RN Adult Medical Surgical Online Practice A
1. NGN
*0900:Client presents with abdominal pain in the upper left quadrant for the
past 2 days. States pain became worse this morning and is radiating to the
back. Rates pain as 8 on a scale of 0 to 10.Hypoactive bowel sounds; reports
, RN Adult Medical Surgical Online Practice A
nausea, no vomiting; client is passing flatus.Febrile, oriented to person, place,
and time.Tachypnea with diminished breath sounds.Sinus tachycardia.Client
voids 300 mL of clear, amber urine.
*0930:Client vomited 100 mL brown liquid.: The client is experiencing
manifestations of pancreatitis as evidenced by the amylase and lipase.
Rational:
Drop Down 1:
Pancreatitis is correct. The client's laboratory results and physical assessment indicate the
client is experiencing manifestations of pancreatitis. Clients who have pancreatitis
experience an increase in pancreatic enzymes, amylase, and lipase.
Paralytic ileus, adult respiratory distress syndrome (ARDS), cardiogenic shock, and a
cerebral vascular accident (CVA) are incorrect. The client is not experiencing
manifestations of paralytic ileus because they have bowel sounds and are passing flatus.
The client is not experiencing manifestations of ARDS because there is no indication the
client is in respiratory distress. The client is not experiencing manifestations of
cardiogenic shock because there is no indication from the client's medical record that
there is a risk for cardiogenic shock. The client is not experiencing manifestations of a CVA
because there is no indication from the client's medical record that there is a risk for a
CVA.
Drop Down 2:
Amylase and lipase is correct. The client's laboratory results and physical assessment
indicate the client is experiencing manifestations of pancreatitis. Clients who have
pancreatitis experience an increase in pancreatic enzymes, amylase, and lipase.
Oxygen saturation, urine output, platelet levels, and blood pressure are incorrect. These
findings do not indicate pancreatitis.
2. A nurse is caring for a client who is postoperative.
, RN Adult Medical Surgical Online Practice A
Client admitted to medical-surgical unit from PACU. Client reports incisional
pain as 2 on a scale of 0 to 10. Client appears restless and frequently asks for
water. Bilateral lower extremities cool with +1 pedal pulses. Urine output is
40 mL for the past 2 hr. Moderate amount of bright red drainage noted on
surgical
incision dressing.: Complete the diagram by dragging from the choices below
to specify what condition the client is most likely experiencing, two actions
the nurse should take to address that condition, and two parameters the
nurse should monitor to assess the client's progress.
Answer:
*Insert a large-gauge
*IV.Initiate a fluid challenge.
*Hypovolemia
*Urine output
*Blood
pressure
Rational:
The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is
most likely experiencing hypovolemia as evidenced by the client's restlessness,
tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine
output. The nurse should monitor the client's urine output and blood pressure to
evaluate the effectiveness of treatment.
3. A nurse on a medical-surgical unit is reviewing the medical record of an
older adult client who is receiving IV fluid therapy. Which of the following client
information should indicate to the nurse that the client requires re-evaluation
of the IV therapy prescription? (Click on the "Exhibit" button for additional
, RN Adult Medical Surgical Online Practice A
information about the client. There are three tabs that contain separate
categories of data.):
Answer:
BUN
Rational:
The client's Hct and BUN levels indicate dehydration and require an increase in the IV
fluid infusion rate.
4. 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?: The client's heart rate increases.
Rational:
Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs,
the nurse should discontinue the suctioning and manually oxygenate the client with 100%
oxygen. The nurse should instruct the client to take three or four deep breaths prior to
suctioning to reduce the risk for hypoxia.
5. A nurse is providing teaching to a client who takes ginkgo biloba as an
herbal supplement. Which of the following statements should the nurse
make?:
"Ginkgo biloba can cause an increased risk for bleeding." Rational:
Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with
peripheral artery disease. The supplement also decreases platelet aggregation, which in
1. NGN
*0900:Client presents with abdominal pain in the upper left quadrant for the
past 2 days. States pain became worse this morning and is radiating to the
back. Rates pain as 8 on a scale of 0 to 10.Hypoactive bowel sounds; reports
, RN Adult Medical Surgical Online Practice A
nausea, no vomiting; client is passing flatus.Febrile, oriented to person, place,
and time.Tachypnea with diminished breath sounds.Sinus tachycardia.Client
voids 300 mL of clear, amber urine.
*0930:Client vomited 100 mL brown liquid.: The client is experiencing
manifestations of pancreatitis as evidenced by the amylase and lipase.
Rational:
Drop Down 1:
Pancreatitis is correct. The client's laboratory results and physical assessment indicate the
client is experiencing manifestations of pancreatitis. Clients who have pancreatitis
experience an increase in pancreatic enzymes, amylase, and lipase.
Paralytic ileus, adult respiratory distress syndrome (ARDS), cardiogenic shock, and a
cerebral vascular accident (CVA) are incorrect. The client is not experiencing
manifestations of paralytic ileus because they have bowel sounds and are passing flatus.
The client is not experiencing manifestations of ARDS because there is no indication the
client is in respiratory distress. The client is not experiencing manifestations of
cardiogenic shock because there is no indication from the client's medical record that
there is a risk for cardiogenic shock. The client is not experiencing manifestations of a CVA
because there is no indication from the client's medical record that there is a risk for a
CVA.
Drop Down 2:
Amylase and lipase is correct. The client's laboratory results and physical assessment
indicate the client is experiencing manifestations of pancreatitis. Clients who have
pancreatitis experience an increase in pancreatic enzymes, amylase, and lipase.
Oxygen saturation, urine output, platelet levels, and blood pressure are incorrect. These
findings do not indicate pancreatitis.
2. A nurse is caring for a client who is postoperative.
, RN Adult Medical Surgical Online Practice A
Client admitted to medical-surgical unit from PACU. Client reports incisional
pain as 2 on a scale of 0 to 10. Client appears restless and frequently asks for
water. Bilateral lower extremities cool with +1 pedal pulses. Urine output is
40 mL for the past 2 hr. Moderate amount of bright red drainage noted on
surgical
incision dressing.: Complete the diagram by dragging from the choices below
to specify what condition the client is most likely experiencing, two actions
the nurse should take to address that condition, and two parameters the
nurse should monitor to assess the client's progress.
Answer:
*Insert a large-gauge
*IV.Initiate a fluid challenge.
*Hypovolemia
*Urine output
*Blood
pressure
Rational:
The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is
most likely experiencing hypovolemia as evidenced by the client's restlessness,
tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine
output. The nurse should monitor the client's urine output and blood pressure to
evaluate the effectiveness of treatment.
3. A nurse on a medical-surgical unit is reviewing the medical record of an
older adult client who is receiving IV fluid therapy. Which of the following client
information should indicate to the nurse that the client requires re-evaluation
of the IV therapy prescription? (Click on the "Exhibit" button for additional
, RN Adult Medical Surgical Online Practice A
information about the client. There are three tabs that contain separate
categories of data.):
Answer:
BUN
Rational:
The client's Hct and BUN levels indicate dehydration and require an increase in the IV
fluid infusion rate.
4. 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?: The client's heart rate increases.
Rational:
Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs,
the nurse should discontinue the suctioning and manually oxygenate the client with 100%
oxygen. The nurse should instruct the client to take three or four deep breaths prior to
suctioning to reduce the risk for hypoxia.
5. A nurse is providing teaching to a client who takes ginkgo biloba as an
herbal supplement. Which of the following statements should the nurse
make?:
"Ginkgo biloba can cause an increased risk for bleeding." Rational:
Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with
peripheral artery disease. The supplement also decreases platelet aggregation, which in
