RN Adult Medical Surgical Online
Practice 2023 B
A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after
hospitalization for heart failure. Based on the information in the client's chart, which of the
following findings should the nurse report to the provider? (Click on the "Exhibit" button for
additional information about the client. There are three tabs that contain separate categories
of data.)
Heart rate 55/min
Rational:
The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can
indicate the development of digoxin toxicity. The nurse should report this finding to the
provider.
A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation
(TENS) for the management of bone cancer pain. Thenurse should explain that applying a
TENS unit to the painful area has which of the following effects?
A tingling sensation replacing the pain
Rational:
A TENS unit applies small electric currents to the painful area, with the client increasing the
current until the "pins and needles" sensation overrides the pain.
Brainpower
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A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a componentof Cushing's triad?
Bradycardia
,Rational:
A client who has increased intracranial pressure from a traumatic brain injury can develop
bradycardia, which is one component of Cushing's triad. The other components of Cushing's
triad are severe hypertension and a widened pulse pressure.
A nurse is teaching a family about the care of a parent who has a new diagnosis of
Alzheimer's disease. Which of the following information shouldthe nurse include in the
teaching?
Create complete outfits and allow the client to select one each day.
Rational:
The family should place completed outfits on hangers and allow the client to select which
one to wear each day.
A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should thenurse include in the plan
of care to prevent a Pseudomonas aeruginosa infection?
Avoid placing plants or flowers in the client's room.
Rational:
Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause
life-threatening complications. The nurse should ensure no one brings live plants or flowers
into the client's room.
A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of
the following instructions should the nurse include in the teaching?
Increase fiber intake to at least 30 g per day.
Rational:
Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
Low urine specific gravity
Rational:
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 caring for a client who has a new prescription for total parenteral nutrition (TPN).
The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump
should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing zero.)
167 mL/hr
Rational:
mL/hr =
4000/24 = 166.6 = 167
A nurse is caring for a client who is 4 hr postoperative following a totalvaginal
hysterectomy.Click to highlight the findings the nurse should report to the provider
immediately.
Perineal pad saturated with blood, large clots present
Change of blood pressure, heart rate of 102/min
Rational:
Perineal pad saturated with blood, large clots present, blood pressure trend, and heart rate
of 102/min are correct. The client has manifestations of vaginal hemorrhage, including
vaginal bleeding, blood clots, reduced blood pressure, and tachycardia. The nurse should
report these findings to the provider.
A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place
which of the following items at the client's bedside?
Suction machine
Rational:
The nurse should ensure that a suction machine is at the bedside of a client who has
dysphagia to clear the client's airway as needed and reduce the risk for aspiration.
A nurse is providing discharge teaching about infection prevention to a client who is
receiving chemotherapy. Which of the following statements by the client indicates
understanding of the teaching?
"I can ask a friend to change my cats litter box."
Rational:
Changing a pet's litter box increases the client's risk of being exposed to toxoplasmosis.
Therefore, the client should wear gloves or avoid changing the pet's litter box.
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago.
Which of the following actions should the nurse take?
Practice 2023 B
A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after
hospitalization for heart failure. Based on the information in the client's chart, which of the
following findings should the nurse report to the provider? (Click on the "Exhibit" button for
additional information about the client. There are three tabs that contain separate categories
of data.)
Heart rate 55/min
Rational:
The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can
indicate the development of digoxin toxicity. The nurse should report this finding to the
provider.
A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation
(TENS) for the management of bone cancer pain. Thenurse should explain that applying a
TENS unit to the painful area has which of the following effects?
A tingling sensation replacing the pain
Rational:
A TENS unit applies small electric currents to the painful area, with the client increasing the
current until the "pins and needles" sensation overrides the pain.
Brainpower
Read More
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:00
Full screen
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a componentof Cushing's triad?
Bradycardia
,Rational:
A client who has increased intracranial pressure from a traumatic brain injury can develop
bradycardia, which is one component of Cushing's triad. The other components of Cushing's
triad are severe hypertension and a widened pulse pressure.
A nurse is teaching a family about the care of a parent who has a new diagnosis of
Alzheimer's disease. Which of the following information shouldthe nurse include in the
teaching?
Create complete outfits and allow the client to select one each day.
Rational:
The family should place completed outfits on hangers and allow the client to select which
one to wear each day.
A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should thenurse include in the plan
of care to prevent a Pseudomonas aeruginosa infection?
Avoid placing plants or flowers in the client's room.
Rational:
Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause
life-threatening complications. The nurse should ensure no one brings live plants or flowers
into the client's room.
A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of
the following instructions should the nurse include in the teaching?
Increase fiber intake to at least 30 g per day.
Rational:
Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
Low urine specific gravity
Rational:
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 caring for a client who has a new prescription for total parenteral nutrition (TPN).
The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump
should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing zero.)
167 mL/hr
Rational:
mL/hr =
4000/24 = 166.6 = 167
A nurse is caring for a client who is 4 hr postoperative following a totalvaginal
hysterectomy.Click to highlight the findings the nurse should report to the provider
immediately.
Perineal pad saturated with blood, large clots present
Change of blood pressure, heart rate of 102/min
Rational:
Perineal pad saturated with blood, large clots present, blood pressure trend, and heart rate
of 102/min are correct. The client has manifestations of vaginal hemorrhage, including
vaginal bleeding, blood clots, reduced blood pressure, and tachycardia. The nurse should
report these findings to the provider.
A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place
which of the following items at the client's bedside?
Suction machine
Rational:
The nurse should ensure that a suction machine is at the bedside of a client who has
dysphagia to clear the client's airway as needed and reduce the risk for aspiration.
A nurse is providing discharge teaching about infection prevention to a client who is
receiving chemotherapy. Which of the following statements by the client indicates
understanding of the teaching?
"I can ask a friend to change my cats litter box."
Rational:
Changing a pet's litter box increases the client's risk of being exposed to toxoplasmosis.
Therefore, the client should wear gloves or avoid changing the pet's litter box.
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago.
Which of the following actions should the nurse take?
