ATI RN MEDSURG 2020/2021 PROCTORED EXAM
1. A nurse working in the emergency department is caring for a client who has a burn injury.
After securing the client's Airway which of the following interventions should the nurse take
first?
A. Cleanse the client wound
B. Administer Analgesic medication
C. Increase the room temperature
D. Start an IV with a large bore needle
2. A nurse is caring for a client who has a central venous access device and notes the tubing has
become disconnected. The client develops dyspnea and tachycardia. Which of the following
actions should the nurse take first?
A. Obtain ABG values
B. Perform an ECG
C. Turn the client to his left side
D. Clamp the catheter
3. A nurse is providing discharge teaching to a client who has impaired immune system due to
chemotherapy. Which of the following information should the nurse include in the teaching?
A. Wash your perineal area 2 times each day with antimicrobial soap
B. Change the water in your drinking glass every 4 hours p.581 avoid fluids sitting at room temp
for longer than 1hr
C. Wash your toothbrush in the dishwasher once each month p.581 wash toothbrush daily in
dishwasher
D. Change your pet litter box daily p.581 avoid changing pet’s litter box
4. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of
the following findings should the nurse report to the surgeon?
A. Heart rate 90/min
B. Absent bowel sounds → normal findings after major bowel surgery; takes several days to
return to normal.
C. Hgb 8.2 g/dl
D. Gastric pH of 3.0
Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible haemorrhaging.
5. A nurse is caring for a client who has diabetes insipidus. Which of the following medications
should the nurse plan to administer?
A. Desmopressin
B. Regular insulin
C. Furosemide
D. Lithium carbonate
Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin
increase ADH and keeps pt. on urinating
6. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times
daily for 3 years. Which of the following test should the nurse monitor?
A. Fasting blood glucose
B. Stool for occult blood
C. Urine for white blood cells
D. Serum calcium
Rationale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry
stools, abd pain).
7. A nurse in the emergency department is assessing a client. Which of the following actions
should the nurse take first (Click on the “Exhibit” button for additional information about the
client. There are three tabs that contain separate categories of data.)
A. Obtain a sputum sample for culture
B. Prepare the client for a chest x-ray
C. Initiate airborne precautions
D. Administer ondansetron.
Rationale: No idea what the Exhibit is all about; won’t be able to answer it.
8. A nurse is contacting the provider for a client who has cancer and is experiencing
breakthrough pain. Which of the following prescriptions should the nurse anticipate?
A. Transmucosal fentanyl
B. Intramuscular meperidine
C. Oral acetaminophen
D. Intravenous dexamethasone
9. A nurse is admitting a client who reports chest pain and has been placed on a telemetry
monitor. Which of the following should the nurse analyze to determine whether the client is
experiencing a myocardial infarction?
A. PR interval
B. QRS duration
C. T wave
D. ST segment
Rationale: ST elevation indicates MI. ST depression indicates ischemia
10. A nurse is teaching a client who has ovarian cancer about skin care following radiation
treatment. Which of the following instructions should the nurse include?
A. Pat the skin on the radiation site to dry it
B. Apply OTC moisturizer to the radiation site
C. Cover the radiation site loosely with a gauze wrap before dressing
D. Use a soft washcloth to clean the area around the radiation site
Rationale: pg. 584. Dry the area thoroughly using patting motions.
11. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the
client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse
should anticipate administering which of the following prescribed medications?
A. Diphenhydramine
B. Acetaminophen
C. Pantoprazole
D. Furosemide
Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics
to prevent cardiovascular/respiratory distress.
12. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the medication?
A. Lungs clear
B. Apical pulse 82/min
C. Hyperactive bowel sounds
D. Blood pressure 90/50 mm Hg
Rationale: ATI p. 494: s/s of hypomagnesemia consist of hypoactive bowel sounds, constipation,
paralytic ileus. So effectiveness would indicate opposite of this
13. A nurse is reviewing a client’s ABG results pH 7.42, PaCO2 30 mm Hg, and HCO3 21
mEq/L. The nurse should recognize these findings as indication of which of the following
conditions?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis
14. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body
which of the following labs should the nurse expect during the first 24 hours
A. Decreased BUN ELEVATED DT fluid loss
B. Hypoglycemia (High due to stress)
C. Hypoalbuminemia (Low due to fluid loss)
D. Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase)
15. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of
the following actions should the nurse take?
A. Offer the client high carbohydrate meal options (High fat, high protein, low fiber, low to
moderate carbs page 317, chapter 49 Peptic ulcer disease med surge ati pdf 10.0)
B. Provide the client with four full meals a day (Small frequent meals)
C. Encourage the client to drink at least 360 ml of fluids with meals (Eliminate liquids with
meals for 1 hr prior and following a meal)
D. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the
movement of food within the intestines)
16. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which
of the following factors should the nurse include in the teaching? SATA. (p.70 chapter 13)
A. Born with a high weight
B. Chronic infections of the middle ear
C. Use a loop diuretic
D. Perforation of the ear drum
E. Frequent exposure to low volume noise
17. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following
actions should the nurse take? (Chapter 92 page 606 med surge ati pdf 10.0)
A. Administer the plasma immediately after thawing.
Correct Approach: Blood must be warmed before administration, and there is a 30-minute
window to give it to prevent bacterial growth. It doesn’t necessarily have to be given right away,
but it should be given promptly after thawing.
B. Transfuse the plasma over 4 hours.
Correct Approach: FFP should be transfused within 2 to 4 hours.
C. Hold the transfusion if the client is actively bleeding.
Incorrect Approach: You must give FFP if the client is actively bleeding since it is used to
replace clotting factors in the case of bleeding or clotting deficiencies.
D. Administer the transfusion through a 24-gauge saline lock.
Incorrect Approach: FFP should be administered through an 18 or 20-gauge IV catheter to
ensure proper flow.
18. A nurse is assessing a clients who reports numbness and tingling of his toes and exhibits a
positive TROUSSEAU. Which of the following electrolyte imbalance should the nurse suspect?
A. Hypoatremia
B. Hyperchloremia
C. Hypermagnesemia
D. Hypocalcemia (low calcium = low ca causes increased firing = spasms. Learned this is
LVN school.)
19. A home health nurse is teaching a clients how to care for a peripherally central catheter in his
right arm. Which of the following statements should the nurse include in the teaching?
A. Change the transparent dressing over the insertion site every 48 hours.
Incorrect Statement: Transparent dressings can remain intact for up to 7 days unless they
become soiled or lose their adherence.
B. Clean the insertion site with mild soap and water.
Partially Correct Statement: While mild soap and water can be used for cleaning, the insertion
site must be covered during showers to prevent water exposure. No water should come into
contact with the site.
C. Measure your right arm circumference once weekly.
Incorrect Statement: The guidelines do not specify a regular measuring schedule for arm
circumference; monitoring for swelling or changes should be done as needed.
D. Use a 10 milliliter syringe when flushing the catheter.
Correct Statement: A 10 mL syringe should be used when flushing the catheter with normal
saline (NS) before and after medication administration to maintain patency.
20. A nurse is caring for a client who has a central venous access device. Which of the following
assessment findings should the nurse report to the provider?
A. RBC count of 4.7 million/mm3
B. BUN 22 mg/ dl - not dramatically high enough to pay attention to.
C. WBC count of 16,000/ mm3 - phlebitis is a complication, infection is a complication that
can happen 7 days after insertion, also temp increase if 1 degree can happen.
D. Blood glucose of 120 mg/dl
21. A nurse is providing dietary teaching to a client who has chronic kidney disease and a
decreased glomerular filtration rate. Which of the following statements by the client indicates an
understanding of the teaching?
A. I will spread my protein allowances over the entire day - the doctor issue the patient an
allowed amount of protein so its ok.
B. I should increase my intake of canned salmon to three times per week (NO SODIUM)
C. I will season my food with lemon pepper rather than salt (We do not want to give the dietary
sodium, potassium, phosphorus, and magnesium. I don’t know what lemon pepper has, but we
want to RESTRICT sodium, potassium, phosphorus and magnesium.)
D. I should limit my intake of hard cheese to 3 ounces each day (NO SODIUM at all)
22. A nurse is caring for a client who has a peripherally inserted central catheter. The client is
receiving an antibiotic via intermittent IV bolus. Which of the following actions should the nurse
take?
A. Administer 20 ml of 0.9 sodium chloride after each dose of medication (you only flush with
10 ml of NS, not 20 is for flushing blood)
B. Flush the catheter using a 5 ml syringe - you use a 10mL syringe to flush
C. Verify the placement with an x ray prior to the initial dose
D. Change the transparent membranes dressing daily (dressing can last for up to 7 days)
23. A nurse is teaching a client using a metered dose rescue inhaler. Which of the following
statements should the nurse include in the teaching?
A. Do not shake your inhaler before use (suppose to shake it)
B. Exhale fully before bringing the inhaler to your lips
C. Depress the canister after you inhale (depress the canister before inhaling, and 5 seconds later
you inhale)
D. Use peroxide to clean the mouthpiece if your inhaler (warm water)
24. A nurse is assessing the pain status of a group of clients. Which of the following findings
indicate a client is experiencing referred pain?
A. A client who has angina reports substernal chest pain
B. A client who has pancreatitis reports pain in the left shoulder
C. A client who is postoperative reports incisional pain
D. A client who has peritonitis reports generalized abdominal pain
25. A nurse is caring for a client who has just returned from surgery with an external fixator to
the left tibia. Which of the following assessments findings requires immediate intervention by
the nurse?
A. The client reports a pain level of 7 on a scale from 0 -10 at the operative site. (This foo just
came from surgery so pain is normal for post op patients for first couple of hours.)
B. The clients capillary refill in the left toe is 6 seconds sxs of compartment syndrome.
ABCs are compromised. (Cap refill should be below 3 seconds. This is sxs for compartment
syndrome. Untreated can lead to necrosis.)
C. The client has an oral temperature of 38.3 (100.9 F) (I wouldn’t pick this because i always see
temp 101 as a priority from previous rationales with other atis.)
D. The client has 100 ml of blood in the closed suction drained. (I believe this is normal for postop patients.)
26. A nurse is assessing a client who has acute pancreatitis and has been receiving total
parenteral nutrition for the past 72 hours. Which of the following findings requires the nurse to
intervene?
A. Right upper quadrant pain (Dude has acute pancreatitis, so it’s normal)
B. Capillary blood glucose level of 164 mg/dl - glucose not significantly high
C. WBC count 13,000/mm3 (Infection is one complication of TPN administration but WBC is in
normal range.)
D. Crackle in bilateral lower lobes (ABC’s compromised, also one of the complications of
TPN is fluid imbalance aka fluid volume excess.)
27. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and
tachypnea. In which of the following positions should the nurse place the client?
A. Reverse Trendelenburg (page 232 says for hypotension patients must be flat with legs
elevated to increase venous return.)
B. Side Lying
C. High Fowlers
D. Feet elevated
28. A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports
that her saliva has turned red-orange in color. Which of the following responses should the nurse
make?
A. “This finding may indicate possible medication toxicity”
B. “Your provider will prescribe a different medication regimen”
C. “This is an expected adverse effect of this medication”
D. “You will need to increase your fluid intake to resolve this problem”
29. A nurse is preparing to administer a unit of packed RBCs for a client who is receiving a
continuous IV infusion of 5% dextrose in water. Which of the following actions should the nurse
take?
A. Administer the unit through secondary IV tubing
B. Verify the blood product with an assistive personnel
C. Begin an IV infusion of 0.9% sodium chloride
D. Insert another 22-gauge IV catheter
30. A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant.
Which of the following actions should the nurse include in the plan of care?
A. Check the client’s blood pressure every 8 hr
B. Administer opioids PO
C. Assess urine output hourly
D. Monitor for hypokalemia as a manifestation of acute rejection
31. A nurse in an emergency department is assessing a client who has cirrhosis of the liver.
Which of the following is a priority finding?
A. Yellow sclera (Normal)
B. Mental confusion can lead to portal systemic encephalopathy (page 358 MS ATI PDF
10.0 which is something to report to provider meaning neuro is worsening)
C. Palmar erythema (Normal)
D. Spider angiomas (Normal)
32. A nurse is obtaining a medication history from a client who is to start therapy with naproxen
for rheumatoid arthritis. Which of the following medications places the client at risk for
bleeding?
A. Captopril
B. Ibuprofen
C. Digoxin
D. Phenytoin
33. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the
priority intervention by the nurse?
A. Administer 0.9% sodium chloride
B. Check potassium levels
C. Initiate a continuous IV insulin infusion
D. Begin bicarbonate continuous IV infusion
34. A nurse is assessing the extremities of a client who has Raynaud’s disease. Which of the
following findings should the nurse expect?
A. Blanching of the hands
B. Hyperactive reflexes
C. Calf pain with foot dorsiflexion
D. Vitiligo on affected extremities
35. A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading
using only the left extremity from which of the following clients?
A. A client who has a peripherally inserted central catheter in the left arm
B. A client who has left-sided Bell’s palsy
C. A client who has a right upper extremity arteriovenous fistula
D. A client who has right-sided weakness due to Parkinson’s disease
36. A nurse is providing teaching to a client who has DVT. Which of the following findings
should the nurse identify as a risk factor for the development of DVTs?
A. Hypertension
B. Cirrhosis
C. NSAIDS use
D. Oral Contraceptive Use
37. A nurse is caring for client who has Cushing’s disease. Which of the following actions should
the nurse take first? (Click Exhibit button for additional information)
A. Check the client’s medication administration record for antihypertensive medication.
B. Verify the client’s understanding of sodium restriction.
C. Auscultate the client’s lung sound
D. Determine the need for further glucose monitoring.
Rationale: Unable to answer. Can’t see the exhibit. But on the chapter of Cushing disease they
talk about monitoring of glucose. The rest are not stated in the chapter.
38. A nurse is assessing a client who has nephrotic syndrome. Which of the findings should the
nurse expect?
A. Proteinuria
B. Flank pain
C. Hyperalbuminemia
D. Hypotension
Rationale: Lewis book page 1075. Clinical manifestation of N.S.: peripheral edema, massive
proteinuria, HTN, hyperlipidemia, and hypoalbuminemia.
39. A nurse is assessing a client who has right-sided heart failure. Which of the following
assessment findings should the nurse expect to find?
A. Oliguria (Left)
B. S3/S4 galloping heart sounds (Left)
C. Poor skin turgor
D. Pitting edema
40. A nurse is caring for a client who has newly inserted chest tube. The nurse should clarify
which of the following prescriptions with the provider?
A. Notify the provider when tidaling ceases. (Yes notify)
B. Assisting the client out of bed three times daily.
C. Vigorously strip the chest tube twice daily. (VIGOROUSLY and TWICE A DAY)
D. Administer morphine 2 mg IV bolus every 3 hr PRN for pain. (Don’t need to clarify)
Rationale: Page 104 chapter 18 of ATI Book it says that: “Do not strip or milk tubing; only
perform when prescribed. Stripping creates a high negative pressure and can damage lung
tissue.”
41. A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the
following instructions should the nurse include for home management of heart failure?
A. Obtain daily weight.
B. Use of salt substitute. (Avoid it)
C. Monitor I and O.
D. Limit daily activity.
42. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of
the following statements by the client indicates an understand of the teaching?
A. I need to maintain pressure over the pacemaker site with an elastic bandage.
B. I need to check my pulse rate every day for a full minute.
C. The pacemaker will deliver shock if I develop a dysrhythmia
D. When a microwave oven is in use, I need to stay out of the room.
43. A nurse in a clinic is providing preventive teaching to an older adult client during well visit.
The nurse should instruct the client that which of the following immunization are recommended
for healthy adults after age 60? SATA.
A. Herpes Zoster
B. Influenza
C. HPV
D. Meningococcal
E. Pneumococcal Polysaccharide
44. A nurse is assessing a client who is 4hr postoperative following arterial revascularization of
the left femoral artery. Which of the following findings should the nurse report immediately?
A. Bruising around the incision site
B. Pallor in the affected extremity
C. Urine output 150mL over 4hr
D. Temperature of 37.9 (100.2)
45. A nurse is caring for an older adult client who has not been eating. Which of the following
findings indicates dehydration?
A. Crackles auscultated bilaterally (S/sx suggestive of fluid overload)
B. Capillary refill of 2 seconds (Brisk; normal)
C. Dimiminished peripheral pulses
D. Engorged neck veins (Also fluid overload)
46. A nurse is preparing to discharge a client who has a halo device and is reviewing new
prescriptions from the provider. The nurse should clarify which of the following prescriptions
with the provider?
A. Increase intake of fiber rich foods
B. May operate a motor vehicle when no longer taking analgesics
C. Take tub baths instead of showers
D. May place a small pillow under the head when sleeping
47. A nurse is assessing for elderly signs of compartment syndrome for a client who has a short
leg fiberglass cast. Which of the following findings should the nurse expect?
A. Bounding distal pulses
B. Capillary refill less than 2 seconds (Pretty much the only thing that makes sense)
C. Erythema of the toes
D. Intense pain with movement
48. A nurse is caring for a client who is postoperative following coronary artery bypass surgery
and reports shortness of breath. The nurse administers oxygen at 3L/min and obtains arterial
blood gases 60 min later. Which of the following lab findings indicates a positive response to the
oxygen therapy?
A. PaCO2 34 mmHg
B. Bicarbonate 20 mEq/L
C. PaO2 90 mmHg (Normal range: 80-100 mmHg)
D. Ph 7.32
49. A nurse is performing a cranial nerve assessment on a client following a head injury. Which
of the following findings should the nurse expect if the client has impaired function of the
vestibulocochlear (VIII)?
A. Loss of the peripheral vision (CN II, is in charge of this)
B. Disequilibrium with movement (Vertigo (room spinning)
C. Deviation of the tongue from midline (CN XII)
D. Inability to smell (CN I)
50. A nurse is caring for a client admitted with a skull fracture. Which of the following
assessment findings should be of greatest concern to the nurse?
A. Glasgow coma scale score changes from 14 to 9
B. Bilateral pupil diameter changes from 4 to 2 mm
C. Pulse pressure changes from 30 to 20 mm Hg
D.WBC count changes from 9000 to 16,000 mm3
51. A nurse is caring for a client who is taking furosemide. The client has a potassium level of
3.1 mEq/L. Which of the following should the nurse assess first?
A. Urine output
B. Level of orientation
C. Cardiovascular status (Potassium imbalances causes DYSRHYTHMIAS which is the
number one reason why potassium levels are crucial to monitor.)
D. Muscle weakness- this is an early sign of K imbalance but i would go with C since ABC’s are
always first.
52. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse
should plan to take which of the following actions?
A. Instruct the client to take deep breaths and hold them during the procedure
B. Administer a stool softener following the procedure
C. Ask the client to empty his bladder prior to the procedure
D. Assist the client into the left lateral position during the procedure- they must be upright with
feet supported.
53. A nurse is caring for a client who is 6 hours postoperatively following a thyroidectomy. The
client reports tingling and numbness in the hands. The nurse should identify this as a sign of
which of following electrolytes imbalances?
A. Hypernatremia
B. Hypomagnesemia
C. Hypokalemia
D. Hypocalcemia (Parathyroid gland which is the gland that secretes calcitonin is right
behind the thyroid. When you have a thyroidectomy, you decrease the production of
calcitonin which decreases production of calcium.)
54. A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed RBC’s.
Which of the following findings is an indication of a hemolytic transfusion reaction?
A. Hypotension
B. Bradypnea-tachypnea ( RR > 20) it will produce
C. Bradycardia-tachycardia it will produce
D. Hypothermia-FEVER is a complication of a hemolytic reaction
55. A nurse in an emergency department is caring for a client who has sinus bradycardia. Which
of the following actions should the nurse take first?
A. Prepare the client for temporary pacing → too invasive
B. Initiate IV fluid therapy for the client → to solve hypotension
C. Measure the client’s blood pressure → related to hypotension
D. Administer atropine to the client (Pg 638 Atropine Sulfate treats Bradycardia)
56. A nurse is caring for a client who has a prescription to discontinue a peripherally inserted
central catheter. Which of the following actions should the nurse take?
A. Apply slight pressure when resistance is met
B. Measure the catheter after removal
C. Remove the catheter with one continuous motion
D. Place a dry sterile dressing to the site after removal
57. A nurse is caring for a client who has a flail chest. Which of the following actions should the
nurse take?
A. Provide humidified oxygen
B. Implement fluid restriction nope
C. Administer antibiotic medication
D. Administer acetaminophen orally nope
58. A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which of
the following manifestations should the nurse include in the teaching?
A. Hypoxemia
B. Hyperventilation (Can’t be this because you are for sure going to have HYPERCARBIA and
>20 RR will excrete CO2.)
C. Hypocarbia- hypercarbia
D. Hypervolemia (You’re going to have hypotension during ARF. If you have too much fluid in
your body then you would have high blood pressure.)
59. A nurse is caring for a client who is experiencing a seizure. Which of the following actions
should the nurse take first?
A. Obtain the client’s vital signs
B. Clear items from the client’s surrounding area
C. Loosen the client’s restrictive clothing
D. Lower the client to the floor
60. A nurse is teaching a client who is receiving total parenteral nutrition at home through a
central venous access device about transparent dressing changes. Which of the following
instructions should the nurse include in the teaching?
A. Change the dressing every 48 hr no
B. Replace the extension tubing with each dressing change no 72 hours
C. Use clean technique when changing the dressing no Surgical aseptic
D. Wear a mask during dressing change Surgical asepsis required
61. A nurse is caring for a client in the emergency department who experienced a full-thickness
burn injury to the lower torso 1 hr ago. Which of the following findings should the nurse expect?
During a major burn the initial phase will activate the Sympathetic nervous system.
A. Decreased respiratory rate - its is increased
B. Hypotension
C. Bradycardia- tachycardia is what you will find
D. Urinary diuresis -decreased urine output is what you will find
62. A nurse in an emergency department is assessing a client who has cirrhosis of the liver.
Which of the following is a priority finding?
A. Spider angiomas
B. Palmar erythema
C. Mental confusion
D. Yellow Sclera
63. A nurse is providing instructions about foot care for a client who has a peripheral arterial
disease. The nurse should identify which of the following statements by the client indicates an
understanding of the teaching?
A. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning” no
B. “I use my heating pad on a low setting to keep my feet warm.” No
C. “I soak my feet in hot water before trimming my toenails”
D. I rest in my recliner with my feet elevated for about an hour every afternoon.”
64. A nurse is teaching a client who has a new prescription for alendronate to treat osteoporosis.
Which of the following instructions should the nurse include in the teaching?
A. Swallow the medication with 120mL (4 oz) of water (Must be 8 oz of water)
B. Take the medication with a vitamin E supplement (Pretty sure you need vitamin D instead
since this drug is for helping with osteoporosis)
C. Sit upright for 30 min after taking the medication (No lying down)
D. Take the medication with lunch (Must be taken early morning before eating)
65. A nurse is teaching a client about using a metered dose rescue inhaler. Which of the following
statements should the nurse include in the teaching?
A. Depress the canister after you inhale
B. Exhale fully before bringing the inhaler to your lips
C. Do not shake your inhaler before use
D. Use peroxide to clean the mouth of your inhaler
66. A nurse is admitting a client to the emergency department after a gunshot wound to the
abdomen. Which of the following actions should the nurse take to help prevent the onset of acute
kidney failure?
A. Initiate beta blocker therapy-it says use CCB to prevent movement of calcium into kidney
cells and maintain cell integrity.
B. Insert a urinary catheter
C. Prepare the client for intravenous pyelogram
D. Administer IV fluids to the client- to promote kidney perfusion if patient is in the
diuretic phase
67. A nurse is completing an assessment of an older adult client and notes redness areas over the
bony prominences, but the client’s skin is intact. Which of the following interventions should the
nurse include in the plan of care?
A. Apply an occlusive dressing
B. Manage the redness areas three times daily
C. Support bony prominences with pillows
D. Turn and reposition the client every 4 hr.
68. A nurse is caring for a client who has completed 10 daily cycles of Total parenteral Nutrition
(TPN). Which of the following findings indicates that the client is receiving adequate TPN
supplementation.
A. Improved Mobility (Doesn’t correlate to TPNs)
B. Weight gain of 9.1 kilograms to 20 pounds
C. Potassium level of 2.5 mEq/L
D. BUN level of 15 mg/dL.
69. A nurse is providing teaching to a client who is post-operative following a partial
glossectomy. Which of the following statements by the client indicates an understanding of the
teaching?
A. I will consume can soup whenever sores appear in my mouth
B. I will drink orange juice to increase my vitamin C intake
C. I will rinse my toothbrush with hydrogen peroxide and water after each use
D. I will inspect my mouth once each week for sores.
70. A nurse is performing an ear irrigation for a client. Which of the following actions should the
nurse take?
A. tilt the client's head 45 degrees
B. Insert the tip of the syringe to.5 centimeters 1 inch into the ear canal
C. Point the tip of the syringe toward the top of the ear canal
D. Use cool fluid for irrigation
71. A nurse is caring for a client who is receiving continuous bladder irrigation following a
transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain.
Which of the following actions should the nurse take first?
A. Check the client's urine output
B. Reposition the client in bed
C. Increase the client's fluid intake
D. administer PRN pain medication
72. A nurse is providing teaching for a client who has diabetes mellitus about the selfadministration of insulin. The client has prescriptions for regular and NPH insulin. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will draw up regular insulin into the syringe first."
B. "I will insert the needle at a 15-degree angle."
C. "I will store prefilled syringes in the refrigerator with the needle pointing downward."
D. "I will shake the NPH vial vigorously before drawing up the insulin."
73. A nurse is caring for a client who is receiving Total parenteral Nutrition (TPN). which of the
following nursing actions are appropriate? (Select all the apply)
A. Obtain the client's weight daily
B. Increase the rate of infusion if Administration is delayed
C. Monitor serum blood glucose during infusion
D. In to use 0.9% sodium chloride if the solution is not available
E. Verify the solution with another RN prior to infusion
74. A nurse is caring for a client in diabetic ketoacidosis DKA. Which of the following is the
priority intervention by the nurse?
A. Check potassium levels
B. Administer 0.9% sodium chloride
C. Begin bicarbonate continuous IV infusion
D. Initiate continuous IV insulin infusion
75. A nurse is reviewing the laboratory results of a female client who asked about acupuncture
treatment for chemotherapy-induced nausea and vomiting. Which of the following laboratory
results indication to receiving acupuncture?
A. Absolute neutrophil count 500/mm3
B. C-reactive protein 0.7 mg/dl
C. platelets 160000/mm3
D. Hemoglobin 12/dl
76. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain
level of 6 on a Pain Scale of 0 to 10. which of the following should the nurse take?
A. Gently massage the area around the clients incision
B. Place pillows under the client's knee
C. Apply and ice path to the client’s knee- prevent swelling
D. Perform range of motion exercises to the client’s knee
77. A nurse is Assessing a client who has heart failure and is receiving a loop diuretic. Which of
the following findings indicates hypokalemia?
A. Hypertension - low K if make low blood pressure, weak thready pulse, and orthostatic hypp.
B. Positive Chvostek’s sign - signs of low calcium
C. Muscle weakness
D. Oliguria
78. A nurse at a long-term care facility is assessing an older adult client. Which of the following
findings should the nurse identify as an indication that the client has recall memory impairment?
A. Inability to state what he has for dinner last night
B. Inability to Name the members of his family
C. Inability to count backwards from 10
D. Inability to state his current age
79. A nurse on an intensive care unit is planning care for a client who has increased intracranial
pressure following a head injury. Which of the following IV medications should the nurse plan to
administer?
A. Chlorpromazine
B. Dobutamine
C. Mannitol
D. Propranolol
80. A nurse on a medical unit is planning care for a group of clients. Which of the following
A. A client who has thrombocytopenia and reports and nosebleed
B. A client who has chronic obstruction pulmonary disease and oxygen saturation of 89%
C. A client who has multiple sclerosis and Ataxia and vertigo
D. A client who has left-sided paralysis and slurred speech from a prior stroke
81. A home care nurse is planning to use non pharmacological pain relief measures for an older
client who has severe chronic back pain. Which of the following guidelines should the nurse use?
A. Use imagery with clients who have difficulty with focus and concentration
B. Pain relief from the use of heat and cold continues for several hours after removal of the
stimulus
C. Discontinue opioids before trying non pharmacological methods of pain relief
D. Distraction changes the client's perception of pain but does not affect the cause
82. A nurse is caring for a client who has pneumothorax and a chest tube with closed water seal
drainage system. Which of the following actions should the nurse take?
A. Strip or clear the chest tube every 8 hours
B. Refill the water chamber if the fluid is low
C. Empty the system at least every 8 hr
D. Change the chest to site dressing every 24 hour
83. A nurse is in an emergency department is reviewing a client's ECG reading. which of the
following findings should the nurse identify as an indication that the client has first degree heart
block?
A. Prolonged PR intervals (Per Tiamson)
B. More p waves than QRS complexes
C. Non discernible p waves
D. No correlation between p and QRS waves
84. A nurse is preparing to administer a unit of packed RBC's to a client who is anemic. Identify
the sequence of steps the nurse should follow.
1. Obtain venous access using a 19 gauge needle.
Rationale: A larger gauge needle (19 gauge or larger) is preferred for blood transfusions to
minimize hemolysis and ensure proper flow.
2. Obtain the unit of packed RBCs from the Blood Bank.
Rationale: The nurse needs to retrieve the blood product to be administered.
3. Verify blood compatibility with another nurse.
Rationale: This is a critical step to ensure that the correct blood type is given to prevent
transfusion reactions. This should be done according to facility policy.
4. Initiate transfusion of the unit of packed RBCs.
Rationale: After ensuring compatibility, the nurse can start the transfusion, monitoring for any
immediate reactions.
5. Remain with the client for the first 15 to 30 minutes of the infusion.
Rationale: Close monitoring is essential during the initial phase of the transfusion for any signs
of transfusion reactions, which are most likely to occur during this time.
Final Sequence:
1. Obtain venous access using a 19 gauge needle.
2. Obtain the unit of packed RBCs from the Blood Bank.
3. Verify blood compatibility with another nurse.
4. Initiate transfusion of the unit of packed RBCs.
5. Remain with the client for the first 15 to 30 minutes of the infusion.
This sequence ensures safe and effective administration of packed RBCs to the client.
85. A nurse is teaching A client who is to begin chemotherapy about peripherally inserted Central
catheter. which of the following statements should the nurse include in the teaching?
A. We will replace the PICC every month
B. We can draw blood samples from the PICC for diagnostic test
C. We will change the dressing daily
D. We can measure your blood pressure in either arm
86. A nurse is assessing a client who has Pyelonephritis and reports flank pain. which of the
following actions should the nurse take?
A. Assist the client to a sitting position
B. Percuss the side of tenderness first
C. Auscultate for a bruit over the coastal vertebral area
D. Thump the area of tenderness directly with a closed fist
87. A nurse is assessing a client who has acute kidney failure. Which of the following findings
should the nurse report to the provider?
A. Peripheral pulses 2 + bilaterally
B. Weight gain 1.1 kilogram to 2.4 pound in 24-hour
C. Urine specific gravity 1.045
D. Creatinine 0.8 millilitre
Rationale: weight gain can indicate fluid retention. Normal urine specific gravity: 1.0001.030,
normal creatinine: 0.5-1.2
88. A nurse is caring for an older adult client who is 72 hour postoperative following a total hip
arthroplasty. the client requires a PRN medication prior to ambulation. Which of the following
medications should the nurse anticipate administering?
A. Indomethacin
B. Meperidine
C. Naproxen
D. Oxycodone
89. A nurse is caring for a client who has Haemophilus Influenzae type B. which of the following
types of isolation should the nurse implement?
A. Droplet
B. Contact
C. Airborne
D. Protective
90. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis.
Which of the following findings should the nurse include as an indication the client is no longer
infectious?
A. Mantoux skin test reveals and induration of less than 1 mm
B. Client no longer coughing up blood tinged sputum
C. Positive QuantiFERON TB gold test
D. Negative sputum culture for acid fast bacillus
