RN ADULT MEDICAL ONLINE PRACTICE 2019 B
A nurse is assessing for compartment syndrome in a client who has a short leg cast.
Which of the following findings should the nurse identify as a manifestation of this
condition?
Pain that increases with passive movement
Rationale: The nurse should identify that a client who has compartment syndrome
experiences pain that increases with passive movement. Compartment syndrome
results from a decrease in blood flow in the extremity caused by a decrease in the
muscle compartment size due to a cast that is too tight.
A nurse is providing teaching to a client who has a severe form of stage II Lyme
disease. Which of the following statements made by the client reflects an understanding
of the teaching?
My joints ache because I have Lyme disease
Rationale: Lyme disease is a vector-borne illness transmitted by the deer tick. The
disease course occurs in three stages beginning with joint and muscle pain in stage I. If
left untreated, these symptoms continue throughout stage II and, by stage III, become
A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount
available is oral solution 125 mg/5 mL. How many mL should the nurse administer?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not
use a trailing zero.)
24
A nurse is caring for a client who has an arterial line. Which of the following actions
should the nurse take?
place a pressure bag around the flush solution
Rationale: The nurse should place a pressure bag around the flush solution of 0.9%
sodium chloride because the pressure from an artery is greater than that of the line.
An arterial line is not appropriate access for administering antibiotics. The nurse should
use the arterial line to obtain arterial blood gas samples and monitor hemodynamic
pressures.
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of
the following findings should the nurse identify as the priority?
Report of sore throat
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is a report of a sore throat, which could be a
manifestation of an infection. The client is at risk for neutropenia due to
myelosuppression; therefore, an infection could lead to sepsis.
A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus (SLE). Which of the following findings should the nurse expect?
Facial butterfly rash
Rationale: A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the
client's cheeks and nose and can disappear during times of remission.
, A nurse is planning care for a client who is postoperative following a parathyroidectomy.
Which of the following actions should the nurse identify as the priority?
Place tracheostomy tray at the bedside
Rationale: The priority action the nurse should take when using the airway, breathing,
circulation approach to client care is to place a tracheostomy tray at the client's bedside
in case of airway obstruction.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
Low urine specific gravity
Rationale: An expected finding for a client who has diabetes insipidus is a urine specific
gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is
caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness
to the hormone.
A nurse is providing teaching to a client who has stage II cervical cancer and is
scheduled for brachytherapy. Which of the following instructions should the nurse
include?
You will need to stay still in the bed during each treatment session."
Rationale: The nurse should instruct the client that they will need to remain on bed rest
with very limited movement because excessive movement can cause the radioactive
source to become dislodged.
The nurse should instruct the client that there is not excreted radiation between
treatments.
The nurse should instruct the client that there will likely be between two and five
treatments, once or twice each week.
The nurse should instruct the client that blood in the urine is an adverse effect of
brachytherapy and is not an expected finding.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the
following interventions should the nurse include in the plan?
Encourage the client to take deep breaths after the procedure.
Rationale: After a thoracentesis, the client should deep breathe to re-expand the lung.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following
actions should the nurse anticipate taking?
Slow the infusion rate
Rationale: Dyspnea, restlessness, and the onset of crackles during a blood transfusion
are manifestations of circulatory overload. The nurse should slow or stop the infusion to
improve the client's ability to breathe, place the client in an upright position, and notify
the provider. The provider might prescribe a diuretic to alleviate the fluid overload.
A nurse is assessing for compartment syndrome in a client who has a short leg cast.
Which of the following findings should the nurse identify as a manifestation of this
condition?
Pain that increases with passive movement
Rationale: The nurse should identify that a client who has compartment syndrome
experiences pain that increases with passive movement. Compartment syndrome
results from a decrease in blood flow in the extremity caused by a decrease in the
muscle compartment size due to a cast that is too tight.
A nurse is providing teaching to a client who has a severe form of stage II Lyme
disease. Which of the following statements made by the client reflects an understanding
of the teaching?
My joints ache because I have Lyme disease
Rationale: Lyme disease is a vector-borne illness transmitted by the deer tick. The
disease course occurs in three stages beginning with joint and muscle pain in stage I. If
left untreated, these symptoms continue throughout stage II and, by stage III, become
A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount
available is oral solution 125 mg/5 mL. How many mL should the nurse administer?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not
use a trailing zero.)
24
A nurse is caring for a client who has an arterial line. Which of the following actions
should the nurse take?
place a pressure bag around the flush solution
Rationale: The nurse should place a pressure bag around the flush solution of 0.9%
sodium chloride because the pressure from an artery is greater than that of the line.
An arterial line is not appropriate access for administering antibiotics. The nurse should
use the arterial line to obtain arterial blood gas samples and monitor hemodynamic
pressures.
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of
the following findings should the nurse identify as the priority?
Report of sore throat
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is a report of a sore throat, which could be a
manifestation of an infection. The client is at risk for neutropenia due to
myelosuppression; therefore, an infection could lead to sepsis.
A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus (SLE). Which of the following findings should the nurse expect?
Facial butterfly rash
Rationale: A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the
client's cheeks and nose and can disappear during times of remission.
, A nurse is planning care for a client who is postoperative following a parathyroidectomy.
Which of the following actions should the nurse identify as the priority?
Place tracheostomy tray at the bedside
Rationale: The priority action the nurse should take when using the airway, breathing,
circulation approach to client care is to place a tracheostomy tray at the client's bedside
in case of airway obstruction.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
Low urine specific gravity
Rationale: An expected finding for a client who has diabetes insipidus is a urine specific
gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is
caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness
to the hormone.
A nurse is providing teaching to a client who has stage II cervical cancer and is
scheduled for brachytherapy. Which of the following instructions should the nurse
include?
You will need to stay still in the bed during each treatment session."
Rationale: The nurse should instruct the client that they will need to remain on bed rest
with very limited movement because excessive movement can cause the radioactive
source to become dislodged.
The nurse should instruct the client that there is not excreted radiation between
treatments.
The nurse should instruct the client that there will likely be between two and five
treatments, once or twice each week.
The nurse should instruct the client that blood in the urine is an adverse effect of
brachytherapy and is not an expected finding.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the
following interventions should the nurse include in the plan?
Encourage the client to take deep breaths after the procedure.
Rationale: After a thoracentesis, the client should deep breathe to re-expand the lung.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following
actions should the nurse anticipate taking?
Slow the infusion rate
Rationale: Dyspnea, restlessness, and the onset of crackles during a blood transfusion
are manifestations of circulatory overload. The nurse should slow or stop the infusion to
improve the client's ability to breathe, place the client in an upright position, and notify
the provider. The provider might prescribe a diuretic to alleviate the fluid overload.
