2021 HESI PN Medical Surgical Proctored Exam Version 5-6 With Answers-325 Solved Questions

ATI Medical-Surgical Test Banks
Version 5
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home.
Which of the following instructions should the nurse include in the teaching?
1) Take temperature once a day.
2) Wash the armpits and genitals with a gentle cleanser daily.
3) Change the litter boxes while wearing gloves.
4) Wash dishes in warm water.
Answer: 1) Take temperature once a day.
Rationale:
The nurse should reinforce to the client to take his temperature once a daily to identify if a
temperature is present due to the client’s altered immune system.
The nurse should instruct the client to use an antimicrobial cleanser to wash his armpits and
genitals twice daily.
The client should avoid changing litter boxes. Litter boxes carry toxoplasmosis which can be
life threatening to a client who has HIV.
The nurse should instruct the client to wash dishes in hot soapy water to destroy the bacteria.
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious
and tenacious secretions. Which of the following is an acceptable method for the nurse to use
to thin this client's secretions?
1) Provide humidified oxygen.
2) Perform chest physiotherapy prior to suctioning.
3) Pre-lubricate the suction catheter tip with sterile saline when suctioning the airway.
4) Hyperventilate the client with 100% oxygen before suctioning the airway.
Answer: 1) Provide humidified oxygen.
Rationale:
Increasing fluid intake as tolerated and providing adequate humidification can help thin
secretions safely.
Performing chest physiotherapy mobilizes secretions but does not thin them.
Pre-lubricating the suction catheter tip with sterile saline helps to ease the insertion of the
catheter, producing less trauma. However, it has no effect on the tenacity of the client's
secretions.

Hyperventilating the client prior to suctioning prevents hypoxia. However, it has no effect on
the tenacity of the client's secretions.
Following admission, a client with a vascular occlusion of the right lower extremity calls the
nurse and reports difficulty sleeping because of cold feet. Which of the following nursing
actions should the nurse take to promote the client's comfort?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client.
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet.
Answer: 2) Obtain a pair of slipper socks for the client.
Rationale:
Massaging the legs or feet could mobilize a clot. Impaired arterial or venous circulation of the
lower extremities is a contraindication for leg massage.
Slipper socks with non-skid soles will help provide warmth and increase the client's level of
comfort.
Increasing the client's fluid intake will not increase circulation to an area an occlusion
impairs.
Impaired arterial or venous circulation to a lower extremity is a contraindication for applying
a heating pad.
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection
of the prostate (TURP). Which of the following is the priority finding for the nurse report to
the provider?
1) Emesis of 100 mL
2) Oral temperature of 37.5° C (99.5° F)
3) Thick, red-coloured urine
4) Pain level of 4 on a 0 to 10 rating scale
Answer: 3) Thick, red-coloured urine
Rationale:
The nurse should recognize postoperative nausea is a complication related to the
administration of anaesthesia and should treat the nausea with antiemetics and provide
supportive measures; however, it is not the priority finding.

The nurse should monitor a client who develops a fever and encourage deep breathing,
coughing, and fluid intake (if permitted); however, it is not the priority finding to report. The
increase in temperature is likely due to decreased respiratory effort related to the use of
anaesthesia and should clear with pulmonary hygiene.
The nurse should recognize viscous drainage that is red in colour may indicate haemorrhage
and should be reported to the provider immediately.
The nurse should assess for and treat postoperative pain which is an expected finding in the
postoperative client; however it is not the priority finding to report. Specific pain, such as
bladder spasms, may indicate complications however and should be reported to the provider.
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of the
following adverse effects of the hypothermia blanket?
1) Shivering
2) Infection
3) Burns
4) Hypervolemia
Answer: 1) Shivering
Rationale:
The hypothermia blanket can cause shivering if the client is cooled too quickly. Shivering can
cause the client’s temperature to increase.
Infection is not a complication of the hypothermia blanket therapy. A manifestation of
infection is hyperthermia.
Burns are associated with the improper use of heating pads, not hypothermia blankets.
Hypervolemia is not a complication of the hypothermia blanket therapy. Dehydration is a risk
associated with hyperthermia due to fluid loss.
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus.
Which of the following statements by the client indicates an understanding of the teaching?
1) "I will carry a complex carbohydrate snack with me when I exercise."
2) "I should exercise first thing in the morning before eating breakfast."
3) "I should avoid injecting insulin into my thigh if I am going to go running."
4) "I will not exercise if my urine is positive for ketones."
Answer: 4) "I will not exercise if my urine is positive for ketones."

Rationale:
The nurse should reinforce that the client should carry a simple carbohydrate such as hard
candy or glucose tablets for use during exercise if the client becomes hypoglycaemic.
The nurse should reinforce that exercise should follow a meal. Exercising first thing in the
morning on an empty stomach places the client at risk for hypoglycemia.
The nurse should reinforce that the client should avoid injecting insulin into an area that will
soon be exercised to avoid increasing the absorption rate of the insulin.
The nurse should reinforce that exercise should be avoided if ketones are present in the urine
as this indicates an elevated blood glucose level or ketoacidosis.
A nurse notes a small section of bowel protruding from the abdominal incision of a client
who is postoperative. After calling for assistance, which of the following actions should the
nurse take first?
1) Cover the client's wound with a moist, sterile dressing.
2) Have the client lie supine with knees flexed.
3) Check the client's vital signs.
4) Inform the client about the need to return to surgery.
Answer: 1) Cover the client's wound with a moist, sterile dressing.
Rationale:
According to evidence-based practice, the nurse's first action should be to cover the wound
with a moist, sterile dressing to prevent entry of bacteria into the wound and to keep the
tissue moist.
The nurse should have the client lie supine with knees flexed to promote adequate circulation
to the vital organs. However, evidence-based practice indicates that this is not the first action
the nurse should take.
The nurse should check the client’s vital signs because the client is at risk for shock following
wound evisceration. However, evidence-based practice indicates that this is not the first
action the nurse should take.
The nurse should inform the client about the need to return to emergency surgery to preserve
the bowel and prevent complications. However, evidence-based practice indicates that this is
not the first action the nurse should take.
A nurse is collecting data from a client who has alcohol use disorder and is experiencing
metabolic acidosis. Which of the following manifestations should the nurse expect?

1) Cool, clammy skin
2) Hyperventilation
3) Increased blood pressure
4) Bradycardia
Answer: 1) Cool, clammy skin
2) Hyperventilation
Rationale:
The nurse should expect to find warm, flushed skin in a client who is experiencing metabolic
acidosis.
The nurse should expect to find hyperventilation in a client who is experiencing metabolic
acidosis. The system attempts to compensate or return the pH to normal by increasing the rate
and depth of respirations.
The nurse should expect to find hypotension in a client who is experiencing metabolic
acidosis.
The nurse should expect to find tachycardia in a client who is experiencing metabolic
acidosis.
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which
of the following should the nurse include in the teaching?
1) Avoid bending at the waist.
2) Remove the eye shield at bedtime.
3) Limit the use of laxatives if constipated.
4) Seeing flashes of light is an expected finding following extraction.
Answer: 1) Avoid bending at the waist.
Rationale:
The nurse should reinforce that the client should avoid bending at the waist as this increases
intraocular pressure; the client should be instructed to flex the knees and crouch instead.
The client should be instructed to use an eye shield when retiring for the night to protect the
eye from accidental injury, such as rubbing that may occur when the client is asleep.
The client should be encouraged to use laxatives in the event of constipation to avoid
straining while attempting to have a bowel movement. Straining increases intraocular
pressure and can cause damage to the surgical site.
The nurse should instruct the client that flashes of light indicates a complication of cataract
extraction, and should be reported to the provider.

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily.
The client refuses breakfast and reports nausea. Which of the following actions should the
nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
3) Check the client's vital signs.
4) Request an order for an antiemetic.
Answer: 3) Check the client's vital signs.
Rationale:
The nurse should encourage frequent rest periods for the client who has heart failure, as
dyspnea and fluid overload increases the workload to consume adequate nutrition; however,
another action is the priority.
The nurse should consider obtaining a dietary consult for the client who has heart failure to
provide nutritional evaluation and counseling; however, another action is the priority.
When using the airway, breathing, circulation approach to client care, the nurse should place
the priority on obtaining vital signs. Nausea is a manifestation of digoxin toxicity, along with
other manifestations such as muscle weakness, confusion, abdominal cramping, and changes
in vision.
The nurse should request antiemetics for the client who is experiencing nausea in order to
maintain client comfort and nutritional intake; however, another action is the priority.
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The
nurse suspects the client's wound is infected because the drainage from the dressing is yellow
and thick. Which of the following findings should the nurse report as the type of drainage
found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent
Answer: 1) Sanguineous
4) Purulent
Rationale:
Sanguineous indicates fresh bleeding.

Serous describes clear, watery plasma.
Serosanguineous describes watery drainage that has some blood in it.
Purulent describes drainage that is thick yellow, green, or brown in color.
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To
prevent postoperative complications which of the following actions should be reinforced
during the teaching?
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
2) Place the client’s affected leg into the CPM machine with the machine in the flexed
position.
3) Place the client into a high Fowler’s position when initiating the CPM exercises.
4) Align the joints of the CPM machine with the knee gatch in the client’s bed.
Answer: 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM
exercises.
Rationale:
The nurse should administer analgesics prior to initiating any exercise program for the client
who has had joint arthroplasty. It is important that analgesics are administered in time for the
medication to work before the start of the exercise program to ensure discomfort is
minimized.
The nurse should place the client’s leg in the CPM machine while the machine is in the
extended position to allow for proper fit and comfort.
The nurse should limit the elevation of the client’s head of the bed to no more than 20 degrees
while the client is using the CPM machine to avoid extreme flexion of the hip and patient
discomfort.
The nurse should align the joints of the CPM machine with the client’s knee joint to ensure
safe operation of the unit and prevent injury to the client.
A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia

Answer: 1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to
inadequate oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the
diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the
rib cage also become rigid, and the ribs flare outward. This produces the barrel chest typical
of emphysema clients.
Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity,
which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung elasticity;
consequently, respirations become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less
oxygen being delivered to the tissues.
A nurse is caring for a client who sustained a basal skull fracture. When performing morning
hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's
right nostril. Which of the following actions should the nurse take first?
1) Take the client's temperature.
2) Place a dressing under the client's nose.
3) Notify the charge nurse.
4) Test the drainage for glucose.
Answer: 4) Test the drainage for glucose.
Rationale:
The nurse should take the client's temperature to ensure the client is afebrile to prevent
infection and brain dysfunction; however, another finding is the priority.
The nurse should place a dressing under the client's nose to measure and collect the amount
of drainage; however, another finding is the priority.
The nurse should notify the charge nurse about the client’s condition; however, another
finding is the priority.

The greatest risk to a client who has a basal skull fracture is injury from cerebral spinal fluid
(CSF) leak; therefore, the nurse should first test the drainage for glucose.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize
that the client is at risk for autonomic dysreflexia. Which of the following interventions
should the nurse take to prevent autonomic dysreflexia?
1) Monitor for elevated blood pressure.
2) Provide analgesia for headaches.
3) Prevent bladder distention.
4) Elevate the client's head.
Answer: 3) Prevent bladder distention.
Rationale:
Elevated blood pressure is a serious manifestation of autonomic dysreflexia. However, it is
not a causative agent.
A severe headache is one of the manifestations of autonomic dysreflexia. However, it is not a
causative agent.
Autonomic dysreflexia can occur in clients who have a spinal cord injury at or above the T-6
level. Autonomic dysreflexia can occur as a result of an irritation, or stimulus to the nervous
system below the level of injury. Triggers of autonomic dysreflexia include bladder
distention, insertion of rectal suppository, enemas, or a sudden change in position
A sudden change in position can trigger autonomic dysreflexia.
A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the
following findings should the nurse expect the client to report?
1) Hot flashes
2) Recurrent urinary tract infections
3) Blood in the stool
4) Abnormal vaginal bleeding
Answer: 4) Abnormal vaginal bleeding
Rationale:
Hot flashes are indicative of hormonal changes such as menopause.
Urinary tract infections are related to the kidney function and can be related to not drinking
enough water.
Blood in the stool can be a sign of gastrointestinal disease.

The nurse should expect the client to experience abnormal vaginal bleeding, including
postmenopausal bleeding and bleeding between normal periods. Abnormal vaginal bleeding
is the most common finding in endometrial cancer in premenopausal women.
A nurse is caring for a client following an open reduction and internal fixation of a fractured
femur. Which of the following findings is the nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache
Answer: 1) Altered level of consciousness
Rationale:
When using the airway, breathing, circulation approach to client care, the nurse determines
that the priority finding is for the nurse to monitor the client's altered level of consciousness.
A fracture of one of the long bones of the body places the client is at risk for fat embolism,
which causes a decrease in oxygenation and alters the client's level of consciousness.
The nurse should monitor the client's temperature, as this can be a risk for infection or a fat
embolism; however, another action is the priority.
The nurse should observe the client for muscle spasms as a manifestation following this type
of procedure; however, another action is the priority.
The nurse should observe the client for a headache to address his pain; however, another
action is the priority.
A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge
resection of the left lung and has a chest tube to suction. Which of the following is the
priority finding the nurse should report to the provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale
Answer: 1) Abdomen is distended
Rationale:
When using the airway, breathing, circulation approach to client care, the nurse should
recognize the presence of abdominal distention has the potential to compromise the client’s

respiratory status as the distention increases abdominal pressure on the diaphragm and
impairs ventilation. This is the priority finding for the nurse to report.
The nurse should monitor the drainage from the chest tube system for quantity and
characteristics of the drainage, as increases in drainage or the presence of bright red drainage
may indicate bleeding. 70 mL of drainage in an hour is within the accepted limits during the
first 3 hours postoperatively; therefore, another finding is the priority.
The nurse should monitor and report subcutaneous emphysema in a client who has a chest
tube as this may be an indication of air leaking from the lung into the tissues; however,
another finding is the priority.
The nurse should assess and manage pain in the postoperative client. Uncontrolled pain
results in prolonged healing time, and decreased depth of respirations which might result in
pneumonia; however, another finding is the priority.
A nurse is reinforcing discharge teaching with a client about how to care for a newly created
ileal conduit. Which of the following instructions should the nurse include in the teaching?
1) Change the ostomy pouch daily.
2) Empty the ostomy pouch when it is 2/3 full.
3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
4) Apply lotion to the peristomal skin when changing the ostomy pouch.
Answer: 2) Empty the ostomy pouch when it is 2/3 full.
Rationale:
The ostomy pouch is changed every 3 to 7 days.
The ileal conduit cannot store urine the way the bladder did; urine will flow continuously into
a collecting device. Emptying the device when the pouch is 2/3 full will prevent leakage, skin
irritation, and infection.
The opening of the ostomy seal should be trimmed to be 1/16 to 1/8 in. wider than the stoma.
A larger opening allows urine to collect on the skin leading to skin breakdown.
When changing the ostomy pouch, the peristomal skin should be washed and dried
completely. Any remaining moisture or lotion on the skin will prevent adherence of the pouch
causing leakage of urine.
A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland.
Which of the following actions should the nurse include in the plan?

1) Position the client supine while in bed.
2) Change the nasal drip pad as needed.
3) Encourage frequent brushing of teeth.
4) Encourage the client to cough every 2 hr following surgery.
Answer: 2) Change the nasal drip pad as needed.
Rationale:
The nurse should place the client in a semi-Fowler's position to decrease intracranial
pressure, which could lead to a cerebrospinal fluid leak.
The nurse should change the nasal drip pad as needed because the client will have nasal
packing and bloody nasal drainage until the surgical site is healed.
The nurse should inform the client not to brush his teeth, because it will interfere with the
healing process.
The nurse should instruct the client to not cough, because it may interfere with the healing
process and may lead to cerebrospinal fluid leak.
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily
following a myocardial infarction. The nurse should instruct the client that aspirin is
prescribed for clients who have coronary artery disease for which of the following effects?
1) To provide analgesia
2) To reduce inflammation
3) To prevent blood clotting
4) To prevent fever
Answer: 3) To prevent blood clotting
Rationale:
Although aspirin is used to provide analgesia for mild to moderate pain, the nurse should
recognize that it is prescribed to this client for a different therapeutic effect.
Although aspirin is used to reduce inflammation for illnesses such as osteoarthritis, the nurse
should recognize that it is prescribed to this client for a different therapeutic effect.
Aspirin is used to prevent clot formation by reducing platelet aggregation. Therefore, the
nurse should instruct the client the aspirin is prescribed for clients who have coronary artery
disease to prevent myocardial infarction caused by clots in the coronary arteries.
Although aspirin is used as an antipyretic agent for adult clients, the nurse should recognize
that it is prescribed to this client for a different therapeutic effect. Aspirin should not be used
to treat fever for client suspected to have meningitis.

A nurse is collecting data from a client who has open-angle glaucoma. Which of the
following findings should the nurse expect?
1) Loss of peripheral vision
2) Headache
3) Halos around lights
4) Discomfort in the eyes
Answer: 1) Loss of peripheral vision
Rationale:
The nurse should expect to find the client experiencing a gradual loss of peripheral vision
with a narrowing of the visual field with open-angle glaucoma.
Headache is associated with acute angle-closure glaucoma.
A halo around lights with blurred vision is associated with acute angle-closure glaucoma.
Discomfort in the eyes is associated with acute angle-closure glaucoma.
A nurse is collecting data from a client who has acute gastroenteritis. Which of the following
data collection findings should the nurse identify as the priority?
1) Weight loss of 3% of total body weight.
2) Blood glucose 150 mg/dL
3) Potassium 2.5 mEq/L
4) Urine specific gravity 1.035
Answer: 3) Potassium 2.5 mEq/L
Rationale:
The nurse should monitor a weight loss of 3% of total body weight, which indicates mild
fluid volume deficit; however, another finding is the priority.
The nurse should monitor a blood glucose of 150 mg/dL, which indicates mild
hyperglycemia; however, another finding is the priority.
When using the airway, breathing, circulation approach to client care, the nurse determines
that the priority finding is a potassium level of 2.5 mEq/dL.
In the presence of fluid volume deficit, potassium depletion can occur. Complications from
hypokalaemia include cardiac and respiratory manifestations.
The nurse should monitor a urine specific gravity of 1.035, which indicates concentrated
urine; however, another finding is the priority.

A nurse is reinforcing discharge teaching with a client who had a total abdominal
hysterectomy and a vaginal repair. Which of the following statements by the client indicates a
need for further teaching?
1) "I should increase my intake of protein and vitamin C."
2) "I will no longer have menstrual periods."
3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience
discomfort."
4) "I will take a tub bath instead of a shower."
Answer: 4) "I will take a tub bath instead of a shower."
Rationale:
The client should increase her intake of protein and vitamin C to promote wound healing.
Following a total abdominal hysterectomy the client may have vaginal discharge for a short
period of time, but the client will no longer have menstrual periods.
The client who has had a vaginal repair may experience discomfort during intercourse. A
water-based lubricant may help to reduce the discomfort.
To reduce the risk of infection, the client should avoid tub baths following a total abdominal
hysterectomy.
A nurse is assisting with the care of a client who has a femur fracture and is in skeletal
traction. Which of the following actions should the nurse take?
1) Loosen the knots on the ropes if the client is experiencing pain.
2) Ensure the client’s weights are hanging freely from the bed.
3) Check the client’s bony prominences every 12 hr.
4) Cleanse the client’s pin sites with povidone-iodine.
Answer: 2) Ensure the client’s weights are hanging freely from the bed.
Rationale:
The knots should never be loosened on the ropes. Doing this will unsecure the traction and
possibly injure the client.
The nurse should ensure that the client’s weights are hanging freely from the bed to maintain
the client in proper body alignment and should never be removed without a provider
prescription or the development of a life threatening situation that requires removal.
The client’s bony prominences and skin should be checked every 8 hr for skin breakdown,
irritation, and inflammation.

The nurse should cleanse the client’s pin sites with chlorhexidine solution to keep the sites
clean and free from bacteria.
A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
Answer: 1) Take this medication between meals.
Rationale:
Although taking iron supplements with food can decrease adverse effects, it also drastically
reduces the absorption of iron. Therefore, the nurse should instruct the client that taking iron
is most effective when supplements are taken in between meals.
Taking Vitamin C (ascorbic acid) at the same time as taking iron can enhance the absorption
of iron, but it can increase the incidence of adverse effects. However, there is no reason for
the client to limit overall intake of ascorbic acid.
The nurse should instruct the client not to take iron with milk because it decreases the
absorption of the iron.
The nurse should instruct the client to increase consumption of high-fiber foods, such as
whole grains, while taking iron to prevent constipation.
A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
Answer: 1) Take this medication between meals.
Rationale:

Although taking iron supplements with food can decrease adverse effects, it also drastically
reduces the absorption of iron. Therefore, the nurse should instruct the client that taking iron
is most effective when supplements are taken in between meals.
Taking Vitamin C (ascorbic acid) at the same time as taking iron can enhance the absorption
of iron, but it can increase the incidence of adverse effects. However, there is no reason for
the client to limit overall intake of ascorbic acid.
The nurse should instruct the client not to take iron with milk because it decreases the
absorption of the iron.
The nurse should instruct the client to increase consumption of high-fiber foods, such as
whole grains, while taking iron to prevent constipation.
A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the
following interventions should the nurse recommend?
1) Apply topical antifungal agents.
2) Apply fresh ice packs every 4 hr.
3) Wash daily with an antibacterial soap.
4) Keep draining lesions uncovered to air dry.
Answer: 3) Wash daily with an antibacterial soap.
Rationale:
Cellulitis is a bacterial infection; therefore, the nurse should not plan to apply an antifungal
agent.
The nurse should plan to use warm compresses for a client who has a bacterial infection to
reduce edema to the area.
The nurse should plan to have the client wash the area daily with an antibacterial soap to
promote tissue health and treat the infection.
The nurse should plan to cover any lesions with exudate using a sterile dressing.
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy
established. Which of the following instructions should the nurse include in the teaching?
1) Empty the pouch immediately after meals.
2) Change the entire appliance once a day.
3) Limit fluid intake.
4) Avoid medications in capsule or enteric form.
Answer: 4) Avoid medications in capsule or enteric form.

Rationale:
The client should wait for up to 4 hr after eating to empty the pouch, because the client’s
bowel is less active.
The client should leave the entire appliance in place for 3 days to a week if not leaking.
The client should drink plenty of water and other liquids to avoid fluid volume deficit, due to
the loss of fluid caused by the ileostomy.
The client should not take medications in capsule or enteric form because the medication may
enter the pouch undigested.
A nurse is caring for a client with severe burns to both lower extremities. The client is
scheduled for an escharotomy and wants to know what the procedure involves. Which of the
following statements is appropriate for the nurse to make?
1) "An escharotomy surgically removes dead tissue."
2) "A cannula will be inserted into the bone to infuse fluids and antibiotics."
3) "A piece of skin will be removed and grafted over the burned area."
4) "Large incisions will be made in the burned tissue to improve circulation."
Answer: 4) "Large incisions will be made in the burned tissue to improve circulation."
Rationale:
This statement refers to surgical debridement. Necrotic tissue and exudate are removed to
stimulate granulation and revascularization of the burn wound. It can be performed surgically
or non-surgically through mechanical or enzymatic actions.
This statement refers to intraosseous infusion therapy. Intraosseous infusion is used in cases
of severe trauma, burns, or other life-threatening conditions when intravenous access cannot
be obtained.
This statement refers to a skin graft. A skin graft is a surgical procedure in which a piece of
skin from one area of the client's body is transplanted to another area.
An escharotomy is a surgical incision made to release pressure and improve circulation in a
part of the body that has had a deep burn and is experiencing significant swelling. The
swelling that occurs secondary to burn injuries that completely encircle a body part, such as
an arm or the chest, can cause tightness and constriction of underlying tissue and can shut off
circulation in the affected area. Making surgical incisions into the burned tissue allows the
skin to expand and re-establish circulation.

A nurse is collecting data from a client who has a possible cataract. Which of the following
manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
4) Eyestrain
Answer: 1) Decreased color perception
Rationale:
Visual manifestations associated with cataracts can include decreased color perception and
decreased visual acuity, even in daylight.
Loss of peripheral vision occurs in clients who have open-angle glaucoma.
Bright flashes of light and floaters are associated with retinal detachment.
Eyestrain is associated with decreased visual acuity.
A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is
receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the
following interventions should the nurse include in the plan of care?
1) Measure abdominal girth daily.
2) Use sterile water to irrigate the nasogastric tube.
3) Maintain the client in Fowler’s position.
4) Moisten the client’s lips with lemon-glycerine swabs.
Answer: 3) Maintain the client in Fowler’s position.
Rationale:
An increase in abdominal girth indicates that the client’s abdominal distension has increased.
The nurse should measure the client’s abdominal girth every 4 to 8 hr.
To preserve the client’s electrolyte balance, the nurse should use 0.9% sodium chloride to
irrigate the nasogastric tube.
The nurse should place the client in Fowler’s position to reduce pressure on the diaphragm
and to promote function of the nasogastric tube.
The nurse should avoid using lemon-glycerine swabs because they cause drying of the lips.
The nurse should use a water-soluble lip lubricant to moisten the client’s lips.

A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
4) Tremors
5) Obese extremities
Answer: 1) Buffalo hump
2) Purple striations
3) Moon face
Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production
of cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between
the shoulders, is a common manifestation of Cushing's syndrome.
Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts
are a common manifestation of Cushing's syndrome. This is due to the collection of body fat
in these areas.
Moon face is correct. Moon face is a common manifestation of Cushing's syndrome. Clients
who have this manifestation present with a round, red, full face.
Tremors is incorrect. Tremors are not a common finding of Cushing's syndrome.
Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity, a
protuberant abdomen, with thin extremities, which is due to an alteration in protein
metabolism.
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the
following actions should the nurse take?
1) Provide a diet high in protein.
2) Provide ibuprofen for retroperitoneal discomfort.
3) Monitor intake and output hourly
4) Encourage the client to consume at least 2 L of fluid daily.
Answer: 1) Provide a diet high in protein.
3) Monitor intake and output hourly
Rationale:

The client with acute kidney injury is limited on their protein intake as this decreases the risk
of the client developing chronic renal failure.
The nurse should avoid administering medications that are nephrotoxic to a client who has
acute kidney injury. The injury to the kidney causes an increase in drug excretion which can
lead to toxic levels.
The nurse should closely monitor the client for signs of fluid imbalance. This includes hourly
monitoring of intake and output, along with daily weights. If there are sudden changes, or the
urinary output is less than 30 mL/hr, the provider must be notified immediately.
The client who is in the oliguric stage of acute kidney injury is not producing urine and will
be placed on fluid restrictions, often less than 1,200 mL daily which includes intravenous
fluids. Excessive fluid intake can result in fluid overload.
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has
upper gastric pain. Which of the following statements should the nurse include in the
teaching?
1) "A flexible tube is introduced through the nose during the procedure."
2) "During the procedure you are in a sitting position."
3) "You will remain NPO for 8 hours before the procedure."
4) "You will be awake while the procedure is performed."
Answer: 1) "A flexible tube is introduced through the nose during the procedure."
3) "You will remain NPO for 8 hours before the procedure."
Rationale:
The nurse should include in the teaching that a flexible tube is introduced through the client's
mouth with the head extended for easier entry and visualization.
The nurse should include in the teaching that the client will lie down with the head of bed
elevated slightly during the procedure. The client's head is extended for easier entry and
visualization.
The nurse should include in the teaching for the client to remain NPO for 8 hr before the
procedure to have the stomach free of food contents, decrease vomiting, and decrease the risk
for aspiration.
The nurse should include in the teaching that the client will receive moderate sedation during
the procedure to promote relaxation for easier entry and visualization.

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours
following a generalized tonic-clonic seizure. Which of the following descriptions should the
nurse use when documenting this finding in the medical record?
1) Aura phase
2) Presence of automatisms
3) Postictal phase
4) Presence of absence seizures
Answer: 3) Postictal phase
Rationale:
The nurse should use the term "aura" to describe manifestations the client experienced prior
to a seizure.
The nurse should use the term "automatisms" to describe repetitive, non-purposeful actions a
client might exhibit as part of a complex, partial seizure.
The postictal phase is the recovery period following a tonic-clonic seizure. The client might
be confused or agitated after a seizure and might sleep for several hours.
The nurse should use the term "absence seizure" to describe a brief loss of consciousness
experienced by a client accompanied by staring.
A nurse is reinforcing teaching with a client who reports right shoulder pain following a
laparoscopic cholecystectomy. Which of the following statements should the nurse make?
1) "The pain results from lying in one position too long during surgery."
2) "The pain occurs as a residual pain from cholecystitis."
3) "The pain will dissipate if you ambulate frequently."
4) "The pain is caused from the nitrous dioxide injected into the abdomen."
Answer: 3) "The pain will dissipate if you ambulate frequently."
Rationale:
The client who lies in one position during surgery can have stiffness following surgery.
The client's right shoulder pain is due to the carbon dioxide injected into the abdominal cavity
to visualize and access the abdominal structure. The carbon dioxide causes referred pain in
the clavicle and shoulder area.
The client who has right shoulder pain following the procedure should ambulate as soon and
as much as possible to dissipate the carbon dioxide gas that was injected into the abdominal
cavity to visualize and access the abdominal structure. The carbon dioxide causes referred
pain in the clavicle and shoulder area.

The client who had a laparoscopic cholecystectomy will have gas (carbon dioxide) injected
into the abdominal cavity to visualize and access the abdominal structures during
laparoscopic procedures, which can irritate the diaphragm and cause referred pain in the
clavicle and shoulder.
A nurse is checking the suction control chamber of a client's chest tube and notes that there is
no bubbling in the suction control chamber.
Which of the following actions should the nurse take?
1) Notify the provider.
2) Verify that the suction regulator is on.
3) Continue to monitor the client because this is an expected finding.
4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Answer: 2) Verify that the suction regulator is on.
Rationale:
The nurse should check for kinks and take other measures before notifying the provider.
The nurse should verify that the suction regulator is turned on because low continual
bubbling will occur when the suction is on and there are no kinks in the tubing.
The nurse should expect the suction control chamber to display gentle bubbling of the water
in the suction control chamber; therefore, the nurse should take measures to discover why the
suction control chamber is not bubbling.
The nurse should milk the chest tube only when indicated and prescribed by the provider.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
Answer: 1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
Rationale:

Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated,
to replace the cerebrospinal fluid that was removed during the procedure and reduce the risk
for a headache.
Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a
hematoma at the insertion site because this can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion.
Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or
more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for
this client.
A nurse is assisting with the care of a client who is postoperative following surgical repair of
a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The
nurse should recognize which of the following is the priority action?
1) Relieve the client's pain.
2) Check the client’s pressure points for redness.
3) Provide oral hygiene.
4) Prevent aspiration.
Answer: 4) Prevent aspiration.
Rationale:
The nurse should provide pain medications and ice as prescribed to reduce the client’s pain;
however, another action is the priority.
The nurse should check the client’s pressure points for redness that could become a pressure
ulcer; however, another action is the priority.
The nurse should provide oral hygiene for the client to promote comfort; however, another
action is the priority.
When using the airway, breathing, circulation approach to client care, the nurse should
determine the priority action is to prevent aspiration. Since the client’s jaws are wired
together, aspiration is a risk if the client vomits. Therefore, the client should receive
medication for nausea, as indicated, and wire cutters and suction are kept at the bedside at all
times in case of vomiting or difficulty breathing.

A nurse is collecting data from a client who has scleroderma. Which of the following findings
should the nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
Answer: 4) Hardened skin
Rationale:
A dry raised rash, usually located on the client's face, is an expected finding with systemic
lupus erythematosus.
Excessive salivation is an expected finding with a cholinergic crisis, which can be cause by
an overdose of anticholinesterase.
Periorbital edema is an expected finding with dermatomyositis or an acute allergic reaction.
Hardened, tight skin is an expected finding with scleroderma. In addition to rigid skin and
subcutaneous tissues, the distal extremities stiffen and lose mobility. It can also cause
disorders of the heart, lungs and kidneys.
A nurse is caring for an older adult client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client's mouth.
3) Add thickener to fluids.
4) Serve food at room temperature.
Answer: 3) Add thickener to fluids.
Rationale:
The nurse should instruct the client to tilt her head forward when she swallows to facilitate
swallowing and prevent aspiration.
The nurse should place food on the unaffected side of the client's mouth to facilitate
swallowing and prevent aspiration.
The nurse should thicken fluids to make them easier to swallow and prevent aspiration.
The nurse should serve food cold or warm to facilitate swallowing and prevent aspiration.

A nurse is caring for a client who has partial-thickness and full thickness burns of his head,
neck, and chest. The nurse should recognize which of the following is the priority risk to the
client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
Answer: 1) Airway obstruction
Rationale:
When using the airway, breathing, circulation approach to client care, the nurse determines
that the priority risk to this client is airway obstruction. Burns in this area can involve damage
to the upper airway, resulting in swelling and respiratory compromise. The nurse should
monitor the client for manifestations of respiratory distress.
The nurse should monitor the client for infection due to compromised skin integrity.
However, another risk is the priority.
The nurse should monitor the client for fluid imbalance due to fluid shift and loss of fluids
through compromised skin integrity. However, another risk is the priority.
The nurse should monitor the client for contractures due to altered tissue elasticity as a result
of scarring. However, another risk is the priority.
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis
and is to start taking neostigmine. Which of the following instructions should the nurse
include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side effect of the neostigmine.
3) If a medication dose is missed, wait until the next scheduled dose to take the medication.
4) Treat nasal rhinitis with an over-the-counter antihistamine.
Answer: 1) Take the medication 45 minutes before eating.
Rationale:
The nurse should instruct the client to take the medication before eating to allow the
medication time to work and limit difficulty chewing and swallowing.
The nurse should reinforce that diaphoresis is an indication of cholinergic crisis caused by
overmedication with the neostigmine. It is a medical emergency.

The nurse should reinforce the importance of taking the medication on a strict schedule to
minimize the potential for myasthenic crisis. This is manifested as increased muscle
weakness, dysphagia, impaired speech, severe respiratory distress and anxiety.
The nurse should emphasize that the client should contact her provider before taking any
over-the-counter medication. Antihistamines can actually worsen the symptoms of
myasthenia gravis and should be avoided.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection
of the prostate (TURP) and has a 3way urinary catheter with continuous irrigation. The nurse
notes there has not been any urinary output in the last hour. Which of the following actions
should the nurse perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
Answer: 4) Determine the patency of the tubing.
Rationale:
The nurse should notify the provider with updates regarding potential complications in the
care of the client; however, another action is the priority.
The nurse should provide the client who has had a TURP with an analgesic if needed, since
bladder spasms are a potential complication of the procedure; however, another action is the
priority.
Increasing oral fluid intake is important for the client who has undergone a TURP in order to
ensure adequate renal functioning and urinary output; however another action is the priority.
The first action the nurse should take when using the nursing process is to determine the
patency of the tubing by assessing for kinks in the tubing or the presence of clots. A lack of
drainage may be the result of kinked drainage tubing, a blood clot, or tissue blocking the
drainage tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear
about the procedure and asks the nurse if the biopsy will hurt. Which of the following
responses should the nurse make?
1) "You must be very worried about what the biopsy will show."
2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’s happening."

3) "Your provider scheduled this, so she will want to know you still have questions about the
procedure."
4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."
Answer: 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as
possible."
Rationale:
This response is nontherapeutic because it is judgmental and does not address the information
that the client is seeking.
This response is nontherapeutic because it discourages further communication from the
client. The nurse should understand the client will not receive general anaesthesia for this
procedure.
This response is nontherapeutic because it puts the client's concerns on hold and focuses on
the provider.
This response is therapeutic because it gives the client the information that she needs to cope,
and reassures the client of the plan to address her comfort, and allows for further
communication of concerns by the client.
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric
stroke. Which of the following interventions should the nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function.
Answer: 3) Re-establish communication.
Rationale:
A client who has a right-hemisphere lesion is likely to be impulsive. Clients who have a lefthemisphere lesion are typically cautious.
A client who has a right-hemisphere lesion is likely to experience visual field deficits of the
right side.
A stroke is an interruption of the blood supply to a part of the brain, resulting in oxygendeprived brain tissue. The left hemisphere is usually dominant for language. Because this
client had a left-hemispheric stroke, the nurse can anticipate that the client will have some
degree of aphasia and will require communication-focused nursing interventions and speech
therapy to reestablish communication.

A client who has a right-hemisphere lesion can experience hemiplegia on the left side.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should
monitor the client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
Answer: 1) Hypotension
Rationale:
The client who has diabetes insipidus produces excessive urine resulting in hypovolemia and
hypotension. The nurse should monitor the client for hypotension and dehydration.
Polyphagia, or excessive hunger, is a manifestation of diabetes mellitus.
Hyperglycemia, or elevated blood glucose, is a manifestation of diabetes mellitus.
Tachycardia is a manifestation of diabetes insipidus.
A nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm Hg
Base excess -2
PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
1) Metabolic acidosis
2) Respiratory acidosis
3) Metabolic alkalosis
4) Respiratory alkalosis
Answer: 2) Respiratory acidosis
Rationale:
The nurse should identify the client who has metabolic acidosis as having an excessive loss
of bicarbonate through diarrhoea, or an increased retention of hydrogen ions such as that seen

in renal failure. A client who has metabolic acidosis would have a pH and a bicarbonate
levels that are lower than the normal reference ranges.
The nurse should identify the client who has respiratory problems such as obstruction or
depression of the respiratory system as at risk for the development of respiratory acidosis.
The expected pH range is 7.35 to 7.45. The pH of 7.22 indicates that this client is acidotic.
The pH is decreased while the PaCO2 is elevated. Therefore, the correct interpretation of the
results is that the client is in respiratory acidosis.
The nurse should identify the client who has metabolic alkalosis as a client who has a loss of
hydrochloric acid through vomiting, gastric suction, or excessive use of antacids. The pH of
the client would be higher than the normal reference range of 7.35 – 7.45 and the bicarbonate
would be higher than the normal reference range of 22 – 26 mEq/L.
The nurse should identify the client who is hyperventilating or has an elevated temperature as
being at risk for respiratory alkalosis. The pH of the client would be higher than the normal
reference range of 7.35 – 7.45 and the PaCO2 would be lower than the normal reference
range of 35 – 45 mm Hg.
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The
nurse should recognize that which of the following statements by the client indicates a need
for further teaching?
1) "I will avoid crossing my legs at the knees."
2) "I will use a thermometer to check the temperature of my bath water."
3) "I will not go barefoot."
4) "I will wear stockings with elastic tops."
Answer: 4) "I will wear stockings with elastic tops."
Rationale:
The nurse should reinforce with the client to avoid crossing her legs at the knees because this
can impair circulation.
The nurse should reinforce with the client to use a thermometer to check the temperature of
bath water to reduce the risk of burns. PVD can impair the client’s ability to sense water
temperature.
The nurse should reinforce with the client to wear shoes at all times to protect her feet from
injury.
The nurse should reinforce with the client to avoid constrictive clothing that can impair
circulation.

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's
disease. The client becomes agitated and combative when the nurse approaches him. Which
of the following actions should the nurse plan to take?
1) Turn the water on and ask the client to test the temperature.
2) Obtain assistance to place mitten restraints on the client.
3) Firmly tell the client that good hygiene is important.
4) Calmly ask the client if he would like to listen to some music.
Answer: 4) Calmly ask the client if he would like to listen to some music.
Rationale:
The nurse should recognize that hearing water running could increase the client’s agitation,
and asking the client to check the water temperature could cause injury to the client.
The nurse should not use restraints unless the client is at risk for harm to himself or others,
and after attempting all other alternatives to restraints first.
The nurse should avoid using firm speech, which could be interpreted by the client as a threat
and could increase his anxiety. The client has impaired cognition and thinking; therefore,
reasoning intellectually with the client is not likely to be effective.
The nurse should remain calm to avoid agitating the client further. By offering to play music,
the nurse may be able to distract the client and then reintroduce the idea of morning care.
A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is
covered with soft, red tissue that bleeds easily. The nurse should recognize this is a
manifestation of which of the following?
1) Decreased perfusion
2) Infection
3) Granulation tissue
4) An inflammatory response
Answer: 3) Granulation tissue
Rationale:
Manifestations of decreased perfusion to wound is tissue is tissue that appears black or
necrotic
Manifestations of a wound infection is tissue that appears erythematous, or red, and can have
exudate or pus.

Granulation tissue forms in healing wounds during the proliferative phase. Granulation tissue
is soft, red tissue with a granular appearance that bleeds easily.
A manifestation of an inflammatory response is tissue that appears reddened and oedematous.
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm 3.
Which of the following food items brought by the family should the nurse prohibit from
being given to the client?
1) Baked chicken
2) Bagels
3) A factory-sealed box of chocolates
4) Fresh fruit basket
Answer: 4) Fresh fruit basket
Rationale:
The nurse should encourage the client to consume a diet that is high in proteins, calories, and
calcium to enhance nutrition and the client’s ability to fight infection. Baked chicken would
be an acceptable food to include in the client’s diet.
The nurse should encourage the client to consume a diet that is high in proteins, calories, and
calcium to enhance nutrition and the client’s ability to fight infection. A bread product, such
as a bagel, is an acceptable food to include in the client’s diet.
The nurse should recommend the client consume nutrient dense foods that are high in calories
and protein; however, a box of chocolates may stimulate the diet and is appropriate as an
occasional treat.
The nurse should instruct the client’s family that certain food products such as fresh fruit and
vegetables should be excluded from the client’s diet to reduce the risk of foodborne illness.
An alternative to the fresh fruits would be a package of dried fruits.
A nurse is contributing to the plan of care for an older adult client who is postoperative
following a right hip arthroplasty. Which of the following interventions should the nurse
include in the plan?
1) Perform the client's personal care activities for her.
2) Limit the client’s fluid intake.
3) Monitor the Homan’s sign.
4) Maintain abduction of the right hip.
Answer: 4) Maintain abduction of the right hip.

Rationale:
The client should be encouraged to perform all of the activities of ADLs possible, in order to
promote independence. This would include grooming (brushing hair and teeth, washing
hands and face) and eating meals.
The nurse should encourage the client to drink 2.5 to 3 L of fluid daily in order to maintain
hydration, bowel and renal function.
The nurse should monitor the postoperative client for the development of deep vein
thrombosis; however, the presence of a positive Homan’s sign is an unreliable indicator of
this complication.
The nurse should use an abductor pillow or other device to maintain abduction of the affected
hip to prevent dislocation.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the
following actions should the nurse take first?
1) Establish IV access.
2) Feel for a carotid pulse.
3) Establish an open airway.
4) Auscultate for breath sounds.
Answer: 2) Feel for a carotid pulse.
Rationale:
The nurse should establish IV access for the delivery of emergency medications; however,
another action is the priority.
The priority action the nurse should take when using the compressions airway-breathing
approach to client care is to feel for a carotid pulse for 5 to 10 seconds to determine the
immediate need for chest compressions.
The nurse should establish an open airway to enable ventilation; however, another action is
the priority.
The nurse should auscultate breath sounds to confirm that there is ventilation; however,
another action is the priority. The nurse already knows the client has a respiratory arrest.
There will be no lung sounds until the nurse establishes ventilation through a patent airway
with a bag-valve-mask.

A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is
no longer certain he wants to have the procedure. Which of the following responses should
the nurse make?
1) "Why have you changed your mind about the surgery?"
2) "Bypass surgery must be very frightening for you."
3) "Your provider would not have scheduled the surgery unless you needed it."
4) "I will call your doctor and have him discuss your surgery with you."
Answer: 2) "Bypass surgery must be very frightening for you."
Rationale:
This response is nontherapeutic because it is probing the client for an explanation, which can
cause the client to become defensive.
This response is therapeutic because it shows empathy and focuses on the client's feelings in
a nonthreatening way, and it encourages the client to express his feelings.
This response is nontherapeutic because it minimizes the client's feelings and can appear
judgmental or disagreeing.
This response is nontherapeutic because it does not address the client's feelings by refusal to
discuss the issue.
A nurse is caring for a client who is postoperative following foot surgery and is not to bear
weight on the operative foot. The nurse enters the room to discover the client hopped on one
foot to the bathroom, using an IV pole for support. Which of the following actions should the
nurse take?
1) Walk the client back to bed immediately and get the client a bedpan.
2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
3) Warn the client she might have to be restrained if she gets up without assistance.
4) Keep the bathroom door open to ensure the client is okay.
Answer: 1) Walk the client back to bed immediately and get the client a bedpan.
2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
Rationale:
The nurse should not plan to walk the client back to bed because the client can’t bear weight
on one foot, and this will require the client to have to hop back to bed. This will alter the
client’s balance and possibly cause injury to the client and nurse.

The greatest risk to the client is falling. Since the client is already in the bathroom, the nurse
should allow the client to void, and then return the client to bed safely in a wheelchair to
prevent a fall.
The nurse should not threaten to restrain the client for non-adherence to the treatment plan
because this is a form of assault, and using restraints without just cause is considered false
imprisonment.
The nurse should respect the client's privacy and close the client’s bathroom door after
determining there is no immediate risk for harm.
A nurse is assisting with the care of a client who is postoperative and has a closed-wound
drainage system in place. Which of the following actions should the nurse take?
1) Fully re-collapse the reservoir after emptying it.
2) Empty the reservoir once per day.
3) Replace the drainage plug after releasing hand pressure on the device.
4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
Answer: 1) Fully re-collapse the reservoir after emptying it.
Rationale:
To reestablish the vacuum, the reservoir must be compressed fully after it is emptied.
The reservoir should be emptied before it becomes full or once per shift to maintain suction
pressure.
The nurse should replace the drainage plug before releasing hand pressure on the device.
The nurse should not irrigate a closed-wound drainage system.
A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the
following statements by the client indicates an understanding of the teaching?
1) "I will not eat fried foods."
2) "I will abstain from sexual intercourse."
3) "I will refrain from international travel."
4) "I will not order a salad in a restaurant."
Answer: 2) "I will abstain from sexual intercourse."
Rationale:
A client who has cholecystitis should avoid fried and fatty foods.
The client who has hepatitis A should abstain from sexual intercourse during the infectious
period.

Clients should receive the hepatitis A vaccine before international travel. However,
international travel is not prohibited.
Hepatitis A is transmitted by the fecal-oral route. The client who is infectious should not
prepare food during the infectious period.
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client
diagnosed with emphysema. Which of the following instructions should be included in the
teaching?
1) Rest in a supine position.
2) Consume a low-protein diet.
3) Breathe in through her nose and out through pursed lips.
4) Limit fluid intake throughout the day.
Answer: 3) Breathe in through her nose and out through pursed lips.
Rationale:
The nurse should reinforce that the client can relieve dyspnea by elevating her head and
aligning her head, body, neck, and chest.
The nurse should reinforce that a high protein, high calorie diet is recommended for the client
who has COPD, as this helps maintain nutrition and reduces fatigue.
The nurse should reinforce that pursed-lip breathing slows expiration, prevents collapse of
alveoli, and helps the client to control the rate and depth of respirations.
The nurse should encourage the client to drink 2.5 to 3L daily in order to thin secretions and
make breathing easier.
A nurse is caring for a client who is postoperative and has a history Addison's disease. For
which of the following manifestations should the nurse monitor?
1) Hypernatremia
2) Hypotension
3) Bradycardia
4) Hypokalaemia
Answer: 2) Hypotension
Rationale:
The client who has Addison's disease is at risk for developing Addisonian crisis following a
major physiological stressor such as surgery. The nurse should monitor for the development
of hyponatremia and dehydration in the client who is at risk for Addisonian crisis.

The client who has Addison's disease is at risk for developing Addisonian crisis following a
major physiological stressor such as surgery. Manifestations such as hypotension and
tachycardia, extreme weakness and a decrease in mental status are noted. Untreated,
Addisonian crisis may result in death.
The client who has Addison's disease is at risk for developing Addisonian crisis following a
major physiological stressor such as surgery. Manifestations the nurse should monitor for
include tachycardia.
The client who has Addison's disease is at risk for developing Addisonian crisis following a
major physiological stressor such as surgery. The nurse should monitor for the development
of hyperkalaemia and dysrhythmias in the client who is at risk for Addisonian crisis.
A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is
to take hydroxyzine preoperatively. Which of the following effects of the medication should
the nurse include in the teaching? (Select all that apply.)
1) Decreasing anxiety
2) Controlling emesis
3) Relaxing skeletal muscles
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer: 1) Decreasing anxiety
2) Controlling emesis
5) Reducing the amount of narcotics needed for pain relief
Rationale:
Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective
antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with
moderate anxiety.
Controlling emesis is correct. The nurse should include that hydroxyzine is an effective
antiemetic and is used to control nausea and vomiting in pre- and postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as
diazepam (Valium), are used to produce skeletal muscle relaxation.
Preventing surgical site infections is incorrect. The nurse should instruct the client that
antibiotics administered prior to surgery are used to diminish the risk of surgical site
infections; hydroxyzine, an antiemetic, does not have any effect on bacteria.

Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the
effects of narcotic pain medications. The nurse should instruct the client that when it is used
for surgical clients, narcotic requirements may be significantly reduced.
A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The
nurse should reinforce to the client to take which of the following dietary supplements with
this medication?
1) Vitamin D
2) Vitamin A
3) Iron
4) Niacin
Answer: 3) Iron
Rationale:
There is no need for the client to take a vitamin D supplement because vitamin D is not
necessary for red blood cell production.
There is no need for the client to take a vitamin A supplement because vitamin A is not
necessary for red blood cell production.
Epoetin alfa treats anaemia by stimulating the production of red blood cells. Supplemental
iron is needed for the production of haemoglobin and red blood cells by the bone marrow.
The client should take supplemental iron when taking epoetin alfa.
There is no need for the client to take a niacin supplement because niacin is not necessary for
red blood cell production.
A nurse is caring for a client after a radical neck dissection. To which of the following should
the nurse give priority in the immediate postoperative period?
1) Malnourishment related to NPO status and dysphagia
2) Impaired verbal communication related to the tracheostomy
3) High risk for infection related to surgical incisions
4) Ineffective airway clearance related to thick, copious secretions
Answer: 4) Ineffective airway clearance related to thick, copious secretions
Rationale:
Although ensuring that the client maintains adequate nutrition is an important nursing action,
this is not the priority during the immediate postoperative period.

Although the client's need to communicate is important, this is not the priority during the
immediate postoperative period.
Although monitoring the client for infection is an important nursing action, this is not the
priority during the immediate postoperative period.
According to the airway, breathing, circulation (ABC) priority-setting framework, the priority
action is the client's need for adequate oxygenation. A client who has a new tracheostomy
requires frequent suctioning in the early postoperative period because of copious secretions
and the decreased effectiveness of the cough mechanism.
A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8
who is admitted for comprehensive rehabilitation. Which of the following long-term goals is
appropriate with regard to the client's mobility?
1) Walk with leg braces and crutches.
2) Drive an electric wheelchair with a hand-control device.
3) Drive an electric wheelchair equipped with a chin-control device.
4) Propel a wheelchair equipped with knobs on the wheels.
Answer: 4) Propel a wheelchair equipped with knobs on the wheels.
Rationale:
Crutch walking, even with supportive braces, is an unrealistic goal for this client. A client
who has an injury at T1 to T10 may be able to walk with braces.
A client who has an injury at C5 would require an electric wheelchair with a hand control
device. A client who has a C8 spinal cord injury should have a greater degree of mobility.
A client who has an injury at C1 to C3 would require an electric wheelchair with a chincontrol device. A client who has a C8 spinal cord injury should have a greater degree of
mobility.
A client who has an injury at C8 has full use of the shoulders and arms but will likely
experience hand weakness. The addition of knobs on the wheels will help the client use the
wheelchair more effectively.
A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the
following risk factors should the nurse identify as the leading cause of non-melanoma skin
cancer?
1) Exposure to environmental pollutants
2) Sun exposure

3) History of viral illness
4) Scars from a severe burn
Answer: 2) Sun exposure
Rationale:
The nurse should identify exposure to environmental pollutants as a risk factor for cancer due
to their potential to change genetic DNA; however, evidence-based practice indicates there is
another risk factor that is the leading cause of skin cancer.
According to evidenced-based practice, the nurse should identify exposure to the sun as the
leading cause of non-melanoma skin cancer. Ultraviolet light radiation from the sun can cause
cancerous changes in the skin. Decreased ozone protection has increased the amount of
radiation exposure and increased the risk of cancer for clients regardless of skin color.
The nurse should identify a history of viral illness as a risk factor for cancer due to the ability
of a virus to alter the genetic material of a cell; however, evidence-based practice indicates
there is another risk factor that is the leading cause of skin cancer.
The nurse should identify a burn injury as a risk for skin cancer due to the skin’s greater
sensitivity to sunlight; however, evidence-based practice indicates there is another risk factor
that is the leading cause of skin cancer.
Based on a client's recent history, a nurse suspects that a client is beginning menopause.
Which of the following questions should the nurse ask the client to help confirm the client is
experiencing manifestations of menopause?
1) "Do you sleep well at night?"
2) "Have you been experiencing chills?"
3) "Have you experienced increased hair growth?"
4) "When did you begin your menses?"
Answer: 1) "Do you sleep well at night?"
Rationale:
Menopause causes vasomotor instability, which can cause night sweats and sleep
disturbances. Therefore, this is an appropriate question for the nurse to ask.
The nurse should ask the client about night sweats, which are a common manifestation of
menopause.
The nurse should ask the client about body hair loss, which is a common manifestation of
menopause related to declining estrogen levels.
The onset of menopause is unrelated to the age of menarche.

A nurse is reinforcing teaching with a client about cancer prevention and plans to address the
importance of foods high in antioxidants. Which of the following foods should the nurse
include in the teaching?
1) Cottage cheese
2) Fresh berries
3) Bran cereal
4) Skim milk
Answer: 1) Cottage cheese
2) Fresh berries
Rationale:
The nurse should identify cottage cheese as a good source of calcium.
The nurse should include fresh berries (blackberries, strawberries, blueberries, and
cranberries), coffee, kale, and dark chocolate as food sources high in antioxidants.
The nurse should identify bran cereal as a good source of fiber.
The nurse should identify skim milk as a good source of calcium.
A nurse is assisting with caring for a client who has a new concussion following a motorvehicle crash. The nurse should monitor the client for which of the following manifestations
of increased intracranial pressure?
1) Polyuria
2) Battle's sign
3) Nuchal rigidity
4) Lethargy
Answer: 4) Lethargy
Rationale:
Polyuria is a manifestation of diabetes insipidus.
Battle sign, or bruising behind the ear, is a manifestation of a skull fracture.
Nuchal rigidity, or neck stiffness, is a manifestation of meningitis or bleeding into the
subarachnoid space.
An early manifestation of increased intracranial pressure is lethargy. The nurse should
monitor and report any changes in the client's level of consciousness, such as restlessness or
disorientation, because these are early manifestations of increased intracranial pressure.

A nurse is reinforcing teaching about a tonometry examination with a client who has
manifestations of glaucoma. Which of the following statements should the nurse include in
the teaching?
1) "Tonometry is performed to evaluate peripheral vision."
2) "This test will diagnose the type of your glaucoma."
3) "Tonometry will allow inspection of the optic disc for signs of degeneration."
4) "This test will measure the intraocular pressure of the eye."
Answer: 4) "This test will measure the intraocular pressure of the eye."
Rationale:
The nurse should identify the visual field test as determining the loss of peripheral vision.
The nurse should identify gonioscopy as the examination used to differentiate between openand and angle-closure glaucoma. An instrument, the gonioscope, is used to measure the depth
of the anterior chamber.
The nurse should identify fundoscopy as the examination performed to assess the color of the
eye’s fundus as well as the optic disc itself.
A tonometry examination provides a precise and simple way to measure intraocular pressure.
This is a component of a comprehensive eye examination and is crucial for clients who have
glaucoma or who are at high risk for developing intraocular hypertension.
A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a
kidney transplant. Which of the following laboratory findings should the nurse identify as the
most important to report to the provider?
1) Increase in serum glucose
2) Increase in serum creatinine
3) Decrease in white blood cell count
4) Decrease in platelets
Answer: 2) Increase in serum creatinine
Rationale:
The nurse should monitor and report the client's glucose level, as cyclosporine can cause
hyperglycemia that can delay healing; however, another finding is the priority.
The nurse should identify the elevated serum creatinine level as the priority finding to report.
Cyclosporine is nephrotoxic, so an increase in the creatinine and BUN levels can indicate the
medication dosage is too high and must be decreased to recover renal function.

The nurse should monitor and report a decrease in white blood cell count, as this is an
indication that the client will have difficulty fighting infection and is an adverse effect of the
medication; however, another finding is the priority.
The nurse should monitor and report a decrease in platelets, as this is an indication of
impaired clotting ability and an adverse effect of the medication; however, another finding is
the priority.
A nurse is checking for paradoxical blood pressure on a client who has constrictive
pericarditis. Which of the following findings should the nurse expect?
1) Apical pulse rate different than the radial pulse rate
2) Increase in heart rate by 20% when standing
3) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position
4) Drop in systolic BP more than 10 mm Hg on inspiration
Answer: 4) Drop in systolic BP more than 10 mm Hg on inspiration
Rationale:
An apical pulse rate different than the radial pulse rate is called a pulse deficit and needs
further investigation by the nurse.
The nurse should check the client for orthostatic hypotension when the pulse rate increases by
20% when standing.
The nurse should check the client for orthostatic hypotension when the client's systolic BP
drops by 20 mm Hg when moving from a lying to a sitting position.
The nurse should expect the client who has constrictive pericarditis to have a decrease in
systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood
pressure. This is also an expected finding for a client who has pulmonary hypertension or
pericardial tamponade.
A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client
entering the room of another client, who becomes upset and frightened. Which of the
following actions should the nurse take?
1) Attempt to determine what the client was looking for.
2) Explain the client’s Alzheimer’s diagnosis to the frightened client.
3) Reprimand the client for invading the other client's privacy.
4) Ask the client to apologize for his behavior.
Answer: 1) Attempt to determine what the client was looking for.

Rationale:
Clients who have Alzheimer's disease frequently exhibit wandering behavior when they have
an unmet need. The nurse should attempt to discover the reason for the client’s wandering,
which could include a need for toileting, uncontrolled pain, or searching for a familiar object.
The nurse should not reveal information about this client’s diagnosis because it violates the
client’s rights to privacy.
The nurse should recognize the client is confused; therefore, this action is inappropriate.
The nurse should recognize the client is confused; therefore, this action is inappropriate.
A nurse is caring for a client immediately following a cardiac catheterization with a femoral
artery approach. Which of the following actions should the nurse take?
1) Check pedal pulses every 15 min.
2) Perform passive range-of-motion for the affected extremity.
3) Remind the client not to turn from side to side.
4) Keep the client in high-Fowler's position for 6 hr.
Answer: 1) Check pedal pulses every 15 min.
Rationale:
The observation of a client who has undergone a cardiac catheterization includes monitoring
the client's pulses below the puncture site.
Moving the affected extremity could dislodge a clot at the femoral access site and cause
haemorrhage.
The client can turn from side to side as long as he keeps the affected extremity straight.
The nurse should keep the head of the client’s bed no higher than a 30° elevation after cardiac
catheterization with a femoral artery approach.
A nurse is assisting with planning an immunization clinic for older adult clients. Which of the
following information should the nurse plan to include about influenza?
1) Individuals at high risk should receive the live influenza vaccine.
2) Immunization for influenza should be repeated every 10 years.
3) The composition of the influenza vaccine changes yearly.
4) The influenza vaccine is necessary only for clients who have never had influenza.
Answer: 3) The composition of the influenza vaccine changes yearly.
Rationale:

The nurse should include that individuals at high risk receive the inactivated influenza
vaccine.
The nurse should include this recommendation for clients with instructions about the tetanus
booster vaccine.
Influenza outbreaks occur annually and the prevalent influenza viruses change yearly.
Consequently, the previous year's influenza immunization will not protect a client exposed to
the current year's influenza strains.
The nurse should recommend the influenza vaccine for any client over the age of 6 months.
Older adult clients are a high-risk group for contracting influenza. Influenza in older adult
clients might result in the development of primary viral influenza pneumonia, which can be
life threatening.
A nurse is caring for an older adult client who has colon cancer. The client asks the nurse
several questions about his treatment plan. Which of the following actions should the nurse
take?
1) Tell the client to have a family member call the provider to ask what options he plans to
recommend.
2) Assure the client that the provider will tell him what is planned.
3) Help the client write down questions to ask his provider.
4) Provide the client with a pamphlet of information about cancer.
Answer: 3) Help the client write down questions to ask his provider.
Rationale:
This action implies that the client's concerns can wait and can suggest the client is not
competent. This option imposes a communication block by placing the client's concerns on
hold.
This action blocks communication by placing the client's concerns on hold and giving false
reassurance.
To empower the client in decision-making, the nurse should help the client write down
questions to ask the provider. In doing this, the nurse acts as a client advocate to address the
client’s specific questions in a concrete, measurable way.
This action does not address the client's concerns about his specific treatment plan.

A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is
distressed over his mother's crying and condition. Which of the following responses should
the nurse make?
1) "If you just sit quietly with your mother, I'm sure she will calm down."
2) "I'll talk with your mother and see if I can comfort her."
3) "It must be hard to see your mother so ill and upset."
4) "Your mother's crying seems to bother you more than it does her."
Answer: 3) "It must be hard to see your mother so ill and upset."
Rationale:
This response is non-therapeutic because it ignores the feelings of the son and provides false
reassurance.
This response is nontherapeutic because it is closed-ended and ignores the son's feelings of
distress.
This response is therapeutic because it demonstrates empathy and acknowledges the son's
feelings of helplessness and powerlessness.
This response is nontherapeutic because it belittles or rejects the son's feelings.
A nurse is reinforcing teaching with the family of a client who has primary dementia. Which
of the following manifestations of dementia should the nurse include in the teaching?
1) Temporary, reversible loss of brain function
2) Forgetfulness gradually progressing to disorientation
3) Sleeping more during the day than nighttime
4) Hyper vigilant behaviors
Answer: 2) Forgetfulness gradually progressing to disorientation
Rationale:
Dementia is a progressive, irreversible, decline that affects thinking and motor skills.
Dementia usually appears first as forgetfulness. Loss of functioning progresses slowly from
impaired language skills and difficulty with ordinary, daily activities to severe memory loss
and complete disorientation with withdrawal from social interaction.
Clients who have dementia wake frequently during the night. The nurse should expect a
client who has acute delirium to exhibit a reversed sleep cycle.
The nurse should expect a client who has delirium to possibly exhibit hypervigilant behavior.

A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the
following interventions should the nurse include in the plan?
1) Limit fluid intake.
2) Monitor client’s cardinal fields of vision.
3) Encourage ambulation.
4) Ensure the room is brightly lit.
Answer: 2) Monitor client’s cardinal fields of vision.
Rationale:
The nurse should encourage fluid intake to minimize the nausea and dizziness experienced by
the client.
The nurse should assess for nystagmus, abnormal jerking movements of the eyes, by
evaluating the six cardinal fields of gaze. Nystagmus is a manifestation of labyrinthitis.
The nurse should encourage bed rest for the client who has labyrinthitis to prevent falls and
injury. The client should be instructed to wait for assistance when getting out of bed.
The nurse should provide dim lighting for the client to minimize the symptoms of
labyrinthitis.
A nurse is contributing to the plan of care for a client who is admitted with a deep vein
thrombosis (DVT) of the left leg. Which of the following interventions should the nurse
include in the plan?
1) Apply ice to the extremity
2) Monitor platelet levels
3) Restrict oral fluids
4) Administer vasodilating medications
Answer: 2) Monitor platelet levels
Rationale:
The nurse should include the application of warm, moist heat, rather than ice to decrease
inflammation and edema, relieve muscle spasms, and promote comfort.
The nurse should monitor platelet levels along with other laboratory results related to blood
coagulability and the medication therapy for the treatment of a deep vein thrombosis.
Initially, medications such as heparin or enoxaparin are administered; laboratory test would
include PTT. Later, warfarin therapy may be initiated for which PT/INR would be monitored.
Platelets are monitored because the client is at risk for heparin inducted thrombocytopenia,
placing the client at risk for bleeding.

The nurse should encourage fluids to reduce blood viscosity.
The nurse should recognize that anticoagulant medications, such as heparin and warfarin, are
used to prevent further clot formation. Administration of vasodilators, which may be used as
antihypertensives, have no beneficial effect for thrombophlebitis.
A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a
close family contact tests positive. Which of the following measures should the nurse
anticipate preparing for this client?
1) Tuberculin skin test
2) Sputum culture for acid fast bacillus (AFB)
3) Bacille Calmette-Guérin (BCG) vaccine
4) Chest x-ray
Answer: 1) Tuberculin skin test
Rationale:
The nurse should anticipate preparing the client to receive the tuberculin skin test (TST). The
TST is an accurate screening tool for the presence of tuberculosis in an individual; however,
it does not distinguish between previous exposure and active illness. The TBT requires
multiple visits to the clinic, one to receive the injection and another visit, 48-72 hours later, to
have the test read by a qualified health professional.
The nurse should recognize that the use of a sputum culture for AFB is used to confirm the
diagnosis of active TB after the initial screening.
The nurse should recognize that the BCG vaccine is administered in many foreign countries
and individuals should be screened to determine if they have received this vaccine in the past.
False-positive results are seen with the TST in individuals who have received the bCG
vaccine.
The nurse should recognize that a chest x-ray is used to confirm the diagnosis after the initial
screening and evaluate the presence of calcified tubercular lesions. A chest x-ray is performed
on any individual with a history of a positive TST.
A nurse is reviewing data for a client who has a head injury. Which of the following findings
should indicate to the nurse that the client might have diabetes insipidus?
1) Serum sodium 145 mEq/L
2) Urine specific gravity 1.028
3) Urine output 650 mL/hr

4) Blood glucose 198 mg/dL
Answer: 3) Urine output 650 mL/hr
Rationale:
A client who has diabetes insipidus will have an elevated serum sodium level. This client's
serum sodium level is within the expected range.
With diabetes insipidus, the specific gravity of the client's urine will be below the expected
reference range. This client's urine specific gravity is within the expected range.
Diabetes insipidus is an endocrine disorder of the anterior pituitary gland. A decrease in
antidiuretic hormone results in an increasingly high output of very dilute urine.
Diabetes mellitus can cause an elevated serum glucose level.
A nurse is caring for a client who has recurrent kidney stones and a history of diabetes
mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should
collect additional data about which of the following statements made by the client?
1) "I took a laxative yesterday."
2) "I took my metformin before breakfast."
3) "I haven't had anything to eat or drink since last night."
4) "The last time I voided it was painful."
Answer: 2) "I took my metformin before breakfast."
Rationale:
The nurse should recognize that laxatives are commonly prescribed for the day before an IVP
to remove feces, fluid, and air from the intestines.
The nurse should identify clients taking metformin are at risk for lactic acidosis when
receiving contrast media. Additional data should be collected about this statement.
It is usually recommended that the client have nothing by mouth after midnight on the night
before an IVP.
The nurse should recognize that pain while voiding is an expected manifestation for clients
with kidney stones.
A nurse is collecting data from a client who is having an acute asthma exacerbation. When
auscultating the client's chest, the nurse should expect to hear which of the following sounds?
1) Expiratory wheeze
2) Pleural friction rub
3) Fine rales

4) Rhonchi
Answer: 1) Expiratory wheeze
Rationale:
Expiratory wheezing is associated with air movement through narrowed airways, as with the
bronchospasm associated with asthma.
A pleural friction rub is a sound that originates outside the airways and is associated with
inflammatory processes, such as pleurisy.
Fine rales are an intermittent sound heard in clients who have pneumonia.
Rhonchi are low pitched course sounds heard in clients who have thick secretions.
A nurse is planning to change an abdominal dressing for a client who has an incision with a
drain. Which of the following actions should the nurse plan to take?
1) Remove the entire dressing at once.
2) Loosen the dressing by pulling the tape away from the wound.
3) Don clean gloves to remove the dressing.
4) Open sterile supplies before removing the dressing.
Answer: 3) Don clean gloves to remove the dressing.
Rationale:
The nurse should remove the outer layer of the dressing first, then the under layer of dressing.
This allows the nurse to monitor the drainage and limits the possibility of disrupting the
healing wound and the drain, which can be hidden in the layers of the dressing.
The nurse should loosen the tape by pulling toward the wound. Pulling the tape away from
the wound can be painful and puts tension on the delicate edges of the healing wound.
Standard precautions require the nurse to don clean gloves whenever there is a possibility of
coming into contact with secretions. Sterile gloves are not necessary until applying the new
sterile dressing.
The nurse should prepare the sterile field after removing the dressing to prevent
contamination of the sterile field.
A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the
following positions should the nurse place the client for the procedure?
1) Prone with arms raised over the head.
2) Sitting, leaning forward over the bedside table.
3) High Fowler’s position

4) Side-lying with knees drawn up to the chest.
Answer: 2) Sitting, leaning forward over the bedside table.
Rationale:
The nurse should place a client who is undergoing postural drainage in a prone position with
the arms raised over the head when drainage of the lower posterior lung fields is desired.
Thoracentesis is aspiration of fluid or air from the pleural space. The nurse should place the
client in a sitting position and leaning over a bedside table to ensure that the diaphragm is
dependent. This facilitates the removal of accumulated fluid, which tends to pool in the bases
of the pleural space.
The nurse should place the client undergoing a paracentesis in a high Fowler’s position.
The nurse should place the client undergoing a lumbar puncture in a knee-to chest, lateral
position.

A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following
reactions from the client should the nurse initially expect?
1) Denial
2) Bargaining
3) Acceptance
4) Anger
Answer: 1) Denial
Rationale:
According to evidenced-based practice, the nurse should expect the client to first exhibit
behaviors of denial following a cancer diagnosis or with other type of loss. This initial stage
of grieving is often a self-protective behavior used until the client tis ready to acknowledge
and deal with the grief-causing issue.
The nurse should expect the client to exhibit bargaining, where the client acknowledges the
disease, but attempts to make a deal or trade in hopes of a cure. However, evidence-based
practice indicates that the nurse should expect the client to demonstrate a different grief
reaction first.
The nurse should expect the client to exhibit acceptance, at the end of the grieving process,
after working through other grief stages and finally resolving that the event is not changing.
Therefore, evidence-based practice indicates that the nurse should expect the client to
demonstrate a different grief reaction first.

The nurse should expect the client to exhibit anger, which can be manifested by defensive
behaviors towards the situation or others. However, evidence based practice indicates that the
nurse should expect the client to have a different grief reaction first.
A nurse is contributing to the plan of care for a client who is postoperative following
peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction
and closed-suction drains in place. Which of the following interventions should the nurse
include in the plan?
1) Irrigate the nasogastric tube with tap water.
2) Mark abdominal girth once daily.
3) Ambulate the client twice daily.
4) Place the client in a high Fowler’s position.
Answer: 4) Place the client in a high Fowler’s position.
Rationale:
The nurse should recognize that the nasogastric tube is primarily used for decompression.
Any irrigation of the stomach should be completed with sterile solution to prevent further risk
of infection as the peritoneum has already been compromised by bacteria.
The nurse should measure abdominal girth every eight hours to monitor for further distention.
The same measuring tape should be used and the area being measured should be marked to
allow for consistency.
The nurse should recognize that the client who has peritonitis should be restricted to bed rest
in order to minimize the spread of the abdominal infection.
The nurse should use measures to facilitate breathing in the client who has peritonitis. Placing
the client into a high Fowler’s position enhances lung expansion preventing respiratory
complications and aids in localizing purulent abdominal materials.
A nurse is caring for a client who is receiving haemodialysis. Which of the following client
measurements should the nurse compare before and after dialysis treatment to determine fluid
losses?
1) Neck vein distention
2) Blood pressure
3) Body weight
4) Abdominal girth
Answer: 3) Body weight

Rationale:
The nurse should monitor the presence of neck vein distention as this is an indication of fluid
volume excess; however, it should not be present following dialysis and does not measurably
reflect fluid losses or gains from dialysis.
The nurse should monitor the client’s blood pressure as this is an indication of fluid volume.
The client may develop hypotension as a result of fluid losses; however, blood pressure does
not measurably reflect fluid losses or gains from haemodialysis.
The nurse should weigh the client prior to and following dialysis in order to determine the
amount of fluid losses/gains from dialysis. Each kilogram (2.2 lb) of weight gained or lost is
equal to 1 L of fluid.
The nurse should measure the abdominal girth of clients receiving peritoneal dialysis to
determine whether the client is retaining any of the dialysate fluid. It is not measured in the
client who is receiving haemodialysis.
A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min
following the start of the transfusion, the nurse notes that the client is flushed and febrile, and
reports chills. To help confirm that the client is having an acute haemolytic transfusion
reaction, the nurse should observe for which of the following manifestations?
1) Urticaria
2) Muscle pain
3) Hypotension
4) Distended neck veins
Answer: 3) Hypotension
Rationale:
Urticaria, wheezing, anxiety, and shock are manifestations of an anaphylactic reaction to a
blood transfusion.
Muscle pain, fever, chills, headache, anxiety, and flushing are manifestations of a febrile,
nonhemolytic transfusion reaction.
Hypotension, tachycardia, tachypnoea, low back pain, flushing, chills, and fever are
manifestations of an acute haemolytic reaction to a blood transfusion.
Distended neck veins, cough, and dyspnoea are manifestations of a transfusion reaction from
circulatory overload.

A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The
nurse should recognize the client is experiencing which of the following conditions?
1) A continuous seizure state in which seizures occur in rapid succession
2) A sensory warning that a seizure is imminent
3) A period of sleepiness following the seizure during which arousal is difficult
4) A brief loss of consciousness accompanied by staring
Answer: 2) A sensory warning that a seizure is imminent
Rationale:
Status epilepticus is a continuous seizure state in which seizures occur in rapid succession.
An aura is a sensory warning that a seizure is imminent. The aura can be similar to a
hallucination and may involve any of the senses. The client can report "hearing bells",
"seeing lights", or "smelling something".
The postictal state is a period of sleepiness or lethargy following a seizure.
An absence, or petit mal, seizure is a brief loss of consciousness accompanied by staring.
A nurse is caring for a client who just had cataract surgery. Which of the following comments
from the client should the nurse report to the provider?
1) "The bright light in this room is really bothering me."
2) "My eye really itches, but I'm trying not to rub it."
3) "It's really hard to see with a patch on one eye."
4) "I need something for the horrible pain in my eye."
Answer: 4) "I need something for the horrible pain in my eye."
Rationale:
Exposure to bright light is uncomfortable after cataract surgery. Wearing sunglasses can
prevent most of the client’s discomfort.
Itching is common after cataract surgery. The nurse should remind the client not to rub or
place pressure on the eyes.
Clients who wear an eye patch lose their depth perception and part of their peripheral vision,
temporarily decreasing visual acuity.
Following cataract surgery, the client should expect only mild pain, and should immediately
report any severe pain in the eye. Severe eye pain after surgery might indicate an increase in
intraocular pressure, which can disrupt the surgical site and cause permanent damage to the
eye if the client does not receive treatment promptly.

A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if
there will be a lot of pain during the procedure. Which of the following responses should the
nurse make?
1) "You shouldn't feel any pain since the local area is anesthetized."
2) "Most clients report more discomfort from the preparation than from the procedure itself."
3) "You may feel some cramping during the procedure."
4) "Don't worry; you won't remember anything about the procedure due to the effects of the
medication."
Answer: 3) "You may feel some cramping during the procedure."
Rationale:
The nurse should recognize the client will receive sedation for the procedure.
This response by the nurse is stereotyping, and is therefore not therapeutic communication.
The nurse should reinforce the use of breathing exercises to decrease the effects of cramping
during the procedure. This response by the nurse is therapeutic because it appropriately
addresses the client's concerns.
While there is a chance the client will experience amnesia following administration of a
sedative for the procedure, the client will be aware during the procedure and could remember
some events. This response by the nurse dismisses the client’s feelings and is therefore not
therapeutic communication.
A nurse caring for a client at risk for increased intracranial pressure is monitoring the client
for manifestations that indicate that the pressure is increasing. To do this, the nurse should
check the function of the third cranial nerve by performing which of the following data
collection activities?
1) Observing for facial asymmetry
2) Checking pupillary responses to light
3) Eliciting the gag reflex
4) Testing visual acuity
Answer: 2) Checking pupillary responses to light
Rationale:
Cranial nerve VII, the facial nerve, is a motor nerve that controls facial symmetry.
Cranial nerve III, the oculomotor nerve, is responsible for pupillary responses to light.
Indications that intracranial pressure is increasing include lethargy, decreasing consciousness,

tachypnea, hypertension, bradycardia, bounding pulse, and changes in the pupils, such as a
sluggish response to light and dilation of one or both pupils.
Cranial nerves IX and X, the glossopharyngeal and vagus nerves, are nerves that control the
gag reflex.
Cranial nerve II, the optic nerve, is responsible for visual acuity.
A nurse is caring for a client during the immediate postoperative period following thoracic
surgery. When administering an opioid analgesic for pain, the nurse should explain that the
medication should have which of the following effects?
1) Reducing anxiety
2) Increasing blood pressure
3) Increasing coughing
4) Increasing the client's respiratory rate
Answer: 1) Reducing anxiety
Rationale:
Besides pain relief, postoperative opioid analgesics can help reduce anxiety and create
feelings of well-being.
A common adverse effect of opioid analgesics is orthostatic hypotension. The nurse should
caution the client that he might feel dizzy when the nurse assists him to sit up and then to
stand up.
A common adverse effect of opioid analgesics is suppressing the client’s cough, which can
cause a buildup of secretions in the airway. The nurse should remind the client to cough and
breathe deeply.
A common adverse effect of opioid analgesics is decreasing the client’s respiratory rate.
A nurse is collecting data on a client who has hyperthyroidism. Which of the following
manifestations should the nurse expect the client to report?
1) Frequent mood changes
2) Constipation
3) Sensitivity to cold
4) Weight gain
Answer: 1) Frequent mood changes
Rationale:

Hyperthyroidism develops when the thyroid gland produces an excess of the thyroid
hormones that regulate the metabolic rate. Nervousness and frequent mood changes; hand
tremors; a rapid, pounding, irregular heartbeat are common manifestations of
hyperthyroidism.
Constipation is a manifestation of hypothyroidism.
Heat intolerance and diaphoresis is a manifestation of hyperthyroidism.
Weight gain is a manifestation of hypothyroidism.
A nurse is collecting data from a client who has skeletal traction. Which of the following
findings should the nurse identify as an indication of infection at the pin sites?
1) Serosanguineous drainage
2) Mild erythema
3) Warmth
4) Fever
Answer: 4) Fever
Rationale:
Purulent drainage from the pin sites is an indication of infection.
Redness is an expected finding after pin insertion. Severe redness at the pin sites is an
indication of infection.
Warmth is an expected finding after pin insertion. Coolness of the extremity, however, might
indicate neurovascular compromise.
Manifestations of inflammation and infection at the pin sites include fever, purulent drainage,
odor, loose pins, and tenting of the skin around the pin sites.
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse
determines that teaching has been effective when the client identifies which of the following
manifestations of hypoglycemia? (Select all that apply.)
1) Polyuria
2) Blurry vision
3) Tachycardia
4) Polydipsia
5) Sweating
Answer: 2) Blurry vision
5) Sweating

Rationale:
Polyuria is incorrect. Hyperglycemia causes polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include blurry vision, tremors,
anxiety, irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia, tremors, anxiety,
irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating, tremors, anxiety,
irritability, headache, and hypotension.
A nurse is collecting data from a client who has an exacerbation of gout. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
5) Symmetrical joint pain
Answer: 1) Edema
2) Erythema
3) Tophi
4) Tight skin
Rationale:
Edema is correct. Swelling over the affected joints is a classic manifestation of gout.
Erythema is correct. Redness over the affected joints is a classic manifestation of gout.
Tophi is correct. Tophi are a classic manifestation of gout. They are nodules that form in
subcutaneous tissue due to the accumulation of urate crystals.
Tight skin is correct. Tight skin over the affected joints is a classic manifestation of gout.
Symmetrical joint pain is incorrect. Symmetrical joint pain is a manifestation of rheumatoid
arthritis, not gout.
A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a
complication of MG for which the nurse should monitor?
1) Respiratory difficulty
2) Confusion

3) Increased intracranial pressure
4) Joint pain
Answer: 1) Respiratory difficulty
Rationale:
With MG, progressive weakness of the diaphragmatic and intercostal muscles can cause
respiratory distress.
Myasthenia gravis is a disorder that affects neuromuscular transmission of neurological
impulses to the voluntary muscles of the body. It does not affect cognition, level of
consciousness, or orientation.
MG is a disorder that affects neuromuscular transmission of neurological impulses to the
voluntary muscles of the body. It does not affect pressure within the brain.
MG is a disorder that affects neuromuscular transmission of neurological impulses to the
voluntary muscles of the body. It does not cause joint pain, but it can cause weakness of the
muscles of the extremities.
A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis.
The nurse should recognize that which of the following actions is the priority?
1) Review stress factors that can cause disease exacerbation.
2) Evaluate fluid and electrolyte levels.
3) Provide emotional support.
4) Promote physical mobility.
Answer: 2) Evaluate fluid and electrolyte levels.
Rationale:
The nurse should review stress factors that can cause disease exacerbation for this client to
reduce the risk for recurrence; however, there is another action that is the priority.
The first action the nurse should take when using the nursing process is to collect data about
the fluid and electrolyte levels. The client who has ulcerative colitis loses fluids and
electrolytes in diarrhoea and can develop hypovolemia. Since problems related to fluid and
electrolyte balance can affect all body systems, this is the most important nursing action for
this client.
The nurse should provide emotional support for this client to increase coping and improve
self-esteem; however, there is another action that is the priority.
The nurse should provide promote physical motility for this client to prevent complications of
immobility; however, there is another action that is the priority.

A nurse is reinforcing teaching about rifampin with a female client who has active
tuberculosis. Which of the following statements should the nurse include in the teaching?
1) "You should wear glasses instead of contacts while taking this medication."
2) "The medication causes amenorrhea if taken along with an oral contraceptive."
3) "A yellow tint to the skin is an expected reaction to the medication."
4) "Lifelong treatment with this medication is necessary."
Answer: 1) "You should wear glasses instead of contacts while taking this medication."
Rationale:
The nurse should reinforce that rifampin turns body fluids such as tears, sweat, saliva, and
urine a reddish-orange color. The nurse should advise the client of possible permanent stains
on clothing and soft contact lenses.
The nurse should reinforce that rifampin will decrease the effectiveness of oral contraceptive
and may cause break through bleeding to occur. The nurse should encourage the client to use
additional forms of birth control while taking rifampin.
The nurse should instruct the client to report any yellowing of the skin or eyes, fever, or flulike symptoms to her provider, as these may indicate or the development of hepatitis or
pancreatitis.
The nurse should reinforce that treatment for tuberculosis involves taking a combination of
medications, including rifampin, which are taken from 6 months to 1 year.
A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following
a renal transplant. Which of the following statements by the client indicates an understanding
of the teaching?
1) "I will take this medication until my BUN returns to normal."
2) "This medication will help my new kidney make adequate urine."
3) "I will need to take this medication for the rest of my life."
4) "This medication will boost my immune system."
Answer: 3) "I will need to take this medication for the rest of my life."
Rationale:
The nurse should emphasize with the client that the serum blood urea nitrogen (BUN) level is
an indication of renal function and is monitored to determine the dosage of the medication.
The nurse should reinforce with the client that cyclosporine is used to prevent the body from
rejecting the transplanted organ.

The nurse should reinforce with the client that cyclosporine is an immunosuppressive agent.
It is used to reduce natural immunity in clients who receive organ transplants and prevent
rejection. They need to take immunosuppressive therapy for the remainder of their lives.
The nurse should emphasize that cyclosporine decreases the body's ability to fight infection.
Client teaching should include monitoring for fever or sore throat, which should be reported
to the provider immediately.
A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by
mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for
with a client who is taking this medication?
1) Improved speech patterns
2) Increased bladder function
3) Decreased tremors
4) Diminished drooling
Answer: 3) Decreased tremors
Rationale:
Selegiline preserves dopamine in the brain and is considered a first line medication for the
treatment of Parkinson’s disease; however, it will not improve speech patterns.
Selegiline slows the progress of Parkinson’s disease; however, it will not increase bladder
function.
Selegiline, an MAO-B inhibitor, improves motor function by decreasing tremors, rigidity and
bradykinesia in the client who has Parkinson’s disease.
Selegiline delays the progression of Parkinson’s disease by preserving motor function;
however, it will not have an effect on drooling.
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood
cells. The client develops itching and hives. Which of the following actions should the nurse
take first?
1) Obtain vital signs.
2) Stop the transfusion.
3) Notify the registered nurse.
4) Administer diphenhydramine.
Answer: 2) Stop the transfusion.
Rationale:

The nurse should obtain vital signs of the client who develops signs of a transfusion reaction
such as itching and hives in order to monitor the client's condition; however, another action is
the priority.
The client who develops itching and hives during a transfusion is at greatest risk for
cardiovascular collapse resulting from the allergic reaction to the blood products; therefore,
the priority action the nurse should take is to stop the transfusion.
The nurse should notify the registered nurse if the client develops hives and itching so a more
in-depth assessment can be made; however, this is not the priority action.
The nurse should administer diphenhydramine as prescribed to minimize the allergic reaction
to the blood products; however, another action is the priority.
A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations
of Raynaud’s phenomenon. Which of the following statements should the nurse identify as an
indication that the client needs further teaching?
1) "I will keep my house at a cool temperature."
2) "I will try to anticipate and avoid stressful situations."
3) "I will complete the smoking cessation program I started."
4) "I will wear gloves when removing food from the freezer."
Answer: 1) "I will keep my house at a cool temperature."
Rationale:
Raynaud's phenomenon occurs during exposure to extreme temperatures or from stress,
resulting in painful vasoconstriction of peripheral blood vessels, typically in the hands and
feet. Keeping the house comfortably warm can help prevent the manifestations of Raynaud's
phenomenon.
Avoiding stressful situations is an action the client should take to manage stress and prevent
the onset of the manifestations of Raynaud's phenomenon.
Smoking cessation is an action the client should take to prevent the onset of the
manifestations of Raynaud's phenomenon. The client should also limit caffeine intake.
Wearing gloves when removing food from the freezer or reaching inside hot ovens is an
action the client should take to prevent the onset of the manifestations of Raynaud's
phenomenon.

A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start
taking ferrous sulphate twice a day. Which of the following statements by the client indicate
an understanding of the teaching?
1) "I will take the medication with orange juice."
2) "I should expect to have loose stools while taking this medication."
3) "I will have clay colored stools while taking this medication."
4) "I should take the medication with milk."
Answer: 1) "I will take the medication with orange juice."
Rationale:
The nurse should reinforce with the client that taking iron pills with a citrus fruit juice, such
as orange juice, helps to increase the bioavailability of the iron.
The nurse should reinforce that ferrous sulphate can be constipating. To prevent constipation
the nurse should recommend the client increase fluid and fiber intake.
The nurse should reinforce that ferrous sulphate can turn stools dark green or black in color,
which is harmless.
The nurse should reinforce that milk will decrease the absorption of the medication and
therefore ferrous sulphate should not be taken with milk.
A nurse is reinforcing teaching about pernicious anaemia with a client following a total
gastrectomy. Which of the following dietary supplements should the nurse include in the
teaching as the treatment for pernicious anaemia?
1) Vitamin B12
2) Vitamin C
3) Iron
4) Folate
Answer: 1) Vitamin B12
Rationale:
The nurse should recommend a lifelong intake of vitamin B12 to prevent pernicious anemia.
A total gastrectomy brings a complete halt to the production of intrinsic factor, the gastric
secretion that is required for the absorption of vitamin B12 from the gastrointestinal tract.
The nurse should recognize that vitamin C aids in wound healing; however, it is not indicated
for treatment of pernicious anemia.

The nurse should recognize that iron is important for the development of red blood cells;
however, it is not indicated for the treatment of pernicious anemia.
The nurse should recognize that folate is important for the formation of hemoglobin and the
synthesis of protein; however, it is not indicated for the treatment of pernicious anemia.
A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a
prescription for lorazepam preoperatively. Which of the following statements by the client
should indicate to the nurse that the medication has been effective?
1) "My mouth is very dry."
2) "I feel very sleepy."
3) "I am not hungry any longer."
4) "My leg feels numb."
Answer: 2) "I feel very sleepy."
Rationale:
The nurse should recognize that oral dryness is most likely a result of the client being NPO
prior to surgery and not an effect of lorazepam.
The nurse should recognize that preoperative doses of benzodiazepines such as lorazepam
relieve anxiety and promote sedation.
The nurse should recognize anorexia as an adverse, but unintended, effect of lorazepam.
The nurse should identify that one of the effects of lorazepam is muscle relaxation, which
may decrease the pain experienced with a femur fracture; however, numbness of the
extremity is not an effect of lorazepam.
A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the
nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should
recognize this is a manifestation of which of the following conditions?
1) Xerostomia
2) Gingivitis
3) Candidiasis
4) Halitosis
Answer: 3) Candidiasis
Rationale:
Xerostomia, or dry mouth, is caused by Sjögren's syndrome or is an adverse effect of certain
medications, such as atropine or sertraline.

Gingivitis is inflammation of the gums or gingiva typically caused by irritation from dental
plaque and poor oral hygiene.
Oral candidiasis is a communicable, opportunistic yeast infection often affecting clients who
have AIDS or immunosuppression. It causes creamy white lesions, usually on the client's
tongue or inner cheeks (buccal mucosa).
Halitosis, or foul-smelling breath, is the result of poor dental health, poor oral hygiene, or
gastrointestinal problems.
A nurse is caring for a client who is postoperative open reduction and internal fixation with
placement of a wound drain to repair a hip fracture. Which of the following actions should
the nurse take?
1) Empty the suction device every 4 hr.
2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr.
3) Position the client’s hip so that it is internally rotated.
4) Encourage foot exercises every 4 hr.
Answer: 1) Empty the suction device every 4 hr.
Rationale:
The nurse should empty the client’s wound drain every 4 hr to monitor for bleeding.
The nurse should monitor neurovascular status of the operative leg every hour for the first 12
to 24 hr to monitor for changes that can indicate impaired circulation.
The nurse should position the client’s hip so that it is abducted to prevent dislocation.
The nurse should encourage foot and calf exercises every 2 hr to prevent a deep vein
thrombosis.
A nurse is assisting with teaching a client who has a history of smoking about recognizing
early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and
report which of the following manifestations of laryngeal cancer?
1) Aphagia
2) Hoarseness
3) Tinnitus
4) Epistaxis
Answer: 2) Hoarseness
Rationale:
Aphagia is a manifestation of a stroke.

Laryngeal cancer is often caused by chronic exposure to tobacco and alcohol. Persistent
hoarseness is an early manifestation of cancer of the larynx because the presences of a tumor
can impede the action of the vocal cords during speech.
Tinnitus is a manifestation of an ear canal obstruction.
Epistaxis is a manifestation of a nasal fracture or a bleeding disorder.
A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which
of the following laboratory values should the nurse review to determine the client’s renal
function?
1) Antinuclear antibody
2) C-reactive protein
3) Erythrocyte sedimentation rate
4) Serum creatinine
Answer: 4) Serum creatinine
Rationale:
The nurse should identify the antinuclear antibody test is used in the diagnosis of SLE and
indicates the presence of an autoimmune disease; however, this test does not reflect renal
function.
Although this test is elevated during acute exacerbations of SLE, it is reflective of
inflammation but does not indicate renal function
Although the client's erythrocyte sedimentation rate might be prolonged during exacerbations
(indicating active inflammation), the nurse should recognize that this test does not reflect
renal function.
Many clients with SLE have deposits of protein within the glomeruli of the kidneys and may
develop lupus nephritis (persistent inflammation in the kidneys) or chronic renal failure. A
disorder of renal function reduces the excretion of creatinine, resulting in increased levels of
serum creatinine. The nurse should identify serum creatinine as a sensitive indicator of renal
function.
A nurse is collecting data from a client who has Cushing's syndrome. Which of the following
manifestations should the nurse expect?
1) Bruising
2) Weight loss
3) Hyperpigmentation

4) Double vision
Answer: 1) Bruising
Rationale:
Clients who have Cushing's syndrome can have thin skin that is fragile and easily bruised.
These clients can develop ecchymoses, petechiae (small intradermal or submucosal
haemorrhages), and striae (purple lines on the skin of the abdomen, thighs, and breasts).
Clients who have Cushing's syndrome will have weight gain due to overproduction of adrenal
cortical hormone.
An insufficient supply of cortisol, as with Addison's disease, results in increased dark
pigmentation (bronzing) of the skin.
Double or blurred vision is a manifestation of hyperthyroidism.
A nurse is caring for a client who is postoperative and requesting something to drink. The
nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance
diet as tolerated." Which of the following actions should the nurse take first?
1) Offer the client apple juice.
2) Elevate the client’s head of bed.
3) Auscultate the client’s abdomen.
4) Order a lunch tray for the client.
Answer: 3) Auscultate the client’s abdomen.
Rationale:
The nurse should offer the client clear liquids if the client is displaying readiness to tolerate
fluids; however, there is another action the nurse should take first.
The nurse should elevate the client’s head to reduce the risk for aspiration before providing
oral fluids; however, there is another action the nurse should take first.
The first action the nurse should take using the nursing process is to collect data by listening
to the client's abdomen to determine the presence of bowel sounds before offering a choice of
clear liquids. A common postoperative complication is paralytic ileus or delayed gastric
emptying due to decreased peristalsis. Administering liquids to a client who does not have
bowel sounds can cause the client to vomit.
The nurse should order a clear liquid lunch tray for the client if the client is displaying
readiness to tolerate fluids; however, there is another action the nurse should take first.

A nurse is collecting data on a client who has a surgical wound healing by secondary
intention. Which of the following findings should the nurse report to the charge nurse?
1) The wound is tender to touch.
2) The wound has pink, shiny tissue with a granular appearance.
3) The wound has serosanguineous drainage.
4) The wound has a halo of erythema on the surrounding skin.
Answer: 4) The wound has a halo of erythema on the surrounding skin.
Rationale:
Tenderness to the touch is an expected finding in a healing wound.
Pink, shiny tissue with a granular appearance is granulation tissue and indicates the wound is
in the proliferative phase of healing.
Serosanguineous drainage, made up of RBCs and plasma, is an expected finding.
A ring of redness on the surrounding skin can indicate underlying infection, and the nurse
should report any indication of infection such as purulent drainage, swelling, warmth, or
strong odor.
A nurse is assisting with the care of a client who has multiple injuries following a motor
vehicle crash. The nurse should monitor for which of the following manifestations of a
pneumothorax?
1) Inspiratory stridor
2) Expiratory wheeze
3) Absence of breath sounds
4) Coarse crackles
Answer: 3) Absence of breath sounds
Rationale:
Inspiratory stridor indicates a narrowed airway and can be heard in clients who have an upper
airway obstruction.
Wheezes, which can be heard on inspiration or expiration, are often present in clients who
have asthma or COPD due to constriction of the bronchus.
A client who has a pneumothorax will have diminished or absent breath sounds on the
affected side due to partial or total collapse of the lung.
Crackles, which are commonly heard on inspiration, can indicate fluid or mucus in the
smaller airways.

A nurse is collecting data from a client who has right-sided heart failure. Which of the
following findings should the nurse expect?
1) Frothy sputum
2) Dyspnoea
3) Orthopnoea
4) Peripheral edema
Answer: 4) Peripheral edema
Rationale:
Frothy sputum is a manifestation of left-sided heart failure.
Dyspnoea is a manifestation of left-sided heart failure.
Orthopnoea is a manifestation of left-sided heart failure.
Peripheral edema is caused by weakness in the right side of the heart, allowing blood to back
up into the venous system and leak into interstitial tissues.
A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer
and experiencing nausea. Which of the following actions should the nurse take?
1) Advise the client to lie down after meals.
2) Instruct the client to restrict food intake prior to treatment.
3) Provide the client with an antiemetic 2 hr prior to the chemotherapy.
4) Encourage the client to drink a carbonated beverage 1 hr before meals.
Answer: 4) Encourage the client to drink a carbonated beverage 1 hr before meals.
Rationale:
The nurse should advise the client to not lie down for 2 hr after meals to reduce the risk for
nausea.
The nurse should instruct the client to eat before treatment to reduce the risk of nausea.
The nurse should administer an antiemetic 30 min to 1 hr prior to treatments, to reduce the
risk of nausea and vomiting. Preventive treatment should start before the chemotherapy is
given and continue for as long as the chemotherapy agent is likely to cause nausea.
The nurse should instruct the client to drink a carbonated beverage 1 hr before or after meals
to reduce the risk for nausea.
A nurse is assisting with the care of a client following a transurethral resection of the prostate
(TURP) and has an indwelling urinary catheter. Which of the following actions should the
nurse take?

1) Weigh the client weekly.
2) Irrigate the catheter as prescribed.
3) Instruct the client to report an urge to urinate.
4) Instruct the client to bear down as if to have a bowel movement every hour.
Answer: 2) Irrigate the catheter as prescribed.
Rationale:
The nurse should weigh the client daily to monitor for hypervolemia.
The nurse should irrigate the catheter to remove blood clots and maintain catheter patency.
The nurse should instruct the client to expect to feel the urge to urinate.
The client should not bear down or strain because this action increases the risk for
haemorrhage
A nurse is evaluating discharge instructions for a client following a right cataract extraction.
Which of the following client statements indicates the teaching is effective?
1) "I will take a stool softener until my eye is healed."
2) "I will expect to have moderately severe pain for 1-2 days."
3) "I will refrain from cooking for 1 week."
4) "I will bend at the waist to tie my shoes."
Answer: 1) "I will take a stool softener until my eye is healed."
Rationale:
The client should avoid straining during bowel movements to prevent an increase in
intraocular pressure.
The client should experience only mild pain post operatively. The client should report severe
pain to the provider immediately.
The client should avoid activities that can increase intraocular pressure, such as vacuuming;
however, the client can perform activities, such as cooking, in moderation.
The client should bend at the knees, not the waist, to prevent an increase in intraocular
pressure.
A nurse is collecting data from a client who is 6 days post craniotomy for removal of an
intracerebral aneurysm. The nurse should monitor the client for which of the following
manifestations of increased intracranial pressure?
1) Decreased pedal pulses
2) Hypertension

3) Peripheral edema
4) Diarrhoea
Answer: 2) Hypertension
Rationale:
Decreased pedal pulses are a manifestation of impaired circulation.
Hypertension is an early manifestation of increased intracranial pressure. Other
manifestations include restlessness, headache, and change in level of consciousness. The
nurse should monitor and report manifestations of increased intracranial pressure.
Peripheral edema is a manifestation of fluid overload.
Diarrhoea is an adverse effect of many antibacterial medications, but not a manifestation of
increased intracranial pressure.
A nurse is caring for a client who has COPD. Which of the following actions should the nurse
take?
1) Encourage the client to drink 8 glasses of water a day.
2) Instruct the client to cough every 4 hr.
3) Provide the client with a low protein diet.
4) Advise the client to lie down after eating.
Answer: 1) Encourage the client to drink 8 glasses of water a day.
Rationale:
The nurse should instruct the client to drink 6 to 8 glasses of noncaffeinated beverages to thin
bronchial secretions.
The nurse should instruct the client to cough every 2 hr to clear secretions.
The nurse should provide a high protein diet to promote healing and reduce fatigue.
The nurse should advise the client to not lie down for 1 hr after eating to increase digestion
and prevent reflux.
A nurse is caring for a client who was admitted with major burns to the head, neck, and chest.
Which of the following complications should the nurse identify as the greatest risk to the
client?
1) Hypothermia
2) Hyponatremia
3) Fluid imbalance
4) Airway obstruction

Answer: 4) Airway obstruction
Rationale:
Hypothermia can occur during the emergent phase of burn care, throughout hospitalization,
and treatment. However, there is another complication is the greatest risk to the client.
Prevention of hyponatremia is an important aspect of burn care throughout the emergent
phase of burn treatment. However, there is another complication is the greatest risk to the
client.
Although adequate fluid replacement is an important aspect of burn care throughout the
emergent phase of burn treatment. However, there is another complication is the greatest risk
to the client.
Burns to the head, neck, and chest may involve damage to the pulmonary tree due to heat as
well as smoke and soot inhalation. This kind of damage can result in severe respiratory
difficulty. A burn to the chest may limit expansion of the thoracic cage, resulting in impaired
breathing. Therefore, using the airway, breathing, circulation (ABC) priority-setting
framework nursing measures to maintain airway patency are the priority nursing actions.
A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the
following client manifestations should the nurse identify as an indication of the development
of Lyme disease?
1) An expanding circular rash
2) Swollen, painful joints
3) Decreased level of consciousness
4) Necrosis at the site of the bite
Answer: 1) An expanding circular rash
Rationale:
Early Lyme disease is characterized by fever, flu-like manifestations, and erythema migrans,
an expanding circular (bull's-eye) rash that often develops at the bite site.
Lyme arthritis (with stiff, swollen, painful joints) is a manifestation of late or chronic Lyme
disease.
A decreased level of consciousness is a manifestation of encephalitis caused by West Nile
virus.
An area of necrosis at the site of a bite is a manifestation of a bite from a brown recluse
spider.

A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a
right radical mastectomy with closed suction drains present. The nurse should expect that the
client will be unable to perform which of the following activities with her right arm?
1) Combing her hair
2) Eating her breakfast
3) Buttoning her blouse
4) Tying her shoes
Answer: 1) Combing her hair
Rationale:
The nurse should recognize that combing the hair requires abduction of the arm. This
movement is avoided for the client who is in the immediate postoperative period until the
drains have been removed. Activities requiring abduction and rotation of the shoulder may
resume following healing of the surgical site.
The arm motion necessary for eating mainly involves the hand, wrist, and elbow. The client
should be able to position her arm appropriately to perform this activity.
The arm motion necessary for buttoning mainly involves the hand, wrist, and elbow. The
client should be able to position her arm appropriately to perform this activity.
The arm motion necessary for tying shoes mainly involves the hand, wrist, and elbow. The
client should be able to position her arm appropriately to perform this activity.
A nurse in a provider’s office is collecting data for a 45-year-old client who is having
manifestations associated with perimenopause. Which of the following findings should the
nurse expect?
1) Report of urinary retention
2) Elevated blood pressure above 140/90
3) Report of dryness with vaginal intercourse
4) Elevated body temperature above 37.8° C (100° F)
Answer: 3) Report of dryness with vaginal intercourse
Rationale:
Estrogen plays a key role in maintaining the function of the bladder and urethra. After
menopause, these organs may weaken or shrink leading to urinary stress incontinence, not
urinary retention.

Blood pressure changes are not related to perimenopause; however, after menopause a
woman's risk for heart disease increases.
Perimenopause includes the years surrounding menopause. During this time the ovaries
produce less estrogen, and a woman’s menstrual periods cease. Because of the changes in the
vagina, some women may have dryness, discomfort, or pain during vaginal intercourse.
Hot flashes are a classic sign of menopause, but they are related to hormonal changes, not
body temperature elevation.
A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a
regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the
following times?
1) On the same day every month
2) Prior to the beginning of menses
3) Three to seven days after menses stops
4) On the second day of menstruation
Answer: 3) Three to seven days after menses stops
Rationale:
The client should not perform breast self-examination on the same day every month because
monthly hormone fluctuations can affect the sensitivity of breast tissue.
The client should avoid performing breast self-examination just prior to menses because the
breasts might be too tender to perform an effective examination.
The client should plan to perform breast self-examination about 3 to 7 days after
menstruation, when the breasts are least tender and not engorged.
The client should avoid performing breast self-examination during menstruation because the
breasts might be too tender to perform an effective examination.
A nurse is caring for a client who has second- and third-degree burns and a prescription for a
high-calorie, high-protein diet. Which of the following menu choices should the nurse
recommend?
1) ½ cup whole-grain pasta with tomato sauce and pears
2) Turkey and cheese sandwich with scalloped potatoes
3) ½ cup black beans with a brownie
4) Roast beef with romaine lettuce salad
Answer: 2) Turkey and cheese sandwich with scalloped potatoes

Rationale:
While this menu choice contains some calories, it is composed primarily of incomplete
proteins; therefore, it does not meet the prescribed dietary regimen.
This menu choice is composed primarily of complete, high-quality proteins and large
quantities of carbohydrates. Therefore, the nurse should recommend this selection to meet the
prescribed dietary regime.
While this menu choice is relatively high in calories, it is composed primarily of incomplete
proteins; therefore, it does not meet the prescribed dietary regimen.
While this menu choice contains some protein, the calorie count is low due to insufficient
carbohydrates; therefore, it does not meet the prescribed dietary regimen.
A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram.
Which of the following should the nurse include in the teaching?
1) Omit your daily dose of aspirin.
2) Take a laxative the evening before the procedure.
3) Expect to be drowsy for 24 hr following the procedure.
4) You will feel cold chills after the dye has been injected.
Answer: 2) Take a laxative the evening before the procedure.
Rationale:
It is not necessary for the client to omit the daily dose of aspirin the day of the procedure.
Clients taking medications that are nephrotoxic should be monitored for renal failure.
Stool or gas in the bowel may make it difficult to visualize the renal system during an
intravenous pyelogram, so typically the bowel is cleansed the day before.
Sedatives are not typically given prior to or during the procedure. The client should be able to
resume normal activities when the test is completed.
Following intravenous administration of the dye, the client typically feels a warm flush
throughout the body.
A nurse is collecting data from a client in the health clinic who is reporting epigastric pain.
Which of the following statements made by the client should the nurse identify as being
consistent with peptic ulcer disease?
1) "The pain is worse after I eat a meal high in fat."
2) "My pain is relieved by having a bowel movement."
3) "I feel so much better after eating."

4) "The pain radiates down to my lower back."
Answer: 3) "I feel so much better after eating."
Rationale:
Clients who have peptic ulcer disease usually experience pain relief after eating. Increased
epigastric pain after consumption of a high-fat meal is a common report by clients who have
gallbladder disease.
There is no association between stool pattern and peptic ulcer disease.
A client who has peptic ulcer disease usually experiences pain when the stomach is empty, 2
to 3 hr after meals or in the middle of the night. It is usually relieved by eating.
Clients who have peptic ulcer disease may complain of chest pain from regurgitation. Pain
radiating down to the lower flank area is associated with pancreatitis.
A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the
following interventions should the nurse identify as the priority?
1) Promote the client’s expression of feelings about loss of self-care ability.
2) Encourage the client to recall positive life events.
3) Schedule pain medication on a routine basis.
4) Suggest ways the client can continue interacting with social contacts.
Answer: 3) Schedule pain medication on a routine basis.
Rationale:
Promoting the client’s expression of feelings about loss of self-care ability is important
because it meets the client’s self-esteem needs; however, there is another intervention that is
the priority.
Encouraging the client to recall positive life events is important because it meets the client’s
self-esteem needs; however, there is another intervention that is the priority.
The priority action the nurse should take when using Maslow’s hierarchy of needs is to meet
the client’s safety and security needs. By scheduling the client’s pain medication on a routine
basis, the nurse can prevent acute pain exacerbations.
Suggesting ways the client can continue interacting with social contacts is important because
it meets the client’s love and belonging needs; however, there is another intervention that is
the priority.

A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic
open angle glaucoma. Which of the following statements by the client indicates an
understanding of the teaching?
1) "When my vision improves, I will be able to stop taking the eye drops."
2) "If I forget to take my eye drops, I should wait until the next time they are due."
3) "I should call the clinic before taking any over-the-counter medications."
4) "Every two years I will need to have my vision checked by an eye doctor."
Answer: 3) "I should call the clinic before taking any over-the-counter medications."
Rationale:
The nurse should reinforce that clients who have open angle glaucoma will need to take eye
drops for the remainder of their lives to preserve their vision.
The nurse should emphasize that it is important that eye drop instillation not be missed, so a
therapeutic level of medication is maintained.
Taking over-the-counter medications that dilate the pupil could cause the client who has
chronic open angle glaucoma to experience an increase in intraocular pressure. The nurse
should instruct the client to always check with the provider before using over-the-counter
medications.
The nurse should reinforce that clients who have open angle glaucoma will need to see their
ophthalmologist yearly, if not more frequently, for the remainder of their lives.

CHAPTER 2
What are the five level system of triage?
Answer: A. Level 1: Resuscitation
B. Level 2: Emergent
C. Level 3: Urgent
D. Level 4: Less urgent
E. Level 5: Nonurgent
Resuscitation requires what?
Answer: Immediate treatment to prevent death
What is required for nonurgent triage (level 5)?

Answer: Non life threatening condition requiring simple evaluation and care management
What is the standard precaution for primary survey during triage?
Answer: A. Gloves
B. Gowns
C. Eye protection
D. Face masks
E. Shoe covers
F. ABCDE → guide the primary survey
What is the ABCDE principle?
Answer: A. Airway/Cervical Spine → brain injury/death = 3-5 min. if airway not patent.
B. Breathing → assess presence & effectiveness of breathing.
C. Circulation
D. Disability
E. Exposure
How to implement airway for patients who is unresponsive without suspicious of trauma?
Answer: Airway opened → head tilt, chin lift maneuver
How to implement airway for patients who is unresponsive WITH suspicious trauma?
Answer: Airway opened → modified jaw thrust maneuver
How is the modified jaw thrust maneuver performed?
Answer: Nurse place both hands on either side of the client’s head. Locate the connection
between maxilla and mandible. Lift the jaw superiorly while maintaining alignment of the
cervical spine.
During triage, what mask is given to patient who are spontaneously breathing?
Answer: Non-breather mask with 100% O2 source
What does the breathing assessment include?
Answer: A. Auscultation of breath sounds
B. Observation of chest expansion and respiratory effort

C. Notation of rate and depth of respiration
D. Identification of chest trauma
E. Assessment of tracheal position
F. Assessment of JVD
How to assess for circulation?
Answer: Nurse assess HR, BP, peripheral pulses, and capillary refill for adequate perfusion.
What are the precursor to shock that nurses need to be aware of?
Answer: A. Cardiac arrest
B. Myocardial dysfunction
C. Haemorrhage
What are some interventions that is geared toward restoring effective circulation?
Answer: A. CPR
B. Assess for external bleeding.
C. Haemorrhage control
D. Obtain IV access using large-bore IV catheters inserted into the antecubital fossa of both
arms, unless there is obvious injury to the extremity.
E. Infuse isotonic IV fluids such as Lactated Ringer’s & 0.9% NaCl &/or Blood products.
What is shock?
Answer: Body response to inadequate tissue perfusion and oxygenation. It manifests with an
increase HR, hypotension and result in tissue ischemia and necrosis.
What are some intervention that can alleviate shock?
Answer: A. Administer oxygen
B. Apply pressure to obvious bleeding
C. Elevate lower extremities to shunt blood to vital organs
D. Administer IV fluids and blood products
E. Monitor VS
F. Remain with client and provide reassurance and support for anxiety.
What is the D portion of the ABCDE protocol during triage?

Answer: A. Disability → quick assessment to determine clients LOC
B. Ex: AVPU (Alert, Response to Voice, Responsive to pain, Unresponsive), GCS
What is the E portion of the ABCDE protocol during triage?
Answer: Exposure
What is the primary concern during the exposure phase during triage?
A. Hypothermia → point core temperature 35 degree Celsius (95-degree F.) or less.
Answer: Why hypothermia for trauma patients? Exposure, un-warmed oxygen, cold IV
fluids
What can hypothermia eventually lead to?
Answer: Coma, hypoxemia, and acidosis
What is a contraindication in the first 6-8 hours after the bite (poisoning)?
Answer: A. Ice
B. Tourniquets
C. Heparin
D. Corticosteroids
Antivenom is effective when?
Answer: Within 4-12 hour and is based on type and severity of a snake bite
What is considered cardiac emergency?
Answer: A. Cardiac arrest
B. V. Fib
C. Pulseless V. tach.
D. V. Asystole
E. Pulseless electrical activity (PEA)
What is a cardiac arrest?
Answer: Sudden cessation of cardiac function causes most commonly by V. fib. or V. sys.
What is Ventricular fibrillation?

Answer: Fluttering of the ventricles causing LOC, pulselessness, no breathing. Requires
collaborative care to defibrillate immediately using ACLS protocol.
What is pulseless V. tach.?
Answer: A. Irritable firing of ectopic ventricular beats at a rate of 140 to 180/min.
B. Pt. overtime become unconscious and deteriorate into V. fib.
What is v. asystole?
Answer: A. Complete absence of electrical activity and ventricular mvmt of heart.
B. Pt. complete cardiac arrest → requires implementation of BLS/ACLS protocol.
What is pulseless electrical activity (PEA)?
Answer: Rhythm appears to have electrical activity but is not sufficient to stimulate effective
cardiac contractions and requires implementation of BLS/ACLS protocol
What are the most common causes of pulseless electrical activity?
Answer:

What is an Alpha-1 Receptor site?
Answer: Activation of receptors in the arterioles of skin, viscera, mucous membranes, veins
→ vasoconstriction
What is Beta-1 Receptor site?
Answer: A. Heart stimulation leads to increased HR, increased myocardial contractility,
increased rate of conduction through the AV node
B. Activation of receptors in the kidney → release of renin

What is a Beta-2 receptor site?
Answer: A. Bronchial stimulation → bronchodilation
B. Activation of receptors in uterine smooth muscle → relaxation
C. Activation of receptors in the liver → breakdown of glycogen into glucose
D. Skeletal muscle receptor activation → muscle contraction → tremors
What is a dopamine receptor site?
Answer: Activation of receptors in the kidney → renal blood vessels to dilate.
What is the AHA ACLS protocol for VF or pulseless VT?
Answer: A. Initiate CPR BLS
B. Defibrillate
C. IV access
D. Administer IV → antidysrhythmic medication → epi. & vasopressin
E. Amiodarone HCL
F. Lidocaine HCL
G. Magnesium Sulphate
What is the AHA ACLS protocol for pulseless electrical activity (PEA)?
Answer: A. Initiate CPR
B. IF shockable rhythm, defibrillate
C. IV access
D. Consider most common cause
E. Administer epi. 1 mg IVP q3-5 min.
What is the AHA ACLS protocol for Asystole?
Answer: A. Initiate CPR
B. IV access
C. Give epi. 1mg IVP q3-4 min.
D. Consider reversible causes
What is the post-resuscitation medication therapy following a successful cardiac arrest?

Answer: IV meds → catecholamine adrenergic effect (can’t be taken by the oral route, do not
cross the BBB, short duration of action) → Epi., Dopamine, Dobutamine
What is the contraindication/precaution for catecholamine?
Answer: A. Pregnancy Risk Category C
B. Tachydysrhythmias
C. Ventricular fibrillation
D. Hyperthyroidism
E. Angina
F. Hx MI
G. HTN
H. DM
How to treat extravasation with a local injection?
Answer: Alpha-adrenergic blocking agent → Phentolamine

Chapter 3: Neurologic Diagnostic Procedure
What is cerebral angiography?
Answer: A. Visualization of the cerebral blood vessels
B. Hides the bones, tissues from the images
C. Detect defects, narrowing, or obstruction of arteries or blood vessels in brain
D. Iodine-based contrast dye injected into artery
E.

What is the indication of cerebral angiography?
Answer: A. Assess blood flow to within the brain
B. Identify aneurysms
C. Vascularity of tumors
D. Blood clots
E. Administer chemotherapy
Pre-procedure for cerebral angiography?
Answer: A. NPO 4-6 before
B. Hx bleed, anticoagulants
C. Assess BUN/serum creatinine
D. Mild sedative before, during
What is the intra-procedure for cerebral angiography?
Answer: Important to stay still.
What is a CT scan?
Answer: • Cross sectional images of the cranial activity
•

When do we do a CT scan on a patient?
Answer: Identify tumors, infarctions, detect abnormalities, monitor response to treatment,
and guide needles used for biopsies.
Education for pt. who are about to undergo a CT scan.
Answer: A. NPO 4-6 hour prior

B. No jewelry
C. No follow up care associated with a CT scan
D. Monitor for any allergic reaction to iodine, changes kidney function
What is an electroencephalography?
Answer: • Non-invasive procedure assesses the electrical activity of the brain and is used to
determine if there are abnormalities in brain wave patterns.
• Procedure 1 hour, no risk associated with this procedure.

What does Glasgow Coma Scale calculate?
Answer: A. Eye opening
B. Verbal
C. Motor
D. Low score = bad
E. High score = good
F. Total score correlate with the degree or level of coma.
A GCS score 13 indicates what?
Answer: Minor head trauma
What is the range for normal ICP?
Answer: 10-15 mm Hg

What are some complications and nursing actions need to be considered for ICP monitoring?
Answer: A. Bleed/Infection
B. Surgical aseptic technique
C. Perform sterile dressing changes per facility protocol
D. Drainage system closed
E. Limit monitoring 3-5 days
F. Irrigate system only as needed
What is the indication for LP (spinal tap)?
Answer: A. Detect some diseases (MS, syphilis, meningitis) infection and malignancies.
B. Reduce CSF pressure → instill contrast medium or air for diagnostic tests
C. Administer medication or chemotherapy directly into spinal fluid
If headache persists after LP procedure, what would be done?
Answer: A. Epidural blood patch to seal hole in the dura if the headache persists.
B. Encourage pt. lie flat in bed & provide fluids.
What is an MRI?
Answer: A. Cross-sectional images of the cranial activity
B. Images obtained using magnets → results in no complication with radiation. Makes is
safer for women who are pregnant.

When will a patient need an MRI testing?

Answer: A. Detect abnormalities, monitor response to tx, guide needles used for biopsies.
B. Discriminates soft tissue from tumor or bone → effective in determining tumor size/blood
vessel location.
What will be let our patient know prior to MRI?
Answer: No jewelry, any metals such as pacemaker, artificial valves, IU devices, aneurysm
clips
What is PET/SPECT scans?
Answer: A. 3 dimensional images of the head. Static (vessels) Functional (brain activity)
B. Can help determine the presence of dementia by the inability of the brain to respond to the
tracer.

What needs to be considered when pt. is about to undergo a PET/SPECT scan?
Answer: Hx DM → hypoglycemia or hyperglycemia due to tracer is glucose based and short
acting ( 65 yrs. old with no previous immunized or have history of disease
What is MCV4?

Answer: A. Neisseria meningitidis
B. Ensure adolescents receive vaccine on schedule and before living residential setting in
college
C. Others live in communal living such as military
D. Initial dose → healthy children 11-12, booster administered at age 16
What are the risk factors of meningitis?
Answer: A. No vaccine for viral meningitis → West Nile, mumps, measles, herpes
B. Direct contamination of spinal fluid
C. Immunosuppression
D. Invasive procedure, skull fracture, penetrating wound
E. Environment → crowded places
What would be expected to see with meningitis pt.?
Answer: A. Bad, constant HA
B. Nuchal rigidity (stiff neck)
C. Photophobia
What are the physical assessment finding of meningitis pt.?
Answer: A. Fever, chills, N, V, altered LOC, DTR, tachycardia, seizures, red macular rash,
B. + kernig’s sign → resistance w/ pain w/ extension of client’s leg from a flexed position
C. + brudzinki’s sign → flexion of knees/hips occurring w/ deliberate flexion of client neck

What are the laboratory tests for meningitis?
Answer: A. Urine, throat, nose, blood culture and sensitivity
B. CBC → elevated WBC
What are some diagnostic procedures for meningitis?
Answer: A. CSF analysis → cloudy (bacterial) or clear (viral)
B. Elevated WBC, protein, CSF pressure
C. Decreased glucose (bacterial)
D. CT scan/MRI → identify increased ICP and/or an abscess
What are some nursing care for meningitis?
Answer: A. Isolate client as soon as meningitis suspected –Droplet precaution until
antibiotics have been administered for 24 hr and oral and nasal secretions are no longer
infectious. → standard precaution
B. Report meningococcal infections to the public health department.
C. Minimize exposure to bright light.
D. Maintain at bed rest with the head of the bed elevated to 30 degree.
E. Monitor for increased ICP
F. Tell the point to avoid coughing and sneezing which increase ICP.
G. Seizure precaution
H. Replace fluid/electrolytes
I. Older adults → secondary complications = pneumonia
What are the medications for meningitis?
Answer: A. Ceftriaxone or cefotaxime in combination with Vancomycin. → bacterial
B. Phenytoin → anticonvulsants given if ICP increases or client experiences a seizure
C. Acetaminophen/Ibuprofen →analgesics for HA and/or fever.
D. Ciprofloxacin/Rifampin/Ceftriaxone → prophylactic antibiotics given to ind. In close
contact with the pt.
What are some complications with meningitis?
Answer: A. Increase ICP
B. SIADH

C. Septic emboli
What is a sign of increased ICP?
Answer: A. Decreased level of consciousness
B. Pupillary changes
C. Impaired extraocular movements
What are some nursing interventions to reduce ICP?
Answer: A. Positioning with head of the bed elevation at 30 degree
B. Avoid cough and strain
C. Mannitol can be administered via IV
What is a sign of SIADH?
Answer: A. Dilute blood, concentrated urine
B. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a condition in
which the body makes too much antidiuretic hormone (ADH). This hormone helps the
kidneys control the amount of water your body loses through the urine. SIADH causes the
body to retain too much water
What are the nursing interventions for SIADH?
Answer: A. Administer Demeclocycline & restrict fluid
B. Monitor weight daily

Chapter 6: Seizures and Epilepsy
Are substance withdrawal or fever consider an epilepsy?
Answer: No
What are the risk factors for seizures?
Answer: A. Genetic
B. Acute febrile state → infants/children <2
C. Head trauma
D. Cerebral edema

E. Abrupt cessation of antiepileptic drugs
F. Infection
G. Metabolic disorder → hypoglycemia/hyponatremia
H. Exposure to toxins
I. Stroke
J. Heart disease
K. Brain tumor
L. Hypoxia
M. Acute substance withdrawal
N. Fluid and electrolyte imbalance
What triggers seizure?
Answer: A. Increase physical activity
B. Excessive stress
C. Hyperventilation
D. Overwhelming fatigue
E. Acute alcohol ingestion
F. Excessive caffeine intake
G. Exposure to flashing lights
H. Substances such as cocaine, aerosols, inhaled glue products
What would you find with a patient who has a generalized seizure?
Answer: A. Both cerebral hemisphere
B. Begin with aura
What is tonic-clonic seizure?
Answer: A. Begins for only few seconds
B. Incontinence

What is tonic episode?
Answer: A. Stiffening of muscles and loss of consciousness
B. Breathing can stop
What is clonic episode?
Answer: A. 1-2 min
B. Breathing irregular
C. Cyanosis
What is tonic seizure?
Answer: A. Only tonic phase is experienced; <30 seconds
B. Sudden loss consciousness
C. Sudden increased muscle tone
D. Loss of consciousness
E. Autonomic manifestations
What is clonic seizure?
Answer: A. Lasts several minutes
B. Muscle contract and relax
C. Only clonic phase
What is myoclonic seizure?
Answer: A. Brief jerking, stiffening of extremities
B. Lasts for seconds
What is atonic or akinetic seizure?

Answer: A. Few seconds in which muscle tone is lost
B. Period of confusion
C. Loss of muscle tone → fall risk
What are the laboratory tests for seizure?
Answer: A. Alcohol, illicit substance levels
B. HIV testing
C. Excessive toxins
What are some diagnostic procedure?
Answer: A. EEG
B. CAT
C. PET
D. CSF
What medication given for seizure pt.?
Answer: A. Phenytoin, antiepileptic drugs
B. Avoid oral contraceptives → decrease effectiveness
C. Other medications→ on notes
What is another therapeutic procedure for partial seizure?
Answer: A. Vagal nerve stimulator → L chest wall, electrode, general anesthesia, intermittent
B. AVOID MRI, Ultrasound, microwave ovens, shortwave radios
What is status epilepticus?
Answer: Repeated seizure activity within 30 min. time frame lasting more than 5 min.
What is the complication for status epilepticus?
Answer: Decreased oxygen levels, inability brain to normal function, assault neuronal tissue
Status epilepticus
Answer: Need Immediate Treatment to prevent further permanent loss of brain function.
What are the usual causes of Status Epilepticus?

Answer: A. Substance withdrawal
B. Sudden withdrawal from AEDS
C. Head injury
D. Cerebral edema
E. Infection
F. Metabolic disturbances
What are some nursing actions for Status epilepticus?
Answer: A. Maintain airway
B. Provide oxygen
C. Establish IV access
D. Perform ECG monitoring, pulse oximetry, ABG results
E. Administer Diazepam or Lorazepam IVP followed by IV Phenytoin or Fosphenytoin

Chapter 7: Parkinson’s Disease
What is the Parkinson’s Disease?
Answer: Progressively debilitating disease that grossly affects motor function.
What are the 4 primary s/s of PD?
Answer: A. Tremor
B. Muscle Rigidity
C. Bradykinesia (slow movement)
D. Postural instability
Why do these s/s occur?
Answer: Overstimulation of the basal ganglia by acetylcholine occurs because degeneration
of the substantia nigra results in decreased dopamine production. Allows acetylcholine to
dominate making smooth, controlled movement difficult.

What is the tx of PD focused on?
Answer: Increase amount of dopamine or decrease the amount of Acetylcholine in a client’s
brain
What are the risk factors of PD?
Answer: A. Onset s/s between age 40-70
B. More common in men
C. Genetic predisposition
D. Exposure to environmental toxins
E. Chronic use of antipsychotic medication
What would you expect to find in PD patients?
Answer: A. Report of fatigue
B. Report of decreased manual dexterity over time
What are some physical assessment findings PD?
Answer: A. Stooped pressure
B. Slow, shuffling, propulsive gait
C. Slow, monotonous speech
D. Tremors/pill-rolling tremor of fingers
E. Muscle rigidity
F. Bradykinesia/akinesia
G. Masklike expression
H. Autonomic s/s → orthostatic hypotension, flushing, diaphoresis
I. Difficulty chewing and swallowing

What are the lab. tests for PD?
Answer: A. No definitive diagnostic procedure
B. Dx made based manifestations, progression, ruling out other diseases
What are the types of food necessary for PD?
Answer: Semisolid foods and thickened liquids
What are the five stages of Parkinson’s disease involvement?
Answer: A. Stage 1: Unilateral shaking or tremor or one limb
B. Stage 2: Bilateral limb involvement occurs, making walking and balance difficult
C. Stage 3: Physical movements slow down significantly, affecting walking more.
D. Stage 4: Tremors can decrease but akinesia and rigidity make day-to-day tasks difficult
E. Stage 5: Client unable to stand or walk, is dependent for all care and might exhibit
dementia
What are dopamine agonists?
Answer: A. Bromocriptine
B. Ropinirole
C. Pramipexole
D. Role: activate release of dopamine
What would the nurse need to monitor for pt. taking Bromocriptine, Ropinirole,
Pramipexole?
Answer: A. Orthostatic hypotension
B. Dyskinesia
C. Hallucinations
What anticholinergic drugs use for PD pt.?
Answer: A. Benztropine
B. Trihexyphenidyl
C. Role: help control tremors and rigidity
What are the SE of anticholinergic drugs?

Answer: A. Dry mouth
B. Constipation, Urinary retention
C. Acute confusion
What are the MAO-B inhibitors such as Selegiline and Rasagiline ?
Answer: Increase dopamine levels, reduce wearing off phenomenon when administered
concurrently with levodopa.
What to considered with Selegiline and Rasagiline?
Answer: Avoid foods high in tyramine → hypertensive crisis
B. Administered Meperidine and Fluoxetine
What are antivirals drugs?
Answer: A. Amantadine
B. Role: release dopamine and prevent its reuptake
What to consider when taking Amantadine?
Answer: Discoloration of skin, anxiety, confusion, anti-cholinergic effects

Chapter 8: Alzheimer’s Disease
What is Alzheimer’s Disease?
Answer: Nonreversible type of dementia that progressively develops over many years.
What is dementia?
Answer: Multiple cognitive deficits that impair memory and can affect language, motor
skills, and/or abstract thinking
What is the survival rate?
Answer: 10 years → some 20 years
What is the age system?
Answer: A. 60s/70s

B. Dx as early as 65
What presence of protein increase the risk of AD?
Answer: Apolipoprotein
What are some nursing care for AD pt.?
Answer: A. Check skin weekly for breakdown
B. Use calendar to assist with orientation
C. Stimulate memory by repeating the clients last statement
What medications given to Dementia pt.?
Answer: A. Antipsychotics
B. Antidepressants
C. Anxiolytics
What medications given to AD pt.?
Answer: A. Temporarily slow course disease and DO NOT work for all clients.
B. Donepezil → prevent breakdown of Ach → increase amt of Ach = increase nerve impulses
at the nerve sites.
C. Cholinesterase → help slow this process
What nursing consideration to focus on AD?
Answer: A. Observe for frequent stools or upset stomach
B. Monitor for dizziness or headache.
C. Caution with asthma or COPD → worsen lung problems
What are alternative therapy for AD?
Answer: A. Estrogen therapy for women → prevent AD → not useful decrease s/s
B. Ginkgo biloba → increase memory and blood circulation

Version 6
ATI- MED SURG PROCTORED PRACTICE QUESTIONS &
ANSWERS(60 Q&A)

A patient informs the nurse that they are taking an OTC garlic supplement. What possible
effect does garlic have on the body?
Answer: Effects blood clotting increases risk of bleeding
A patient has a complete spinal cord injury at the third cervical vertebra. At what level would
you expect the patient to respond to light sensation?
Answer: Diagram Of Body with boxes that you must select to indicate the level. Top box
only Face
After placement of a permanent pacemaker what which would you report as a complication
of placement?
Answer: Hiccups (Pg. 325)
How to take off a condom
Answer: Take of off while penis is still erect
Ph of 7.30 paCO2 49 others WNL– what are they in?
Answer: Respiratory acidosis
Left sided weakness while using a cane – what is indicative of needing further teaching?
Answer: Puts cane on weak side (cane should be on stronger side)
What causes intrarenal failure?
Answer: Trauma, contrast dye, infection, vasculitis, acute glomerulonephritis, NSAIDS,
blood transfusion reaction Pg 675
Signs of Peripheral vascular complication?
Answer: Ulcer formations, Pulmonary embolism Pg. 404
A patient returns to the clinic 72 hours after receiving a subcutaneous dose of purified protein
derivative (PPD) to test for tuberculosis exposure. The nurse inspects the injection site on the
patient’s forearm and finds an induration measuring 12 mm. The nurse informs the client that

Answer: “Your skin test was positive for TB exposure, we need to perform an acid-fast
bacillus test and a chest X-ray Pg. 250
What to do after a hemolytic reaction to a blood transfusion?
Answer: Stop the infusion, change the tubing and give NS
How do you insert a PICC?
Answer: PICC- Flat on back (Review Pg. 303)
Subclavian IV catheter- Trendelenburg position (head below feet)
You are removing a peripheral inserted central catheter, which of the following would you do
following removal?
Answer: Measure the length of the external portion of the catheter
Removing a peripheral IV catheter
Answer: make sure the tip is intact
Patient has INR of 1.5 prior to surgery. What are you going to do?
Answer: Prep the patient for surgery
Following the surgical placement of a new ileostomy, which of the following would you
teach them?
Answer: chew food well
Rationale: Patients with a new ostomy involving the small intestine (i.e. an ileostomy) are
told post-op to avoid foods that increase flatus (green leafy vegetables, beer, carbonated
beverages, dairy, and corn); avoid high-fiber foods for first 2 months; chew food well;
increase fluid intake; and evaluate evidence of blockage.
A patient is on isolation due to C difficile infection; which of the following represents correct
infection protection protocol?
Answer: Collect fecal sample with gloves

A patient ____(has either a list of symptoms or a new prescription for
anticoagulant)________ during medical history they report they have been taking ibuprofen
for 3 years . What lab would you expect to be drawn?
Answer: Fecal Testing/Stool Guaiac/ Fecal Occult Blood Test (FOBT)
A patient has been on total parenteral nutrition for 10 full days, which of the following would
be an indication that the nutrition therapy is effective?
Answer: Potassium 4.0 (Pg.524)
Which of the following clients is MOST at risk for developing atelectasis?
Answer: Post anaesthesia for bowel resection
Rationale: This patient was the only patient who had abdominal surgery; patients with
abdominal surgery are at the HIGHEST risk for atelectasis because the pain from
incision/surgical procedure causes them to reflexively breathe in a shallow, cautious way.
Positioning (guarding) also causes decreased in lung expansion.
The nurse is preparing a patient for paracentesis procedure, which of the following
instructions would be given to the patient to decrease the risk of perforation?
Answer: Instruct patient to empty their bladder prior to the procedure, this is done in order to
decrease the size of a bladder and it reduces the chance of accidental bladder perforation. Pg
527
The nurse is providing home care for a patient receiving peritoneal dialysis, the patient has a
fever of 102, and the catheter has decreased dialysate outflow. Which of the following should
the nurse perform first?
Answer: Reposition the patient
Rationale: Nursing Actions regarding reduced or inadequate outflow include: repositioning
the client (b/c this moves the distal lumen of the catheter which may become pressed up
against the abdominal wall = obstruction); milk the tubing if a visible clot is present in the
catheter; check the tubing for kinks or closed clamps, determine when the patient’s last bowel
movement was (constipation can also cause low outflow, pts on peritoneal dialysis are
instructed to use a stool softener daily and consume a high-fiber diet).

The nurse is caring for a patient with Crohn’s Disease. Which of the following would be an
expected lab value for this patient? Pg 582
Answer: • HCT and HGB – LOW in crohn’s due to anemia
• ESR, CRP – HIGH
• WBC Count = Increased because of inflammatory response Anti-glycan Antibodies=
Antiglycan is a certain type of protein present on the cells of individuals with Crohn’s
Disease. These are found in the vast majority of patient’s with Crohn’s.
• Electrolytes (K+, Mg, Ca, etc), Protein/Albumin, Iron and Other Measures of Nutrition =
LOW
Rationale:
ESR & CRP are reflections of non-specific/general inflammation, think Inflammatory bowel
condition
Points with crohn’s experience 5 or more loose stools a day and are almost always
malnourished due to self-limitation of foods b/c of pain and GI upset caused by ingestion
AND because inflammation of the GI tract causes malabsorption.
The nurse is caring for a patient a patient with cancer who is hospitalized following
chemotherapy and has an extremely low WBC count of 500? The family asks to bring the
patient the following items, which should the nurse allow the patient to have?
Answer: boxed chocolates
Rationale: commercially prepared goods have been prepared under sterilized conditions and
candy is heated to a very high temp in order to convert it to candy.
Gun shot wound to abdomen. What would you do to prevent acute kidney failure?
Answer: Fluids
The nurse is assessing a patient with open-angle glaucoma, which of the following would be
an expected assessment finding?
Answer: Loss of Peripheral Vision
Rationale: Blurred Vision, Halos, Nausea, and Severe Pain are s/s of acute Angle Closure
Glaucoma, not open-angle. Open Angle Glaucoma = a disruption of structure and function of
the optic nerve that causes decreased drainage of aqueous humor due to blockage. Impaired
drainage of fluid increases the intraocular pressure (IOP) and impairs straight-line and
peripheral vision.

A nurse is caring for a patient who is s/p knee arthroplasty, the patient reports pain and
swelling at the incision site. Which of the following non-pharmacological nursing
interventions should the nurse perform to help relieve the patient’s pain?
Answer: Apply Cold Pack/Ice
A nurse is caring for a patient immediately following hip arthroplasty. Which of the following
interventions should be performed in order to immobilize the joint? (Pg 761)
Answer: Use an abduction pillow or pillow between legs
• Incorrect: Perform passive ROM exercises
• Incorrect: Place pillow behind the knee for support
A nurse is caring for a patient post-op after an appendectomy, while assessing the patient she
notices bleeding on the bandages. How should the nurse measure and record the volume of
blood?
Answer: Draw circle around it.
The nurse is caring for an older adult patient immediately following a total hip arthroplasty
procedure. To prevent dislocation of the hip, the nurse should do which of the following?
Answer: Place a pillow between legs when turning to the un-operative side.
Who would you assess first?
Answer: Tracheal deviation to the right.
A nurse is caring for a patient who requires intubation for respiratory support. An
Endotracheal tube is inserted, but the patient’s respiratory status is still compromised and the
nurse suspects the tube may be in the right bronchus. How would the nurse confirm her
suspicion?
Answer: The patient would have absent lung sounds on left
The nurse is caring for a patient receiving radiation therapy for a malignancy. What
instructions would the nurse give the patient regarding the care of the site following the
radiation treatment? Pg1004
Answer: Gently pat the area dry, do not rub.

Rationale: Patient’s receiving external radiation therapy (ERT) are instructed to wash the
area with mild soap or water, gently pat the area dry. They are told to be careful not to wash
off the radiation “tattoos” which are skin markings that mark where to apply the radiation.
Patients are also advised to wear soft, loose, non-restrictive clothing which implies an
occlusive dressing is contraindicated as well. They are instructed not to apply any lotions,
perfumes, powders, or deodorants to the site.
When performing a wound culture of a wound with eschar and exudate; using a sterile cotton
swab, the culture should be obtained by:
Answer: Using a circular motion in the pool of exudate
The nurse is performing wound care for a patient whose wound requires debridement using
wet-to-dry packing. What type of debridement is this considered.
Answer: mechanical
Instructions for a post op thyroidectomy patient. ATI Pg. 872-77
Answer: Maintain a soft diet, avoid straining, and keep the surgical area clean and dry.
Monitor for signs of infection or difficulty breathing, and follow up with your healthcare
provider as instructed.
Positive Trousseau sign. What electrolyte imbalance is occurring?
Answer: hypocalcaemia
Click on the exhibit to view the patient record and answer the question. According to the
exhibit, which medication would you hold?
Answer: captopril (ACE, monitor HR)
Teaching regarding TB meds.
Answer: you will be on meds for 6-12 months
The nurse is caring for a patient newly prescribed metformin. What instructions should the
nurse include?
Answer: Med should be taken WITH food to minimize GI SE, Patients should take B12 &
folic acid, never crush or chew Pg 917

The nurse is caring for a patient who is experiencing thyroid storm. Which of the following
would you expect to be done:
Answer: Cooling blanket Pg. 875
Myxedema Review page (page 887)
Answer: Myxedema is a severe form of hypothyroidism, characterized by swelling, low
energy, and cognitive impairment. It requires immediate medical treatment to restore thyroid
hormone levels.
Urography findings? Review (page 633)
Answer: Urography findings can include the visualization of kidney size and shape, ureteral
obstructions, renal stones, and any abnormal masses or lesions in the urinary tract.
Additionally, it may reveal functional aspects like urine flow and any urinary tract
abnormalities.
Diabetes/ PVD foot care?
Answer: cut toe nails straight across Pg 920
Which of the following would require airborne precautions?
Answer: measles
Lupus question
Review (page 964)
Answer: Lupus, or systemic lupus erythematosus (SLE), is an autoimmune disease where the
immune system mistakenly attacks healthy tissues, leading to inflammation and damage in
various organs. Common symptoms include fatigue, joint pain, skin rashes, and organ
involvement, requiring a multidisciplinary approach for management.
Raynaud’s phenomenon
Review (page 965) - pallor in extremities
Answer: Raynaud’s phenomenon is a condition characterized by episodic narrowing of blood
vessels in response to cold or stress, leading to color changes in the fingers and toes—often

turning white or blue. Management involves lifestyle modifications, such as keeping warm,
and in severe cases, medications to improve blood flow.
Would evisceration
Answer: Cover with warm sterile saline dressing (Pg1111)
Administering Digioxin, what’s a finding to report to provider immediately?
Nausea, Vomiting, visual disturbances
3rd degree heart block, what do you do?
Answer: Initiate Temporary Pacing with an External Pacemaker Immediately
A fib – what drug would you give?
Answer: Meds: Antiarrhythmic medications- Amiodarone, adenosine, verapamil (Pg. 314)
Lisinopril
Answer: ACE inhibitor that treats high blood pressure and heart failure. Prevents
vasoconstriction.
Monitor BP and pulse. Hypotension is a common AE. Patient should report cough (Pg 412)
The nurse is caring for a patient who has a new prescription for metoprolol “Lopressor” (Beta
Blocker) What would the nurse monitor for.
Answer: Pg. 413- Monitor BP and Pulse, can mask hypoglycemia in patients with diabetes.
How do you irrigate an ear?
Answer: Tilt head at 45 degrees up
Care of a stroke patient?
Answer: (Review pg. 155) Monitor Vitals q1-2 hours, elevate clients HOB 30 degrees to
reduce ICP, TPA should be given within 4.5 hours of the initial symptoms, monitor for
changes of LOC, ECG monitoring, have suction on standby, seizure precaution, encourage
passive ROM q2h
Which mask delivers 70% O2?

A. Nasal cannula (24-44 percent)
B. Partial rebreather (60-75 percent)
C. Non rebreather (80-95 percent)
D. Venturi (24- 55 percent)
Answer: Partial rebreather (60-75 percent)
What would you teach a group of radiation patients and what to avoid? Pg. 1005
Answer: Large crowds
What would you delegate to LPN regarding TURP?
Answer: Measuring output in the drainage bag
You’re going to administer meds through a peripheral line with continuous fluids running.
After determining compatibility what would you do?
Answer: Flushing line before admin of medication
What would you teach a patient getting Chemo about her picc line?
Answer: resume activity 4 weeks Pg. 304
Which is indicative of decreased cardiac output?
Answer: Orthostatic hypotension
Peptic ulcer disease. How do you know there is a perforation?
Answer: Rigid, board-like abdomen (Pg. 553)