Review PN Adult Medical Surgical 2020

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PN Adult Medical Surgical 2020 - Exam 2

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Total Questions : 91

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Question 1:

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. Use the client's left arm to obtain blood samples. C. Obtain blood pressure readings using the client's right arm. D. Limit range-of-motion exercises with the affected arm.

Answer and Explanation

Choice A:

Keeping both arms below the level of the client's heart can increase venous pressure and fluid accumulation in the affected arm, which can lead to lymphedema.

Choice B:

After a mastectomy, it’s important to avoid procedures like blood draws, injections, or blood pressure measurements on the side where the surgery was performed to prevent lymphedema. Therefore, using the client’s left arm for blood samples is a preventive measure.

Choice C:

Obtaining blood pressure readings using the client's right arm is an incorrect action that can increase lymphatic fluid accumulation and impair circulation in the affected arm.

Choice D:

Limiting range-of-motion exercises with the affected arm is an incorrect action that can decrease lymphatic drainage and increase swelling in the affected arm. The nurse should encourage the client to perform gentle exercises, such as squeezing a soft ball or raising and lowering the arm, to promote lymphatic flow and prevent stiffness.

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Question 2:

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

Answer and Explanation

Choice A:

Glucocorticoids are anti-inflammatory drugs that can increase blood glucose levels and worsen diabetes mellitus, which is a risk factor for stroke.

Choice B:

HbA1c is a measure of average blood glucose levels over the past three months. A higher HbA1c level indicates poor glycemic control and increases the risk for stroke. The target HbA1c level for most people with diabetes mellitus is less than 7 percent.

Choice C:

Having a high total cholesterol level is a risk factor for stroke, as it can lead to atherosclerosis and plaque formation in the blood vessels. The target total cholesterol level for most people is less than 200 mg/dL.

Choice D:

Losing excess weight can lower blood pressure, improve blood glucose levels, and reduce inflammation, which are all beneficial for preventing stroke.

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Question 3:

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

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

Answer and Explanation

Choice A:

Changed mental status, such as confusion, agitation, or delirium, can be a sign of a bladder infection in older adults, as they may not have the typical symptoms of dysuria, frequency, or urgency.

Choice B:

WBC count 9,000/mm³ is within the normal range of 4,500 to 11,000/mm³ and does not indicate an infection.

Choice C:

Diminished reflexes are not related to a bladder infection and may be due to aging, neurological disorders, or medication side effects.

Choice D:

Temperature 37.3°C (99.1°F) is slightly elevated but not indicative of a bladder infection. Older adults may have lower baseline temperatures and may not develop fever in response to an infection.

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Question 4:

A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of the following foods should the nurse encourage the client to eat?

A. Cheese B. Eggs C. Yogurt D. Pears

Answer and Explanation

Choice A:

Cheese is a dairy product that contains protein and fat but little or no fiber.

Choice B:

Eggs are an animal product that contains protein and fat but no fiber.

Choice C:

Yogurt is a dairy product that contains protein and calcium but little or no fiber.

Choice D:

Pears are a fruit that contains dietary fiber, which can help prevent constipation, lower cholesterol levels, and regulate blood sugar levels.

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Question 5:

A nurse is reviewing the medical record of a client who reports his urine is red-orange. The nurse should identify that which of the following medications can cause this adverse effect?

A. Isoniazid B. Metoprolol C. Rifampin D. Furosemide

Answer and Explanation

Choice A:

Isoniazid is an antitubercular drug that can cause urine to turn dark yellow or brown, not red-orange.

Choice B:

Metoprolol is a beta-blocker that can cause urine to turn blue-green, not red-orange.

Choice C:

Rifampin is an antitubercular drug that can cause urine to turn red-orange, as well as other body fluids such as saliva, sweat, and tears.

Choice D:

Furosemide is a diuretic that can cause urine to become more concentrated and darker in color, but not red-orange.

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Question 6:

A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?

A. Pupillary dilation B. Hypotension C. Chest pain D. Diaphoresis

Answer and Explanation

Choice A:

Pupillary dilation is not a sign of opioid toxicity, but rather of opioid withdrawal or stimulant overdose. Opioid toxicity causes pupillary constriction or miosis.

Choice B:

Hypotension is a sign of opioid toxicity sign of opioid toxicity, as opioids can depress the central nervous system and reduce cardiac output and peripheral resistance.

Choice C:

Chest pain is not a sign of opioid toxicity, but rather of cardiac ischemia or infarction, which can be caused by cocaine or other stimulants.

Choice D:

Diaphoresis is not a sign of opioid toxicity, but rather of opioid withdrawal or hyperthermia, which can be caused by ecstasy or other stimulants.

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Question 7:

A nurse is caring for a client who has dementia and wanders frequently. Which of the following actions should the nurse take?

A. Apply a motion sensor mat to the client's bed. B. Move the overbed table away from the bed. C. Raise all four side rails while the client is in bed. D. Leave the television on in the client's room.

Answer and Explanation

Choice A:

Applying a motion sensor mat to the client's bed is an appropriate action to prevent wandering and alert the staff if the client tries to get out of bed.

Choice B:

Moving the overbed table away from the bed is not an effective action to prevent wandering, as it does not restrict the client's mobility or provide any supervision.

Choice C:

Raising all four side rails while the client is in bed is an inappropriate action that can increase the risk of injury or entrapment if the client attempts to climb over them.

Choice D:

Leaving the television on in the client's room is not an effective action to prevent wandering, as it does not provide any stimulation or distraction for the client.

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Question 8:

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

A. Replace the unit when the drainage chamber is full. B. Pin the tubing to the client's bed sheets. C. Monitor for at least 150 mL of drainage every hour. D. Clamp the tube for 30 min every 8 hr.

Answer and Explanation

Choice A:

Replacing the unit when the drainage chamber is full. This ensures continuous, effective drainage. A full chamber cannot collect more fluid, risking system compromise and patient safety.

Choice B:

Pinning the tubing to the bed sheets is incorrect because it can cause kinks in the tubing, leading to obstruction of drainage and potential complications.

Choice C:

Monitoring for at least 150 mL of drainage every hour is not a standard practice. Normal chest tube drainage is variable; excessive drainage, such as 150 mL/hour, could indicate a serious condition like hemorrhage.

Choice D:

Clamping the tube routinely for 30 minutes every 8 hours is not recommended. Clamping may be done during tube removal or to check for air leaks but doing so routinely can lead to tension pneumothorax.

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Question 9:

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

A. "I will perform breast exams every other month." B. "It is common for one breast to be larger than the other." C. "I will perform breast exams the day my period begins." D. "It is common for the skin on my breasts to dimple."

Answer and Explanation

Choice A:

Performing breast exams every other month is not an adequate frequency, as it can delay the detection of any changes or abnormalities. The client should perform breast exams monthly, preferably a few days after their period ends.

Choice B:

Having one breast larger than the other is a common variation and not a cause for concern, unless there is a sudden change in size or shape. The client should be aware of their normal breast appearance and report any changes to their provider.

Choice C:

Performing breast exams the day their period begins is not an optimal time, as their breasts may be swollen, tender, or lumpy due to hormonal fluctuations. The client should perform breast exams when their breasts are not affected by their menstrual cycle, such as a week after their period ends.

Choice D:

Having skin dimpling on their breasts is not a common variation and may indicate an underlying tumor that pulls on the connective tissue and causes puckering of the skin. The client should inspect their breasts for any changes in skin texture, such as dimpling, peau d'orange, or redness, and report them to their provider.

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Question 10:

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

A. The client takes ibuprofen for headaches. B. The client had a hemorrhoidectomy 1 year ago. C. The client has a history of breast cancer. D. The client consumed citrus juice 3 days before the test.

Answer and Explanation

Choice A:

Taking ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs) can cause a false-positive result on a fecal occult blood screening test, as they can irritate the gastrointestinal mucosa and cause bleeding.

Choice B:

Having a hemorrhoidectomy 1 year ago is unlikely to cause a false-positive result on a fecal occult blood screening test, as hemorrhoids are usually a source of bright red blood that can be seen with naked eye, not occult blood that requires chemical detection.

Choice C:

Having a history of breast cancer is not related to a false-positive result on a fecal occult blood screening test, as breast cancer does not affect the gastrointestinal tract or cause bleeding in stool.

Choice D:

Consuming citrus juice 3 days before the test is not likely to cause a false-positive result on a fecal occult blood screening test, as citrus juice does not contain any substances that can interfere with the chemical reaction of the test. However, consuming red meat, raw vegetables, vitamin C supplements, or iron supplements within 3 days before the test can cause false-negative results, as they can mask or degrade occult blood in stool.

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Total Questions : 91

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PN Adult Medical Surgical 2020 - Exam 2

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