ATI RN ADULT MEDICAL SURGICAL PROCTORED EXAM 2019
WITH NGN QUESTIONS / A+ GRADE
1. A nurse is assessing for compartment syndrome in a patient who has a short leg cast. Which of
the following findings should the nurse identify as a manifestation of this condition?
a. Bounding pedal pulse
b. Capillary refill less than 2 seconds
c. Pain that increases with passive movement
d. Areas of warmth on the cast
Answer: Pain that increases with passive movement
2. A nurse is providing teaching to a patient who has a severe form of stage II Lyme disease.
Which of the following statements made by the patient reflects an understanding of the teaching?
a. "I will need to take antibiotics for 1 year"
b. "My partner will need to take an antiviral medication"
c. "My joints ache because I have Lyme disease"
d. "I will bruise easily because I have Lyme disease"
Answer: "My joints ache because I have Lyme disease"
3. A nurse is preparing to administer phenytoin 600 mg PO daily to a patient. The amount
available is oral solution 125 mg/5 mL. How many mL should the nurse administer? 24 A nurse
is caring for a patient who has an arterial line. Which of the following actions should the nurse
take?
a. Flush the line before administering antibiotics
b. Position the patient in Trendelenburg to obtain measurements
c. Have the patient bear down when readings are obtained
d. Place a pressure bag around the flush solution
Answer: Place a pressure bag around the flush solution
4. A nurse is updating the plan of care for a patient who is receiving chemotherapy. Which of the
following findings should the nurse identify as the priority?
a. Report of sore throat
b. Report of memory loss
c. Alopecia
d. Mucositis
Answer: Report of sore throat
5. A nurse is reviewing the medical record of a patient who has systemic lupus erthematosus
(SLE). Which of the following findings should the nurse expect?
a. Facial butterfly rash
b. Bradycardia
c. Esophagitis
d. Interstitial fibrosis
Answer: Facial butterfly rash
6. A nurse is planning care for a patient who is postoperative following a parathyroidectomy.
Which of the following actions should the nurse identify as the priority?
a. Use pillows to support the patient's head and neck
b. Offer opioid medication
c. Place a tracheostomy tray at the bedside
d. Place the patient in semi-Fowler's position
Answer: Place a tracheostomy tray at the bedside
7. A nurse is assessing a patient who has diabetes insipidus. Which of the following findings
should the nurse expect?
a. Low urine specific gravity
b. Hypertension
c. Bounding peripheral pulses
d. Hyperglycemia
Answer: Low urine specific gravity
8. A nurse is providing teaching to a patient who has stage II cervical cancer and is scheduled for
brachytherapy. Which of the following instructions should the nurse include?
a. "You will have an implant placed twice each month for the duration of the treatment"
b. "You should remain at least 6 feet away from others between treatments"
c. "You should expect to have blood in your urine for a few days after treatment"
d. "You will need to stay still in the bed during each treatment session"
Answer: "You will need to stay still in the bed during each treatment session"
9. A nurse is planning care for a patient who is scheduled for a thoracentesis. Which of the
following interventions should the nurse include in the plan?
a. Encourage the patient to take deep breaths after the procedure
b. Assist the patient to hold their arms up during the procedure
c. Instruct the patient to remain NPO after midnight prior to the procedure
d. Keep the patient on bedrest for 8 hr following the procedure
Answer: Encourage the patient to take deep breaths after the procedure
10. A nurse is caring for a patient who is receiving a blood transfusion. The patient becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions
should the nurse anticipate taking?
a. Administer an antihistamine
b. Slow the infusion rate
c. Give the patient a corticosteriod
d. Elevate the patient's lower extremities
Answer: Slow the infusion rate
11. A nurse is providing teaching to a patient who has end-stage kidney disease and is waiting for
a kidney transplant. Which of the following information should the nurse provide?
a. Kidney donation must come from a living donor
b. Immunosuppressive therapy is necessary until the donated kidney begins producing urine
c. Hemodialysis is sometimes required following surgery
d. Kidney transplant recipients can resume their regular diet following surgery
Answer: Hemodialysis is sometimes required following surgery
12. A nurse is caring for a patient who has hypothyroidism. Which of the following
manifestations should the nurse expect?
a. Constipation
b. Insomnia
c. Tachycardia
d. Diaphoresis
Answer: Constipation
13. A nurse is providing preoperative teaching for a patient who is scheduled for a mastectomy.
Which of the following statements should the nurse make?
a. "You should accept your body image change before discharge"
b. "It is important for you to look at the incisional site when the dressings are removed"
c. "I will refer you to community resources that can provide support"
d. "The scar will remain red and raised for many years after surgery"
Answer: "I will refer you to community resources that can provide support"
14. A nurse is caring for a patient who had a nephrostomy tube inserted 12 hr ago. Which of the
following findings should the nurse report to the provider?
a. The patient's urinary output has increased
b. The patient reports back pain
c. The patient's urine color is red tinged
d. The patient's BUN is 18 mg/dL
Answer: The patient reports back pain
15. A nurse is teaching a family about the care of a patient who has a new diagnosis of
Alzheimer's disease. Which of the following information should the nurse include in the
teaching?
a. Position tabletop clocks with multi-colored backgrounds throughout the home
b. Explain how to complete a task while having the patient do the task
c. Place a calendar on the wall with days and weeks included
d. Create complete outfits and allow the patient to select one each day
Answer: Create complete outfits and allow the patient to select one each day
16. A nurse is caring for a patient who has breast cancer and tells the nurse that they would like
to have acupunture because it provides greater relief than pain medication. Which of the
following statements should the nurse make?
a. "Acupuncture is not an approved treatment for cancer pain"
b. "I can speak to the provider about incorporating acupuncture into your treatment plan"
c. "I will ask the provider to prescribe a stronger medication to help ease your pain"
d. "I can contact a family member or spiritual advisor for you to speak with"
Answer: "I can speak to the provider about incorporating acupuncture into your treatment plan"
17. A nurse is caring for a patient following extubation of an edotracheal tube 10 min ago. Which
of the following findings should the nurse report to the provider immediately?
a. Stridor
b. Oral secretions
c. Hoarseness
d. Sore throat
Answer: Stridor
18. A nurse is reviewing the laboratory findings of a patient who developed chest pain 6 hr ago.
The nurse should identify which of the following findings as an indication of a myocardial
infarction (MI)?
a. Creatine kinase (CK-MB) 85 mg/dL
b. High-density lipoprotein (HDL) 65 mg/dL
c. Alanine aminotransferase (ALT) 28 units/L
d. Troponin I 8 ng/mL
Answer: Troponin I 8 ng/mL
19. A nurse is preparing to administer a blood transfusion to a patient who has anemia. Which of
the following actions should the nurse take first?
a. Obtain the patient's vital signs
b. Describe the blood transfusion procedure to the patient
c. Check for the type and number of units of blood to administer
d. Initiate a peripheral IV line
Answer: Check for the type and number of units of blood to administer
20. A nurse is reviewing the laboratory results of a patient who has aplastic anemia. Which of the
following findings indicates a potential complication?
a. RBC count 5.2 million/mm3
b. WBC count 2,000/mm3
c. Platelets 380,000/mm3
d. Potassium 4 mEq/L
Answer: WBC count 2,000/mm3
21. A nurse is providing discharge teaching to a patient who is postoperative following a
modified radical mastectomy. Which of the following instructions should the nurse include?
a. Flex the affected arm when ambulating
b. Numbness can occur along the inside of the affected arm
c. Begin active range-of-motion exercises 1 day after surgery
d. Dress in clothing that fits snugly B. Numbness can occur along the inside of the affected arm
Answer: Numbness can occur along the inside of the affected arm
22. A nurse is preparing to present a program about prevention of atherosclerosis at a health far.
Which of the following recommendations should the nurse plan to include? (Select all that
apply.)
a. Follow a smoking cessation program
b. Maintain an appropriate weight
c. Eat a low-fat diet
d. Increase fluid intake
e. Decrease intake of complex carbohydrates
Answer: Follow a smoking cessation program
Maintain an appropriate weight
Eat a low-fat diet
23. A nurse is caring for a patient who has homonymous hemianopsia as a result of a stroke. To
reduce the risk of falls when ambulating, the nurse should provide which of the following
instructions to the patient?
a. "Wear an eye patch over one eye"
b. "Make sure to have a staff member walk on your stronger side"
c. "Scan the environment by turning your head from side to side"
d. "Make sure to look at your feet while walking"
Answer: "Scan the environment by turning your head from side to side"
24. A nurse is caring for a patient who has a pneumothorax and a closed-chest drainage system.
Which of the following findings is an indication of lung re-expansion?
a. The chest tube is draining serosanguineous fluid at 65 mL/hr
b. The patient tolerates gentle milking of the tubing
c. Bubbling in the water seal chamber has ceased
d. There is tidaling in the water seal chamber
Answer: Bubbling in the water seal chamber has ceased
25. A nurse is providing discharge teaching to a patient who is to self-administer heparin
subcutaneously. Which of the following statements by the patient indicates an understanding of
the teaching?
a. "I can expect to have blood in my urine during the first week of injections"
b. "I will floss my teeth after each meal"
c. "I will gently massage the site after I inject my medication"
d. "I will use an electric razor to shave"
Answer: "I will use an electric razor to shave"
26. A nurse is providing follow-up care for a patient who is sustained a compound fracture 3
weeks ago. The nurse should recognize that an unexpected finding for which of the following
laboratory values is a manifestation of osteomyelitis and should be reported to the provider?
a. Sedimentation rate
b. Hematocrit
c. Calcium
d. Acid phosphatase
Answer: Sedimentation rate
27. A nurse is performing a preoperative assessment for a patient. The nurse should identify that
an allergy to which of the following foods can indicate a latex allergy?
a. Shellfish
b. Peanuts
c. Avocados
d. Eggs
Answer: Avocados
28. A nurse is caring for a patient who has DKA. Which of the following findings should indicate
to the nurse that the patient's condition is improving?
a. Potassium 3.5 mEq/L
b. pH 7.28
c. Glucose 272 mg/dL
d. HCO3 14 mEq/L
Answer: Glucose 272 mg/dL
29. A nurse is caring for a patient who has diabetic ketoacidosis (DKA). Which of the following
should the nurse plan to administer?
a. 240 mL (8oz) of orange juice
b. 1 ampule of 50% dextrose IV bolus
c. NPH insulin 60 units subcutaneous
d. Regular insulin 20 units IV bolus
Answer: Regular insulin 20 units IV bolus
30. A nurse is evaluating the plan of care for four patients after 2 days of hospitalization.
The nurse should identify the need to revise the plan for which of the following patients?
a. A patient who is taking potassium supplements, has a potassium level of 3.2 mEq/L and
reports constipation
b. A patient who has Alzeimer's Disease (AD), has a room near the nurse's station, and is agitated
c. A patient who is postoperative following abdominal surgery and reports feeling that something
"popped" when they coughed
d. A patient who has a conductive hearing loss, speaks softly, and is scheduled for a cerumen
removal
Answer: A patient who is postoperative following abdominal surgery and reports feeling that
something "popped" when they coughed
31. A nurse is providing teaching to a patient who has a new prescription for psyllium. Which of
the following information should the nurse include in the teaching?
a. Drink 240 mL (8 oz) of water after administration
b. Expect results in 4 to 6 hr
c. Take this medication before meals to increase appetite
d. Reduce dietary fiber intake to improve medication absorption
Answer: Drink 240 mL (8 oz) of water after administration
32. A nurse is providing discharge instructions to a patient who has laryngeal cancer and is
receiving radiation therapy. Which of the following statements by the patient indicates an
understanding of the teaching?
a. "I will wear a badge to measure how much radiation I am receiving"
b. "I will remove the markings on my skin after each radiation treatment"
c. "I will avoid direct exposure to the sun"
d. "I will rinse my mouth with a commercial mouthwash"
Answer: "I will avoid direct exposure to the sun"
33. A nurse is admitting a patient who has active tuberculosis. Which of the following types of
transmission precautions should the nurse initiate?
a. Airborne
b. Droplet
c. Contact
d. Protective environment
Answer: Airborne
34. A nurse is reviewing the medical record of a patient who has osteomyelitis and a prescription
for gentamicin. Which of the following findings from the patient's medical record should indicate
to the nurse the need to withhold the medication and notify the provider?
a. WBC count
b. Temperature
c. Blood pressure
d. Serum creatinine
Answer: Serum creatinine
35. A nurse is providing teaching to a patient who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the patient to notify the provider? (Select all that apply.)
a. Night sweats
b. Calf pain
c. Vaginal dryness
d. Numbness in the arms
e. Intense headache
Answer: Calf pain
Numbness in the arms
Intense headache
36. A nurse is planning discharge teaching for a patient who has an external fixation device for a
fracture of the lower extremity. Which of the following instructions should the nurse include in
the plan of care?
a. Secure the straps firmly around the boot
b. Remove the device before showering
c. Use crutches with rubber tips
d. Adjust the screws to maintain alignment
Answer: Use crutches with rubber tips
37. A nurse is teaching a group of newly licensed nurses about pain management for older adult
patients. Which of the following statements by a newly licensed nurse indicates an understanding
of the teaching?
a. "Older adult patients might require up to 6 grams of acetaminophen over 24 hours for effective
pain control"
b. "Ibuprofen can cause gastrointestinal bleeding in older adult patients"
c. "Meperidine is the medication of choice for older adult patients experiencing severe pain"
d. "Older adult patients taking oxycodone are at risk for diarrhea"
Answer: "Ibuprofen can cause gastrointestinal bleeding in older adult patients"
38. A nurse is caring for a patient who has a cervical spinal cord injury sustained 1 month ago.
Which of the following manifestations indicates that the patient is experiencing autonomic
dysreflexia (AD)?
a. Temperature 38.9 C (102 F)
b. Systolic blood pressure 70 mm Hg
c. Heart rate 52/min
d. Respiratory rate 8/min
Answer: Heart rate 52/min
39. A nurse is assessing a patient who has advanced lung cancer and is receiving palliative care.
The patient has just undergone thoracentesis. The nurse should expect a reduction in which of the
following common manifestations of advanced cancer?
a. Dyspnea
b. Hemoptysis
c. Mucus production
d. Dysphagia
Answer: Dyspnea
40. A nurse is providing teaching to a patient who takes ginkgo biloba as an herbal supplement.
which of the following statements should the nurse make?
a. "Ginkgo biloba relieves nausea for people who have vertigo"
b. "Taking ginkgo biloba will help relieve your joint pain"
c. "Ginko biloba can cause an increased risk for bleeding"
d. "Taking ginkgo biloba decreases the risk of migraine headache"
Answer: "Ginko biloba can cause an increased risk for bleeding"
41. A nurse on a medical-surgical unit is reviewing the medical record of an older adult patient
who is receiving IV fluid therapy. Which of the following patient information should indicate to
the nurse that the patient requires re-evaluation of the IV therapy prescription?
a. Blood pressure
b. Prescribed medications
c. Oxygen saturation
d. BUN
Answer: BUN
42. A nurse is obtaining a medication history from a patient who is scheduled to undergo cataract
surgery. The nurse should recognize that which of the following patient medications is a
contradiction for the surgery and notify the provider?
a. Hydrocondone
b. Bupropion
c. Lactulose
d. Warfarin
Answer: Warfarin
43. A nurse is assessing a patient who has peripheral arterial disease. Which of the following
findings should the nurse expect?
a. Painless ulcerations on the ankles
b. Hair loss on the lower legs
c. No extremity pain when resting
d. Rubor with elevation of the extremity
Answer: Hair loss on the lower legs
44. A home health nurse is providing teaching to a patient who has a stage 1 pressure injury on
the greater trochanter of his left hip. Which of the following instructions should the nurse include
in the teaching?
a. Clean the wound daily with an antiseptic
b. Use a donut-shaped pillow when sitting in a chair
c. Change positions every hour
d. Massage the area two times daily
Answer: Change positions every hour
45. A nurse is assessing a patient who has a diagnosis of rheumatoid arthritis. Which of the
following nonpharmacological interventions should the nurse suggest to the patient to reduce
pain?
a. Increase intake of foods containing calcium
b. Alternate application of heat and cold to the affected joints
c. Keep the affected extremities elevated
d. Limit movement of the affected joints
Answer: Alternate application of heat and cold to the affected joints
46. A nurse is assessing a patient following the completion of hemodialysis. Which of the
following findings is the nurse's priority to report to the provider?
a. Temperature 37.2 C (99 F)
b. Blood pressure 100/70 mmHg
c. Weight loss
d. Restlessness
Answer: Restlessness
47. A nurse is caring for a patient who is 4 hr postoperative following an open reduction internal
fixation of the right ankle. Which of the following assessment findings should the nurse report to
the provider?
a. Extremity cool upon palpation
b. Serosanguineous drainage on the dressing
c. Capillary refill of 2 seconds
d. patient report of discomfort when moving toes
Answer: Extremity cool upon palpation
48. A nurse is assessing a patient who is postoperative following a thyroidectomy.
Which of the following findings is the nurse's priority?
a. Moderate serosanguinous drainage on the dressing
b. Calcium 9.5 mg/dL
c. Temperature 38.9 C (102 F)
d. Decreased bowel sounds
Answer: Temperature 38.9 C (102 F)
49. A nurse is planning care for a patient who is having a modified radical mastectomy of the
right breast. Which of the following interventions should the nurse include in the plan of care?
a. Instruct the patient that the drain will be removed when there is 25 mL of output or less over a
24 hr period
b. Assist the patient to start arm exercises 48 hr after surgery
c. Maintain the right arm in an extended position at the patient's side when in bed
d. Place the patient in a supine position for the first 24 hr after surgery
Answer: Instruct the patient that the drain will be removed when there is 25 mL of output or less
over a 24 hr period
50. A nurse is teaching a patient about the use of transcutaneous electrical nerve stimulation
(TENS) for the management of bone cancer pain. The nurse should explain that applying a
TENS unit to the painful area has which of the following effects?
a. Electrically generated feelings of heat
b. Cryotherapy for painful areas
c. A tingling sensation replacing the pain
d. Realignment of energy flow through meridians
Answer: A tingling sensation replacing the pain
51. A nurse is providing teaching to a patient who has a recent diagnosis of constipationpredominant irritable bowel syndrome. Which of the following instructions should the nurse
include in the teaching?
a. Take a calcium antacid before meals and at bedtime
b. Consume at least 30 g of fiber daily
c. Take a stimulant laxative daily
d. Consume no more than 1,000 mL of water per day
Answer: Consume at least 30 g of fiber daily
52. A nurse is providing teaching to a patient who has AIDS. Which of the following statements
by the patient indicated an understanding of the teaching?
a. "I should clean my toothbrush in the dishwasher once a month"
b. "I should eat more fresh fruits and vegetables"
c. "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes
d. "I will take my temperature once a day"
Answer: "I will take my temperature once a day"
53. A nurse is reviewing the medical record of a patient who is taking warfarin for chronic atrial
fibrillation. Which of the following values should the nurse identify as a desired outcome for this
therapy?
a. INR 1
b. INR 2.5
c. aPTT 45 seconds
d. aPTT 90 seconds
Answer: INR 2.5
54. A nurse is caring for a newly admitted patient who has a gastric hemorrhage and is going into
shock. Identify the sequence of actions the nurse should take
a. Administer oxygen via a nonrebreather
b. Initiate IV therapy with a large-bore catheter
c. Insert an NG tube
d. Adminster ranitidine
Answer: Administer oxygen via a nonrebreather
Initiate IV therapy with a large-bore catheter
Insert an NG tube
Administer ranitidine
55. A nurse is assessing heart sounds of a patient who reports substernal precordial pain. Identify
which of the following sounds the nurse should document in the patient's medical record by
listening to the audio clip.
a. Murmur
b. S4
c. Pericardial friction rub
d. Ventricular gallop
Answer: Pericardial friction rub
56. A nurse is teaching a patient about osteoporosis prevention. The nurse should instruct the
patient that which of the following medications can increase their risk for developing
osteoporosis?
a. Conjugated estrogens
b. Enalapril
c. Prednisone
d. Colchicine
Answer: Prednisone
57. A nurse is providing education to a patient who is at risk for osteoporosis. Which of the
following instructions should the nurse include?
a. Begin taking glucosamine supplements
b. Walk for 30 mins four times per week
c. Jog for 15 mins two times per week
d. Avoid taking over-the-counter calcium supplements
Answer: Walk for 30 mins four times per week
58. A nurse is teaching a patient who has a cardiac dysrhythmia about the purpose of undergoing
continuous telemetry monitoring. Which of the following statements by the patient reflects an
understanding of the teaching?
a. "This measures how much blood my heart is pumping"
b. "This identifies if I have a defective heart valve"
c. "This identifies if the pacemaker cells of my heart are working properly"
d. "This measures the blood circulating to my heart muscle"
Answer: "This identifies if the pacemaker cells of my heart are working properly"
59. A nurse is caring for a patient who is 8 hr postoperative following a total hip arthroplasty.
The patient is unable to void on the bedpan. Which of the following actions should the nurse take
first?
a. Document the patient's intake and output
b. Scan the bladder with a portable ultrasound
c. Pour warm water over the patient's perineum
d. Perform a straight catheterization
Answer: b. Scan the bladder with a portable ultrasound
60. A nurse is assessing a patient while suctioning the patient's tracheostomy tube. Which of the
following findings should indicate to the nurse the patient is experiencing hypoxia?
a. The patient starts to cough
b. The patient's heart rate increases
c. The patient is diaphoretic
d. The patient's blood pressure decreases
Answer: b. The patient's heart rate increases
61. A nurse is providing discharge instructions to a patient who has active tuberculosis (TB).
Which of the following information should the nurse include in the instructions?
a. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures
b. The contagious period generally lasts for 6 to 8 weeks after the initiation of medication
therapy
c. Family members should follow airborne precautions at home
d. A follow-up tuberculosis skin test is necessary in 2 months
Answer: Sputum specimens are necessary every 2 to 4 weeks until there are three negative
cultures
62. A PACU nurse is assessing a patient who is postoperative following a right nephrectomy. The
patient's initial vital signs were HR 80, BP 130/70, R 16, and temp 96.8. Which of the following
vital sign changes should alert the nurse that the patient might be hemorrhaging?
a. Heart rate 110
b. BP 160/70
c. R 14
d. Temp 101.1
Answer: a. Heart rate 110
63. A nurse is caring for a patient who has a positive culture for methicillin-resistant
Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
a. Obtain a sputum specimen to determine if there is colonization
b. Bathe the patient using chlorhexidine solution
c. Place the patient in droplet isolation
d. Restrict visits from the patient's friends and family
Answer: Bathe the patient using chlorhexidine solution
64. A nurse is assessing a patient's hydration status. Which of the following findings indicates
fluid volume overload?
a. Warm, moist skin
b. Distended neck veins
c. Dark amber, odiferous urine
d. Orthostatic hypotension
Answer: Distended neck veins
65. A nurse is providing postoperative teaching for a patient who had a total knee arthroplasty.
Which of the following instructions should the nurse include?
a. Flex the foot every hour when awake
b. Place a pillow under the knee when lying in bed
c. Lower the leg when sitting in a chair
d. Ensure the leg is abducted when resting in bed
Answer: a. Flex the foot every hour when awake
66. A nurse at an urgent care clinic is caring for a patient who is experiencing an anaphylactic
reaction. After ensuring a patent airway, which of the following nursing interventions is the
priority?
a. Applying oxygen via face mask
b. Placing the patient in Fowler's position
c. Administering epinephrine
d. Initiating an IV infusion of 0.9% sodium chloride
Answer: Applying oxygen via face mask
67. A nurse in an emergency department is assessing an older adult patient who has a fractured
wrist following a fall. During the assessment, the patient states, "Last week I crashed my car
because my vision suddenly became blurry." Which of the following actions is the nurse's
priority?
a. Check the patient's neurologic status
b. Document the patient's statements
c. Prepare the patient for a CT scan
d. Teach the patient about using safety precautions for falls
Answer: Check the patient's neurologic status
68. A nurse is caring for an older adult patient who has dementia and requires acute care for a
respiratory infection. The patient is agitated and is attempting to remove their IV catheter.
Which of the following actions should nurse take to avoid restraining the patient?
a. Check on the patient every 2 hr
b. Provide a quiet environment with no distractions
c. Turn on the television in the patient's room
d. Keep the patient occupied with a manual activity
Answer: Keep the patient occupied with a manual activity
69. A nurse is caring for a patient who has terminal cancer. The patient tells the nurse, "I wish I
could stop these treatments. I am ready to die." Which of the following statements should the
nurse make?
a. "Discontinuing the treatments is your choice if it is your wish to do so."
b. "Your daughter is named as your health care surrogate. I will ask her if you can stop them"
c. "I will call your spiritual advisor to come in, so you can discuss this with them"
d. "Next time you have an oncology appointment, you should as the oncologist"
Answer: "Discontinuing the treatments is your choice if it is your wish to do so."
70. A nurse is planning care for an older adult patient who has dementia. Which of the following
interventions should the nurse include in the plan of care?
a. Explain procedures as they occur to the patient
b. Place personal items, such as pictures, at the patient's bedside
c. Orient the patient to their location once a shift
d. Encourage the family members to remain home until the patient has adjusted
Answer: Place personal items, such as pictures, at the patient's bedside
71. A nurse is providing teaching to a patient who has asthma about the use of a metered-dose
inhaler. The nurse should identify that which of the following patient actions indicates an
understanding of the teaching?
a. Breathing in rapidly while administering the medication
b. Washing the plastic case and cap of the inhaler in the dishwasher
c. Holding breath for 10 seconds after inhaling
d. Waiting 15 seconds between puffs, if two puffs are required
Answer: Holding breath for 10 seconds after inhaling
72. A nurse is administering packed RBCs to a patient. Which of the following assessment
findings indicates a hemolytic transfusion reaction?
a. Anorexia and jaundice
b. Bronchospasm and urticaria
c. Hypertension and bounding pulse
d. Low back pain and apprehension
Answer: Low back pain and apprehension
73. A nurse is caring for a patient who is having a tonic-clonic seizure while in bed and has
become cyanotic. Which of the following actions should the nurse take? (Select all that apply.)
a. Restrain the patient
b. Prepare to suction the patient's airway
c. Insert a tongue blade in the patient's mouth
d. Raise the head of the patient's bed to a semi-Fowler's position
e. Loosen restrictive clothing on the patient
Answer: b. Prepare to suction the patient's airway
e. Loosen restrictive clothing on the patient
74. A nurse is caring for a patient who has increased intracranial pressure (ICP) and is receiving
mannitol via continuous IV infusion. Which of the following findings should the nurse report to
the provider as an adverse effect of this medication?
a. Decreased heart rate
b. Crackles heard on auscultation
c. Increased urinary output
d. Decreased deep tendon reflexes
Answer: Crackles heard on auscultation
75. A nurse is providing teaching to a patient who has anemia and a new prescription for an oral
iron supplement. Which of the following statements by the patient indicates an understanding of
the teaching?
a. "I will take my iron with a glass of milk"
b. "I will take an antacid with my iron"
c. "I will limit my intake of red meat"
d. "I will eat more high-fiber foods"
Answer: "I will eat more high-fiber foods"
76. A nurse is providing discharge teaching about infection prevention to a patient who has
AIDS. Which of the following statements by the patient indicates understanding of the teaching?
a. "I will eat a salad at least once each day to increase my intake of vitamin K"
b. "I can work in my flower garden as long as I wear gardening gloves to cover my skin"
c. "I will no longer floss my teeth after brushing my teeth"
d. "I can sip on a glass of juice for at least 2 hours before I should discard it"
Answer: "I will no longer floss my teeth after brushing my teeth"
77. A nurse is assessing a patient who is postoperative following a transurethral resection of the
prostate (TURP) and notes clots in the patient's indwelling urinary catheter and a decrease in
urinary output. Which of the following actions should the nurse take?
a. Remove the patient's indwelling urinary catheter
b. Irrigate the indwelling urinary catheter
c. Clamp the indwelling urinary catheter
d. Apply traction to the indwelling urinary catheter
Answer: Irrigate the indwelling urinary catheter
78. A nurse is providing teaching to a patient who has hypertension and a new prescription for
verapamil. Which of the following information should the nurse include in the teaching?
a. "Take this medication on an empty stomach"
b. "Eczema is an immediate expected adverse effect of this medication"
c. "Increase fiber intake to avoid constipation"
d. "Monitor your blood pressure monthly"
Answer: "Increase fiber intake to avoid constipation"
79. A nurse is checking the ECG rhythm strip for a patient who has a temporary pacemaker. The
nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions
should the nurse take?
a. Document that depolarization has occurred
b. Increase the pacemaker's voltage
c. Decrease the pacemaker's sensitivity
d. Check the placement of the ECG leads
Answer: Document that depolarization has occurred
80. A nurse is caring for a patient who is receiving total paretneral nutrition (TPN) and is NPO.
When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC
and HS. Which of the following actions should the nurse take?
a. Check the patient's blood glucose according to facility mealtimes
b. Contact the provider to clarify the prescription
c. Request for meals to be provided for the patient
d. Hold the prescription until the patient is no longer NPO
Answer: Contact the provider to clarify the prescription
81. A nurse is caring for a patient who is receiving mechanical ventilation via a tracheostomy
tube. The nurse should recognize that which of the following complications is associated with
long- term mechanical ventilation?
a. Elevated blood pressure
b. Dehydration
c. Stress ulcers
d. Hypernatremia
Answer: Stress ulcers
82. A nurse is reviewing the ABG results of a patient who has advanced COPD. Which of the
following results should the nurse expect?
a. PaCO2 56 mm Hg
b. pH 7.38
c. HCO3 24 mEq/L
d. PaO2 90 mm Hg
Answer: PaCO2 56 mm Hg
83. A nurse is providing education to a patient who has tuberculosis (TB) and their family.
Which of the following information should the nurse include in the teaching?
a. After 1 week of medication, TB is no longer communicable
b. Dispose of contaminated tissues in a paper bag
c. Airborne precautions are necessary in the home
d. Family members in the household should undergo TB testing
Answer: Family members in the household should undergo TB testing
84. A nurse is planning for a patient who is postoperative following a laparotomy and has a
closed- suction drain. Which of the following actions should the nurse take to manage the drain?
a. Set the wall suction to 80 to 100 mm Hg
b. Compress the drain reservoir after emptying
c. Allow the drainage to collect on a sterile gauze dressing
d. Position the drain below the bed to promote drainage
Answer: Compress the drain reservoir after emptying
85. A nurse is planning care for a patient who has a sealed radiation implant for cervical cancer.
Which of the following interventions should the nurse include in the plan of care?
a. Limit each visitor to 1 hr per day
b. Keep a lead-lined container in the patient's room
c. Place a dosimeter badge on the patient
d. Remove soiled linens from the patient's room each day
Answer: Keep a lead-lined container in the patient's room
86. A nurse is reviewing the laboratory results of a patient who has AIDS and is taking
amphotericin B for a fungal infection. The nurse should identify that which of the following
values is an indication of an adverse effect of the medication?
a. Potassium 4.8 mEq/L
b. Magnesium 1.7 mEq/L
c. BUN 34 mg/dL
d. Hematocrit 45%
Answer: BUN 34 mg/dL
87. A nurse is planning a health promotional presentation for a group of African American
patients at a community center. Which of the following disorders presents the greatest risk to this
group of patients?
a. Multiple sclerosis
b. Skin cancer
c. Urolithiasis
d. Hypertension
Answer: Hypertension
