RN ADULT MEDICAL SURGICAL 2023 WITH NGN 2
LATEST VERSIONS (VERSION A AND VERSION B)
ACTUAL EXAM 180 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
VERSION A
A nurse is teaching a young adult client how to perform testicular selfexamination. Which of the following instructions should the nurse
include? – CORRECT ANSWER- Roll each testicle between the thumb
and fingers.
Rationale: The nurse should instruct the client to roll each testicle
horizontally between the thumbs and fingers to feel for any lumps deep
in the center of the testicle.
A nurse is caring for a client who has a new diagnosis of
hyperthyroidism. Which of the following is the priority assessment
finding that the nurse should report to the provider? – CORRECT
ANSWER- Blood pressure 170/80 mm Hg
Rationale: Using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is a systolic blood
pressure of 170 mm Hg, which indicates that the client is at risk for
thyroid storm.
A nurse is caring for a client who is undergoing hemodialysis to treat
end-stage kidney disease (ESKD). The client reports muscle cramps and
a tingling sensation in their hands. Which of the following medications
should the nurse plan to administer? – CORRECT ANSWER- Calcium
carbonate
Rationale: Hypocalcemia is a manifestation of ESKD and an adverse
effect of dialysis. Often occurring late in the dialysis session,
hypocalcemia can cause the client to experience muscle cramping and
tingling to extremities. The nurse should plan to administer a calcium
supplement, such as calcium carbonate, as a calcium replacement.
A nurse is caring for a client who is having a seizure. Which of the
following interventions is the nurse’s priority? – CORRECT ANSWERTurn the client to the side.
Rationale: The greatest risk to this client is hypoxia from an impaired
airway. Therefore, the priority intervention the nurse should take is to
place the client in a side-lying position to prevent aspiration.
A nurse is preparing a client who has supraventricular tachycardia for
elective cardioversion. Which of the following prescribed medications
should the nurse instruct the client to withhold for 48 hr prior to
cardioversion? – CORRECT ANSWER- Digoxin
Rationale: Cardiac glycosides, such as digoxin, are withheld prior to
cardioversion. These medications can increase ventricular irritability and
put the client at risk for ventricular fibrillation after the synchronized
countershock of cardioversion.
A nurse in a provider’s office is assessing a client who has hypertension
and takes propranolol. Which of the following findings should indicate
to the nurse that the client is experiencing an adverse reaction to this
medication? – CORRECT ANSWER- Report of a night cough
Rationale: The nurse should recognize that a night cough is an early
indication of heart failure and report this adverse reaction to the
provider.
A nurse is creating a plan of care for a client who has neutropenia as a
result of chemotherapy. Which of the following interventions should the
nurse include in the plan? – CORRECT ANSWER- Monitor the client’s
temperature every 4 hr.
Rationale: The nurse should monitor the temperature of a client who
has neutropenia every 4 hr because the client’s reduced amount of
leukocytes greatly increases the client’s risk for infection.
A nurse is caring for a client who was just admitted from the emergency
department (ED) – CORRECT ANSWER- Acute chest syndrome and
pneumonia
Rationale: Fluid volume overload is incorrect. While the client is
experiencing an increased respiratory rate and shortness of breath, fluid
volume overload typically includes moist crackles on auscultation,
pitting edema in dependent areas, neck vein distension, and
hypertension.
Right-sided heart failure is incorrect. While clients who have sickle-cell
disease are at risk for developing heart failure, the client does not have
manifestations of right-sided heart failure. Right-sided heart failure
typically presents with signs of fluid volume overload, which includes
jugular vein distention, dependent edema, and blood pressure alterations.
Acute chest syndrome is correct. The client is most likely experiencing
acute chest syndrome, which can be caused by respiratory infections and
debris from sickled cells. The client is displaying manifestations of acute
chest syndrome, which include cough, shortness of breath, wheezing,
tachypnea, fever, and chest pain.
Pneumonia is correct. The client is most likely experiencing pneumonia
as evidenced by the manifestations of cough, shortness of breath, fever,
tachypnea, blood-tinged sputum, and chest pain.
Pneumothorax is incorrect. While the client is experiencing increased
respiratory distress, a pneumothorax typically presents with reduced or
absent breath sounds and unequal chest expansion.
A nurse is caring for a client who has pancreatitis. The nurse should
expect which of the following laboratory results to be below the
expected reference range? – CORRECT ANSWER- Calcium
Rationale: A client who has pancreatitis is expected to have decreased
calcium and magnesium levels due to fat necrosis.