Adult Proctored 1

Question 1

Pt who has a femur fracture and is in skeletal traction. what actions should the nurse take about weight?

Answer 1

Ensure the client’s weights are hanging freely from the bed.

Question 2

a) Pt who has anemia and has been taking ferrous gluconate for several weeks.what teaching?
b) pt who has cellulitis of the leg. what interventions should be recommended?

Answer 2

a) take with meal
b) Wash daily with an antibacterial soap

Question 3

a) pt who is postoperative after having an ileostomy established.what teaching about med?
b) pt with severe burns to both lower extremities. The client is scheduled for an escharotmy, what is this?

Answer 3

a) Avoid medications in capsule or enteric form.
b) Large incisions will be made in the burned tissue to improve circulation.”

Question 4

a) pt who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?
b) when pt use NG tube, what position should be?

Answer 4

a) Decreased color perception
b) Maintain the client in Fowler’s position.

Question 5

a) pt who has Cushing’s syndrome. Which of the following clinical manifestations should the nurse expect to observe?

Answer 5

1) Buffalo hump 2) Purple striations 3) Moon face

Question 6

a) pt who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?
b) pt who has esophagogastroduodenoscopy. what teaching pre-procedure?

Answer 6

a) Monitor intake and output hourly
b) “You will remain NPO for 8 hours before the procedure.”

Question 7

pt who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. what documenting of this?

Answer 7

Postictal phase

tonic phase-less than 30 secs
suddenly lose consciousness

Question 8

a) pt reports right shoulder pain following a laparoscopic cholecystectomy. What to teach?
b) checking the suction control chamber of a client’s chest tube and notes that there is no bubbling in the suction control chamber. what action?

Answer 8

a) “The pain will dissipate if you ambulate frequently.”
b) Verify that the suction regulator is on.

Question 9

a) care of a pt immediately following a lumbar puncture.what action? 2
b) pt who has scleroderma. EF?

Answer 9

a) Encourage fluid intake. 2) Monitor the puncture site for hematoma.
b) Hardened skin
autoimmune disease that causes inflammation and fibrosis (thickening) in the skin and other areas of the body

Question 10

a) taking neostigmine, what to teach?
b) pt who is recovering from a left-hemispheric stroke. waht plan include?

Answer 10

a) Take the medication 45 minutes before eating.
b) Re-establish communication

Question 11

a) pt who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations?
b) pt who has HIV and is being discharged to home. what teaching should include?

Answer 11

a) Hypotension
b) Take temperature once a day

Question 12

a) tracheostomy, and has copious and tenacious secretions. What method for the nurse to use to thin this client’s secretions?
b) pt with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. what to do?

Answer 12

a) Provide humidified oxygen.
b) Obtain a pair of slipper socks for the client.
occlusion=the blockage or closing

Question 13

a) pt who is 4 hr postoperative following a transurethral resection of the prostate (TURP). what finding report to the provider?
b) pt who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket.ADR?

Answer 13

a) Thick, red-colored urine
b) Shivering

Question 14

a) teaching about exercise with type 1 DM. waht sentance indicates an understanding?
b) A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. what to do?

Answer 14

a) “I will not exercise if my urine is positive for ketones.”
b) Cover the client’s wound with a moist, sterile dressing.
protruding=sticking

Question 15

a) metabolic acidosis.s/s?
b) cataract extraction. avoid what?

Answer 15

a) Hyperventilation
b) Avoid bending at the waist

Question 16

a) pt who has heart failure and has been taking digoxin daily. pt refuses breakfast and reports nausea. what to do?
b) drainage from the dressing is yellow and thick.what type of drainage is this?

Answer 16

a) Check the client’s vital signs.
b) Purulent

Question 17

a) pt following arthroscopic surgery. To prevent postoperative complications, what action?
b) emphysema. s/s?

Answer 17

a) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
b) Dyspnea 2) Barrel chest 3) Clubbing of the fingers 4) Shallow respirations

Question 18

a) pt who sustained a basal skull fracture. notices a thin stream of clear drainage coming out, what to do?
b) pt who has a spinal cord injury at T-4. at risk for autonomic dysreflexia. what interventions should take to prevent autonomic dysreflexia?

Answer 18

a) Test the drainage for glucose.
b) Prevent bladder distention.
when the pouch that holds your pee (urine) is enlarged.

Question 19

a) pt who has endometrial cancer. what findings should the nurse expect the client to report?
b) pt following an open reduction and internal fixation of a fractured femur. what findings is the nurse’s priority?

Answer 19

a) Abnormal vaginal bleeding
-A type of cancer that begins in the lining of the womb (uterus)
b) Altered level of consciousness

Question 20

a) pt who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. what finding the nurse should report to the provider?
b) teaching pt about how to care for a newly created ileal conduit. what to teach?

Answer 20

a) Abdomen is distended
b) Change the ostomy pouch daily

Question 21

a) pt who had a removal of the pituitary gland. what needs to change?
b) pt who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction.

Answer 21

a) Change the nasal drip pad as needed.
b) To prevent blood clotting

Question 22

a) open-angle glaucoma.EF?
b) gastroenteritis. what electrolyte effect?

Answer 22

a) Loss of peripheral vision
less severe than close one
b) hypokalemia

Question 23

a) pt immediately following a lumbar puncture. what action?
b) pt who has peripheral vascular disease (PVD) What statement needed to teaching?

Answer 23

a) Encourage fluid intake
Monitor the puncture site for hematoma.
b) “I will wear stockings with elastic tops.”

Question 24

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer’s disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take?

Answer 24

Calmly ask the client if he would like to listen to some music.

Question 25

a) observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of waht?
b) pt who has multiple myeloma and has a WBC count of 2,200/mm3 . What food prohibit ?

Answer 25

a) Granulation tissue=a type of new connective tissue
b) Fresh fruit basket

Question 26

a) pt who has heart failure and respiratory arrest. What actions should the nurse take first?
b)pt scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. What responses should the nurse make?

Answer 26

a) Feel for a carotid pulse.
b) “Bypass surgery must be very frightening for you.”

Question 27

A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?

Answer 27

Tell the client to remain in the bathroom after toileting and obtain a wheelchair

Question 28

a) pt who is postoperative and has a closed-wound drainage system in place. What action after empty it?
b) ptwho has hepatitis A. what statements indicates an understanding?

Answer 28

a) Fully recollapse the reservoir after emptying it
b) “I will abstain from sexual intercourse.”

Question 29

a) improve gas exchange to a pt diagnosed with emphysema. which brathing?
b) Addison’s disease. s/s?

Answer 29

a) Pursed lip breathing
Breathe in through her nose and out through pursed lips.
b) hypotension

Question 30

a) take hydroxyzine preoperatively.what the following effects?
b) epoetin alfa,what dietary supplements with this medication?

Answer 30

a) 1) Decreasing anxiety 2) Controlling emesis 5) Reducing the amount of narcotics needed for pain relief
b) iron

Question 31

a) pt’s wounds cover wht a heterograft derssing. what made this of?
b) what med for herpes zoster?
c) skin cancer, basal cell carcinoma originates form which part of tissue?

Answer 31

a) pig skin
b) Acyclovir
c) Epidermis

Question 32

What is ABCDE method for skin cancer screening?

Answer 32

Question 33

Stage of pressure ulcer

Answer 33

1:nonblanchable redness, swollen and congested, discomfort on the site
2:visivle, blister shallow crater, pain
3:full thickness, a deep crater with or without exposure to muscle or bone
drainage and infection are common
4:full thickness,tissue necrosis and visible damage to muscle and bone

Question 34

a) what is melanoma and risk factors?
b) ED pt who had snack bite on her arm,what to do?

Answer 34

a) the most serious type of skin cancer
light skin color
avoid exposure to the midday sun(1000-1600)
pit sunscreen 15 min prior sun exposure
b) The affected limb should be immobilized at the level og the heart
clothes and ring should be off before swellon