PN Adult Medical Surgical 2023

Extract:

Question 1 of 5

A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer. Which of the following actions should the nurse plan to take?

A. Prepare the sterile dressing supplies 30 min before the dressing change. B. Don sterile gloves before removing the dressing, C. Disinfect the wound bed with alcohol before applying tape. D. Offer the client pain medication before the procedure.

Correct Answer: D

Rationale: Offering pain medication beforehand reduces discomfort during the dressing change for a stage III ulcer. Supplies should be prepared just before, sterile gloves are used after removal, and alcohol isn't used on open wounds.

Question 2 of 5

A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr. to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 mL How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Your Answer:

Correct Answer: 10

Rationale: Calculation: (25 mg / 12.5 mg) × 5 mL = 10 mL. This delivers the prescribed dose accurately.

Question 3 of 5

A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?

A. Instruct the client to tilt their head back to facilitate swallowing B. Encourage the client to use a straw. C. Provide oral care before meals. D. Schedule physical therapy directly before meals.

Correct Answer: C

Rationale: Oral care before meals removes debris and reduces aspiration risk in dysphagia. Tilting back worsens swallowing, straws may not be safe, and therapy timing isn't relevant.

Question 4 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 5 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.

PN Adult Medical Surgical 2023 | Nurselytic

Nurselytic

ATI LPN

ATI LPN