Exam (elaborations)
PN Adult Medical Surgical Online Practice 2020 A Questions With Completed & Verified Solutions.
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PN Adult Medical Surgical Online Practice 2020 A Questions With Completed & Verified Solutions.
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A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty.Which of the following actions should the nurse take?
Use a traction boot to keep the client's right leg internally rotated.
Have the client sit in a reclining chair when out of bed.
Maintain abduction of the client's right leg while in bed.
Encourage the client to perform passive range-of-motion exercises. - ANS Maintain abduction of
the client's right leg while in bed.
Rationale: The nurse should maintain abduction of the client's right leg to prevent dislocation of
the affected hip by placing an abductor pillow between the client's legs when resting in bed.
A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think
I can go on any longer." Which of the following responses should the nurse make?
"Are you experiencing abdominal pain?"
"You should talk about this with the people you're closest to."
"Many people who have cancer feel this way."
"You feel like you want to discontinue treatment?" - ANS "You feel like you want to discontinue
treatment?"
Rationale: The nurse is clarifying and acknowledging the client's feelings by establishing a
trusting relationship. This question encourages the client to expand on their feelings.
A nurse is contributing to the plan of care for a client who is having difficulty eating following a
stroke. Which of the following actions should the nurse take first?
Collaborate with a dietitian.
Ensure that the client is provided with a high-ber diet.
Implement recommendations from the speech-language pathologist.
Request a referral for an occupational therapist. - ANS Implement recommendations from the
speech-language pathologist.
Rationale: The greatest risk to the client following a stroke is injury from aspiration. Therefore,
the first intervention the nurse should include in the plan of care is to implement
recommendations from the speech language pathologist. A speech language pathologist can
conduct a swallow study to determine the client's risk for aspiration, provide teaching to the
client regarding swallowing techniques, and recommend the consistency of foods and liquids for
the client.
A nurse is contributing to the plan of care for a client who was admitted to the neurological unit
following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the
priority?
Encourage the client to participate in self-care.
Assist the client with active range-of-motion exercises.
,Keep the client in a side-lying position.
Maintain the client's body alignment - ANS Keep the client in a side-lying position.
Rationale: The greatest risk to the client following a stroke is aspiration. The nurse should
position the client in a lateral, or side-lying, position to allow any secretions to drain out of the
mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment
available in the event that any secretions are present in the oral cavity.
A nurse is participating in a health fair for older adult clients. Which of the following vaccines
should the nurse recommend for this age group?
Meningococcal
Herpes zoster
Human papillomavirus (HPV) Measles, mumps, and rubella (MMR) - ANS Herpes zoster
(Shingles)
A nurse is contributing to the plan of care for a client who has a new prescription for nystatin
suspension for oral candidiasis. Which of the following interventions should the nurse include in
the plan?
Use a commercial mouthwash before taking the medication.
Instruct the client to swish the medication in their mouth.
Discontinue the medication as soon as the lesions are healed.
Combine the medication with applesauce - ANS Instruct the client to swish the medication in
their mouth.
Rationale: The nurse should instruct the client to place half the dose in each side of their mouth,
swish the medication, and then swallow. This action will allow the medication to coat the entire
oral mucosa and treat the fungal infection.
A nurse is preparing to perform intermittent urinary catheterization for a female client who has
been unable to void following surgery 6 hr ago. Which of the following catheters should the
nurse use to perform this procedure? - ANS intermittent straight catheter (clear tube with blue
top)
Rationale: This is an intermittent straight catheter and is the correct catheter for the nurse to
use.
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel
obstruction in the descending colon. When listening in the left upper quadrant, the nurse should
identify this sound as which of the following?
Hyperactive bowel sounds
Friction rub
Normal bowel sounds
Abdominal bruit - ANS Hyperactive bowel sounds
, Rationale: A mechanical bowel obstruction prevents a portion or all of the bowel contents from
moving forward through the bowel. The nurse should expect to auscultate high-pitched,
hyperactive bowel sounds above the point of the intestinal obstruction as the intestines attempt
to propel the blockage forward.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking
dantrolene to manage muscle spasms. Which of the following interventions should the nurse
include?
Apply hot packs to the client's muscles.
Schedule physical therapy in the afternoon
Encourage the client to complete ADLs.
Administer valerian to promote sleep - ANS Encourage the client to complete ADLs.
Rationale: The nurse should encourage the client to complete ADLs and provide assistance as
needed. Performing self-care increases the client's independence, strength, and level of
functioning.
A nurse is assisting with the care of a client who had a cardiac catheterization via the right
femoral artery. Which of the following actions should the nurse take to prevent postprocedure
complications?
Monitor the insertion site for bleeding
Position the affected extremity at a 45º
Restrict the client's fluid intake
Maintain the pressure dressing
Check the client's peripheral pulses - ANS Monitor the insertion site for bleeding is
Maintain the pressure dressing
Check the client's peripheral pulses
A home health nurse is reinforcing teaching about preventing asthma attacks with a client who
has asthma. Which of the following instructions should the nurse include in the teaching?
"Cover the floor of your bedroom with carpet."
"Do not allow visitors to smoke cigarettes in your home."
"Breathe cold air to ease feelings of shortness of breath."
"Open the windows in your home during the spring to increase air flow." - ANS "Do not allow
visitors to smoke cigarettes in your home."
Rationale: The nurse should inform the client that cigarette smoke is a common allergen that
can increase the risk for triggering an asthma attack. Therefore, the client should not allow
anyone to smoke cigarettes in their home.
A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following
findings should the nurse identify as a therapeutic effect of the medication?
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