Preview Extract
ATI Medsurg Proctored 2019
Medical and Surgical Nursing I (Medgar Evers College)
1. A nurse in an emergency department is preparing to perform an ocular irrigation for a
client. Which of the following actions should the nurse plan to take?
a. Assess the client's visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation
Answer: d. Perform the irrigation with sterile water for irrigation
Rationale:
Sterile water for irrigation is the appropriate solution for ocular irrigation to prevent
introducing contaminants into the eye. It helps to flush out any irritants or foreign bodies
from the eye.
2. A nurse is preparing to administer lactated Ringer's via continuous IV infusion at 200
ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the nurse set
the IV pump to administer? Round to near whole number
Answer: 33 gtt/min
Rationale:
To calculate the infusion rate in gtt/min, use the following formula:
Infusion rate (gtt/min) = (Volume to be infused in ml × Drop factor) ÷ Time in minutes
In this case, the calculation would be:
(200 ml/hr × 10 drops/ml) ÷ 60 min/hr = 2000 ÷ 60 ≈ 33.33 gtt/min, rounded to 33 gtt/min.
3. A nurse is providing discharge teaching to a client who has a new prescription for
sublingual nitroglycerin. Which of the following client statements indicates an understanding
of the teaching?
a. I can keep my medications for 1 year before replacing it
b. I should lie down when I take this medication
c. I should discontinue this medication if I develop a headache
d. I can take up to five tablets in 15 minutes before seeking medical attention
Answer: b. I should lie down when I take this medication
Rationale:
Sublingual nitroglycerin can cause a sudden drop in blood pressure, leading to dizziness or
fainting. Lying down when taking the medication can help prevent injury from falls.
4. A nurse is providing discharge teaching to an older adult client following a left total hip
arthroplasty. Which of the following instructions should the nurse include in the teaching?
a. Clean the incision daily with hydrogen peroxide
b. You can cross your legs at the ankles when sitting down
c. You should use an incentive spirometer every 8 hours
d. Install a raised toilet seat in your bathroom
Answer: d. Install a raised toilet seat in your bathroom
Rationale:
After hip arthroplasty, it is important to avoid bending the hip beyond 90 degrees to prevent
dislocation. Using a raised toilet seat can help maintain the hip in the proper position and
prevent injury.
5. A nurse is planning care for a client following a cardiac catheterization. Which of the
following actions should the nurse take?
a. Keep the client on bed rest for 24 hours
b. Limit the client's fluid intake to 1 liter per day
c. Maintain the client's affected extremity in extension
d. Change the client's dressing every 8 hours
Answer: c. Maintain the client's affected extremity in extension
Rationale:
After a cardiac catheterization, it is important to maintain the affected extremity in extension
to prevent bleeding or hematoma formation at the catheter site.
6. A nurse is caring for a client who has a lower extremity fracture and a prescription for
crutches. Which of the following client statements indicates that the client is adapting to their
role change?
a. I will need to have my partner take over shopping for groceries and cooking the meals for
us
b. These crutches will make it impossible to care for my child
c. I feel bad that I have to ask my partner to keep the house clean
d. It's going to be difficult to tell my parents I can't take them to their appointments anymore
Answer: a. I will need to have my partner take over shopping for groceries and cooking the
meals for us
Rationale:
Acceptance and adaptation to the use of crutches involve recognizing and adjusting to
limitations, such as the need for assistance with daily activities.
7. A nurse is caring for a client who has gastroenteritis. Which of the following assessment
findings should the nurse recognize as an indication that the client is experiencing
dehydration?
a. Pitting, dependent edema
b. Distended jugular veins
c. Increased BP
d. Decreased BP
Answer: d. Decreased BP
Rationale:
Dehydration can lead to a decrease in blood pressure due to a decrease in circulating volume.
This can be an indication of dehydration in a client with gastroenteritis.
8. A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The
client's urinary output was 4,000 ml over the past 24 hours. The nurse should anticipate a
prescription for which of the following IV medications?
a. Desmopressin
b. Epinephrine
c. Furosemide
d. Nitroprusside
Answer: a. Desmopressin
Rationale:
A contusion of the brainstem can lead to diabetes insipidus, which is characterized by
excessive thirst and polyuria. Desmopressin is a medication used to treat diabetes insipidus
by reducing urinary output and helping to maintain fluid balance.
9. A nurse in a clinic receives a phone call from a client who recently started therapy with an
ACE inhibitor and reports a nagging dry cough. Which of the following responses by the
nurse is appropriate?
a. "Your cough may require that you stop or change your medication."
b. "Increasing your daily fluid intake may eliminate your cough."
c. "Sucking on lozenges may reduce the frequency of your cough."
d. "Your cough should go away in time."
Answer: a. "Your cough may require that you stop or change your medication."
Rationale:
Dry cough is a common side effect of ACE inhibitors. If the cough is bothersome, the
medication may need to be changed to an alternative class of antihypertensive medication.
10. A nurse is taking an admission history from a client who reports Raynaud's disease.
Which of the following assessment findings should the nurse identify as a potential trigger
for exacerbations of Raynaud's?
a. Eating a strict vegetarian diet
b. A history of herpes zoster
c. Taking amiodipine for hypertension
d. Using a nicotine transdermal patch
Answer: d. Using a nicotine transdermal patch
Rationale:
Nicotine is a vasoconstrictor that can exacerbate symptoms of Raynaud's disease, which is
characterized by vasospasm of the small arteries, leading to reduced blood flow to the
extremities.
11. A nurse is caring for a client who has a central venous access device and notes the tubing
has become disconnected. The client develops dyspnea and tachycardia. Which of the
following actions should the nurse take first?
a. Perform an ECG
b. Obtain ABG values
c. Turn the client to his left side
d. Clamp the catheter
Answer: d. Clamp the catheter
Rationale:
Clamping the catheter is the priority to prevent air from entering the central venous system,
which can lead to an air embolism. This is a life-threatening complication that can cause
dyspnea and tachycardia.
12. A nurse is completing an assessment of an older adult client and notes reddened areas
over the bony prominences, but the client's skin is intact. Which of the following
interventions should the nurse include in the plan of care?
a. Turn and reposition the client every 4 hr
b. Apply an occlusive dressing
c. Support bony prominences with pillows
d. Massage the reddened areas three times a day
Answer: c. Support bony prominences with pillows
Rationale:
Supporting bony prominences with pillows helps to relieve pressure and reduce the risk of
developing pressure ulcers in older adults with intact skin.
13. A home health nurse is making an initial visit to a client who has multiple sclerosis.
Which of the following actions is the priority for the nurse to take?
a. Discuss recommendations for eating and swallowing techniques
b. List strategies for family coping when dealing with possible role changes
c. Review the use of adaptive grooming devices to promote client independence
d. Give the client information about the local national multiple sclerosis society
Answer: a. Discuss recommendations for eating and swallowing techniques
Rationale:
Multiple sclerosis can affect swallowing and eating abilities. Discussing recommendations
for eating and swallowing techniques is a priority to ensure the client can maintain adequate
nutrition and hydration.
14. A nurse in the emergency department is assessing a client. Which of the following actions
should the nurse take first? Exhibit
a. Obtain a sputum sample for culture
b. Administer ondansetron
c. Initiate airborne precautions
d. Prepare the client for a chest x-ray
Answer: c. Initiate airborne precautions
Rationale:
Initiating airborne precautions is the priority when assessing a client who may have a
contagious airborne disease, such as tuberculosis, to prevent the spread of infection to others.
15. A nurse is reviewing the medical record of a client to identify risk factors for colorectal
cancer. The nurse should identify which of the following findings as increasing the client's
risk?
a. History of Crohn's disease
b. BMI of 24
c. Diet high in fiber
d. Age 46 years
Answer: a. History of Crohn's disease
Rationale:
Crohn's disease is a risk factor for colorectal cancer due to chronic inflammation in the
gastrointestinal tract, which can increase the risk of developing cancerous changes in the
colon or rectum.
16. A nurse is caring for a client who is scheduled for a mastectomy. The client tells the
nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should
the nurse make?
a. "I can give you a list of other people who had the same procedure"
b. "You will be cancer-free if you have the procedure"
c. "I can give you additional information about the procedure"
d. "You should get a second opinion regarding the procedure"
Answer: c. "I can give you additional information about the procedure"
Rationale:
Providing the client with additional information about the mastectomy can help the client
make an informed decision about their treatment.
17. A nurse is preparing to administer a unit of packed RBCs to a client who is anemic.
Identify the sequence of steps the nurse should follow.
a. Obtain venous access using 19-gauge needle
b. Obtain the unit of packed RBCs from blood bank
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
e. Remain with the client for the first 15 to 30 min of the infusion
Answer: The correct sequence is:
b. Obtain the unit of packed RBCs from blood bank,
c. Verify blood compatibility with another nurse,
a. Obtain venous access using 19-gauge needle,
d. Initiate transfusion of the unit of packed RBCs,
e. Remain with the client for the first 15 to 30 min of the infusion
Rationale:
The steps for administering packed RBCs include verifying blood compatibility, obtaining
venous access, initiating transfusion, and monitoring the client during the infusion.
18. A nurse is preparing a teaching plan for a client who has mucositis related to
chemotherapy treatment. Which of the following instructions should the nurse include?
a. "Rinse your mouth with hydrogen peroxide"
b. "Brush your teeth for 60 seconds twice daily"
c. "Wear your dentures only during meals"
d. "Floss your teeth following each meal"
Answer: d. "Floss your teeth following each meal"
Rationale:
Flossing following each meal can help prevent infection and promote healing of the oral
mucosa in clients with mucositis.
19. A critical care nurse is assessing a client who has a severe head injury. In response to
painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes
incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the
nurse assign the client?
a. 5
b. 2
c. 13
d. 10
Answer: a. 5
Rationale:
The client's responses indicate a severe level of neurological impairment, which corresponds
to a Glasgow Coma Scale score of 5.
20. A nurse is providing discharge teaching to a client who has heart failure and instructs him
to limit sodium intake to 2 g per day. Which of the following statements by the client
indicates an understanding of the teaching?
a. "I can season my foods with garlic and onion salts"
b. "I can have mayonnaise on my sandwiches"
c. "I can have a frozen fruit juice bar for dessert"
d. "I can drink vegetable juice with a meal"
Answer: c. "I can have a frozen fruit juice bar for dessert"
Rationale:
Frozen fruit juice bars are typically low in sodium and can be a suitable dessert option for
someone with heart failure who needs to limit their sodium intake.
21. A nurse is preparing to perform ocular irrigation for a client following a chemical splash
to the eye. Which of the following actions should the nurse plan to take first?
a. In still 0.9% sodium chloride solution into the affected eye
b. Administer proparacaine eyedrops into the affected eye
c. Collect information about the irritant that caused the injury
Answer: c. Collect information about the irritant that caused the injury
Rationale:
Collecting information about the irritant is the first step in determining the appropriate
treatment for the chemical splash to the eye.
22. A nurse is assessing a client following extubation from a ventilator. For which of the
following findings should the nurse intervene immediately?
a. Rhonchi
b. SaO2 92%
c. Sore throat
d. Stridor
Answer: d. Stridor
Rationale:
Stridor indicates airway obstruction and requires immediate intervention to ensure adequate
oxygenation.
23. A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which
of the following findings should the nurse expect?
a. Elevated serum calcium
b. Elevated blood glucose
c. Decreased serum amylase
d. Decreased erythrocyte sedimentation rate
Answer: b. Elevated blood glucose
Rationale:
Elevated blood glucose can occur due to the stress response of acute pancreatitis and insulin
resistance.
24. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of
the following findings should the nurse expect?
a. Hypothermia
b. Urine specific gravity 1.001 (<1.005)
c. Elevated blood pressure
d. BUN 15 mg/dl
Answer: b. Urine specific gravity 1.001 (<1.005)
Rationale:
Diabetes insipidus is characterized by dilute urine with a specific gravity of less than 1.005.
25. A nurse is planning care for a client who has a pulmonary embolism. Which of the
following interventions should the nurse include?
a. Initiate a continuous IV heparin infusion
b. Instruct the client to massage the lower extremities
c. Position the client on the left side
d. Measure vital signs every 4 hours
Answer: a. Initiate a continuous IV heparin infusion
Rationale:
Heparin therapy is the primary treatment for pulmonary embolism to prevent further clot
formation.
26. A nurse is providing discharge teaching to a client who is recovering from a sickle cell
crisis. Which of the following instructions should the nurse include?
a. Avoid extremely hot or cold temperatures
b. Limit fluids to 1.5 L per day
c. Limit alcohol intake to one drink per day
d. Avoid getting a flu vaccination
Answer: a. Avoid extremely hot or cold temperatures
Rationale:
Avoiding extreme temperatures can help prevent sickle cell crisis triggers.
27. A nurse in the emergency department is caring for a client who is in hypovolemic shock.
Which of the following actions should the nurse take first?
a. Obtain a blood specimen for type and crossmatch
b. Insert a large-bore IV catheter
c. Administer IV therapy
d. Monitor urine output
Answer: b. Insert a large-bore IV catheter
Rationale:
Establishing IV access is the first priority to begin fluid resuscitation in hypovolemic shock.
28. A nurse is caring for a client who has an arteriovenous graft. Which of the following
findings indicates adequate circulation of the graft?
a. Dilated appearance of the graft
b. Absence of a bruit
c. Normotensive blood pressure
d. Palpable thrill
Answer: d. Palpable thrill
Rationale:
A palpable thrill indicates blood flow through the arteriovenous graft, indicating adequate
circulation.
29. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which
of the following findings indicates hypokalemia?
a. Oliguria
b. Hypertension
c. Muscle weakness
d. Positive Chvostek's sign
Answer: c. Muscle weakness
Rationale:
Muscle weakness is a common symptom of hypokalemia, which can result from loop diuretic
use.
30. A nurse is caring for a client who has a full-thickness burn injury covering 15% of their
body. Which of the following actions should the nurse take?
a. Weigh the client once per week
b. Provide the client with a protein intake of 1g/kg/day
c. Maintain a daily count of the client's calorie intake
d. Place the client on a low-carb diet
Answer: c. Maintain a daily count of the client's calorie intake
Rationale:
Monitoring calorie intake is important for burn recovery to ensure adequate nutrition for
healing.
31. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the
following client statements indicates an understanding of the teaching?
a. "I will expect my stools to be loose"
b. "I will eat a high fiber diet"
c. "I will take a laxative when I'm constipated"
d. "I will empty my bag when it is full"
Answer: a. "I will expect my stools to be loose"
Rationale:
With an ileostomy, stool consistency is typically loose due to the location of the stoma in the
small intestine.
32. A nurse is caring for a client who is receiving total parenteral nutrition through a central
line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy.
Which of the following actions should the nurse take?
a. Switch the infusion to a 10% dextrose solution
b. Discontinue the infusion and flush the line
c. Decrease the rate of infusion to last until the new bag is available
d. Start an infusion of 0.45% sodium chloride solution
Answer: a. Switch the infusion to a 10% dextrose solution
Rationale:
Switching to a dextrose solution can prevent hypoglycemia until a new bag of total parenteral
nutrition is available.
33. A nurse is caring for a client who is 6 hr postoperative following a thyroidectomy. The
client reports tingling and numbness in the hands. The nurse should identify this as a sign of
which of the following electrolyte imbalances?
a. Hypocalcemia
b. Hypokalemia
c. Hypermagnesemia
d. Hypernatremia
Answer: a. Hypocalcemia
Rationale:
Tingling and numbness in the hands are classic signs of hypocalcemia, which can occur postthyroidectomy due to inadvertent removal or injury to the parathyroid glands.
34. A nurse is caring for a client who is a caregiver for a relative who has a chronic disease.
Which of the following statements indicates the client is adapting to the role change?
a. "I had to reschedule my doctor's appointment last week"
b. "I have lunch with my friends once a week"
c. "I've lost 15 pounds in the past 2 months"
d. "I need to get my blood pressure medicine refilled"
Answer: d. "I need to get my blood pressure medicine refilled"
Rationale:
This statement indicates that the client is managing their own health needs despite the
caregiver responsibilities.
35. A nurse is reviewing medications taken at home with a client who has angina. Which of
the following statements by the client indicates an understanding of the teaching?
a. "I should withhold my metoprolol if my heart rate is above 100 bpm"
b. "I should take my daily aspirin on an empty stomach"
c. "I should lie down before taking dose of isosorbide dinitrate"
d. "I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four
doses"
Answer: c. "I should lie down before taking dose of isosorbide dinitrate"
Rationale:
Isosorbide dinitrate can cause dizziness and light-headedness, so lying down before taking it
can help prevent falls.
36. A nurse in the post-anesthesia care unit is assessing a client following an appendectomy
and finds a 2-cm (3/4in) area of blood on the postoperative dressing. Which of the following
actions should the nurse take?
a. Apply pressure
b. Loosen the dressing
c. Circle the drainage
d. Apply a new dressing
Answer: c. Circle the drainage
Rationale:
Circling the drainage allows the nurse to monitor if the bleeding is increasing or decreasing.
37. A nurse is caring for a client who is receiving mechanical ventilation. Which of the
following interventions should the nurse implement?
a. Empty water from the ventilator tubing daily
b. Suction the client's airway every 4 hours
c. Maintain the client in supine position
d. Perform oral care every 2 hours
Answer: a. Empty water from the ventilator tubing daily
Rationale:
Emptying water from the ventilator tubing helps prevent the accumulation of secretions that
could lead to infections.
38. A nurse is planning care for a client who has full-thickness burns on the lower
extremities. Which of the following interventions should the nurse include?
a. Apply new gloves when alternating between wound care sites
b. Provide a diet of fresh fruits and vegetables for the client
c. Limit visitation time for the client's children to 40 min per day
d. Clean the equipment in the client's room once per week
Answer: a. Apply new gloves when alternating between wound care sites
Rationale:
Applying new gloves helps prevent infection when moving between wound care sites.
39. A nurse is providing teaching for a client who has tuberculosis and a new prescription for
pyrazinamide. The nurse should instruct the client to notify the provider if which of the
following adverse effects occurs?
a. Hair loss
b. Polyuria
c. Weight gain
d. Jaundice
Answer: d. Jaundice
Rationale:
Jaundice can indicate liver toxicity, a potential adverse effect of pyrazinamide.
40. A nurse is planning care for a client who has left-sided hemiplegia following a stroke.
Which of the following actions should the nurse include in the plan of care?
a. Position the bedside table on the client's left side
b. Place the plate guard on the client's meal tray
c. Provide the client with a short handled reacher
d. Remind the client to use a cane on the left side while ambulating
Answer: b. Place the plate guard on the client's meal tray
Rationale:
Placing a plate guard can help the client with left-sided hemiplegia eat independently and
prevent spills.
41. A nurse is performing an ear irrigation for a client. Which of the following actions should
the nurse take?
a. Use a cool fluid for irrigation
b. Insert the tip of the syringe 2.5cm (1in) into the ear canal
c. Tilt the client's head 45 degrees
d. Point the tip of the syringe toward the top of the ear canal
Answer: d. Point the tip of the syringe toward the top of the ear canal
Rationale:
Pointing the tip of the syringe toward the top of the ear canal helps prevent damage to the
eardrum.
42. A nurse is caring for a client who has a history of chemotherapy-induced nausea and
vomiting. Which of the following medications should the nurse administer prior to
chemotherapy?
a. Ondansetron
b. Sertraline
c. Methylprednisolone
d. Diphenhydramine
Answer: a. Ondansetron
Rationale:
Ondansetron is an antiemetic commonly used to prevent chemotherapy-induced nausea and
vomiting.
43. A nurse is preparing to discharge a client who has a halo device and is reviewing new
prescriptions from the provider. The nurse should clarify which of the following prescriptions
with the provider?
a. Increase intake of fiber-rich foods
b. May place a small pillow under the head when sleeping
c. May operate a motor vehicle when no longer taking analgesics
d. Take a tub bath instead of showers
Answer: c. May operate a motor vehicle when no longer taking analgesics
Rationale:
Clients with a halo device should not operate a motor vehicle due to impaired mobility and
risk of injury.
44. A nurse is providing discharge teaching to a client who has tuberculosis. Which of the
following information should the nurse include in the teaching?
a. "You should wear an N95 respirator mask when you are at home"
b. "You will need to return in 2 weeks to provide a sputum specimen"
c. "You can drink alcohol after the first 6 weeks of treatment"
d. "Your provider will discontinue your medications after 3 months of therapy"
Answer: b. "You will need to return in 2 weeks to provide a sputum specimen"
Rationale:
Follow-up sputum specimens are important to monitor the effectiveness of tuberculosis
treatment.
45. A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse expect?
a. Flushed skin
b. Frothy sputum/hacking cough
c. Jugular vein distention
d. Bradycardia
Answer: b. Frothy sputum/hacking cough
Rationale:
Frothy sputum and a hacking cough are common symptoms of left-sided heart failure due to
fluid accumulation in the lungs.
46. A nurse is planning care for a client who has osteoarthritis of the knees. Which of the
following interventions should the nurse include in the plan?
a. Avoid using a topical salicylate cream
b. Administer acetaminophen for pain management
c. Place a large pillow under the client's knees when resting
d. Apply an ice pack directly to the client's knees
Answer: b. Administer acetaminophen for pain management
Rationale:
Acetaminophen is a recommended pain management option for clients with osteoarthritis due
to its analgesic properties.
47. A nurse is caring for a client who is receiving continuous bladder irrigation following a
transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain.
Which of the following actions should the nurse first take?
a. Increase the client's fluid intake
b. Reposition the client in bed
c. Check the client's urine output
d. Administer PRN pain medication
Answer: c. Check the client's urine output
Rationale:
Sharp lower abdominal pain in a client with continuous bladder irrigation may indicate a
blockage or other issue with the catheter and should be assessed first.
48. A nurse is caring for a client who has Parkinson's disease and is prescribed a level 1
dysphagia diet. Which of the following items should the nurse remove from the client's tray?
a. Vanilla milkshake
b. Peanut butter
c. Chocolate pudding
d. Applesauce
Answer: b. Peanut butter
Rationale:
Peanut butter is typically not allowed on a level 1 dysphagia diet due to its thick and sticky
consistency.
49. A nurse in a provider's office is teaching a client about the self-management of GERD.
Which of the following instructions should the nurse include?
a. "Eat a light meal 1 hour before bedtime"
b. "Sleep with the head of your bed elevated 6 inches"
c. "Increase your caloric intake by 250 calories per day"
d. "Lie down for 30 min after each meal"
Answer: b. "Sleep with the head of your bed elevated 6 inches"
Rationale:
Elevating the head of the bed can help prevent GERD symptoms by reducing acid reflux.
50. A nurse is caring for a client who is postoperative following a partial thyroidectomy.
Which of the following findings is the priority for the nurse to report to the provider?
a. Client report of pain at the incision site
b. High-pitched sound on inspiration
c. Hypoactive bowel sounds
d. Loose tracheal secretions
Answer: b. High-pitched sound on inspiration
Rationale:
A high-pitched sound on inspiration can indicate airway obstruction, which is a serious
complication following thyroidectomy.
51. A nurse is caring for a client who is 2 days postoperative following a below-the-knee
amputation and asks about the purpose of maintaining an elastic bandage around the residual
limb of the extremity. Which of the following is an appropriate response by the nurse?
a. "The elastic bandage will prevent a post-op wound infection"
b. "The elastic bandage will prevent excessive edema"
c. "The elastic bandage will keep the sutures from loosening"
d. "The elastic bandage will keep you from seeing the surgical site"
Answer: b. "The elastic bandage will prevent excessive edema"
Rationale:
Elastic bandages help to reduce swelling (edema) by applying gentle pressure to the residual
limb, promoting proper healing and fitting of prosthetic devices.
52. A nurse is planning care for a client who is 8 hours post-op following a coronary artery
bypass grafting. Which of the following assessments should the nurse plan to perform first?
a. Examine the surgical incision for drainage
b. Auscultate breath sounds
c. Palpate pulses distal to the graft donor site
d. Measure the client's core body temperature
Answer: b. Auscultate breath sounds
Rationale:
Auscultating breath sounds is a priority assessment to monitor for signs of respiratory
complications, such as atelectasis or pneumonia, which are common after surgery.
53. A nurse is providing instructions to a client who has primary syphilis. Which of the
following instructions should the nurse include in the discharge plan?
a. "You will need cryotherapy for 1 to 2 weeks"
b. "You will need to take an antiviral medication for 6 months"
c. "You will need 3 follow-up blood tests within a 24-month period"
d. "You will need to be monitored for 15 minutes after receiving each medication dose"
Answer: c. "You will need 3 follow-up blood tests within a 24-month period"
Rationale:
Follow-up blood tests are necessary to monitor the effectiveness of treatment and to ensure
the infection has been cured.
54. A nurse is caring for a client who has hypotension, cool clammy skin, tachycardia, and
tachypnea. In which of the following positions should the nurse place the client?
a. Reverse Trendelenburg
b. Feet elevated
c. High Fowler's
d. Side-lying
Answer: c. High Fowler's
Rationale:
Placing the client in high Fowler's position helps improve venous return and cardiac output,
which can be beneficial in cases of hypotension.
55. A nurse is teaching a client how to use a quad cane for ambulation following a righthemispheric stroke. Which of the following client actions indicates an understanding of the
teaching?
a. Client takes a step before advancing the cane
b. Client holds the cane with the left hand
c. Client moves the cane 2 feet ahead
d. Client advances the weaker leg forward first
Answer: d. Client advances the weaker leg forward first
Rationale:
When using a quad cane, the client should advance the weaker leg forward first, followed by
the stronger leg and then the cane.
56. A nurse is providing discharge teaching for a client who has a new tracheostomy. Which
of the following statements by the client indicates an understanding of the teaching?
a. "I'll remove the soiled tracheostomy ties prior to cleansing my stoma"
b. "I'll cut a slit in a clean gauze pad to use as a stoma dressing"
c. "I'll insert the obturator after cleaning my stoma"
d. "I'll cleanse the cannula with half-strength hydrogen peroxide"
Answer: c. "I'll insert the obturator after cleaning my stoma"
Rationale:
The obturator should be inserted into the tracheostomy tube after cleaning the stoma to
facilitate easier reinsertion of the tube.
57. A nurse is preparing to administer furosemide to a client who has acute heart failure.
Which of the following laboratory results should the nurse identify as contraindications for
receiving the medication?
a. BUN 18 mg/dL
b. Creatinine 0.8 mg/dL
c. Potassium 3.2 mEq/L
d. Sodium 136 mEq/L
Answer: c. Potassium 3.2 mEq/L
Rationale:
Furosemide can cause potassium depletion, so a low potassium level (hypokalemia) would be
a contraindication for its use.
58. A nurse is caring for a client admitted with a skull fracture. Which of the following
assessment findings should be of the greatest concern to the nurse?
a. Bilateral pupil diameter changes from 4 to 2 mm
b. WBC count changes from 9,000 to 16,000/mm³
c. Pulse pressure changes from 30 to 20 mm Hg
d. Glasgow Coma Scale score changes from 14 to 9
Answer: d. Glasgow Coma Scale score changes from 14 to 9
Rationale:
A decrease in Glasgow Coma Scale score indicates a decline in neurological status, which is
a significant concern in a client with a skull fracture.
59. A nurse is assessing a client who has myasthenia gravis. Which of the following client
statements should indicate to the nurse that the client needs a referral for occupational
therapy?
a. "I have a hard time with brushing my hair"
b. "I would rather be in a wheelchair than use a walker to get around"
c. "I've been having problems with bladder control"
d. "I have difficulty swallowing food"
Answer: a. "I have a hard time with brushing my hair"
Rationale:
Difficulty with activities of daily living, such as grooming, indicates a need for occupational
therapy to improve functional independence.
60. A nurse is providing discharge teaching to a client who will be self-administering insulin
at home. Which of the following information should the nurse include regarding needle
disposal?
a. "Secure the cap tightly over the needle before you discard it"
b. "Remove the needle from the syringe before you place it in the trash"
c. "You can discard needles in an empty bleach bottle with a lid"
d. "Place your storage container in a recycle bin when it is full"
Answer: c. "You can discard needles in an empty bleach bottle with a lid"
Rationale:
Discarding needles in a puncture-proof container, such as an empty bleach bottle with a
secure lid, helps prevent accidental needle sticks and ensures safe disposal.
61. A nurse is assessing a client who has an arteriovenous (AV) graft in the left forearm.
Which of the following findings should indicate to the nurse a complication of vascular
access?
a. 2+ left radial pulse
b. Absence of a bruit
c. Presence of a palpable thrill
d. Dilated appearance of the AV site
Answer: b. Absence of a bruit
Rationale:
A bruit is a whooshing sound heard over an AV graft or fistula and indicates adequate blood
flow. The absence of a bruit may indicate a complication, such as a thrombosis or occlusion,
that requires further assessment.
62. A client who is deaf and communicates using sign language is being admitted by a nurse
who does not know sign language. Which of the following actions should the nurse take?
a. Familiarize themselves with commonly used sign language
b. Ask a family member to be present during the admission
c. Obtain a board that uses colored pictures as communication
d. Request an interpreter during the initial assessment
Answer: d. Request an interpreter during the initial assessment
Rationale:
To ensure effective communication and understanding of the client's needs, the nurse should
request an interpreter who is proficient in sign language.
63. A nurse is planning care for a client who has an unrepaired intertrochanteric fracture and
has Buck's traction placed on the affected leg. Which of the following interventions should
the nurse include?
a. Situate the client's heel in the heel of the traction boot
b. Apply weights to the traction to total 9.1 kg (20 lb)
c. Place the footplate against the foot of the bed
d. Remove the boot for skin inspection every 12 hours
Answer: a. Situate the client's heel in the heel of the traction boot
Rationale:
Proper alignment of the heel in the traction boot helps maintain correct positioning and
traction effectiveness.
64. A nurse is caring for a client who sustained a spinal cord injury in a diving accident.
Which of the following actions should the nurse take?
a. Assess the client's neurological status every 8 hours
b. Monitor urine output hourly
c. Provide the client with a low-fiber diet
d. Logroll the client every 4 hours
Answer: b. Monitor urine output hourly
Rationale:
Hourly monitoring of urine output is essential to assess for urinary retention, which is a
common complication of spinal cord injury.
65. A nurse is planning care for a client who has a central venous access device for
intermittent infusions. Which of the following actions should the nurse include in the plan of
care?
a. Flush the catheter using a 10 mL syringe
b. Change the dressing every 24 hours
c. Use clean technique when changing the dressing
d. Cleanse the site with povidone-iodine
Answer: a. Flush the catheter using a 10 mL syringe
Rationale:
Flushing the catheter helps maintain patency and prevent occlusion.
66. A nurse in the emergency department is caring for a client who has a gunshot wound to
the abdomen. Which of the following actions should the nurse take first?
a. Check the color of the client's skin
b. Remove all of the client's clothing
c. Administer an opioid analgesic
d. Prepare the client for peritoneal lavage
Answer: a. Check the color of the client's skin
Rationale:
Checking the color of the client's skin helps assess for signs of shock, which is a priority in
trauma care.
67. A nurse is caring for a client following a bronchoscopy. Which of the following actions
should the nurse take first?
a. Check the client's gag reflex
b. Inform the client they might experience a low-grade fever
c. Instruct the client to report bleeding
d. Provide the client with sips of water
Answer: a. Check the client's gag reflex
Rationale:
Checking the gag reflex helps assess for potential airway compromise or aspiration following
the procedure.
68. A nurse is developing a plan of care for a client who is returning from the PACU
following a left below-the-knee amputation. Which of the following interventions should the
nurse include in the plan?
a. Provide the client with a firm mattress
b. Wrap the client's residual limb with an elastic bandage in a distal to proximal direction
c. Place the client's residual limb in a dependent position when possible
d. Keep the client in a supine position for 48 hours
Answer: a. Provide the client with a firm mattress
Rationale:
A firm mattress helps prevent contractures and promotes proper positioning of the residual
limb.
69. A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about
the sick-day rules. Which of the following statements by the client indicates an understanding
of the teaching?
a. "I will monitor my blood glucose every 8 hours"
b. "I will consume 250 grams of carbs daily while I'm sick"
c. "I will not take my diabetes medications while I am sick"
d. "I will check urine for ketones if my blood glucose is greater than 240 mg/dL"
Answer: d. "I will check urine for ketones if my blood glucose is greater than 240 mg/dL"
Rationale:
Checking urine for ketones helps monitor for diabetic ketoacidosis, a potential complication
of uncontrolled diabetes during illness.
70. A nurse is reviewing ABG results for a client who has COPD. Which of the following
findings should the nurse expect?
a. pH 7.38
b. PaO2 85 mm Hg
c. PaCO2 48 mm Hg
d. HCO3- 25 mEq/L
Answer: c. PaCO2 48 mm Hg
Rationale:
In COPD, the retention of carbon dioxide (PaCO2) is common, leading to respiratory
acidosis and an increased PaCO2 level.
71. A nurse is admitting a client to a medical unit following placement of a permanent
pacemaker. Which of the following findings requires further assessment by the nurse?
a. Sneezing
b. Hiccups
c. Presence of a sharp spike prior to the QRS complex on the ECG
d. Presence of intrinsic P waves following a QRS complex on the ECG
Answer: b. Hiccups
Rationale:
While sneezing, presence of a sharp spike prior to the QRS complex on the ECG, and
presence of intrinsic P waves following a QRS complex on the ECG are normal findings
following pacemaker placement, hiccups may indicate diaphragmatic irritation and should be
further assessed.
72. A nurse is caring for a client who experienced extensive burns to the arms and torso.
Which of the following actions should the nurse take regarding the client's oral nutritional
intake?
a. Adhere to scheduled meal times three times daily
b. Encourage the client to eat as many calories as possible
c. Limit the client's fluid intake to 1,500 ml/day
d. Avoid the use of supplemental feedings throughout the day
Answer: b. Encourage the client to eat as many calories as possible
Rationale:
Clients with extensive burns require increased caloric intake to promote wound healing and
recovery.
73. A nurse is planning care for a client who is 1 day postoperative following an open
cholecystectomy. Which of the following interventions should the nurse include in the plan of
care?
a. Place pillows under the client's knees
b. Apply compression stockings to the lower extremities
c. Avoid use of anticoagulants
d. Discourage leg exercises while in bed
Answer: b. Apply compression stockings to the lower extremities
Rationale:
Compression stockings help prevent deep vein thrombosis (DVT) in postoperative clients.
74. A nurse is caring for a client who has a duodenal ulcer. Which of the following actions
should the nurse take?
a. Restrict the client's fluid intake to 1,000 ml/day
b. Infuse packed RBCs
c. Administer the client's naproxen prescription
d. Offer a snack before bedtime
Answer: b. Infuse packed RBCs
Rationale:
Infusion of packed RBCs may be indicated for a client with a duodenal ulcer who is
experiencing significant bleeding and anemia.
75. A nurse is assessing an older adult client at a health fair. Which of the following
statements by the client is the nurse's priority?
a. "I can't seem to get reading materials far enough away to see the words"
b. "I'm having more difficulty telling the difference between blues and greens"
c. "I've noticed that there is a gray ring around the colored part of my eye"
d. "In the last day, I have had a severe headache and pain around my right eye"
Answer: d. "In the last day, I have had a severe headache and pain around my right eye"
Rationale:
This statement may indicate a serious eye condition, such as glaucoma, which requires
immediate attention.
76. A nurse is caring for an adolescent client who has an acute kidney injury. Which of the
following laboratory findings should the nurse anticipate?
a. BUN 8 mg/dL
b. Hgb 20 g/dL
c. Potassium 6.8 mEq/L
d. Creatinine 0.4 mg/dL
Answer: c. Potassium 6.8 mEq/L
Rationale:
Hyperkalemia is a common finding in acute kidney injury due to impaired potassium
excretion by the kidneys.
77. A nurse is planning care for an older adult client who has Meniere's disease. Which of the
following interventions should the nurse include in the plan?
a. Perform range-of-motion exercises to the client's neck every 4 hours
b. Limit the client's fluid intake to 1,500 ml/day
c. Encourage the client to change positions slowly
d. Administer aspirin if the client reports a headache
Answer: c. Encourage the client to change positions slowly
Rationale:
Changing positions slowly can help prevent vertigo, which is a common symptom of
Meniere's disease.
78. A nurse is preparing to receive a client from surgery following a transverse colon
resection with colostomy placement. The nurse should expect to assess the stoma at which of
the following locations?
a. Upper left abdomen
b. Lower right abdomen
c. Upper right abdomen
d. Lower left abdomen
Answer: a. Upper left abdomen (THIS ONE IS A DIAGRAM CHOOSE THE POINT ON
THE TOP LEFT OF ABDOMEN)
Rationale:
A transverse colon resection involves removing part of the transverse colon, which is located
across the upper part of the abdomen. After resection, a colostomy is often created to allow
waste to exit the body through an opening in the abdominal wall (stoma).
79. A nurse is admitting a client to the emergency department after a gunshot wound to the
abdomen. Which of the following actions should the nurse take to help prevent the onset of
acute kidney failure?
a. Initiate beta blocker therapy
b. Insert a urinary catheter
c. Prepare the client for an intravenous pyelogram
d. Administer IV fluids to the client
Answer: d. Administer IV fluids to the client
Rationale:
Administering IV fluids can help maintain adequate perfusion to the kidneys and prevent
acute kidney failure, especially in cases of trauma where there may be hypovolemia.
80. A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the
following actions should the nurse take?
a. Administer through a 22-gauge IV catheter
b. Prime the IV tubing with 0.45% sodium chloride
c. Complete the transfusion within 2 hours
d. Slow the transfusion rate if the client reports itching
Answer: c. Complete the transfusion within 2 hours
Rationale:
Packed RBCs should be administered within 2 hours to minimize the risk of bacterial
contamination and other complications.
81. A nurse is planning care for a client who has developed nephrotic syndrome. Which of the
following dietary recommendations should the nurse include?
a. Increase phosphorus intake
b. Decrease protein intake
c. Increase potassium intake
d. Decrease carbohydrate intake
Answer: b. Decrease protein intake
Rationale:
Decreasing protein intake can help reduce proteinuria and alleviate the workload on the
kidneys in nephrotic syndrome.
82. A nurse is caring for an older adult client who has dementia. Which of the following
questions should the nurse ask to assess the client's abstract thinking?
a. "Can you count backwards from 100 intervals of 7?"
b. "What is meant by the saying, 'don't beat around the bush'?"
c. "What do you understand about your condition?"
d. "Can you tell me the state where you were born?"
Answer: b. "What is meant by the saying, 'don't beat around the bush'?"
Rationale:
Asking about the meaning of a common saying assesses the client's ability to understand
abstract concepts.
83. A nurse is caring for a client who has cervical cancer and is receiving brachytherapy.
Which of the following actions should the nurse take?
a. Keep the soiled bed linens in the client's room
b. Instruct visitors to remain 3 feet from the client
c. Discard the radioactive device in the client's trash can
d. Limit time for visitors to 2 hours per day
Answer: a. Keep the soiled bed linens in the client's room
Rationale:
Soiled bed linens should be kept in the client's room to prevent the spread of radiation to
others.
84. A nurse is preparing a client for a lumbar puncture. Which of the following images
indicates the position should the nurse assist the client into for this procedure?
a. Side-lying (Fetal position)
b. Supine
c. Prone
d. Sitting and leaning forward
Answer: a. Side-lying (THIS IS A DIAGRAM CHOOSE THE PERSON IN A FETAL
POSITION)
Rationale:
The side-lying (fetal) position is the optimal position for a lumbar puncture because it helps
to widen the spaces between the vertebrae, allowing easier access to the spinal canal. This
position involves the client lying on their side with their knees drawn up towards their chest
and their chin tucked down towards their knees, resembling a fetal position.
85. A nurse is caring for a client who has cervical cancer and a sealed radiation implant.
Which of the following actions should the nurse take?
a. Place long-handled forceps at the client's bedside
b. Attach a dosimeter badge to the client's gown
c. Leave unused equipment in the client's room until discharge
d. Move the client's soiled linens to a designated container outside the room
Answer: a. Place long-handled forceps at the client's bedside
Rationale:
Long-handled forceps should be placed at the client's bedside to allow for safe handling of
any radioactive material that may become dislodged.
86. A nurse is teaching a client who has Graves' disease about recognizing the manifestations
of the thyroid storm. Which of the following findings should the nurse include in the
teaching?
a. Increased temperature
b. Decreased heart rate
c. Hypotension
d. Lethargy
Answer: a. Increased temperature
Rationale:
A thyroid storm is characterized by an increased temperature, not decreased heart rate,
hypotension, or lethargy.
87. A nurse is caring for a client who is postoperative following a complete thyroidectomy.
Which of the following findings is the priority for the nurse to report to the provider?
a. Serosanguineous drainage
b. Muscle twitching
c. Client report of nausea
d. Client report of incisional pain
Answer: b. Muscle twitching
Rationale:
Muscle twitching can be a sign of hypocalcemia, which can occur after a thyroidectomy due
to damage or removal of the parathyroid glands. Hypocalcemia can lead to serious
complications if not treated promptly.
88. A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify
that which of the following rhythms indicates bradycardia?
Answer: pick the brady strip
Rationale:
It seems the question was missing the ECG rhythm strips for identification. Bradycardia is
typically identified by a heart rate less than 60 beats per minute on the ECG rhythm strip.
89. A nurse is caring for a client who is receiving epidural analgesics. Which of the following
assessment findings is the nurse's priority?
a. Bladder distention
b. Hypoactive bowel sounds
c. Hypotension
d. Weakness in lower extremities
Answer: c. Hypotension
Rationale:
Hypotension can be a serious complication of epidural analgesia and should be addressed
promptly to prevent further complications.
90. A nurse is planning care for a client who has status epilepticus. Which of the following
interventions is the nurse's priority to include?
a. Turn the client to the lateral position during seizure activity
b. Provide the client with oxygen at 6 L/min using a nasal cannula
c. Administer phenytoin IV bolus to the client
d. Administer diazepam intravenously to the client
Answer: a. Turn the client to the lateral position during seizure activity
Rationale:
Turning the client to the lateral position during a seizure helps prevent aspiration and ensures
that the airway remains clear.
91. A nurse is caring for a client following a below-the-knee amputation. The client states,
"my life is over." Which of the following responses should the nurse make?
a. "You are upset. We can talk about this later."
b. "Would you like to meet with another client who is an amputee?"
c. "Why do you think your life is over?"
d. "Most people can adjust following this surgery."
Answer: b. "Would you like to meet with another client who is an amputee?"
Rationale:
Offering to connect the client with another individual who has undergone a similar
experience can provide valuable support and reassurance.
92. A nurse in a clinic is providing preventive teaching to an older adult client during a well
visit. The nurse should instruct the client that which of the following immunizations are
recommended for healthy adults after the age of 60? (Select All That Apply)
a. Herpes zoster
b. Influenza
c. Meningococcal
d. Human papillomavirus
e. Pneumococcal polysaccharide
Answer: a. Herpes zoster
b. Influenza
e. Pneumococcal polysaccharide
Rationale:
a. Herpes zoster: The herpes zoster vaccine (also known as the shingles vaccine) is
recommended for adults aged 60 years and older to prevent shingles, which is a reactivation
of the varicella-zoster virus (the virus that causes chickenpox). Shingles can cause severe
pain and complications, especially in older adults.
b. Influenza: The influenza vaccine is recommended annually for all adults, including those
over 60, as older adults are at higher risk for severe illness and complications from the flu.
e. Pneumococcal polysaccharide: The pneumococcal polysaccharide vaccine (PPSV23) is
recommended for all adults aged 65 years and older. It helps protect against pneumococcal
diseases, including pneumonia, meningitis, and bloodstream infections, which can be more
severe in older adults.
93. A nurse is planning care for a client who has dementia. Which of the following
interventions should the nurse plan to include?
a. Turn off all lights in the client's room at night
b. Place the client's bed at the lowest height
c. Request a prescription for a nightly sedative
d. Assist the client with toileting at least once every 4 hours
Answer: b. Place the client's bed at the lowest height
Rationale:
Placing the bed at the lowest height helps prevent injuries from falls, which are a common
concern for clients with dementia.
94. A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus. Which
of the following findings indicates that the client is experiencing hypoglycemia?
a. Abdominal cramping
b. Increased perspiration
c. Dehydration
d. Fruity odor to breath
Answer: b. Increased perspiration
Rationale:
Increased perspiration is a common symptom of hypoglycemia, along with other symptoms
such as shakiness, dizziness, and hunger.
95. A nurse in the PACU is assessing a client who is postoperative following general
anesthesia. Which of the following findings is the priority to address?
a. Vomiting upon arousal
b. Decreased body temperature
c. Indistinct, rambling speech
d. Piloerection of the skin
Answer: a. Vomiting upon arousal
Rationale:
Vomiting upon arousal can indicate airway obstruction or aspiration, which require
immediate attention to prevent respiratory complications.
96. A nurse is caring for a client who has hypervolemia. Which of the following is an
expected assessment finding?
a. Bradycardia
b. Hypotension
c. Loss of skin turgor
d. Weight gain
Answer: d. Weight gain
Rationale:
Hypervolemia is characterized by an excess of fluid in the body, leading to weight gain due to
increased fluid retention.
97. A nurse is teaching about measures to prevent recurring urinary tract infections with a
female client. Which of the following information should the nurse include in the teaching?
a. Take a warm bubble bath daily
b. Void every 6 hours during the day
c. Drink low-fructose cranberry juice
d. Wipe the perineal area from front to back after urinating
e. Drink 3L of fluids daily
Answer: c. Drink low-fructose cranberry juice
d. Wipe the perineal area from front to back after urinating
e. Drink 3L of fluids daily
Rationale:
These measures can help prevent recurring urinary tract infections by reducing bacterial
growth and promoting urinary tract health.
98. A nurse is caring for a client following a cardiac catheterization who has hives and
urticaria following administration of IV contrast dye. Which of the following medications
should the nurse plan to administer?
a. Spironolactone
b. Desmopressin
c. Metoclopramide
d. Diphenhydramine
Answer: d. Diphenhydramine
Rationale:
Diphenhydramine is an antihistamine that can help alleviate allergic reactions such as hives
and urticaria.
99. A home care nurse is planning to use nonpharmacological pain relief measures for an
older adult client who has severe chronic back pain. Which of the following guidelines
should the nurse use?
a. Discontinue opioids before trying nonpharmacological methods of pain relief
b. Use imagery with clients who have difficulty with focus and concentration
c. Distraction changes the client's perception of pain, but does not affect the cause
d. Pain relief from the use of heat and cold continues for several hours after removal of the
stimulus
Answer: c. Distraction changes the client's perception of pain, but does not affect the cause
Rationale:
Distraction can be an effective nonpharmacological pain relief measure, but it does not
address the underlying cause of pain.
100. A nurse is caring for a female client who is receiving total parenteral nutrition without
fat emulsion. Which of the following findings should the nurse report?
a. Crackles in the bilateral lung bases
b. Weight gain of 1.3 kg (3 lb) over the past 7 days
c. Triglyceride 110 mg/dl
d. Bowel sounds absent in lower quadrants
Answer: a. Crackles in the bilateral lung bases
Rationale:
Crackles in the lung bases can indicate fluid overload, which can be a complication of total
parenteral nutrition without fat emulsion.
