ATI ADVANCED MED SURG PROCTORED 2023 WITH GLASGOW
COMA SCALE REAL EXAM
1. A nurse in a burn treatment centre is caring for a client who is admitted with severe burns to
both lower extremities and is pending an escharotomy. The client’s spouse asks the nurse what
the procedure entails. Which of the following nursing statements is appropriate?
A. “large incisions will be made in the eschar to improve circulation”
B. “ I can call the doctor back here if you want me to”
C. “a piece of skin will be removed and grafted over the burned area”
D. “dead tissue will be surgically removed”
Answer: A. “large incisions will be made in the eschar to improve circulation”
2. A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the
following fluids is used in the first 24 hours following a burn injury?
A. 5% dextrose in water
B. 5% dextrose in normal saline
C. normal saline
D. lactated ringers
Answer: D. lactated ringers
3. A nurse is caring for a client who has full-thickness burns all over 75% of his body. Which of
the following methods is appropriate to accurately monitor the cardiovascular system?
A. auscultate cuff blood pressure
B. palpate pulse pressure
C. obtain a central venous pressure
D. monitor the pulmonary artery pressure
Answer: C. obtain a central venous pressure
4. A nurse is assessing the depth and extent of a client who has severe burns to the face, neck,
and upper extremities. Which of the following factors is the first priority when assessing the
severity of the burn?
A. Age of the client
B. Associated medical history
C. Location of the burn
D. Cause of the burn
Answer: D. Cause of the burn
5. A client arrives at the emergency dept following an explosion at the chemical plant. He has
deep partial and full-thickness chemical burns over more than 25 % of his body surface area.
What is the nurse’s priority intervention?
A. Initiate fluid resuscitation
B. Medication for pain
C. Administer antibiotics
D. Maintain a patent airway
Answer: D. Maintain a patent airway
6. A nurse is caring for a client who came the emergency dept reporting chest pain. The provider
suspects a myocardial infarction. While waiting for the laboratory to report the client’s troponin
levels, the client asks what this blood test will show. The nurse should explain that troponin is
A. An enzyme that indicates damage to brain, heart, and skeletal muscle tissues
B. A protein whose levels reflect the risk for coronary artery disease
C. A heart muscle protein that appears in the bloodstream when there is damage to the heart
D. A protein that helps transport oxygen throughout the body
Answer: C. A heart muscle protein that appears in the bloodstream when there is damage to the
heart
7. A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of
the following should the nurse expect in the findings?
A. Excessive thrombosis and bleeding
B. Progressive increase in platelet production
C. Immediate sodium and fluid retention
D. Increased clotting factors
Answer: D. Increased clotting factors
8. A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation.
When the client asks what his medication will do, which of the following is an appropriate
nursing response?
A. It helps convert atrial fibrillation to sinus rhythm
B. Is dissolves clots in the bloodstream
C. It slows the response of the ventricles to the fast atrial impulses
D. It prevents strokes in clients who have atrial fibrillation
Answer: D. It prevents strokes in clients who have atrial fibrillation
9. A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of the
following findings should the nurse expect?
A. Decreased brain natriuretic peptide (BNP)
B. Elevated central venous pressure (CVP)
C. Decreased pulmonary pressure
D. Increases urinary output
Answer: B. Elevated central venous pressure (CVP)
10. A client comes into the ED reporting nausea and vomiting that worsens when lying down and
without relief from antacids. The provider suspects acute pancreatitis. Which of the following lab
test results should the nurse expect to see if the client has acute pancreatitis?
A. Decreased WBC
B. Increased serum amylase
C. Decreased serum lipase
D. Increased serum calcium
Answer: B. Increased serum amylase
11. A nurse in the ICU is caring for a client who has acute respiratory distress syndrome (ARDS)
and is receiving mechanical via an endotracheal tube. The provider plans to extubate her within
the next 24 hour. Which of the following is an important criterion for extubating the client?
A. Ability to cough effectively
B. Adequate tidal volume without manually assisted breaths
C. No indication of infection
D. No need for supplemental oxygen
Answer: B. Adequate tidal volume without manually assisted breaths
12. A nurse is caring for a client following a CT scan with dye who suffered from an
anaphylactic reaction. Which of the following conditions requires a priority nursing response?
A. urticaria
B. stridor
C. tachypnoea
D. angioedema
Answer: B. stridor
13. A nurse is caring for a female client who came in to the ED reporting SOB and pain in the
lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure 140/80 m8juiimHg.
Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg, PaO2 60 mm Hg, HCO3 20 mEq/L, and
SaO2 86%. Which of the following is the priority intervention?
A. Prepare for mechanical ventilation
B. Administer oxygen via face mask
C. Prepare to administer a sedative
D. Monitor for pulmonary embolism
Answer: B. Administer oxygen via face mask
14. A nurse is monitoring a client who has just had a thoracentesis to remove pleural fluid.
Which of the following clinical manifestations indicate a complication that requires notifying the
provider immediately?
A. Serosanguineous drainage from the puncture site
B. Discomfort at the puncture site
C. Increased heart rate
D. Decreased temperature
Answer: C. Increased heart rate
15. A group of college students was attending a weekend football rally when one of the students
stumbled and fell into the bonfire. Although several friends quickly intervened, the client
sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the
following is priority nursing action when the client is brought to the ED?
A. cover the burned area with sterile gauze
B. inspect mouth for signs of inhalation
C. administer intravenous pain medication
D. draw blood for a CBC
Answer: B. inspect mouth for signs of inhalation
16. A triage nurse in an emergency dept is caring for a client who has gunshot wound to the right
side of chest. The nurse notices thick dressing on the chest and sucking noise coming from the
wound. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a
respiratory rate of 40/min. Which of the following actions should the nurse take initially?
A. Raise the foot of the bed to a 90 degree angle
B. Remove the dressing to inspect the wound
C. Prepare to insert a central line
D. Administer oxygen via nasal cannula
Answer: B. inspect mouth for signs of inhalation
17. A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client’s
heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that
the client requires which of the following?
A. A cardiology consult
B. Less frequent suctioning
C. An antidysrhythmic medication
D. Pre-oxygenation prior to suctioning
Answer: D. Pre-oxygenation prior to suctioning
18. The nurse is caring for a client who is receiving a blood transfusion. The transfusion started
30 minutes ago at a rate of 100 mL/hr. The client begins to complain of low back pain and
headache and is increasingly restless. What is the first nursing action?
A. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of normal
saline solution
B. Slow the infusion and evaluate the vital signs and the client’s history of transfusion reactions
C. Slow the infusion of blood and begin infusion of normal saline solution from the Y connector.
D. Recheck the unit of blood for correct identification numbers and crossmatch information
Answer: A. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of
normal saline solution
19. A client with a diagnosis of disseminated intravascular coagulation (DIC) has the following
assessment findings: blood pressure of 76/56, temperature 102.6 degrees, resp. 24 breath/min.,
with complaints of severe neck and back pain. Which nursing action should the nurse implement
first?
A. Administer acetaminophen (Tylenol) PO.
B. Administer ibuprofen (Motrin) PO.
C. Draw coagulation study blood work in the AM
D. Give morphine sulphate IV
Answer: A. Administer acetaminophen (Tylenol) PO.
20. The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI) to a client
who has a history of coronary artery disease is now in congestive heart failure. What side effects
will be particularly important to observe for when the client takes the medication?
A. Tremors and central nervous system stimulation
B. Tachycardia and chest discomfort
C. Development of oral candidiasis
D. An increase in blood pressure
Answer: A. Tremors and central nervous system stimulation
21. The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place.
What data confirms that the tube has migrated too far into the trachea?
A. Decreased breath sounds are heard over the left side of the chest
B. Increased rhonchi are present at the lung bases bilaterally
C. Ventilator pressure alarm continues to sound
D. Client is able to speak and coughs excessively
Answer: A. Decreased breath sounds are heard over the left side of the chest
22. What is the desired action of dopamine (Intropin) when administered in the treatment of
shock?
A. It increases myocardial contractility
B. It is associated with fewer severe allergic reactions
C. It causes rapid vasodilation of the vascular bed
D. It supports renal perfusion by dilation of the renal arteries
Answer: A. It increases myocardial contractility
23. The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen minutes
after the infusion is started, the client’s BP goes from 190/120 mm Hg to 120/90 mm Hg. What is
the priority nursing action?
A. Recheck the BP and call the doctor
B. Decrease the infusion rate and recheck the blood pressure in 5 minutes
C. Stop the medication and keep the IV open with D5W.
D. Assess the client’s tolerance of the current level of BP
Answer: B. Decrease the infusion rate and recheck the blood pressure in 5 minutes
24. Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock. Before
administering the drug, the nurse should make sure that the client has:
A. A heart rate of less than 120 beats/min
B. Urine output of at least 30 mL/hr.
C. Received adequate anticoagulation
D. Been receiving adequate IV fluid replacement
Answer: D. Been receiving adequate IV fluid replacement
25. The client returns to his room after a thoracotomy. What will the nursing assessment reveal if
hypovolemia from excessive blood loss is present?
A. CVP of 3 cm H20 and urine output of 20 mL/hr
B. Jugular vein distention with the head elevated 45 degrees
C. Chest tube drainage of 50 mL/hr in the first 2 hours
D. Persistent increased BP and increased pulse pressure
Answer: A. CVP of 3 cm H20 and urine output of 20 mL/hr
26. The nurse is performing an assessment and finds the client has cold, clammy skin, pulse of
130 beats/min and weak, blood pressure of 84/56 mm Hg, and urinary of 20 mL for the past hour.
The nurse would interpret these findings as suggestive of which pathophysiology?
A. Reduction of circulation to the coronary arteries, this increasing the preload
B. Decreased glomeruli filtration rate, resulting in volume overload
C. Stimulation of the sympathetic nervous system, causing severe vasoconstriction
D. Decrease in the cardiac output and inadequate tissue perfusion
Answer: D. Decrease in the cardiac output and inadequate tissue perfusion
27. The nurse applies a Nitro-Dur patch on a client who has undergone cardiac surgery. What
nursing observation indicates that a Nitro-Dur patch is achieving the desired effect?
A. Chest pain is completely relieved
B. Client performs activities of daily living without chest pain
C. Pain is controlled with frequent changes of patch
D. Client tolerates increased activity without pain
Answer: B. Client performs activities of daily living without chest pain
28. The V/S of a client with Cardiac disease are as follows: BP 102/76 mm/hg, Pulse 52, RR 16.
Atropine is administered IV push. What nursing assessment indicates a therapeutic response to
the medication?
A. Pulse rate has increased to 70 beats/min
B. systolic BP has increased by 20
C. pupils are dilated
D. oral secretions have decreased
Answer: A. Pulse rate has increased to 70 beats/min
29. An older adult client comes into ER stating that he has no appetite, is nauseated, his heart
feels funny and has noticed a haziness in his vision. The client states that he has been taking an
antihypertensive drug and digitalis for more than a year. Based on the presenting symptoms,
what would be the priority nursing action?
A. Obtain an order for an EKG and serum potassium and digitalis levels
B. Perform a neurological assessment to determine whether he has one side weakness.
C. Assess lungs for decreased breath sounds and/or adventitious breath sounds.
D. Obtain an order for an EKG
Answer: A. Obtain an order for an EKG and serum potassium and digitalis levels
30. The nurse is administering alteplase to a client who has been diagnosed with acute coronary
syndrome. What are important nursing implications for this medication?
A. Monitor the ECG for dysrthymias
B. Place the client on bleeding precautions
C. monitor urine output hourly
D. Monitor for activity tolerance
Answer: B. Place the client on bleeding precautions
31. The nurse is caring for a client who underwent cardiac catheterization 1 hour ago. What is an
important nursing measure at this time?
A. Measure urinary output hourly and maintain continuous cardiac monitoring
B. Encourage client to perform slow pressure exercise of the affected side to promote circulation.
C. Maintain pressure over catheter insertion site and determine distal circulation status.
D. Evaluate apical pulse and determine presence of pulse deficit.
Answer: C. Maintain pressure over catheter insertion site and determine distal circulation status.
32. The nurse in a cardiac stepdown unit has received a hand-off shift report for these clients.
Which client should assess first?
A. a client who has just returned from a coronary artierogram with placement of an intracoronary
stent.
B. A client who is in heart failure and has gained 2 pnds in the last 24 hours.
C. a client with endocarditis who has temperature elevation of 100F and P 100 beats/min
D. A client who was cardioverted from atrial fib 24 hours ago and has had 3 atrial premature
Answer: A. a client who has just returned from a coronary arteriogram with placement of an
intracoronary stent.
33. What ECG changes would reflect myocardial ischemia in a client who has been admitted for
observation after experiencing an episode of chest pain?
A. Prolonged PR interval
B. Wide QRS complex
C. ST- Segment elevation or depression
D. Tall, peak T-waves
Answer: C. ST- Segment elevation or depression
34. A new employee at a facility needs a hepatitis vaccine. Which statement reflects accurate
understanding of the immunization?
A. I need to get 6 shots of hep C
B. Once I receive the Hep vaccine, I will always be immune
C. I will receive 3 injections over a period of months, which should protect me from hep B
D. Hep vaccine is an oral vaccine with live attenuated Virus
Answer: C. I will receive 3 injections over a period of months, which should protect me from
hep B
35. While talking with a client with a diagnosis of end stage liver disease. The nurse notices the
client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse
recognizes these symptoms to be indicative of what condition?
A. Hyperglycaemia
B. Increased Bile production
C. Increased blood ammonia levels
D. Hypocalcaemia
Answer: C. Increased blood ammonia levels
36. The nurse is caring for a client with chronic hep B. What will the teaching plan for this client
include?
A. use a condom for sexual intercourse
B. Report any clay- coloured stools.
C. Eat a high protein diet
D. Perform daily urine bilirubin checks
Answer: A. use a condom for sexual intercourse
37. A patient with massive trauma and possible spinal cord injury is admitted to the emergency
department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?
A. cool clammy skin
B. inspiratory crackles
C. apical heart rate of 48 beats/min
D. temperature 101.2 F
Answer: C. apical heart rate of 48 beats/min
38. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate
is 120 and the central venous and pulmonary artery wedge pressure are 4. Which of these orders
by the health care provider will the nurse question?
A. Give furosemide (Lasix) 40 mg IV
B. increase normal saline infusion to 150 mL/hr
C. Administer hydrocortisone (SoluCortef) 100 mg IV
D. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr
Answer: A. Give furosemide (Lasix) 40 mg IV
39. After receiving 1000 mL of normal saline, the central venous pressure for a patient who has
septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate
the administration of which of the following?
A. Nitro-glycerine (Tridil)
B. Sodium nitroprusside (Nipride)
C. Drotrecogin alpha (Xigris)
D. Norepinephrine (Levophed)
Answer: D. Norepinephrine (Levophed)
40. Which of these findings is the best indicators that the fluid resuscitation for a patient with
hypovolemic shock has been successful?
A. haemoglobin is within normal limits
B. Urine output is 60 mL over the last hour
C. Pulmonary artery wedge pressure (PAWP) is 10 mmHg
D. Mean arterial pressure (MAP) is 55 mm Hg
Answer: B. Urine output is 60 mL over the last hour
41. Which interventions will the nurse include in the plan of the care for a patient who has
cardiogenic shock?
A. Avoid elevating head of bed
B. Check temperature every 2 hours
C. Monitor breath sounds frequently
D. Assess skin for flushing and itching
Answer: C. Monitor breath sounds frequently
42. Which assessment is most important for the nurse to make in order to evaluate whether
treatment of a patient with anaphylactic shock has been effective?
A. Pulse rate
B. Orientation
C. Blood pressure
D. Oxygen saturation
Answer: D. Oxygen saturation
43. When caring for the patient who has septic shock, which assessment finding is most
important for the nurse to report to the health care provider? (TB ch.67 Q.17)
A. BP 92/56 mm Hg
B. Skin cool and clammy
C. apical pulse 118 beats/min
D. Arterial oxygen saturation 91%
Answer: B. Skin cool and clammy
44. During change-of-shift report, the nurse learns that a patient has been admitted with
dehydration and hypotension after having vomiting and diarrhoea for 3 days. Which findings is
most important for the nurse to report to the HCP?
A. Decreased bowel sounds
B. Apical pulse 110 beats/min
C. Pale, cool, and dry extremities
D. New onset of confusion and agitation
Answer: D. New onset of confusion and agitation
45. A patient is admitted to the burn unit with burns the upper body and head after a garage fire.
Initially, wheezes are heard, but an hour later, the lung sounds are decreased ad no wheezes are
audible. What is the best action for the nurse to take?
A. encourage the patient to cough and auscultate the lungs again
B. Notify the HCP and prepare for endotracheal intubation
C. Document the results and continue to monitor the patient’s resp. rate
D. Reposition pt in high-Fowler’s position and reassess breath sounds
Answer: B. Notify the HCP and prepare for endotracheal intubation
46. During the emergent phase of burn care, which nursing action will be most useful in
determining whether the patient is receiving adequate fluid infusion?
A. Check skin turgor
B. Monitor daily weight
C. Assess mucous membranes
D. Measures hourly urine output
Answer: D. Measures hourly urine output
47. After receiving change-of-shift report, which of these patients should the nurse assess first?
A. A patient with smoke inhalation who has wheezes and altered mental status
B. A patient with full-thickness leg burns who has a dressing change scheduled
C. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain.
D. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500
mL/hr
Answer: A. A patient with smoke inhalation who has wheezes and altered mental status
48. The RN observes all of the following actions begin taken by a staff nurse who has floated to
the unit. Which action requires that the RN intervene?
A. The nurse uses latex gloves when applying antibacterial cream to a burn wound
B. The float nurse obtains burn cultures when the patient has a temp of 101 F
C. The float nurse administers PRN fentanyl (Sublimaze) IV to a pt 5 minutes before a dressing
change
D. The float nurse calls the health care provider for an insulin order when a nondiabetic pt has an
elevated serum glucose
Answer: A. The nurse uses latex gloves when applying antibacterial cream to a burn wound
49. A client with cervical neck fracture is admitted to the intensive care unit. Which findings
would the nurse recognize as indicative of spinal shock?
A. Spastically, neuromuscular irritability, hyperreflexia
B. Flaccidity and lack of sensation below the level of spinal cord lesion.
C. Automatic dysreflexia with neurogenic bladder symptoms
D. Muscular spasticity and loss of motor reflexes in all parts of the body below the level of
spinal cord lesion.
Answer: B. Flaccidity and lack of sensation below the level of spinal cord lesion.
50. A client with T6 spinal cord injury is being discharged. The PT is concerned about autonomic
dysreflexia. S/S include the following:
A. Dilated pupils
B. Sudden vomiting and diarrhoea
C. drop in BP and pulse
D. Diaphoresis above the level of the lesion
Answer: D. Diaphoresis above the level of the lesion
51. A woman has been recently diagnosed with systemic lupus and shares with the nurse, I want
to get pregnant, but I don’t know how I will tolerate pregnancy because I have lupus. Which
response is best?
A. Most women find that they feel better when they are pregnant
B. How long have you been in remission?
C. Women with lupus frequently have slightly longer gestation
D. Its best to become pregnant within the first 6 months of diagnosis
Answer: B. How long have you been in remission?
52. The nurse is assessing the patency of an arteriovenous fistula and suspects clotting in the
fistula if which finding are noted? Select all that apply
A. presence of a thrill on palpation over the fistula
B. Absence of a bruit on auscultation over the fistula
C. Presence of a pulse in the extremity below the fistula
D. Complaints of tingling or discomfort in the extremity
E. Warm hand and fingers in the extremity in which the fistula is located.
Answer: B. Absence of a bruit on auscultation over the fistula
D. Complaints of tingling or discomfort in the extremity
53. Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal failure. The
client asks the nurse about the purpose of the medication. The appropriate response would be
which of the following?
A. It is used to lower your blood pressure
B. It is used to treat anaemia
C. It will help to increase the potassium levels in your body
D. It is an anticonvulsant medication given to all clients after dialysis to prevent seizure activity.
Answer: B. It is used to treat anaemia
54. A client with and ECG reading showing sinus bradycardia has a blood pressure of 47/28
mmhg. Which drugs does the nurse expect the physician to order for this client?
A. Lidocaine (Xylocaine)
B. Atropine sulphate
C. Isoproterenol hydrochloride (Isuprel)
D. Epinephrine
Answer: B. Atropine sulphate
55. Chemical cardioversion is prescribed for the client with atrial fibrillation. The nurse who is
assisting in preparing the client would expect that which medication specific for chemical
cardioversion will be needed?
A. Nitro-glycerine
B Nifedipine (Procardia)
C. Lidocaine (Xylocaine)
D. Amiodarone (Cordarone)
Answer: D. Amiodarone (Cordarone)
56. A nurse assesses a comatose, head-injured client and finds flexion of the arms, wrists, and
fingers and adduction of the upper extremities. Which of the following describes these findings?
A. Stroke
B. Epileptic Seizure
C. Decorticate posturing
D. Decerebrate posturing
Answer: C. Decorticate posturing
57. The client diagnosed with ARDS is transferred to the intensive care department and placed
on a ventilator. Which intervention should the nurse implement first?
A Confirm that the ventilator settings are correct
B Verify that the ventilator alarms are functioning properly
C. Assess the respiratory status and pulse oximeter reading.
D Monitor the clients arterial blood gas results.
Answer: C. Assess the respiratory status and pulse oximeter reading.
58. The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts
to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the
alarm and takes what initial action?
A. Administer oxygen
B. Checks the client’s vital signs
C Ventilates the client manually
D. Starts cardiopulmonary resuscitation
Answer: C Ventilates the client manually
59. The client is admitted to the ED with chest trauma. Which signs/symptoms would the nurse
expect to assess that supports the diagnosis of pneumothorax?
A. Bronchovesicular lung sounds and friction rub
B. Absent breath sounds and tachypnea
C. Nasal flaring and lung consolidation
D. Symmetrical chest expansion and bradypnea.
Answer: B. Absent breath sounds and tachypnea
60. A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage
system. The nurse includes which interventions in the plan? Select all that apply
A. Clamping the chest tube intermittently
B. Changing the client’s position frequently
C. Maintaining the collection chamber below the client’s waist
D. Adding water to the suction control chamber as it evaporates.
E Taping the connection between the chest tube and the drainage system.
Answer: B. Changing the client’s position frequently
C. Maintaining the collection chamber below the client’s waist
D. Adding water to the suction control chamber as it evaporates.
E Taping the connection between the chest tube and the drainage system.
61. A client has a total serum calcium level of 7.5 mg/dl. Which clinical manifestations would the
nurse expect to note on assessment of the client? Select all
A. Constipation
B. Muscle twitches
C. Hypoactive bowel sounds
D. Hyperactive deep tendon reflexes
E. Positive Trousseau’s sign and positive Chvostek’s sign
F. Prolong ST interval and QT interval on ECG
Answer: B. Muscle twitches
D. Hyperactive deep tendon reflexes
E. Positive Trousseau’s sign and positive Chvostek’s sign
F. Prolong ST interval and QT interval on ECG
62. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while
walking to the bathroom. Which action should the nurse implement first?
A. Administer sublingual nitro-glycerine.
B. Obtain a STAT electrocardiogram
C. Have the client sit down immediately
D. Assess the clients vital signs.
Answer: C. Have the client sit down immediately
63. The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which
interventions should the nurse implement. Select all
A. Assess the client’s level of consciousness
B. Monitor clients urine output
C. Perform passive range of motion exercise
D. maintain intravenous fluids as ordered
E. Place the client with the HOB flat
Answer: A. Assess the client’s level of consciousness
B. Monitor clients urine output
C. Perform passive range of motion exercise
D. maintain intravenous fluids as ordered
64. The nurse is assessing a client experiencing motor loss as a result of a left sided
cerebrovascular accident (CVA). Which clinical manifestations would the nurse document?
Answer: The most common motor dysfunction of a CVA is paralysis of one side of the body,
hemiplegia; in this case with a left-sided CVA, paralysis would affect the right side. Ataxia is an
impaired ability to coordinate movement.
65. When teaching a client about the expected outcomes after intravenous administration of
furosemide, the nurse would include which outcome?
A. Increased blood pressure
B. Increased urine output
C. Decreased pain
D. Decreased PVCs
Answer: B. Increased urine output
66. A client arrives at the emergency department with deep partial thickness and burns over 15%
of his body. At admission his vital signs are blood pressure 100/50 mm Hg, heart rate 130
beats/minute and respiratory rate 20 breaths/minute. Which nursing intervention are appropriate
for this client? Select all that apply
A. Starting an IV infusion of lactated Ringers solution
B. Administering 6mg of morphine IV
C. Administering tetanus prophylaxis as ordered
Answer: A. Starting an IV infusion of lactated Ringers solution
B. Administering 6mg of morphine IV
C. Administering tetanus prophylaxis as ordered
67. If dietary trays are usually brought to the nursing unit at 8:00am the nurse should plan to
administer intermediate- acting insulin (Humlin N) 40 units SQ to the client between?
Answer: 630am and 700 am
68. What ECG changes would reflect myocardial ischemia in a client who has been admitted for
observation after experiencing an episode of chest pain?
Answer: ST segment elevation or depression
69. The client with acute renal failure has a serum potassium level of 6.0 mEq/L. The nurse
would plan which of the following as a priority action?
Answer: Place the client on a cardiac monitor
70. The nurse is caring for a client who underwent cardiac catheterization 1 hour ago. What is an
important nursing measures at this time?
Answer: Maintain Pressure Over Catheter Insertion Site And Determine Distal Circulation
Status.
71. "A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client’s
heart rate increases to 110/min and becomes irregular. The nurse should know that the client
requires what intervention?"
Answer: oxygenate prior to suctioning
72. A client comes into the ER with complains of midsternal chest pain radiating to the neck and
left arm which is unrelieved by sublingual neuroligin. An electrocardiogram (ECG) is obtained.
What observation on the ECG or on the cardiac monitor would indicate to the nurse the need to
immediately notify the physician?
A. PR impulse 0.20 sec
B. Tachycardia rate of 125 beat of premature
C. premature ventricle beat
D. An ST segment elevation from the isoelectric baseline.
Answer: D. An ST segment elevation from the isoelectric baseline.
73. A client begins complains of chills and discomfort after about 50ml of blood has packed red
blood cells. The best nursing action at this time is to
A. Discontinue the transfusion and move the IV and restart IV transfusion at another site.
B. compare the VS now and what they were before the transfusion begin
C. stop the transfusion and maintain a patent line with normal saline solution and new tubing
D. slow down the transfusion blood and dilute with normal saline solution
Answer: C. stop the transfusion and maintain a patent line with normal saline solution and new
tubing
74. "The vital signs of a client with cardiac disease are as follows: blood pressure of 103/78 mm
Hg, heart rate of beats/min, and respiratory rate of 16 breaths/min. Atropine is administered IV
push. What nursing assessment findings would indicate a therapeutic response to the
medication?"
Answer: Pulse rate has increased to 70 beats/min
75. Order rocephen 1g over 30minutes Q6H. Supply 1g/100mL. How many mL per hour will the
nurse infuse? Round the nearest whole number.
Answer: 200 ml/hr
76. The nurse is caring for client who is 1 day postoperative following an open thoracotomy. The
client is receiving oxygen mist at 40 percent. The O2 saturation measured by pulse oximeter was
83 ABG results are pH 7.31, PACO2 93mmHg, HCO3 25 meq/L. Which of the following is an
appropriate action by the nurse?
Answer: position client in high- fowlers and encourage use of incentive spirometer and
coughing.
77. The diabetic educator is teaching a class on Diabetes Type 1 and is discussing sick day rules.
Which interventions should the diabetes counsellor include in the teaching? Select all that apply
A. Take diabetic medication even if unable to eat the client’s normal diet.
B. If unable to eat, drink liquids equal to the client’s normal diet.
C. Test the blood glucose levels and test the urine ketones once a day and keep a record.
Answer: A. Take diabetic medication even if unable to eat the client’s normal diet.
B. If unable to eat, drink liquids equal to the client’s normal diet.
C. Test the blood glucose levels and test the urine ketones once a day and keep a record.
78. The nurse is monitoring a client receiving pertional dialysis notes that the client’s outflow is
less than inflow. What action should the nurse take? Select all that apply?
A. Reposition the client to facilitate fluid drainage
B. Increase the inflow volume to compensate for the decreased outflow
C. Assess the dialysis catheter and tubing for obstructions or kinks
D. Notify the physician immediately without taking further action
Answer: A. Reposition the client to facilitate fluid drainage
C. Assess the dialysis catheter and tubing for obstructions or kinks
79. The nurse is obtaining a health history from a client who is visiting the clinic with complaints
of a severe headache. The client provides the following data to the nurse based on a review of
systems. The nurse identifies the following as a modifiable risk for stroke? Select all the apply.
A. smoking
B. alcohol consumption
C. decreased physical activity
D. obesity
Answer: A. smoking
B. alcohol consumption
C. decreased physical activity
D. obesity
80. The nurse is caring for a client diagnosed with ARDS who is on a ventilator. Which
intervention should the nurse implement? Select all that apply
A. Assess the client’s level of consciousness.
B. Monitor the client’s urine output
C. Perform passive range of motion (ROM) exercise.
D. Maintain intravenous fluids as ordered.
Answer: A. Assess the client’s level of consciousness.
B. Monitor the client’s urine output
C. Perform passive range of motion (ROM) exercise.
D. Maintain intravenous fluids as ordered.
81. The nurse is performing an assessment on a client who has returned from dialysis unit
following haemodialysis. The client is complaining of headache, nausea,
and is extremely restless. Which of the following ?? the most appropriate nursing action?
Answer: Notify The Physicians
82. The nurse determines that a client with diabetes- mellitus is experiencing fat breakdown for
conversion to glucose if the client has elevated levels of which substance in the urine?
Answer: ketones
83. The client is admitted the ED with chest trauma. Which signs and symptoms would the nurse
expect to assess that supports the diagnosis of pneumothorax?
Answer: Absent Breaths Sounds Tachypnoea
84. The nurse is caring for hospitalized clients. Which of the following clients is at greatest risk
for fluid volume deficit?
Answer: The Client Who Has Just Been Admitted Has Severe Diarrhoea and is Febrile.
85. PT & INR for Coumadin, INR 2.8
Answer: continue medication
86. Hot spot
Answer: apical pulse
87. Hot spot
Answer: T wave
88. Hot spot:
Answer: P wave
89. P wave:
Answer: atrial depolarization
90. Assessing response in an unconscious patient:
Answer: nail bed pressure (peripheral)
91. HbA1c considerations for about 3 months of glucose monitoring
A. less than 6% for nondiabetic
B. diabetic controlled should be less than 7%
C. Greater than 8% indicates poor glucose control
D. HbA1c is not useful for monitoring long-term glucose levels
Answer: A. less than 6% for nondiabetic
B. diabetic controlled should be less than 7%
92. Sengstaken-Blakemore tube prevents bleeding (esophageal varices)
A. Triple lumen
B. Have scissors at the bedside
C. Provide oral and nasal care every 3 hours
D. Used to reduce bleeding
Answer: D. Used to reduce bleeding
93. Planning rehabilitation for a stroke patient
A. Assess functional status before developing plan
B. Walking, speaking, eating, ADLs
C. Cranial nerve II: Snellen test
D. T2-T3: Paraplegia
E. ICP: no lumbar puncture
Answer: A. Assess functional status before developing plan
94. A nurse observing a close chest tube drainage system is postop 1 day thoracotomy? Continue
bubbling in the suction chamber?
A. check the control outlet against the wall
B. observe all the connection tubing
C. Continue to monitor client respiratory status
D. Notify MD of the oxidation
Answer: C. Continue to monitor client respiratory status
95. A client admit to hospital report recurrent flank pain, nausea, and vomiting within 24 hours.
Which of the following priority nursing action?
A. Administered pain medication
B. Monitor intake and output
C. Administered antiemetics
D. Strain urine
Answer: D. Strain urine
96. A nurse is caring for client who have type 1 DM. The nurse misread client morning blood
glucose level at 210 mg/dL instead of 120 mg/dL base on this error. She admitted insulin dose of
200 mg/dL before client breakfast. Which of the nursing priority?
Answer: Monitor client for hypoglycaemia
97. A nurse is caring a client who is schedule of colonoscopy. The client ask the nurse if there
will be a lot of pain during procedure. Which of the following is appropriate nursing response?
A. No, you shouldn’t feel any pain because your rectum will be anaesthesia
B. You may be sedated but you will feel discomfort during the instrument insertion
C. You will feel some pain, but we will give you pain medications to manage it.
D. The procedure will be painless, as you will be given general anaesthesia.
Answer: B. You may be sedated but you will feel discomfort during the instrument insertion
98. A nurse is performing teaching for client who have recently diagnosis type 2 DM. nurse
should recognize that the client understood the teaching. Identify hypoglycaemia? Select all
A. Moist, clammy skin
B. Tachycardia
C. Polyuria
D. Polydipsia
E. Polyphagia
Answer: A. Moist, clammy skin
B. Tachycardia
99. A nurse admitted morphine 2 mg IV push after client report pain and evaluate client 15 min.
later injection. Which follow adverse effect?
A. pain scale level of 6 to 4
B. sleepy but arouse when name call
C. O2 sat 94%
D. RR 8 bpm
Answer: D. RR 8 bpm
100. Nurse assess a client who 8 score using the Glasgow coma scale to elevate of
consciousness. Describe the score.
A. Reflex alert client
B. Need of total nursing caring
C. Client in deep coma
D. Stable neurological status
Answer: C. Client in deep coma
101. client low sodium diet and reduce fluid intake to choose lunch.
A. Tuna sandwich on wheat bread, can of cocktail fruit, salad, and soda
B. Grill chicken sandwich on white bread, apple, salad, and ice tea
C. Grill cheese sandwich, tomato soup
D. Ham and bean
Answer: B. Grill chicken sandwich on white bread, apple, salad, and ice tea
102. Client acute MI. a cardiac enzyme obtain. Cardiac enzyme identify?
A. damage to the myocardial
B. determine the size MI
C. help to determine the location MI
D. Assist in determining the timing of the MI
Answer: A. damage to the myocardial
103. Administered DDAVP to client diagnosis DI. Therapeutic effect
Answer: Specific gravity (1.015)
