, PN Medical Surgical 2020
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?
- Herpes zoster
Rationale:
The nurse should recommend the herpes zoster vaccine for adults who are 60 years
of age and older.
--------------
The nurse should recommend the meningococcal vaccine to college students and
military recruits who are living in shared housing.
The nurse should recommend the HPV vaccine for clients who are 9 to 26 years of
age.
The nurse should recommend the MMR vaccine to clients who are 62 years of age.
A nurse is reviewing the laboratory results of a client who is scheduled for a CT
scan with an IV contrast agent. Which of the following laboratory findings should
the nurse report to the provider prior to the procedures?
- Creatinine 1.9 mg/dL
Rationale:
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the
nurse should report the finding to the provider before the client has a CT scan with
an IV contrast agent. This finding places the client at risk for developing contrast-
induced nephropathy.
---------------------
Expected ranges:
,Calcium (ca) 9 - 10.5 mg/dL
Sodium (Na) 136 - 145 mEq/L
Potassium (K) 3.5 - 5 mEq/L
A nurse is reinforcing teaching about home care with a client who had knee
arthroplasty. Which of the following factors should the nurse identify as an
indication that a barrier to learning might be present?
- The client stops the nurse and asks for pain medication
Rationale:
The nurse should identify that a client who is in pain will not be able to
concentrate, which can interfere with their ability to learn.
A nurse is caring for a client who has a acute ischemic stroke 1 day ago. Which of
the following actions should the nurse take to reduce the risk for aspirations?
- Allow for 30 min of rest before meals.
Rationale:
The nurse should allow the client to rest for 30 min before meals to prevent
aspiration.
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?
- 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 reinforcing about joint protection with a clietn who has an acute
exacerbation of rheumatoid arthritis. Which of the following information should
the nurse include in the teaching?
- Apply cold packs to the inflamed joints
, Rationale: The nurse should instruct the client to use both warm and cold packs on
inflamed joints to decrease pain.
-----------------
The nurse should instruct the client to participate in low-impact aerobic exercises,
which will not inflame the client's joints.
The nurse should instruct the client to carry a shoulder bag, which places the stress
on larger muscles.
The nurse should instruct the client to sleep on a firm mattress to support their
joints.
A nurse is caring for a client who is schedules for surgery and is experiencing
anxiety. Which of the following interventions should the nurse identify as the
priority? - Determine the client's understanding of the procedure.
Rationale: When using the nursing process, the first action the nurse should take is
to collect data from the client. Therefore, the nurse should determine the client's
understanding of the procedure to reinforce necessary teaching, which can help
manage their anxiety.
A nurse is caring for a client who reports stomatitis. Which of the following dietary
recommendations should the nurse make? - Eat soft foods.
Rationale:
The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods
to decrease irritation to the oral mucosa.
-----------------
Instruct the client to avoid seasoning foods with salt or spices that can irritate the
oral mucosa.
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?
- Herpes zoster
Rationale:
The nurse should recommend the herpes zoster vaccine for adults who are 60 years
of age and older.
--------------
The nurse should recommend the meningococcal vaccine to college students and
military recruits who are living in shared housing.
The nurse should recommend the HPV vaccine for clients who are 9 to 26 years of
age.
The nurse should recommend the MMR vaccine to clients who are 62 years of age.
A nurse is reviewing the laboratory results of a client who is scheduled for a CT
scan with an IV contrast agent. Which of the following laboratory findings should
the nurse report to the provider prior to the procedures?
- Creatinine 1.9 mg/dL
Rationale:
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the
nurse should report the finding to the provider before the client has a CT scan with
an IV contrast agent. This finding places the client at risk for developing contrast-
induced nephropathy.
---------------------
Expected ranges:
,Calcium (ca) 9 - 10.5 mg/dL
Sodium (Na) 136 - 145 mEq/L
Potassium (K) 3.5 - 5 mEq/L
A nurse is reinforcing teaching about home care with a client who had knee
arthroplasty. Which of the following factors should the nurse identify as an
indication that a barrier to learning might be present?
- The client stops the nurse and asks for pain medication
Rationale:
The nurse should identify that a client who is in pain will not be able to
concentrate, which can interfere with their ability to learn.
A nurse is caring for a client who has a acute ischemic stroke 1 day ago. Which of
the following actions should the nurse take to reduce the risk for aspirations?
- Allow for 30 min of rest before meals.
Rationale:
The nurse should allow the client to rest for 30 min before meals to prevent
aspiration.
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?
- 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 reinforcing about joint protection with a clietn who has an acute
exacerbation of rheumatoid arthritis. Which of the following information should
the nurse include in the teaching?
- Apply cold packs to the inflamed joints
, Rationale: The nurse should instruct the client to use both warm and cold packs on
inflamed joints to decrease pain.
-----------------
The nurse should instruct the client to participate in low-impact aerobic exercises,
which will not inflame the client's joints.
The nurse should instruct the client to carry a shoulder bag, which places the stress
on larger muscles.
The nurse should instruct the client to sleep on a firm mattress to support their
joints.
A nurse is caring for a client who is schedules for surgery and is experiencing
anxiety. Which of the following interventions should the nurse identify as the
priority? - Determine the client's understanding of the procedure.
Rationale: When using the nursing process, the first action the nurse should take is
to collect data from the client. Therefore, the nurse should determine the client's
understanding of the procedure to reinforce necessary teaching, which can help
manage their anxiety.
A nurse is caring for a client who reports stomatitis. Which of the following dietary
recommendations should the nurse make? - Eat soft foods.
Rationale:
The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods
to decrease irritation to the oral mucosa.
-----------------
Instruct the client to avoid seasoning foods with salt or spices that can irritate the
oral mucosa.
