PN Medical Surgical Practice 2020
ALL CORRECT ANSWERS 100%
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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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.
Instruct the client to eat foods that are high in protein and calories to increase their caloric
intake and nutrition.
Instruct the client to choose foods that are a lukewarm or cool temperature to prevent irritation
, of the client's oral mucosa.
A nurse is planning to implement droplet precautions for a client who has manifestations of
pertussis. Which of teh following interventions should the nurse include when contributing to
the plan of care? - ANS ✅Apply a mask on the client if transport is needed.
Raitonale:
The nurse should apply a mask to a client who has manifestations of pertussis during transport
to prevent exposure to others.
A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities
should the nurse recommend to promote sleep? - ANS ✅Listen to soft music before sleeping.
Rationale:
Listening to soft music can help the client to relax and reduces environmental stressors.
A nurse is contributing to the plan of care for a client who is having difficulty eating following a
stroke. Which of the following actions should the nurse take first? - ANS ✅Implement
recommendation from the speech language pathologist.
Rationale:
The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first
intervention the nurse should include in the plan of care is to implement recommendations from
the speech language pathologist. A speech language pathologist can conduct a swallow study to
determine the client's risk for aspiration, provide teaching to the client regarding swallowing
techniques, and recommend the consistency of foods and liquids for the client.
A nurse is assisting in the plan of care regarding bowel retraining for a client who has acervical
spinal cord injury. Which of the following interventions should the nurse plan to implement first?
- ANS ✅Determine the client's daily elimination habits.
Rationale:
ALL CORRECT ANSWERS 100%
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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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? - ANS ✅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.
Instruct the client to eat foods that are high in protein and calories to increase their caloric
intake and nutrition.
Instruct the client to choose foods that are a lukewarm or cool temperature to prevent irritation
, of the client's oral mucosa.
A nurse is planning to implement droplet precautions for a client who has manifestations of
pertussis. Which of teh following interventions should the nurse include when contributing to
the plan of care? - ANS ✅Apply a mask on the client if transport is needed.
Raitonale:
The nurse should apply a mask to a client who has manifestations of pertussis during transport
to prevent exposure to others.
A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities
should the nurse recommend to promote sleep? - ANS ✅Listen to soft music before sleeping.
Rationale:
Listening to soft music can help the client to relax and reduces environmental stressors.
A nurse is contributing to the plan of care for a client who is having difficulty eating following a
stroke. Which of the following actions should the nurse take first? - ANS ✅Implement
recommendation from the speech language pathologist.
Rationale:
The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first
intervention the nurse should include in the plan of care is to implement recommendations from
the speech language pathologist. A speech language pathologist can conduct a swallow study to
determine the client's risk for aspiration, provide teaching to the client regarding swallowing
techniques, and recommend the consistency of foods and liquids for the client.
A nurse is assisting in the plan of care regarding bowel retraining for a client who has acervical
spinal cord injury. Which of the following interventions should the nurse plan to implement first?
- ANS ✅Determine the client's daily elimination habits.
Rationale:
