PN Adult Medical Surgical 2023 | Nurselytic

Questions 168

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PN Adult Medical Surgical 2023 Questions

Extract:

Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air

History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.

Nurses' Notes
1100:
Reinforced education about iron supplements and dietary recommendations.


Question 1 of 5

Which of the following 3 statements indicate the client understands the instructions? (Iron deficiency anemia)

Correct Answer: A,B,D

Rationale: Green leafy vegetables provide iron, black stools are a side effect, and taking it before meals enhances absorption.

Extract:

44


Question 2 of 5

A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.

Correct Answer:

Rationale: Clamping allows urine to collect, wiping ensures sterility, aspirating collects the sample, transferring maintains sterility, and documenting completes the process.

Extract:

47


Question 3 of 5

A nurse is caring for a client who has deep-vein thrombosis. Which of the following interventions should the nurse plan to take?

Correct Answer: D

Rationale: Measuring the calf monitors for swelling (worsening DVT); massage and cold can dislodge clots, and reverse Trendelenburg isn't specific.

Extract:

48


Question 4 of 5

A nurse is reinforcing bladder management instructions with a client who has urinary incontinence. Which of the following statements by the client indicates an understanding?

Correct Answer: A

Rationale: Scheduled voiding helps manage incontinence; coffee and alcohol worsen it, and self-catheterization isn't routine.

Extract:

Medication Administration Record
Ceftriaxone 2 gm IV BID
Acetaminophen 325 mg PO every 4 hr PRN fever over 39° C (102.2° F)
Guaifenesin 200 mg PO every 4 hr PRN cough

Diagnostic Results
Complete Blood Count:
Hemoglobin 15 g/dL (12 to 16 g/dL)
Hematocrit 45% (37% to 47%)
WBC count 15,000/mm* (5000 to 10,000/mm*)

Basic Metabolic Profile:
Creatinine 2.8 mg/dL (0.5 to 1.1 mg/di)
BUN 19 mg/dL (10 to 20 mg/dL)

Sputum Culture and Sensitivity:
Klebsiella pneumonia


Question 5 of 5

A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse report to the provider?

Correct Answer: B

Rationale: Elevated creatinine (2.8 mg/dL) indicates potential kidney injury, a priority over sputum (expected Klebsiella), WBC (infection), or temperature.

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