PN Adult Medical Surgical
A nurse is preparing to administer furosemide to a client who has heart failure. Which of
the following findings should the nurse report before administering the medication? -
correct answersDecreased potassium
A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which
was precipitated by the client not taking their medication for several days. The nurse
should identify that withdrawal from which of the following medications potentiated the
adrenal crisis? - correct answersPrednisone
A nurse is assisting with the care for a client who has a prescription for digoxin 0.25 mg
PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which
of the following actions should the nurse take? - correct answersWithhold the dose.
A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a
client who has diabetes mellitus. Which of the following statements indicates that the
client understands the teaching? - correct answers"I will have my HbA1c checked twice
per year."
A nurse is providing information regarding transmission-based precautions for a client
who has Clostridium difficile to an assistive personnel (AP). Which of the following
instructions should the nurse include? (Select all that apply.) - correct answers"Provide
the client with disposable utensils and dishes for meals."
"Leave blood pressure equipment in the client's room."
"Clean contaminated surfaces with a bleach solution."
A nurse is reinforcing teaching with a client who has coronary artery disease. Which of
the following instructions should the nurse include in the teaching? - correct
answers"Add oily fish to your diet twice weekly."
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client
who has skin cancer. Which of the following information should the nurse include in the
teaching? - correct answersMohs surgery is a horizontal shaving of thin layers of the
tumor.
A nurse is collecting data from an older adult client who has several concerns. Which of
the following concerns should the nurse recognize as an expected change associated
with aging? - correct answers"My food tastes bland even after I add seasoning."
A nurse is reinforcing dietary teaching with a client about increasing the intake of foods
containing vitamin C to enhance absorption of oral iron supplements. Which of the
following food choices should the nurse include in the teaching? - correct answers1 cup
of boiled broccoli
, A nurse is assisting with the care for a client who is 2 hr postoperative following the
amputation of a foot. Which of the following actions should the nurse take first? - correct
answersCheck the incisional dressing.
A nurse is assisting with the care of a client who is postoperative following abdominal
surgery.
Exhibit 1
Nurses' Notes
1100:
Client received from PACU; initial vital signs recorded. Client is drowsy but arouses to
verbal stimuli. Oriented to person, place, and time. Client is able to move all extremities.
Normal sinus rhythm noted. Breath sounds are clear upon auscultation. Dressing to
abdomen is intact with a small amount of serosanguinous drainage noted and marked.
No bowel sounds in all four quadrants. Indwelling urinary catheter is in place and
draining clear, yellow urine. Lactated Ringer's is infusing at 100 mL/hr via IV catheter in
the right forearm.1200:
Client reports nausea and pain as an 8 on a scale of 0 to 10. Abdominal dressing is
intact with no further drainage noted. Urine output of 15 mL noted since arrival from
PACU. Analgesic and antiemetic were administered as prescribed.1230:
Client reports rel - correct answersWhich of the following actions should the nurse take?
Select all that apply.
Instruct the client to splint their abdomen with a pillow when coughing.
Report the client's urinary output to the charge nurse.
Monitor the client's pain level.
A nurse is assisting with monitoring a client who is receiving dialysis treatment.
Exhibit 1
Nurses' Notes
0530:Client is awake and alert. Arteriovenous fistula (AVF) to right forearm with thrill
palpated and auscultated for bruit. Breath sounds are clear upon auscultation; client
denies shortness of breath. No peripheral edema noted; capillary refill is less than 3
seconds; +2 bilateral pedal and radial pulses.AVF access prepared and cannulated
twice with no difficulty. Lines are taped and secured; treatment is initiated.0600:Client is
reading a book. Access is visible, and lines are secure. Client reports no discomfort or
pain.0630:Client reports feeling warm, nauseated, and lightheaded; appears restless
and slightly confused.
Exhibit 2
Vital Signs
0530:Current weight 88 kg (194 lb)Temperature 37° C (98.6° F)Blood pressure• Lying -
152/92 mm Hg• Sitting - 148/90 mm Hg• Standing - 144/88 mm HgHeart rate
90/minRespir - correct answersFor each potential nursing intervention, click to specify if
the intervention is indicated or not indicated.
Nursing Intervention
Request a chest x-ray - not indicated
Place the client in reverse Trendelenburg position - indicated
Assist with administering a 0.9% sodium chloride 200 mL IV bolus - indicated
Apply oxygen at 2 L/min via nasal cannula - indicated
A nurse is preparing to administer furosemide to a client who has heart failure. Which of
the following findings should the nurse report before administering the medication? -
correct answersDecreased potassium
A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which
was precipitated by the client not taking their medication for several days. The nurse
should identify that withdrawal from which of the following medications potentiated the
adrenal crisis? - correct answersPrednisone
A nurse is assisting with the care for a client who has a prescription for digoxin 0.25 mg
PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which
of the following actions should the nurse take? - correct answersWithhold the dose.
A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a
client who has diabetes mellitus. Which of the following statements indicates that the
client understands the teaching? - correct answers"I will have my HbA1c checked twice
per year."
A nurse is providing information regarding transmission-based precautions for a client
who has Clostridium difficile to an assistive personnel (AP). Which of the following
instructions should the nurse include? (Select all that apply.) - correct answers"Provide
the client with disposable utensils and dishes for meals."
"Leave blood pressure equipment in the client's room."
"Clean contaminated surfaces with a bleach solution."
A nurse is reinforcing teaching with a client who has coronary artery disease. Which of
the following instructions should the nurse include in the teaching? - correct
answers"Add oily fish to your diet twice weekly."
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client
who has skin cancer. Which of the following information should the nurse include in the
teaching? - correct answersMohs surgery is a horizontal shaving of thin layers of the
tumor.
A nurse is collecting data from an older adult client who has several concerns. Which of
the following concerns should the nurse recognize as an expected change associated
with aging? - correct answers"My food tastes bland even after I add seasoning."
A nurse is reinforcing dietary teaching with a client about increasing the intake of foods
containing vitamin C to enhance absorption of oral iron supplements. Which of the
following food choices should the nurse include in the teaching? - correct answers1 cup
of boiled broccoli
, A nurse is assisting with the care for a client who is 2 hr postoperative following the
amputation of a foot. Which of the following actions should the nurse take first? - correct
answersCheck the incisional dressing.
A nurse is assisting with the care of a client who is postoperative following abdominal
surgery.
Exhibit 1
Nurses' Notes
1100:
Client received from PACU; initial vital signs recorded. Client is drowsy but arouses to
verbal stimuli. Oriented to person, place, and time. Client is able to move all extremities.
Normal sinus rhythm noted. Breath sounds are clear upon auscultation. Dressing to
abdomen is intact with a small amount of serosanguinous drainage noted and marked.
No bowel sounds in all four quadrants. Indwelling urinary catheter is in place and
draining clear, yellow urine. Lactated Ringer's is infusing at 100 mL/hr via IV catheter in
the right forearm.1200:
Client reports nausea and pain as an 8 on a scale of 0 to 10. Abdominal dressing is
intact with no further drainage noted. Urine output of 15 mL noted since arrival from
PACU. Analgesic and antiemetic were administered as prescribed.1230:
Client reports rel - correct answersWhich of the following actions should the nurse take?
Select all that apply.
Instruct the client to splint their abdomen with a pillow when coughing.
Report the client's urinary output to the charge nurse.
Monitor the client's pain level.
A nurse is assisting with monitoring a client who is receiving dialysis treatment.
Exhibit 1
Nurses' Notes
0530:Client is awake and alert. Arteriovenous fistula (AVF) to right forearm with thrill
palpated and auscultated for bruit. Breath sounds are clear upon auscultation; client
denies shortness of breath. No peripheral edema noted; capillary refill is less than 3
seconds; +2 bilateral pedal and radial pulses.AVF access prepared and cannulated
twice with no difficulty. Lines are taped and secured; treatment is initiated.0600:Client is
reading a book. Access is visible, and lines are secure. Client reports no discomfort or
pain.0630:Client reports feeling warm, nauseated, and lightheaded; appears restless
and slightly confused.
Exhibit 2
Vital Signs
0530:Current weight 88 kg (194 lb)Temperature 37° C (98.6° F)Blood pressure• Lying -
152/92 mm Hg• Sitting - 148/90 mm Hg• Standing - 144/88 mm HgHeart rate
90/minRespir - correct answersFor each potential nursing intervention, click to specify if
the intervention is indicated or not indicated.
Nursing Intervention
Request a chest x-ray - not indicated
Place the client in reverse Trendelenburg position - indicated
Assist with administering a 0.9% sodium chloride 200 mL IV bolus - indicated
Apply oxygen at 2 L/min via nasal cannula - indicated
