PN Adult Medical Surgical 2023

PN Adult Medical Surgical 2023 Related

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Vital Signs
Day 1:
• Temperature 36°C (96.8°F)
• Blood pressure 140/80 mm Hg
• Heart rate 98/min
• Respiratory rate 24/min
• Oxygen saturation 97% on room air
Day 2, 0800:
• Temperature 37°C (98.6°F)
• Blood pressure 122/60 mm Hg
• Heart rate 85/min
• Respiratory rate 18/min
• Oxygen saturation 98% on room air

A nurse is assisting in the plan of care for the client who has compartment syndrome. Which potential prescription is anticipated?

  • A. Open the splint
  • B. Obtain a urinalysis
  • C. Place the client on NPO status
  • D. Place the client's right leg in a dependent position
Correct Answer: A, D

Rationale: Compartment syndrome requires relieving pressure to restore perfusion. Opening the splint (or cast) reduces external compression, an anticipated step pre-fasciotomy if tightness contributes to ischemia, per orthopedic protocols. Urinalysis checks for myoglobinuria from muscle breakdown, a diagnostic aid, but not immediate relief. NPO status prepares for surgery, a later consideration after pressure relief. A dependent leg position increases venous pooling, worsening swelling and pressure contraindicated here. Opening the splint directly addresses the mechanical cause, buying time for surgical evaluation, aligning with emergency management (e.g., AAOS guidelines), making it the expected prescription to prioritize limb viability.

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A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?

  • A. Ask the client to describe her feelings about the loss of the affected limb.
  • B. Encourage the client to talk with another client who completed rehabilitation for amputation.
  • C. Restrict visitors to family members until the client is able to wear a prosthesis.
  • D. Suggest that family members bring clothing for the client from home.
  • E. Instruct the client to ignore phantom pain sensations.
  • F. Apply heat to the stump.
  • G. Limit physical therapy.
Correct Answer: A,B,D

Rationale: Expressing feelings aids coping, peer support helps adjustment, and familiar clothing boosts morale; phantom pain should be addressed, not ignored.

A nurse is caring for a client who has dysphagia following a stroke. The nurse should recommend a referral to which of the following members of the interdisciplinary team?

  • A. Speech therapist
  • B. Respiratory therapist
  • C. Occupational therapist
  • D. Physical therapist
Correct Answer: A

Rationale: A speech therapist addresses dysphagia by assessing swallowing and recommending strategies, critical after a stroke. Other therapists focus on different rehabilitation aspects.

A nurse in a provider's office is assisting in the care of a client. For each potential provider's prescription, which is anticipated for the client?

  • A. Administer an iron supplement.
  • B. Collaborate with a nutritional consultant.
  • C. Place the client on a low sodium diet.
  • D. Restrict fluid intake.
Correct Answer: A

Rationale: Given the client's vegan diet, fatigue, weakness, pale mucous membranes, and rapid pulse (Exhibit 1), iron deficiency anemia is likely. Administering an iron supplement is anticipated it corrects low hemoglobin, a common vegan shortfall without meat or fortified sources, directly addressing the suspected etiology. Nutritional consultation helps long-term, but immediate supplementation is urgent for symptom relief and oxygen delivery. A low-sodium diet suits heart failure or hypertension, not anemia blood pressure (132/60 to 102/50 mm Hg) reflects orthostasis, not sodium issues. Fluid restriction applies to fluid overload, not here, where hydration supports circulation. Iron supplementation aligns with anemia management guidelines (e.g., ferrous sulfate), offering rapid hematologic improvement, making it the expected prescription for this presentation.

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

  • A. Place the client's bed in reverse Trendelenburg position.
  • B. Massage the affected extremity every 4 hr.
  • C. Apply cold compresses to the affected extremity.
  • D. Measure the calf of the affected extremity each shift.
  • E. Elevate the leg.
  • F. Apply warm compresses.
  • G. Administer heparin.
Correct Answer: D

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

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

  • A. Elevate the head of the client's bed for 1 hr after the feeding
  • B. Administer the feeding solution at a cold temperature.
  • C. Rotate the jejunostomy tube once per day.
  • D. Flush the tube with 90 mL of sterile water before and after the feeding
Correct Answer: A

Rationale: Elevating the head for 1 hour prevents aspiration, essential for jejunostomy feeding safety. Cold solutions, rotation, and large flushes are not recommended.

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