RN Adult Medical Surgical Online Practice -A.pdf file:///C:/Users/HP/Desktop/SSSSSSS/RN%20Adult%20Medical%20S
RN Adult Medical Surgical Online Practice A
1. A nurse is caring for a client who is receiving dialysis treatment.
For each potential nursing intervention, click to specify if the intervention is indicated or
not indicated.
ANS Perform a 12-lead ECG is not indicated. The client is not reporting chest pain; therefore, a
12-lead ECG is not indicated at this time.
Place the client in Trendelenburg position is indicated. The client should be placed in the
Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ
perfusion.
Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should administer
200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's blood
pressure.
Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should administer oxygen at 2
L/min via nasal cannula to increase the amount of oxygen carried in the blood.
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Notify the provider immediately is indicated. The nurse should notify the provider immediately
as part of the nurse's role to provide an update on the client's condition.
Obtain the client's blood glucose level is not indicated. There is no indication that the client is
experiencing hypoglycemia; therefore, obtaining a blood glucose level is not indicated.
2. A nurse is caring for a client who is postoperative following abdominal surgery.
A nurse is caring for a client who is postoperative. Which of the following actions should
the nurse take?
ANS Apply oxygen via a face mask is incorrect. It is not necessary to place a face mask on the
client because their SaO2 is within the expected reference range of 95% to 100%.
Instruct the client to splint the abdomen with a pillow for coughing is correct. It is
important for the client to turn, cough, and deep breathe to reduce the risk for
respiratory complications. The nurse should instruct the client to splint the incision while
performing these actions to reduce the risk of complications to the surgical incision.
Plan to ambulate the client as soon as possible is correct. The nurse should plan to ambulate the
client as soon as possible to promote ventilation and decrease the risk of thrombosis.
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Report urinary output to the provider is correct.The client should produce at least 30 mL of urine
per hour. Therefore, the nurse should report this finding to the provider.
Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse
should have the client rate their pain prior to and following the administration of pain medication
to evaluate its effectiveness.
3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag
is not available when the current infusion is nearly completed. which actions should the
nurse take?
Keep the line open with 0.9% sodium chloride until the new bag arrives. Administer
dextrose 10% in water until the new bag arrives.
Flush the line and cap the port until the new bag arrives.
Decrease the infusion rate until the new bag arrives.
ANS Administer dextrose 10% in water until the new bag arrives
4. A nurse is caring for a client who had a nephrostomy tube inserted 12 hr. ago. Which of
the following findings should the nurse report to the provider?
The client's urinary output has increased. The client
reports back pain.
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The client's urine color is red tinged.
The client's tube requires irrigation.
ANS The client reports back pain
The nurse should notify the provider if the client reports back pain, which can indicate that the
nephrostomy tube is dislodged or clogged.
5. A nurse is caring for a client who is having a seizure. Which of the following
interventions is the nurse's priority?
ANS Turn the client to the side.
6. A nurse in a provider's office is assessing a client who has hypertension and takes
propranolol. Which of the following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication?
ANS Report of a night cough.
(the nurse should recognize that this is an early indication of heart failure and report this adverse
reaction to the provider)
7. A nurse is planning to irrigate and dress a clean, granulating wound for a client who
has a pressure injury. Which of the following actions should the nurse take?
ANS Use a 30-mL syringe.
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