PN Adult Medical Surgical 2023

Extract:

Question 1 of 5

A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?

A. Abdominal wound dry, without redness B. Client received an adequate amount of fluid C. Client status unchanged throughout shift D. Incision healing well E. Pain level stable F. No fever noted G. Ambulated without difficulty

Correct Answer: A

Rationale: Specific, objective data like 'dry, without redness' is required; vague terms like 'adequate' or 'unchanged' are insufficient.

Question 2 of 5

A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?

A. Encourage the client to increase oral intake of fluids. B. Auscultate the client's abdomen for bowel sounds. C. Provide the client privacy with a set time to defecate. D. Administer a fiber-based laxative to the client. E. Increase physical activity. F. Check medication history. G. Apply heat to the abdomen.

Correct Answer: B

Rationale: Auscultating bowel sounds assesses the underlying issue (e.g., ileus) before interventions like fluids or laxatives.

Question 3 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?

A. Tingling of the fingers B. Positive Trousseau's sign C. Increased respiratory rate D. Dizziness upon standing E. Hypotension F. Muscle weakness G. Dry mouth

Correct Answer: C

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

Question 4 of 5

A nurse is reinforcing dietary teaching with an older adult client who has an increased LDL level. Which of the following foods should the nurse encourage the client to limit?

A. Canola oil B. Swiss cheese C. Avocados D. Walnuts E. Olive oil F. Fatty fish G. Whole grains

Correct Answer: B

Rationale: Swiss cheese is high in saturated fat, raising LDL; canola oil, avocados, and walnuts are heart-healthy.

Question 5 of 5

A nurse is reinforcing teaching with a client who will be wearing a Holter monitor for the next 24 hr. Which of the following information should the nurse include?

A. You will need to record daily activities in a diary. B. You should remove the electrodes when you go to bed. C. You can bathe while wearing the electrodes. D. You should not have sexual intercourse while the monitor is in place. E. Avoid exercise entirely. F. Keep the monitor in water. G. Remove it if it beeps.

Correct Answer: A

Rationale: Recording activities helps correlate symptoms with heart activity; electrodes stay on, and bathing is avoided.

PN Adult Medical Surgical 2023 | Nurselytic

Nurselytic

ATI LPN

ATI LPN