RN Adult MedSurg Practice B Multiple
Choice
A nurse is providing teaching to a client who has a severe form of stage II Lyme disease.
Which of the following statements made by the client reflects an understanding of the
teaching?
A. "I will need to take antibiotics for 1 year"
B. "My partner will need to take an antiviral medication"
C. "My joints ache because I have Lyme disease"
D. "I will bruise easily because I have Lyme disease"
C
Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course
occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these
symptoms continue throughout stage II and, by stage III, become chronic. Other chronic
complications include memory problems and fatigue.
A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin
subcutaneous. Which of the following actions should the nurse take?
A. monitor the clients' INR daily.
B. expel air bubbles when using a prefilled syringe.
C. inject the medication into the anterolateral abdominal wall.
D. massage the injection site after administration.
C
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall
to enhance medication absorption and prevent hematoma formation.
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube.
The nurse should recognize that which of the following complications is associated with
long-term mechanical ventilation?
A. Elevated blood pressure
B. Dehydration
C. Stress ulcers
D. Hypernatremia
C
,Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by
elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for
systemic infection and require pharmacological treatment.
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the
following findings should the nurse identify as the priority?
A. Report of sore throat
B. Report of memory loss
C. Alopecia
D. Mucositis
A
When using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is a report of a sore throat, which could be a manifestation of an
infection. The client is at risk for neutropenia due to myelosuppression; therefore, an
infection could lead to sepsis.
The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which
intervention?
A. Intravenous administration of regular insulin
B. Administer insulin glargine subcutaneously at hour of sleep
C. Maintain nothing prescribed orally (NPO) status
D. Intravenous administration of 10% dextrose
A
DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic
acidosis, and elevated blood glucose levels. Management of DKA involves providing
hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular
insulin is a fast-acting insulin that can be effective within 10 min when administered
intravenously.
A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing
continuous telemetry monitoring. Which of the following statements by the client reflects an
understand of the teaching?
A. this measures how much blood my heart is pumping
B. this identifies if i have a defective heart valve
C. this identifies if the pacemaker cells of my heart are working properly
D. this measures the blood circulating to my heart muscle
C
Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive
electrical impulse through the heart muscle.
,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?
Instruct the client to allow the machine to breathe for them.
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."
A nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client understands
the teaching?
"I will wear clean graduated compression stockings every day."
The client should apply a clean pair of graduated compression stockings each day and clean
soiled stockings with mild detergent and warm water by hand.
A nurse is caring for client who is experiencing supraventricular tachycardia. Upon assessing
the client, the nurse observes the following findings: heart rate 200/min, blood pressure
78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should then nurse
take?
A. Defibrillate the client's heart.
B. Perform synchronized cardioversion.
C. Begin cardiopulmonary resuscitation.
D. Administer lidocaine IV bolus.
B
The nurse should perform synchronized cardioversion for a client who has supraventricular
tachycardia.
A nurse is planning care for a client who is having modified radical mastectomy of the right
breast. Which of the following interventions should the nurse include in the plan of care?
A. Instruct the client that the drain will be removed when there is 25 mL of output or less over
a 24-hr period.
B. Assist the client to start arm exercises 48 hr after surgery.
C. Maintain the right arm in an extended position at the client's side when in bed.
D. Place the client in a supine position for the first 24 hr after surgery.
A
, The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after
surgery and will be removed when there is 25 mL of output or less in a 24-hr period.
We have an expert-written solution to this problem!
A nurse in an ICY is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing's triad?
Bradycardia
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 providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statements should the nurse identify as an
indication that the client understands the teaching?
A. I will wash the ink markings off the radiation area after each treatment
B. I will use my hands rather than a washcloth to clean the radiation area
C. I will be able to be out in the sun one month after my radiation treatments are over
D. I will use a heating pad on my neck if it becomes sore during radiation therapy
B
The client should gently wash the radiation area with their hands using warm water and mild
soap to protect the skin from further irritation.
A nurse is performing a preoperative assessment for a client. The nurse should identify that
an allergy to which of the following foods can indicate a latex allergy?
A. Shellfish
B. Peanuts
C. Eggs
D. Avocados
D
Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex.
Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy
or sensitivity.
A nurse is assessing a client who is postoperative following a transurethral resection of the
prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in
a urinary output. Which of the following actions should the nurse take?
A. Remove the client's indwelling urinary catheter.
Choice
A nurse is providing teaching to a client who has a severe form of stage II Lyme disease.
Which of the following statements made by the client reflects an understanding of the
teaching?
A. "I will need to take antibiotics for 1 year"
B. "My partner will need to take an antiviral medication"
C. "My joints ache because I have Lyme disease"
D. "I will bruise easily because I have Lyme disease"
C
Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course
occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these
symptoms continue throughout stage II and, by stage III, become chronic. Other chronic
complications include memory problems and fatigue.
A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin
subcutaneous. Which of the following actions should the nurse take?
A. monitor the clients' INR daily.
B. expel air bubbles when using a prefilled syringe.
C. inject the medication into the anterolateral abdominal wall.
D. massage the injection site after administration.
C
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall
to enhance medication absorption and prevent hematoma formation.
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube.
The nurse should recognize that which of the following complications is associated with
long-term mechanical ventilation?
A. Elevated blood pressure
B. Dehydration
C. Stress ulcers
D. Hypernatremia
C
,Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by
elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for
systemic infection and require pharmacological treatment.
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the
following findings should the nurse identify as the priority?
A. Report of sore throat
B. Report of memory loss
C. Alopecia
D. Mucositis
A
When using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is a report of a sore throat, which could be a manifestation of an
infection. The client is at risk for neutropenia due to myelosuppression; therefore, an
infection could lead to sepsis.
The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which
intervention?
A. Intravenous administration of regular insulin
B. Administer insulin glargine subcutaneously at hour of sleep
C. Maintain nothing prescribed orally (NPO) status
D. Intravenous administration of 10% dextrose
A
DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic
acidosis, and elevated blood glucose levels. Management of DKA involves providing
hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular
insulin is a fast-acting insulin that can be effective within 10 min when administered
intravenously.
A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing
continuous telemetry monitoring. Which of the following statements by the client reflects an
understand of the teaching?
A. this measures how much blood my heart is pumping
B. this identifies if i have a defective heart valve
C. this identifies if the pacemaker cells of my heart are working properly
D. this measures the blood circulating to my heart muscle
C
Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive
electrical impulse through the heart muscle.
,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?
Instruct the client to allow the machine to breathe for them.
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."
A nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client understands
the teaching?
"I will wear clean graduated compression stockings every day."
The client should apply a clean pair of graduated compression stockings each day and clean
soiled stockings with mild detergent and warm water by hand.
A nurse is caring for client who is experiencing supraventricular tachycardia. Upon assessing
the client, the nurse observes the following findings: heart rate 200/min, blood pressure
78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should then nurse
take?
A. Defibrillate the client's heart.
B. Perform synchronized cardioversion.
C. Begin cardiopulmonary resuscitation.
D. Administer lidocaine IV bolus.
B
The nurse should perform synchronized cardioversion for a client who has supraventricular
tachycardia.
A nurse is planning care for a client who is having modified radical mastectomy of the right
breast. Which of the following interventions should the nurse include in the plan of care?
A. Instruct the client that the drain will be removed when there is 25 mL of output or less over
a 24-hr period.
B. Assist the client to start arm exercises 48 hr after surgery.
C. Maintain the right arm in an extended position at the client's side when in bed.
D. Place the client in a supine position for the first 24 hr after surgery.
A
, The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after
surgery and will be removed when there is 25 mL of output or less in a 24-hr period.
We have an expert-written solution to this problem!
A nurse in an ICY is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing's triad?
Bradycardia
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 providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statements should the nurse identify as an
indication that the client understands the teaching?
A. I will wash the ink markings off the radiation area after each treatment
B. I will use my hands rather than a washcloth to clean the radiation area
C. I will be able to be out in the sun one month after my radiation treatments are over
D. I will use a heating pad on my neck if it becomes sore during radiation therapy
B
The client should gently wash the radiation area with their hands using warm water and mild
soap to protect the skin from further irritation.
A nurse is performing a preoperative assessment for a client. The nurse should identify that
an allergy to which of the following foods can indicate a latex allergy?
A. Shellfish
B. Peanuts
C. Eggs
D. Avocados
D
Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex.
Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy
or sensitivity.
A nurse is assessing a client who is postoperative following a transurethral resection of the
prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in
a urinary output. Which of the following actions should the nurse take?
A. Remove the client's indwelling urinary catheter.
