N201 MEDSURG 2 : PRACTICE ASSESSMENT EXAM QUESTIONS
AND ANSWERS WITH COMPLETE SOLUTIONS GRADED A++
A nurse is caring for a client who has emphysema and is receiving mechanical
ventilation. The client appears anxious and restless, and the high-pressure alarm
is sounding. Which of the following actions should the nurse take first?
Obtain ABGs.
Administer propofol to the client.T
Instruct the client to allow the machine to breathe for them.
Disconnect the machine and manually ventilate the client.
c. When providing client care, the nurse should first use the least restrictive intervention.
Therefore, the first action the nurse should take is to provide verbal instructions and
emotional support to help the client relax and allow the ventilator to work. Clients can
exhibit anxiety and restlessness when trying to "fight the ventilator."
The nurse should monitor ABG results to determine the effectiveness of mechanical
ventilation, but this is not the first action the nurse should take.
The nurse might need to administer propofol to provide sedation and increase the
client's tolerance of mechanical ventilation, but this is not the first action the nurse
should take.
,Many factors can cause a high-pressure alarm to sound. The nurse might have to
disconnect the machine and manually ventilate the client if the ventilator fails or the
client experiences respiratory distress, but this is not the first action the nurse should
take.
a nurse is teaching a client who has a family history of colo-rectal cancer. to help
mitigate this risk, which of the following dietary alterations should he nurse
recommend?
add cabbage to the diet.high in fiber, low in fat, and low in refined carbohydrates.
Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
A home health nurse is assigned to a client who was recently discharged from a
rehabilitation center after experiencing a right-hemispheric stroke. Which of the
following neurologic deficits should the nurse expect to find when assessing the
client? (Select all that apply.)
Visual spatial deficits, Left hemianopsia, One-sided neglect.
Rationale: Visual spatial deficits and loss of depth perception occur secondary to a right
hemispheric stroke. Left hemianopsia, or blindness in the left half of the visual field,
occur secondary to right hemispheric stroke. One-sided neglect, or in unawareness of
the affected side, occur secondary to a right hemispheric stroke.
A nurse in an emergency department is reviewing the provider's prescriptions for
a client who sustained a rattlesnake bite to the lower leg. Which of the following
prescriptions should the nurse expect?
, Administer an opioid analgesic to the client.Rationale: the nurse should expect a
prescription for an opioid analgesic to promote comfort following a rattlesnake bite.
A nurse is teaching a young adult client how to perform testicular self-
examination. Which of the following instructions should the nurse include?
Roll each testicle between the thumb and fingers.Rationale: the nurse should instruct
the client to roll each testicle horizontally between the thumbs and fingers to fill for any
lumps deep in the center of the testicle.
A nurse is providing instructions to a client who has type 2 diabetes mellitus and
a new prescription for metformin. Which of the following statements by the client
indicates an understanding of the teaching?
"I should take this medication with a meal."Rationale: the client should take metformin
with or immediately following Mills to improve absorption and to minimize
gastrointestinal distress.
nurse is assessing a client who has acute cholecystitis. Which of the following
findings is the nurse's priority?
TachycardiaRationale: when using the urgent versus non-urgent approach to client
care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a
manifestation of biliary colic, which can lead to shock. The nurse should position the
head of the clients bed flat airport this finding immediately to the provider.
A nurse is
A nurse is reviewing the health record of a client who is scheduled for allergy
skin testing. The nurse should postpone the testing and report to the provider
which of the following findings? (Click on the "Exhibit" button for additional
AND ANSWERS WITH COMPLETE SOLUTIONS GRADED A++
A nurse is caring for a client who has emphysema and is receiving mechanical
ventilation. The client appears anxious and restless, and the high-pressure alarm
is sounding. Which of the following actions should the nurse take first?
Obtain ABGs.
Administer propofol to the client.T
Instruct the client to allow the machine to breathe for them.
Disconnect the machine and manually ventilate the client.
c. When providing client care, the nurse should first use the least restrictive intervention.
Therefore, the first action the nurse should take is to provide verbal instructions and
emotional support to help the client relax and allow the ventilator to work. Clients can
exhibit anxiety and restlessness when trying to "fight the ventilator."
The nurse should monitor ABG results to determine the effectiveness of mechanical
ventilation, but this is not the first action the nurse should take.
The nurse might need to administer propofol to provide sedation and increase the
client's tolerance of mechanical ventilation, but this is not the first action the nurse
should take.
,Many factors can cause a high-pressure alarm to sound. The nurse might have to
disconnect the machine and manually ventilate the client if the ventilator fails or the
client experiences respiratory distress, but this is not the first action the nurse should
take.
a nurse is teaching a client who has a family history of colo-rectal cancer. to help
mitigate this risk, which of the following dietary alterations should he nurse
recommend?
add cabbage to the diet.high in fiber, low in fat, and low in refined carbohydrates.
Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
A home health nurse is assigned to a client who was recently discharged from a
rehabilitation center after experiencing a right-hemispheric stroke. Which of the
following neurologic deficits should the nurse expect to find when assessing the
client? (Select all that apply.)
Visual spatial deficits, Left hemianopsia, One-sided neglect.
Rationale: Visual spatial deficits and loss of depth perception occur secondary to a right
hemispheric stroke. Left hemianopsia, or blindness in the left half of the visual field,
occur secondary to right hemispheric stroke. One-sided neglect, or in unawareness of
the affected side, occur secondary to a right hemispheric stroke.
A nurse in an emergency department is reviewing the provider's prescriptions for
a client who sustained a rattlesnake bite to the lower leg. Which of the following
prescriptions should the nurse expect?
, Administer an opioid analgesic to the client.Rationale: the nurse should expect a
prescription for an opioid analgesic to promote comfort following a rattlesnake bite.
A nurse is teaching a young adult client how to perform testicular self-
examination. Which of the following instructions should the nurse include?
Roll each testicle between the thumb and fingers.Rationale: the nurse should instruct
the client to roll each testicle horizontally between the thumbs and fingers to fill for any
lumps deep in the center of the testicle.
A nurse is providing instructions to a client who has type 2 diabetes mellitus and
a new prescription for metformin. Which of the following statements by the client
indicates an understanding of the teaching?
"I should take this medication with a meal."Rationale: the client should take metformin
with or immediately following Mills to improve absorption and to minimize
gastrointestinal distress.
nurse is assessing a client who has acute cholecystitis. Which of the following
findings is the nurse's priority?
TachycardiaRationale: when using the urgent versus non-urgent approach to client
care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a
manifestation of biliary colic, which can lead to shock. The nurse should position the
head of the clients bed flat airport this finding immediately to the provider.
A nurse is
A nurse is reviewing the health record of a client who is scheduled for allergy
skin testing. The nurse should postpone the testing and report to the provider
which of the following findings? (Click on the "Exhibit" button for additional
