PN Adult Medical Surgical 2023

Extract:

Question 1 of 5

A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?

A. Absence of Chvostek's sign B. Presence of Kussmaul respirations C. Presence of diaphoresis D. Absence of urinary ketones

Correct Answer: B

Rationale: Kussmaul respirations indicate hyperglycemia-induced metabolic acidosis as the body compensates for high glucose. Chvostek's is unrelated, diaphoresis suggests hypoglycemia, and ketones may be present but aren't definitive here.

Question 2 of 5

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

A. Elevate the head of the client's bed for 1 hr. after the feeding. B. Administer the feeding solution at a cold temperature. C. Rotate the jejunostomy tube once per day. D. Flush the tube with 90 mL of sterile water before and after the feeding.

Correct Answer: A

Rationale: Elevating the head for 1 hour post-feeding prevents aspiration, a key concern with jejunostomy feedings. Cold solutions, rotation, and excessive flushing aren't standard.

Question 3 of 5

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

A. Elevate the head of the client's bed for 1 hr. after the feeding. B. Administer the feeding solution at a cold temperature. C. Rotate the jejunostomy tube once per day. D. Flush the tube with 90 mL of sterile water before and after the feeding.

Correct Answer: A

Rationale: Head elevation for 1 hour reduces aspiration risk, critical for jejunostomy care. Other options are incorrect or unnecessary.

Question 4 of 5

A nurse is assisting with the care of a postoperative client who has developed malignant hyperthermia. Which of the following actions should the nurse take?

A. Administer meperidine IM. B. Instill a warm enema solution. C. Apply a cooling blanket. D. Ventilate client with 50% oxygen.

Correct Answer: C

Rationale: A cooling blanket lowers body temperature in malignant hyperthermia, a life-threatening condition. Meperidine, warm enemas, and oxygen alone don't address the hyperthermia directly.

Question 5 of 5

A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client asks the nurse why she needs to take four different antituberculotic medications. Which of the following replies should the nurse make?

A. The organism that causes TB becomes resistant to antituberculotic medications when you only take one medication. B. Taking several antituberculotic medications will protect your liver from toxic effects. C. People who have a severe form of TB need several antituberculotic medications, but those who have less severe TB need just one medication. D. Adverse effects occur more often and are more severe when you take only one antituberculotic medication.

Correct Answer: A

Rationale: Multiple medications prevent resistance in TB treatment, as Mycobacterium tuberculosis can quickly adapt to a single drug, necessitating a combination regimen.

PN Adult Medical Surgical 2023 | Nurselytic

Nurselytic

ATI LPN

ATI LPN