Questions 164

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PN Adult Medical Surgical 2023 Questions

Extract:

Vital Signs
Day 1:
• Temperature 36°C (96.8°F)
• Blood pressure 140/80 mm Hg
• Heart rate 98/min
• Respiratory rate 24/min
• Oxygen saturation 97% on room air
Day 2, 0800:
• Temperature 37°C (98.6°F)
• Blood pressure 122/60 mm Hg
• Heart rate 85/min
• Respiratory rate 18/min
• Oxygen saturation 98% on room air


Question 1 of 5

A nurse is assisting in the plan of care for the client who has compartment syndrome. Which potential prescription is anticipated?

Potential PrescriptionAnticipated Contraindicated
Open the splint
Obtain a urinalysis
Place the client on NPO status
Place the client's right leg in a dependent position

Correct Answer: A, D

Rationale: Compartment syndrome requires relieving pressure to restore perfusion. Opening the splint (or cast) reduces external compression, an anticipated step pre-fasciotomy if tightness contributes to ischemia, per orthopedic protocols. Urinalysis checks for myoglobinuria from muscle breakdown, a diagnostic aid, but not immediate relief. NPO status prepares for surgery, a later consideration after pressure relief. A dependent leg position increases venous pooling, worsening swelling and pressure contraindicated here. Opening the splint directly addresses the mechanical cause, buying time for surgical evaluation, aligning with emergency management (e.g., AAOS guidelines), making it the expected prescription to prioritize limb viability.

Extract:


Question 2 of 5

A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL. Which of the following findings should the nurse identify as an indication of metabolic acidosis?

Correct Answer: C

Rationale: Increased respiratory rate (Kussmaul breathing) compensates for acidosis in diabetic ketoacidosis.

Question 3 of 5

A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care?

Correct Answer: A

Rationale: Moist heat reduces stiffness and improves mobility in osteoarthritis.

Question 4 of 5

A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?

Correct Answer: A

Rationale: Prescribed trazodone addresses agitation pharmacologically. Other options are less effective or inappropriate for immediate management of agitation in Alzheimer's.

Question 5 of 5

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

Correct Answer: B

Rationale: Fecal occult blood tests detect hidden blood in stool, often for colorectal cancer screening, but false positives can skew results. Ibuprofen, an NSAID, irritates the gastric mucosa, causing microbleeding that may appear in stool, unrelated to colonic sources. Citrus juice doesn't affect heme detection vitamin C may cause false negatives, not positives, and 3 days prior minimizes impact. A hemorrhoidectomy 1 year ago is healed, unlikely to bleed now unless complications persist, which isn't suggested. Breast cancer history doesn't influence gastrointestinal bleeding unless metastatic, an unlikely scenario here. Ibuprofen's known GI side effects align with testing guidelines (e.g., avoiding NSAIDs pre-test), making it the most likely false-positive trigger, requiring the nurse to clarify timing and adjust interpretation.

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