PN Adult Medical Surgical 2023

Extract:

Question 1 of 5

A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?

A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL) B. Aspartate aminotransferase 34 units/L (0 to 34 units/L) C. Ammonia 55 mcg/dL (10 to 80 mcg/dL) D. Platelets 60,000/mm3 (150,000 to 400,000/mm3)

Correct Answer: D

Rationale: A platelet count of 60,000/mm3 is significantly below the normal range and increases the risk of bleeding during a liver biopsy, so it should be reported. The other values are within normal limits and do not pose an immediate concern.

Question 2 of 5

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

A. Keep both arms below the level of the client's heart. B. Limit range-of-motion exercises with the affected arm. C. Use the client's left arm to obtain blood samples. D. Obtain blood pressure readings using the client's right arm.

Correct Answer: C

Rationale: Using the unaffected (left) arm for blood samples prevents trauma to the right arm, reducing the risk of lymphedema after a radical mastectomy. The affected arm should be elevated, exercised appropriately, and avoided for procedures like blood pressure readings.

Question 3 of 5

A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

A. Temperature 37.3Â°C (99.1Â°F) B. Changed mental status C. WBC count 9,000/mm3 (5000 to 10,000/mm3) D. Diminished reflexes

Correct Answer: B

Rationale: Changed mental status is a common sign of a bladder infection (UTI) in older adults, often due to systemic effects of infection. The temperature and WBC count are within normal limits, and diminished reflexes are unrelated to a UTI.

Question 4 of 5

A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

A. Having a total cholesterol level below 200 mg/dL increases my risk for a stroke. B. My risk for a stroke increases if my HbA1c level is 6 percent or less. C. My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke. D. I can decrease my risk for a stroke by losing excess weight.

Correct Answer: D

Rationale: Losing excess weight reduces stroke risk by improving cardiovascular health, a key factor in diabetes management. High cholesterol, uncontrolled HbA1c, and glucocorticoids increase, not decrease, stroke risk.

Question 5 of 5

A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?

A. Discard soiled wound care supplies in a trash receptacle outside the client's room. B. Administer antibiotic therapy before culturing the client's wound. C. Place the client in a private room with a private bathroom. D. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client's room.

Correct Answer: C

Rationale: A private room with a private bathroom helps control infection spread from a foul-smelling, infectious wound. Supplies should be discarded in biohazard containers, cultures taken before antibiotics, and hand hygiene should be thorough, not just 5 seconds.

PN Adult Medical Surgical 2023 | Nurselytic

Nurselytic

ATI LPN

ATI LPN