2023-2024 ATI Medical Surgical Final Exam With Answers-219 Solved Questions

ATI MEDSURG PROCTORED FINAL EXAM 2023/24
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Medical Surgical Final Exam
1. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse
should expect to find an elevation of which of the following values?
A. Lipase
B. Amylase
C. Blood glucose
D. White blood cell count
Answer: B. Amylase
Rationale:
Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the
body. It is produced by the pancreas and salivary glands and released into the mouth, stomach,
and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually
increases within 12 to 24 hr and can remain elevated for 2 to 3 days.
2. A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis.
Which of the following findings in the client's history should the nurse recognize as consistent
with a diagnosis of endometriosis?
A. Dysmenorrhea that is unresponsive to NSAIDs
B. Irregular menstrual cycles
C. Heavy menstrual bleeding
D. Menopause symptoms
Answer: A. Dysmenorrhea that is unresponsive to NSAIDs.
Rationale:
Endometriosis is a condition in which the type of tissue that lines the uterus implants in locations
outside the uterus. This typically causes pelvic pain around the time of the menstrual period but
can cause pain at other times in the cycle. The discomfort is often unrelieved by the use of
NSAIDs.

3. A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in
paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly
resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse
take?
A. Increase the frequency of physical therapy sessions.
B. Establish a plan of care with the client that sets attainable goals.
C. Encourage the client to express feelings about their condition.
D. Discuss the client's progress with the healthcare team.
Answer: B. Establish a plan of care with the client that sets attainable goals.
Rationale:
The nurse should develop a plan of care for this client with mutually set goals. This action
invests the client in the rehabilitation process, which encourages feelings of ownership for it, and
sees the goals as more attainable
4. A nurse in a burn treatment center is caring for a client who is admitted with severe burns to
both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse
what the procedure entails. Which of the following nursing statements is appropriate?
A. The procedure will involve skin grafting to repair the burns.
B. Large incisions will be made in the eschar to improve circulation.
C. The procedure is done to remove all the burned tissue.
D. This will involve applying topical medications to the burns.
Answer: B. Large incisions will be made in the eschar to improve circulation.
Rationale:
An escharotomy is a surgical incision made to release pressure and improve circulation in a part
of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that
encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected
area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the
skin to expand, reduces tightness and pressure, and improves circulation.

5. A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the
client's urine to appear which of the following colors?
A. Clear and pale
B. Dark and foamy
C. Bright red
D. Yellow and cloudy
Answer: B. Dark and foamy
Rationale:
The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are
filtering excess bilirubin from the blood.
6. A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking
aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor
to evaluate the effectiveness of this medication?
A. Complete blood count (CBC)
B. C-reactive protein (CRP)
C. Erythrocyte sedimentation rate (ESR)
D. Liver function tests (LFTs)
Answer: C. Erythrocyte sedimentation rate (ESR)
Rationale:
Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and
monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases.
7. A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate
kidney stones. Which of the following instructions should the nurse include in the teaching?
A. Limit fluid intake to 1 L per day.
B. Drink 3 L of fluid every day.
C. Increase intake of high-oxalate foods.
D. Avoid calcium-rich foods.
Answer: B. Drink 3 L of fluid every day.
Rationale:

The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine
and reduce the risk for stone formation.
8. A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of
the following findings should the nurse expect?
A. Increased platelet count
B. Excessive thrombosis and bleeding
C. Decreased fibrinogen levels
D. Improved clotting time
Answer: B. Excessive thrombosis and bleeding.
Rationale:
The nurse should expect excessive thrombosis and bleeding of mucous membranes because DIC
impairs both coagulation and anticoagulation pathways.
9. A nurse is caring for a middle adult client who has just received the diagnosis of endometrial
cancer. In taking a nursing history, which of the following manifestations is likely to be reported
by this client?
A. Dysmenorrhea
B. Postmenopausal bleeding
C. Severe pelvic pain
D. Increased menstrual flow
Answer: B. Postmenopausal bleeding
Rationale:
Endometrial cancer involves cancerous growth of the endometrium (lining of the uterus). The
most common manifestation of endometrial cancer is abnormal uterine bleeding, including
postmenopausal bleeding and bleeding between normal periods in premenopausal women.
10. A nurse is giving a presentation to a community group about preventing atherosclerosis.
Which of the following should the nurse include as a modifiable risk factor?
A. Family history
B. Age

C. Hypercholesterolemia
D. Gender
Answer: C. Hypercholesterolemia
Rationale:
Hypercholesterolemia, hypertension, obesity, and smoking are all modifiable risk factors for
atherosclerosis.
11. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit.
Which of the following room assignments should the nurse make for the client?
A. A private room with a HEPA filter
B. A room with air exhaust directly to the outdoor environment
C. A room shared with another client with a respiratory infection
D. A negative pressure room with recirculated air
Answer: B. A room with air exhaust directly to the outdoor environment
Rationale:
A room with air exhaust directly to the outside environment eliminates contamination of other
client-care areas. This type of ventilation system is referred to as an airborne infection isolation
room.
12. A nurse is caring for a client who has Cushing's syndrome. Which of the following
interventions should the nurse expect to perform? (Select all that apply.)
A. Assess blood glucose level
B. Assess for neck vein distention
C. Monitor for an irregular heart rate
D. Monitor for postural hypotension
E. Weigh the client daily
Answer: A. Assess blood glucose level
B. Assess for neck vein distention
E. Weigh the client daily
Rationale:

• Assessing blood glucose levels is important due to the risk of hyperglycemia in Cushing's
syndrome.
• Neck vein distention may indicate fluid overload or hypertension, which can occur in this
condition.
• Weighing the client daily helps monitor for fluid retention.
13. A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors
should the nurse include in the teaching? (Select all that apply.)
A. Sedentary lifestyle
B. Obesity
C. Aging
D. Caffeine intake
E. Second hand smoke
Answer: A. Sedentary lifestyle
C. Aging
D. Caffeine intake
E. Second hand smoke
Rationale:
• Obesity is generally not considered a risk factor for osteoporosis, as it can provide some
protective effects through estrogen storage.
• Sedentary lifestyle contributes to bone depletion due to lack of weight-bearing activity.
• Aging is a risk factor as women lose bone density due to estrogen depletion after menopause.
• Excessive caffeine intake causes calcium loss in urine.
• Second hand smoke is a risk factor for osteoporosis.
14. A nurse is caring for a client who has a history of exposure to TB and symptoms of night
sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable
to confirm the diagnosis of active pulmonary TB?
A. Mantoux (skin test)
B. Sputum culture for acid-fast bacillus
C. Chest X-ray

D. Interferon-gamma release assay (IGRA)
Answer: B. Sputum culture for acid-fast bacillus
Rationale:
Although the Mantoux test and chest X-ray may be useful screening tools for TB, the presence of
acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can
actually confirm the diagnosis.
15. A nurse is caring for a client who has emphysema. Which of the following findings should
the nurse expect to assess in this client? (Select all that apply.)
A. Dyspnea
B. Bradycardia
C. Barrel chest
D. Clubbing of the fingers
E. Deep respirations
Answer: A. Dyspnea
C. Barrel chest
D. Clubbing of the fingers
Rationale:
• Dyspnea is expected due to lung damage, where the lungs try to increase oxygen availability.
• Barrel chest occurs due to loss of lung elasticity and hyperinflation.
• Clubbing of the fingers can result from chronic low arterial oxygen levels.
• Bradycardia is incorrect as heart rate typically increases in emphysema.
• Deep respirations are also incorrect; clients often have shallow respirations due to muscle
fatigue and loss of lung elasticity.
16. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to
both lower legs, chest, face, and both forearms. Which of the following is the priority action the
nurse should take?
A. Inspect the mouth for signs of inhalation injuries.
B. Apply topical antibiotics to the burn areas.
C. Cover the burns with sterile dressings.

D. Assess the client's pain level.
Answer: A. Inspect the mouth for signs of inhalation injuries.
Rationale:
Since the client sustained burns to the chest and face, there is a possibility of inhalation injury
from flames and smoke. The nurse should inspect the mouth and throat for soot and swelling, as
airway concerns take priority in the ABC framework.
17. A nurse is planning care for a client who is being treated with chemotherapy and radiation for
metastatic breast cancer, and who has neutropenia. The nurse should include which of the
following restrictions in the client's plan of care?
A. Avoid crowded places.
B. No fresh flowers and potted plants in the room.
C. Use of an electric razor.
D. Limit visitors to family only.
Answer: B. No fresh flowers and potted plants in the room.
Rationale:
Clients with neutropenia are at increased risk for infections, and fresh flowers and plants can
harbor bacteria and mold, posing a risk to their health.
18. A nurse is preparing dietary instructions for a client who has episodes of biliary colic from
chronic cholecystitis. Which of the following instructions should the nurse include in the
teaching plan?
A. Avoid foods high in carbohydrates.
B. Include more dairy products in the diet.
C. Avoid foods high in fat.
D. Increase intake of high-fiber foods.
Answer: C. Avoid foods high in fat.
Rationale:
The nurse should instruct the client to follow a low-fat diet to decrease episodes of biliary colic,
as those with chronic cholecystitis often have intolerance to fatty foods.

19. A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy.
Which of the following information regarding prevention of postoperative complications should
the nurse include in the teaching?
A. Instruct the client about the use of a sequential compression device.
B. Encourage the client to limit fluid intake after surgery.
C. Teach the client about the importance of bed rest for the first 48 hours.
D. Advise the client to avoid deep breathing exercises postoperatively.
Answer: A. Instruct the client about the use of a sequential compression device.
Rationale:
The nurse should instruct the client about the use of a sequential compression device to prevent
deep vein thrombosis, a common postoperative complication.
20. A nurse is caring for a middle adult female client who reports that her menstrual periods have
become irregular and she has been having hot flashes. The nurse should expect the client to have
which of the following manifestations associated with early menopause?
A. Increased libido
B. Dryness with intercourse
C. Heavy menstrual bleeding
D. Ovarian cysts
Answer: B. Dryness with intercourse
Rationale:
Menopause, the cessation of menstrual periods, occurs when the ovaries stop making estrogen,
which can lead to vaginal dryness, discomfort, or pain during sexual intercourse.
21. During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's
chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should
recognize that this finding is suggestive of which of the following types of skin cancer?
A. Squamous cell carcinoma
B. Basal cell carcinoma
C. Melanoma
D. Merkel cell carcinoma

Answer: B. Basal cell carcinoma
Rationale:
A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent, pearly
borders. Telangiectatic vessels can also be present, and it may undergo central ulceration as it
grows.
22. A nurse is teaching a group of newly licensed nurses on effective techniques for counseling
clients about sexually transmitted infections (STIs). Which of the following statements should
the nurse include in the teaching?
A. Encourage clients to self-diagnose STIs.
B. Ask about the client's exposure to any past or present STIs.
C. Recommend that all clients be tested for STIs regardless of risk factors.
D. Suggest that STIs are only a concern for sexually active individuals.
Answer: B. Ask about the client's exposure to any past or present STIs.
Rationale:
The nurse should assess the client's exposure to any past or present STIs and any treatment
received to provide appropriate counseling and care.
23. A nurse is teaching a client who has hepatitis A about preventing transmission of the virus.
Which of the following strategies should the nurse include in the teaching?
A. Practice effective hand hygiene.
B. Avoid all contact with other people.
C. Limit fluid intake to prevent dehydration.
D. Use antibiotics to prevent infection.
Answer: A. Practice effective hand hygiene.
Rationale:
Effective hand hygiene, along with immunization, sewer sanitation, and a safe water supply, are
the most effective strategies for preventing the transmission of hepatitis A.
24. A nurse is assessing a client who has fluid overload. Which of the following findings should
the nurse expect? (Select all that apply.)

A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
D. Increased hematocrit
E. Increased temperature
Answer: A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
Rationale:
• Increased heart rate: Clients with fluid volume excess often experience tachycardia as the heart
works harder to manage the excess fluid.
• Increased blood pressure: Elevated blood pressure and a bounding pulse are expected due to the
increased blood volume.
• Increased respiratory rate: An increased respiratory rate may be observed, along with moist
crackles in the lungs due to fluid overload.
• Increased hematocrit is incorrect as it is typically elevated in fluid volume deficit due to
hemoconcentration.
• Increased temperature is also incorrect; clients with fluid volume deficit may experience an
increase in temperature due to fluid loss.
25. A staff nurse is teaching a client who has Addison's disease about the disease process. The
client asks the nurse what causes Addison's disease. Which of the following responses should the
nurse make?
A. It is caused by the lack of production of aldosterone by the adrenal gland.
B. It is caused by an overproduction of cortisol by the adrenal gland.
C. It is caused by a deficiency in thyroid hormones.
D. It is caused by an autoimmune destruction of the adrenal glands.
Answer: D. It is caused by an autoimmune destruction of the adrenal glands.
Rationale:

Addison's disease is primarily caused by the lack of production of adrenocorticotropic hormones
(cortisol and aldosterone) due to autoimmune destruction of the adrenal glands, leading to
insufficient hormone production.
26. A nurse is providing discharge teaching for a client who is postoperative following a simple
mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the
following instructions about maintaining skin integrity should the nurse include?
A. Apply heat to the area of irradiation.
B. Keep the area dry and clean.
C. Do not apply heat to the area of irradiation.
D. Use moisturizing lotion on the irradiated area before therapy.
Answer: C. Do not apply heat to the area of irradiation.
Rationale:
This instruction helps the client avoid tissue damage. Radiated tissue becomes thinner and may
lack tissue receptors, increasing the risk of burns. Additionally, protective clothing should be
worn when outdoors in sunlight.
27. A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the
following statements should the nurse include in the teaching?
A. A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer.
B. A CA 125 test is used as a definitive diagnostic tool for ovarian cancer.
C. A CA 125 test can predict the onset of ovarian cancer.
D. A CA 125 test is used to screen all women for ovarian cancer.
Answer: A. A CA 125 test is used to monitor a client's progress during treatment of ovarian
cancer.
Rationale:
CA 125 tests are useful for monitoring the progress of ovarian cancer during and after treatment,
although they are not definitive for diagnosis.
28. A nurse is teaching a client about the seven warning signs of cancer. Which of the following
signs should the nurse include as manifestations of cancer? (Select all that apply.)

A. A non-healing sore
B. Bloating
C. Change in bowel pattern
D. Change in moles
E. Nagging cough
Answer: A. A non-healing sore
C. Change in bowel pattern
D. Change in moles
E. Nagging cough
Rationale:
• A non-healing sore: Can be a sign of skin cancer or other malignancies.
• Change in bowel pattern: Changes can indicate colorectal cancer.
• Change in moles: Changes in moles can indicate skin cancer.
• Nagging cough: A persistent cough can be a sign of lung cancer.
• Bloating is not typically listed as a warning sign of cancer; however, it can be a symptom in
certain contexts, but it is not one of the classic warning signs.
29. A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV
fluid resuscitation therapy. The nurse should identify a decrease in which of the following
findings as an indication of adequate fluid replacement?
A. Blood pressure
B. Heart rate
C. Respiratory rate
D. Urine output
Answer: B. Heart rate
Rationale:
When a client's circulating fluid volume is low, the heart rate increases to maintain adequate
blood pressure. Therefore, a decrease in heart rate indicates adequate fluid replacement.
30. A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The
nurse should monitor the client for which of the following adverse effects?

A. Increased appetite
B. Bleeding from the gums
C. Elevated blood pressure
D. Weight gain
Answer: B. Bleeding from the gums
Rationale:
Bleeding from the gums is directly related to myelosuppression due to inhibited bone marrow
production of blood cells and platelets, increasing the risk of bleeding.
31. A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the
right forearm. Which of the following manifestations should the nurse include in the teaching as
a possible indication of venous insufficiency?
A. Warmth and swelling at the fistula site
B. Cold and numbness distal to the fistula site
C. Increased pulsation over the fistula
D. Redness and tenderness at the fistula site
Answer: B. Cold and numbness distal to the fistula site
Rationale:
Cold and numbness, along with pallor distal to the fistula site, are possible indicators of venous
insufficiency and should be immediately reported to the provider.
32. A nurse is planning an educational program about basal cell carcinoma. Which of the
following information should the nurse plan to include?
A. Basal cell carcinoma has a high incidence of metastasis.
B. Basal cell carcinoma often presents as a painful lesion.
C. Basal cell carcinoma has a low incidence of metastasis.
D. Basal cell carcinoma is more common in younger adults.
Answer: C. Basal cell carcinoma has a low incidence of metastasis.
Rationale:
Basal cell carcinoma is primarily a localized lesion that seldom metastasizes, making it less
aggressive compared to other forms of skin cancer.

33. A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130.
The nurse should begin the infusion at which of the following times?
A. At 1200
B. As soon as the nurse can prepare the client and the administration set
C. At 1145
D. Within 1 hour of receiving the unit
Answer: B. As soon as the nurse can prepare the client and the administration set
Rationale:
The nurse should infuse the blood as soon as possible and complete the procedure within 4
hours.
34. A nurse is teaching self-management to a client who has hepatitis B. Which of the following
instructions should the nurse include in the teaching?
A. Avoid all physical activity.
B. Rest frequently throughout the day.
C. Increase protein intake significantly.
D. Drink alcohol in moderation.
Answer: B. Rest frequently throughout the day.
Rationale:
Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The
nurse should recommend that the client rest frequently throughout the day to reduce the
metabolic demands upon the liver and decrease energy demands.
35. A nurse is caring for a client who has HIV. Which of the following laboratory values is the
nurse's priority?
A. CD4-T-cell count 180 cells/mm³
B. Viral load of 20,000 copies/mL
C. Hemoglobin level of 12 g/dL
D. Platelet count of 150,000 cells/mm³
Answer: A. CD4-T-cell count 180 cells/mm³

Rationale:
A CD4-T-cell count of less than 180 cells/mm³ indicates that the client is severely
immunocompromised and at high risk for infection. Therefore, this value is the priority for the
nurse to report to the provider.
36. A nurse is instructing a client how to decrease the nausea associated with chemotherapy and
radiation. Which of the following statements indicates an understanding of the teaching?
A. I will eat foods that are served hot.
B. I will eat foods that are served at room temperature.
C. I will drink beverages that are carbonated.
D. I will skip meals if I feel nauseated.
Answer: B. I will eat foods that are served at room temperature.
Rationale:
The nurse should instruct the client to eat foods served at room temperature or chilled, as foods
served hot may contribute to nausea.
37. A nurse is reviewing discharge instructions with a client following a right cataract extraction.
Which of the following instructions should the nurse include?
A. Avoid reading for at least 2 weeks.
B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
C. Use eye drops every hour for the first 24 hours.
D. Apply a hot compress to the eye daily.
Answer: B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Rationale:
The nurse should instruct the client to avoid activities that increase intraocular pressure, so
avoiding lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery is important.
38. A nurse is teaching about adverse effects of anastrozole with a client who has advanced
breast cancer and is postmenopausal. Which of the following adverse effects should the nurse
recommend the client report to the provider?
A. Fatigue

B. Musculoskeletal pain
C. Mild nausea
D. Hot flashes
Answer: B. Musculoskeletal pain
Rationale:
The client who is experiencing musculoskeletal pain should notify the provider, as it is a
common adverse effect affecting about 50% of clients and is possibly caused by estrogen
deprivation.
39. A nurse is reviewing the laboratory findings for a client who developed fat embolism
syndrome (FES) following a fracture. Which of the following laboratory findings should the
nurse expect?
A. Increased serum calcium level
B. Decreased serum calcium level
C. Elevated white blood cell count
D. Increased serum glucose level
Answer: B. Decreased serum calcium level
Rationale:
A decreased serum calcium level is an expected finding in fat embolism syndrome (FES),
although the reason for this finding is unknown.
40. A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her
prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments.
Which of the following prognoses should the nurse discuss with the client?
A. Excellent
B. Fair
C. Good
D. Poor
Answer: D. Poor
Rationale:

At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is the leading
cause of death from female reproductive cancers, and survival rates are low because it is often
not discovered until its late stages.
41. A nurse is providing teaching to a client who has had a total abdominal hysterectomy and
bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should
the nurse include in the teaching?
A. Avoid sexual intercourse for at least 6 months.
B. Artificial lubrication can be used to treat vaginal itching and dryness.
C. Regular pelvic examinations are still necessary.
D. Hormone replacement therapy is mandatory after surgery.
Answer: B. Artificial lubrication can be used to treat vaginal itching and dryness.
Rationale:
The nurse should instruct the client that atrophic vaginal changes occur due to the loss of
estrogen postoperatively, which can cause pain and dryness during sexual intercourse. Artificial
lubricants can help reduce these manifestations.
42. A nurse at a rehabilitation center is planning care for a client who had a left hemispheric
cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse
include in the client's rehabilitation program?
A. Improve balance and coordination.
B. Establish the ability to communicate effectively.
C. Increase independence in activities of daily living.
D. Develop strategies for memory improvement.
Answer: B. Establish the ability to communicate effectively.
Rationale:
A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain
tissue. The left hemisphere is usually dominant for language. Since this client had a left-side
CVA, the nurse should anticipate that the client will have some degree of aphasia and will require
speech therapy to establish communication.

43. A nurse is teaching a client about the causes of osteoporosis. The nurse should include which
of the following types of medication therapy as a risk factor for osteoporosis?
A. Long-term corticosteroids
B. Selective serotonin reuptake inhibitors (SSRIs)
C. Antihypertensives
D. Thyroid hormones
Answer: D. Thyroid hormones
Rationale:
Long-term use of synthetic thyroid hormone, such as levothyroxine, can accelerate bone loss,
making it a risk factor for osteoporosis.
44. A nurse is teaching a newly licensed nurse about gynecological examination. Which of the
following information should the nurse include in the teaching?
A. The clitoris is assessed by palpation.
B. The urethral orifice is assessed by separating the labia minora.
C. The vaginal walls are assessed with a speculum.
D. The cervix is visualized using a colposcope.
Answer: B. The urethral orifice is assessed by separating the labia minora.
Rationale:
The urethral orifice, clitoris, and vaginal orifice are examined for lesions, inflammation, and
discharge by separating the labia minora.
45. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the
following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
A. Tall, peaked T waves
B. Abnormally prominent U wave
C. Widened QRS complex
D. Shortened PR interval
Answer: B. Abnormally prominent U wave
Rationale:

Although U waves are rare, their presence can be associated with hypokalemia. For a client who
has hypokalemia, the nurse should monitor the EKG strip for flattened T waves, prolonged PR
intervals, prominent U waves, or ST depression.
46. A nurse is assessing a client who reports numbness and pain in his right palm, index finger,
and middle finger. The client reports working with a keyboard most of the time while at work.
The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse
request that the client perform?
A. Tinel's sign (tapping over the median nerve)
B. Phalen's test (holding the wrist at 90-degree flexion)
C. Grip strength test
D. Flexibility assessment of the wrist
Answer: B. Phalen's test (holding the wrist at 90-degree flexion)
Rationale:
Carpal tunnel syndrome is the compression of the median nerve at the wrist. Bending the wrist at
a 90-degree flexion will usually result in numbness, tingling, or weakness. Tapping over the
median nerve may also cause pain.
47. A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral
hepatitis. Which of the following information should the nurse include in the presentation?
A. Avoid foods prepared with tap water.
B. Consume only pasteurized dairy products.
C. Practice safe sex and use barrier methods.
D. Get vaccinated against hepatitis A and B.
Answer: A. Avoid foods prepared with tap water.
Rationale:
To decrease the risk for acquiring viral hepatitis, clients should prepare foods with purified water
to avoid contamination.
48. A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which
of the following statements by the client should indicate to the nurse a need for further teaching?

A. I feel pressure or heaviness in my pelvic area.
B. I notice a bulge in my vagina.
C. Feces can be present in the vagina.
D. I have urinary incontinence sometimes.
Answer: C. Feces can be present in the vagina.
Rationale:
The presence of feces in the vagina is a manifestation of a genital fistula, indicating a need for
further teaching about the symptoms of uterine prolapse.
49. A nurse is assessing a client who has had staples removed from an abdominal wound
postoperatively. The nurse notes separation of the wound edges with copious light-brown serous
drainage. Which of the following actions should the nurse perform first?
A. Notify the healthcare provider.
B. Cover the wound with a moist, sterile gauze dressing.
C. Assess the client's vital signs.
D. Document the findings in the client's record.
Answer: B. Cover the wound with a moist, sterile gauze dressing.
Rationale:
The client's wound has dehisced, or opened along the suture line, and is now draining. The
priority action is to keep the wound clean and moist, which is accomplished by covering it with a
moist, sterile, saline-soaked gauze dressing.
50. A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse
should document this drainage as which of the following?
A. Serous
B. Sanguineous
C. Serosanguineous
D. Purulent
Answer: C. Serosanguineous
Rationale:

Watery red drainage should be documented as serosanguineous, indicating a mix of serum and
blood.
51. A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy.
The client reports that he has not had the procedure before and is very anxious about feeling pain
during the procedure. Which of the following responses by the nurse is appropriate?
A. You won't feel anything during the procedure.
B. Before the examination, your provider will give you a sedative that will make you sleepy.
C. It's normal to feel some discomfort.
D. The procedure only takes a few minutes, so it will be over quickly.
Answer: B. Before the examination, your provider will give you a sedative that will make you
sleepy.
Rationale:
This response addresses the client's concerns by providing accurate information about the
sedation used during the procedure, which can alleviate anxiety.
52. A nurse is teaching a client about preventing osteoporosis. Which of the following statements
by the client indicates a need for further teaching?
A. I will increase my intake of calcium.
B. I will reduce my intake of vitamin K-rich foods.
C. I will engage in weight-bearing exercises.
D. I will avoid smoking.
Answer: B. I will reduce my intake of vitamin K-rich foods.
Rationale:
Vitamin K is necessary for bone health, and the client should be encouraged to increase their
intake of vitamin K-rich foods, such as green leafy vegetables.
53. A nurse is selecting a qualified staff member to double check a blood label with a client ID
bracelet prior to infusing a unit of blood. The nurse should identify that which of the following
persons is qualified?
A. Nursing assistant

B. Oncology nurse
C. Licensed practical nurse
D. Unlicensed personnel
Answer: B. Oncology nurse
Rationale:
The nurse should ask another qualified nurse or a provider to double check the blood label and
client ID prior to an infusion to ensure safety.
54. A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI)
scan. The client asks the nurse what to expect during the procedure. Which of the following
statements should the nurse make?
A. You will be required to hold your breath during the scan.
B. An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner.
C. The scan will take place in a dark room to help you relax.
D. You will not be able to move at all during the procedure.
Answer: B. An MRI scan is very noisy, and you will be allowed to wear earplugs while in the
scanner.
Rationale:
This information prepares the client for the experience, as many clients find the noise
disconcerting, and earplugs can help reduce discomfort.
55. A nurse is planning care for a client who has end-stage cirrhosis of the liver with
encephalopathy. Which of the following interventions should the nurse plan to implement to
decrease the client's ammonia level?
A. Increase the client's intake of protein.
B. Reduce the client's intake of protein.
C. Administer lactulose as prescribed.
D. Monitor the client's fluid intake.
Answer: B. Reduce the client's intake of protein.
Rationale:

Ammonia is formed by bacteria acting on protein in the gastrointestinal tract. Limiting dietary
protein can help decrease ammonia levels, while still considering the client's nutritional needs for
healing.
56. A nurse is caring for a client who is unconscious and has a breathing pattern characterized by
alternating periods of hyperventilation and apnea. The nurse should document that the client has
which of the following respiratory alterations?
A. Biot's respirations
B. Kussmaul's respirations
C. Cheyne-Stokes respirations
D. Apneustic respirations
Answer: C. Cheyne-Stokes respirations
Rationale:
Cheyne-Stokes respirations are characterized by a rhythmic pattern of increased and decreased
respiratory effort, alternating with periods of apnea. This pattern is often seen in clients who are
unconscious or comatose.
57. A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of
the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side
effect would be:
A. Nausea
B. Dysphagia
C. Alopecia
D. Skin rash
Answer: B. Dysphagia
Rationale:
Dysphagia (difficulty swallowing) is a common side effect of radiation therapy to the neck,
affecting the larynx. Other possible side effects can include hoarseness and dry mouth.
58. A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and
has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse

notes that there is no bubbling in the suction control chamber. Which of the following actions
should the nurse take?
A. Reposition the client.
B. Verify that the suction regulator is on and check the tubing for leaks.
C. Document the finding and continue monitoring.
D. Increase the suction pressure.
Answer: B. Verify that the suction regulator is on and check the tubing for leaks.
Rationale:
Lack of bubbling may indicate that the suction is turned off or that there is a leak in the system,
so it's important to verify these factors.
59. A nurse is caring for a client who has a severe gangrenous infection of the right lower
extremity. The nurse should plan preoperative teaching based on the possibility of which of the
following amputation procedures?
A. Above-the-knee amputation
B. Below-the-knee amputation
C. Partial foot amputation
D. No amputation is necessary
Answer: A. Above-the-knee amputation (implied).
Rationale:
Given the severity of the infection, an above-the-knee amputation may be necessary to ensure
complete removal of affected tissue.
60. A female middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene.
The nurse should recognize that the client is at an increased risk for which of the following
situations?
A. Developing breast cancer
B. Developing ovarian cancer
C. Developing both breast and ovarian cancer
D. Developing uterine cancer
Answer: C. Developing both breast and ovarian cancer

Rationale:
The BRCA1 gene mutation is associated with a significantly increased risk for both breast and
ovarian cancers in women.
61. A nurse is planning a teaching session about hysterosalpingography for a client who has a
diagnosis of infertility. The nurse should include which of the following information in the
teaching plan?
A. The client might experience shoulder pain following the procedure.
B. The procedure requires general anesthesia.
C. The client will need to stay overnight in the hospital.
D. There is no need for any pre-procedure preparation.
Answer: A. The client might experience shoulder pain following the procedure.
Rationale:
Shoulder pain can occur due to phrenic nerve irritation caused by the contrast media used in
hysterosalpingography.
62. A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse
about menopausal hormone therapy (HT). The nurse should inform the client that HT is not
recommended due to which of the following findings in the client's medical history?
A. History of hypertension
B. History of diabetes
C. History of breast cancer
D. History of osteoporosis
Answer: C. History of breast cancer
Rationale:
Women with a history of breast cancer should be counseled against using hormone therapy due
to increased risk.
63. A nurse is planning care for a client who has immunosuppression following chemotherapy.
Which of the following interventions should the nurse include in the plan of care?
A. Encourage visitors at any time.

B. Limit the number of health care workers entering the client's room.
C. Use a regular cleaning schedule for the room.
D. Allow the client to share personal items with roommates.
Answer: B. Limit the number of health care workers entering the client's room.
Rationale:
Limiting the number of healthcare workers reduces the risk of exposing the immunosuppressed
client to potential infections.
64. A nurse is preparing a client who has AIDS for discharge. Which of the following statements
should the nurse include in the discharge instructions?
A. Avoid all physical contact with others.
B. Prevent the spread of infection with good household cleaning practices.
C. There is no need for special precautions at home.
D. The client does not need to inform family members about their condition.
Answer: B. Prevent the spread of infection with good household cleaning practices.
Rationale:
The client should follow standard precautions, including using a 1:10 solution of bleach to
disinfect areas that come into contact with blood and body fluids.
65. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse
identify as being at risk for fluid volume deficit?
A. The client who is receiving IV fluids.
B. The client who has gastroenteritis and is febrile.
C. The client who has been diagnosed with hypertension.
D. The client who has a recent history of heart failure.
Answer: B. The client who has gastroenteritis and is febrile.
Rationale:
This client has two risk factors for fluid volume deficit: gastroenteritis, which can cause diarrhea
and vomiting, and fever, which can lead to fluid loss through diaphoresis.

66. A nurse is caring for a client with a tracheostomy. The client's partner has been taught to
perform suctioning. Which of the following actions by the partner should indicate to the nurse a
readiness for the client's discharge?
A. Asking the nurse for assistance.
B. Performing the procedure independently.
C. Demonstrating the procedure with guidance.
D. Showing concern about the procedure.
Answer: B. Performing the procedure independently.
Rationale:
The partner is ready for discharge when they can demonstrate the ability to perform the
suctioning procedure independently, indicating confidence and competence.
67. A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several
treatments, the client reports fatigue. Which of the following actions should the nurse take?
A. Encourage the client to increase physical activity.
B. Check the results of the client's most recent CBC.
C. Suggest dietary changes to increase energy levels.
D. Administer a vitamin supplement.
Answer: B. Check the results of the client's most recent CBC.
Rationale:
Fatigue may indicate anemia due to myelosuppression from chemotherapy, so checking the CBC
can help assess the need for treatment or changes to the chemotherapy regimen.
68. A nurse is teaching a client who has septic shock about the development of disseminated
intravascular coagulation (DIC). Which of the following statements should the nurse make?
A. DIC is caused by abnormal coagulation involving fibrinogen.
B. DIC results in excessive clotting without bleeding.
C. DIC is a reversible condition in all cases.
D. DIC is primarily caused by bacterial infections.
Answer: A. DIC is caused by abnormal coagulation involving fibrinogen.
Rationale:

DIC involves the formation of small clots that consume clotting factors and fibrinogen, leading
to a paradoxical increase in bleeding risk.
69. A nurse is caring for a client who is HIV positive and is one day postoperative following an
appendectomy. The nurse should wear a gown as personal protective equipment when taking
which of the following actions?
A. Administering oral medication.
B. Taking vital signs.
C. Completing a dressing change.
D. Assisting the client to the bathroom.
Answer: C. Completing a dressing change.
Rationale:
Standard precautions require wearing personal protective equipment, such as gowns, when there
is a risk of exposure to body fluids, which is present during a dressing change.
70. A nurse in a clinic is teaching information about cervical polyps to a client who has a new
diagnosis. Which of the following information should the nurse include in the teaching?
A. They are always cancerous.
B. Postcoital bleeding may occur.
C. They require surgical removal in all cases.
D. They are painless and do not cause symptoms.
Answer: B. Postcoital bleeding may occur.
Rationale:
Cervical polyps are soft and fragile, which can lead to bleeding after sexual intercourse.
71. A nurse is planning a presentation about HIV for a church-based group. Which of the
following information about HIV transmission should the nurse include?
A. It is primarily transmitted through contaminated food.
B. It can be spread by casual contact.
C. It is primarily transmitted through direct contact with infected body fluids.
D. It is only transmitted through sexual intercourse.

Answer: C. It is primarily transmitted through direct contact with infected body fluids.
Rationale:
HIV is transmitted through direct contact with infected blood, seminal fluid, vaginal secretions,
amniotic fluid, breast milk, and other body fluids.
72. A nurse is preparing a client for radiation treatment who is postoperative following a
mastectomy. The nurse should inform the client to expect which of the following adverse effects
from the treatment?
A. Nausea
B. Hair loss
C. Fatigue
D. Skin rash
Answer: C. Fatigue
Rationale:
Fatigue is a common adverse effect of radiation treatment, regardless of the target site.
73. A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3
vertebrae. When planning care, the nurse should anticipate which of the following types of
disability?
A. Quadriplegia
B. Hemiplegia
C. Paraplegia
D. Monoplegia
Answer: C. Paraplegia
Rationale:
Paraplegia occurs with spinal cord injuries below T1, leading to paralysis of both legs.
74. A nurse is caring for a client who recently had surgery for the insertion of a permanent
pacemaker. Which of the following prescriptions should the nurse clarify?
A. Chest X-ray
B. MRI of the chest

C. ECG monitoring
D. Routine blood tests
Answer: B. MRI of the chest
Rationale:
An MRI is contraindicated for clients with a permanent pacemaker due to the risk of
electromagnetic interference, which can cause the pacemaker to malfunction.
75. A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus
(SLE). Which of the following values should give the nurse the best indication of the client's
renal function?
A. Blood urea nitrogen (BUN)
B. Serum creatinine
C. Urinalysis
D. Electrolyte panel
Answer: B. Serum creatinine
Rationale:
Serum creatinine is a specific and sensitive indicator of renal function, as kidney dysfunction
reduces the excretion of creatinine, leading to increased levels.
76. A nurse is teaching a client about risk factors for osteoarthritis. Which of the following
factors should the nurse include in the teaching? (Select all that apply.)
A. Bacteria
B. Diuretics
C. Aging
D. Obesity
E. Smoking
Answer: C. Aging
D. Obesity
E. Smoking
Rationale:
• Aging is a risk factor because joints bear weight over time.

• Obesity increases stress on weight-bearing joints, contributing to osteoarthritis.
• Smoking is linked to cartilage loss, increasing the risk of osteoarthritis.
• Bacteria and diuretics are not risk factors for osteoarthritis.
77. A nurse is admitting a client who has acute pancreatitis. Which of the following provider
prescriptions should the nurse anticipate?
A. Pantoprazole 80 mg IV bolus twice daily
B. Morphine sulfate for pain management
C. Metoclopramide for nausea
D. Dextrose IV for nutrition
Answer: A. Pantoprazole 80 mg IV bolus twice daily
Rationale:
A proton pump inhibitor like pantoprazole decreases gastric acid production, which can help
reduce pancreatic secretions.
78. A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of
the prostate (TURP) gland. Which of the following assessments should the nurse view to be an
indication of a postoperative complication?
A. Output of burgundy colored urine
B. Output of clear yellow urine
C. Mild bladder discomfort
D. Urinary output of 30 mL/hr
Answer: A. Output of burgundy colored urine
Rationale:
Burgundy urine may indicate venous bleeding, which is a potential complication after TURP.
This should be reported to the provider for further action.
79. A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease.
Which of the following sets of values should the nurse expect?
A. pH 7.35, HCO3 20 mEq/L, PaCO2 40 mm Hg
B. pH 7.25, HCO3 19 mEq/L, PaCO2 30 mm Hg

C. pH 7.40, HCO3 24 mEq/L, PaCO2 35 mm Hg
D. pH 7.50, HCO3 30 mEq/L, PaCO2 25 mm Hg
Answer: B. pH 7.25, HCO3 19 mEq/L, PaCO2 30 mm Hg
Rationale:
These values indicate metabolic acidosis, which is expected in clients with renal failure,
characterized by low HCO3 and low pH.
80. A nurse is caring for a client who was admitted with bleeding esophageal varices and has an
esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding.
Which of the following actions should the nurse take?
A. Provide frequent oral and nares care
B. Assess the balloon's inflation pressure every hour
C. Administer IV fluids as prescribed
D. Monitor the client's vital signs every 4 hours
Answer: A. Provide frequent oral and nares care
Rationale:
Clients with a Sengstaken-Blakemore tube cannot swallow; therefore, oral and nares care is
important to maintain hygiene and comfort.
81. A nurse is providing teaching to a client who is postoperative following coronary artery
bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside
from managing pain, which of the following desired effects of medications should the nurse
identify as most important for the client's recovery?
A. It facilitates the client's deep breathing.
B. It improves the client's mobility.
C. It enhances the client's appetite.
D. It reduces anxiety levels.
Answer: A. It facilitates the client's deep breathing.
Rationale:
Opioids can impact respiratory function, so facilitating deep breathing is crucial to prevent
complications like atelectasis.

82. A nurse is presenting a community-based program about HIV and AIDS. A client asks the
nurse to describe the initial symptoms experienced with HIV infection. Which of the following
manifestations should the nurse include in the explanation of initial symptoms?
A. Rash and fever.
B. Flu-like symptoms and night sweats.
C. Severe weight loss.
D. Persistent cough.
Answer: B. Flu-like symptoms and night sweats.
Rationale:
The initial symptoms of HIV infection often resemble flu-like symptoms, including fever,
fatigue, and night sweats.
83. A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia.
Which of the following actions should the nurse take?
A. Administer oxygen therapy.
B. Obtain a sputum culture.
C. Start broad-spectrum antibiotics.
D. Encourage increased fluid intake.
Answer: B. Obtain a sputum culture.
Rationale:
Obtaining a sputum culture helps identify the specific organism causing pneumonia and guides
antibiotic therapy.
84. A nurse is caring for a client who reports a new onset of severe chest pain. Which of the
following actions should the nurse take to determine if the client is experiencing a myocardial
infarction?
A. Administer aspirin.
B. Perform a 12-lead ECG.
C. Assess vital signs.
D. Obtain a detailed health history.

Answer: B. Perform a 12-lead ECG.
Rationale:
A 12-lead ECG is essential for diagnosing a myocardial infarction and determining the
appropriate interventions.
85. A nurse is caring for a client who has advanced lung cancer. The client's provider has
recommended hospice services for the client. Which of the following statements by the client
indicates a correct understanding of hospice care?
A. I will only receive pain medication.
B. I should expect the hospice team to help me manage my dyspnea.
C. Hospice is for clients who are not receiving any treatment.
D. My family will not be involved in my care.
Answer: B. I should expect the hospice team to help me manage my dyspnea.
Rationale:
Hospice care focuses on providing symptom relief, including managing dyspnea, for clients with
terminal illnesses.
86. A nurse is establishing health promotion goals for a female client who smokes cigarettes, has
hypertension, and has a BMI of 26. Which of the following goals should the nurse include?
A. The client will walk for 30 min 5 days a week.
B. The client will stop smoking within one month.
C. The client will reduce her BMI to 24.
D. The client will attend a nutrition class.
Answer: A. The client will walk for 30 min 5 days a week.
Rationale:
The CDC recommends engaging in moderate exercise, such as walking, for a total of 150
minutes each week, which aligns with this goal.
87. A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is
unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
A. Administer oxygen.

B. Start chest compressions.
C. Defibrillation.
D. Call for help.
Answer: C. Defibrillation.
Rationale:
The highest priority is defibrillation, as the greatest risk to the client is death from lack of cardiac
output due to ventricular fibrillation. Defibrillation is critical to restore a sustainable rhythm.
88. A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which
of the following findings should the nurse expect?
A. Decreased urine output.
B. Elevated central venous pressure (CVP).
C. Increased heart rate.
D. Peripheral edema.
Answer: B. Elevated central venous pressure (CVP).
Rationale:
CVP measures the pressure in the right atrium or ventricle at the end of diastole, and it is
elevated in right-sided heart failure due to increased volume and pressure.
89. A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider
suspects has metabolic acidosis. Which of the following results should the nurse expect to see?
A. pH below 7.35.
B. pH above 7.45.
C. PaCO2 above 45 mmHg.
D. HCO3 above 28 mEq/L.
Answer: A. pH below 7.35.
Rationale:
In metabolic acidosis, the pH is typically below 7.35. This indicates acidosis, though further tests
are needed to distinguish between metabolic and respiratory causes.

90. A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which
of the following findings should the nurse include as adverse effects of this medication?
A. Bradycardia.
B. Hypertension.
C. Weight gain.
D. Tachycardia.
Answer: A. Bradycardia.
Rationale:
Atenolol is a beta-blocker that slows the heart rate, and the nurse should instruct the client to
monitor for bradycardia and report any significant changes.
91. While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse
notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of
the following actions should the nurse take first?
A. Apply a warm compress.
B. Discontinue the existing IV line.
C. Change the IV site to the right arm.
D. Notify the healthcare provider.
Answer: B. Discontinue the existing IV line.
Rationale:
The greatest risk to the client is injury from the IV infiltration damaging surrounding tissues.
Therefore, the first action should be to discontinue the IV line.
92. A nurse in an emergency department is caring for a client who reports substernal chest pain
and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests
are used to diagnose a myocardial infarction? (Select all that apply.)
A. Troponin I
B. Troponin T
C. Plasma low-density lipoproteins
D. CPK
E. Myoglobin

Answer: A. Troponin I
B. Troponin T
D. CPK
E. Myoglobin
Rationale:
Troponin I and T are specific markers for myocardial injury. CPK (creatine phosphokinase) is
also used, along with myoglobin, to help diagnose myocardial infarction. Plasma low-density
lipoproteins are not used for this purpose.
93. A nurse is caring for a client who has a chest tube connected to a closed drainage system and
needs to be transported to the x-ray department. Which of the following actions should the nurse
take?
A. Keep the drainage system above the level of the client's chest.
B. Keep the drainage system below the level of the client's chest at all times.
C. Disconnect the chest tube during transport.
D. Clamp the chest tube before transport.
Answer: B. Keep the drainage system below the level of the client's chest at all times.
Rationale:
The drainage system should be kept below the level of the client's chest to prevent air and fluid
from re-entering the thoracic cavity during transport.
94. A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the
following actions should the nurse take after noticing a rise in the water seal chamber with client
inspiration?
A. Notify the healthcare provider.
B. Continue to monitor the client.
C. Increase the suction.
D. Check for kinks in the tubing.
Answer: B. Continue to monitor the client.
Rationale:

The rise in the water seal chamber during inspiration is known as tidaling and is a normal
finding, indicating that the chest tube is functioning properly.
95. A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse
should document this drainage as which of the following?
A. Serous
B. Sanguineous
C. Serosanguineous
D. Purulent
Answer: C. Serosanguineous.
Rationale:
Serosanguineous drainage is a combination of serum (clear fluid) and blood, appearing watery
and red.
96. A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and
low-cholesterol diet. Which of the following food choices by the client indicates the need for
further teaching?
A. A slice of cheese
B. A piece of fruit
C. Raw vegetables with hummus
D. Air-popped popcorn
Answer: A. A slice of cheese.
Rationale:
Cheese is typically high in fat and sodium, so it should be limited on a low-fat, low-sodium, and
low-cholesterol diet.
97. A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates
cardiac monitoring. Which of the following findings should the nurse expect during the initial
assessment?
A. Increased muscle strength
B. Lethargy

C. Bradycardia
D. Hypotension
Answer: B. Lethargy.
Rationale:
A serum calcium level of 12.3 mg/dL indicates hypercalcemia, which can lead to symptoms such
as lethargy, generalized weakness, and confusion.
98. A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia.
Which of the following actions should the nurse plan to take?
A. Check the client's vital signs every hour during the transfusion.
B. Verify the blood type and crossmatch with another nurse.
C. Start the transfusion at a rapid rate.
D. Administer a diuretic before starting the transfusion.
Answer: B. Verify the blood type and crossmatch with another nurse.
Rationale:
The nurse should check vital signs every 15 minutes at the start of the transfusion and verify
blood compatibility to prevent transfusion reactions.
99. A nurse is planning to teach a client about a low-potassium diet. Which of the following
foods should the nurse instruct the client to avoid? (Select all that apply.)
A. Butter
B. Poultry
C. Yogurt
D. Frozen vegetables
E. Orange juice
Answer: C. Yogurt
E. Orange juice
Rationale:
Both yogurt and orange juice are high in potassium and should be limited in a low-potassium
diet. Butter and poultry are not significant sources of potassium, and frozen vegetables can vary
in potassium content depending on the type.

100. A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse
should identify an elevation in which of the following laboratory values as an indication that the
client has developed an infection?
A. Hemoglobin level
B. Platelet count
C. WBC count
D. Serum albumin level
Answer: C. WBC count.
Rationale:
An elevation in the WBC count (leukocytosis) indicates that the client’s immune system is
responding to an infection.
101. A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the
emergency response team will administer which of the following medications if the client's
restored rhythm is symptomatic bradycardia?
A. Atropine
B. Epinephrine
C. Magnesium
D. Sodium bicarbonate
Answer: A. Atropine
Rationale:
Atropine is administered during CPR for clients with symptomatic bradycardia who are
hemodynamically unstable.
Epinephrine
The team administers epinephrine during cardiopulmonary resuscitation (CPR) to clients who
have asystole or pulseless electrical activity.
Magnesium
The team administers magnesium during CPR for clients who have torsade de pointes, which is a
specific type of ventricular tachycardia.
Sodium bicarbonate

The team administers sodium bicarbonate to correct metabolic acidosis that does not improve
with CPR.
102. A nurse is developing a plan of care for a client who is postoperative. Which of the
following interventions should the nurse include in the plan to prevent pulmonary complications?
A. Encourage the use of an incentive spirometer.
B. Administer opioid pain medication.
C. Restrict fluid intake.
D. Position the client flat in bed.
Answer: A. Encourage the use of an incentive spirometer.
Rationale:
Using an incentive spirometer helps expand the lungs and promotes gas exchange, which can
help prevent pulmonary complications after surgery.
103. A nurse is planning care for a client who is being treated with chemotherapy and radiation
for metastatic breast cancer, and who has neutropenia. The nurse should include which of the
following restrictions in the client's plan of care?
A. Fresh flowers and potted plants in the room
B. Fresh fruit and vegetables in the diet
C. Wearing a mask when out of bed
D. Visitors from family members
Answer: A. Fresh flowers and potted plants in the room
Rationale:
Immunocompromised clients, such as those with neutropenia, are at a higher risk of infection
from microorganisms found on fresh flowers and potted plants. To reduce infection risk, these
should not be allowed in their environment.
104. A nurse is caring for a client who has heart failure and a new prescription for furosemide.
For which of the following adverse effects should the nurse monitor?
A. Hyponatremia
B. Hyperkalemia

C. Hypokalemia
D. Hypernatremia
Answer: C. Hypokalemia
Rationale:
Furosemide is a loop diuretic that can lead to the loss of potassium through increased urination,
causing hypokalemia. It is crucial to monitor potassium levels, as hypokalemia can lead to
cardiac arrhythmias and other complications.
105. A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained
2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse
monitor the client for?
A. Increased sodium level
B. Increased calcium level
C. Decreased potassium level
D. Decreased magnesium level
Answer: C. Decreased potassium level
Rationale:
Prolonged nasogastric suctioning can lead to a loss of potassium, resulting in hypokalemia
(serum potassium level less than 3.5 mEq/L). Hypokalemia can occur due to vomiting, diarrhea,
and NG drainage, making it critical for the nurse to monitor the client's potassium levels.
106. A nurse is caring for a client who has hypertension and develops epistaxis. Which of the
following actions should the nurse take? (Select all that apply.)
A. Apply pressure to the nares
B. Place ice to the bridge of the client's nose
C. Instruct the client to blow his nose
D. Tilt the client's head backward
E. Move the client into high-Fowler's position
Answer: A. Apply pressure to the nares
B. Place ice to the bridge of the client's nose
E. Move the client into high-Fowler's position

Rationale:
• Apply pressure to the nares: Applying direct pressure helps clot the blood and should be done
for several minutes until coagulation occurs.
• Place ice to the bridge of the client's nose: Ice causes vasoconstriction, which can help stop the
bleeding.
• Move the client into high-Fowler's position: Sitting upright facilitates breathing and reduces the
risk of aspiration or swallowing blood.
Incorrect Actions:
• Instruct the client to blow his nose: Blowing the nose can dislodge clots and is discouraged for
at least 24 hours.
• Tilt the client's head backward: This increases the risk of aspiration and swallowing blood, so
the client should be tilted forward instead.
107. A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr
ago. The nurse should expect which of the following laboratory values to be elevated?
A. Creatine kinase (CK)
B. Myoglobin
C. Troponin I
D. Lactate dehydrogenase (LDH)
Answer: C. Troponin I
Rationale:
Troponin I is a cardiac-specific marker that begins to elevate within 2 to 3 hours after a
myocardial infarction (MI). It is highly specific to heart injury and remains elevated for a longer
duration, making it a reliable indicator of myocardial damage.
108. A nurse is performing an ECG on a client who is experiencing chest pain. Which of the
following statements should the nurse make?
A. "You will need to lie completely still during the procedure."
B. "This test involves a mild electrical shock to the heart."
C. "I will need to apply electrodes to your chest and extremities."
D. "You may feel some discomfort during the procedure."

Answer: C. "I will need to apply electrodes to your chest and extremities."
Rationale:
The nurse should explain to the client that small electrodes will be placed on the chest and
extremities to record the electrical activity of the heart during the ECG. This is a non-invasive
procedure, and the electrodes transmit the heart’s electrical signals without causing discomfort or
electrical shock.
109. A nurse is preparing to administer potassium chloride (KCl) to a client who is receiving
diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the
client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
A. Withhold the KCl and notify the provider
B. Give the ordered KCl as prescribed
C. Encourage the client to increase dietary potassium intake instead
D. Administer half of the prescribed KCl dose
Answer: B. Give the ordered KCl as prescribed
Rationale:
The client’s potassium level of 3.2 mEq/L is below the normal reference range (3.5-5.0 mEq/L),
indicating hypokalemia. Administering potassium chloride as prescribed is necessary to correct
the imbalance and prevent complications such as cardiac arrhythmias.
110. A nurse is completing discharge teaching with a client following arthroscopic knee surgery.
Which of the following instructions should the nurse include in the teaching?
A. Elevate the leg for 48 hours
B. Apply ice to the affected area
C. Begin weight-bearing exercises immediately
D. Apply heat to the surgical site for pain relief
Answer: B. Apply ice to the affected area
Rationale:
Ice application helps reduce pain and swelling in the immediate postoperative period, especially
in the first 24 hours following arthroscopic knee surgery. The client should also avoid heat
initially, as it can increase inflammation.

111. A nurse is caring for a client who has pericarditis and reports feeling a new onset of
palpitations and shortness of breath. Which of the following assessments should indicate to the
nurse that the client may have developed atrial fibrillation?
A. Bradycardia
B. Elevated blood pressure
C. Different apical and radial pulses
D. S3 heart sound
Answer: C. Different apical and radial pulses
Rationale:
A pulse deficit, where the apical pulse is faster than the radial pulse, is a key indication of atrial
fibrillation. Atrial fibrillation causes disorganized electrical activity, leading to irregular
ventricular contractions and pulse deficits.
112. A nurse is planning to perform nasotracheal suction for a client who has COPD and an
artificial airway. Which of the following actions should the nurse take?
A. Limit suctioning to 15 seconds
B. Preoxygenate the client with 100% oxygen for up to 3 min
C. Lubricate the suction catheter with petroleum jelly
D. Apply continuous suction while inserting the catheter
Answer: B. Preoxygenate the client with 100% oxygen for up to 3 min
Rationale:
To prevent hypoxemia during nasotracheal suctioning, the nurse should preoxygenate the client
with 100% oxygen for 30 seconds to 3 minutes before suctioning. This helps maintain oxygen
saturation levels during the procedure.
113. A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse
should monitor the client for which of the following findings that is consistent with this
diagnosis?
A. Bradycardia
B. Hypotension

C. Vertigo
D. Increased urine output
Answer: C. Vertigo
Rationale:
Vertigo, along with other symptoms such as headache, facial flushing, and fainting, can be
consistent with a new diagnosis of essential hypertension. These symptoms may occur due to the
increased pressure in the blood vessels affecting cerebral circulation.
114. A nurse in an urgent care center is caring for a client who is having an acute asthma
exacerbation. Which of the following actions is the nurse's highest priority?
A. Administering a nebulized beta-adrenergic
B. Instructing the client on deep-breathing exercises
C. Placing the client in a high-Fowler's position
D. Obtaining a sputum sample
Answer: A. Administering a nebulized beta-adrenergic
Rationale:
The greatest risk to a client with acute asthma exacerbation is airway obstruction. Betaadrenergic medications (such as albuterol) act as bronchodilators, providing prompt relief of
airflow obstruction by relaxing the bronchiolar smooth muscle. This is the highest priority to
ensure the client’s airway is open and breathing is improved.
115. The nurse is caring for a client who has heart failure and a history of asthma. The nurse
reviews the provider's orders and recognizes that clarification is needed for which of the
following medications?
A. Lisinopril
B. Furosemide
C. Carvedilol
D. Spironolactone
Answer: C. Carvedilol
Rationale:

Carvedilol is a beta-blocker that blocks both beta-1 and beta-2 receptors. Beta-2 blockade can
cause bronchoconstriction, which is contraindicated in clients with asthma. The nurse should
request clarification from the provider, as this medication could exacerbate the client's asthma
symptoms.
116. A nurse is caring for a client who the provider suspects might have pernicious anemia. The
nurse should expect the provider to prescribe which of the following diagnostic tests?
A. Complete blood count (CBC)
B. Schilling test
C. Bone marrow biopsy
D. Serum ferritin test
Answer: B. Schilling test
Rationale:
The Schilling test is used to determine whether the body is properly absorbing vitamin B12,
which can help diagnose pernicious anemia. Pernicious anemia occurs when the body cannot
absorb enough vitamin B12 due to a lack of intrinsic factor in the stomach.
117. A nurse is teaching a client who has been taking prednisone to treat asthma and has a new
prescription to discontinue the medication. The nurse should explain to the client to reduce the
dose gradually to prevent which of the following adverse effects?
A. Hyperglycemia
B. Adrenocortical insufficiency
C. Hypokalemia
D. Bradycardia
Answer: B. Adrenocortical insufficiency
Rationale:
Long-term use of prednisone can suppress the adrenal glands' production of cortisol. Abruptly
stopping the medication can result in adrenocortical insufficiency, a potentially life-threatening
condition. Gradually tapering the dose allows the adrenal glands to resume normal cortisol
production.

118. A nurse is providing teaching for a client who has hypertension and a prescription change
from metoprolol to metoprolol/hydrochlorothiazide. Which of the following statements by the
client indicates an understanding of the teaching?
A. I will need to monitor my potassium levels regularly.
B. With the new medication, I should experience fewer side effects.
C. I will not need to monitor my blood pressure as often.
D. This medication will cure my hypertension.
Answer: B. With the new medication, I should experience fewer side effects.
Rationale:
Combining metoprolol with hydrochlorothiazide (HCTZ) allows for a lower dose of the betablocker, which can reduce side effects such as fatigue and dizziness. The combination also helps
in controlling hypertension more effectively.
119. A nurse is teaching a client who has a new prescription for hydrochlorothiazide for the
management of hypertension. Which of the following instructions should the nurse include?
A. Take the medication at night.
B. Avoid potassium-rich foods.
C. Monitor for leg cramps.
D. Decrease fluid intake.
Answer: C. Monitor for leg cramps.
Rationale:
Hydrochlorothiazide is a diuretic that can cause hypokalemia (low potassium levels), which can
result in leg cramps, muscle weakness, and fatigue. The client should be instructed to monitor for
these symptoms.
120. A nurse is providing teaching to a client who has hypertension and a new prescription for
hydrochlorothiazide. Which of the following instructions should the nurse provide?
A. Take the medication at bedtime.
B. Take the medication with food.
C. Take the medication early in the day.
D. Take the medication on an empty stomach.

Answer: C. Take the medication early in the day.
Rationale:
Hydrochlorothiazide is a diuretic, which increases urine output. To prevent nocturia (frequent
urination at night), the nurse should instruct the client to take the medication early in the day.
121. A nurse in a provider's office is reviewing the laboratory results of a client who takes
furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The
nurse should monitor the client for which of the following complications?
A. Hypertension
B. Cardiac dysrhythmias
C. Hyperglycemia
D. Muscle spasms
Answer: B. Cardiac dysrhythmias
Rationale:
The client’s potassium level is below the expected reference range (3.5-5.0 mEq/L).
Hypokalemia, such as the level of 3.3 mEq/L, can lead to cardiac dysrhythmias, which include
flattened T waves, prominent U waves, and S-T segment depression.
122. A nurse is providing teaching about a heart-healthy diet to a group of clients with
hypertension. Which of the following statements by one of the clients indicates a need for further
teaching?
A. I will choose foods with low sodium.
B. I may eat 10 ounces of lean protein each day.
C. I will include more fruits and vegetables in my diet.
D. I will limit my intake of processed foods.
Answer: B. I may eat 10 ounces of lean protein each day.
Rationale:
Clients with hypertension should limit their intake of lean meat to 5-6 ounces per day to reduce
the risk of cardiovascular complications. The statement about consuming 10 ounces of lean
protein daily indicates a need for further teaching.

123. A nurse on a medical-surgical unit is performing an admission assessment of a client who
has COPD with emphysema. The client reports that he has a frequent productive cough and is
short of breath. The nurse should anticipate which of the following assessment findings for this
client?
A. Increased anteroposterior diameter of the chest
B. Decreased respiratory rate
C. Clubbing of the fingers
D. Shallow respirations
Answer: A. Increased anteroposterior diameter of the chest
Rationale:
In clients with COPD and emphysema, chronic hyperinflation of the lungs leads to a barrel chest
(increased anteroposterior diameter).
124. A nurse is evaluating teaching on a client who has a new prescription for montelukast to
treat asthma. Which of the following statements by the client indicates an understanding of the
teaching?
A. I'll take this medication twice a day, once in the morning and once at night.
B. I'll take this medication as soon as I start having an asthma attack.
C. I'll take this medication once a day in the evening.
D. I'll take this medication only when my symptoms get worse.
Answer: C. I'll take this medication once a day in the evening.
Rationale:
Montelukast, a leukotriene modifier, is used for the long-term prevention of asthma symptoms
and should be taken once daily in the evening.
125. A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should
monitor the client for which of the following adverse effects?
A. Tremors
B. Oral candidiasis
C. Tachycardia
D. Dry mouth

Answer: B. Oral candidiasis
Rationale:
Fluticasone is an inhaled corticosteroid that can cause oral candidiasis (thrush). To prevent this,
the client should rinse their mouth after each use.
126. A nurse is providing discharge teaching to a client who has asthma and new prescriptions
for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client
indicates an understanding of the teaching?
A. I will be sure to take the albuterol before taking the cromolyn.
B. I will take the cromolyn before using the albuterol.
C. I should take these medications only when I feel symptoms coming on.
D. I will take both medications at the same time.
Answer: A. I will be sure to take the albuterol before taking the cromolyn.
Rationale:
Albuterol is a bronchodilator and should be taken before cromolyn to open the airways and allow
for better absorption of the second medication.
127. A nurse is discharging a child who has sickle cell anemia after an acute crisis episode.
Which of the following instructions should the nurse include in the teaching?
A. Avoid all physical activity.
B. Offer fluids to your child multiple times every day.
C. Restrict your child's intake of fruits and vegetables.
D. Increase the child's calcium intake.
Answer: B. Offer fluids to your child multiple times every day.
Rationale:
Preventing dehydration is key to avoiding a sickle cell crisis. The nurse should advise the parents
to ensure the child drinks plenty of fluids throughout the day.
128. A nurse is monitoring a client who is receiving a blood transfusion. Which of the following
findings should alert the nurse to a possible transfusion reaction?
A. Fever

B. Bradycardia
C. Hypertension
D. Generalized urticaria
Answer: D. Generalized urticaria
Rationale:
Urticaria (hives) is a common sign of an allergic reaction to a blood transfusion. Other signs may
include itching, bronchospasm, and anaphylaxis.
129. A nurse is collaborating on care for a client who has COPD. Which of the following tasks
should the nurse recommend be referred to an occupational therapist for assistance?
A. Administering respiratory treatments
B. Instructing how to use kitchen tools to prepare a meal
C. Managing medication regimen
D. Developing a nutrition plan
Answer: B. Instructing how to use kitchen tools to prepare a meal
Rationale:
Occupational therapists assist clients with skills needed for daily living, such as preparing meals,
using kitchen tools, and managing activities of daily living (ADLs).
130. A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following
manifestations should the nurse expect?
A. Agitation
B. Bradycardia
C. Diaphoresis
D. Hypotension
Answer: A. Agitation
Rationale:
Agitation is an early sign of hypoxemia during an asthma attack due to neurological changes
caused by poor oxygenation.

131. A nurse is planning to perform a blood transfusion for a client. Which of the following
actions should the nurse plan to take? (Select all that apply.)
A. Prime the blood tubing with dextrose 5% in water.
B. Transfuse the blood product within 5 hr after removing it from refrigeration.
C. Check the expiration date of the blood product with a second nurse.
D. Obtain vital signs before starting the transfusion.
E. Use a filter in the blood transfusion setup.
Answer: C. Check the expiration date of the blood product with a second nurse.
D. Obtain vital signs before starting the transfusion.
E. Use a filter in the blood transfusion setup.
Rationale:
• C. It is essential to check the expiration date of the blood product with a second nurse to ensure
safety and accuracy.
• D. Obtaining vital signs before starting the transfusion is a standard procedure to establish a
baseline for monitoring the client's response.
• E. A filter is used in blood transfusions to prevent the infusion of blood clots and debris.
• A is incorrect because dextrose 5% in water should not be used to prime blood tubing; normal
saline is the appropriate solution.
• B is incorrect as blood products should typically be transfused within 4 hours after removing
them from refrigeration to minimize the risk of bacterial growth.
132. A nurse is providing discharge teaching to a client who has asthma and a new prescription
for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct
the client to report to the provider?
A. Weight gain
B. White coating in the mouth
C. Increased energy levels
D. Dry skin
Answer: B. White coating in the mouth
Rationale:

Fluticasone/salmeterol is an inhaled glucocorticoid and long-acting beta2 adrenergic agonist
combination inhalation medication used for the daily management of asthma. One of the adverse
effects associated with this medication is oropharyngeal candidiasis, which can present as a
white coating in the mouth. The nurse should instruct the client to gargle after each use, use a
spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside
the mouth or on the tongue to the provider.
133. A nurse is monitoring a client who has a chest tube in place connected to wall suction due to
a right-sided pneumothorax. The client complains of chest burning. Which of the following
actions should the nurse take?
A. Reposition the client.
B. Administer a bronchodilator.
C. Notify the provider immediately.
D. Increase the suction pressure.
Answer: A. Reposition the client.
Rationale:
Repositioning the client can help alleviate discomfort and burning sensations associated with the
chest tube, potentially improving lung expansion and drainage.
134. A nurse is teaching a middle-aged client about hypertension. Which of the following
information should the nurse include in the teaching?
A. Beta-blockers are the first-line treatment for hypertension.
B. Diuretics are the first type of medication to control hypertension.
C. Calcium channel blockers should be avoided.
D. Angiotensin-converting enzyme (ACE) inhibitors are used as the primary treatment.
Answer: B. Diuretics are the first type of medication to control hypertension.
Rationale:
Diuretics are commonly used as first-line agents in managing hypertension as they help decrease
blood volume, leading to lower blood pressure.

135. The nurse is caring for a postoperative client who has a chest tube connected to suction and
a water seal drainage system. Which of the following indicates to the nurse that the chest tube is
functioning properly?
A. Absence of bubbling in the water seal chamber.
B. Fluctuation of the fluid level within the water seal chamber.
C. Constant drainage without any change in fluid level.
D. Continuous bubbling in the suction control chamber.
Answer: B. Fluctuation of the fluid level within the water seal chamber.
Rationale:
Fluctuation of fluid within the water seal chamber occurs with inspiration and expiration until the
client’s lungs have re-expanded or the system is occluded, indicating proper function of the chest
tube.
136. A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a
chest tube drainage system in place. Which of the following findings by the nurse indicates a
need for intervention?
A. Mild coughing
B. Development of subcutaneous emphysema
C. Drainage of 50 mL from the chest tube
D. Fluctuation of fluid level in the water seal chamber
Answer: B. Development of subcutaneous emphysema
Rationale:
Subcutaneous emphysema indicates air trapped under the skin, which may suggest a
pneumothorax or other complications requiring immediate reporting to the provider.
137. A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The
nurse should monitor for which of the following findings?
A. Impaired sense of humor
B. Difficulty with spatial awareness
C. Language deficits
D. Hemispatial neglect

Answer: C. Language deficits
Rationale:
A stroke in the left cerebral hemisphere typically results in language deficits, including difficulty
in speaking or understanding language. An impaired sense of humor is more associated with
right hemisphere strokes.
138. A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client
findings should the nurse identify as an indication the client is at risk for experiencing autonomic
dysreflexia?
A. The client's bladder becomes distended.
B. The client has a severe headache.
C. The client experiences sudden hypotension.
D. The client shows signs of infection.
Answer: A. The client's bladder becomes distended.
Rationale:
Distended bladder can trigger autonomic dysreflexia in clients with spinal cord injuries at or
above T6. Other potential triggers include bowel distention and skin irritation.
139. A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several
treatments, the client reports fatigue. Which of the following actions should the nurse take?
A. Encourage increased fluid intake.
B. Check the results of the client's most recent CBC.
C. Administer a blood transfusion.
D. Provide a high-protein diet.
Answer: B. Check the results of the client's most recent CBC.
Rationale:
The fatigue may indicate anemia due to myelosuppression from cisplatin treatment. Checking the
CBC will help assess for anemia and determine if intervention is necessary.
140. A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury
with a halo fixation device. Which of the following statements should the nurse make?

A. The device can be removed for showering.
B. The purpose of this device is to immobilize the cervical spine.
C. The device is only needed for 1 week.
D. The client can wear a regular collar over the halo.
Answer: B. The purpose of this device is to immobilize the cervical spine.
Rationale:
The halo fixation device is designed to immobilize the head and neck to allow healing of cervical
spine injuries and is typically used for an extended period (8 to 12 weeks).
141. A nurse is developing a plan of care for a client who has a spinal fracture and complete
spinal cord transection at the level of C5. Which of the following rehabilitation goals should the
nurse add to the client's plan of care?
A. Ability to self-feed with the use of adaptive equipment
B. Ability to walk independently
C. Ability to perform bowel and bladder management independently
D. Ability to use a manual wheelchair
Answer: A. Ability to self-feed with the use of adaptive equipment
Rationale:
A client with a C5 spinal cord injury should have full neck and partial upper limb movement,
allowing for the use of adaptive equipment for self-feeding.
142. A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure
disorder. Which of the following interventions should the nurse include? (Select all that apply.)
A. Provide a suction setup at the bedside.
B. Elevate the side rails near the head when the client is in bed.
C. Place the bed in the lowest position.
D. Keep an oxygen setup at the bedside.
E. Furnish restraints at the bedside.
Answer: A. Provide a suction setup at the bedside.
B. Elevate the side rails near the head when the client is in bed.
C. Place the bed in the lowest position.

D. Keep an oxygen setup at the bedside.
Rationale:
These interventions ensure the client's safety during a seizure and provide necessary support for
airway management.
143. A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment
of cranial nerves IX and X. Which of the following actions should the nurse take?
A. Place suction equipment at the client's bedside.
B. Administer a speech therapy referral.
C. Monitor the client's vital signs every hour.
D. Assess the client's ability to swallow.
Answer: A. Place suction equipment at the client's bedside.
Rationale:
Impairment of cranial nerves IX and X increases the risk of aspiration; suction equipment is
necessary for immediate intervention if needed.
144. A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports
having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and
suspects the client is experiencing autonomic dysreflexia. Which of the following actions should
the nurse take first?
A. Place the client in a high-Fowler's position.
B. Administer antihypertensive medication.
C. Check the client's urinary catheter for obstruction.
D. Call the rapid response team.
Answer: A. Place the client in a high-Fowler's position.
Rationale:
This position helps to lower blood pressure and reduce the risk of cerebrovascular accident due
to hypertension.

145. A nurse is performing a mental status examination (MSE) on a client who has a new
diagnosis of dementia. Which of the following components should the nurse include? (Select all
that apply.)
A. Grooming
B. Long-term memory
C. Support systems
D. Affect
E. Presence of pain
Answer: A. Grooming
B. Long-term memory
D. Affect
Rationale:
These components are important for assessing the cognitive function and emotional state of a
client with dementia.
146. A nurse in the emergency room is assessing a client who was brought in following a seizure.
The nurse suspects the client may have meningococcal meningitis when assessment findings
include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of
the following actions should the nurse initiate next?
A. Assess the cranial nerves.
B. Start intravenous antibiotics.
C. Perform a lumbar puncture.
D. Monitor vital signs every 15 minutes.
Answer: A. Assess the cranial nerves.
Rationale:
Monitoring for neurological changes is crucial, particularly for increased intracranial pressure.
147. A nurse is receiving a transfer report for a client who has a head injury. The client has a
Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best
motor response. Which of the following is an appropriate conclusion based on this data?
A. The client opens his eyes when spoken to.

B. The client can follow simple motor commands.
C. The client is unable to make vocal sound.
D. The client is unconscious.
Answer: A. The client opens his eyes when spoken to.
Rationale:
A GCS of 3-5-5 indicates eye opening in response to speech and a reasonably good motor
response.
148. A nurse is caring for four hospitalized clients. Which of the following clients should the
nurse identify as being at risk for fluid volume deficit?
A. The client who has gastroenteritis and is febrile.
B. The client who is receiving diuretics.
C. The client who has chronic kidney disease.
D. The client who is on a clear liquid diet.
Answer: A. The client who has gastroenteritis and is febrile.
Rationale:
This client has multiple risk factors for dehydration due to diarrhea, vomiting, and fever.
149. A nurse is performing discharge teaching for a client who has seizures and a new
prescription for phenytoin. Which of the following statements by the client indicates a need for
further teaching?
A. "I'll be glad when I can stop taking this medicine."
B. "I need to avoid drinking alcohol."
C. "I should take this medication at the same time every day."
D. "I will notify my doctor if I have a rash."
Answer: A. "I'll be glad when I can stop taking this medicine."
Rationale:
Phenytoin is often a lifelong medication for seizure management, and stopping it without
medical advice can be dangerous.

150. A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg.
Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply.)
A. Confusion
B. Tachycardia
C. Hypotension
D. Nonreactive dilated pupils
E. Slurred speech
Answer: D. Nonreactive dilated pupils
E. Slurred speech
Rationale:
These signs indicate significant deterioration and are associated with late-stage increased ICP.
151. A nurse is assessing a client who has Parkinson's disease. Which of the following
manifestations should the nurse expect?
A. Bradykinesia
B. Tremors
C. Rigidity
D. Postural instability
Answer: A. Bradykinesia
Rationale:
The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's
disease.
152. A nurse is teaching a female client who has a new prescription for transdermal sumatriptan
to treat migraine headaches. Which of the following instructions should the nurse include?
A. Use contraception while taking this medication.
B. Take the medication on an empty stomach.
C. Limit fluid intake while using the patch.
D. Do not use this medication with other pain relievers.
Answer: A. Use contraception while taking this medication.
Rationale:

Sumatriptan can cause teratogenesis and should not be used during pregnancy.
153. A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The
client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following
nursing statements are appropriate?
A. Implement a schedule to include periods of rest.
B. Engage in high-intensity exercise daily.
C. Avoid all physical activity.
D. Limit rest periods to less than one hour.
Answer: A. Implement a schedule to include periods of rest.
Rationale:
The nurse should assist the client in developing a schedule that includes periods of exercise
followed by periods of rest to maintain muscle strength and coordination.
154. A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following
manifestations should indicate to the nurse the client is experiencing an increase in intracranial
pressure (ICP)? (Select all that apply.)
A. Headache
B. Neck pain and stiffness
C. Slurred speech
D. Pupillary changes
E. Disorientation
Answer: A. Headache
C. Slurred speech
D. Pupillary changes
E. Disorientation
Rationale:
• Headache is correct. A client who has increasing ICP might manifest a headache.
• Neck pain and stiffness is incorrect. Neck pain and stiffness are not manifestations of
increasing ICP.
• Slurred speech is correct. A client who has increasing ICP might manifest slurred speech.

• Pupillary changes is correct. A client who has increasing ICP might manifest pupillary changes.
• Disorientation is correct. A client who has increasing ICP might display disorientation or
confusion.
155. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing's triad?
A. Bradycardia
B. Tachycardia
C. Hypotension
D. Increased respiratory rate
Answer: A. Bradycardia
Rationale:
Bradycardia is part of Cushing's triad, which also includes severe hypertension and widened
pulse pressure.
156. A nurse in an ICU is planning care for a client who is in cardiogenic shock. The nurse
should prepare to administer which of the following medications to increase cardiac output?
A. Epinephrine
B. Dobutamine
C. Dopamine
D. Norepinephrine
Answer: C. Dopamine
Rationale:
Dopamine increases output by strengthening the force of contractions.
157. A nurse in a provider's office is assessing a client who has hypertension and takes
propranolol. Which of the following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication?
A. Report of a night cough
B. Weight loss
C. Increased appetite

D. Frequent headaches
Answer: A. Report of a night cough
Rationale:
A night cough can indicate pulmonary issues related to the use of propranolol.
158. A nurse is assessing a client who has a comminuted fracture of the femur. Which of the
following findings should the nurse identify as an early manifestation of a fat embolism?
A. Dyspnea
B. Rash
C. Fever
D. Nausea
Answer: A. Dyspnea
Rationale:
Dyspnea can be an early sign of a fat embolism.
159. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the
following non-pharmacological interventions should the nurse suggest to the client to reduce
pain?
A. Apply heat only to the affected joints.
B. Engage in intense physical activity.
C. Alternate application of heat and cold to the affected joints.
D. Limit all movement of the joints.
Answer: C. Alternate application of heat and cold to the affected joints.
Rationale:
Alternating heat and cold can help reduce pain and inflammation in the joints.
160. A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
A. Low urine specific gravity
B. High urine specific gravity
C. Decreased thirst

D. Hypervolemia
Answer: A. Low urine specific gravity
Rationale:
A client with diabetes insipidus typically has low urine specific gravity due to the excretion of
large volumes of dilute urine.
161. A nurse is assessing an older adult client who has heart failure and takes digoxin. Which of
the following findings should the nurse recognize as an indication of digoxin toxicity?
A. Bradycardia
B. Hypertension
C. Tachycardia
D. Increased appetite
Answer: A. Bradycardia
Rationale:
Bradycardia is a common indication of digoxin toxicity.
162. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the
formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity.
Which of the following interventions is the nurse's priority?
A. Apply firm pressure to the insertion site
B. Administer pain medication
C. Notify the healthcare provider
D. Assess the client's vital signs
Answer: A. Apply firm pressure to the insertion site
Rationale:
Applying firm pressure is the priority intervention to prevent further bleeding.
163. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system.
Which of the following findings is an indication of lung re-expansion?
A. Bubbling in the water-seal chamber has ceased
B. Increased chest pain

C. Increased respiratory rate
D. Presence of subcutaneous emphysema
Answer: A. Bubbling in the water-seal chamber has ceased
Rationale:
The cessation of bubbling indicates that the air has been evacuated and the lung is re-expanding.
164. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following
assessment findings should the nurse expect?
A. Hyperactive bowel sounds
B. Abdominal cramps
C. Hypoactive bowel sounds
D. Diarrhea
Answer: C. Hypoactive bowel sounds
Rationale:
A low potassium level (hypokalemia) can lead to decreased bowel motility, resulting in
hypoactive bowel sounds.
165. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
should the nurse plan to administer?
A. Regular insulin (fast acting) 20 units IV bolus
B. Dextrose 10% in water
C. Metformin 500 mg orally
D. Sodium bicarbonate IV
Answer: A. Regular insulin (fast acting) 20 units IV bolus
Rationale:
Regular insulin is the primary treatment for DKA to lower blood glucose levels quickly.
166. A nurse is caring for a client who has HIV. Which of the following findings indicates a
positive response to the prescribed HIV treatment?
A. Increased CD4 count
B. Elevated white blood cell count

C. Increased viral load
D. Decreased hemoglobin level
Answer: A. Increased CD4 count
Rationale:
A positive response to HIV treatment is indicated by an increased CD4 count and decreased viral
load.
167. A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse
should identify which of the following findings as a manifestation of cardiogenic shock?
A. Bradycardia
B. Hypertension
C. Hypotension
D. Elevated temperature
Answer: C. Hypotension
Rationale:
Hypotension is a key manifestation of cardiogenic shock due to decreased cardiac output.
168. A nurse is caring for a client who is eight hours post-operative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following actions should
the nurse take first?
A. Scan the bladder with a portable ultrasound
B. Encourage the client to drink more fluids
C. Perform a straight catheterization
D. Notify the healthcare provider
Answer: A. Scan the bladder with a portable ultrasound
Rationale:
The first action should be to determine the amount of urine in the bladder using a portable
ultrasound.
169. A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a Holter
monitor. Which of the following information should the nurse include in the teaching?

A. This device can detect when you have an irregular heart rate
B. This device is only used during exercise
C. This device will prevent palpitations
D. This device records your blood pressure
Answer: A. This device can detect when you have an irregular heart rate
Rationale:
A Holter monitor records heart activity over time and can identify irregular heart rates and
dysrhythmias.
170. A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter,
the client reports pain in the insertion area. Which of the following actions should the nurse take?
A. Remove the catheter and insert another into a different site
B. Flush the catheter with saline
C. Apply a warm compress to the site
D. Reassure the client that pain is normal
Answer: A. Remove the catheter and insert another into a different site
Rationale:
If the client reports pain, the catheter may be against a valve or nerve, so it should be removed,
and a new site should be established.
171. A nurse is reviewing the laboratory findings for a client who developed fat embolism
syndrome (FES) following a fracture. Which of the following laboratory findings should the
nurse expect?
A. Decreased erythrocyte sedimentation rate
B. Decreased serum calcium level
C. Increased platelet count
D. Increased serum albumin level
Answer: B. Decreased serum calcium level
Rationale:
A decreased serum calcium level is an expected finding for FES, though the reason for this is
unknown.

172. A nurse is assessing a client who is in skeletal traction. Which of the following findings
should the nurse identify as an indication of infection at the pin sites?
A. Cool skin temperature
B. Serous drainage
C. Fever
D. Increased appetite
Answer: C. Fever
Rationale:
Manifestations of infection at the pin sites include fever, purulent drainage, odor, loose pins, and
tenting of the skin around the pin sites.
173. A nurse is caring for a middle adult female client who reports that her menstrual periods
have become irregular and she has been having hot flashes. The nurse should expect the client to
have which of the following manifestations associated with early menopause?
A. Weight gain
B. Breast tenderness
C. Dryness with intercourse
D. Hair loss
Answer: C. Dryness with intercourse
Rationale:
Menopause occurs when the ovaries stop making estrogen. Due to changes in the vagina,
dryness, discomfort, or pain during sexual intercourse may occur.
174. A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen
minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills
and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
A. Febrile non-hemolytic
B. Allergic
C. Hemolytic
D. Circulatory overload

Answer: C. Hemolytic
Rationale:
A hemolytic transfusion reaction involves fever, chills, and red-tinged urine due to the
destruction of red blood cells.
175. A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus
(SLE). Which of the following values should give the nurse the best indication of the client's
renal function?
A. Blood urea nitrogen (BUN)
B. Serum creatinine
C. Urine specific gravity
D. Serum sodium
Answer: B. Serum creatinine
Rationale:
Serum creatinine is a specific and sensitive indicator of renal function because renal disorders
reduce creatinine excretion, leading to increased blood levels.
176. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes
mellitus. The nurse should recognize that the client understands the teaching when he identifies
which of the following as manifestations of hypoglycemia? (Select all that apply.)
A. Blurred vision
B. Polyuria
C. Tachycardia
D. Moist, clammy skin
E. Polydipsia
Answer: A. Blurred vision
C. Tachycardia
D. Moist, clammy skin
Rationale:
These are common manifestations of hypoglycemia, which may occur in individuals with
diabetes.

177. A nurse is reviewing the arterial blood gas values of a client who has chronic kidney
disease. Which of the following sets of values should the nurse expect?
A. pH 7.45, HCO3 25 mEq/L, PaCO2 40 mm Hg
B. pH 7.38, HCO3 28 mEq/L, PaCO2 50 mm Hg
C. pH 7.25, HCO3 19 mEq/L, PaCO2 30 mm Hg
D. pH 7.50, HCO3 22 mEq/L, PaCO2 48 mm Hg
Answer: C. pH 7.25, HCO3 19 mEq/L, PaCO2 30 mm Hg
Rationale:
These values indicate metabolic acidosis, a condition associated with chronic kidney disease.
178. A nurse is caring for a client who has congestive heart failure and is taking digoxin daily.
The client refused breakfast and is complaining of nausea and weakness. Which of the following
actions should the nurse take first?
A. Encourage the client to eat the meal.
B. Check the client's vital signs.
C. Request an order for an antiemetic.
D. Suggest the client rest before eating.
Answer: B. Check the client's vital signs.
Rationale:
Nausea may indicate digoxin toxicity. Assessing vital signs helps identify bradycardia, a key
symptom of toxicity.
179. A nurse is teaching a female client who has a new diagnosis of systemic lupus
erythematosus (SLE). The nurse should recognize the need for further teaching when the client
identifies which of the following as a factor that can exacerbate SLE?
A. Sunlight
B. Infection
C. Pregnancy
D. Exercise
Answer: D. Exercise

Rationale:
Physical exercise does not exacerbate SLE. In fact, it is encouraged to prevent deconditioning
and muscle atrophy.
180. A nurse is caring for a client who has HIV. Which of the following laboratory values is the
nurse's priority?
A. Positive Western blot test
B. Platelet count 150,000/mm3
C. CD4-T-cell count 180 cells/mm3
D. WBC count 5,000/mm3
Answer: C. CD4-T-cell count 180 cells/mm3
Rationale:
A CD4 count below 180 cells/mm3 indicates severe immunosuppression, which increases the risk
for opportunistic infections.
181. A nurse is working with a licensed practical nurse (LPN) to care for a client who is
receiving a continuous IV infusion. Which of the following findings reported by the LPN
indicates to the nurse the client has phlebitis at the IV insertion site?
A. The area surrounding the insertion site feels warm to the touch.
B. The area surrounding the insertion site is pale.
C. The IV infusion is running slowly.
D. The client has a blood pressure of 104/62 mm Hg.
Answer: A. The area surrounding the insertion site feels warm to the touch.
Rationale:
Warmth around the insertion site indicates inflammation and phlebitis.
182. A community health nurse is developing a pamphlet about breast self-examination (BSE)
for a local health fair. Which of the following instructions should the nurse include?
A. Press firmly on the breast to feel deeper tissue.
B. Use the palm of the hand to perform the examination.
C. Breasts can be examined in the shower with soapy hands.

D. Perform BSE every other month.
Answer: C. Breasts can be examined in the shower with soapy hands.
Rationale:
The nurse should instruct clients that they can perform a BSE in the shower because soapy hands
make it easier to feel for tissue changes, lumps, or abnormalities.
183. A nurse is caring for four clients. Which of the following clients is at greatest risk for a
pulmonary embolism?
A. A client who is 8 hr postoperative following an open cholecystectomy.
B. A client who is 12 hr postoperative following a total hip arthroplasty.
C. A client who is 24 hr postoperative following an appendectomy.
D. A client who is 2 hr postoperative following a transurethral resection of the prostate.
Answer: B. A client who is 12 hr postoperative following a total hip arthroplasty.
Rationale:
Clients who have undergone orthopedic surgeries, such as total hip arthroplasty, are at a higher
risk of developing deep vein thrombosis (DVT), which can lead to a pulmonary embolism.
184. A nurse is assessing a client with diabetes insipidus. Which of the following assessment
findings is typical of this condition?
A. Oliguria.
B. Polyuria.
C. Dysuria.
D. Hematuria.
Answer: B. Polyuria.
Rationale:
Diabetes insipidus is characterized by excessive urination (polyuria) due to a lack of antidiuretic
hormone (ADH), which results in the inability to concentrate urine.
185. A nurse is caring for a client after a craniotomy for a pituitary tumor who has developed
diabetes insipidus. The client is receiving vasopressin (Pitressin). The desired response to the
medication is evident when the nurse observes which of the following findings?

A. Decreased thirst.
B. Decrease in urine output.
C. Decreased heart rate.
D. Increase in blood pressure.
Answer: B. Decrease in urine output.
Rationale:
Vasopressin is used to treat diabetes insipidus by reducing excessive urination, so a decrease in
urine output indicates the medication is effective.
186. A nurse in a provider's office is reviewing the lab results of a client who is being evaluated
for secondary hypothyroidism. Which of the following lab findings is expected for a client who
has this condition?
A. Elevated T4.
B. Increased TSH.
C. Decreased serum T3.
D. Elevated serum calcium.
Answer: C. Decreased serum T3.
Rationale:
Secondary hypothyroidism is characterized by low levels of thyroid hormones, including T3, due
to a malfunction in the pituitary gland or hypothalamus.
187. A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial
fibrillation. Which of the following values should the nurse identify as a desired outcome for this
therapy?
A. INR 1.2
B. INR 2.5
C. INR 4.5
D. INR 0.9
Answer: B. INR 2.5.
Rationale:

For clients on warfarin therapy, the desired therapeutic range for INR (International Normalized
Ratio) is typically between 2.0 and 3.0 to prevent thromboembolic events such as strokes.
188. A nurse is providing teaching for a female client who has recurrent urinary tract infections.
Which of the following information should the nurse include in the teaching?
A. Take a tub bath daily.
B. Void before and after intercourse.
C. Wipe from back to front after urination.
D. Limit fluid intake to decrease urination.
Answer: B. Void before and after intercourse.
Rationale:
Urinating before and after intercourse helps to flush out bacteria from the urethra, reducing the
risk of developing urinary tract infections.
189. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving
mannitol via continuous IV infusion. The nurse should report which of the following adverse
effects of this medication to the provider?
A. Weight loss.
B. Crackles heard on auscultation.
C. Decreased deep tendon reflexes.
D. Peripheral edema.
Answer: B. Crackles heard on auscultation.
Rationale:
Crackles may indicate fluid overload or pulmonary edema, which can occur as a side effect of
mannitol, a diuretic used to reduce intracranial pressure.
190. A nurse is providing teaching to a client who has breast cancer about the adverse effects of
chemotherapy. Which of the following client statements indicates an understanding of the
teaching?
A. "I will avoid brushing my teeth until chemotherapy is complete."
B. "I'll call my doctor if I notice any unusual bleeding."

C. "I'll wait until after chemotherapy to get my flu shot."
D. "I might experience hair regrowth while receiving chemotherapy."
Answer: B. "I'll call my doctor if I notice any unusual bleeding."
Rationale:
Chemotherapy can cause thrombocytopenia, which increases the risk of bleeding. The client
should report any unusual bleeding to the healthcare provider.
191. A nurse is caring for a client who has chemotherapy-induced peripheral neuropathy. The
nurse should expect the client to report having experienced which of the following symptoms?
A. Diarrhea
B. Muscle cramping
C. Tingling feeling in the extremities
D. Headaches
Answer: C. Tingling feeling in the extremities
Rationale:
Peripheral neuropathy involves damage to the peripheral nerves, often causing symptoms such as
tingling, numbness, or a burning sensation in the extremities.
192. A nurse is providing discharge teaching for a client who is postoperative following a simple
mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the
following instructions about maintaining skin integrity should the nurse include?
A. Apply heat to the area of irradiation daily.
B. Massage the irradiated area daily.
C. Do not apply heat to the area of irradiation.
D. Cover the area of irradiation with a tight bandage.
Answer: C. Do not apply heat to the area of irradiation.
Rationale:
Applying heat to the irradiated area can cause tissue damage as the skin in that area becomes
more sensitive and thinner after radiation therapy. Protective measures should be taken to avoid
burns.

193. A nurse is caring for a client who is being evaluated for acromegaly. Which of the following
manifestations should the nurse expect to find during assessment? (Select all that apply.)
A. Diaphoresis
B. Coarse facial features
C. Enlarged distal extremities
D. Muscle weakness
E. Weight loss
Answer: A. Diaphoresis
B. Coarse facial features
C. Enlarged distal extremities
D. Muscle weakness
Rationale:
Acromegaly is a disorder caused by an excess of growth hormone, leading to enlarged hands and
feet, coarse facial features, excessive sweating, and muscle weakness.
194. A nurse in the post-anesthesia care unit is caring for a client who is postoperative following
a thoracotomy and lobectomy. Which of the following postoperative assessments should the
nurse give highest priority to?
A. Arterial blood gases
B. Temperature
C. Pain level
D. Urine output
Answer: A. Arterial blood gases
Rationale:
According to the ABC (airway, breathing, circulation) priority framework, assessing oxygenation
via arterial blood gases is the highest priority in the postoperative phase after thoracic surgery.
195. A nurse is reviewing discharge instructions with a client following a right cataract
extraction. Which of the following instructions should the nurse include?
A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
B. Sleep on the side of the affected eye for comfort.

C. Rub your eyes if they feel dry.
D. Take a tub bath immediately following the procedure.
Answer: A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Rationale:
Activities that increase intraocular pressure, such as lifting heavy objects, should be avoided
after cataract surgery to prevent complications.
196. A nurse is teaching a client about the seven warning signs of cancer. Which of the following
signs should the nurse include as manifestations of cancer? (Select all that apply.)
A. A nonhealing sore
B. Bloating
C. Change in bowel pattern
D. Change in moles
E. Nagging cough
Answer: A. A nonhealing sore
C. Change in bowel pattern
D. Change in moles
E. Nagging cough
Rationale:
These are common warning signs of cancer, including changes in bowel habits, persistent cough,
nonhealing sores, and changes in moles.
197. A nurse is caring for a client who has expressive aphasia following a cerebrovascular
accident (CVA). Which of the following parameters should the nurse use first in order to assess
the client's pain level?
A. Behavioral observation
B. Family reports
C. A self-report pain rating scale
D. Medical history
Answer: C. A self-report pain rating scale
Rationale:

Even though the client has expressive aphasia, they can often use non-verbal pain scales, such as
pointing to a number or face on a pain rating scale.
198. A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is
started on ethambutol therapy. The nurse should understand that which of the following should
be monitored?
A. Visual acuity
B. Liver function
C. Kidney function
D. Hearing
Answer: A. Visual acuity
Rationale:
Ethambutol can cause optic neuritis, leading to loss of vision and color discrimination. Regular
monitoring of visual acuity is required.
199. A nurse in a clinic is teaching information about cervical polyps with a client who has a new
diagnosis. Which of the following information should the nurse include in the teaching?
A. Postcoital bleeding may occur.
B. Polyps are usually cancerous.
C. Hormonal therapy is required for treatment.
D. Polyps often cause severe pain.
Answer: A. Postcoital bleeding may occur.
Rationale:
Cervical polyps are often fragile and can cause bleeding, especially after intercourse.
200. A nurse is providing teaching to a client who has breast cancer about the adverse effects of
chemotherapy. Which of the following client statements indicates an understanding of the
teaching?
A. "I'll call my doctor if I have any unusual menstrual bleeding."
B. "I'll take ibuprofen to prevent fever."
C. "I'll stop chemotherapy if my hair falls out."

D. "I'll get my flu shot during chemotherapy."
Answer: A. "I'll call my doctor if I have any unusual menstrual bleeding."
Rationale:
Chemotherapy can lead to thrombocytopenia, which increases the risk of bleeding. Unusual
bleeding, including menstrual bleeding, should be reported to the healthcare provider.
201. A nurse is teaching a client who has vulvodynia about self-care measures to alleviate
symptoms. Which statement by the client indicates an understanding of the teaching?
A. "I should avoid the use of any lubricants."
B. "I should wear cotton undergarments."
C. "I should use scented soaps for hygiene."
D. "I should wear tight-fitting clothes."
Answer: B. "I should wear cotton undergarments."
Rationale:
Cotton underwear is recommended for clients with vulvodynia because it allows air circulation
and helps prevent irritation.
202. A staff nurse is teaching a client who has Addison's disease about the disease process. The
client asks the nurse what causes Addison's disease. Which of the following responses should the
nurse make?
A. "It is caused by the lack of production of hormones by the adrenal gland."
B. "It is caused by the overproduction of growth hormone by the pituitary gland."
C. "It is caused by the overproduction of parathormone by the parathyroid gland."
D. "It is caused by the overproduction of insulin by the pancreas."
Answer: A. "It is caused by the lack of production of hormones by the adrenal gland."
Rationale:
Addison's disease is caused by insufficient production of cortisol and aldosterone by the adrenal
glands.

203. A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for
acquiring urinary tract infections. Which of the following actions should the nurse include in the
client's plan of care?
A. Limit fluid intake between meals.
B. Encourage fluid intake at and between meals.
C. Restrict high-protein foods in the diet.
D. Apply intermittent catheterization only when the client is in discomfort.
Answer: B. Encourage fluid intake at and between meals.
Rationale:
Increasing fluid intake helps dilute urine and reduce urinary stasis, lowering the risk of UTIs.
204. A nurse in an emergency department is caring for a client who has a sucking chest wound
resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of
118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
A. Perform chest compressions.
B. Administer oxygen via nasal cannula.
C. Administer an anticoagulant.
D. Apply a tourniquet.
Answer: B. Administer oxygen via nasal cannula.
Rationale:
The client likely has a pneumothorax, and supplemental oxygen helps increase oxygen exchange
and prevent further tissue hypoxia.
205. A nurse is teaching a client who has septic shock about the development of disseminated
intravascular coagulation (DIC). Which of the following statements should the nurse make?
A. "DIC is caused by abnormal coagulation involving fibrinogen."
B. "DIC is caused by a lack of clotting factors."
C. "DIC is caused by a deficiency in white blood cells."
D. "DIC is caused by reduced red blood cell production."
Answer: A. "DIC is caused by abnormal coagulation involving fibrinogen."
Rationale:

DIC is characterized by widespread clotting that consumes clotting factors, including fibrinogen,
leading to an increased risk of bleeding.
206. A nurse is providing dietary teaching to a client who has a history of recurring calcium
oxalate kidney stones. Which of the following instructions should the nurse include in the
teaching?
A. Avoid consuming foods high in calcium.
B. Limit fluid intake to 1 L daily.
C. Drink 3 L of fluid every day.
D. Decrease intake of citrus fruits.
Answer: C. Drink 3 L of fluid every day.
Rationale:
Drinking sufficient fluids helps dilute the urine and reduces the formation of calcium oxalate
kidney stones.
207. A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse
about menopausal hormone therapy (HT). The nurse should inform the client that HT is not
recommended due to which of the following findings in the client's medical history?
A. History of osteoporosis
B. History of cardiovascular disease
C. History of breast cancer
D. History of thyroid disease
Answer: C. History of breast cancer.
Rationale:
HT is contraindicated for clients with a history of breast cancer, as it may increase the risk of
cancer recurrence.
208. A home health nurse is assessing an older adult client in the home who has decreased vision
due to a history of glaucoma. Which of the following findings should the nurse identify as a
safety risk?
A. The kitchen is well-lit.

B. Scatter rugs are present in the kitchen.
C. The client wears shoes when moving around the house.
D. The client has grab bars in the bathroom.
Answer: B. Scatter rugs are present in the kitchen.
Rationale:
Scatter rugs pose a tripping hazard, especially for clients with impaired vision, increasing the risk
of falls.
209. A nurse is preparing a client for a radiation treatment who is postoperative following a
mastectomy. The nurse should inform the client to expect which of the following adverse effects
from the treatment?
A. Alopecia
B. Diarrhea
C. Fatigue
D. Weight gain
Answer: C. Fatigue.
Rationale:
Fatigue is a common side effect of radiation therapy regardless of the target site.
210. After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring
within the designated radiation treatment markings. The nurse should instruct the client to take
which of the following actions?
A. Apply hydrating lotions.
B. Apply sunscreen.
C. Use soap and water to clean the area frequently.
D. Cover the area with a heating pad.
Answer: A. Apply hydrating lotions.
Rationale:
Hydrating lotions that do not contain metal, alcohol, or perfume are recommended to soothe
radiation-affected skin.

211. A nurse is assessing a client who is in skeletal traction. Which of the following findings
should the nurse identify as an indication of infection at the pin sites?
A. Warmth at the site
B. Pain around the pin site
C. Fever
D. Swelling at the site
Answer: C. Fever
Rationale:
Manifestations of infection at the pin sites include fever, purulent drainage, odor, loose pins, and
tenting of the skin around the pin sites.
212. A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr
postoperative. Which of the following surgical procedures places the client at risk for deep-vein
thrombosis (DVT)?
A. Cataract surgery
B. Hip arthroplasty
C. Hysterectomy
D. Appendectomy
Answer: B. Hip arthroplasty
Rationale:
Clients who undergo orthopedic procedures of the lower extremities, such as hip arthroplasty, are
at higher risk of developing deep-vein thrombosis.
213. A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of
the prostate (TURP) gland. Which of the following assessments should the nurse view as an
indication of a postoperative complication?
A. Clear yellow urine output
B. Output of burgundy-colored urine
C. Bladder spasms
D. Decreased urine output
Answer: B. Output of burgundy-colored urine

Rationale:
Burgundy-colored urine may indicate a complication such as hemorrhage or clot formation
following a TURP procedure.
214. A nurse is assessing a client before administering a unit of packed RBCs. The nurse should
identify which of the following data as most important to obtain prior to the infusion?
A. Blood pressure
B. Temperature
C. Oxygen saturation
D. Respiratory rate
Answer: B. Temperature
Rationale:
The priority is to obtain a baseline temperature as a rise in temperature during the infusion can
indicate a blood transfusion reaction.
215. A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary
care provider for suspicion of cataracts. The nurse should expect the client to report which of the
following?
A. Eye pain
B. Increased sensitivity to light
C. Loss of peripheral vision
D. Decreased ability to perceive colors
Answer: D. Decreased ability to perceive colors
Rationale:
Clients with cataracts often experience painless blurred vision and decreased color perception.
216. A nurse is evaluating a client's laboratory results. The nurse should recognize that an
increase in the client's prostate-specific antigen (PSA) laboratory value is indicative of which of
the following diagnoses?
A. Bladder cancer
B. Testicular cancer

C. Prostatic cancer
D. Renal cancer
Answer: C. Prostatic cancer
Rationale:
An elevated PSA level can indicate the presence of prostate cancer.
217. A nurse is providing postoperative care for a client who has two chest tubes in place
following a lobectomy. The client asks the nurse the reason for having two chest tubes. The nurse
should inform the client that the lower chest tube is placed for which of the following reasons?
A. Draining air from the pleural space
B. Monitoring intrathoracic pressure
C. Draining blood and fluid from the pleural space
D. Preventing infection
Answer: C. Draining blood and fluid from the pleural space
Rationale:
The lower chest tube is placed to drain blood and fluid, while the upper tube helps remove air.
218. A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who
has herpes zoster. The AP asks the nurse if herpes zoster is contagious. Which of the following
responses should the nurse make?
A. "Herpes zoster is contagious only to people who have never had chickenpox."
B. "Herpes zoster is contagious to everyone."
C. "Herpes zoster is not contagious."
D. "Herpes zoster is only contagious through the respiratory route."
Answer: A. "Herpes zoster is contagious only to people who have never had chickenpox."
Rationale:
Herpes zoster (shingles) is caused by the varicella-zoster virus, and it can be spread to
individuals who have never had chickenpox.
219. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the
following actions should the nurse take?

A. Monitor the client’s weight weekly
B. Check the client’s capillary blood glucose level every 4 hr
C. Change the tubing every 72 hr
D. Administer the TPN through a peripheral IV line
Answer: B. Check the client’s capillary blood glucose level every 4 hr
Rationale:
TPN can cause hyperglycemia, so it is essential to monitor the client’s blood glucose level
regularly, typically every 4 to 6 hours.