RN Adult Medical Surgical All Questions and
answers 100% verified
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 providing teaching to a client who has end-stage kidney disease and is waiting for a
kidney transplant. Which of the following information should the nurse provide?
Hemodialys is something required following surgery.
Rationale: When a kidney comes from a deceased donor, it might not function immediately,
requiring the recipient to continue hemodialysis postoperatively.
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations
should the nurse expect?
answers 100% verified
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 providing teaching to a client who has end-stage kidney disease and is waiting for a
kidney transplant. Which of the following information should the nurse provide?
Hemodialys is something required following surgery.
Rationale: When a kidney comes from a deceased donor, it might not function immediately,
requiring the recipient to continue hemodialysis postoperatively.
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations
should the nurse expect?
