Prophecy medical surgical-telemetry exam Grade A+ 2023-
Medical-Surgical RN A Prophecy Relias Exam 2023 latest
update&Prophecy health medical surgical RN A with complete
solution 2023
A nurse notes a small section of bowel protruding from the abdominal incision of a client whois
postoperative. After calling for assistance, which of the following actions should the nurse take first?
A. Cover the client's wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client's vital signs.
D. Inform the client about the need to return to surgery. - ANSWER: A. Cover the client's wound with
a moist, sterile dressing.
For the client undergoing hemodialysis, the nurse suspects the client has an air embolism. What
symptoms lead the nurse to this conclusion? (Select all that apply.)
A.
Dyspnea
B.
B/P 168/92 mm Hg
C.
Chest pain
D.
Anxiety
E.
O2 saturation of 98%
F.
Blue nail beds - ANSWER: A. Dyspnea
C. Chest Pain
D. Anxiety
F. Blue nail neds
Rationale: For the client experiencing an air embolism, the nurse will see hypotension and not
hypertension. The O2 saturation will also fall with an air embolism. The remaining are signs of an air
embolism.
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the
prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
C. Thick, red-colored urine
D. Pain level of 4 on a 0 to 10 rating scale - ANSWER: C. Thick, red-colored urine
A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed
placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have
not yet been started. Which action should the nurse take prior to administering the prescribed
medication?
A.Assess for signs of jugular venous distention.
B.Obtain the needed intravenous solution.
C.Flush the line with heparinized solution.
D.Flush the line with normal saline. - ANSWER: D. Flush the line with normal saline.
,Rationale:Medication can be administered via a central line without additional IV fluids. The line
should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on
the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer
the medication and is not a priority. Administration of the medication STAT is of greater priority than
option B.
One day after a Billroth II surgery, the client suddenly grabs his right chest and becomes pale and
diaphoretic. Vital signs are assessed as blood pressure 100/80 mm Hg, pulse 110 beats/min, and
respirations 36 breaths/min. Which action is most important for the nurse to take?
A. Provide a paper bag for his hyperventilation.
B. Administer a prescribed PRN analgesic.
C. Have the client drink a glass of sweetened fruit juice.
D. Apply oxygen at 2 L via nasal cannula. - ANSWER: D. Apply oxygen at 2 L via nasal cannula.
Rationale: Pulmonary embolism and pneumothorax are risks associated with major abdominal
surgery. The nurse should immediately provide oxygen while performing further assessment. A rapid
respiratory rate should not be treated as hyperventilation. Option B should not be administered until
more ominous causes are ruled out or treated. There is no evidence that the client is hypoglycemic.
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a
hypothermia blanket. The nurse should monitor the client for which of the following adverse effects
of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia - ANSWER: A. Shivering
A 77-year-old client is admitted to the hospital with confusion and anorexia of several days' duration.
Additional symptoms reported are nausea and vomiting, and current complaints of a headache. The
client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to
which medication?
A. Warfarin
B. Ibuprofen
C. Nitroglycerin
D. Digoxin - ANSWER: D. Digoxin
Rationale: Older persons are particularly susceptible to the buildup of cardiac glycosides, such as
digoxin or digitoxin (medications derived from digitalis), to a toxic level in their systems. Toxicity can
cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Options A, B, and C are unlikely to
result in the symptoms described.
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of
the following statements by the client indicates an understanding of the teaching?
A. "I will carry a complex carbohydrate snack with me when I exercise."
B. "I should exercise first thing in the morning before eating breakfast."
C. "I should avoid injecting insulin into my thigh if I am going to go running."
D. "I will not exercise if my urine is positive for ketones." - ANSWER: D. "I will not exercise if my urine
is positive for ketones."
The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA).
What actions will the nurse include in the client's plan of care? (Select all that apply.)
A. Frequent vital signs.
B. Determine if the client is allergic to aspirin.
C. Assist out of bed 2 hours after return from the procedure.
D. Offer fluids of choice.
E. Assess distal pulses on the side of the procedure.
F. Monitor infusion of IV nitroglycerine. - ANSWER: A. Frequent vital signs.
, B. Determine if the client is allergic to aspirin.
D. Offer fluids of choice.
F. Monitor infusion of IV nitroglycerine.
Rationale: The client's incisional leg needs to stay straight for 6 to 8 hours to decrease the risk of
hemorrhage from the incision site. Pulses must be assessed bilaterally for a point of comparison. The
remaining actions are included in the care plan for the client after a PTCA.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test
results to indicate a decreased serum level of which substance?
A. Sodium
B. Phosphate
C. Potassium
D. Glucose - ANSWER: C. Potassium
Rationale: Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium;
hypokalemia; hypertension is the most prominent and universal sign. The serum sodium level is
normal or elevated, depending on the amount of water resorbed with the sodium. Option B is
influenced by parathyroid hormone (PTH). Option D is not affected by primary aldosteronism.
A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of
102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment?
(Select all that apply.)
A. Nausea and vomiting
B. Loss of appetite
C. Abdominal cramping
D. Guarding with abdominal palpation
E. Low urine output
F. Cool, clammy skin - ANSWER: A. Nausea and vomiting
B. Loss of appetite
C. Abdominal cramping
D. Guarding with abdominal palpation
Rationale:The client is showing signs of peritonitis with the sudden spike in temperature. Low urine
output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical emergency and the
health care provider must be notified immediately.
The client is return demonstrating wrapping of the left limb amputated above the knee. The nurse
evaluates the client is starting the wrapping method correctly when the client places the end of the
bandage at which point?
A. Around the waist
B. At the inner aspect of the left stump
C. At the outer aspect of the left stump
D. At the left groin area - ANSWER: A. Around the waist
Rationale: The waist is the anchor point for the bandage for an above the knee amputation.
The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing in place to the
mid abdomen. The nurse notes a spot of red staining centrally on the dressing. What is the nurse's
next action?
A. Note the size of the stain in the chart.
B. Circle the stain with an ink pen.
C. Remove the dressing to assess the source of the bleeding.
D. Place a pressure dressing on the existing dressing - ANSWER: B. Circle the stain with an ink pen.
Rationale: By circling the existing stain upon admission to the unit, the nurse can then assess any
increase, though subtle, in the amount of drainage over time. The size of the stain will need to be
noted in the chart, but it is not the first action. The nurse removes the dressing under the prescription
Medical-Surgical RN A Prophecy Relias Exam 2023 latest
update&Prophecy health medical surgical RN A with complete
solution 2023
A nurse notes a small section of bowel protruding from the abdominal incision of a client whois
postoperative. After calling for assistance, which of the following actions should the nurse take first?
A. Cover the client's wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client's vital signs.
D. Inform the client about the need to return to surgery. - ANSWER: A. Cover the client's wound with
a moist, sterile dressing.
For the client undergoing hemodialysis, the nurse suspects the client has an air embolism. What
symptoms lead the nurse to this conclusion? (Select all that apply.)
A.
Dyspnea
B.
B/P 168/92 mm Hg
C.
Chest pain
D.
Anxiety
E.
O2 saturation of 98%
F.
Blue nail beds - ANSWER: A. Dyspnea
C. Chest Pain
D. Anxiety
F. Blue nail neds
Rationale: For the client experiencing an air embolism, the nurse will see hypotension and not
hypertension. The O2 saturation will also fall with an air embolism. The remaining are signs of an air
embolism.
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the
prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
C. Thick, red-colored urine
D. Pain level of 4 on a 0 to 10 rating scale - ANSWER: C. Thick, red-colored urine
A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed
placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have
not yet been started. Which action should the nurse take prior to administering the prescribed
medication?
A.Assess for signs of jugular venous distention.
B.Obtain the needed intravenous solution.
C.Flush the line with heparinized solution.
D.Flush the line with normal saline. - ANSWER: D. Flush the line with normal saline.
,Rationale:Medication can be administered via a central line without additional IV fluids. The line
should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on
the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer
the medication and is not a priority. Administration of the medication STAT is of greater priority than
option B.
One day after a Billroth II surgery, the client suddenly grabs his right chest and becomes pale and
diaphoretic. Vital signs are assessed as blood pressure 100/80 mm Hg, pulse 110 beats/min, and
respirations 36 breaths/min. Which action is most important for the nurse to take?
A. Provide a paper bag for his hyperventilation.
B. Administer a prescribed PRN analgesic.
C. Have the client drink a glass of sweetened fruit juice.
D. Apply oxygen at 2 L via nasal cannula. - ANSWER: D. Apply oxygen at 2 L via nasal cannula.
Rationale: Pulmonary embolism and pneumothorax are risks associated with major abdominal
surgery. The nurse should immediately provide oxygen while performing further assessment. A rapid
respiratory rate should not be treated as hyperventilation. Option B should not be administered until
more ominous causes are ruled out or treated. There is no evidence that the client is hypoglycemic.
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a
hypothermia blanket. The nurse should monitor the client for which of the following adverse effects
of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia - ANSWER: A. Shivering
A 77-year-old client is admitted to the hospital with confusion and anorexia of several days' duration.
Additional symptoms reported are nausea and vomiting, and current complaints of a headache. The
client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to
which medication?
A. Warfarin
B. Ibuprofen
C. Nitroglycerin
D. Digoxin - ANSWER: D. Digoxin
Rationale: Older persons are particularly susceptible to the buildup of cardiac glycosides, such as
digoxin or digitoxin (medications derived from digitalis), to a toxic level in their systems. Toxicity can
cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Options A, B, and C are unlikely to
result in the symptoms described.
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of
the following statements by the client indicates an understanding of the teaching?
A. "I will carry a complex carbohydrate snack with me when I exercise."
B. "I should exercise first thing in the morning before eating breakfast."
C. "I should avoid injecting insulin into my thigh if I am going to go running."
D. "I will not exercise if my urine is positive for ketones." - ANSWER: D. "I will not exercise if my urine
is positive for ketones."
The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA).
What actions will the nurse include in the client's plan of care? (Select all that apply.)
A. Frequent vital signs.
B. Determine if the client is allergic to aspirin.
C. Assist out of bed 2 hours after return from the procedure.
D. Offer fluids of choice.
E. Assess distal pulses on the side of the procedure.
F. Monitor infusion of IV nitroglycerine. - ANSWER: A. Frequent vital signs.
, B. Determine if the client is allergic to aspirin.
D. Offer fluids of choice.
F. Monitor infusion of IV nitroglycerine.
Rationale: The client's incisional leg needs to stay straight for 6 to 8 hours to decrease the risk of
hemorrhage from the incision site. Pulses must be assessed bilaterally for a point of comparison. The
remaining actions are included in the care plan for the client after a PTCA.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test
results to indicate a decreased serum level of which substance?
A. Sodium
B. Phosphate
C. Potassium
D. Glucose - ANSWER: C. Potassium
Rationale: Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium;
hypokalemia; hypertension is the most prominent and universal sign. The serum sodium level is
normal or elevated, depending on the amount of water resorbed with the sodium. Option B is
influenced by parathyroid hormone (PTH). Option D is not affected by primary aldosteronism.
A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of
102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment?
(Select all that apply.)
A. Nausea and vomiting
B. Loss of appetite
C. Abdominal cramping
D. Guarding with abdominal palpation
E. Low urine output
F. Cool, clammy skin - ANSWER: A. Nausea and vomiting
B. Loss of appetite
C. Abdominal cramping
D. Guarding with abdominal palpation
Rationale:The client is showing signs of peritonitis with the sudden spike in temperature. Low urine
output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical emergency and the
health care provider must be notified immediately.
The client is return demonstrating wrapping of the left limb amputated above the knee. The nurse
evaluates the client is starting the wrapping method correctly when the client places the end of the
bandage at which point?
A. Around the waist
B. At the inner aspect of the left stump
C. At the outer aspect of the left stump
D. At the left groin area - ANSWER: A. Around the waist
Rationale: The waist is the anchor point for the bandage for an above the knee amputation.
The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing in place to the
mid abdomen. The nurse notes a spot of red staining centrally on the dressing. What is the nurse's
next action?
A. Note the size of the stain in the chart.
B. Circle the stain with an ink pen.
C. Remove the dressing to assess the source of the bleeding.
D. Place a pressure dressing on the existing dressing - ANSWER: B. Circle the stain with an ink pen.
Rationale: By circling the existing stain upon admission to the unit, the nurse can then assess any
increase, though subtle, in the amount of drainage over time. The size of the stain will need to be
noted in the chart, but it is not the first action. The nurse removes the dressing under the prescription
