Question

A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

Answer 1

Correct Answers:

Play serene, soothing music.

Rationale :

💎 Soothing music helps reduce agitation and confusion in clients with dementia.

💎 Calming sensory stimulation promotes relaxation and orientation.

💎 It supports non-pharmacologic management of postoperative delirium.

💎 Avoiding overstimulation prevents behavioral escalation.

💎 This method fosters a safe, therapeutic environment for cognitive disorders

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Answer 2

Correct Answers:

Apply a vest restraint daily at bedtime to prevent nighttime wandering.

Rationale :

💎 Vest restraints are only used as a last resort and never for convenience or routine control.

💎 This order violates patient safety and autonomy standards.

💎 Restraints increase the risk of injury, asphyxiation, and psychological distress.

💎 Alternative interventions (alarms, reorientation, supervision) must be tried first.

💎 The nurse must verify and clarify restraint use orders with the provider per facility policy and law.

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Answer 3

Correct Answers:

“I will have to work with a vocational counselor to find out what kinds of jobs I can do."

Rationale :

💎 This statement reflects positive adaptation and acceptance of the amputation by focusing on future goals.

💎 Seeking vocational counseling demonstrates problem-solving and proactive coping, key indicators of adjustment.

💎 The client acknowledges the change in ability while maintaining self-efficacy and hope for productivity.

💎 It signifies a shift from grief to rehabilitation and reintegration into normal life roles.

💎 This attitude supports emotional recovery and promotes psychological well-being and independence.

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Answer 4

Correct Answers:

“Once the cast is dry, you can shower if you cover it with a plastic covering.”

Rationale :

🔷 Water exposure can weaken or damage the cast and underlying skin.

🔷 Plastic covering prevents moisture from soaking the cast.

🔷 A wet cast can cause skin maceration, infection, or odor.

🔷 The client should report tightness, numbness, or swelling immediately.

🔷 Never trim or insert objects into the cast, as it damages skin and structure.

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Answer 5

Correct Answers:

30

Rationale :

✳️ Ordered: 2 mg/min → multiply by 60 = 120 mg/hr.

✳️ Available: 400 mg in 100 mL → 4 mg/mL.

✳️ Divide 120 mg/hr ÷ 4 mg/mL = 30 mL/hr.

✳️ Correct IV pump setting ensures safe lidocaine infusion rate.

✳️ Accurate calculations prevent toxicity and cardiac complications.

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Answer 6

Correct Answers:

Omega-3 fish oil

Rationale :

💠 Omega-3 fatty acids help reduce triglyceride and LDL cholesterol levels.

💠 They promote cardiovascular health by improving arterial elasticity and reducing inflammation.

💠 Supplements support patients with hyperlipidemia and coronary artery disease.

💠 Should be used with a balanced diet and lifestyle changes for best results.

💠 Clients on anticoagulants should use it cautiously as it can prolong bleeding time.

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Answer 7

Correct Answers:

Calcium 9.6 mg/dL (9 to 10.5 mg/dL)

Rationale :

🟢 Hypoparathyroidism causes low calcium due to decreased PTH secretion.

🟢 Treatment effectiveness is shown by a normal calcium level.

🟢 Normal calcium supports neuromuscular stability and bone health.

🟢 Symptoms like tetany, muscle cramps, and tingling resolve as calcium stabilizes.

🟢 Ongoing monitoring prevents rebound hypercalcemia or cardiac effects.

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Answer 8

Correct Answers:

Pedal pulses +1

Rationale :

♦ Weak pedal pulses indicate impaired circulation and possible compartment syndrome.

♦ Cast pressure can compromise arterial blood flow to distal extremities.

♦ The nurse must assess for pain, pallor, paresthesia, and swelling immediately.

♦ Loosen or report tight casts to restore perfusion.

♦ Prompt intervention prevents tissue ischemia and necrosis.

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Answer 9

Correct Answers:

Administer a bronchodilator.

Rationale :

💎 Bronchodilators relax smooth muscles in the airways, improving airflow in COPD exacerbations.

💎 They relieve wheezing and dyspnea, the most acute symptoms of obstruction.

💎 This intervention enhances gas exchange and oxygenation efficiency.

💎 High-flow oxygen (like 10 L/min) can suppress the client’s hypoxic drive to breathe — unsafe.

💎 Early administration prevents respiratory failure by promoting airway clearance.

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Answer 10

Correct Answers:

Peripheral edema

Rationale :

🔷 In right-sided heart failure, blood backs up into the systemic circulation, causing fluid retention.

🔷 This leads to dependent edema, especially in the legs, ankles, and feet.

🔷 Other findings include jugular vein distention and weight gain.

🔷 The left side of the heart pumps oxygenated blood; the right side manages venous return.

🔷 Monitoring daily weight helps track fluid volume status.

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RN Adult Medical Surgical 2023 (2025)

No.

1 :
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

2 :
A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?

3 :
A nurse is caring for a client who has a below-the-knee amputation. Which of the following statements should indicate to the nurse that the client has adapted to role changes after their injury?

4 :
A nurse is instructing a client on the maintenance of their cast. Which of the following instructions should be given to the client?

6 :
A nurse is evaluating the supplement intake of a client who has high cholesterol. The nurse should identify that which of the following supplements will help lower the client's lipid levels?

7 :
A nurse is caring for a client who has hypoparathyroidism. Which of the following findings should indicate to the nurse that the treatment is effective?

8 :
A nurse is evaluating a client who has impaired mobility after receiving casting on their legs bilaterally. Which of the following findings requires intervention by the nurse?

9 :
A nurse in the emergency department is caring for a client who has COPD with exacerbations. Which of the following interventions should the nurse provide?

10 :
A nurse is caring for a client who has right-sided heart failure. The nurse should assess the client for which of the following manifestations?

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RN Adult Medical Surgical 2023 (2025)

No.

1 : A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

2 : A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?

3 : A nurse is caring for a client who has a below-the-knee amputation. Which of the following statements should indicate to the nurse that the client has adapted to role changes after their injury?

4 : A nurse is instructing a client on the maintenance of their cast. Which of the following instructions should be given to the client?

6 : A nurse is evaluating the supplement intake of a client who has high cholesterol. The nurse should identify that which of the following supplements will help lower the client's lipid levels?

7 : A nurse is caring for a client who has hypoparathyroidism. Which of the following findings should indicate to the nurse that the treatment is effective?

8 : A nurse is evaluating a client who has impaired mobility after receiving casting on their legs bilaterally. Which of the following findings requires intervention by the nurse?

9 : A nurse in the emergency department is caring for a client who has COPD with exacerbations. Which of the following interventions should the nurse provide?

10 : A nurse is caring for a client who has right-sided heart failure. The nurse should assess the client for which of the following manifestations?

1 :
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

2 :
A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?

3 :
A nurse is caring for a client who has a below-the-knee amputation. Which of the following statements should indicate to the nurse that the client has adapted to role changes after their injury?

4 :
A nurse is instructing a client on the maintenance of their cast. Which of the following instructions should be given to the client?

6 :
A nurse is evaluating the supplement intake of a client who has high cholesterol. The nurse should identify that which of the following supplements will help lower the client's lipid levels?

7 :
A nurse is caring for a client who has hypoparathyroidism. Which of the following findings should indicate to the nurse that the treatment is effective?

8 :
A nurse is evaluating a client who has impaired mobility after receiving casting on their legs bilaterally. Which of the following findings requires intervention by the nurse?

9 :
A nurse in the emergency department is caring for a client who has COPD with exacerbations. Which of the following interventions should the nurse provide?

10 :
A nurse is caring for a client who has right-sided heart failure. The nurse should assess the client for which of the following manifestations?