2021 HESI PN Medical Surgical Proctored Exam Version 3-4 With Answers-225 Solved Questions

VERSION 3
ATI MED-SURG PROCTORED EXAM PRACTICE QUESTIONS WITH
ANSWERS (100 Q/A)
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter
placed. Which of the following findings indicates that the client is experiencing increased
ICP?
A. Flat jugular veins
B. GCS score of 15
C. Sleepiness exhibited by the client
D. Widening pulse pressure
E. Decerebrate posturing
Answer: C. Sleepiness exhibited by the client
Rationale:
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15 indicates
neurological functioning within the expected reference range for eye opening, motor, and
verbal response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended.
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the clients to
withhold for 48hr prior to cardioversion?
A. Enoxaparin
B. Metformin
C. Diazepam
D. Digoxin
E. Anticoagulants

Answer: J. Digoxin
Rationale:
Anticoagulants can be beneficial during cardioversion due to their ability to prevent blood
clots that can be released into the client's circulatory system after cardioversion. This
medication should not be withheld.
Metformin might be withheld for a client scheduled for cardiac catheterization or other
procedures involving contrast dye in order to prevent damage to the kidneys. However,
metformin should not be withheld prior to cardioversion.
Sedatives are generally administered to clients prior to cardioversion to reduce anxiety and
minimize the discomfort associated with the procedure. This medication should not be
withheld.
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications
can increase ventricular irritability and put the client at risk for ventricular fibrillation after
the synchronized countershock of cardioversion.
A nurse is assessing a client who has acute cholecystitis. which of the following findings is
the nurse’s priority?
A. Anorexia
B. Abdominal pain radiating to the right shoulder
C. Tachycardia
D. Rebound abdominal tenderness
Answer: B. Abdominal pain radiating to the right shoulder
Rationale:
Anorexia is nonurgent because it is an expected finding for a client who has acute
cholecystitis. Therefore, there is another finding that is the nurse's priority.
Abdominal pain radiating to the right shoulder Abdominal pain radiating to the right shoulder
is nonurgent because it is an expected finding for a client who has acute cholecystitis.
Therefore, there is another finding that is the nurse's priority.
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can
lead to shock. The nurse should position the head of the client's bed flat and report this
finding immediately to the provider. Rebound abdominal tenderness
Rebound abdominal tenderness is nonurgent because it is an expected finding for a client who
has acute cholecystitis. Therefore, there is another finding that is the nurse's priority.

A nurse is preparing to admit a client who has dysphagia. The nurse should plant to place
which of the following items at the client’s bedside?
A. Suction machine
B. Wire cutters
C. Padded clamp
D. Communication board
E. Suction machine:
Answer: E. Suction machine:
Rationale:
Communication board: The nurse should ensure a communication board is at the bedside of a
client who has aphasia to assist the client with communicating.
The nurse should ensure that a suction machine is at the bedside of a client who has
dysphagia to clear the client's airway as needed and reduce the risk for aspiration.
The nurse should ensure wire cutters are at the bedside of a client who has an inner maxillary
fixation to cut the wires in case the client vomits. This enables the client to clear their airway
and reduce the risk for aspiration.
The nurse should ensure a padded clamp is at the bedside of a client who has a chest tube to
clamp the tube and prevent air from entering the client's chest if there is an interruption in the
sealed drainage system.
A nurse is caring for a client who is having a seizure. Which of the following intervention is
the nurse’s priority?
A. Loosen the clothing around the client’s neck
B. Check the client’s pupillary response
C. Turn the client to the side.
D. Move furniture away from the client
Answer: C. Turn the client to the side.
Rationale:
Loosen the clothing around the client's neck: The nurse should loosen any restrictive clothing
the client is wearing to prevent injury to the client. However, another action is the priority.
Check the client's pupillary response: The nurse should perform neurologic checks after the
seizure to monitor the client's recovery. However, another action is the priority.

Turn the client to the side.: The greatest risk to this client is hypoxia from an impaired airway.
Therefore, the priority intervention the nurse should take is to place the client in a side-lying
position to prevent aspiration.
Move furniture away from the client.: The nurse should move furniture away from the client
to prevent self-injury. However, another action is the priority.
A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following supplements
can interfere with the effectiveness of the medication?
A. Ginkgo biloba
B. Glucosamine
C. Calcium
D. Vitamin C
Answer: C. Calcium
Rationale:
Ginkgo biloba reduces the pain associated with peripheral vascular disease by promoting
vasodilation. It can interact with medications that have anticoagulant properties, but it is not
known to interfere with the absorption of levothyroxine.
Glucosamine: Glucosamine treats osteoarthritis by decreasing inflammation and stimulating
the body's production of synovial fluid and cartilage. It can interact with medications that
have antiplatelet or anticoagulant properties, but it is not known to interfere with the
absorption of levothyroxine.
Calcium limits the development of osteoporosis in clients who are postmenopausal and works
as an antacid. Calcium supplements can interfere with the metabolism of a number of
medications, including levothyroxine. The nurse should instruct the client to avoid taking
calcium within 4 hr of levothyroxine administration.
Vitamin C: Vitamin C promotes wound healing. It can cause a false negative in fecal occult
blood tests, but it is not known to interfere with the absorption of levothyroxine.
A nurse is planning to irrigate and dress a clean, granulation wound for a client who has a
pressure injury. Which of the following actions should the nurse take?
A. Apply a wet-to-dry gauze dressing
B. Irrigate with hydrogen peroxide solution
C. Use a 30-ml syringe

D. Attach a 24-gauge Angio catheter to the syringe.
Answer: C. Use a 30-ml syringe
Rationale:
Apply a wet-to-dry gauze dressing.: The nurse should not apply wet-to-dry dressings to clean,
granulating wounds as they interrupt viable, healing tissues when they are removed.
Appropriate dressings for a wound that is developing granulation tissue include a
hydrocolloid dressing and a transparent film dressing.
Irrigate with hydrogen peroxide solution: the nurse should use hydrogen peroxide to clean
contaminated surfaces. Hydrogen peroxide should not be used on a pressure injury wound
because it destroys newly granulated tissue. Instead, the nurse should use solutions
specifically designed as wound cleansers or 0.9% sodium chloride irrigation to irrigate the
wound.
Use a 30-mL syringe: The nurse should use a 30-mL to 60-mL syringe with an 18- or 19gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a
wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at
between 4 and 15 psi.
Attach a 24-gauge Angio catheter to the syringe: the nurse should use an 18- or 19gauge
catheter that will apply the appropriate irrigation pressure. A 24-gauge Angio catheter
delivers solutions at a higher pressure than necessary for irrigation and a can potentially
damage the developing granulation tissues.
A nurse Is assessing a client who has Graves’ disease. Thich of the following images should
indicate to the nurse that the client has exophthalmos:
A.

B.

C.

D.

Answer: D.

Rationale:
This image depicts entropion, which occurs when the skin of the eyelids turns inward,
causing the eyelids to rub the eye. Entropion is caused by spasms of the eyelid muscle or
trauma and occurs most often in older adult clients due to the loss of supportive tissue.
This image depicts ectropion, which occurs when the skin of the eyelids turns outward,
causing sagging of the lower lids due to muscle weakness. Ectropion occurs with aging and
can cause drying of the cornea and ulceration.
This image depicts ptosis, which occurs when excess skin of the upper eyelid drops down
over the eye. Ptosis can occur due to aging or at any age due to diabetes, myasthenia gravis,
or stroke.
The nurse should identify an outward protrusion of the eyes as exophthalmos, a common
finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the
extraocular muscle and increases fatty tissue behind the eye, which results in the eyes
protruding outward. Exophthalmos can cause the client to experience problems with vision,
including focusing on objects, as well as pressure on the optic nerve.

The nurse is providing teaching to a female client who has a history of UTI’s. which of the
following information should the nurse include in the teaching?
A. Avoid foods that are high in ascorbic acid
B. Add oatmeal to the water when taking a tub bath
C. Urinate every 6 hours
D. Take daily cranberry supplements?
Answer: D. Take daily cranberry supplements?

A nurse is providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which off the following statements should the nurse identify as an
indication that the client understands the teaching?
A. “ I will wash the ink markings off the radiation area after each treatment.”
B. “I will use my hands rather than a washcloth to clean the radiation area.”
C. “I will be able to be out in the sun 1 month after my radiation treatments are over.”
D. “I will use a heating pad on my neck it if becomes sore during the radiation therapy.”
Answer: B. “I will use my hands rather than a washcloth to clean the radiation area.”
Rationale:
The ink markings designate the exact radiation area. The client should not remove these
markings until they complete the entire radiation treatment.
The client should gently wash the radiation area with their hands using warm water and mild
soap to protect the skin from further irritation.
Radiation therapy causes skin to become sensitive to the effects of sun exposure and
increases the risk for developing skin cancer. The client should avoid direct sunlight during
the radiation treatments and for at least 1 year following the conclusion of the therapy.
The client should avoid exposing the treatment area to heat as this can cause further irritation
to the skin.
A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the
formation of a hematoma at the insertion site and a decreased pulse rate in the affected
extremity. Which of the following interventions is the nurse’s priority?
A. Initiate oxygen at 2 L via nasal cannula
B. Apply firm pressure to the insertion site
C. Take the client’s vital signs
D. Obtain a stat order for an aPTT
Answer: B. Apply firm pressure to the insertion site
Rationale:
Initiate oxygen at 2 L/min via nasal cannula.: The nurse can apply oxygen to promote
adequate tissue oxygenation. However, another intervention is the priority.
Apply firm pressure to the insertion site: The greatest risk to the client is bleeding. Therefore,
the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the
bleeding.

Take the client's vital signs.: The nurse should take the client's vital signs to further determine
the client's status. However, another intervention is the priority.
Obtain a stat order for an aPTT.: The nurse can request laboratory data to provide information
about the client's coagulation status. However, another intervention is the priority.
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation.
The client appears anxious and restless, and the high-pressure alarm is sounding. Which of
the following actions should the nurse take first?
A. Obtain ABGs
B. Administer propofol to the client
C. Instruct the client to allow the machine to breathe for them
D. Disconnect the machine and manually ventilate the client.
Answer: C. Instruct the client to allow the machine to breathe for them
Rationale:
Obtain ABGs. The nurse should monitor ABG results to determine the effectiveness of
mechanical ventilation, but this is not the first action the nurse should take.
Administer propofol to the client.: The nurse might need to administer propofol to provide
sedation and increase the client's tolerance of mechanical ventilation, but this is not the first
action the nurse should take. iii. Instruct the client to allow the machine to breathe for them.:
When providing client care, the nurse should first use the least restrictive intervention.
Therefore, the first action the nurse should take is to provide verbal instructions and
emotional support to help the client relax and allow the ventilator to work. Clients can exhibit
anxiety and restlessness when trying to "fight the ventilator."
Disconnect the machine and manually ventilate the client.: Many factors can cause a highpressure alarm to sound. The nurse might have to disconnect the machine and manually
ventilate the client if the ventilator fails or the client experiences respiratory distress, but this
is not the first action the nurse should take.
A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following
laboratory values should the nurse expect?
A. Decreased prothrombin time
B. Elevated bilirubin level
C. Decreased ammonia level
D. Elevated albumin level

Answer: B. Elevated bilirubin level
Rationale:
Decreased prothrombin time: liver disease and severe liver cell damage causes the liver cells
to produce less prothrombin, which prolongs prothrombin time.
Elevated bilirubin level: Bilirubin levels reflect the liver's ability to conjugate and excrete
bilirubin, a byproduct of the haemolysis of red blood cells. Bilirubin levels rise with liver
disease and clinically reflect the client's degree of jaundice.
Decreased ammonia level: The liver converts ammonia to urea. When this process is
interrupted, as it is with liver disease or liver failure, ammonia levels rise.
Elevated albumin level: Albumin forms in the liver. When liver function is impaired, as it is
with cirrhosis, albumin levels decrease.
A nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client understands the
teaching?
A. “ I should avoid walking as much as possible.”
B. “I should sit down and read for several hours a day”
C. “I will wear clean graduated compression stockings every day.”
D. “I will keep my legs level with my body when I sleep at night.”
Answer: C. “I will wear clean graduated compression stockings every day.”
Rationale:
"I should avoid walking as much as possible.": A client who has venous insufficiency should
maintain an exercise regimen, such as routine walking, to decrease venous stasis.
"I should sit down and read for several hours a day.": A client who has venous insufficiency
should avoid sitting or standing for prolonged periods of time due to the risk of developing
deep-vein thrombosis or skin breakdown.
"I will wear clean graduated compression stockings every day.": The client should apply a
clean pair of graduated compression stockings each day and clean soiled stockings with mild
detergent and warm water by hand.
"I will keep my legs level with my body when I sleep at night.": A client who has venous
insufficiency should elevate the legs above heart level while in bed to facilitate venous return
and avoid venous stasis.

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of
the following laboratory values should the nurse report to the provider?
A. Potassium 4 mEq/L
B. WBC count 10,000/mm3
C. Hct 45%
D. Hgb 8 g/dL
Answer: D. Hgb 8 g/dL
Rationale:
Potassium 4 mEq/L: A potassium level of 4 mEq/L is within the expected reference range.
WBC count 10,000/mm3: A WBC count of 10,000/mm3 is within the expected reference
range.
Hgb 8 g/dL: The nurse should report an Hgb level of 8 g/dL, which is below the expected
reference range and is an indicator of postoperative haemorrhage or anaemia.
A nurse is caring for a client who has a stage III pressure injury. Which of the following
findings contributes to delayed would healing?
A. WBC count 6K
B. BMI 24
C. Urine output 25ml/hr
D. Albumin 4
Answer: C. Urine output 25ml/hr
Rationale:
WBC count 6,000/mm3: BCs fight infection and respond to foreign bodies. Increased
amounts are seen in clients who have an infectious process, and decreased amounts are seen
in clients who are immunocompromised.
A WBC count of 6,000/mm3 is within the expected reference range.
BMI 24: BMI readings provide a means of determining a client's nutritional status. Clients
who have a BMI less than 18.5 are considered at risk for complications, such as poor wound
healing.
Urine output 25 mL/hr: Urinary output reflects fluid status. Inadequate urine output can
indicate dehydration, which can delay wound healing.
Albumin 4 g/dL: Albumin reflects nutritional status. A low level can indicate malnutrition,
which would impair wound healing. An albumin level of 4 g/dL is within the expected
reference range and indicates adequate nutritional status.

A nurse is caring for a client who is undergoing haemodialysis to treat ESKD. The client
reports muscle cramps and a tingling sensation in their hands. Which of the following
medications should the nurse plan to administer?
A. Epoetin alfa
B. Furosemide
C. Captopril
D. Calcium carbonate
Answer: D. Calcium carbonate
Rationale:
Epoetin alfa: A client who has ESKD is at risk for anaemia manifested by malaise, fatigue,
and activity intolerance. The nurse should plan to administer an erythrocyte-stimulating
agent, such as epoetin alfa, to a client who has anaemia.
Furosemide: A client who has ESKD can develop pulmonary edema manifested by
restlessness, shortness of breath, crackles, and blood-tinged sputum. The nurse should plan to
administer a loop diuretic, such as furosemide, to a client who has pulmonary edema.
Captopril: A client who has ESKD often is hypertensive, which can further damage renal
function. The nurse should plan to administer an antihypertensive medication, such as
captopril, to a client who is hypertensive.
Calcium carbonate: Hypocalcaemia is a manifestation of ESKD and an adverse effect of
dialysis. Often occurring late in the dialysis session, hypocalcaemia can cause the client to
experience muscle cramping and tingling to extremities. The nurse should plan to administer
a calcium supplement, such as calcium carbonate, as a calcium replacement.
A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal
implant to treat endometrial cancer. Which of the following actions should the nurse include
in the client’s plan of care?
A. Collect and place the client’s urine or feces in a biohazard bag
B. Limit the client’s ambulation to their own room
C. Wear a lead apron while providing care to the client
D. Limit each visitor to 1 hr per day.
Answer: C. Wear a lead apron while providing care to the client
Rationale:

With sealed implants, the client's excretions are not radioactive. Standard precautions require
gloves when handling body fluids or waste, but there are no special precautions required for
this client's excreta.
Limit the client's ambulation to their own room. iv. Not only does the client require bedrest in
a private room while the radiation implant is in place, but the nurse must also discourage the
client from any excessive movements while in bed to prevent dislodging the implant.
The nurse should wear a lead apron when providing direct care to provide protection from the
radiation source and not turn their back toward the client, because the apron only shields the
front of the body. The nurse should also wear a dosimeter film badge to measure radiation
exposure.
Limit each visitor to 1 hr per day.: The nurse should limit each of the client's visitors to 30
min per day and instruct them to remain at least 1.8 m (6 ft) from the client at all times.
A nurse is preparing to administer a unit of PRBCs to a client. Which of the following
A. Remain with the client for the first 15 min of the infusion:
B. The nurse should remain with the client for the first 15 to 30 min of the infusion
C. Prime the blood administration IV tubing with lactated Ringer's solution.
D. The nurse should use 0.9% sodium chloride when transfusing blood to prevent clotting or
haemolysis of the RBCs.
Answer: B. The nurse should remain with the client for the first 15 to 30 min of the infusion
Rationale:
The nurse should remain with the client for the first 15 to 30 min of the infusion because
haemolytic reactions usually occur during the infusion of the first 50 mL of blood.
Verify the client's identity by using the client's room number prior to starting the transfusion.
The client's room number is not an acceptable client identifier. The nurse should ensure that
the name and number on the client's identification band matches the name and identification
number on the blood label. The client's identification, the blood compatibility, and the
expiration date of the blood should be verified by two nurses.
Infuse the unit of packed RBCs within 8 hr.: The nurse should transfuse the packed RBCs
within 2 to 4 hr based upon the client's age and cardiovascular status. Longer infusion times
increase the risk for bacterial contamination of the blood product.

A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after
hospitalization for heart failure. Based on the information in the client’s chart, which of the
following findings should the nurse report to the provider?
A. Potassium 4.1 mEq/L
B. Heart rate 55/min
C. SaO2 92%
D. Weight 67.1 kg (148 lb)
Answer: B. Heart rate 55/min
Rationale:
A. Potassium 4.1 mEq/L : The client's potassium level of 4.1 mEq/L is within the expected
reference range.
B. Heart rate 55/min: The client's heart rate of 55/min is a decrease from the client's baseline
of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report
this finding to the provider.
C. SaO2 92%: The nurse should ensure that the client's SaO2 level remains at or above 90%.
This finding is within the expected reference range.
D. Weight 67.1 kg (148 lb): The nurse should report a client's weight gain of 1.4 kg (3 lb) in a
day or 2.3 kg (5 lb) or more in a week.
A nurse is caring for a client who has a potassium level of 3 mEq/L/ Which of the following
assessment findings should the nurse expect?
A. Positive trousseaus sign
B. 4+ deep tendon reflexes
C. Deep respirations
D. Hypoactive bowel sounds
Answer: D. Hypoactive bowel sounds
Rationale:
Positive Trousseau's sign: positive Trousseau's sign indicates altered calcium levels.
4+ deep tendon reflexes: Deep tendon reflexes are used to monitor magnesium levels.
Deep respirations: Shallow respirations occur with hypokalaemia due to respiratory muscle
weakness.
Hypoactive bowel sounds: Hypokalaemia decreases smooth muscle contraction in the
gastrointestinal tract leading to decreased peristalsis.

A nurse is providing dietary teaching to a client who is postoperative following a
thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to
include which of the following foods that has the greatest amount of calcium in her diet.
A. 12 almonds
B. One small banana
C. 1 tbsp peanut butter
D. 1/2 cup tomato juice
Answer: A. 12 almonds
Rationale:
A. 12 almonds: The nurse should determine that almonds are the best source of calcium to
recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid
glands, which regulate calcium in the body, can result in hypocalcaemia.
B. One small banana: The nurse should recommend a different food because there is another
choice that contains more calcium. One small banana contains 5 mg of calcium.
C. 1 tbsp peanut butter: The nurse should recommend a different food because there is
another choice that contains more calcium. One tbsp of peanut butter contains 8 mg of
calcium.
D. 1/2 cup tomato juice: The nurse should recommend a different food because there is
another choice that contains more calcium. A half cup of tomato juice contains 12 mg of
calcium
A nurse in a community clinic is caring for a client who reports an increase in the frequency
of migraine headaches. To reduce the risk for migraine headaches, which of the following
foods should the nurse recommend the client avoid?
A. Shellfish
B. Aged cheese:
C. Enriched pasta
D. Peppermint candy
Answer: B. Aged cheese:
Rationale:
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine
headaches.

A nurse in an emergency department is caring for a client who reports vomiting and diarrhoea
for the past 3 days. Which of the following findings should indicate to the nurse that the
client is experiencing FVD?
A. HR 110/min
B. BP 138/90
C. Urine Specific Gravity 1.020
D. BUN 15 mg/dL
Answer: A. HR 110/min
Rationale:
Heart rate 110/min client who has a 3-day history of vomiting and diarrhoea is likely to have
fluid volume deficit and an elevated heart rate.
Blood pressure 138/90 mm Hg: A blood pressure of 138/90 mm Hg is within the expected
reference range. A client who has a 3-day history of vomiting and diarrhoea is likely to have
fluid volume deficit and hypotension.
Urine specific gravity 1.020: A urine specific gravity of 1.020 is within the expected
reference range. A client who has a 3-day history of vomiting and diarrhoea is likely to have
fluid volume deficit, which is indicated by a urine specific gravity greater than 1.030.
BUN 15 mg/dL: A BUN of 15 mg/dL is within the expected reference range. A client who has
a 3-day history of vomiting and diarrhoea is likely to have fluid volume deficit and a BUN
greater than 20 mg/dL.
A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new
prescription for metformin. Which of the following statements by the client indicates and
understanding of the teaching?
A. “I will monitor my blood sugar carefully”
B. I should take the medication with a meal
C. I can expect to gain weight while taking this medication
D. While taking this medication, I will experience flushing of my skin.”
Answer: B. I should take the medication with a meal
Rationale:
Metformin decreases the amount of glucose produced in the liver and increases tissue
sensitivity to insulin.
The client should take metformin with or immediately following meals to improve absorption
and to minimize gastrointestinal distress.

Typically, clients lose weight when beginning to take metformin due to nausea and vomiting.
Flushing of the skin is not an adverse effect of metformin. x.
I will monitor my blood sugar carefully because the medication increases the secretion of
insulin.”
A nurse is caring for a client who has anorexia, low grade fever, night sweats, and a
productive cough. Which of the following actions should the nurse take first?
A. Obtain a sputum sample.
B. Administer antipyretics.
C. Provide hand hygiene education.
D. Initiate isolation precautions.
Answer: A. Obtain a sputum sample.
The nurse should obtain a sputum sample to identify the micro-organisms that are causing the
client's illness. However, there is another action that the nurse should take first.
The nurse should administer antipyretics to treat the client's fever. However, there is another
action that the nurse should take first.
The nurse should provide hand hygiene education. However, there is another action that the
nurse should take first. vii. Initiate airborne precautions.
This client is exhibiting manifestations of tuberculosis. The greatest risk in this client
situation is for other people in the facility to acquire an airborne disease from this client.
Therefore, the first action the nurse should take is to initiate airborne precautions.
A nurse is assessing a male client for an inguinal hernia. Which of the following areas should
the nurse palpate to verify that the client has an inguinal hernia?
A. Palpate the area above the pubic bone.
B. Palpate the groin area, specifically the inguinal canal.
C. Palpate the lower abdomen near the umbilicus.
D. Palpate the scrotum and testicles.
Answer: B. Palpate the groin area, specifically the inguinal canal.
Rationale:
The nurse should palpate this location to assess the client for an inguinal hernia. An inguinal
hernia forms from the peritoneum, which contains part of the intestine, and can protrude into
the scrotum in men.

A nurse is performing a cardiac assessment for a client who has a MIM 2 days ago. Which of
the following actions should the nurse take first after hearing the following sound?
A. Obtain a 12-lead ECG for the client.
B. Request to obtain the client's cardiac enzymes
C. Check the client's blood pressure manually
D. Listen with the client on their left side
Answer: C. Check the client's blood pressure manually
Rationale:
Obtain a 12-lead ECG for the client. The nurse should obtain a 12-lead ECG to view the
electrical activity of the heart. However, there is another action that the nurse should take
first.
Request to obtain the client's cardiac enzymes: The nurse should request cardiac enzymes to
assess the client's cardiovascular status. However, there is another action that the nurse should
take first.
Check the client's blood pressure manually: The nurse should check the client's blood
pressure manually to obtain a baseline. However, there is another action that the nurse should
take first.
Listen with the client on their left side: When providing nursing care, the nurse should first
use the least invasive intervention. Therefore, after auscultating a murmur, the first action the
nurse should take is to place the client on their left side and listen to the heart again so that
the murmur can be heard more clearly.
A nurse is caring for a client who as ALS and is being admitted to the hospital with
pneumonia. Which of the following assessment findings is the nurse’s priority?
A. Temp 38.4 C
B. Increased respiratory secretion
C. Fluid intake of 200ml in the prior 8 hr
D. Limited range of motion
Answer: B. Increased respiratory secretion
Rationale:
Temperature 38.4º C (101.1º F) ii. A temperature of 38.4º C can indicate an infection, but it is
not the priority finding.
Using the airway, breathing, circulation approach to client care, the nurse should determine
that the priority assessment finding is increased respiratory secretions. These secretions place

the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the
ALS and the pneumonia. vi. Fluid intake of 200 mL in the prior 8 hr
Fluid intake of 200 mL in the past 8 hr can indicate a risk for dehydration, but it is not the
priority finding. viii. Limited range of motion
Limited range of motion can indicate a risk for impaired skin integrity, but it is not the
priority finding.
A nurse is conduction and admission history for a client who is to undergo a CT scan with an
IV contrast agent. The nurse should identify which of the following findings requires further
assessment?
A. History of asthma
B. Appendectomy 1 year ago
C. Penicillin allergy
D. TKA 6 months ago
Answer: A. History of asthma
Rationale:
A history of asthma requires further assessment before a CT scan with an IV contrast agent
because individuals with asthma may be at higher risk for allergic reactions to contrast media.
The nurse should evaluate the severity and control of the asthma, as well as any previous
experiences with contrast agents. Understanding the client’s respiratory status is crucial to
mitigate potential complications during the procedure. Additionally, if the client has a history
of asthma-related reactions to medications, this could further elevate the risk, warranting
closer monitoring or alternative imaging options. Overall, thorough assessment helps ensure
patient safety and optimal care.
A client who has a history of asthma has a greater risk of reacting to the contrast dye used
during the procedure. Other conditions that can result in a reaction to contrast media include
allergies to foods, such as shellfish, eggs, milk, and chocolate.
A. Appendectomy 1 year ago
B. Penicillin allergy
C. Total knee arthroplasty 6 months ago
D. Appendectomy 3 year ago
Answer: B. Penicillin allergy
Rationale:

Appendectomy 1 year ago: A history of an appendectomy does not have an effect on a CT
scan. However, clients who have a history of diabetes mellitus, renal impairment, or heart
failure have an increased risk for renal failure when contrast media is used and require further
screening.
Penicillin allergy: A penicillin allergy does not have an effect on a CT scan. However, a client
who is taking certain medications, such as aminoglycosides, NSAIDs, and the biguanide
metformin, is at increased risk for renal damage and requires further screening.
Total knee arthroplasty 6 months ago: A total knee arthroplasty does not have an effect on a
CT scan.
A nurse is providing discharge instruction to a client who has a partial thickness burn on the
hand. Which of the following instructions should the nurse include?
A. Change the dressing every 72 hr
B. Immobilize the hand with a pressure dressing
C. Take pain medication 30 minutes after changing the dressing
D. Wrap fingers with individual dressings
Answer: A. Change the dressing every 72 hr.
Rationale:
The instruction to change the dressing every 72 hours is appropriate for a partial thickness
burn because it allows for adequate healing while preventing infection. However, it’s
essential to ensure that the dressing is checked more frequently if there are signs of increased
drainage or infection. Proper wound care promotes healing and minimizes discomfort.
Additionally, the nurse should educate the client on signs of infection and when to seek
further medical attention. Regular assessment of the wound during dressing changes is crucial
for effective healing.
The nurse should instruct the client to change the dressing every 12 to 24 hr to allow for
wound inspection. The client should observe the wound closely for manifestations of
increased redness, warmth, drainage, edema, or foul odor, which can indicate an infection.
A. Immobilize the hand with a pressure dressing.
B. Take pain medication 30 min after changing the dressing.
C. Wrap fingers with individual dressings.
D. Use a regular adhesive bandage for coverage.
Answer: C. Wrap fingers with individual dressings.

Rationale:
A client who undergoes surgery to receive skin grafts for full-thickness burns should elevate
and immobilize the graft site with cotton pressure dressings for 3 to 5 days following the
procedure. This action prevents the graft from dislodging and allows for revascularization of
the wound.
The nurse should instruct the client to take pain medication 30 min before a dressing change
to decrease the level of pain during the procedure.
The nurse should instruct the client to wrap the fingers individually to allow for functional
use of the hand while healing occurs. The nurse should also instruct the client to perform
range-of-motion exercises to each finger every hour while awake to promote function of the
injured hand.
A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client
has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the
following actions should the nurse take first?
A. Obtain a prescription for ABGs
B. Administer IV Abx to the client
C. Instruct the client to use the incentive spirometer
D. Place the client in high fowler’s position.
Answer: D. Place the client in high fowler’s position.
Rationale:
The nurse should obtain a prescription for ABGs to monitor the client's oxygenation status
and determine the need for supplemental oxygen; however, another action is the priority.
The nurse should administer IV antibiotics to treat the type of pneumonia the client has
acquired; however, another action is the priority.
The nurse should instruct the client to use the incentive spirometer to improve their oxygen
status and expansion of the lungs; however, another action is the priority.
The greatest risk to this client is injury from airway obstruction. Therefore, the priority
intervention the nurse should take is to move the client into high-Fowler's position. HighFowler's position facilitates lung expansion and improves ventilation and gas exchange.
Positioning the client in high Fowler’s position helps to facilitate better lung expansion and
improve oxygenation, which is critical given the client's low SaO2 and dyspnea. Once the
client is positioned appropriately, the nurse can then proceed with other interventions.

A nurse is providing teaching for a female client who has recurrent UTI’s/ which of the
following information should the nurse include in the teaching?
A. Take tub baths daily
B. Drink at least 1 L of fluid daily
C. Wear underwear made of nylon
D. Void before and after intercourse
Answer: D. Void before and after intercourse
Rationale:
Take tub baths daily. ii. The client should take showers instead of tub baths to prevent
bacteria present in bath water from entering the urethra.
The client should drink 2 to 3 L of fluid daily to keep her urine dilute and to flush bacteria out
of the urinary tract.
The nurse should encourage the client to wear underwear made of cotton, which provides
improved airflow through the perineal area. Underwear made from nylon traps moisture and
provides an opportunity for bacterial growth.
The nurse should instruct the client to empty her bladder before and after intercourse, which
flushes bacteria out of the urinary tract and prevents the occurrence of infection.
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing.
A. Disease processes
B. Laboratory findings
C. Current medications
D. Family history
Answer: C. Current medications
Rationale:
A. Disease processes: A history of gout and hypertension will not affect the results of the
allergy skin testing. When reviewing a client's health record, the nurse should identify a
history of diseases that alter the immune response as an interfering factor that can cause false
negative results.
B. Laboratory findings: The client's laboratory values are within the expected reference
ranges and are not an indication for postponing allergy skin testing.
C. Current medications: The nurse should review the client's medication record and identify
medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and
glucocorticoids, such as prednisone, that can alter the allergy skin test results. These

medications can diminish the client's reaction to the allergens. The nurse should notify the
provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin
testing.
D. Family history: allergy skin testing results can be affected by age; infants and older adult
clients can have decreased reactivity to allergens. However, family history is not a factor in
consideration for postponing allergy skin testing.
A nurse in and emergency department is reviewing the provider’s prescription for a client
who sustained a rattlesnake bite to the lower leg. Which of the following prescription should
the nurse expect?
A. Apply ice to the client’s puncture wounds
B. Initiate corticosteroid therapy for the client
C. Keep the client’s leg above the heart level
D. Administer an opioid analgesic to the client
Answer: D. Administer an opioid analgesic to the client
Rationale:
The nurse should apply ice for a bite from a black widow spider to reduce the action of the
neurotoxin from the spider.
Initiate corticosteroid therapy for the client. iv. The nurse should expect a prescription for
antihistamines and corticosteroids for stings from bees and wasps.
The nurse should keep the affected extremity at heart level, not above or below it.
The nurse should expect a prescription for an opioid analgesic to promote comfort following
a rattlesnake bite.
A nurse is planning to provide discharge teaching for the family of an older adult client who
has hemianopsia and is at risk for falls. Which of the following instruction should the nurse
include?
A. Keep the clients personal care items in the bathroom
B. Keep the overhead lights on in the client’s bedroom while the client is sleeping
C. Remind the client to scan their complete range of vision during ambulation
D. Secure the client’s extension cords under carpeting.
Answer: C. Remind the client to scan their complete range of vision during ambulation
Rationale:

The nurse should instruct the client's family to keep the client's personal care items within the
client's reach to reduce the risk for falls.
The nurse should instruct the family to use nightlights in the client's bedroom and bathroom
to reduce the risk for falls. Keeping the overhead lights on while the client is sleeping can
disrupt the client's circadian rhythm.
The nurse should instruct the family to remind a client who has hemianopsia, or blindness in
half of the visual field, to use visual scanning to look over their complete range of vision
during ambulation. This practice can accommodate for the loss of vision and help to reduce
the risk for falls.
The nurse should instruct the client's family that they should secure extension cords to the
client's baseboards using electrical tape, rather than placing them under carpeting. This
practice can help to reduce the risk for falls.
A nurse is caring for a group of clients. The nurse should plan to make a referral to physical
therapy for which of the following clients?
A. A client who is receiving preoperative teaching for a right knee arthroplasty
B. A client who states they will have difficulty obtaining a walker for home use
C. A client who reports an increase in pain following a left hip arthroplasty
D. A client who is having emotional difficulty accepting they have a prosthetic leg.
Answer: A. A client who is receiving preoperative teaching for a right knee arthroplasty
Rationale:
A client who is receiving preoperative teaching for a right knee arthroplasty: The nurse
should make a referral to physical therapy for a client who is receiving preoperative teaching
for a knee arthroplasty so the client can begin understanding postoperative exercises and
physical restrictions.
A client who states they will have difficulty obtaining a walker for home use: The nurse
should make a referral to a social worker for a client who reports difficulty obtaining a walker
for home use.
A client who reports an increase in pain following a left hip arthroplasty: The nurse should
contact the provider for a client who is experiencing increased pain following a left hip
arthroplasty.
A client who is having emotional difficulty accepting that they have a prosthetic leg: The
nurse should refer the client to a counselor to assist with coping with the adjustment to the
need of a prosthetic leg.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty.
Which of the following actions should the nurse take?
A. Maintain adduction of the client’s legs
B. Encourage ROM of the hip up to a 120 degree angle
C. Place a pillow between the client’s legs
D. Keep the client’s hip internally rotated
Answer: C. Place a pillow between the client’s legs
Rationale:
The nurse should assist the client to maintain their legs in abduction. iii. Encourage range of
motion of the hip up to a 120° angle.
The client should not flex their hip greater than 90° to prevent hip dislocation.
The nurse should place a pillow between the client's legs to prevent hip dislocation.
Keep the client's hip internally rotated. ix. The nurse should not keep the client's hip
internally rotated, as this can lead to hip dislocation.
A nurse and an AP are caring for a client who has bacterial meningitis. The nurse should give
the AP which of the following instructions?
A. Wear a mask
B. Wear a gown
C. Keep the client’s room well lit
D. Maintain the HOB at a 45 degree elevation
Answer: A. Wear a mask
Rationale:
Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear
a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun
receiving antibiotic therapy.
Wear a gown.: A gown is necessary when caring for clients who require contact precautions.
Bacterial meningitis does not spread via direct contact.
Keep the client's room well-lit.: Staff caring for this client should keep the illumination in the
room dim and avoid bright light from windows to promote comfort and rest and avoid
photophobia.
Maintain the head of the bed at a 45° elevation.: Staff caring for this client should keep the
head of the bed at a 30° elevation.

A nurse is caring for a client who has hepatic encephalopathy that is being treated with
lactulose. The client is experiencing excessive stools. Which of the following findings is an
adverse effect of this medication
A. Hypokalaemia
B. Hypercalcemia
C. Gastrointestinal bleeding
D. Confusion
Answer: A. Hypokalaemia
Rationale:
Lactulose works by stimulating the production of excess stools to rid the body of excess
ammonia. These excessive stools can result in hypokalaemia and dehydration.
Lactulose rids the body of excess ammonia and can result in hyponatremia if the client
experiences diarrhoea. It does not have any specific effects on calcium levels.
A client who has hepatic encephalopathy is at risk for gastrointestinal bleeding due to the
decreased ability of the liver to produce clotting factors and the potential presence of
oesophageal varices. However, treatment with lactulose should not increase the risk for
bleeding.
Lactulose works by stimulating the production of excess stools to rid the body of excess
ammonia. Because ammonia is a toxin that contributes to hepatic encephalopathy, effective
treatment with lactulose should reduce confusion.
A nurse in an emergency dept is caring for a client who has full-thickness burns over 20% of
their total body surface area. After ensuring a patent airway and administering oxygen, which
of the following items should the nurse prepare to administer first?
A. IV fluids
B. Analgesia
C. Antibiotics
D. Tetanus toxoid
Answer: A. IV fluids
Rationale:
After establishing that the client's airway is secure and administering oxygen, evidence-based
practice indicates that the nurse should prepare to administer IV fluids to provide circulatory
support.

The nurse should prepare to administer analgesia to manage the client's pain. However,
evidence-based practice indicates that another action is the priority.
The nurse should prepare to administer antibiotics to prevent infection. However, evidencebased practice indicates that another action is the priority.
The nurse should prepare to administer tetanus toxoid. However, evidence-based practice
indicates that another action is the priority.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is
not available when the current infusion is nearly completed. Which of the following actions
should the nurse take?
A. Keep the line open with 0.9% sodium chloride until the new bag arrives
B. Administer dextrose 10% in water until the new bag arrives
C. Flush the line and cap the port until the new bag arrives
D. Decrease the infusion rate until the new bag arrives.
Answer: B. Administer dextrose 10% in water until the new bag arrives
Rationale:
Infusing 0.9% sodium chloride can injure the client by causing an alteration in blood glucose
levels.
TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is
temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid
a precipitous drop in the client's blood glucose level.
Flush the line and cap the port until the new bag arrives. vi. The nurse should maintain an
open IV line with an appropriate IV solution to prevent the client from experiencing an
alteration in blood glucose levels.
The nurse should continue infusing IV fluids with an appropriate IV to prevent the client
from experiencing an alteration in blood glucose levels.
A nurse is caring for a client in an acute care facility who is at risk for seizures. Which of the
following precautions should the nurse implement?
A. Place a padded tongue blade at the client’s bedside
B. Keep the side rails lowered on the client’s bed.
C. Maintain the client’s bed at hip level or above
D. Ensure that the client has a patent IV
Answer: C. Maintain the client’s bed at hip level or above.

Rationale:
Place a padded tongue blade at the client's bedside. ii. The nurse should never insert a padded
tongue blade in the client's mouth, because it can cause injury or occlude the client's airway.
Keep the side rails lowered on the client's bed. iv. The nurse should keep two or three side
rails up on the client's bed to prevent falls.
The nurse should keep the client's bed in the lowest position to prevent falls.
The nurse should ensure the client has IV access in the event that the client requires
medication to stop seizure activity.
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend?
A. Add full-fat yogurt to the diet
B. Add cabbage to the diet
C. Replace butter with coconut oil
D. Replace shellfish with red meat.
Answer: B. Add cabbage to the diet
Rationale:
Add full-fat yogurt to the diet.: To help reduce the risk for colorectal cancer, the client should
consume a diet that is low in fat and refined carbohydrates. Full-fat yogurt contains fat, and
many yogurt products also contain refined sugar.
Add cabbage to the diet.: to help reduce the risk for colorectal cancer, the client should
consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica
vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
Replace butter with coconut oil.: to help reduce the risk for colorectal cancer, the client
should consume a diet that is low in fat. Coconut oil, containing 100 g of fat per 100 g, is
higher in total fat than butter, which contains 81 g of fat per 100 g.
Replace shellfish with red meat.to help reduce the risk for colorectal cancer, the client should
avoid red meat because it is high in fat. The client's diet should contain lower-fat proteins,
such as shellfish and poultry with the skin removed.
A nurse in a provider’s office is assessing a client who has migraine headaches and is taking
feverfew to prevent headaches. The nurse should Identify what which of the following client
medications interacts with feverfew?
A. Meoprolol

B. Bupropion
C. Naproxen
D. Atorvastatin
Answer: C. Naproxen
Rationale:
Metoprolol: metoprolol does not interact with feverfew.
Bupropion: bupropion does not interact with feverfew.
Naproxen: both naproxen and feverfew impair platelet aggregation and place the client at risk
for bleeding.
Atorvastatin: the nurse should recognize that the effect of atorvastatin is decreased by St.
John's wort.
A nurse is providing teaching to a client who is receiving chemotherapy and has a new
prescription for epoetin alfa. Which of the following client statements indicates an
understanding of the teaching?
A. "I will monitor my blood pressure while taking this medication."
B. "I should take a vitamin D supplement to increase the effectiveness of the medication."
C. "I should inform the provider if I experience an increased appetite while taking this
medication."
D. "I will decrease the amount of protein in my diet while taking this medication."
Answer: A. "I will monitor my blood pressure while taking this medication."
Rationale:
The client should monitor their blood pressure while taking this medication because
hypertension is a common adverse effect and can lead to hypertensive encephalopathy.
The client requires an adequate intake of iron, folic acid, and vitamin B12 while taking this
medication because they are essential to the production of erythrocytes.
"I should inform the provider if I experience an increased appetite while taking this
medication."
Increased appetite is not an adverse effect of epoetin alfa. Adverse effects of epoetin alfa
include seizures, heart failure, myocardial infarction, stroke, thrombolytic event, and
hypertension.
The client should increase the amount of protein in their diet while receiving chemotherapy to
decrease the risk for infection.

A nurse is caring for a client who has a prescription for enalapril. The nurse should identify
which of the following findings as an adverse effect of the medication
A. Bradycardia
B. Tremors
C. Orthostatic hypotension
D. drowsiness
Answer: C. Orthostatic hypotension
Rationale:
The nurse should identify that tachycardia, not bradycardia, is an adverse effect of enalapril.
A client who is taking enalapril can experience dizziness rather than tremors.
The nurse should identify that dilation of arteries and veins causes orthostatic hypotension,
which is an adverse effect of enalapril.
The nurse should identify insomnia as an adverse effect of enalapril.
An older adult client is brought to an emergency department by a family member. Which of
the following assessment findings should cause the nurse to suspect that the client has
hypertonic dehydration?
A. Serum sodium level 145 mEq/L
B. Forearm skin tents when pinched
C. Respiratory rate decreased
D. Urine specific gravity 1.045
Answer: D. Urine specific gravity 1.045
Rationale:
A serum sodium level of 145 mEq/dL is within the expected reference range. A sodium level
higher than the expected reference range, or greater than 145 mEq/L, can be an indication of
excessive free water loss resulting in hypertonic dehydration.
Skin turgor can be an unreliable indication of dehydration in older adult clients because of
age-related changes to skin elasticity. The nurse should check an older adult client's skin
turgor on the sternum, rather than on the limbs, for a more reliable indicator.
The nurse should expect the client's respiratory rate to increase if dehydration occurs because
the decreased vascular fluid volume seen with dehydration decreases oxygenation and organ
perfusion, requiring a compensatory increase in the respiratory rate.
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an
increase in osmolarity, which is a manifestation of hypertonic dehydration.

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
A. Insert a padded tongue blade.
B. Apply oxygen.
C. Restrain the client.
D. Loosen restrictive clothing.
Answer: D. Loosen restrictive clothing.
Rationale:
The nurse should not insert anything into the client's mouth during the seizure. A tongue
blade can create a choking hazard and cause injury to the client's teeth and mouth.
Clients who experience a tonic-clonic seizure can become hypoxic for brief intervals and may
be offered in the postictal phase, but supplemental oxygen is not usually necessary.
The nurse should not restrain the client in any way during the seizure but should instead clear
the area of objects close to the client to prevent injury.
The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.
A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of
the following client statements indicates the client is successfully coping with the change?
A. "It is just easier to let my partner administer my insulin."
B. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror."
C. "I'm concerned I won't be able to read my blood sugar level"
D. "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to."
Answer: B. "I used to never worry about my feet. Now, I inspect my feet every day with a
mirror."
Rationale:
I. This statement does not indicate that the client is successfully coping with the change.
This statement indicates that the client is successfully coping with the change because the
client is performing preventive foot care to reduce the risk for complications.
"I'm concerned I won't be able to read my blood sugar level because the screen is so small."
This statement does not indicate that the client is successfully coping with the change. The
nurse should provide the client with a monitor that has a larger screen.
"I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to."
This statement does not indicate that the client is successfully coping with the change.

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed
with food after a meal. Which of the following actions should the nurse take first?
A. Check laboratory values for recent haemoglobin and haematocrit levels.
B. Establish a peripheral IV line for possible transfusion.
C. Call the laboratory to obtain a stat platelet count.
D. Obtain vital signs.
Answer: D. Obtain vital signs.
Rationale:
The nurse should check the client's most recent laboratory results, including haemoglobin and
haematocrit levels, as these provide information regarding the need for eventual blood
product replacement. However, there is another action the nurse should take first.
Although the nurse should initiate a peripheral IV line for saline or blood administration,
there is another action the nurse should take first.
Although drawing the client's blood to check for a low platelet count is important because a
low platelet level indicates problems with blood clotting, there is another action the nurse
should take first.
The first action the nurse should take using the nursing process is to assess the client's vital
signs. A client who has portal hypertension can develop esophageal varices, which are fragile
and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs
provides information about the client's condition that can contribute to decision making.
A nurse is providing discharge teaching to a client who has heart failure and a new
prescriptions for a potassium-sparing diuretic. Which of the following information should the
nurse include in the teaching?
A. Try to walk at least three times per week for exercise.
B. The development of a regular exercise routine can improve outcomes in clients who have
heart failure.
C. To increase stamina, walk for 5 min after fatigue begins.
D. Walking for 5 min after the onset of fatigue will not increase stamina and can exacerbate
the client's heart failure.
E. Take over-the-counter cough medicine for persistent cough.
F. The provider should approve the use of over-the-counter cough medication for a persistent
cough prior to use. A persistent cough can exacerbate the client's heart failure.

G. Use a salt substitute to reduce sodium intake.
H. Salt substitutes contain an increased amount of potassium, which can place the client at an
increased risk for hyperkalaemia.
Answer: A. Try to walk at least three times per week for exercise.
B. The development of a regular exercise routine can improve outcomes in clients who have
heart failure.
F. The provider should approve the use of over-the-counter cough medication for a persistent
cough prior to use. A persistent cough can exacerbate the client's heart failure.
Rationale:
Regular moderate exercise, like walking, improves cardiovascular health and quality of life in
heart failure patients. Clients should stop exercising if they experience fatigue to prevent
exacerbating heart failure symptoms. Consultation with a healthcare provider is essential
before using over-the-counter medications, as some can worsen heart failure. While reducing
sodium is crucial, clients on potassium-sparing diuretics should avoid salt substitutes that
may increase potassium levels. Education should emphasize safe manage.
A nurse is providing discharge instructions to a client following an upper GI series with
barium contrast. Which of the following information should the nurse provide?
A. Increase fluid intake
B. Take an over-the-counter antidiarrheal medication
C. Expect black, tarry stools
D. Follow a low-fiber diet
Answer: A. Increase fluid intake
Rationale:
Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct
the client to increase fluid intake to facilitate the elimination of the barium used during the
test.
Taking an over-the-counter antidiarrheal following an upper gastrointestinal series would
slow the elimination of the barium used during the test. The nurse should instruct the client to
take a laxative.
The client should expect stools to appear chalky white until the barium is completely
eliminated, which typically takes between 24 and 72 hr. Black, tarry stools are an indication
of gastrointestinal bleeding.

A low-fiber diet, used to treat diarrhoea, does not facilitate the elimination of the barium used
during the test. The nurse should recommend an increase in fiber intake instead.
A nurse is providing teaching to an older adult client who has cancer and a new prescription
for an opioid analgesic for pain management. Which of the following information should the
nurse include with the teaching?
A. "It is an expected effect to sleep through the day when taking this medication."
B. "Your constipation will be lessened as you develop a tolerance to the medication."
C. "You should void every 4 hours to decrease the risk of urinary retention."
D "If you experience ringing in your ears, your dose will need to be reduced."
Answer: C. "You should void every 4 hours to decrease the risk of urinary retention."
Rationale:
The nurse should instruct the client to report oversedation, which increases the risk for
respiratory depression.
The nurse should instruct the client that constipation is an adverse effect of opioid analgesics
and can be managed by increasing intake of fiber.
The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary
retention, which is an adverse effect of opioid analgesics.
Many medications, including aspirin and aminoglycosides, can cause ringing of the ears, but
this is not an adverse effect of opioid analgesics.
A nurse is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
A. Instruct the client to remain NPO after midnight before surgery.
B. Tell the client to practice deep breathing and coughing exercises before surgery.
C. Advise the client to take all prescribed medications, including anticoagulants, before
surgery.
D. Explain that they may need to have a drain after surgery.
Answer: A. Instruct the client to remain NPO after midnight before surgery.
Rationale:
Instructing the client to remain NPO (nothing by mouth) after midnight is crucial to prevent
aspiration during anesthesia. This is a standard preoperative instruction for most surgical
procedures, especially those involving general anesthesia.

While practicing deep breathing and coughing exercises is beneficial, this is typically
discussed during postoperative teaching rather than preoperative.
Clients are usually advised to hold anticoagulants before surgery to reduce the risk of
bleeding, so this statement is incorrect.
While explaining the possibility of needing a drain postoperatively is important, it is not the
priority action to take during preoperative teaching.
A nurse is providing preoperative teaching to a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?.
A. Teach the importance of a clear liquid diet after discharge.
B. Tell the client to remove the incisional adhesive strips 3 days after discharge.
C. Demonstrate ways to deep breath and cough.
D. Instruct the client to maintain bed rest for 48 hr.
Answer: C. Demonstrate ways to deep breath and cough.
Rationale:
The nurse should teach the client to advance to solid foods with the return of peristalsis,
which usually occurs within 1 to 2 days after surgery, and to introduce foods high in fat one at
a time to determine tolerance.
The nurse should tell the client that the incisional adhesive strips will begin to fall off 7 to 10
days after application and that the provider might remove the adhesive strips during that
timeframe.
The nurse should demonstrate deep breathing and coughing exercises and explain the
importance of splinting the incision to reduce the risk for respiratory complications.
The nurse should instruct the client to ambulate as soon as possible to prevent postoperative
complications, such as deep-vein thrombosis or pneumonia.
A nurse in in the emergency department is assessing a client who has a detached retina.
Which of the following should the nurse expect the client to report?
A. "It's like a curtain closed over my eye."
B. "This sharp pain in my eye started 2 hours ago."
C. "I've been having more and more difficulty seeing over the last few weeks."
D. Retinal detachment usually has a sudden onset.
E. "I seem to have more problems seeing different colors."
Answer: A. "It's like a curtain closed over my eye."

Rationale:
A retinal detachment is the separation of the retina from the epithelium. It can occur because
of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment
typically report the sensation of a curtain being pulled over part of the visual field.
Clients who have a retinal detachment may report seeing sudden flashes of light, a sensation
of a curtain being pulled over the eye, or floating dark spots. Retinal detachment is usually
painless.
Clients who have cataracts experience a loss in color perception. However, this is not a
manifestation of retinal detachment.
A home health nurse is assigned to a client who was recently discharged from a rehab center
after experiencing a right-hemispheric stroke. Which of the following neuro deficits should
the nurse expect to find when assessing the client?
A. Expressive aphasia
B. Left hemianopsia
C. Right hemiplegia
D. One-sided neglect
E. Visual spatial deficits
Answer: B. Left hemianopsia
D. One-sided neglect
E. Visual spatial deficits
Rationale:
Expressive aphasia is incorrect. Expressive aphasia, or an inability to express what one wants
to convey, occurs secondary to a left-hemispheric stroke.
Left hemianopsia is correct. Left hemianopsia, or blindness in the left half of the visual field,
occurs secondary to a right-hemispheric stroke.
Right hemiplegia is incorrect. Right hemiplegia occurs secondary to a left hemispheric stroke.
One-sided neglect is correct. One-sided neglect, or an unawareness of the affected side,
occurs secondary to a right-hemispheric stroke.
Visual spatial deficits is correct. Visual spatial deficits and loss of depth perception occur
secondary to a right-hemispheric stroke.

A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for
the past 3 days. Which of the following statements should the nurse include when instructing
a client?
A. "Take insulin even if you are unable to eat your regular diet."
B. "It's okay if your ketone levels are temporarily high."
C. "Monitor your blood glucose levels every 12 hours."
D. "Call the provider if your glucose levels reach 170 milligrams per deciliter."
Answer: A. "Take insulin even if you are unable to eat your regular diet."
Rationale:
The client should continue the prescribed medication regimen when ill to prevent
hyperglycemia.
The client should notify the provider if moderate to large amounts of ketones appear in the
urine.
The client should monitor blood glucose levels at least every 4 hr when ill.
The client should notify the provider if their blood glucose level is greater than 250 mg/dL.
A nurse is caring for a client who has a new prescription for TPN. The client is to receive
2,000 kcal per day. The TPN solution has 500 kcal/l. the IV pump should be set at how many
ml/hr?
Answer: Follow these steps to calculate the infusion rate using the Ratio and Proportion or
Desired Over Have method of calculation:
Step 1: What is the unit of measurement the nurse should calculate?
mL/hr
Step 2: What is the volume the nurse should infuse?
4,000 mL
Step 3: What is the total infusion time?
24 hr
Step 4: Should the nurse convert the units of measurement?
No
Step 5: Set up an equation and solve for X.
Volume (mL)
X mL/hr =
Time (hr)
4,000 mL

X mL/hr =
24 hr
X mL/hr = 166.67
Step 6: Round if necessary. 166.67 = 167 mL/hr
A nurse is assessing a client who had extracorporeal show wave lithotripsy (ESWL) 6 hr ago.
Which of the following findings should the nurse expect?
A. Stone fragments in the urine
B. Fever
C. Decreased urine output
D. Bruising on the lower abdomen
Answer: A. Stone fragments in the urine
Rationale:
Stone fragments in the urine: ESWL is an effort to break the calculi so that the fragments pass
down the ureter, into the bladder, and through the urethra during voiding. Following the
procedure, the nurse should strain the client's urine to confirm the passage of stones.
Fever: Fever following ESWL is a complication that is a result of microorganisms from an
underlying urinary tract infection colonizing or pyelonephritis.
Decreased urine output: A decrease in urine output following ESWL is a complication caused
by stone fragments obstructing urine flow.
Bruising on the lower abdomen: bruising on the lower back or flank of the affected side is
caused by the repeated shock waves directed toward the body during the ESWL procedure.
A nurse has received change of shift report for a group of clients. Which of the following
should the nurse assess first?
A. A client who is 1 day postoperative following abdominal surgery and reports pain of 4 on a
scale of 0 to 10
B. A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN
sublingual nitro-glycerine tablet
C. A client who has atopic dermatitis manifesting with scaling and excoriation of the skin and
reports severe itching
D. A client who has pneumonia manifesting with bilateral crackles and diminished breath
sounds

Answer: D. A client who has pneumonia manifesting with bilateral crackles and diminished
breath sounds
Rationale:
A client who is 1 day postoperative following abdominal surgery and reports pain of 4 on a
scale of 0 to 10 is stable because pain following surgery is an expected finding. Therefore,
there is another client the nurse should assess first.
When using the stable vs. unstable approach to client care, the nurse should assess this client
first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual
nitro-glycerine tablet could be unstable. This client might be experiencing angina or could be
having another MI.
A client who has atopic dermatitis with scaling and excoriation of the skin and reports severe
itching is stable because these are expected findings. Therefore, there is another client the
nurse should assess first.
A client who has pneumonia manifesting with bilateral crackles and diminished breath sounds
is stable because these are expected findings. Therefore, there is another client the nurse
should assess first.
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hrs ago.
Which of the following actions should the nurse take?
A. Inspect the cast for drainage once every 24 hr.
B. Check that one finger fits between the cast and the leg.
C. Perform neurovascular checks every 2 to 3 hr.
D. Make sure the client has a warm blanket covering the cast.
Answer: C. Perform neurovascular checks every 2 to 3 hr.
Rationale:
The nurse should inspect the cast for drainage and alignment at least once every 8 to 12 hr.
To make sure the cast is not too tight, the nurse should be able to slide one finger under the
cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an
issue 2 hr after application.
For the first 24 hr after cast application, the nurse should check the neurovascular status of
the client's leg every hour. The nurse does this by assessing sensation, motion, and
circulation.
The nurse should make sure the cast is uncovered to allow for thorough air drying of the
plaster. Also, the heat that is generated by the drying process has to escape.

A nurse is providing teaching to an older female client who has stress incontinence and a
BMI of 32. Which of the following statements by the client indicates an understanding of the
teaching?
A. "I am taking my progesterone daily."
B. "I am dieting to lose weight."
C. "I am limiting my daily fluid intake."
D. "I have switched my morning cups of coffee to hot tea."
Answer: B. "I am dieting to lose weight."
Rationale:
Topical estrogen, not progesterone, can improve the circulation of blood to the perineal area
and improve the tone of the periurethral muscles for a client who has experienced
menopause.
Excess weight creates increased abdominal pressure that can result in stress incontinence.
The client should maintain adequate intake of water for proper kidney function and hydration.
A client who has stress incontinence should avoid intake of caffeine because it is a bladder
irritant. Many tea and coffee beverages contain caffeine.
A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the
following is the priority assessment finding that the nurse should report to the provider?.
A. Restlessness
B. T3 level 215 ng/dL
C. Blood pressure 170/80 mm Hg
D. Decreased weight
Answer: C. Blood pressure 170/80 mm Hg
Rationale:
Restlessness is nonurgent because it is an expected finding for a client who has
hyperthyroidism. Therefore, there is another finding that is the priority to report.
An elevated T3 level is nonurgent because it is an expected finding for a client who has
hyperthyroidism. Therefore, there is another finding that is the priority to report.
Using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at
risk for thyroid storm.

Decreased weight is nonurgent because it is an expected finding for a client who has
hyperthyroidism. Therefore, there is another finding that is the priority to report.
A nurse is caring for a client who is experiencing super ventricular tachycardia. Upon
assessing the client, the nurse observes the following findings: heart rate 200/min, BP 78/40,
RR 30/min. Which of the following actions should the nurse take?
A. Defibrillate the client's heart.
B. Perform synchronized cardioversion.
C. Begin cardiopulmonary resuscitation.
D. Administer lidocaine IV bolus.
Answer: B. Perform synchronized cardioversion.
Rationale:
The nurse should defibrillate the client's heart for ventricular tachycardia or ventricular
fibrillation.
The nurse should perform synchronized cardioversion for a client who has supraventricular
tachycardia.
The nurse should initiate CPR for a client who is pulseless or not breathing.
The nurse should administer lidocaine IV bolus for a client who has a ventricular
dysrhythmia.
A nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin. Which of the following statements by the client indicates and
understanding of the teaching?
A. "I should take calcium supplements so the medication will work better in my system."
B. "I am taking this medication to increase my energy level."
C. "This medication can cause my blood pressure to drop."
D. "I will not need to restrict protein in my diet while taking this medication."
Answer: B. "I am taking this medication to increase my energy level."
Rationale:
A client who has chronic kidney disease should have adequate iron stores for erythropoietin
therapy to be effective. Clients are encouraged to consume foods high in iron such as beef,
liver, pork, and veal.

The goal of erythropoietin therapy is to increase the level of haematocrit in clients who have
anaemia. When the medication is effective, the client should have a decrease in fatigue and an
improvement in activity tolerance.
Therapy with erythropoietin increases RBC production, which can result in hypertension, not
hypotension.
Erythropoietin does not affect the client's protein requirements, but the client should continue
to restrict protein as prescribed by the provider to manage kidney disease.
A nurse is creating a plan of care for a client who has neutropenia as a result of
chemotherapy. Which of the following interventions should the nurse include in the plan?
A. Monitor the client's temperature every 4 hr.
B. Insert an indwelling urinary catheter for the client.
C. Request the client's bathroom to be cleaned three times each week.
D. Place a box of latex gloves just outside the client's room.
Answer: A. Monitor the client's temperature every 4 hr.
Rationale:
The nurse should monitor the temperature of a client who has neutropenia every 4 hr because
the client's reduced amount of leukocytes greatly increases the client's risk for infection.
The nurse should avoid the insertion of an indwelling urinary catheter for a client who has
neutropenia because it can greatly increase the client's risk for an infection.
The nurse should ensure that the client's room and bathroom are cleaned at least once each
day, rather than three times each week, to decrease the client's risk for infection.
The nurse should keep a dedicated box of disposable gloves in the client's room to decrease
the risk of contamination, which can lead to infection.
A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in the
plan of care to prevent Pseudomonas aeruginosa infection?
A. Encourage the client to eat raw fruits and vegetables.
B. Avoid placing plants or flowers in the client's room.
C. Limit visitors to members of the client's immediate family.
D. Wear an N95 respirator mask when providing care to the client.
Answer: B. Avoid placing plants or flowers in the client's room.
Rationale:

The nurse should identify that P. aeruginosa can be found in raw fruits and vegetables.
Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause
life-threatening complications. The nurse should ensure no one brings live plants or flowers
into the client's room.
The nurse does not need to limit visits to family members. However, the nurse should
prohibit visits from those at risk for P. aeruginosa infection, such as anyone who is ill, other
hospitalized clients, and small children.
P. aeruginosa spreads by contact, either on health care workers' hands or contaminated
equipment. It is not airborne, so respirator masks are unnecessary.
A nurse is planning teaching for a client who has bladder cancer and is to undergo a
cutaneous diversion procedure to establish a ureterostomy. Which of the following statements
should the nurse include in the teaching?
A. "You will still have the urge to void."
B. "You can apply an aspirin tablet to the pouch to reduce odor."
C. "You should cut the opening of the skin barrier one-eighth inch wider than the stoma."
D. "You should use a moisturizing soap when washing the skin around the stoma."
Answer: C. "You should cut the opening of the skin barrier one-eighth inch wider than the
stoma."
Rationale:
During the procedure, the client's bladder is removed and the ureters are brought to the skin
surface of the abdomen to form a stoma, from which urine will flow into an external ostomy
bag. Therefore, the client will not have an urge to void.
The client should not add an aspirin tablet to the pouch, because it can ulcerate the stoma.
The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to
minimize irritation of the skin from exposure to urine.
The client should avoid using moisturizing soaps to clean the skin around the stoma because
it will prevent the pouch from adhering to the skin.
A nurse is teaching a young adult client how to perform testicular self-examination. Which of
the following instructions should the nurse include?
A. Compare both testicles by examining them simultaneously.
B. Roll each testicle between the thumb and fingers.
C. Perform testicular self-examination before a warm bath or shower.

D. Perform self-examination of the testicles every 2 weeks.
Answer: B. Roll each testicle between the thumb and fingers.
Rationale:
The nurse should instruct the client to use both hands to examine each testicle separately.
The nurse should instruct the client to roll each testicle horizontally between the thumbs and
fingers to feel for any lumps deep in the center of the testicle.
The nurse should inform the client that testicle self-examination should be performed either
during or after a warm bath or shower.
It is unnecessary to self-examine the testicles every 2 weeks. Once a month is sufficient.
A nurse is assessing a client following the administration of magnesium sulphate 1g IV bolus.
For which of the following adverse effect should the nurse monitor?
A. Hyperreflexia
B. Increased blood pressure
C. Respiratory paralysis
D. Tachycardia
Answer: C. Respiratory paralysis
Rationale:
Hyperreflexia is seen in clients who have hypomagnesemia. Depressed or absent reflexes are
an adverse effect of magnesium sulphate.
Magnesium sulphate is used to treat cardiac dysrhythmias, such as torsade’s de pointes and
refractory ventricular fibrillation. However, magnesium sulphate administration can result in
systemic vasodilation and subsequent hypotension.
The nurse should monitor a client who is receiving magnesium sulphate via IV bolus closely
as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory
system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulphate.
Magnesium sulphate is used to treat cardiac dysrhythmias, such as torsade’s de pointes and
refractory ventricular fibrillation. Depressed cardiac function, including heart block, is an
adverse effect of magnesium sulphate.
A nurse is caring for a client who has diabetic ketoacidosis DKA. Which of the following
laboratory findings should the nurse expect?
A. Negative urine ketones
B. BUN 32 mg/dL

C. pH 7.43
D. HCO3- 23 mEq/L
Answer: B. BUN 32 mg/dL
Rationale:
A client who has DKA experiences ketosis, which results in ketones in the urine and blood.
DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client
who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the
excess glucose present in the urine.
The nurse should expect a client who has DKA to have a pH level less than 7.35 due to the
increased production of ketones, which results in metabolic acidosis. The client might exhibit
Kussmaul respirations, which are deep and rapid respirations that compensate for the
decreased pH. Sodium bicarbonate is administered for severe acidosis when the client's pH
level is less than 7.
The nurse should expect a client who has DKA to have an HCO3- less than 15 mEq/L. This
decreased value is due to an increased production of ketones, resulting in metabolic acidosis.
A nurse is assessing a client who has hypertension and takes propranolol. Which of the
following findings should indicate that the client is having an adverse reaction to this
medication?
A. Report of a night cough
B. Report of tinnitus
C. Report of excessive tearing
D. Report of increased salivation
Answer: A. Report of a night cough
Rationale:
The nurse should recognize that a night cough is an early indication of heart failure and report
this adverse reaction to the provider.
Propranolol is a nonselective beta-adrenergic antagonist that has sensory effects, including
dry eyes and vision changes. However, tinnitus is not an adverse effect of propranolol.
Propranolol is a nonselective beta-adrenergic antagonist that can affect the heart, the lungs,
and the eyes. Ophthalmic adverse effects include blurred vision and dry eyes.
Propranolol is a nonselective beta-adrenergic antagonist that has several gastrointestinal
effects, such as dry mouth, abdominal cramping, constipation, and diarrhoea.

A nurse is caring for a client who has viral pneumonia. The client’s pulse oximeter readings
have fluctuated between 79% and 88% for the last 30 minutes. Which of the following
oxygen delivery systems should the nurse initiate to provide the highest concentration of
oxygen?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial rebreather mask
Answer: A. Nonrebreather mask
Rationale:
The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the
client. A client who has an unstable respiratory status should receive oxygen via a
nonrebreather mask.
The nurse should initiate a Venturi mask for a client who requires an exact oxygen flow. A
Venturi mask can only deliver an oxygen concentration between 24% and 50%.
The nurse should initiate a simple face mask for a client who requires short-term
supplemental oxygen. A simple face mask can only deliver an oxygen concentration between
40% and 60%. A simple face mask does not usually fit well and can lead to skin breakdown.
The nurse should initiate a partial rebreather mask for a client who can sustain adequate
oxygen saturation levels with a mixture of room air and oxygen. A partial rebreather allows a
portion of room air to be inhaled along with the oxygen, diluting the oxygen concentration to
a range between 60% and 75%.
A nurse is planning care to decrease psychosocial health issues for a client who is starting
dialysis treatments for chronic kidney disease. Which of the following interventions should
the nurse include in the plan?
A. Remind the client that dialysis treatments are not difficult to incorporate into daily life.
B. Inform the client that dialysis will result in a cure.
C. Tell the client that it is possible to return to similar previous levels of activity.
D. Begin health promotion teaching during the first dialysis treatment.
Answer: C. Tell the client that it is possible to return to similar previous levels of activity.
Rationale:
The nurse should inform the client of the difficulty of incorporating dialysis into daily life to
allow the client to develop realistic expectations.

The nurse should inform the client that dialysis is not a cure and is a life-long management
for chronic kidney disease.
The nurse should help the client develop realistic goals and activities to have a productive
life.
The nurse should begin health and lifestyle teaching in the first weeks after starting the
dialysis treatment once the client feels better physically and emotionally.
A nurse is caring for a client who is receiving morphine for daily dressing changes. The client
tells the nurse, “I don’t want any more morphine because I don’t want to get addicted.”
Which of the following actions should the nurse take?
A. Administer a placebo to the client without their knowledge.
B. Instruct the client on alternative therapies for pain reduction.
C. Tell the client not to worry about addiction to prescribed narcotics.
D. Suggest the client receive a different opioid for pain reduction.
Answer: B. Instruct the client on alternative therapies for pain reduction.
Rationale:
The nurse should not administer a placebo to a client who thinks it is an active medication,
because this action is a violation of client rights.
The nurse should respect the client's concerns and offer nonpharmacologic alternatives to
pain management, such as relaxing activities and distraction.
This response by the nurse is nontherapeutic because it dismisses the client's concerns.
By suggesting the client receive a different opioid for pain reduction, the nurse is
disregarding the client’s concerns about opioid use disorder.
A nurse is assessing a client who has had a suspected stroke. The nurse should place the
priority on which of the following findings?
A. Dysphagia
B. Aphasia
C. Ataxia
D. Hemianopsia
Answer: A. Dysphagia
Rationale:
Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation
and function within the oral cavity. Therefore, the nurse should place priority on this finding.

Aphasia indicates that the client is at risk for communication impairment. However, another
finding is the priority.
Ataxia indicates that the client is at risk for injury from falling. However, another finding is
the priority.
Hemianopsia indicates the client is at risk for injury when ambulating. However, another
finding is the priority.
A nurse is caring for a client who has HIV. Which of the following findings indicates a
positive response to the prescribed HIV treatment?
A. Decreased T cells
B. Increased creatinine clearance
C. Increased eosinophils
D. Decreased viral load
Answer: D. Decreased viral load
Rationale:
T cells are responsible for cellular immunity. The T cell count indicates the body's ability to
fight opportunistic infections and cancer. A decreased T cell count indicates the progression
of HIV. Once the T cell count falls below 200 cells/mm3, the client receives a diagnosis of
AIDS.
Creatinine clearance measures the ability of the kidneys to filter the blood. An increased
creatinine clearance level indicates compromised renal function, which is a common
occurrence in clients who have HIV.
Eosinophils are a type of leukocyte that are responsive to parasitic infections and allergic
reactions. An increase in eosinophils indicates the presence of infection.
Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased
viral load indicates a positive response to the prescribed HIV treatment.
A nurse in an emergency department is caring for a client who is experiencing Thyroid
Storm. Which of the following manifestations should the nurse expect?
A. Fever
B. Nonpitting edema
C. Hypertension
D. Tachycardia
E. Hypoglycemia

Answer: A. Fever
Rationale:
Fever is correct. The nurse should expect the client to have a fever because of the excessive
thyroid hormone release.
Nonpitting edema is incorrect. Nonpitting edema is a manifestation of myxedema coma, a
complication of hypothyroidism.
Hypertension is correct. The nurse should expect one of the early manifestations of thyroid
storm to include systolic hypertension because of the excessive thyroid hormone release.
Tachycardia is correct. The nurse should expect the client to have tachycardia because of the
excessive thyroid hormone release.
Hypoglycemia is incorrect. Hypoglycemia is a manifestation of myxedema coma, a
complication of hypothyroidism.
A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the
following findings should the nurse identify as a manifestation of chronic
glomerulonephritis?
A. Metabolic alkalosis
B. Hyperkalaemia
C. Increased haemoglobin
D. Hypophosphatemia
Answer: B. Hyperkalaemia
Rationale:
A client who has chronic glomerulonephritis can experience metabolic acidosis as a result of
bicarbonate loss and retention of hydrogen ions.
The nurse should identify that a client who has chronic glomerulonephritis can experience
hyperkalaemia as a result of kidney failure. Kidney failure results in decreased excretion of
potassium.
A client who has chronic glomerulonephritis can experience anaemia as a result of decreased
RBC production.
A client who has chronic glomerulonephritis can experience hyperphosphatemia as a result of
decreased excretion of phosphorus through the kidneys.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing’s triad?

A. Hypotension
B. Tachypnea
C. Nuchal rigidity
D. Bradycardia
Answer: D. Bradycardia
Rationale:
A client who has increased intracranial pressure from a traumatic brain injury can develop
hypertension, which is one component of Cushing's triad.
A client who has a traumatic brain injury can develop decreased cerebral blood flow, which
results in increased arterial pressure. The changes to arterial pressure cause changes in blood
pressure. However, respirations are not affected.
Nuchal rigidity, or neck stiffness, is an indication of meningitis.
A client who has increased intracranial pressure from a traumatic brain injury can develop
bradycardia, which is one component of Cushing's triad. The other components of Cushing's
triad are severe hypertension and a widened pulse pressure.
A nurse in a provider’s office is caring for a client who requests sildenafil to treat erectile
dysfunction? Which of the following statements should the nurse make?
A. "You might need to take a stool softener while taking this medication."
B. "You will not be able to use sildenafil if you have diabetes."
C. "You will need to limit your caffeine intake if you start taking sildenafil."
D. "You will not be able to use sildenafil if you are taking nitro-glycerine."
Answer: D. "You will not be able to use sildenafil if you are taking nitro-glycerine."
Rationale:
Sildenafil can cause diarrhea, rather than constipation.
Diabetes mellitus is not a contraindication for the use of sildenafil. Clients who have renal,
hepatic, or cardiovascular disease should use sildenafil cautiously.
A client who is taking sildenafil does not need to limit caffeine intake. However, high-fat
meals can decrease absorption of the medication.
The client should not use sildenafil when taking nitro-glycerine because both medications can
cause vasodilation and lead to significant hypotension.
A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of
the following instructions should the nurse include in the teaching?

A. Take an antacid before meals and at bedtime.
B. Increase fiber intake to at least 30 g per day.
C. Drink ginger tea daily.
D. Consume no more than 1 L of water per day.
Answer: B. Increase fiber intake to at least 30 g per day.
Rationale:
Antacids are used to manage manifestations of gastric reflux and dyspepsia, not cramps and
pain associated with diarrhoea and constipation. Anticholinergic or antispasmodic agents can
be prescribed to control cramping.
Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
Ginger tea is useful for treating nausea, not cramping. Additionally, a client who has IBS
should avoid dairy products, raw fruits, and grains that can cause bloating.
The client should consume at least 2 L of water daily to promote regular bowel function.
A nurse is caring for a client who is on bed rest and has new prescription for enoxaparin
subcutaneous. Which of the following actions should the nurse take?
A. Monitor the client's INR daily.
B. Expel air bubbles when using a prefilled syringe.
C. Inject the medication into the anterolateral abdominal wall.
D. Massage the injection site after administration.
Answer: C. Inject the medication into the anterolateral abdominal wall.
Rationale:
A client who is taking enoxaparin does not require a daily INR. The nurse should periodically
compare the client's CBC with a baseline CBC.
The nurse should plan to follow the injection of the medication with the air bubble located at
the site of the plunger in the prefilled syringe. The air bubble ensures that the client receives
the whole dose of the medication.
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall
to enhance medication absorption and prevent hematoma formation.
The nurse should avoid massaging the client's injection site after administration to minimize
bruising.

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for
omeprazole. The nurse should instruct the client that the medication provides relief by which
of the following actions?
A. Neutralizing gastric acid
B. Reducing the growth of ulcer-causing bacteria
C. Coating the stomach lining
D. Suppressing gastric acid production
Answer: D. Suppressing gastric acid production
Rationale:
Antacids, such as aluminium hydroxide, neutralize gastric acid.
Antibiotics, such as amoxicillin, reduce the growth of ulcer-causing bacteria Helicobacter
pylori.
Anti-ulcer medications, such as sucralfate, coat the stomach lining and adhere to the ulcer
site.
Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by
suppressing gastric acid production.
A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory results to be below the expected reference range?
A. Amylase
B. Alkaline phosphatase
C. Bilirubin
D. Calcium
Answer: D. Calcium
Rationale:
An elevated amylase level is an expected finding in a client who has pancreatitis due to
injured pancreatic cells.
An elevated alkaline phosphatase level is an expected finding in a client who has pancreatitis
with biliary involvement.
An elevated bilirubin level is an expected finding in a client who has pancreatitis with biliary
involvement.
A client who has pancreatitis is expected to have decreased calcium and magnesium levels
due to fat necrosis

A nurse is assessing group of clients for indications of role changes. The nurse should
identify that which of the following clients is at risk for experiencing a role change?
A. A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose
B. A client who had a cholecystectomy and is starting on a modified-fat diet
C. A client who has Crohn's disease and is experiencing diarrhoea three times a day
D. A client who has multiple sclerosis and is experiencing progressive difficulty ambulating
Answer: D. A client who has multiple sclerosis and is experiencing progressive difficulty
ambulating
Rationale:
The client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose can
remain independent and active and is not at risk for experiencing a role change.
The client who had a cholecystectomy with a diet change can remain independent and active
and is not at risk for experiencing a role change.
The client who has Crohn's disease and is experiencing diarrhoea can remain independent and
active and is not at risk for experiencing a role change.
The nurse should identify that progression of a neurologic disease such as multiple sclerosis
can lead to a role change as the client becomes less independent.
A nurse is caring for a client who has a leg cast and is returning demonstration on the proper
use of crutches while climbing stairs.
A. The client should first place their body weight on the crutches.
B. The client should step up with the injured leg first, followed by the crutches.
C. The client should advance the crutches and then step up with the uninjured leg.
D. The client should keep the crutches under their arms while climbing stairs.
Answer: C. The client should advance the crutches and then step up with the uninjured leg.
Rationale:
Next, they should advance the unaffected leg onto the stair. Third, they should shift their
weight from the crutches to the unaffected leg. Last, they should bring the crutches and the
affected leg up to the stair.
A nurse is performing a dressing change for a client who is recovering from a hemicolectomy.
When removing the dressing, the nurse notices that part of the bowel is protruding through
the abdomen. Which of the following actions should the nurse take first?
A. Place the client in a supine position.

B. Measure vital signs.
C. Cover the wound with a sterile, saline-moistened dressing.
D. Call for help.
Answer: C. Cover the wound with a sterile, saline-moistened dressing.
Rationale:
The nurse should place the client in a supine position to promote blood flow to the vital
organs. However, evidence-based practice indicates that another action is the priority.
The nurse should measure the client's vital signs to monitor for complications. However,
evidence-based practice indicates that another action is the priority.
The nurse should cover the wound with a sterile, saline-moistened dressing to protect the
organs. However, evidence-based practice indicates that another action is the priority.
Evidence-based practice indicates that the nurse should first stay with the client and call for
assistance. The client will require emergency surgery and is at risk for shock; therefore, the
nurse should obtain immediate assistance.

VERSION 4
ATI MED-SURG PROCTORED EXAM PRACTICE QUESTIONS WITH
ANSWERS (134 Q/A)
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 25 mEq/L
4) Urine specific gravity 1.035
Answer: 3) Potassium 25 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) Limit intake of whole grains while taking this medication.
4) Take this medication with milk.
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-glycerin 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 3way 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."
The biopsy
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) 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
5) Reducing the amount of narcotics needed for pain relief
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 motorvehicle 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.
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
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 anaemia 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 anaemia 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 anaemia?
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."