Preview Extract
ATI MED SURG PROCTORED 2019 EXAM-STUDY GUIDE
99 Q & A(All Answers are Correct)
1. A Nurse is assessing for early signs of compartment syndrome for a client who has a
short-leg fiberglass cast. Which of the following findings should the nurse expect?
A. Capillary refill less than 2 seconds
B. Bounding distal pulses
C. Intense pain with movement
D. Erythema of the toes
Answer: C. Intense pain with movement
Rationale:
Intense pain with movement is an early sign of compartment syndrome due to increased
pressure within a confined space, such as a cast. This pain occurs because the nerves and
blood vessels are compressed.
2. A Nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the
following manifestations indicates a hemolytic transfusion reaction?
A. Chills
B. Hypertension
C. Bradycardia
D. Back pain
Answer: D. Back pain
Rationale:
Back pain is a symptom of a hemolytic transfusion reaction, which occurs due to the
destruction of red blood cells leading to the release of hemoglobin into the bloodstream,
causing renal tubular damage and subsequent back pain.
3. A Nurse is caring for a client who had a total hip arthroplasty. Which of the following
actions should the nurse take to prevent hip dislocation?
A. Remove the wedge device when turning
B. Place two bed pillows between the legs when in bed
C. Encourage the client to lean forward when attempting to stand
D. Elevate the knees higher than the hips when sitting
Answer: B. Place two bed pillows between the legs when in bed
Rationale:
Placing two bed pillows between the legs when in bed helps maintain proper alignment and
prevents the legs from crossing, which can lead to hip dislocation after hip arthroplasty.
4. A Nurse is assessing a client who is preoperative and reports an allergy to bananas. The
nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the
following substances?
A. Povidone-iodine
B. Adhesive tape
C. Latex
D. Anesthetics
Answer: C. Latex
Rationale:
A client with a banana allergy is at risk for cross-reactivity with latex due to the similarity of
certain proteins found in both bananas and latex.
5. A Nurse is teaching a client about the use of an incentive spirometer. Which of the
following instructions should the nurse include in the teaching?
A. Place hands on the upper abdomen during inhalation.
B. Position the mouthpiece 2.5 cm (1 in) from the mouth
C. Exhale slowly through pursed lips
D. Hold breaths about 3 to 5 seconds before exhaling
Answer: D. Hold breaths about 3 to 5 seconds before exhaling
Rationale:
Holding breaths for 3 to 5 seconds before exhaling helps to fully expand the lungs and
improve lung function when using an incentive spirometer.
6. A Nurse is caring for a client who arrives at the emergency department and reports
vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8mEq/L.
Which of the following interventions should the nurse implement first?
A. Check the client's hand grasps
B. Administer an IV potassium drip
C. Listen to the client's bowel sounds
D. Initiate cardiac monitoring for the client
Answer: D. Initiate cardiac monitoring for the client
Rationale:
A serum potassium level of 2.8 mEq/L indicates severe hypokalemia, which can lead to
cardiac dysrhythmias. Therefore, the priority intervention is to initiate cardiac monitoring to
assess for any cardiac complications.
7. A Nurse is preparing to administer peritoneal dialysis to a client. Which of the following
actions should the nurse take?
A. Chill the dialysate before administration
B. Hang the drainage bag below the client's abdomen
C. Place the client in high-Fowler's position
D. Use clean technique to access the catheter
Answer: B. Hang the drainage bag below the client's abdomen
Rationale:
Hanging the drainage bag below the client's abdomen allows for the gravitational flow of
dialysate and ensures proper drainage during peritoneal dialysis.
8. A Nurse is performing a cranial nerve assessment on a client following a head injury.
Which of the following findings should the nurse expect if the client has impaired function
of the vestibulocochlear nerve (cranial nerve VIII)?
A. Inability to smell
B. Loss of peripheral vision
C. Disequilibrium with movement
D. Deviation of the tongue from midline
Answer: C. Disequilibrium with movement
Rationale:
Impaired function of the vestibulocochlear nerve (cranial nerve VIII) can result in
disequilibrium with movement due to its role in balance and spatial orientation.
9. A Nurse is planning care for a client who is one 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. Avoid the use of anticoagulants
C. Discourage leg exercises while in bed
D. Apply compression stockings to the lower extremities
Answer: A. Place pillows under the client's knees
Rationale:
Placing pillows under the client's knees helps to reduce tension on the abdominal incision
and minimizes discomfort after open cholecystectomy.
10. A Nurse is caring for a male client who has an exacerbation of heart failure. Which of
the following prescriptions should the nurse expect to receive from the provider?
A. Atropine 1 mg IV bolus every 5 min up to 3 mg
B. Adenosine 6 mg rapid IV bolus now
C. Verapamil 80 mg PO TID
D. Furosemide 40 mg IV bolus every 6 hr.
Answer: D. Furosemide 40 mg IV bolus every 6 hr.
Rationale:
Furosemide is a loop diuretic commonly used to manage fluid overload in heart failure by
promoting diuresis and reducing fluid volume. This helps alleviate symptoms of heart
failure exacerbation such as dyspnea and edema.
11. A Nurse is providing discharge teaching to a client following a modified left radical
mastectomy with breast expander. Which of the following statements by the client indicates
an understanding of the teaching?
A. "I will keep my left arm flexed at the elbow as much as possible"
B. "I should expect less than 25 mL of secretions per day in the drainage devices"
C. "I will perform strength-building arm exercises using a 15-pound weight"
D. "I will have to wait 2 months before additional saline can be added to my breast
expander"
Answer: B. "I should expect less than 25 mL of secretions per day in the drainage devices"
Rationale:
Expecting less than 25 mL of secretions per day in the drainage devices indicates that the
client understands the expected postoperative drainage amount, which is essential for
monitoring for complications such as infection or seroma formation.
12. A Nurse is teaching a client about using a metered-dose rescue inhaler. Which of the
following statements should the nurse include in the teaching?
A. "Do not shake your inhaler before use"
B. "Exhale fully before bringing the inhaler to your lips"
C. "Use peroxide to clean the mouthpiece of your inhaler"
D. "Depress the canister after you inhale"
Answer: B. "Exhale fully before bringing the inhaler to your lips"
Rationale:
Inhaling deeply after exhaling fully helps ensure optimal medication delivery from the
inhaler into the lungs, maximizing its therapeutic effect.
13. A Nurse is caring for a client who has been receiving total parenteral nutrition (TPN) for
1 week. For which of the following findings should the nurse notify the provider?
A. Calcium level 11.5 mg/dL
B. Serum albumin level 3.9 g/dL
C. Output 200 mL more than intake over the past 12 hr
D. Fasting blood glucose level 105 mg/dL
Answer: A. Calcium level 11.5 mg/dL
Rationale:
A calcium level of 11.5 mg/dL indicates hypercalcemia, which can occur as a complication
of TPN administration. Hypercalcemia can lead to various adverse effects, including cardiac
dysrhythmias and neurological symptoms, necessitating prompt intervention by the
healthcare provider.
14. 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. Take tub baths instead of showers
B. May place a small pillow under the head while sleeping
C. May operate a motor vehicle when no longer taking analgesics
D. Increase intake of fiber-rich foods
Answer: C. May operate a motor vehicle when no longer taking analgesics
Rationale:
Operating a motor vehicle while wearing a halo device is unsafe due to restricted mobility
and impaired vision. This prescription needs clarification to ensure patient safety.
15. A Nurse is setting up a sterile field before performing a dressing change on a client who
is postoperative. Which of the following actions should the nurse plan to take to maintain
the sterile field? (Select all that apply)
A. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap
B. Open the first flap of the sterile package toward the nurse's body
C. Place a surgical pack with a sterile drape on the work surface
D. Select a work surface at the nurse's waist level
E. Apply sterile gloves
Answer: C. Place a surgical pack with a sterile drape on the work surface; E. Apply sterile
gloves
Rationale:
Placing a surgical pack with a sterile drape on the work surface maintains sterility, while
applying sterile gloves ensures that the nurse's hands remain sterile during the procedure.
Opening the first flap of the sterile package away from the nurse's body, not grasping the
outer edge of the sterile wrap, and selecting a work surface at or above waist level also help
maintain sterility.
16. A Nurse in the emergency department is preparing a client for emergency surgery. The
client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's
priority?
A. Obtain consent for surgery
B. Insert an indwelling urinary catheter
C. Insert an NG tube
D. Apply antembolic stockings
Answer: A. Obtain consent for surgery
Rationale:
Obtaining informed consent for surgery is the priority action because the client's ability to
provide informed consent may be impaired due to alcohol intoxication.
17. A Nurse is assessing a client who has increased intracranial pressure. The nurse should
recognize that which of the following is the first sign of deteriorating neurological status?
A. Pupillary dilation
B. Cheyne-Stokes respirations
C. Decorticate posturing
D. Altered level of consciousness
Answer: D. Altered level of consciousness
Rationale:
Altered level of consciousness is often the first sign of deteriorating neurological status in a
client with increased intracranial pressure. It can indicate worsening brain function and
impending neurological deterioration.
18. A Nurse is performing skin cancer screening on a group of clients. Which of the
following findings should the nurse identify as an indication of melanoma?
A. Flat lesion with irregular borders
B. Raised lesion with a rolled border
C. Scaly lesion with a crusted appearance
D. Reddened lesion with dilated blood vessels
Answer: B. Raised lesion with a rolled border
Rationale:
A raised lesion with a rolled border is characteristic of melanoma, which is a type of skin
cancer. Melanomas often have irregular borders, variations in color, and asymmetry.
19. A Nurse is caring for a client who has diabetes insipidus. Which of the following
medications should the nurse plan to administer?
A. Lithium
B. Desmopressin
C. Regular insulin
D. Furosemide
Answer: B. Desmopressin
Rationale:
Desmopressin is a medication used to treat diabetes insipidus by replacing or supplementing
the antidiuretic hormone (ADH), which is deficient in this condition.
20. A Nurse is preparing to assist with the insertion of a non-tunneled central venous
catheter for a client who is malnourished. Which of the following actions should the nurse
plan to take?
A. Cleanse the site with a hydrogen peroxide solution
B. Instruct the client to cough as the catheter is inserted
C. Confirm the correct position of the line by obtaining a blood sample
D. place the head of the client is bed lower than the foot gloves before opening the pack
Answer: C. Confirm the correct position of the line by obtaining a blood sample
Rationale:
Confirming the correct position of the central venous catheter by obtaining a blood sample
ensures that the catheter is properly placed in the central circulation, minimizing the risk of
complications such as pneumothorax or catheter malposition.
21. A Nurse is caring for a client who had an arterial revascularization of the lower
extremity. Which of the following is the priority action the nurse should plan to take after
contacting the provider? (Click on the "Exhibit" button for additional information about the
client. There are three tabs that contain separate categories of data.)
A. Increase the insulin rate per protocol.
B. Increase the heparin infusion rate per protocol.
C. Change the PCA timing of the patient control bolus to every 15 min.
D. Start an IV fluid bolus of 0.9% sodium chloride 500 mL to infuse over 1 hr.
Answer: A. Increase the insulin rate per protocol.
Rationale:
The priority action for a client who had arterial revascularization of the lower extremity is to
address any signs of decreased tissue perfusion, which may indicate a complication such as
thrombosis. Increasing the insulin rate per protocol may be necessary to manage
hyperglycemia, which can contribute to impaired tissue perfusion.
22. A Nurse is providing discharge teaching to a client who has chronic urinary tract
infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of
the following instructions should the nurse include in the teaching?
A. Monitor heart rate once daily.
B. Take a laxative to prevent constipation.
C. Drink 2 to 3 L of fluids daily.
D. Take an antacid 30 min before taking the medication.
Answer: C. Drink 2 to 3 L of fluids daily.
Rationale:
Increasing fluid intake helps flush bacteria from the urinary tract, reducing the risk of
urinary tract infections. Adequate hydration is essential for preventing recurrence of urinary
tract infections.
23. A Nurse is providing discharge teaching for a client who has HIV. Which of the
following information is the priority for the nurse to review with the client?
A. "List some ways you can cope with the stress of your illness."
B. "Name a few things you will change about your diet."
C. "Tell me why it's important to have your CD4+ count checked."
D. "Describe your daily medication schedule."
Answer: C. "Tell me why it's important to have your CD4+ count checked."
Rationale:
Monitoring CD4+ count is crucial for assessing the progression of HIV infection and
determining the need for antiretroviral therapy. Maintaining adequate CD4+ counts helps
prevent opportunistic infections and AIDS-related complications.
24. A Nurse is administering packed RBCs to a client. The client reports chills, lower back
pain, and nausea 10 min after the infusion begins. Which of the following actions should the
nurse take first?
A. Stop the infusion.
B. Collect a urine sample.
C. Check the client's vital signs.
D. Administer oxygen to the client.
Answer: A. Stop the infusion.
Rationale:
The client's symptoms are indicative of a transfusion reaction, and stopping the infusion is
the priority action to prevent further complications. The nurse should then assess the client's
vital signs, notify the healthcare provider, and follow facility protocol for managing
transfusion reactions.
25. A Nurse is preparing to assist the provider with a thoracentesis for a client who has a left
pleural effusion. Which of the following interventions is the priority for the nurse?
A. Reinforce the importance of lying still during the procedure.
B. Determine whether the client has an allergy to local anesthetics.
C. Administer a sedative medication.
D. Describe the sensations the client will feel during the procedure.
Answer: B. Determine whether the client has an allergy to local anesthetics.
Rationale:
Determining whether the client has an allergy to local anesthetics is the priority to prevent
potential allergic reactions during the procedure. Ensuring the client's safety and comfort is
essential before proceeding with the thoracentesis.
26. A Nurse is caring for a client who has bladder cancer and a WBC count of 9000/mm³.
Which of the following actions should the nurse take?
A. Use contact isolation while providing care.
B. Move the client to a negative pressure room.
C. Apply pressure to venipuncture site.
D. Instruct the client to avoid eating raw fruit.
Answer: A. Use contact isolation while providing care.
Rationale:
A WBC count of 9000/mm³ is within the normal range, and no specific precautions are
necessary solely based on this value. However, considering the client's diagnosis of bladder
cancer, using contact isolation while providing care helps prevent the spread of potential
pathogens between the client and others.
27. A Nurse is reviewing the medical record of a client who is 1 day postoperative following
an appendectomy. Which of the following findings should the nurse report to the provider?
A. Reports pain of 4 on a scale from 0 to 10 when coughing.
B. WBC count 8,400/mm³.
C. Serosanguineous exudate noted on dressing change.
D. Hemoglobin 10 g/dL.
Answer: C. Serosanguineous exudate noted on dressing change.
Rationale:
Serosanguineous exudate may indicate potential wound complications, such as infection or
inadequate healing. The nurse should report this finding to the provider for further
evaluation and intervention.
28. A Nurse is caring for a client who was admitted with nausea, vomiting, and possible
bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the
following findings should the nurse report to the provider?
A. The amount of drainage is gradually decreasing.
B. The drainage is bright green in color with brown fecal material.
C. The client's abdomen becomes distended and firm.
D. The client reports being extremely thirsty with a sore throat.
Answer: C. The client's abdomen becomes distended and firm.
Rationale:
A distended and firm abdomen may indicate increased abdominal pressure, which can
worsen bowel obstruction or indicate a complication such as bowel perforation. The nurse
should report this finding to the provider for further evaluation and intervention.
29. A Nurse is reviewing the medical record of a client who is scheduled for a CT scan with
contrast media. Which of the following medications should the nurse instruct the client to
withhold for 48 hr following the procedure?
A. Carvedilol
B. Metformin
C. Clopidogrel
D. Furosemide
Answer: B. Metformin
Rationale:
Metformin should be temporarily withheld before and after contrast media administration to
reduce the risk of contrast-induced nephropathy. Typically, it is withheld for 48 hours
following the procedure and resumed after ensuring renal function is stable.
30. 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. Instill 0.9% sodium chloride solution into the affected eye.
B. Administer proparacaine eye drops into the affected eye.
C. Place a strip of pH paper onto the cul-de-sac of the affected eye.
D. Collect a sample of the chemical for analysis.
Answer: D. Collect a sample of the chemical for analysis.
Rationale:
The first action the nurse should take when a client experiences a chemical splash to the eye
is to collect a sample of the chemical for analysis. Identifying the specific chemical involved
will guide appropriate treatment and help prevent further damage to the eye.
31. A Nurse is providing instructions about foot care for a client who has peripheral arterial
disease. The nurse should identify that which of the following statements by the client
indicates an understanding of the teaching?
A. "I use my heating pad on a low setting to keep my feet warm."
B. "I apply a lubricating lotion to the cracked areas on the soles of my feet every morning."
C. "I rest in my recliner with my feet elevated for about an hour every afternoon."
D. "I soak my feet in hot water before trimming my toenails."
Answer: C. "I rest in my recliner with my feet elevated for about an hour every afternoon."
Rationale:
Resting with the feet elevated helps improve blood flow to the feet, which is essential for
clients with peripheral arterial disease. Elevating the feet reduces swelling and promotes
circulation, thus aiding in wound healing and preventing complications.
32. A Nurse is collecting data from a client who has toxoplasmosis and is HIV positive.
Which of the following questions should the nurse ask to gather data about toxoplasmosis?
A. "Do you have any household pets, such as a cat?"
B. "Was anyone in your family recently exposed to a viral disease?"
C. "Are your immunizations current?"
D. "Have you a been out of the country in the past 30 days?"
Answer: A. "Do you have any household pets, such as a cat?"
Rationale:
Toxoplasmosis is commonly associated with exposure to infected cat feces or contaminated
soil. Asking about household pets, particularly cats, can provide valuable information about
potential sources of infection.
33. A Nurse in a long-term care facility is caring for a bedridden client. Which of the
following findings should alert the nurse to a potential complication of the client's
immobility?
A. Polyuria
B. Confusion
C. Blurred vision
D. Diarrhea
Answer: B. Confusion
Rationale:
Confusion is a common complication of immobility in bedridden clients, often associated
with factors such as sensory deprivation, social isolation, and decreased stimulation. It can
also be indicative of other complications such as infection or medication side effects.
34. A Nurse is checking a client's ventilator settings. The nurse should understand that
positive end-expiratory pressure has which of the following purposes?
A. To deliver a set tidal volume
B. To prevent alveolar collapse
C. To control the rate of ventilations
D. To provide positive airway pressure during inspiration
Answer: B. To prevent alveolar collapse
Rationale:
Positive end-expiratory pressure (PEEP) is applied during mechanical ventilation to prevent
alveolar collapse at the end of expiration. It helps maintain functional residual capacity
(FRC) and improves oxygenation by keeping the alveoli open.
35. 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. Loose tracheal secretions
C. Hypoactive bowel sounds
D. High-pitched sound on inspiration
Answer: D. High-pitched sound on inspiration
Rationale:
A high-pitched sound on inspiration (stridor) can indicate airway obstruction or
compromise, which is a medical emergency following thyroidectomy. Prompt intervention is
necessary to prevent respiratory distress or compromise.
36. A Nurse on a medical unit is planning care for a group of clients. Which of the following
clients should the nurse attend to first?
A. A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89%
B. A client who has left-sided paralysis and slurred speech from a prior stroke
C. A client who has multiple sclerosis and reports ataxia and vertigo
D. A client who has thrombocytopenia and reports a nosebleed.
Answer: D. A client who has thrombocytopenia and reports a nosebleed.
Rationale:
Thrombocytopenia (low platelet count) increases the risk of bleeding, and a nosebleed can
indicate active bleeding. Addressing the nosebleed is the priority to prevent further blood
loss and potential complications.
37. A Nurse is caring for a client who has a newly inserted chest tube. The nurse should
clarify which of the following prescriptions with the provider?
A. Vigorously strip the chest tube twice daily.
B. Notify the provider when tidaling ceases.
C. Administer morphine 2 mg IV bolus every 3 hr PRN for pain.
D. Assist the client out of bed three times daily.
Answer: A. Vigorously strip the chest tube twice daily.
Rationale:
Stripping or milking a chest tube can create excessive negative pressure, eading to damage
to the lung tissue and increased risk of complications such as pneumothorax or hemothorax.
It is not recommended practice and should be clarified with the provider.
38. A Nurse is planning care for a client who has a newly implanted arteriovenous graft in
the right arm. Which of the following actions should the nurse include in the plan of care?
A. Instruct the client to avoid lifting the right arm for 72 hr.
B. Check blood pressure in the right arm.
C. Insert a saline lock into a site 10 cm (4 in) distal to the graft.
D. Palpate the site for a thrill.
Answer: D. Palpate the site for a thrill.
Rationale:
Palpating the site for a thrill is an essential nursing intervention to assess the patency and
function of an arteriovenous graft. A thrill indicates adequate blood flow through the graft,
which is necessary for dialysis access.
39. A Nurse is providing discharge teaching for a client who has osteomyelitis in the left leg.
Which of the following findings should the nurse identify as requiring a referral?
A. The client has a prescription for furosemide.
B. The client has a prescription for long-term IV antibiotic therapy.
C. The client has a WBC count of 20,000/mm³.
D. The client has type 2 diabetes mellitus and HbA1c of 5%.
Answer: C. The client has a WBC count of 20,000/mm³.
Rationale:
An elevated white blood cell (WBC) count can indicate infection or inflammation, which
may require further evaluation and management by a healthcare provider. Referral for
additional assessment and treatment may be necessary in this case.
40. A Nurse is caring for a client who has an IV in the left forearm and whose infusion pump
has alarmed several times. Which of the following actions should the nurse take first?
A. Ensure the tubing connections are secure.
B. Reposition the client's left arm.
C. Flush the IV catheter.
D. Check the IV site for redness.
Answer: A. Ensure the tubing connections are secure.
Rationale:
Alarms from the infusion pump can indicate various issues, including occlusion or
disconnection of tubing. The first action should be to ensure that all tubing connections are
secure to maintain proper fluid delivery and prevent interruption of therapy.
41. A Nurse is caring for a client who is 6hr postoperative following application of an
external fixator for a tibial fracture. Which of the following actions should the nurse take?
A. Maintain the affected extremity in a dependent position
B. Wrap sterile gauze on the sharp point of the pins
C. Adjust the clamps on the fixator frame
D. Palpate the dorsalis pedis pulse.
Answer: D. Palpate the dorsalis pedis pulse.
Rationale:
Palpating the dorsalis pedis pulse helps assess distal perfusion and circulation in the affected
extremity, which is essential following the application of an external fixator to detect any
signs of vascular compromise or compartment syndrome.
42. A Nurse is caring for a client following a total knee arthroplasty. The client reports a pain
level on a pain scale of 0 to 10. Which of the following interventions should the nurse take?
A. Place pillows under the client's knee
B. Gently massage the area around the client's incision
C. Apply an ice pack to the client's knee
D. Perform range-of-motion exercises to the client's knee
Answer: C. Apply an ice pack to the client's knee
Rationale:
Applying an ice pack can help reduce swelling and provide pain relief following knee
arthroplasty by numbing the area and decreasing inflammation.
43. A Nurse is teaching a client and his partner about performing peritoneal dialysis at home.
When discussing peritonitis, which of the following manifestations should the nurse identify
as the earliest indication of this complication?
A. Fever
B. Cloudy effluent
C. Increased heart rate
D. Generalized abdominal pain
Answer: B. Cloudy effluent
Rationale:
Cloudy effluent (peritoneal fluid) is an early sign of peritonitis in clients undergoing
peritoneal dialysis. It indicates the presence of infection or inflammation within the
peritoneal cavity and should be reported promptly for further evaluation and treatment.
44. A Nurse in an emergency department is caring for a client who is to receive tissue
plasminogen activator (TPA) for the treatment of an ischemic stroke. In which order should
the nurse complete the following actions? (Move the steps into the box on the right, placing
them into the selected order of performance. Use all the steps.)
A. Weigh the client
B. Check for contraindications.
C. Administer the TPA
D. Transfer the client to the CCU
Answer: B. Check for contraindications → C. Administer the TPA → A. Weigh the client →
D. Transfer the client to the CCU
Rationale:
Before administering tissue plasminogen activator (TPA) for ischemic stroke, it is essential
to first check for contraindications to ensure the safety and appropriateness of the
medication. Once it is confirmed that there are no contraindications, TPA can be
administered. Weighing the client is part of the process for determining the appropriate
dosage of TPA. After administration, the client should be transferred to the critical care unit
(CCU) for close monitoring and management of potential complications.
45. A Nurse in the emergency department admitted a client who is having a myocardial
infarction. The client has been placed on the heart monitor. Which of the following
electrocardiogram strips is indicative of a myocardial infarction?
A) ST-segment elevation in leads II, III, and aVF
B) Tall, peaked T waves in leads V2-V6
C) Presence of a U wave in leads I, aVL, and V1-V6
D) Inverted T waves in leads I, aVL, V5, and V6
Answer: A) ST-segment elevation in leads II, III, and aVF
Rationale:
ST-segment elevation in multiple leads (II, III, and aVF) is indicative of myocardial
infarction involving the inferior wall of the heart. This ECG finding is consistent with acute
myocardial infarction and warrants immediate intervention.
46. A Nurse is assessing a client who has acute pancreatitis and has been receiving total
parenteral nutrition for the past 72 hr. Which of the following findings requires the nurse to
intervene? priority
A. Capillary blood glucose level 164 mg/dL
B. Crackles in bilateral lower lobes
C. WBC count 13,000/mm³
D. Right upper quadrant pain
Answer: B. Crackles in bilateral lower lobes
Rationale:
Crackles in the bilateral lower lobes indicate the presence of pulmonary edema, which is a
potential complication of acute pancreatitis and total parenteral nutrition. Prompt
intervention is necessary to assess and manage respiratory status.
47. A Nurse is caring for a group of clients. The nurse should obtain a blood pressure
reading using only the left extremity for which of the following clients?
A. A client who has a right upper extremity arteriovenous fistula
B. A client who has left-sided Bell's palsy
C. A client who has right-sided weakness due to Parkinson's disease
D. A client who has a peripherally inserted central catheter (PICC) in the left arm
Answer: A. A client who has a right upper extremity arteriovenous fistula
Rationale:
When a client has an arteriovenous fistula or graft in one arm, blood pressure measurements
should be obtained from the opposite arm to avoid disruption of the access site and
inaccurate readings.
48. A Nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is
the priority intervention by the nurse?
A. Administer 0.9% sodium chloride
B. Initiate a continuous IV insulin infusion
C. Check potassium levels.
D. Begin bicarbonate continuous IV infusion
Answer: B. Initiate a continuous IV insulin infusion
Rationale:
The priority intervention in DKA is to lower blood glucose levels rapidly with insulin
therapy to correct hyperglycemia and ketoacidosis. Insulin is essential for shifting glucose
into cells and halting the production of ketones.
49. A Nurse is preparing to administer levofloxacin 750 mg via intermittent over 90 min to a
client. Available is levofloxacin 750 mg in 150 mL. How many mL/hr should the nurse set
the IV pump to administer? (Round to the nearest whole number. Use a leading zero if it
applies. Do not use a trailing zero.)
A. 75 mL/hr
B. 90 mL/hr
C. 100 mL/hr
D. 125 mL/hr
Answer: A. 75 mL/hr
Rationale:
To calculate the infusion rate for the medication, divide the total volume (150 mL) by the
total infusion time (90 minutes) and then multiply by 60 to convert minutes to hours.
Thus, the infusion rate is approximately 100 mL/hr. Rounded to the nearest whole number, it
is 100 mL/hr.
50. A Nurse is caring for a client who has been prescribed an antibiotic. The client tells the
nurse, "I don't like taking medications because I don't think I need them." Which of the
following responses should the nurse make?
A. “If you don't take this medication, you will feel worse.”
B. "Most clients feel better after taking the antibiotic."
C. "Your provider wouldn't prescribe this medication if it weren't necessary."
D. "I will tell your provider that you do not want to take this medication."
Answer: C. "Your provider wouldn't prescribe this medication if it weren't necessary."
Rationale:
This response acknowledges the client's concerns while providing reassurance about the
necessity of the prescribed medication based on the healthcare provider's assessment.
51. A Nurse is teaching the family of a client who has Alzheimer's disease about caring for
the client at home. Which of the following instructions should the nurse include?
A. Cover electrical outlets in the client's home with tape.
B. Keep the client's bedroom dark at night.
C. Hang a monthly calendar in the client's bedroom?
D. Place a large-face clock in the client's bedroom
Answer: D. Place a large-face clock in the client's bedroom
Rationale:
Clients with Alzheimer's disease often experience difficulties with time perception and
orientation. A large-face clock can help the client and their family members easily read and
understand the time, aiding in daily routines and reducing confusion.
52. A Nurse is assessing the pain status of a group of clients. Which of the following
findings indicates a client is experiencing referred pain?
A. A client who has peritonitis reports generalized abdominal pain.
B. A client who is postoperative reports incisional pain.
C. A client who has angina reports substernal chest pain.
D. A client who has pancreatitis reports pain in the left shoulder.
Answer: D. A client who has pancreatitis reports pain in the left shoulder.
Rationale:
Referred pain is felt at a site distant from the actual source of the pain. Pain in the left
shoulder is a classic referred pain pattern associated with pancreatitis due to irritation of the
diaphragm and adjacent structures.
53. A Nurse is reviewing the medical record of a client who is to undergo open-heart
surgery. Which of the following findings should the nurse report to the provider as a
contraindication to receiving heparin?
A. Rheumatoid arthritis
B. Thalassemia
C. COPD
D. Thrombocytopenia
Answer: D. Thrombocytopenia
Rationale:
Thrombocytopenia, or low platelet count, is a contraindication to heparin therapy due to the
increased risk of bleeding. Heparin works by enhancing the activity of antithrombin III,
which inhibits clot formation, but it can exacerbate bleeding in clients with low platelet
counts.
54. 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, an inflammatory bowel disease, is associated with an increased risk of
colorectal cancer due to chronic inflammation and changes in the intestinal mucosa. Clients
with a history of Crohn's disease require regular screening for colorectal cancer.
55. A Nurse is completing discharge teaching with a client who has a peripherally inserted
central catheter (PICC) line in the left arm. Which of the following instructions should the
nurse include in the teaching?
A. Do not elevate the arm above the level of the heart
B. Use a 10-mL syringe to flush the line
C. Change the catheter dressing daily
D. Clean the insertion site using 20 mL of hydrogen peroxide
Answer: B. Use a 10-mL syringe to flush the line
Rationale:
Using a smaller syringe (e.g., 10 mL) to flush the PICC line reduces the risk of excessive
pressure, which can damage the line or dislodge it from the vein. It also allows for better
control during flushing.
56. A Nurse is preparing to administer daily medications to a client who is undergoing a
procedure at 10:00 that requires IV contrast dye. Which of the following routine medications
to give at 08:00 should the nurse withhold?
A. Metoprolol
B. Fluticasone
C. Metformin
D. Valproic acid
Answer: C. Metformin
Rationale:
Metformin should be withheld before and after procedures involving IV contrast dye
administration to reduce the risk of lactic acidosis, a rare but serious complication. It is
typically held for 48 hours before and after the procedure.
57. A Nurse is caring for a client who has developed a heart rate of 38 bpm and reports
tremors and feeling faint. Which of the following medications should the nurse anticipate
administering?
A. Digoxin
B. Atropine sulfate
C. Diltiazem
D. Magnesium sulfate
Answer: B. Atropine sulfate
Rationale:
Atropine sulfate is a vagolytic medication that increases heart rate by blocking the
parasympathetic nervous system. It is commonly used to treat symptomatic bradycardia and
can improve symptoms such as dizziness, fainting, and tremors.
58. A Nurse is reviewing the medical record of a client who has pneumonia. Which of the
following serum laboratory values should the nurse expect?
A. Hematocrit 35%
B. Sodium 130 mgttidL
C. WBC count 15.000ttimm3
D. BUN 8 mgttidL
Answer: C. WBC count 15,000/mm3
Rationale:
Pneumonia is an infection of the lower respiratory tract, typically caused by bacteria or
viruses. An elevated white blood cell (WBC) count is a common finding in bacterial
pneumonia as the body's immune response increases to fight the infection.
59. A Nurse in an emergency department is caring for a client who has sinus bradycardia.
Which of the following actions should the nurse take first?
A. Prepare the client for temporary pacing
B. Initiate IV fluid therapy for the client
C. Administer atropine to the client
D. Measure the client's blood pressure
Answer: D. Measure the client's blood pressure
Rationale:
Before initiating interventions for sinus bradycardia, it is essential to assess the client's
perfusion status, which includes measuring blood pressure. Signs of hemodynamic
instability, such as hypotension, may necessitate immediate interventions such as IV fluid
therapy or pharmacological treatment.
60. A Nurse is caring for a client who has tuberculosis and is taking rifampin. The client
reports that her saliva has turned red-orange in color. Which of the following responses
should the nurse make?
A. "You will need to increase your fluid intake to resolve this problem.”
B. "This finding may indicate possible medication toxicity."
C. "This is an expected adverse effect of this medication."
D. "Your provider will prescribe a different medication regimen."
Answer: C. "This is an expected adverse effect of this medication."
Rationale:
Red-orange discoloration of bodily fluids, including saliva, urine, sweat, and tears, is a
common and harmless side effect of rifampin therapy. It is important to reassure the client
that this is expected and not a cause for concern.
61. A Nurse is providing discharge teaching about foot care to a client who is newly
diagnosed with type 1 diabetes mellitus. Which of the following information should the
nurse include?
A. Inspect the feet every other day
B. Apply lotion between the toes.
C. Soak the feet twice a day
D. Trim toenails straight across
Answer: D. Trim toenails straight across
Rationale:
Trimming toenails straight across helps prevent ingrown toenails, which can lead to
complications such as infection in individuals with diabetes. It is important to avoid cutting
nails too short or rounding the edges to reduce the risk of injury.
62. A Nurse is reviewing the following ABG results for a postoperative client pH 7.27,
PaCO2 49 mm Hg, HCO3 22 mEq/L. The nurse should interpret the findings as which of the
following imbalances?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Respiratory acidosis
Answer: D. Respiratory acidosis
Rationale:
In respiratory acidosis, the pH is low (45 mm Hg), and the
HCO3 may be normal or elevated as a compensatory mechanism. These findings indicate
that the client's acid-base balance is primarily affected by an increase in carbon dioxide
(respiratory component).
63. A Nurse is caring for a client who has amnesia. Which of the following assessment
findings should the nurse anticipate with the client's condition?
A. Flushed skin color
B. Bradycardia
C. Heat intolerance
D. Headache
Answer: C. Heat intolerance
Rationale:
Heat intolerance is a common symptom in clients with amnesia, as the condition affects the
hypothalamus, which regulates body temperature. Clients may have difficulty regulating
body temperature and may experience discomfort in warm environments.
64. 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 food with garlic and onion salts."
B. "I can have a frozen fruit juice bar for dessert."
C. "I can have mayonnaise on my sandwich."
D. "I can drink vegetable juice with a meal."
Answer: B. "I can have a frozen fruit juice bar for dessert."
Rationale:
Frozen fruit juice bars typically contain minimal added sodium, making them a suitable
dessert option for clients with heart failure who need to limit sodium intake.
65. A Nurse on an oncology unit is caring for a client who is receiving internal radiation
therapy. Which of the following actions should the nurse take?
A. Allow visitors to hold the client's hand.
B. Leave the door to the client's room open
C. Place the dosimeter film badge on the client's door
D. Wear a lead apron when providing client care
Answer: D. Wear a lead apron when providing client care
Rationale:
Internal radiation therapy (brachytherapy) involves the placement of radioactive sources
inside or near the tumor site. Nurses and other healthcare providers should wear lead aprons
and other protective equipment to minimize exposure to radiation when caring for clients
receiving internal radiation therapy.
66. A Nurse is assessing a client for a positive Chvostek's sign following a thyroidectomy.
Which of the following areas on the client's head should the nurse tap to assess the client for
tetany?
A. Over the facial nerve
B. Over the temporal nerve
C. Over the trigeminal nerve
D. Over the facial artery
Answer: A. Over the facial nerve
Rationale:
To elicit Chvostek's sign, the nurse should tap gently over the facial nerve (facial nerve
territory) just anterior to the earlobe and below the zygomatic arch. A positive Chvostek's
sign is indicated by facial muscle twitching in response to the tapping, which suggests
hypocalcemia and increased neuromuscular irritability.
67. A Nurse is teaching a group of clients who have cancer about radiation therapy. Which of
the following activities should the nurse include in the teaching?
A. Limit engaging in sport activities that can cause bruising
B. Decrease intake of fresh fruits and vegetables
C. Limit socializing in large crowds
D. Decrease time spent outdoors
Answer: D. Decrease time spent outdoors
Rationale:
Clients receiving radiation therapy should limit exposure to sunlight and outdoor activities,
especially during peak sunlight hours, to reduce the risk of skin damage and burns.
Sunscreen should be applied when outdoors, and protective clothing should be worn to
minimize exposure.
68. A Nurse is planning care for a client who is receiving heparin IV to treat a pulmonary
embolism. Which of the following medications should the nurse plan to have at the bedside?
A. Acetylcysteine
B. Flumazenil
C. Protamine sulfate
D. Vitamin K
Answer: C. Protamine sulfate
Rationale:
Protamine sulfate is the antidote for heparin overdose or excessive anticoagulation. If a
client receiving heparin develops bleeding or experiences other signs of heparin toxicity,
protamine sulfate can be administered to reverse the effects of heparin.
69. 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 empty my bag when it is full."
B. "I will take a laxative when I am constipated."
C. "I will eat a high-fiber diet."
D. "I will expect my stools to be loose."
Answer: A. "I will empty my bag when it is full."
Rationale:
Clients with an ileostomy should empty their pouch when it is about one-third to one-half
full to prevent leakage and skin irritation. Waiting until the pouch is full increases the risk of
leakage and can be uncomfortable for the client.
70. A Nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following
findings should the nurse identify as an indication for the placement of a permanent
pacemaker?
A. Complete AV block with rates slower than 40 ttimin
B. Sinus tachycardia with rates faster than 80 ttimin
C. Vasovagal bradycardia without syncope
D. Asymptomatic second-degree AV block
Answer: A. Complete AV block with rates slower than 40 ttimin
Rationale:
Complete atrioventricular (AV) block with rates slower than 40 bpm is an indication for the
placement of a permanent pacemaker. AV block results in a dissociation between atrial and
ventricular activity, leading to a slow ventricular rate that can cause symptoms such as
syncope, dizziness, and fatigue.
71. A Nurse is caring for a client who is receiving chemotherapy and requests information
about acupuncture to relieve some of the side effects. Which of the following findings
should the nurse identify as a contraindication to receiving this alternate therapy?
A. Urticaria
B. Lymphedema
C. Headaches
D. Mouth sores
Answer: D. Mouth sores
Rationale:
Mouth sores, also known as oral mucositis, can be a common side effect of chemotherapy.
Acupuncture involves inserting needles into specific points on the body, which could
potentially worsen mouth sores or cause discomfort. Therefore, mouth sores would be
considered a contraindication to receiving acupuncture therapy in this scenario.
72. 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 take first?
A. Increase the client's fluid intake.
B. Administer PRN pain medication
C. Check the client's urine output
D. Reposition the client in bed
Answer: C. Check the client's urine output
Rationale:
Sharp lower abdominal pain in a client receiving continuous bladder irrigation following a
TURP may indicate bladder spasm or obstruction. The nurse should first assess the client's
urine output to determine if there is adequate drainage. Decreased or absent urine output
could indicate a blockage in the irrigation system or urinary retention, which requires
immediate intervention to prevent complications.
73. A Nurse is assessing a client who has malnutrition. Which of the following findings
should the nurse expect?
A. Hypermagnesemia
B. Diplopia
C. Hyperthermia
D. Cachexia
Answer: D. Cachexia
Rationale:
Cachexia, or severe muscle wasting and weight loss, is a common finding in clients with
malnutrition. It is characterized by weakness, fatigue, and loss of muscle mass and adipose
tissue. Hypermagnesemia, diplopia, and hyperthermia are not typically associated with
malnutrition.
74. A Nurse is assessing a client who has a gravity drain in place following an open
cholecystectomy. Which of the following images should the nurse identify as a gravity
drain?
A. Peak flow meter
B. NG tube with suction apparatus
C. Chest physiotherapy vest
D. Chest tube with a drainage system
Answer: D. Chest tube with a drainage system
Rationale:
A gravity drain relies on the force of gravity to allow drainage from the body. A chest tube
with a drainage system, often used after thoracic or abdominal surgery, allows fluid or air to
drain passively from the chest cavity or surgical site into a collection chamber, relying on
gravity to facilitate drainage. The other options listed do not involve gravity drainage.
75. A home health nurse is assessing the home environment of a client who has cystic
fibrosis. Which of the following equipment should the nurse plan to recommend?
A. Peak flow meter
B. NG tube with suction apparatus
C. Chest physiotherapy vest
D. Chest tube with a drainage system
Answer: A. Peak flow meter
Rationale:
A peak flow meter is a device used to measure a person's peak expiratory flow rate, which
can be helpful in monitoring lung function in clients with cystic fibrosis. It can assist in
assessing the effectiveness of treatments and detecting changes in respiratory status. The
other options listed are not typically used in the management of cystic fibrosis.
76. A Nurse is caring for a client who has a severe burn injury. The nurse should recognize
which of the following client findings as an indication of hypovolemic shock?
A. Urine output 45 mL/hr.
B. PaCO2 37 mm Hg
C. Capillary refill 1.5 seconds
D. Potassium 5.2 mEq/L
Answer: A. Urine output 45 mL/hr.
Rationale:
Hypovolemic shock occurs when there is a significant decrease in blood volume, leading to
inadequate tissue perfusion and oxygen delivery. Decreased urine output (oliguria) is a
hallmark sign of hypovolemic shock, as the body attempts to conserve fluid by reducing
urine production. The other options do not specifically indicate hypovolemic shock.
77. A Nurse is assessing a client who has a serum sodium level of 120 mEq/L. Which of the
following findings should the nurse expect?
A. Decreased bowel sounds
B. Increased central venous pressure
C. Confusion
D. Hyperreflexia
Answer: C. Confusion
Rationale:
Hyponatremia, or low serum sodium level, can lead to neurological symptoms such as
confusion, lethargy, and altered mental status due to changes in brain cell function and
osmotic imbalances. Decreased bowel sounds, increased central venous pressure, and
hyperreflexia are not typically associated with hyponatremia.
78. A Nurse is assessing a client who is receiving valsartan to treat heart failure. Which of
following findings should the nurse identify as an indication that the medication is effective?
A. Increased heart rate
B. Decreased urinary output
C. Increased potassium level
D. Decreased blood pressure
Answer: D. Decreased blood pressure
Rationale:
Valsartan is an angiotensin II receptor blocker (ARB) used to treat heart failure and
hypertension by dilating blood vessels and reducing blood pressure. A decrease in blood
pressure would indicate that the medication is effectively lowering blood pressure and
potentially improving cardiac function. Increased heart rate, decreased urinary output, and
increased potassium level are not expected findings with valsartan therapy.
79. 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 additional information about the procedure."
B. "You will be cancer-free if you have the procedure."
C. "I can give you a list of other people who had the same procedure."
D. "You should get a second opinion regarding the procedure."
Answer: A. "I can give you additional information about the procedure."
Rationale:
Providing the client with additional information about the mastectomy allows them to make
an informed decision regarding their treatment. It respects the client's autonomy and
provides support in understanding the procedure and its potential outcomes. Offering
resources and support for decision-making empowers the client to participate actively in
their healthcare choices. Options B, C, and D do not address the client's concerns or provide
relevant assistance in decision-making.
80. A Nurse caring for a client who has cervical and a sealed radiation implant. Which of the
following actions should the nurse take?
A. Attach a dosimeter badge to the client's gown.
B. Place long-handled forceps at the client's bedside
C. Leave unused equipment in the client's room until discharged
D. Move the client's soiled linens to a designated container outside the room
Answer: B. Place long-handled forceps at the client's bedside
Rationale:
Long-handled forceps should be placed at the client's bedside to handle any radioactive
materials or implants to minimize radiation exposure to the nurse and other healthcare
personnel. This is a safety measure to ensure proper handling of radioactive materials.
Attaching a dosimeter badge to the client's gown would not be necessary as the client is
already being monitored for radiation exposure. Leaving unused equipment in the client's
room or moving soiled linens to a designated container would not specifically address the
handling of radioactive materials.
81. A Nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for
developing digoxin toxicity. The nurse should monitor the client for an imbalance of which
of the following electrolytes because it can increase the risk for digoxin toxicity?
A. Phosphatase
B. Calcium
C. Potassium
D. Magnesium
Answer: C. Potassium
Rationale:
Hypokalemia (low potassium levels) can increase the risk of digoxin toxicity by enhancing
the drug's effect on the heart. Digoxin competes with potassium for binding sites on the
sodium-potassium ATPase pump, and low potassium levels can potentiate digoxin's cardiac
effects, leading to toxicity. Therefore, monitoring potassium levels is essential in clients
taking digoxin to prevent toxicity.
82. A Nurse is admitting a client who reports chest pain and has been placed on a telemetry
monitor. Which of the following should the nurse analyze to determine whether the client is
experiencing a myocardial infarction?
A. ST segment
B. wave
C. PR interval
D. fIRS
Answer: A. ST segment
Rationale:
The ST segment on an electrocardiogram (ECG) indicates the time between ventricular
depolarization and repolarization. Changes in the ST segment, such as ST-segment elevation
or depression, can indicate myocardial ischemia or infarction. ST-segment elevation is a
hallmark sign of acute myocardial infarction (heart attack), and analyzing the ST segment is
crucial in determining whether the client is experiencing myocardial infarction.
83. PACU nurse is monitoring the drainage from a client's NG tube following abdominal
surgery. Which of the following findings in the first postoperative hour should the nurse
report to the provider?
A. 200 mL of brown drainage
B. 100 mL of red drainage
C. 75 mL of greenish-yellow drainage
D.150 mL of serosanguineous drainage
Answer: B. 100 mL of red drainage
Rationale:
Red drainage from an NG tube following abdominal surgery may indicate gastrointestinal
bleeding, which is a significant concern in the immediate postoperative period. The nurse
should report this finding to the provider promptly for further evaluation and intervention to
prevent complications.
84. A Nurse is caring for a client who understands a prescribed surgical procedure but
cannot read or write. Which of the following actions should the nurse take?
A. Allow the client to sign the consent with an X
B. Notify the surgical team that the client is unable to sign the content
C. Inform a family member of the need to sign the consent
D. Contact the client's power of attorney to sign the consent.
Answer: C. Inform a family member of the need to sign the consent
Rationale:
If a client cannot read or write, the nurse should inform a family member or legal guardian
about the need to sign the surgical consent form on behalf of the client. This ensures that the
client's rights are protected, and the surgical procedure can proceed with appropriate
consent.
85. A Nurse is providing dietary teaching to a client who has heart failure and a new
prescription for a 2-g sodium diet. Which of the following client statements should the nurse
identify as an understanding of the teaching?
A. "I can season my foods with lemon juice."
B. "I should use canned instead of frozen vegetables."
C. "I can use baking soda when I bake."
D. "I should use salt sparingly while cooking."
Answer: D. "I should use salt sparingly while cooking."
Rationale:
Clients with heart failure are often prescribed low-sodium diets to help manage fluid
retention and reduce the risk of exacerbations. Using salt sparingly while cooking is an
appropriate dietary strategy to reduce sodium intake. Lemon juice, canned vegetables, and
baking soda may contain significant amounts of sodium and are not suitable alternatives for
a low-sodium diet.
86. A Nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify
which of the following rhythms indicates bradycardia?
Answer: Sinus bradycardia
Rationale:
Sinus bradycardia is characterized by a regular rhythm with a rate less than 60 beats per
minute and originates from the sinus node. It is commonly seen in athletes, during sleep, or
as a result of vagal stimulation. Bradycardia is identified by a slow heart rate, typically
below 60 beats per minute, regardless of the underlying rhythm.
87. A Nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which
of the following is an appropriate nursing action?
A. Obtain a stool specimen with gloves
B. Wash hands with alcohol-based hands rub
C. Clean surfaces with chlorhexidine
D. Place the client in a protective environment
Answer: B. Wash hands with alcohol-based hands rub
Rationale:
Clostridium difficile is a bacterium that can cause diarrhea and colitis, particularly in
healthcare settings. Hand hygiene is essential in preventing its transmission. Washing hands
with an alcohol-based hand rub is an appropriate nursing action to prevent the spread of C.
difficile infection. It is more effective than soap and water in killing the spores of C.
difficile.
88. A Nurse is preparing to administer a unit of packed RBCs over 1 hr. Which of the
following actions should the nurse plan to take?
A. Initiate venous access with a 21-gauge needle
B. Obtain the client's first set of vital signs 1 hr after initiating the transfusion
C. Administer the unit of packed RBCs over 1 hr.
D. Use Y tubing with 0.9% sodium chloride when administering the transfusion
Answer: C. Administer the unit of packed RBCs over 1 hr.
Rationale:
Packed red blood cells (PRBCs) are typically administered over a period of 1 to 4 hours,
depending on the institution's protocol and the client's condition. Administering the unit of
PRBCs over 1 hour is within the standard practice for transfusion therapy. Options A, B, and
D are not directly related to the administration of PRBCs.
89. 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. "Why do you think your life is over?"
B. "You are upset. We can talk about this later."
C. "Would you like to meet with another client who is an amputee?"
D. "Most people can adjust following this surgery."
Answer: A. "Why do you think your life is over?"
Rationale:
This response encourages open communication and allows the nurse to explore the client's
feelings and concerns. It demonstrates empathy and a willingness to address the client's
emotional needs. Options B, C, and D may dismiss or minimize the client's feelings without
addressing the underlying issues.
90. A Nurse is assessing a client who has a pressure ulcer. Which of the following findings
should the nurse expect as an indication that the wound is healing?
A. Light yellow exudate
B. Dry brown eschar
C. Dark red granulation tissue
D. Wound tissue firm to palpation
Answer: C. Dark red granulation tissue
Rationale:
Granulation tissue is a sign of the proliferative phase of wound healing and indicates tissue
repair and regeneration. Dark red granulation tissue is typically indicative of a healthy,
healing wound. Light yellow exudate may indicate infection, dry brown eschar may indicate
necrosis, and firm wound tissue may suggest poor perfusion or healing complications.
91. A nurse is providing teaching to a client who has left-sided heart failure. Which of the
following manifestations should the nurse include in the teaching?
A. Hacking cough
B. Neck vein distention
C. Ankle edema
D. Anorexia
Answer: A. Hacking cough
Rationale:
Left-sided heart failure often manifests with pulmonary symptoms such as a hacking cough
due to pulmonary congestion. The left ventricle fails to adequately pump blood, causing
fluid buildup in the lungs and leading to symptoms like coughing. Neck vein distention,
ankle edema, and anorexia are more commonly associated with right-sided heart failure.
92. A nurse in a provider's office is caring for a client who has total vision loss and is the
handler of a service dog. Which of the following actions should the nurse take to show
consideration for the client and the service animal?
A. Command the dog to sit while talking to the client
B. Pet the dog briefly to demonstrate acceptance
C. Consult the client before approaching the dog
D. Offer the dog a bowl of water to demonstrate caring
Answer: C. Consult the client before approaching the dog
Rationale:
It is essential to respect the client's autonomy and relationship with their service animal.
Before interacting with the service dog, the nurse should consult the client to ensure they are
comfortable with the interaction. This demonstrates respect for the client's independence and
fosters a collaborative relationship.
93. A nurse is reviewing laboratory results for 4 clients who are scheduled for surgery.
Which of the following laboratory values should the nurse report to the surgeon?
A. HCT 42%
B. INR of 1.6
C. Platelets 95,000/mm3
D. WBC count 8,000/mm3
Answer: B. INR of 1.6
Rationale:
An elevated INR (International Normalized Ratio) indicates an increased risk of bleeding,
which can be problematic during surgery. The nurse should report an INR of 1.6 to the
surgeon for further evaluation and consideration of the client's bleeding risk during the
surgical procedure.
94. A nurse is providing discharge teaching to a client who has an impaired immune system
due to chemotherapy. Which of the following information should the nurse include in the
teaching?
A. "Wash your toothbrush in the dishwasher once each month."
B. "Wash your perineal area two times each day with antimicrobial soap."
C. "Change your pet's litter box daily."
D. "Change the water in your drinking glass every 4 hours."
Answer: C. "Change your pet's litter box daily."
Rationale:
Changing the pet's litter box daily helps reduce the risk of exposure to infectious agents,
such as Toxoplasma gondii, which can pose a risk to immunocompromised individuals.
Proper hygiene measures, such as washing hands frequently and avoiding contact with
potentially contaminated materials, are essential for preventing infections in clients with
impaired immune systems.
95. A nurse is assessing a client who has acute kidney failure. Which of the following
findings should the nurse report to the provider?
A. Urine specific gravity 1.045
B. Peripheral pulses 2 + bilaterally
C. Creatinine 0.8 mg/dL
D. Weight gain 1.1 kg (2.4 lb) in 24 hours
Answer: D. Weight gain 1.1 kg (2.4 lb) in 24 hours
Rationale:
Weight gain of 1.1 kg (2.4 lb) in 24 hours may indicate fluid retention, which can exacerbate
acute kidney failure. Rapid weight gain is concerning for fluid overload and may warrant
immediate intervention to prevent further kidney damage and complications such as
pulmonary edema.
96. A home health nurse is providing care to an older adult client during the winter. During
an in-home visit, the nurse notes that the thermostat is set to 12.8 degrees Celsius (55
degrees Fahrenheit). The client tells the nurse, "I keep the heat set low because I cannot
afford to pay the bill." Which of the following actions should the nurse take?
A. Contact the client's family members to discuss the client's financial status.
B. Recommend staying at a local shelter until the client can afford the bill.
C. Contact the local Department of Health and Human Services for the client.
D. Provide the client with written information about the degrees of hypothermia.
Answer: C. Contact the local Department of Health and Human Services for the client.
Rationale:
The client's inability to afford heating poses a risk to their health and safety, especially
during the winter months. Contacting the local Department of Health and Human Services
can help connect the client with resources and assistance programs for heating assistance or
financial support. It is essential to address the client's financial concerns while ensuring their
well-being.
97. A nurse is caring for a client following a bronchoscopy. Which of the following actions
should the nurse take first?
A. Inform the client they might experience a low-grade fever.
B. Check the client's gag reflex.
C. Instruct the client to report bleeding.
D. Provide the client with sips of water.
Answer: C. Instruct the client to report bleeding.
Rationale:
Bleeding is a potential complication following a bronchoscopy and requires immediate
attention. Instructing the client to report any signs of bleeding ensures prompt intervention
to prevent further complications. While informing the client about potential post-procedure
experiences and providing comfort measures are important, addressing bleeding takes
priority in this situation.
98. A nurse is teaching about measures to prevent urinary infections with a female client.
Which of the following information should the nurse include in the teaching? (Select all that
apply.)
A. Void every 6 hours during the day.
B. Take a warm bubble bath daily.
C. Drink low-fructose cranberry juice.
D. Wipe the perineal area from front to back after urinating.
E. Drink 3 L of fluid daily.
Answer: D. Wipe the perineal area from front to back after urinating, E. Drink 3 L of fluid
daily.
Rationale:
Wiping from front to back after urination helps prevent the introduction of bacteria into the
urethra, reducing the risk of urinary tract infections (UTIs). Drinking an adequate amount of
fluids, such as 3 liters per day, promotes urinary tract health by flushing out bacteria and
preventing stagnation of urine. Voiding regularly, avoiding baths (especially bubble baths
that may irritate the urethra), and drinking cranberry juice may also help prevent UTIs.
99. A nurse is caring for a client who is experiencing an acute asthma attack. Which of the
following should the nurse identify as a contributing factor to the client's manifestations?
A. Decreased responsiveness of airways to allergens
B. Acute loss of alveolar elasticity
C. Suppressed bronchiolar inflammatory response
D. Inability to exhale retained carbon dioxide
Answer: A. Decreased responsiveness of airways to allergens
Rationale:
During an acute asthma attack, there is increased bronchial hyperresponsiveness, leading to
bronchoconstriction and airway inflammation in response to various triggers, such as
allergens, irritants, or exercise. This decreased responsiveness of the airways to allergens
contributes to the client's manifestations of wheezing, dyspnea, and chest tightness
characteristic of an asthma exacerbation.
