PRACTICE 2023 B QUESTIONS WELL
SOLVED
Aplnurseplinplaplmedical-surgicalplunitplisplcaringplforplsixplclients.
Completepltheplfollowingplsentenceplbyplusingplthepllistplofploptions.
Theplfirstplclientpltheplnurseplshouldplassessplispl_____plfollowedplbypl_____.
Clientpl1:plClientplispladmittedplwithplaplnewpldiagnosisplofplrheumatoidplarthritis.Clientpl2:plClie
ntplhasplaplhistoryplofplhyperlipidemia.plAtorvastatinpl20plmgplPOpladministeredplasplprescribed
.Clientpl3:plClientplispl1pldayplpostoperative.plReportsplpainplaspl8plonplaplscaleplofpl0pltopl10.plMor
phinepl5plmgplsubcutaneouspladministeredplasplprescribed.Clientpl4:plClientplispladmittedplwith
plaplnewpldiagnosisplofplheartplfailure.Clientpl5:plClientplhasplaplstagepl2plpressureplinjuryplonplthe
plleftplheel.Clientpl6:plClientplispladmittedplwithplaplnewpldiagnosisplofpldiabetesplmellitus.pl-
plANS--CorrectplAnswerpl(1):
Clientpl3
Whenplusingpltheplairway,plbreathing,plcirculationplapproachpltoplclientplcare,pltheplnurseplshou
ldpldetermineplthatplthisplclientplispltheplpriorityplclientpltoplassess.plTheplclientplhasplanploxygenpl
saturationplthatplispllessplthanpltheplexpectedplreferenceplrange,plwhichplisplanplindicationplofplhy
poxia.
CorrectplAnswerpl(2):
Clientpl4
Whenplusingpltheplairway,plbreathing,plcirculationplapproachpltoplclientplcare,pltheplnurseplshou
ldpldetermineplthatplthisplclientplispltheplnextplpriorityplclientpltoplassess.plTheplclientplhasplaplpota
ssiumpllevelplthatplispllessplthanpltheplexpectedplreferenceplrange,plwhichplplacespltheplclientplat
plriskplforpldysrhythmias.
IncorrectplAnswerspl(1):
Clientpl1plisplincorrect.plTheplnurseplshouldplassessplthisplclientplbecausepltheplclient'splC-
reactiveplproteinplisplgreaterplthanpltheplexpectedplreferenceplrange,plwhichplisplanplindicationpl
ofplinflammation.plHowever,plthereplisplanotherplclientpltheplnurseplshouldplassessplfirst.
Clientpl2plisplincorrect.plTheplnurseplshouldplassessplthisplclientplbecausepltheplclient'splcholest
erolpllevelplisplgreaterplthanpltheplexpectedplreferenceplrange,plwhichplplacesplthemplatplriskplfor
plcoronaryplheartpldisease.plHowever,plthereplisplanotherplclientpltheplnurseplshouldplassessplfir
st.
,IncorrectplAnswerspl(2):
Clientpl5plisplincorrect.plTheplnurseplshouldplassessplthisplclientplbecausepltheirplprealbuminplle
velplispllessplthanpltheplexpectedplreferenceplrange,plwhichplplacesplthemplatplriskplforpldelayedpl
woundplhealing.plHowever,plthisplclientplisplnotpltheplnextplpriorityplclientpltoplassess.
Clientpl6plisplincorrect.plTheplnurseplshouldplassessplthisplclientplbecausepltheirplglycosylatedplh
emoglobinpllevelplisplgreaterplthanpltheplexpectedplreferenceplrange,plwhichplindicatesplpoorpldi
abeticplcontrol.plHowever,plthisplclientplisplnotpltheplnextplpriorityplclientpltoplassess.
AplnurseplisplcaringplforplaplclientplwhoplhasplCOPD.
Selectplthepl3plfindingsplthatplrequireplfollow-up.
Breathplsounds
Bloodplpressure
Oxygenplsaturation
Temperature
Heartplratepl-plANS--CorrectplAnswer:
BreathplSounds
Cracklesplareplcausedplbyplmucousplinpltheplairwaysplandplareplaplmanifestationplofplpneumoni
a.plDecreasedplbreathplsoundsplindicatepldecreasedplventilationplandplrequireplfollow-
upplbypltheplnurse.
OxygenplSaturation
Theplclient'sploxygenplsaturationplisplbelowpltheplexpectedplreferenceplrangeplofpl95%pltopl100
%,plindicatingplhypoxia,plandplrequiresplfollow-upplbypltheplnurse.
Temperature
Theplclient'spltemperatureplisplgreaterplthanpltheplexpectedplreferenceplrange,plindicatingplanpli
nfection,plandplrequiresplfollow-upplbypltheplnurse.
IncorrectplAnswer:
Bloodplpressureplisplincorrect.plTheplclient'splbloodplpressureplisplwithinpltheplexpectedplreferen
ceplrangeplandpldoesplnotplrequireplfollow-upplbypltheplnurse.
Heartplrateplisplincorrect.plTheplclient'splheartplrateplisplwithinpltheplexpectedplreferenceplrangepl
ofpl60pltopl100/minplandpldoesplnotplrequireplfollow-upplbypltheplnurse.
Aplnurseplinpltheplemergencypldepartmentpl(ED)plisplcaringplforplaplclientplwhoplreportsplabdomi
nalplpain.pl
Basedplonpltheplclient'splclinicalplfindings,plwhichplofpltheplfollowingplactionsplshouldpltheplnurse
pltake?plSelectplallplthatplapply.
Assistpltheplclientpltoplaplleftplside-lyingplpositionplwithpltheplrightplkneeplflexed.
Preparepltheplclientplforplaplchestplx-ray.
,Administerplaplcleansingplenema.
Auscultatepltheplclient'splbowelplsounds.
Performplaplmanualpldigitalplexaminationplofpltheplclient'splrectum.
Administerploxycodoneplextended-releasepltablets.
PreparepltheplclientplforplNGpltubeplplacement.pl-plANS--CorrectplAnswer:
Assistpltheplclientpltoplaplleftplside-lyingplpositionplwithpltheplrightplkneeplflexedpl
Theplnurseplshouldplplacepltheplclientplinplaplleftplside-
lyingplpositionplwithpltheplrightplkneeplflexedplpriorpltopladministeringplanplenema.plBecauseplth
eplproviderplprescribedplaplcleansingplenemaplforpltheplclient,pltheplnurseplshouldplprepareplthepl
clientplforpltheplprocedure.
Administerplaplcleansingplenemapl
Theplnurseplshouldpladministerplaplcleansingplenemaplforpltheplclientplasplaplresultplofpltheplprovi
der'splprescription.plAplcleansingplenemaplisplintendedpltoplassistplwithplbowelpleliminationpland
plremoveplanyplimpactedplfecalplmatterplindicatedplbypltheplabdominalplx-ray.
Auscultatepltheplclient'splbowelplsoundspl
Theplnurseplshouldplauscultatepltheplclient'splbowelplsoundspltopldeterminepltheplstatusplofplthepl
client'splperistalsis.plThisplisplaplnecessaryplpartplofpldeterminingpltheplpresenceplofplbowelplsou
nds,plwhichplareplanplindicationplofpltheplstatusplofpltheplclient'splgastrointestinalpltract.
Performplaplmanualpldigitalplexaminationplofpltheplclient'splrectum
Theplnurseplshouldplperformplaplmanualpldigitalplexaminationplofpltheplclient'splrectumpltopldeter
mineplifplimpactedplstoolplisplpresent.plThisplisplaplpartplofpltheplnecessaryplevaluationplofpltheplst
atusplofpltheplclient'splgastrointestinalpltract.
IncorrectplAnswer:
Preparepltheplclientplforplaplchestplx-rayplisplincorrect.plAplchestplx-
rayplispltypicallyplperformedplforplaplclientplwhoplhasplanplimpairmentplofpltheplupperplthoraxplorpll
ungs,plnotpltheplabdomen.plTheplclientplhasplalreadyplreceivedplanplabdominalplx-
ray;pltherefore,plaplchestplx-rayplisplnotplnecessary.
PreparepltheplclientplforplNGpltubeplplacementplisplincorrect.plTheplnurseplshouldplnotplpreparepl
theplclientplforplplacementplofplanplNGpltubeplbecauseplthereplisplnoplindicationplorplprescriptionpl
topldoplso.plPlacementplofplanplNGpltubeplisplrequiredplwhenplthereplisplanplobstructionplofpltheplg
astrointestinalpltractplandplperistalsisplisplabsent.
Aplnurseplisplcaringplforplaplclientplwhoplasksplaboutpltheplpurposeplofpladvancepldirectives.plWhi
chplofpltheplfollowingplstatementsplshouldpltheplnurseplmake?
"Theyplallowpltheplcourtpltoploverruleplanpladultplclient'splrefusalplofplmedicalpltreatment."
"Theyplindicatepltheplformplofpltreatmentplaplclientplisplwillingpltoplacceptplinplthepleventplofplaplseri
ousplillness."
"Theyplpermitplaplclientpltoplwithholdplmedicalplinformationplfromplhealthplcareplpersonnel."
"Theyplallowplhealthplcareplpersonnelplinpltheplemergencypldepartmentpltoplstabilizeplaplclient's
plcondition."pl-plANS--CorrectplAnswer:
, "Theyplindicatepltheplformplofpltreatmentplaplclientplisplwillingpltoplacceptplinplthepleventplofplaplseri
ousplillness."
Advancepldirectivesplincludeplapllivingplwill,plwhichplpermitsplclientspltopldirectplthepltreatmentplt
heyplwillplreceiveplinplthepleventplofplaplmedicalplemergencyplorplseriousplillness.
IncorrectplAnswer:
"Theyplallowpltheplcourtpltoploverruleplanpladultplclient'splrefusalplofplmedicalpltreatment."
Aplcourtplcanplonlyploverruleplanpladultplclient'splrefusalplofplmedicalpltreatmentplifpltheplclientplispl
legallyplincompetent.
"Theyplpermitplaplclientpltoplwithholdplmedicalplinformationplfromplhealthplcareplpersonnel."
TheplAmericansplwithplDisabilitiesplAct,plnotpladvancepldirectives,plprotectspltheplprivacyplofplapl
clientplwhoplchoosesplnotpltopldiscloseplaplmedicalpldisability.
"Theyplallowplhealthplcareplpersonnelplinpltheplemergencypldepartmentpltoplstabilizeplaplclient's
plcondition."
TheplEmergencyplMedicalplTreatmentplandplActiveplLaborplAct,plnotpladvancepldirectives,pldir
ectsplemergencyplpersonnelpltoplprovideplscreeningplandplstabilizingplcareplbeforepldischargin
gplorpltransferringplclientspltoplanotherplfacility.
Aplnurseplisplcaringplforplaplclientplwhoplhasplaplprescriptionplforpl5plunitsplofplregularplinsulinpland
pl10plunitsplofplNPHplinsulinpltoplmixpltogetherplandpladministerplsubcutaneously.plDetermineplt
heplcorrectplorderplofplstepsplforplthisplprocedure.pl
Injectpl5plunitsplofplairplintopltheplbottleplofplregularplinsulin
WithdrawpltheplcorrectpldoseplofplNPHplinsulinplfrompltheplbottle
Injectpl10plunitsplofplairplintopltheplbottleplofplNPHplinsulin
Withdrawpltheplcorrectpldoseplofplregularplinsulinplfrompltheplbottlepl-plANS--CorrectplAnswer:
Injectpl10plunitsplofplairplintopltheplbottleplofplNPHplinsulin
Injectpl5plunitsplofplairplintopltheplbottleplofplregularplinsulin
Withdrawpltheplcorrectpldoseplofplregularplinsulinplfrompltheplbottle
WithdrawpltheplcorrectpldoseplofplNPHplinsulinplfrompltheplbottle
TheplnurseplshouldplfirstplinjectplairplintopltheplvialplofplNPHplinsulinplwithoutpltouchingpltheplneed
lepltopltheplsolution.plNext,pltheplnurseplshouldplinjectplairplintopltheplvialplofplregularplinsulinplandpl
withdrawpltheplcorrectplamountplofpltheplregularplinsulin.plFinally,pltheplnurseplshouldplinsertplth
eplneedleplintopltheplNPHplinsulinplvialplandplwithdrawpltheplcorrectplamountplofplNPHplinsulin.plT
heplnurseplshouldplfollowpltheseplstepspltoplpreventplcontaminatingpltheplregularplinsulinplwithpl
NPHplinsulin.
AplnurseplisplperformingplaplRombergpltestplduringpltheplphysicalplassessmentplofplaplclient.plW
hichplofpltheplfollowingpltechniquesplshouldpltheplnursepluse?
Touchpltheplfaceplwithplaplcottonplball.
Applyplaplvibratingpltuningplforkpltopltheplclient'splforehead.
Havepltheplclientplstandplwithpltheirplarmsplatpltheirplsidesplandpltheirplfeetpltogether.