Question

A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Answer 1

Correct Answers:

Turn the client on their side.

Rationale :

🔹During a tonic-clonic seizure, the priority action is to turn the client on their side to prevent aspiration and promote drainage of secretions.

🔹Seizures often cause loss of consciousness, muscle rigidity, and excessive salivation, increasing the risk of choking.

🔹Side-lying positioning helps maintain airway patency, which is the first step in seizure safety.

🔹Other interventions such as neurological checks and vital signs are important but follow once the airway is protected.

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Answer 2

Correct Answers:

Daytime oliguria

Rationale :

⫸ Left-sided heart failure results in decreased cardiac output, impairing renal perfusion, which leads to oliguria, particularly during the day.

⫸ At night, when the client lies flat, perfusion improves slightly, resulting in nocturia.

⫸ Other symptoms include

° Dyspnea,

° Orthopnea,

° Crackles,

° Fatigue,

⫸The symptoms stem from pulmonary congestion due to backward flow from the failing left ventricle.

⫸ Unlike right-sided heart failure, which causes systemic fluid retention (e.g., pedal edema, JVD), left-sided failure primarily affects the lungs and kidneys.

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Answer 3

Correct Answers:

Request an interpreter during the initial assessment.

Rationale :

✍️For a client who is deaf and uses sign language;

• The nurse must request a professional interpreter to ensure accurate, unbiased, and confidential communication, especially during admission and assessment.

✍️ Relying on family members can result in miscommunication or breaches in privacy.

✍️ It is the nurse’s responsibility to adhere to ethical and legal standards that promote patient autonomy and linguistic access.

✍️Visual tools like boards can support communication but do not replace interpreters for detailed interactions.

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Answer 4

Correct Answers:

"The elastic bandage will prevent excessive edema."

Rationale :

🔸After a below-the-knee amputation (BKA), applying an elastic bandage helps control postoperative edema, reduce pain, and shape the residual limb for prosthetic fitting.

🔸Preventing edema supports tissue healing, enhances circulation, and reduces the risk of complications like infection or delayed wound closure.

🔸Elastic bandaging is a critical component of residual limb care in the immediate postoperative phase.

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Answer 5

Correct Answers:

Decreased anxiety

Rationale :

✍️In acute heart failure, morphine is administered not only for pain but also to reduce preload and anxiety by causing venodilation and central nervous system calming.

✍️ A decrease in anxiety is a positive therapeutic response, indicating improved oxygenation and emotional comfort.

✍️ It also helps reduce oxygen demand, which is essential in heart failure.

✍️ Other indicators like urinary output or emesis are not primary measures of morphine’s effectiveness in this scenario.

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Answer 6

Correct Answers:

Alopecia

Rationale :

🔹In clients with malnutrition, particularly protein and iron deficiencies, alopecia (hair thinning or loss) is a common manifestation.

🔹 Malnourishment compromises the body’s ability to maintain skin, hair, and nail integrity, leading to dry, brittle, or thinning hair.

🔹Other signs may include

• Muscle wasting

• Delayed wound healing

• Lethargy.

🔹 Recognizing alopecia helps nurses identify underlying nutritional deficiencies requiring dietary intervention and support.

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Answer 7

Correct Answers:

Strawberries

Rationale :

🔥Clients with latex allergies often have cross-sensitivity to certain fruits due to shared protein structures, including

• Strawberries

• Bananas

• Kiwis

• Avocados,

🔥This association is critical to recognize during preoperative assessments, as latex is present in many medical devices like gloves and catheters.

🔥A history of fruit allergy, especially to strawberries, should prompt use of latex-free equipment to prevent severe allergic reactions, including anaphylaxis.

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Answer 8

Correct Answers:

"You will need to follow up with your provider."

Rationale :

👉A positive PPD skin test, indicated by erythema and induration ≥10 mm in size, suggests that the client has been exposed to Mycobacterium tuberculosis.

👉 For most people, a 12 mm induration is a positive result that calls for additional medical testing, usually a chest X-ray and possibly a sputum culture to identify whether the patient has latent or active tuberculosis.

👉The nurse’s role is to ensure that the client understands the next step is clinical follow-up, not treatment or a repeat skin test.

👉 It is also inappropriate to delay care with vague reassurances or imply the test must be repeated.

👉 Early identification and follow-up are essential to prevent the progression or spread of the disease.

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Answer 9

Correct Answers:

Obtain an ECG.

Rationale :

✅ In the case of an electrical injury, particularly from high-voltage exposure, the heart is at significant risk for electrical conduction disturbances, including ventricular fibrillation or arrhythmias.

✅ These effects may not be immediately evident, which makes early cardiac evaluation critical.

✅The first priority is to perform an ECG to assess for acute changes in heart rhythm.

✅ Interventions such as fluid resuscitation, pain control, and dressing wounds are important, but they follow after ensuring cardiac stability.

✅ Immediate ECG monitoring is lifesaving and allows early detection of abnormalities that could otherwise go unnoticed until the patient deteriorates.

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Answer 10

Correct Answers:

Consider respite care services.

Rationale :

💎 Caregivers of individuals with moderate Alzheimer’s disease often experience physical, emotional, and psychological exhaustion, which can lead to burnout and impaired caregiving capacity.

💎The signs of irritability, fatigue, and impatience suggest the caregiver is becoming overwhelmed.

💎Recommending respite care offers a temporary relief and allows the caregiver time to rest and recover, ultimately supporting the long-term caregiving relationship.

💎 It also helps prevent caregiver resentment or potential neglect or harm.

💎 Referrals to community resources such as adult day programs or in-home respite services are integral to holistic and family-centered nursing care.

💎 The nurse must proactively address the needs of both the client and their primary support system.

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RN Medical Surgical~2023

No.

1 : A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first?

2 : A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?

3 : A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse

4 : A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?

5 : A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

6 : A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?

7 : A nurse is reviewing the health history of a client who is scheduled for exploratory surgery. Which of the following food allergies indicates a risk for an allergic reaction to latex?

8 : A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 12 mm at the injection site. Which of the following instructions should the nurse provide to the client?

9 : A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

10 : A nurse is caring for a client who has moderate Alzheimer's disease. During weekly home visits, the nurse notices that the client's caregiver is tired, irritable, and impatient with the client. Which of the following actions should the nurse recommend to the caregiver?

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