PN Adult Medical Surgical 2023

Extract:

Question 1 of 5

A nurse is collecting data from a client who had a long arm cast applied 2 hr. ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?

A. The client's fingers are cool to the touch. B. The client reports severe itching under the cast. C. The client's capillary refill is 3 seconds. D. The client reports increased pain at the area of the fracture.

Correct Answer: A

Rationale: Cool fingers suggest impaired circulation, a potential emergency post-cast application requiring immediate reporting. Itching and pain are common, and 3-second refill is borderline normal.

Question 2 of 5

A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching?

A. I will use a skin sealant before I apply the bag. B. I will use moisturizing soap to clean around the stoma before applying the bag. C. I will cut the wafer opening one-fourth of an inch larger than the stoma D. I will need to empty the bag every 4 to 6 hours.

Correct Answer: A

Rationale: Using a skin sealant protects the peristomal skin, showing understanding of ileostomy care. Moisturizers can interfere, the wafer should be 1/8 inch larger, and emptying frequency varies but isn't the best indicator here.

Question 3 of 5

A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

A. Use a fire extinguisher at the source of the smoke. B. Close the doors to the room and to the bathroom. C. Activate the fire alarm system. D. Assist the client to a nearby common area.

Correct Answer: D

Rationale: Assisting the client to safety is the first priority in a fire emergency per the RACE protocol (Rescue, Alarm, Contain, Extinguish).

Question 4 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 5 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.

PN Adult Medical Surgical 2023 | Nurselytic

Nurselytic

ATI LPN

ATI LPN