PN Adult Medical Surgical 2023

Extract:

Question 1 of 5

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

A. Replace the unit when the drainage chamber is full. B. Clamp the tube for 30 min every 8 hr. C. Pin the tubing to the client's bed sheets. D. Monitor for at least 150 mL of drainage every hour.

Correct Answer: A

Rationale: Replacing the unit when full maintains system function. Clamping risks tension pneumothorax, pinning can dislodge tubing, and 150 mL/hr is excessive and not a standard expectation.

Question 2 of 5

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

A. Leave the television on in the client's room B. Raise all four side rails while the client is in bed. C. Move the overbed table away from the bed. D. Apply a motion sensor mat to the client's bed

Correct Answer: D

Rationale: A motion sensor mat alerts staff to movement, reducing fall risk in dementia clients. TV can agitate, four rails are a restraint, and moving the table doesn't directly prevent falls.

Question 3 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?

A. The client had a hemorrhoidectomy 1 year ago. B. The client takes ibuprofen for headaches. C. The client has a history of breast cancer. D. The client consumed citrus juice 3 days before the test

Correct Answer: B

Rationale: Ibuprofen, an NSAID, can cause GI irritation and bleeding, leading to a false-positive fecal occult blood test. The other factors are unlikely to affect the result directly.

Question 4 of 5

A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching?

A. Place on airborne precautions. B. Avoid direct contact. C. Isolate for 24 hr. after lesions appear. D. Administer a broad-spectrum antibiotic.

Correct Answer: B

Rationale: Avoiding direct contact prevents the spread of tinea corporis, a fungal infection. Airborne precautions and antibiotics are inappropriate, and isolation isn't required beyond contact precautions.

Question 5 of 5

A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?

A. Assist the client to the restroom 30 min after meals. B. Limit the client's physical activity until bowel continence is achieved. C. Limit the client's fluid intake to 1500 mL/day. D. Instruct the client to limit their intake of high-fiber foods

Correct Answer: A

Rationale: Assisting to the restroom 30 minutes after meals leverages the gastrocolic reflex to promote bowel regularity. Limiting activity, fluids, or fiber would hinder continence efforts.

PN Adult Medical Surgical 2023 | Nurselytic

Nurselytic

ATI LPN

ATI LPN