RN ADULT MEDICAL SURGICAL ONLINE
PRACTICE 2019 B QUESTIONS AND
ANSWERS(WEST COAST UNIVERSITY)
A home health nurse is providing teaching to a client who has a stage 1 pressure
injury on the greater trochanter of his left hip. Which of the following instructions
should the nurse include in the teaching? - CORRECT ANSWE✅✅ - Change
position every hour.
Changing positions every 1 to 2 hr decreases pressure on bony prominences. The
nurse should also instruct the client to limit the angle of the hips when in a lateral
position to no more than 30 degrees. This positioning prevents direct pressure on
the trochanter.
.A nurse at an urgent care clinic is caring for a client who is experiencing an
anaphylactic reaction. After ensuring a patent airway, which of the following
nursing interventions is the priority? - CORRECT ANSWE✅✅ - Applying
oxygen via face mask
Rationale:
Evidence-based practice indicates that the priority intervention is for the nurse to
apply oxygen. The nurse should use a high-flow nonrebreather mask to deliver
oxygen at 90% to 100%.
.A nurse in an emergency department is assessing an older adult client who has a
fractured wrist following a fall. During the assessment, the client states, "Last week
I crashed my car because my vision suddenly became blurry." Which of the
following actions is the nurse's priority? - CORRECT ANSWE✅✅ - Check the
client's neurologic status.
,Rationale:
The first action the nurse should take using the nursing process is to assess the
client. Therefore, the nurse should first check the neurologic status of the client.
.A nurse is administering packed RBCs to a client. Which of the following
assessment findings indicates a hemolytic transfusion reaction? - CORRECT
ANSWE✅✅ - Low back pain and apprehension
Rationale:
Hemolytic transfusion reactions result from the infusion of incompatible blood
products and create a systemic inflammatory response. Manifestations include low
back pain, hypotension, tachycardia, and apprehension.
.A nurse is admitting a client who has active tuberculosis. Which of the following
types of transmission precautions should the nurse initiate? - CORRECT
ANSWE✅✅ - Airborne.
Rationale: Airborne precautions are required for clients who have infections due to
micro-organisms that can remain suspended in air for lengthy periods of time, such
as tuberculosis, measles, varicella, and disseminated varicella zoster.
.A nurse is assessing a client following the completion of hemodialysis. Which of
the following findings is the nurse's priority to report to the provider? - CORRECT
ANSWE✅✅ - Restlessness
Rationale:
Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding to report to the provider is restlessness, which can be an
, indication the client is experiencing disequilibrium syndrome. Disequilibrium
syndrome is caused by the rapid removal of electrolytes from the client's blood and
can lead to dysrhythmias or seizures. Other manifestations include nausea,
vomiting, fatigue, and headache.
.A nurse is assessing a client while suctioning the client's tracheostomy tube.
Which of the following findings should indicate to the nurse the client is
experiencing hypoxia? - CORRECT ANSWE✅✅ - The client's heart rate
increases.
.A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of
the following nonpharmacological interventions should the nurse suggest to the
client to reduce pain? - CORRECT ANSWE✅✅ - Alternate application of heat
and cold to the affected joints.
Rationale:
The nurse should instruct the client to alternate heat and cold applications to
decrease joint inflammation and pain. The application of cold can relieve joint
swelling and the application of heat can decrease joint stiffness and pain.
.A nurse is assessing a client who has advanced lung cancer and is receiving
palliative care. The client has just undergone thoracentesis. The nurse should
expect a reduction in which of the following common manifestations of advanced
cancer? - CORRECT ANSWE✅✅ - Dyspnea
Rationale: Thoracentesis, the removal of pleural fluid, can temporarily relieve
hypoxia and thus ease the client's breathing and improve comfort.
PRACTICE 2019 B QUESTIONS AND
ANSWERS(WEST COAST UNIVERSITY)
A home health nurse is providing teaching to a client who has a stage 1 pressure
injury on the greater trochanter of his left hip. Which of the following instructions
should the nurse include in the teaching? - CORRECT ANSWE✅✅ - Change
position every hour.
Changing positions every 1 to 2 hr decreases pressure on bony prominences. The
nurse should also instruct the client to limit the angle of the hips when in a lateral
position to no more than 30 degrees. This positioning prevents direct pressure on
the trochanter.
.A nurse at an urgent care clinic is caring for a client who is experiencing an
anaphylactic reaction. After ensuring a patent airway, which of the following
nursing interventions is the priority? - CORRECT ANSWE✅✅ - Applying
oxygen via face mask
Rationale:
Evidence-based practice indicates that the priority intervention is for the nurse to
apply oxygen. The nurse should use a high-flow nonrebreather mask to deliver
oxygen at 90% to 100%.
.A nurse in an emergency department is assessing an older adult client who has a
fractured wrist following a fall. During the assessment, the client states, "Last week
I crashed my car because my vision suddenly became blurry." Which of the
following actions is the nurse's priority? - CORRECT ANSWE✅✅ - Check the
client's neurologic status.
,Rationale:
The first action the nurse should take using the nursing process is to assess the
client. Therefore, the nurse should first check the neurologic status of the client.
.A nurse is administering packed RBCs to a client. Which of the following
assessment findings indicates a hemolytic transfusion reaction? - CORRECT
ANSWE✅✅ - Low back pain and apprehension
Rationale:
Hemolytic transfusion reactions result from the infusion of incompatible blood
products and create a systemic inflammatory response. Manifestations include low
back pain, hypotension, tachycardia, and apprehension.
.A nurse is admitting a client who has active tuberculosis. Which of the following
types of transmission precautions should the nurse initiate? - CORRECT
ANSWE✅✅ - Airborne.
Rationale: Airborne precautions are required for clients who have infections due to
micro-organisms that can remain suspended in air for lengthy periods of time, such
as tuberculosis, measles, varicella, and disseminated varicella zoster.
.A nurse is assessing a client following the completion of hemodialysis. Which of
the following findings is the nurse's priority to report to the provider? - CORRECT
ANSWE✅✅ - Restlessness
Rationale:
Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding to report to the provider is restlessness, which can be an
, indication the client is experiencing disequilibrium syndrome. Disequilibrium
syndrome is caused by the rapid removal of electrolytes from the client's blood and
can lead to dysrhythmias or seizures. Other manifestations include nausea,
vomiting, fatigue, and headache.
.A nurse is assessing a client while suctioning the client's tracheostomy tube.
Which of the following findings should indicate to the nurse the client is
experiencing hypoxia? - CORRECT ANSWE✅✅ - The client's heart rate
increases.
.A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of
the following nonpharmacological interventions should the nurse suggest to the
client to reduce pain? - CORRECT ANSWE✅✅ - Alternate application of heat
and cold to the affected joints.
Rationale:
The nurse should instruct the client to alternate heat and cold applications to
decrease joint inflammation and pain. The application of cold can relieve joint
swelling and the application of heat can decrease joint stiffness and pain.
.A nurse is assessing a client who has advanced lung cancer and is receiving
palliative care. The client has just undergone thoracentesis. The nurse should
expect a reduction in which of the following common manifestations of advanced
cancer? - CORRECT ANSWE✅✅ - Dyspnea
Rationale: Thoracentesis, the removal of pleural fluid, can temporarily relieve
hypoxia and thus ease the client's breathing and improve comfort.
