2021 HESI PN Medical Surgical Proctored Exam Version 8-10 With Answers-197 Solved Questions

VERSION 8
ATI MED SURG REMEDIATION COMPLTE SOLUTION
A nurse is caring for a client following a bone marrow biopsy. What information should the
nurse include in the discharge education?
Answer: • Teach the client to report excessive bleeding and evidence of infection to the
provider.
• Teach the client to check the biopsy site daily. Keep the dressing clean, dry, and intact.
• If sutures are in place, remind the client to return in 7-10 days to have them removed.
What dietary education should the nurse provide to a client diagnosed with a hiatal hernia?
Answer: • Avoid eating immediately prior to going to bed.
• Avoid foods and beverages that decrease LES pressure (fatty and fried foods, chocolate,
coffee, peppermint, spicy foods, tomatoes, citrus fruits, and alcohol).
A nurse is caring for a client with chronic gastritis. Provide three (3) dietary
recommendations the nurse should include in client education?
Answer: • Assist the client in identifying foods that are triggers.
• Provide small, frequent meals and encourage the client to eat slowly.
• Advise the client to avoid alcohol, caffeine, and foods that can cause gastric irritation.
A nurse is caring for a client who has been admitted with renal calculi. List three (3)
interventions the nurse will take in the management of renal calculi.
Answer: • Strain all urine to check for passage of the calculus and save the calculus for
laboratory analysis.
• Encourage increased oral intake to 3L/day unless contraindicated.
• Encourage ambulation to promote passage of calculus.
Define the following types of urinary incontinence: Stress, urge, overflow, reflex, functional,
total.
Answer: • Stress: loss of small amounts of urine from increased abdominal pressure without
bladder muscle contraction with laughing, sneezing, or lifting.

• Urge: inability to stop urine flow long enough to reach the bathroom due to an overactive
detrusor muscle with increased bladder pressure.
• Overflow: urinary retention from bladder overdistention and frequent loss of small amounts
of urine due to obstruction of the urinary outlet or an impaired detrusor muscle.
• Reflex: involuntary loss of moderate amount of urine usually without warning due to
hyperreflexia of the detrusor muscle, usually from spinal cord dysfunction.
• Functional: loss of urine due to factors that interfere with responding to the need to urinate,
such as cognitive, mobility, and environmental barriers.
• Total: unpredictable, involuntary loss of urine that generally does not respond to treatment.
A nurse is caring for a client with pneumonia. What are three (3) physical assessment
findings that are noted with the development of pneumonia?
Answer: • Pleuritic chest pain (sharp)
• Sputum production (yellow-tinged)
• Dull percussion over areas of consolidation
• Decreased oxygen saturation levels
A nurse is caring for a client scheduled for a liver biopsy. What nursing actions should be
taken before, during and after this procedure?
Answer: • Inform client that biopsy through venous route reduces the risk of haemorrhage.
• Position the client to the right side for 1-2 hours to ensure haemostasis.
• Monitor for haemorrhage (coagulation studies, frank bleeding).
A nurse is caring for a client with colorectal cancer who is scheduled for a colectomy. What
preoperative and post-operative education should be provided to this client?
Answer: • Preoperative:
• Educate the client regarding preoperative diet (clear liquids several days prior to surgery).
• Instruct the client to complete bowel prep with cathartics.
• Inform client of the administration of antibiotics (neomycin, metronidazole) to eradicate
intestinal flora.
• Post-operative:
• Teach client regarding turning and deep breathing.
• Educate the client regarding the care of the incision, activity limits, and ostomy care, if
applicable.

• Provide information regarding management of postoperative complications, including
incontinence or sexual dysfunction (most likely to occur with AP resection).
A nurse is caring for a client with Cushing’s disease. Would the nurse expect this client’s
plasma cortisol levels to be increased or decreased?
Answer: Increased
A client is diagnosed with Addisonian Crisis. List the lab values that will be affected by this
disease process.
Answer: • Serum electrolytes
• Potassium: increased
• Sodium: decreased
• Calcium: increased
• BUN: increased
• Creatinine: increased
• Serum glucose: normal to decreased
• Serum cortisol: decreased
• ACTH stimulation test: ACTH is infused, and the cortisol response is measured 30 minutes
and 1 hour after the injection. With primary adrenal insufficiency, plasma cortisol levels do
not rise. With secondary adrenal insufficiency, plasma cortisol levels are decreased.
What are the manifestations of diabetic ketoacidosis?
Answer: • Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• GI effects: nausea, vomiting, abdominal pain
• Blurred vision
• Headache
• Weakness
• Orthostatic hypotension
• Fruity odor of breath
• Kussmaul respirations
• Metabolic acidosis

• Mental status changes
A nurse is caring for a client undergoing a clonidine suppression test to identify a
pheochromocytoma. If a client has a pheochromocytoma and is administered clonidine, what
will the outcome be?
Answer: • If a client does not have a pheochromocytoma, clonidine suppresses
catecholamines release and decreases the level of catecholamines (decreases blood pressure).
• If the client has a pheochromocytoma, the clonidine has no effect (no decreased blood
pressure).
A nurse is caring for a client who underwent a kidney transplant. List the cause,
manifestations and treatment for the following types of transplant rejection: Hyperacute,
Acute, Chronic.
Answer: • Hyperacute (occurs within 48 hours after surgery)
• Cause: an antibody-mediated response causing small blood clots to form in the transplanted
kidney that occlude vessels and result in massive cellular destruction. This process is not
reversible.
• Manifestations: fever, hypertension, pain at the transplant site
• Treatment: immediate removal of the donor kidney
• Acute (occurs within 1 week to 2 years after surgery) o Cause: an antibody mediated
response causing vasculitis in the donor kidney, and cellular destruction starts with
inflammation that causes lysis of the donor kidney.
• Manifestations: oliguria, anuria, low-grade fever, hypertension, tenderness over transplanted
kidney, lethargy, azotemia, and fluid retention
• Treatment: involves increased doses of immunosuppressive medications
• Chronic (occurs gradually over months to years) o Causes: blood vessel injury from
overgrowth of the smooth muscles of the blood vessels causing fibrotic tissue to replace
normal tissue resulting in a nonfunctioning donor kidney.
• Manifestations: gradual return of azotemia, fluid retention, electrolyte imbalance, and
fatigue
• Treatment: conservative (monitor kidney status, continue immunosuppressive therapy) until
dialysis is required.
What are some common complications related to internal pacemaker insertion?

Answer: • Infection or hematoma at insertion site
• Pneumothorax or hemothorax
• Arrhythmias
To remember right sided versus left side heart failure symptoms (HEAD/CHOP)
Answer: Right sided (HEAD) H- Hepatomegaly
E- Edema (Bipedal)
A- Ascites
D- Distended Neck Vein
Left sided (CHOP)
C- Cough
H- Hemoptysis
O- Orthopnea
P- Pulmonary Congestion (crackles/ rales)
To remember signs and symptoms of Cushing's:
Answer: • Remember the mnemonic: “STRESSED” (remember there is too much of the
STRESS hormone CORTISOL)
• Skin fragile
• Truncal obesity with small arms
• Rounded face (appears like moon), Reproductive issues amennorhea and ED in male(due to
adrenal cortex’s role in secreting sex hormones)
• Ecchymosis, Elevated blood pressure
• Striae on the extremities and abdomen (Purplish)
• Sugar extremely high (hyperglycemia)
• Excessive body hair especially in women…and Hirsutism (women starting to have male
characteristics), Electrolytes imbalance: hypokalemia
• Dorsocervical fat pad (Buffalo hump), Depression
To remember signs and symptoms of Addison's:
Answer: • Remember the phrase: “Low STEROID Hormones” (remember you have low
production of aldosterone & cortisol which are STEROID hormones)
• Sodium & Sugar low (due to low levels of cortisol which is responsible for retention
sodium and increases blood glucose), Salt cravings

• Tired and muscle weakness
• Electrolyte imbalance of high Potassium and high Calcium
• Reproductive changes…irregular menstrual cycle and ED in men low blood pressure (at
risk for vascular collapse)….aldosterone plays a role in regulating BP
• Increased pigmentation of the skin (hyperpigmentation of the skin) Diarrhea and nausea,
Depression
Also, quick note on Hepatitis - the way that I remember the routes of transmission.... If it has
a VOWEL (A or E) it comes from the BOWEL
Answer: • All others are blood transmission. Thyroid disorders and analogy with Tigger and
Eeyore (silly, but it works)
• Tigger has hyperthyroidism: bouncing around (tremors, excitability. Nervousness,
irritability) weight loss as he is always moving, tachycardic as he never stops moving,
everything is heightened: sweating, more frequent bowel movements, increased appetite,
can't sleep, fatigued, increased sensitivity to heat
Eeyore has hypothyroidism: everything is slowing down: constipation, weight gain, puffy
face, slowed heart rate, depression, increased sensitivity to cold
• Lab Value Review
• While lab values vary slightly according to the source, knowing an average range for the
following common lab tests will be very helpful when answering questions.
Answer: • Sodium 136-145 mEq/L
• Potassium 3.5-5.0 mEq/L
• Total Calcium 9.0-10.5 mg/dL
• Magnesium 1.3-2.1 mEq/dL
• Phosphorus 3.0 – 4.5 mg/dL
• Chloride 98-106 mEq/L
• BUN 10-20 mg/dL
• Glucose 70-105 mg/dL
• HgbA1c 4-6%
• WBC 5,000-10,000/mm3
• RBC Men 4.7-6.1 million/uL, Women 4.2-5.4 million/uL
• Hemoglobin Men 14-18 g/dL, Women 12-16 g/dL
• Hematocrit Men 42-52%, Women 37-47% Platelet 150,000-400,000/mm3 pH 7.35-7.45

• pCO2 35 to 45 mm Hg p02 80-100 mm Hg HCO3 21-28 mEq/L
• Normal PT = 11-12.5 sec, Normal INR = 0.8-1.1 (Therapeutic INR 2-3)
• Normal PTT = 30-40 sec (Therapeutic PTT 45-80 sec)
• Digoxin 0.8 to 2.0 ng/mL
• Lithium 0.4 to 1.4 mEq/L
• Phenobarbital 10-40 mcg/mL
• Dilantin 10-20 mcg/mL
• Theophylline 10-20 mcg/mL

Version 9
ATI MED-SURG PART A
A nurse is reinforcing discharge teaching about wound care with a family member of a client
who is postoperative. Which of the following should the nurse include in the teaching?
A. Administer an analgesic following wound care.
B. Irrigate the wound with povidone iodine.
C. Cleanse the wound with a cotton-tipped applicator.
D. Report purulent drainage to the provider.
Answer: D. Report purulent drainage to the provider.
Rationale:
The nurse should remind the family member to administer an analgesic prior to wound care
to prevent discomfort.
The nurse should remind the family member to irrigate the wound with 0.9% sodium
chloride.
The nurse should remind the family member to avoid using a cotton-tipped applicator to
cleanse the wound because the fibers can become embedded in the wound, cause infection,
and delay wound healing.
The nurse should remind the family member to report signs of infection, including purulent
drainage.
A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which
of the following findings should the nurse expect?

A. Flaccid neck
B. Stooped posture with shuffling gait
C. Red macular rash
D. Masklike facial expression
Answer: C. Red macular rash
Rationale:
The nurse should recognize that nuchal rigidity, rather than a flaccid neck, is a manifestation
of meningitis.
The nurse should recognize that a stooped posture with shuffling gait is a manifestation of
Parkinson's disease, not a manifestation of meningitis.
The nurse should expect to find a red macular rash, sometimes called a petechial rash, which
is a manifestation of meningococcal meningitis.
The nurse should recognize that a masklike expression is a manifestation of Parkinson's
disease, not a manifestation of meningitis.
A nurse is contributing to the plan of care for an older adult client who is at risk for
osteoporosis. Which of the following interventions should the nurse include to prevent bone
loss?
A. Increase fluid intake.
B. Encourage range-of-motion exercises.
C. Massage bony prominences.
D. Encourage weight-bearing exercises.
Answer: D. Encourage weight-bearing exercises.
Rationale:
Fluid intake is beneficial for general health and wellness, and it helps to treat some disorders.
Caffeine and alcohol intake can increase the client's risk of developing osteoporosis.
However, fluid intake does not prevent bone loss.
Range-of-motion exercises are beneficial for general health and wellness, and they help to
maintain flexibility and prevent contractures. However, range-of-motion exercises do not
prevent bone loss.
Massaging bony prominences should be avoided because it can traumatize deep tissues.
Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone
demineralization, thus helping to prevent osteoporosis.

A nurse is collecting data from a client and notices several skin lesion. Which of the
following findings should the nurse report as possible melanoma?
A. Scaly patches
B. Silvery white plaques
C. Irregular borders
D. Raised edges
Answer: C. Irregular borders
Rationale:
The nurse should report scaly patches as possible basal or squamous cell carcinoma.
The nurse should report silvery white plaques as possible psoriasis.
The nurse should report irregular borders of a skin lesion to the provider because it can
indicate malignant melanoma.
The nurse should report raised edges of a skin lesion as possible basal cell carcinoma.
A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following
a partial gastrectomy for ulcers. Which of the following information should the nurse include
in the teaching?
A. Avoid liquids at mealtimes.
B. Exclude eating starchy vegetables.
C. Avoid eating high-protein meals.
D. Plan to increase intake of sweetened fruits.
Answer: A. Avoid liquids at mealtimes.
Rationale:
The nurse should remind the client to avoid drinking liquids at mealtimes to prevent the food
from emptying into the small bowel too quickly.
The nurse should remind the client to include starchy vegetables in the meal plan to slow
gastric emptying.
The nurse should remind the client to eat high protein meals to help slow gastric emptying.
The nurse should remind the client to exclude sweetened fruits from the diet to help slow
gastric emptying.

A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of
the following laboratory levels should the nurse review prior to the procedure?

A. Albumin
B. Phosphorus
C. TSH
D. BUN
Answer: D. BUN
Rationale:
Albumin levels determine the amount of protein the liver produces in the body and is an
indication of hepatic function and nutritional status. However, it is not impacted by contrast
media used for cardiac catheterization. Therefore, the nurse does not need to review this
laboratory level prior to a cardiac catheterization.
Phosphorus is an electrolyte that combines with calcium to maintain bone health and is
involved as an energy source in metabolism. However, it is not impacted by contrast media
used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory
level prior to a cardiac catheterization.
TSH levels determine thyroid function. However, it is not impacted by contrast media used
for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level
prior to a cardiac catheterization.
BUN levels indicate kidney function. Contrast media used during cardiac catheterization can
cause renal failure. The nurse should review this laboratory level to determine if the client
can tolerate the IV contrast dye during the procedure.
A nurse is reinforcing glycosylated haemoglobin (HbA1c) testing with a client who has
diabetes mellitus. Which of the following statements indicates that the client understands the
teaching?
A. "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates."
B. "The HbA1c test can help detect the presence of ketones in my body."
C. "I will have my HbA1c checked twice per year."
D. "I will plan to fast before I have my HbA1c tested."
Answer: C. "I will have my HbA1c checked twice per year."
Rationale:
The nurse should remind the client that carbohydrate consumption is not required for HbA1c
testing.
The nurse should remind the client that urine testing can detect ketone bodies.

An HbA1c test provides the client's average glucose level for the preceding 3 months. The
nurse should instruct the client to have her HbA1c tested twice yearly to manage her glucose.
The nurse should remind the client that fasting is not required for HbA1C testing.
A nurse is examining a client’s IV site and notes a red line up his arm. The client reports a
throbbing, burning pain at the IV site. The nurse should identify that the client’s
manifestations indicate which of the following complications of IV therapy?
A. Thrombophlebitis
B. Infiltration
C. Hematoma
D. Venous spasms
Answer: A. Thrombophlebitis
Rationale:
The nurse should identify pain, warmth, and a red streak up the arm as indications of
thrombophlebitis.
The nurse should identify swelling and cool skin at the IV site as indications of infiltration.
The nurse should identify swelling and bruising as indications of a hematoma that can
develop by not holding enough pressure after discontinuing the IV.
The nurse should identify cramping at or above the insertion site and numbness as indications
of venous spasms.
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following should the nurse include in the teaching?
A. Increase intake of fiber-rich foods.
B. Take a laxative every morning.
C. Maintain a fluid intake of 1200 mL per day.
D. Limit activity to preserve energy.
Answer: A. Increase intake of fiber-rich foods.
Rationale:
The nurse should instruct the client to increase the amount of fiber-rich foods in his diet.
Dried beans and brown rice are examples of fiber-rich foods.
The nurse should instruct the client to initially take a laxative in the evening to stimulate the
evacuation of stool. However, the nurse should instruct the client to use laxatives sparingly.

The nurse should instruct the client to increase his fluid intake to 2,000 mL per day to
maintain soft stools.
The nurse should instruct the client to increase activity to stimulate the evacuation of stool.
A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the
following actions should the nurse take?
A. Position pillows between the bony prominences.
B. Check for incontinence every 3 hr.
C. Massage reddened areas of the skin.
formation of a pressure ulcer by damaging underlying tissue.
D. Elevate the head of the bed to 45°
Answer: A. Position pillows between the bony prominences.
Rationale:
The nurse should use positioning devices to keep bony prominences from being in direct
contact with each other, which will prevent skin breakdown and pressure ulcer development.
The nurse should check the client for incontinence at least every 2 hr to prevent skin
breakdown.
The nurse should avoid massaging reddened areas of the skin, which can lead to the
The nurse should avoid elevating the head of the bed to an angle greater than 30°. An angle
greater than 30° can cause shearing of the skin, which leads to tissue injury and pressure ulcer
development.
A nurse is contributing to the plan of care for a client who has peripheral arterial disease
(PAD) of the lower extremities. Which of the following interventions should the nurse
include?
A. Place moist heat pads on the extremities.
B. Perform manual massage of the affected extremities.
C. Dangle the extremities off the side of the bed.
D. Apply support stockings before getting out of bed.
Answer: C. Dangle the extremities off the side of the bed.
Rationale:
The nurse should avoid applying heat to the client's extremities to prevent injury due to
decreased sensation.

The nurse should avoid massaging the client's lower extremities if the client is having pain
from ischemia. A warm environment and keeping the client warm will help with circulation
to the extremities and decrease pain through vasodilation.
The nurse should include in the plan of care to have the client dangle the lower extremities
off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client
should not raise the lower extremities above the level of the heart when resting in bed
because it impairs arterial blood flow.
The nurse should avoid applying support stockings to the lower extremities because support
stockings interfere with the arterial blood flow to the lower extremities.
A nurse is caring for a client who has meningococcal pneumonia. Which of the following
personal protective equipment should the nurse use?
A. Gown
B. Mask
C. Sterile gloves
D. Protective eyewear
Answer: B. Mask
Rationale:
The nurse should wear a gown when caring for a client who requires contact precautions.
The nurse should identify that a client who has Meningococcal pneumonia requires droplet
precautions, which include wearing a mask when providing care within 3 feet of the client.
The performance of sterile dressing changes or tracheostomy care requires the nurse to wear
sterile gloves. However, clean gloves are used to provide medical aseptic care.
A nurse should wear protective eyewear when there is a risk for splashing, such as during the
irrigation of a wound.
A nurse is assisting with the care of a client who has a cardiac catheterization via the right
femoral artery. Which of the following actions should the nurse take to prevent post
procedure complications (Select all that apply?)
A. Should wait at least 2 hours after eating before going to bed."
B. "I should eat three meals a day without eating snacks between meals."
C. "I should season my food with garlic."
D. "I should drink my liquids through a straw."
Answer: A. Should wait at least 2 hours after eating before going to bed."

Rationale:
The client should wait to lie down or go to bed at least 2 hr after eating to minimize reflux.
The client should eat four to six small meals per day rather than three large meals to
minimize bloating and abdominal distention.
The client should avoid spicy foods, including garlic, to minimize reflux.
The client should avoid drinking through a straw, which can promote belching and reflux.
A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the
following findings should the nurse recognize as the priority?
A. Pruritus
B. Nausea
C. Urinary retention
D. Dyspnea
Answer: D. Dyspnea
Rationale:
The nurse should identify pruritus as an adverse effect of an epidural infusion. However,
another finding is the priority.
The nurse should identify nausea as an adverse effect of an epidural infusion. However,
another finding is the priority.
The nurse should identify urinary retention as an adverse effect of an epidural infusion.
However, another finding is the priority
When using the airway, breathing, circulation approach to client care, the nurse should
determine that the priority finding is dyspnea, which is a complication of the epidural
infusion.
A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client.
Which of the understanding of the teaching?
A. I should wait at least 2 hours after eating before going to bed."
B. "I should eat three meals a day without eating snacks between meals."
C. "I should season my food with garlic."
D. "I should drink my liquids through a straw."
Answer: A. I should wait at least 2 hours after eating before going to bed."
Rationale:
The client should wait to lie down or go to bed at least 2 hr after eating to minimize reflux.

The client should eat four to six small meals per day rather than three large meals to
minimize bloating and abdominal distention.
The client should avoid spicy foods, including garlic, to minimize reflux.
The client should avoid drinking through a straw, which can promote belching and reflux.
A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the
following information should the nurse include in the teaching?
A. This type of insulin should be given at the same time every day."
B. "This insulin can be mixed with short-acting insulin in a single syringe."
C. "This type of insulin can be used in a pump."
D. "This insulin has an increased risk for hypoglycemia."
Answer: A. This type of insulin should be given at the same time every day."
Rationale:
Insulin glargine is released in the body over a 24 hr period. The nurse should instruct the
client to administer the insulin at the same time each day to maintain consistent serum levels
for optimal therapeutic effect.
The nurse should remind the client that insulin glargine should not be mixed with any other
insulin.
The nurse should inform the client insulin glargine is a long-acting insulin that is
administered once daily at the same time and is not to be administered intravenously.
The nurse should inform the client that insulin glargine has a low risk for hypoglycemia
because serum levels of the insulin do not peak and remain consistent over time.
A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an
INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer?
(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing
zero.)
Answer: Ratio and Proportion
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the dose the nurse should administer? Dose to administer = Desired 7 mg
Step 3: What is the dose available? Dose available = Have 10 mg
Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity
of the dose available? 1 mL Step 6: Set up an equation and solve for X.
Have/Quantity = Desired/X

10 mg/1 mL = 7 mg/X mL
X = 0.7
Step 7: Round if necessary.
Step 8: Reassess to determine whether the amount to administer makes sense. If there are 10
mg/mL and the provider prescribed 7 mg, it makes sense to administer 0.7 mL. The nurse
should administer phytonadione 0.7 mL subcutaneously.
Desired Over Have
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the dose the nurse should administer? Dose to administer = Desired 7 mg
Step 3: What is the dose available? Dose available = Have 10 mg
Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity
of the dose available? 1 mL Step 6: Set up an equation and solve for X.
Desired x Quantity/Have = X
7 mg x 1 mL/10 mg = X mL
0.7 = X
Step 7: Round if necessary.
Step 8: Reassess to determine whether the amount to administer makes sense. If there are 10
mg/mL and the provider prescribed 7 mg, it makes sense to administer 0.7 mL. The nurse
should administer phytonadione 0.7 mL subcutaneously.
Dimensional Analysis
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the quantity of the dose available? 1 mL
Step 3: What is the dose available? Dose available = Have 10 mg
Step 4: What is the dose the nurse should administer? Dose to administer = Desired 7 mg
Step 5: Should the nurse convert the units of measurement? No Step 6: Set up an equation
and solve for X.
X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/
X mL = 1 mL/10 mg x 7 mg/
X = 0.7
Step 7: Round if necessary.
Step 8: Reassess to determine whether the amount to administer makes sense. If there are 10
mg/mL and the provider prescribed 7 mg, it makes sense to administer 0.7 mL. The nurse
should administer phytonadione 0.7 mL subcutaneously.

A nurse is reinforcing teaching with an adolescent client regarding testicular selfexamination. Which of the following statements by the client demonstrates an understanding
of the teaching?
A. “I will perform the exam before I shower.”
B. “I will check my testicles every 6 months.”
C. "I understand that testicular cancer is painless."
D. "I understand that pea-sized lumps are normal."
Answer: C. "I understand that testicular cancer is painless."
Rationale:
Clients should perform a testicular self examination after a warm shower.
Clients should perform a testicular self examination monthly.
Clients should report a lump that is not painful because testicular cancer is typically painless.
Clients should report pea-sized lumps in the testes to a provider.
A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which
of the following interventions should the nurse identify as the priority?
A. Determine the client's understanding of the procedure.
B. Encourage the client to express his feelings.
C. Allow the client's family to stay with him.
D. Provide music as a distraction.
Answer: A. Determine the client's understanding of the procedure.
Rationale:
Using the nursing process, the first action the nurse should take is to collect data from the
client. Therefore, the nurse should determine the client's understanding of the procedure to
provide necessary teaching, which can help manage his anxiety.
Encouraging the client to express his feelings can reduce anxiety. However, this is not the
first action the nurse should take.
Allowing the client's family to stay with him can reduce anxiety. However, this is not the first
action the nurse should take.
Providing music as a distraction can reduce anxiety. However, this is not the first action the
nurse should take.

A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty.
Which of the following factors should the nurse identify as an indication that a barrier to
learning might be present?
A. The client asks questions each time the nurse stops talking.
B. The client stops the nurse and asks for pain medication.
C. While the nurse is speaking, the client refers to the written materials.
D. A family member who is present asks the client to repeat important points.
Answer: B. The client stops the nurse and asks for pain medication.
Rationale:
The nurse should identify that asking questions indicates active listening by the client and
enhances learning.
The nurse should identify that a client who is in pain will not be able to concentrate, which
can interfere with his ability to learn.
The nurse should identify that clients learn in different ways. Using multiple methods of
teaching, including hands-on practice and providing written materials, enhances learning.
The nurse should identify that family member who are actively engaged in the teaching
session and ask questions can enhance learning.
A nurse is reinforcing discharge instructions with a client who is postoperative following a
right hip arthroplasty. Which of the following statements should the nurse make?
A. You may cross your legs in 60 days."
B. "Avoid lying on your operative side."
C. "Avoid bending your hips more than 90 degrees."
D. "You may sleep on a soft mattress."
Answer: C. "Avoid bending your hips more than 90 degrees."
Rationale:
The nurse should instruct the client to wait 90 days before crossing her legs. Crossing her
legs early in the postoperative period can result in dislocation of the replacement hip.
The nurse should inform the client that she may lie on her operative side with a pillow
between her legs. This will not injure the suture site or cause dislocation of the replacement
hip.
The nurse should instruct the client to avoid bending her hips more than 90° to prevent
dislocation of the replacement hip.

The nurse should instruct the client to sleep on a firm mattress to avoid potential dislocation
of the replacement hip.
A nurse is caring for a client who has a compound fracture of the femur and was placed in
balanced suspension skeletal traction 4 days ago. Which of the following actions should the
nurse take?
A. Perform pin site care daily.
B. Remove the overbed trapeze.
C. Remove the boot every 2 hr.
D. Keep the weights on a stable, flat surface.
Answer: A. Perform pin site care daily.
Rationale:
The nurse should perform pin site care daily with chlorhexidine solution or use a solution
according to facility protocol. The nurse should also monitor the pin sites for manifestations
of infection.
The nurse should ensure the client has an overbed trapeze to aid in lifting the upper body off
the bed when necessary and to help prevent skin breakdown of the heels and elbows with
client repositioning.
The nurse should identify that balanced suspension skeletal traction is managed through the
use of pins, pulleys, weights, and frames and that the client does not wear a boot.
The nurse should ensure the weights hang freely at all times.
A nurse is assisting the charge nurse with developing an in-service about caring for clients
who have internal sealed radiation implants. Which of the following information should the
nurse include?
A. Restrict the time pregnant women are allowed in the client's room to 15 min.
B. Pick up a radiation implant with a double-gloved hand if it becomes dislodged.
C. Limit time spent in the client's room to 2 hr during an 8 hr shift.
D. Dispose of radiation implants in a lead container.
Answer: D. Dispose of radiation implants in a lead container.
Rationale:
Pregnant women and children should not be allowed to visit a client who is receiving internal
radiation therapy because of the risk for exposure to radiation emissions.
The nurse should use forceps to pick up a radiation implant if it becomes dislodged.

The nurse should limit time spent in the client's room to 30 min during an 8 hr shift.
Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation
implants in a lead container in accordance with facility protocol.
A nurse in a long-term care facility is collecting data from a client who reports fullness in the
rectum and abdominal cramping. Which of the following findings should indicates to the
nurse that the client might have a fecal impaction?
A. Halitosis
B. Hemorrhoids
C. Rebound tenderness
D. Small liquid stools
Answer: D. Small liquid stools
Rationale:
Halitosis, or bad breath, is associated with the ingestion of certain foods and medications, and
it can also be an indication of infection.
Hemorrhoids indicate that the client is straining when defecating. However, the presence of
hemorrhoids does not indicate fecal impaction.
Rebound tenderness is an indication of appendicitis. A client who has a fecal impaction can
experience abdominal cramping and distention.
Small liquid stools can be the result of fecal material being expelled around an impaction.
A nurse is providing discharge teaching for the family of a client who has Parkinson’s
disease. Which of the following information should the nurse include in the teaching?
A. Place the client on a low-calorie diet to prevent weight gain.
B. Remind the client to avoid watching her feet when walking.
C. Use small area rugs in the client's home for traction.
D. Instruct the client to take tub baths instead of showers.
Answer: B. Remind the client to avoid watching her feet when walking.
Rationale:
The nurse should instruct the client's family to provide the client with extra calories and
protein to prevent unintentional weight loss from expenditure of energy due to tremors,
dyskinesia, and difficulty swallowing.
The nurse should instruct the client's family to frequently remind the client to maintain
correct posture and prevent falls by not watching her feet when walking.

The nurse should instruct the client's family to avoid using area rugs in the client's home
because her foot may drag or be stiff and catch on an area rug, which can cause a fall.
The nurse should instruct the family to encourage the client to take walk-in, sit-down
showers, because skeletal muscle rigidity can cause difficulty in moving, coordination, and
balance, which increases the risk of a fall.
A home health nurse is reinforcing teaching with a client about preventing complications of
peripheral vascular disease. Which of the following statements indicates that client is
adhering to the nurse’s instructions?
A. "I apply rubbing alcohol to my feet every day to prevent infection."
B. "I will wear clean, knee-high wool socks every day to help improve my circulation."
C. "I use hot water bottles to keep my feet warm at night."
D. "I don't cross my legs anymore."
Answer: D. "I don't cross my legs anymore."
Rationale:
Rubbing alcohol has a drying effect on skin and can increase cracking, allowing an entry
point for infection. The client should apply lotions that do not contain alcohol.
Wool socks can result in perspiration, which puts the client at risk for developing a fungal
infection. The client should use light-weight socks to promote arterial blood flow.
Clients who have peripheral vascular disease have decreased sensation of the affected
extremities. Therefore, they are unable to detect the temperature of the water bottle, which
increases the risk for burns.
Clients who have peripheral vascular disease should not cross their legs because it can
impede circulation.
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an
IV contrast agent. Which of the following laboratory findings should the nurse report to the
provider prior to the procedure?
A. Sodium 136 mEq/L
B. Potassium 4.8 mEq/L
C. Creatinine 1.9 mg/dL
D. Calcium 10 mg/dL
Answer: C. Creatinine 1.9 mg/dL
Rationale:

Sodium 136 mEq/L is within the expected reference range. Therefore, the nurse does not need
to report this finding to the provider before the client has a CT scan with an IV contrast agent.
Potassium 4.8 mEq/L is within the expected reference range. Therefore, the nurse does not
need to report this finding to the provider before the client has a CT scan with an IV contrast
agent.
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should
report the finding to the provider before the client has a CT scan with an IV contrast agent.
This finding places the client at risk for developing contrast-induced nephropathy.
Calcium 10 mg/dL is within the expected reference range. Therefore, the nurse does not need
to report this finding to the provider before the client has a CT scan with an IV contrast agent.
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA)
infections in a surgical wound. Which of the following information should the nurse plan to
share with visitors?
A. Visitors should call prior to visiting the client.
B. Visitors must don a gown and gloves prior to entering the client's room.
C. Visitors need to wear a mask when in close proximity to the client.
D. Visitors may not bring fresh flowers into the client's room.
Answer: B. Visitors must don a gown and gloves prior to entering the client's room.
Rationale:
Visitors do not need to make arrangements prior to visiting a client who is on contact
isolation precautions, but visitors should receive assistance before entering the client's room.
The nurse should provide teaching to the visitors regarding the infection control measures for
a client who is on contact isolation precautions. Contact precautions require visitors to put on
a gown and gloves prior to entering the room of a client who has MRSA to prevent the spread
of infection.
The nurse should identify that visitors of clients who are on airborne or droplet precautions
should wear a mask when within 3 feet of the client. However, MRSA is not spread through
the respiratory tract and does not require airborne or droplet precautions.
The nurse should identify that fresh flowers are contraindicated for a client who is on
neutropenic precautions. However, they are not contraindicated for a client who has MRSA.

A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular
disease. Which of the following images indicates the type of cooking fat the nurse should
recommend the client use when preparing meals?

A. Butter is high in saturated fat, which contributes to the development of cardiovascular
disease. It should be used sparingly or avoided.

B. Coconut oil is high in saturated fat, which contributes to the development of
cardiovascular disease. It should be used sparingly or avoided.

C. The nurse should instruct the client who has cardiovascular disease to consume foods
which contain primarily monounsaturated and polyunsaturated fats, such as olive oil or other
vegetable oils, rather than foods that are high in saturated fat. The nurse should reinforce that
oils high in monounsaturated fats help decrease the client's cardiovascular risk by lowering
LDL cholesterol and triglyceride levels.

D. Shortening is high in saturated fat, which contributes to the development of cardiovascular
disease. It should be used sparingly or avoided.
Answer:

C. The nurse should instruct the client who has cardiovascular disease to consume foods
which contain primarily monounsaturated and polyunsaturated fats, such as olive oil or other
vegetable oils, rather than foods that are high in saturated fat. The nurse should reinforce that
oils high in monounsaturated fats help decrease the client's cardiovascular risk by lowering
LDL cholesterol and triglyceride levels.

A nurse is reinforcing teaching with a client who has heart failure and a new prescription for
hydrochlorothiazide. Which of the following findings should the nurse instruct the client to
report to the provider?
A. Onset of nausea
B. Increased urinary output
C. Weight loss of 0.9 kg (2 lb) per week
D. Missed dose of the medication
Answer: A. Onset of nausea
Rationale:
The nurse should instruct the client to report a new onset of nausea, which can be an
indication of hyponatremia or hypokalaemia resulting from the diuretic effects of the
hydrochlorothiazide.
The nurse should remind the client that an increase in urinary output is a desired effect of
hydrochlorothiazide.
The nurse should remind the client to report weight gain of 0.9 kg (2 lb) or more per week to
the provider.
The nurse should instruct the client to take a missed dose of the medication as soon as the
client remembers. However, the client should not take a double-dose of the medication.
A nurse is preparing to suction a client who has a tracheostomy. Which of the following
actions should the nurse take first?
A. Insert the suction catheter into the tracheostomy.
B. Rinse the catheter with sterile 0.9% sodium chloride.
C. Ventilate with 100% oxygen.
D. Occlude the vent on the catheter for 10 seconds.
Answer: C. Ventilate with 100% oxygen.
Rationale:
The nurse should insert the catheter tip into the tracheostomy during inspiration until it meets
resistance, then pull back 2.5 cm (1 in). However, evidence-based practice indicates that there
is another action the nurse should take first.
The nurse should rinse or flush the catheter with 0.9% sodium chloride to clear the catheter of
secretions before repeating the suctioning procedure. However, evidence-based practice
indicates that there is another action the nurse should take first.

According to evidence-based practice, the nurse should ventilate the client with 100% oxygen
before suctioning to prevent hypoxemia when removing air and debris from the upper airway.
The nurse should occlude the vent on the catheter for 10 to 15 seconds while removing the
catheter during suctioning. However, evidence-based practice indicates that there is another
action the nurse should take first.
A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how
to improve the taste of bland food. Which of the following should the nurse recommend?
A. Ketchup
B. Mayonnaise
C. Soy sauce
D. Lemon juice
Answer: D. Lemon juice
Rationale:
The nurse should not recommend ketchup to the client because it is high in sodium.
The nurse should not recommend mayonnaise to the client because it is high in sodium.
The nurse should not recommend soy sauce to the client because it is high in sodium.
The nurse should recommend that the client use lemon juice to flavor his food because it is
low in sodium.
A nurse is reviewing the medical record of a client who has a prescription for morphine.
Which of the following findings should the nurse reports to the provider?
A. Urinary retention
B. Administration of celecoxib 24 hr ago
C. History of immunosuppression
D. Administration of levothyroxine 12 hr ago
Answer: A. Urinary retention
Rationale:
The nurse should recognize that administering morphine to the client can cause urinary
retention. Therefore, the nurse should report this finding to the provider.
Celecoxib is not a contraindication to morphine administration.
A history of immunosuppression is not a contraindication to morphine administration.
Levothyroxine is not a contraindication to morphine administration.

A nurse is caring for a client who is 13 days postoperative following a total right hip
arthroplasty. Which of the following actions should the nurse take?
A. Use a traction boot to keep the client's right leg internally rotated.
B. Have the client sit in a reclining chair when out of bed.
C. Maintain abduction of the client's right leg while in bed.
D. Encourage the client to perform passive range-of-motion exercises.
Answer: C. Maintain abduction of the client's right leg while in bed.
Rationale:
The nurse should not apply any type of traction boot or allow the client's leg to rotate
internally or externally because it can cause a dislocation of the affected hip.
The nurse should provide a chair that does not allow the client to recline because a reclining
chair increases the risk of the client flexing at the hips beyond 90° when moving to a standing
position.
The nurse should maintain abduction of the client's right leg to prevent dislocation of the
affected hip by placing an abductor pillow between the client's legs when resting in bed.
The nurse should encourage the client to stand at the bedside on the day of surgery and, if
prescribed by the provider, to walk using a walker. Passive range-of-motion exercises require
flexion and extension of the joints and are not recommended 3 days following surgery.
A nurse is monitoring a client who is taking acarbose. Which of the following findings should
the nurse identify as an adverse effect of the medication?
A. Polyuria
B. Abdominal cramps
C. Renal insufficiency
D. Insomnia
Answer: B. Abdominal cramps
Rationale:
Polyuria is an adverse effect of furosemide.
Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client
for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this
medication.
Long-term and high-dose use of acarbose can cause liver dysfunction, not renal insufficiency.
Insomnia is an adverse effect of methylphenidate.

A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is
receiving epoetin alfa. The nurse should identify that which of the following laboratory
values indicates the treatment is effective?
A. BUN 40 mg/dL
B. Hgb 11 g/Dl
C. Urine specific gravity 1.035
D. Blood glucose 105 mg/dL
Answer: B. Hgb 11 g/Dl
Rationale:
Clients who have chronic kidney failure will demonstrate elevated BUN levels, but this does
not measure the effectiveness of epoetin alfa.
Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in
increased haemoglobin levels. Therefore, a haemoglobin level of 11 g/dL indicates the
epoetin alfa treatment is effective.
Clients who have chronic kidney failure will demonstrate concentrated urine and elevated
specific gravity, but this does not measure the effectiveness of epoetin alfa.
Epoetin alfa does not affect blood glucose levels.
A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the
following actions should the nurse take when communicating with the client?
A. Rephrase client instructions when not understood.
B. Cup hands around the mouth and direct speech toward the client.
C. Accentuate vowel sounds by using a higher pitch when speaking.
D. Sit to the side of the client and speak instructions into her best ear.
Answer: A. Rephrase client instructions when not understood.
Rationale:
When communicating with a client who has hearing loss, the nurse should rephrase, rather
than repeat, discharge instructions when they are not understood.
When communicating with a client who has hearing loss, the nurse should keep hands away
from the mouth to promote lip reading.
When communicating with a client who has hearing loss, the nurse should speak in a lower
tone of voice and use a lower pitch. Higher pitched sounds can impede hearing by
accentuating vowel sounds and concealing consonants.

When communicating with a client who has hearing loss, the nurse should sit or stand facing
the client on the same level so that the nurse's mouth and lips can be seen for lip reading.
A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The
client is exhibiting hypotension, tachycardia, and tachypnoea. The nurse should recognize
that these findings indicate which of the following complications?
A. Wound infection
B. Pulmonary embolism
C. Thrombophlebitis
D. Paralytic ileus
Answer: B. Pulmonary embolism
Rationale:
Manifestations of a wound infection include fever, inflammation of the incision, and foulsmelling drainage. Hypotension, tachycardia, and tachypnoea do not indicate a wound
infection in a client who is 1 day postoperative.
Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnoea.
Thrombophlebitis is the inflammation of a blood vessel, which can lead to a thrombus
formation. Hypotension, tachycardia, and tachypnoea do not indicate thrombophlebitis.
Paralytic ileus is the absence of bowel peristalsis, or movement. Hypotension, tachycardia,
and tachypnoea do not indicate a paralytic ileus.
A nurse is monitoring a client who recently had a cast placed on the right lower extremity for
a bone fracture. Which of the following findings should the nurse recognize as abnormal?
A. Report of a dull, throbbing pain
B. Extremities that are cool bilaterally
C. Capillary refill of 3 seconds in the nail beds of the toes
D. Lack of sensation between the first and second toes
Answer: D. Lack of sensation between the first and second toes
Rationale:
Dull, throbbing pain is an expected finding for a client who has a bone fracture.
Cool, bilateral extremities are an indication of the client's overall body temperature and
general circulatory status and are an expected finding.
A capillary refill of 3 seconds in the nail beds of the toes is slowed but still within the
expected reference range after application of a cast.

Lack of sensation between the toes indicates peripheral nerve impairment and is an abnormal
finding that can indicate the client has compartment syndrome. The nurse should notify the
provider immediately.
A nurse is caring for a client who has a history of breast cancer. The client asks the nurse
about birth control. Which of the following methods of birth control is contraindicated for
this client?
A. Intrauterine device
B. Latex condom
C. Combination oral contraceptives
D. Contraceptive sponge
Answer: C. Combination oral contraceptives
Rationale:
The nurse should identify that the use of an intrauterine device requires the client to check the
placement monthly and is not contraindicated for this client.
The nurse should identify that the use of latex condoms is contraindicated for clients, or their
partners, who are allergic to latex. However, it is not contraindicated for this client.
The nurse should identify that combination oral contraceptives are contraindicated for this
client because they increase estrogen levels, which can stimulate the growth of any remaining
cancerous breast cells.
The nurse should identify that prolonged use of a contraceptive sponge can increase the risk
for toxic shock syndrome. However, it is not contraindicated for this client.
A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of
the following outcome from the medication should the nurse expect?
A. Increased weight
B. Increased heart rate
C. Decreased urinary output
D. Decreased shortness of breath
Answer: D. Decreased shortness of breath
Rationale:
The nurse should expect the client's weight to decrease because of the increased excretion of
fluid that is caused by improved cardiac output.

The nurse should expect the client's heart rate to decrease because digoxin decreases the
client's sympathetic nerve tone, which slows the heart rate.
The nurse should expect the client to have an increase in urinary output because digoxin
improves cardiac output and increases the client's renal blood flow through the kidneys,
which results in an increased excretion of urine.
The nurse should expect the client to have decreased shortness of breath. Digoxin increases
the contractility of the heart, which decreases pulmonary congestion.
A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE)
and is to begin taking methylprednisolone orally. Which of the following statements should
the nurse include in the teaching?
A. "Take the medication on an empty stomach."
B. "Limit contact with large groups of people."
C. "Avoid taking over-the-counter calcium supplements."
D. "Follow a low-protein diet."
Answer: B. "Limit contact with large groups of people."
Rationale:
The client should take glucocorticoids with food to prevent gastrointestinal upset and
bleeding.
Glucocorticoids cause immunosuppression and may mask infection. The client should limit
contact with sources of possible infections, such as large groups of people.
Clients who take glucocorticoids are at risk for osteoporosis, so they should take additional
vitamin D and calcium supplements.
It is not necessary for a client who has SLE and is taking a glucocorticoid to restrict protein
intake.
A nurse is caring for a client who is 24 hr. postoperative following abdominal surgery and has
an NG tube. Which of the following actions should the nurse plan to take to decrease the risk
of postoperative complications?
A. Offer sips of water to the client following oral care.
B. Massage the client's lower extremities with lotion every 2 hr.
C. Encourage the client to use an incentive spirometer every hour while awake.
D. Place one or two pillows beneath the client's knees while he is in bed.
Answer: C. Encourage the client to use an incentive spirometer every hour while awake.

Rationale:
The nurse should provide frequent oral care and the use of moistened oral swabs to alleviate
dry mucous membranes. However, oral fluids are contraindicated for a client who had
abdominal surgery and has an NG tube.
The nurse should monitor the client's lower extremities for tenderness, warmth, or redness.
However, massaging the client's lower extremities is contraindicated because, if there is a
blood clot formation in the a lower extremity, it can loosen the clot and cause a pulmonary
embolism.
The nurse should assist the client to use the incentive spirometer in addition to coughing and
deep breathing every hour while awake for the first 24 hr postoperatively and at least every 2
hr while awake thereafter. An incentive spirometer will inflate the client's alveoli and
improve ventilation to prevent postoperative pneumonia.
The nurse should elevate the foot of the bed slightly and apply prescribed compression
stockings or sequential compression devices to promote venous return. However, pillows
beneath the client's knees can create pressure and decrease venous return in the lower
extremities, which can lead to thrombosis.
A nurse is reinforcing teaching with a client who has multiple sclerosis and a new
prescription for baclofen. Which of the following instructions should the nurse include in the
teaching?
A. Consume a low-purine diet.
B. Avoid stopping this medication suddenly.
C. Use chamomile tea to alleviate insomnia.
D. Take this medication on an empty stomach.
Answer: B. Avoid stopping this medication suddenly.
Rationale:
The nurse should recommend a low-purine diet for a client who has gout and a prescription
for colchicine.
The nurse should instruct the client to avoid stopping baclofen suddenly because it can result
in adverse reactions, including seizures, paranoia, and hallucinations.
The nurse should instruct the client to avoid chamomile because it can interact with baclofen
to increase CNS depression.
The nurse should instruct the client to take baclofen with milk or food to minimize gastric
upset.

A nurse reviewing the laboratory results of a client who has type 2 diabetes mellitus. The
nurse should identify that which of the following laboratory values indicates the client is at
risk for delayed wound healing?
A. HbA1c 6%
B. Prealbumin 12 mg/dL
C. WBC 8,000/mm3
D. Creatinine 0.8 mg/dL
Answer: B. Prealbumin 12 mg/dL
Rationale:
This laboratory value indicates glycaemic control and does not indicate that the client is at
risk for delayed wound healing. The nurse should identify that elevated HbA1c levels can
increase the risk for delayed wound healing.
This laboratory value is below the expected reference range, indicating that the client's
protein status is inadequate and that he is at risk for delayed wound healing due to
malnutrition.
This laboratory value is within the expected reference range and indicates immune function.
The nurse should identify that an elevated WBC count increases the risk for delayed wound
healing.
This laboratory value is within the expected reference range and indicates adequate kidney
function. The nurse should identify that the client who is diabetic is at increased risk for the
development of renal failure, which can increase the risk for infection and delayed wound
healing.
A nurse is assisting with the discharge planning for a client who is postoperative following a
total hip arthroplasty. Which of the following instructions should the nurse include in the
discharge plan?
A. Expect decreased sensation for the first postoperative week.
B. Avoid lying on the operative side.
C. Obtain a raised toilet seat.
D. Cross legs at the ankles.
Answer: C. Obtain a raised toilet seat.
Rationale:

The nurse should instruct the client to report decreased sensation in the affected foot or leg
because this can indicate neurovascular compromise.
The nurse should instruct the client that lying on the operative side is allowed but the client
should place pillows between the legs to prevent dislocation of the hip.
The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more
than 90°, which increases the risk for dislocation.
The nurse should instruct the client to avoid crossing her legs to prevent dislocation of the
hip.
A nurse is preparing to move a client’s NG tube. Which of the following interventions should
the nurse take to decrease the risk of aspiration?
A. Instill 10 mL of air through the NG tube.
B. Place the client in the supine position.
C. Irrigate the NG tube.
D. Pinch the NG tube.
Answer: D. Pinch the NG tube.
Rationale:
The nurse should instill 50 mL of air through the NG tube to remove mucus and gastric
secretions from the tube and to prevent aspiration of these secretions.
The nurse should place the client in a sitting position to prevent the risk of aspiration.
The nurse should identify that irrigating the NG tube before removal can put the client at risk
for aspiration and should be avoided.
The nurse should pinch the NG tube to prevent secretions from draining into the client's
throat, which can cause aspiration.
A nurse is collecting data from a client who has chronic kidney disease with hyperkalaemia.
Which of the following findings should the nurse expect related to hyperkalaemia?
A. Polyuria
B. Constipation
C. Anorexia
D. Bradycardia
Answer: D. Bradycardia
Rationale:
Polyuria is a manifestation of hypokalaemia.

Constipation is a manifestation of hypokalaemia.
Anorexia is a manifestation of hypokalaemia.
The client who has hyperkalaemia can have an irregular, slow heart rate, known as
bradycardia.

A nurse is reinforcing teaching with a client who has asthma. Which of the following client
statements indicate an understanding of the use of budesonide and albuterol inhalers? (Select
all that apply.)
A. "I should expect to feel sleepy after using my albuterol inhaler"
B. "I never forget to rinse my mouth after using my budesonide inhaler.
C. "Between office visits, I keep a record of how many times I use my albuterol inhaler"
D. "I use my albuterol inhaler before I go swimming"
E. "I should use my budesonide inhaler before using my albuterol inhaler"
Answer: B. "I never forget to rinse my mouth after using my budesonide inhaler.
D. "I use my albuterol inhaler before I go swimming"
E. "I should use my budesonide inhaler before using my albuterol inhaler"
Rationale:
The client should recognize that albuterol stimulates the sympathetic nervous system, which
can cause nervousness and insomnia, along with increased heart rate and blood pressure.
The client should rinse his mouth after using a budesonide inhaler to reduce the risk for oral
fungal infection.
The client should record the number of times that he uses his albuterol inhaler. This
information can assist the provider to determine the effectiveness of the medication.
The client should use the albuterol inhaler before exercise to prevent exercise-induced
bronchospasms.
The client should first use the albuterol inhaler, a bronchodilator, to open the airway and
enhance the absorption of the budesonide, which is an inhaled corticosteroid.
A nurse is caring for a client and administers penicillin IM. the client begins exhibiting hives
and has severe difficulty breathing. After establishing a patent airway, which of the following
actions should the nurse take next?
A. Administer epinephrine.
B. Monitor the client's vital signs.

C. Monitor the client's oxygen saturation level.
D. Administer an antihistamine.
Answer: A. Administer epinephrine.
Rationale:
The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should
administer epinephrine to reduce bronchospasms and laryngeal edema.
The nurse should monitor the client's vital signs during the crisis to detect a decrease in blood
pressure and an increase in respiratory effort. However, there is another action the nurse
should take first.
The nurse should monitor the client's oxygen saturation level to ensure respiratory support.
However, there is another action the nurse should take first.
The nurse should administer an antihistamine to treat the hives and reduce the histamine
release. However, there is another action the nurse should take first.
A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the
following statements by the client indicates an understanding of the disease process?
A. "I should call my doctor if I get a headache."
B. "I may develop gastric reflux."
C. "I may develop excessive bruising."
D. "I should call my doctor if my ankles swell."
Answer: D. "I should call my doctor if my ankles swell."
Rationale:
Headaches are not a complication of mitral valve disease.
Mitral valve disease does not cause gastric reflux.
A provider may prescribe anticoagulants to prevent thrombus formation on the valve, which
can cause excessive bruising for a client who has mitral valve disease. However, excessive
bruising is not a direct result of the disease.
Swelling of the ankles can indicate heart failure. The client should report this finding to the
provider.
A nurse is monitoring an older adult client who has a history of an enlarged prostate and is
experiencing suprapubic discomfort. Which of the following actions should the nurse take
first?
A. Administer doxazosin.

B. Palpate the abdomen.
C. Insert an indwelling urinary catheter.
D. Notify the primary care provider.
Answer: B. Palpate the abdomen.
Rationale:
The nurse may need to administer doxazosin to relax the smooth muscle of the bladder to
increase urine flow. However, the nurse should use a less restrictive intervention first.
When providing client care, the nurse should first use the least restrictive intervention.
Therefore, the nurse should palpate the abdomen to determine if the client has a distended
bladder from urinary retention.
The nurse may need to insert an indwelling urinary catheter for a distended bladder.
However, the nurse should use a less restrictive intervention first.
The nurse may need to notify the primary care provider if the client has a distended bladder.
However, the nurse should use a less restrictive intervention first.
A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary
disease (COPD) and is dyspneic. Which of the following interventions should the nurse
include in the plan?
A. Encourage abdominal breathing.
B. Direct the client to inhale with pursed lips.
C. Set the oxygen therapy at 5 L/min.
D. Instruct the client to lean back when coughing.
Answer: A. Encourage abdominal breathing.
Rationale:
The nurse should encourage abdominal breathing, which reduces the workload on the
accessory muscles of respiration during dyspneic episodes.
The nurse should direct the client to exhale using pursed-lip breathing during dyspneic
episodes to maintain positive airway pressure.
The nurse should set the oxygen therapy between 1 to 3 L/min to prevent the client's urge to
breathe from decreasing during dyspneic episodes
The nurse should instruct the client to lean forward and repeatedly "huff" followed by relaxed
breathing to clear secretions during dyspneic episodes.

A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the
following provider prescriptions should the nurse implement first?
A. Collect a sputum culture.
B. Administer ceftriaxone by intermittent IV bolus.
C. Initiate oxygen at 4 L/min via nasal cannula.
D. Obtain blood cultures.
Answer: D. Obtain blood cultures.
Rationale:
The nurse should collect a sputum culture to identify the organism causing the client's
infection. Antimicrobial sensitivities are obtained from the sputum culture to guide the
provider in prescribing antibiotics. However, there is another prescription the nurse should
implement first.
The nurse should administer antibiotics to treat the infection. A broad spectrum antibiotic,
such as ceftriaxone, is administered when sepsis is suspected because it treats both grampositive and negative bacteria. After the results of the blood and sputum cultures are obtained,
the provider will often change to a more specific antibiotic. However, there is another
prescription the nurse should implement first.
When using the airway, breathing, circulation approach to client care, the first action the
nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often
hypoxic, tachypnoeic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide
supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which
will maximize the ability of the haemoglobin to support the oxygen needs of the body.
The nurse should obtain blood cultures to identify the organism causing the client's infection.
Antimicrobial sensitivities obtained from the blood cultures will guide the provider in
prescribing treatment. However, there is another prescription the nurse should implement
first.
A nurse is caring for a client who has terminal pancreatic cancer. The client states, “I don’t
think I can go on any longer.” Which of the following responses should the nurse make?
A. "Can I get you something for the pain?"
B. "You should talk about this with your family."
C. "Tomorrow will be a better day."
D. "Tell me more about the way you are feeling."
Answer: D. "Tell me more about the way you are feeling."

Rationale:
The nurse should monitor the client's pain level and provide analgesics as needed. However,
this response changes the subject, does not acknowledge the client's feelings, and is a barrier
to a continued trusting relationship.
This response is an example of giving common advice and is dismissive of the client's
feelings, which are barriers to a trusting relationship and open communication.
This response is an example of false reassurance and is dismissive of the client's feelings,
provides false hope, and does not promote open communication.
The nurse is establishing a trusting relationship by seeking clarification and encouraging the
client to verbalize feelings.
A nurse is collecting data from a 55-year old female client who reports vaginal dryness and
hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of
the following should the nurse recognize as a contraindication to HRT?
A. Five-year history of menopause manifestations
B. History of treatment for blood clots
C. Topiramate use for migraine headaches
D. Increased serum cholesterol levels
Answer: B. History of treatment for blood clots
Rationale:
The nurse should identify that manifestations of menopause can last for 10 years or more and
HRT is not contraindicated for a client whose menopause manifestations began 5 years ago.
Estrogen increases the risk of blood clots. Therefore, a woman who has a history of blood
clots should not receive HRT.
The nurse should identify that the use of topiramate to treat migraine headaches can cause
decreased absorption of estrogen when used as a contraceptive. However, topiramate is not a
contraindication to HRT.
The nurse should identify that one of the benefits of HRT is a decrease in LDL and an
increase in HDL levels. Therefore, HRT is not contraindicated for a client who has increased
serum cholesterol levels.
A nurse in an oncology clinic is reinforcing teaching is reinforcing teaching about Mohs
surgery with a client who has skin cancer. Which for the following information should the
nurse include in the teaching?

A. Mohs surgery is a horizontal shaving of thin layers of the tumor.
B. Mohs surgery uses liquid nitrogen to destroy the cancerous tissue.
C. Mohs surgery is the preferred treatment for melanoma skin cancer.
D. Mohs surgery is a palliative treatment for metastatic skin cancer.
Answer: A. Mohs surgery is a horizontal shaving of thin layers of the tumor.
Rationale:
Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which
involves a horizontal shaving of thin layers of a tumor, has a high treatment rate.
Cryosurgery, rather than Mohs surgery, uses liquid nitrogen to destroy cancerous tissue.
Mohs surgery is the preferred treatment for basal and squamous cell carcinoma. The preferred
treatment for melanoma is a wide, full thickness surgical excision.
Radiation, rather than Mohs surgery, can be used as a palliative treatment for metastatic skin
cancer.
A nurse I performing ECG on a client who is scheduled for surgery the following morning. In
which of the following locations should the nurse place the V1 electrode? (You will find hot
spots to select in the artwork below. Select only the hot spot that corresponds to your answer)

A. A
B. B
C. C
D. D
Answer: A. A
C. C
Rationale:

A. A is incorrect. The nurse should identify that the Right Arm (RA) electrode should be
positioned just below the right clavicle.
B. B is incorrect. The nurse should identify that the Left Arm (LA) electrode should be
positioned just below the left clavicle.
C. C is correct. The nurse should identify that the V1 electrode should be placed in the 4th
intercostal space just to the right of the sternum. Correct placement of the electrodes is vital
in obtaining accurate information about the electrical activity of the heart.
D. D is incorrect. The nurse should identify that the V2 electrode should be placed in the 4th
intercostal space just to the left of the sternum.
A nurse is collecting data from a client who has hypokalaemia. Which of the following
findings should the nurse identify as the priority?
A. Muscle weakness
B. Dysrhythmia
C. Abdominal pain
D. Lethargy
Answer: B. Dysrhythmia
Rationale:
The nurse should address muscle weakness to prevent injury for a client who has
hypokalaemia. However, another finding is the priority.
When using the airway, breathing, circulation approach to client care, the nurse should
identify that the priority finding for a client who has hypokalaemia is dysrhythmia.
The nurse should address abdominal pain to promote comfort for a client who has
hypokalaemia. However, another finding is the priority.
The nurse should address lethargy for a client who has hypokalaemia to prevent injury.
However, another finding is the priority.
A nurse is caring for an older adult client who has reddened area over the sacrum.
Which of the following actions should the nurse take?
A. Minimize the time the head of the bed is elevated.
B. Apply a sterile gauze dressing to the site.
C. Massage the site with moisturizing lotion.
D. Place a donut-shaped cushion under the client's sacral area.
Answer: A. Minimize the time the head of the bed is elevated.

Rationale:
The nurse should minimize the time the head of the bed is elevated to reduce pressure on the
sacral area.
The nurse should collect further data before determining what type of dressing is needed. For
a stage I pressure injury, skin preparation can be applied to preserve the integrity of the skin
and prevent further direct injury. Alternatively, a dressing such as a hydrocolloid or
transparent dressing can be applied. However, gauze dressings are not used in the treatment
of a stage I pressure injury.
The nurse should not massage nor apply moisturizing lotion to a reddened area because it can
cause further skin injury.
The nurse should not place a donut-type device under the client's sacral area because it can
contribute to the development of a pressure injury.
A nurse is caring for a client who is in Buck’s traction. Which of the following interventions
should the nurse perform to reduce skin breakdown?
A. Keep the skin dry and free of perspiration.
B. Use hot water and antibacterial soap to bathe the client.
C. Massage the skin over bony prominences to promote circulation.
D. Limit the use of moisturizers on the skin over bony prominences.
Answer: A. Keep the skin dry and free of perspiration.
Rationale:
The nurse should not leave moisture on the skin for prolonged periods of time because it can
cause skin breakdown.
The nurse should bathe the client in tepid water and use mild soap to prevent skin breakdown.
The nurse should not massage bony prominences because it can cause skin damage.
The nurse should moisturize skin that is intact to help prevent cracks and breaks in the skin.
A nurse is contributing to the plan of care for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. Which of
the following actions should the nurse take?
A. Keep the door of the client's room closed at all times.
B. Remove gloves after leaving the client's room.
C. Wear a mask when working within 1 m (3 feet) of the client.
D. Have a designated stethoscope in the client's room.

Answer: D. Have a designated stethoscope in the client's room.
Rationale:
The nurse should keep the door of a client's room closed at all times if the client requires
airborne precautions.
The nurse should remove gloves before leaving the client's room.
The nurse should wear a mask when working within 1 m (3 feet) of a client who requires
droplet precautions.
The nurse should designate equipment to leave in the client's room to avoid crosscontamination. The designated equipment should be disposed of or decontaminated before
leaving the client's room.
A nurse is caring for a client who has a prescription for phenazopyridine. Which of the
following findings should the nurse identify as a therapeutic effect of the medication?
A. Reduces bacteria in the urinary tract
B. Suppresses urge to void
C. Prevents nerve stimulation to the bladder muscle
D. Decreases pain during urination
Answer: D. Decreases pain during urination
Rationale:
Bacteria in the urinary tract is reduced with the use of an antimicrobial medication, such as
Fosfomycin.
The urge to void is suppressed with the use of an antispasmodic for urinary incontinence,
such as oxybutynin.
Nerve stimulation to the bladder muscle is prevented with the use of an antispasmodic, such
as hyoscyamine.
Phenazopyridine reduces pain and burning during urination by exerting an anaesthetic effect
on the mucosa of the urinary tract.
A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the
following instructions should the nurse include?
A. "You can take acetaminophen for pain."
B. "Consume a diet high in animal protein."
C. "Sleep lying flat on your back."
D. "Consume foods low in sodium."

Answer: D. "Consume foods low in sodium."
Rationale:
The nurse should instruct the client to avoid taking any over-the-counter medications,
including acetaminophen, which is toxic to the liver.
The nurse should instruct the client to increase vegetable proteins and reduce animal proteins
in the diet to limit the development of encephalopathy.
The nurse should instruct the client to elevate the head of the bed while sleeping to prevent
shortness of breath from the pressure of ascites or hydrothorax.
The nurse should instruct the client to consume foods low in sodium to reduce the
development of edema and ascites.
A nurse is planning to implement droplet precautions for a client who has manifestations of
pertussis. Which of the following interventions should the nurse include when contributing to
the plan of care?
A. Apply a mask on the client if transport is needed.
B. Wear a mask when working within 4 feet of the client.
C. Don a gown when visiting with the client.
D. Wear an N95 mask when entering the client's room.
Answer: A. Apply a mask on the client if transport is needed.
Rationale:
The nurse should apply a mask to the client who has manifestations of pertussis during
transport to prevent exposure to others.
The nurse should wear a surgical mask when working within 1 m (3 feet) of the client who
has manifestations of pertussis.
The nurse should wear a gown when providing direct care to a client if there is potential for
soiling clothes during contact. However, it is not required for the care of the client who
requires droplet precautions; unwarranted use of the gown increases costs.
The nurse should wear an N95 mask when caring for a client who has been placed on
airborne precautions, such a client who has tuberculosis.
A nurse is assisting a client who reports difficulty falling asleep. Which of the following
activities should the nurse recommend to promote sleep?
A. Get out of bed if unable to fall asleep within 60 min.
B. Take a brisk walk before sleeping.

C. Listen to soft music before sleeping.
D. Drink adequate amounts of fluids before sleeping.
Answer: C. Listen to soft music before sleeping.
Rationale:
The client should get out of bed after 30 min if unable to fall asleep.
The client should avoid stimulating activities, such as exercise, before bedtime.
Listening to soft music can help the client to relax and reduces environmental stressors.
The client should reduce fluids 2 to 4 hr before sleep. Drinking fluids before bedtime can
cause the client to wake up during the night to use the bathroom.
A nurse is caring for a client who has an acute ischemic stroke 1 day ago. Which of the
following actions should the nurse take to reduce the risk for aspiration?
A. Allow for 30 min of rest before meals.
B. Provide a straw for drinking liquids.
C. Serve foods at room temperature.
D. Place 2 tsp of food in the client's mouth at a time.
Answer: A. Allow for 30 min of rest before meals.
Rationale:
The nurse should allow the client to rest for 30 min before meals to prevent aspiration.
The nurse should provide a cup for drinking liquids, rather than a straw.
The nurse should serve foods that are cold or heated. It is more difficult for the client to
swallow food that is lukewarm or at room temperature.
The nurse should place only 1 tsp of food in the client's mouth at a time.
A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min
ago by the RN. The client reports dyspnea and urticaria. Which of the following actions
should the nurse perform first?
A. Count the client's respiratory rate.
B. Ask the client if chest pain is present.
C. Stop the infusion.
D. Administer an antihistamine.
Answer: C. Stop the infusion.
Rationale:

The nurse should take the client's vital signs, which includes counting the client's respiratory
rate. However, evidence-based practice indicates that the nurse should take a different action
first.
The nurse should inquire about the presence of chest pain and other manifestations to
determine the severity of the reaction. However, evidence-based practice indicates that the
nurse should take a different action first.
Evidence-based practice indicates the nurse should stop the infusion of the blood product as
soon as manifestations occur because they can indicate a transfusion reaction.
The nurse should administer antihistamines when allergic transfusion manifestations are
present. However, evidence-based practice indicates that the nurse should take a different
action first.
A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a
halo vest in place. Which of the following safety precautions should the nurse include in the
teaching?
A. Clean the pin sites every 72 hr.
B. Use the halo ring to reposition the client when in bed.
C. Change the sheepskin liner weekly.
D. Tighten the traction bar as needed.
Answer: C. Change the sheepskin liner weekly.
Rationale:
The nurse should instruct the family to clean the pin sites every day to decrease the risk for
infection.
The nurse should instruct the family to never lift or reposition the client by pulling on the
halo ring, which can cause further cervical injury.
The nurse should provide instruction regarding the care and maintenance of the vest. The
instruction should include changing the sheepskin liner when soiled, or at least once per
week, to prevent skin irritation.
The nurse should instruct the family to call a provider if the pins or traction bar is loose. The
pin sites or traction bar supports should not be manipulated in any way because it could cause
injury to the client.
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel
obstruction in the descending colon. When listening in the left upper quadrant, the nurse

should identify this sound as which of the following? (Click on the audio button to listen to
the clip.)
A. Hyperactive bowel sounds
B. Friction rub
C. Normal bowel sounds
D. Abdominal bruit
Answer: A. Hyperactive bowel sounds
Rationale:
A mechanical bowel obstruction prevents a portion or all of the bowel contents from moving
forward through the bowel. The nurse should expect to auscultate high-pitched, hyperactive
bowel sounds above the point of the intestinal obstruction as the intestines attempt to propel
the blockage forward.
The nurse should expect to auscultate a pericardial friction rub, a high pitched scratchy sound
over the heart, for a client who has pericarditis.
When auscultating normal bowel sounds, the nurse should expect to hear 5 to 35 gurgles and
clicks in 1 min.
When auscultating an abdominal bruit, the nurse should expect to hear a whooshing sound
that indicates impaired blood flow through an artery.
A nurse is reinforcing teaching with a client a client who has gonorrhoea. Which for the
following information should the nurse include?
A. "Your partner will not require treatment for this infection."
B. "You can resume sexual activity as soon as you begin treatment."
C. "You are at risk for infertility with this infection, regardless of treatment."
D. "You will not be at further risk for this infection following treatment."
Answer: C. "You are at risk for infertility with this infection, regardless of treatment."
Rationale:
The nurse should inform the client that sexual partners will require treatment to prevent the
risk of reoccurrence of the infection.
The nurse should instruct the client to abstain from sexual contact until treatment is
completed and cultures are negative.
The nurse should inform the client that there is a risk for infertility as a result of this
infection.

The nurse should inform the client that immunity does not occur with this infection and that
reoccurrence is possible.
A nurse is assisting in the plan of care regarding bowel retraining for a client who has
cervical spinal cord injury. Which of the following interventions should the nurse plan to
implement first?
A. Determine the client's daily elimination habits.
B. Administer a suppository to the client 30 min prior to defecation time.
C. Offer the client 4 oz of warm prune juice to promote elimination.
D. Provide dietary bulk to the client to ease the passage of stool.
Answer: A. Determine the client's daily elimination habits.
Rationale:
The first action the nurse should take using the nursing process is to collect data on the
client's daily bowel elimination habits to establish a routine defecation time.
The nurse should administer a suppository to the client 30 min prior to defecation time to
stimulate bowel elimination. However, there is another action the nurse should take first.
The nurse should offer the client warm prune juice to stimulate peristalsis to promote
elimination. However, there is another action the nurse should take first.
The nurse should provide dietary bulk to the client to ease the passage of stool and stimulate
bowel elimination. However, there is another action the nurse should take first.
A nurse is contributing to the plan of care for a client who was admitted to the neurological
unit following a stroke 3 hr. ago. Which of the following interventions should the nurse
identify as the priority?
A. Encourage the client to participate in self-care.
B. Assist the client with active range-of-motion exercises.
C. Keep the client in a side-lying position.
D. Maintain the client's body alignment.
Answer: C. Keep the client in a side-lying position.
Rationale:
The nurse should encourage the client to complete self-care to the extent that he is able. Selfcare promotes mobility of the joints and increases the client's feelings of independence and
self-esteem. However, there is another intervention that is the priority.

The nurse should assist the client with active range-of-motion exercises and should provide
passive range-of motion exercises to the client's affected side to maintain joint mobility and
improve muscle strength. However, there is another intervention that is the priority.
The greatest risk to the client following a stroke is aspiration. The nurse should position the
client in a lateral, or side-lying position, which will allow any secretions to drain out of the
mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction
available in the event that any secretions are present in the oral cavity.
The nurse should keep the client's body in alignment to maintain joint function and prevent
skin breakdown caused by pressure on bony prominences. However, there is another
intervention that is the priority.
A nurse is preparing to administer furosemide to a client who has heart failure. Which of the
following findings should the nurse report before administering the medication?
A. Elevated sodium
B. Elevated blood pressure
C. Decreased potassium
D. Decreased urine output
Answer: C. Decreased potassium
Rationale:
The nurse should report a decreased sodium level to the provider before administering the
medication because furosemide can cause hyponatremia.
The nurse should expect the client who has heart failure to have an elevated blood pressure
and does not need to report this finding to the provider before administering the medication.
Furosemide is a diuretic that should help to lower the client's blood pressure.
The nurse should notify the provider immediately of a decreased potassium level because
potassium is lost when a diuretic such as furosemide is administered, which can cause
hypokalaemia.
The nurse should expect the client who has heart failure to have a decreased urine output and
does not need to report this finding to the provider before administering the medication.
Furosemide is a diuretic, which should cause an increase in urine output for a client who has
heart failure.
A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of
the following actions should the nurse take?

A. Lower the side rails of the client's bed.
B. Apply wrist restraints to the client.
C. Position the client in the semi-Fowler's position.
D. Loosen clothing around the client's neck.
Answer: D. Loosen clothing around the client's neck.
Rationale:
The nurse should leave the bed rails up to prevent the client from falling out of bed, which
can cause injury
The nurse should not apply restraints that can place the client at risk for a fracture injury
The nurse should place the client in a lateral position to allow for the drainage of oral
secretions and to maintain an open airway.
The nurse should loosen clothing around the client's neck to maintain an open airway and
prevent aspiration.
A nurse is reinforcing teaching about joint protection with a client who has an acute
exacerbation of rheumatoid arthritis. Which of the following information should the nurse
include in the teaching?
A. Apply cold packs to the inflamed joints.
B. Participate in high-impact exercise.
C. Carry a hand purse rather than a shoulder bag.
D. Sleep on a soft foam mattress.
Answer: A. Apply cold packs to the inflamed joints.
Rationale:
The nurse should instruct the client to use both warm and cold packs on inflamed joints to
decrease pain.
The nurse should instruct the client to participate in low-impact aerobic exercises, which will
not inflame the client's joints.
The nurse should instruct the client to carry a shoulder bag, which places the stress on larger
muscles.
The nurse should instruct the client to sleep on a firm mattress to support the joints.
A nurse is participating in a health fair for older adult clients. Which for the following
immunizations should the nurse recommend for this age group?
A. Meningococcal

B. Herpes zoster
C. Human papillomavirus (HPV)
D. Measles, mumps, and rubella (MMR)
Answer: B. Herpes zoster
Rationale:
The nurse should recommend the meningococcal immunization to college students and
military recruits living in shared housing.
The nurse should recommend the herpes zoster immunization for adults 60 years of age and
older.
The nurse should recommend the HPV immunization for clients who are 9 to 26 years old.
The nurse should recommend the MMR immunization to clients who were born after 1956.
A nurse is caring for a client who has difficulty swallowing. Which of the following actions
should the nurse implement to prevent aspiration?
A. Provide small, frequent meals.
B. Tell the client to extend his neck when swallowing.
C. Provide mouth care before meals.
D. Give the client liquids with increased viscosity.
Answer: D. Give the client liquids with increased viscosity.
Rationale:
Providing small, frequent meals can improve the client's nutritional intake, but it does not
decrease the risk for aspiration.
The client should tilt his neck forward while swallowing to decrease the risk for aspiration.
Mouth care can enhance the client's sense of taste, but it does not decrease the risk for
aspiration.
Thickened liquids are easier for the client to swallow and can prevent aspiration.
A nurse is contributing to the plan of care for a client who has a new prescription for nystatin
suspension for oral candidiasis. Which of the following interventions should the nurse
include in the plan?
A. Use a commercial mouthwash before taking the medication.
B. Instruct the client to swish the medication in her mouth.
C. Discontinue the medication as soon as the lesions are healed.
D. Combine the medication with applesauce.

Answer: B. Instruct the client to swish the medication in her mouth.
Rationale:
The client should avoid commercial mouthwashes while the mouth infection is present
because using mouthwash can increase pain and does not contribute to treatment of the
infection.
The nurse should instruct the client to place half the dose in each side of her mouth, swish the
medication, and then swallow. This action will allow the medication to coat the entire oral
mucosa and treat the fungal infection.
The client should continue nystatin for two days after the lesions have healed.
The client should not mix nystatin with food because it will alter the absorption of the
medication and prevent adequate coating of the oral lesions.
A nurse is collecting data from a client who has hypothyroidism. Which of the following
manifestations should the nurse anticipate?
A. Blurred vision
B. Insomnia
C. Bradycardia
D. Weight loss
Answer: C. Bradycardia
Rationale:
The nurse should identify that blurred vision is a manifestation of hyperthyroidism.
The nurse should identify that insomnia is a manifestation of hyperthyroidism that is caused
by an increase in the client's metabolic rate.
The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused
by a decrease in the client's metabolic rate.
The nurse should identify that weight loss is a manifestation of hyperthyroidism caused by an
increase in the client's metabolic rate.
A nurse is discussing health screening guidelines with an older adult client. Which of the
following statements should the nurse include?
A. "You should have a screening for glaucoma every 5 years."
B. "You should have a physical examination every other year."
C. "You should have your hearing checked every 2 years."
D. "You should have a pneumococcal immunization every 10 years."

Answer: D. "You should have a pneumococcal immunization every 10 years."
Rationale:
The nurse should remind the client to have a screening for glaucoma every 2 to 3 years along
with an annual visual acuity exam.
The nurse should remind the client to have a physical examination every year.
The nurse should remind the client to have her hearing checked every year.
The nurse should remind the client to have a pneumococcal immunization at age 65 and
every 10 years thereafter to protect her from acquiring pneumonia.
A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by
continuous IV infusion. The client reports pain and swelling at the IV site. In which order
should the nurse perform the following steps? (Move the steps into the box on the right,
placing them in order of performance. Use all the steps.)
Answer:
Notify the Charge nurse

Check the IV Site

Stop the infusion

Stop the infusion

Elevate the affected arm

Withdraw the IV catheter

Withdraw the IV catheter

Elevate the affected arm

Check the IV site

Notify the charge nurse

The first action the nurse should take using the nursing process is to check the IV site for
infiltration. If infiltration is found, the next step is to stop the infusion to prevent vein and
tissue damage. Once the infusion is stopped, the nurse should remove the IV catheter. Then,
the nurse should elevate the affected extremity to decrease swelling and notify the charge
nurse.
A nurse is contributing to the plan of care for a client who is postoperative following a total
knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of
the following interventions should the nurse recommend for the plan of care?
A. Store the CPM machine on the floor when it is not in use.
B. Keep a sheepskin pad between the client's extremity and the CPM.
C. Check the cycle and range-of-motion settings at least every 12 hr.
D. Align the frame joint of the CPM with the middle of the client's calf.

Answer: B. Keep a sheepskin pad between the client's extremity and the CPM.
Rationale:
The nurse should avoid placing the CPM machine on the floor, as this exposes it to potential
contamination, which can increase the client's risk for infection.
The nurse should plan to keep a sheepskin pad between the client's extremity and the CPM
machine to protect the client's skin. The nurse should check the client's skin condition
frequently while the client is using the CPM.
The nurse should plan to check the settings of the CPM machine at least every 8 hr.
The nurse should plan to align the frame joint of the CPM with the client's knee joint to
provide appropriate flexion and extension.
A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse
observes ecchymosis around the umbilicus. The nurse should identify that this is a
manifestation of which of the following?
A. Cirrhosis of the liver
B. Hypermotility of the bowel
C. Intra-abdominal bleeding
D. Acute cholecystitis
Answer: C. Intra-abdominal bleeding
Rationale:
A client who has cirrhosis of the liver can have a manifestation of bluish varicose veins that
radiate from the umbilicus, which can indicate portal hypertension. However, cirrhosis of the
liver does not cause ecchymosis around the umbilicus.
A client who has hypermotility of the bowel can exhibit diarrhoea as a manifestation, not
ecchymosis around the umbilicus.
Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding
consistent with pancreatitis.
A client who has acute cholecystitis has an inflammation of the gallbladder that can indicate
gallstones, but acute cholecystitis does not cause ecchymosis around the umbilicus.
A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has
a loss of appetite because she has sores in her mouth and that food no longer tastes good.
Which of the following suggestions to the client should the nurse make?
A. Drink water before and after each bite.

B. Consume foods that are served hot rather than cold.
C. Rinse with a glycerine-based mouthwash before meals.
D. Eat several, small-portioned meals daily.
Answer: D. Eat several, small-portioned meals daily.
Rationale:
The nurse should suggest that the client add gravy, broth, or sauces to foods to increase the
moisture content of the food. Drinking water before and after each bite can lead to early
satiety, which might cause the client to consume less food.
Cold foods are usually tolerated better by a client who is receiving chemotherapy because
they emit less odor.
Clients who have sores in their mouths or mucositis should rinse with a solution of water and
0.9% sodium chloride, or with water and baking soda. Using a glycerine- or alcohol-based
mouthwash can lead to irritation and burning of the oral mucosa.
Clients who have difficulty eating because of pain or anorexia can usually tolerate small
amounts of food at one time. Eating several small meals daily can increase the client's caloric
intake.
A nurse is contributing to the plan of care for a client who is having difficulty eating
following a stroke. Which of the following interventions should the nurse plan to implement
first?
A. Collaborate with a dietitian.
B. Provide nutritional supplements.
C. Recommend a referral for a speech language pathologist.
D. Inform assistive personnel about proper positioning.
Answer: C. Recommend a referral for a speech language pathologist.
Rationale:
The nurse should collaborate with the dietician to evaluate the client's nutritional status and
incorporate the client's food likes and dislikes into the meal plan. However, there is another
intervention the nurse should plan to implement first.
The nurse should provide nutritional supplements as needed to ensure the client's nutritional
needs are being met. However, there is another intervention the nurse should plan to
implement first.
The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first
intervention the nurse should include in the plan of care is to recommend a referral for a

speech language pathologist. A speech language pathologist can conduct a swallow study to
determine the client's risk for aspiration, provide teaching to the client regarding swallowing
techniques, and recommend the consistency of foods and liquids.
The nurse should provide instruction to assistive personnel regarding proper positioning of
the client during mealtimes. The client should be positioned upright during meals to help
prevent aspiration and facilitate swallowing and should remain in this position for at least 45
min after eating. However, there is another intervention the nurse should plan to implement
first.
Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the
nurse, “I’m glad they took my blood because I’m really hungry. All I’ve had since midnight is
water and some juice.” Which of the following actions should the nurse take?
A. Offer the client breakfast then repeat the FBS request.
B. Reschedule the FBS test for early the next morning.
C. Request that the phlebotomist obtain another specimen.
D. Ask the laboratory technician to repeat the test on the same specimen.
Answer: B. Reschedule the FBS test for early the next morning.
Rationale:
An FBS test requires the client to have no food or juice for at least 8 hr. The result of the FBS
test would be invalid after the client had breakfast.
An FBS test requires the client to have no food or juice for at least 8 hr. The result of the FBS
test would be invalid because the client drank juice during the fasting time period. The nurse
should reinforce with the client to only drink water and have no food or other beverages for 8
hr before the phlebotomist obtains the blood specimen.
The client had juice within the past 8 hr. The nurse should request that the phlebotomist
obtain another specimen when the client has ingested no food or other beverages for 8 hr.
Repeating the test on the same specimen will yield the same result, which will also be invalid.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking
dantrolene to manage muscle spasms. Which of the following interventions should he nurse
include?
A. Apply hot packs to the client's muscles.
B. Schedule physical therapy in the afternoon.
C. Encourage the client to complete ADLs.

D. Administer valerian to promote sleep.
Answer: C. Encourage the client to complete ADLs.
Rationale:
The nurse should avoid exposing the client's muscles to extreme temperatures because it
decreases muscle strength.
The nurse should schedule physical therapy and other activities in the morning when the
client's strength is at its peak. Fatigue increases in the afternoon.
The nurse should encourage the client to complete ADLs and provide assistance as needed.
Performing self-care increases the client's independence, strength, and level of functioning.
The nurse should instruct the client to avoid using valerian to promote sleep because this
herbal supplement can increase CNS depression when taken with dantrolene.
A nurse is preparing to administer scheduled medications to a client. Which of the following
prescriptions should the nurse verify with the provider? (Click on the “Exhibit” button for
additional information about the client. There are three tabs that contain separate categories
of data.)

A. Ceftriaxone
B. Diltiazem
C. Pioglitazone.
D. Hydrocodone 5 mg/acetaminophen 500 mg
Answer: A. Ceftriaxone
Rationale:

Clients who have a severe sensitivity to penicillin can have a cross-sensitivity reaction to
ceftriaxone, a cephalosporin. Therefore, the nurse should contact the provider to clarify the
prescription.
The nurse should administer diltiazem because the client's heart rate and blood pressure are
within the expected reference ranges.
The nurse should administer pioglitazone because the client's blood glucose level is within
the expected reference range.
The nurse should administer hydrocodone and acetaminophen to manage the client's pain
because the client's respiratory rate is within the expected reference range.
A nurse is caring for a client who is postoperative and is receiving an IV infusion of cefzolin.
Ten minutes after beginning the infusion, the client reports intense itching. Which of the
following actions should the nurse take first?
A. Stop the medication infusion.
B. Notify the charge nurse.
C. Administer a PRN dose of diphenhydramine.
D. Follow facility policy for appropriate reporting of the adverse reaction.
Answer: A. Stop the medication infusion.
Rationale:
The greatest risk to the client is injury from an allergic response to the medication. Therefore,
the priority action the nurse should take is to stop the medication infusion.
The nurse should notify the charge nurse about what has occurred. However, there is another
action the nurse should take first.
The nurse should administer a PRN dose of diphenhydramine to keep the allergic reaction
from worsening. However, there is another action the nurse should take first.
The nurse should follow facility policy when reporting an adverse reaction. However, there is
another action the nurse should take first.

Version 10
ATI MED-SURG PART B
A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the
following instructions should the nurse in the teaching?

A. "Place throw rugs on wooden floors at home."
B. "Supplement your diet with vitamin E."
C. "Swim laps for 20 minutes twice per week."
D. "Take calcium supplements with meals."
Answer: D. "Take calcium supplements with meals."
Rationale:
The nurse should instruct the client to take calcium carbonate supplements with or following
meals to increase absorption and effectiveness.
A nurse is reviewing the medication record of a client who is taking digoxin. Which of the
following medications should the nurse identify as increasing the risk for the client to develop
digoxin toxicity?
A. Potassium chloride
B. Famotidine
C. Levothyroxine
D. Furosemide
Answer: D. Furosemide
Rationale:
The nurse should identify that loop diuretics, such as furosemide, increase the urinary
excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk for
the development of digoxin toxicity.
A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4
kg (100 lb.). Which of the following statements by the client indicates an understanding of
the teaching?
A. "I should insert the needle at a 90-degree angle."
B. "I should give my shot in my belly tissue."
C. "I will pull back on the syringe plunger to look for blood before I push the medication in."
D. "I will use the side of my hand to pull my skin to the side prior to administering the
insulin."
Answer: B. "I should give my shot in my belly tissue."
Rationale:

Clients who have low body weights can have very little subcutaneous tissue. Therefore, the
nurse should instruct the client to administer the medication in the upper abdomen for proper
absorption.
A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve
replacement. Which of the following statements by the client indicates an understanding of
the teaching?
A. "I will notify my dentist about this procedure."
B. "I will take an enteric-coated aspirin daily."
C. "I will use a firm-bristled toothbrush."
D. "I will weigh myself once a week."
Answer: A. "I will notify my dentist about this procedure."
Rationale:
The nurse should instruct the client to notify his dentist about the mechanical mitral valve
replacement before any procedures so antibiotic therapy can be initiated to reduce the risk of
endocardial infection.
A nurse is reviewing the medical record for an older adult client who is experiencing nausea
and vomiting. Based on the client data, which of the following actions should the nurse take?
(Click on the “Exhibit” button for additional client information. There are three tabs that
contain separate categories of data.) View the Exhibit

A. Encourage the client to ambulate.
B. Administer an antipyretic medication.
C. Notify the charge nurse of the client's BUN level

D. Keep the temperature in the client's room warm.
Answer: C. Notify the charge nurse of the client's BUN level
Rationale:
The client's BUN level is above the expected reference range of 10 to 20 mg/dL, which
indicates dehydration and impaired renal function. The nurse should notify the charge nurse
of this finding and anticipate interventions to restore the client's fluid volume.
A nurse is providing information regarding transmission-based precautions for a client who
has Clostridium difficile to an assistive personnel (AP). Which of the following instructions
should the nurse include? (Select all that apply).
A. "Provide the client with disposable utensils and dishes for meals."
B. "Leave blood pressure equipment in the client's room."
C. "Clean contaminated surfaces with a bleach solution." (
D. "Use an alcohol-based hand sanitizer after client care."
E. "Wear a face mask when in the client's room."
Answer: A. "Provide the client with disposable utensils and dishes for meals."
B. "Leave blood pressure equipment in the client's room."
C. "Clean contaminated surfaces with a bleach solution." (
Rationale:
Clients who have C. difficile require contact precautions, which include using disposable
utensils and dishes during meals to prevent exposure to contaminants by others.
When using contact precautions, the health care staff should dedicate equipment to singleclient use to prevent transmission of the pathogen.
The health care staff should use a bleach solution to clean equipment to prevent transmission
of the pathogen.
A nurse is admitting a client who is suspected having active tuberculosis (TB). Which of the
following actions should the nurse take first? (chap. 20)
A. Administer antituberculosis medication.
B. Institute airborne precautions.
C. Obtain sputum cultures.
D. Auscultate breath sounds.
Answer: B. Institute airborne precautions.
Rationale:

The greatest risk from this client is transmitting TB to staff and other clients. Therefore, the
first action the nurse should take is to implement airborne precautions.
A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain.
Which of the following actions should the nurse take?
A. Fill the bulb reservoir with 0.9% sodium chloride.
B. Allow the Jackson-Pratt drain to hang freely.
C. Cut a slit in a gauze sponge and apply it around the tubing insertion site.
D. Compress the bulb reservoir and then close the drainage valve. (
Answer: D. Compress the bulb reservoir and then close the drainage valve. (
Rationale:
The nurse should fully compress the bulb reservoir and then replace the valve plug using
aseptic technique to establish suction after emptying or activating a Jackson-Pratt drain.)
A nurse is reinforcing teaching with the parent of a toddler who has type I diabetes mellitus
and whose prescription has been changed from regular insulin to lispro insulin. Which of the
following information should the nurse include in the teaching?
A. Lispro is given once a day.
B. Lispro should be given before eating.
C. Lispro cannot be given with other insulin.
D. Lispro does not cause hypoglycemia.
Answer: B. Lispro should be given before eating.
Rationale:
Lispro insulin should be given around mealtime, within 15 min before or after eating.)
A nurse is reinforcing teaching with a client who has microcytic anemia and is prescribed a
daily iron supplement. The nurse tells the client to consume foods containing vitamin C when
taking the supplement to enhance iron absorption. Which of the following client food choices
indicates an understanding of the teaching?
A. 1 cup cooked brown rice
B. 1 cup boiled broccoli
C. 1 cup cottage cheese
D. 1 cup cooked kidney beans
Answer: B. 1 cup boiled broccoli

Rationale:
The nurse should determine that choosing boiled broccoli indicates an understanding of the
teaching because 1 cup contains 101 mg of vitamin C per serving.
A nurse is assisting with the development of a plan of care to manage pain for a client who
has herpes zoster with lesions on the lower extremities. Which of the following interventions
should the nurse include in the plan of care?
A. Keep bed linens off of the affected areas.
B. Position a heat lamp over the lower extremities.
C. Apply warm, moist compresses to the affected areas.
D. Initiate droplet isolation precautions.
Answer: A. Keep bed linens off of the affected areas.
Rationale:
The nurse should keep bed linens off of the affected areas using a bed cradle, which will
relieve pain caused by the linens rubbing against the lesions.
A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should
recommend which of the following foods as the best source of fiber?
A. ½ cup cooked kidney beans
B. ½ cup raw cauliflower
C. 1 cup cucumber with peel
D. 1 cup parboiled brown rice
Answer: A. ½ cup cooked kidney beans
Rationale:
The nurse should recommend kidney beans as the best source of fiber because ½ cup contains
6.5 g of fiber per serving.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is
receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following
findings should indicate to the nurse that the client’s therapeutic regimen is effective?
A. Adventitious lung sounds
B. Decrease in exertional dyspnea
C. Respiratory rate of 26/min while sitting in a chair
D. Elevation of the head of the bed is required to sleep

Answer: B. Decrease in exertional dyspnea
Rationale:
A decrease in exertional dyspnea indicates the antibiotics are resolving the infection and the
albuterol treatments are facilitating effective ventilation. Therefore, the nurse should evaluate
the therapeutic regimen as effective for the client.
A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the
cast. Which of the following actions should the nurse take?
A. Blow cool air into the cast using a blow dryer on a cool setting.
B. Obtain a prescription for pregabalin.
C. Ask the provider to bivalve the cast.
D. Provide the client with a tongue blade to rub the skin under the cast.
Answer: A. Blow cool air into the cast using a blow dryer on a cool setting.
Rationale:
Using a blow dryer on a cool setting to blow cold air into the cast is an effective way to
relieve the client's itching without damaging the skin.
A nurse is preparing to insert a double-lumen gastric (Salem) sump tube for a client who has
peptic disease and has developed gastrointestinal bleeding. Which of the following images
indicates the tube that the nurse should select?
A.

B.

C.

D.

Answer:
A.

Rationale:
In a double-lumen gastric (Salem) sump tube, the clear portion of the tube allows for
aspiration of stomach contents. The blue portion of the tube, or the "pig tail", vents the tube
to the atmosphere, which prevents the tube from becoming lodged against the wall of the
stomach and protects the stomach from damage.
This image shows a percutaneous endoscopic gastrostomy (PEG) feeding tube. A provider
inserts a PEG feeding tube surgically through the abdomen and into the stomach to allow for
longer-term medication administration and tube feedings.
This image shows a Levin tube. It is a single-lumen nasogastric tube which facilitates gastric
decompression. Damage to the gastric mucosa can occur during aspiration of stomach
contents with this tube.
This image shows a Sengstaken-Blakemore tube. The provider prescribes this tube in the
treatment of bleeding esophageal varices.
A nurse is caring for a client who has just returned to the unit following a bronchoscopy.
Which of the following findings should the nurse report to the provider?
A. Absent gag reflex
B. Blood-tinged mucus
C. Diminished breath sounds

D. Oxygen saturation 95%
Answer: C. Diminished breath sounds
Rationale:
Diminished breath sounds might indicate a pneumothorax or laryngeal edema. The nurse
should report this finding to the provider for further evaluation of the client.)
A nurse is caring for a client who has been taking enalapril. The nurse should monitor the
client for which of the following adverse effects?
A. Bradycardia
B. Tremors
C. Cough
D. Hyperglycemia
Answer: C. Cough
Rationale:
Enalapril is an ACE inhibitor, which can cause a dry, nonproductive cough. Therefore, the
nurse should monitor the client for this adverse effect.
A nurse is preparing a client for a cardiac catheterization. Which of the following actions
should the nurse take first?
A. Verify the client has given informed consent.
B. Administer preoperative medication.
C. Mark the location of the pedal pulses.
D. Have the client void.
Answer: A. Verify the client has given informed consent.
Rationale:
The greatest risk to the client in this situation is performing an unauthorized invasive
procedure. Therefore, the first action the nurse should take is to verify that the client has
given informed consent. If documentation of informed consent is not on the client's medical
record, the nurse should withhold medications, which can alter the client’s consciousness
until consent is obtained.
A nurse is caring for an adult client who has age-related macular degeneration.
Which of the following findings should the nurse expect?
A. Seeing halos around artificial lights

B. Distorted central vision of the eyes
C. Colored spots before the visual fields
D. Spontaneous tearing of the eyes
Answer: A. Seeing halos around artificial lights
Rationale:
Macular degeneration results in a distortion and blurring of central vision. The client might
completely lose central vision and view a dark spot in the center.
A nurse is planning care for a group of clients after receiving change-of-shift report. Which of
the following clients should the nurse plan to see first?
A. A client who had a colectomy 2 days ago and has a nasogastric tube, Jackson-Pratt drain,
and indwelling urinary catheter
B. A client who is dehydrated, has mental confusion, and was found getting out of bed several
times during the night
C. A client who had a right lower lobe lobectomy 4 days ago and has a chest tube set to
continuous suction
D. A client who has pneumonia and an oral temperature of 38.7º C (101.7º F)
Answer: B. A client who is dehydrated, has mental confusion, and was found getting out of
bed several times during the night
Rationale:
(When using the urgent vs. nonurgent approach to client care, the nurse determines to first see
the client who has mental confusion and is getting out of bed without assistance. The client is
experiencing manifestations of dehydration that can cause injury due to falls. Therefore, the
nurse should see this client first.)
A nurse is collecting data from a client who is receiving sumatriptan. Which of the following
is an outcome?
A. Reduced cough
B. Diminished headache
C. Relaxed muscles
D. Decreased peripheral edema
Answer: B. Diminished headache
Rationale:

Sumatriptan is a vascular headache suppressant prescribed for relief of migraines or cluster
headaches. Therefore, the nurse should monitor the client for a diminished headache as an
expected outcome of the medication.
A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of
90%. Which of the following actions should the nurse take?
A. Prepare for intubation of the client.
B. Administer opioid medication.
C. Administer oxygen via nasal cannula.
D. Place the client in low-Fowler's position
Answer: C. Administer oxygen via nasal cannula.
Rationale:
The nurse should administer oxygen via nasal cannula to a client who reports shortness of
breath and has an oxygen saturation below the expected reference range. The nurse should
continue to monitor the client and adjust the oxygen flow rate as needed.
A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While
taking the client’s apical pulse, the nurse notes a rate of 58/min. which of the following
actions should the nurse takes?
A. Give the dose as prescribed.
B. Use a different route to administer the medication.
C. Administer half of the prescribed dose.
D. Withhold the dose.
Answer: D. Withhold the dose.
Rationale:
The nurse should withhold the digoxin dose for an apical pulse less than 60/min and notify
the provider. Digoxin slows the heart rate, so administering the dose can cause harm to the
client.
A nurse is caring for a client who has neutropenia. Which of the following nursing
interventions should the nurse implement?
A. Offer the client fresh fruits and vegetables.
B. Monitor the client's platelet count daily.
C. Limit visitors to healthy adults.

D. Apply firm pressure to injection sites.
Answer: C. Limit visitors to healthy adults.
Rationale:
The nurse should limit visitors to healthy adults to minimize the client's risk of exposure to
infection.
A nurse is caring for client who has an intestinal obstruction and reports a new onset of
nausea. The client has an NG tube set at low intermittent suction and is receiving continuous
IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take
first?
A. Check for kinks in the NG tube.
B. Increase the IV fluid rate.
C. Provide ice chips.
D. Administer an antiemetic.
Answer: A. Check for kinks in the NG tube.
Rationale:
The first action the nurse should take when using the nursing process is to collect data from
the client. Therefore, the priority action is to check the NG tube to determine if the tube is
kinked, which can interfere with the suctioning function and result in nausea.
A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the
following information should the nurse recommend to include in the pamphlet?
A. The number of sexual partners does not affect the risk for STIs.
B. Oral contraceptive use decreases the risk for STIs.
C. Men seek treatment for STIs later than women.
D. Women have a higher risk of contracting STIs than men.
Answer: D. Women have a higher risk of contracting STIs than men.
Rationale:
The nurse should include that oral contraceptive use, prolonged contact with male secretions,
and increased cervical permeability during hormone fluctuations increase a woman's risk of
acquiring STIs.
A nurse is reinforcing teaching with a client who is postoperative following a cemented total
hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

A. Avoid weight-bearing until healing of the hip incision is complete.
B. Cross legs intermittently several times a day.
C. Lean forward to change positions when sitting in a chair.
D. Maintain hip flexion to 90° or less when sitting.
Answer: D. Maintain hip flexion to 90° or less when sitting.
Rationale:
A client who has had a cemented total hip arthroplasty should maintain hip flexion to 90° or
less when sitting to prevent hip dislocation.
A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery.
Which of the following findings requires immediate attention from the nurse?
A. Reported pain level of 6 on a scale of 0 to 10
B. Urinary output of 110 mL in the past 4 hr
C. Temperature of 38.0º C (100.4º F)
D. Oxygen saturation of 88%
Answer: D. Oxygen saturation of 88%
Rationale:
When using the airway, breathing, circulation approach to client care, the nurse determines
that the finding that requires immediate attention is an oxygen saturation of 88%. This
finding is below the expected reference range of 95% to 100% and requires intervention to
restore oxygenation to the client's tissues.
A nurse is caring for a client following a gastrectomy. Which of the following actions should
the nurse take to decrease episodes of dumping syndrome?
A. Place the client in the supine position after meals.
B. Administer pancreatic enzymes before meals.
C. Encourage the client to drink 240 mL (8 oz) of fluids with meals.
D. Offer the client three meals daily.
Answer: A. Place the client in the supine position after meals.
Rationale:
The nurse should encourage the client to lie in the supine position for a short time following
meals to decrease rapid gastric emptying.

A nurse is assisting with the care of a client who has a stroke and is unable to speak. The
nurse should identify that the client’s injury occurred in which of the following lobes of the
brain? (You will find hot spots to select in the artwork below. Select only the hot spot that
corresponds to your answer.)

A. A
B. B
C. C
D. D
Answer: A. A
Rationale:
A is correct. Injury to the frontal lobe can result in alterations to motor function or voluntary
movement. This involves the ability to speak and the ability to move purposefully.
B is incorrect. The nurse should identify that injury to the parietal lobe results in alterations to
higher-level activities, such as writing, and processing sensory information, such as
proprioception, pain, temperature, touch, and pressure.
C is incorrect. The nurse should identify that injury to the occipital lobe results in alterations
in visual perception and the ability to track movement of an object. Injuries to this area can
result in an inability to recognize objects, faces, or the written word.
D is incorrect. The nurse should identify that injury to the temporal lobe results in alterations
in the ability to understand the spoken language and impaired short term memory.
A home health nurse is caring for a client who has COPD. The client tells the nurse that he
becomes short of breath while eating despite the use of home oxygen. Which of the following
instructions should the nurse include?

A. Limit protein in daily meal plan.
B. Use a bronchodilator 1 hr before meals.
C. Drink beverages at the end of meals.
D. Lie down for 1 hr. after meals.
Answer: C. Drink beverages at the end of meals.
Rationale:
Lie down for 1 hr after meals. The client should drink beverages at the end of meals, rather
than during meals, to prevent shortness of breath while eating. This also prevents early satiety
and promotes adequate nutrient intake during the meal
A nurse is reinforcing teaching with a client who has chronic kidney disease about
management. Which of the following statements by the client indicates an understanding of
the teaching?
A. "I will add a banana to my morning cereal."
B. "I will decrease my intake of carbohydrates."
C. "I will limit my daily intake of protein."
D. "I will season my foods with a salt substitute."
Answer: C. "I will limit my daily intake of protein."
Rationale:
The client should decrease his intake of protein to slow the progression of kidney failure.
Therefore, the nurse should identify this statement as an understanding of the teaching.
A nurse is caring for a client who has dementia due to Alzheimer’s disease.
Which of the following actions should the nurse take to reduce the client’s confusion?
A. Restrict visitors to three at a time.
B. Avoid touching the client during care.
C. Encourage reminiscence of past experiences.
D. Give the client multiple options for daily events.
Answer: C. Encourage reminiscence of past experiences.
Rationale:
The nurse should encourage reminiscence of past experiences to reduce the client's confusion.

A nurse is caring for a client who has Cushing’s syndrome and expresses concern regarding
body image changes. Which of the following should the nurse recognize as a physical change
caused by this disease?
A. Bronze skin
B. Truncal obesity
C. Lordosis
D. Exophthalmos
Answer: B. Truncal obesity
Rationale:
Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a redistribution
of fat. The client also usually has fatty tissue edema between the scapula, also known as
"buffalo hump". The nurse should use therapeutic communication techniques to investigate
the client's body image concerns.
A nurse is delegating the task of repositioning a client who is in skeletal traction to an
assistant personnel (AP). Which of the following instructions should the nurse give the AP?
A. Allow the weights to hang freely.
B. Release the tension of the ropes.
C. Remove the weights when rewrapping bandages.
D. Manually lift the weights when moving the client up in bed.
Answer: A. Allow the weights to hang freely.
Rationale:
The nurse should instruct the AP to allow the weights to hang freely and to refrain from
bumping the weights. Skeletal traction maintains alignment of fractured bones through the
use of counterweights. If these weights rest on the floor or another object, they do not
maintain the counterbalance necessary to maintain the alignment of the fracture, which can
result in client injury or pain.
A nurse is contributing to the plan of care for a client who has a head injury and is at risk for
increased intracranial pressure (ICP). Which of the following actions should the nurse include
in the plan?
A. Measure rectal temperature every 4 hr.
B. Remind the client to cough as needed.
C. Use a turn sheet to reposition the client.

D. Apply wrist restraints.
Answer: C. Use a turn sheet to reposition the client.
Rationale:
The nurse should change the client's position slowly to prevent sudden increases in ICP. The
use of a turn sheet to reposition the client provides the nurse with the ability to better control
the client's movement and alignment. The nurse should instruct the client to exhale during the
position change to prevent an increase in ICP.
A nurse is preparing to administer an influenza vaccine to a client. Which of the following
statements by the client should cause the nurse to postpone administration of the vaccine?
A. "I am allergic to shrimp."
B. "I am allergic to latex balloons."
C. "I had a tuberculosis skin test 2 days ago."
D. "I had a low fever this morning."
Answer: D. "I had a low fever this morning."
Rationale:
Clients who have a febrile illness should not receive the influenza vaccine.
A nurse is repositioning a client who has lower back pain. Which of the following position is
appropriate for the client?
A. Semi-Fowler's with knees flexed
B. Orthopneic
C. Dorsal recumbent
D. Prone with legs straight
Answer: A. Semi-Fowler's with knees flexed
Rationale:
Sitting in semi-Fowler's position with the head of bed elevated 15° to 45° and flexing the
knees will help relax the lumbar area of the client's back and relieve pressure on the nerves.)
A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes.
Which of the following information should the nurse include in the teaching?
A. "Use condoms when lesions are present."
B. "Look for lesions that have a wart-like appearance."
C. "The virus can be transmitted without lesions present."

D. "The lesions resolve in 2 weeks and usually do not recur."
Answer: C. "The virus can be transmitted without lesions present."
Rationale:
The nurse should inform the client that viral shedding and spreading of the infection can
occur even when lesions are not present
A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM)
machine with a client who is schedules for a total knee arthroplasty. Which of the following
information should the nurse include in the teaching? (Select all that apply.)
A. "Your knee is flexed and extended as prescribed by your provider."
B. "The machine is padded with sheep skin."
C. "You might have the head of the bed elevated to 45 degrees while using this machine."
D. "To use the machine, you must pedal as if you are riding a bike."
E. "We will store the CPM machine on the floor under the bed when not in use."
Answer: A. "Your knee is flexed and extended as prescribed by your provider."
B. "The machine is padded with sheep skin."
Rationale:
The provider will give specific instructions concerning the CPM flexion and extension
motion each day.
Padding the CPM machine with sheep skin prevents injury to pressure points on the
extremity.
A nurse is caring for a client who begins to have a seizure while ambulating in the hall.
Identify the sequence of actions the nurse should follow. (Move the steps the nurse should
take into the box on the right, placing them in order of performance. Use all the steps.)
Answer:

First, the nurse should lower the client to the floor to prevent the client from falling. Second,
the nurse should place a pad beneath the client's head to protect the client from injury. Third,
the nurse should loosen clothing around the client's neck to allow for easier ventilation.
Fourth, the nurse should note the time the seizure began for accurate reporting. Fifth, the
nurse should reorient and reassure the client because confusion and embarrassment are
common following a seizure.
A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB)
and a prescription for isoniazid and rifampin. Which of the following information should the
nurse include in the teaching?
A. Weekly sputum cultures will be needed.
B. Household family members should be tested for TB.
C. TB is no longer contagious after 2 to 3 days of medication therapy.
D. Family members should wear N95 masks when in contact with the client.
Answer: B. Household family members should be tested for TB.
Rationale:
The nurse should instruct the client that family members or others who have been in close
contact with the client should schedule testing for TB.
A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a
statin medication to lower cholesterol levels. Which of the following instructions should the
nurse include in the teaching?
A. "Maintain fat intake of 40 percent of total calories."
B. "Have your white blood cell count checked."
C. "Sustain an HDL level of 25 milligrams per deciliter."
D. "Add oily fish to your diet twice weekly." (
Answer: D. "Add oily fish to your diet twice weekly." (
Rationale:
The nurse should reinforce teaching about dietary changes to manage coronary artery disease,
such as eating fish that are rich in omega-3 fatty acids, like tuna, mackerel, or salmon, twice
weekly or taking a fish oil supplement daily.

A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription
for regular and NPH insulin. Which of the following instructions on preparing the insulin
should the nurse include?
A. Withdraw both types of insulin and then add 0.2 mL of air to the syringe.
B. Gently shake the NPH insulin prior to withdrawing the dose.
C. Withdraw the regular insulin before withdrawing the NPH insulin.
D. Inject air into the NPH vial after withdrawing regular insulin.
Answer: C. Withdraw the regular insulin before withdrawing the NPH insulin.
Rationale:
The nurse should instruct the client to draw air into the syringe prior to withdrawing the
insulins. No additional air should be added to the syringe after withdrawing the insulins.
The nurse should instruct the client to gently rotate the vial of NPH insulin to mix it prior to
withdrawing the dose.
The nurse should instruct the client to withdraw the regular insulin before withdrawing the
NPH insulin. This will protect the regular insulin from contamination with the NPH insulin.
The nurse should instruct the client to inject air into both insulin vials before withdrawing
either medication.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis.
Which of the following instructions should the nurse include to promote comfort?
A. Sleep on a firm mattress.
B. Try jogging in place when joints feel stiff.
C. Use a soft chair or recliner for sitting.
D. Apply ice packs to painful joints.
Answer: A. Sleep on a firm mattress.
Rationale:
A firm mattress or a bed board helps the client maintain joint alignment while sleeping.)
A nurse is assisting in the plan of care for a client who has a recent left hemispheric stroke.
Which of the following actions should the nurse include in the plan?
A. Observe for impulsive behavior.
B. Approach the client from the right side.
C. Use simple verbal cues when directing tasks.
D. Place the client in low-Fowler's position during meals.

Answer: C. Use simple verbal cues when directing tasks.
Rationale:
The nurse should expect a client who experiences a left hemispheric stroke to manifest some
degree of expressive and/or receptive aphasia. Using simple verbal cues will assist the client
in understanding spoken communication.
A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the
following laboratory results indicates the client is experiencing a myocardial infarction?
A. Decreased lipase
B. Decreased erythrocyte sedimentation rate (ESR)
C. Elevated creatinine
D. Elevated troponin
Answer: D. Elevated troponin
Rationale:
Laboratory evaluation of troponin is used specifically to detect cardiac muscle injury.
Therefore, the nurse should identify an elevated troponin level as an indication that the client
is experiencing a myocardial infarction.
A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will need to take the medication until my thyroid function returns to normal."
B. "The medication should be taken before I eat breakfast every morning."
C. "The medication might lower my blood sugar."
D. "I will take the medication with an antacid if it gives me heartburn."
Answer: B. "The medication should be taken before I eat breakfast every morning."
Rationale:
The nurse should instruct the client to take levothyroxine at the same time each day,
preferably 1 hr. before breakfast.
A nurse is contributing to the plan of care to promote a restful night's sleep for a client who
has Alzheimer’s disease. Which of the following interventions should the nurse include in the
plan?
A. Encourage stimulating activities after dinner.
B. Encourage a late afternoon nap.

C. Offer a small snack at bedtime
D. Offer hot chocolate at bedtime.
Answer: C. Offer a small snack at bedtime
Rationale:
The nurse should offer the client a small snack of carbohydrates or a glass of milk as part of
the bedtime routine, which can help the client relax and prepare for sleep.
A nurse is reviewing medical record of a client who is postoperative. Which of the following
findings should the nurse identify as a complication of surgery?
A. Serous drainage from the incision
B. WBC count of 15,000/mm3
C. Temperature of 37.2° C (99° F)
D. Urine output of 400 mL over the past 8 hr.
Answer: B. WBC count of 15,000/mm3
Rationale:
The nurse should monitor laboratory findings for indications of a postoperative complication.
This WBC count is above the expected reference range and indicates the presence of
infection.
A nurse is changing the dressing for a client who has an abdominal incision and a Hemovac
drain. Which of the following actions should the nurse take?
A. Secure the drainage tube to the client's bedding.
B. Wear sterile gloves to empty the drainage system.
C. Cut an absorbent gauze dressing to fit around the drainage tube.
D. Cleanse the drainage plug with alcohol swabs.
Answer: D. Cleanse the drainage plug with alcohol swabs.
Rationale:
The nurse should cleanse the drain opening and plug with alcohol swabs to remove excess
drainage and discourage pathogens from entering the drainage system.
A nurse is reviewing the medication administration record of a client who has osteoarthritis.
Which of the following analgesic prescriptions should the nurse expert to administer when
the client reports pain?
A. Methotrexate

B. Acetaminophen
C. Gabapentin
D. Etanercept
Answer: B. Acetaminophen
Rationale:
Acetaminophen is a nonopioid analgesic that is a good choice for a client who has
osteoarthritis because its adverse effects are less toxic than many other analgesics. However,
clients should be advised that an overdose of acetaminophen can cause liver damage.
A nurse is reinforcing teaching with a client who has asthma and a new prescription for a
corticosteroid. Which of the following findings should the nurse include as an adverse effect
of the medication?
A. Frequent colds
B. Vitamin deficiency
C. Increased urination
D. Orthostatic hypotension
Answer: A. Frequent colds
Rationale:
The nurse should inform the client that corticosteroids can increase susceptibility to infection
by suppressing the immune response. The nurse should instruct the client about infection
prevention measures to implement while taking a corticosteroid.
A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for
calcitonin. Which of the following statements should the nurse make to describe the effect the
calcitonin in treating osteoporosis?
A. "Calcitonin will slow the breakdown of bone in your body."
B. "Calcitonin will increase the level of cortisol in your blood."
C. "Calcitonin will decrease the amount of calcium you are losing in your urine."
D. "Calcitonin will increase the blood flow to your skeletal muscles."
Answer: A. "Calcitonin will slow the breakdown of bone in your body."
Rationale:
Calcitonin inhibits osteoclast activity, therefore minimizing bone loss. The medication helps
to preserve bone for a client who has osteoporosis.

A nurse is assisting with an educational program for clients who have newly diagnosed with
diabetes mellitus. Which of the following instructions should the nurse include in the
program regarding insulin?
A. Store unopened insulin vials in the freezer for up to 1 month.
B. Opened insulin can be stored on a cool countertop away from light.
C. Roll discolored insulin gently to mix it before use.
D. Use refrigerated insulin immediately after removing it from the refrigerator.
Answer: B. Opened insulin can be stored on a cool countertop away from light.
Rationale:
The nurse should inform the clients that opened insulin vials do not require refrigeration, but
can be placed in a cool location for up to 4 weeks, out of direct sunlight.
A nurse is caring for a client who is suspected of having myocardial infarction. Which of the
following actions should the nurse take to prepare the client for an ECG?
A. Position the client in Sims' position before electrode placement.
B. Ensure that each electrode is dry before application.
C. Cleanse the client's skin prior to electrode placement.
D. Place the electrodes on the client's abdomen and back.
Answer: C. Cleanse the client's skin prior to electrode placement.
Rationale:
The nurse should place the client in a supine position to prepare the procedure.
The nurse should expect the electrodes to be pre-lubricated so they will adhere to the client's
skin and provide clear signal transmission and an adequate ECG reading.
The nurse should cleanse the client's skin prior to electrode placement to improve electrode
conduction.
The nurse should place the electrodes on the client's chest and limbs.
A nurse is contributing to the plan of care for a client who has just transferred to the medicalsurgical unit from the PACU following a right total knee arthroplasty.
Which of the following interventions should the nurse include in the plan?
A. Massage both lower extremities to promote comfort.
B. Begin the client on a regular diet when the gag reflex returns.
C. Encourage the client to use the incentive spirometer every 4 hr while awake.

D. Assist the client to change positions at least every 2 hr.
Answer: D. Assist the client to change positions at least every 2 hr.
Rationale:
The nurse should never massage the extremities, because doing so could dislodge a blood
clot, causing a pulmonary embolus.
The nurse should only offer the client ice chips or sips of water when the gag reflex returns to
determine how well the client will tolerate PO intake. The provider will advance the client's
diet when bowel sounds are present.
The nurse should have the client use the incentive spirometer once per hr while awake during
the first 24 hr postoperative to prevent respiratory complications.
The nurse should assist the client to change positions at least every 2 hr to promote return of
respiratory function following anesthesia and prevent atelectasis and pneumonia.
A nurse is reinforcing teaching with a client who has circulatory compromise in the lower
extremities due to peripheral vascular disease. Which of the following actions should the
nurse take?
A. Educate the client about choosing low-fat, low-cholesterol foods.
B. Have the client flex hips and knees when lying in bed.
C. Encourage the client to wear elastic support hose during the day time.
D. Instruct the client to use an electric heating pad.
Answer: A. Educate the client about choosing low-fat, low-cholesterol foods.
Rationale:
The nurse should educate the client about a low-fat, low-cholesterol diet, which is prescribed
for clients who have atherosclerosis. This diet can also aid in weight reduction, which can
improve activity tolerance.
The nurse should have the client avoid flexing the hips and knees because it can further
impede the peripheral blood flow.
The nurse should instruct the client to avoid the use of elastic support hose because they can
reduce circulation to the skin.
The nurse should instruct the client to avoid the use of electric heating pads due to an
increased risk of burns from decreased sensation of the extremities.
A nurse is caring for a client who is postoperative following a transurethral resection of the
prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased

output from the urethral catheter. Which of the following provider prescriptions should the
nurse expect?
A. Clamp the urethral catheter for 30 min.
B. Place the urethral catheter drainage bag at the client's heart level.
C. Slow the bladder irrigation flow rate.
D. Irrigate the urethral catheter with 0.9% sodium chloride.
Answer: D. Irrigate the urethral catheter with 0.9% sodium chloride.
Rationale:
Applying a clamp to the urethral catheter will prevent drainage from the bladder and increase
the risk of bladder trauma.
Placing the urethral catheter drainage bag at the client's heart level will slow bladder output
and increase the risk for infection.
Slowing the bladder irrigation flow rate will increase the risk of clotting in the tubing and
disrupt the irrigation output.
The nurse should expect a prescription to irrigate the urethral catheter because this will clear
the tubing of any blood clots or tissue pieces and allow for a better flow.
A nurse is preparing to assist a client out of bed 4 hr. following a laparoscopic
cholecystectomy. Which of the following actions should the nurse take first?
A. Place the client in Fowler's position.
B. Obtain the client's blood pressure.
C. Dangle the client's legs at the bedside.
D. Apply nonskid slippers.
Answer: B. Obtain the client's blood pressure.
Rationale:
The nurse should place the client in Fowler's position, which raises the client's head to
prevent vertigo and facilitate movement out of bed. However, there is another action the
nurse should take first.
The greatest risk to the client is postural hypotension due to decreased blood volume
following surgery. Therefore, the first action the nurse should take is to obtain the client's
baseline blood pressure to determine whether it is safe to have the client get out of bed.
The nurse should assist the client to dangle his legs at the bedside to prevent vertigo and
decrease the client's risk of falling. However, there is another action the nurse should take
first.

The nurse should apply non-skid slippers to prevent the client from falling when out of bed.
However, there is another action the nurse should take first.
A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis (TB)
about transmission of the disease. Which of the following client statements indicates an
understanding of the teaching?
A. "I inhaled the infected droplets that were in the air."
B. "I must have touched someone who had TB."
C. "I probably caught this disease from a mosquito bite."
D. "I developed TB from having unprotected sex."
Answer: A. "I inhaled the infected droplets that were in the air."
Rationale:
TB is spread by airborne transmission. Therefore, the nurse should identify this statement as
an understanding of the teaching.
The nurse should reinforce that TB is not spread by direct contact.
The nurse should reinforce that TB is not spread by vectors, such as mosquitos.
The nurse should reinforce that TB is not spread by having unprotected sex.
A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the following
findings should the nurse expect?
A. Muscle spasticity
B. Tremors at rest
C. Ptosis
D. Ascending paralysis
Answer: B. Tremors at rest
Rationale:
Muscle spasticity is a manifestation of multiple sclerosis.
Tremors at rest is a manifestation of Parkinson's disease.
Ptosis is a manifestation of myasthenia gravis.
Ascending paralysis is a manifestation of Guillain-Barré syndrome.
A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was
precipitated by the client not taking her medication for several days. The nurse should

identify that withdrawal from which of the following medications potentiated the adrenal
crisis?
A. Metoprolol
B. Methimazole
C. Furosemide
D. Prednisone
Answer: D. Prednisone
Rationale:
Metoprolol is a beta-adrenergic antagonist used to treat hypertension. Discontinuation of this
medication does not cause an adrenal crisis.
Methimazole is an antithyroid hormone used to treat hyperthyroidism. Discontinuation of this
medication does not cause an adrenal crisis.
Furosemide is a high-ceiling loop diuretic used to treat heart failure. Discontinuation of this
medication does not cause an adrenal crisis.
Prednisone is administered to replace glucocorticoids, which are deficient in adrenocortical
insufficiency. Abrupt withdrawal of the medication can lead to an adrenal crisis.
A nurse is caring for a client following a thyroidectomy. Which of the following findings
should alert the nurse to the possibility of parathyroid gland injury?
A. Anorexia
B. Hoarseness
C. Muscle twitching
D. Blurred vision
Answer: C. Muscle twitching
Rationale:
Anorexia is not an indication of a parathyroid gland injury.
A client might experience hoarseness following a thyroidectomy, which can result from
intubation during surgery. Persistent hoarseness can also indicate damage to the vocal cords.
However, hoarseness is not an indication of parathyroid gland injury.
A common complication of a thyroidectomy is parathyroid gland injury, leading to
hypocalcaemia. Clients experiencing hypocalcaemia can have twitching, numbness, and
tingling of fingers, toes, and around the mouth.
Blurred vision is not an indication of a parathyroid gland injury but can be an adverse effect
of some medications or an indication of hyperglycemia.

A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot.
Which of the following actions should the nurse take first?
A. Obtain the client's temperature.
B. Observe for phantom pain.
C. Measure urinary output.
D. Check the incisional dressing.
Answer: C. Measure urinary output.
Rationale:
The nurse should obtain the client's temperature to monitor for hyperthermia, which can
indicate an infection, or hypothermia following anaesthesia administration. However, there is
another action the nurse should take first
The nurse should observe the client for phantom pain to promote prompt pain treatment and
relief. However, there is another action the nurse should take first.
The nurse should measure the client's urinary output to monitor for fluid imbalance.
However, there is another action the nurse should take first.
The greatest risk to the client is haemorrhage following an amputation of the lower extremity.
Therefore, the first action the nurse should take is to check the client's incisional dressing for
excessive bleeding.
A nurse is caring for a client who has a new cast on her left forearm and report severe pain in
the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with
sluggish capillary refill. Which of the following fracture complication should the nurse
suspect?
A. Compartment syndrome
B. Fat embolism.
C. Deep-vein thrombosis
D. Osteomyelitis
Answer: A. Compartment syndrome
Rationale:
Compartment syndrome is a complication that involves increased pressure within a
compartment (an area that supports blood vessels, bones, and nerves) leading to circulatory
compromise to the limb. The pressure can be caused externally by a cast that is too tight or
internally by the inflammation or edema from the injury. Circulatory impairment causes

pallor and paresthesia of the extremities and a delay in capillary refill, and without immediate
treatment, can cause nerve damage and necrosis.
A bone fracture can result in globules of fat migrating from the bone marrow into the
circulation. Depending on where these globules travel, the nurse should expect manifestations
of a blockage to the brain or lungs. Fat embolus usually occur in the long bones, pelvis, or
ribs.
The nurse should expect pain with possible tenderness, redness, and warmth of the extremity
for a client who has a deep-vein thrombosis (DVT). DVTs usually occur in the iliac or
femoral veins.
Osteomyelitis occurs when pathogens enter the blood stream from the wound of an open
fracture, causing bone infection. The nurse should expect manifestations of severe pain and
tenderness at the site and systemic manifestations of infection, such as fever, chills, headache,
and malaise.
A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new
diagnosis of COPD. The nurse should identify which of the following client statements
indicates an understanding of the teaching?
A. "I should perform pursed-lip breathing exercises before going to bed."
B. "When I'm fatigued, I should inhale slowly through pursed lips."
C. "Pursed-lip breathing works best for activities like walking up stairs."
D. "I will exhale through my nose after breathing in through pursed lips."
after breathing in through the nose.)
Answer: C. "Pursed-lip breathing works best for activities like walking up stairs."
Rationale:
The nurse should reinforce with the client that the use of pursed-lip breathing can help reduce
fatigue during times of activity. However, there is no indication that pursed-lip breathing
exercises are beneficial to the client before going to bed.
The nurse should reinforce with the client that the use of pursed-lip breathing can help reduce
fatigue. However, pursed-lip breathing involves exhaling slowly through pursed lips to keep
the airways open.
The nurse should acknowledge that performing pursed-lip breathing during times of activity,
such as walking upstairs, helps increase airway pressure and reduce the amount of trapped air
in the lungs. This breathing technique helps eliminate excess carbon dioxide that clients who
have COPD might retain.

The nurse should reinforce with the client that the use of pursed-lip breathing can improve
dyspnea with activity. However, pursed-lip breathing involves exhaling through pursed-lips
A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative
following a total hip arthroplasty. Which of the following interventions should the nurse
contribute to the plan of care?
A. Check neurovascular status on the extremity every 8 hr.
B. Have the client perform incentive spirometry every 4 hr.
C. Keep an abduction pillow between the client's legs.
D. Maintain the client on bed rest until the third postoperative day.
Answer: C. Keep an abduction pillow between the client's legs.
Rationale:
The nurse should check the neurovascular status on the extremity every 2 to 4 hr.
The nurse should have the client perform incentive spirometry every 2 hr as well as deep
breathing and coughing every 2 hr to prevent atelectasis.
The nurse should keep an abduction pillow or a splint between the client's legs to prevent hip
dislocation after surgery.
The nurse should encourage and assist the client to get out of bed as soon as possible after the
surgery.

A nurse is collecting data from an older adult client who has several concerns. Which of the
following concerns should the nurse recognize as a normal change associated with aging?
A. "I sweat more than I used to."
B. "Sometimes I can't remember my kids' names."
C. "I seem to have more loose stools than I used to."
D. "My food tastes bland even after I add seasoning."
Answer: D. "My food tastes bland even after I add seasoning."
Rationale:
Perspiration decreases in older adult clients as sweat glands produce less sweat. Increased
sweating could indicate a disorder in the endocrine system.
Older adult clients usually retain long-term memory better than short-term memory. An
inability to remember family members' names is not a normal part of the aging process and
might indicate deteriorating cognitive function.

Constipation is common in older adult clients because peristalsis decreases with age.
Diarrhoea can indicate a disorder in the gastrointestinal system.
As clients’ age, their sense of smell decreases, causing a secondary decrease in taste.
A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the
following findings should the nurse anticipate?
A. Elevated serum amylase level
B. Hypertension
C. Bradycardia
D. Decreased leukocyte count
Answer: A. Elevated serum amylase level
Rationale:
The nurse should anticipate an elevation in the client's serum amylase level due to injury of
the pancreatic cells.
The nurse should expect a client who has acute pancreatitis to have hypotension as a result of
third spacing and fluids shifts.
The nurse should expect a client who has acute pancreatitis to have tachycardia as a result of
the inflammatory response and pain associated with the illness.
The nurse should expect a client who has acute pancreatitis to have an elevated white blood
cell count due to the inflammation and necrosis of the pancreas.
A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse
should document the sound as which of the following? (Click on the audio button to listen to
the clip)
A. Pleural friction rub
B. Wheezes
C. Vesicular
D. Crackles
Answer: B. Wheezes
Rationale:
The nurse should expect to hear a pleural friction rub, which is a dry, grating sound during
respirations, when auscultating the lungs of a client who has pleurisy.

The nurse should identify the breath sound auscultated as wheezes. These are high-pitched,
musical sounds that occur as air passes through narrowed airways, such as when a client is
experiencing an asthma attack.
The nurse should expect to hear vesicular breath sounds when auscultating the periphery of a
lung field of a client who is without pulmonary illness or disease. These sounds are soft, lowpitched blowing sounds that occur as air passes through the smaller airways.
The nurse should expect to hear crackles, which are crackling or bubbling sounds heard
during inspiration, when auscultating the lungs of a client who has fluid overload. Crackles
can be termed fine, medium, or coarse, and are an indication of air passing through fluid or
mucus. Crackles do not tend to clear with coughing.
A nurse is caring for a client who has restricted movement of the chest due to a burn injury.
The nurse should anticipate preparing the client for which of the following procedures?
A. Fasciotomy
B. Escharotomy
C. Skin grafting
D. Hyperbaric oxygen therapy
Answer: B. Escharotomy
Rationale:
A fasciotomy is used to treat compartment syndrome for clients following traumatic
musculoskeletal injury.
The nurse should anticipate a prescription for an escharotomy to relieve constriction of the
client's chest due to a burn injury. Following removal of the eschar, chest wall movement will
be possible and the client's oxygenation should improve.
Skin grafting is used to promote wound healing for clients who have large wounds, like burn
injuries.
Hyperbaric oxygen therapy involves high pressure oxygen therapy and is part of treatment for
life-threatening wound infections.
A nurse is caring for four clients. Which of the following conditions should the nurse identify
as a risk for developing vascular disease?
A. Rheumatoid arthritis
B. Diabetes mellitus
C. Myasthenia gravis

D. Crohn's disease
Answer: B. Diabetes mellitus
Rationale:
Clients who have rheumatoid arthritis are at increased risk for iron deficiency anemia.
However, rheumatoid arthritis does not increase the client's risk of developing vascular
disease.
Clients who have diabetes mellitus are at increased risk for developing cardiovascular and
peripheral vascular disease due to the changes in the microvasculature resulting from elevated
levels of glucose.
Clients who have myasthenia gravis are at increased risk for pneumonia due to aspiration
resulting from muscle weakness. However, myasthenia gravis does not increase the client's
risk of developing vascular disease.
Clients who have Crohn's disease are at increased risk for malabsorption, malnutrition, and
eventually colon cancer resulting from repeated damage to the intestinal mucosa. However,
Crohn's disease does not increase the client's risk of developing vascular disease.
A nurse is caring for a client who has end-stage liver disease and just underwent an
abdominal paracentesis. For which of the following manifestations should the nurse monitor
as an adverse effect of the procedure?
A. Changes in the client's sputum
B. Decreased blood pressure
C. Changes in neurological status
D. Increased urinary output
Answer: B. Decreased blood pressure
Rationale:
The nurse should expect changes in the client's sputum as an adverse effect following a
bronchoscopy.
Following an abdominal paracentesis, the nurse should monitor the client for a decrease in
blood pressure. This finding indicates hypovolemia as a result of excess fluid withdrawal.
Depending on the amount of fluid withdrawn, hypovolemia can lead to shock.
The nurse should monitor for changes in the client's neurological status as an adverse effect
following a lumbar puncture.
Following an abdominal paracentesis, the nurse should monitor the client for a decrease in
urinary output. This finding can indicate hypovolemia as a result of excess fluid withdrawal

A nurse is caring for a female client who is being treated for dehydration due to due to nausea
and vomiting. Which of the following findings should the nurse report to the provider?
A. Haemoglobin 13 g/dL
B. Blood pressure 110/55 mm Hg
C. Heart rate 120/min
D. Potassium 3.6 mEq/L
Answer: C. Heart rate 120/min
Rationale:
The client's hemoglobin level is within the expected reference range.
The client's blood pressure is within the expected reference range.
The client's heart rate of 120/min is above the expected reference range and indicates the
client's dehydration has not resolved. Therefore, the nurse should report this finding to the
provider to obtain additional prescriptions for fluid replacement.
The client's potassium level is within the expected reference range.
A nurse is contributing to the plan of care for a client who had a cerebrovascular accident
(CVA). For which of the following interdisciplinary term members should the nurse
recommend a referral prior to initiating oral intake for the client?
A. Occupational therapist
B. Speech-language pathologist
C. Physical therapist
D. Case manager
Answer: B. Speech-language pathologist
Rationale:
The nurse should recommend a referral for an occupational therapist to assist the client with
activities of daily living. An occupational therapist will help develop the client's self-care
skills, taking into consideration any impaired functions the client might have as a result of the
CVA.
The nurse should recommend a referral for a speech-language pathologist to evaluate the
client's ability to safely swallow. A client who has had a CVA is at increased risk for
dysphagia and aspiration of fluids, food, and medications. The speech-language pathologist
should conduct a swallowing study to determine the client's risk for aspiration and provide
teaching to the client regarding swallowing techniques.

The nurse should recommend a referral for a physical therapist to assist with the client's
mobility needs. A client who has had a CVA can experience paralysis or muscle weakness.
The physical therapist will help the client safely manage mobility needs, such as changing
positions, transferring from bed to chair, and ambulating.
The nurse should recommend a referral for a case manager to coordinate resources the client
might need. The case manager will help the client, family members or caregivers, and health
care team members to identify needs and ensure the client receives appropriate services
across the care continuum.
A nurse is reinforcing teaching to a client about preventing osteoporosis. Which of the
following client statements indicates an understanding of the teaching?
A. "I will eat more bananas."
B. "I will walk for 20 minutes 3 days a week."
C. "I will limit my coffee intake."
D. "I will take a calcium supplement at bed time."
Answer: C. "I will limit my coffee intake."
Rationale:
The nurse should recommend a diet high in calcium for a client who is at risk for
osteoporosis. A medium banana is low in calcium, containing only 6 mg. Low-fat cheese,
yogurt, and calcium-fortified orange juice are better options for ensuring the client receives
an adequate amount of calcium.
The nurse should recommend the client walk 20 min or more 5 days per week or 30 min 3
days per week. Weight-bearing exercises, such as walking, can help prevent the development
of osteoporosis.
Coffee contains caffeine, which can cause excretion of calcium through diuretic effects.
Clients often drink caffeinated beverages instead of beverages that contain calcium, and
caffeine might interfere with the absorption of Vitamin D. Therefore, the nurse should
identify this statement as an indication that the client understands the teaching.
The nurse should inform the client that supplementing the diet with calcium can help prevent
the development of osteoporosis and limit fractures. However, the client should take calcium
supplements in divided doses throughout the day.
A nurse is reinforcing discharge teaching with a client who has Crohn’s disease. Which of the
following statements should the nurse include in the teaching?

A. "Increase your intake of dietary fat."
B. "Maintain a low-residue diet."
C. "Avoid taking antidiarrheal medications."
D. "Plan to weigh yourself weekly."
Answer: B. "Maintain a low-residue diet."
Rationale:
The nurse should instruct the client to decrease dietary fat because it can exacerbate the
manifestations of Crohn's disease.
The nurse should instruct the client to maintain a low-fiber, low-residue diet, which helps
control pain and inflammation in the small intestine and reduces episodes of diarrhoea.
The nurse should instruct the client to take antidiarrheal medications as prescribed by the
provider to relieve abdominal cramping and loose stools.
The nurse should instruct the client to weigh himself daily because diarrhoea can lead to
dehydration and nutritional deficits, causing weight loss.
A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is
having difficulty with urination. Which of the following responses should the nurse make?
A. "The kidneys' ability to filter urine is decreased."
B. "The tumor causes obstruction of urine from the urethra."
C. "The cancer results in hormonal changes, which affect urination."
D. "The protein-specific antigen in your blood is decreased."
Answer: B. "The tumor causes obstruction of urine from the urethra."
Rationale:
Prostate cancer does not affect the function of the kidneys.
As a prostate tumor grows, it compresses the urethra, resulting in obstructed urine flow.
Prostate cancer does not affect hormonal changes. However, hormone therapy is one of the
treatment options for prostate cancer.
An increased protein specific antigen is a diagnostic finding of prostate cancer.
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of
the following interventions should he nurse include?
A. Place a "no visitors" sign on the client's door.
B. Have the client wear an N95 respiratory mask during transport.
C. Initiate droplet precautions for the client.

D. Place the client in a negative-pressure airflow room.
Answer: D. Place the client in a negative-pressure airflow room.
Rationale:
Clients who have TB can have visitors. However, visitors should follow transmission
precautions.
The nurse should place a surgical mask on the client when transporting her outside of the
room to prevent the transmission of micro-organisms.
The nurse should implement droplet precautions for a client who has rubella or pertussis
The nurse should place the client in a negative-pressure airflow room to filter the air and
prevent the transmission of micro-organisms.
A nurse is reinforcing teaching with a client about testicular self-examination. Which of the
following instructions should the nurse include in the teaching?
A. "Perform testicular self-examination after taking a warm shower."
B. "Examine both testicles at the same time."
C. "Use the palm of your hand to palpate for abnormalities."
D. "Perform testicular self-examination every 6 months."
Answer: A. "Perform testicular self-examination after taking a warm shower."
Rationale:
The nurse should instruct the client to perform testicular self-examination after taking a warm
shower or bath. This causes relaxation of the scrotal skin, which allows for better palpation of
the testes.
The nurse should instruct the client to examine each testicle individually to feel for any lumps
or abnormalities.
The nurse should instruct the client to use the thumbs and fingers of both hands when
palpating each testicle.
The nurse should instruct the client to perform testicular self-examination monthly on
approximately the same day of each month
A nurse is caring for a client who is in Buck’s traction for a fractured hip. The client reports
increased pain at the sited of the fracture. Which of the following actions should the nurse
take?
A. Massage the area.
B. Remove the weights.

C. Loosen the ropes.
D. Reposition the client.
Answer: D. Reposition the client.
Rationale:
The nurse should avoid massaging the areas, because it might increase the client's pain. The
nurse should monitor the bony prominences of a client in traction to detect findings of tissue
breakdown or impaired circulation.
The nurse should not remove the weights unless there is a prescription to do so
The nurse should not loosen the ropes because this can affect the weight applied to the
traction.
When the client's body is out of alignment with the traction, muscle spasms develop, causing
increased pain. Therefore, the nurse should reposition the client, ensuring there is a straight
line from the client's hip to the traction rope and pulley, evaluate the client's response, and
provide other interventions as needed.
A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client indicates a
therapeutic response of the medication?
A. "I have been sleeping less since I started the medication."
B. "I have gained 3 pounds since my last appointment."
C. "My bowel movements have become more frequent."
D. "I urinate more often than before."
Answer: B. "I have gained 3 pounds since my last appointment."
Rationale:
The nurse should expect the client to report improved sleeping patterns after 4 weeks of
methimazole therapy.
Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as
an indication that the methimazole therapy has been effective.
The nurse should expect the client to report regular bowel movements and absence of
diarrhea after 4 weeks of methimazole therapy.
The nurse should expect the client to report urinating less frequently after 4 weeks of
methimazole therapy.

A nurse is collecting data from a client who has 30% body surface area partial thickness and
full-thickness burns. Which of the following findings indicates that fluid resuscitation is
adequate?
A. Granulation tissue is present.
B. Urine output is 50 mL/hr.
C. Lung sounds are clear.
D. Oxygen saturation level is 95%.
Answer: B. Urine output is 50 mL/hr.
Rationale:
The nurse should monitor the client's wounds because infection is a complication of burns.
The presence of granulation tissue is an indicator used to monitor the effectiveness of wound
therapy.
The nurse should closely monitor the client's urinary output as an indicator of effective fluid
resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is
adequate.
The nurse should monitor the client's lung sounds because pneumonia is a complication of
burns. Clear lung sounds only indicate that the client has not had excessive fluid replacement,
not whether fluid resuscitation was adequate.
The nurse should monitor the client's oxygen saturation level because respiratory problems
are a complication of burns. An oxygen saturation within the expected reference range
indicates adequate perfusion of oxygen to the tissues.
A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the
following statements should indicate to the nurse that the client understands the teaching?
A. "I will scrub the skin to remove the old skin flakes."
B. "I can expect to my leg to be swollen after the cast is removed."
C. "I can go back to my usual activities as soon as the cast is off."
D. "I will feel vibrations on my leg from the cast cutter."
Answer: D. "I will feel vibrations on my leg from the cast cutter."
Rationale:
Scrubbing the skin can damage its deeper layers. The client should use a gentle technique,
such as soaking the skin or applying moisturizing lotion, to remove dry, scaly flakes.
The nurse should instruct the client that the leg might appear atrophied following cast
removal due to disuse of the muscles.

The client should resume activities gradually to avoid placing unnecessary stress on the
healing bone.
The client will feel heat and vibrations from the cast cutter on the affected extremity. The
nurse should assure the client that cast removal should not cause any pain.
A nurse is contributing to the plan of care for a client who has pericarditis. In which of the
following positions should the nurse plan to place the client to decrease plan?
A. Semi-Fowler's
B. Supine with lower extremities elevated
C. Upright, leaning forward
D. Side-lying with knees bent
Answer: C. Upright, leaning forward
Rationale:
The nurse should place a client in Semi-Fowler's position to facilitate breathing as part of
management of peritonitis.
The nurse should place a client who is in shock in the supine position with lower extremities
elevated or modified Trendelenburg position, to increase the venous return to the heart.
The nurse should plan to place a client who has pericarditis in an upright position, leaning
forward, to facilitate breathing and decrease pain.
The nurse should place a client in side-lying position with knees bent to assist in decreasing
the pain related to a unilateral or sensory motor deficit on one side of the body.
A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2
cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest
whole number. Use a leading zero if applicable. Do not use a trailing zero.)
Answer: Follow these steps to calculate the calorie intake:
Step 1: What is the unit of measurement the nurse should calculate? calories
Step 2: What is the volume the nurse should infuse? 60 mL/hr x 12 hr = 720 mL
Step 3: What is the total infusion time? 12 hr
Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation
and solve for X.
720 mL x 1.2 cal/mL = calories
X = 864 cal

Step 6: Round if necessary.
Step 7: Reassess to determine if the amount to administer makes sense. If the provider
prescribed 60 mL to infuse over 12 hr, it makes sense to administer 720 mL/12 hr. If there are
1.2 cal/mL, it makes sense that the total number of calories the nurse will deliver in 12 hr is
864.
A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is
receiving chemotherapy. The nurse should identify that which of the following statements by
the client indicates an understanding of the teaching?
A. "I drink bottled water."
B. "I eat at a salad bar for lunch."
C. "I like to eat steak cooked medium."
D. "I put plenty of pepper on my soft-boiled eggs."
Answer: A. "I drink bottled water."
Rationale:
To avoid exposure to bacteria, clients who have cancer and are receiving chemotherapy
should be sure that drinking water is safe. Drinking fresh, bottled water limits exposure to
bacteria.
Clients who have cancer and are receiving chemotherapy are at risk for leukopenia. The nurse
should recommend the client avoid salad bars and buffets because of the risk of exposure to
bacteria.
Clients who have cancer and are receiving chemotherapy should cook foods that can contain
bacteria, such as meat, to the well done stage to prevent infection.
Clients who have cancer and are receiving chemotherapy should avoid undercooked eggs and
pepper because of the risk of exposure to bacteria.