ATI Cardiovascular
1. A nurse is providing teaching about a heart healthy diet to a group of clients with
hypertension. Which of the following statements by one of the clients indicates a need for further
teaching?
Answer: "I may eat 10 ounces of lean protein each day."
2. A nurse is providing teaching for client who has a new diagnosis of angina pectoris. The nurse
should give the client which of the following Information about anginal pain?
Answer: exertion and anxiety can trigger the pain
3. A nurse in an emergency department is assessing a client who is having a suspected acute
myocardial infarction (MI). Which of the following manifestations should the nurse expect to
find for a client experiencing an acute MI? (Select all that apply.)
Answer: • Nausea
• Tachycardia
• Diaphoresis
4. A nurse is providing teaching to a client who has hypertension and a new prescription for
captopril. Which of the following instructions should the nurse provide?
Answer: do not use salt substitutes while taking this medication
5. A nurse caring for a client who came to the emergency department reporting chest pain. The
provider suspects a myocardial infarction. While waiting for the troponin levels report the client
asks what this blood test will show. Which of the following explanations should the nurse
provide the client?
Answer: troponin is a heart muscle protein that appears in the bloodstream when there is damage
to the heart
6. A nurse providing teaching to a client who has stable angina and a new prescription for
transdermal nitroglycerin. Which of the following Instructions should the nurse include? (Select
all that apply.)
Answer:
• apply the patch to a hairless area and rotate sites
• apply a new patch each morning
• remove the patch for 10 to 12 hr daily
7. A nurse teaching a client who has hypertension and a new prescription for atenolol. Which of
the following findings should the nurse include as adverse effects of this medication?
Answer: bradycardia
8. A nurse providing teaching to a client who has hypertension and a new prescription for
hydrochlorothiazide. Which of the following instructions should the nurse provide?
Answer: take the medication early in the day
9. A nurse in the emergency room is caring for a client who presents with manifestations that a
myocardial infarction. Which of the following prescriptions should the nurse take first?
Answer: initiate oxygen therapy
10. A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational
hypertension. Which of the following actions should the nurse expect to implement? (Select all
that apply.)
Answer: • administer magnesium sulfate IV
• provide a dark, quiet environment
• ensure that calcium gluconate is readily available
11. A nurse is reviewing blood pressure classifications with a group of nurses at an in-service
meeting. Which of the following should the nurse include as a risk factor for the development of
hypertension?
Answer: obstructive sleep apnea (OSA)
12. A nurse is providing teaching to a client who has stable angina and a new prescription for
nitroglycerin oral, sustained-release capsules. Which of the following instructions should the
nurse include?
Answer: Swallow the capsules whole
13. A nurse caring for a client who has hypertension and has a potassium level of 6.8mEq /L.
Which of the following actions should the nurse taken?
Answer: obtain a 12-lead ECG
14. A nurse is caring for a client who reports a new onset of severe chest pain. Which of the
following actions should the nurse take to determine the is experiencing a myocardial infarction?
Answer: perform a 12-lead ECG
15. A is providing instructions to a client who has a new prescription for sublingual nitroglycerin
(Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include?
Answer: place the tablet under your tongue, and then take a small sip of water
16. A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the
following findings a priority to report?
Answer: swelling of the tongue
17. A nurse is reviewing the laboratory values of a client who had an infarction 3 hrs ago. The
nurse should expect which of the following laboratory values to be elevated?
Answer: troponin I
18. A nurse caring for a client who has hypertension develops epistaxis. Which of the following
actions the nurse rake? (Select all that apply.)
Answer: • apply pressure to the nares
• place ice to the bridge of the client’s nose
• move the client into high-Fowler’s position
19. A nurse is providing discharge teaching to a client who has a new prescription for verapamil
for angina. Which of the following Instructions should the nurse include?
Answer: Increase your daily intake of dietary fiber.
20. A nurse caring for a client who has a new diagnosis of essential hypertension. The nurse
should monitor the client for which of the following findings that is consistent with this
diagnosis?
Answer: vertigo
21. A nurse establishing health promotion goals for a female client who smokes cigarettes, has
hypertension, and has a BMI of 26. Which of the following goals should the nurse include?
Answer: the client will walk for 30 min 5 days a week
22. A nurse teaching the partner of a client who had an acute myocardial infarction (MI) about
the reason blood was drawn from the client. Which of the following statements should the nurse
make regarding cardiac enzymes studies?
Answer: these tests help determine the degree of damage to the heart tissues
23. A nurse is caring for a client who has had a myocardial Infarction. Upon his first visit to
cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there
because there nothing more to do, as the damage done. Which of the following is the correct
nursing response?
Answer: cardiac rehabilitation cannot undo the damage to your heart but it can help you get back
to your previous level of activity safely
24. A client is teaching a client who has a new prescription for hydrochlorothiazide for
management of hypertension. Which of the following instructions should the nurse include?
Answer: monitor for leg cramps
25. A nurse reviewing the serum laboratory findings for a client who has hypertension and
prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the
provider?
Answer: potassium 2.3 mEq/L
26. A nurse in the emergency department is caring for a client who is experiencing
manifestations of a myocardial infarction (MI). Which of the following laboratory tests should
the nurse expect the provider to prescribe?
Answer: troponin I
27. A nurse teaching a client who has a new prescription for transdermal nitroglycerin to treat
angina pectoris. Which of the following instructions should the nurse include in the teaching?
Answer: apply the transdermal patch in the morning
28. A nurse in the antepartum unit caring for a client who at 36 weeks of gestation and has
pregnancy induced hypertension. Suddenly, the client reports continuous abdominal pain and
vaginal bleeding. The nurse should suspect which of the following complications?
Answer: abruptio placentae
29. A nurse providing teaching for a client who has hypertension and a prescription change from
metoprolol to metoprolol/hydrochlorothiazide Which of the following statements by the client
indicates an understanding of the teaching?
Answer: with the new medication, I should experience fewer side effects
30. A nurse in a provider's office is reviewing the laboratory results of a client who takes
furosemide for hypertension. The nurse notes that the client's potassium level is 3.3mEq/L. The
nurse should monitor the client for which of the following complications?
Answer: cardiac dysrhythmias
31. A nurse is providing teaching to a client who has angina pectoris and a new prescription for
nitroglycerin sublingual tablets. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: I will dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2
more tablets 5 minutes apart while waiting
32. A nurse is monitoring an older adult female client who had a myocardial Infarction (MI) for
the development of an acute kidney Injury Which of the following findings should the nurse
identify as indicating an increased risk of acute kidney injury (AKI)?
Answer: serum creatinine 1.8 mg/dL
33. A nurse teaching a client who has angina pectoris about starting therapy with SL
nitroglycerin tablets. The nurse should include which of the following instructions regarding how
to take the medication?
Answer: take one tablet at the first indication of chest pain
34. A nurse caring for a client who has hypertension and is afraid to take his blood pressure
medication. Which of the following nursing statements is an example of the therapeutic
communication response of reflection?
Answer: you seem upset about taking your blood pressure medication
35. A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for
stable angina. The client reports getting a headache each time he takes the medication. Which of
the following statements should the nurse make?
Answer: try taking a mild analgesic to relieve the headache
36. A nurse is reviewing the health history for a client who has angina pectoris and a prescription
for propranolol hydrochloride PO 40 mg twice daily Which of the following findings in the
history should the nurse report to the provider?
Answer: the client has a history of bronchial asthma
37. A nurse is providing teaching to a client who has hypertension and a new prescription for
verapamil. Which of the following beverages should the nurse tell the client to avoid while
taking this medication?
Answer: grapefruit juice
38. A nurse is admitting a client who has acute heart failure following myocardial infarction
(MI). The nurse recognizes that which of the following prescriptions by the provider requires
clarification?
Answer: 0.9% normal saline IV at 50mL/hr continuous
39. A client has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse
recognizes that the aspirin given due to which of the following actions of the medication?
Answer: antiplatelet aggregate
40. A nurse an emergency department is planning care for a client who is having an acute
myocardial infarction (). The nurse should planta administer which of the following medications
after the initial acute phase to manage the client's pain and anxiety?
Answer: morphine
41. A nurse teaching a middle-aged client about hypertension. Which of the following
information should the nurse include in the teaching?
Answer: diuretics are the first type of medication to control hypertension
42. A nurse caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices,
and portal hypertension. The nurse recognizes which of the following laboratory findings as
indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?
Answer: elevated BUN
43. A nurse providing teaching to a client who has a family history of hypertension. The nurse
should inform the client that his blood pressure of 124/84 mm Hg places him in which of the
following categories?
Answer: prehypertension
44. A on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain
with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet.
After 5 min the states that his chest pain is now a severity of Which of the following actions
should the nurse take?
Answer: administer another nitroglycerin tablet
45. A nurse is providing teaching about the Mediterranean diet to a client who has a new
diagnosis of 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 twice weekly
46. A nurse caring for a client who has hypertension and asks the nurse about a prescription for
propranolol. The nurse should inform the client that this medication is contraindicated in clients
who have a history of which of the following conditions?
Answer: asthma
47. A nurse in an emergency department caring for a client who reports substernal chest pain and
dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are
used to diagnose a myocardial infarction? (Select all that apply.)
Answer: • Troponin I
• Troponin T
• CPK
• Myoglobin
48. A nurse in an emergency department is preparing to administer alteplase accelerated therapy
to a client who is having a myocardial infarction. Which of the following actions should the
nurse plan to take? (Select all that apply)
Answer: • administer the med within 30 minutes of the client’s arrival to the department
• reconstitute the med with sterile water
• administer a 15mg IV bolus
• asses the client for back pain
49. A nurse is teaching a client who has angina about nitroglycerin sublingual tablets. Which of
the following statements should the nurse include in the teaching?
Answer: nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart
50. A nurse is reviewing the medical record of a client who has hypertension and a new
prescription for metoprolol. Which of the following findings should the nurse investigate
further?
Answer: a history of left sided heart failure
ATI Cancer and Urinary
1. A nurse is caring for a client who has cancer and is 20 weeks pregnant. The client's provider
recommends chemotherapy for the client, but the client is uncertain about the recommend
treatment. Which of the following statements by the nurse is appropriate?
Answer: This must be a difficult decision for you
2. A nurse is reviewing the laboratory results of a client who has acute leukemia and received an
aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory
values should the nurse expect? (Select all that apply.)
Answer: • Decreased platelet count
• Decreased leukocyte count
• Decreased erythrocyte count
3. A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate
kidney stones. Which of the following instructions should the nurse include in the teaching?
Answer: Drink 3L of fluid every day
4. A nurse is teaching a client about the side effects of chemotherapy medication. Which of the
following nursing statements should the nurse include in the teaching?
Answer: Hair loss is common and includes eyebrows and eyelashes
5. A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an
intravenous pyelogram. Which of the following statements by the client should the nurse report
to the provider?
Answer: I do not eat shellfish because it gives me hives
6. A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her
prognosis. The client plans to have aggressive surgical, radiation and chemotherapy treatments.
Which of the following prognoses should the nurse discuss with the client?
Answer: Poor
7. A nurse is teaching a client who is receiving radiation therapy about skin care. Which of the
following instructions should the nurse include?
Answer: Walk outside in the early mornings
8. A nurse is reviewing the CBC findings for a female client who is receiving combination
chemotherapy for breast cancer. Which of the following findings should the nurse report to the
provider?
Answer: Wbc:2300/mm3
9. A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI).
Which of the following findings should the nurse recognize as a risk factor?
Answer: Diabetes mellit
10. A nurse is providing discharge teaching for a client who is postoperative following a simple
mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the
following instructions about maintaining skin integrity should the nurse include?
Answer: Do not apply heat to the area of irradiation
11. A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The
nurse should monitor the client for which of the following adverse effects?
Answer: Bleeding from the gums
12. A nurse is teaching a client who has a urinary tract infection (UTI) and is taking
ciprofloxacin. Which of the following instructions should the nurse give to the client?
Answer: You should report any tendon discomfort you experience while taking this medication
13. A nurse is planning care for a client who has immunosuppression following chemotherapy.
Which of the following interventions should the nurse include in the plan of care?
Answer: Limit the number of health care workers entering the room
14. A nurse is caring for a client who is participating in a research study for an experimental
chemotherapy medication. After three treatments, the experimental medication is discontinued
due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing
this medication demonstrates which of the following ethical principles?
Answer: Non maleficence
15. A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of
the following manifestations should the nurse identify as a finding specifically associated with
this client?
Answer: Confusion
16. A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of
the following actions should the nurse take?
Answer: Observe for signs of infection
17. A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of
the following actions should the nurse take?
Answer: Tingling feeling in the extremities
18. A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She
tells the nurse she is worried about the adverse effects of the treatment. Which of the following
responses should the nurse make?
Answer: What is it about the adverse effects that concern you?
19. A nurse is providing teaching to a client about measures to prevent urinary tract infections
(UTI) Which of the following client statements indicates a need for further teaching?
Answer: I will need to wipe my perineal area from back to front after urination
20. A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy.
The client tells the nurse that she wants to try nontraditional treatments first. Which of the
following responses should the nurse make?
Answer: Tell me more about your concern about taking chemotherapy
21. A nurse providing dietary teaching to a client who has frequent kidney stones. Which of the
following instructions should the nurse include in the teaching?
Answer: Avoid eating tree nuts such as almonds
22. A-nurse is teaching a client about the physical effects of chemotherapy. Following the
teaching, the nurse asks the client to describe one physical effect. The nurse is focusing on which
of the following elements of the communication process?
Answer: Feedback
23. A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation
therapy for the treatment of lung cancer. Which of the following should the nurse plan to include
in the teaching?
Answer: Bottled water is an appropriate choice to increase fluid intake
24. A nurse teaching a client who has urolithiasis (renal calculi). The nurse should explain that
which of the following conditions can increase the risk for renal calculi?
Answer: Dehydration
25. A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat
chemotherapy induced nausea. For which of the following adverse effects should the nurse
monitor?
Answer: Headache
26. A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks
if she needs to make any dietary changes. Which of the following statements should the nurse
make?
Answer: You should avoid drinking liquids an hour before the treatments
27. A nurse is caring for an older adult client who has a WBC count of 2, 000 / mm 3 after three
rounds of chemotherapy. Which of the following actions should the nurse take?
Answer: Serve cooked fruits with meals
28. A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer.
Which of the following actions should the nurse plan to take?
Answer: Administer an antiemetic prior to the procedure
29. A nurse caring for a client who is experiencing severe nausea and vomiting after a course of
chemotherapy. The nurse should monitor the client for which of the following clinical
manifestations?
Answer: Metabolic alkalosis
30. A nurse is providing teaching to a client who has breast cancer about the adverse effects of
chemotherapy Which of the following client statements indicates an understanding of the
teaching?
Answer: I will call my doctor if I notice any unusual menstrual bleeding
31. A nurse is instructing a client how to decrease the nausea associated with chemotherapy and
radiation Which of the following statements indicates an understanding of the teaching?
Answer: I will eat foods that are served at room temperature
32. A nurse is providing dietary teaching to client who has calcium oxalate kidney stones. Which
of the following statements indicates an understanding of the teaching?
Answer: I may eat a banana with my breakfast
33. A nurse is planning care for a client who is being treated with chemotherapy and radiation for
metastatic breast cancer who has neutropenia. The nurse should include which of the following
restrictions in the client's plan of care?
Answer: Fresh flowers and potted plants in the room
34. A nurse at a provider's office is providing teaching to a client who is taking chemotherapy
and losing weight Which of the following should the nurse recommend increasing calorie and
protein intake? (Select all that apply.)
Answer: • Top fruits with yogurt
• Add cream to soups
• Use milk instead of water
• Dip meats in breadcrumbs before cooking
35. A nurse is planning care for a female client who has T4 spinal cord injury and is at risk for
acquiring urinary tract infections. Which of the following actions should the nurse include in the
client's plan of care?
Answer: Encourage fluid intake at and between meals
ATI Respiratory & Fluid/Electrolytes/Acid-Bases
1. A nurse is caring for a client who has an endotracheal tube and is receiving mechanical
ventilation. Which of the following interventions should the nurse take to reduce the risk for
ventilator-associated pneumonia?
Answer: Rinse the clients mouth with an antimicrobial solution every 4 hr
2. A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia
Which of the following actions should the nurse take?
Answer: Obtain a sputum culture
3. A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects
has metabolic acidosis. Which of the following results should the nurse expect to see?
Answer: Ph below 7.35
4. A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for
treatment of pneumonia. During the night shift the client is found climbing into the bed of
another client who becomes upset and frightened. Which of the following actions should the
nurse take?
Answer: Assist the client to the correct room
5. A nurse caring for a client who is at 6 weeks of gestation and has pneumonia While the nurse
is obtaining the client's history, the client tells the nurse that she takes the herb feverfew for
migraine headaches. Which of the following actions should the nurse take?
Answer: Explain to the client that she should not take this herb while she is pregnant
6. A nurse in the emergency department is assessing an older adult client who has communityacquired pneumonia. Which of the following findings should the nurse expect?
Answer: Confusion
7. A nurse is caring for a client who has drainage tubes. Which of the following clients should the
nurse recognize as being at risk for hypokalemia?
Answer: the client who has a nasogastric tube NG suction
8. A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin
G by intermittent IV bolus. 10 minutes into the infusion of the third dose the climb reports that
the IV site itches and that he feels dizzy and short of breath. Which of the following action
should the nurse take first?
Answer: Stop the infusion
9. A nurse is caring for a client who has pneumonia. Which of the following actions should the
nurse take to promote thinning of respiratory secretions?
Answer: Encourage the client to increase fluid intake
10. A nurse is caring for a client who has tuberculosis and new prescriptions for rifampin and
pyrazinamide. Which of the following laboratory tests should the nurse instruct the client will be
required while on this medication regimen?
Answer: Liver function test
11. A nurse is assessing a client who has pulmonary tuberculosis. Which of the following
findings should the nurse expect?
Answer: Lethargy
12. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a
new prescription for rifampin. Which of the following information should the nurse provide?
Answer: Urine and other secretion might turn orange
13. A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical
manifestations should the nurse monitor? (Select all that apply.)
Answer: Bicarbonate excess-Circumoral paresthesia
14. A nurse is assessing a client who has volume deficit. The nurse should expect which of the
following findings
Answer: Increased BUN
15. A nurse is providing teaching to a group of adult athletes about prevention the effects of
dehydration on the body. Which of the following manifestations should the nurse include in the
teaching?
Answer: Impaired motor control
16. A nurse is assessing an older adult client who is receiving IV therapy. The nurse should
recognize that which of the following findings indicates fluid volume excess? (Select all that
apply.)
Answer: • Bounding pulse
• Pitting edema
• Crackles upon auscultation
17. A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes
which of the following as a manifestation of hypokalemia?
Answer: Shallow respirations
18. A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a new
prescription for IV rifampin. The nurse should instruct the client that they should expect to
experience which of the following manifestations while taking this medication?
Answer: Red colored urine
19. A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at
5L/mL via nasal cannula. Which of the following actions should the nurse take?
Answer: Attach a humidifier bottle to the base of the flow meter
20. A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor.
The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the
graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave.
(Selectable areas, or "Hot Spots," can be found by moving your cursor over the artwork until the
cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to
your answer.)
Answer: Box on the far right
21. A nurse is performing pulmonary hygiene for a client who has pneumonia and positions the
client on his left side in Trendelenburg position. From which of the following lung segments
should the nurse expect secretions to be mobilized with the client in this position?
Answer: Lateral segment of the right lower lobe
22. A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and
diarrhea. Which of the following findings should the nurse expect?
Answer: Weak, irregular pulse
23. A nurse in a community clinic is assessing an older adult client for manifestations of
dehydration. Which of the following findings should the nurse expect?
Answer: Furrows in the tongue
24. A nurse is caring for four hospitalized clients. Which of the following clients should the nurse
identify as being at risk for fluid volume deficit?
Answer: The client who has gastroenteritis and is febrile
25. A nurse in a clinic is collecting a history from a client who reports that a member of his
family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the
provider will prescribe which of the following diagnostic tests first?
Answer: Nucleic acid amplification test NAAT
26. A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney
failure and determines the client has respiratory acidosis. Which of the following findings should
the nurse expect?
Answer: Widened QRS complexes
27. A nurse reviewing the laboratory results of a client who has fluid volume deficit. The nurse
would expect which of the following findings?
Answer: Urine specific gravity 1.035
28. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit.
Which of the following room assignments should the nurse make for the client?
Answer: A room with air exhaust directly to the outdoor environment
29. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the
following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
Answer: Abnormally prominent U wave
30. A nurse is preparing for the admission of client who has suspected active tuberculosis. Which
of the following precautions should the nurse plan to implement to safely care for this client?
Answer: Place the client in a private room with a special ventilation system
31. A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and
postural drainage. Prior to the procedure, which of the following nursing actions should the nurse
complete first?
Answer: Auscultate lung fields
32. A nurse in a community health center is assessing the results of a tuberculin skin test she
performed for a client. Which of the following results indicates exposure to and a possible
infection with tuberculosis (TB)?
Answer: 15 mm induration
33. A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of
the following findings should the nurse expect?
Answer: PaCO2 50 mm Hg
34. A nurse is planning care for a client who has dehydration and is receiving a continuous IV
infusion of 0.9 % sodium chloride. Which of the following interventions should the nurse include
in the plan of care?
Answer: Offer the client 240 mL (8oz) of oral fluids every 4hr
35. A nurse is admitting a client who has tuberculosis and a productive cough. Which of the
following types of isolation precautions should the nurse initiate for the client?
Answer: Airborne
36. A nurse is teaching a client who is to begin medicated treatment of tuberculosis The nurse
should instruct the client that which of the following herbal supplements can interact adversely
with the treatment?
Answer: Echinacea
37. A nurse is teaching a client who has tuberculosis and is to start medication therapy with
isoniazid, rifampin, and pyrazinamide. Which of the following instructions should the nurse
include?
Answer: Drink at least 8 ounces of water when you take the pyrazinamide tablet
38. A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB)
about the use of antitubercular medications. Which of the following information should the nurse
include in the teaching?
Answer: A typical course of treatment involves 6 to 9 months of consistent medication use
39. A nurse is providing instruction to a new nurse about caring for clients who are receiving
diuretic therapy to treat heart failure. The nurse should explain that which of the following
medications puts clients at risk for both hyperkalemia and hyponatremia?
Answer: Spironolactone
40. A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his
NPO status Which of the following solutions should the nurse prepare to infuse for this client?
Answer: 0.45% sodium chloride
41. A nurse in a provider's office is assessing a client. The nurse should identify that which of the
following findings are manifestations of pulmonary tuberculosis? (Select all that apply)
Answer: Night sweats-Low grade fever-Blood in the sputum
42. A nurse is reviewing the medical records of four clients who have an acid base imbalance.
The nurse should recognize that which of the following clients is at risk for metabolic acidosis?
Answer: A client who has diarrhea
43. A nurse is teaching a client who has tuberculosis and is to start combination drug therapy.
Which of the following medications should the nurse plan to administer? (Select all that apply)
Answer: Rifampin-Isoniazid-Pyrazinamide
44. A nurse is caring for a client who is receiving fluids to correct dehydration. Which of the
following laboratory values should indicate to the nurse that the client effectively responding to
treatment?
Answer: Urine specific gravity 1.020
45. A nurse in a provider's office is assessing an older adult client whose son reports that the
client has been sick with a respiratory illness for the past 6 days. Which of the following
assessment findings is a manifestation of pneumonia in the older adult client?
Answer: Confusion
46. A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is
started on ethambutol therapy. The nurse should understand that which of the following should
be monitored?
Answer: Visual acuity
47. A nurse is caring for a client who has active pulmonary tuberculosis (TB)The client requires
airborne precautions and is receiving multi drug therapy. Which of the following precautions
should the nurse transport the client safely to the radiology department for a chest x-ray?
Answer: Have the client wear a mask
48. A nurse is assessing four clients for balance. The nurse should identify that which of the
following clients is exhibiting manifestations of dehydration?
Answer: A client who has a temperature of 39.2 (102)
49. A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which
of the following precautions should the nurse include when creating a sign to post outside of the
client's room? (Select all that apply.)
Answer: • Protective mask
• Closed door
• Puncture proof sharp container
• Hand hygiene
50. A nurse is caring for an adolescent who has pneumonia and a prescription for cefpodoxime
5mg/kg PO every 12hr for 5 days. The client weights 88 lb. How many mg should the nurse
administer per dose? round the answer to the nearest whole number. Use a leading zero if it
applies. Do not use trailing zero
Answer: 200 mg
ATI GI & DM
1. A nurse is assessing a client who has diabetes mellitus. Which of the following findings is a
manifestation of hypoglycemia?
Answer: cool, clammy skin
2. A nurse is caring for a client who has type diabetes mellitus and is not following the guidelines
for therapy. Which of the following should the nurse consider as contributing factors to the
client's nonadherence? (Select all that apply.)
Answer: • culture
• literacy
• dexterity
• motivation
3. A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of
the following interventions should the nurse include the plan of care?
Answer: check urine specific gravity
4. A nurse is preparing a teaching session about reducing the risk of complications of diabetes
mellitus. Which of the following information should the nurse plan to include in the teaching?
(Select all that apply.)
Answer: • reduce cholesterol and saturated fat intake
• increase physical activity and daily exercise
• enroll in a smoking-cessation program
• maintain optimal blood pressure to prevent kidney damage
5. A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
Answer: urine specific gravity 1.002
6. A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The
nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the
medication?
Answer: urine specific gravity 1.015
7. A nurse teaching a client who is taking metformin XR for type diabetes mellitus. Which of the
following Instructions should the nurse include in the teaching?
Answer: take the medication with a meal
8. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus.
The nurse should recognize that the client understands the teaching when he identities which of
the following as manifestations of hypoglycemia? (Select all that apply.)
Answer: • blurred vision
• tachycardia
• moist, clammy skin
9. A nurse is caring for a client who has uncontrolled type 1 diabetes mellitus. Which of the
following findings should the nurse expect?
Answer: weight loss
10. A nurse is providing teaching for a client who newly diagnosed with type 2 diabetes mellitus
and has a prescription for glipizide. Which of the following statements by the nurse best
describes the action of glipizide?
Answer: glipizide stimulates your pancreas to release insulin
11. A nurse is planning a community diabetes mellitus management program. Which of the
following goals should the nurse include for the program?
Answer: clients will have a decreased incidence of foot amputations
12. A nurse is teaching a client who has diabetes mellitus and a new prescription for glimepiride.
The nurse should teach the client to avoid which of the following drinks while taking this
medication?
Answer: alcohol
13. A nurse is caring for a client who is type 1 diabetes mellitus. The nurse misread the client’s
morning blood glucose level as 210 instead of 120 and administered the insulin dose appropriate
for a reading over 200 before the client’s breakfast. Which of the following actions is the nurse’s
priority?
Answer: monitor the client for hypoglycemia
14. A nurse is providing teaching to a female client who has type 2 diabetes and a new
prescription for pioglitazone. Which of the following instructions should the nurse include in the
teaching? (Select all that apply.)
Answer: • monitor weight daily
• increase calcium intake
15. A nurse is teaching a client who has type 1 diabetes mellitus about exercise. Which of the
following instructions should the nurse include?
Answer: do not exercise if ketones are present in your urine
16. A nurse providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the
following should the nurse include the teaching?
Answer: obtain an influenza vaccine annually
17. A nurse caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse
should identify which of the following findings as an indication that the medication is effective?
Answer: a decrease in urine output
18. A nurse is providing teaching to a client who has peptic ulcer disease and a new prescription
for sucralfate tablets. Which of the following information should the nurse provide?
Answer: take sucralfate 1hr before meals
19. A nurse reviewing the laboratory results of a client who Is at risk for developing diabetes
mellitus. The nurse should recognize that which of the following results indicates the client
meets the criteria for diagnosis of diabetes mellitus?
Answer: fasting blood glucose 155
20. A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a
client who has diabetes mellitus. When mixing the two types of insulin, which of the following
actions should the nurse take first?
Answer: inject 20 units of air into the NPH insulin vial
21. A nurse is providing teaching to a client who has diabetes mellitus about carbohydrate intake
needs when exercising. Which of the following foods should the nurse include as containing a 15
g serving of carbohydrates?
Answer: 1 cup milk
22. A nurse working for a home health agency is teaching a client who has diabetes mellitus
about disease management. Which of the following glycosylated hemoglobin (HbA1c) values
should the nurse include in the teaching as an indicator that the client is appropriately controlling
his glucose levels?
Answer: 6.3%
23. A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the for
which of the following findings as an indication of gastrointestinal perforation?
Answer: sudden abdominal pain
24. A nurse is reviewing the medication list for a client who has a new diagnosis of type 2
diabetes mellitus. The nurse should recognize which of the following medications can cause
glucose?
Answer: prednisone
25. A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative
colitis. which of the following actions should the nurse take first?
Answer: review the clients electrolyte values
26. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is
being admitted to the emergency department confused, flushed, and with an acetone odor on the
breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the
following type of insulin to treat this client?
Answer: regular
27. A nurse assessing a client who has type 1 diabetes mellitus and finds the client lying in bed,
sweating, and reporting feeling anxious. Which of the following complications should the nurse
suspect?
Answer: hypoglycemia
28. A nurse is performing a monofilament sensory assessment of a client who has diabetes
mellitus. When performing this assessment, for which of the following complications is the nurse
monitoring?
Answer: neuropathy
29. A nurse a provider's office is collecting a health history from a client who has a new
prescription for glyburide to treat type 2 diabetes mellitus Which of the following statements by
the client indicates a contraindication for taking this medication?
Answer: I plan to continue nursing my baby until he is at least a year old.
30. A nurse is providing dietary teaching for a client who has just learned that she has type 2
diabetes mellitus. The nurse should explain that which of the following sweeteners will add
calories to the client's carbohydrate count?
Answer: sorbitol
31. A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse
should evaluate the client for which of the following alterations as indications that the client has
an infection? (Select all that apply.)
Answer: • an increase in neutrophils
• localized edema
32. A client who has Type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?"
Which of the following responses should the nurse make?
Answer: your body has insulin resistance and decreased insulin secretion
33. A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and
having palpitations. When the nurse finds the client's blood glucose to be 48 on the glucometer,
he should give the client which of the following?
Answer: graham crackers
34. A nurse is providing teaching about self-administration of insulin to the parent of a schoolage child who has a new of diabetes mellitus. Which the following statement by the parent
indicates a need for further teaching?
Answer: I will be sure my child aspirates before injecting the insulin
35. A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2
diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the
most likely cause of the respiratory distress is which of the following?
Answer: hyperinsulinemia
36. A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control
her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a
prescription from the provider for which of the following medications for the client?
Answer: glyburide
37. A nurse is creating a plan of care to maintain the skin integrity of a client who experiences
frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse
include in the plan?
Answer: Wipe the perianal area with warm water and apply a barrier cream
38. A nurse teaching a client who has type 1 diabetes mellitus about foot care. Which of the
following statements by the client indicates understanding of the teaching?
Answer: I’ll check my feet every day for sores and bruises
39. A nurse teaching about disease management for a client who has type 1 diabetes mellitus.
Which statement made by the client indicates an understanding of the teaching?
Answer: I give the insulin injections in my abdominal area
40. A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is
eager to return to school and participate in social events The mother tells the nurse she is afraid
to let him take part in physical activities at school. Which of the following responses should the
nurse make?
Answer: tell me more about how you are feeling about your sons’ activities
41. A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
Answer: dehydration
42. A nurse is providing teaching for a client who has diabetes and a new prescription for insulin
glargine. Which of the following instructions should the nurse provide regarding this type of
insulin?
Answer: insulin glargine has a duration of 18-24 hr
43. A nurse is completing dietary teaching on consuming a low fiber diet with a client who has
ulcerative colitis. Which of the following food should be eliminated in the client's diet?
Answer: dried apricots
44. A nurse is caring for a newborn who has macrosomia and whose mother has diabetes
mellitus. The nurse should recognize which of the following newborn complications as the
priority focus of care?
Answer: hypoglycemia
45. A nurse is caring for a client with dm who is prescribed regular insulin via a sliding scale.
After administering the correct dose at 0715, the nurse should ensure the client receives breakfast
at which of the following times?
Answer: 0745
46. A nurse is providing dietary teaching to a who has nephropathy secondary to diabetes
mellitus and plans to make dietary adjustments Which of the following instructions should the
nurse include?
Answer: consume less than 0.8 g/kg of body weight of protein per day
47. A nurse is teaching about self-monitoring to a client who type 1 diabetes mellitus. Which of
the following statements by the client indicates an understanding of the teaching?
Answer: I will check my blood glucose every 4 hours when I am sick
48. A nurse assessing a female client who is at risk for developing type 2 diabetes mellitus. The
nurse should Identify that which of the following manifestations increases the client's risk for
developing type 2 diabetes?
Answer: BP of 138/98
49. A nurse is caring for a 7-year-old child who has an upper respiratory infection and type 1
diabetes mellitus. Which of the following statements by the mother indicates a need for further
instruction?
Answer: I will continue to check his blood sugar two times every day
50. A nurse is assessing a client who has diabetes insipidus. Which of the following findings is a
manifestation of this diagnosis?
Answer: tachycardia
51. A nurse caring for a client who has diabetes and a new prescription for 14 units of regular
Insulin and 28 units of NPH Insulin subcutaneously at breakfast daily. What is the total number
of units of Insulin that the nurse should prepare in the insulin syringe?
Answer: 42 units
52. A nurse is teaching a client who has diabetes about which dietary source should provide the
greatest percentage of calories. Which of the following statements indicates the client
understands the teaching?
Answer: I should eat more calories from complex carbohydrates than anything else
53. A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about
illness management. Which of the following Instructions should the nurse include?
Answer: test the urine for ketones
54. A nurse is teaching a client who has a new prescription for cimetidine to treat peptic ulcer
disease. Which of the following statements by the client indicates an understanding of the
teaching? (Select all that apply)
Answer: • I can take this medication with or without food
• I will eat five small meals each day
55. A nurse is caring for a client who has Crohn's disease. Which of the following food choices
would follow the recommended diet for clients who have Crohn's disease?
Answer: toast with jelly
56. A nurse is teaching a client who has a new diagnosis of Type 1 diabetes mellitus about selfadministration of insulin. Which of the following Instructions should the nurse include?
Answer: store the current bottle of insulin at room temperature
57. A nurse preparing to administer lispro to a client who has type 1 diabetes mellitus. Which of
the following actions should the nurse take?
Answer: inject the insulin 15 minutes before a meal
58. A nurse teaching a client who has a history of ulcerative colitis and a new diagnosis of
anemia. Which of the following manifestations of colitis should the nurse Identify as a
contributing factor to the development of the anemia?
Answer: chronic blood loss
59. A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of
diabetes mellitus. Which of the following statements by the parents indicates an understanding of
the teaching?
Answer: "My son might complain of feeling shaky when he has a low blood glucose level."
60. A nurse is caring for a client who has type 1 DM. Which of the following recommendations
should the nurse make to the client for a sweetener?
Answer: nonnutritive sugar substitute
61. A nurse is teaching a client who has diabetes mellitus about the manifestations of
hypoglycemia Which of the following statements by the client Indicates an understanding of the
teaching?
Answer: I will feel shaky
62. A nurse caring a client who has diabetes and plans to administer his regular insulin
subcutaneously before he eats breakfast at 0800. After checking the client's morning level, which
of the following actions should the nurse take?
Answer: give the insulin at 0730
63. A nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus.
Which of the following statements by the client Indicates an understanding of the teaching?
Answer: I should buy new shoes late in the day
64. A nurse teaching a client who has diabetes mellitus and receives 25 units of NPH every
morning if her blood glucose level above 200 mg/dl. Which of the following information should
the nurse include?
Answer: expect the NPH insulin to peak in 6-14 hrs.
65. A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and
distressed after an insulin injection. Which of the following play activities should the nurse
recognize is therapeutic in helping the child deal with the injection?
Answer: a needless syringe and a doll
66. A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who
has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the
teaching?
Answer: check your urine for ketones when blood glucose levels are greater than 240
67. A nurse observes mild hand tremors in a client who has diabetes mellitus. Which of the
following actions should the nurse take after obtaining glucose meter reading of 60?
Answer: administer 15g of carbohydrates
68. A nurse assessing a client who has peptic ulcer disease. Which of the following findings
should the nurse identify as the priority?
Answer: hematemesis
69. A nurse providing teaching to a school-age child who has a new diagnosis of type 1 diabetes
mellitus. Which of the following statements by the child indicates an understanding of the
teaching?
Answer: I should eat a snack half an hour before playing soccer
70. A nurse developing a teaching plan for a client who has a new diagnosis of type 2 diabetes
mellitus. Which of the following actions should the nurse plan to take ?
Answer: determine what the client knows about managing diabetes
71. a nurse is caring for a client who has ulcerative colitis and is teaching the client about the
common link with Crohn's disease? which of the following information should the nurse
include?
Answer: both are inflammatory
72. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on
effective learning with this client, which of the following interventions should the nurse use?
Answer: Explore the client's feelings about dietary modifications
73. A nurse teaching an older adult client who has diabetes mellitus about preventing the longterm complications of retinopathy and nephropathy Which of the following instructions should
the nurse include?
Answer: maintains stable blood glucose levels
74. A nurse a prenatal clinic teaching a client who is in her second trimester and has a new
diagnosis of gestational diabetes. Which of the following statements by the client indicates a
need for further teaching?
Answer: I will reduce my exercise schedule to 3 days a week
75. A nurse teaching a client who has diabetes mellitus and a new prescription for prednisone for
a rash. Which of the following statements by the client indicates the need for further teaching?
Answer: I will gradually stop the prednisone when my rash goes away
76. A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the
following findings should the nurse recognize as a risk factor for this condition?
Answer: history of NSAID use
ATI Sensory & Neuro
1. A nurse is caring for a client who has right sided paralysis from a stroke, which of the
following interventions should the nurse implement to prevent footdrop?
Answer: Apply a protective boot to the right ankle.
2. A nurse in a long-term care facility is caring for an older adult client who has dementia and
begins to have frequent episodes of urinary incontinence. After the provider determines no
medical cause for the client's incontinence, which of the following interventions should the nurse
initiate to manage this behavior?
Answer: Take the client to the bathroom every 2 hr.
3. A nurse is caring for a client who has dementia. When performing a Mental Status
Examination (MSE) the nurse should include which of the following data? (Select all that apply.)
Answer: • Ability to perform calculations
• Recall ability-Long term memory
• Level of orientation
4. A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which
of the following information should the nurse include in the teaching?
Answer: Syncope episodes may occur when taking this medication
5. A nurse is caring for an older adult client who has dementia and handles anxiety by
confabulating. The nurse should recognize confabulation when the client?
Answer: Makes up stories when he is unable to remember actual events
6. A nurse is reviewing discharge instructions with a client following a right cataract extraction.
Which of the following instructions should the nurse include?
Answer: Avoid lifting anything heavier than 4.5 kg (10 lb.) for 1 week
7. A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous
hemianopsia when eating. Which of the following actions should the nurse take?
Answer: Remind the client to look for food on the left side of the tray
8. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident
(CVA). Which of the following parameters should the nurse use first in order to assess the client's
pain level?
Answer: A self report pain rating scale
9. A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The
nurse should monitor for which of the following findings?
Answer: Poor impulse control
10. A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted
to a long-term care facility following the death of her partner of 40 years. The client states, want
to go home; my husband is waiting for me to cook dinner." Which of the following responses by
the nurse is appropriate?
Answer: Tell me what you like to cook for dinner
11. A nursing is caring for a client who has aphasia following a stroke. A family member asks the
nurse how she should communicate with the client. Which of the following responses by the
nurse is appropriate?
Answer: Incorporate nonverbal cues in the conversation
12. A nurse an ophthalmology clinic is interviewing a client who was referred by his primary
care provider for suspicion of cataracts. The nurse should expect the client to report-Having a
decreases ability to perceive colors A nurse is caring for a client following cataract surgery.
Which of the following comments from the client should the nurse report to the client's provider?
Answer: I need something for the pain in my eye I cant stand it.
13. A nurse is teaching a group of newly licensed nurses about the progressive nature of
Alzheimer's disease. Which of the following should the nurse include in the teaching as
manifestations seen in the moderate stage of Alzheimer's disease? (Select all that apply.)
Answer: • Inability to perform common task
• Difficulty with talking or reading
14. A home health nurse is assessing an older adult client in the home who has decreased vision
due to a history of glaucoma. Which of the following findings should the nurse identify as a
safety risk?
Answer: Scatter rugs are present in the kitchen
15. A nurse at a rehabilitation center is planning care for a client who had a left hemispheric
cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse
include in the client's rehabilitation program?
Answer: Establish the ability to communicate effectively
16. A home health nurse is teaching an older adult client who just had cataract surgery. Which of
the following instructions should the nurse include?
Answer: Keep your head up and straight
17. A nurse is administering timolol eye drops to a client who has glaucoma. Which of the
following actions should the nurse take?
Answer: Drop prescribed amount of medication into the conjunctival sac
18. A nurse is instructing a client's family members about feeding safety for a client who has
dysphagia following stroke. Which of the following instructions should the nurse include?
Answer: Encourage the client to take small bites
19. A nurse is caring for a client who is recovering from a cerebrovascular accident (CVA).
Which of the following information should the nurse include when teaching family members
about repositioning the client? (Select all that apply.)
Answer: • Remove pillows prior to repositioning
• Elevate bed to waist height
• Stand with wide feet apart
• Face the direction of movement when positioning the client
20. A nurse at an outpatient surgery center is providing discharge teaching to a client and his
spouse following surgical removal of a cataract. Which of the following should the nurse include
in the teaching?
Answer: The client should wear dark glasses while outdoors
21. A nurse is caring for a client who who has had a stroke involving the right hemisphere.
Which of the following alterations in function should the nurse expect?
Answer: Inability to recognize family members
22. A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle
glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the
following instructions should the nurse provide?
Answer: Administer medications 5 min apart
23. A nurse is providing education for a client who has glaucoma. Which of the following
statements should the nurse include in the teaching?
Answer: Without treatment glaucoma can cause blindness
24. A nurse in an acute care facility is admitting an older adult client who has dementia due to
Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he
is finding it more difficult to care for his wife. Which of the following interventions is the nurse's
priority?
Answer: Ask the partners to talk about his difficulties in caring for the client
25. A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery.
Which of the following information should the nurse include?
Answer: Vision will be greatly improved on the day of the surgery
26. A nurse is caring for an older adult client who had a cerebrovascular accident and has rightsided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist
that his mother live with him. Which of the following responses should the nurse make?
Answer: So, it seems that you feel responsible for what happened to your mother
27. A nurse is providing discharge instructions for a client following cataract surgery with
insertion of an intraocular lens. Which of the following instructions should the nurse include?
Answer: Restrict lifting objects greater than 10 pounds
28. A home health nurse is reinforcing coping strategies with the family caregiver of a client who
has Alzheimer's disease. Which of the following information should the nurse include in the
teaching? (Select all that apply.)
Answer: • Actions to reduce stress
• Identification of a social support system
• Referral to available community resources
• Expected physiological changed of the disease
29. A nurse is caring for an older adult client who had a cerebrovascular accident, and has leftsided weakness The client's partner told the nurse she is worried about the next steps of treatment
for her partner. Which of the following responses should the nurse make?
Answer: We have begun plans to send your partner to a rehabilitation facility as soon as he is
stable
30. A nurse is making a home visit to a client who has Alzheimer's disease and the client's
partner. Which of the following observations indicates to the nurse that the partner is
experiencing caregiver role strain?
Answer: The partner has lost 20lb in the past 2 month
31. A nurse is planning care for a client who has dementia. Which of the following interventions
should the nurse include in the plan of care?
Answer: Limit the clients’ choices for daily activities
32. A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral
aneurysm. Which of the following manifestations should the nurse expect?
Answer: Manifestations precede by a severe headache
33. A nurse is teaching about risk factors of developing a stroke with a group of older adult
clients. Which of the following nonmodifiable risk factors should the nurse include in the
teaching?
Answer: Race
34. A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The
nurse should monitor for which of the following findings?
Answer: Intellectual impairment
35. A community health nurse is providing teaching to the family of a client who has primary
dementia. Which of the following manifestations should the nurse tell the family to expect?
Answer: Forgetfulness gradually progressing to disorientation
36. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle
glaucoma and a new prescription for timolol eye drops. Which of the following instructions
should the nurse provide?
Answer: The medication should be applied regular schedule for the rest of the client’s life
37. A nurse is talking with a client who is scheduled for surgery to repair retinal detachment.
Which of the following preoperative instructions should the nurse include?
Answer: Restrict head movements
38. A home health nurse is planning care for a client who has Alzheimer's disease. The client's
partner is her primary caregiver and reports not having enough time to complete his errands.
Which of the following referrals should the nurse plan to make?
Answer: Respite care
39. A home health nurse is planning care for a client who has Alzheimer's disease. The client's
partner is her primary caregiver and reports not having enough time to complete his errands.
Which of the following referrals should the nurse plan to make?
Answer: You are feeling drawn in two separate directions
40. A nurse is teaching the family of an older adult client who has a new diagnosis of dementia.
Which of the following statements should the nurse include in the teaching?
Answer: The signs if dementia are progressive and irreversible
41. A nurse is performing a mental status examination (MSE) on a client who has a new
diagnosis of dementia Which of the following components should the nurse include? (Select all
that apply.)
Answer: • Grooming
• Long term memory
• Affect
42. A nurse in a long-term care facility is caring for an older adult client who had a stroke 4
weeks ago and who is unable to move independently. The nurse should monitor for which of the
following complications of immobility?
Answer: Reddens area over the sacrum
43. A nurse is caring for a client who has dementia. The client is agitated and is having difficulty
staying in his chair. Which of the following actions should the nurse take first?
Answer: Place a seat alarm in the clients chair
44. A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for
treatment of pneumonia. During the night shift, the client is found climbing into the bed of
another client who becomes upset and frightened. Which of the following actions should the
nurse take?
Answer: Assist the client to the correct room
45. A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the
following statements by the client's partner should indicate to the nurse that the teaching was
effective?
Answer: My partner should tilt their head forward when swallowing
46. A nurse is caring for a client who has a history of dementia. The client is alert and oriented to
person, place, and time, and has advance directives. The client is scheduled for a procedure that
requires informed consent. Which of the following persons should sign the informed consent?
Answer: The client should sign the informed consent.
47. A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's
disease. The nurse asks the client how therapy went that morning. Which of the following
statements by the client should the nurse document as confabulation?
Answer: It was good the queen of England visited me there
