RN Adult Medical Surgical Online Practice 2019 A
1. A home health nurse is assigned to a client who was recently discharged from a rehabilitation
center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits
should the nurse expect to find when assessing the client? (select all that apply)
A. Visual spatial deficits
B. Left hemianopsia (blindness in the left half of the visual field)
C. One-sided neglect
D. Difficulty with judgment and reasoning.
Answer: A. Visual spatial deficits
B. Left hemianopsia (blindness in the left half of the visual field)
C. One-sided neglect
D. Difficulty with judgment and reasoning.
2. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The
nurse should postpone the testing and report to the provider which of the following findings?
A. History of seasonal allergies
B. Current use of antihistamine medications
C. Recent exposure to known allergens
D. Family history of asthma
Answer: B. Current use of antihistamine medications
3. A nurse is caring for a group of clients. The nurse should plan to make a referral to physical
therapy for which of the following clients?
A. A client who is receiving preoperative teaching for a right knee arthroplasty
B. A client who was recently diagnosed with hypertension
C. A client who is prescribed antibiotic therapy for a urinary tract infection
D. A client who is recovering from a mild upper respiratory infection
Answer: A. A client who is receiving preoperative teaching for a right knee arthroplasty
4. A nurse is caring for a client who is having a seizure. Which of the following interventions is
the nurse’s priority?
A. Turn the client to the side
B. Administer anticonvulsant medication
C. Place a padded tongue blade in the client's mouth
D. Provide oxygen after the seizure has ended
Answer: A. Turn the client to the side
5. A nurse is caring for a client who is 12 hours postoperative following a total hip arthroplasty.
Which of the following actions should the nurse take?
A. Place a pillow between the client’s legs
B. Encourage the client to sit up at a 90-degree angle
C. Allow the client to cross their legs while sitting
D. Keep the affected leg straight without movement
Answer: A. Place a pillow between the client’s legs
6. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place
which of the following items at the client’s bedside?
A. Suction machine
B. Oxygen tank
C. Nasogastric (NG) tube
D. Bedside commode
Answer: A. Suction machine
7. A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous
diversion procedure to establish a ureterostomy. Which of the following statements should the
nurse include in the teaching?
A. “You should cut the opening of the skin barrier one-eighth inch wider than the stoma.”
B. “You will need to irrigate your stoma daily.”
C. “You should expect the stoma to be dark blue or purple in color.”
D. “You will be able to swim after your stoma is healed completely.”
Answer: A. “You should cut the opening of the skin barrier one-eighth inch wider than the
stoma.”
8. A nurse in an emergency department is caring for a client who reports vomiting and diarrhea
for the past 3 days. Which of the following findings should indicate to the nurse that the client is
experiencing fluid volume deficit?
A. Heart rate 110/min
B. Blood pressure 120/80 mm Hg
C. Urine output of 40 mL/hour
D. Skin turgor within normal limits
Answer: A. Heart rate 110/min
9. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal
implant to treat endometrial cancer. Which of the following actions should the nurse include in
the client’s plan of care?
A. Wear a lead apron while providing care to the client
B. Maintain close proximity to the client during treatment
C. Encourage the client to ambulate frequently
D. Allow visitors to stay with the client for extended periods
Answer: A. Wear a lead apron while providing care to the client
10. A nurse is planning to provide discharge teaching for the family of an older adult client who
has hemianopsia and is at risk for falls. Which of the following instructions should the nurse
include?
A. Remind the client to scan their complete range of vision during ambulation
B. Encourage the client to walk without assistance to promote independence
C. Advise the family to keep furniture and obstacles in the same place
D. Instruct the client to close their eyes while walking to enhance focus
Answer: A. Remind the client to scan their complete range of vision during ambulation
11. A nurse is planning care to decrease psychosocial health issues for a client who is starting
dialysis treatments for chronic kidney disease. Which of the following interventions should the
nurse include in the plan?
A. Tell the client that it is possible to return to similar previous levels of activity
B. Provide information about financial assistance programs for dialysis
C. Encourage the client to isolate themselves to avoid infection
D. Suggest the client avoid discussing their feelings about the diagnosis
Answer: B. Provide information about financial assistance programs for dialysis
12. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter
placed. Which of the following findings indicates that the client is experiencing increased
intracranial pressure (ICP)?
A. Sleepiness exhibited by the client
B. Widening pulse pressure
C. Decerebrated posturing
Answer: B. Widening pulse pressure
13. An older adult client is brought to an emergency department by a family member. Which of
the following assessment findings should cause the nurse to suspect that the client has hypertonic
dehydration?
A. Urine specific gravity 1.045
B. Blood pressure 120/80 mm Hg
C. Heart rate 68 beats per minute
D. Temperature 98.6°F (37°C)
Answer: A. Urine specific gravity 1.045
14. A nurse is caring for a client who has a prescription for enalapril. The nurse should identify
which of the following findings as an adverse effect of the medication?
A. Orthostatic hypotension
B. Hypertension
C. Bradycardia
D. Hyperkalemia
Answer: A. Orthostatic hypotension
15. A nurse in a provider’s office is caring for a client who requests sildenafil to treat erectile
dysfunction. Which of the following statements should the nurse make?
A. “You will not be able to use sildenafil if you are taking nitroglycerin.”
B. “Sildenafil can be taken with food for better absorption.”
C. “You should take sildenafil only when you are planning to have sexual activity.”
D. “Sildenafil can be used to increase sexual desire.”
Answer: A. “You will not be able to use sildenafil if you are taking nitroglycerin.”
16. A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in the plan
of care to prevent a pseudomonas aeruginosa infection?
A. Avoid placing plants or flowers in the client’s room
B. Limit visitors to those who have received the influenza vaccine
C. Use sterile saline for wound care only when dressing changes are done
D. Encourage the client to engage in physical therapy exercises
Answer: A. Avoid placing plants or flowers in the client’s room
17. A nurse is teaching a class about client rights. Which of the following instructions should the
nurse include?
A. A client should sign an informed consent when receiving a placebo during a research trial.
B. A client should always waive their right to confidentiality during a research trial.
C. A client should be informed that participation in research is mandatory.
D. A client should never ask questions about the research they are participating in.
Answer: A. A client should sign an informed consent when receiving a placebo during a research
trial.
18. A nurse is caring for a client who is receiving morphine for daily dressing changes. The client
tells the nurse, "I don’t want any more morphine because I don’t want to get addicted." Which of
the following actions should the nurse take?
A. Instruct the client on alternative therapies for pain reduction.
B. Disregard the client's concern and administer the morphine.
C. Tell the client that addiction to morphine is inevitable.
D. Refuse to provide any pain management options.
Answer: A. Instruct the client on alternative therapies for pain reduction.
19. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the client to withhold
for 48 hr prior to cardioversion?
A. Digoxin
B. Metoprolol
C. Diltiazem
D. Warfarin
Answer: A. Digoxin
20. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the
formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity.
Which of the following interventions is the nurse’s priority?
A. Apply firm pressure to the insertion site
B. Elevate the affected extremity
C. Administer pain medication
D. Apply a warm compress to the insertion site
Answer: A. Apply firm pressure to the insertion site.
21. A nurse is assessing a client who has Graves’ disease. Which of the following images should
indicate to the nurse that the client has exophthalmos?
A. Outward protrusion of the eyes
B. Sunken eyes
C. Yellowing of the eyes
D. Eye redness without protrusion
Answer: A. Outward protrusion of the eyes.
22. A nurse is caring for a client who has a stage III pressure injury. Which of the following
findings contributes to delayed wound healing?
A. Urine output 25 mL/hr
B. Blood glucose level within normal range
C. Adequate nutritional intake
D. Proper wound care techniques
Answer: A. Urine output 25 mL/hr.
23. A nurse is providing teaching to a client who is receiving chemotherapy and has a new
prescription for epoetin alfa. Which of the following client statements indicates an understanding
of the teaching?
A. “I will monitor my blood pressure while taking this medication.”
B. “I can stop taking this medication once I feel better.”
C. “I should take this medication on an empty stomach.”
D. “I don't need to worry about my diet while on this medication.”
Answer: A. “I will monitor my blood pressure while taking this medication.”
24. A nurse is providing discharge instructions to a client following an upper gastrointestinal
series with barium contrast. Which of the following information should the nurse provide?
A. Increase fluid intake
B. Avoid drinking fluids for 24 hours
C. Consume a high-fat diet immediately
D. Stay in bed and avoid physical activity
Answer: A. Increase fluid intake.
25. A nurse is assessing a client who has acute cholecystitis. Which of the following findings is
the nurse’s priority?
A. Tachycardia
B. Mild abdominal pain
C. Slight fever
D. Elevated white blood cell count
Answer: A. Tachycardia
26. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend?
A. Add cabbage to the diet
B. Increase red meat consumption
C. Reduce fiber intake
D. Increase sugary snacks
Answer: A. Add cabbage to the diet
27. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation.
The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the
following actions should the nurse take first?
A. Instruct the client to allow the machine to breathe for them.
B. Increase the ventilator settings.
C. Administer a sedative.
D. Check the ventilator for any obstruction.
Answer: A. Instruct the client to allow the machine to breathe for them
28. A nurse is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
A. Demonstrate ways to deep breathe and cough
B. Instruct the client to avoid all physical activity
C. Tell the client not to worry about postoperative care
D. Skip the preoperative teaching session entirely
Answer: A. Demonstrate ways to deep breathe and cough.
29. A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis.
The nurse should give the AP which of the following instructions?
A. Wear a mask
B. Limit fluid intake
C. Avoid washing hands frequently
D. Disregard isolation protocols
Answer: A. Wear a mask
30. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following
actions should the nurse take?
A. Remain with the client for the first 15 min of infusion
B. Leave the client immediately after starting the infusion
C. Administer the unit without checking the client’s identity
D. Increase the infusion rate to complete it faster
Answer: A. Remain with the client for the first 15 min of infusion
31. A nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin. Which of the following statements by the client indicates an
understanding of the teaching?
A. “I am taking this medication to increase my energy level.”
B. “I am taking this medication to lower my blood pressure.”
C. “I am taking this medication to reduce my calcium levels.”
D. “I am taking this medication to cure my kidney disease.”
Answer: A. “I am taking this medication to increase my energy level.”
32. A nurse is caring for a client who has hepatic encephalopathy that is being treated with
lactulose. The client is experiencing excessive stools. Which of the following findings is an
adverse effect of this medication?
A. Hypokalemia
B. Hypercalcemia
C. Elevated blood pressure
D. Decreased appetite
Answer: A. Hypokalemia
33. A nurse is providing teaching to an older adult female client who has stress incontinence and
a BMI of 32. Which of the following statements by the client indicates an understanding of the
teaching?
A. "I am dieting to lose weight."
B. "I am reducing my water intake."
C. "I am avoiding physical activity."
D. "I am taking more diuretics."
Answer: A. "I am dieting to lose weight."
34. A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis
for the past 3 days. Which of the following statements should the nurse include when instructing
the client?
A. "Take insulin even if you are unable to eat your regular diet."
B. "Stop taking insulin if you feel better."
C. "Avoid checking your blood sugar levels."
D. "Increase carbohydrate intake drastically."
Answer: A. "Take insulin even if you are unable to eat your regular diet."
35. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin
(Lovenox) subcutaneous. Which of the following actions should the nurse take?
A. Inject the medication into the anterolateral abdominal wall.
B. Inject the medication into the upper arm.
C. Inject the medication into the thigh.
D. Inject the medication into the buttock.
Answer: A. Inject the medication into the anterolateral abdominal wall.
36. A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney
disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which
of the following medications should the nurse plan to administer?
A. Calcium carbonate
B. Acetaminophen
C. Furosemide
D. Lisinopril
Answer: A. Calcium carbonate.
37. A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus.
For which of the following adverse effects should the nurse monitor?
A. Respiratory paralysis
B. Hypertension
C. Hyperactivity
D. Constipation
Answer: A. Respiratory paralysis.
38. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
laboratory findings should the nurse expect?
A. BUN 32 mg/dL
B. Decreased blood glucose levels
C. Low ketone levels
D. Normal arterial pH
Answer: A. BUN 32 mg/dL.
39. A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of
the following instructions should the nurse include in the teaching?
A. Increase fiber intake to at least 30 g per day.
B. Reduce water intake significantly.
C. Avoid all forms of exercise.
D. Eliminate fruits and vegetables from the diet.
Answer: A. Increase fiber intake to at least 30 g per day.
40. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory results to be below the expected reference range?
A. Calcium
B. Glucose
C. Sodium
D. Potassium
Answer: A. Calcium.
41. A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago.
Which of the following findings should the nurse expect?
A. Stone fragments in the urine
B. Blood in the stool
C. Decreased urine output
D. Severe lower back pain
Answer: A. Stone fragments in the urine.
42. A nurse is creating a plan of care for a client who has neutropenia as a result of
chemotherapy. Which of the following interventions should the nurse include in the plan?
A. Monitor the client’s temperature every 4 hr
B. Encourage the client to engage in vigorous exercise
C. Advise the client to increase their exposure to large crowds
D. Instruct the client to stop all medications
Answer: A. Monitor the client’s temperature every 4 hr.
43. A nurse is assessing a group of clients for indications of role changes. The nurse should
identify that which of the following clients is at risk for experiencing a role change?
A. A client who has multiple sclerosis and is experiencing progressive difficulty ambulating
B. A client who has seasonal allergies and is managing symptoms with over-the-counter
medication
C. A client who has a sprained ankle and is using crutches temporarily
D. A client who has mild hypertension and is managing it with diet and exercise
Answer: A. A client who has multiple sclerosis and is experiencing progressive difficulty
ambulating.
44. A nurse is assessing a client who has migraine headaches and is taking feverfew to prevent
headaches. The nurse should identify that which of the following client medications interacts
with feverfew?
A. Naproxen
B. Paracetamol
C. Metformin
D. Levothyroxine
Answer: A. Naproxen
45. A nurse is conducting an admission history for a client who is to undergo a CT scan with an
IV contrast agent. The nurse should identify that which of the following findings requires further
assessment?
A. History of asthma
B. Presence of a tattoo
C. Recent mild headache
D. Daily exercise routine
Answer: A. History of asthma.
46. A nurse has received change-of-shift report for a group of clients. Which of the following
clients should the nurse assess first?
A. A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual
nitro-glycerine tablet
B. A client who is scheduled for a routine medication at 08:00
C. A client who needs assistance with bathing
D. A client who is due for a physical therapy session
Answer: A. A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN
sublingual nitro-glycerine tablet.
47. A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN).
The client is to receive 2,000 Kcal per day. The TPN solution has 500 Kcal/L. The IV pump
should be set at how many mL/hr?
Answer: 1/500x2000/24 = 0.16666667 round the answer to 167mL/hr
48. A nurse in an emergency department is caring for a client who has full-thickness burns over
20% of their total body surface area. After ensuring a patent airway and administering oxygen,
which of the following items should the nurse prepare to administer first?
A. IV fluids
B. Pain medication
C. Antibiotics
D. Blood transfusion
Answer: A. IV fluids.
49. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a
pressure injury. Which of the following actions should the nurse take?
A. Use a 30-mL syringe
B. Use a 10-mL syringe
C. Avoid using any syringe
D. Use a 50-mL syringe
Answer: A. Use a 30-mL syringe.
50. A nurse is providing teaching for a female client who has recurrent urinary tract infections.
Which of the following information should the nurse include in the teaching?
A. Void before and after intercourse
B. Wear tight-fitting underwear
C. Limit fluid intake
D. Ignore the urge to urinate
Answer: A. Void before and after intercourse.
51. A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon
assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure
78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse
take?
A. Perform synchronized cardioversion
B. Administer a beta-blocker
C. Provide oxygen therapy
D. Encourage the Valsalva maneuver
Answer: A. Perform synchronized cardioversion.
52. A nurse is providing teaching to an older adult client who has cancer and a new prescription
for an opioid analgesic for pain management. Which of the following information should the
nurse include in the teaching?
A. "You should void every 4 hours to decrease the risk of urinary retention."
B. "You should ignore any signs of constipation."
C. "You should avoid drinking fluids."
D. "You should stop the medication if you feel drowsy."
Answer: A. "You should void every 4 hours to decrease the risk of urinary retention."
53. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the
following precautions should the nurse implement?
A. Ensure that the client has a patent IV
B. Leave the client's side rails down
C. Administer a sedative without monitoring
D. Ignore seizure precautions
Answer: A. Ensure that the client has a patent IV.
54. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for
omeprazole. The nurse should instruct the client that the medication provides relief by which of
the following actions?
A. Suppressing gastric acid production
B. Increasing gastric acid production
C. Coating the stomach lining
D. Neutralizing stomach acid
Answer: A. Suppressing gastric acid production.
55. A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has
dyspnea with a productive cough and is using accessory muscles to breathe. Which of the
following actions should the nurse take first?
A. Place the client in high-Fowler’s position
B. Administer pain medication
C. Start an IV antibiotic
D. Encourage the client to rest quietly
Answer: A. Place the client in high-Fowler’s position.
56. A nurse is assessing a male client for an inguinal hernia. Which of the following areas should
the nurse palpate to verify that the client has an inguinal hernia?
A. The groin area, particularly along the inguinal canal
B. The lower back
C. The upper abdomen
D. The chest area
Answer: A. The groin area, particularly along the inguinal canal.
57. A nurse in an emergency department is caring for a client who is experiencing a thyroid
storm. Which of the following manifestations should the nurse expect?
A. Fever
B. Hypertension
C. Tachycardia
D. All of the above
Answer: D. All of the above.
58. A nurse is performing a dressing change for a client who is recovering from a
hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is
protruding through the abdomen. Which of the following actions should the nurse take first?
A. Call for help
B. Cover the bowel with sterile gauze soaked in saline
C. Reinsert the bowel
D. Apply pressure to the abdomen
Answer: A. Call for help.
59. A nurse is providing discharge instructions to a client who has a partial-thickness burn on the
hand. Which of the following instructions should the nurse include?
A. Wrap fingers with individual dressings
B. Soak the hand in ice water
C. Apply butter to the burn
D. Avoid moving the hand entirely
Answer: A. Wrap fingers with individual dressings.
60. A nurse is caring for a client who has HIV. Which of the following findings indicates a
positive response to the prescribed HIV treatment?
A. Decreased viral load
B. Increased CD4 cell count
C. Improved overall health
D. All of the above
Answer: D. All of the above.
61. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is
not available when the current infusion is nearly completed. Which of the following actions
should the nurse take?
A. Administer dextrose 10% in water until the new bag arrives
B. Administer normal saline until the new bag arrives
C. Discontinue the infusion and wait for the new bag
D. Switch to enteral feeding immediately
Answer: A. Administer dextrose 10% in water until the new bag arrives.
62. A nurse is assessing a client who has had a suspected stroke. The nurse should place the
priority on which of the following findings?
A. Dysphagia
B. Elevated temperature
C. Mild headache
D. Slight nausea
Answer: A. Dysphagia.
63. A nurse in a provider’s office is assessing a client who has hypertension and takes
propranolol. Which of the following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication?
A. Increased heart rate
B. Report of night cough
C. Weight gain
D. Cold extremities
Answer: B. Report of night cough
64. A nurse in an emergency department is assessing a client who has a detached retina . Which
of the following should the nurse expect the client to report?
A. “I see flashing lights in my vision.”
B. “I have a sudden increase in floaters.”
C. “It feels like a curtain closed over my eye.”
D. “Everything looks blurry, like I’m looking through a fog.”
Answer: C. “It feels like a curtain closed over my eye.”
65. A nurse is providing teaching to a female client who has a history of urinary tract infections.
Which of the following information should the nurse include in the teaching?
A. Drink plenty of water to help flush the urinary system.
B. Take daily cranberry supplements.
C. Urinate after sexual intercourse to help prevent UTIs.
D. Wipe from back to front after using the toilet.
Answer: B. Take daily cranberry supplements.
66. A nurse in an emergency department is reviewing the provider’s prescriptions for a client
who sustained a rattlesnake bite to the lower leg. Which of the following prescription should the
nurse expect?
A. Administer an opioid analgesic to the client.
B. Administer antivenom if indicated.
C. Provide intravenous fluids for hydration.
D. Apply a tourniquet to the affected limb.
Answer: A. Administer an opioid analgesic to the client.
67. A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the
following findings should the nurse identify as a manifestation of chronic glomerulonephritis?
A. Hyperkalemia
B. Hypotension
C. Decreased blood urea nitrogen (BUN)
D. Hypercalcemia
Answer: A. Hyperkalemia.
68. A nurse in a community clinic is caring for a client who reports an increase in the frequency
of migraine headaches. To help reduce the risk of migraine headaches, which of the following
foods should the nurse recommend?
A. Aged cheese
B. Dark chocolate
C. Processed meats
D. Fresh fruits and vegetables
Answer: D. Fresh fruits and vegetables
69. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago.
Which of the following actions should the nurse take?
A. Check that one finger fits between the cast and the leg.
B. Assess the client's skin temperature and color distal to the cast.
C. Instruct the client to move their toes regularly.
D. Encourage the client to keep the leg elevated above heart level.
Answer: B. Assess the client's skin temperature and color distal to the cast.
70. A nurse is caring for a client who has viral pneumonia. The client’s pulse oximeter readings
have fluctuated between 79% and 88% for the last 30. Which of the following oxygen delivery
systems should the nurse initiate to provide the highest concentration of oxygen?
A. Nasal cannula
B. Simple face mask
C. Non-rebreather mask
D. Venturi mask
Answer: C. Non-rebreather mask
71. A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the
following is the priority assessment finding that the nurse should report to the provider?
A. Blood pressure 170/80 mm Hg
B. Heart rate of 110 beats per minute
C. Weight loss of 5 pounds in the past week
D. Tremors in the hands
Answer: A. Blood pressure 170/80 mm Hg.
72. A nurse is teaching a young adult client how to perform a testicular self-examination. Which
of the following instructions should the nurse include?
A. Roll each testicle between the thumb and fingers.
B. Perform the examination while standing only.
C. Check for testicular size and symmetry only.
D. Only perform the examination once a year.
Answer: A. Roll each testicle between the thumb and fingers.
73. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following
assessment findings should the nurse expect?
A. Hypoactive bowel sounds
B. Elevated heart rate
C. Muscle twitching
D. Hyperactive reflexes
Answer: A. Hypoactive bowel sounds
74. A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the
following laboratory values should the nurse expect?
A. Elevated bilirubin level
B. Decreased albumin level
C. Elevated ammonia level
D. Decreased platelet count
E. All of the above
Answer: E. All of the above
75. A nurse is providing discharge teaching to a client who has heart failure and a new
prescription for a potassium-sparing diuretic. Which of the following information should the
nurse include in the teaching?
A. Try to walk at least three times per week for exercise.
B. Limit fluid intake to less than 1 liter per day.
C. Monitor your weight daily and report any sudden increases.
D. Avoid foods high in potassium, such as bananas and oranges.
Answer: A. Try to walk at least three times per week for exercise.
76. A nurse is elevating a client who has a new diagnosis of type 1 diabetes mellitus. Which of
the following client statements indicates the client is successfully coping with the change?
A. “I used to never worry about my feet. Now, I inspect my feet every day with a mirror.”
B. “I feel overwhelmed by all the new information I have to learn.”
C. “I don’t think I will ever be able to manage my diabetes.”
D. “I plan to eat whatever I want; I’ll just take more insulin.”
Answer: A. “I used to never worry about my feet. Now, I inspect my feet every day with a
mirror.”
77. A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following supplements can
interfere with the effectiveness of the medication?
A. Calcium
B. Vitamin C
C. Vitamin D
D. Magnesium
Answer: A. Calcium
78. A nurse is providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statements should the nurse identify as an indication
that the client understands the teaching?
A. “I will use my hands rather than a washcloth to clean the radiation area.”
B. “I should apply lotion directly to the radiation area every day.”
C. “I will wear tight clothing to protect the area from irritation.”
D. “I will avoid sun exposure on the radiation area during treatment.”
Answer: A. “I will use my hands rather than a washcloth to clean the radiation area.”
79. A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2
days ago. Which of the following actions should the nurse take first after hearing the following
sound?
A. Listen with the client on their left side.
B. Assess the client's vital signs.
C. Document the finding in the chart.
D. Notify the healthcare provider.
Answer: A. Listen with the client on their left side.
80. A nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client understands the
teaching?
A. “I will wear clean graduated compression stockings every day.”
B. “I will keep my legs elevated at all times.”
C. “I will avoid walking to prevent strain on my legs.”
D. “I will only wear my compression stockings at night.”
Answer: A. “I will wear clean graduated compression stockings every day.”
81. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
A. Loosen restrictive clothing.
B. Place a pillow under the client’s head.
C. Time the duration of the seizure.
D. Move objects away from the client to prevent injury.
Answer: A. Loosen restrictive clothing.
82. A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after
hospitalization for heart failure. Based on the information in the client’s chart, which of the
following findings should the nurse report to the provider?
A. Heart rate 55/min
B. Blood pressure 130/80 mm Hg
C. Weight increase of 2 pounds since discharge
D. Respiratory rate of 18/min
Answer: A. Heart rate 55/min
83. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new
prescription for metformin. Which of the following statements by the client indicates an
understanding of the teaching?
A. “I should take this medication with a meal.”
B. “I can stop taking this medication if my blood sugar is low.”
C. “I need to avoid all carbohydrates while on this medication.”
D. “I will take this medication at bedtime for best results.”
Answer: A. “I should take this medication with a meal.”
84. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of cushing’s triad?
A. Bradycardia
B. Tachycardia
C. Hypotension
D. Hyperventilation
Answer: A. Bradycardia
85. A nurse is providing dietary teaching to a client who is postoperative following a
thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to
include which of the following foods that has the greatest amount of calcium in her diet?
A. 12 almonds
B. 1 cup of yogurt
C. 1 cup of cooked spinach
D. 1 slice of cheddar cheese
Answer: B. 1 cup of yogurt
86. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed
with food after a meal. Which of the following actions should the nurse take first?
A. Obtain vital signs.
B. Place the client in a lateral position.
C. Administer antiemetic medication.
D. Assess the characteristics of the vomit.
Answer: A. Obtain vital signs.
87. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of
the following laboratory values should the nurse report to the provider?
A. HGB 8 g/dL
B. WBC 10,000/mm³
C. Platelets 150,000/mm³
D. Sodium 140 mEq/L
Answer: A. HGB 8 g/dL
88. A nurse is caring for a client who has amyotrophic lateral sclerosis(ASL) and is being
admitted to the hospital with pneumonia. Which of the following assessment findings is the
nurse’s priority?
A. Increased respiratory secretions
B. Weakness in the extremities
C. Difficulty swallowing
D. Fatigue.
Answer: A. Increased respiratory secretions
89. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper
use of crutches while climbing stairs. Identify the sequence the client should follow when
demonstrating crutch use.
A. Place their body weight on the crutches
B. Advance the unaffected leg onto the stair
C. Shift their weight from the crutches to the unaffected leg
D. Then bring the crutches and the affected leg up to the stairs.
Answer: A. Place their body weight on the crutches
B. Advance the unaffected leg onto the stair
C. Shift their weight from the crutches to the unaffected leg
D. Then bring the crutches and the affected leg up to the stairs.
