2023 ATI Medical Surgical Practice Exam Set 1-3 With Answers-334 Solved Questions

Med Surg ATI Med Test Bank QUESTIONS AN CORRECT ANSWERS
VERIFIED 2023 UPDATE
Set 1
1. A nurse is preparing to administer a blood transfusion to a client who has anaemia. Which
of the following actions should the nurse take first?
Answer: check for the type and number of units of blood to administer
2. A nurse is providing teaching to an older adult female client who has stress incontinence
and a BMI of 32. Which of the following statements by the client indicates an understanding
of the teaching?
Answer: I am dieting to lose weight
3. A nurse is providing instructions to a client who has type 2 diabetes and a new prescription
of metformin. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: I should take this medication with a meal
4. A nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin. Which of the following statements by the client indicates an
understanding if the teaching?
Answer: I am taking this medication to increase my energy level
5. A nurse is caring for a client who has a prescription for enalapril. The nurse should identify
which of the following findings as an adverse effect of the medication?
Answer: orthostatic hypotension
6. A nurse is caring for a client who has hypothyroidism. which of the following
manifestations should the nurse expect?
Answer: constipation

7. A charge nurse is instructing a newly licensed nurse about caring for a client who has
MRSA. which of the following statements by the new nurse indicates an understanding of the
teaching?
Answer: I will leave assessment equipment in the room to use on this patient
8. A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). which of
the following instructions should the nurse include in the teaching?
Answer: increase fibre intake to at least 30 g/day
9. A nurse is caring for a client who has a positive culture for c. diff. which of the following
actions should the nurse take?
Answer: implement contact precautions for the client
10. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the
following is the priority assessment finding that the nurse should report to the provider?
Answer: BP 170/80
11. A nurse is planning care for a client who is scheduled for a thoracentesis. which of the
following interventions should the nurse include in the plan?
Answer: encourage the client to take deep breaths after the procedure
12. A nurse is assessing a client who has had a suspected cerebrovascular accident. the nurse
should place the priority on which of the following findings?
Answer: dysphagia
13. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the
following result should the nurse expect?
Answer: PaCO2 56
14. A nurse is providing discharge instructions to a client who has laryngeal cancer and is
receiving radiation treatment. which of the following statements by the client indicates an
understanding of the teaching?
Answer: I will avoid direct exposure to the sun

15. A nurse is assessing for compartment syndrome in a client who has a short leg cast. which
of the following findings should the nurse identify as a manifestation of this condition?
Answer: pain that increases with passive movement
16. A nurse is providing teaching to a client who has a gastric ulcer a d a new prescription for
omeprazole. the nurse should instruct the client that the medication provides relief by which
of the following actions.
Answer: suppressing gastric acid production
17. A nurse is assessing a client who has peripheral arterial disease. which of the following
findings should the nurse expect?
Answer: hair loss on the lower legs
18. A nurse is assessing a client following the completion of haemodialysis. which of the
following findings is the nurse's priority to report to the provider?
Answer: restlessness
19. A nurse is reviewing the medical record of a client who has osteomyelitis and a
prescription of gentamicin. which of the following findings from the client's medical record
should indicate to the nurse the need to withhold the med?
Answer: serum creatinine
20. A nurse is reviewing the medical record of a client who has SLE. which of the following
findings should the nurse expect?
Answer: facial butterfly rash
21. A nurse is providing teaching to a client who has a new prescription for psyllium. which
of the following information should the nurse include in the teaching?
Answer: drink 240 mL of water after administration
22. A nurse in a provider's office is assessing a client who has migraine headaches and is
taking feverfew to prevent her headaches. the nurse should identify that which of the
following client meds interacts with feverfew?
Answer: naproxen

23. A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile
dysfunction. which of the following statements should the nurse make?
Answer: you will not be able to use sildenafil if you are taking nitro-glycerine
24. A nurse is caring for a client who is receiving TPN. a new bag is not available when the
current infusion is nearly completed. which of the following actions should the nurse take?
Answer: administer dextrose 10% in water until the new bag arrives
25. A nurse is providing discharge teaching to a client who has HF and a new prescription for
a potassium-sparing diuretic. which of the following information should the nurse include in
the teaching?
Answer: try to walk at least 3 times per week for exercise
26. A nurse is planning care for a client who is postop following a laparotomy and has a
closed-suction drain. which of the following actions should the nurse take to manage the
drain?
Answer: compress the drain reservoir after emptying
27. A nurse in an emergency department is admitting a client who reports dyspnea and SOB.
which of the following actions is the priority for the nurse to perform prior to administering
oxygen?
Answer: determine if the client has a history of COPD
28. A nurse is obtaining a med history from a client who is scheduled to undergo cataract
surgery. the nurse should recognize that which of the following client meds is a
contraindication for the surgery and notify the provider?
Answer: warfarin
29. A nurse is caring for a client following extubation of her endotracheal tube 10 min ago.
which of the following findings should the nurse report to the provider immediately
Answer: stridor

30. A nurse is providing dietary teaching to a client who is postop following a thyroidectomy
with removal of the parathyroid glands. the nurse should instruct the client to include which
of the following foods to increase calcium in the diet?
Answer: 12 almonds
31. A nurse is preparing to assist with the insertion of a nontunneled percutaneous central
venous catheter into a subclavian vein. the nurse should plan to place the client in which of
the following positions?
Answer: Trendelenburg
32. Teaching to client with HTN and new med verapamil. what juice should client avoid?
Answer: grapefruit
33. Client experiencing anaphylactic reaction, after patent airway, which is priority nursing
intervention?
Answer: apply oxygen vi face mask
34. Client had nephrostomy tube inserted 12hrs ago. what should the nurse report to the
provider?
Answer: client reports back pain
35. Teaching to perimenopausal and has hormone replacement therapy. adverse effects to
notify provider?
Answer: calf pain, numbness in arms, and intense headache
36. Older adult with cancer and a new prescription of opioid analgesic. which info should the
nurse include in teaching?
Answer: you should increase your fiber intake to prevent constipation
37. A nurse is providing med teaching to a group with seizure disorders. instruction about
phenytoin?
Answer: phenytoin decreases the effectiveness of oral contraceptives

38. A nurse is caring for client with supraventricular tachycardia. which action should nurse
take next?
Answer: perform synchronized cardioversion
39. Change of shift report with four clients. client with greatest risk of developing infection?
Answer: COPD and receiving steroid therapy
40. Teach with self-administration of heparin?
Answer: use electric razor
41. Client having seizure, nurse priority?
Answer: turn client on the side
42. Female client with hx of UTI, nurse include in teaching?
Answer: clean perineum front to back
43. Cardiac assessment with MI 2 days ago. action after hearing this sound?
Answer: listen with client on left side
44. Client on bed rest and enoxaparin sub cut, actions nurse take?
Answer: administer med at the same time each day
45. Postop following parathyroidectomy. priority action?
Answer: place a trach tray at bedside
46. Pt with arterial line, following actions should nurse taking?
Answer: place a pressure bag around the flush solution
47. Teaching client about a fib and purpose of wearing a Holter monitor. info should nurse
include in the teaching?
Answer: this device can detect when you have an irregular HR
48. Client with DKA, client condition improving?
Answer: glucose 272

49. Stroke on right hemisphere. nurse expect?
Answer: impulsive behavior
50. Client who has external fixation device for fracture. instruction for nurse plan of care?
Answer: use crutches with rubber tips
51. Receiving mechanical ventilation via trach tube. nurse recognizes complications with
long term mechanical ventilation?
Answer: stress ulcers
52. Teaching about asthma use of metered-dose inhaler. understand teaching?
Answer: holding breath for 10 secs after inhaling
53. Graves’ disease, picture with exophthalmos?
Answer: big eyes, last picture
54. Leg cast and demonstration w/crutches on climbing stairs.
Answer: identify steps body weight on crutches, advance unaffected leg onto stair, shift
weight from crutch to unaffected, bring crutches and affected leg up to the stair
55. Older adult with fractured wrist following fall. last week I crashed my car by my vision
Answer: suddenly blurry.
Check for neuro status
56. Performing dressing change recovering from hemicolectomy. large part of bowel is
protruding, action take first?
Answer: call for help
57. Older adult about osteoporosis prevention. meds increase risk for developing
osteoporosis?
Answer: fludrocortisone
58. Client having modified radical mastectomy of right breast. intervention for plan of care?

Answer: instruct the client that the drain is removed when there is 25mL of output or less
over a 24hr period
59. Client with anaemia and a prescription for an oral iron supplement. which of the
following statements by teaching?
Answer: I will eat more high fibre foods
60. Program about prevention of atherosclerosis at health fair. recommendations plan to
include?
Answer: follow smoking cessation, maintain appropriate weight, eat low fat diet
61. TPN 2000kcal per day. 500kcal/L; mL/hr
Answer: 167
62. Client with chronic glomerulonephritis with oliguria. manifestation?
Answer: hyperkalaemia
63. Reviewing lab results with aplastic anaemia. potential complication?
Answer: WBC 2,000/mm3
64. ED with full thickness burns over 20% of total body surface. administer first after patent
airway and administer O2?
Answer: IV fluids
65. Client with UTI and prescription ciprofloxacin. instructions?
Answer: avoid taking magnesium containing antacids with this med
66. Teaching with AIDS. understanding of teaching?
Answer: I will take my temp once a day
67. Compound fracture 3 weeks ago, unexpected finding lab value of manifestation of
osteomyelitis and report to provider?
Answer: sedimentation rate

68. Bilateral pneumonia, client is dyspneic with productive cough. action nurse take first?
Answer: place the client in high-fowlers position
69. Client who is hypokalaemia. manifestations?
Answer: decreased peristalsis
70. Client with suctioning the clients trach tube. indication for hypoxia?
Answer: the clients HR increases
71. Med hx who undergo allergy testing. nurse should discontinue which med before testing?
Answer: prednisone
72. Client with type 1 DM and new prescription for insulin lispro. understands teaching?
Answer: I will need to take the lispro in addition to my other prescribed insulin.
73. Client postop total hip arthroplasty. lab value should nurse report?
Answer: hgb 8g/dL
74. Checking ECG rhythm strip for client has temp pacemaker. spike followed by QRS
complex. Action take first?
Answer: document the depolarization has occurred
75. ED client reports vomiting and diarrhoea past 3 days. findings client experience fluid
volume deficit?
Answer: HR 110/min
76. PACU nurse client postop right nephrectomy. VS changes alert nurse client might be
haemorrhaging?
Answer: HR 110/min
77. ED planning care for flail chest on right side in motor vehicle crash. action plan to take?
Answer: prepare the client for positive pressure ventilation
78. Providing discharge w patient with active TB, nurse teach?

Answer: sputum specimens are necessary every 2-4 wks. until there are three neg cultures
79. Client who is 12hr postop following total hip arthroplasty. action nurse take?
Answer: place a pillow between the client's legs
80. Reviewing lab results w client has acute leukaemia. expected finding?
Answer: increased WBC count
81. Client has venous insufficiency about self-care. client understands teaching?
Answer: I will wear clean graduated compression stockings every day
82. Client has end stage kidney disease about organ donation. nurse include in teaching?
Answer: the client who receives a kidney from a live donor has a lower rate of transplant
rejection
83. Client is exhibiting manifestations of a febrile reaction while receiving blood transfusion.
meds should nurse administer?
Answer: acetaminophen
84. Client receiving plasmapheresis through venous access site. action nurse take?
Answer: check electrolyte levels before and after therapy
85. Client at client for a 1 week follow up visit after HF. nurse report to provider?
Answer: HR 55/min
86. Preop teaching for client with scheduled for open cholecystectomy, action nurse take?
Answer: demonstrate ways to deep breath and cough
87. Acute care facility caring for client at risk for seizures. precautions nurse implement?
Answer: ensure that the client has a patent IV
88. Client has bladder cancer and undergo cutaneous diversion procedure to establish
ureterostomy. nurse include in teaching?
Answer: cut the opening of the skin barrier 1/8inch wider than the stoma

89. Assessing male client for inguinal hernia. which area should the nurse palpate to verify
has inguinal hernia?
Answer: Inguinal canal and inguinal rings.
90. Client is 8hr postop total hip arthroplasty, client unable to void on bedpan. action nurse
take first?
Answer: scan bladder with portable ultrasound
Set 2
1. A nurse is reviewing the medical record of a client who has systemic lupus erythematosus.
Which of the following findings should the nurse expect?
Answer: Facial butterfly rash.
Rationale:
A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks
and nose and can disappear during times of remission.
2. A nurse is caring for a client who is receiving plasmapheresis through a venous access site.
Which of the following actions should the nurse take?
Answer: Check electrolyte levels before and after therapy.
Rationale:
Plasmapheresis can cause citrate induced hypocalcaemia. Therefore the nurse should monitor
the clients electrolyte levels before and after therapy.
3. A nurse is assessing a client who has Graves’ disease. Which of the following images
should indicate to the nurse that the client has exophthalmos?
Answer: The nurse should identify an outward protrusion of the eyes is exophthalmos a
common finding of graves’ disease. An overproduction of the thyroid hormone causes edema
of the extraocular muscle and increases fatty tissue behind the eye which results in the eyes
protruding outward. Exophthalmos can cause the client to experience problems with vision
including focusing on objects as well as pressure on the optic nerve.

4. A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2
days ago. Which of the following actions should the nurse take first after hearing the
following sound?
Answer: Listen with the client on his left side. When providing nursing care the nurse should
first use the least invasive intervention. Therefore after auscultating a murmur the first action
the nurse should take is to place the client on his left side and listen to his heart again.
5. A nurse is providing teaching to an older adult female client who has stress incontinence
and a BMI of 32. Which of the following statements by the client indicates an understanding
of the teaching question mark
Answer: I am dieting to lose weight. Excess weight cut creates increased abdominal pressure
that can result in stress incontinence.
6. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the
following results should the nurse expect?
Answer: Paco2 of 56. A client who has COPD retains paco2 due to the weakening and the
collapse of the alveolar sacs which decreases the area and lungs for gas exchange and causes
the paco2 to increase above the expected reference range.
7. A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the client to notify the provider? Select all that apply.
Answer: Calf pain, numbness in the arms and intense headache. Calf pain is an indication of
DVT and the client should report this finding to the provider immediately. Numbness in the
arms can indicate cerebrovascular accident which is an adverse effect of hormone
replacement therapy and an intense headache can indicate a cerebrovascular accident.
8. A nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: I am taking this medication to increase my energy level. The goal of erythropoietin
therapy is to increase the level of haematocrit and clients who have anaemia. When the
medication is effective the client should have a decreasing fatigue and an improvement and
activity tolerance.

9. A nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client understands
teaching?
Answer: I will wear clean graduated compression stockings every day. The client should
apply a clean pair of graduated compression stockings each day and clean soiled stockings
with mild detergent and warm water by hand.
10. A nurse is preparing to present a program about atherosclerosis at a health fair. Which of
the following recommendations should the nurse plan to include? Select all that apply.
Answer: Follow a smoking cessation program maintain an appropriate weight eat a low-fat
diet and increase fluid intake. Smoking cessation is an important lifestyle modification to
prevent Arthur sclerosis and preventing obesity through diet and exercise can help prevent
atherosclerosis. Eating a low fat diet decreases LDL cholesterol and can prevent
atherosclerosis.
11. A nurse is caring for a client who is 12 hours post-operative following a total hip
arthroplasty. Which of the following actions should the nurse take?
Answer: Place a pillow between the clients legs. The nurse should place a pillow between the
clients legs to prevent hip dislocation.
12. A nurse is reviewing the medication history of a client who is to undergo allergy testing.
The nurse should instruct the client to discontinue which of the following medications before
the testing?
Answer: The nurse should instruct the client to discontinue antihistamines before allergy
testing, as they can interfere with test results. Examples include diphenhydramine, loratadine,
and cetirizine.
13. A nurse is preparing to administer a blood transfusion to a client who has anaemia. Which
of the following actions should the nurse take first?
Answer: Check for the type and number of units of blood to administer. According to
evidence based practice the nurse should first confirm that the type and number of units of
blood to administer matches what is indicated in the clients medication administration record.

14. A nurse is providing teaching to a client who has anaemia and a new prescription for an
oral iron supplement. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: I will eat more high-fibre foods. The client should eat high-fibre foods to help
prevent constipation which is a common adverse effect of oral iron supplements.
15. A nurse is caring for a client who is post-operative following a total hip arthroplasty.
Which of the following laboratory values should the nurse report to the provider?
Answer: HGB of 8. The nursery report and HGB level of 8 which is below the expected
reference range and as an indicator of postoperative haemorrhage or anaemia.
16. A nurse is caring for a client who has a leg cast and is returning demonstration on the
proper use of crutches while climbing stairs. Identify the sequence the client should follow
when demonstrating crutch use.
Answer: Place body weight on the crutches Advance the unaffected leg onto the stair shift
weight from the crutches to the unaffected leg and then bring the crutches and the affected leg
up to the stair
17. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin
subcutaneous. Which of the following actions should the nurse take?
Answer: Administer the medication at the same time each day. The nurse administer the
medication to the client at the same time each day to maintain consistent serum levels
18. A nurse is reviewing the laboratory results of a client who has aplastic anaemia. Which of
the following findings indicates a potential complication?
Answer: White blood cell count of 2000. This white blood cell count is below the expected
reference range and indicates a risk for severe immunosuppression.
19. A nurse in an emergency department is admitting a client who reports dyspnea and
shortness of breath. Which of the following actions is the priority for the nurse to perform
prior to administering oxygen?
Answer: Determine if the client has a history of COPD. According to evidence based
practice the nurse should first assess if the client has COPD. Administering oxygen can
worsen chronic hypercarbia in a client who has COPD

20. A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile
dysfunction. Which of the following statements should the nurse make?
Answer: You will not be able to use sildenafil if you are taking nitro-glycerine. The client
should not use sildenafil when taking nitro-glycerine because both medications can cause
vasodilation and lead to significant hypotension
21. A nurse is in a provider's office is providing teaching to a client who has a urinary tract
infection and a new prescription for ciprofloxacin. Which of the following instructions should
the nurse include
Answer: Avoid taking magnesium containing antacids with this medication. The nurse
should instruct the client to take Ciprofloxacin either two hours before or 6 hours after taking
an antacid but not to take Ciprofloxacin with an antacid because magnesium containing
antacids decrease the absorption of Ciprofloxacin
22. A nurse is providing follow-up care for a client who sustained a compound fracture three
weeks ago. The nurse should recognize that an unexpected finding for which of the following
laboratory values is a manifestation of osteomyelitis and should be reported to the provider
Answer: Sedimentation rate. And increased sedimentation rate occurs when a client has any
type of inflammatory process such as osteomyelitis
23. A nurse is caring for a client who has hypothyroidism. Which of the following
manifestations should the nurse expect
Answer: Constipation. A client who has hypothyroidism can experience constipation due to
the decrease in the client's metabolism resulting and slow motility of the gastrointestinal tract.
The nurse should instruct the client to increase fibre and fluid and take to reduce the risk of
constipation
24. A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic
reaction. After ensuring a patent Airway which of the following interventions is the priority
Answer: applying oxygen via face mask because the priority intervention is for the nurse to
apply oxygen using a high-flow non-rebreather mask to deliver oxygen at 90 to 100% Where
would you palpate to assess for an inguinal hernia .
The nurse should palpate at the right groin area because an inguinal hernia forms of the
peritoneum which contains part of the intestine and can protrude into the scrotum in males

25. A nurse is checking the ECG Rhythm strip for a client who has a temporary pacemaker
the nurse notes a spike or a pacemaker artifact followed by a QRS complex. Which of the
following actions should the nurse take
Answer: Document that depolarization has occurred. When a pacing stimulus is delivered to
The ventricle a spike appears on the ECG Rhythm strip this bike should be followed by a
QRS complex which indicates pacemaker capture or depolarization
26. A nurse is caring for a client who is eight hours post-operative following a total hip
arthroplasty the client is unable to void on the bed pan Which of the following actions should
the nurse take first
Answer: Scan the bladder with a portable ultrasound the first action should be using the
nursing process which is assisting the client scanning the bladder with a portable ultrasound
device will determine the amount of urine in the bladder
27. A nurse is caring for a client who is receiving tpn a new bag is not available when the
current infusion is nearly completed which of the following actions should the nurse take
Answer: Administer dextrose 10% in water until the new bag arrives. Tpn Solutions have a
high concentration of dextrose therefore if a t-pn solution is temporarily unavailable the nurse
administer dextrose 10% or 20% and water to avoid a precipitous drop in the client's blood
glucose level
28. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for
Omeprazole. The nurse should instruct the client that the medication provides Relief by
which of the following actions
Answer: Suppressing gastric acid production. I love her soul is a proton pump inhibitor it
relieves manifestations of gastric ulcers by suppressing gastric acid production
29. A nurse is providing discharge teaching to a client who is to self-administer heparin
subcutaneously. Which of the following responses by the client indicates an understanding of
the teaching
Answer: I will use an electric razor to shave. Heparin is an anticoagulant that places the
client at risk for bleeding therefore the nurse should instruct the client to use an electric razor
when shaving to reduce the risk of cuts to the skin

30. A nurse is caring for a client following excavation of her endotracheal tube 10 minutes
ago. Which of the following findings should the nurse report to the provider immediately
Answer: Strider. Using the Urgent vs. Non-urgent approach to client care the nurse should
determine that the priority finding a Strider. Strider can indicate and narrowing Airway or
possible obstruction caused by edema or laryngeal spasms the nurse should report the finding
immediately Implement an intervention
31. A nurse is caring for a client who had a nephrostomy tube inserted 12 hours ago. Which
of the following findings should the nurse report to the provider
Answer: The client reports back pain the nurse should notify the provider if the client reports
back pain which can indicate that the nephrostomy tube is dislodged or clogged
32. A nurse is assessing a client while suctioning the clients tracheostomy tube which of the
following findings should indicate to the nurse that the client is experiencing hypoxia
Answer: The clients heart rate increases because hypoxia related to suctioning can cause the
clients heart rate to increase if this occurs the nurse should discontinue the sectioning and
immediately oxygenate the client with 100% oxygen the nurse should instruct the client to
take three or four deep breaths prior to suctioning to reduce the risk for hypoxia
33. A nurse is planning teaching for a client who has bladder cancer and is to undergo a
cutaneous diversion procedure to establish and ureterostomy. Which of the following
statements should the nurse include in the teaching
Answer: Cut the opening of The Skin Barrier one eighth of an inch wider than the stoma.
The client should cut the opening of The Skin Barrier 1/8 inch wider than the stoma to
minimize irritation of the skin from exposure to urine
34. A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a
Holter monitor. Which of the following information should the nurse include in the teaching
Answer: This device can detect when you have an irregular heart rate because it reports and
transmits electrical impulses of the heart and alerts the nurse to dysrhythmias myocardial
injury or conduction defects a Holter monitor allows the client freedom of movement while
cardiac activity is recorded

35. A nurse is providing discharge teaching to a client who has heart failure and a new
prescription for potassium sparing diuretic which of the following information should the
nurse include in the teaching
Answer: Try to walk at least 3 times per week for exercise because the development of a
regular exercise routine can improve outcomes in clients who have heart failure
36. A nurse is caring for a client who has chronic glomerulonephritis with oliguria which of
the following findings should the nurse identify as a manifestation of chronic
glomerulonephritis
Answer: Hyperkalaemia as a result of kidney failure because kidney failure results in
decreased excretion of potassium
37. A nurses in an acute care facility is caring for a client who is at risk for seizures which of
the following precautions should the nurse implement
Answer: Ensure that the client has a patent IV in the event that the client requires medication
to stop seizure activity
38. A nurse is caring for a client who has bilateral pneumonia and an spo 2 of 88% the client is
dyspneic and productive cough and is using accessory muscles to breathe which of the
following actions should the nurse take first
Answer: Place the client in a high Fowler's position
39. A nurse is caring for a client who has a new diagnosis of hyperthyroidism which of the
following is the priority assessment finding that the nurse should report to the provider
Answer: Blood pressure of 170 over 80 because using the Urgent vs. Non-urgent approach to
client care the nurse determines that the priority funding is a systolic blood pressure of 170
which indicates that the client is at risk for thyroid storm
40. A nurse is reviewing the medication history of a client who is to undergo allergy testing
the nurse should instruct the client to discontinue which of the following medications before
testing
Answer: Prednisone because it is a glucocorticoid that can cause the client to have false
negative test results, they should discontinue antihistamine medications several weeks prior
to testing

41. A nurse is caring for a client who has an arterial line. Which of the following actions
should the nurse take?
Answer: Place a pressure bag around the flush solution. The nurse should place a pressure
bag around the flush solution because the pressure from an artery is greater than that of the
line
42. A nurse is caring for a client who has a new prescription for tpn the client is to receive
2,000 k calories per day the t-pn solution has 500 k calories per liter the IV pump should be
set at how many milliliters per hour
Answer: 167 millilitres per hour
43. A nurse is providing teaching to a client who has AIDS which of the following statements
by the client indicates an understanding of the teaching
Answer: I will take my temperature once a day a client who has AIDS is
immunocompromised and is at risk for infection the client should take his temperature daily
to identify a temperature greater than 100 degrees which is an early manifestation of an
infection
44. A nurse is assessing a client who has peripheral artery disease which of the following
findings should the nurse expect
Answer: Hair loss on the lower legs the nurse should expect a client who is Peripheral
arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation
affecting follicular growth
45. A nurse is providing teaching to an older adult client who has cancer and a new
prescription for an opioid analgesic for pain management which of the following information
should the nurse include in the teaching
Answer: You should increase your fibre intake to prevent constipation because opioids slow
Paracelsus in the gastrointestinal tract which causes constipation
46. A nurse is planning care for a client who is scheduled for a thoracentesis which of the
following interventions should the nurse include in the plan

Answer: Encourage the client to take deep breaths after the procedure to read expand the
lung
47. A nurse is caring for a client who has a prescription for Enalapril the nurse should identify
which of the following findings as an adverse effect of the medication
Answer: Orthostatic hypotension because dilation of arteries and veins causes orthostatic
hypotension which is an adverse effect of Enalapril
48. A charge nurse is instructing a newly licensed nurse about caring for a client who has
MRSA which of the following statements by the newly licensed nurse indicates an
understanding of the teaching
Answer: I will leave assessment equipment in the room to use on this client the nurse should
follow contact precautions and use dedicated equipment when assessing the client to prevent
cross- contamination with other clients
49. A nurse is caring for a client who recently had a stroke of the right hemisphere which of
the following manifestations should the nurse expect
Answer: Impulsive behavior
50. A nurse is caring for a client who is exhibiting manifestations of a febrile reaction while
receiving a blood transfusion which of the following medications should the nurse administer
Answer: Acetaminophen to reduce fever and decreased the manifestation of the febrile
reaction manifestations of a febrile reaction include tachycardia fever hypotension and chills
the nurse should discontinue the transfusion and return the blood bag and tubing to the blood
bank
51. A nurse is assessing a client who has hypokalaemia which of the following manifestations
should the nurse expect
Answer: Decreased peristalsis due to a decrease in gastrointestinal smooth muscle
contraction a nurse is caring for a client who is experiencing supraventricular tachycardia
upon assessing the client the nurse observes the following findings heart rate 200 per minute
blood pressure 78 over 40 and respiratory rate 30 per minute which of the following actions
should the nurse take Perform synchronized cardioversion

52. A nurse is providing dietary teaching to a client who is post-operative following a
thyroidectomy with removal of the parathyroid glands the nurse should instruct the client to
include which of the following foods that has the greatest amount of calcium in her diet
Answer: 12 almonds because they are the best source of calcium to recommend because they
contain 36 milligrams of calcium removal of the parathyroid glands which regulate calcium
in the body can result in hypocalcaemia
53. A nurse is caring for a client who has dka which of the following findings should indicate
to the nurse at the client's condition is improving
Answer: Glucose of 272 because a glucose reading less than 300 indicates Improvement in
the client's status
54. A nurse is performing a dressing change for a client who is recovering from a
hemicolectomy when removing the dressing with the nurse notes that a large part of the
bowel is protruding through the abdomen which of the following actions should the nurse
take first
Answer: Call for help because evidence based practice indicates that the nurse should first
stay with the client and call for assistance the client will require emergency surgery and is at
risk for shock therefore the nurse should attain immediate assistance
55. A nurse is caring for a client who presents to a clinic for a one-week follow-up visit after
hospitalization for heart failure based on the information in the clients chart which of the
following findings should the nurse report to the provider
Answer: Heart rate of 55 per minute is a significant drop from the clients Baseline of 74
permanent and it can indicate the development of digoxin toxicity
56. A nurse is assessing for compartment syndrome in a client who has a short leg cast which
of the following findings should the nurse identify as a manifestation of this condition
Answer: Pain that increases with passive movement because compartment syndrome results
from a decrease in blood flow in the extremities because of a decrease in the muscle
compartment size due to a cast that is too tight

57. A nurse is planning care for a client who is post-operative following a laparotomy and has
a closed suction drain which of the following actions should the nurse take to manage the
drain
Answer: Compress the drain Reservoir after emptying because it creates a vacuum that
draws fluid out of the room through the drain and into the reservoir
58. A pacu nurse is assessing a client who is post-operative following a right nephrectomy the
client's initial vital signs for heart rate 80 permanent blood pressure 130 over 70 respiratory
rate 16 and temperature 96.8 which of the following Vital sign changes should alert the nurse
the client might be haemorrhaging
Answer: heart rate of 110 per minute because one of the first signs of haemorrhage is an
increase in the heart rate from the clients Baseline which occurs to compensate for blood
59. A nurse is assessing a client following the completion of haemodialysis which of the
following findings is the nurses priority to report to the provider
Answer: Restlessness because using the Urgent vs. Non-virgin approach to client care the
nurse to determine that the priority funding to report to the provider is restlessness which can
be an indication of the client is experiencing disequilibrium syndrome which is caused by the
rapid removal of electrolytes for the clients blood and can lead to dysrhythmias or seizures
other manifestations include nausea vomiting fatigue and headache
60. A nurse is caring for a client who is having a seizure which of the following interventions
is the nurses priority
Answer: Turn the client to the side because the greatest risk to this client is hypoxia from an
impaired Airway
61. A nurse is obtaining a medication history from a client who is scheduled to undergo
cataract surgery the nurse should recognize that which of the following client medications is a
contraindication for the surgery and notify the provider
Answer: Warfarin because it is an anticoagulant which increases the client's risk for bleeding
and is contraindicated for a client scheduled for I or Central Nervous System since surgery
62. A nurse is providing teaching to a female client who has a history of urinary tract
infections which of the following information should the nurse include in the teaching

Answer: Clean the perineum from front to back after voiding or defecating to avoid
introducing bacteria to the urethra
63. A nurse is assessing a client who has had a suspected cerebrovascular accident the nurse
should place the priority on which of the following findings
Answer: Dysphasia because it indicates that the client is at greatest risk for aspiration due to
impaired sensation and function within the oral cavity
64. A nurse is planning care for a client who is post-operative following a parathyroidectomy
which of the following actions should the nurse identify as the priority
Answer: Placed a tracheostomy tray at the bedside in case of Airway obstruction
65. A nurse is providing teaching to a client who has Type 1 diabetes mellitus and a new
prescription for insulin lispro which of the following statements by the client indicates an
understanding of the teaching
Answer: I will need to take this bro in addition to my other prescribed insulin because it is a
rapid-acting insulin that the client can use in conjunction with an intermediate or long-acting
insulin
66. A nurse is providing medication teaching to a group of clients who have seizure disorders
which of the following information should the nurse include about phenytoin
Answer: Phenytoin decreases the effectiveness of oral contraceptives because it stimulates
the synthesis of hepatic enzymes which can decrease the activity of other medications
including oral contraceptives
67. A nurse is providing discharge instructions to a client who has active tuberculosis which
of the following information should the nurse include in the instructions
Answer: Sputum specimens are necessary every 2 to 4 weeks until there are three negative
cultures after three negative sputum cultures the client is no longer considered infectious
68. A nurse is planning care for a client who was having a modified radical mastectomy of the
right breast which of the following interventions should the nurse include in the plan of care

Answer: Instruct the client that the drain is removed when there is 25 milliliters of output or
less over a 24-hour period the drain will remain in place for one to three weeks after surgery
and we've removed when there is 25 millilitres of output or less in a 24-hour period
69. A nurse is teaching to a client who has hypertension and a new prescription for Verapamil.
Which of the following juices should the nurse instruct the client to avoid
Answer: Grapefruit because it inhibits the hepatic metabolism of the medication and then
place the current client at risk for toxicity
70. A nurse is providing teaching to a client who has asthma about the use of a metered dose
inhaler the nurse should identify that which of the following client actions indicates an
understanding of the teaching
Answer: Holding breath for 10 seconds after inhaling so that the medication can move deep
into the Airways
71. A nurse is providing instructions to a client who has Type 2 diabetes mellitus and a new
prescription for metformin which of the following statements by the client indicates an
understanding of the teaching
Answer: I should take this medication with a meal to improve absorption and to minimize
gastrointestinal distress
72. A nurse is providing teaching to a client who has irritable bowel syndrome which of the
following instructions should the nurse include in teaching
Answer: Increase fibre intake to at least 30 grams per day to produce bulky soft stools and
establish regular bowel patterns
73. A nurse in an emergency department is assessing an older adult client who has a fractured
wrist following a fall during the assessment the client states last week I crashed my car
because my vision suddenly became blurry which of the following actions is the nurses
priority
Answer: Check the clients neurologic status because the first action you should take is to
assess the client

74. A nurse is providing teaching to a client who has a new prescription for psyllium which of
the following information should the nurse include in the teaching
Answer: Drink 240 millilitres of water after Administration
75. A nurse on a medical-surgical unit is receiving change of shift report on four clients
which of the following clients should the nurse identify as having the greatest risk for
developing an infection
Answer: The client who has a urinary catheter is at the greatest risk for developing an
infection, as indwelling catheters are a common source of healthcare-associated infections
due to the potential for bacterial entry into the urinary tract.
76. A client who has COPD and is receiving steroid therapy because of decreased
oxygenation and increased mucus production additionally
Answer: taking a steroid medication increases the client's risk for infection by suppressing
the immune system and masking the presence of an infection
77. A nurse is planning discharge teaching for a client who has an external fixation device for
a fracture of the lower extremity which of the following instructions should the nurse include
in the plan of care
Answer: Used crutches with rubber tips to prevent the client from slipping and decrease the
risk of Falls
78. A nurse in an emergency department is caring for a client who has full thickness Burns
over 20% of his total body surface area after ensuring a patent Airway and administering
oxygen which of the following items should the nurse prepared to administer first
Answer: IV fluids to provide circulatory support
79. A nurse is reviewing the medical record of a client who has osteomyelitis and a
prescription for Gentamicin which of the following findings from the client's medical record
should indicate to the nurse the need to withhold the medication and notify the provider
Answer: Serum creatinine because a client who has an elevated serum creatinine level should
not receive Gentamicin because the medication is nephrotoxic

80. A nurse is reviewing the laboratory results of a client who has a new diagnosis of acute
leukaemia which of the following findings should the nurse identify as an expected finding
Answer: Increased white blood cell count do to overproduction of white blood cells by the
bone marrow
81. A nurse in an emergency department is caring for a client who reports vomiting and
diarrhoea for the past 3 days which of the following findings should indicate to the nurse that
the client is experiencing fluid volume deficit
Answer: Heart rate of 110 per minute
82. A nurse is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy which of the following actions should the nurse take
Answer: Demonstrate ways to deep breath and cough to prevent respiratory complications
83. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy
to the nurse should recognize that which of the following complications is associated with
long-term mechanical ventilation
Answer: Stress ulcers because of elevated levels of hydrochloric acid in the stomach. They
increased risk for systemic infection and require pharm treatment
84. A nurse is providing discharge instructions to a client who has laryngeal cancer and
received is receiving radiation treatment which of the following statements by the client
indicates an understanding of the teaching
Answer: I will avoid direct exposure to the Sun because the client should avoid exposure of
irradiated skin areas to the Sun for at least one year after completing radiation therapy skin in
the radiation path is especially sensitive to sun damage
85. A nurse is caring for a client who has a positive culture for Clostridium difficile which of
the following actions should the nurse take
Answer: Implement contact precautions for the client because direct contact is the mode of
transmission

86. A nurse in a provider's office is assessing a client who has migraine headaches and is
taking Feverfew to prevent her headaches the nurse should identify that which of the
following client medications interact with Feverfew
Answer: Naproxen because they both impaired platelet aggregation and place the client at
risk for bleeding
87. A nurse in an emergency department is planning care for a client who has a flail chest on
the right side following a motor vehicle crash which of the following actions should the nurse
plan to take
Answer: Prepare the client for positive pressure ventilation to promote lung expansion and
stabilize the pressure within the client's chest then there should also administer analgesics to
alleviate pain while breathing to achieve optimal lung expansion
88. A nurse is preparing to assist with the insertion of a non-tunnelled percutaneous central
venous catheter into a client's subclavian vein the nurse should plan to place the client in
which of the following positions
Answer: Trendelenburg disposition facilitates the insertion of the catheter by dilating the
blood vessels of the clients neck
89. A nurse is teaching an older adult client about osteoporosis prevention the nurse should
instruct the client that which of the following medications can increase her risk for
developing osteoporosis
Answer: Fludrocortisone due to an increase in bone resorption by osteoclasts it can also
reduce intestinal absorption of calcium
90. A nurse is teaching a client who has end-stage kidney disease about organ donation which
of the following information should the nurse include in the teaching
Answer: The client who receives a kidney from a live donor has a lower rate of transplant
rejection because the donor is often more medically compatible than a donor who is deceased
91. A client is admitted to the ER with anxiety loss of muscle coordination and skin is hot and
dry the client had been working on the yard prior to coming to the hospital which of the
following actions should the nurse anticipate taking first

Answer: Place the client on a cooling blanket because these findings indicate the client is at
greatest risk for hyperthermia
92. A nurse is caring for a client who has an arteriovenous fistula for dialysis which of the
following requires intervention by the nurse
Answer: Numb fingers distal to the fistula it indicates impaired circulation and requires
intervention
93. A nurse is caring for a client who had an open thoracotomy with chest tube insertion
which of the following actions should the nurse take
Answer: Keep the chest tube collection chamber below the level of the lungs
94. A nurse is providing instruction about traveling for a client who has a new diagnosis of
type 1 diabetes mellitus and is planning a trip by airplane which of the following should the
nurse include in the teaching
Answer: Take an additional pair of shoes
95. A nurse is providing teaching to a client who has hypothyroidism and is receiving
Levothyroxine the nurse should instruct the client that which of the following could interfere
with the absorption of the medication
Answer: Calcium supplements

Set 3
1. A nurse is caring for a school age child on a children's mental health unit. What comment
by the nurse would foster rapport to engage the client in conversation?
A. "Do you like school?
B. "Tell me about your favourite video game."
C. "We have another child your age on the unit."
D. "Would you like some juice or milk to drink?
Answer: B. "Tell me about your favourite video game."
Rationale:
This open-ended statement encourages the child to respond with more than just the name of
the game. This would foster rapport and encourage communication.

2. A nurse is planning recreational activity for a young adult client with an acute exacerbation
of schizophrenia. Assuming that the client is capable of all of the following, which activity
should the nurse consider appropriate?
A. Walking with a staff member around the gated grounds
B. Playing ping-pong in the dayroom with another client
C. Shooting baskets with several other clients in the gym
D. Riding on the stationary bike alone in the fitness room
Answer: A. Walking with a staff member around the gated grounds
Rationale:
This client should be encouraged to participate in nonthreatening, noncompetitive physical
activities. This also provides an opportunity for verbal interaction with a member of the
health care team.
3. A nurse is caring for a child who is diagnosed with strabismus. The nurse explains to the
parents that to prevent the development of amblyopia, it will be necessary to do which of the
following?
A. Patch the unaffected eye.
B. Administer mydriatic eye drops daily.
C. Obtain prescription eyeglasses. Administer IV antibiotics.
Answer: A. Patch the unaffected eye
Rationale:
Amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of
another condition, such as strabismus. In strabismus, muscle weakness allows one eye to
wander so that the child cannot focus on an object with both eyes at the same time. This
confusion causes the brain to ignore the signals from the weak eye in Favor of the strong one.
This will result in central blindness if not treated by 6 years of age. To strengthen the weak
eye muscles, the unaffected eye is patched.
4. During preoperative teaching for a client scheduled for laser assisted in situ keratomileusis
(LASIK) surgery, the nurse should tell the client that he
A. may need to wear reading glasses after the surgery.
B. can drive home after the procedure.
C. should continue to wear his contact lenses until the day of the surgery.

D. will not have to wear glasses after the surgery.
Answer: A. may need to wear reading glasses after the surgery.
Rationale:
LASIK is a type of refractive laser eye surgery ophthalmologists perform to correct myopia,
hyperopia, and astigmatism, which are common causes of near-sightedness. However, many
people develop presbyopia (farsightedness) with age and may need reading glasses, despite
having had LASIK surgery.
5. A nurse is reinforcing teaching with the family of a child who has Asperger's syndrome.
Which comment would indicate to the nurse that adequate learning has taken place?
A. "Aricept may slow the progression of the disorder."
B. "Group therapy is important for children with cognitive delays.
C. "It will help our child if we keep a structured daily routine."
D. This disorder is related to our child's prematurity."
Answer: C. "It will help our child if we keep a structured daily routine."
Rationale:
The child with Asperger's syndrome has a high functioning form of autism spectrum disorder;
typically the child will have normal to high cognitive skills. A structured environment can
help to minimize the problems these children experience with sudden schedule changes,
socialization requirements, and the preference for ritualistic behavior.
6. A nurse has been notified by the post anaesthesia care unit that a client who has had a
subtotal thyroidectomy is returning to the nursing unit. Which emergency equipment should
the nurse have available on the unit for this client?
A. Cardiac monitor
B. Defibrillator
C. Thoracotomy tray
D. Tracheostomy tray
Answer: D. Tracheostomy tray
Rationale:
In the event of laryngeal edema or tetany, respiratory distress could result in airway
obstruction. Emergency intubation may be difficult due to laryngeal swelling, and
endotracheal intubation may increase the risk for haemorrhage by increasing tension on the
incision during insertion. A tracheostomy tray should be easily accessible.

7. A nurse is caring for a client with a tracheostomy who is receiving mechanical ventilation.
The low-pressure alarm on the ventilator sounds, indicating which of the following to the
nurse?
A. Excessive airway secretions
B. A leak within the ventilator circuitry
C. Decreased lung compliance
D. Client is coughing or attempting to talk
Answer: B. A leak within the ventilator circuitry
Rationale:
The low-pressure alarm means that either the tubing has come apart or that client has become
disconnected from the ventilator tubing. Almost all low-pressure alarms are the result of a
malfunction or displacement of connections somewhere between the endotracheal or
tracheostomy tube and the ventilator.
8. A nurse has delegated an assistive personnel (AP) to provide one on one observation to a
client who is recovering from a closed head injury. The nurse notes that the client is
impulsive and has experienced one fall. Which of the following actions by the AP indicates to
the nurse further teaching is needed?
A. Accompanies the client to physical and occupational therapy
B. Ambulates the client's roommate while the client sleeps
C. Asks another AP to perform this task while at lunch
D. Remains with the client while family members are visiting
Answer: B. Ambulates the client's roommate while the client sleeps
Rationale:
One-on-one observation requires constant supervision of the client. The client might wake up
while the AP is out of the room, get out of bed, and fall.
9. A client is scheduled to have an electroencephalogram (EEG) in the morning. While
preparing the client for the EEG, it is appropriate for the nurse to tell the client which of the
following?
A. "You will be given a sedative for the procedure, so you won't feel the small electrical
shock."
B. "After midnight you will not be able to eat or drink, so be sure you have enough at dinner."

C. "You need to shampoo your hair tonight, and don't put any styling products on it
afterwards." D. "It's common to experience temporary short-term memory loss following the
procedure."
Answer: C. "You need to shampoo your hair tonight, and don't put any styling products on it
afterwards."
Rationale:
An electroencephalogram (EEG) is a painless test that records the electrical activity of the
brain. During the test, electrodes are attached to the scalp to record the tiny electrical charges
released by the nerve cells in the brain. So that the electrodes will adhere properly to the
scalp, the client's hair has to be clean and free of oil and hair-care products.
10. A nurse is caring for a client who is receiving IV ampicillin (Unasyn). Which of the
following actions should the nurse take first if the client develops urticaria and dyspnea?
A. Administer diphenhydramine (Benadryl).
B. Call the primary care provider.
C. Obtain an oximetry reading.
D. Stop the ampicillin infusion.
Answer: D. Stop the ampicillin infusion.
Rationale:
The greatest risk to the client is an allergic reaction that may progress to anaphylaxis. The
nurse should stop the infusion immediately so that further exposure to the client of the
potential allergen is halted.
TEST-TAKING STRATEGY: This question requires you to choose a priority action for a
client with drug toxicity when all the actions appear plausible. Any time that a question
involving medication toxicity requires you to make a choice about which action the nurse
should take first, a choice that has the nurse discontinuing the client's exposure to the
medication or toxic substance should always be the first choice.
11. A community health nurse is conducting a class on body mechanics for county office
workers. Which of the following should the nurse include in the teaching? (Select all that
apply.)
A. "Sit with your back supported."
B. "Knees should be at the hip level."
C. "Wrist and forearms should be parallel to the ground."

D. "Keep the elbows far away from the body."
E. "Adjust the monitor screen so that you have to tilt your head slightly to look at it."
Answer: A. "Sit with your back supported."
B. "Knees should be at the hip level."
C. "Wrist and forearms should be parallel to the ground."
Rationale:
A. "Sit with your back supported" is correct. Sitting with the back supported while at the
computer helps to prevent back strain, which can lead to lower-back disc disease.
B. "Knees should be at the hip level" is correct. Keeping the knees at the hip level while at
the computer helps to prevent unnecessary strain on the hips and lower back.
C. "Wrist and forearms should be parallel to the ground" is correct. Keeping the wrist and the
forearms parallel to the ground while typing will help to prevent unnecessary strain on the
wrists that could result in carpal tunnel syndrome.
D. "Keep the elbows far away from the body" is incorrect. The arms should be kept close to
the body. Keeping elbows far away from the body puts undue strain on the shoulders and the
arms.
E. "Adjust the monitor screen so that you have to tilt your head slightly to look at it" is
incorrect. The head should be level when looking at the computer screen. Tilting the screen,
and tilting the head to look at it, can place undue strain on the cervical spine (neck) region.
12. A nurse is reviewing the laboratory data of a client who reports symptoms that suggest
systemic lupus erythematosus (SLE). If this diagnosis is accurate, the nurse expects to note an
increased
A. platelet aggregation.
B. red blood cell count.
C. haemoglobin and haematocrit.
D. erythrocyte sedimentation rate (ESR).
Answer: D. erythrocyte sedimentation rate (ESR).
Rationale:
SLE is a chronic systemic autoimmune disease that causes skin, heart, lung, and kidney
inflammation. Like most autoimmune diseases, a series of exacerbations and remissions is
typical and, while it varies considerably in severity, clients typically die from end-stage renal
disease. Diagnosis is based on the client's history of manifestations and serologic tests. Most
clients with an exacerbation of SLE will have an increased ESR.

13. A client with an acute visual disturbance describes it as a "curtain" pulled over the visual
area with occasional flashes of light. The nurse should notify the provider immediately of the
possibility of
A. cataracts.
B. angle-closure glaucoma.
C. a detached retina.
D. macular degeneration
Answer: C. a detached retina.
Rationale:
The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. A
detached retina is a medical emergency in which the retina of the eye peels away from its
underlying layer of support tissue. Without immediate treatment, the entire retina can detach,
leading to permanent vision loss. Manifestations include a sudden onset of decreased
peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part
of the visual field.
14. A client with Addison's disease comes to the emergency department reporting nausea,
vomiting, diarrhoea, and abdominal pain. To prevent Addisonian crisis, the nurse anticipates
that the provider will prescribe IV administration of
A. calcium.
B. potassium.
C. insulin.
D. corticosteroids.
Answer: D. corticosteroids.
Rationale:
Addison's disease is characterized by adrenal gland hypofunction and inadequate production
of glucocorticoids. Acute adrenal insufficiency can be a life-threatening event, with severe
fluid and electrolyte imbalances. Without treatment, sodium levels fall and potassium levels
increase. Rapid infusion of IV fluids, such as 0.9% sodium chloride boluses, with
administration of high dose corticosteroids, such as hydrocortisone sodium succinate (SoluCortef), are started as soon as venous access is established.

15. A nurse is assisting with breastfeeding immediately following the birth of a newborn.
Which of the following is the most important benefit of breastfeeding during the fourth stage
of labor?
A. The nurse is available to assist the mother with breastfeeding techniques.
B. Maternal-newborn bonding is promoted while the neonate is in an alert phase.
C. Warmth is provided for the newborn being held against the mother's skin.
D. Oxytocin secretion is stimulated causing uterine contractions.
Answer: D. Oxytocin secretion is stimulated causing uterine contractions.
Rationale:
Production and secretion of oxytocin causes the uterus to contract, thus promoting involution
and decreasing the risk for maternal haemorrhage and blood loss.
16. A nurse is performing an assessment on a client. Which of the following in the client's
history is a contraindication to use of sildenafil (Viagra)?
A. Diabetes mellitus
B. Current use of isosorbide (Isordil) for heart failure
C. Eyeglasses required for presbyopia
D. Osteoarthritis
Answer: B. Current use of isosorbide (Isordil) for heart failure
Rationale:
Sildenafil (Viagra), a medication used in the treatment of erectile dysfunction, is
contraindicated in clients taking any nitrates, such as isosorbide (Isordil). These medications
taken concurrently may cause life-threatening hypotension.
17. A nurse is caring for a client who has recently had a myocardial infarction (MI). The
client calls the nurse to report some manifestations similar to those the client experienced the
day of the MI. Which of the following should alert the nurse to the possibility of a
recurrence? (Select all that apply.)
A. Nausea and vomiting
B. Diaphoresis and dizziness
C. Chest and left arm pain
D. Anxiety and feelings of doom
E. Leg cramps and restlessness
Answer: A. Nausea and vomiting

B. Diaphoresis and dizziness
C. Chest and left arm pain
D. Anxiety and feelings of doom
18. A client asks the nurse if it is common to experience vaginal yeast infections during
pregnancy. Which of the following is an appropriate response?
A. "Have you discussed this with your primary care provider yet?
B. "The hormonal changes in pregnancy affect the vaginal pH, making yeast infections
common."
C. "Only women who are already prone to vaginal yeast infections get them during
pregnancy." D. "Why are you concerned about yeast infections during pregnancy?
Answer: B. "The hormonal changes in pregnancy affect the vaginal pH, making yeast
infections common."
Rationale:
This is an information-seeking question, so the therapeutic response is an answer that
provides the client with the information that is requested. This therapeutic answer not only
tells the client that the infections are common, but also gives the client information about why
this occurs.
19. A nurse is participating in a disaster drill with the local health department. Staged victims
are being used in the drill to simulate a bomb explosion at a sporting event. The nurse is one
of the first responders on the scene and starts to triage the victims. Which of the following
actions should the nurse take first?
A. Call out to people who can walk and ask them to move from the incident area to the
concession stand.
B. Perform quick head-to-toe assessments of victims.
C. Immediately start cardiopulmonary resuscitation on victims who are not breathing.
D. Identify those victims that need to be transported to a health care facility.
Answer: A. Call out to people who can walk and ask them to move from the incident area to
the concession stand.
Rationale:
All clients who can walk are asked to move away from the incident area to a specific
location. This allows the nurse to quickly assess those who may need immediate assistance
and reduces the chance of further injury from the disaster to these people.

20. A client is admitted with a suspected diagnosis of tuberculosis. Which nursing action is of
highest priority?
A. Place the client on airborne isolation.
B. Initiate the prescribed antimicrobial therapy.
C. Ask the client about potential community exposures.
D. Teach the client the manifestations of tuberculosis.
Answer: A. Place the client on airborne isolation.
Rationale:
Clients strongly suspected of having tuberculosis (TB) should be placed on airborne isolation
precautions immediately because of the highly communicable nature of the infection.
Airborne precautions prevent transmission of infectious agents that remain infectious over
long distances when suspended in the air, including Mycobacterium tuberculosis, the agent
that causes TB.
21. A nurse is caring for a 3-year-old toddler who is undergoing insertion of pressure
equalization (PE) tubes. The toddler's parent asks the nurse, "When will these tubes be
removed? " Which of the following responses by the nurse is the most appropriate?
A. "When the doctor determines it is time to remove the tubes, your toddler will be admitted
to the ambulatory surgery centre."
B. "Unless they need to be replaced, the tubes are permanent."
C. "The tubes remain in place for approximately 1 to 2 years until they fall out on their own."
D. "You don't need to worry about that now. The doctor will decide what to do when the time
comes."
Answer: C. "The tubes remain in place for approximately 1 to 2 years until they fall out on
their own."
Rationale:
Children generally outgrow PE tubes, and they usually fall out on their own about 1 to 2
years after insertion.
22. A nurse manager notes that several staff members are late in completing an annual
mandatory educational session related to restraint safety. Which of the following actions
should the nurse plan to take?

A. Make a general announcement at the next staff meeting asking all employees to check
their compliance with the requirement.
B. Post a list in the employee break room naming those who are in noncompliance and the
date that the requirement must be completed.
C. Speak to each noncompliant employee individually and document the meeting in the
employee's personnel file.
D. Send an e-mail to each noncompliant employee that includes a link to future upcoming
educational sessions.
Answer: D. Send an e-mail to each noncompliant employee that includes a link to future
upcoming educational sessions.
Rationale:
E-mail provides a simple, yet efficient way for the nurse manager to get the news out to each
noncompliant employee without embarrassing anyone with a public announcement. In
addition, including the appropriate link in the e-mail facilitates the employee's compliance by
helping the employee to identify upcoming session(s) that coordinate with the employee's
work schedule.
23. A nurse is developing a plan of care for a client with gastroesophageal reflux disease
(GERD). Because of the complications commonly associated with this disorder, the nurse
plans to monitor the client for
A. aspiration.
B. infection.
C. anaemia.
D. weight loss.
Answer: A. aspiration.
Rationale:
Aspiration is a common complication associated with GERD. GERD results when the
esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into
the esophagus placing the client at risk for aspiration. GERD is characterized by effortless,
uncontrolled regurgitation whether the client is in an upright position or reclining. The most
common results of regurgitation are heartburn and indigestion, but aspiration is also possible.
Therefore, the client should be monitored for crackles in the lung fields, which is an
indication of aspiration.

24. A nurse is caring for a 2 year old child. The parents request a toy for their child. The nurse
understands that the most appropriate toy from the playroom for this child is which of the
following?
A. Doll with clothes
B. Cartoon DVD
C. Video game
D. 10-piece wood puzzle
Answer: D. 10-piece wood puzzle
Rationale:
Age-appropriate toys for a 2-year-old child include puzzles, large crayons, blocks, picture
books, push-pull toys, finger paints, modelling clay, and musical toys. These toys all allow
for manipulation and exploration and meet the child's developmental and diversional activity
needs.
25. A clinic nurse is assessing a 66 year old client a for a routine physical. The client is new
to the area and does not have old medical or immunization records available. When the nurse
asks if the client has received the pneumococcal vaccine, the client replies, "I am not sure but
I haven't had any immunizations in at least 5 years." The nurse should recognize that in this
circumstance
A. it is unsafe for the client to receive another vaccination.
B. the client will need a series of three injections.
C. this vaccination is contraindicated for clients older than 65 years of age.
D. the client should receive the pneumococcal vaccine.
Answer: D. the client should receive the pneumococcal vaccine.
Rationale:
One dose of the pneumococcal vaccine should be given to all clients age 65 or older. If the
client received the immunization more than 5 years ago and was less than 65 years of age, the
CDC recommends a one-time revaccination.
26. A nurse is caring for a child who is receiving bleomycin (Blenoxane) IV and is not
voiding adequately. What is the appropriate nursing action?
A. Assess the child's hydration status.
B. Stop the medication immediately.
C. Give the child a diuretic.

D. Take no action because a decrease in urine is an expected side effect.
Answer: A. Assess the child's hydration status.
Rationale:
The nurse should monitor renal function with bleomycin and other antibiotic antineoplastic
medications. Monitoring includes checking laboratory values for BUN and creatinine
clearance, as well as I&O.
27. A nurse is caring for a 2 year old child who was admitted for laryngotracheobronchitis.
The child is placed in a crib with a cool mist tent. Which toy would be most suitable for the
child at this time?
A. A stuffed teddy bear
B. A cloth crib gym
C. A plastic fire engine
D. A cardboard picture book
Answer: C. A plastic fire engine
Rationale:
Acute laryngotracheobronchitis, or croup, is a condition of respiratory difficulty caused by
infection, inflammation, and swelling of the upper airway (larynx, trachea, and bronchus).
The cool mist tent is ordered to provide a high-humidity environment to ease the child's work
of breathing. Consequently, the nurse selects an age-appropriate toy made of plastic that can
be easily wiped clean and dry.
28. A nurse is providing teaching to a client who is prescribed doxycycline (Vibramycin) for
actinomycosis. The nurse should observe the client for which of the following?
A. Photosensitivity
B. Constipation
C. Ototoxicity
D. Discoloration of teeth
Answer: A. Photosensitivity
Rationale:
Doxycycline is a tetracycline antibiotic. Photosensitivity is an adverse effect of tetracyclines
in which the skin reacts abnormally to light, especially ultraviolet radiation or sunlight. The
result is an intense sunburn reaction with erythema, maculas, and Gray-blue patches.

Prevention involves avoiding direct exposure to sunlight and ultraviolet light and using a
sunscreen with a sun protection factor (SPF) of 15 or greater.
29. A nurse observes tachycardia, dyspnea, dry cough, and distended neck veins in a client
with leukaemia who is receiving a blood transfusion of packed red blood cells. Which
intervention should the nurse use to prevent these manifestations with the client's next
transfusion?
A. Warm the unit of blood to room temperature before administering it.
B. Administer acetaminophen (Tylenol) prior to the blood transfusion.
C. Give an antihistamine prior to the transfusion.
D. Use a transfusion pump to regulate and maintain the flow rate.
Answer: D. Use a transfusion pump to regulate and maintain the flow rate.
Rationale:
These are the manifestations of a hypervolemic reaction due to circulatory overload, likely if
the blood is transfused too rapidly for the client's size or condition. To prevent this problem
with future transfusions, the nurse must ensure that the proper amount of blood is transfused
and that a transfusion pump is used to regulate the flow rate.
30. A client has pseudomembranous colitis caused by clostridium difficile. The priority
nursing intervention for this client is
A. performing hand hygiene before and after contact with the client.
B. reducing the client's anxiety due to isolation procedures.
C. assisting the client in making nutritional choices to reduce diarrhoea.
D. monitoring the client's intake and output closely for signs of fluid deficit.
Answer: A. performing hand hygiene before and after contact with the client.
Rationale:
C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two virulent
exotoxins that attack the lining of the intestine. The toxins destroy cells and produce pseudo
membranes, patches (plaques) of inflammatory cells, and decaying cellular debris on the
interior surface of the colon. The spores of C. difficile are easily transported from one client
to another without hand hygiene.
31. A nurse is planning to delegate care of a postoperative client following an appendectomy.
Which of the following should the nurse delegate to an assistive personnel (AP)?

A. Teach the client to use the patient-controlled analgesia pump.
B. Record urinary output after emptying the indwelling urinary catheter.
C. Get the client out of bed and to the chair for the first time after surgery.
D. Check the client's abdominal wound dressing.
Answer: B. Record urinary output after emptying the indwelling urinary catheter.
Rationale:
Emptying an indwelling urinary catheter and recording I&O is within the scope of practice
for an AP.
32. A nurse on a mental health unit is taking care of a client diagnosed with depression.
Which nursing intervention would foster a therapeutic environment for this client?
A. Tell the client that the nurse will talk to him at her request.
B. Allow the client to skip group activities if he chooses.
C. Leave the client alone for frequent rest periods throughout the day.
D. Build trust with the client by sitting quietly with him.
Answer: D. Build trust with the client by sitting quietly with him.
Rationale:
Building trust with the client will give him the idea that the nurse is interested in his issues.
Establishing client trust encourages him to speak more openly about issues and concerns.
33. A pregnant client who is Hindu is being seen at the women's health centre for a 12 week
check-up. The primary care provider tells the client that she must get more protein in her diet
and suggests that the client eat more animal products. Although the client initially states that
she agrees, after the primary care provider leaves the examination room, the client tells the
nurse that "eating animal products will cause her to miscarry." Which of the following is an
appropriate response?
A. "Let's discuss other foods that are also high in protein that you could substitute for meat."
B. "Eating meat during pregnancy provides necessary protein and does not cause
miscarriage." C. "Why do you think that eating animal products will cause you to have a
miscarriage?
D. " "Your primary care provider is recommending what is best for you and your baby.
Answer: A. "Let's discuss other foods that are also high in protein that you could substitute
for meat."
Rationale:

Many cultures have beliefs about food that should or should not be consumed during life
transitions, such as pregnancy. The nurse is also aware that many Hindu clients are vegetarian
due to religious reasons. The nurse should discuss alternative protein sources with the client
to help the client identify those consistent with both her religious and traditional medical
beliefs.
34. During a client care unit meeting, the nurse manager discusses potential problems with
data security related to confidential client information. The nurse manager explains that safe,
effective environments where client information may be discussed include
A. areas closed off from the public.
B. outside the door of a client's room.
C. lunch breaks in the cafeteria.
D. in the hallway near the nurse's station.
Answer: A. areas closed off from the public.
Rationale:
Client information may be discussed in a room on the unit with a closed door to prevent
accidental disclosure of a client's personal health information.
35. A nurse is talking with a parent of a preschooler. The parent reports that it is very difficult
to get her child to go to bed at a proper time consistently. She tells the nurse that the child
gets out of bed, enters her room, and cries when told to stay in bed. Which instructions should
the nurse give the parent to foster a consistent bedtime for this child?
A. "Use a stable relaxing routine, such as a bath and story time before bed."
B. "Make sure the room is completely dark when placing the child in bed."
C. "Let the child go to sleep in your lap and then put the child in his bed."
D. "It's okay to let your child cry himself to sleep."
Answer: A. "Use a stable relaxing routine, such as a bath and story time before bed."
Rationale:
Routines are very reassuring to preschoolers because they allow the child to be able to
anticipate their environment and adapt appropriately. These actions will help the child to
settle down prior to bedtime. They also provide for parental-child interaction prior to bed.

36. A nurse is caring for a client who has had a bone marrow transplant and is on protective
isolation. Which of the following statements indicates that the client understands the
restrictions of this type of isolation?
A. "I must keep the door to my room closed at all times."
B. "My family will be bringing me fresh flowers today."
C. "I'm really going to miss taking my daily shower."
D. "I should try to avoid straining during bowel movements."
Answer: A. "I must keep the door to my room closed at all times."
Rationale:
Protective isolation is prescribed to protect immunocompromised clients from exposure to
potentially lethal micro-organisms and includes keeping the door to the room closed at all
times.
37. A nurse at the family planning clinic is preparing to teach a class on the use of a
diaphragm. Which of the following should the nurse include in the teaching session?
A. "When using a diaphragm, it is necessary to also use spermicidal jelly."
B. "A diaphragm will remain in place until you're ready to have children."
C. "You can leave a diaphragm in longer than 8 hours without any complications."
D. "A diaphragm comes in one size and does not need to be fitted."
Answer: A. "When using a diaphragm, it is necessary to also use spermicidal jelly."
Rationale:
A diaphragm is a barrier device used to prevent pregnancy. It is inserted by the client prior to
sexual intercourse. Use of a diaphragm alone is not 100% effective at preventing pregnancy,
but the use of spermicidal jelly with it increases the effectiveness of the device.
38. A client's provider informs the nurse that the client's abdominal aortic aneurysm (AAA) is
extending. The nurse must assess the client for
A. increases in blood pressure and respiratory rate.
B. jugular-vein distention and peripheral edema.
C. abdominal pain with the onset of back pain.
D. retrosternal chest pain radiating to the left arm.
Answer: C. abdominal pain with the onset of back pain.
Rationale:

An aortic aneurysm is a weak spot in the wall of the aorta, the primary artery that carries
blood from the heart to the head and extremities and allows the aorta to expand and increase
in diameter. Increasing abdominal and back pain indicates that the aneurysm is extending
downward and pressing on the lumbar sacral nerve roots.
39. At the first prenatal visit, a nurse learns that a pregnant client is lactose intolerant. Which
of the following foods should the nurse include on a list of calcium sources for this client?
A. Collard greens
B. Cottage cheese
C. Orange juice
D. Broccoli
Answer: A. Collard greens
Rationale:
Collard greens are a good source of lactose-free calcium. One cup of collard greens provides
approximately the same amount of calcium as 1 cup of milk.
40. A nurse is caring for a 3-year-old child who has persistent otitis media. When obtaining
the history of the child from her parent, which of the following would be the most appropriate
for the nurse to ask regarding the child's recurrent otitis media?
A. "Is the child playing with other children with otitis media?"
B. "Does anyone smoke around, or in the same house as, the child?
C. "Does the child get water in her ears during a tub bath?"
D. "Has the child had a fever recently?"
Answer: B. "Does anyone smoke around, or in the same house as, the child?"
Rationale:
Otitis media is an infection of the middle ear (eustachian tube behind the tympanic
membrane). Allergies to common irritants, such as smoke, can cause eustachian tube
congestion and chronic otitis media.
41. A nurse is caring for a toddler with acquired immune deficiency syndrome. During the
assessment, the nurse understands that which of the following would indicate an
opportunistic infection?
A. Koplik spots
B. Gingivitis

C. Chancre
D. Candidiasis
Answer: D. Candidiasis
Rationale:
Candidiasis, or oral thrush, is caused by the overgrowth of Candida albicans, an opportunistic
fungus that commonly infects the oral cavity of infants, diabetics, and other clients with
immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque
that may appear like milk curds on the buccal mucosa and tongue. Thrush is often the initial
opportunistic infection noted in a human immunodeficiency virus (HIV) positive child who is
developing AIDS.
42. A nurse is caring for a hospitalized client who is dying. The family has been involved in
the client's care for several days. The family is exploring the possibility of caring for the
client at home. Which of the following statements indicates that the nurse has a good
understanding of family-centred care?
A. "I have contacted various community resources that will be helpful."
B. "I will review the care plan to make changes that are necessary."
C. "Let's set up a meeting time with the primary care provider to discuss your options for
home care."
D. "I will make a list of things that need to be done before discharge."
Answer: C. "Let's set up a meeting time with the primary care provider to discuss your
options for home care."
Rationale:
In family-centred care, the client and family help determine their outcomes and goals. Setting
up a meeting to discuss this with the provider will give them a sense of autonomy and foster
the family-centred care environment.
43. A client who has been treated for a transient ischemic attack (TIA) is being discharged.
The nurse's discharge teaching plan related to this admission should reinforce the importance
of monitoring
A. blood pressure at regular intervals.
B. blood glucose using a glucometer.
C. pulse rate with aerobic exercise.
D. temperature and sensation in the feet

Answer: A. blood pressure at regular intervals.
Rationale:
Transient ischemic attacks (TIA) are caused by a temporary disturbance of blood supply to
the brain, resulting in brief neurologic dysfunction. One third of clients who have had a TIA
later have recurrent TIAs, and another one third have a cerebrovascular accident (CVA) that
results in permanent nerve cell loss. The most common causes of TIA are atherosclerotic
plaque in the carotid arteries and hypertension. Consequently, managing hypertension is
important in reducing the risk of CVA.
44. A nurse is caring for an infant with dehydration. Which of the following is the most
accurate assessment for hydration status?
A. Obtain daily weights.
B. Check for the presence of tears.
C. Palpate the fontanel.
D. Assess skin turgor.
Answer: A. Obtain daily weights.
Rationale:
Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily
weights are especially critical in children under 2 years of age because a greater portion of
body weight is composed of fluid.
45. A nurse in the emergency department cares for several children who all are admitted with
symptoms of influenza. After routine laboratory work is obtained from the children, which
child should the nurse bring to the primary care provider's attention immediately?
A. 6-year-old child with urine specific gravity of 1.030
B. 2-year-old toddler with BUN level of 25 mg/dL and creatinine level of 0.5 mg/dL
C. 6-month-old infant with WBC count of 24,000/mm3
D. 12-year-old child with positive beta human chorionic gonadotropin
Answer: C. 6-month-old infant with WBC count of 24,000/mm3
Rationale:
This WBC count (normal is 4,000 to 10,000/mm3) is highly elevated for a 6-month-old infant
who has manifestations of influenza. A septic work up (blood, urine, and spinal fluid cultures)
will need to be done immediately; therefore, the provider should be notified immediately of
the infant's condition.

46. A nurse is caring for a client who is receiving haemodialysis for the first time. Which of
the following indicates to the nurse that the client is at imminent risk for developing dialysis
disequilibrium syndrome (DDS)?
A. Elevated BUN
B. Bradycardia
C. Headache
D. Temperature of 39.2°C (102.5°F)
Answer: C. Headache
Rationale:
DDS is a central nervous system (CNS) disorder. It is a complication that may develop in
clients who are new to dialysis due to the rapid removal of solutes and changes in blood pH
levels. Clients beginning haemodialysis are at greatest risk, particularly if the BUN is above
175. DDS is characterized by CNS manifestations of varying severity due primarily to
cerebral edema. They include headache, nausea, disorientation, restlessness, blurred vision,
and asterixis. More severely affected clients progress to confusion, seizures, coma, and death.
47. An individual wearing a hospital-issued identification badge greets the charge nurse on
the postsurgical unit and states, "I am a surgical resident assigned to this unit." The individual
then asks the charge nurse for an access code to review a client's online record stating, "I'm
not scheduled to attend the computer class until next week." Which of the following actions
should the nurse take?
A. Explain that it is against policy to share access codes and refer the resident to his
supervisor.
B. Access the requested client's online data and observe as the resident obtains the
information needed.
C. Access the online client data system and allow the resident to locate the client's data.
D. Ask the client to give permission for the resident to access his medical records.
Answer: A. Explain that it is against policy to share access codes and refer the resident to his
supervisor.
Rationale:
Access codes and passwords should never be shared. Likewise, allowing access to the system
for an individual who does not have their own access code is also not permitted. An integral
part of computer training is learning about client data security, confidentiality, and signing

documents that attest to your intention to follow these federal guidelines. The resident should
be politely referred to his supervisor to obtain the information needed or to make
arrangements to be trained sooner if necessary.
48. A nurse is developing a teaching plan for a client diagnosed with type 2 diabetes mellitus.
The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following
is an appropriate nursing response?
A. "Let's discuss this with your physician; it may not be necessary."
B. "Isn't there another favourite dish you can substitute?"
C. "You don't have to give up pasta, just adjust the amount you eat."
D. "You can use no-added-salt tomato products on your pasta."
Answer: C. "You don't have to give up pasta, just adjust the amount you eat."
Rationale:
The American Diabetes Association (ADA) recommends that carbohydrate restriction be
individualized for each client as needed. A careful assessment of the client's usual dietary
practices and modifications is an important part of teaching the client with diabetes to
manage this disease and to ensure long-term success with the ADA diet.
49. A client presents to the emergency department following a motor vehicle crash. She
reports pain in her left leg, and the nurse notes that the left leg has manifestations of a
fracture including bruising, swelling, and displacement of the bones. What action should the
nurse take first?
A. Ask the provider to prescribe an x-ray of the leg.
B. Apply ice packs to the affected area.
C. Check neurovascular status distal to the injury.
D. Elevate the affected leg on two pillows.
Answer: C. Check neurovascular status distal to the injury.
Rationale:
This action includes checking the circulation, sensation, and movement distal to (below) the
level of the injury. If the nurse notes a weak or absent pulse distal to the injury, the limb's
circulation is compromised, and immediate action is critical. This is the nurse's highest
priority at this time.

50. A nurse is talking with an unmarried couple who have come to the family planning clinic
for advice. Which of the following is an appropriate response regarding the risks associated
with an intrauterine device (IUD)?
A. "If you experience any weight changes, you will need to be refitted for your IUD."
B. "An IUD is more effective when it is used with a spermicidal jelly."
C. "There is an increased risk for ectopic pregnancy when using an IUD."
D. "An IUD should only be used by couples who have completed their family."
Answer: C. "There is an increased risk for ectopic pregnancy when using an IUD."
Rationale:
An IUD is a family planning device that is inserted through the cervix into the uterus to
prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes,
making it more difficult for fertilization to occur in the uterus. Consequently, a known
complication when using the IUD is an increased risk for ectopic pregnancy.
51. A client receiving chemotherapy has developed neutropenia. Which statement by the
client indicates to the nurse that the client needs further instructions?
A. "I make sure I always keep an antibacterial hand gel in my purse."
B. "I guess my spouse will have to take care of the cat boxes for a while."
C. "I'm planning a large gathering of friends and family for the holidays."
D. "I will eat a lot of frozen and canned fruits and vegetables."
Answer: C. "I'm planning a large gathering of friends and family for the holidays."
Rationale:
A client with neutropenia must be careful to avoid exposure to infection, so this is a statement
that warrants more teaching. A client experiencing neutropenia should avoid large crowds of
people because a large gathering increases the client's risk for exposure to infection.
TEST- TAKING STRATEGY: This question asks which statement indicates that the client
needs FURTHER teaching, thus the CORRECT answer is an INCORRECT statement.
52. A nurse is providing discharge instructions to a client who is prescribed metoprolol
(Toprol-XL). Which of the following instructions should the nurse include? (Select all that
apply.)
A. Do not suddenly stop taking this medication.
B. Take medication right before bedtime.
C. Avoid exposure to the sunlight.

D. Take radial pulse daily.
E. Chew sugarless gum to relieve dry mouth.
Answer: A. Do not suddenly stop taking this medication.
D. Take radial pulse daily.
E. Chew sugarless gum to relieve dry mouth.
Rationale:
A. Take radial pulse daily is correct. The client should take a radial pulse daily and report a
heart rate less than 60/min.
E. Chew sugarless gum to relieve dry mouth is correct. Chewing sugarless gum or sucking on
sugarless candy can help relieve dry mouth caused by metoprolol.
A. Do not suddenly stop taking this medication is correct. There is an increased risk of
angina, hypertension, and possible myocardial infarction when metoprolol, a beta blocker, is
discontinued suddenly. If the provider discontinues the medication, it should be gradually
reduced over 1 to 2 weeks to prevent worsening of manifestations.
53. A home care nurse is discussing fire safety with a homebound client. The nurse identifies
which of the following safety measure to help protect the client in case of a fire?
A. Use a night light in the bedroom.
B. Reduce water temperature.
C. Keep stairs free from clutter.
D. Keep a phone close to the bed.
Answer: D. Keep a phone close to the bed.
Rationale:
Most fires happen during the night. Placing a phone close to the bed enables the client to call
the fire department quickly. The client should bring the phone (if portable) with him if he
tries to exit the house. The client should be familiar with the exits, have working smoke
alarms, and have a flashlight near the bed.
54. Due to staffing shortages, an adult medical-surgical nurse is asked to work on a paediatric
unit. The nurse has limited experience with paediatric clients. Which of the following actions
should the charge nurse take?
A. Provide constant supervision for the adult medical-surgical nurse.
B. Have the adult medical-surgical nurse provide relief for unit nurses during break and lunch
times.

C. Assign a unit nurse to act as a resource for the adult medical-surgical nurse.
D. Delegate to the adult medical-surgical nurse tasks that are performed by an assistive
personnel.
Answer: C. Assign a unit nurse to act as a resource for the adult medical-surgical nurse.
Rationale:
Assigning a nurse who usually works on the paediatric unit to work with the adult medicalsurgical nurse will provide consistent support.
55. The nurse is caring for a toddler who is hospitalized for Pneumocystis carinii pneumonia.
The child is taking zidovudine (AZT). Which laboratory tests should the nurse monitor
related to this medication?
A. BUN and creatinine
B. Hgb and Hct
C. Chest x-ray and oximetry
D. SGOT (AST) and SGPT (ALT)
Answer: B. Hgb and Hct
Rationale:
Zidovudine may cause severe anaemia, so it is important to monitor the CBC, which includes
the Hgb and Hct, closely for at least the first 2 weeks. As anaemia may occur up to 2 to 4
weeks after beginning AZT therapy, the Hgb and Hct are monitored regularly for the first 2
months and then periodically after that.
56. A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and
expecting twins. The client reports feeling "lightheaded." Which position should the nurse
assist the client into at this time?
A. Lateral
B. Fowler's position
C. Trendelenburg
D. Prone with lower extremities elevated
Answer: A. Lateral
Rationale:
The lateral, or side-lying position (especially left side-lying), provides for the best
uteroplacental blood flow. This is the most appropriate position for improving both maternal
and fetal circulation in the pregnant client who is feeling faint.

57. A nurse caring for a client with hypocalcaemia should expect to see which of the
following on the client's ECG?
A. Flattened T-wave
B. Prolonged QT interval
C. Shortened QT interval
D. Widened QRS
Answer: B. Prolonged QT interval
Rationale:
Manifestations of hypocalcaemia include tingling, numbness, tetany, seizures, abdominal
cramps, prolonged QT intervals, and hypotension. Causes include decreased parathyroid
function, chronic renal disease, massive blood transfusions, and diarrhoea.
58. After an exploratory laparotomy, a client is admitted to the medical surgical unit with an
indwelling urinary catheter and a Jackson Pratt (JP) drainage tube. Which finding should
indicate to the nurse that the client may be experiencing a postoperative complication?
A. Pain scale score of 5 out of 10
B. Urine output of 65 mL/hr
C. 20 mL of bright red drainage from the JP drain
D. Pulse oximetry of 85%
Answer: D. Pulse oximetry of 85%
Rationale:
Clients who are recovering from abdominal surgery should have an oxygen saturation of 90
to 100%. A client with an oxygen saturation of 85% is poorly oxygenated.
59. An older adult client is having trouble sleeping and comes to the primary care provider's
office for evaluation. Which of the following statements should the nurse recognize as a
potential rationale for the sleeping difficulties?
A. "I take a warm shower when getting ready to go to bed."
B. "I frequently have a cup of coffee with my dessert before going to bed."
C. "I usually read a chapter in a book before I go to bed."
D. "I often have a small glass of wine in the evening."
Answer: B. "I frequently have a cup of coffee with my dessert before going to bed."
Rationale:

Beverages with caffeine should be avoided in the evening as it may cause stimulation to the
CNS and result in sleep disturbances.
60. A nurse working at a senior centre notes that a client who is in the early stages of
Alzheimer's disease has been having problems with orientation. Which of the following
actions should the nurse take to improve the client's level of orientation?
A. Encourage the client to participate in the group activities.
B. Have the client attend daily reminiscence therapy sessions.
C. Post a large calendar on the bulletin board.
D. Place a wander alert electronic alarm bracelet on the client's wrist.
Answer: C. Post a large calendar on the bulletin board.
Rationale:
Posting a large calendar in a central location will assist this client with orientation.
61. A provider prescribes sertraline (Zoloft) for a client. The client asks the nurse if he should
continue to take St. John's Wort for depression. The nurse should advise the client to do
which of the following?
A. Take the medication and herbal supplement together.
B. Discontinue the herbal supplement while taking the medication.
C. Take the herbal supplement and the medication at least 2 hr apart.
D. Tell the client that it is not known whether or not St. John's Wort and sertraline can be used
together.
Answer: B. Discontinue the herbal supplement while taking the medication.
Rationale:
When taken with the antidepressant sertraline (Zoloft), St. John's Wort, an herbal supplement
used in the treatment of mild to moderate depression, may cause an additive effect that could
lead to serotonin syndrome. They should not be used concurrently.
62. A nurse is caring for a group of clients in a long-term care setting. One of the clients is
found walking in the hallway, bumping into walls, and unresponsive to his name. Which of
the following actions should the nurse take first?
A. Obtain a baseline assessment of the client.
B. Accompany the client back to his room.
C. Notify the client's primary care provider.

D. Administer a PRN antianxiety medication
Answer: B. Accompany the client back to his room.
Rationale:
The highest priority is safety. The nurse ensures safety by accompanying the client back to
his room. Assessment is also essential because the client's incoordination may indicate
impairment of the client's balance and level of consciousness, which may be a manifestation
of an emerging complication.
63. An adolescent client who has had no prenatal care is admitted in labor and gives birth to a
stillborn preterm fetus. The client is crying and says to the nurse, "Why did this happen to
me?" Which of the following responses is appropriate from the nurse at this time?
A. "I understand how you feel."
B. "You are young and can have healthy babies when you are older."
C. "Sometimes this is nature's way."
D. "I am so sorry that this has happened."
Answer: D. "I am so sorry that this has happened."
Rationale:
This statement is an example of a therapeutic response that shows empathy for the client's
feelings. It is an open-ended statement that allows the client to continue to express her own
feelings.
64. A nurse participating in a community health fair is giving general information to clients
who have an elevated reading during a blood pressure screening. While explaining the
meaning of the results to a client, the nurse should
A. provide the client with written information including the numeric value of the client's
blood pressure.
B. encourage the client to go directly to the nearest emergency room to be evaluated.
C. reassure the client that hypertension can be cured with proper medication.
D. explain that modifiable risk factors for hypertension include family history.
Answer: A. provide the client with written information including the numeric value of the
client's blood pressure.
Rationale:
When a client has an elevated reading at a hypertension screening, the nurse should
encourage the client to see the provider for further evaluation. To help facilitate this process,

the nurse should give the client a written record of the blood pressure result obtained at the
screening so that the client can share it with the provider.
65. A nurse is caring for an infant with a cleft palate. The parents ask the nurse when it will
be repaired. The nurse replies that the palate is generally repaired between 12 and 18 months
of age to prevent the child from experiencing which of the following?
A. Repeated ear infections
B. Nutritional deficits
C. Any memory of the hospitalization
D. Difficulty with language acquisition
Answer: D. Difficulty with language acquisition
Rationale:
An infant with a cleft palate may have difficulty acquiring language for two reasons. First,
repeated middle ear infections are associated with transient hearing loss that can become
permanent. In addition, the palate is used in vocalizing sounds, and the infant may develop
poor speech habits.
66. A nurse at an extended care facility hears an assistive personnel (AP) talking with an
older adult client with dementia who has periods of confusion. Which of the following
statements made by the AP should indicate to the nurse that the AP needs additional teaching
about working with clients who have dementia?
A. "We will be serving breakfast in 10 minutes. I will stay here while you get ready."
B. "It's Monday morning. I know that your favourite television shows are on this evening."
C. "I see that you have a new picture on the wall. Can you tell me who that girl is?"
D. "You are running late. Let me do your hair for you and brush your teeth."
Answer: D. "You are running late. Let me do your hair for you and brush your teeth."
Rationale:
When a client with dementia has periods of confusion, the nurse should allow the client
additional time, as needed, to complete activities of daily living and other tasks that the client
is able to perform independently. Insisting on completing the task for the client, or attempting
to "hurry" the client, may make the client with dementia agitated. Rather, the nurse should
encourage independence and provide assistance only if requested or required. In addition,
there is no information in the case scenario to indicate that the client is, in fact, "running
late."

67. A nurse is planning care for a client admitted with syndrome of inappropriate antidiuretic
hormone (SIADH). The nurse expects the treatment for this client to include
A. increased fluids with hypertonic sodium chloride and fludrocortisone (Florinef).
B. fluid restriction plus hypertonic sodium chloride and furosemide (Lasix).
C. physiological amounts of hypotonic sodium chloride solution and vasopressin (Pitressin).
D. isotonic 0.9% sodium chloride to replace urine output plus desmopressin (DDAVP).
Answer: B. fluid restriction plus hypertonic sodium chloride and furosemide (Lasix).
Rationale:
SIADH is a disorder of water intoxication caused by the inappropriate, continuous secretion
of ADH by the posterior pituitary gland, causing hypervolemia and hyponatremia. Treatment
of SIADH may include fluid restriction, sodium replacement with small amounts of sodium
chloride, and IV furosemide (Lasix).
68. A nurse is caring for a client who has developed hypovolemic shock. Which of the
following laboratory values should the nurse expect this client to have?
A. Urine specific gravity of 1.026
B. Haematocrit of 35%
C. Haematocrit of 55%
D. Urine specific gravity of 1.001
Answer: B. Haematocrit of 55%
Rationale:
An elevated haematocrit indicates hypovolemia. Other signs of hypovolemia are a weak
pulse, hypotension, decreased central venous pressure, decreased cardiac output, elevated
BUN and serum osmolality, increased urine specific gravity and osmolality, and decreased
urine output.
69. The disaster plan for a hospital has been initiated following a community flood. Which of
the following actions is the responsibility of the nurse during the disaster?
A. Turn client televisions in order for them to be kept informed of the disaster.
B. Identify the stable clients in the intensive care unit (ICU) who can be transferred to the
medical- surgical floor.
C. Ask family members to come to the hospital to provide support to clients.
D. Make announcements of the status of the disaster on the public address system.

Answer: B. Identify the stable clients in the intensive care unit (ICU) who can be transferred
to the medical- surgical floor.
Rationale:
Transferring the stable clients from the ICU to the medical-surgical floor allows for more
intensive care beds to be used in the event that the clients from the external disaster (flood
region) are deemed critically ill. As part of the disaster plan, the charge nurse will compile a
list of clients who require a level of care that is consistent with the level of care that can be
provided on a medical-surgical unit.
70. A nurse is caring for a child with celiac disease. Which of the following nursing
assessments is consistent with celiac disease?
A. Elevated sweat chloride
B. Foul-smelling stool
C. Clubbing of the fingernails
D. Jaundice
Answer: B. Foul-smelling stool
Rationale:
Foul, fatty stools (steatorrhea) are a manifestation of celiac disease, a malabsorption
syndrome.
71. A nurse educator is facilitating a group discussion with preschool teachers about child
abuse, and is discussing different examples of when teachers should suspect abuse. Which
example should the nurse educator use to best illustrate a suspicious finding?
A. Bruising of both knees with sutures on one
B. Arm cast for spiral fracture of the forearm
C. Consistent bedwetting at nap time
D. Frequent, vague reports of a stomach ache or a headache
Answer: B. Arm cast for spiral fracture of the forearm
Rationale:
Spiral fractures can only occur from twisting of an appendage, in this case the arm. They are
treated by casting the involved limb from the joint above to the joint below the fracture to
limit mobility and allow healing. In most instances, spiral fractures of the arm are cited as an
example of an abusive injury in children, adults, and older adults.

72. A client diagnosed with multidrug resistant tuberculosis (MDR TB) has been prescribed
ethambutol (Myambutol). The nurse plans to instruct the client that it is likely he will
experience
A. large purple bruises on the legs.
B. orange-red urine and bodily secretions.
C. yellowing of the sclera.
D. loss of red/green colour discrimination.
Answer: D. loss of red/green colour discrimination.
Rationale:
Ethambutol (Myambutol) is an antitubercular drug that impairs ribonucleic acid synthesis. A
common adverse reaction associated with the use of ethambutol is the loss of red/green color
discrimination.
73. A nurse is administering a transfusion of packed RBCs. Which of the following actions
should the nurse take first if a transfusion reaction is suspected?
A. Notify the primary care provider.
B. Obtain a set of vital signs.
C. Stop the infusion.
D. Send the IV bag and tubing to the laboratory.
Answer: C. Stop the infusion.
Rationale:
The greatest risk to the client is a life-threatening event such as circulatory collapse.
Therefore, the first action the nurse should take is to stop the infusion to prevent any further
administration of blood.
74. A new computerized charting system is going to be implemented in a health care
organization. This change has been initiated by the organization's leadership and not the nurse
managers. Before implementing the new system, the nurse manager should first
A. discuss with the charge nurses their responsibility in implementing the change.
B. post a sign-up sheet for in-service training sessions about the method.
C. ask informal leaders to participate in the early implementation process.
D. announce the change in a staff meeting, allowing time for staff comments.
Answer: D. announce the change in a staff meeting, allowing time for staff comments.
Rationale:

It is important that the staff get important information related to changes in the system that
impact their daily job performance directly from the manager. Using the nursing process as a
priority setting framework, the nurse manager should first collect more data by allowing time
for staff comment. This will allow the nurse to take further steps when implementing the new
system.
75. A primary care provider prescribes 10 units of insulin glargine (Lantus) and 4 units of
NPH insulin (Humulin N) to be given subcutaneously at 1700. The nurse should plan to
A. draw up each insulin dose into a separate insulin syringe and then combine the doses into
one tuberculin syringe to inject simultaneously.
B. draw the insulin glargine (Lantus) into an insulin syringe first, and then draw up the NPH
insulin into the same syringe.
C. draw the NPH insulin into an insulin syringe first, and then draw up the insulin glargine
(Lantus) into the same syringe.
D. draw the insulin glargine (Lantus) into one insulin syringe and the NPH insulin into a
different insulin syringe and inject separately.
Answer: D. draw the insulin glargine (Lantus) into one insulin syringe and the NPH insulin
into a different insulin syringe and inject separately.
Rationale:
Insulin glargine (Lantus) cannot be mixed with any other insulin.
76. A nurse is caring for a client who has been hospitalized due to methicillin-resistant
Staphylococcus aureus (MRSA) in the sputum. The dietary assistant asks the nurse what
precautions are necessary to enter the client's room with the lunch tray. Which instructions
should the nurse provide to the dietary assistant?
A. Don a gown before entering the room and remove it before exiting.
B. Wear a mask at all times while in the client's room.
C. Don gloves when entering the room and use hand sanitizer when exiting.
D. No special precautions are required unless there is contact with the client.
Answer: C. Don gloves when entering the room and use hand sanitizer when exiting.
Rationale:
Clients with MRSA are on contact precautions. In addition to the use of standard precautions
and appropriate hand hygiene, contact precautions require that any staff who will have
contact with the client's environment must don gloves prior to entering the room. Additional

precautions, such as a gown, are required for contact with the client; a mask and goggles
could be required if secretions from the infected area could spray into the face. Delivering the
tray would require contact with the environment, therefore gloves are required.
77. A nurse is admitting a client to the medical unit and asks if the client has an advance
directive. The client states "I have a document with me that names someone who can make
health care decisions for me if I am not able." The client is referring to which of the following
documents?
A. Informed consent form
B. Living will document
C. Do-not-resuscitate directive
D. Medical power of attorney document
Answer: D. Medical power of attorney document
Rationale:
This type of advance directive names a surrogate who can make health care decisions for the
client if he is unable to do so. This document may also be called a health care proxy.
78. In planning care for a child with severe reactive airway disease, the nurse knows that
when chronic steroid use is indicated, inhaled steroids are preferred over oral steroids for
which of the following reasons?
A. Inhaled steroids are less likely to cause thrush.
B. Oral steroids in liquid preparations taste bad.
C. Oral steroids can slow linear growth in children.
D. Inhaled steroids are more effective for acute bronchospasm.
Answer: C. Oral steroids can slow linear growth in children.
Rationale:
Chronic use of oral steroids in children can result in decreased linear growth. Inhaled steroids
are also preferred because they deliver the anti-inflammatory agent directly to the local target
area (the client's airways) without the risks of side effects associated with oral administration
of steroids, such as immunosuppression and adrenal suppression.
79. When assessing a child with lymphocytic leukaemia who is being treated with vincristine
(Oncovin), the nurse should give the highest priority to which of the following reports?
A. Paraesthesia

B. Alopecia
C. Fatigue
D. Constipation
Answer: A. Paraesthesia
Rationale:
The greatest risk to the client is neurotoxicity. Vincristine, a cell-cycle specific chemotherapy
agent, interrupts cellular reproduction at mitosis. One of its side effects is neurotoxicity. An
early finding with neurotoxicity is paraesthesia, or numbing, of the peripheral extremities. As
the neurotoxicity progresses, the client may develop autonomic and central nervous system
dysfunction. If paraesthesia occurs, the child's provider must be notified immediately, since a
change in the dosage or therapy may be indicated.
80. A client with extensive deep partial and full thickness burns has been prescribed a topical
antimicrobial drug. The nurse understands that the goal of this therapy is to reduce
A. bacterial growth.
B. scarring.
C. skin graft size.
D. pain.
Answer: A. bacterial growth.
Rationale:
The use of topical antimicrobial drugs (particularly broad-spectrum antimicrobials) is an
important intervention to help prevent bacteria from entering the body when the protective
covering of skin is impaired, as with burns. A topical antimicrobial is generally used on deep
partial-thickness (2nd-degree) and full-thickness (3rd-degree) burn wounds to provide a
protective barrier, along with the dressing, between bacteria and the exposed body tissues.
81. A client diagnosed with acute systemic lupus erythematosus (SLE) is to begin treatment
for systemic manifestations. The nurse should recognize that the preferred classification of
medications to be used is
A. corticosteroids.
B. antimalarials.
C. nonsteroidal anti-inflammatories.
D. cytotoxic.
Answer: A. corticosteroids.

Rationale:
Corticosteroids, such as prednisone (Deltasone), are the treatment of choice for systemic
manifestations of SLE because of their rapid anti-inflammatory action.
82. A nurse is caring for an unaccompanied infant who is brought to the emergency
department following a multiple car crash. During assessment, the nurse notes that the
infant's posterior fontanel is closed, and the anterior fontanel is soft and flat. The infant has
six teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever a new
person enters the room and is asking for "mama" and "dada." Which of the following is an
appropriate age assessment for this child?
A. 12 months
B. 6 months
C. 18 months
D. 24 months
Answer: A. 12 months
Rationale:
The nurse knows that the infant must be less than 18 months old due to the anterior fontanel
still being open and at approximately 12 months due to the presence of six teeth. The infant's
skills - sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety
(8 months), and ability to say two words (12 months) help the nurse to estimate the infant's
age as 12 months.
83. A nurse on an oncology unit receives a report about the postoperative clients assigned to
the nurse's team. Which client should the nurse see first?
A. Postoperative day 1: Chest tube placement following lobectomy for small-cell carcinoma.
Finding: Chest tube with 20 to 50 mL/hr of bright red bloody drainage
B. Postoperative day 2: Colectomy with creation of an ostomy due to colon cancer. Finding:
Ostomy bag full of bright red bloody drainage
C. Postoperative day 2: Excision of abdominal mass with placement of a portable wound
suction. Finding: Device filled with serosanguineous drainage approximately 150 mL/8 hr
D. Postoperative day 1: Excision of bladder wall tumour and prostate. Finding: Continuous
bladder irrigation reveals cherry-coloured urine of 300 mL/hr
Answer: B. Postoperative day 2: Colectomy with creation of an ostomy due to colon cancer.
Finding: Ostomy bag full of bright red bloody drainage

Rationale:
An ostomy bag full of blood is an ominous finding at any time. It indicates that the client's
bowel is haemorrhaging and must be reported to the client's surgeon immediately. The client
may require fluid replacement, transfusion, and additional surgery to repair the bleeding
vessel.
84. Four clients are brought to the emergency department after sustaining injuries at a bar.
They all have an Odor of alcohol on their breath, facial lacerations, and bruising of the head
and extremities. The triage nurse makes the following additional observations: Client 1:
Lethargic. Awakens to name but unable to answer questions regarding date or place. Client 2:
Slurred speech. Refuses to answer questions "until a doctor looks at my broken arm." Client
3: Alert and oriented to person, place, and time. Reports nausea and is vomiting. Client 4:
Belligerent and uncooperative. Responds to all questions and requests with profanity. Which
client should the nurse admit first?
A. Client 1
B. Client 2
C. Client 3
D. Client 4
Answer: A. Client 1
Rationale:
While acute alcohol intoxication may cause lethargy, the nurse should not assume that all of
this client's behavior is related to the client's apparent alcohol ingestion. This client's situation
includes the potential for a head injury due to facial lacerations and bruising. The nurse must
consider that his lethargy and inability to answer questions could indicate a decreased level of
consciousness related to acute head trauma. This client is at greatest physiological risk and
must be admitted first.
85. A nurse is caring for a school age child who has received a fiberglass cast following a
lower extremity fracture. Which instructions should the nurse give the child and his parents
about caring for the casted extremity in the first 48 hr?
A. "Use only a toothbrush to scratch under the cast if your skin itches."
B. "Keep the casted leg below the level of the heart at all times."
C. "Apply ice to the cast at the level of the injury to help prevent swelling."
D. "If soiled, clean the cast with soapy water to prevent Odor from developing."

Answer: C. "Apply ice to the cast at the level of the injury to help prevent swelling."
Rationale:
Immediately following the injury, and for at least the first 48 hr, ice should be applied to the
affected limb. This will help to prevent edema and pain, which could lead to impaired
circulation.
86. A nurse is caring for a client with chronic atrial fibrillation who takes warfarin
(Coumadin). The client has early manifestations of Alzheimer's disease. The client's spouse
asks the nurse if the client would benefit from taking ginkgo biloba. Which of the following
is an appropriate response?
A. "It is likely that ginkgo biloba may interfere with the effectiveness of his other
medications."
B. "You should ask the primary care provider if ginkgo biloba is safe."
C. "Ginkgo biloba is most effective in the later stages of Alzheimer's disease."
D. "Client's with Alzheimer's disease should maintain the medication regimen prescribed by
the provider."
Answer: A. "It is likely that ginkgo biloba may interfere with the effectiveness of his other
medications."
Rationale:
Overall, the research has shown that ginkgo biloba may be effective in delaying the mental
deterioration of Alzheimer's disease if taken in the early stages. However, ginkgo biloba is
likely to alter the effectiveness of warfarin.
87. A client comes to the emergency department reporting fever and severe upper left
quadrant abdominal pain. The primary care provider suspects pancreatitis. Based on this
information, the nurse expects to see an elevation in the client's serum
A. amylase and lipase.
B. potassium and sodium.
C. calcium and phosphorus.
D. haemoglobin and haematocrit.
Answer: A. amylase and lipase.
Rationale:
With pancreatitis, laboratory results typically show elevated serum amylase and lipase up to
two or three times the expected values. Liver enzymes may also be elevated, depending on

the cause of pancreatitis. Serum glucose may also be elevated (hyperglycemia) due to
inflammation of the pancreas
88. A client admitted with borderline personality disorder is expressing concern about
requiring a prolonged hospitalization. What is the therapeutic statement the nurse could make
when interacting with this client?
A. "Most clients are only hospitalized for about a week."
B. "Why do you think you'll be hospitalized for a long time?"
C. "This will be over soon. You just need to be patient."
D. "Tell me what concerns you the most about being hospitalized."
Answer: D. "Tell me what concerns you the most about being hospitalized."
Rationale:
Clients with borderline personality disorder have a hard time identifying their feelings. This
response allows the client to focus on her concerns regarding hospitalization. It is a form of
open-ended therapeutic communication.
89. A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client
transfer from the bed to a wheelchair. Which action taken by the AP indicates to the nurse an
understanding of the proper technique to use for this type of transfer?
A. Locks the brakes on the bed and the wheelchair before moving the client
B. Tells the client to reach for the side arms of the wheelchair while transferring
C. Lowers the bed so that it is lower than the wheelchair seat
D. Places the wheelchair on the client's weaker side prior to the transfer
Answer: A. Locks the brakes on the bed and the wheelchair before moving the client
Rationale:
Prior to starting the transfer, the AP should ensure that both the wheelchair and the bed are
stationary and will not shift when the client moves into the chair. Therefore, locking the
brakes on the bed and the wheelchair is an important action.
90. A nurse is caring for a gravida 3 para 3 client who has had a precipitous delivery. During
the fourth stage of labor, which nursing assessment must be performed every 10 to 15 min to
prevent the most common complication due to this type of delivery?
A. Monitor the level of consciousness.
B. Obtain the blood pressure.

C. Palpate the fundus.
D. Assess the perineum.
Answer: C. Palpate the fundus.
Rationale:
A precipitous delivery is one in which the client delivered suddenly or excessively fast.
Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum
haemorrhaging. Although fundal assessment is always appropriate following delivery, this
situation requires a more frequent examination of the fundus, as well as the amount of lochia.
91. A nurse is caring for a client who is scheduled for discharge this morning and does not
speak English. The client's child arrives accompanied by a neighbour to pick up the client.
Both the child and neighbour speak the client's native language and English fluently. Which
of the following actions should the nurse take when providing discharge instructions?
A. Have a hospital staff member who speaks the client's language translate.
B. Ask the client's neighbour to translate the information.
C. Obtain the services of a translator.
D. Allow the client's child to translate the information.
Answer: C. Obtain the services of a translator.
Rationale:
Medical information should be communicated by a qualified medical interpreter who speaks
the client's native language. Federal law provides that the hospital is required to provide a
qualified medical interpreter to translate the client's health care information into the client's
native language.
92. A charge nurse on a paediatric floor receives the results from the morning laboratory
work. Which of the following client results will require the nurse call to the primary care
provider first?
A. A client who has tetralogy of Fallot and a haematocrit of 56%
B. A client who has chronic renal failure and a serum potassium of 4.5 mEq/L
C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL
D. A client who has bronchopulmonary dysplasia (BPD) and a serum PCO 2 level of 45 mm
Hg
Answer: C. A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/Dl
Rationale:

The normal range for a fasting blood glucose is 70 to 100 mg/dL. When treating a client in
DKA, the initial goal of therapy is to get the blood glucose level less than 200 mg/dL. To
accomplish this, the client should receive regular insulin via continuous IV drip, and the
glucose should be monitored hourly. The nurse needs to notify the client's primary care
provider immediately of this very elevated level so that the necessary adjustments in the
insulin drip dosage can be made.
93. A nurse is preparing to care for a client in balanced skeletal traction with a femur fracture.
Which of the following is an appropriate nursing intervention for this client?
A. Offering the client a diet high in fluid and fibre
B. Encouraging active range of motion of the affected leg
C. Removing the weights prior to repositioning the client
D. Performing daily pin site care with isopropyl alcohol
Answer: A. Offering the client a diet high in fluid and fibre
Rationale:
An immobilized client is at risk for constipation. The nurse should encourage a diet high in
fluid and fibre to promote gastrointestinal function.
94. A nurse is assessing a client who is prescribed rosiglitazone (Avandia). For which of the
following should the nurse monitor?
A. Fever
B. Swollen ankles
C. Tinnitus
D. Urinary retention
Answer: B. Swollen ankles
Rationale:
Rosiglitazone is prescribed, along with diet and exercise, to treat type 2 diabetes.
Rosiglitazone can lead to fluid retention, exacerbation of heart failure, and an increased
incidence of angina and myocardial infarction.
95. A nurse is caring for a postoperative client following a hip arthroplasty. In the client's
medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD).
The nurse knows that the oxygen delivery system appropriate for the client is a
A. simple face mask.

B. continuous positive airway pressure (CPAP) device.
C. bag-valve-mask device.
D. nasal cannula.
Answer: D. nasal cannula.
Rationale:
A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate
device for a client with COPD who requires a precise percentage of inspired oxygen.
96. A client who has been treated for a transient ischemic attack (TIA) is being discharged.
The nurse's discharge teaching plan related to this admission should reinforce the importance
of monitoring
A. blood glucose using a glucometer.
B. blood pressure at regular intervals.
C. pulse rate with aerobic exercise.
D. temperature and sensation in the feet.
Answer: B. blood pressure at regular intervals.
Rationale:
TIAs are caused by a temporary disturbance of blood supply to the brain, resulting in brief
neurologic dysfunction. One third of clients who have had a TIA later have recurrent TIAs,
and another one third have cerebrovascular accidents (CVA) that results in permanent nerve
cell loss. The most common causes of TIAs is atherosclerotic plaque in the carotid arteries
and hypertension. Consequently, managing hypertension is important in reducing the risk of
CVA.
97. A clinic nurse is caring for an older adult client with an in-the-canal hearing aid. The
client states that the hearing aid is making a whistling sound. The nurse explains that
whistling in hearing aids is often caused by
A. low battery power.
B. excessive wax in the ear canal.
C. a volume setting that is too low.
D. a crack in the ear tube.
Answer: B. excessive wax in the ear canal.
Rationale:

Whistling from the hearing aid can be caused by a poor seal with the ear mold, an ear
infection, excessive wax in the ear canal, or a malfunction. Ear Molds should be cleaned
regularly, turned off and removed at night, and protected from water and direct heat.
98. A nurse is helping plan a health fair for adults in the community. One booth will focus on
primary and secondary prevention actions for colorectal cancer. The nurse should include
information on the
A. prevention and treatment of constipation.
B. benefits of a diet low in cruciferous vegetables.
C. new types of ostomy appliances available.
D. importance of colonoscopy screening starting at age 50.
Answer: D. importance of colonoscopy screening starting at age 50.
Rationale:
Screening exams for colorectal cancer are considered secondary prevention (early detection
of disease). While it is recommended that some high-risk clients have a colonoscopy before
age 50, most clients should have a baseline colonoscopy done at age 50.
99. A nurse is providing teaching to a client who is prescribed albuterol (Proventil) via a
metered- dose inhaler. After removing the cap from the inhaler and shaking the canister, the
nurse should instruct the client to take which of the following actions next? (Move the
following steps into the box on the right, placing them in the selected order of performance.
All steps must be used.) The client should hold the mouth piece 1/2 to 2 inches from his
mouth, tilt his head back slightly and then open his mouth. Next, he should press the inhaler
while taking a deep breath to facilitate delivery of the medication to the air passages. After
holding his breath for 10 seconds, the client should resume normal breathing. During a
change of shift, a nurse is reviewing the medication administration records (MAR) for her
assigned clients. The nurse notes that a prescribed dose of a medication is above the
recommended safe range, and the dose was administered on the previous shift by a nurse.
Which of the following actions should the nurse take?
A. Call the previous nurse to verify that the dose was given.
B. Give the calculated safe dose.
C. Give the dose as prescribed.
D. Call the prescriber to get the dose clarified.
Answer: D. Call the prescriber to get the dose clarified.

Rationale:
The nurse needs to clarify the prescribed dose to determine what the next action will be.
100. A client comes to the emergency department with deep, rapid respirations. Arterial blood
gas analysis includes these values: pH 7.25, PCO2 40, and HCO3- 18. The nurse reports to
the provider that the client is experiencing
A. respiratory alkalosis.
B. metabolic alkalosis.
C. respiratory acidosis.
D. metabolic acidosis.
Answer: D. metabolic acidosis.
Rationale:
When evaluating arterial blood gas reports, the nurse first checks the acid-base balance. Since
the pH (7.25) is acidic (expected range = 7.35 to 7.45) the client is acidotic. Next the nurse
determines the cause. If the cause is respiratory, the pH and PCO2 values deviate in opposite
directions. Since the PCO2 (40) is acceptable (expected range = 35 to 45) despite the low pH,
the cause must be metabolic. Therefore, the nurse correctly reports to the provider that the
client is experiencing metabolic acidosis.
101. After 30 min of rambling about the "ozone layer" and being "doomed to die," a client
begins pacing in an increasingly agitated manner. What should the nurse do first?
A. Obtain a prescription for PRN medication for agitation.
B. Remain with the client and attempt to reduce the environmental stimuli.
C. Explain to the client that the delusion is a manifestation of his illness.
D. Suggest that the client participate in group therapy.
Answer: B. Remain with the client and attempt to reduce the environmental stimuli.
Rationale:
The nurse should remain with the client, even if that requires walking alongside the client.
Also, attempts should be made to reduce the client's external stimuli.
102. A newly licensed nurse is caring for a child who is brought to the emergency department
with bruises that the nurse believes are due to child abuse. What should be the nurse's action
at this time?
A. Ask the child who is responsible for the bruises.

B. Call local law enforcement.
C. Question the child's parents.
D. Notify the charge nurse.
Answer: D. Notify the charge nurse.
Rationale:
The nurse has noted that the bruises are suspicious. The proper action at this point is to follow
the chain of command to ensure that the incident is reported to the authorities for
investigation
103. A client who is regularly exposed to sunlight comes to the clinic to have several skin
lesions evaluated. Which assessment finding should alert the nurse to the possibility of
malignant melanoma?
A. A pearly papule that is 0.5 cm in size with raised, indistinct borders on the upper right
shoulder
B. Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose
C. A raised, circumscribed lesion on the face, containing yellow-white purulent material
D. An irregularly shaped brown lesion with light blue areas on the neck
Answer: D. An irregularly shaped brown lesion with light blue areas on the neck
Rationale:
Malignant melanoma, the leading cause of death from skin cancer, is a neoplasm derived
from dermal or epidermal cells. Exposure to sunlight increases the risk, with fair-skinned
people at greatest risk. Malignant melanoma commonly starts in exposed skin areas like the
back, scalp, face, and neck, and metastasizes readily to other areas. Manifestations include a
change in the colour, size, or shape of a skin lesion, with irregular borders in hues of tan,
black, or blue.
104. A nurse is caring for a client who is mechanically ventilated due to acute respiratory
failure. At 1600, the client had a heart rate of 80/min and a respiratory rate of 20/min, with an
oxygen saturation (SaO2) of 98%. At 1800, the client has a heart rate of 120/min, a
respiratory rate of 32/min, and a SaO2 of 87%. The nurse should
A. provide 100% oxygen by bag-valve-mask ventilation.
B. suction the client's secretions via the endotracheal tube.
C. auscultate the client's anterior and posterior lung fields.
D. notify the primary care provider immediately.

Answer: C. auscultate the client's anterior and posterior lung fields.
Rationale:
When a client is intubated and ventilator-dependent, oxygen saturation levels (SaO2) are a
crucial factor in evaluating respiratory status. Note that the client was stable at 1600, with an
acceptable SaO2 at 98% and respirations of 20/min; however, 2 hr later, the SaO2 has dropped
to an unacceptably low 87% with an associated increase in respirations to 32/min. There are
many potential reasons for these findings, so the first step is to complete a respiratory
assessment, including auscultation of all lung fields.
105. A client is in the dayroom when another client asks if two items of clothing match. The
client with schizophrenia replies, "A match. I like matches. They are the givers of light, the
light of the world. God will light the world if you let Him. Let your light shine in." Which of
the following is the client demonstrating?
A. Clang association
B. Flight of ideas
C. Word salad
D. Loose association
Answer: D. Loose association
Rationale:
This client is demonstrating loose association, a pattern of disordered language that
represents disordered thought.
106. A nurse is caring for a client with a history of an above-knee amputation and chronic
phantom pain. Which of the following medication prescriptions should the nurse question?
A. Meperidine HCL (Demerol)
B. Amitriptyline (Elavil)
C. Gabapentin (Neurontin)
D. Ibuprofen (Motrin)
Answer: A. Meperidine HCL (Demerol)
Rationale:
The nurse should question the use of meperidine HCL in the client with chronic pain. Chronic
pain should not be managed with an opioid analgesic due to the risk of dependence and
tolerance. Also, meperidine should not be used long-term due to the build-up of a toxic
metabolite that occurs when the medication is metabolized.

107. An 18 month old infant admitted with Pneumocystis carinii pneumonia has enzyme
linked immunosorbent assay (ELISA) testing and is diagnosed as being human
immunodeficiency virus (HIV) positive. In planning care, the nurse should be aware that
A. the infant's mother is also HIV positive.
B. the infant may still convert to HIV negative.
C. antiretroviral medications cannot be given to infants or children.
D. the infant will need to be placed on respiratory isolation.
Answer: A. the infant's mother is also HIV positive.
Rationale:
Transmission from an HIV-infected mother to an infant can occur during pregnancy, delivery,
or through breastfeeding. An 18-month-old infant would be unlikely to have contracted HIV
via any of the other known high-risk transmission behaviours such as sexual contact or IV
drug use. Acquisition of HIV via contaminated blood products is also very unlikely for this
infant (although not impossible) because of improved accuracy of testing for the presence of
HIV antibodies in all donated blood since 1985.
108. A client being treated for antisocial personality disorder is becoming increasingly loud
and belligerent on the mental health unit. Which approach should the nurse use to manage
this client's potentially violent behavior?
A. Confront the client for breaking the rules.
B. Stand close to the client to offer comfort and support.
C. Use clear, calm statements and set limits on the behavior.
D. Move to the safety of the nurses' station and notify security.
Answer: C. Use clear, calm statements and set limits on the behavior.
Rationale:
In order to remain in control of the situation, the nurse should use clear, calm statements
when the client is highly anxious. Limits should be set for the client who exhibits potentially
violent behavior.
109. A disabled client is taking phenelzine (Nardil) for depression. The nurse is teaching the
client's new home health aide about the client's diet restrictions due to the medication. The
nurse evaluates that the teaching has been effective when the home health aid selects which
of the following for the client's lunch?

A. Bologna sandwich on wheat bread and orange slices
B. Chicken salad and carrot sticks
C. Cheddar cheese and crackers with chicken noodle soup
D. Pizza with pepperoni and apple slices
Answer: B. Chicken salad and carrot sticks
Rationale:
Phenelzine is a monoamine oxidase inhibitor (MAOI). Clients taking MAOIs must avoid
foods with tyramine due to a dangerous food-drug interaction. Foods high in tyramine include
those that are processed and aged, such as lunch meats and cheeses. This menu selection does
not contain food high in tyramine; therefore, it is the best choice.
110. A nurse is caring for a 4 year old child who is admitted to the paediatric unit through the
emergency department and will be having a procedure in the morning. The child has been
crying throughout the night and experiencing night terrors despite the parent's presence at the
bedside. The nurse should understand that engaging the child in therapeutic play may provide
which of the following benefits?
A. Decreases the child's fear of the dark
B. Allows the child to manipulate play medical equipment
C. Helps the child deal with the fear of body mutilation
D. Encourages parents to become more engaged with their child
Answer: B. Allows the child to manipulate play medical equipment
Rationale:
A major function of play in play therapy is making potentially unmanageable situations
manageable through symbolic representation, which provides children with opportunities to
learn to cope. A preschooler does not have the language development to express his fear of
the unfamiliar medical equipment used in the hospital. The nurse encourages the child to
touch the equipment to decrease the child's fear and intimidation in a safe environment using
age- appropriate vocabulary. The use of toys enables children to transfer anxieties, fears,
fantasies, and guilt to objects rather than people.
111. A charge nurse in the labor and delivery suite is coordinating the care of four clients.
When the reporting nurses bring the charge nurse assessments, which client must the charge
nurse see first?
A. Client in active labor with late decelerations on the monitor strip

B. Client in transition screaming and disturbing other clients
C. Client with an epidural catheter reporting breakthrough pain
D. Client receiving oxytocin (Pitocin) drip with contractions every 2 min lasting 60 seconds
Answer: A. Client in active labor with late decelerations on the monitor strip
Rationale:
Late decelerations are no reassuring patterns that reflect impaired placental exchange or
placental insufficiency. Interventions include improving placental blood flow and fetal
oxygenation with such actions as changing the mother's position, giving the mother oxygen,
increasing the mother's IV fluids, and possibly even an immediate caesarean birth. This is the
client who must be assessed by the charge nurse immediately.
112. A nurse is instructing a client on postoperative care related to a surgical procedure that
will occur later in the day. The client states that no one has spoken to him about this before.
Which of the following actions should the nurse take?
A. Continue the teaching, but check afterward with the surgeon related to informed consent.
B. Stop the teaching and check with the surgeon related to informed consent.
C. Stop the teaching and obtain an informed consent form for the client to sign.
D. Continue the teaching and check the chart afterward for a signed consent form
Answer: A. Stop the teaching and check with the surgeon related to informed consent.
Rationale:
The client's statement indicates that informed consent has not been obtained. Therefore, the
nurse should stop the teaching and contact the surgeon.
113. A nurse is preparing to administer medications to an unconscious client. The nurse
should bring the medication administration record (MAR) to the client's bedside and
A. check the client's name and medical record number on the MAR against the room and bed
number.
B. call the client by name and check the name on the identification bracelet against the
client's MAR.
C. compare the medical record number and name on the MAR with the client's identification
band.
D. ask the client's visitor to identify the client by name and give the client's birth date.
Answer: C. compare the medical record number and name on the MAR with the client's
identification band.

Rationale:
The Joint Commission requires the use of two client identifiers when administering
medications. It is correct for the nurse to compare the medical record number and name on
the MAR with the client's identification band.
114. Which of the following actions should a nurse take after discontinuing IV therapy for a
client with a platelet count of 50,000/mm3?
A. Monitor the client's vital signs frequently.
B. Apply pressure to the catheter removal site for 5 min.
C. Elevate the affected arm.
D. Restrict movement of the affected limb for 8 hr.
Answer: B. Apply pressure to the catheter removal site for 5 min.
Rationale:
The expected platelet (thrombocyte) count ranges from 150,000 to 450,000/mm3. Any value
below 100,000/mm3 is considered thrombocytopenia, a problem that puts the client at
increased risk for bleeding. By applying pressure to the site for at least 5 min, the nurse
promotes coagulation and prevents additional blood loss.
115. A nurse is caring for a child who has epistaxis. Which of the following actions would be
the most appropriate for the nurse to take?
A. Administer aspirin for pain.
B. Tilt the head back and apply pressure.
C. Have the child lie down and rest.
D. Apply a cold cloth to the bridge of the nose.
Answer: D. Apply a cold cloth to the bridge of the nose.
Rationale:
Applying a cold cloth to the bridge of the nose causes vasoconstriction, which decreases the
bleeding.
116. A nurse manager notes conflicts between nurses on different shifts. These problems are
likely due to several factors, including generational differences, experience, and the
expectations of care on each shift. Which of the following strategies should the nurse use to
resolve these conflicts?
A. Have the charge nurses for each shift get together and discuss the issues between shifts.

B. Direct the nurses from each shift to discuss their issues and present their solutions to the
nurse manager.
C. Set up a series of meetings for all staff members to attend to discuss issues.
D. Allow the nurses from each shift to resolve the issues amongst themselves.
Answer: C. Set up a series of meetings for all staff members to attend to discuss issues.
Rationale:
The nurse manager realizes that conflict resolution requires bringing the groups together to
communicate common issues. Inviting all staff members to participate allows this to happen.
117. A hospital receives a bomb threat and the charge nurse has to coordinate the evacuation
of the clients. Which of the following actions should the nurse take when implementing the
evacuation process?
A. Call in the clients' family members to provide additional help in moving the clients.
B. Ask clients who are able to ambulate to assist in moving the unstable clients.
C. Instruct clients who are able to ambulate to leave.
D. Direct staff members to move unstable clients first.
Answer: C. Instruct clients who are able to ambulate to leave.
Rationale:
Clients who are able to ambulate should be asked to leave first because this is the fastest way
to start the evacuation process.
118. Clients on neuroleptic antipsychotic medications are at a higher risk for developing
agranulocytosis. What client data should the nurse review for the earliest indication of this
problem?
A. Urinalysis
B. Haemoglobin and hematocrit
C. Blood pressure
D. Temperature
Answer: D. Temperature
Rationale:
Agranulocytosis is a blood dyscrasia. It is the depletion of WBCs, which makes the client
more susceptible to infection. An assessment of the client's temperature will provide easy,
non-invasive baseline data to determine if laboratory work, such as a WBC count, should be
requested.

119. A nurse is providing teaching to a client who is prescribed insulin for a new diagnosis of
diabetes mellitus. The nurse should explain the need for subcutaneous injections of insulin by
responding that insulin
A. is a hormone that cannot be converted to a pill form.
B. works faster by the subcutaneous route than the oral route.
C. is destroyed by the digestive enzymes in the stomach if taken orally.
D. interacts directly with fat cells in the subcutaneous tissue.
Answer: C. is destroyed by the digestive enzymes in the stomach if taken orally.
Rationale:
Insulin must be given by a parenteral route because it is destroyed by the digestive enzymes
of the stomach. Taken orally, it would be deactivated before it could be absorbed.
120. A nurse is assigned to care for several postoperative clients. The nurse identifies a client
as having a high risk for delayed wound healing if the client has
A. hypertension treated with nifedipine (Procardia).
B. adrenal insufficiency treated with prednisone (Deltasone).
C. asthma treated with albuterol (Proventil).
D. schizophrenia treated with chlorpromazine (Thorazine).
Answer: B. adrenal insufficiency treated with prednisone (Deltasone).
Rationale:
Prednisone is a potent glucocorticoid (steroid) that is associated with delayed wound healing.
In addition, the client with adrenal insufficiency will have a poor stress response, therefore
requiring high steroid doses to adapt to the stress of surgery.
121. A nurse is providing teaching to parents of a child who is prescribed lamotrigine
(Lamictal) for a seizure disorder. The nurse should instruct the parents to notify the primary
care provider immediately if the child develops which of the following?
A. Headache
B. Dizziness
C. Rash
D. Dyspepsia
Answer: C. Rash
Rationale:

A rash is the first indication of both Stevens-Johnson syndrome and toxic epidermal
necrolysis, which can occur typically in the first 2 to 8 weeks of treatment with lamotrigine.
The greatest risk to the client is a life-threatening adverse reaction to lamotrigine that can
result in permanent disability or death.
122. A female client with a history of recurrent cystitis asks the nurse about preventing future
episodes. Which client statement describes a self-care activity that the nurse should
discourage?
A. "I drink at least 2 Liters of fluid per day."
B. "I prefer tub baths to showering."
C. "I urinate before and after sexual relations."
D. "I wipe from front to back after urinating."
Answer: B. "I prefer tub baths to showering."
Rationale:
Cystitis is an inflammation of the bladder lining that commonly occurs with a urinary tract
infection (UTI). Women at risk for UTIs should avoid tub baths as they are associated with an
increased risk for infection. This is a self-care activity the nurse should discourage.
TEST-TAKING STRATEGY: This question asks which activity the nurse should
DISCOURAGE; thus the CORRECT answer is an INCORRECT activity.
123. A community health nurse is planning the day's schedule for visiting four high risk
neonates discharged yesterday. Which of the following neonates should the nurse plan to visit
first?
A. 1 week old who needs a repeat phenylketonuria (PKU) screening test
B. 4 day old with an elevated bilirubin level who is prescribed phototherapy
C. 10 day old, small-for-gestational-age (SGA) who needs daily weights
D. 2 week old preterm born at 35 weeks who was discharged at 2,250 g
Answer: B. 4 day old with an elevated bilirubin level who is prescribed phototherapy
Rationale:
An elevated bilirubin level can lead to kernicterus (bilirubin encephalopathy), a form of brain
damage associated with newborn hyperbilirubinemia and jaundice. This neonate must be seen
first so that the prescribed phototherapy can be initiated as soon as possible. If initiated early,
the neonate may be successfully treated at home with exposure to sunlight, avoiding the need
for hospitalization.

124. A nurse in a substance abuse program is interacting with a client. The client is a nurse
who has entered into the program as requirement of the state's board of nursing. Which
statement by the client indicates to the nurse that the client is using intellectualization as a
way of coping with the anxiety of admission?
A. "I was just using the medication to help me out during a rough time in my life, that's all. I
can stop whenever I want."
B. "This all happened because my spouse is unemployed. That puts an enormous amount of
stress on me."
C. "In my experience, problems with substances can have a variety of predisposing factors."
D. "I just don't want to talk about it. There is nothing you can do about it anyway."
Answer: C. "In my experience, problems with substances can have a variety of predisposing
factors."
Rationale:
Intellectualization is an attempt to use intellectual processes to avoid expressing emotions
associated with stressful situations. It is a common defense mechanism used by professionals
in the medical field as a way of coping with their anxiety related to either their own diagnoses
or hospitalizations.
125. A nurse is caring for a client diagnosed with hyperthyroidism. When developing a
teaching plan, it is important for the nurse to encourage the client to
A. reduce her hours of sleep.
B. keep the immediate environment warm.
C. increase nutritional intake with meals.
D. gradually increase her activity.
Answer: C. increase nutritional intake with meals.
Rationale:
Clients with elevated thyroid hormone levels have increased protein, lipid, and carbohydrate
metabolism, resulting in the loss of protein stores and a negative nitrogen balance. Even with
an increased appetite, it is often difficult to meet energy demands, and weight loss is
common.
Muscle weakness and wasting can develop without adequate caloric and protein intake.

126. A family member of a client receiving hospice services asks the hospice nurse for
assistance. The family member states that the client has insomnia almost nightly. The nurse
assesses the client and documents the following: "Vital signs are stable, takes a short nap
once a day as needed, walks around the neighbourhood once a day if feeling ok, likes to
watch television (TV) in bed during the day, goes to bed at 10 pm every night, drinks hot
herbal tea before going to bed, and gets up to go to the bathroom once during the night."
Which of the following mostly likely contributes to the client's insomnia?
A. The client watches TV in the bed during the day.
B. The client drinks hot herbal tea before bedtime.
C. The client goes to bed at 10 pm every night.
D. The client gets up to use the bathroom once during the night.
Answer: A. The client watches TV in the bed during the day.
Rationale:
General sleep strategies include establishing a regular sleep schedule and staying out of bed
during the day, except for naps.
127. A high carbohydrate, low protein diet is prescribed for a client who has chronic renal
failure. The nurse explains to the client that the carbohydrates in this diet will help
A. prevent ketosis.
B. promote diuresis.
C. maintain urine acidity.
D. reduce hepatic demands.
Answer: A. prevent ketosis.
Rationale:
Clients in chronic renal failure have diets restricted in protein, sodium, potassium,
magnesium, phosphorus, and saturated fats. Carbohydrates provide the client with adequate
calories to meet metabolic and energy needs while preventing the development of ketosis.
Carbohydrates also have a protein-sparing effect that makes protein available for growth and
tissue building.
128. A nurse is assessing a client who is taking varenicline (Chantix) for smoking cessation.
Which of the following client reports is the highest priority finding?
A. Irritability
B. Gastroesophageal reflux

C. Weight gain
D. Arthralgia
Answer: A. Irritability
Rationale:
The greatest risk to the client is the development of CNS side effects that can progress to
depression and suicide. Therefore, the highest priority finding is irritability.
129. A nurse is teaching a client who is a paraplegic to perform intermittent urinary selfcatheterization at home after discharge. Which statement by the client demonstrates to the
nurse that the client understands the procedure?
A. "I will not use the Valsalva maneuver while performing self-catheterization."
B. "I must use sterile technique to do each of the catheterizations."
C. "I should stop the catheterization when I have removed 150 mL of urine."
D. "I will perform intermittent self-catheterization every 4 to 6 hours."
Answer: D. "I will perform intermittent self-catheterization every 4 to 6 hours."
Rationale:
The standard interval for intermittent catheterization is every 4 to 6 hr . Although some adult
clients may wait up to 8 hr, that greatly increases the risk for urinary tract infection.
130. A nurse is planning care for an older adult client. An increase in which of the following
is a normal physiological change associated with aging?
A. Vital capacity
B. Adipose tissue
C. Hepatic metabolism
D. Bone mineral mass
Answer: B. Adipose tissue
Rationale:
Physiological changes occur with aging in all organ systems. Tissue composition changes the
nurse should be aware of include an increase in adipose tissue, a decrease in lean body mass,
and a decrease in total body water. Because of these normal alterations, medication dosages
may need to be reduced in the older adult client. For example, an increase in adipose tissue
may prolong the half-life of lipid-soluble medications.

131. A nurse is caring for a client who is at 38 weeks of gestation and in the active phase of
the first stage of labor. The client's electronic fetal monitoring reveals two early decelerations
in the last five contractions. Which of the following is an appropriate nursing intervention?
A. Increase the IV solution rate.
B. Alter the client's position to a lateral position.
C. Assess the bladder for retained urine.
D. Notify the primary care provider immediately.
Answer: B. Alter the client's position to a lateral position.
Rationale:
An early deceleration is a common, normal variation in the fetal heart rate. It is caused by
pressure on the fetal head from the walls of the birth canal. This may be relieved by changing
the maternal position. Lateral, or side-lying positioning provides for the best uteroplacental
blood flow.
132. A nurse is taking a history from a client with presbyopia. With which of the following
should the nurse expect the client to have difficulty?
A. Finding the bathroom in the dark
B. Driving at night
C. Seeing numbers on highway signs
D. Reading the newspaper
Answer: D. Reading the newspaper
Rationale:
In presbyopia, the lens is unable to change shape to focus on objects close up. Presbyopia
occurs most often with aging, beginning in the forties, and is due to the decreased flexibility
of the lens.
133. A client with a history of chronic renal failure (CRF) has routine laboratory tests done
with the following results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL,
and albumin 3.0 g/dL. Which result should the nurse report to the client's primary care
provider immediately?
A. Hypocalcaemia
B. Hyperkalaemia
C. Anaemia
D. Hypoalbuminemia

Answer: B. Hyperkalaemia
Rationale:
Hyperkalaemia (elevated potassium) is common among clients with CRF. The other values
are outside of the expected range but are expected with CRF. However, even for a client with
CRF, this potassium level is associated with life-threatening cardiac dysrhythmias.
134. At a maternal health clinic, a nurse talks with several prenatal clients on the phone.
Which client report does the nurse realize is a normal physiologic adaptation to pregnancy?
A. Spotting with urination
B. Breast tenderness
C. Thick, white vaginal discharge
D. Facial swelling
Answer: B. Breast tenderness
Rationale:
Breast tenderness is commonly experienced during both the first and third trimesters of
pregnancy. The nurse explains to the client that this is a normal adaptation to pregnancy and
should also teach the client to wear a well-fitting, supportive bra to alleviate the tenderness
135. A client comes to the emergency department in severe respiratory distress with a knife
protruding from his left chest. The nurse finds that the client has tachycardia, hypotension,
and has a tracheal shift to the right. The nurse should prepare the client for
A. tracheostomy placement.
B. removal of the knife.
C. computed tomography (CT) scan of the chest.
D. chest tube insertion.
Answer: D. chest tube insertion.
Rationale:
The client's manifestations indicate pneumothorax due to the open chest wound. The provider
must insert a chest tube immediately and connect it to a water-seal drainage system.
136. A nurse is caring for a client with hypothyroidism who is taking levothyroxine sodium
(Synthroid). The nurse teaches the client to report which adverse effect of this medication to
the provider immediately?
A. Weight gain

B. Constipation
C. Chest pain
D. Fatigue
Answer: C. Chest pain
Rationale:
Chest pain may result if a client takes too much levothyroxine. It is important to increase the
dosage gradually as needed to prevent rapid changes in cardiac output that can cause
tachycardia and angina, especially for clients with longstanding hypothyroidism or
cardiovascular disorders.
137. A nurse is teaching the parents of an infant about treatment options for profound
sensorineural hearing loss. The nurse explains that cochlear implants work by which of the
following?
A. Direct stimulation of auditory nerve endings
B. Conduction of sound waves through the mastoid bone to the cochlea
C. Processing of digital sound to amplify several sound frequencies
D. Transferring of sound waves from one ear to the other
Answer: A. Direct stimulation of auditory nerve endings
Rationale:
Cochlear implants work by directly stimulating nerve endings in the cochlea.
138. A nurse is talking with the parent of a 4 month old infant about normal growth and
development. Which comment made by the parent should indicate to the nurse a need for
further teaching?
A. "I need to remind my older kids to keep small objects out of the baby's reach."
B. "I let my baby play on her stomach when she is awake and I am watching."
C. "My baby loves to play with the musical mobile in the crib."
D. "I always place my baby into a rear-facing car seat in the back seat of the car."
Answer: C. "My baby loves to play with the musical mobile in the crib."
Rationale:
Crib mobiles should be removed from the crib at 4 months. Infants at this age are beginning
to reach for objects and pull on them. The crib mobile could fall and become a choking or
strangulation hazard.

139. A client recently received a Mantoux skin test. After 48 hr , the test was evaluated by the
nurse and reveals 10 mm of induration with slight redness. This indicates to the nurse that the
A. client has active tuberculosis (TB).
B. client has been exposed to tuberculosis (TB).
C. test must be re-evaluated in 72 hr.
D. test is negative for tuberculosis (TB).
Answer: B. client has been exposed to tuberculosis (TB).
Rationale:
A Mantoux test is done to determine if a client has been exposed to TB. Forty-eight to 72 hr
after the Mantoux is performed, the client will need to return to the provider to have the
results read. This involves a brief examination of the test site. The nurse will look at the test
site and palpate the area to determine if the test site is raised and feels hard to the touch
(induration) and will record the results in millimetres to represent the size of the raised bump.
Redness does not count toward reading the test as negative or positive.
140. A nurse responds to a call from the nursing assistant that a client has had a seizure and is
unconscious. What is the nurse's priority at this time?
A. Notify the client's primary care provider.
B. Perform a comprehensive neurological examination.
C. Check airway patency.
D. Administer PRN intravenous lorazepam (Ativan).
Answer: C. Check airway patency.
Rationale:
The nurse's highest priority in this situation is to establish and maintain the client's airway to
prevent respiratory arrest and/or hypoxia.
141. A nurse has taught the parent of a child diagnosed with type 1 diabetes mellitus how to
manage the child's condition during illness, such as colds or flu. The nurse evaluates that the
child's parent understands the teaching when the parent states, “On sick days I will”
A. reduce my child's food intake to prevent nausea and vomiting.
B. increase the frequency of checking my child's blood glucose.
C. monitor urine ketones.
D. avoid administering my child's long-acting insulin dose.
Answer: B. increase the frequency of checking my child's blood glucose

Rationale:
Blood glucose should be monitored every 3 hr during an illness because it will often rise,
even if food intake decreases.
142. Which statement made by an assistive personnel (AP) to a nurse indicates that the AP
needs more education about the use of side rails as a safety device?
A. "All four side rails cannot be left raised at all times unless there is a prescription from the
provider for client restraints."
B. "An alert client will be safest if I leave the two upper side rails at the head of the bed
elevated."
C. "If the client is confused, I'm going to raise all four side rails, so that the client doesn't hurt
himself."
D. "If a client at risk of falling attempts to get out of bed, I will raise the two upper side rails
and one lower side rail."
Answer: C. "If the client is confused, I'm going to raise all four side rails, so that the client
doesn't hurt himself."
Rationale:
Raising all four side rails can put the client at greater risk for injury. If the client becomes
confused and tries to climb over the side rails, it could result in a much more serious fall.
Therefore, one side rail at the bottom of the bed should remain down.
TEST-TAKING STRATEGY: With a negative-format question like this one, the CORRECT
answer is an INCORRECT statement.
143. A nurse is caring for a client with schizophrenia in an inpatient mental health facility.
The client asks the nurse, "Can I vote in the upcoming presidential election? " Which of the
following is an appropriate response?
A. "No, clients with mental health disorders requiring hospitalization cannot vote."
B. "Yes, you can vote. However, you will have to get a pass to leave the unit."
C. "Yes, you can vote. Can I assist you with obtaining an absentee ballot?"
D. "No, you cannot vote because you are not able to leave the hospital to do so."
Answer: B. "Yes, you can vote. Can I assist you with obtaining an absentee ballot?"
Rationale:
Clients that are hospitalized in an inpatient mental health facility may vote, but they
frequently need assistance to vote with an absentee ballot. Clients with mental health

disorders have all the legal rights of any other United States citizen, unless the client is under
a specific court order (or other legal ruling) to the contrary.
144. A nurse admits a child with a urinary tract infection (UTI) who has a history of
myelomeningocele. After completion of the admission history, which action should the nurse
take?
A. Label the client's identification band with a "latex allergy" alert.
B. Place the client on contact precautions.
C. Post signs in the client's bathroom to "strain all urine."
D. Administer folic acid with all meals.
Answer: A. Label the client's identification band with a "latex allergy" alert.
Rationale:
Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which
the spinal cord and meninges are external to the spinal bones and contained in a cerebrospinal
fluid- filled sac at birth. The nurse is aware that clients with neural tube defects are at an
increased risk for latex allergy; therefore, these clients are placed on latex alert as a matter of
caution. Exposure to common medical products containing latex, such as latex gloves, must
be avoided.
145. A nurse is providing discharge teaching to parents whose infant has had a
ventriculoperitoneal shunt placed. The nurse evaluates that teaching was effective when the
parent states which of the following?
A. "We will check the abdomen daily for signs of fluid accumulation."
B. "A new shunt will probably be needed in a couple of years."
C. "The doctor will need to be notified if urine output decreases."
D. "We will cleanse the catheter site daily using sterile technique."
Answer: B. "A new shunt will probably be needed in a couple of years."
Rationale:
When the ventriculoperitoneal shunt is inserted, the surgeon will leave the distal tubing
longer than necessary and coiled in the peritoneum to allow for growth. Even so, by about the
preschool period, the child will outgrow the tubing length and require a revision of the
original shunt. Another common complication is shunt malfunction, which also requires
surgical revision, typically within a few years.

146. A nurse is teaching a group of clients at an older adult centre about the risk for the
development of osteoporosis. Which of the following statements should the nurse include in
the teaching session?
A. "Extended periods of immobility increase your risk for osteoporosis."
B. "Prolonged periods of sun exposure may increase your risk for osteoporosis."
C. "Eating a diet high in protein can reduce your risk for osteoporosis."
D. "A prescription for steroids will reduce your risk for osteoporosis."
Answer: A. "Extended periods of immobility increase your risk for osteoporosis."
Rationale:
Osteoporosis is a condition in which bones become weakened due to a loss of bone mass and
a change in bone structure. Immobility can result in osteoporosis; therefore, weight-bearing
exercise, such as walking, is one way for the client to prevent osteoporosis.
147. A nurse is caring for a client taking warfarin (Coumadin). Which of the following
laboratory values indicates to the nurse an effective response to the medication?
A. Hct of 45%
B. Hgb 15 g/dL
C. Activated partial thromboplastin time (aPTT) of 35 seconds
D. INR of 3.0
Answer: D. INR of 3.0
Rationale:
Warfarin is an anticoagulant used to prevent thrombus formation in susceptible clients. The
INR is used to monitor for the desired response to warfarin. A therapeutic INR for a client on
warfarin is 2.5 to 3.0, but varies by diagnosis and provider preference. An INR greater than
4.0 may result in an increased risk for bleeding.
148. A nurse at an acute care clinic is talking with a client who reports that her arthritis pain is
increasing each day. The client wants to discuss nonpharmacological approaches that would
help relieve her. Which intervention should the nurse suggest?
A. Increasing dietary intake of omega-3 fatty acids
B. Immobilizing affected joints during a flare-up Keeping
C. joints extended during rest periods Applying cold packs to
D. sore joints
Answer: A. Increasing dietary intake of omega-3 fatty acids

Rationale:
Taking omega-3 fatty acids has been found to be effective in reducing inflammation. It may
also help prevent cardiovascular disease. Omega-3 fatty acids can be found in fish oil and can
be taken as a dietary supplement.
149. A nurse is preparing to administer a feeding via a gastrostomy tube to a client recovering
from a cerebrovascular accident. The prescription is for tube feedings to be administered
every 4 hr. Which action should the nurse take prior to initiating the feeding?
A. Warm the feeding in the microwave.
B. Elevate the head of the bed.
C. Check the client's gag reflex.
D. Verify that the gastric pH is above
Answer: B. Elevate the head of the bed.
Rationale:
A common reason that clients recovering from brain injury require gastrostomy tube feedings
is that they are unable to swallow due to aphagia and cannot adequately protect their airway
from aspiration due to an impaired gag reflex. Even though this route bypasses the
nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral
cavity. Consequently, itis important to take actions to prevent aspiration, such as elevating the
head of the bed, prior to initiating the feeding.