ATI PN Comprehensive Exam with Answers-175 Solved Questions

ATI PN COMPREHENSIVE EXIT EXAM LATEST A+ GRADED (175 QUESTIONS
WITH ANSWERS)
1) A nurse in an emergency department completes an assessment on an adolescent client that
has conduct disorder. The client threatened suicide to teacher at school. Which of the
following statements should the nurse include in the assessment?
a) Tell me about your siblings
b) Tell me what kind of music you like
c) Tell me how often do you drink alcohol
d) Tell me about your school schedule
Answer: c) Tell me how often do you drink alcohol
Rationale:
In this scenario, the adolescent client has conduct disorder and has threatened suicide,
indicating potential risk factors. Asking about alcohol consumption is pertinent as it can
exacerbate impulsive behaviors and may contribute to the client's overall risk level.
2) A nurse is observing bonding to the client her newborn. Which of following actions by the
client requires the nurse to intervene?
a) Holding the newborn in an en face position
b) Asking the father to change the newborn's diaper
c) Requesting the nurse take the newborn nursery so she can rest
d) Viewing the newborn’s actions to be uncooperative
Answer: d) Viewing the newborn’s actions to be uncooperative
Rationale:
Bonding with a newborn is a crucial aspect of postnatal care. Viewing the newborn's actions
as uncooperative could indicate potential misunderstanding or frustration on the part of the
mother, which may hinder bonding. Intervening to provide support and guidance can help
foster a positive bonding experience.

3) A nurse is caring for client who is taking levothyroxin. Which of the following findings
should indicate that the medication is effective?
a) Weight loss
b) Decreased blood pressure
c) Absence of seizures
d) Decrease inflammation
Answer: a) Weight loss
Rationale:
Levothyroxine is a thyroid hormone replacement medication used to treat hypothyroidism.
One of its primary effects is to increase metabolism, which can lead to weight loss in
individuals with hypothyroidism who were gaining weight due to the condition.
4) A nurse is planning discharge teaching for cord care for the parent of a newborn. Which
instructions would you include in the teaching?
a) Contact provider if the cord still turns black
b) Clean the base of the cord with hydrogen peroxide daily
c) Keep the cord dry until it falls off
d) The cord stump will fall off in five days
Answer: c) Keep the cord dry until it falls off
Rationale:
Keeping the cord dry until it falls off helps prevent infection and promotes healing. Hydrogen
peroxide can be too harsh and delay healing, and the cord typically falls off in 10-14 days,
not five.
5) A nurse is assessing a client in the PACU. Which of the following findings indicates
decreased cardiac output?
a) Shivering
b) Oliguria

c) Bradypnea
d) Constricted pupils
Answer: b) Oliguria
Rationale:
Oliguria, or decreased urine output, can indicate decreased cardiac output as the kidneys
receive less blood flow, leading to reduced urine production. This can occur in response to
decreased cardiac function or inadequate tissue perfusion.
6) A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the
following client should the nurse identify as the priority?
a) A client that has massive head trauma
b) A client has full thickness burns to face and trunk
c) A client with indications of hypovolemic shock
d) A client with open fracture of the lower extremity
Answer: c) A client with indications of hypovolemic shock
Rationale:
In mass casualty situations, prioritizing care is crucial. A client with indications of
hypovolemic shock, such as low blood pressure, rapid heart rate, and altered mental status,
requires immediate intervention to stabilize their condition and prevent further deterioration.
7) A nurse is receiving report on four clients. Which of the following clients should the nurse
assess first?
a) A client who has illeal conduit and mucus in the pouch
b) Client pleasant arteriovenous additional vibration palpated
c) A client whose chronic kidney disease with cloudy diasylate outflow
d) A client was transurethral resection of the prostate with a red tinged urine in the bag
Answer: d) A client was transurethral resection of the prostate with a red tinged urine in the
bag

Rationale:
Red tinged urine after a transurethral resection of the prostate could indicate bleeding, which
requires immediate assessment to determine the extent of bleeding and initiate appropriate
interventions.
8) A nurse is caring for a client who just received the first dose of lisinopril. Which of the
following is an appropriate nursing intervention?
a) Place’s cardiac monitoring
b) Monitor the clients oxygen saturation level
c) Provide standby assist with the client from bed
d) Encourage foods high in potassium
Answer: a) Place’s cardiac monitoring
Rationale:
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor commonly used to treat
hypertension. The first dose can cause hypotension or other adverse reactions, so cardiac
monitoring is appropriate to assess for any cardiac effects.
9) A nurse is caring for a client who is in labor and is receiving electronic fetal monitoring.
The nurse is reviewing the monitor tracing and notes early decelerations. Which of the
following should the nurse expect?
a) Fetal hypoxia
b) Abruptio placentae
c) Post maturity
d) Head Compression
Answer: d) Head Compression
Rationale:
Early decelerations are typically associated with fetal head compression during contractions.
They are generally benign and not indicative of fetal distress.

10) A nurse is caring for a client who has chronic kidney disease. The nurse should identify
which of the following laboratory values as an indication for hemodialysis?
a) Glomerular filtration rate of 14 mL/minute
b) BUN 16 mg/DL
c) Serum magnesium 1.8 mg/dL
d) Serum phosphorus 4.0 mg/dL
Answer: a) Glomerular filtration rate of 14 mL/minute
Rationale:
A glomerular filtration rate (GFR) of 14 mL/minute indicates severe kidney dysfunction and
is indicative of the need for renal replacement therapy, such as hemodialysis.
11) A nurse is caring for an infant who has a prescription for continuous pulse oximetry.
Which of the following is an appropriate action for the nurse to take?
a) Place infant under radiant warmer
b) Move the probe site every 3 hours
c) Heat the skin one minute prior to placing the probe
d) Place a sensor on the index finger
Answer: b) Move the probe site every 3 hours
Rationale:
Moving the probe site every 3 hours helps prevent skin breakdown and ensures accurate
readings. Placing the sensor on the index finger is appropriate for infants.
12) A nurse in a mental health facility receives a change of shift report on four clients. Which
of the following clients should the nurse plan to assess first?
a) Client placed in restraints due to aggressive behavior
b) A new client with a history of 4.5 kg weight loss in the past two months
c) Client receiving a PRN dose of haloperidol two hours ago for increased anxiety
d) Client scheduled to receive their first electroconvulsive therapy (ECT) treatment today

Answer: a) Client placed in restraints due to aggressive behavior
Rationale:
The client in restraints due to aggressive behavior requires immediate assessment to ensure
their safety and address any escalating issues.
13) A nurse working at the clinic is teaching a group of pregnant clients on the use of
nonpharmacological pain management. Which of the following statements by the nurse is an
appropriate description of the use of hypnosis during labor?
a) Hypnosis focuses on biofeedback as a relaxation technique
b) Hypnosis promotes increased control of pain perception during contractions
c) Hypnosis uses therapeutic touch to reduce anxiety during labor
d) Hypnosis provides instruction to minimize pain
Answer: b) Hypnosis promotes increased control of pain perception during contractions
Rationale:
Hypnosis during labor can help individuals manage pain perception and promote relaxation,
providing a sense of control during contractions.
14) A nurse in a County Jail health clinic is leading a group therapy session. A client who was
incarcerated for theft is addressing the group. Which of the following is an example of
reaction formation?
a) I steal things because it’s the only way I can keep my mind off my bad marriage
b) I can’t believe I was accused of something I didn’t do
c) I don’t want to talk about my feelings right now. We will talk more next time
d) I think that people who steal are just lazy and should earn money honestly
Answer: d) I think that people who steal are just lazy and should earn money honestly
Rationale:
Reaction formation involves expressing feelings or behaviors that are the opposite of one's
true feelings or impulses. In this case, the client is projecting an attitude of honesty and hard
work, which contrasts with their own behavior of theft.

15) A nurse is obtaining the medical history of a client who has a new prescription for
isosorbide mononitrate. Which of the following should the nurse identify as a
contraindication to the medication?
a) Glaucoma
b) Hypertension
c) Polycythemia
d) Migraine headaches
Answer: a) Glaucoma
Rationale:
Isosorbide mononitrate is contraindicated in patients with glaucoma due to its potential to
increase intraocular pressure.
17) The nurse is caring for a client recovering from an acute myocardial infarction. Which
intervention should the nurse include in the plan of care?
a) Draw a troponin level every four hours
b) Perform an EKG every 12 hours
c) Administer oxygen via rebreather mask at 4 L/min
d) Obtain a cardiac rehabilitation consult
Answer: d) Obtain a cardiac rehabilitation consult
Rationale:
Cardiac rehabilitation is an essential component of recovery after a myocardial infarction,
promoting physical and psychological well-being and reducing the risk of future cardiac
events.
18) A nurse is caring for a client who has breast cancer and has been receiving chemotherapy.
Which of the following laboratory values should the nurse report to the provider?
a) WBC 3,000/mm3
b) Hemoglobin 14 g/dl

c) Platelet 250,000/mm3
d) aPTT 30 seconds
Answer: a) WBC 3,000/mm3
Rationale:
A low white blood cell count (WBC) can indicate bone marrow suppression, a common side
effect of chemotherapy, which increases the risk of infection. Therefore, it should be reported
to the provider for further evaluation and possible intervention.
19) A home health nurse is caring for a client with Alzheimer’s disease. Which of the
following actions should the nurse include in the plan of care?
a) Place a daily calendar in the kitchen
b) Replace button clothing with zippered items
c) Replace the carpet with hardwood floors
d) Create variation in daily routine
Answer: d) Create variation in daily routine
Rationale:
Creating variation in the daily routine can help stimulate the client's cognitive functioning
and reduce agitation or restlessness commonly seen in Alzheimer's disease.
20) A nurse is performing change of shift assessments on 4 clients. Which of the following
findings should the nurse report to the provider first?
a) The client with cystic fibrosis has a thick productive cough and reports thirst
b) Client who has gastroenteritis and is lethargic and confused
c) The client with diabetes mellitus has a morning fasting blood glucose of 185 mg/dL
d) The client with sickle cell anemia reports pain 15 minutes after receiving oral analgesic
Answer: b) Client who has gastroenteritis and is lethargic and confused
Rationale:

Lethargy and confusion in a client with gastroenteritis could indicate dehydration or
electrolyte imbalances, which require immediate medical attention to prevent complications.
21) A nurse is caring for a client in the second trimester of pregnancy who asks how to treat
constipation. Which of the following statements by the nurse is appropriate?
a) Decrease taking vitamins and supplements to every other day
b) Eat 15 g of fiber per day
c) Consume 48 ounces of water each day
d) Drink hot water with lemon juice each morning when you wake up
Answer: c) Consume 48 ounces of water each day
Rationale:
Adequate hydration is important for preventing and treating constipation during pregnancy.
Pregnant individuals should aim for at least 64 ounces of water per day.
23) A nurse is caring for a client who is preparing advance directives. Which of the following
statements by the client indicates an understanding of advance directives? Select all that
apply.
a) I can’t change my instructions once written
b) My doctor will need to approve my advance directives
c) I need an attorney to witness my signature on the advance directives
d) I have the right to refuse treatment
e) My health care proxy can make medical decisions for me
Answer: d) I have the right to refuse treatment
e) My health care proxy can make medical decisions for me
Rationale:
These statements indicate an understanding of advance directives, including the right to
refuse treatment and the role of a healthcare proxy in making medical decisions.

24) A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac
disease. Which of the following positions should the nurse place the client in to best promote
optimal cardiac output?
a) High Fowler's
b) Standing
c) Supine
d) Left lateral
Answer: d) Left lateral
Rationale:
The left lateral position helps relieve pressure on the vena cava, improving venous return and
cardiac output, which is particularly important for clients with cardiac disease during
pregnancy.
25) A nurse is caring for a group of clients. Which of the following clients should the nurse
assign to an AP?
a) Client who has chronic obstructive pulmonary disease and needs guidance on incentive
spirometry
b) Client who has awoken following a bronchoscopy and requests a drink
c) Client who had a myocardial infarction 3 days ago and reports chest discomfort
d) Client who had a cerebrovascular accident two days ago and needs help toileting
Answer: d) Client who had a cerebrovascular accident two days ago and needs help toileting
Rationale:
Assisting with toileting is a task within the scope of practice for an unlicensed assistive
personnel (AP), and the client's condition is stable enough to allow for assistance with
activities of daily living.
26) A nurse is providing discharge teaching to a client who has schizophrenia and is starting
therapy with clozapine. Which of the following is the highest priority for the client to report
to the provider?

a) Constipation
b) Blurred vision
c) Fever
d) Dry mouth
Answer: c) Fever
Rationale:
Fever can indicate a potentially serious adverse reaction called agranulocytosis, which is a
significant risk associated with clozapine therapy and requires immediate medical attention.
27) A nurse observes an AP providing care to a child who is in skeletal traction. Which of the
following actions requires intervention?
a) Providing a high-protein snack
b) Assisting the child to reposition
c) Placing weights at the foot of the child's bed
d) Massaging pressure points
Answer: c) Placing weights at the foot of the child's bed
Rationale:
Placing weights at the foot of the child's bed can cause uneven traction and is not the correct
method for maintaining skeletal traction. The weights should be freely hanging off the bed to
provide continuous and even traction.
28) A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who
has diabetes mellitus. Which of the following actions should the nurse take?
a) Determine if the AP is qualified to perform the test.
b) Help the AP perform the blood glucose test.
c) Assign the AP to ask the client if they have taken their diabetic medication today.
d) Have the AP check the medical record for prior blood glucose test results.
Answer: a) Determine if the AP is qualified to perform the test.

Rationale:
Before delegating a task, the nurse must ensure that the assistive personnel (AP) is competent
and qualified to perform the specific procedure, in this case, fasting blood glucose testing.
29) A nurse is assessing a client brought to the hospital psychiatric emergency services by a
law enforcement officer. The client has disorganized, incoherent speech with loose
associations and religious content. You should recognize the signs and symptoms as being
consistent with which of the following?
a) Alzheimer’s disease
b) Schizophrenia
c) Substance intoxication
d) Depression
Answer: b) Schizophrenia
Rationale:
The symptoms described are characteristic of schizophrenia, particularly the disorganized
speech with loose associations, which is a hallmark feature of this disorder.
30) A nurse is caring for a child who has infectious mononucleosis. Which of the following
findings are associated with this diagnosis? Select all that apply.
a) Splenomegaly
b) Koplik spots
c) Malaise
d) Vertigo
e) Sore throat
Answer: a) Splenomegaly, c) Malaise, e) Sore throat
Rationale:
Infectious mononucleosis is characterized by symptoms such as splenomegaly, malaise, and
sore throat. Koplik spots are associated with measles, not mononucleosis.

31) A nurse is performing a dressing change for a client with a sacral wound using negative
pressure wound therapy. Which of the following actions should the nurse take first?
a) Apply skin preparation to wound edges.
b) Irrigate the wound with normal saline.
c) Don sterile gloves.
d) Determine the client's pain level.
Answer: c) Don sterile gloves.
Rationale:
Before performing any wound care procedure, it is essential for the nurse to maintain sterile
technique by donning sterile gloves.
32) A nurse is caring for a client recovering from bowel surgery who has a nasogastric tube
connected to low intermittent suction. Which of the following assessment findings should
indicate to the nurse that the NG tube may not be functioning properly?
a) Drainage fluid is greenish-yellow.
b) Aspirate pH of 3.
c) Abdominal rigidity.
d) Air bubbles noted in the NG tube.
Answer: c) Abdominal rigidity.
Rationale:
Abdominal rigidity can indicate abdominal distention, which may occur if the NG tube is not
functioning properly and gastric contents are not being adequately drained.
33) A nurse is preparing to administer TPN with added fat supplements to a client who has
malnutrition. Which of the following actions should the nurse take?
a) Piggyback 0.9% sodium chloride with the TPN solution.
b) Check for an allergy to eggs.
c) Discuss the TPN solution for 12 hours.

d) Monitor for hypoglycemia.
Answer: b) Check for an allergy to eggs.
Rationale:
TPN solutions may contain egg-based fat emulsions. Checking for allergies to eggs is crucial
to prevent potential allergic reactions in the client.
34) A charge nurse is discussing the use of applying ice to a client’s injured knee with a
newly licensed nurse. Which of the following should the nurse identify as a benefit?
a) Systemic analgesic effect
b) Increase in metabolism
c) Decreased capillary permeability
d) Vasodilation
Answer: c) Decreased capillary permeability.
Rationale:
Applying ice to an injured area can help decrease capillary permeability, which can reduce
inflammation and swelling at the site of injury.
35) A nurse is developing discharge care plans for a client with osteoporosis. To prevent
injury, the nurse should instruct the client to:
a) Perform weight-bearing exercises.
b) Avoid crossing the legs beyond the midline.
c) Avoid sitting in one position for prolonged periods.
d) Splint the affected area.
Answer: a) Perform weight-bearing exercises.
Rationale:
Weight-bearing exercises help to strengthen bones and reduce the risk of fractures in clients
with osteoporosis.

36) A nurse on an acute med-surgical unit is performing assessments on a group of clients.
Which is the highest priority?
a) The client has surgical hypoparathyroidism and a positive Trousseau’s sign.
b) A client with Clostridium difficile with acute diarrhea.
c) A client with acute kidney injury and urine with a low specific gravity.
d) The client who has oral cancer and reports a sore on his gums.
Answer: a) The client has surgical hypoparathyroidism and a positive Trousseau’s sign.
Rationale:
A positive Trousseau's sign indicates hypocalcemia, which can lead to serious complications
such as tetany or seizures, making this client the highest priority for assessment and
intervention.
37) A nurse is caring for a client with congestive heart failure. Which of the following
prescriptions from the provider should the nurse anticipate?
a) Call the provider if the client's respiratory rate is less than 18/min.
b) Give the client a 500 mL IV bolus of 0.9% sodium chloride over 1 hr.
c) Give the client enalapril 2.5 mg PO twice daily.
d) Call the provider if the client's pulse rate is less than 80/min.
Answer: a) Call the provider if the client's respiratory rate is less than 18/min.
Rationale:
A respiratory rate less than 12-20 breaths/min in a client with congestive heart failure may
indicate respiratory distress and warrants immediate medical attention.
38) A nurse is caring for a client who has a prescription for sertraline to treat depression.
Which of the following statements by the client indicates an understanding of the medication
treatment plan?
a) I will be able starting this medication with feel better
b) I can expect to urinate frequently while on this medication

c) I understand I may experience difficulty sleeping on this medication
d) I should decrease my sodium intake while on this medication
Answer: c) I understand I may experience difficulty sleeping on this medication
Rationale:
Difficulty sleeping, or insomnia, is a common side effect of sertraline. Understanding and
anticipating this potential side effect indicate the client's comprehension of the medication's
effects.
39) A nurse has been caring for a female client who has bruises on her arms that she explains
are a result of physical abuse by her husband. The client states, “I don’t know how much
longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is
an appropriate nursing intervention?
a) Offer to speak to the client’s husband regarding his abusive behavior.
b) Help the client to recognize the signs of escalation of abusive behavior.
c) Assist the client to identify personal behaviors that trigger abusive behavior.
d) Assist the client to report abusive behavior to the proper authority.
Answer: d) Assist the client to report abusive behavior to the proper authority.
Rationale:
Safety is the priority for a client experiencing abuse. Reporting the abusive behavior to the
proper authority can help ensure the client's safety and provide necessary support and
resources.
40) A client who was having suicidal thoughts tells the nurse, “It just does not seem worth it
anymore. Why not end my misery?” Which of the following responses from the nurse is
appropriate?
a) Why do you think your life is not worth it anymore?
b) Do you have a plan to end your life?
c) I need to know what you mean by misery.
d) You can trust me and tell me what you’re thinking.

Answer: a) Why do you think your life is not worth it anymore?
Rationale:
This response acknowledges the client's feelings and opens the door for further discussion
about their suicidal ideation and underlying reasons, facilitating therapeutic communication.
41) A nurse is caring for a client who has schizophrenia. Which of the following assessment
findings should the nurse expect?
a) Decreased level of consciousness
b) Unable to identify common objects
c) Poor problem-solving ability
d) Preoccupation with somatic disturbances
Answer: d) Preoccupation with somatic disturbances
Rationale:
Clients with schizophrenia may experience hallucinations or delusions related to somatic
concerns, such as believing they have a serious illness despite lack of evidence.
42) A nurse is caring for a client who has deep vein thrombosis of the left lower extremity.
Which of the following actions should the nurse take?
a) Position the client with the affected extremity lower than the heart
b) Administration of acetaminophen
c) Massage the affected extremity every 4 hrs.
d) Withhold heparin IV infusion
Answer: d) Withhold heparin IV infusion
Rationale:
Heparin is commonly used to treat deep vein thrombosis. However, the question asks for an
action the nurse should take, and withholding the heparin could be necessary if there are
contraindications or complications, such as active bleeding or a low platelet count.

43) Is caring for a client with a new prescription for enoxaparin for the prevention of DVT.
Which of the following is an appropriate action by the nurse?
a) Expel air bubble at the top of the prefilled syringe
b) Massage the injection site to evenly distribute the medication
c) Inject the medication the lateral abdominal wall
d) Administer an NSAID for injection site discomfort
Answer: a) Expel air bubble at the top of the prefilled syringe
Rationale:
Expelling air bubbles from the syringe before administering enoxaparin helps ensure accurate
dosing and prevents air embolism.
44) A nurse is caring for four clients. Which of the following client data should the nurse
report to the provider?
a) A client who has pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
b) A client who drained a total of 110 mL of serosanguineous fluid from the Jackson Pratt
drain within the first 24 hours following surgery
c) A client who is 4 hours postoperative and has a heart rate of 98 beats per minute
d) A client with a prescription for chemotherapy and an absolute neutrophil count of 75/mm³
Answer: d) A client with a prescription for chemotherapy and an absolute neutrophil count of
75/mm³
Rationale:
An absolute neutrophil count of 75/mm³ indicates severe neutropenia, which puts the client at
high risk for infection and requires immediate attention from the provider.
45) A nurse is caring for a client in end-stage osteoporosis who is reporting severe pain. The
client's respiratory rate is 14 per minute. Which of the following medications should the nurse
expect to be the highest priority to administer to the client?
a) Promethazine
b) Hydromorphone

c) Ketorolac
d) Amitriptyline
Answer: b) Hydromorphone
Rationale:
Hydromorphone is a potent opioid analgesic used to manage severe pain, which is
appropriate for a client experiencing severe pain in end-stage osteoporosis.
46) A nurse is caring for a client who has DVT. Which of the following instructions should
the nurse include in the plan of care?
a) Live with the clients fluid intake to 1500 mL per day
b) Massage place affected extremity to relieve pain
c) Apply cold packs of clients affected extremity
d) Elevate the client’s affected extremity when in bed
Answer: d) Elevate the client’s affected extremity when in bed
Rationale:
Elevating the affected extremity helps promote venous return and reduce edema associated
with deep vein thrombosis.
47) A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The
client’s contractions are occurring every 45 seconds with a duration of nine seconds, and the
fetal heart rate is 170 to 180/minute. Which of the following actions should the nurse take?
a) Discontinue oxytocin infusion
b) Increased oxytocin infusion
c) Decreased oxytocin infusion
d) Maintain oxytocin infusion

Answer: c) Decrease oxytocin infusion
Rationale:

The frequency and duration of contractions, along with the fetal tachycardia, indicate
hyperstimulation of the uterus, which can lead to fetal distress. Decreasing the oxytocin
infusion can help reduce uterine activity and alleviate fetal distress.
48) A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal
newborn unit. The client has a history of herpes simplex virus 2. Which of the following
questions is most appropriate for the nurse to ask the client?
a) Have your membranes ruptured?
b) How far apart are your contractions?
c) Do you have any active lesions?
d) Are you positive for beta strap?
Answer: c) Do you have any active lesions?
Rationale:
Active lesions of herpes simplex virus 2 can increase the risk of transmission to the newborn
during delivery. It is crucial to assess if the client has any active lesions present to take
appropriate precautions.
49) Nurse is providing teaching for a child prescribed ferrous sulfate. Which of the following
instructions should the nurse include?
a) Take with meals
b) Take at bedtime
c) Take with a glass of milk
d) Take with a glass of orange juice
Answer: d) Take with a glass of orange juice
Rationale:
Taking ferrous sulfate with a source of vitamin C, such as orange juice, can enhance iron
absorption. It is commonly recommended to take iron supplements with a source of vitamin
C to improve absorption.

50) Four clients present to the emergency department. The nurse should plan to see which of
the following clients first?
a) A 6-year-old client whose left shoulder is dislocated
b) A 26-year-old client with sickle cell disease and severe joint pain
c) A 76-year-old client who is confused, febrile, and has foul-smelling urine (UTI)
d) A 50-year-old client who has slurred speech, is disoriented, and reports a headache (stroke)
Answer: d) A 50-year-old client who has slurred speech, is disoriented, and reports a
headache (stroke)
Rationale:
The client with slurred speech, disorientation, and headache is exhibiting signs of a stroke,
which requires immediate medical attention due to the potential for serious complications and
neurological damage.
51) A nurse is completing a dietary assessment for a client who is Jewish and observes kosher
dietary practices. Which of the following behaviors should the nurse expect to find?
a) Leavened bread may be eaten during Passover.
b) Shellfish is commonly consumed in the diet.
c) Meat and dairy products are eaten separately.
d) Fasting from meat occurs during Hanukkah.
Answer: c) Meat and dairy products are eaten separately.
Rationale:
Observant Jews typically adhere to kosher dietary laws, which include separating meat and
dairy products and following specific guidelines for food preparation and consumption.
53) A nurse is in an ER caring for a client with multiple wounds due to a motor vehicle crash.
Which of the following interventions are appropriate? Select all that apply.
a) Apply direct pressure to bleeding wounds.
b) Clean rest lacerations and abrasions with hydrogen peroxide.

c) Cover wounds with a sterile dressing.
d) Administer 650 mg aspirin PO as needed for pain.
e) Determine the date of the last tetanus toxoid vaccination.
Answer: a) Apply direct pressure to bleeding wounds, c) Cover wounds with a sterile
dressing, e) Determine the date of the last tetanus toxoid vaccination.
Rationale:
Direct pressure helps control bleeding, covering wounds with sterile dressings reduces the
risk of infection, and determining the date of the last tetanus toxoid vaccination is important
for assessing the need for tetanus prophylaxis.
54) The nurse is reviewing a client's admission laboratory results. Which of the findings
requires further evaluation?
a) Sodium 138
b) Creatinine 1.8
c) Hemoglobin 15
d) Potassium 4.2
Answer: b) Creatinine 1.8
Rationale:
A creatinine level of 1.8 indicates impaired kidney function and requires further evaluation,
as it may indicate renal insufficiency or dysfunction.
55) A nurse is providing teaching for a client who has a new prescription for methadone.
Which of the following client statements indicates the need for further teaching?
a) I understand that methadone tends to slow my breathing.
b) I understand that methadone may cause me to have difficulty sleeping.
c) I will avoid alcohol while I’m taking this medication.
d) I’ll change positions gradually, especially from lying down to standing.
Answer: a) I understand that methadone tends to slow my breathing.

Rationale:
While methadone is an opioid analgesic that can cause respiratory depression, the client's
statement indicates a misunderstanding, as it suggests acceptance rather than a recognition of
the potential danger. Further teaching is needed to emphasize the importance of monitoring
for signs of respiratory depression and seeking medical attention if symptoms occur.
56) Which of the following clients is appropriate for the nurse to refer to speech therapy for
swallowing evaluation?
a) Premature infant with a poor suck reflex and failure to thrive.
b) An older adult who has difficulty taking in fluids.
c) An adolescent with anorexia who is cachectic.
d) A middle-aged adult with gastroesophageal reflux disease.
Answer: b) An older adult who has difficulty taking in fluids.
Rationale:
Difficulty swallowing, or dysphagia, is common in older adults and may require evaluation
and management by a speech therapist to prevent complications such as aspiration
pneumonia.
57) A nurse is caring for a group of clients. Which of the following clients should the nurse
assess first?
a) A client with benign prostatic hyperplasia who is unable to urinate.
b) A client with heart failure who reports shortness of breath while ambulating.
c) A client who is post-cholecystectomy and has green drainage from the T-tube.
d) A client with abdominal pain and vomiting coffee ground emesis.
Answer: d) A client with abdominal pain and vomiting coffee ground emesis.
Rationale:
Coffee ground emesis can indicate upper gastrointestinal bleeding, which is a medical
emergency requiring immediate assessment and intervention to identify and treat the
underlying cause.

58) A nurse is taking a medication history from a client with type II diabetes mellitus who is
scheduled for an arteriogram. Which of the following medications should the nurse instruct
the client to discontinue 48 hrs prior to the procedure?
a) Atorvastatin
b) Digoxin
c) Nifedipine
d) Metformin
Answer: d) Metformin
Rationale:
Metformin should be discontinued 48 hours prior to a procedure involving contrast dye (such
as an arteriogram) due to the risk of lactic acidosis when combined with contrast dye.
59) The nurse is assessing a client with posttraumatic stress disorder. Which of the following
findings should the nurse expect to find?
a) Dependence on family and friends
b) Loss of interest in usual activities
c) Ritualistic behavior
d) Passive-aggressive behavior
Answer: c) Ritualistic behavior
Rationale:
Ritualistic behavior is a common symptom of posttraumatic stress disorder (PTSD) and can
include repetitive actions or routines aimed at reducing anxiety or preventing perceived harm.
60) A nurse working in a long-term care facility is caring for an older adult client with
dementia. The client is often agitated and frequently wanders the halls. Which of the
following interventions should the nurse include in the plan of care?
a) Give the client several choices when scheduling activities.
b) Confront the client regarding unacceptable behavior.

c) Maintain nutritional requirements by offering finger foods.
d) Stimulate the client by leaving the television on throughout the day.
Answer: a) Give the client several choices when scheduling activities.
Rationale:
Providing choices can help empower the client with dementia, reduce agitation, and promote
a sense of control over their environment, potentially decreasing wandering behavior.
61) A nurse on a mental health unit receives a report on four clients. Which of the following
clients should the nurse attend to first?
a) A client who has begun to demonstrate catatonic behavior
b) The client with compulsive behavior who is frequently drinking from the water fountain
c) A client who is having auditory hallucinations and is becoming agitated
d) A client who is making sexual comments to clients of the opposite sex
Answer: a) A client who has begun to demonstrate catatonic behavior
Rationale:
Catatonic behavior can indicate a severe psychiatric emergency, such as catatonic
schizophrenia or neuroleptic malignant syndrome, and requires immediate assessment and
intervention to ensure the client's safety.
62) A nurse is caring for a full-term newborn immediately following birth. Which of the
following actions should the nurse take first?
a) Instill erythromycin ophthalmic ointment in the newborn’s eyes.
b) Place identification bracelets on the newborn.
c) Weigh the newborn.
d) Dry the newborn.
Answer: d) Dry the newborn.
Rationale:

Drying the newborn helps prevent heat loss and promotes thermal regulation, which is crucial
immediately after birth to prevent hypothermia.
63) A nurse receives a report on a group of clients. Which of the following clients should the
nurse attend to first?
a) A client who was admitted with asthma and has an SaO2 of 92% while receiving oxygen at
1 L per minute via nasal cannula
b) A client who was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10
c) The client with type II diabetes mellitus whose blood glucose level is 80 mg/dL
d) A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per
hour of green fluid
Answer: a) A client who was admitted with asthma and has an SaO2 of 92% while receiving
oxygen at 1 L per minute via nasal cannula
Rationale:
A SaO2 of 92% indicates hypoxemia, which requires immediate intervention to optimize
oxygenation and prevent respiratory compromise, particularly in a client with asthma.
64) A client at 38 weeks of gestation enters the emergency department. The nurse should
recognize that which of the following indicates that the client is in the latent phase of labor?
a) The client reports the urge to push
b) The cervix is dilated 2 cm
c) Contractions are 2 to 3 minutes apart
d) The client reports nausea and vomiting
Answer: b) The cervix is dilated 2 cm
Rationale:
The latent phase of labor is characterized by cervical dilation from 0 to 3 cm. The cervix
being dilated to 2 cm indicates that the client is in the latent phase of labor.
65) The charge nurse for the medical-surgical unit discovers client care assignments that
should be reassigned. Which of the following delegated tasks should be reassigned?

a) An AP is to calculate intake and output every two hours for a client in acute renal failure.
b) An AP is to collect vital signs every 30 minutes for a client who had a cholecystectomy.
c) A licensed practical nurse is to check nasogastric tube placement for a client who had a
bowel resection.
d) A licensed practical nurse is to provide initial feeding for a client who had a
cerebrovascular accident.
Answer: b) An AP is to collect vital signs every 30 minutes for a client who had a
cholecystectomy.
Rationale:
Collecting vital signs every 30 minutes is a high-frequency task typically performed for
clients requiring close monitoring, such as those in critical condition or postoperative clients.
This task should be reassigned to a licensed nurse for appropriate assessment and
intervention.
66) A nurse is caring for a client who has a cast due to a compound fracture to the right ankle.
Which of the following findings requires immediate intervention?
a) Pruritus under the cast
b) Localized stabbing pain upon movement
c) Paresthesia of the distal extremity
d) Edema present when the leg is in the dependent position
Answer: c) Paresthesia of the distal extremity
Rationale:
Paresthesia of the distal extremity may indicate neurovascular compromise, such as
compartment syndrome, which is a medical emergency requiring immediate intervention to
prevent tissue damage and loss of function.
67) The nurse is providing care for a preschooler with acute gastroenteritis. Basing
information below, which of the following is an appropriate nursing action?

Client Information: The child has had several episodes of vomiting and diarrhea and has signs
of dehydration, including sunken eyes and decreased skin turgor.
a) Offer the child a cup of chicken broth.
b) Encourage the child’s intake of gelatin.
c) Administer oral rehydration solutions.
d) Institute a banana, rice, applesauce, and toast (BRAT) diet.
Answer: c) Administer oral rehydration solutions.
Rationale:
Oral rehydration solutions are recommended for children with acute gastroenteritis and
dehydration to replace lost fluids and electrolytes. They are specifically formulated to prevent
dehydration and restore electrolyte balance in children with diarrhea and vomiting.
68) The nurses caring for a client who's taking allopurinol. The nurse should monitor which
of the following laboratory findings to determine the effectiveness of the medication?
a) Serum chloride
b) Uric acid level
c) Serum albumin
d) Magnesium level
Answer: b) Uric acid level
Rationale:
Allopurinol is used to lower uric acid levels in the blood by inhibiting xanthine oxidase, the
enzyme involved in the production of uric acid. Monitoring the uric acid level helps
determine the effectiveness of the medication in achieving its therapeutic goal of reducing
uric acid levels.
69) A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable.
Which of the following dysrhythmias should the nurse plan for cardioversion?
a) Ventricular asystole
b) Third-degree AV block

c) Atrial fibrillation
d) Ventricular fibrillation
Answer: d) Ventricular fibrillation
Rationale:
Ventricular fibrillation is a life-threatening dysrhythmia characterized by chaotic,
disorganized electrical activity in the ventricles, leading to ineffective contractions and loss of
cardiac output. Immediate cardioversion is necessary to restore normal rhythm and prevent
cardiac arrest.
70) Nurse managers preparing an educational program on infection control measures. Which
of the following should the nurse include when discussing contact precautions?
a) Scarlet fever
b) Herpes simplex
c) Varicella
d) Streptococcal pharyngitis
Answer: b) Herpes simplex
Rationale:
Contact precautions are used to prevent the transmission of infections that are spread by
direct or indirect contact with the patient or their environment. Herpes simplex virus
infections are transmitted through direct contact with lesions or infected secretions, making
them appropriate for contact precautions.
71) A nurse assesses an older adult client with decreased caloric intake and weight loss.
Which of the following findings should the nurse report to the provider immediately?
a) The client experiences coughing and wheezing after eating.
b) The client reports abdominal pain at a five on a scale of 0 to 10.
c) The client experiences a drop in oxygen saturation to 91% while eating.
d) The client reports a burning sensation in the epigastric area.
Answer: c) The client experiences a drop in oxygen saturation to 91% while eating.

Rationale:
A drop in oxygen saturation while eating suggests a potential aspiration risk, which can lead
to respiratory compromise and requires immediate attention to prevent further complications
such as aspiration pneumonia.
72) A nurse and an assistive personnel are caring for a group of clients. Which of the
following tasks is appropriate for the nurse to delegate to an AP?
a) Applying a condom catheter for a client with a spinal cord injury
b) Administering oral fluids to a client with dysphagia
c) Documenting the report of pain from a postoperative client
d) Reviewing active range of motion exercises with a client who had a stroke
Answer: b) Administering oral fluids to a client with dysphagia
Rationale:
Administering oral fluids to a client with dysphagia requires knowledge of the client's
swallowing ability and potential risks of aspiration. This task can be safely delegated to an
assistive personnel under the supervision of the nurse.
73) A nurse from the state health department is instructing a group of nurses regarding
reportable infections. Which of the following infections should the nurse report to the CDC?
a) Candida albicans
b) Herpes simplex virus 2
c) Staphylococcus aureus
d) Lyme disease
Answer: d) Lyme disease
Rationale:
Lyme disease is a nationally notifiable infectious disease, meaning healthcare providers are
required to report cases to the CDC for surveillance and monitoring purposes.
74) The nurse is assessing an adolescent client for sickle cell anemia. Which of the following
is a priority finding by the nurse?

a) A pain score of 7 on a scale of 0 to 10
b) Shortness of breath
c) New onset of enuresis
d) Priapism
Answer: b) Shortness of breath
Rationale:
Shortness of breath in a client with sickle cell anemia may indicate a potentially serious
complication such as acute chest syndrome or a pulmonary embolism, which requires
immediate medical attention to prevent respiratory failure.
75) Nurses are caring for a client who is 1 day post-op following a Hypophysectomy for the
removal of a pituitary tumor. Which of the following findings requires further assessment by
the nurse?
a) Glasgow Coma Scale score of 15
b) Blood drainage on initial dressing measuring 3 cm
c) Report of dry mouth
d) Urinary output greater than fluid intake
Answer: d) Urinary output greater than fluid intake
Rationale:
Excessive urinary output greater than fluid intake could indicate diabetes insipidus, a
potential complication following a hypophysectomy due to disruption of antidiuretic hormone
secretion. This finding requires further assessment and intervention to maintain fluid balance.
76) A client with a left leg cast is using crutches for ambulation. The nurse recognizes the
client needs further instruction. Which of the following actions by the client indicates the
need for further instruction?
a) Flexes elbows at 30 degrees when using the handgrips
b) Maintains 3 to 4 finger widths between the crutch pad and axilla
c) Places the crutches 6 inches in front and side of each foot when standing.

d) Pushes up from a chair with crutches on the unaffected side.
Answer: d) Pushes up from a chair with crutches on the unaffected side.
Rationale:
When using crutches, the client should push up from a chair with the crutches placed on the
affected side to provide support and stability to the injured limb. Pushing up from the chair
with crutches on the unaffected side may increase the risk of falls and further injury.
77) A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following
actions should the nurse plan to take?
a) Use a designated stethoscope when caring for the toddler.
b) Wear an N95 respiratory mask while caring for the toddler.
c) Remove the disposable gown after leaving the toddler’s room.
d) Place the toddler in a room with negative air pressure.
Answer: a) Use a designated stethoscope when caring for the toddler.
Rationale:
Respiratory syncytial virus (RSV) is spread through respiratory droplets, so using a
designated stethoscope helps prevent cross-contamination between patients and reduces the
risk of spreading the infection to other individuals.
78) A nurse is admitting to a client to emergency department and initiates continuous cardiac
monitoring. Which of the following ECG with strips indicates sinus tachycardia?

Answer:

79) A nurse is planning care for a client to prevent complications of immobility. Which of the
following actions should the nurse include in the plan of care?
a) Massage lower extremities daily to prevent DVT
b) Limit intake of food high in calcium to prevent renal calculi.
c) Encourage the client to lie supine to prevent constipation.
d) Remove anti-embolism stockings for 3 hours each day to decrease skin breakdown.
Answer: a) Massage lower extremities daily to prevent DVT
Rationale:

Massaging the lower extremities promotes circulation and helps prevent deep vein
thrombosis (DVT), a common complication of immobility. This intervention enhances blood
flow and reduces the risk of blood clots forming in the veins.
80) A nurse discovers that the wrong dosage of medication was given to a client. When
determining what action to take, you should recognize that which of the following ethical
principles should be applied?
a) Utility
b) Paternalism
c) Veracity
d) Fidelity
Answer: d) Fidelity
Rationale:
Fidelity refers to the principle of loyalty and faithfulness to the client. In this situation,
fidelity would involve taking actions that prioritize the well-being of the client, such as
reporting the medication error, ensuring the client's safety, and following institutional
protocols for error reporting and correction.
82) A nurse is reviewing the prescription for doxazosin with a client. Which of the following
should be included in the teaching?
a) Decrease caloric intake to reduce weight gain.
b) Increase dietary fiber to prevent constipation.
c) Rise slowly when sitting up from bed.
d) Take this medication each morning.
Answer: c) Rise slowly when sitting up from bed.
Rationale:
Doxazosin is an alpha-blocker used to treat hypertension and benign prostatic hyperplasia.
One of the common side effects of alpha-blockers is orthostatic hypotension, which can cause

dizziness or fainting upon standing. Instructing the client to rise slowly when sitting up from
bed helps prevent orthostatic hypotension and reduces the risk of falls.
83) A nurse is planning to provide teaching to a young adult client who has insomnia. Which
of the following should the nurse include in the teaching?
a) Exercising an hour before bedtime
b) Take a short nap today
c) Keep the bedroom cool at night
d) Consume a high carbohydrate snack at bedtime.
Answer: c) Keep the bedroom cool at night
Rationale:
Keeping the bedroom cool at night promotes better sleep hygiene by creating a comfortable
environment conducive to sleep. Maintaining a cool room temperature is recommended as
part of sleep hygiene practices to improve sleep quality and duration.
84) A nurse is caring for a client who has a stool culture that is positive for Clostridium
difficile. Which of the following infection control precautions is appropriate?
a) Wear a face shield prior to entering the room.
b) Place the client in a private room.
c) Place the client in a negative pressure room.
d) Use alcohol-based hand rub following client care.
Answer: b) Place the client in a private room.
Rationale:
Contact precautions are indicated for clients with Clostridium difficile infection to prevent
the transmission of spores to other patients. Placing the client in a private room helps contain
the infection and reduce the risk of spreading it to others.
85) A nurse is planning care for a child who has increased intracranial pressure with a
decreased level of consciousness. Which of the following interventions should the nurse
include in the plan of care?

a) Perform active range of motion exercises.
b) Perform neurological checks every 4 hours.
c) Suction the airway frequently.
d) Maintain the head at a midline position.
Answer: d) Maintain the head at a midline position.
Rationale:
Maintaining the head at a midline position helps promote optimal cerebral perfusion and
reduces the risk of further increases in intracranial pressure. This position facilitates venous
drainage and reduces obstruction to cerebral blood flow.
86) The nurse is assessing a client receiving radiation therapy. Which of the following
findings should the nurse expect?
a) White blood cell count at 12,500 mm3
b) Excessive salivation
c) +3 pitting edema
d) Platelets at 95,000 mm3
Answer: b) Excessive salivation
Rationale:
Excessive salivation, also known as sialorrhea, is a common side effect of radiation therapy,
particularly when the head and neck area is irradiated. Radiation can stimulate salivary
glands, leading to increased saliva production and drooling.
87) A nurse is caring for a client who has preeclampsia and is experiencing postpartum
hemorrhage. The nurse should identify that which of the following medications is
contraindicated?
a) Methylergonovine.
b) Misoprostol
c) Dinoprostone

d) Oxytocin
Answer: a) Methylergonovine.
Rationale:
Methylergonovine is a uterotonic medication used to prevent or control postpartum
hemorrhage. However, it is contraindicated in clients with preeclampsia due to its potential to
increase blood pressure, which can exacerbate the hypertensive crisis associated with
preeclampsia.
88) A nurse is caring for a client with GERD. Which of the following assessment findings
should the nurse expect to find?
a) Shortness of breath
b) Rebound tenderness
c) Atypical chest pain
d) Vomiting blood
Answer: c) Atypical chest pain
Rationale:
Gastroesophageal reflux disease (GERD) often presents with atypical chest pain, which may
be described as a burning sensation in the chest (heartburn) or discomfort in the upper
abdomen. This pain typically worsens after eating or lying down and improves with antacids
or acid-suppressing medications.
89) A nurse is caring for a newborn who is under phototherapy lights. Which of the following
is an appropriate nursing action?
a) Ensure the eye shield is covering the eyes.
b) Apply lotion to exposed skin.
c) Offer glucose water between feedings.
d) Discontinue breastfeeding during treatment.
Answer: a) Ensure the eye shield is covering the eyes.
Rationale:

Phototherapy is used to treat hyperbilirubinemia (jaundice) in newborns. To protect the
infant's eyes from the bright lights, eye shields should be placed over the eyes during
phototherapy sessions. This prevents potential damage to the infant's developing eyes from
exposure to the intense light.
90) A nurse is assessing a client who has a long arm cast. Which of the following findings
should the nurse monitor for when assessing for acute compartment syndrome?
a) Shortness of breath
b) Petechiae
c) Change in mental status
d) Edema
Answer: b) Petechiae
Rationale:
Petechiae may indicate compromised circulation and tissue perfusion, which can occur with
acute compartment syndrome due to increased pressure within the compartment. Monitoring
for petechiae is important in assessing for tissue ischemia.
91) A nurse is caring for a client who is receiving IV moderate (conscious) sedation with
midazolam. The client has a respiratory rate of 9/min and is not responding to commands.
Which of the following is an appropriate action by the nurse?
a) Place the client in a prone position.
b) Implement positive pressure ventilation.
c) Perform nasopharyngeal suctioning.
d) Administer flumazenil.
Answer: b) Implement positive pressure ventilation.
Rationale:
A respiratory rate of 9/min and unresponsiveness to commands indicate respiratory
depression, which is a potential complication of sedation with midazolam. Implementing

positive pressure ventilation can help maintain adequate oxygenation and ventilation until the
effects of the sedation wear off.
92) A nurse in a hospital cafeteria overhears two assistive personnel (AP) discussing a client.
They are using the client's name and discussing details of his diagnosis. Which of the
following actions should the nurse take first?
a) Report the AP’s behavior to the supervisor.
b) Complete an incident report regarding the APs' conversation.
c) Provide the AP with written documentation regarding client confidentiality.
d) Tell the AP to discontinue their conversation.
Answer: d) Tell the AP to discontinue their conversation.
Rationale:
The first action the nurse should take is to address the immediate situation by instructing the
APs to discontinue their conversation to protect the client's confidentiality.
93) A community health nurse is teaching a group of adults about the importance of health
screenings. The nurse should include African American males are almost twice as likely as
Caucasian males to experience which of the following?
a) Testicular cancer
b) Obesity
c) Stroke
d) Melanoma
Answer: c) Stroke
Rationale:
African American males are at a higher risk of experiencing stroke compared to Caucasian
males. Including this information in health education can promote awareness and encourage
appropriate screening and prevention measures.
94) A nurse is caring for a client who sprained his left ankle 12 hrs ago. Which of the
following prescriptions given by the provider should the nurse clarify?

a) Elevate the affected extremity on two pillows.
b) Apply heat to the affected extremity for 45 minutes on and 45 minutes off.
c) Wrap the affected extremity with a compression dressing.
d) Assess the affected extremity for sensation, movement, and impulse every four hours.
Answer: b) Apply heat to the affected extremity for 45 minutes on and 45 minutes off.
Rationale:
Heat application is contraindicated for acute sprains due to the risk of increasing
inflammation and swelling. The nurse should clarify this prescription with the provider to
ensure appropriate management of the injury.
95) A nurse is providing dietary teaching for a client who has hepatic encephalopathy. Which
of the following food selections indicates that the client understands teaching?
a) A sandwich and milkshake
b) Rice with black beans
c) Cottage cheese and tuna lettuce
d) Three-egg omelet with low-sodium ham
Answer: d) Three-egg omelet with low-sodium ham
Rationale:
A three-egg omelet with low-sodium ham is a suitable food choice for a client with hepatic
encephalopathy because it provides protein without excessive sodium, which can exacerbate
symptoms of hepatic encephalopathy.
96) A nurse is planning care for a client with a sealed radiation implant and is to remain in the
hospital for 1 week. Which of the following should the nurse include in the plan of care?
a) Remove dirty linens from the room after double bagging.
b) Wear a dosimeter film badge while in the client’s room.
c) Limit each of the client's visitors to one hour per day.
d) Ensure family members remain at least 3 feet from the client.

Answer: b) Wear a dosimeter film badge while in the client’s room.
Rationale:
Wearing a dosimeter film badge while in the client's room helps monitor the nurse's radiation
exposure and ensures adherence to safety protocols when caring for a client with a sealed
radiation implant.
97) A nurse is caring for four clients. Which of the following clients should the nurse care for
first?
a) A client receiving chemotherapy for a first national
b) A client who has had an appendectomy and has diminished bowel sounds
c) A client with hypothyroidism who is stuporous
d) A client who has a burn requiring a sterile dressing change
Answer: c) A client with hypothyroidism who is stuporous
Rationale:
Stupor in a client with hypothyroidism may indicate myxedema coma, a life-threatening
condition requiring immediate intervention to stabilize the client's condition and prevent
complications.
98) The nurse is planning care for a newly admitted adolescent who has bacterial meningitis.
Which of the following instructions is appropriate for the nurse to include in the plan of care?
a) Initiate droplet precautions for the client.
b) Assist the client to a supine position.
c) Perform Glasgow Coma Scale every 24 hrs.
d) Recommend prophylactic acyclovir therapy for the client's family.
Answer: a) Initiate droplet precautions for the client.
Rationale:
Bacterial meningitis is transmitted through respiratory droplets, so initiating droplet
precautions helps prevent the spread of infection to others and protects healthcare providers.

99) A nurse is giving discharge instructions to a client with a new ileostomy. The nurse
should recognize that the teaching has been effective when the client states:
a) "I want to ensure that my medications are enteric-coated."
b) "My stoma will drain liquid fluid continuously."
c) "I will change my pouch system every two weeks."
d) "My stoma size will stay the same even after healed."
Answer: b) "My stoma will drain liquid fluid continuously."
Rationale:
A correctly functioning ileostomy typically drains liquid stool continuously. This statement
indicates that the client understands the expected outcome of the ileostomy.
100) A nurse in a provider’s office is interviewing a client who is requesting an oral
contraceptive. Which of the following findings in the client’s history is a contraindication to
use in combination oral contraceptives?
a) Thyroid disease
b) Allergy to penicillin
c) Impaired liver function
d) Abnormal blood glucose
Answer: c) Impaired liver function
Rationale:
Impaired liver function is a contraindication to the use of combination oral contraceptives due
to the risk of impaired metabolism and potential liver toxicity. Combination oral
contraceptives contain estrogen and progestin, which are metabolized in the liver. Impaired
liver function can affect the metabolism of these hormones, increasing the risk of adverse
effects and complications.
101) The nurse is providing teaching to a client who has mild persistent asthma and has been
prescribed montelukast. Which of the following statements by the nurse is correct in the
teaching?

a) This medication can be used to help you when you have an acute asthma attack.
b) This medication should be taken before exercise and physical activity.
c) This medication can be taken for 10 days and then gradually discontinued.
d) This medication helps decrease swelling and mucus production.
Answer: d) This medication helps decrease swelling and mucus production.
Rationale:
Montelukast is a leukotriene receptor antagonist used for the long-term management of
asthma and allergic rhinitis. It works by blocking leukotriene receptors, thereby reducing
inflammation, swelling, and mucus production in the airways.
102) A nurse on the medical-surgical unit is receiving reports on four clients. Which of the
following clients should the nurse assess first?
a) A client who is receiving warfarin and has an INR of 3.3
b) A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL
c) A client who had an NG tube inserted 6 hours ago and has abdominal distention
d) A client who is 4 hours postoperative following a thyroidectomy and reports fullness in the
back of the throat
Answer: c) A client who had an NG tube inserted 6 hours ago and has abdominal distention
Rationale:
Abdominal distention following NG tube insertion could indicate complications such as
bowel perforation or ileus. This client requires immediate assessment to determine the cause
of abdominal distention and intervene promptly to prevent further complications.
103) A nurse is assessing a client who has pericarditis. Which of the following findings is a
priority?
a) Paradoxical pulse
b) Dependent edema
c) Pericardial friction rub

d) Substernal chest pain
Answer: a) Paradoxical pulse
Rationale:
Paradoxical pulse, also known as pulsus paradoxus, is a key sign of cardiac tamponade, a
potentially life-threatening complication of pericarditis. It is characterized by a decrease in
systolic blood pressure of more than 10 mmHg during inspiration. Prompt recognition and
intervention are essential to prevent further hemodynamic compromise.
104) A charge nurse is providing teaching to a new licensed nurse on how to clean up
surfaces contaminated with blood. Which of the following agents should the nurse include in
the teaching?
a) Hydrogen peroxide
b) Chlorhexidine
c) Isopropyl alcohol
d) Chlorine bleach
Answer: d) Chlorine bleach
Rationale:
Chlorine bleach (sodium hypochlorite) is an effective agent for cleaning surfaces
contaminated with bloodborne pathogens such as HIV and hepatitis B and C viruses. It has
strong disinfectant properties and can effectively kill a wide range of microorganisms,
making it suitable for decontaminating surfaces in healthcare settings.
105) A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the
following actions is appropriate to take?
a) Instruct the client to lift her chin when swallowing.
b) Discourage the client from coughing during feedings.
c) Sit at or below the client's eye level during feedings.
d) Talk with the client during her feeding.
Answer: c) Sit at or below the client's eye level during feedings.

Rationale:
Sitting at or below the client's eye level during feedings helps facilitate eye contact and
communication, which can enhance the feeding experience for the patient with dysphagia. It
also allows the nurse to monitor the patient's facial expressions and response to feeding cues
more effectively.
106) A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an
assistive personnel telling the client, “If you don't eat, I’ll put restraints on your wrists and
feed you.” The nurse should intervene and explain to the AP that this statement constitutes
which of the following torts?
a) Assault
b) Battery
c) Malpractice
d) Negligence
Answer: a) Assault
Rationale:
Assault involves the threat of harm or unwanted touching, which creates fear or apprehension
in the victim. In this situation, the statement made by the assistive personnel constitutes
assault because it involves the threat of restraining the client if they refuse to eat, which could
cause fear or distress to the client.
107) A charge nurse is evaluating the time management skills of a new licensed nurse. The
charge nurse should intervene when a newly licensed nurse does which of the following?
a) Re-evaluate priorities halfway through the shift.
b) Delegate changing sterile dressings to a licensed practical nurse.
c) Group activities for the same client.
d) Work on several tasks simultaneously.
Answer: d) Work on several tasks simultaneously.
Rationale:

Multitasking, or working on several tasks simultaneously, can lead to decreased efficiency,
increased errors, and potential oversight of important details. Effective time management
involves prioritizing tasks, focusing on one task at a time, and delegating appropriately to
ensure safe and efficient patient care.
108) A nurse is monitoring the client during an IV urography procedure. Which of the
following client reports is the priority finding?
a) Feeling flushed and warm
b) Abdominal fullness
c) Swollen lips
d) Metallic taste in mouth
Answer: c) Swollen lips
Rationale:
Swollen lips could indicate an allergic reaction to the contrast dye used during the IV
urography procedure. An allergic reaction can progress rapidly and lead to anaphylaxis, a lifethreatening emergency. Prompt recognition and intervention are essential to prevent further
complications and ensure the client's safety.
109) A nurse is planning to delegate client assignments to the assistive personnel. Which of
the following tasks is appropriate for the nurse to delegate?
a) Adjust the flow rate of the client's oxygen tank.
b) Collecting a urine sample.
c) Measuring the client's pain level.
d) Monitoring blood glucose levels.
Answer: b) Collecting a urine sample.
Rationale:
Collecting a urine sample is within the scope of practice for assistive personnel and does not
require specialized nursing knowledge or skills. However, it is essential to provide
appropriate training and supervision to ensure accurate and safe collection of the urine

sample. Adjusting the flow rate of the client's oxygen tank, measuring the client's pain level,
and monitoring blood glucose levels require
110) A nurse is assessing a client with the following vital signs: Oral temperature of 37.2°C
(99°F), apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and
blood pressure of 132/40 mm Hg. What is the client's pulse pressure?

a) 92 mm Hg
b) 52 mm Hg
c) 72 mm Hg
d) 102 mm Hg

Answer: a) 92 mm Hg
Rationale:
Pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic
blood pressure. In this case:
Systolic blood pressure = 132 mm Hg
Diastolic blood pressure = 40 mm Hg
Pulse Pressure = Systolic blood pressure - Diastolic blood pressure = 132 mm Hg - 40 mm
Hg = 92 mm Hg.
Therefore, the client's pulse pressure is 92 mm Hg.
111) A nurse is caring for a group of clients in a medical-surgical unit. Which of the following
situations requires completion of an incident report?
a) A client who has absent gag reflex following a bronchoscopy
b) A client whose IV pump has malfunctioned
c) A client who requires insertion of NG tube due to a bowel obstruction
d) A client who has absent bowel sounds following a gastrectomy

Answer: b) A client whose IV pump has malfunctioned
Rationale:
An incident report should be completed for any unexpected event or deviation from the
standard of care, such as equipment malfunction. This helps to document the incident,
investigate the cause, and implement measures to prevent future occurrences.
112) A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin.
Which of the following should the nurse monitor?
a) Fasting blood glucose
b) Carbohydrate intake
c) Hematocrit
d) Weight
Answer: d) Weight
Rationale:
Desmopressin is a medication used to treat diabetes insipidus by promoting water
reabsorption in the kidneys. Monitoring the client's weight is essential to assess fluid balance
and determine the effectiveness of desmopressin therapy in managing polyuria and polydipsia
associated with diabetes insipidus.
113) The nurse is providing discharge instructions about engorgement for a client who has
decided not to breastfeed. Which of the following statements by the client indicates a need for
further instruction by the nurse?
a) "I can wear a support bra."
b) "I will apply cold compression to my breasts."
c) "I will manually express breastmilk."
d) "I can take a mild analgesic."
Answer: c) "I will manually express breastmilk."
Rationale:

Manually expressing breast milk can stimulate milk production and exacerbate engorgement.
In a client who has decided not to breastfeed, manually expressing breast milk is not
recommended and could lead to increased discomfort and engorgement. Further instruction is
needed to ensure the client understands appropriate management of engorgement without
stimulating milk production.
114) A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by
continuous IV infusion. Which of the following client findings indicates medication toxicity?
a) Blood glucose of 150 mg/dL
b) Urine output of 20 mL per hour
c) Systolic blood pressure at 140 mm Hg
d) BUN of 20 mg/dL
Answer: b) Urine output of 20 mL per hour
Rationale:
Magnesium sulfate toxicity can lead to decreased urine output due to its effects on renal
blood flow and glomerular filtration rate. Monitoring urine output is essential to detect signs
of magnesium toxicity, such as oliguria or anuria, which require immediate intervention to
prevent further complications.
115) The nurse is completing an assessment for a newborn who is 2 hours old. Which of the
following findings are indicative of cold stress?
a) Respiratory rate of 60 per minute
b) Jitteriness of the hands
c) Diaphoresis
d) Bounding peripheral pulses in all extremities
Answer: c) Diaphoresis
Rationale:

Diaphoresis in a newborn is a sign of cold stress, indicating the body's attempt to generate
heat to maintain normothermia. Cold stress can lead to increased metabolic rate and oxygen
consumption, potentially resulting in respiratory distress and other complications.
116) A nurse is planning care for four clients. Which of the following clients is the highest
priority?
a) A client who has dry, black eschar on the heel
b) A client who is wearing an arm cast and reports numb fingers
c) A client who has reddened skin area with blanching around the coccyx
d) A client who has frequent incontinence
Answer: b) A client who is wearing an arm cast and reports numb fingers
Rationale:
Numbness in the fingers of a client wearing an arm cast may indicate compartment syndrome
or nerve compression, which requires immediate assessment and intervention to prevent
neurovascular compromise. Compartment syndrome is a medical emergency that can lead to
tissue ischemia, nerve damage, and loss of limb function if not promptly treated.
117) A nurse is caring for a male adolescent client who has heart failure. Based on the client’s
chart finds. Which of the following actions should the nurse plan to take?
a) Withhold spironolactone
b) Administer ferrous sulfate
c) Administer furosemide
d) Withhold digoxin
Answer: a) Withhold spironolactone
Rationale:
Spironolactone is a potassium-sparing diuretic commonly used in the management of heart
failure. However, in clients with heart failure, hyperkalemia is a potential complication, and
spironolactone may exacerbate hyperkalemia due to its potassium-sparing effects. Therefore,

if the client has heart failure, it may be necessary to withhold or adjust the dose of
spironolactone to prevent hyperkalemia.
118) The nurse is assessing a client with a blood glucose level of 250 mg/dL. Which of the
following clinical manifestations are associated with this finding?
a) Confusion
b) Thirst
c) Diaphoresis
d) Shakiness
Answer: b) Thirst
Rationale:
Thirst is a common clinical manifestation of hyperglycemia (high blood glucose levels) in
clients with diabetes mellitus. Elevated blood glucose levels lead to osmotic diuresis and
dehydration, resulting in increased thirst as the body attempts to maintain fluid balance.
119) A nurse is assessing for allergies before administering Propofol to a client placed on the
mechanical ventilator. Which of the following allergies is a contraindication to the
medication?
a) Eggs
b) Milk
c) Shrimp
d) Peanuts
Answer: a) Eggs
Rationale:
Propofol contains egg lecithin, and individuals with egg allergy may experience allergic
reactions, including anaphylaxis, when exposed to egg-derived products such as Propofol.
Therefore, a known allergy to eggs is a contraindication to the use of Propofol.
120) A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to
interpret the following statement, “When the cat’s away, the mice will play.” The client's

response was, “The mice come out when the cat is not around.” The nurse should document
this finding as which of the following in the client’s chart?
a) Echolalia
b) Associative looseness
c) Neologisms
d) Concrete thinking
Answer: d) Concrete thinking
Rationale:
Concrete thinking refers to a literal interpretation of words and phrases without grasping their
underlying meaning or metaphorical implications. In this scenario, the client's response
indicates a concrete understanding of the statement without recognizing its 121) A nurse
caring for a client who is receiving total parenteral nutrition. Which of the following
assessment findings requires immediate intervention by the nurse?
a) Prealbumin level of 20 mg/dL
b) Weight increase of two kg/day
c) Temperature of 37.6°C
d) Blood glucose level of 120 mg/dL
Answer: b) Weight increase of two kg/day
Rationale:
A rapid weight increase of two kg/day in a client receiving total parenteral nutrition could
indicate fluid overload or worsening of the underlying condition. This finding requires
immediate nursing intervention, such as notifying the healthcare provider, assessing for signs
of fluid overload (e.g., edema, increased blood pressure), and adjusting the parenteral
nutrition regimen as necessary.
122) A nurse in the telemetry unit is receiving the laboratory findings for an adult male client
who's been treated for myocardial function. Which of the following is an expected finding for
the client?

a) Troponin 1 (TNI) 8 ng/mL
b) Brain natriuretic peptide (BNP) 10 ng/L
c) Alanine aminotransferase (ALT) 45 unit/L
d) High-density lipoprotein (HDL) 75 mg/dL
Answer: b) Brain natriuretic peptide (BNP) 10 ng/L
Rationale:
Brain natriuretic peptide (BNP) is a hormone secreted by the heart in response to increased
ventricular volume and pressure, commonly elevated in conditions such as heart failure.
Therefore, an elevated BNP level is an expected finding in a client treated for myocardial
dysfunction.
123) A nurse is reviewing the results of an arterial blood gas (ABG) performed on a client
with chronic emphysema. Which of the following results suggests the need for further
treatment?
a) PaO2 level of 89 mm Hg
b) PaCO2 level of 55 mm Hg
c) HCO3 level of 25 mEq/L
d) pH level of 7.37
Answer: b) PaCO2 level of 55 mm Hg
Rationale:
In chronic emphysema, an elevated PaCO2 level (hypercapnia) indicates impaired gas
exchange and respiratory acidosis. Therefore, a PaCO2 level of 55 mm Hg suggests
inadequate ventilation and the need for further treatment, such as bronchodilators, oxygen
therapy, or mechanical ventilation, to improve gas exchange and acid-base balance.
124) A nurse is teaching a client about nutritional intake. The nurse should include which of
the following in the teaching?
a) "Carbohydrates should be at least 45% of your caloric intake."
b) "Protein should be at least 55% of your calorie intake."

c) "Carbohydrates should be at least 30% of your caloric intake."
d) "Protein should be at least 60% of your caloric intake."
Answer: c) "Carbohydrates should be at least 30% of your caloric intake."
Rationale:
The Dietary Guidelines for Americans recommend that carbohydrates should constitute 4565% of total daily calories, while protein should constitute 10-35%. Therefore, advising the
client that carbohydrates should be at least 30% of caloric intake aligns with these dietary
guidelines.
125) A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr.
The client is scheduled to have the morning dose at 0700. The nurse should schedule the
trough level to be drawn at which of the following times?
a) 2100
b) 0900
c) 1300
d) 1800
Answer: a) 2100
Rationale:
A trough level is typically drawn just before the next dose of a medication is administered to
ensure that the lowest concentration (trough level) is measured. Since the morning dose is
scheduled at 0700, the trough level should be drawn just before this time, which would be at
2100 the previous evening.
126) A nurse is planning an education session for a client who has type 1 diabetes mellitus.
Which of the following should the nurse plan to include when teaching the client to monitor
for hypoglycemia?
a) Diaphoresis
b) Polyuria
c) Abdominal pain

d) Thirst
Answer: a) Diaphoresis
Rationale:
Diaphoresis (excessive sweating), along with other symptoms such as tremors, tachycardia,
hunger, and confusion, is a common manifestation of hypoglycemia in clients with diabetes
mellitus. Teaching clients to recognize the signs and symptoms of hypoglycemia is crucial for
prompt intervention to prevent complications.
127) A nurse in an urgent care clinic is collecting admission history from a client who is 16
weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the
following clinical findings is associated with this infection?
a) Frequency and dysuria
b) Profuse milky-white discharge
c) Hematuria
d) Low-grade fever
Answer: b) Profuse milky-white discharge
Rationale:
Bacterial vaginosis is characterized by a profuse, malodorous, milky-white vaginal discharge.
It is often accompanied by an unpleasant fishy odor, especially after intercourse or during
menses. Other symptoms may include vaginal itching or irritation, but not frequency and
dysuria, hematuria, or low-grade fever.
128) A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the
following foods should be included when initiating feeding?
a) Beef broth
b) Oatmeal
c) Apple juice
d) Toast
Answer: a) Beef broth

Rationale:
When initiating feeding for a client with dysphagia, it is essential to start with foods of a
specific consistency that are easier to swallow and less likely to cause aspiration. Liquids
such as beef broth are often recommended as they are thin and less likely to cause choking or
aspiration compared to thicker foods like oatmeal or solid foods like toast.
129) A nurse receives a change-of-shift report. Which of the following clients should the
nurse attend to first?
a) A client who reports tingling in the fingers following a thyroidectomy
b) A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr
c) A client who is in a long leg cast and reports cool feet bilaterally
d) A client who has a productive cough and an oral temperature of 36°C (96.8°F)
Answer: c) A client who is in a long leg cast and reports cool feet bilaterally
Rationale:
Cool feet bilaterally in a client with a long leg cast may indicate impaired circulation or
compartment syndrome, a serious condition that requires immediate assessment and
intervention to prevent tissue damage and neurovascular compromise. Therefore, this client
should be attended to first.
130) A nurse is caring for a client who has lactose intolerance and has eliminated dairy
products from his diet. The nurse should instruct the client to increase consumption of which
of the following foods?
a) Spinach
b) Peanut
butter
c) Ground beef
d) Carrots
Answer: b) Peanut butter
Rationale:

Peanut butter is a suitable source of protein for individuals with lactose intolerance who have
eliminated dairy products from their diet. It is low in lactose and can provide essential
nutrients such as protein and healthy fats without exacerbating lactose intolerance symptoms.
Other options such as spinach, ground beef, and carrots do not directly address the need for a
lactose-free protein source.metaphorical meaning. It is characteristic of thought disturbances
seen in schizophrenia, where abstract thinking may be impaired.
131) A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune
globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborn's
blood type is B positive. Which of the following statements is appropriate?
a) "You only need to receive Rh immune globulin if you have a positive blood type."
b) "You should receive Rh immune globulin within 72 hours of delivery."
c) "Both you and your baby should receive Rh immune globulin at your -week appointment."
d) "Immune globulin is not necessary since this is your second pregnancy."
Answer: b) "You should receive Rh immune globulin within 72 hours of delivery."
Rationale:
Rh immune globulin (RhoGAM) should be administered to Rh-negative mothers who give
birth to Rh-positive infants within 72 hours of delivery to prevent sensitization to Rh-positive
blood cells in future pregnancies.
132) A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle
crash after a school event. The mother states, "I never should have let him take the car. It's all
my fault!" Which of the following responses by the nurse is appropriate?
a) "You had no way of knowing this would happen."
b) "Most parents blame themselves when losing a child."
c) "Tell me why you feel this is your fault."
d) "You appear to be feeling overwhelmed."
Answer: c) "Tell me why you feel this is your fault."
Rationale:

This response encourages the mother to express her feelings and provides an opportunity for
therapeutic communication and exploration of her emotions.
133) A nurse is educating a client about caloric intake and weight reduction. Which of the
following client statements indicates an understanding of the teaching?
a) “If I eat 500 fewer calories per day, I should lose 1 pound per week.”
b) “If I eat 500 fewer calories per day, I should lose 1 pound per week."
c) "If I eat 450 fewer calories per day, I should lose 2 pounds per week."
d) "If I eat 250 fewer calories per day, I should lose 2 pounds per week."
e) "If I eat 300 fewer calories per day, I should lose 1 pound per week.”
Answer: a) “If I eat 500 fewer calories per day, I should lose 1 pound per week.”
Rationale:
A reduction of approximately 500 calories per day can lead to a weight loss of about 1 pound
per week, as one pound of body weight is roughly equivalent to 3,500 calories.
134) A nurse is teaching post-operative care with the parents of a toddler following a cleft
palate repair. Which of the following should be included in the teaching?
a) Provide an orthodontic pacifier for comfort.
b) Offer fluids by using a straw.
c) Cleanse suture line with a cotton tip swab.
d) Remove elbow splints periodically to perform range of motion.
Answer: c) Cleanse suture line with a cotton tip swab.
Rationale:
After a cleft palate repair, it is important to keep the suture line clean to prevent infection.
Using a cotton tip swab moistened with normal saline to gently cleanse the suture line helps
maintain cleanliness without causing trauma to the surgical site.
135) A nurse is caring for four clients. Which of the following tasks can the nurse delegate to
an assistive personnel?

a) Perform chest compressions during cardiac resuscitation.
b) Perform a dressing change for a new amputee.
c) Assess effectiveness of antiemetic medication.
d) Provide discharge instructions.
Answer: b) Perform a dressing change for a new amputee.
Rationale:
Performing a dressing change for a new amputee falls within the scope of practice for an
assistive personnel and can be delegated by the nurse.
136) A nurse in an emergency department is serving on a committee that is reviewing the
facility protocol for disaster readiness. The nurse should recommend that the protocol include
which of the following as a clinical manifestation of smallpox?
a) Bloody diarrhea
b) Ptosis of the eyelids
c) Descending paralysis
d) Rash in the mouth
Answer: d) Rash in the mouth
Rationale:
A rash in the mouth is a characteristic clinical manifestation of smallpox, which can help in
identifying and containing outbreaks. It is important to include this sign in the facility's
disaster readiness protocol for early detection and appropriate response.
137) A nurse is preparing to perform closed intermittent bladder irrigation for a client
following a transurethral resection of the prostate (TURP). Which of the following actions is
appropriate by the nurse?
a) Aspirate the irrigation solution from the bladder.
b) Insert the tip of the irrigation syringe into the catheter opening.
c) Apply sterile gloves.

d) Open the flow clamp to the irrigating fluid infusion tubing.
Answer: d) Open the flow clamp to the irrigating fluid infusion tubing.
Rationale:
Opening the flow clamp allows the irrigating fluid to flow into the bladder and perform
bladder irrigation effectively. Aspiration of the irrigation solution from the bladder is not a
typical step in closed intermittent bladder irrigation.
138) A nurse is caring for a client who has been taking haloperidol for several years. Which
of the following assessment findings should the nurse recognize as a long-term side effect of
this medication?
a) Lipsmacking
b) Agranulocytosis
c) Clang association
d) Alopecia
Answer: a) Lipsmacking
Rationale:
Lipsmacking, or orofacial dyskinesia, is a movement disorder commonly associated with
long-term use of antipsychotic medications such as haloperidol.
139) A nurse is planning care for a client who has Alzheimer's disease and demonstrates
confusion and wandering behavior. Which of the following should the nurse include in the
plan of care?
a) Place the client in seclusion when she is confused.
b) Request a prescription for PRN restraints when the client is wandering.
c) Dim the lighting in the client's room.
d) Leave one side rail up on the client's bed.
Answer: c) Dim the lighting in the client's room.
Rationale:

Dimming the lighting in the client's room can help reduce agitation and confusion in clients
with Alzheimer's disease. It creates a calm and soothing environment, which may help
prevent wandering behavior.
140) A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of
the following laboratory tests is an indicator of long-term disease management?
a) Postprandial blood glucose
b) Glycosylated hemoglobin (HbA1c)
c) Glucose tolerance test
d) Fasting blood glucose
Answer: b) Glycosylated hemoglobin (HbA1c)
Rationale:
Glycosylated hemoglobin (HbA1c) provides an indication of the average blood glucose levels
over the past 2-3 months and is used as a measure of long-term glycemic control in
individuals with diabetes mellitus. It reflects the effectiveness of diabetes management and
helps guide treatment decisions. 141) A nurse on a pediatric care unit is delegating client care.
Which of the following tasks should the nurse delegate to an assistive personnel?
a) Initiate a dietary consult for a toddler.
b) Administer a glycerin suppository to a preschool-age child.
c) Evaluate gastric residual following intermittent feeding of an adolescent.
d) Transport a school-age child to x-ray.
Answer: d) Transport a school-age child to x-ray.
Rationale:
Transporting a school-age child to x-ray is a task that can be safely delegated to an assistive
personnel. It does not involve any complex nursing assessments or interventions.
142) A nurse is caring for a client who has been taking propranolol. Which of the following
findings indicates a need to withhold the medication?
a) sodium 130 mEq/L

b) Blood pressure 156/90 mm Hg
c) Potassium 5.2 mEq/L
d) Pulse 54/min
Answer: d) Pulse 54/min
Rationale:
Propranolol is a beta-blocker medication that can cause bradycardia as a side effect. A pulse
rate of 54/min suggests bradycardia, so the nurse should withhold the medication and notify
the healthcare provider.
143) A nurse working in a mental health facility observes a client who has bipolar disorder
walk over to a table occupied by other clients and knock their game off the table. Which of
the following is an appropriate response by the nurse?
a) "Apologize to the others for your behavior."
b) "I am disappointed that you continue to act out when you are angry."
c) "Come outside with me for a walk."
d) "If you don't calm down, you will have to go into seclusion."
Answer: c) "Come outside with me for a walk."
Rationale:
Taking the client outside for a walk provides a chance to remove the client from the
triggering situation and offers an opportunity for the nurse to engage in therapeutic
communication and de-escalation.
144) A nurse is caring for a client who has human immunodeficiency virus (HIV) with
neutropenia. Which of the following precautions should the nurse take while caring for this
client?
a) Wear an N95 respirator while caring for the client.
b) Use a dedicated stethoscope for the client.
c) Insert an indwelling urinary catheter to monitor urinary output.
d) Monitor the client’s vital signs every 8 hr.

Answer: b) Use a dedicated stethoscope for the client.
Rationale:
Using a dedicated stethoscope helps prevent the transmission of infectious agents between
clients. It is a standard precaution when caring for clients with known or suspected infections.
145) A nurse is checking laboratory results for a client. Which of the following laboratory
findings indicates hypervolemia?
a) serum sodium 138 mEq/L
b) Urine specific gravity 1.001
c) serum calcium 10 mg/dL
d) Urine pH 6
Answer: b) Urine specific gravity 1.001
Rationale:
A urine specific gravity of 1.001 indicates dilute urine, which is a sign of hypervolemia or
overhydration. In hypervolemia, the kidneys excrete large amounts of water, resulting in low
urine specific gravity.
146) A nurse is caring for a group of clients in a long-term care facility. Which of the
following situations should the nurse recognize as a safety hazard?
a) A client’s wrist restraints tied to the bed rails
b) A client’s bedside table placed across the foot of the bed
c) A meal tray left at the bedside from breakfast
d) A call light extension cord pinned to the bedspread
Answer: a) A client’s wrist restraints tied to the bed rails
Rationale:
Tying wrist restraints to bed rails can pose a safety hazard by restricting the client's
movement and potentially causing injury. Restraints should be applied according to facility
policies and guidelines to ensure client safety.

147) A nurse is caring for a client in a mental health facility. The client's daughter is crying
and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the
following is an appropriate response?
a) "I’d like to know more about what’s bothering you."
b) "Why are you feeling this way?"
c) "You did the right thing by bringing him here."
d) "I’m sure your father doesn’t blame you."
Answer: a) "I’d like to know more about what’s bothering you."
Rationale:
This response shows empathy and encourages the daughter to express her feelings,
facilitating therapeutic communication and understanding of her concerns.
148) A nurse is planning care for a client following gastric bypass surgery. The nurse should
include which of the following dietary instructions when preparing the client for discharge?
a) Start each meal with a protein source.
b) Consume at least 25 g of fiber daily.
c) Check your blood glucose level before each meal.
d) Limit your meals to three times per day.
Answer: a) Start each meal with a protein source.
Rationale:
Following gastric bypass surgery, it is important for clients to prioritize protein intake to
support healing and prevent muscle loss. Starting each meal with a protein source helps
ensure an adequate intake of essential nutrients.
149) A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the
following findings requires intervention by the nurse?
a) Tidaling with spontaneous respirations
b) Drainage collection chamber is 1/3 full

c) 1 cm of water present in the water seal chamber
d) Suction chamber pressure of -20 cm H2O
Answer: d) Suction chamber pressure of -20 cm H2O
Rationale:
A suction chamber pressure of -20 cm H2O indicates excessive negative pressure, which can
lead to excessive drainage and potential complications. The nurse should adjust the suction to
maintain the prescribed pressure range.
150) A provider has written a do not resuscitate order for a client who is comatose and does
not have advance directives. A member of the client's family says to the nurse, “I wonder
when the doctor will tell us what’s going on." Which of the following actions should the
nurse take first?
a) Request that the provider provide more information to the family.
b) Refer the family to a support group for grief counseling.
c) Offer to answer questions that family members have.
d) Ask the family what the provider has discussed with them.
Answer: c) Offer to answer questions that family members have.
Rationale:
Offering to answer questions shows support and provides an opportunity to clarify any
misunderstandings or concerns the family may have about the client's condition and the do
not resuscitate order. It allows the nurse to facilitate effective communication and address the
family's needs during a difficult time.
151) A nurse is performing a skin assessment on a client who has risk factors for the
development of skin cancer. The nurse should understand that a suspicious lesion is:
a) scaly and red
b) asymmetric, with variegated coloring
c) firm and rubbery
d) brown with a wart-like texture

Answer: b) asymmetric, with variegated coloring
Rationale:
Suspicious lesions for skin cancer often exhibit asymmetry, irregular borders, variations in
color, and a diameter larger than 6 millimeters. This description aligns with the characteristics
of melanoma, a type of skin cancer.
152) A nurse is interviewing an older adult client about the physiological changes he has been
experiencing. Which of the following changes should the nurse recognize is normally
associated with the aging process?
a) Decreased sense of taste
b) Decreased blood pressure
c) Increased gastric secretions
d) Increased accommodation to near vision
Answer: a) Decreased sense of taste
Rationale:
Age-related changes often include a decline in the sense of taste, which can affect appetite
and nutritional intake in older adults.
153) A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal
syndrome. Which of the following should the nurse include in the plan of care?
a) Administer disulfiram.
b) Provide frequent orientation to time and place.
c) Engage the client in group therapy.
d) Perform gastric lavage.
Answer: b) Provide frequent orientation to time and place.
Rationale:
Providing frequent orientation to time and place helps to reduce confusion and disorientation,
which are common symptoms of alcohol withdrawal syndrome. It helps the client maintain a
sense of reality and may decrease agitation and anxiety.

155) A nurse manager is planning an audit to measure the quality of care on the unit. Which
of the following is the most appropriate source for the nurse to consult?
a) Nursing manager colleagues
b) Evidence-based practice data
c) Hospital administrators
d) Protocols in other hospitals
Answer: b) Evidence-based practice data
Rationale:
When planning an audit to measure the quality of care, consulting evidence-based practice
data is the most appropriate source. Evidence-based practice data provides objective and
research-supported information about best practices and standards of care, which can be used
to evaluate and improve the quality of care on the unit. Consulting with nursing manager
colleagues, hospital administrators, or protocols in other hospitals may provide additional
perspectives, but evidence-based practice data directly informs decisions about quality
improvement initiatives.
156) A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs
of early dumping syndrome. Which of the following findings should the nurse expect? (Select
all that apply)
a) Facial flushing
b) Syncope
c) Diaphoresis
d) Vertigo
e) Bradycardia
Answer: a) Facial flushing
c) Diaphoresis
Rationale:

Early dumping syndrome is characterized by rapid emptying of the stomach contents into the
small intestine, leading to a shift of fluid into the intestine and subsequent fluid shifts in the
body. This can result in symptoms such as facial flushing and diaphoresis (excessive
sweating). Syncope (fainting), vertigo (dizziness), and bradycardia (slow heart rate) are less
commonly associated with early dumping syndrome.
157) A nurse is caring for a client who is experiencing mild anxiety. Which of the following
findings should the nurse expect?
a) feelings of dread
b) rapid speech
c) purposeless activity
d) heightened perceptual field
Answer: d) heightened perceptual field
Rationale:
Mild anxiety is associated with a heightened perceptual field, meaning the client's senses are
more acute and their awareness of their surroundings is increased. This can lead to increased
alertness and vigilance. Feelings of dread, rapid speech, and purposeless activity are more
commonly associated with moderate to severe anxiety.
158) A nurse is delegating tasks to an assistive personnel. Which of the following instructions
demonstrates appropriate communication of the task?
a) "Take a blood glucose fingerstick on the client in room 102 before breakfast and then place
the glucometer into the docking station."
b) "Obtain a blood pressure reading from the client in room 116 after lunch and report a
systolic level less than 90."
c) "Assist the client in room 110 to ambulate once around the unit and stop if she gets short of
breath."
d) "Turn the client in room 126 to prevent pressure areas on his hip bones."
Answer: a) "Take a blood glucose fingerstick on the client in room 102 before breakfast and
then place the glucometer into the docking station."

Rationale:
This instruction is clear and specific, detailing the task to be performed (blood glucose
fingerstick), the client it pertains to (client in room 102), the timing (before breakfast), and
what to do with the equipment afterward (place the glucometer into the docking station).
Clear communication ensures that tasks are performed accurately and safely.
159) A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased
blood pressure. The nurse should recognize that these findings are potential manifestations of
which of the following?
a) Nicotine withdrawal
b) Heroin intoxication
c) Alcohol withdrawal
d) Amphetamine intoxication
Answer: b) Heroin intoxication
Rationale:
Constricted pupils, delayed reflexes, and decreased blood pressure are classic signs of central
nervous system depression, which is commonly seen in opioid intoxication, such as heroin.
Opioids like heroin depress the central nervous system, leading to respiratory depression,
decreased blood pressure, and altered level of consciousness.
160) A nurse is assessing an older adult client who had a stroke. Which of the following
findings should the nurse recognize as an indication of dysphagia?
a) Abnormal movements of the mouth
b) Inability to stand without assistance
c) Paralysis of the right arm
d) Loss of appetite
Answer: a) Abnormal movements of the mouth
Rationale:

Dysphagia, or difficulty swallowing, can manifest as abnormal movements of the mouth
during attempts to swallow. This may include difficulty forming a cohesive bolus, delayed
initiation of swallowing, or observed struggles with oral control during eating or drinking.
Dysphagia can increase the risk of aspiration pneumonia and malnutrition in stroke survivors.
161) A nurse is providing preoperative teaching to a client who will use PCA morphine
sulfate following surgery. Which of the following information should the nurse include?
a) The client should notify the nurse when administering a dose of the medication.
b) The client can administer a dose of medication every 6 to 8 min.
c) The client should be cautious to avoid overmedication (OD).
d) Family members can administer a dose the client.
Answer: a) The client should notify the nurse when administering a dose of the medication.
Rationale:
With PCA (Patient-Controlled Analgesia), the client should be educated to notify the nurse
when administering a dose of the medication. This allows the nurse to monitor the client's
pain relief and assess for any signs of overmedication or adverse effects. The client should
not administer a dose of medication without informing the nurse, and family members should
not administer medication through the PCA pump.
162) A nurse is assisting the provider with a paracentesis for a client who has ascites.
Following collection of the specimen, which of the following actions should the nurse take
next?
a) Document the procedure.
b) Measure the drainage.
c) Record the color of the drainage.
d) Label the specimen.
Answer: b) Measure the drainage.
Rationale:

Following a paracentesis, the nurse should measure the amount of drainage collected. This
information helps assess the effectiveness of the procedure and monitor the client for signs of
complications such as hypovolemia or hemorrhage. Documentation of the procedure,
including the amount of drainage, is essential for accurate record-keeping and continuity of
care.
163) A nurse is caring for a client in an inpatient facility who tells the nurse that she is
leaving because the facility policy prohibits smoking inside. Which of the following actions
should the nurse take?
a) Notify security to monitor the facility exits.
b) Place the client in seclusion.
c) Inform the client of the risks involved if she leaves.
d) Call the provider for a discharge prescription.
Answer: c) Inform the client of the risks involved if she leaves.
Rationale:
The nurse should inform the client of the potential risks involved if she leaves against
medical advice, such as worsening of her condition or complications. This allows the client to
make an informed decision about her health and safety. While notifying security or calling the
provider may be appropriate depending on the situation, the priority is to ensure the client
understands the implications of their decision. Placing the client in seclusion is not
appropriate unless there is an immediate risk to their safety or the safety of others.
164) A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a
child. Which of the following is a contraindication for administration?
a) Recent blood transfusion
b) Allergy to penicillin
c) Minor acute illness
d) Low-grade fever
Answer: b) Allergy to penicillin
Rationale:

An allergy to penicillin is a contraindication for administering the MMR vaccine. Individuals
with a history of severe allergic reactions to any component of the vaccine, including
neomycin or gelatin, should not receive the MMR vaccine due to the risk of an allergic
reaction.
165) A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult
client. Which of the following is the safest site for the nurse to use?
a) Ventrogluteal
b) Dorsogluteal
c) Vastus lateralis
d) Rectus femoris
Answer: a) Ventrogluteal
Rationale:
The ventrogluteal site is considered one of the safest and preferred sites for intramuscular
injections in adults. It has fewer major blood vessels and nerves compared to the dorsogluteal
site, reducing the risk of injury or injection into a blood vessel.
166) A nurse is teaching a female client how to reduce the risk of urinary tract infections
(UTIs). Which of the following should the nurse include as a risk factor for developing a
UTI?
a) Wearing underwear with a cotton crotch
b) Wiping from front to back
c) Using perfumed toilet paper
d) Urinating immediately after intercourse
Answer: c) Using perfumed toilet paper
Rationale:
Using perfumed or scented toilet paper can irritate the genital area and potentially disrupt the
normal flora, increasing the risk of urinary tract infections (UTIs). It is recommended to use
unscented and gentle hygiene products to reduce the risk of UTIs.

167) A nurse is providing discharge instructions for a client who has a new prescription for
furosemide. Which of the following client statements indicates a need for further teaching?
a) "I will take my morning pills with food or milk."
b) "I will weigh myself every day."
c) "I will notify the nurse if I have muscle cramps."
d) "I will limit my intake of fish."
Answer: d) "I will limit my intake of fish."
Rationale:
Furosemide is a loop diuretic that can cause potassium depletion. Fish, especially certain
types like salmon and tuna, are high in potassium. Limiting potassium-rich foods like fish can
exacerbate potassium depletion caused by furosemide, leading to hypokalemia. Therefore, the
client should not limit their intake of fish, but rather consume them moderately to maintain
potassium balance.
168) A nurse is caring for a client who has a prescription for atorvastatin. Which of the
following client conditions is a contraindication to this medication?
a) hepatitis C
b) peptic ulcer disease
c) bronchitis
d) Crohn’s disease
Answer: a) hepatitis C
Rationale:
Atorvastatin is a statin medication used to lower cholesterol levels. Hepatitis C is a
contraindication to atorvastatin due to the potential risk of hepatotoxicity, as the liver is
already compromised in hepatitis C. Atorvastatin can exacerbate liver dysfunction in these
individuals, leading to further liver damage.
169) A nurse is planning care for an adolescent who has chronic renal failure. Which of the
following actions should the nurse include in the plan of care?

a) Encourage a diet high in calcium.
b) Provide a diet high in potassium.
c) Ensure increased fluid intake.
d) Restrict protein intake to the RDA.
Answer: c) Ensure increased fluid intake.
Rationale:
Chronic renal failure leads to decreased kidney function, impairing the body's ability to
excrete waste products and maintain fluid balance. Ensuring increased fluid intake helps
prevent dehydration and supports kidney function by aiding in the elimination of waste
products through urine output. However, the nurse should monitor fluid intake closely to
prevent fluid overload.
170) A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and
located 2 cm above the umbilicus. Which of the following actions should the nurse take first?
a) Take vital signs.
b) Assess lochia.
c) Massage the fundus.
d) Give oxytocin IV bolus.
Answer: c) Massage the fundus.
Rationale:
A boggy uterus located above the umbilicus indicates uterine atony, which can lead to
postpartum hemorrhage. Massaging the fundus helps to stimulate uterine contractions and
firmness, reducing the risk of excessive bleeding. It is the priority action to address uterine
atony before further assessment or interventions.
171) A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which
of the following interventions should the nurse perform
a) Give 100 mL of water with every feeding.
b) Obtain gastric residuals every 24 hr.

c) Position the head of bed at 30 degrees during feeding.
d) Mix the client's medications with the tube feedings.
Answer: c) Position the head of bed at 30 degrees during feeding.
Rationale:
Positioning the head of the bed at 30 degrees during enteral feedings helps prevent aspiration
by promoting gastric emptying and reducing the risk of reflux. This position also minimizes
the risk of regurgitation and aspiration pneumonia. Giving water with feedings can be
appropriate depending on the client's fluid needs but is not the priority intervention related to
tube feeding safety.
172) A nurse is caring for a 7-month-old infant who is being treated for severe dehydration.
Which of the following assessment findings indicates treatment has been effective?
a) Skin turgor displays tenting
b) Flat anterior fontanel
c) Cool, mottled skin
d) Hyperpnea
Answer: b) Flat anterior fontanel
Rationale:
A flat anterior fontanel indicates adequate hydration in infants. In cases of severe
dehydration, the fontanel may be sunken due to fluid loss. As hydration improves with
treatment, the fontanel becomes less sunken and eventually flat or slightly bulging. This
indicates that fluid balance is being restored, and treatment is effective.
173) A nurse is providing teaching to a client who has esophageal cancer and is scheduled to
start radiation therapy. Which of the following should the nurse include in the teaching?
a) Remove dye markings after each radiation treatment.
b) Apply a warm compress to the irradiated site.
c) Wear clothing over the area of radiation treatment.
d) Use a washcloth to bathe the treatment area.

Answer: c) Wear clothing over the area of radiation treatment.
Rationale:
Wearing clothing over the area of radiation treatment helps protect the skin from direct
exposure to sunlight, which can exacerbate radiation-induced skin reactions like erythema
and blistering. It is important for clients undergoing radiation therapy to protect the treated
area from sun exposure to prevent further damage to the skin.
174) A nurse in a provider's office is providing education to a client who is 16 weeks of
gestation and has a new prescription for ferrous sulfate. Which of the following instructions
should the nurse provide?
a) "Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is
effective."
b) "Take your iron medication with fluids other than coffee or tea."
c) "It is important to take your iron medication on a full stomach."
d) "If you miss a dose one day, take two doses the next day."
Answer: b) "Take your iron medication with fluids other than coffee or tea."
Rationale:
Taking iron medication with fluids other than coffee or tea enhances iron absorption. Coffee
and tea contain tannins, which can inhibit iron absorption. Therefore, the client should be
instructed to take their iron supplement with water or juice to maximize its effectiveness.
175) A nurse receives a change-of-shift report on four clients. Based on the shift report
information, which of the following clients should the nurse plan to assess?
a) A client who had a hip arthroplasty reports pain and erythema in his calf.
b) A client who has anorexia and peripheral edema.
c) A client who has Addison's disease with a blood glucose level of 75 mg/dL.
d) A client who had a barium enema 2 days ago and reports constipation.
Answer: a) A client who had a hip arthroplasty reports pain and erythema in his calf.
Rationale:

Pain and erythema in the calf can be indicative of deep vein thrombosis (DVT), a potential
complication following hip arthroplasty due to immobility and altered circulation. It is
essential to assess this client promptly to rule out DVT and prevent potential complications
such as pulmonary embolism.
176) A nurse administers a dose of metoclopramide to a client prior to chemotherapy
treatment. Which of the following medications should the nurse administer?
a) Albuterol sulfate.
b) Hydromorphone.
c) Diphenhydramine.
d) Amitriptyline.
Answer: c) Diphenhydramine.
Rationale:
Metoclopramide is commonly used to prevent chemotherapy-induced nausea and vomiting by
promoting gastric emptying. Diphenhydramine is often administered concurrently with
metoclopramide to prevent extrapyramidal side effects such as dystonia and akathisia. This
combination helps to minimize adverse effects associated with metoclopramide therapy.
177) A client who does not speak English arrives at the emergency department accompanied
by a child. Which of the following actions should the nurse take?
a) Ask the assistive personnel to assist the client in signing consent for treatment.
b) Ask the child to interpret for the client.
c) Ascertain what language the client speaks and get an interpreter.
d) Try to find an adult relative to help the client communicate.
Answer: c) Ascertain what language the client speaks and get an interpreter.
Rationale:
It is essential to ensure effective communication with the client to provide safe and
appropriate care. Relying on a child or untrained personnel to interpret can lead to
miscommunication or misunderstanding of important information. The nurse should identify

the client's language and arrange for a professional interpreter to facilitate communication
accurately.
178) A nurse is caring for a client who has severe preeclampsia and is receiving magnesium
sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays
toxicity. Which of the following actions should the nurse take?
a) Position the client supine.
b) Prepare an IV bolus of dextrose 5% in water.
c) Administer calcium gluconate IV.
d) Administer methylergonovine IM.
Answer: c) Administer calcium gluconate IV.
Rationale:
Magnesium sulfate toxicity can lead to neuromuscular and cardiovascular complications,
including respiratory depression and cardiac arrest. Calcium gluconate is the antidote for
magnesium sulfate toxicity, as it antagonizes the effects of magnesium on neuromuscular and
cardiovascular function. Administering calcium gluconate promptly helps reverse the toxic
effects of magnesium sulfate.
179) A nurse is using Naegele's rule to calculate the expected delivery date for a newly
pregnant primigravida) The first day of the client's last period was October. What is the
expected delivery date?

a) July 1 0101
b) July 3 0101
c) July 5 0101
d) July 7 0101

Answer: c) July 5 0101
Rationale:

According to Naegele's rule, you add 7 days to the first day of the last menstrual period
(LMP), then subtract 3 months, and finally add 1 year.
First day of LMP: October
Adding 7 days: October 7
Subtracting 3 months: July 7
Adding 1 year: July 7, next year.
Therefore, the expected delivery date is July 5th.
180) A nurse on a medical-surgical unit is receiving report on four clients. Which of the
following clients should the nurse assess first?
a) A client who is scheduled for chemotherapy and has a hemoglobin of 9
b) A client who is 24 hr postoperative following a transurethral resection of the prostate
(TURP) and has small blood clots in the urinary catheter
c) A client who is receiving a blood transfusion and reports low-back pain
d) A client who has a new colostomy with a reddish-pink stoma
Answer: c) A client who is receiving a blood transfusion and reports low-back pain
Rationale:
This client is experiencing a potential adverse reaction to the blood transfusion, which can
manifest as low-back pain and other symptoms such as fever, chills, dyspnea, and flushing.
This reaction could indicate a transfusion reaction, such as transfusion-associated circulatory
overload (TACO) or hemolytic reaction, which require immediate assessment and
intervention to prevent further complications, including renal failure, shock, or even death.