COMPREHENSIVE ATI MEDICAL SURGICAL EXIT EXAM 2023-2024
1. A nurse is reinforcing teaching about dietary measures with a client who is at risk for
developing osteoporosis. Which of the following food choices should the nurse recommend
increasing the client’s calcium level?
Answer: One cup of cooked spinach contains 245mg of calcium. Most vegetables contain
considerably less calcium, except for kale, collard greens with stems, and turnip greens, which
are also good sources of calcium
2. A nurse is collecting data from a client who has anaemia and a haemoglobin level of 7.2 g/dL.
Which of the following findings should the nurse expect?
Answer: Brittle Fingernails
3. A nurse is collecting data from a client who has acute gastroenteritis. Which of the following
data collection findings should the nurse identify as the priority?
Answer: Potassium 2.5 mEq/L
4. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) the nurse should
monitor the client for which of the following conditions as a complication TPN?
Answer: POLYURIA
5. A nurse is reinforcing teaching with a client about the oliguric phase of acute kidney injury.
Which of the following information should the nurse include in the teaching?
Answer: the client’s urine output is less than 400 mL per 24 hrs
6. A nurse is reviewing a provider’s admission orders for a client who has acute heart failure. For
which of the following prescriptions should the nurse obtain clarifications?
Answer: Ambulate three times daily
7. A nurse provides teaching to a client who is being fitted for a prosthetic leg. Which of the
following statements indicate to the nurse a need for further instruction?
Answer: I’ll learn to balance well on one leg, so I don’t have to use crutches
8. A nurse is planning client care for the shift. Which of the following tasks should the nurse
delegate to assistive personnel (AP)
Answer: Measuring a client’s intake and output
9. A nurse is assessing an order adult client who has a urinary tract infection (UTI). Which of the
following findings should the nurse identify as unique for this age group?
Answer: Confusion
10. A client who is 7 days postpartum calls the provider’s office and reports pain, swelling, and
redness of her left calf. Besides the client seeing the provider, which of the following
interventions should the nurse suggest?
Answer: Elevate the leg
11. A nurse is shopping and finds a woman who has collapsed with right-sided weakness and
slurred speech. Which of the following actions should the nurse take?
Answer: Call emergency medical services
12. A nurse is collecting data on a client who has acute pancreatitis. Which of the following
factors should the nurse anticipate in the client’s history?
Answer: Gallstones
13. A nurse is reinforcing teaching with a client who has a urinary tract infection (UTI) which of
the following risk factors should the nurse include in the teaching?
Answer: Diabetes mellitus
14. A nurse is collecting data from a female client who has a cystocele. Which of the following
findings should the nurse expect?
Answer: Difficulty Voiding
15. A nurse is reinforcing teaching with a young adult client who has a family history of
osteoporosis which of the following health promotion activities should the nurse recommend?
Answer: Engaging in weight-bearing exercise regularly
16. A nurse is checking a client’s abdominal incision several hours following surgery and realizes
that it is eviscerating. Which of the following actions should the nurse take?
Answer: Apply a sterile normal saline dressing to the wound
17. A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC).
Which of the following findings should the nurse expect?
Answer: Excessive thrombosis and bleeding
18. A nurse is admitting a client who is having an exacerbation of asthma. When reviewing the
provider’s orders, the nurse recognizes that clarification is needed for which of the following
prescribed medications?
Answer: Propranolol
19. A nurse is caring for an older adult client who has left-sided heart failure. which of the
following findings should the nurse expect?
Answer: Frothy sputum
20. A nurse is assisting with the plan of care for a client who has leukaemia and whose platelet
count is 50,000 mm3. Which of the following intervention should the nurse include in the plan of
care?
Answer: Administer a stool softener
21. A nurse is reinforcing teaching with a client about how to use a patient-controlled analgesia
(PCA) pump. Which of the following statements should the nurse include in the teaching?
Answer: Use the pain scale to determine if you should push the medication self-administration
button
22. A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of
hypoxia. Which of the following findings should the nurse include in the teaching?
Answer: Agitation
23. A nurse is collecting data from a client who has meningitis. When passively flexing the
client’s neck, the nurse notes an involuntary flexion of both legs. Which of the following
conditions is the client displaying?
Answer: Brudzinski sign
24. A nurse is preparing a client who has hypotension for gastric lavage using a large-bore
nasogastric (NG) tube. In which of the following positions should the nurse place the client?
Answer: Left lateral
25. A nurse is caring for a client who is postoperative following a colon resection. For which of
the following findings should the nurse monitor to identify a pulmonary embolus?
Answer: Sudden shortness of breath
26. A nurse is reinforcing teaching about the manifestations of hyperglycaemia with a client who
has diabetes mellitus. Which of the following statements by the client indicates an understanding
of the teaching?
Answer: I will be more thirsty than usual
27. A nurse at a community centre is assisting with a presentation about sun protection to a group
of residents. Which of the following responses by the residents indicates an understanding of the
teaching?
Answer: I should apply a sunscreen with an SPF of 30
28. A nurse is reinforcing infection control practices for hand hygiene with a group of unit
nurses. Which of the following information should the nurse reinforce in the teaching?
Answer: Change gloves between tasks on the same client
29. A nurse is discussing the nurse’s role in obtaining informed consent with a group of
coworkers. Which of the following statements should the nurse include?
Answer: The nurse should sign the form as confirmation that a client appears competent
30. A nurse is assigned a group of postoperative clients. Which of the following client findings
should the nurse identify as the priority?
Answer: SaO2 88%
31. A nurse is reinforcing teaching about self-care techniques with a client who has rheumatoid
arthritis. Which of the following strategies should the nurse include to illustrate the concept of
joint protection?
Answer: Turn doorknobs in a counterclockwise motion to open them
32. A nurse is reviewing data for a client who has chronic kidney disease. Which of the following
data should the nurse identify as the best indicator of fluid volume status?
Answer: Daily weight
33. A nurse is monitoring a client who has dehydration and is receiving iv fluid replacement.
Which of the following findings should the nurse identify as effectiveness of the treatment?
Answer: Urine output 200 mL/4hr
34. A nurse is reviewing the plan of care for a client who has cellulitis of the leg which of the
following interventions should the nurse recommend?
Answer: Wash daily with an antibacterial soap
35. A nurse is collecting data from a client who has a score of 8 using the Glasgow coma scale.
Which of the following findings should the nurse expect?
Answer: The client requires total nursing care
36. A nurse is planning care for a client who has a deep-vein thrombosis (DVT) in the right leg.
Which of the following interventions should be included in the plan of care?
Answer: Apply compression stockings
37. A home health nurse is planning care for a client who has COPD which of the following
interventions should the nurse include in the plan of care?
Answer: Advise the client to keep snacks handy
38. A nurse is reinforcing teaching with a client who is having difficulty using an incentive
spirometer. Which of the following instructions should the nurse include in the teaching?
Answer: Start slowly and increase volume over several sessions
39. A nurse is reinforcing dietary teaching with a client who has iron deficiency anaemia. Which
of the following foods should the nurse recommend?
Answer: Cooked oatmeal
40. A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease (Gerd)
which of the following statements should the nurse include in the teaching?
Answer: Avoid wearing constricting clothing
41. A nurse is reinforcing teaching with a client who has a new diagnosis of systemic lupus
erythematosus (SLE). Which of the following information should the nurse include in the
teaching?
Answer: SLE affects the connective tissue of the body
42. A nurse is collecting data from a client who has diabetes mellitus. Which of the following
findings indicates that the client is experiencing DKA?
Answer: Polydipsia
43. A nurse has received change-of-shift report on four clients. Which of the following clients
should the nurse plan to see first?
Answer: A client who is short of breath
44. A nurse is collecting data from an older adult client who has a hip fracture and is in Buck’s
traction. The nurse notes the client has a sudden decrease in level of consciousness, dyspnoea,
and crackles to the lungs upon auscultation. Which of the following actions should the nurse
take?
Answer: Apply high-flow oxygen
45. A nurse is caring for a client several days following acute radiation exposure at the client’s
workplace. Which of the following findings should the nurse identify as an indication of bone
marrow suppression?
Answer: Fever
46. A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the
following fluids should the nurse use in the first 24hrs following a client’s burn injury?
Answer: Lactated Ringer’s
47. A nurse is collecting data from a client who has a gastric ulcer. Which of the following
should the nurse identify as a priority finding and notify the provider?
Answer: Abdominal pain radiating to the shoulder
48. A nurse is collecting data from a client who has increased intracranial pressure and is
informed by the charge nurse that the client demonstrates decorticate posturing. Which of the
followings should the nurse expect to observe?
Answer: Plantar flexion of the legs
49. A nurse is collecting data from a client who is to have an intravenous pyelogram (IVP).
Which of the following data is a contraindication to this procedure?
Answer: Client has an allergy to shellfish
50. A nurse is reinforcing discharge teaching with an older adult client who has peripheral artery
disease (PAD) which of the following instructions should the nurse include in the teaching?
Answer: Adjust the thermostat so that the environment is warm
51. A nurse is caring for a client who has acute dehydration is receiving IV fluids. Which of the
following laboratory values indicates to the nurse that the current treatment regimen is effective?
Answer: Urine specific gravity 1.020
52. A nurse on a medical-surgical unit is checking the bowel sounds of a client who has epilepsy.
The client begins to experience a tonic-clonic seizure. Identify the sequence of steps the nurse
should follow. (Move the steps into the box on the right
Answer: Remain with the client and call for help Place the client in the lateral position Check
the client for injuries
Reorient and reassure the client
53. A nurse is reinforcing teaching about the frequency of breast self-examination (BSE) with a
young adult client. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: The best day to perform BSE is 7 days after the menstrual cycle begins
54. A nurse is reviewing the admission prescriptions for a client who has benign prostatic
hyperplasia. Which of the following medications should the nurse expect to administer?
Answer: Silodosin
55. A nurse is collecting data from a client who has herpes zoster (shingles) which of the
following is an expected finding?
Answer: Pain full vesicles following a nerve pathway
56. A nurse is caring for a client who has a gastrointestinal (GI) bleed. Which of the following
findings is the priority for the nurse to report to the provider?
Answer: Urine output of 50 mL in 2 hrs.
57. A nurse is collecting data from a client who has a hip fracture. Which of the following
findings should the nurse expect when checking the extremity?
Answer: Muscle spasms
58. A nurse is reviewing HIPAA with a newly licensed nurse. Which of the following statements
by the newly licensed nurse indicates a need for further instruction?
Answer: Information about a client can be disclosed to family members at any time
59. A nurse collecting data from a client who has manifestations of appendicitis. Where would
the nurse palpate to monitor for pain at McBurney’s point? (You will find hot spots to select in
the artwork below. Select only the hot spot that corresponds to your answer.)
Answer: McBurney’s point is found between the navel and the anterior iliac crest.
60. A nurse is assisting in planning care for a client who has cystitis. Which of the following
interventions should be included in the plan of care?
Answer: Instruct the client to avoid drinking caffeinated beverages.
61. A nurse is evaluating client laboratory findings. The nurse should identify that an increase in
a client’s prostate-specific antigen (PSA) level can indicate which of the following conditions?
Answer: Prostatitis
62. A nurse is reinforcing dietary instructions with a client who has chronic kidney disease.
Which of the following information should the nurse include?
Answer: Reduce intake of foods high in potassium
63. A nurse is monitoring a client who reports having chills and back pain during a blood
transfusion. Which of the following actions should the nurse take first?
Answer: Stop the transfusion
64. A nurse is reviewing discharge instructions with a client who has pruritus following treatment
for scabies. Which of the following instructions should the nurse include?
Answer: Wear loose fitting clothing while you are experiencing itching.
65. A nurse is collecting data from a client who fell at home and reported a brief loss of
consciousness. Which of the following findings should the immediately report to the charge
nurse
Answer: Small drops of clear fluid in left ear
66. A nurse is reinforcing teaching with a client who is scheduled for a CT scan of the head with
contrast. Which of the following statements by the client should the nurse identify as
understanding of the teaching?
Answer: I can take medication up to 2 hr before the procedure.
67. The nurse is caring for a client on the third day following abdominal surgery and assesses the
absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings
indicated the client is experiencing which of the following postoperative complications?
Answer: Paralytic ileus
68. A nurse is caring for a client who has a cerebral aneurysm. Which following actions should
the nurse take?
Answer: Monitor vital signs at least once each hour
69. A nurse is contributing to the plan of care of a client who has increased intracranial pressure
following a closed-head injury. Which of the following interventions should the nurse
recommend?
Answer: Elevate the head of the bed
70. A nurse is reinforcing dietary teaching with a client who has GERD. Which of the following
food choices by the client indicates an understanding of the teaching?
Answer: Baked turkey breast
71. A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about selfcare
during illness. Which of the following instructions should the nurse include in the teaching?
Answer: Administer your usual daily dose of insulin
72. A nurse is assisting with triaging clients after a mass casualty event. Which of the following
clients should the nurse attend to first?
Answer: A client who has severe respiratory stridor and a deviated trachea
73. A nurse is reviewing the medical record of a client who has osteoarthritis which of the
following findings should the nurse expect?
Answer: Stiffness of the joints
74. A nurse is collecting data on a client who has hyperthyroidism. Which of the following
manifestations should the nurse expect the client to report?
Answer: Frequent mood changes
75. A nurse is assisting with menu selections for a client who has recovered from the acute phase
of diverticulitis. Which of the following foods should the nurse recommend?
Answer: Bean soup with steamed broccoli
76. A nurse is checking the laboratory tests for a client who has glomerulonephritis. The nurse
should expect to find an increase in which of the following test results?
Answer: BUN
77. A nurse is reinforcing teaching with an older adult client who has been newly diagnosed with
a heart murmur. Which of the following statements should the nurse make?
Answer: This indicates turbulent blood flow through a valve
78. A nurse is collecting data from a client who has a traumatic head injured which of the
following findings should the nurse report to the provider immediately?
Answer: Sudden sleepiness
79. A nurse is reviewing the laboratory results of a group of clients which of the following
laboratory findings should the nurse report to the provider?
Answer: Haemoglobin of 6.2 g/dL in a client who is receiving chemotherapy
80. A nurse is caring for a client who is scheduled for a Tensilon challenge test to check for
myasthenia gravis. Which of the following findings should the nurse identify as a positive result?
Answer: Muscle strength becomes temporarily stronger
81. A nurse is caring for a client who has acute kidney injury. The client’s
ABGS are: Ph: 7.26
PaCO2: 30 mm Hg HCO3; 14 mEq/L
Which of the following acid-imbalances should the nurse identify the client is experiencing?
Answer: Metabolic acidosis
82. A nurse is collecting data from a client who has Cushing’s syndrome. Which of the following
findings should the nurse expect?
Answer: Hyperpigmentation
83. A nurse in a clinic is caring for a client who is postmenopausal and has risk factors for
osteoporosis. The nurse anticipates the client will be prescribed which of the following
medications?
Answer: Raloxifene hydrochloride
84. A nurse is preparing to administer medications to four clients. Which of the following clients
should the nurse administer medication to first?
Answer: A client who has a potassium level of 5.8 mEq/L that is to receive sodium polystyrene
sulfonate
85. A nurse is reinforcing dietary teaching to a client who is at risk for osteoporosis about
increasing her calcium intake. Which of the following foods should the nurse recommend the
client consume frequently?
Answer: Collards
86. A nurse is contributing to a plan of care for a client who has Hepatitis B which of the
following should the nurse include in the plan?
Answer: Limit Activity
87. A nurse is caring for a client who has a diagnosis of acute glomerulonephritis. Which of the
following should be reported immediately to the provider?
Answer: Blood Pressure 162/90 mm Hg
88. A nurse is reinforcing teaching about ileostomy care with a client. The nurse should
recognize which of the following statements by the client indicates a need for further teaching?
Answer: I will be certain to take enteric-coated medication
89. A nurse is caring for a client who enters an ambulatory clinic bleeding profusely from a deep
laceration on his left lower forearm. After donning gloves, which of the following actions should
the nurse take first?
Answer: Apply pressure directly over the wound
90. A nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. the arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm
Hg Base excess
-2 PaO2 78 mm
Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
Answer: Respiratory Acidosis
91. A nurse is contributing to the plan of care for a client following a lumbar puncture. Which of
the following interventions should the nurse include?
Answer: Encourage oral fluids
92. A nurse is caring for a client who is immunocompromised which of the following actions
should the nurse take first?
Answer: Perform hand hygiene before and after care
93. A school nurse is reinforcing teaching to a group of teenage clients about prevention of
sexually transmitted infections (STIs). Which of the following practices is the most effective
form of protection to include in the teaching?
Answer: The use of latex condoms
94. A nurse is caring for a client who has dysphagia following a stroke which of the following is
the priority action for the nurse to take when feeding the client?
Answer: Place the client in the upright position
95. A nurse is reviewing the urinalysis results of a client who reports urinary frequency and
burning. Which of the following findings should the nurse report to the provider?
Answer: Microscopic haematuria
96. A nurse is caring for a client who has developed a Clostridium Difficile infection following
antibiotic therapy. Which of the following actions should the nurse take?
Answer: Disinfect equipment with bleach solution
97. A nurse is caring for a client who has a large wound that has a vacuum-assisted closure
device placed over it which of the following findings by the nurse indicates healing of the
wound?
Answer: Granulation tissue on the surface of the wound
98. A nurse is caring for a client who recently had a permanent pacemaker placed. The nurse is
reinforcing teaching following the initial pacemaker check. Which of the following statements by
the client indicates understanding?
Answer: I will let my dentist know that I have a pacemaker
99. A nurse is reinforcing discharge teaching about self-administered peritoneal dialysis with a
client. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: The amount of the liquid output should be greater than what was put in
100. A nurse is collecting data from a client who has peripheral arterial disease (PAD) which of
the following findings should the nurse expect
Answer: Intermittent claudication
101. A nurse is reinforcing teaching with a client following surgery who has antiembolism
stockings in place. Which of the following information should the nurse include in the teaching?
Answer: The stockings prevent venous stasis
102. A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/ min
via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of
the following actions is the nurse priority at this time?
Answer: Evaluate the client’s respiratory status
103. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH) and a sodium level of 123 mEq/L which of the following actions should the nurse take?
Answer: Restrict oral fluids to 800 to 1000mL/day
104. A nurse is reinforcing discharge teaching to a client who will be performing intermittent
self- catheterizations. Which of the following statement should the nurse include in the teaching?
Answer: Advance the catheter 5 cm (2 in) after urine begins to flow
105. A client arrives for initial evaluation following a diagnosis of systemic lupus erythematosus
(SLE) the nurse understands that which of the following is a classic cutaneous manifestation of
SLE?
Answer: Butterfly rash on face
106. A nurse is reinforcing discharge teaching with a client who has undergone a transurethral
resection of the prostate (TRUP) which of the following statements should the nurse include in
the teaching
Answer: Increase fluid intake if urine becomes blood tinged
107. A nurse at an urgent care center is reinforcing information with a new employee about the
difference between sprains and strains. Which of the following examples should the nurse
include as a cause of sprain injury?
Answer: Twisting a ligament while walking
108. A nurse is monitoring a client following a haemodialysis treatment through an arteriovenous
(AV) fistula. Which of the following findings should the nurse report to the provider
Answer: Headache, restlessness
109. A nurse is collecting a data for a female client who has genital herpes which of the
following findings should the nurse expect
Answer: Dysuria
110. A charge nurse is observing a nurse who is caring for a client who has continuous skeletal
traction of a lower extremity. For which of the following actions should the charge nurse
intervene?
Answer: Removes the traction weights for a brief period each day
111. A nurse is reinforcing teaching to a female client who has risk factors for stroke. Which of
the following statements by the client indicates an understanding of the teaching?
Answer: Managing my cholesterol will reduce my chances of having a stroke
112. A nurse is assisting with teaching a newly licensed nurse about parenteral nutrition (PN)
which of the following information should the nurse include in the teaching?
Answer: Reduce the rate of the solution gradually to discontinue
113. Upon inspection of a client’s skin, a nurse identifies a stage 3 pressure ulcer on the sacrum.
Which of the following statement by the nurse describes a stage 3 pressure ulcer
Answer: The nurse describes a stage 3 pressure ulcer
114. A nurse is reinforcing teaching about cast care with a client who has a long-leg fiberglass
cast on the right tibia. Which of the following instructions should the nurse include in the
teaching
Answer: Report any worsening or unrelieved pain
115. A nurse is assisting in planning care for a client who has a head injury and is in a halo
traction device. which of the following actions should the nurse recommend for the plan of care?
Answer: Monitor the client for elevated temperature
116. A nurse in a clinic is collecting data from a client who reports wrist pain caused by carpal
tunnel syndrome. The nurse should expect which of the following findings
Answer: Positive Phalen’s sign
117. A nurse is reviewing the laboratory results for a male adult client who is at risk for
peripheral arterial disease from atherosclerosis. The nurse should identify that which of the
following results places the client at risk
Answer: LDL 172 mg/dL
118. A nurse is caring for a client who has a three-chamber closed chest tube system. Which of
the following should the nurse do after noticing a rise in the water seal with client inspiration?
Answer: Continue to monitor the client
119. A nurse is caring for a client who is experiencing hypovolemic shock. Which of the
following of the findings should the nurse expect?
Answer: Oliguria
120. A nurse is caring with the plan of care for a client who is scheduled a transurethral resection
of the prostate. Which of the following intervention should the nurse include in the plan of care
Answer: Inform the client to expect insertion of a large indwelling urinary catheter following
surgery
121. A nurse in a provider’s office is reinforcing teaching with a client who has risk factor for
atherosclerosis. The nurse should help the client identify which of the following as treatment
goals
Answer: Maintain blood pressure at less than 14-/90 mm Hg
122. A nurse is assisting with the care of a client who has partial-thickness and full-thickness
burns to his upper torse and face. Which of the following actions should the nurse take to prevent
infection?
Answer: Change gloves between sites when providing wound care to multiple wounds
123. A nurse at a health fair is collecting data form a group of clients. Which of the following
clients is at risk for developing an obesity-related disease?
Answer: A female client who has a BMI of 32 and a waist circumference of 102 cm (40 in)
124. A nurse is collecting data from a client who is African American has cholecystitis which of
the following areas should the nurse inspect to monitor for the presence of jaundice?
Answer: Head palate
125. A nurse is caring for a group of clients on an adult medical-surgical unit. Which of the
following clients should the nurse identify as having the highest risk for aspiration?
Answer: A client receiving enteral feedings through an NG tube
126. A nurse is reinforcing teaching with a client who has rheumatoid arthritis (RA) about
selfcare techniques which of the following strategies should the nurse include in the teaching
Answer: Avoid exercising joints that are swollen
127. A nurse is reinforcing preoperative teaching with a client who is scheduled to have hip
arthroplasty. Which of the following information should the nurse provided in the teaching
Answer: Bending the hip within 90 is allowed
128. A nurse is caring for a client who is receiving peritoneal dialysis the nurse should monitor
the client for which of the following manifestations of peritonitis
Answer: Nausea and vomiting
129. A nurse is collecting data from a client while changing his ileostomy pouch. Which of the
following data should the nurse report immediately
Answer: The stoma is pale in colour
130. A nurse is collecting data from a client following a bee sting which of the following findings
can indicate an anaphylactic reaction to the venom
Answer: Urticaria
131. A nurse is collecting a health history form a client which of the following client data should
the nurse identify as a risk factor for contracting hepatitis C
Answer: Presence of multiple tattoos
132. A nurse is assisting with the care of a newly admitted client who has acute osteomyelitis
which of the following interventions is the priority for the nurse to implement
Answer: Antibiotic therapy
133. A nurse is collecting data from a client who has right-sided heart failure. Which of the
following findings should the nurse expect
Answer: Hepatomegaly
134. A nurse is planning care for several clients and is considering the clients risk for stroke.
Which of the following conditions places the client at risk for an ischemic embolic stroke?
Answer: A client who has chronic atrial fibrillation
135. A nurse is caring for a client who is postoperative and has a history Addison’s disease. For
which of the following manifestations should the nurse monitor?
Answer: Hypotension
136. A nurse is collecting data from a male client who has been exposed to syphilis and has
genital chancre. Which of the following prescriptions should the nurse anticipate when notifying
the provider of these findings
Answer: Venereal disease research laboratory (VDRL)
137. A nurse is caring for a client who develops a pulmonary embolism which of the following
interventions is the priority for the nurse to take?
Answer: Begin oxygen therapy
138. A nurse is assisting with the care of a client following a left femoral cardiac angiography.
The nurse should place a sandbag on the client over which of the following areas (you will find
hot spots to select in the artwork below select only the hot spot that corresponds to your answer)
Answer: The nurse should place a sandbag on the client’s left groin area for 1 to 3 hr to prevent
bleeding from the insertion site
139. A nurse is assisting with the plan of care for a client who has a cerebral aneurysm. The nurse
should plan to monitor the client for which of the following early indications of increased
intracranial pressure
Answer: Disorientation to time and place
140. A nurse is monitoring a client who received desmopressin (DDAVP) to treat diabetes
insipidus. Which of the following findings indicates effectiveness of the medication?
Answer: Urine specific gravity 1.015
141. A nurse is reinforcing health screening education with a group of clients. The nurse should
recognize that which of the following clients has the greatest risk for hypertension?
Answer: A client who is African American
142. A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis.
The nurse should recognize that which of the following actions is the priority
Answer: Evaluate fluid and electrolyte levels
143. A nurse in a health clinic is reinforcing teaching to a newly licensed nurse about vaginal
yeast infections. Which of the following information should the nurse include in the teaching
Answer: Vaginal yeast infections present as a thick, white discharge
144. A nurse is assisting with the plane of care for a client who has thrombocytopenia. Which of
the following interventions should the nurse include in the plan of care?
Answer: Monitor level of consciousness every 4hr
145. A nurse is reviewing the medical record of a client who hyperthyroidism (Graves’ disease)
which of the following serum laboratory findings should the nurse expect to be below the
expected reference range?
Answer: Thyroid stimulating hormone (TSH) level
146. A nurse is assisting with the care of a client who has hypocalcaemia. For which of the
following signs should the nurse monitor?
Answer: Chvostek’s sign
147. A nurse is contributing to the care plan for a client who has developed deep-vein
thrombosis. Which of the following interventions should the nurse include?
Answer: Elevate the affected extremity when the client is resting
148. A nurse is reinforcing teaching about pernicious anaemia with a client following a total
gastrectomy. Which of the following dietary supplements should the nurse include in the
teaching as the treatment for pernicious anaemia?
Answer: Vitamin B12
149. A nurse is assisting with the care of a client who has multiple facial injuries which of the
following equipment should the nurse place at the client’s bedside?
Answer: Suction catheter
150. The nurse is collecting data form an older adult female client who has chronic
hypothyroidism which of the following findings should the nurse report to the provider
immediately?
Answer: Decreased level of consciousness
151. A nurse is planning care for a client who is to receive a unit of packed RBSs within which
of the following time spans must the nurse complete the infusion
Answer: 4hrs
152. A nurse is assisting in the care of a client who is to receive a blood transfusion. Prior to the
transfusion which of the following staff members should the nurse select to assist her in checking
the blood
Answer: Oncology nurse
153. A nurse is reinforcing teaching about the Mediterranean diet with a client who is at risk for
hypertension. Which of the following statements by the client indicates a need for further
teaching
Answer: I will limit my intake of red meat to two times per week
154. A nurse is caring for a client who is conscious and has an airway obstruction which of the
following actions should the nurse take
Answer: Begin the Heimlich maneuver
155. A nurse is collecting data from a client who has pneumonia and is experiencing acute
respiratory acidosis. Which of the following manifestations should the nurse expect to find?
Answer: Decreased level of consciousness
156. A nurse is reinforcing teaching with a client who has a new diagnosis of gout the client asks
the nurse how she got the disorder. Which of the following information should the nurse include
in the teaching?
Answer: Intra-articular urate crystal deposits cause inflammation
157. A nurse is assisting with the care of a client who 1 day postoperative following a
thyroidectomy and reports sever muscle spasms of the lower extremities. Which of the following
actions should the nurse take?
Answer: Determine the client’s calcium level
158. A nurse is a provider’s office is reviewing the health histories of four clients for which of
the following clients should the nurse anticipate scheduling a colonoscopy
Answer: 32yr old who has a sister who died of colon cancer
159. A nurse is reviewing the arterial blood gas (ABG) results of a client. The client’s
ABGs are: pH: 7.6
PaCO2: 40 mm Hg HCO3 32 mEq/L
Which of the following acid base conditions should the nurse identify the client is experiencing
Answer: Metabolic alkalosis
160. A nurse is monitoring a client who is dehydrated which of the following laboratory findings
should the nurse report to the provider
Answer: BUN 25 mg/dL
