HESI PN MED SURGE PROCTORED EXAM - (14 DIFFERENT
VERSIONS)- COMPLETE RESOURCES FOR HESI PN MED SURGE
PROCTORED EXAM 2021
100% SUCCESS GUARENTEED
HESI PN MED SURGE PROCTORED EXAM
VERSION 1
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the
following actions should the nurse take?
1) Provide a diet high in protein.
2) Provide ibuprofen for retroperitoneal discomfort.
3) Monitor intake and output hourly
4) Encourage the client to consume at least 2 L of fluid daily.
Answer: 3) Monitor intake and output hourly
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has
upper gastric pain. Which of the following statements should the nurse include in the
teaching?
1) "A flexible tube is introduced through the nose during the procedure."
2) "During the procedure you are in a sitting position."
3) You will remain NPO for 8 hours before the procedure."
4) "You will be awake while the procedure is performed."
Answer: 3) You will remain NPO for 8 hours before the procedure."
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours
following a generalized tonic-clonic seizure. Which of the following descriptions should the
nurse use when documenting this finding in the medical record?
1) Aura phase
2) Presence of automatisms
3) Postictal phase
4) Presence of absence seizures
Answer: 3) Postictal phase
A nurse is reinforcing teaching with a client who reports right shoulder pain following a
laparoscopic cholecystectomy. Which of the following statements should the nurse make?
1) "The pain results from lying in one position too long during surgery."
2) "The pain occurs as a residual pain from cholecystitis."
3) " The pain will dissipate if you ambulate frequently"
4) "The pain is caused from the nitrous dioxide injected into the abdomen."
Answer: 3) " The pain will dissipate if you ambulate frequently"
A nurse is checking the suction control chamber of a client's chest tube and notes that there is
no bubbling in the suction control chamber. Which of the following actions should the nurse
take?
1) Notify the provider.
2) Verify that the suction regulator is on.
3) Continue to monitor the client because this is an expected finding.
4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Answer: 2) Verify that the suction regulator is on.
Rationale:
The nurse should check for kinks and take other measures before notifying the provider.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma .
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client. which of the following is the priority action?
Answer: 1) Encourage fluid intake.
2) Monitor the puncture site for hematoma .
A nurse is assisting with the care of a client who is postoperative following surgical repair of
a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The
nurse should recognize which of the following is the priority action?
1) Relieve the client's pain.
2) Check the client’s pressure points for redness.
3) Provide oral hygiene.
4) Prevent aspiration
Answer: 4) Prevent aspiration
A nurse is collecting data from a client who has scleroderma. Which of the following findings
should the nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
Answer: 4) Hardened skin
A nurse is caring for an older adult client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client's mouth.
3) Add thickener to fluids
4) Serve food at room temperature.
Answer: 3) Add thickener to fluids
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head,
neck, and chest. The nurse should recognize which of the following is the priority risk to the
client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
Answer: 1) Airway obstruction
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis
and is to start taking neostigmine. Which of the following instructions should the nurse
include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side effect of the neostigmine.
3) If a medication dose is missed, wait until the next scheduled dose to take the medication.
4) Treat nasal rhinitis with an over-the-counter antihistamine.
Answer: 1) Take the medication 45 minutes before eating.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection
of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse
notes there has not been any urinary output in the last hour. Which of the following actions
should the nurse perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
Answer: 4) Determine the patency of the tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear
about the procedure and asks the nurse if the biopsy will hurt. Which of the following
responses should the nurse make?
1) "You must be very worried about what the biopsy will show."
2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’s happening."
3) "Your provider scheduled this, so she will want to know you still have questions about the
procedure."
4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."
Answer: 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as
possible."
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric
stroke. Which of the following interventions should the nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function.
Answer: 3) Re-establish communication.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should
monitor the client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
Answer: 1) Hypotension
A nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm Hg
Base excess -2 PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make
1) Metabolic acidosis
2) Respiratory acidosis
3) Metabolic alkalosis
4) Respiratory alkalosis
Answer: 2) Respiratory acidosis
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The
nurse should recognize that which of the following statements by the client indicates a need
for further teaching?
1) "I will avoid crossing my legs at the knees."
2) "I will use a thermometer to check the temperature of my bath water."
3) "I will not go barefoot."
4) "I will wear stockings with elastic tops."
Answer: 4) "I will wear stockings with elastic tops."
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's
disease. The client becomes agitated and combative when the nurse approaches him. Which
of the following actions should the nurse plan to take?
1) Turn the water on and ask the client to test the temperature.
2) Obtain assistance to place mitten restraints on the client.
3) Firmly tell the client that good hygiene is important.
4) Calmly ask the client if he would like to listen to some music.
Answer: 4) Calmly ask the client if he would like to listen to some music.
A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is
covered with soft, red tissue that bleeds easily. The nurse should recognize this is a
manifestation of which of the following?
1) Decreased perfusion
2) Infection
3) Granulation tissue
4) An inflammatory response
Answer: 3) Granulation tissue
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm 3.
Which of the following food items brought by the family should the nurse prohibit from
being given to the client?
1) Baked chicken
2) Bagels
3) A factory-sealed box of chocolates
4) Fresh fruit basket
Answer: 4) Fresh fruit basket
A nurse is contributing to the plan of care for an older adult client who is postoperative
following a right hip arthroplasty. Which of the following interventions should the nurse
include in the plan?
1) Perform the client's personal care activities for her.
2) Limit the client’s fluid intake.
3) Monitor the Homan’s sign.
4) Maintain abduction of the right hip.
Answer: 4) Maintain abduction of the right hip.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the
following actions should the nurse take first?
1) Establish IV access.
2) Feel for a carotid pulse.
3) Establish an open airway.
4) Auscultate for breath sounds.
Answer: 2) Feel for a carotid pulse.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is
no longer certain he wants to have the procedure. Which of the following responses should
the nurse make?
1) "Why have you changed your mind about the surgery?"
2) "Bypass surgery must be very frightening for you."
3) "Your provider would not have scheduled the surgery unless you needed it."
4) "I will call your doctor and have him discuss your surgery with you."
Answer: 2) "Bypass surgery must be very frightening for you."
A nurse is caring for a client who is postoperative following foot surgery and is not to bear
weight on the operative foot. The nurse enters the room to discover the client hopped on one
foot to the bathroom, using an IV pole for support. Which of the following actions should the
nurse take?
1) Walk the client back to bed immediately and get the client a bedpan.
2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
3) Warn the client she might have to be restrained if she gets up without assistance
4) Keep the bathroom door open to ensure the client is okay.
Answer: 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
A nurse is assisting with the care of a client who is postoperative and has a closed-wound
drainage system in place. Which of the following actions should the nurse take?
1) Fully re-collapse the reservoir after emptying it.
2) Empty the reservoir once per day.
3) Replace the drainage plug after releasing hand pressure on the device.
4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
Answer: 1) Fully re-collapse the reservoir after emptying it.
A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the
following statements by the client indicates an understanding of the teaching?
1) "I will not eat fried foods."
2) "I will abstain from sexual intercourse."
3) "I will refrain from international travel."
4) "I will not order a salad in a restaurant."
Answer: 2) "I will abstain from sexual intercourse."
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client
diagnosed with emphysema. Which of the following instructions should be included in the
teaching?
1) Rest in a supine position.
2) Consume a low-protein diet.
3) Breathe in through her nose and out through pursed lips.
4) Limit fluid intake throughout the day.
Answer: 3) Breathe in through her nose and out through pursed lips.
A nurse is caring for a client who is postoperative and has a history Addison's disease. For
which of the following manifestations should the nurse monitor?
1) Hypernatremia
2) Hypotension
3) Bradycardia
4) Hypokalemia
Answer: 2) Hypotension
VERSION 2
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home.
Which of the following instructions should the nurse include in the teaching?
1) Take temperature once a day
2) Wash the armpits and genitals with a gentle cleanser daily.
3) Change the litter boxes while wearing gloves.
4) Wash dishes in warm water.
Answer: 1) Take temperature once a day
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious
and tenacious secretions. Which of the following is an acceptable method for the nurse to use
to thin this client's secretions?
1) Provide humidified oxygen.
2) Perform chest physiotherapy prior to suctioning.
3) Pre-lubricate the suction catheter tip with sterile saline when suctioning the airway.
4) Hyperventilate the client with 100% oxygen before suctioning the airway..
Answer: 1) Provide humidified oxygen.
Following admission, a client with a vascular occlusion of the right lower extremity calls the
nurse and reports difficulty sleeping because of cold feet. Which of the following nursing
actions should the nurse take to promote the client's comfort?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet.
Answer: 2) Obtain a pair of slipper socks for the client
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection
of the prostate (TURP). Which of the following is the priority finding for the nurse report to
the provider?
1) Emesis of 100 mL
2) Oral temperature of 37.5° C (99.5° F)
3) Thick, red -colored urine
4) Pain level of 4 on a 0 to 10 rating scale
Answer: 3) Thick, red -colored urine
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of the
following adverse effects of the hypothermia blanket?
1) Shivering
2) Infection
3) Burns
4) Hypervolemia
Answer: 1) Shivering
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus.
Which of the following statements by the client indicates an understanding of the teaching?
1) "I will carry a complex carbohydrate snack with me when I exercise."
2) "I should exercise first thing in the morning before eating breakfast."
3) "I should avoid injecting insulin into my thigh if I am going to go running."
4) "I will not exercise if my urine is positive for ketones."
Answer: 4) "I will not exercise if my urine is positive for ketones."
A nurse notes a small section of bowel protruding from the abdominal incision of a client
who is postoperative. After calling for assistance, which of the following actions should the
nurse take first?
1) Cover the client's wound with a moist, sterile dressing.
2) Have the client lie supine with knees flexed.
3) Check the client's vital signs.
4) Inform the client about the need to return to surgery.
Answer: 1) Cover the client's wound with a moist, sterile dressing.
A nurse is collecting data from a client who has alcohol use disorder and is experiencing
metabolic acidosis. Which of the following manifestations should the nurse expect?
1) Cool, clammy skin.
2) Hyperventilation
3) Increased blood pressure
4) Bradycardia
Answer: 2) Hyperventilation
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which
of the following should the nurse include in the teaching?
1) Avoid bending at the waist.
2) Remove the eye shield at bedtime.
3) Limit the use of laxatives if constipated.
4) Seeing flashes of light is an expected finding following extraction.
Answer: 1) Avoid bending at the waist.
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily.
The client refuses breakfast and reports nausea. Which of the following actions should the
nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
3) Check the client's vital signs.
4) Request an order for an antiemetic.
Answer: 3) Check the client's vital signs.
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The
nurse suspects the client's wound is infected because the drainage from the dressing is yellow
and thick. Which of the following findings should the nurse report as the type of drainage
found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent
Answer: 4) Purulent
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To
prevent postoperative complications which of the following actions should be reinforced
during the teaching?
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
2) Place the client’s affected leg into the CPM machine with the machine in the flexed
position
3) Place the client into a high Fowler’s position when initiating the CPM exercises.
4) Align the joints of the CPM machine with the knee gatch in the client’s bed.
Answer: 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM
exercises.
A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
Answer: 1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
A nurse is caring for a client who sustained a basal skull fracture. When performing morning
hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's
right nostril. Which of the following actions should the nurse take first?
1) Take the client's temperature.
2) Place a dressing under the client's nose.
3) Notify the charge nurse.
4) Test the drainage for glucose.
Answer: 4) Test the drainage for glucose.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize
that the client is at risk for autonomic dysreflexia. Which of the following interventions
should the nurse take to prevent autonomic dysreflexia?
1) Monitor for elevated blood pressure.
2) Provide analgesia for headaches.
3) Prevent bladder distention.
4) Elevate the client's head.
Answer: 3) Prevent bladder distention.
A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the
following findings should the nurse expect the client to report?
1) Hot flashes
2) Recurrent urinary tract infections
3) Blood in the stool
4) Abnormal vaginal bleeding
Answer: 4) Abnormal vaginal bleeding
A nurse is caring for a client following an open reduction and internal fixation of a fractured
femur. Which of the following findings is the nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache
Answer: 1) Altered level of consciousness
A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge
resection of the left lung and has a chest tube to suction. Which of the following is the
priority finding the nurse should report to the provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale
Answer: 1) Abdomen is distended
A nurse is reinforcing discharge teaching with a client about how to care for a newly created
ileal conduit. Which of the following instructions should the nurse include in the teaching?
1) Change the ostomy pouch daily.
2) Empty the ostomy pouch when it is 2/3 full.
3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
4) Apply lotion to the peristomal skin when changing the ostomy pouch.
Answer: 1) Change the ostomy pouch daily.
A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland.
Which of the following actions should the nurse include in the plan?
1) Position the client supine while in bed.
2) Change the nasal drip pad as needed.
3) Encourage frequent brushing of teeth.
4) Encourage the client to cough every 2 hr following surgery.
Answer: 2) Change the nasal drip pad as needed.
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily
following a myocardial infarction. The nurse should instruct the client that aspirin is
prescribed for clients who have coronary artery disease for which of the following effects?
1) To provide analgesia
2) To reduce inflammation
3) To prevent blood clotting
4) To prevent fever
Answer: 3) To prevent blood clotting
A nurse is collecting data from a client who has open-angle glaucoma. Which of the
following findings should the nurse expect?
1) Loss of peripheral vision
2) Headache
3) Halos around lights
4) Discomfort in the eyes
Answer: 1) Loss of peripheral vision
A nurse is collecting data from a client who has acute gastroenteritis. Which of the following
data collection findings should the nurse identify as the priority?
1) Weight loss of 3% of total body weight.
2) Blood glucose 150 mg/dL.
3) Potassium 2.5 mEq/L
4) Urine specific gravity 1.035
Answer: 3) Potassium 2.5 mEq/L
A nurse is reinforcing discharge teaching with a client who had a total abdominal
hysterectomy and a vaginal repair. Which of the following statements by the client indicates a
need for further teaching?
1) "I should increase my intake of protein and vitamin C."
2) "I will no longer have menstrual periods."
3) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience
discomfort."
4) "I will take a tub bath instead of a shower."
Answer: 4) "I will take a tub bath instead of a shower."
A nurse is assisting with the care of a client who has a femur fracture and is in skeletal
traction. Which of the following actions should the nurse take?
1) Loosen the knots on the ropes if the client is experiencing pain.
2) Ensure the client’s weights are hanging freely from the bed.
3) Check the client’s bony prominences every 12 hr.
4) Cleanse the client’s pin sites with povidone-iodine.
Answer: 2) Ensure the client’s weights are hanging freely from the bed.
A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
Answer: 1) Take this medication between meals.
A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
Answer: 1) Take this medication between meals.
A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the
following interventions should the nurse recommend?
1) Apply topical antifungal agents.
2) Apply fresh ice packs every 4 hr.
3) Wash daily with an antibacterial soap.
4) Keep draining lesions uncovered to air dry.
Answer: 3) Wash daily with an antibacterial soap.
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy
established. Which of the following instructions should the nurse include in the teaching?
1) Empty the pouch immediately after meals.
2) Change the entire appliance once a day.
3) Limit fluid intake.
4) Avoid medications in capsule or enteric form.
Answer: 4) Avoid medications in capsule or enteric form.
A nurse is caring for a client with severe burns to both lower extremities. The client is
scheduled for an escharotomy and wants to know what the procedure involves. Which of the
following statements is appropriate for the nurse to make?
1) "An escharotomy surgically removes dead tissue."
2) "A cannula will be inserted into the bone to infuse fluids and antibiotics."
3) "A piece of skin will be removed and grafted over the burned area."
4) "Large incisions will be made in the burned tissue to improve circulation."
Answer: 4) "Large incisions will be made in the burned tissue to improve circulation."
A nurse is collecting data from a client who has a possible cataract. Which of the following
manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
4) Eyestrain
Answer: 1) Decreased color perception
A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is
receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the
following interventions should the nurse include in the plan of care?
1) Measure abdominal girth daily.
2) Use sterile water to irrigate the nasogastric tube..
3) Maintain the client in Fowler’s position.
4) Moisten the client’s lips with lemon-glycerine swabs.
Answer: 3) Maintain the client in Fowler’s position.
A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
4) Tremors
5) Obese extremities
Answer: 1) Buffalo hump
2) Purple striations
3) Moon face
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the
following actions should the nurse take?
1) Provide a diet high in protein.
2) Provide ibuprofen for retroperitoneal discomfort.
3) Monitor intake and output hourly
4) Encourage the client to consume at least 2 L of fluid daily.
Answer: 3) Monitor intake and output hourly
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has
upper gastric pain. Which of the following statements should the nurse include in the
teaching?
1) "A flexible tube is introduced through the nose during the procedure."
2) "During the procedure you are in a sitting position."
3) "You will remain NPO for 8 hours before the procedure."
4) "You will be awake while the procedure is performed."
Answer: 3) "You will remain NPO for 8 hours before the procedure."
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours
following a generalized tonic-clonic seizure. Which of the following descriptions should the
nurse use when documenting this finding in the medical record?
1) Aura phase
2) Presence of automatisms
3) Postictal phase
4) Presence of absence seizures
Answer: 3) Postictal phase
A nurse is reinforcing teaching with a client who reports right shoulder pain following a
laparoscopic cholecystectomy. Which of the following statements should the nurse make?
1) "The pain results from lying in one position too long during surgery."
2) "The pain occurs as a residual pain from cholecystitis."
3) "The pain will dissipate if you ambulate frequently."
4) "The pain is caused from the nitrous dioxide injected into the abdomen."
Answer: 3) "The pain will dissipate if you ambulate frequently."
A nurse is checking the suction control chamber of a client's chest tube and notes that there is
no bubbling in the suction control chamber. Which of the following actions should the nurse
take?
1) Notify the provider.
2) Verify that the suction regulator is on.
3) Continue to monitor the client because this is an expected finding.
4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Answer: 2) Verify that the suction regulator is on.
Rationale:
The nurse should check for kinks and take other measures before notifying the provider.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
Answer: 1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
A nurse is assisting with the care of a client who is postoperative following surgical repair of
a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture.
The nurse should recognize which of the following is the priority action?
1) Relieve the client's pain.
2) Check the client’s pressure points for redness.
3) Provide oral hygiene.
4) Prevent aspiration
Answer: 4) Prevent aspiration
A nurse is collecting data from a client who has scleroderma. Which of the following findings
should the nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
Answer: 4) Hardened skin
A nurse is caring for an older adult client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client's mouth.
3) Add thickener to fluids.
4) Serve food at room temperature.
Answer: 3) Add thickener to fluids.
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head,
neck, and chest. The nurse should recognize which of the following is the priority risk to the
client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
Answer: 1) Airway obstruction
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis
and is to start taking neostigmine. Which of the following instructions should the nurse
include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side effect of the neostigmine.
3) If a medication dose is missed, wait until the next scheduled dose to take the medication.
4) Treat nasal rhinitis with an over-the-counter antihistamine.
Answer: 1) Take the medication 45 minutes before eating.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection
of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse
notes there has not been any urinary output in the last hour. Which of the following actions
should the nurse perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
Answer: 1) Notify the provider.
4) Determine the patency of the tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear
about the procedure and asks the nurse if the biopsy will hurt. Which of the following
responses should the nurse make?
1) "You must be very worried about what the biopsy will show."
2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’s happening."
3) "Your provider scheduled this, so she will want to know you still have questions about the
procedure."
4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."
Answer: 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as
possible."
A nurse is assisting with planning care for a client who is recovering from a left hemispheric
stroke. Which of the following interventions should the nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function.
Answer: 3) Re-establish communication.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should
monitor the client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
Answer: 1) Hypotension
A nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm Hg
Base excess -2
PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
1) Metabolic acidosis
2) Respirator y acidosis
3) Metabolic alkalosis
4) Respiratory alkalosis
Answer: 2) Respirator y acidosis
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The
nurse should recognize that which of the following statements by the client indicates a need
for further teaching?
1) "I will avoid crossing my legs at the knees."
2) "I will use a thermometer to check the temperature of my bath water."
3) "I will not go barefoot."
4) "I will wear stockings with elastic tops."
Answer: 4) "I will wear stockings with elastic tops."
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's
disease. The client becomes agitated and combative when the nurse approaches him.
Which of the following actions should the nurse plan to take?
1) Turn the water on and ask the client to test the temperature.
2) Obtain assistance to place mitten restraints on the client.
3) Firmly tell the client that good hygiene is important.
4) Calmly ask the client if he would like to listen to some music.
Answer: 4) Calmly ask the client if he would like to listen to some music.
A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is
covered with soft, red tissue that bleeds easily. The nurse should recognize this is a
manifestation of which of the following?
1) Decreased perfusion
2) Infection
3) Granulation tissue
4) An inflammatory response
Answer: 3) Granulation tissue
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm 3.
Which of the following food items brought by the family should the nurse prohibit from
being given to the client?
1) Baked chicken
2) Bagels
3) A factory-sealed box of chocolates
4) Fresh fruit basket
Answer: 4) Fresh fruit basket
A nurse is contributing to the plan of care for an older adult client who is postoperative
following a right hip arthroplasty. Which of the following interventions should the nurse
include in the plan?
1) Perform the client's personal care activities for her.
2) Limit the client’s fluid intake.
3) Monitor the Homan’s sign.
4) Maintain abduction of the right hip.
Answer: 4) Maintain abduction of the right hip.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the
following actions should the nurse take first?
1) Establish IV access.
2) Feel for a carotid pulse.
3) Establish an open airway.
4) Auscultate for breath sounds.
Answer: 2) Feel for a carotid pulse.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is
no longer certain he wants to have the procedure. Which of the following responses should
the nurse make?
1) "Why have you changed your mind about the surgery?"
2) "Bypass surgery must be very frightening for you."
3) "Your provider would not have scheduled the surgery unless you needed it."
4) "I will call your doctor and have him discuss your surgery with you."
Answer: 2) "Bypass surgery must be very frightening for you."
A nurse is caring for a client who is postoperative following foot surgery and is not to bear
weight on the operative foot. The nurse enters the room to discover the client hopped on one
foot to the bathroom, using an IV pole for support. Which of the following actions should the
nurse take?
1) Walk the client back to bed immediately and get the client a bedpan.
2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
3) Warn the client she might have to be restrained if she gets up without assistance.
4) Keep the bathroom door open to ensure the client is okay.
Answer: 2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
A nurse is assisting with the care of a client who is postoperative and has a closed-wound
drainage system in place. Which of the following actions should the nurse take?
1) Fully re-collapse the reservoir after emptying it.
2) Empty the reservoir once per day.
3) Replace the drainage plug after releasing hand pressure on the device.
4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
Answer: 1) Fully re-collapse the reservoir after emptying it.
A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the
following statements by the client indicates an understanding of the teaching?
1) "I will not eat fried foods."
2) "I will abstain from sexual intercourse."
3) "I will refrain from international travel."
4) "I will not order a salad in a restaurant."
Answer: 2) "I will abstain from sexual intercourse."
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client
diagnosed with emphysema. Which of the following instructions should be included in the
teaching?
1) Rest in a supine position.
2) Consume a low-protein diet.
3) Breathe in through her nose and out through pursed lips.
4) Limit fluid intake throughout the day.
Answer: 3) Breathe in through her nose and out through pursed lips.
A nurse is caring for a client who is postoperative and has a history Addison's disease. For
which of the following manifestations should the nurse monitor?
1) Hypernatremia
2) Hypotension
3) Bradycardia
4) Hypokalaemia
Answer: 2) Hypotension
A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is
to take hydroxyzine preoperatively. Which of the following effects of the medication should
the nurse include in the teaching? (Select all that apply.)
1) Decreasing anxiety
2) Controlling emesis
3) Relaxing skeletal muscles
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer: 1) Decreasing anxiety
2) Controlling emesis
A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The
nurse should reinforce to the client to take which of the following dietary supplements with
this medication?
1) Vitamin D
2) Vitamin A
3) Iron
4) Niacin
Answer: 3) Iron
A nurse is caring for a client after a radical neck dissection. To which of the following should
the nurse give priority in the immediate postoperative period?
1) Malnourishment related to NPO status and dysphagia
2) Impaired verbal communication related to the tracheostomy
3) High risk for infection related to surgical incisions
4) Ineffective airway clearance related to thick, copious secretions
Answer: 4) Ineffective airway clearance related to thick, copious secretions
A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8
who is admitted for comprehensive rehabilitation. Which of the following long-term goals is
appropriate with regard to the client's mobility?
1) Walk with leg braces and crutches.
2) Drive an electric wheelchair with a hand-control device.
3) Drive an electric wheelchair equipped with a chin-control device.
4) Propel a wheelchair equipped with knobs on the wheels.
Answer: 4) Propel a wheelchair equipped with knobs on the wheels.
A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the
following risk factors should the nurse identify as the leading cause of non-melanoma skin
cancer?
1) Exposure to environmental pollutants
2) Sun exposure
3) History of viral illness
4) Scars from a severe burn:
Answer: 2) Sun exposure
Based on a client's recent history, a nurse suspects that a client is beginning menopause.
Which of the following questions should the nurse ask the client to help confirm the client is
experiencing manifestations of menopause?
1) "Do you sleep well at night?"
2) "Have you been experiencing chills?"
3) "Have you experienced increased hair growth?"
4) "When did you begin your menses?"
Answer: 1) "Do you sleep well at night?"
A nurse is reinforcing teaching with a client about cancer prevention and plans to address the
importance of foods high in antioxidants. Which of the following foods should the nurse
include in the teaching?
1) Cottage cheese
2) Fresh berries
3) Bran cereal
4) Skim milk
Answer: 2) Fresh berries
A nurse is assisting with caring for a client who has a new concussion following a motor
vehicle crash. The nurse should monitor the client for which of the following manifestations
of increased intracranial pressure?
1) Polyuria
2) Battle's sign
3) Nuchal rigidity
4) Lethargy
Answer: 4) Lethargy
A nurse is reinforcing teaching about a tonometry examination with a client who has
manifestations of glaucoma. Which of the following statements should the nurse include in
the teaching?
1) "Tonometry is performed to evaluate peripheral vision."
2) "This test will diagnose the type of your glaucoma."
3) "Tonometry will allow inspection of the optic disc for signs of degeneration."
4) "This test will measure the intraocular pressure of the eye."
Answer: 4) "This test will measure the intraocular pressure of the eye."
A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a
kidney transplant. Which of the following laboratory findings should the nurse identify as the
most important to report to the provider?
1) Increase in serum glucose
2) Increase in serum creatinine
3) Decrease in white blood cell count
4) Decrease in platelets
Answer: 2) Increase in serum creatinine
A nurse is checking for paradoxical blood pressure on a client who has constrictive
pericarditis. Which of the following findings should the nurse expect?
1) Apical pulse rate different than the radial pulse rate
2) Increase in heart rate by 20% when standing
3) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position
4) Drop in systolic BP more than 10 mm Hg on inspiration
Answer: 4) Drop in systolic BP more than 10 mm Hg on inspiration
A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client
entering the room of another client, who becomes upset and frightened. Which of the
following actions should the nurse take?
1) Attempt to determine what the client was looking for.
2) Explain the client’s Alzheimer’s diagnosis to the frightened client.
3) Reprimand the client for invading the other client's privacy.
4) Ask the client to apologize for his behavior.
Answer: 1) Attempt to determine what the client was looking for.
A nurse is caring for a client immediately following a cardiac catheterization with a femoral
artery approach. Which of the following actions should the nurse take?
1) Check pedal pulses every 15 min.
2) Perform passive range-of-motion for the affected extremity.
3) Remind the client not to turn from side to side.
4) Keep the client in high-Fowler's position for 6 hr.
Answer: 1) Check pedal pulses every 15 min.
A nurse is assisting with planning an immunization clinic for older adult clients. Which of the
following information should the nurse plan to include about influenza?
1) Individuals at high risk should receive the live influenza vaccine.
2) Immunization for influenza should be repeated every 10 years.
3) The composition of the influenza vaccine changes yearly.
4) The influenza vaccine is necessary only for clients who have never had influenza.
Answer: 3) The composition of the influenza vaccine changes yearly.
A nurse is caring for an older adult client who has colon cancer. The client asks the nurse
several questions about his treatment plan. Which of the following actions should the nurse
take?
1) Tell the client to have a family member call the provider to ask what options he plans to
recommend.
2) Assure the client that the provider will tell him what is planned.
3) Help the client write down questions to ask his provider.
4) Provide the client with a pamphlet of information about cancer.
Answer: 3) Help the client write down questions to ask his provider.
A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is
distressed over his mother's crying and condition. Which of the following responses should
the nurse make?
1) "If you just sit quietly with your mother, I'm sure she will calm down."
2) "I'll talk with your mother and see if I can comfort her."
3) "It must be hard to see your mother so ill and upset."
4) "Your mother's crying seems to bother you more than it does her."
Answer: 3) "It must be hard to see your mother so ill and upset."
A nurse is reinforcing teaching with the family of a client who has primary dementia. Which
of the following manifestations of dementia should the nurse include in the teaching?
1) Temporary, reversible loss of brain function
2) Forgetfulness gradually progressing to disorientation
3) Sleeping more during the day than nighttime
4) Hyper vigilant behaviors
Answer: 2) Forgetfulness gradually progressing to disorientation
A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the
following interventions should the nurse include in the plan?
1) Limit fluid intake..
2) Monitor client’s cardinal fields of vision.
3) Encourage ambulation.
4) Ensure the room is brightly lit.
Answer: 2) Monitor client’s cardinal fields of vision.
80 .A nurse is contributing to the plan of care for a client who is admitted with a deep vein
thrombosis (DVT) of the left leg. Which of the following interventions should the nurse
include in the plan?
1) Apply ice to the extremity
2) Monitor platelet levels
3) Restrict oral fluids
4) Administer vasodilating medications
Answer: 2) Monitor platelet levels
A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a
close family contact tests positive. Which of the following measures should the nurse
anticipate preparing for this client?
1) Tuberculin skin test
2) Sputum culture for acid fast bacillus (AFB)
3) Bacille Calmette-Guérin (bCG) vaccine
4) Chest x-ray
Answer: 4) Chest x-ray
A nurse is reviewing data for a client who has a head injury. Which of the following findings
should indicate to the nurse that the client might have diabetes insipidus?
1) Serum sodium 145 mEq/L
2) Urine specific gravity 1.028
3) Urine output 650 mL/hr
4) Blood glucose 198 mg/dL
Answer: 3) Urine output 650 mL/hr
A nurse is caring for a client who has recurrent kidney stones and a history of diabetes
mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should
collect additional data about which of the following statements made by the client?
1) "I took a laxative yesterday."
2) "I took my metformin before breakfast."
3) "I haven't had anything to eat or drink since last night."
4) "The last time I voided it was painful."
Answer: 2) "I took my metformin before breakfast."
A nurse is collecting data from a client who is having an acute asthma exacerbation. When
auscultating the client's chest, the nurse should expect to hear which of the following sounds?
1) Expiratory wheeze
2) Pleural friction rub
3) Fine rales
4) Rhonchi
Answer: 1) Expiratory wheeze
A nurse is planning to change an abdominal dressing for a client who has an incision with a
drain. Which of the following actions should the nurse plan to take?
1) Remove the entire dressing at once.
2) Loosen the dressing by pulling the tape away from the wound.
3) Don clean gloves to remove the dressing.
4) Open sterile supplies before removing the dressing.
Answer: 3) Don clean gloves to remove the dressing.
A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the
following positions should the nurse place the client for the procedure?
1) Prone with arms raised over the head.
2) Sitting, leaning forward over the bedside table.
3) High Fowler’s position
4) Side-lying with knees drawn up to the chest.
Answer: 2) Sitting, leaning forward over the bedside table.
A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following
reactions from the client should the nurse initially expect?
1) Denial
2) Bargaining
3) Acceptance
4) Anger
Answer: 1) Denial
A nurse is contributing to the plan of care for a client who is postoperative following
peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction
and closed-suction drains in place. Which of the following interventions should the nurse
include in the plan?
1) Irrigate the nasogastric tube with tap water.
2) Mark abdominal girth once daily.
3) Ambulate the client twice daily.
4) Place the client in a high Fowler’s position.
Answer: 4) Place the client in a high Fowler’s position.
A nurse is caring for a client who is receiving haemodialysis. Which of the following client
measurements should the nurse compare before and after dialysis treatment to determine fluid
losses?
1) Neck vein distention
2) Blood pressure
3) Body weight
4) Abdominal girth
Answer: 3) Body weight
A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min
following the start of the transfusion, the nurse notes that the client is flushed and febrile, and
reports chills. To help confirm that the client is having an acute haemolytic transfusion
reaction, the nurse should observe for which of the following manifestations?
1) Urticaria
2) Muscle pain
3) Hypotension
4) Distended neck veins
Answer: 3) Hypotension
A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The
nurse should recognize the client is experiencing which of the following conditions?
1) A continuous seizure state in which seizures occur in rapid succession
2) A sensory warning that a seizure is imminent
3) A period of sleepiness following the seizure during which arousal is difficult
4) A brief loss of consciousness accompanied by staring
Answer: 2) A sensory warning that a seizure is imminent
A nurse is caring for a client who just had cataract surgery. Which of the following comments
from the client should the nurse report to the provider?
1) "The bright light in this room is really bothering me."
2) "My eye really itches, but I'm trying not to rub it."
3) "It's really hard to see with a patch on one eye."
4) "I need something for the horrible pain in my eye."
Answer: 4) "I need something for the horrible pain in my eye."
A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if
there will be a lot of pain during the procedure. Which of the following responses should the
nurse make?
1) "You shouldn't feel any pain since the local area is anesthetized."
2) "Most clients report more discomfort from the preparation than from the procedure itself."
3) "You may feel some cramping during the procedure."
4) "Don't worry; you won't remember anything about the procedure due to the effects of the
medication."
Answer: 3) "You may feel some cramping during the procedure."
A nurse caring for a client at risk for increased intracranial pressure is monitoring the client
for manifestations that indicate that the pressure is increasing. To do this, the nurse should
check the function of the third cranial nerve by performing which of the following data
collection activities?
1) Observing for facial asymmetry
2) Checking pupillary responses to light
3) Eliciting the gag reflex
4) Testing visual acuity
Answer: 2) Checking pupillary responses to light
A nurse is caring for a client during the immediate postoperative period following thoracic
surgery. When administering an opioid analgesic for pain, the nurse should explain that the
medication should have which of the following effects?
1) Reducing anxiety
2) Increasing blood pressure
3) Increasing coughing
4) Increasing the client's respiratory rate
Answer: 1) Reducing anxiety
A nurse is collecting data on a client who has hyperthyroidism. Which of the following
manifestations should the nurse expect the client to report?
1) Frequent mood changes
2) Constipation
3) Sensitivity to cold
4) Weight gain
Answer: 1) Frequent mood changes
A nurse is collecting data from a client who has skeletal traction. Which of the following
findings should the nurse identify as an indication of infection at the pin sites?
1) Serosanguineous drainage
2) Mild erythema
3) Warmth
4) Fever
Answer: 4) Fever
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse
determines that teaching has been effective when the client identifies which of the following
manifestations of hypoglycemia? (Select all that apply.)
1) Polyuria
2) Blurry vision
3) Tachycardia
4) Polydipsia
5) Sweating
Answer: 2) Blurry vision
3) Tachycardia
5) Sweating
A nurse is collecting data from a client who has an exacerbation of gout. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
5) Symmetrical joint pain
Answer: 1) Edema
2) Erythema
3) Tophi
4) Tight skin
A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a
complication of MG for which the nurse should monitor?
1) Respiratory difficulty
2) Confusion
3) Increased intracranial pressure
4) Joint pain
Answer: 1) Respiratory difficulty
A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis.
The nurse should recognize that which of the following actions is the priority?
1) Review stress factors that can cause disease exacerbation.
2) Evaluate fluid and electrolyte levels.
3) Provide emotional support.
4) Promote physical mobility.
Answer: 2) Evaluate fluid and electrolyte levels.
A nurse is reinforcing teaching about rifampin with a female client who has active
tuberculosis. Which of the following statements should the nurse include in the teaching?
1) "You should wear glasses instead of contacts while taking this medication."
2) "The medication causes amenorrhea if taken along with an oral contraceptive."
3) "A yellow tint to the skin is an expected reaction to the medication."
4) "Lifelong treatment with this medication is necessary."
Answer: 1) "You should wear glasses instead of contacts while taking this medication."
A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following
a renal transplant. Which of the following statements by the client indicates an understanding
of the teaching?
1) "I will take this medication until my BUN returns to normal."
2) "This medication will help my new kidney make adequate urine."
3) "I will need to take this medication for the rest of my life."
4) "This medication will boost my immune system."
Answer: 3) "I will need to take this medication for the rest of my life."
A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by
mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for
with a client who is taking this medication?
1) Improved speech patterns
2) Increased bladder function.
3) Decreased tremors
4) Diminished drooling
Answer: 3) Decreased tremors
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood
cells. The client develops itching and hives. Which of the following actions should the nurse
take first?
1) Obtain vital signs.
2) Stop the transfusion
3) Notify the registered nurse.
4) Administer diphenhydramine.
Answer: 2) Stop the transfusion
A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations
of Raynaud’s phenomenon. Which of the following statements should the nurse identify as an
indication that the client needs further teaching?
1) "I will keep my house at a cool temperature."
2) "I will try to anticipate and avoid stressful situations."
3) "I will complete the smoking cessation program I started."
4) "I will wear gloves when removing food from the freezer."
Answer: 1) "I will keep my house at a cool temperature."
A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start
taking ferrous sulphate twice a day. Which of the following statements by the client indicate
an understanding of the teaching?
1) "I will take the medication with orange juice."
2) "I should expect to have loose stools while taking this medication."
3) "I will have clay colored stools while taking this medication."
4) "I should take the medication with milk."
Answer: 1) "I will take the medication with orange juice."
A nurse is reinforcing teaching about pernicious anemia with a client following a total
gastrectomy. Which of the following dietary supplements should the nurse include in the
teaching as the treatment for pernicious anemia?
1) Vitamin B12
2) Vitamin C
3) Iron
4) Folate
Answer: 1) Vitamin B12
A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a
prescription for lorazepam preoperatively. Which of the following statements by the client
should indicate to the nurse that the medication has been effective?
1) "My mouth is very dry."
2) "I feel very sleepy."
3) "I am not hungry any longer."
4) "My leg feels numb."
Answer: 2) "I feel very sleepy."
A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the
nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should
recognize this is a manifestation of which of the following conditions?
1) Xerostomia
2) Gingivitis
3) Candidiasis
4) Halitosis
Answer: 3) Candidiasis
A nurse is caring for a client who is postoperative open reduction and internal fixation with
placement of a wound drain to repair a hip fracture. Which of the following actions should
the nurse take?
1) Empty the suction device every 4 hr.
2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr.
3) Position the client’s hip so that it is internally rotated.
4) Encourage foot exercises every 4 hr.
Answer: 1) Empty the suction device every 4 hr.
A nurse is assisting with teaching a client who has a history of smoking about recognizing
early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and
report which of the following manifestations of laryngeal cancer?
1) Aphagia
2) Hoarseness
3) Tinnitus
4) Epistaxis
Answer: 2) Hoarseness
A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which
of the following laboratory values should the nurse review to determine the client’s renal
function?
1) Antinuclear antibody
2) C-reactive protein
3) Erythrocyte sedimentation rate
4) Serum creatinine
Answer: 4) Serum creatinine
A nurse is collecting data from a client who has Cushing's syndrome. Which of the following
manifestations should the nurse expect?
1) Bruising
2) Weight loss
3) Hyperpigmentation
4) Double vision
Answer: 1) Bruising
A nurse is caring for a client who is postoperative and requesting something to drink. The
nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance
diet as tolerated." Which of the following actions should the nurse take first?
1) Offer the client apple juice.
2) Elevate the client’s head of bed.
3) Auscultate the client’s abdomen.
4) Order a lunch tray for the client.
Answer: 3) Auscultate the client’s abdomen.
A nurse is collecting data on a client who has a surgical wound healing by secondary
intention. Which of the following findings should the nurse report to the charge nurse?
1) The wound is tender to touch.
2) The wound has pink, shiny tissue with a granular appearance.
3) The wound has serosanguineous drainage.
4) The wound has a halo of erythema on the surrounding skin.
Answer: 4) The wound has a halo of erythema on the surrounding skin.
A nurse is assisting with the care of a client who has multiple injuries following a motor
vehicle crash. The nurse should monitor for which of the following manifestations of a
pneumothorax?
1) Inspiratory stridor
2) Expiratory wheeze
3) Absence of breath sounds
4) Coarse crackles
Answer: 3) Absence of breath sounds
A nurse is collecting data from a client who has right-sided heart failure. Which of the
following findings should the nurse expect?
1) Frothy sputum
2) Dyspnea
3) Orthopnea
4) Peripheral edema
Answer: 4) Peripheral edema
A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer
and experiencing nausea. Which of the following actions should the nurse take?
1) Advise the client to lie down after meals.
2) Instruct the client to restrict food intake prior to treatment.
3) Provide the client with an antiemetic 2 hr prior to the chemotherapy.
4) Encourage the client to drink a carbonated beverage 1 hr before meals.
Answer: 4) Encourage the client to drink a carbonated beverage 1 hr before meals.
A nurse is assisting with the care of a client following a transurethral resection of the prostate
(TURP) and has an indwelling urinary catheter. Which of the following actions should the
nurse take?
1) Weigh the client weekly.
2) Irrigate the catheter as prescribed.
3) Instruct the client to report an urge to urinate.
4) Instruct the client to bear down as if to have a bowel movement every hour.
Answer: 2) Irrigate the catheter as prescribed.
A nurse is evaluating discharge instructions for a client following a right cataract extraction.
Which of the following client statements indicates the teaching is effective?
1) "I will take a stool softener until my eye is healed."
2) "I will expect to have moderately severe pain for 1-2 days."
3) "I will refrain from cooking for 1 week."
4) "I will bend at the waist to tie my shoes."
Answer: 1) "I will take a stool softener until my eye is healed."
A nurse is collecting data from a client who is 6 days post craniotomy for removal of an
intracerebral aneurysm. The nurse should monitor the client for which of the following
manifestations of increased intracranial pressure?
1) Decreased pedal pulses
2) Hypertension
3) Peripheral edema
4) Diarrhea
Answer: 2) Hypertension
A nurse is caring for a client who has COPD. Which of the following actions should the nurse
take?
1) Encourage the client to drink 8 glasses of water a day.
2) Instruct the client to cough every 4 hr.
3) Provide the client with a low protein diet.
4) Advise the client to lie down after eating.
Answer: 1) Encourage the client to drink 8 glasses of water a day.
A nurse is caring for a client who was admitted with major burns to the head, neck, and chest.
Which of the following complications should the nurse identify as the greatest risk to the
client?
1) Hypothermia
2) Hyponatremia
3) Fluid imbalance
4) Airway obstruction
Answer: 4) Airway obstruction
A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the
following client manifestations should the nurse identify as an indication of the development
of Lyme disease?
1) An expanding circular rash
2) Swollen, painful joints
3) Decreased level of consciousness
4) Necrosis at the site of the bite
Answer: 1) An expanding circular rash
A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a
right radical mastectomy with closed suction drains present. The nurse should expect that the
client will be unable to perform which of the following activities with her right arm?
1) Combing her hair
2) Eating her breakfast
3) Buttoning her blouse
4) Tying her shoes
Answer: 1) Combing her hair
A nurse in a provider’s office is collecting data for a 45-year-old client who is having
manifestations associated with perimenopause. Which of the following findings should the
nurse expect?
1) Report of urinary retention
2) Elevated blood pressure above 140/90
3) Report of dryness with vaginal intercourse
4) Elevated body temperature above 37.8° C (100° F)
Answer: 3) Report of dryness with vaginal intercourse
A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a
regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the
following times?
1) On the same day every month
2) Prior to the beginning of menses
3) Three to seven days after menses stops
4) On the second day of menstruation
Answer: 3) Three to seven days after menses stops
A nurse is caring for a client who has second- and third-degree burns and a prescription for a
high-calorie, high-protein diet. Which of the following menu choices should the nurse
recommend?
1) ½ cup whole-grain pasta with tomato sauce and pears
2) Turkey and cheese sandwich with scalloped potatoes
3) ½ cup black beans with a brownie
4) Roast beef with romaine lettuce salad
Answer: 2) Turkey and cheese sandwich with scalloped potatoes
A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram.
Which of the following should the nurse include in the teaching?
1) Omit your daily dose of aspirin.
2) Take a laxative the evening before the procedure.
3) Expect to be drowsy for 24 hr following the procedure.
4) You will feel cold chills after the dye has been injected.
Answer: 2) Take a laxative the evening before the procedure.
A nurse is collecting data from a client in the health clinic who is reporting epigastric pain.
Which of the following statements made by the client should the nurse identify as being
consistent with peptic ulcer disease?
1) "The pain is worse after I eat a meal high in fat."
2) "My pain is relieved by having a bowel movement."
3) " I feel so much better after eating."
4) "The pain radiates down to my lower back."
Answer: 3) " I feel so much better after eating."
A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the
following interventions should the nurse identify as the priority?
1) Promote the client’s expression of feelings about loss of self-care ability.
2) Encourage the client to recall positive life events.
3) Schedule pain medication on a routine basis.
4) Suggest ways the client can continue interacting with social contacts.
Answer: 3) Schedule pain medication on a routine basis.
A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic
open angle glaucoma. Which of the following statements by the client indicates an
understanding of the teaching?
1) "When my vision improves, I will be able to stop taking the eye drops."
2) "If I forget to take my eye drops, I should wait until the next time they are due."
3) "I should call the clinic before taking any over-the-counter medications."
4) "Every two years I will need to have my vision checked by an eye doctor."
Answer: 3) "I should call the clinic before taking any over-the-counter medications."
VERSION 2
ATI MED-SURG PROCTORED EXAM PRACTICE QUESTIONS WITH
ANSWERS (73 Q/A)
A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
Answer: 1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to
inadequate oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the
diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the
rib cage also become rigid, and the ribs flare outward. This produces the barrel chest typical
of emphysema clients.
Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity,
which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung elasticity;
consequently, respirations become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less
oxygen being delivered to the tissues.
A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
4) Tremors
5) Obese extremities
Answer: 1) Buffalo hump
2) Purple striations
3) Moon face
Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production
of cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between
the shoulders, is a common manifestation of Cushing's syndrome.
Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts
are a common manifestation of Cushing's syndrome. This is due to the collection of body fat
in these areas.
Moon face is correct. Moon face is a common manifestation of Cushing's syndrome. Clients
who have this manifestation present with a round, red, full face.
Tremors is incorrect. Tremors are not a common finding of Cushing's syndrome. Obese
extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity, a
protuberant abdomen, with thin extremities, which is due to an alteration in protein
metabolism.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
Answer: 1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
Rationale:
Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated,
to replace the cerebrospinal fluid that was removed during the procedure and reduce the risk
for a headache.
Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a
hematoma at the insertion site because this can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion.
Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or
more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for
this client.
A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is
to take hydroxyzine preoperatively. Which of the following effects of the medication should
the nurse include in the teaching? (Select all that apply.)
1) Decreasing anxiety
2) Controlling emesis
3) Relaxing skeletal muscles
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer: 1) Decreasing anxiety
2) Controlling emesis
5) Reducing the amount of narcotics needed for pain relief
Rationale:
Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective
antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with
moderate anxiety.
Controlling emesis is correct. The nurse should include that hydroxyzine is an effective
antiemetic and is used to control nausea and vomiting in pre- and postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as
diazepam (Valium), are used to produce skeletal muscle relaxation.
Preventing surgical site infections is incorrect. The nurse should instruct the client that
antibiotics administered prior to surgery are used to diminish the risk of surgical site
infections; hydroxyzine, an antiemetic, does not have any effect on bacteria.
Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the
effects of narcotic pain medications. The nurse should instruct the client that when it is used
for surgical clients, narcotic requirements may be significantly reduced.
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse
determines that teaching has been effective when the client identifies which of the following
manifestations of hypoglycemia? (Select all that apply.)
1) Polyuria
2) Blurry vision
3) Tachycardia
4) Polydipsia
5) Sweating
Answer: 2) Blurry vision
3) Tachycardia
5) Sweating
Rationale:
Polyuria is incorrect. Hyperglycemia causes polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include blurry vision, tremors,
anxiety, irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia, tremors, anxiety,
irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating, tremors, anxiety,
irritability, headache, and hypotension.
A nurse is collecting data from a client who has an exacerbation of gout. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
5) Symmetrical joint pain
Answer: 1) Edema
2) Erythema
3) Tophi
4) Tight skin
Rationale:
Edema is correct. Swelling over the affected joints is a classic manifestation of gout.
Erythema is correct. Redness over the affected joints is a classic manifestation of gout.
Tophi is correct. Tophi are a classic manifestation of gout. They are nodules that form in
subcutaneous tissue due to the accumulation of urate crystals.
Tight skin is correct. Tight skin over the affected joints is a classic manifestation of gout.
Symmetrical joint pain is incorrect. Symmetrical joint pain is a manifestation of rheumatoid
arthritis, not gout.
A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction.
The client has a nasogastric tube in place. Which of the following actions should the nurse
include in the client's plan of care? (Select all that apply.)
1) Perform leg exercises every 2 hr.
2) Encourage hourly use of an incentive spirometer while awake.
3) Document the color, consistency, and amount of nasogastric drainage.
4) Irrigate the nasogastric tube every 4 to 8 hr.
5) Maintain bed rest for 48 hr following surgery.
Answer: 1) Perform leg exercises every 2 hr.
2) Encourage hourly use of an incentive spirometer while awake.
3) Document the color, consistency, and amount of nasogastric drainage.
Rationale:
Perform leg exercises every 2 hr is correct. Postoperative clients should frequently perform
leg exercises, independently or with assistance, to prevent skin breakdown.
Encourage hourly use of an incentive spirometer while awake is correct. Postoperative clients
should be encouraged to use the incentive spirometer ten times each hour while awake to
prevent atelectasis.
Document the color, consistency, and amount of nasogastric drainage is correct. Documenting
the color, consistency, and amount of nasogastric drainage is appropriate to include in the
client's plan of care.
Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Following abdominal surgery, the NG
tube should not be moved or irrigated unless prescribed by the provider.
Maintain bed rest for 48 hr following surgery is incorrect. Maintaining bed rest following
surgery should not be included in the plan of care. Early ambulation prevents distention and
improves intestinal mobility.
A nurse is assisting with discharge teaching for a client who is postoperative following a
laryngectomy. Which of the following instructions should the nurse include in the teaching?
(Select all that apply.)
1) To aid in swallowing food, tip the chin before swallowing.
2) Avoid using liquid supplements.
3) Include warm foods in your diet because they are easier to swallow.
4) Swallow twice after each bite.
5) Take a sip of water with each bite of food.
Answer: 1) To aid in swallowing food, tip the chin before swallowing.
4) Swallow twice after each bite.
Rationale:
To aid in swallowing food, tip the chin before swallowing is correct. This action decreases the
risk of aspiration.
Avoid using liquid supplements is incorrect. Following a laryngectomy, the client is at risk
for malnutrition. Liquid supplements provide needed protein and calories.
Include warm foods in your diet because they are easier to swallow is incorrect.
The client should include cold foods in her diet because they are easier to swallow.
Swallow twice after each bite is correct. Swallowing once when initially propelling food
down the esophagus and a second time (dry swallowing) to fully clear the esophagus of food
will decrease the risk of aspirating food left in the esophagus.
Take a sip of water with each bite of food is incorrect. This action places the client at risk for
aspiration.
A nurse is assisting with discharge teaching for a client who is postoperative from a
mastectomy including the removal of axillary lymph nodes. Which of the following
instructions should the nurse include? (Select all that apply.)
1) Use talcum powder instead of deodorant on the affected side for the first two weeks after
surgery.
2) Perform range-of-motion exercises of the affected arm.
3) Avoid lifting arm above shoulder level on the affected side.
4) Wait 72 hr before consuming a regular diet.
5) Elevated the affected arm on a pillow when resting in bed.
Answer: 2) Perform range-of-motion exercises of the affected arm.
5) Elevated the affected arm on a pillow when resting in bed.
Rationale:
Use talcum powder instead of deodorant on the affected side for the first two weeks after
surgery is incorrect. The client should avoid the use of talcum powder and deodorant until the
incision is healed.
Perform range-of-motion exercises of the affected arm is correct. The client should perform
range-of-motion exercises on the affected arm to improve circulation and reduce the risk of
lymphedema.
Avoid lifting arm above shoulder level on the affected side is incorrect. The client should face
a wall with the arms slightly bent and “walk” both arms up the wall as high as possible.
Wait 72 hr before consuming a regular diet is incorrect. The client can eat a regular diet 24 hr
after surgery.
Elevated the affected arm on a pillow when resting in bed is correct. The client should elevate
the affected arm to increase circulation and reduce the risk of lymphedema.
A client who is postoperative returns to the unit in skeletal traction. When collecting data
from the client, the nurse should expect which of the following findings? (Select all that
apply.)
1) Redness at the pin sites
2) Warmth at the pin sites
3) Movement of the pins at the insertion sites
4) No drainage from the pin sites
5) Tenting of the skin around the pin sites
Answer: 1) Redness at the pin sites
2) Warmth at the pin sites
Rationale:
Redness at the pin sites is correct. The nurse should expect the client to have redness at the
pin sites, as it is a manifestation of the expected reaction after insertion.
Warmth at the pin sites is correct. The nurse should expect the client to have warmth at the
pin sites, as it is a manifestation of the expected reaction after insertion.
Movement of the pins at the insertion sites is incorrect. The nurse should report movement of
the pins to the surgeon immediately, as it is a manifestation of infection.
No drainage from the pin sites is incorrect. Up to 72 hr after surgery, serosanguineous
drainage from the pin sites can be heavy; therefore, it is important to clean the pin sites daily.
Tenting of the skin around the pin sites is incorrect. The nurse should report tenting to the
surgeon immediately, as it is a manifestation of infection.
A nurse is reinforcing teaching about dietary recommendations for a client who has a hiatal
hernia. Which of the following client statements indicate understanding of the teaching?
(Select all that apply.)
1) "I will lie down for one half hour after meals."
2) "I will consume less caffeine and spicy foods."
3) "I will sleep with the head of my bed elevated."
4) "I will try not to gain weight."
5) "I will drink less fluid."
Answer: 2) "I will consume less caffeine and spicy foods."
3) "I will sleep with the head of my bed elevated."
4) "I will try not to gain weight."
Rationale:
“I will lie down for one half hour after meals.” is incorrect. A client who has a hiatal hernia
should remain upright for at least 1 hr after meals and preferably for several hours.
“I will consume less caffeine and spicy foods.” is correct. These foods and beverages can
worsen the symptoms of a hiatal hernia.
“I will sleep with the head of my bed elevated.” is correct. The client should raise the head of
the bed on blocks to avoid lying flat when sleeping.
“I will try not to gain weight.” is correct. Obesity raises intra-abdominal pressure and makes
the hernia worse.
“I will drink less fluid.” is incorrect. Clients should consume adequate and appropriate
amounts of fluid, whether or not they have a hiatal hernia.
A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which
of the following clinical manifestations should the nurse expect to find? (Select all that
apply.)
1) Orthopnea
2) Headache
3) Nausea
4) Tachycardia
5) Diaphoresis
Answer: 3) Nausea
4) Tachycardia
5) Diaphoresis
Rationale:
Orthopnea is incorrect. Orthopnea is a manifestation of heart failure, which can develop from
a myocardial infarction, but it is not a common manifestation of acute MI.
Headache is incorrect. Chest pain and sometimes jaw and shoulder pain, not headache, are
classic manifestations of acute MI.
Nausea is correct. Nausea and vomiting are classic manifestations of acute MI.
Tachycardia is correct. Tachycardia and dysrhythmias are classic manifestations of acute MI.
Diaphoresis is correct. Profuse sweating and anxiety are classic manifestations of acute MI.
A nurse is reinforcing nutrition teaching for a client who has chronic kidney disease about
limiting foods high in potassium. Which of the following foods should the nurse instruct the
client to avoid? (Select all that apply).
1) Orange juice
2) Watermelon
3) Bananas
4) Corn flakes cereal
5) White rice
Answer: 1) Orange juice
3) Bananas
Rationale:
Orange juice is correct. Orange juice is high in potassium; 240 mL (8 oz) contains 496 mg of
potassium
Watermelon is incorrect. Watermelon is low in potassium; 152 g (1 cup) of diced watermelon
contains 170 mg of potassium.
Bananas is correct. Bananas are high in potassium; one medium banana contains 422 mg of
potassium.
Corn flakes cereal is incorrect. Corn flakes cereal is low in potassium; 34 g (1 cup) of corn
flakes cereal contains 60 mg of potassium.
White rice is incorrect. White rice is low in potassium; 158 g (1 cup) of cooked white rice
contains 55 mg of potassium.
A nurse is reinforcing nutrition teaching to a client who has chronic kidney disease about
limiting foods high in phosphorus. Which of the following foods should the nurse instruct the
client to avoid? (Select all that apply).
1) Milk
2) Sunflower seeds
3) Orange juice
4) Frozen kale
5) Poultry
Answer: 1) Milk
2) Sunflower seeds
5) Poultry
Rationale:
Milk is correct. All animal products, including dairy, are a source of phosphorus and should
be avoided by a client who is on a phosphorus restricted diet.
Sunflower seeds is correct. Sunflower seeds are a food source high in phosphorus and should
be avoided by a client who is on a phosphorus restricted diet.
Orange juice is incorrect. Orange juice is not a food source high in phosphorus and is safe for
clients on a phosphorus restricted diet.
Frozen kale is incorrect. Frozen kale is not a food source high in phosphorus and is safe for
clients on a phosphorus restricted diet.
Poultry is correct. All animal products, including poultry, are a source of phosphorus and
should be avoided by a client who is on a phosphorus restricted diet.
A nurse is assisting in the plan of care for a client who is scheduled to have a renal biopsy.
Which of the following actions should the nurse include in the plan? (Select all that apply).
1) Collect a urine specimen prior to the procedure.
2) Obtain an informed consent prior to the procedure.
3) Administer diphenhydramine prior to the procedure.
4) Maintain a clear liquid diet 4 hr prior to the procedure.
5) Complete coagulation studies prior to the procedure.
Answer: 1) Collect a urine specimen prior to the procedure.
2) Obtain an informed consent prior to the procedure.
5) Complete coagulation studies prior to the procedure.
Rationale:
Collect a urine specimen prior to the procedure is correct. A urine specimen is needed prior to
the procedure to allow for post procedure comparison.
Obtain an informed consent is correct. Because the procedure is invasive it requires written,
informed consent.
Administer diphenhydramine prior to the procedure is incorrect. Benadryl is sometimes used
prior to a procedure that uses dye, but not for a renal biopsy.
Maintain a clear liquid diet 4 hr prior to the procedure is incorrect. NPO for 6 to 8 hr prior to
the procedure is usually required.
Complete coagulation studies prior to the procedure is correct. Coagulation studies are
obtained prior to the procedure to evaluate the risk for bleeding from the biopsy site.
A nurse is caring for a client following a renal biopsy. Which of the following actions should
the nurse take? (Select all that apply).
1) Monitor for hematuria.
2) Check for flank pain.
3) Observe for extravasation of tissue surrounding the biopsy site.
4) Encourage ambulation.
5) Administer aspirin PRN for pain.
Answer: 1) Monitor for hematuria.
4) Encourage ambulation.
Rationale:
Monitor for hematuria is correct. The nurse should monitor the client for bleeding, such as
hematuria, tachycardia, hypotension, or bleeding at the biopsy site.
Check for flank pain is correct. Flank pain is a manifestation of internal bleeding from the
renal biopsy.
Observe for extravasation of tissue surrounding the biopsy site is incorrect. Extravasation is
associated with the infiltration of dye or medication around an IV site and is not a risk
following a renal biopsy.
Encourage ambulation is incorrect. The client should be on strict bedrest following a renal
biopsy.
Administer aspirin PRN for pain is incorrect. Aspirin is contraindicated for a client who is
postoperative renal biopsy due to the increased risk for bleeding.
A nurse is reinforcing preoperative teaching to a client who is to undergo a radical
prostatectomy. Which of the following statements should the nurse include in the teaching?
(Select all that apply).
1) "You may feel the need to urinate even though a catheter is in place."
2) "Performing Kegel exercises following the surgery will help you to manage incontinence."
3) "There is very little postoperative pain with this procedure."
4) "You will be on a low-fiber diet following the surgery."
5) "You should expect your urine to be blood-tinged for a few days following the surgery."
Answer: 1) "You may feel the need to urinate even though a catheter is in place."
2) "Performing Kegel exercises following the surgery will help you to manage incontinence."
5) "You should expect your urine to be blood-tinged for a few days following the surgery."
Rationale:
”You may feel the need to urinate even though a catheter is in place.” is correct. Pressure
from the taping of the catheter to the thigh or abdomen may cause the sensation of the need to
void.
“Performing Kegel exercises following the surgery will help you to manage incontinence.” is
correct. Urinary incontinence is a common complication following a radical prostatectomy.
Kegel exercises can reduce the severity of the incontinence.
“There is very little postoperative pain with this procedure.” is incorrect. Along with
incisional pain, the client may also experience pain from bladder spasms. Clients are often
provided a patient-controlled analgesia pump for the first 24 hr postoperative period.
“You will be on a low-fiber diet following the surgery.” is incorrect. Straining with defecation
can lead to postoperative bleeding. A high-fiber diet and a stool softener are often prescribed.
“You should expect your urine to be blood-tinged for a few days following the surgery.” is
correct. The flow of bladder irrigation is maintained to keep the urine a reddish pink, which
should clear to a pink tinge within 48 hr following surgery. Urine which turns bright red
indicates bleeding and should be reported immediately.
A nurse is reinforcing teaching about possible treatments with a client who has psoriasis.
Which of the following treatment options should the nurse include in the teaching? (Select all
that apply.)
1) Tar preparations
2) Corticosteroids
3) Ultraviolet light therapy
4) Laser therapy
5) Topical antibiotics
Answer: 1) Tar preparations
2) Corticosteroids
3) Ultraviolet light therapy
Rationale:
Tar preparations is correct. Tar preparations help to impede the proliferation of skin cells and
are effective to remove scales as well as increase remission.
Corticosteroids is correct. Corticosteroids help reduce the inflammation and pruritus
associated with psoriasis.
Ultraviolet light therapy is correct. Ultraviolet light therapy is effective in the treatment of
psoriasis by decreasing the growth rate of epidermal cells.
Laser therapy is incorrect. Laser therapy is appropriate for the removal of skin lesions rather
than for the treatment of psoriasis.
Topical antibiotics is incorrect. Antibiotics are not appropriate for the treatment of psoriasis,
as it is not a bacterial condition.
A nurse is assisting in planning an educational session regarding risk factors for skin cancer
to a group of clients. Which of the following information should the nurse plan to include in
the session? (Select all that apply.)
1) Being dark-skinned
2) Age under 40 years
3) Overexposure to ultraviolet light
4) Chronic skin irritations
5) Genetic predisposition
Answer: 3) Overexposure to ultraviolet light
4) Chronic skin irritations
Rationale:
Being dark-skinned is incorrect. Light-skinned individuals are at greater risk for developing
skin cancer.
Age under 40 years is incorrect. Individuals between the ages of 30 and 60 are at the greatest
risk for developing nonmelanoma skin cancers.
Overexposure to ultraviolet light is correct. Overexposure to ultraviolet light is a risk factor
for developing skin cancer. Rays from the sun are known to be carcinogenic and can result in
malignant changes.
Chronic skin lesions is correct. Chronic skin lesions are a risk factor for developing skin
cancer. Clients are taught to monitor for a change in these chronic lesions as a precursor to a
malignancy.
Genetic predisposition is correct. Genetic predisposition is a risk factor for developing skin
cancer, particularly malignant melanoma.
A nurse is reinforcing teaching with a client who has questions concerning the various
treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the
following treatments should she include in the teaching? (Select all that apply).
1) Cryosurgery
2) Electrodessication
3) Radiation therapy
4) Photochemotherapy
5) Mohs surgery
Answer: 1) Cryosurgery
2) Electrodessication
4) Photochemotherapy
5) Mohs surgery
Rationale:
Cryosurgery is correct. Cryosurgery freezes the cancerous tissue and is used in the treatment
of BCC.
Electrodessication is correct. Electrodessication uses electrical energy to destroy and remove
cancerous tissue and is used in the treatment of BCC.
Radiation therapy is correct. Radiation therapy can be used in the treatment of BCC
depending on client age and the location of the tumor.
Photochemotherapy is incorrect. Photochemotherapy is used in the treatment of psoriasis
rather than BCC.
Mohs surgery is correct. Mohs micrographic surgery is used in the treatment of BCC as the
most accurate method of removing the tumor while preserving healthy tissue.
A nurse is collecting data for a client who has giant cell arteritis. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Chest pain
2) Loss of vision
3) Weight gain
4) Dyspnea
5) Headache
Answer: 1) Chest pain
2) Loss of vision
4) Dyspnea
5) Headache
Rationale:
Chest pain is correct. Chest pain is a finding associated with giant cell arteritis because of the
inflammation of the coronary arteries that can occur.
Loss of vision is correct. Loss of vision is a finding associated with giant cell arteritis because
of the inflammation that can occur with the vessels of the eyes.
Weight gain is incorrect. Weight loss can occur because of the inflammatory process and
metabolic process.
Dyspnea is correct. Dyspnea is a finding associated with giant cell arteritis that may occur
with inflammation of the pulmonary arteries.
Headache is correct. Headache is a finding associated with giant cell arteritis that may occur
with inflammation of the cranial arteries.
A nurse is collecting data from a client who has a herniated intervertebral cervical disc.
Which of the following findings should the nurse expect? (Select all that apply.)
1) Tingling in the arms
2) Low back pain
3) Shoulder pain
4) Hip pain
5) Neck stiffness
Answer: 1) Tingling in the arms
3) Shoulder pain
5) Neck stiffness
Rationale:
Tingling in the arms is correct. Numbness and tingling in the upper extremities are common
findings of a herniated cervical intervertebral disc.
Low back pain is incorrect. Low back pain with muscle spasms is a common finding of a
herniated lumbar intervertebral disc.
Shoulder pain is correct. Shoulder pain, particularly on the top of the shoulders, is a common
finding of a herniated cervical intervertebral disc.
Hip pain is incorrect. Hip pain is a common finding of a herniated lumbar intervertebral disc.
Neck stiffness is correct. Stiffness and pain in the neck are common findings of a herniated
cervical intervertebral disc.
A nurse is collecting data from a client who has Paget's disease. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Cranial enlargement
2) Skeletal pain
3) Waddling gait
4) Cold extremities
5) Muscle weakness
Answer: 1) Cranial enlargement
2) Skeletal pain
3) Waddling gait
Rationale:
Cranial enlargement is correct. When the skull is involved, Paget's disease causes thickening
and enlargement of the skull bones and enlargement of the cranium.
Skeletal pain is correct. Paget's disease causes pain and tenderness over the affected bones.
Waddling gait is correct. When the legs are involved, Paget's disease causes bowing of the
legs and a waddling gait.
Cold extremities is incorrect. Paget's disease causes warmth over the affected bones.
Muscle weakness is incorrect. The nurse should expect muscle weakness for a client who has
osteomalacia.
An occupational health nurse is instructing workers at an industrial facility about emergency
procedures to follow in the event of a traumatic amputation. Which of the following
guidelines should the nurse include about preserving the amputated part for possible surgical
reattachment? (Select all that apply.)
1) Wrap the part in sterile gauze.
2) Place the severed end of the part directly into crushed ice.
3) Put the severed part in a plastic bag.
4) Scrub the severed part with antibacterial solution.
5) Prevent the severed part from coming in contact with water.
Answer: 1) Wrap the part in sterile gauze.
3) Put the severed part in a plastic bag.
5) Prevent the severed part from coming in contact with water.
Rationale:
Wrap the part in sterile gauze is correct. The person at the scene should wrap the severed part
in sterile gauze or a clean cloth, and soak it with saline solution, if available.
Place the severed end of the part directly into crushed ice is incorrect. The person at the scene
should not allow direct contact between the part and ice.
Put the severed part in a plastic bag is correct. The person at the scene should place the
severed part in a sealed, waterproof plastic bag and then put the bag in ice water.
Scrub the severed part with antibacterial solution is incorrect. The person on the scene should
only rinse the amputated part if needed to remove visible debris.
Prevent the severed part from coming in contact with water. The person at the scene should
not allow the severed part to become wet but should keep it dry.
A nurse in a provider’s office is reinforcing teaching with a client about the risk factors for
osteoarthritis. Which of the following information should the nurse include? (Select all that
apply.)
1) Bacterial infections
2) Use of diuretic medications
3) Aging
4) Obesity
5) Heredity
Answer: 3) Aging
4) Obesity
5) Heredity
Rationale:
Bacteria is incorrect. Bacterial infections can lead to infectious arthritis or rheumatoid
arthritis, but it is not a risk factor for osteoarthritis.
Diuretics is incorrect. Diuretic therapy is a possible risk factor for gout, but not for
osteoarthritis.
Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load of the
body’s weight over time.
Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load of the
body’s weight over time.
Heredity is correct. There is a genetic component to the development of osteoarthritis.
A nurse in a provider’s office is reinforcing teaching with a female client about risk factors
for osteoporosis. Which of the following factors should the nurse include in the teaching?
(Select all that apply.)
1) Sedentary lifestyle
2) Obesity
3) Aging
4) Excessive caffeine
5) Hormone therapy
Answer: 1) Sedentary lifestyle
3) Aging
4) Excessive caffeine
Rationale:
Sedentary lifestyle is correct. Immobility depletes bone.
Obesity is incorrect. Women who are obese have a greater capacity for storing estrogen to
help maintain acceptable levels of calcium.
Aging is correct. Women lose bone due to estrogen depletion after menopause.
Caffeine intake is correct. Excessive caffeine intake causes calcium loss in the urine.
Hormone therapy is incorrect. Estrogen protects women from developing osteoporosis.
A nurse is instructing coworkers about how to minimize lower back pain and avoid repeated
episodes of back pain. Which of the following strategies should the nurse include? (Select all
that apply.)
1) Avoid prolonged sitting.
2) Apply cold packs frequently.
3) Do partial sit-ups with the knees bent.
4) Sleep on a soft mattress.
5) Ask for help when moving clients.
Answer: 1) Avoid prolonged sitting.
3) Do partial sit-ups with the knees bent.
5) Ask for help when moving clients.
Rationale:
Avoid prolonged sitting is correct. Staying in any one position for too long, even lying down,
can worsen back pain. Changing positions frequently is essential.
Apply cold packs frequently is incorrect. For back pain, the nurse should recommend heat,
but for no longer than 30 min at a time to prevent rebound effects.
Do partial sit-ups with the knees bent is correct. Exercises that strengthen back muscles and
help prevent pain include partial sit-ups with the knees bent, knee-chest exercises, and pelvic
tilts.
Sleep on a soft mattress is incorrect. The recommendation is to sleep on a firm mattress for
good back support.
Ask for help when moving clients is correct. The nurse should remind coworkers to use good
body mechanics when handling clients and never to attempt lifting or moving clients by
themselves.
A nurse is caring for a client who has an acute respiratory illness. For which of the following
manifestations of an airway obstruction should the nurse monitor? (Select all that apply.)
1) Inspiratory stridor
2) Cyanosis
3) Muscle tremors
4) Retractions
5) Nausea
Answer: 1) Inspiratory stridor
2) Cyanosis
4) Retractions
Rationale:
Inspiratory stridor is correct. The client who has an obstruction of the airway may exhibit
inspiratory stridor as the inspired air is partially blocked.
Nausea is incorrect. Gastrointestinal upset may occur in response to antibiotic therapy used to
treat the respiratory infection. However, it is not an indication of impending airway
obstruction.
Retractions is correct. Substernal, suprasternal, and intercostal retractions as well as flaring
nares are indications of an impended or obstructed airway.
Muscle tremors is incorrect. Muscle tremors may occur in a client who has an electrolyte
imbalance. However, they are not an indication of an airway obstruction.
Cyanosis is correct. The client who has an airway obstruction may become cyanotic due to a
lack of oxygen transfer to the cells. Other manifestations include coughing and labored
respirations.
A nurse is reinforcing teaching with the parent of a school-age client who has asthma about
the use of a peak flow meter. Which of the following statements about the yellow zone should
the nurse include in the teaching? (Select all that apply.)
1) The child should increase his routine medications.
2) The child is having an exacerbation of the asthma.
3) The child is blowing too hard into the meter.
4) The child needs to go to the hospital.
5) The child can participate in strenuous physical activity.
Answer: 1) The child should increase his routine medications.
2) The child is having an exacerbation of the asthma.
Rationale:
The child should increase his routine medications is correct. A peak flow reading in the
yellow zone indicates a decrease in airflow. The child should increase the prescribed routine
medications and recheck the peak flow rate several minutes after using a relief medication.
The child is having an exacerbation of the asthma is correct. A peak flow reading in the
yellow zone signals that usual airflow has decreased, indicating an exacerbation of the
asthma.
The child is blowing too hard into the meter is incorrect. A reading in the yellow zone is an
indication that the child’s breathing is less than baseline measures. In order to use a peak flow
meter, the child should blow into the device as hard and quickly as possible.
The child needs to go to the hospital is incorrect. A child whose peak flow is in the yellow
zone should increase his prescribed medication and recheck the peak flow rate. A child with a
red zone reading needs to go to the hospital if he is still in the red zone after taking his
medications.
The child can participate in strenuous physical activity. A child whose peak flow rate is in the
green zone can perform his usual activities. A child whose rate is in the yellow zone can
perform some activities. However, he will be limited in the amount of physical exertion he
can expend because this may aggravate his shortness of breath and further exacerbate the
asthma symptoms.
A nurse is giving a presentation to a community group about preventing atherosclerosis.
Which of the following should the nurse include as a modifiable risk factor for this disorder?
(Select all that apply.)
1) Genetic predisposition
2) Hypercholesterolemia
3) Hypertension
4) Obesity
5) Smoking
Answer: 2) Hypercholesterolemia
3) Hypertension
4) Obesity
5) Smoking
Rationale:
Genetic predisposition is incorrect. Although it is a risk factor for heart disease, clients cannot
change their genetic predisposition; therefore it is not a modifiable risk factor.
Hypercholesterolemia is correct. Cholesterol levels outside the healthful range increase
clients’ risk for heart disease, and they can change these levels.
Hypertension is correct. Although it may not always be possible to eliminate hypertension,
clients can change their blood pressure levels and thus reduce their risk for cardiovascular
disease.
Obesity is correct. Clients who are overweight or obese can reduce their risk for heart disease
by losing weight.
Smoking is correct. Clients who smoke can reduce their risk for heart disease by quitting
smoking.
A nurse is reinforcing teaching with a class about preventing deep-vein thrombosis. The nurse
should include in the teaching that which of the following is a risk factor for this disorder?
(Select all that apply.)
1) Dehydration
2) Oral contraceptive use
3) Hypertension
4) High calcium intake
5) Immobility
Answer: 1) Dehydration
2) Oral contraceptive use
5) Immobility
Rationale:
Dehydration is correct. Dehydration increases the blood's viscosity, thus increasing the risk
for clot formation.
Oral contraceptive use is correct. Thromboembolic events are an adverse effect of oral
contraceptives.
Hypertension is incorrect. Hypertension does not increase the risk for clot formation.
High calcium intake is incorrect. High calcium intake does not increase the risk for clot
formation.
Immobility is correct. Immobility leads to stasis of blood, thus increasing the risk for clot
formation.
A nurse is assisting with the care of a client who is postoperative following a cardiac
catheterization via the femoral artery. Which of the following actions should the nurse take?
(Select all that apply.)
1) Check peripheral pulses in the affected extremity.
2) Place the client in high-Fowler's position.
3) Measure the client's vital signs every 8 hr.
4) Keep the client's hip and leg extended.
5) Have the client remain in bed up to 6 hr.
Answer: 1) Check peripheral pulses in the affected extremity.
4) Keep the client's hip and leg extended.
5) Have the client remain in bed up to 6 hr.
Rationale:
Check peripheral pulses in the affected extremity is correct. The nurse should check
peripheral pulses, skin temperature, and color in the affected extremity.
Place the client in high Fowler's position is incorrect. The client should remain flat for 6 hr
following the procedure.
Measure the client's vital signs every 8 hr is incorrect. The nurse should measure the client's
vital signs every 15 min for the first hr, every 30 min for 2 hr or until stable, and then every 1
hr until stable.
Keep the client's hip and leg extended is correct. Preventing the leg and hip from flexing
helps promote clot formation.
Have the client remain in bed up to 6 hr is correct. The client should remain flat in bed for 6
hours following a cardiac catheterization via the femoral artery.
A nurse is reinforcing teaching for a client who is postoperative following the insertion of a
permanent pacemaker. Which of the following instructions should the nurse include? (Select
all that apply.)
1) Count your pulse for 1 min each morning.
2) Count your respiratory rate for 1 min each morning.
3) Report hiccups to the provider.
4) Avoid metal detectors.
5) Do not operate microwave ovens.
Answer: 1) Count your pulse for 1 min each morning.
3) Report hiccups to the provider.
Rationale:
Count your pulse for 1 min each morning is correct. Clients who have a permanent
pacemaker should count their heart rate daily, document the information, and report changes.
Count your respiratory rate for 1 min each morning is incorrect. There is no need for clients
who have a permanent pacemaker to record their respiratory rate.
Report hiccups to the provider is correct. The client should report any indication the
pacemaker is not functioning correctly, such as hiccups.
Avoid metal detectors is incorrect. There is no danger to the client in going through a metal
detector, but the client should inform airport personnel because the pacemaker will trigger an
alarm.
Do not operate microwave ovens is incorrect. It is safe for clients who have a pacemaker to
operate microwave ovens unless the pacemaker is old and does not have the appropriate
shielding or is defective.
A nurse is caring for a client who has a surgical wound. Which of the following factors places
the client at risk for dehiscence? (Select all that apply.)
1) Poor nutritional state
2) Altered mental status
3) Obesity
4) Pain medication administration
5) Wound infection
Answer: 1) Poor nutritional state
3) Obesity
5) Wound infection
Rationale:
Poor nutritional state is correct. The client who is malnourished is at risk for dehiscence due
to impaired healing.
Altered mental status is incorrect. The client who has an altered mental status is not at risk for
dehiscence.
Obesity is correct. The client who is obese is at risk for dehiscence due to poor healing
abilities of adipose tissue and the constant strain placed on the incision.
Pain medication administration is incorrect. The client who is taking pain medication is not at
risk for dehiscence.
Wound infection is correct. The client who has a wound infection is at risk for dehiscence due
to delayed healing.
A nurse is contributing to the plan of care for a client who has cirrhosis of the liver. Which of
the following interventions should the nurse include in the plan? (Select all that apply.)
1) Implement fall precautions.
2) Obtain a weekly weight.
3) Initiate a low sodium diet.
4) Measure abdominal girth daily.
5) Administer enemas to manage constipation.
Answer: 1) Implement fall precautions.
3) Initiate a low sodium diet.
4) Measure abdominal girth daily.
Rationale:
Implement fall precautions is correct. The client who has cirrhosis of the liver has an
increased risk of changes in mental status and confusion due to increased levels of serum
ammonia and hepatic encephalopathy, which place the client at increased risk for falls.
Obtain a weekly weight is incorrect. The client who has cirrhosis also has impaired salt and
fluid regulation leading to fluid overload. Obtaining a daily weight would be an intervention
that allows the nurse to more closely monitor fluid status.
Initiate a low sodium diet is correct. The client who has cirrhosis also has impaired salt and
fluid regulation leading to fluid overload. Regulating sodium intake by placing the client on a
low sodium diet will assist in minimizing water retention.
Measure abdominal girth daily is correct. The client who has cirrhosis develops fluid
retention that manifests as ascites in the abdomen. Measuring abdominal girth daily is one
measure the nurse can use to monitor fluid status.
Administer enemas to manage constipation is incorrect. The client who has cirrhosis is at an
increased risk for bleeding due to a lack of vitamin K and a low platelet levels. The nurse
should place the client on bleeding precautions, which would exclude the use of enemas and
intramuscular injections.
A nurse is reinforcing teaching with a female client who has thrombocytopenia. Which of the
following instructions should the nurse include? (Select all that apply.)
1) Lubricate lips with water-soluble ointment.
2) Brush teeth with a soft toothbrush.
3) Blow nose gently.
4) Limit fruit consumption.
5) Manage constipation with the use of glycerine suppositories.
Answer: 1) Lubricate lips with water-soluble ointment.
2) Brush teeth with a soft toothbrush.
3) Blow nose gently.
Rationale:
Lubricate lips with water-soluble ointment is correct. The nurse should recognize that the
client who has thrombocytopenia is at risk for bleeding and should instruct the client to
lubricate lips with water-soluble ointment to avoid cracking, which may result in spontaneous
bleeding from the site.
Brush teeth with a soft toothbrush is correct. The nurse should instruct the client to brush
teeth with a soft toothbrush to avoid spontaneous bleeding of the gums. The nurse should also
reinforce that flossing should be avoided, as this can increase the risk of bleeding.
Blow nose gently is correct. The nurse should instruct the client to blow the nose gently to
minimize spontaneous bleeding from the nares.
Limit fruit consumption is incorrect. The nurse should reinforce teaching that fruit
consumption will not affect the bleeding risk of the client who has thrombocytopenia.
Manage constipation with the use of glycerine suppositories is incorrect.
The nurse should instruct the client to avoid inserting anything into the rectum, vagina, or
urinary tract, as this can result in internal bleeding in the client who has thrombocytopenia. A
high-fiber diet and fluids along with activity can prevent the development of constipation.
The nurse should instruct the client to avoid bearing down excessively when trying to have a
bowel movement, as this also may cause spontaneous bleeding of the rectal tissues.
A nurse is reinforcing discharge teaching with a client who is immunocompromised. Which
of the following instructions should the nurse include in the teaching? (Select all that apply.)
1) Drink 6 to 8 glasses of chilled tap water each day.
2) Restrict visitor with active infections.
3) Limit the client from bathing daily.
4) Instruct the client to eat cooked foods only.
5) Clean the toothbrush by placing it under hot running water.
Answer: 1) Drink 6 to 8 glasses of chilled tap water each day.
2) Restrict visitor with active infections.
4) Instruct the client to eat cooked foods only.
Rationale:
Drink 6 to 8 glasses of chilled tap water each day is incorrect. The nurse should encourage
the client to drink adequate amounts of fluid. However, the client who is
immunocompromised should drink only bottled water to minimize the risk of ingesting
pollutants and bacteria that may be present in the tap water.
Restrict visitor with active infections is correct. The nurse should instruct the client to restrict
visitors with an active infection to protect the client from contacting an infection due to the
suppressed immune system.
Limit the client from bathing daily is incorrect. The nurse should have the client bathe daily
with an anti-microbial soap to clean bacteria off of skin that might cause an infection.
Instruct the client to eat cooked foods only is correct. The nurse should instruct the client eat
cooked foods only to protect the client from contracting an infection from bacteria present on
raw or undercooked food.
Clean the toothbrush by placing it under hot running water. The nurse should instruct the
client to clean the toothbrush frequently to decrease the risk of infection from oral bacteria.
This should be accomplished by running the toothbrush through the dishwasher or soaking it
in a solution of bleach or hydrogen peroxide.
A nurse is reviewing the laboratory data of a client who has acute leukaemia and received
aggressive chemotherapy treatment 10 days ago. Which of the following abnormalities
should the nurse expect to see? (Select all that apply.)
1) Decreased platelet count
2) Increased haemoglobin count
3) Decreased WBC count
4) Increased creatinine kinase level
5) Decreased RBC count
Answer: 1) Decreased platelet count
3) Decreased WBC count
5) Decreased RBC count
Rationale:
Decreased platelet count is correct. The nurse should expect to see a decreased platelet count
due to bone marrow suppression from the chemotherapy treatment.
Increased haemoglobin count is incorrect. The nurse should expect to see a decreased
haemoglobin count, not increased, due to bone marrow suppression from the chemotherapy
treatment.
Decreased WBC count is correct. The nurse should expect to see a decreased WBC count due
to bone marrow suppression from the chemotherapy treatment.
Increased creatinine kinase level is incorrect. The nurse should not expect to see an increase
in the client’s creatinine kinase level. The client may experience muscle aches, but
chemotherapy does not result in muscle damage.
Decreased RBC count is correct. The nurse should expect a decreased RBC count due to bone
marrow suppression from the chemotherapy treatment.
A nurse is contributing to the care plan of a client who is postoperative and has an increased
risk for deep vein thrombosis (DVT). Which of the following interventions should the nurse
include in the plan? (Select all that apply.)
1) Encourage fluid intake.
2) Apply elastic compression stockings.
3) Encourage frequent leg exercises.
4) Measure thighs.
5) Massage calves.
Answer: 1) Encourage fluid intake.
2) Apply elastic compression stockings.
3) Encourage frequent leg exercises.
4) Measure thighs.
Rationale:
Encourage fluid intake is correct. The nurse should recognize that one of the factors
increasing the risk for the development of a DVT is dehydration. Encouraging the client to
increase fluid intake will help minimize the risk for the development of a DVT.
Apply elastic compression stockings is correct. The nurse should recognize that elastic
compression stockings decrease venous stasis and are used prophylactically to prevent DVT
formation.
Encourage frequent leg exercises is correct. The nurse should identify that one of the ways to
prevent DVT formation is to enhance the blood flow through the lower extremities. One
means of doing this is through exercising the lower extremities using quadriceps and gluteal
sets as well as ankle flexion and extension.
Measure thighs is correct. The nurse should recognize the manifestations of a DVT include
redness, swelling, warmth and pain of the affected extremity. Measuring calf and thigh
diameters daily will assist in the identification of a DVT should one develop.
Massage calves is incorrect. The nurse should recognize that massage is contraindicated in a
client who is at risk for DVT development. Massage can cause small thrombi to break loose
from the vein wall and move through the circulatory system, potentially resulting in
complications such as a stroke, myocardial infarction, or pulmonary embolism.
A nurse is contributing to the plan of care for a client who has a spinal cord injury and
paralysis. Which of the following actions should the nurse include in the plan to decrease the
client’s risk of skin breakdown? (Select all that apply.)
1) Massage erythematous bony prominences.
2) Implement turning schedule every 4 hr.
3) Use pillows to keep heels off the bed surface.
4) Keep environmental humidity less than 30%.
5) Minimize skin exposure to moisture.
Answer: 3) Use pillows to keep heels off the bed surface.
5) Minimize skin exposure to moisture.
Rationale:
Massage erythematous bony prominences is incorrect. The nurse should avoid massaging
erythematous bony prominences, which would cause further skin breakdown.
Implement turning schedule every 4 hr is incorrect. The nurse should implement a turning
schedule to prevent skin breakdown. This includes turning the client every 2 hr while in bed
and repositioning hourly if the client is up in a chair.
Use pillows to keep heels off the bed surface is correct. The nurse should pad all bony
prominences and use devices such as pillows to keep the heels off the bed surface and prevent
skin breakdown.
Keep environmental humidity less than 30% is incorrect. The nurse should manage humidity
in the client’s room and keep the humidity above 40%. Humidity less than 40% is drying to
the skin and increases the risk of skin breakdown.
Minimize skin exposure to moisture is correct. The nurse should include actions to minimize
exposure of the skin to moisture from sweating, wound drainage or incontinence as this
causes maceration of the skin which leads to skin breakdown.
A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of
the following interventions should the nurse include in the plan? (Select all that apply.)
1) Provide a suction setup at the bedside.
2) Elevate the side rails when in bed.
3) Place a bite stick at the bedside.
4) Keep an oxygen setup at the bedside.
5) Furnish restraints at the bedside.
Answer: 1) Provide a suction setup at the bedside.
2) Elevate the side rails when in bed.
4) Keep an oxygen setup at the bedside.
Rationale:
Provide a suction setup at the bedside is correct. The nurse should provide a suction setup at
the bedside to provide oral suctioning following the seizure to prevent aspiration.
Elevate the side rails when in bed. The nurse should elevate the rails of the bed to prevent a
fall in the event the client has a seizure. Additional measures may be taken such as padding
the side rails to prevent injury from hitting the side rails during seizure activity.
Place a bite stick at the bedside is incorrect. The nurse should recognize that attempting to
insert anything into the mouth of a client who is having a seizure can result in injury to the
client or the nurse.
Keep an oxygen setup at the bedside is correct. The nurse should keep an oxygen setup at the
bedside to administer oxygen during any seizure activity if this can be done safely. The nurse
should recognize that, during tonic seizure activity, respirations cease and the client becomes
cyanotic.
Furnish restraints at the bedside is incorrect. The nurse should recognize that the client who is
experiencing seizure activity should not be restrained, as this can lead to injury to the client,
such as fractures.
A nurse is caring for a client who has an acute ankle sprain. Which of the following actions
should the nurse take? (Select all that apply.)
1) Rest
2) Movement
3) Heat application
4) Compression
5) Elevation
Answer: 1) Rest
4) Compression
5) Elevation
Rationale:
Rest is correct. Rest helps limit the movement of the extremity and prevents further injury.
Movement is incorrect. Movement of the sprained area can cause pain and further injury.
Heat application is incorrect. Ice application causes vasoconstriction and reduces nerve
impulse transmission, which provides pain relief and reduces swelling and muscle spasms.
Compression is correct. Compression reduces edema, helping to relieve pain.
Elevation is correct. Elevation reduces edema, helping to relieve pain.
A nurse is reinforcing teaching with a client who has a new diagnosis of testicular cancer.
Which of the following statements should the nurse include in in the teaching? (Select all that
apply.)
1) Close male relatives are at increased risk for the disease.
2) It typically occurs between ages 15 to 40.
3) It occurs in both testicles equally.
4) Impotence usually occurs after an orchiectomy.
5) An early sign is scrotal warmth and redness.
Answer: 1) Close male relatives are at increased risk for the disease.
2) It typically occurs between ages 15 to 40.
Rationale:
Close male relatives are at increased risk for the disease is correct. Testicular cancers are
more common in clients with a family history of testicular cancer. Therefore, close male
relatives are at increased risk.
It typically occurs between ages 15 to 40 is correct. Testicular cancer occurs in the productive
years and has significant economic, social, and psychological impact on the client and his
family.
It occurs in both testicles equally is incorrect. Testicular cancer is rarely bilateral.
Impotence usually occurs after an orchiectomy is incorrect. Erectile dysfunction is a rare
complication following orchiectomy.
An early sign is scrotal warmth and redness is incorrect. Painless scrotal swelling, backache,
and weight loss are early signs.
A nurse is reinforcing discharge teaching to a client about nutrition therapy for wound healing
following major surgery. Which of the following vitamins should the nurse include in the
teaching as promoting wound healing? (Select all that apply.)
1) Vitamin A
2) Vitamin B12
3) Vitamin C
4) Vitamin D
5) Vitamin E
Answer: 1) Vitamin A
3) Vitamin C
Rationale:
Vitamin A is correct. The nurse should reinforce the importance of including vitamin A in the
diet to promote wound healing. It promotes tissue synthesis, wound healing, and immune
function. Foods containing vitamin A include sweet potatoes, carrots, spinach, and
cantaloupe.
Vitamin B12 is incorrect. The nurse should recognize that vitamin B12 assists in the
development of red blood cells and maintenance of nerve function but has no specific role in
wound healing.
Vitamin C is correct. The nurse should include the importance of vitamin C in wound healing.
It plays a role in capillary formation, tissue synthesis, and wound healing. Foods high in
vitamin C include oranges, kiwi, cantaloupe, strawberries, and broccoli.
Vitamin D is incorrect. Vitamin D functions in maintaining serum levels of calcium and
phosphorus, but has no specific role in wound healing.
Vitamin E is incorrect. Vitamin E functions as an antioxidant to protect from cell
proliferation, but has no specific role in wound healing.
A nurse is reviewing home medications of a male client who has a new prescription for
warfarin. Which of the following of the client's herbal medications should the nurse identify
as being contraindicated to warfarin? (Select all that apply.)
1) Saw palmetto
2) Echinacea
3) Glucosamine
4) Flaxseed
5) Gingko biloba
Answer: 1) Saw palmetto
3) Glucosamine
5) Gingko biloba
Rationale:
Saw palmetto is correct. The nurse should identify saw palmetto as an herbal supplement that
is used to improve urinary stream in some men who have benign prostatic hypertrophy
(BPH). It has antiplatelet effects and is contraindicated for use along with warfarin.
Echinacea is incorrect. The nurse should recognize that echinacea is used to stimulate
immune function, suppress inflammation and has been shown to shorten the duration of viral
infections, such as influenza and the common cold. It does not interact with warfarin.
Glucosamine is correct. The nurse should recognize that glucosamine is used to reduce the
pain associated with osteoarthritis and may increase joint mobility. It may increase the risk of
bleeding and should not be used in conjunction with warfarin.
Flaxseed is incorrect. The nurse should identify flaxseed use as aiding in the reduction of
serum cholesterol and for the treatment of constipation. It does not interact with warfarin.
Gingko biloba is correct. The nurse should recognize that ginkgo biloba has been shown to
improve blood circulation, which might help the brain, eyes, ears, and legs function better. It
also has anticoagulant effects, so it should not be used in conjunction with warfarin.
A nurse is reinforcing teaching with a group of clients about common findings that can
indicate cancer. The nurse should instruct the clients to monitor for and report which of the
following findings? (Select all that apply.)
1) A nonhealing sore
2) Unintended weight gain
3) Change in bowel pattern
4) Unilateral calf tenderness
5) Nagging cough
Answer: 1) A nonhealing sore
3) Change in bowel pattern
4) Unilateral calf tenderness
5) Nagging cough
Rationale:
A nonhealing sore is correct. A client who has cancer might exhibit a nonhealing sore.
Unintended weight gain is incorrect. The nurse should instruct the clients that unintended
weight loss can indicate cancer.
Change in bowel pattern is correct. A client who has cancer might exhibit a change in bowel
pattern.
Unilateral calf tenderness is incorrect. A client who has unilateral calf tenderness can have a
venous thromboembolism.
Nagging cough is correct. A client who has cancer might exhibit a nagging cough.
A nurse is caring for a client who was placed on isolation precautions for active pulmonary
tuberculosis (TB). Which of the following actions should the nurse plan to take? (Select all
that apply.)
1) Use an alcohol-based hand cleaner unless hands are visibly soiled.
2) Remind the client to cover her mouth with a tissue when coughing.
3) Determine whether the client lives alone or with others.
4) Place the client in a room with positive airflow.
5) Instruct the client about taking antifungal medications.
Answer: 1) Use an alcohol-based hand cleaner unless hands are visibly soiled.
2) Remind the client to cover her mouth with a tissue when coughing.
3) Determine whether the client lives alone or with others.
Rationale:
Use an alcohol-based hand cleaner unless hands are visibly soiled is correct. The nurse
should plan to use an alcohol-based hand cleaner after client care tasks when caring for a
client who has TB. The nurse should wash her hands with soap and water after performing
care for any client in which the hands become visibly contaminated.
Remind the client to cover her mouth with a tissue when coughing is correct. The nurse
should remind the client to cover her mouth with a tissue when coughing to minimize
contamination of the air in the client’s room.
Determine whether the client lives alone or with others is correct. The nurse should determine
any close contacts the client has and recommend that those individuals undergo Mantoux
testing.
Place the client in a room with positive airflow is incorrect. The nurse should plan to place
the client in a room with negative airflow to prevent air contaminated with TB from entering
the hallways.
Instruct the client about taking antifungal medications is incorrect. The nurse should instruct
the client about taking antibiotic medications to treat TB.
A nurse is collecting data from a client. The provider suspects the client may have syndrome
of inappropriate antidiuretic hormone (SIADH). When obtaining a medical history, the nurse
should ask for additional information about which of the following conditions? (Select all
that apply.)
1) Osteoarthritis
2) Lung cancer
3) Liver cirrhosis
4) Dyspepsia
5) Seizures
Answer: 2) Lung cancer
5) Seizures
Rationale:
Osteoarthritis is incorrect. It is not necessary for the nurse to ask about osteoarthritis when
obtaining a medical history because it does not impact the secretion of antidiuretic hormone.
Lung cancer is correct. The nurse should ask the client about lung cancer when obtaining a
medical history because some of the treatment options for small cell lung cancer can cause
secretion of antidiuretic hormone. This results in the body retaining water and can cause
SIADH.
Liver cirrhosis is incorrect. It is not necessary for the nurse to ask about liver cirrhosis when
obtaining a medical history because it does not impact the secretion of antidiuretic hormone.
Dyspepsia is incorrect. It is not necessary for the nurse to ask about dyspepsia when obtaining
a medical history because it does not impact the secretion of antidiuretic hormone.
Seizures is correct. The nurse should ask the client about seizures when obtaining a medical
history. Due to increase fluid volume, the excess results in hyponatremia which can cause
confusion.
A nurse is reinforcing teaching with a client about risk factors for osteoarthritis. Which of the
following risk factors should the nurse identify as contributing to this diagnosis? (Select all
that apply.)
1) Bacteria
2) Diuretics
3) Aging
4) Obesity
5) Smoking
Answer: 3) Aging
4) Obesity
Rationale:
Bacteria is incorrect. Bacterial infections can lead to infectious arthritis, which does not cause
irreversible damage to joints. Infection is not a risk factor for osteoarthritis.
Diuretics is incorrect. Diuretic therapy is a possible risk factor for gout, but not for
osteoarthritis.
Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load of the
body’s weight over time.
Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load of the
body’s weight over time.
Smoking is incorrect. Smoking is a risk factor for osteoporosis, but not for osteoarthritis.
A nurse is assisting with the care of an older adult client who is scheduled for surgery. The
nurse should identify that the client is at risk for which of the following? (Select all that
apply.)
1) A decrease in kidney function
2) A decrease in the skin elasticity
3) A decrease in medication efficacy
4) An increase in metabolism
5) An increase in cardiac output
Answer: 1) A decrease in kidney function
2) A decrease in the skin elasticity
Rationale:
A decrease in kidney function is correct. This is a surgical risk the nurse should be aware of.
Older adults have a risk for complications that is three times higher than that of younger
adult.
A decrease in the skin elasticity is correct. Older adults have a decrease in skin elasticity. This
is a surgical risk the nurse should be aware of.
A decrease in medication efficacy is incorrect. Older adults have an increase in medication
efficacy. A decline in cardiac, renal, or liver function can delay the metabolism or excretion
of medications.
An increase in metabolism is incorrect. Older adults have a decrease in metabolism. A decline
in cardiac, renal, or liver function can delay the metabolism or excretion of medications.
An increase in cardiac output is incorrect. Older adults have a decreased cardiac output. A
decline in cardiac output can delay the metabolism or excretion of medications.
A nurse is obtaining informed consent from a client prior to surgery. Which of the following
is necessary for informed consent to be valid? (Select all that apply.)
1) Client's ability to pay for the consented surgical procedure
2) Client's ability to read the consent form
3) Disclosure of the treatment is provided
4) Client understands the surgical procedure
5) Voluntary consent is given
Answer: 3) Disclosure of the treatment is provided
4) Client understands the surgical procedure
5) Voluntary consent is given
Rationale:
Client's ability to pay for the consented surgical procedure is incorrect. The client's ability to
pay for the consented surgical procedure is not related to informed consent.
Client's ability to read the consent form is incorrect. It is not necessary for the client to
personally read the consent form.
Disclosure of the treatment is provided is correct. The client should be informed of treatment
that is to be provided as well as the risks involved. Informed consent protects the client, the
provider, the institution, and the employees.
Client understands the surgical procedure is correct. The client should understand the surgical
procedure as well as the risks. Informed consent protects the client, the provider, the
institution, and the employees.
Voluntary consent is given is correct. The client should give voluntary consent for the
procedure without influence. Informed consent protects the client, provider, the institution,
and the employees.
A nurse is reinforcing teaching with a female client about risk factors for osteoporosis. Which
of the following factors should the nurse include? (Select all that apply.)
1) Sedentary lifestyle
2) Obesity
3) Aging
4) Caffeine intake
5) Smoking
Answer: 1) Sedentary lifestyle
3) Aging
4) Caffeine intake
5) Smoking
Rationale:
Sedentary lifestyle is correct. Immobility depletes bone.
Obesity is incorrect. Obesity is a risk factor for developing osteoarthritis.
Aging is correct. Women lose bone density due to estrogen depletion after menopause.
Caffeine intake is correct. Excessive caffeine intake causes calcium loss in the urine.
Smoking is correct. Smoking is a risk factor for osteoporosis, both active and passive (second
hand) smoking.
A nurse is reinforcing teaching about ergonomic principles with a group of assistive
personnel. Which of the following strategies should the nurse include in the teaching? (Select
all that apply.)
1) Tighten the abdominal muscles when lifting objects.
2) Limit lifting to no more than 22.68 kg (50 lb) without assistance.
3) Flex knees and hips periodically when standing for a period of time.
4) Maintain straight knees when picking items up from the floor.
5) Enlarge the distance between the front foot and the back foot when pulling a client towards
you.
Answer: 1) Tighten the abdominal muscles when lifting objects.
3) Flex knees and hips periodically when standing for a period of time.
5) Enlarge the distance between the front foot and the back foot when pulling a client towards
you.
Rationale:
Tighten the abdominal muscles when lifting objects is correct. The abdominal muscles can
provide balance and support to the back when lifting if they are tightened and the pelvis is
tucked under.
Limit lifting to no more than 22.68 kg (50 lb) without assistance is incorrect. The nurse
should emphasize that no more than 15.88 kg (35 lb) should be lifted without assistance. An
amount greater than 35 lb increases the risk of musculoskeletal injury.
Flex knees and hips periodically when standing for a period of time is correct. The nurse
should emphasize that occasionally flexing the knees and hips when standing for long periods
of time helps relieve the strain on the lower back and prevents back injuries.
Maintain straight knees when picking items up from the floor is incorrect. The nurse should
emphasize that bending at the knees when lifting an object off the floor helps maintain the
center of gravity and allows the stronger muscles of the thighs to do the lifting. Acute flexion
of the back while keeping the knees straight should be avoided as this can result in
musculoskeletal injury.
Enlarge the distance between the front foot and the back foot when pulling a client towards
you is correct. The nurse should emphasize that when pulling or pushing an object, increasing
the base of support by widening the stance increases balance and limits the risk of
musculoskeletal injury.
A nurse is completing a neurovascular check for a client who had an open reduction internal
fixation surgery. Which of the following findings should the nurse identify as possible
manifestations of compartment syndrome? (Select all that apply.)
1) Cool skin
2) Absence of pulse
3) Pain relieved by narcotics
4) Capillary refill 1 second
5) Altered sensation of the toes
Answer: 1) Cool skin
2) Absence of pulse
5) Altered sensation of the toes
Rationale:
Cool skin is correct. The nurse should identify pallor as a possible manifestation of
compartment syndrome.
Absence of pulse is correct. The nurse should identify pulselessness as a possible
manifestation of compartment syndrome.
Pain that is relieved by narcotics is incorrect. The nurse should expect pain that is beyond the
expected level for the client’s condition and is unrelieved by narcotics as a possible
manifestation of compartment syndrome.
Capillary refill 1 second is incorrect. The nurse should expect a client who has compartment
syndrome to have delayed capillary refill (2 seconds or greater).
Altered sensation of the toes is correct. The nurse should identify paresthesias as a possible
manifestation of compartment syndrome.
A nurse is assisting with a presentation at a community center about knee disorders and
injuries. The nurse should include which of the following as risk factors for developing
osteoarthritis? (Select all that apply.)
1) Obesity
2) Family history of osteoarthritis
3) Calcium deficiency
4) Aging
5) Regular, strenuous exercise
Answer: 1) Obesity
2) Family history of osteoarthritis
4) Aging
5) Regular, strenuous exercise
Rationale:
Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load of the
body's weight over time.
Family history of osteoarthritis is correct. A client can have a genetic predisposition for
developing osteoarthritis.
Calcium deficiency is incorrect. Too little calcium leads to osteoporosis, rather than
osteoarthritis.
Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load of the
body's weight over time.
Regular, strenuous exercise is correct. Strenuous exercise and repetitive motion can result in
osteoarthritis.
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The
ankle appears swollen and ecchymotic. Which of the following interventions should the nurse
take? (Select all that apply.)
1) Apply heat to the client’s ankle.
2) Encourage range of motion of the client’s foot.
3) Check the client’s toes for color, temperature, and sensation.
4) Apply a compression bandage to the client’s ankle.
5) Elevate the client’s foot.
Answer: 4) Apply a compression bandage to the client’s ankle.
5) Elevate the client’s foot.
Rationale:
Apply heat to the client’s ankle is incorrect. The nurse should apply Ice to reduce swelling
and pain.
Encourage range of motion of the client’s foot is incorrect. The client should avoid any
movement that could cause further pain and tissue injury.
Check the client’s toes for color, temperature, and sensation is correct. The nurse should
check the circulation and sensation of the client’s foot to evaluate for nerve or circulatory
impairment.
Apply a compression bandage is correct. Wrapping an elastic bandage around the ankle can
reduce edema and pain.
Elevate the foot is correct. Elevation can reduce edema and pain.
A nurse is working with community members to prepare for an external disaster. The nurse is
assisting the community members to compile a list of basic supplies needed in the case of a
disaster. Which of the following supplies should the nurse instruct the community members
to include? (Select all that apply.)
1) Three quarts of water per person
2) Clean clothing
3) Personal identification
4) Matches
5) Family possessions
Answer: 2) Clean clothing
3) Personal identification
4) Matches
Rationale:
Three quarts of water per person is incorrect. One gallon or 4 quarts of water per person per
day is the recommended amount of water for basic supplies for personal preparedness. A
three day supply minimum is recommended.
Clean clothing is correct. Clean clothing is recommended to include in basic supplies for
personal preparedness.
Personal identification is correct. Personal identification is recommended to include in basic
supplies for personal preparedness.
Matches is correct. Matches are recommended to include in basic supplies for personal
preparedness.
Family personal possessions are incorrect. This is not a part of basic supplies that will assist
in the case of a disaster event.
A nurse is caring for a client who has multiple injuries following a motor-vehicle crash. The
nurse should collect data concerning which of the following areas when using primary survey
triage? (Select all that apply.)
1) Airway
2) Circulation
3) Disability
4) Exposure
5) Urinary output
Answer: 1) Airway
2) Circulation
3) Disability
4) Exposure
Rationale:
Airway is correct. Airway is part of the ABCDE mnemonic that is used to guide a primary
survey of a client who has traumatic injuries.
Circulation is correct. Circulation is part of the ABCDE mnemonic that is used to guide a
primary survey of a client who has traumatic injuries.
Disability is correct. Disability is part of the ABCDE mnemonic that is used to guide a
primary survey of a client who has traumatic injuries.
Exposure is correct. Exposure is part of the ABCDE mnemonic that is used to guide a
primary survey of a client who has traumatic injuries.
Urinary output is incorrect. Urinary output is not part of the ABCDE mnemonic that is used
to guide a primary survey of a client who has traumatic injuries.
A nurse at a provider’s office is reviewing information about management of osteoarthritis
with a client. Which of the following interventions should the nurse recommend? (Select all
that apply.)
1) Weight management
2) Aerobic exercise
3) Massage therapy
4) Cold compresses
5) Isometric exercise
Answer: 1) Weight management
2) Aerobic exercise
3) Massage therapy
5) Isometric exercise
Rationale:
Weight management is correct. The client should maintain appropriate body weight to reduce
strain on the joints and helps relieve pain.
Aerobic exercise is correct. The nurse should encourage the client to engage in regular low
impact aerobic exercise.
Massage therapy is correct. Massage therapy increases circulation, relieves pain, and
promotes relaxation.
Cold compresses is incorrect. The nurse should encourage the client to use moist heat to
provide pain relief and reduce muscle spasms (warm packs, tub baths, showers, and heated
gloves or wax dips).
Isometric exercise is correct. The nurse should recommend isometric exercise to maintain
mobility and prevent joint contractures.
A nurse is assisting with the care of a client who has hypertension and chronic kidney
disease. The client is scheduled for haemodialysis. Which of the following actions should the
nurse plan to take while caring for this client? (Select all that apply.)
1) Document vital signs.
2) Obtain the client's weight.
3) Verify the glomerular filtration rate.
4) Administer a sedative to the client.
5) Check the graft site for a palpable thrill.
Answer: 1) Document vital signs.
2) Obtain the client's weight.
5) Check the graft site for a palpable thrill.
Rationale:
Document vital signs is correct. The client's vital signs should be taken and documented prior
to dialysis for baseline data. The client's blood pressure, in particular, should be monitored
prior to, during, and after dialysis due to the potential for hypotension during and after the
treatment. If the blood pressure drops too low, an infusion of intravenous normal saline may
be required to replace fluid volume and restore the blood pressure.
Obtain the client's weight is correct. Haemodialysis shunts the client's blood from the body
through a dialyzer and back into the client's circulation. During haemodialysis, the blood is
passed through the dialysis machine to remove waste products and excess fluid. The amount
of fluid to be removed is determined by the client's weight immediately prior to dialysis. The
client's dry weight, which is determined by the provider, is subtracted from the weight
immediately prior to the start of dialysis. For example, if the dry weight is 70 kg (154.32 lb)
and the current weight is 72 kg (158.73 lb), the dialysis machine is programmed to remove 2
kg (4.4 lb), or 2 L (0.5 gal) of fluid.
Verify the glomerular filtration rate is incorrect. End-stage kidney disease (ESKD) is a
progressive, irreversible kidney disease. End-stage kidney disease, also known as end-stage
renal failure (ESRD), exists when 90% of the functioning nephrons have been destroyed and
are no longer able to maintain fluid, electrolyte, or acid-base homeostasis. This means the
kidneys are no longer able to sustain life, and the client will die if dialysis is not initiated. The
client's glomerular filtration rate (GFR) is used to determine the severity of kidney damage.
The GFR is expected to be greater than 90 mL/min. Chronic kidney disease (CKD) is
comprised of five stages: Stage 1, minimal kidney damage with normal GFR; Stage 2, mild
kidney damage with mildly decreased GFR; Stage 3, moderate kidney damage with a
moderate decrease in GFR; Stage 4, severe kidney damage with a severe decrease in GFR;
and Stage 5, kidney failure and end-stage kidney disease with little or no glomerular filtration
and renal replacement therapy required. Glomerular filtration rate is an indicator of renal
function and is checked to evaluate how well the kidneys are working. Because ESKD is
irreversible, it is not necessary to check the GFR prior to dialysis because the GFR level in
these clients is elevated and will remain that way unless a renal transplantation is performed.
Administer a sedative is incorrect. The client is awake during haemodialysis and is a painless
procedure for the client. Therefore, a sedative is not needed.
Check the graft site for a palpable thrill is correct. Haemodialysis requires access to the
client's blood by way of a graft, arteriovenous (AV) fistula, or central venous access device.
The nurse should check patency of the access site (presence of bruit, palpable thrill, distal
pulses, and circulation). This ensures vascular flow and proper functioning of the graft prior
to the dialysis procedure. If a thrill is not found, this can indicate the graft has clotted and
haemodialysis will not be possible. This would need to be reported to the provider. Measures
to protect the graft include avoiding taking blood pressure, administering injections,
performing venipuncture, or inserting IV lines on an extremity with an access site.
A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary
artery disease. Which of the following statements by the client indicates an understanding of
the teaching? (Select all that apply.)
1) "I must stop smoking."
2) "I should lower my HDL cholesterol level."
3) "I will stop consuming alcohol."
4) "I need to monitor my weight."
5) "I am limiting my intake of fast foods."
Answer: understanding of the teaching? (Select all that apply.)
4) "I need to monitor my weight."
5) "I am limiting my intake of fast foods."
Rationale:
"I must stop smoking." is correct. Smoking places the client at three to four times higher risk
for developing coronary disease, but the benefits of stopping smoking occur almost
immediately.
"I should lower my HDL cholesterol level." is incorrect. The nurse should remind the client
that this type of cholesterol is beneficial to removing bad cholesterol from the body.
"I will stop consuming alcohol." is incorrect. The client should limit alcohol consumption to
2 drinks per day for men and 1 drink per day for women.
"I need to monitor my weight." is correct. Obesity, or an increase in weight, is a significant
factor in developing coronary artery disease. Weight management is vital to decreasing the
risk of coronary artery disease.
"I am limiting my intake of fast foods." is correct. Fast foods typically are prepared with high
sodium and high fat, which increase the risk of atherosclerosis and coronary artery disease.
To promote cardiovascular health, clients should select healthier food options, such as fruits
and vegetables, or foods prepared by baking or broiling.
A nurse is caring for a client who is 1 day postoperative following a transurethral resection of
the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following
actions should the nurse take? (Select all that apply.)
1) Add the amount of bladder irrigation to the total output.
2) Use sterile technique when preparing the irrigation solution.
3) Make sure the drainage tubing is patent and without obstruction.
4) Contact the surgeon if the client reports a continual need to void.
5) Notify the surgeon if the urine is bright red or has large clots.
Answer: 2) Use sterile technique when preparing the irrigation solution.
3) Make sure the drainage tubing is patent and without obstruction.
5) Notify the surgeon if the urine is bright red or has large clots.
Rationale:
Add the amount of bladder irrigation to the total output is incorrect. The nurse should subtract
the amount of bladder irrigation solution from the total urine output amount. For example, if
the total urine output is 2,500 mL and the amount of irrigation is 1,000 mL, the nurse should
subtract 1,000 from 2,500 and record 1,500 mL as the total urine output.
Use sterile technique when preparing the irrigation solution is correct. Using sterile technique
decreases the risk of contamination with micro-organisms and reduces the possibility of
infection. Many clients who undergo a TURP are older adults who may have other chronic
diseases that increase their susceptibility to infection. The nurse should observe these clients
closely for manifestations of infection, such as fever and elevated WBC counts.
Make sure the drainage tubing is patent and without obstruction is correct. For continuous
drainage, the nurse should be sure that the clamp on the drainage tubing is open and check the
volume of fluid in the drainage bag. The nurse should make sure the drainage tubing is patent
and without obstruction or kinks. This ensures a continuous, even irrigation of the catheter
system. It prevents accumulation of solution in the bladder, which can cause bladder
distention and possible injury.
Contact the surgeon if the client reports a continual need to void is incorrect. The post TURP
catheter is large; the surgeon pulls it taut and secures it to the client’s leg. This provides
traction that holds the catheter balloon against the internal sphincter of the bladder. As a
result, the client probably will feel a continual need to void. The nurse should tell the client to
expect this urge to void. However, the client should not attempt to void around the catheter
because this can cause bladder spasms, which can be painful and can initiate bleeding.
Notify the surgeon if the urine is bright red or has large clots is correct. It is important to
record the type and amount of irrigation solution and the character of the drainage. The nurse
should expect to see a few small blood clots, but urine that is bright red, ketchup-like, or has
large clots is an indication of bleeding. The nurse should report this to the surgeon
immediately and monitor the client’s Hgb and Hct to help determine the degree of blood loss.
A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary
artery disease. Which of the following statements by the client indicates an understanding of
the teaching? (Select all that apply.)
1) "I must stop smoking."
2) "I should lower my HDL cholesterol level."
3) "I will stop consuming alcohol."
4) "I need to monitor my weight."
5) "I am limiting my intake of fast foods."
Answer: 1) "I must stop smoking."
4) "I need to monitor my weight."
5) "I am limiting my intake of fast foods."
Rationale:
"I must stop smoking." is correct. Smoking places the client at three to four times higher risk
for developing coronary disease, but the benefits of stopping smoking occur almost
immediately.
"I should lower my HDL cholesterol level." is incorrect. The nurse should remind the client
that this type of cholesterol is beneficial to removing bad cholesterol from the body.
"I will stop consuming alcohol." is incorrect. The client should limit alcohol consumption to
2 drinks per day for men and 1 drink per day for women.
"I need to monitor my weight." is correct. Obesity, or an increase in weight, is a significant
factor in developing coronary artery disease. Weight management is vital to decreasing the
risk of coronary artery disease.
"I am limiting my intake of fast foods." is correct. Fast foods typically are prepared with high
sodium and high fat, which increase the risk of atherosclerosis and coronary artery disease.
To promote cardiovascular health, clients should select healthier food options, such as fruits
and vegetables, or foods prepared by baking or broiling.
A nurse is caring for a client who is 1 day postoperative following a transurethral resection of
the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following
actions should the nurse take? (Select all that apply.)
1) Add the amount of bladder irrigation to the total output.
2) Use sterile technique when preparing the irrigation solution.
3) Make sure the drainage tubing is patent and without obstruction.
4) Contact the surgeon if the client reports a continual need to void.
5) Notify the surgeon if the urine is bright red or has large clots.
Answer: 2) Use sterile technique when preparing the irrigation solution.
3) Make sure the drainage tubing is patent and without obstruction.
5) Notify the surgeon if the urine is bright red or has large clots.
Rationale:
Add the amount of bladder irrigation to the total output is incorrect. The nurse should subtract
the amount of bladder irrigation solution from the total urine output amount. For example, if
the total urine output is 2,500 mL and the amount of irrigation is 1,000 mL, the nurse should
subtract 1,000 from 2,500 and record 1,500 mL as the total urine output.
Use sterile technique when preparing the irrigation solution is correct. Using sterile technique
decreases the risk of contamination with micro-organisms and reduces the possibility of
infection. Many clients who undergo a TURP are older adults who may have other chronic
diseases that increase their susceptibility to infection. The nurse should observe these clients
closely for manifestations of infection, such as fever and elevated WBC counts.
Make sure the drainage tubing is patent and without obstruction is correct. For continuous
drainage, the nurse should be sure that the clamp on the drainage tubing is open and check the
volume of fluid in the drainage bag. The nurse should make sure the drainage tubing is patent
and without obstruction or kinks. This ensures a continuous, even irrigation of the catheter
system. It prevents accumulation of solution in the bladder, which can cause bladder
distention and possible injury.
Contact the surgeon if the client reports a continual need to void is incorrect. The post TURP
catheter is large; the surgeon pulls it taut and secures it to the client’s leg. This provides
traction that holds the catheter balloon against the internal sphincter of the bladder. As a
result, the client probably will feel a continual need to void. The nurse should tell the client to
expect this urge to void. However, the client should not attempt to void around the catheter
because this can cause bladder spasms, which can be painful and can initiate bleeding.
Notify the surgeon if the urine is bright red or has large clots is correct. It is important to
record the type and amount of irrigation solution and the character of the drainage. The nurse
should expect to see a few small blood clots, but urine that is bright red, ketchup-like, or has
large clots is an indication of bleeding. The nurse should report this to the surgeon
immediately and monitor the client’s Hgb and Hct to help determine the degree of blood loss.
A nurse is planning care for a client who is postoperative. Which of the following
interventions should the nurse include in the plan of care? (Select all that apply.)
1) Instruct the client to cough and deep breathe every 4 hr.
2) Have the client sit at the bedside prior to getting up.
3) Remove compression stockings once per day.
4) Provide pain medications around the clock for the first 48 hr.
5) Encourage intake of foods high in carbohydrates.
Answer: 2) Have the client sit at the bedside prior to getting up.
4) Provide pain medications around the clock for the first 48 hr.
Rationale:
Instruct the client to cough and deep breathe every 4 hr is incorrect. The nurse should
encourage the client to cough and deep breathe every 1 to 2 hr while awake to decrease the
risk of atelectasis and pneumonia.
Have the client sit at the bedside prior to getting up is correct. Sitting at the bedside prior to
rising reduces the risk of the client experiencing orthostatic hypotension.
Remove compression stockings once per day is incorrect. Compression stockings should be
removed at least once per shift in order to perform a through skin assessment.
Provide pain medications around the clock for the first 48 hr is correct. Relieving pain allows
the client to better participate in postoperative therapies and minimize risks associated with
surgery.
Encourage intake of foods high in carbohydrates is incorrect. Once the client is able to
tolerate oral intake, the nurse should encourage consumption of foods high in protein and
vitamin C to promote wound healing.
A nurse is contributing to the plan of care for a client who has a new diagnosis of type 2
diabetes mellitus. Which of the following interventions should the nurse include? (Select all
that apply.)
1) Assist the client to develop an individualized meal plan.
2) Give the client an extra dose of insulin for a blood glucose level of 50 mg/dL.
3) Instruct the client to soak his feet daily.
4) Offer the client 240 mL (8 oz) of skim milk if the client’s skin becomes cool and clammy.
5) Check the client’s blood glucose level before meals and bedtime.
Answer: 1) Assist the client to develop an individualized meal plan.
4) Offer the client 240 mL (8 oz) of skim milk if the client’s skin becomes cool and clammy.
5) Check the client’s blood glucose level before meals and bedtime.
Rationale:
Assist the client to develop an individualized meal plan is correct. A client who has a new
diagnosis of type 2 diabetes mellitus will need assistance to develop a meal plan that will help
him achieve his weight goals, maintain his lifestyle, and meet his food preferences.
Give the client an extra dose of insulin for a blood glucose level of 50 mg/dL is incorrect. A
blood glucose level of 50 mg/dL is below the expected reference range. Giving an extra dose
of insulin can further lower the client’s blood glucose level.
Instruct the client to soak his feet daily is incorrect. Soaking the feet daily can cause skin
impairment and lead to cracking of the skin. This can increase the client’s risk for infection.
The client should wash his feet in warm water and mild soap and dry them thoroughly before
putting on socks.
Offer the client 8 oz of skim milk if the client’s skin becomes cool and clammy is correct.
Cool, clammy skin, pallor, irritability, and shakiness can indicate the client’s blood glucose is
below the expected reference range and that the client is having hypoglycemia. The nurse
should offer the client a snack of 15 to 20 g of carbohydrate, such as 8 oz of skim milk, 1
small box of raisins, or 4 oz of juice.
Check the client’s blood glucose level before meals and bedtime is correct. The nurse should
check the client’s blood glucose level at least before each meal and at bedtime to monitor
glucose control and identify the need for medication.
A nurse is caring for a client following a lumbar puncture. Which of the following actions
should the nurse take? (Select all that apply.)
1) Provide oral fluids
2) Monitor for nausea
3) Maintain fetal position
4) Check level of consciousness
5) Check sensation in the toes
Answer: 1) Provide oral fluids
2) Monitor for nausea
4) Check level of consciousness
5) Check sensation in the toes
Rationale:
Provide oral fluids is correct. The nurse should encourage fluid intake to replace fluid loss
during the procedure.
Monitor for nausea is correct. The nurse should monitor nausea as a possible manifestation of
increased intracranial pressure. Additional findings to report include headache or drainage or
redness at the puncture site.
Maintain fetal position is incorrect. Following a lumbar puncture (LP), the nurse should keep
the client flat and still for 4 to 8 hr to decrease leakage of cerebral spinal fluid from the LP
site. The fetal position is used during the LP procedure to open the spaces in the vertebrae.
Check level of consciousness is correct. The nurse should monitor for a change in the client’s
level of consciousness as a possible manifestation of increased intracranial pressure. The
nurse should also monitor for photophobia.
Check sensation in the toes is correct. A lumbar puncture could cause injury to the spinal
cord; therefore, the nurse should monitor the client’s neurological status in both lower
extremities.
A nurse is caring for a client who has a closed wound drainage system connected to a
portable bulb suction device. Which of the following actions should the nurse take to care for
the drain? (Select all that apply.)
1) Allow the drain fill completely before emptying.
2) Flush the drainage tube with sterile water each shift.
3) Wipe the top of the drainage port with an alcohol swab after emptying.
4) Milk the drainage port to promote emptying.>
5) Squeeze the suction bulb while inserting the plug into the drainage port.
Answer: 3) Wipe the top of the drainage port with an alcohol swab after emptying.
5) Squeeze the suction bulb while inserting the plug into the drainage port.
Rationale:
Allow the drain fill completely before emptying is incorrect. The nurse is responsible for
maintaining negative pressure suction on the drainage device and should not allow the bulb to
fill completely as it would no longer provide wound suction. The nurse should empty the
drain at least every shift and as needed.
Flush the drainage tube with sterile water each shift is incorrect. The nurse should not insert
anything into the drainage tube in order to protect the sterility of the device.
Wipe the top of the drainage port with an alcohol swab after emptying is correct. The nurse
should wipe the opening of the port with an alcohol swab to remove fluid and contaminants
prior to reactivating and closing the device. This action promotes sterility of the device.
Milk the drainage port to promote emptying is incorrect. The nurse should avoid touching the
drainage port to promote asepsis of the drainage system.
Squeeze the suction bulb while inserting the plug into the drainage port is correct. The nurse
should squeeze the bulb and maintain it in that position while inserting the drainage plug to
reactivate negative pressure and ensure the drainage device continues to evacuate fluid from
the drain.
A nurse working in an assisted living facility has been made aware that a chemical disaster
has occurred within the community and is a threat to the facility. Which of the following
actions should the nurse take? (select all that apply)
1) Evacuate the facility of all residents and staff.
2) Place wet towels under the doors.
3) Close the doors and windows of each resident's apartment.
4) Open the fireplace dampers in each resident's apartment.
5) Turn off fans and heaters.
Answer: 2) Place wet towels under the doors.
3) Close the doors and windows of each resident's apartment.
5) Turn off fans and heaters.
Rationale:
Evacuate the facility of all residents and staff is incorrect. During a chemical disaster, the
nurse should ensure that all residents and staff members stay inside until told it is safe to go
outside.
Place wet towels under the doors is correct. The nurse should place wet towels under the
doors to prevent the chemical from traveling into residents’ rooms.
Close the doors and windows of each resident's apartment is correct. The nurse should closed
all of the doors and windows of each client's apartments to prevent the chemical from coming
into the building.
Open the fireplace dampers in each resident's apartment is incorrect.
The nurse should close all fireplace dampers. This prevents the chemical from coming in
from the outside.
Turn off fans and heaters is correct. This prevents the circulation of air, and possibly
chemicals, in from the outside and contaminating the air inside the building.
A nurse is reinforcing breast self- examination (BSE) teaching with a client who is
menopausal. Which of the following statements by the client indicate an understanding of the
teaching? (Select all that apply.)
1) "I can stand in the shower to perform the examination."
2) "I will use my fingertips to check my breasts."
3) "It is important to press my breasts firmly to detect any lumps."
4) "Since I no longer have periods, I can do the exam at any time of the month."
5) "I will make sure to feel for changes in my underarm area."
Answer: 1) "I can stand in the shower to perform the examination."
3) "It is important to press my breasts firmly to detect any lumps."
4) "Since I no longer have periods, I can do the exam at any time of the month."
5) "I will make sure to feel for changes in my underarm area."
Rationale:
"I can stand in the shower to perform the examination." is correct. A client can perform a
BSE while in a lying position, or when bathing or showering."
I will use my fingertips to check my breasts." is incorrect. The client should be instructed to
use her finger pads since they are more sensitive than fingertips."
It is important to press my breasts firmly to detect any lumps." is correct. Women should
press firmly on the breasts to detect changes in underlying tissues. The nurse should
demonstrate the proper amount of pressure and the correct positioning of the hands."
Since I no longer have periods, I can do the exam at any time of the month." is correct.
Women who no longer have the monthly hormonal influences of menstruation can perform an
examination at any time. Inform the client that It is best to select a specific date each month
for her BSE."I will make sure to feel for changes in my underarm area." is correct. It is
important to check the area between the breast tissue and the underarm as well as the
underarm itself for any changes. Lymph nodes located in this area are assessed for
inflammation, tenderness, and firmness.
A nurse is planning to perform an electrocardiogram (ECG) for a client who has a history of
coronary heart disease. Which of the following actions should the nurse take? (Select all that
apply.)
1) Keep the client NPO after midnight.
2) Inspect the electrode pads.
3) Use alcohol to wipe the skin before placing the electrodes.
4) Instruct the client to breath normally.
5) Administer an analgesic prior to the procedure.
Answer: 2) Inspect the electrode pads.
3) Use alcohol to wipe the skin before placing the electrodes.
4) Instruct the client to breath normally.
Rationale:
Keep the client NPO after midnight is incorrect. The client will not receive anaesthesia for to
the test so he does not need to follow a food or fluid restriction prior to the test.
Inspect the electrode pads is correct. The nurse should inspect the electrode pads to check that
the gel is present because the gel is necessary to promote electrical conduction between the
skin and the electrodes.
Use alcohol to wipe the skin before placing the electrodes is correct. The nurse should wipe
the skin where she will place the electrodes to ensure the skin is free of oils and other matter.
Instruct the client not to talk is correct. The nurse should instruct the client to lie quietly, not
talk, or move to prevent the recording of artifact.
Administer an analgesic prior to the procedure is incorrect. The client does not need to
receive an analgesic prior to the test because the test is non-invasive and does cause any
discomfort.
A nurse is reinforcing preoperative teaching about breathing exercises with a client. Which of
the following instructions should the nurse include? (Select all that apply.)
1) Make the chest and shoulders move when inhaling.
2) Exhale through pursed lips.
3) Perform deep breathing every 2 hr around the clock.
4) Sit in an upright position before beginning coughing exercises.
5) Take a deep breath between each attempt to cough.
Answer: 2) Exhale through pursed lips.
4) Sit in an upright position before beginning coughing exercises.
Rationale:
Make the chest and shoulders move when taking inhaling is incorrect. The nurse should
instruct the client to use abdominal muscles for deep breathing, and to avoid using the chest
and shoulders while inhaling.
Exhale through pursed lips is correct. The nurse should have the client exhale as if blowing
out a candle to promote slow release of air from the lungs.
Perform deep breathing every 2 hr around the clock is incorrect. The nurse should instruct the
client to perform deep breathing exercises every hour while awake to prevent atelectasis.
Sit in an upright position before beginning coughing exercises is correct. The nurse should
instruct the client to sit in a semi-Fowler’s or sitting position to promote expansion of the
diaphragm and thoracic region.
Take a deep breath between each attempt to cough is incorrect. The nurse should instruct the
client to take two deep breaths, then inhale deeply. After holding the breath several seconds,
the clients should cough two to three times consecutively to promote mucus expulsion from
the lungs.
A nurse is caring for a client who is in Buck’s traction. Which of the following actions should
the nurse take? (Select all that apply.)
1) Monitor peripheral pulses in the affected extremity.
2) Position weights against the foot of the bed.
3) Adjust the prescribed weights every shift.
4) Examine the skin under the traction splint.
5) Assess the temperature of the affected extremity.
Answer: 1) Monitor peripheral pulses in the affected extremity.
4) Examine the skin under the traction splint.
5) Assess the temperature of the affected extremity.
Rationale:
Monitor peripheral pulses in the affected extremity is correct. The fracture and the traction
device can compromise circulation to the extremity, so checking peripheral pulses is
necessary to evaluate tissue perfusion.
Position weights against the foot of the bed is incorrect. The weights should hang freely away
from the foot of bed to promote proper traction and healing.
Adjust the prescribed weights every shift is incorrect. Once the weights are in place, the nurse
should not adjust or remove them unless the provider prescribes changes.
Examine the skin under the traction splint is correct. The nurse should monitor the client’s
skin integrity because immobility can reduce sensation in the extremity. The client might not
feel any breakdown in the skin.
Assess the temperature of the affected extremity is correct. The fracture and the traction
device can compromise circulation to the extremity, so checking the temperature is necessary
to evaluate tissue perfusion.
