acidosis.
57. A nurse is assessing a client with a nephrostomy tube inserted 12 hours ago.
ANSWER: The client reports back pain. Rationale: Back pain may indicate a complication with the nephrostomy tube.
58. A nurse is reviewing the medical record of an older adult client receiving IV fluid therapy.
ANSWER: BUN. Rationale: Elevated BUN can indicate fluid overload or dehydration in clients receiving IV fluids.
59. A nurse is preparing to administer a blood transfusion to a client with anemia.
ANSWER: Check for the type and number of units of blood to administer. Rationale: Verification of blood type and unit is the first step in ensuring safe transfusion.
60. A nurse is caring for a client who is experiencing a tonic-clonic seizure.
ANSWER: Loosen restrictive clothing. Rationale: Loosening clothing prevents injury and promotes airway patency during a seizure.
61. A nurse is providing teaching to a client with a new prescription for metformin.
ANSWER: “I should take this medication with a meal.” Rationale: Metformin should be taken with food to reduce gastrointestinal side effects.
62. A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago.
ANSWER: Sedimentation rate. Rationale: An elevated sedimentation rate indicates inflammation, possibly due to osteomyelitis.
63. A nurse is assessing a client while suctioning the tracheostomy tube. What indicates hypoxia?
ANSWER: The client’s heart rate increases. Rationale: Tachycardia is a common sign of hypoxia.
64. A nurse is providing preoperative teaching for a client scheduled for a mastectomy.
ANSWER: “I will refer you to community resources that can provide support.” Rationale: Providing emotional support and resources is an important part of preoperative teaching.
65. A nurse is preparing to present a program about the prevention of atherosclerosis at a health fair.
ANSWER: Follow a smoking cessation program, maintain an appropriate weight, eat a low-fat diet. Rationale: These lifestyle changes reduce the risk of atherosclerosis.
66. A nurse is caring for a client receiving total parenteral nutrition (TPN) and NPO.
ANSWER: Contact the provider to clarify the prescription. Rationale: Clarification is needed when blood glucose testing is ordered for a client who is NPO and receiving TPN.
67. A nurse is caring for a client with an arterial line.
ANSWER: Place a pressure bag around the flush solution. Rationale: A pressure bag ensures the arterial line remains patent and prevents clotting.
68. A nurse is caring for a client who is having a seizure.
ANSWER: Turn the client to the side. Rationale: Turning the client to the side helps maintain airway patency and prevents aspiration.
69. A nurse at an urgent care clinic is caring for a client experiencing an anaphylactic reaction.
ANSWER: Administer epinephrine. Rationale: Epinephrine is the first-line treatment for anaphylaxis to prevent airway obstruction and shock.
70. A nurse is caring for a client receiving mannitol for increased intracranial pressure (ICP).
ANSWER: Crackles heard on auscultation. Rationale: Crackles suggest fluid overload, an adverse effect of mannitol.
71. A nurse is providing discharge teaching to a client following a modified radical mastectomy.
ANSWER: Numbness can occur along the inside of the affected arm. Rationale: Numbness is a common postoperative complication due to nerve damage.
72. A nurse is caring for a client with diabetic ketoacidosis (DKA).
ANSWER: Glucose 272 mg/dL. Rationale: A decreasing glucose level indicates that the client’s condition is improving.
73. A nurse is providing teaching to a client taking ginkgo biloba.
ANSWER: “Ginkgo biloba can cause an increased risk for bleeding.” Rationale: Ginkgo biloba has anticoagulant properties and can increase bleeding risk.
74. A nurse is providing teaching to a client with stress incontinence and a BMI of 32.
ANSWER: “A risk factor for my condition is obesity.” Rationale: Obesity increases pressure on the bladder, contributing to stress incontinence.
75. A nurse is caring for a client with portal hypertension who is vomiting blood.
ANSWER: Obtain vital signs. Rationale: Checking vital signs helps assess the severity of the client’s condition and guides further interventions.
76. A nurse is caring for a client post-hip arthroplasty with a hemoglobin of 8 g/dL.
ANSWER: Report the hemoglobin level to the provider. Rationale: A low hemoglobin level indicates possible blood loss or anemia, requiring intervention.
77. A nurse is teaching a client with a family history of colorectal cancer about diet.
ANSWER: Add cabbage to the diet. Rationale: Cabbage is high in fiber, which helps reduce the risk of colorectal cancer.
78. A nurse is assessing a client with a detached retina.
ANSWER: “It’s like a curtain closed over my eye.” Rationale: A detached retina often presents with a sudden loss of vision resembling a curtain being pulled over the eye.
79. A nurse is caring for a client receiving a blood transfusion who becomes restless and dyspneic.
ANSWER: Slow the infusion rate. Rationale: Slowing the transfusion helps manage fluid overload or transfusion-related complications.
80. A nurse is assessing a client with rheumatoid arthritis. What nonpharmacological intervention reduces pain?
ANSWER: Alternate application of heat and cold to the affected joints. Rationale: Heat and cold therapy reduce inflammation and alleviate joint pain.
81. A nurse is caring for a client with hypothyroidism.
ANSWER: Constipation. Rationale: Hypothyroidism slows metabolism, which can lead to constipation.
82. A nurse is teaching a client how to use crutches while climbing stairs.
ANSWER: Place body weight on the crutches, advance the unaffected leg onto the stair, shift weight from the crutches to the unaffected leg, bring the crutches and the affected leg up the stairs. Rationale: This sequence ensures safe and effective use of crutches while climbing stairs.
83. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider?
ANSWER: Hgb 8 g/dL. Rationale: A hemoglobin level of 8 g/dL is low and may indicate bleeding or anemia, which requires intervention.
84. A nurse is assessing a client postoperatively with a urinary catheter and IV fluids.
ANSWER: Report urinary output to the provider is correct. Plan to ambulate the client as soon as possible is correct. Instruct the client to splint the abdomen with a pillow for coughing is correct. Rationale: These actions are appropriate to prevent complications such as infection, deep vein thrombosis, and respiratory issues.
85. A nurse is teaching a client who has a family history of colorectal cancer. Which dietary recommendation should the nurse make?
ANSWER: Add cabbage to the diet. Rationale: A high-fiber diet that includes vegetables like cabbage can help reduce the risk of colorectal cancer.
86. A nurse is assessing a client with a detached retina. Which of the following should the nurse expect the client to report?
ANSWER: “It’s like a curtain closed over my eye.” Rationale: A detached retina often presents as a sudden curtain-like shadow over part of the visual field.
87. A nurse is caring for a client receiving a blood transfusion. The client becomes restless and dyspneic. What action should the nurse take?
ANSWER: Slow the infusion rate. Rationale: Slowing the transfusion helps to manage the client’s symptoms, which may indicate fluid overload or transfusion reaction.
88. A nurse is assessing a client with rheumatoid arthritis. Which nonpharmacological intervention should the nurse suggest to reduce pain?
ANSWER: Alternate application of heat and cold to the affected joints. Rationale: Heat and cold therapy are effective nonpharmacological methods for reducing inflammation and relieving pain in rheumatoid arthritis.
89. A nurse is caring for a client with hypothyroidism. Which manifestation should the nurse expect?
ANSWER: Constipation. Rationale: Hypothyroidism slows metabolic processes, which can result in constipation.
90. A nurse is caring for a client with a leg cast. Which sequence should the client follow when demonstrating crutch use on stairs?
ANSWER: Place body weight on the crutches, advance the unaffected leg onto the stair, shift weight from the crutches to the unaffected leg, bring the crutches and the affected leg up the stairs. Rationale: This sequence ensures proper weight distribution and safety while using crutches on stairs.
