2023 ATI RN Adult Medical Surgical NGN form A, B and C Practice Exam With Answers-270 Solved Question

ATI RN ADULT MEDICAL SURGICAL 2023 FOR NGN FORM A, B & C||
ACTUAL EXAM 100 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES ALREADY GRADED A+
1. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the
following precautions should the nurse implement?
Answer: Ensure the client has a patient IV.
Rationale:
The nurse should ensure the client has IV access in the client requires medication to stop seizure
activity.
2. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of
the following laboratory values should the nurse report to the provider?
Answer: Hgb 8 g/dL
Rationale:
The nurse should report an Hgb level of 8 g/dL, which is the expected reference range and is an
indicator of postoperative haemorrhage oranemia.
3. A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago.
Which of the following findings should the nurse expect?
Answer: Stone fragments in the urine
Rationale: ESWL is an effort to break the calculi so that the fragments pass down the ureter, into
the bladder, and through the urethra during voiding.
Following the procedure, the nurse should strain the client's urine to confirm the passage of
stones.
4. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive
cough. Which of the following actions should the nurse take first?
Answer: Initiate airborne precautions.

Rationale: This client is exhibiting manifestations of tuberculosis. The greatest risk in this client
situation is for other people in the facility to acquire an airborne disease from this client.
Therefore, the first action the nurse should take is to initiate airborne precautions.
5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Anew bag is not
available when the current infusion is nearly completed. Which of the following actions should
the nurse take?
Answer: Administer dextrose 10% in water until the new bag arrives.
Rationale: TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is
temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a
precipitous drop in the client's blood glucose level.
6. A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following supplements can
interfere with the effectiveness of the medication?
Answer: Calcium
Rationale:
Calcium limits the development of osteoporosis in clients who postmenopausal and works as an
antacid. Calcium supplements can interfere with the metabolism of a number of medications,
including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr
of levothyroxine administration.
7. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The
client appears anxious and restless, and the high-pressure alarm is sounding. Which of the
following actions should the nurse take first?
Answer: Instruct the client to allow the machine to breathe for them.
Rationale:
When providing client care, the nurse should first use the restrictive intervention. Therefore, the
first action the nurse should take is to provide verbal instructions and emotional support to help
the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness
when trying to "fight the ventilator."

8. A nurse is caring for a client who has a prescription for enalapril. The nurse should identify
which of the following findings as an adverse effect of the medication?
Answer: Orthostatic hypotension
Rationale:
The nurse should identify that dilation of arteries and veins orthostatic hypotension, which is an
adverse effect of enalapril.
9. A nurse is caring for a client who has a stage III pressure injury. Which of the following
findings contributes to delayed wound healing?
Answer: Urine output 25 mL/hr
Rationale:
Urinary output reflects fluid status. Inadequate urine output indicate dehydration, which can
delay wound healing.
10. A nurse is providing teaching to an older adult client who has cancer and a new prescription
for an opioid analgesic for pain management. Which of the following information should the
nurse include in the teaching?
Answer: "You should void every 4 hours to decrease the risk of urinary retention."
Rationale:
The nurse should instruct the client to void at least every 4 hr decrease the risk of urinary
retention, which is an adverse effect of opioid analgesics.
11. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed
with food after a meal. Which of the following actions should the nurse take first?
Answer: Obtain vital signs.
Rationale:
The first action the nurse should take using the nursing to assess the client's vital signs. A client
who has portal hypertension can develop esophageal varices, which are fragile and can rupture,
resulting in large amounts of blood loss and shock. Obtaining vital signs provides information
about the client's condition that can contribute to decision making.

12. A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a
gastrectomy A nurse is providing teaching for the client. Which of the following instructions
should the nurse include?
A. Avoid drinking fluids with meals
B. Eat several small meals per day
C. Consume high protein snacks
D. Avoid highly seasoned foods
Answer: A. Avoid drinking fluids with meals
B. Eat several small meals per day
C. Consume high protein snacks
D. Avoid highly seasoned foods
Rationale: Maintain a high carbohydrate intake is incorrect. Dumping syndrome requires a low
carbohydrate diet because of reactive hypoglycemia.
Eat five servings of fresh fruit per day is incorrect. The client should limit intake to three
servings of unsweetened cooked or canned fruit per day.
Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink fluids 30
min before or after meals.
Eat several small meals per day is correct. The nurse should instruct the client to eat several
small, frequent meals instead of three large meals per day.
Consume high-protein snacks is correct. The client should eat snacks that are high in protein and
low in carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in dumping
syndrome.
Avoid highly seasoned foods is correct. The nurse should instruct the client to avoid excessive
amounts of spices and salt.
13. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing's triad?
Answer: Bradycardia
Rationale:

A client who has increased intracranial pressure from a brain injury can develop bradycardia,
which is one component of Cushing's triad. The other components of Cushing's triad are severe
hypertension and a widened pulse pressure.
14. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of
the following client statements indicates the client is successfully coping with the change?
Answer: "I used to never worry about my feet. Now, I inspect my feet every day with a mirror."
Rationale:
This statement indicates that the client is successfully coping the change because the client is
performing preventive foot care to reduce the risk for complications.
15. A nurse is assessing a male client for an inguinal hernia. Which of the following areas should
the nurse palpate to verify that the client has an inguinal hernia? (You will find hot spots to select
in the artwork below. Select only the hot spot that corresponds to your answer.)
A. The upper abdomen or epigastric region
B. The umbilical area (near the belly button)
C. The inguinal region (groin area)
D. The femoral area (upper thigh, near the groin)
Answer: C. The inguinal region (groin area)
Rationale:
A is incorrect. The nurse should palpate this location to assess the client for a femoral hernia. A
femoral hernia is composed of fat and forms in the femoral canal, which, as a result, enlarges and
pulls on the peritoneum and sometimes the bladder.
B is incorrect. The nurse should palpate this location to assess the client for an umbilical hernia.
This type of hernia can be congenital or acquired as a result of pregnancy or obesity and places
increased pressure on the abdominal wall.
C is correct. The nurse should palpate this location to assess the client for an inguinal hernia. An
inguinal hernia forms from the peritoneum, which contains part of the intestine, and can protrude
into the scrotum in men.

16. A nurse in an emergency department is reviewing the provider's prescriptions for a client who
sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the
nurse expect?
Answer: Administer an opioid analgesic to the client.
Rationale:
The nurse should expect a prescription for an opioid promote comfort following a rattlesnake
bite.
17. A nurse is caring for a client who is receiving dialysis treatment.
Answer: Perform a 12-lead ECG is not indicated. The client is not reporting chest pain;
therefore, a 12-lead ECG is not indicated at this time.
Rationale:
Place the client in Trendelenburg position is indicated. The client should be placed in the
Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ
perfusion. Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should
administer 200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's
blood pressure. Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should
administer oxygen at 2 L/min via nasal cannula to increase the amount of oxygen carried in the
blood.
Notify the provider immediately is indicated. The nurse should notify the provider immediately
as part of the nurse's role to provide an update on the client's condition.
Obtain the client's blood glucose level is not indicated. There is no indication that the client is
experiencing hypoglycemia; therefore, obtaining a blood glucose level is not indicated.
18. A nurse is teaching a class about client rights. Which of the following instructions should the
nurse include?
Answer: A client should sign an informed consent before receiving a placebo during a research
trial.
Rationale:

A nurse should ensure a client has provided informed before administering a placebo. The nurse
should not administer a placebo to a client who thinks it is an active medication, because this
action is a violation of client rights.
19. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for
omeprazole. The nurse should instruct the client that the medication provides relief by which of
the following actions?
Answer: Suppressing gastric acid production
Rationale:
Omeprazole is a proton pump inhibitor. It relieves of gastric ulcers by suppressing gastric acid
production.
20. A nurse is caring for a group of clients. The nurse should plan to make a referral to physical
therapy for which of the following clients?
Answer: A client who is receiving preoperative teaching for a right knee arthroplasty
Rationale:
The nurse should make a referral to physical therapy for a who is receiving preoperative teaching
for a knee arthroplasty so the client can begin understanding postoperative exercises and physical
restrictions.
21. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis.
The nurse should give the AP which of the following instructions?
Answer: Wear a mask
Rationale:
Bacterial meningitis requires droplet precautions; therefore, AP and the nurse should wear a
mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun
receiving antibiotic therapy.
22. A nurse is providing teaching to an older adult female client who has stress incontinence and
a BMI of 32. Which of the following statements by the client indicates an understanding of the
teaching?

Answer: "I am dieting to lose weight."
Rationale:
Excess weight creates increased abdominal pressure that result in stress incontinence.
23. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following
assessment findings should the nurse expect?
Answer: Hypoactive bowel sounds
Rationale: Hypokalaemia decreases smooth muscle contraction in the gastrointestinal tract
leading to decreased peristalsis.
24. The nurse is reviewing the client's diagnostic results. Which of the following findings
requires follow-up by the nurse? Select all that apply.
A. PCO2level
B. WBC
C. count Chest X- ray
D. Oxygen saturation level
E. BUN level
Answer: A. PCO2level
B. WBC
C. count Chest X- ray
D. Oxygen saturation level
E. BUN level
Rationale:
PCO2 level is correct. The client has an elevated PCO2 level, which indicates there tension of
carbon dioxide. Therefore, this finding requires follow-up by the nurse.
WBC count is correct. The client has an elevated WBC count, which indicates an infection.
Therefore, this finding requires follow-up by the nurse.
Chest x-ray is correct. The client's chest x-ray indicates increased opacity in the bilateral
posterior lobes, which is a manifestation of pneumonia. Therefore, this finding requires followup by the nurse.

Oxygen saturation level is correct. The client's oxygen saturation is decreased, which is a
manifestation of pneumonia. Therefore, this finding requires follow-upby the nurse.
Calcium level is incorrect. The client's calcium level is within the expected reference range.
Therefore, this finding does not require follow-up by the nurse.
HCO3- level is incorrect. The client's HCO3- level is within the expected reference range.
Therefore, this finding does not require follow-up by the nurse.
BUN level is correct. The client's BUN is elevated, which is a manifestation of dehydration or
kidney disease. Therefore, this finding requires follow-up by the nurse.
25. Click to highlight the findings below that indicate that the client has a potential problem. To
deselect a finding, click on the finding again.
A. Client is short of breath and has a productive cough with yellow mucus
B. "I could barely breathe when I got up this morning and I had a throbbing headache."
C. Crackles heard in posterior lungs Client is diaphoretic
D. Capillary refill less than 2 seconds
E. Client is diaphoretic
F. Pedal pulses +2 bilaterally
Answer: A. Client is short of breath and has a productive cough with yellow mucus
B. "I could barely breathe when I got up this morning and I had a throbbing headache."
C. Crackles heard in posterior lungs Client is diaphoretic
D. Capillary refill less than 2 seconds
E. Client is diaphoretic
F. Pedal pulses +2 bilaterally
Rationale:
Client is short of breath and has a productive cough with yellow mucus is correct. Shortness of
breath, along with a productive cough with yellow mucus, indicates a potential problem.
"I could barely breathe when I got up this morning and I had a throbbing headache" is correct.
Difficulty breathing and a throbbing headache indicates a potential problem.
Crackles heard in posterior lungs is correct. Crackles heard in the posterior lower lobes indicate a
potential problem.

Capillary refill less than 2 seconds is incorrect. A capillary refill less than 2 seconds is within the
expected reference range and indicates adequate perfusion.
Client is diaphoretic is correct. Diaphoresis is a manifestation of an elevated temperature or
hypoglycaemia and indicates a potential problem.
Pedal pulses +2 bilaterally is incorrect. Pedal pulses +2 bilaterally is within the expected
reference range and indicates adequate perfusion.
26. The nurse should first address the client's followed by the client's
Answer: Oxygen saturation
Temperature
Rationale:
Dropdown 1
Oxygen saturation is correct. The first action the nurse should take when using the airway,
breathing, and circulation approach to client care is to address the client's oxygen saturation. The
client's oxygen saturation is 88%, which indicates hypoxemia and requires supplemental oxygen.
Loss of appetite is incorrect. The nurse should address the client's loss of appetite, which is a
manifestation of an infection. However, there is another finding the nurse should address first.
BUN level is incorrect. The nurse should address the client's BUN level because itis elevated.
However, there is another finding the nurse should address first.
Dropdown 2
Heart rate is incorrect. The nurse should address the client's elevated heart rate, which can result
in decreased cardiac output. However, there is another finding the nurse should address first.
Temperature is correct. The nurse should next address the client's elevated temperature, which is
a manifestation of an infection. The client's elevated temperature can cause an increase in other
vital signs, such as heart rate.
Headache is incorrect. The nurse should address the client's headache, which is a manifestation
of an infection. However, there is another finding the nurse should address first.
27. For each potential provider's prescription, click to specify if the potential prescription is
anticipated, nonessential, or contraindicated for the client.
Answer: Cough and deep breathe every 2 hr is anticipated.

Rationale:
The nurse should anticipate a prescription for coughing and deep breathing to promote lung
expansion and improve impaired gas exchange. Obtain a sputum culture and sensitivity is
anticipated.
The nurse should anticipate a prescription for a sputum culture and sensitivity to determine the
type of bacteria present and to identify antibiotics to be prescribed. Perform neurological checks
every 2 hr is nonessential.
The client is alert and oriented to person, place, and time. Therefore, the nurse does not need to
perform neurological checks every 2 hr.
Administer oxygen at 3 L/min via nasal cannula is anticipated. The client's oxygen saturation
level is 88% on room air, which indicates hypoxemia. Therefore, the nurse should administer
oxygen at 3 L/min via nasal cannula.
Limit the client's fluid intake to 1,500 mL per day is contraindicated.
The client has manifestations of dehydration. Therefore, fluid restriction is contraindicated.
Acetaminophen 500 mg PO every 6 hr as needed is anticipated.
The nurse should anticipate a prescription for acetaminophen to reduce the client's temperature
and promote comfort. Famotidine 40 mg PO daily is nonessential.
Famotidine is a histamine2 antagonist that is used in short-term therapy for the treatment of
peptic ulcers. Therefore, the nurse does not need to administer famotidine 40 mg PO daily.
28. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing
intervention.
Answer: Temperature
WBC count
Potassium level
Rationale:
Temperature is correct. The nurse should identify that the client continues to have a fever as a
result of the body's immune system fighting the infection. Therefore, this finding requires
nursing intervention.
WBC count is correct. The nurse should identify that the client's WBC count remains elevated,
which indicates an infection. Therefore, this finding requires nursing intervention.

Heart rate is incorrect. The nurse should identify the client's heart rate is within the expected
reference range. Therefore, this finding does not require nursing intervention.
Potassium level is correct. The nurse should identify that the client's potassium level is elevated,
which places them at risk for cardiac dysrhythmias. Therefore, this finding requires nursing
intervention.
Oxygen saturation is incorrect. The nurse should identify the client's oxygen saturation has
improved and is within the expected reference range.
Therefore, this finding does not require nursing intervention.
29. The nurse is reviewing the client's medical record from Day 5.Click to highlight the findings
below that indicate the client is improving. To deselect a finding, click on the finding again.
Answer: Heart rate is 72/min
Respiratory rate is 20/min
Blood pressure is 128/56 mm Hg
Oxygen saturation is 95% on room air
Rationale:
Heart rate is 72/min is correct. The client's heart rate, respiratory rate, and blood pressure are
within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and
cardiovascular statuses are improving.
Respiratory rate is 20/min is correct. The client's heart rate, respiratory rate, and blood pressure
are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary
and cardiovascular statuses are improving.
Blood pressure is 128/56 mm Hg is correct. The client's heart rate, respiratory rate, and blood
pressure are within the expected reference ranges. Therefore, this finding indicates the client's
pulmonary and cardiovascular statuses are improving.
Oxygen saturation is 95% on room air is correct. The client's oxygen saturation is within the
expected reference range and no longer requires supplemental oxygen. Therefore, this finding
indicates the client's pulmonary status is improving.
Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard upon
auscultation is incorrect. The nurse should identify that the client's lungs sounds are still
diminished in the bilateral posterior bases with occasional crackles heard upon auscultation due

to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory
status is not improving. Cough is productive with yellow mucus is incorrect. The client's cough
is still productive with yellow mucus due to the client's acute respiratory infection. Therefore,
this finding indicates the client's respiratory status is not improving.
30. A nurse is teaching a young adult client how to perform testicular self- examination. Which
of the following instructions should the nurse include?
Answer: Roll each testicle between the thumb and fingers.
The nurse should instruct the client to roll each testicle horizontally between the thumbs and
fingers to feel for any lumps deep in the centre of the testicle.
31. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the
following is the priority assessment finding that the nurse should report to the provider?
Answer: Blood pressure 170/80 mm Hg determine Hg, which indicates that the client is at risk
for thyroid storm.
32. A nurse is caring for a client who is undergoing haemodialysis to treat end- stage kidney
disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which
of the following medications should the nurse plan to administer?
Answer: Calcium carbonate
Rationale:
Hypocalcaemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring
late in the dialysis session, hypocalcaemia can cause the client to experience muscle cramping
and tingling to extremities. The nurse should plan to administer a calcium supplement, such as
calcium carbonate, as a calcium replacement.
33. A nurse is caring for a client who is having a seizure. Which of the following interventions is
the nurse's priority?
Answer: Turn the client to the side.
Rationale:

The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority
intervention the nurse should take is to place the client in a side- lying position to prevent
aspiration.
34. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the client to withhold
for 48 hr prior to cardioversion?
Answer: Digoxin
35. A nurse in a providers office is caring from a client who requests sildenafil to treat erectile
dysfunction. Which of the following statements should the nurse make?
Answer: "You will not be able to use sildenafil if you are taking nitro-glycerine."
Rationale:
The client should not use sildenafil when taking nitro-glycerine because both medications can
cause vasodilation and lead to significant hypotension.
36. A nurse is assessing a client following the administration of magnesium sulphate 1 gIV bolus.
For which of the following adverse effects should the nurse monitor?
Answer: Respiratory paralysis
Rationale:
The nurse should monitor a client who is receiving magnesium sulphate via IV bolus closely as
the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system.
Respiratory paralysis is a life threatening adverse effect of magnesium sulphate.
Tachycardia- Magnesium sulphate is used to treat cardiac dysrhythmias, such astorsades de
pointes and refractory ventricular fibrillation. Depressed cardiac function, including heart block,
is an adverse effect of magnesium sulfate.
Increased BP- Magnesium sulfate is used to treat cardiac dysthymias, such as torsade’s des
pointes and refractory ventricular fibrillation. However, magnesium sulfate administration can
result in systemic vasodilation and subsequent hypotension. hyperreflexia- Hyperreflexia is seen
in clients who have hypomagnesemia. Depressed or absent reflexes are an adverse effect of
magnesium sulfate.

37. A nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: "I am taking this medication to increase my energy level."
Rationale:
The goal of erythropoietin therapy is to increase the level of haematocrit in clients who have
anaemia. When the medication is effective, the client should have a decrease in fatigue and an
improvement in activity tolerance.
38. A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of
the following findings should the nurse identify as a manifestation of chronic
glomerulonephritis?
Answer: Hyperkalaemia
Rationale:
The nurse should identify that a client who has chronic glomerulonephritis can experience
hyperkalaemia as a result of kidney failure. Kidney failure results in decreased excretion of
potassium.
39. A nurse in a provider's office is assessing a client who has migraine headaches and is taking
feverfew to prevent headaches. The nurse should identify that which of the following client
medications interacts with feverfew?
Answer: Naproxen
Rationale:
Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.
40. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend?
Answer: Add cabbage to the diet.
Rationale:

To help reduce the risk for colorectal cancer, the client should consume a diet that is high in
fibre, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage,
cauliflower, and broccoli, are high in fibre.
41. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place
which of the following items at the client's bedside?
Answer: Suction machine
Rationale:
The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to
clear the client's airway as needed and reduce the risk for aspiration.
42. A nurse is conducting an admission history for a client who is to undergo a CT scan with an
IV contrast agent. The nurse should identify that which of the following findings requires further
assessment?
Answer: History of asthma
Rationale:
A client who has a history of asthma has a greater risk of reacting to the contrast dye used during
the procedure. Other conditions that can result in a reaction to contrast media include allergies to
foods, such as shellfish, eggs, milk, and chocolate.
43. A nurse is assessing a client who has Graves' disease. Which of the following images should
indicate to the nurse that the client has exophthalmos?
Answer: wide-open or bulging eyes
Rationale:
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can
increase ventricular irritability and put the client at risk for ventricular fibrillation after the
synchronized countershock of cardioversion.
44. A nurse in a provider's office is assessing a client who has hypertension and takes
propranolol. Which of the following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication?

Answer: Report of a night cough
Rationale:
The nurse should recognize that a night cough is an early indication of heart failure and report
this adverse reaction to the provider.
45. A nurse is creating a plan of care for a client who has neutropenia as a result of
chemotherapy. Which of the following interventions should the nurse include in the plan?
Answer: Monitor the client's temperature every 4 hr.
Rationale:
The nurse should monitor the temperature of a client who has neutropenia every 4hr because the
client's reduced amount of leukocytes greatly increases the client's risk for infection.
46. A nurse is caring for a client who was just admitted from the emergency department (ED)
Answer: Acute chest syndrome and pneumonia
Rationale:
Fluid volume overload is incorrect. While the client is experiencing an increased respiratory rate
and shortness of breath, fluid volume overload typically includes moist crackles on auscultation,
pitting edema in dependent areas, neck vein distension, and hypertension.
Right-sided heart failure is incorrect. While clients who have sickle-cell disease are at risk for
developing heart failure, the client does not have manifestations of right-sided heart failure.
Right-sided heart failure typically presents with signs of fluid volume overload, which includes
jugular vein distention, dependent edema, and blood pressure alterations.
Acute chest syndrome is correct. The client is most likely experiencing acute chest syndrome,
which can be caused by respiratory infections and debris from sickled cells. The client is
displaying manifestations of acute chest syndrome, which include cough, shortness of breath,
wheezing, tachy pnea, fever, and chest pain.
Pneumonia is correct. The client is most likely experiencing pneumonia as evidenced by the
manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and chest
pain.

Pneumothorax is incorrect. While the client is experiencing increased respiratory distress, a
pneumothorax typically presents with reduced or absent breath sounds and unequal chest
expansion.
47. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory results to be below the expected reference range?
Answer: Calcium
Rationale:
A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to
fat necrosis.
48. A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN).
The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump
should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing zero.)
Answer: 167
X mL/hr = Volume (mL)/Time
(hr)X mL/hr = 4000mL/24 hr
X mL/hr = 166.67
Round if necessary. 166.67 = 167 mL/hr
49. A nurse is planning teaching for a client who has bladder cancer and is to undergo a
cutaneous diversion procedure to establish a ureterostomy. Which of the following statements
should the nurse include in the teaching?
Answer: "You should cut the opening of the skin barrier one- eighth inch wider than the stoma."
Rationale:
The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to
minimize irritation of the skin from exposure to urine.

50. A nurse in an emergency department is caring for a client who reports vomiting and diarrhoea
for the past 3 days. Which of the following findings should indicate to the nurse that the client is
experiencing fluid volume deficit?
Answer: Heart rate 110/min
Rationale:
A client who has a 3-day history of vomiting and diarrhoea is likely to have fluid volume deficit
and an elevated heart rate.
51. A nurse is providing teaching to a client who is receiving chemotherapy and has a new
prescription for epoetin alfa. Which of the following client statements indicates an understanding
of the teaching?
Answer: "I will monitor my blood pressure while taking this medication."
Rationale:
The client should monitor their blood pressure while taking this medication because hypertension
is a common adverse effect and can lead to hypertensive encephalopathy.
52. A nurse is caring for a client who is postoperative. Which of the following actions should the
nurse take?
Answer: Instruct the client to splint the abdomen with a pillow for coughing
Plan to ambulate the client as soon as possible
Report urinary output to the provider
Ask the client to rate their pain on a 0 to 10 pain scale
Rationale:
Apply oxygen via a face mask is incorrect. It is not necessary to place a face mask on the client
because their SaO2 is within the expected reference range of 95% to 100%.
Instruct the client to splint the abdomen with a pillow for coughing is correct. It is important for
the client to turn, cough, and deep breathe to reduce the risk for respiratory complications. The
nurse should instruct the client to splint the incision while performing these actions to reduce the
risk of complications to the surgical incision.
Plan to ambulate the client as soon as possible is correct. The nurse should plan to ambulate the
client as soon as possible to promote ventilation and decrease the risk of thrombosis.

Report urinary output to the provider is correct. The client should produce at least30 mL of urine
per hour. Therefore, the nurse should report this finding to the provider.
Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse should have the client
rate their pain prior to and following the administration of pain medication to evaluate its
effectiveness.
53. A nurse is planning care to decrease psychosocial health issues for a client who is starting
dialysis treatments for chronic kidney disease. Which of the following interventions should the
nurse include in the plan?
Answer: Tell the client that it is possible to return to similar previous levels of activity.
Rationale:
The nurse should help the client develop realistic goals and activities to have a productive life.
54. A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in the plan
of care to prevent a Pseudomonas aeruginosa infection?
Answer: Avoid placing plants or flowers in the client's room.
Rationale:
Live plants can harbour P. aeruginosa, and this bacterium can infect burn wounds and cause lifethreatening complications. The nurse should ensure no one brings live plants or flowers into the
client's room.
55. A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being
admitted to the hospital with pneumonia. Which of the following assessment findings is the
nurse's priority?
Answer: Increased respiratory secretions
Rationale:
Using the airway, breathing, circulation approach to client care, the nurse should determine that
the priority assessment finding is increased respiratory secretions. These secretions place the
client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS
and the pneumonia.

56. A nurse is assessing a group of clients for indications of role changes. The nurse should
identify that which of the following clients is at risk for experiencing a role change?
Answer: A client who has multiple sclerosis and is experiencing progressive difficulty
ambulating
Rationale:
The nurse should identify that progression of a neurologic disease such as multiple sclerosis can
lead to a role change as the client becomes less independent.
57. A nurse is caring for a client who has hepatic encephalopathy that is being treated with
lactulose. The client is experiencing excessive stools. Which of the following findings is an
adverse effect of this medication?
Answer: Hypokalaemia
Rationale:
Lactulose works by stimulating the production of excess stools to rid the body of excess
ammonia. These excessive stools can result in hypokalaemia and dehydration.
58. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
laboratory findings should the nurse expect?
Answer: BUN 32 mg/dL
Rationale:
DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client
who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the
excess glucose present in the urine.
59. Select the 4 findings that require follow-up by the nurse.
Answer: Virtual disturbances
Tingling of the lips
Hand grasps
Expressive aphasia
Rationale:

Visual disturbances is correct. Visual disturbances are manifestations of a neurological event.
Therefore, the nurse should follow-up on this finding.
Blood pressure is incorrect. The client's blood pressure is within the expected reference range.
Therefore, this finding does not require follow-up by the nurse.
Tingling of the lips is correct. Tingling in the face is a manifestation of a neurological event.
Therefore, the nurse should follow-up on this finding.
Orientation is incorrect. The client is alert and orientated x3, which is an expected finding.
Therefore, this finding does not require follow-up by the nurse.
Hand grasps is correct. The client's hand grasps are unequal, which could indicate a neurological
deficit. Therefore, this finding requires follow-up by the nurse.
Expressive aphasia is correct. Expressive aphasia is a manifestation of a neurological event.
Therefore, the nurse should follow-up on this finding.
Pain is incorrect. The client denies pain. Therefore, this finding does not require follow-up by the
nurse.
60. For each finding below, click to specify if the finding is consistent with migraine, stroke, or
meningitis. Each finding can support more than one disease process.
Answer: Hand grasps is consistent with migraine, stroke, and meningitis.
Rationale:
Unilateral weakness can occur due to neurological vascular changes and inflammation that can
be present with migraine, stroke, and meningitis. Numbness is consistent with migraine and
stroke. Numbness and tingling of the lips and tongue can occur with migraines due to
neurological vascular changes and inflammation that can be present. Numbness can also occur
with middle cerebral artery strokes. Aphasia is consistent with migraine and stroke. Aphasia can
occur due to neurological vascular changes and inflammation that can be present with a migraine
and stroke.
Visual changes are consistent with migraine, stroke, and meningitis. Visual changes can occur
with migraine, stroke, and meningitis due to neurological vascular changes and inflammation
that can be present.
Family history is consistent with migraine and stroke. Family history is a risk factor associated
with migraine and stroke.

61. The nurse should identify that the client is most likely experiencing Select...and the nurse
should address the client's Select.
Answer: A migraine Pain
Rationale:
Dropdown 1
A migraine is correct. The client is exhibiting manifestations of a migraine. The client presented
initially with neurological manifestations of flashing lights, aphasia, unilateral weakness, and
numbness of the lips.
These findings are consistent with the first phase, or aura phase, of a migraine. These changes
resolved after an hour and were followed by throbbing pain with nausea and vomiting.
A stroke is incorrect. A client who is experiencing a stroke will have neurological manifestations;
however, these changes would not resolve after 1 hr.
Meningitis is incorrect. A client who is experiencing meningitis will have neurological
manifestations; however, these changes would not resolve after 1 hr.
Dropdown 2
Blood pressure is incorrect. Although the client's blood pressure is mildly elevated, it does not
require intervention by the nurse.
Pain is correct. The client reports pain as 7 on a scale of 0 to 10, which indicates significant
discomfort. The nurse should address the client's pain level to promote comfort.
Neurological status is incorrect. The client's neurological changes have resolved. Therefore, this
finding does not require intervention by the nurse.
62. A nurse is caring for a client who has a migraine. Which of the following interventions
should the nurse anticipate? Select all that apply.
Answer: Administer sumatriptan
Dim the lights in the client's room
Rationale:
Administer sumatriptan is correct. The nurse should plan to administer a medication, such as
sumatriptan, to produce cerebral artery vasoconstriction and relieve the client's manifestations.

Prepare the client for a lumbar puncture is incorrect. A lumbar puncture is indicated for clients
who are having manifestations of meningitis.
Administer phenobarbital is incorrect. Phenobarbital is indicated for clients who are experiencing
seizures.
Dim the lights in the client's room is correct. The nurse should plan to dim the lights in the
client's room to promote comfort because the client is experiencing photophobia.
Prepare to initiate fibrinolytic therapy is incorrect. The nurse should prepare to initiate
fibrinolytic therapy for clients who are experiencing a stroke. Fibrinolytic therapy is
administered during the acute phase of a stroke to decrease clot formation.
Place the client in seizure precautions is incorrect. The nurse should initiate seizure precautions
for clients who are at risk for a seizure.
63. Following the administration of sumatriptan, the nurse should monitor for Select due to the
risk of Select.
Answer: Chest pain
Myocardial ischemia
Rationale:
Dropdown 1
Dehydration is incorrect. Sumatriptan does not cause fluid loss, which could lead to dehydration.
Chest pain is correct. The nurse should monitor the client for chest pain because sumatriptan can
cause coronary vasospasms.
Reflux is incorrect. Reflux is not an adverse effect of sumatriptan.
Dropdown 2
Peptic ulcer disease is incorrect. Peptic ulcer disease is not an adverse effect of sumatriptan.
Diuresis is incorrect. Fluid loss is not an adverse effect of sumatriptan. Myocardial ischemia is
correct. Sumatriptan can cause coronary vasospasms, which can lead to myocardial ischemia.
64. The nurse is evaluating the client's understanding of discharge instructions. Which of the
following client statements indicates an understanding of the teaching?
Answer: "Foods that contain tyramine might trigger my headaches"
"I will keep a food and headache diary"

"I will place a cool cloth on my forehead when I experience a migraine"
Rationale:
"Foods that contain tyramine might trigger my headaches" is correct. Tyramine-containing foods,
such as aged cheeses, smoked sausage, pickles, and beer are common triggers for migraines.
"I will keep a food and headache diary" is correct. The nurse should instruct he client to keep a
food and headache diary to identify migraine triggers.
"I will place a cool cloth on my forehead when I experience a migraine" is correct. The nurse
should instruct the client to lie down, dim the lights, and place a cool cloth on the forehead to
relieve migraine pain. "I will take the sumatriptan once every day" is incorrect. Sumatriptan is
not administered to prevent a migraine, rather, it is used to treat an occurring migraine. The nurse
should instruct the client to take the sumatriptan only as needed for migraine pain.
"I should stay awake until my headache is gone" is incorrect. The nurse should instruct the client
to lie down, dim the lights, and place a cool cloth on the forehead to relieve migraine pain. The
client should be encouraged to sleep until the migraine is resolved.
65. A nurse is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
Answer: Demonstrate ways to deep breath and cough.
Rationale:
The nurse should demonstrate deep breathing and coughing exercises and explain the importance
of splinting the incision to reduce the risk for respiratory complications.
66. A nurse is providing teaching to a female client who has a history of urinary tract infections
(UTIs). Which of the following information should the nurse include in the teaching?
Answer: Take daily cranberry supplements.
Rationale:
The client should take cranberry supplements or drink low-fructose cranberry juice because it
contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a
UTI.

67. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal
implant to treat endometrial cancer. Which of the following actions should the nurse include in
the client's plan of care?
Answer: Wear a lead apron while providing care to the client.
Rationale:
The nurse should wear a lead apron when providing direct care to provide protection from the
radiation source and not turn their back toward the client, because the apron only shields the
front of the body. The nurse should also wear a dosimeter film badge to measure radiation
exposure.
68. A nurse is providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statements should the nurse identify as an indication
that the client understands the teaching?
Answer: "I will use my hands rather than a washcloth to clean the radiation area."
Rationale:
The client should gently wash the radiation area with their hands using warm water and mild
soap to protect the skin from further irritation.
69. A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after
hospitalization for heart failure. Based on the information in the client's chart, which of the
following findings should the nurse report to the provider?
Answer: Heart rate 55/min
Rationale:
The client's heart rate of 55/min is a decrease from the client's baseline of 74/mainland it can
indicate the development of digoxin toxicity. The nurse should report this finding to the provider.
70. A nurse is providing instructions to a client who has type 2 diabetes mellitus and anew
prescription for metformin. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: "I should take this medication with a meal."
Rationale:

The client should take metformin with or immediately following meals to improve absorption
and to minimize gastrointestinal distress.
71. The client is experiencing manifestations of due to.
Answer: Peritonitis X-ray results
Rationale:
Dropdown 1
Peritonitis is correct. The client is experiencing manifestations of peritonitis, such as abdominal
pain, cloudy dialysate, and an elevated white blood cell count.
Myxedema coma, haemorrhage, dysrhythmias and pneumonia are incorrect. The client does not
exhibit manifestations of any of these conditions based on assessment and laboratory findings.
Dropdown 2
X-ray results are correct. The client's abdominal x-ray shows fluid in the abdomen along with
inflammation, both of which are indications of peritonitis. Thyroid level, platelet count,
potassium level and oxygen saturation are incorrect. These laboratory findings and the oxygen
saturation are within the expected reference range and do not indicate peritonitis.
72. A nurse is providing discharge instructions to a client who has a partial- thickness burn on the
hand. Which of the following instructions should the nurse include?
Answer: Wrap fingers with individual dressings.
Rationale:
The nurse should instruct the client to wrap the fingers individually to allow for functional use of
the hand while healing occurs. The nurse should also instruct the client to perform range-ofmotion exercises to each finger every hour while awake to promote function of the injured hand.
73. An older adult client is brought to an emergency department by a family member. Which of
the following assessment findings should cause the nurse to suspect that the client has hypertonic
dehydration?
Answer: Urine specific gravity 1.045
Rationale:

A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase
in osmolarity, which is a manifestation of hypertonic dehydration.
Normal range: 1.010 - 1.020
74. A nurse is providing discharge instructions to a client following an upper gastrointestinal
series with barium contrast. Which of the following information should the nurse provide?
Answer: Increase fluid intake.
Rationale:
Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the
client to increase fluid intake to facilitate the elimination of the barium used during the test.
75. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following
actions should the nurse take?
Answer: Remain with the client for the first 15 min of the infusion.
Rationale:
The nurse should remain with the client for the first 15 to 30 min of the infusion because
haemolytic reactions usually occur during the infusion of the first 50 mL of blood.
76. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago.
Which of the following actions should the nurse take?
Answer: Check that one finger fits between the cast and the leg.
Rationale:
To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast.
It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr
after application.
77. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin
subcutaneous. Which of the following actions should the nurse take?
Answer: Inject the medication into the anterolateral abdominal wall.
Rationale:

The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to
enhance medication absorption and prevent hematoma formation.
78. A nurse has received change-of-shift report for a group of clients. Which of the following
clients should the nurse assess first?
Answer: A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN
sublingual nitro-glycerine tablet
Rationale:
When using the stable vs. unstable approach to client care, the nurse should assess this client
first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual
nitro-glycerine tablet could be unstable.
This client might be experiencing angina or could be having another MI.
79. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the
formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity.
Which of the following interventions is the nurse's priority?
Answer: Apply firm pressure to the insertion site.
Rationale:
The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to
apply firm pressure to the hematoma to stop the bleeding.
80. A nurse is assessing a client who has acute cholecystitis. Which of the following findings is
the nurse's priority?
Answer: Tachycardia
Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to
shock. The nurse should position the head of the client's bed flat and report this finding
immediately to the provider.

81. A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the
following laboratory values should the nurse expect?
Answer: Elevated bilirubin level
Rationale:
Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the
haemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the
client's degree of jaundice.
82. A nurse is caring for a client in the emergency department (ED).
Answer: Administer morphine
Ensure the patient is NPO Cholecystitis
Monitor the colour of the client's stools Monitor the client for dark urine
Rationale:
The nurse should plan to administer an opioid analgesic, such as morphine, for acute pain. Since
the client is experiencing nausea and vomiting, the nurse should also ensure they are NPO. The
client is likely experiencing cholecystitis, which typically presents with nausea, vomiting, upper
abdominal pain that radiates to the right shoulder, fever, and dyspepsia. The client also has
elevated liver enzymes and a WBC count, which is consistent with cholecystitis. Surgical
management for cholecystitis might be indicated. The nurse should monitor the client's stool and
urine colour because a biliary obstruction from gallstones may cause clay-coloured stools and
dark urine.
83. A nurse is performing a dressing change for a client who is recovering from a
hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is
protruding through the abdomen. Which of the following actions should the nurse take first?
Answer: Call for help.
Rationale:
Evidence-based practice indicates that the nurse should first stay with the client and call for
assistance. The client will require emergency surgery and is at risk for shock; therefore, the nurse
should obtain immediate assistance.

84. A nurse in a community clinic is caring for a client who reports an increase in the frequency
of migraine headaches. To help reduce the risk for migraine headaches, which of the following
foods should the nurse recommend the client avoid?
Answer: Aged cheese
Rationale:
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.
85. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter
placed. Which of the following findings indicates that the client is experiencing increased
intracranial pressure (ICP)? (Select all that apply.)
Answer: Sleepiness exhibited by the client
Widening pulse pressure
Decerebrate posturing
Rationale:
Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15 indicates
neurological functioning within the expected reference range for eye opening, motor, and verbal
response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased
ICP.
86. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a
pressure injury. Which of the following actions should the nurse take?
Answer: Use a 30-mL syringe
Rationale:

The nurse should use a 30-mL to 60-mL syringe with an 18- or 19gauge catheter to deliver the
ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy
granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.
87. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
Answer: Loosen restrictive clothing.
Rationale:
The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.
88. A nurse is assessing a client who has had a suspected stroke. The nurse should place the
priority on which of the following findings?
Answer: Dysphagia
Rationale:
Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and
function within the oral cavity. Therefore, the nurse should place priority on this finding.
89. A nurse is planning to provide discharge teaching for the family of an older adult client who
has hemianopsia and is at risk for falls. Which of the following instructions should the nurse
include?
Answer: Remind the client to scan their complete range of vision during ambulation.
Rationale:
The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half
of the visual field, to use visual scanning to look over their complete range of vision during
ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for
falls.
90. A nurse is caring for a client who is receiving morphine for daily dressing changes. The client
tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of
the following actions should the nurse take?
Answer: Instruct the client on alternative therapies for pain reduction.

Rationale:
The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain
management, such as relaxing activities and distraction.
91. A nurse is providing follow-up care for a client who sustained a compound fracture3 weeks
ago. The nurse should recognize that an unexpected finding for which of the following laboratory
values is a manifestation of osteomyelitis and should be reported to the provider?
Answer: An increased sedimentation rate occurs when a client has any type of inflammatory
process, such as osteomyelitis
92. A nurse is reviewing the medical records of a client who is taking WARFARIN for chronic
arterial fibrillation. Which of the following values should the nurse identify as a desired outcome
for this therapy?
Answer: INR 2.5
Rationale:
Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or
pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication
must be monitored to ensure the anticoagulation is within the therapeutic range and prevent
haemorrhage (levels of anticoagulation) or stroke, MI, PE (low levels of anticoagulation). An
INR 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.
93. A nurse is planning a health promotional presentation for a group of African American clients
at a community centre. Which of the following disorders presents the greatest risk to this group
of clients?
Answer: Hypertension
Rationale:
When using the safety/risk reduction approach to client care, the nurse should determine that the
disorder with the greatest risk for this group of clients is hypertension. The prevalence of
hypertension is highest among African American clients, followed by Caucasian clients, and then
Hispanic clients.

94. A nurse is reviewing the laboratory results of a client who has aplastic anaemia. Which of the
following findings indicates a potential complication?
Answer: WBC count 2,000/mm3
Rationale:
A WBC count of 2,000/mm3 is below the expected reference range and indicates a risk for severe
immunosuppression
95. A nurse is caring for an older adult client who has dementia and requires acute care for a
respiratory infection. The client is agitated and is attempting to remove the IV catheter. Which of
the following actions should nurse take to avoid restraining the client?
Answer: Keep the client occupied with a manual activity.
Rationale:
The nurse should provide the client with a manual activity such as a puzzle or an art project. This
can help to distract the client from the IV catheter.
96. A nurse is planning care for a client who has a sealed radiation implant for cervical cancer.
Which of the following interventions should the nurse include in the plan of care?
Answer: Keep a lead-lined container in the client's room
Rationale:
The nurse should keep a lead-lined container and forceps in the client's room in case of
accidental dislodgement of the implant.
97. A nurse reviewing the ABG results of a client who has advanced COPD. Which of the
following results should the nurse expect?
Answer: PaCO2 56 mm Hg
Rationale:
A client who has COPD retains PaCO2 duet to the weakening and the collapse of the alveolar
sacs, which is decreases the area in the lings for gas exchange and causes the PaCO2 to increase
above the expected reference range.

98. A nurse is assessing a client who has peripheral arterial disease. Which of the following
findings should the nurse expect?
Answer: Hair loss on the lower legs
Rationale:
The nurse should expect a client who has a peripheral arterial disease to have hair loss on the
lower legs as a result of impaired arterial circulation affecting follicular growth. they pain
99. A nurse is caring for a client who has breast cancer and tells the nurse that would like to have
acupuncture because it provides greater relief than medication Which of the following statements
should the nurse make?
Answer: " I can speak to the provider about incorporating acupuncture into your treatment plan."
Rationale:
The nurse should serve as an advocate for the client by acting on behalf of the client and offering
to speak with the provider. The client has the right to make choices and decisions about their
treatment and the nurse should support these decisions and assist the client to carry them out.
100. A nurse is providing teaching to a client who has hypertension and a NEW prescription for
verapamil. Which of the following information should the nurse include in the teaching?
Answer: " Increase fibre intake to avoid constipation."
Rationale:
The nurse should instruct the client that constipation is an adverse effect of verapamil. The client
should increase fibre intake to promote regular bowel function.
101. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the
following interventions should the nurse include in the plan?
Answer: Encourage the client to take deep breaths after the procedure
Rationale:
After a thoracentesis, the client should deep breathe to re-expand the lung.

102. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription
for gentamicin. Which of the following findings from the client's medical record should indicate
to the nurse the need to withhold the medication and notify the provider?
Answer: Serum Creatinine
Rationale:
A client who has an elevated serum creatinine level should not receive gentamicin because the
medication is nephrotoxic.
103. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty.
Which of the following instructions should the nurse include?
Answer: Flex the foot every hour when awake
Rationale:
The nurse should instruct the client to flex the foot every hour to reduce the risk for
thromboembolism and promote venous return.
104. A nurse is teaching a group of newly licensed nurses about pain management for older adult
clients. Which of the following statements by a newly licensed nurse indicates an understanding
of the teaching?
Answer: "Ibuprofen can cause gastrointestinal bleeding in older adult clients."
105. A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the
client that which of the following medications can increase their risk for developing
osteoporosis?
Answer: Prednisone
Rationale:
The nurse should instruct the client that prednisone can increase the risk of developing
osteoporosis due to suppression of bone formation, and an increase in bone resorption by
osteoclasts. Prednisone can also reduce intestinal absorption of calcium.

106. A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To
reduce the risk of falls when ambulation, the nurse should provide which of the following
instructions to the client?
Answer: " Scan the environment by turning your head from side to side."
Rationale:
Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head
from side to side helps enlarge a client's visual field. This technique is also useful for the client
during mealtimes.
107. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the
following nonpharmacological interventions should the nurse suggest to the client to reduce
pain?
Answer: The nurse should instruct the client to alternate heat and cold applications to decrease
join inflammation and pain. Then application of cold can relieve joint swelling and the
application of heat can decrease joint stiffness and pain.
108. A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
Answer: Low urine specific gravity
Rationale:
An expected finding for a client who has diabetes insipidus is a urine specific gravity between
1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in
antidiuretic hormone release or the kidneys responsiveness to the hormone.
109. A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy.
which of the following statements should the nurse make?
Answer: "I will refer you to community resources that can provide support."
Rationale:
The nurse should provide the client with support resources, including community programs, to
assist the client with acceptance of body image changes.

110. A nurse is providing teaching to a client who has a new prescription for psyllium. Which of
the following information should the nurse include in the teaching?
Answer: Drink 240 mL (8 oz) of water after administration
111. A nurse is preparing to present a program about prevention of atherosclerosis at a health fair.
Which of the following recommendations should the nurse plan to include? (Select all that
apply.)
Answer: Follow a smoking cessation program
Maintain an appropriate weight
Eat a low-fat diet
112. A nurse is providing education to a client who is at risk for osteoporosis. Which of the
following instructions should the nurse include.
Answer: Walk for 30 min four times per week
Rationale:
Weight-bearing exercises promote bone mass. Therefore, walking can help the client prevent
osteoporosis.
113. Client presents with abdominal pain in the upper left quadrant for the past 2 days. States
pain became worse this morning and is radiating to the back. Rates pain as 8on a scale of 0 to 10.
Answer: Drop down1: Pancreatitis
Drop down 2: Amylase and lipase
Rationale:
The client's laboratory results, and physical assessment indicate the client is experiencing
manifestations of pancreatitis. Clients who have pancreatitis experience and increase in
pancreatic enzymes, amylase and lipase.
114. A nurse is caring for a client following extubation of an endotracheal tube 10 min ago.
Which of the following findings should the nurse report to the provider immediately?
Answer: Stridor
Rationale:

Urgent vs. nonurgent, stridor can indicate a narrowing airway or possible obstruction caused by
edema or laryngeal spasms.
115. A nurse is assessing a client who has advanced lung cancer and is receiving palliative care.
the client has just undergone thoracentesis. The nurse should expect a reduction in which of the
following common manifestations of advanced cancer?
Answer: Dyspnea
Rationale:
Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the
clients breathing and improve comfort.
116. A nurse is planning care for a client who is postoperative following a parathyroidectomy.
Which of the following actions should the nurse identify as the priority?
Answer: Place a tracheostomy tray at bedside
Rationale:
The priority action the nurse should take when using the airway, breathing, circulation approach
to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction.
117. A nurse is planning care for an older adult client who has dementia. Which of the following
interventions should the nurse include in the plan of care?
Answer: Place personal items, such as pictures, at the client's bedside
Rationale:
The nurse should plan to have the family bring personal items such as pictures to place at the
client's bedside for cognitive support
118. A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement.
Which of the following statement should the nurse make?
Answer: "Ginkgo biloba can cause increased risk for bleeding."
Rationale:
Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with
peripheral artery disease.

119. A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of
the following should the nurse identify as the priority?
Answer: Report of sore throat
Rationale:
Sore throat, which could be a manifestation of an infection.
120. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The
nurse should identify the need to revise the plan for which of the following clients?
Answer: A client who is postoperative following abdominal surgery and reports feeling that
something "popped" when they coughed
121. A nurse is reviewing the laboratory results of a client who has AIDS and is taking
amphotericin B for fungal infection. The nurse should identify that which of the following values
is an indication of an adverse effect of the medication?
Answer: BUN 34 mg/dL
122. A nurse is providing discharge instructions to a client who has active tuberculosis(TB).
Which of the following information should the nurse include in the instructions?
Answer: Sputum specimens are necessary every 2 to 4 weeks until there are three negative
cultures.
Rationale:
After 3 negative sputum cultures, the client is no longer considered infectious.
123. A nurse is caring for a client who is 4 hr postoperative following a total vaginal
hysterectomy
Answer: Perineal pad saturated with blood, large clots present Change of blood pressure, heart
rate of 102/min
124. A nurse is caring for a client who has a positive culture for methicillin resistant
Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

Answer: Bathe the client using chlorhexidine solution.
The nurse should bathe the client using Chlorhexidine solution because it reduces the risk of
transmission of MRSA to other areas of the body.
125. A nurse is assessing a client following the completion of haemodialysis. Which of the
following findings is the nurse's priority to report to the provider?
Answer: Restlessness
Rationale:
Restlessness, which can be an indication the client is experiencing disequilibrium syndrome.
Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood
and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue,
and headache.
126. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO.
When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC
and HS. Which of the following actions should the nurse take?
Answer: Contact the provider to clarify the prescription.
Mealtimes do not pertain to this client due to the NPO status.
127. A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the client to notify the provider? (Select all that apply)
Answer: Calf pain
Numbness in the arms Intense headache
128. During the emergent phase of burn care, the client is at risk for developing
Answer: Hypovolemia and Respiratory failure
Rationale:
Hypovolemia is indicated by the client's blood pressure declining and heart rate increasing. The
client has burns to the face and chest, which will compromise respiratory function, placing them
at risk for respiratory failure.

129. A nurse is preparing to administer a blood transfusion to a client who has anaemia. Which
of the following actions should the nurse take first?
Answer: Check for the type and number of units of blood to administer.
130. A nurse is assessing a clients hydration status. Which of the following findings indicates
fluid volume overload?
Answer: Distended neck veins
131. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the
following findings is the nurse's priority?
Answer: Temperature38.9 C (102 F)
Rationale:
An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid
storm, due to an increase in metabolic rate.
132. A nurse is planning discharge teaching for a client who has an external fixation device for a
fracture of the lower extremity. Which of the following Instructions should the nurse include in
the plane of care?
Answer: Use crutches with rubber tips.
Rationale:
Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls.
133. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy
tube. The nurse should recognize that which of the following complications is associated with
long term mechanical ventilation?
Answer: Stress ulcers
Rationale:
Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by
elevated levels of hydrochloric acid in the stomach.

134. A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which
of the following findings should the nurse identify as a manifestation of this condition?
Answer: Pain that increases with passive movement
Rationale:
Client who has compartment syndrome experiences pain that increases with passive movement.
135. A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled
for brachytherapy. Which of the following instructions should the nurse include?
Answer: "You will need to stay still in the bed during each treatment session."
Rationale: Excessive movement can cause the radioactive source to become dislodged
136. Client has a penetrating wound to the anterior upper right chest. Client is alert and oriented
with a Glasgow Coma Scale score of 15. Clients' shirt covered with bright red blood. Client
reports pain as 6 on a scale of 0 to10. Shortness of breath noted.
Answer: Oxygen saturation
Pain level
Wound drainage
137. The client is most likely experiencing a ________ as evidenced by the clients
Answer: Haemothorax Respiratory findings
138. The nurse should first address the clients __________ followed by the clients
Answer: Oxygenation Blood pressure
139. For each potential providers prescription, click to specify if the potential prescription is
anticipated or contraindicated for the client.
Answer: Transfuse packed RBCs is anticipated Prepare the client for chest tube insertion is
anticipated Initiate NPO status is anticipated
140. The nurse is caring for the client following the placement of a chest tube for haemothorax.
Which of the following actions should the nurse take? Select all that apply

Answer: Place the client in high-fowler's position
Place two rubber-tipped haemostats in the client's room
Palpate the chest tube insertion site for subcutaneous emphysema
Ensure that all chest tube connections are securely attached
141. The nurse is caring for the client 1 hour following chest tube insertion.
Answer: Client reports pain as 3 on scale of 0 to 10 Client reports shortness of breath has
decreased Wound dressing is dry and intact Respiratory rate, Blood pressure, and oxygen
saturation
142. A nurse is reviewing the laboratory findings of a client who developed chest pain 6hr. ago.
The nurse should identify which of the following findings as an indication of a myocardial
infarction (MI)?
Answer: Troponin I 8 ng/mL
Rationale:
Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle
contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury.
143. A nurse is caring for a client who has a pneumothorax and a closed chest drainage system.
which of the following findings is an indication of lung re- expansion?
Answer: Bubbling in the water seal chamber ceases when the lung re-expands.
144. A nurse is administering packed RBCs to a client. Which of the following assessment
findings indicate a haemolytic transfusion reaction?
Answer: Low back pain and apprehension
Rationale:
Haemolytic transfusion reactions result from the infusion of incompatible blood products and
create a systemic inflammatory response.

145. A nurse is providing discharge teaching to a client who is to self-administer heparin
subcutaneously. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: " I will use an electric razor to shave."
146. A nurse is providing teaching to a client who has a severe form of stage II Lyme disease.
Which of the following statements made by the client reflects an understanding of the teaching?
Answer: " My joints ache because I have Lyme disease."
Rationale:
Lyme disease is a vector-borne illness transmitted by the deer tick.
147. A nurse is caring for a client who has an arterial line. Which of the following actions should
the nurse take?
Answer: Place a pressure bag around the flush solution
The pressure from an artery is greater than that of the line.
148. A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The
nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions
should the nurse take?
Answer: Document that depolarization has occurred
149. The nurse provided preoperative teaching to the client. Which of the following statements
by the client indicates an understanding of the teaching? select all that apply
Answer: "I will need to do the breathing exercises every 1to 2 hours after the surgery"
"I will be sure to ask for pain medication before my knee starts to hurt too bad”
“I will probably be going home with a walker"
150. A nurse is performing a preoperative assessment for a client. The nurse should identify that
an allergy to which of the following foods can indicate a latex allergy?
Answer: Avocados
Rationale:

Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or
sensitivity.
151. A nurse is caring for a client who's is 4 hr postoperative following an open reduction
internal fixation of the right ankle. Which of the following assessment findings should the nurse
report to the provider?
Answer: Extremity cool upon palpation
152. A nurse is admitting a client who has active tuberculosis. Which of the following types of
transmission precautions should the nurse initiate?
Answer: Airborne
153. A nurse is obtaining a medication history from a client who is scheduled to undergo cataract
surgery. The nurse should recognize that which of the following client medications is a
contraindication for the surgery and notify the provider?
Answer: Warfarin
Rationale:
Increases the client's risk for bleeding and is contraindicated for a client scheduled for eye or
central nervous system surgery.
154. A nurse in an emergency department is assessing an older adult client who has a fractured
wrist following a fall. During the assessment, the client states, " Last week I crashed my car
because I my vision suddenly became blurry." Which of the following actions is the nurses
priority?
Answer: Check the clients neurologic status
155. A nurse is providing teaching to a client who has asthma about the use of a metered-dose
inhaler. The nurse should identify that which of the following client actions indicates an
understanding of the teaching?
Answer: Holding breath for 10 seconds after inhaling
Rationale:

The client should hold their breath for 10 seconds after inhaling so the medication can move
deep into the airways.
156. Complete the diagram by dragging from the choices below to specify what condition the
client is most likely experiencing, two actions that the nurse should take to address the condition,
and two parameters the nurse should monitor to assess the client's progress.
Answer: insert a large- gauge iv and initiate a fluid challenge because the client is most likely
experiencing hypovolemia. The nurse should monitor the clients urine output and blood pressure
to evaluate the effectiveness of treatment.
157. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving
mannitol via continuous IV infusion. Which of the following findings should the nurse report to
the provider as an adverse effect of this medication?
Answer: Crackles heard on auscultation
Rationale:
Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus
increasing urinary output.
158. A nurse is providing education to a client who has tuberculosis (TB) and their family. Which
of the following information should the nurse include in the teaching?
Answer: Family members in the household should undergo Testing.
Rationale:
Family members who live in the same household with the client have been exposed to TB.
therefore, the nurse should recommend TB screening to foster early detection and treatment of
TB.
159. A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty.
The client is unable to void on the bedpan. Which of the following actions should the nurse take
first?
Answer: Scan the bladder with a portable ultrasound.

160. A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions
should the nurse anticipate taking?
Answer: Slow the infusion rate.
Rationale:
Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of
circulatory overload.
161. A nurse is providing teaching to a client who has anaemia and a new prescription for an oral
iron supplement. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: “I will eat mor high-Fiber foods."
Rationale:
To help prevent constipation, which is a common adverse effect of oral iron supplements.
162. After reviewing the findings in the client's medical record, the nurse should first address the
clients ________ followed by the clients__________
Answer: Abdominal distention
Acute pain
163. The nurse is performing an assessment on the client For each assessment finding, click to
specify if the findings are consistent with appendicitis, diverticular disease or Crohn's disease.
each finding may support more than one disease process.
Answer: Blood in stools is consistent with diverticular disease and Crohn's disease.
Pain in the lower quadrant is consistent with appendicitis and Crohn's disease. Diarrhoea is
consistent with Crohn's disease.
Nausea is consistent with appendicitis, diverticular disease and Crohn's disease.
164. The nurse is caring for the client who has manifestation of therefore, the priority finding for
the nurse to report is
Answer: Peritonitis

Laboratory values
Rationale:
Manifestations of peritonitis, including rigid abdomen and elevated WBC count and ESR.
Peritonitis is an inflammation and infection of the abdominal cavity that can occur when bacteria
enter the peritoneum through a perforation in the bowel as a complication of Crohn's disease.
165. The nurse is planning care for the client who has peritonitis and Crohn's disease. For each
potential providers prescription, click to specify if each potential prescription is anticipated or
contraindicated for the client.
Answer: Obtain blood cultures is indicated
Obtain vital signs every hour is indicated
Administer a hypotonic IV solution is contraindicated.
Insert a nasogastric tube in indicated
166. The nurse is caring for the client who is preoperative for an exploratory laparotomy.
Answer: Administer phenytoin with a sip of water prior to the surgery
Administer gentamicin mg IV
Administer dextrose 5% in lactated Ringers(D5LR) is a hypertonic IV solution.
Contact the wound, ostomy, and continence nurse
167. The nurse is providing discharge teaching to the client. Which of the following statements
made by the client indicates an understanding of the teaching?
Answer: "I should schedule several rest periods throughout the day."
"I should notify my provider if my temperature is higher than 101 F"
168. A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic
reaction. After ensuring a patent airway, which of the following nursing interventions is the
priority.
Answer: Applying oxygen via face mask

169. A nurse is providing discharge teaching about infection prevention to a client who has
AIDS. Which of the following statements by the client indicates understanding of the teaching.
Answer: " I will no longer floss my teeth after brushing my teeth."
Rationale:
The nurse should instruct the client to avoid flossing teeth to prevent gum inflammation, which
could create the opportunity for infection.
170. A nurse is caring for a client who has DKA. Which of the following findings should indicate
to the nurse that the client's condition is improving?
Answer: Glucose 272 mg/dL
Rationale:
A glucose reading less than 300 mg/dL indicates improvement in the client's status.
171. A nurse is teaching a family about the care of a parent who has a new diagnosis of
Alzheimer's disease. Which of the following information should the nurse include in the
teaching?
Answer: Create complete outfits and allow the client to select one each day.
Rationale:
The family should place completed outfits on hangers and allow the client to select which one to
wear each day.
172. A nurse is planning care for a client who's is having a modified radical mastectomy of the
right breast. Which of the following interventions should the nurse include in the plan of care?
Answer: Instruct the client that the drain will be removed when there is 25 mL of output or less
over a 24- hour period.
Rationale:
The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after
surgery and will be removed when there is 25 mL of output or less in a24-hr period.
173. A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the
following findings should indicate to the nurse the client is experiencing hypoxia.

Answer: The clients heart rate increases.
174. A nurse is caring for a client who has terminal cancer. The client tells the nurse, " I wish I
could stop these treatments. I am ready to die." Which of the following statements should the
nurse make?
Answer: "Discontinuing with the treatments is your choice if it is your wish to do so."
175. For each assessment findings, click to specify if the finding is consistent with emphysema,
asthma, or pneumonia. Each finding may support more than 1 disease process.
Answer: Temperature-Pneumonia
Breath sounds- Emphysema, asthma, and pneumonia
ABG- Emphysema and pneumonia
Respiratory rate - Emphysema, asthma, and pneumonia
Heart rate - Emphysema and pneumonia
Cough- emphysema, asthma, and pneumonia
176. A home health nurse is providing teaching to a client who has a stage 1 pressure injury on
the greater trochanter of his left hip. Which of the following instructions should the nurse include
in the teaching?
Answer: Change position every hour.
177. A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The
clients' initial vital signs were heart rate 80/min, blood pressure130/70mm Hg, respiratory rate
16/min, and temperature 36 C (96.8F). Which of the following vital changes should alert the
nurse that the client might be haemorrhaging?
Answer: Heart rate 110/min
Rationale:
One of the first signs of haemorrhage is an increase in the heart rate from the client’s baseline,
which occurs to compensate for blood loss.

178. A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation
(TENS) for the management of bone cancer pain. The nurse should explain to applying a TENS
unit to the painful area has which of the following effects?
Answer: A tingling sensation replacing the pain
179. A nurse is planning care for a client who is postoperative following a laparotomy and has a
close-suction drain. Which of the following actions should the nurse Taketo manage the drain?
Answer: Compress the drain reservoir after emptying
180. A nurse is preparing to administer phenytoin 600 m PO daily to a client. The amount
available is oral solution 125 mg/5mL. How many mL should the nurse administer?
Answer: 24 mL
181. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago.
Which of the following actions should the nurse take?
Answer: Check that one finger fits between the cast and the leg.
Rationale:
To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast.
It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr
after application.
182. A nurse is providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statements should the nurse identify as an indication
that the client understands the teaching?
Answer: "I will use my hands rather than a washcloth to clean the radiation area."
Rationale:
The client should gently wash the radiation area with their hands using warm water and mild
soap to protect the skin from further irritation.

183. A nurse is planning to provide discharge teaching for the family of an older adult client who
has hemianopsia and is at risk for falls. Which of the following instructions should the nurse
include?
Answer: Remind the client to scan their complete range of vision during ambulation.
Rationale:
The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half
of the visual field, to use visual scanning to look over their complete range of vision during
ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for
falls.
184. A nurse has received change-of-shift report for a group of clients. Which of the following
clients should the nurse assess first?
Answer: A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN
sublingual nitro-glycerine tablet
185. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which
of the following laboratory values should the nurse report to the provider?
Answer: Hgb 8 g/dL
186. A nurse in a provider's office is assessing a client who has migraine headaches and is taking
feverfew to prevent headaches. The nurse should identify that which of the following client
medications interacts with feverfew?
Answer: Naproxen
187. An older adult client is brought to an emergency department by a family member. Which of
the following assessment findings should cause the nurse to suspect that the client has hypertonic
dehydration?
Answer: Urine specific gravity 1.045
188. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place
which of the following items at the client's bedside?

Answer: Suction machine
189. A nurse in a provider's office is assessing a client who has hypertension and takes
propranolol. Which of the following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication?
Answer: Report of a night cough
190. A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN).
The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump
should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing zero.)
Answer:167
X mL/hr = Volume (mL)/Time
(hr)X mL/hr =4000mL/24 hr
X mL/hr = 166.67
Round if necessary. 166.67 = 167 mL/hr
191. A nurse is caring for a client who is having a seizure. Which of the following interventions
is the nurse's priority?
Answer: Turn the client to the side.
192. A nurse is creating a plan of care for a client who has neutropenia as a result of
chemotherapy. Which of the following interventions should the nurse include in the plan?
Answer: Monitor the client's temperature every 4 hr.
193. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal
implant to treat endometrial cancer. Which of the following actions should the nurse include in
the client's plan of care?
Answer: Wear a lead apron while providing care to the client.

194. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following
actions should the nurse take?
Answer: Remain with the client for the first 15 min of the infusion.
195. A nurse is preparing a client who has supraventricular tachycardia for elective
cardioversion. Which of the following prescribed medications should the nurse instruct the client
to withhold for 48 hr prior to cardioversion?
Answer: Digoxin
196. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a
productive cough. Which of the following actions should the nurse take first?
Answer: Initiate airborne precautions.
197. A nurse in a community clinic is caring for a client who reports an increase in the frequency
of migraine headaches. To help reduce the risk for migraine headaches, which of the following
foods should the nurse recommend the client avoid?
Answer: Aged cheese
198. A nurse is caring for a client who has hepatic encephalopathy that is being treated with
lactulose. The client is experiencing excessive stools. Which of the following findings is an
adverse effect of this medication?
Answer: Hypokalaemia
199. A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr
ago. Which of the following findings should the nurse expect?
Answer: Stone fragments in the urine
200. A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile
dysfunction. Which of the following statements should the nurse make?
Answer: "You will not be able to use sildenafil if you are taking nitro-glycerine."

201. A nurse is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
Answer: Demonstrate ways to deep breath and cough.
202. A nurse is caring for a client in the emergency department(ED).
Answer: Administer morphine
Ensure the patient is NPO Cholecystitis
Monitor the colour of the client's stools
Monitor the client for dark urine
203. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for
omeprazole. The nurse should instruct the client that the medication provides relief by which of
the following actions?
Answer: Suppressing gastric acid production
204. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory results to be below the expected reference range?
Answer: Calcium
Rationale:
A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to
fat necrosis.
205. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of
the following precautions should the nurse implement?
Answer: The nurse should ensure the client has IV access in the event that the client requires
medication to stop seizure activity.
206. A nurse is providing discharge instructions to a client who has a partial- thickness burn on
the hand. Which of the following instructions should the nurse include?
Answer: Wrap fingers with individual dressings.

207. A nurse is assessing a client who has had a suspected stroke. The nurse should place the
priority on which of the following findings?
Answer: Dysphagia
208. A nurse is caring for a client who is undergoing haemodialysis to treat end- stage kidney
disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which
of the following medications should the nurse plan to administer?
Answer: Calcium carbonate
209. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing's triad?
Answer: Bradycardia
210. A nurse is caring for a client who was just admitted from the emergency department (ED)
Answer: Acute chest syndrome and pneumonia
211. A nurse is providing teaching to a female client who has a history of urinary tract infections
(UTIs). Which of the following information should the nurse include in the teaching?
Answer: Take daily cranberry supplements.
212. A nurse is conducting an admission history for a client who is to undergo a CT scan with an
IV contrast agent. The nurse should identify that which of the following findings requires further
assessment?
Answer: History of asthma
213. A nurse in an emergency department is caring for a client who reports vomiting and
diarrhoea for the past 3 days. Which of the following findings should indicate to the nurse that
the client is experiencing fluid volume deficit?
Answer: Heart rate 110/min

214. A nurse is caring for a client who has a prescription for enalapril. The nurse should identify
which of the following findings as an adverse effect of the medication?
Answer: Orthostatic hypotension
215. A nurse is assessing a client following the administration of magnesium sulfate 1 gIV bolus.
For which of the following adverse effects should the nurse monitor?
Answer: Respiratory paralysis
216. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a
pressure injury. Which of the following actions should the nurse take?
Answer: Use a 30-mL syringe
217. Select the 4 findings that require follow-up by the nurse.
Answer: Virtual disturbances
Rationale:
Tingling of the lips Hand grasps Expressive aphasia
218. For each finding below, click to specify if the finding is consistent with migraine, stroke, or
meningitis. Each finding can support more than one disease process.
Answer: Hand grasps is consistent with migraine, stroke, and meningitis
Rationale:
Numbness is consistent with migraine and stroke. Aphasia is consistent with migraine and stroke
Visual changes are consistent with migraine, stroke, and meningitis Family history is consistent
with migraine and stroke.
219. The nurse should identify that the client is most likely experiencing Select and the nurse
should address the client's Select
Answer: A migraine Pain
220. A nurse is caring for a client who has a migraine. Which of the following interventions
should the nurse anticipate? Select all that apply.

Answer: Administer sumatriptan is correct. Dim the lights in the client's room is correct
221. Following the administration of sumatriptan, the nurse should monitor for Select. Due to the
risk of Select
Answer: Chest pain Myocardial ischemia
222. The nurse is evaluating the client's understanding of discharge instructions. Which of the
following client statements indicates an understanding of the teaching?
Answer: "Foods that contain tyramine might trigger my headaches" "I will keep a food and
headache diary"
"I will place a cool cloth on my forehead when I experience a migraine"
223. A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being
admitted to the hospital with pneumonia. Which of the following assessment findings is the
nurse's priority?
Answer: Increased respiratory secretions
224. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis.
The nurse should give the AP which of the following instructions?
Answer: Wear a mask.
225. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation.
The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the
following actions should the nurse take first?
Answer: Instruct the client to allow the machine to breathe for them.
226. A nurse is caring for a client who is receiving morphine for daily dressing changes. The
client tells the nurse, "I don't want any more morphine because I don't want to get addicted."
Which of the following actions should the nurse take?
Answer: Instruct the client on alternative therapies for pain reduction.

227. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is
not available when the current infusion is nearly completed. Which of the following actions
should the nurse take?
Answer: Administer dextrose 10% in water until the new bag arrives.
228. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of
the following client statements indicates the client is successfully coping with the change?
Answer: "I used to never worry about my feet.
Now, I inspect my feet every day with a mirror."
229. A nurse is teaching a class about client rights. Which of the following instructions should
the nurse include?
Answer: A client should sign an informed consent before receiving a placebo during a research
trial.
230. A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in the plan
of care to prevent a Pseudomonas aeruginosa infection?
Answer: Avoid placing plants or flowers in the client's room.
231. For each potential nursing intervention, click to specify if the intervention is indicated or
not indicated
Answer: Perform a 12-lead ECG is not indicated
Place the client in Trendelenburg position is indicated
Administer a 0.9% sodium chloride 200 mL IV bolus is indicated
Apply oxygen at 2 L/min via nasal cannula is indicated
Notify the provider immediately is indicated.
Obtain the client's blood glucose level is not indicated
232. A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the
following laboratory values should the nurse expect?

Answer: Elevated bilirubin level
233. A nurse is teaching a young adult client how to perform testicular self- examination. Which
of the following instructions should the nurse include?
Answer: Roll each testicle between the thumb and fingers.
234. A nurse is providing teaching to a client who is receiving chemotherapy and has a new
prescription for epoetin alfa. Which of the following client statements indicates an understanding
of the teaching?
Answer: "I will monitor my blood pressure while taking this medication."
235. A nurse is assessing a group of clients for indications of role changes. The nurse should
identify that which of the following clients is at risk for experiencing a role change?
Answer: A client who has multiple sclerosis and is experiencing progressive difficulty
ambulating
236. A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which
of the following findings should the nurse identify as a manifestation of chronic
glomerulonephritis?
Answer: hyperkalaemia
237. A nurse is assessing a client who has acute cholecystitis. Which of the following findings is
the nurse's priority?
Answer: Tachycardia
238. The client is experiencing manifestations of. due to
Answer: Peritonitis
X-ray results
239. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
laboratory findings should the nurse expect?

Answer: BUN 32 mg/dL
240. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the
formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity.
Which of the following interventions is the nurse's priority?
Answer: Apply firm pressure to the insertion site.
241. A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following supplements can
interfere with the effectiveness of the medication?
Answer: Calcium
242. A nurse is caring for a group of clients. The nurse should plan to make a referral to physical
therapy for which of the following clients?
Answer: A client who is receiving preoperative teaching for a right knee arthroplasty
243. The nurse is reviewing the client's diagnostic results. Which of the following findings
requires follow-up by the nurse? Select all that apply
Answer: PCO2
WBC
Chest X-ray
Oxygen saturation
BUN
244. Click to highlight the findings below that indicate that the client has a potential problem. To
deselect a finding, click on the finding again.
Answer: Client is short of breath and has a productive cough with yellow mucus "I could barely
breathe when I got up this morning and I had a throbbing headache Crackles heard in posterior
lungs Client is diaphoretic
245. The nurse should first address the client's followed by the client's

Answer: Oxygen saturation Temperature
246. For each potential provider's prescription, click to specify if the potential prescription is
anticipated, nonessential, or contraindicated for the client.
Answer: Cough and deep breathe every 2 hr is anticipated.
Obtain a sputum culture and sensitivity is anticipated.
Perform neurological checks every 2 hr is nonessential.
Administer oxygen at 3 L/min via nasal cannula is anticipated.
Limit the client's fluid intake to 1,500 mL per day is contraindicated.
Acetaminophen 500 mg PO every 6 hr as needed is anticipated.
Famotidine 40 mg PO daily is nonessential.
247. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing
intervention.
Answer: Temperature
WBC
Potassium
248. The nurse is reviewing the client's medical record from Day 5. Click to highlight the
findings below that indicate the client is improving. To deselect a finding, click on the finding
again.
Answer: Heart rate is72/min
Respiratory rate is 20/min
Blood pressure is 128/56
Oxygen saturation is 96%
249. A nurse is providing discharge instructions to a client following an upper gastrointestinal
series with barium contrast. Which of the following information should the nurse provide?
Answer: Increase fluid intake.

250. A nurse is assessing a client who has Graves' disease. Which of the following images should
indicate to the nurse that the client has exophthalmos?
Answer: Exophthalmos in Graves' disease presents as abnormal protrusion of the eyes, with
visible sclera around the iris.
251. A nurse is providing teaching to an older adult client who has cancer and a new prescription
for an opioid analgesic for pain management. Which of the following information should the
nurse include in the teaching?
Answer: "You should void every 4 hours to decrease the risk of urinary retention."
252. A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a
gastrectomy A nurse is providing teaching for the client. Which of the following instructions
should the nurse include?
Answer: Avoid drinking fluids with meals
Eat several small meals per day
Consume high-protein snacks
Avoid highly seasoned foods
253. A nurse is caring for a client who presents to a clinic for a 1-week follow up visit after
hospitalization for heart failure. Based on the information in the client's chart, which of the
following findings should the nurse report to the provider?
Answer: Heart rate 55/min
254. A nurse is providing teaching to an older adult female client who has stress incontinence
and a BMI of 32. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: "I am dieting to lose weight."
255. A nurse in an emergency department is reviewing the provider's prescriptions for a client
who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the
nurse expect?

Answer: Administer an opioid analgesic to the client.
256. A nurse is performing a dressing change for a client who is recovering from a
hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is
protruding through the abdomen. Which of the following actions should the nurse take first?
Answer: Call for help.
257. A nurse is caring for a client who has portal hypertension. The client is Vomiting blood
mixed with food after a meal. Which of the following actions should the nurse take first?
Answer: Obtain vital signs.
258. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend?
Answer: Add cabbage to the diet.
259. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new
prescription for metformin. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: "I should take this medication with a meal."
260. A nurse is caring for a client who is postoperative. Which of the following actions should
the nurse take? Select all that apply.
Answer: Instruct the client to splint the abdomen with a pillow for coughing
Plan to ambulate the client as soon as possible
Report urinary output to the provider
Ask the client to rate their pain on a 0 to 10 pain scale
261. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following
assessment findings should the nurse expect?
Answer: Hypoactive bowel sounds

262. A nurse is assessing a male client for an inguinal hernia. Which of the following areas
should the nurse palpate to verify that the client has an inguinal hernia? (You will find hot spots
to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Answer: To assess for an inguinal hernia, the nurse should palpate the inguinal canal and
inguinal ring in the groin area.
263. A nurse is caring for a client who has a stage III pressure injury. Which of the following
findings contributes to delayed wound healing?
Answer: Urine output 25 mL/hr
264. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
Answer: Loosen restrictive clothing.
265. A nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: "I am taking this medication to increase my energy level."
266. A nurse is planning teaching for a client who has bladder cancer and is to undergo a
cutaneous diversion procedure to establish a ureterostomy. Which of the following statements
should the nurse include in the teaching?
Answer: "You should cut the opening of the skin barrier one-eighth inch wider than the stoma."
267. A nurse is planning care to decrease psychosocial health issues for a client who is starting
dialysis treatments for chronic kidney disease. Which of the following interventions should the
nurse include in the plan?
Answer: Tell the client that it is possible to return to similar previous levels of activity.
268. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the
following is the priority assessment finding that the nurse should report to the provider?

Answer: Blood pressure 170/80 mm Hg
269. A nurse is caring for a client who has a closed head injury and has an intraventricular
catheter placed. Which of the following findings indicates that the client is experiencing
increased intracranial pressure (ICP)? (Select all that apply.)
Answer: Sleepiness exhibited by the client
Widening pulse pressure
Decerebrate posturing
270. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin
subcutaneous. Which of the following actions should the nurse take?
Answer: Inject the medication into the anterolateral abdominal wall.