PN Adult Medical Surgical 2023

PN Adult Medical Surgical 2023 Related

Review PN Adult Medical Surgical 2023 related questions and content

A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?

  • A. The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.
  • B. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr.
  • C. The client arouses easily but quickly falls back asleep.
  • D. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr.
Correct Answer: B

Rationale: Postoperative priorities follow the ABCs (Airway, Breathing, Circulation). Dark red drainage of 20 mL over 4 hours suggests potential bleeding, a circulation issue that could indicate hemorrhage a life-threatening complication after bowel resection. Pain of 6/10 is expected post-surgery and manageable with analgesics, not immediately urgent. Easy arousal with sleepiness reflects sedation or fatigue, not an acute threat unless airway compromise emerges. Urine output of 60 mL over 4 hours (15 mL/hr) is below normal (30 mL/hr), signaling oliguria, but bleeding takes precedence as it's more immediately lethal. Excessive drainage could destabilize the client faster than oliguria or pain, requiring urgent provider notification to assess for internal bleeding or anastomosis leakage. This aligns with postoperative monitoring protocols, emphasizing early detection of hemorrhage, making it the top priority to report.

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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 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.

A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?

  • A. LDL
  • B. INR
  • C. BUN
  • D. Hct
Correct Answer: B

Rationale: INR (International Normalized Ratio) measures clotting time and must be monitored with warfarin to ensure therapeutic anticoagulation and prevent bleeding or clotting complications in atrial fibrillation.

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

Rationale: It's normal for one breast to be slightly larger than the other, and this statement reflects an accurate understanding of breast anatomy. Dimpling can be a sign of concern, and exams should be done monthly, about a week after the period starts, not on the first day or every other month.

A nurse is reinforcing teaching with a client who has a prescription for sublingual nitroglycerin for unstable angina. Which of the following instructions should the nurse include in the instructions?

  • A. Refill the prescription every 12 months.
  • B. Take a second tablet after 5 min for unrelieved chest pain.
  • C. Swallow the tablet whole with a glass of water.
  • D. Store the medication in the refrigerator.
Correct Answer: B

Rationale: Taking a second dose after 5 minutes for unrelieved pain is standard protocol for nitroglycerin, which is taken sublingually, not swallowed, and stored at room temperature, refilled every 6 months.

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