ATI MEDICAL SURGICAL ASSESSMENT 2 WITH 100+ VERIFIED
QUESTIONS AND ANSWERS FOR 2023-2024
A nurse is reinforcing teaching about dietary measures with a client who is at risk for
developing osteoporosis. Which of the following food choices should the nurse recommend
increasing the client’s calcium level?
A) 1 cup of cooked spinach
B) 1 cup of cooked kale
C) 1 cup of cooked broccoli
D) 1 cup of cooked carrots
Answer: A) 1 cup of cooked spinach
A nurse is collecting data from a client who has anemia and a hemoglobin level of 7.2 g/dL.
Which of the following findings should the nurse expect?
A) Brittle fingernails
B) Increased appetite
C) Elevated blood pressure
D) Weight gain
Answer: A) Brittle fingernails
A nurse is collecting data from a client who has acute gastroenteritis. Which of the following
data collection findings should the nurse identify as the priority?
A) Potassium 2.5 mEq/L
B) Blood pressure 120/80 mmHg
C) Heart rate 92 beats per minute
D) Temperature 101.2°F (38.4°C)
Answer: A) Potassium 2.5 mEq/L
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) the nurse
should monitor the client for which of the following conditions as a complication TPN?
A) Polyuria
B) Hypoglycemia
C) Hyperkalemia
D) Hypothermia
Answer: A) Polyuria
A nurse is reinforcing teaching with a client about the oliguric phase of acute kidney injury.
Which of the following information should the nurse include in the teaching?
A) The client’s urine output is less than 400 mL per 24 hours
B) The client will have increased urine output
C) The client’s urine output will be normal
D) The client will require dialysis during this phase
Answer: A) The client’s urine output is less than 400 mL per 24 hours
A nurse is reviewing a provider’s admission orders for a client who has acute heart failure.
For which of the following prescriptions should the nurse obtain clarifications?
A) Ambulate three times daily
B) Administer furosemide 40 mg IV push
C) Provide low-sodium diet
D) Monitor oxygen saturation levels continuously
Answer: A) Ambulate three times daily
A nurse provides teaching to a client who is being fitted for a prosthetic leg. Which of the
following statements indicate to the nurse a need for further instruction?
A) "I’ll learn to balance well on one leg, so I don’t have to use crutches."
B) "I should avoid standing for long periods of time to prevent fatigue."
C) "I’ll need to clean my prosthesis regularly to prevent skin irritation."
D) "I should wear a sock underneath the prosthesis to protect my skin."
Answer: A) "I’ll learn to balance well on one leg, so I don’t have to use crutches."
A nurse is planning client care for the shift. Which of the following tasks should the nurse
delegate to assistive personnel (AP)
A) Measuring a client’s intake and output
B) Assessing a client's vital signs
C) Administering a medication to a client
D) Developing a care plan for a client
Answer: A) Measuring a client’s intake and output
A nurse is assessing an order adult client who has a urinary tract infection (UTI). Which of
the following findings should the nurse identify as unique for this age group?
A) Confusion
B) Fever
C) Dysuria
D) Flank pain
Answer: A) Confusion
A client who is 7 days postpartum calls the provider’s office and reports pain, swelling, and
redness of her left calf. Besides the client seeing the provider, which of the following
interventions should the nurse suggest?
A) Elevate the leg
B) Apply a warm compress to the leg
C) Massage the leg
D) Apply a cold compress to the leg
Answer: A) Elevate the leg
A nurse is shopping and finds a woman who has collapsed with right-sided weakness and
slurred speech. Which of the following actions should the nurse take?
A) Call emergency medical services (EMS)
B) Assist the woman to sit down and rest
C) Offer the woman water to drink
D) Try to assess her blood sugar level
Answer: A) Call emergency medical services (EMS)
A nurse is collecting data on a client who has acute pancreatitis. Which of the following
factors should the nurse anticipate in the client’s history?
A) Gallstones
B) Hypertension
C) Recent viral infection
D) Family history of diabetes
Answer: A) Gallstones
A nurse is reinforcing teaching with a client who has a urinary tract infection (UTI) which of
the following risk factors should the nurse include in the teaching?
A) Diabetes mellitus
B) Hypertension
C) Hypothyroidism
D) Osteoarthritis
Answer: A) Diabetes mellitus
A nurse is collecting data from a female client who has a cystocele. Which of the following
findings should the nurse expect?
A) Difficulty voiding
B) Heavy vaginal bleeding
C) Increased urine output
D) Severe pelvic pain
Answer: A) Difficulty voiding
A nurse is reinforcing teaching with a young adult client who has a family history of
osteoporosis which of the following health promotion activities should the nurse recommend?
A) Engaging in weight-bearing exercise regularly
B) Taking calcium supplements daily
C) Limiting vitamin D intake
D) Avoiding dairy products
Answer: A) Engaging in weight-bearing exercise regularly
A nurse is checking a client’s abdominal incision several hours following surgery and realizes
that it is eviscerating. Which of the following actions should the nurse take?
A) Apply a sterile normal saline dressing to the wound
B) Notify the provider and prepare the client for surgery
C) Apply a dry dressing to the wound
D) Place the client in a prone position
Answer: A) Apply a sterile normal saline dressing to the wound
A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC).
Which of the following findings should the nurse expect?
A) Excessive thrombosis and bleeding
B) Hypotension and bradycardia
C) Elevated hemoglobin and hematocrit levels
D) Increased platelet count and prolonged prothrombin time (PT)
Answer: A) Excessive thrombosis and bleeding
A nurse is admitting a client who is having an exacerbation of asthma. When reviewing the
provider’s orders, the nurse recognizes that clarification is needed for which of the following
prescribed medications?
A) Propranolol
B) Albuterol
C) Prednisone
D) Ipratropium
Answer: A) Propranolol
A nurse is caring for a older adult client who has left-sided heart failure. which of the
following findings should the nurse expect?
A) Frothy sputum
B) Jugular vein distention
C) Dependent edema
D) Hepatomegaly
Answer: A) Frothy sputum
A nurse is assisting with the plan of care for a client who has leukemia and whose platelet
count is 50,000 mm3. Which of the following intervention should the nurse include in the
plan of care?
A) Administer a stool softener
B) Apply compression stockings
C) Ambulate the client frequently
D) Encourage a high-fiber diet
Answer: A) Administer a stool softener
A nurse is reinforcing teaching with a client about how to use a patient-controlled analgesia
(PCA) pump. Which of the following statements should the nurse include in the teaching?
A) "Use the pain scale to determine if you should push the medication self-administration
button."
B) "You can push the button as often as you like, and the pump will administer more
medication if needed."
C) "The PCA pump will automatically administer medication even if you do not push the
button."
D) "You should wait until your pain is severe before pressing the button to receive more
medication."
Answer: A) "Use the pain scale to determine if you should push the medication selfadministration button."
A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of
hypoxia. Which of the following findings should the nurse include in the teaching?
A) Agitation
B) Hypertension
C) Bradycardia
D) Hyperthermia
Answer: A) Agitation
A nurse is collecting data from a client who has meningitis. When passively flexing the
client’s neck, the nurse notes an involuntary flexion of both legs. Which of the following
conditions is the client displaying?
A) Brudzinski sign
B) Kernig sign
C) Romberg sign
D) Trousseau sign
Answer: A) Brudzinski sign
A nurse is preparing a client who has hypotension for gastric lavage using a largebore
nasogastric (NG) tube. In which of the following positions should the nurse place the client?
A) Left lateral
B) High Fowler's
C) Supine
D) Trendelenburg
Answer: A) Left lateral
A nurse is caring for a client who is postoperative following a colon resection. For which of
the following findings should the nurse monitor to identify a pulmonary embolus?
A) Sudden shortness of breath
B) Abdominal distension
C) Wound dehiscence
D) Hematuria
Answer: A) Sudden shortness of breath
A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who
has diabetes mellitus. Which of the following statements by the client indicates an
understanding of the teaching?
A) "I will be more thirsty than usual."
B) "I will feel more tired than usual."
C) "I will notice my skin getting dry and flaky."
D) "I will be hungrier than usual."
Answer: A) "I will be more thirsty than usual."
A nurse at a community center is assisting with a presentation about sun protection to a group
of residents. Which of the following responses by the residents indicates an understanding of
the teaching?
A) "I should apply a sunscreen with an SPF of 30."
B) "I should only apply sunscreen when it's sunny outside."
C) "I don’t need to wear sunscreen if I’m in the shade."
D) "I should reapply sunscreen every 4 hours, even if I haven’t been swimming."
Answer: A) "I should apply a sunscreen with an SPF of 30."
A nurse is reinforcing infection control practices for hand hygiene with a group of unit
nurses. Which of the following information should the nurse reinforce in the teaching?
A) Change gloves between tasks on the same client
B) Wash hands with soap and water after using alcohol-based hand rub
C) Wear gloves for all patient interactions, even if the patient has no signs of infection
D) Use alcohol-based hand rub after removing gloves if hands are visibly soiled
Answer: A) Change gloves between tasks on the same client
A nurse is discussing the nurse’s role in obtaining informed consent with a group of
coworkers. Which of the following statements should the nurse include?
A) "The nurse should sign the form as confirmation that a client appears competent."
B) "The nurse is responsible for explaining the procedure in detail to the client."
C) "The nurse's role is to ensure that the client has received adequate information about the
procedure from the provider."
D) "The nurse is responsible for obtaining the informed consent for any procedure that
requires it."
Answer: C) "The nurse's role is to ensure that the client has received adequate information
about the procedure from the provider."
A nurse is assigned a group of postoperative clients. Which of the following client findings
should the nurse identify as the priority?
A) SaO2 88%
B) Temperature 100.4°F (38°C)
C) Pain level of 6 on a scale of 0-10
D) Incision site with moderate drainage
Answer: A) SaO2 88%
A nurse is reinforcing teaching about self-care techniques with a client who has rheumatoid
arthritis. Which of the following strategies should the nurse include to illustrate the concept
of joint protection?
A) Turn doorknobs in a counterclockwise motion to open them.
B) Use the palms of the hands rather than the fingers to grip objects.
C) Cross the legs while sitting to improve comfort.
D) Use a soft cloth when lifting heavy objects.
Answer: B) Use the palms of the hands rather than the fingers to grip objects.
A nurse is reviewing data for a client who has chronic kidney disease. Which of the following
data should the nurse identify as the best indicator of fluid volume status?
A) Daily weight
B) Serum creatinine level
C) Blood pressure
D) Urine output
Answer: A) Daily weight
A nurse is monitoring a client who has dehydration and is receiving iv fluid replacement.
Which of the following findings should the nurse identify as effectiveness of the treatment?
Urine A) Urine output 200 mL/4 hours
B) Blood pressure 110/70 mmHg
C) Heart rate 112 beats/min
D) Serum sodium 152 mEq/L
Answer: A) Urine output 200 mL/4 hours
A nurse is reviewing the plan of care for a client who has cellulitis of the leg which of the
following interventions should the nurse recommend?
A) Wash daily with an antibacterial soap
B) Apply a warm compress to the affected area
C) Keep the leg elevated above heart level
D) Wear tight-fitting stockings to improve circulation
Answer: B) Apply a warm compress to the affected area
A nurse is collecting data from a client who has a score of 8 using the Glasgow coma scale.
Which of the following findings should the nurse expect?
A) The client requires total nursing care
B) The client is fully alert and oriented
C) The client is able to follow commands and speak coherently
D) The client is unresponsive and cannot open their eyes
Answer: A) The client requires total nursing care
A nurse is planning care for a client who has a deep-vein thrombosis (DVT) in the right leg.
Which of the following interventions should be included in the plan of care?
A) Apply compression stockings
B) Massage the affected leg to promote circulation
C) Elevate the affected leg while the client is in bed
D) Ambulate the client to improve circulation
Answer: C) Elevate the affected leg while the client is in bed
A home health nurse is planning care for a client who has COPD which of the following
interventions should the nurse include in the plan of care?
A) Advise the client to keep snacks handy
B) Encourage the client to perform vigorous exercise daily
C) Instruct the client to limit fluid intake to 1,000 mL per day
D) Teach the client to breathe rapidly during periods of shortness of breath
Answer: A) Advise the client to keep snacks handy
A nurse is reinforcing teaching with a client who is having difficulty using an incentive
spirometer. Which of the following instructions should the nurse include in the teaching?
A) Start slowly and increase volume over several sessions
B) Inhale rapidly to reach the goal volume as quickly as possible
C) Exhale into the spirometer before inhaling
D) Use the spirometer only when feeling short of breath
Answer: A) Start slowly and increase volume over several sessions
A nurse is reinforcing dietary teaching with a client who has iron deficiency anemia. Which
of the following foods should the nurse recommend?
A) Cooked oatmeal
B) Skim milk
C) White rice
D) Chicken soup
Answer: A) Cooked oatmeal
A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease (Gerd)
which of the following statements should the nurse include in the teaching?
A) Avoid wearing constricting clothing
B) Lie down immediately after eating to aid digestion
C) Consume large meals to prevent acid buildup
D) Drink coffee to increase gastric motility
Answer: A) Avoid wearing constricting clothing
A nurse is reinforcing teaching with a client who has a new diagnosis of systemic lupus
erythematosus (SLE). Which of the following information should the nurse include in the
teaching?
A) SLE affects the connective tissue of the body
B) SLE is a condition that only affects the skin
C) SLE is caused by a bacterial infection
D) SLE is more common in men than in women
Answer: A) SLE affects the connective tissue of the body
A nurse is collecting data from a client who has diabetes mellitus. Which of the following
findings indicates that the client is experiencing DKA?
A) Polydipsia
B) Hypotension
C) Polyuria
D) Kussmaul respirations
Answer: D) Kussmaul respirations
A nurse has received change-of-shift report on four clients. Which of the following clients
should the nurse plan to see first?
A) A client who is short of breath
B) A client with a blood pressure of 110/70 mmHg
C) A client who is 24 hours postoperative and reports mild incisional pain
D) A client with a blood glucose of 180 mg/dL
Answer: A) A client who is short of breath
A nurse is collecting data from an older adult client who has a hip fracture and is in Buck’s
traction. The nurse notes the client has a sudden decrease in level of consciousness, dyspnea,
and crackles to the lungs upon auscultation. Which of the following actions should the nurse
take?
A) Apply high-flow oxygen
B) Increase the weight of the traction
C) Encourage the client to cough and deep breathe
D) Administer a diuretic
Answer: A) Apply high-flow oxygen
A nurse is caring for a client several days following acute radiation exposure at the client’s
workplace. Which of the following findings should the nurse identify as an indication of bone
marrow suppression?
A) Fever
B) Tachycardia
C) Increased appetite
D) Weight gain
Answer: A) Fever
A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the
following fluids should the nurse use in the first 24hrs following a client’s burn injury?
A) Lactated Ringer’s
B) 0.9% Sodium chloride (Normal saline)
C) Dextrose 5% in water
D) 0.45% Sodium chloride (Half-normal saline)
Answer: A) Lactated Ringer’s
A nurse is collecting data from a client who has a gastric ulcer. Which of the following should
the nurse identify as a priority finding and notify the provider?
A) Abdominal pain radiating to the shoulder
B) Mild epigastric discomfort
C) Occasional nausea
D) Decreased appetite
Answer: A) Abdominal pain radiating to the shoulder
A nurse is collecting data from a client who has increased intracranial pressure and is
informed by the charge nurse that the client demonstrates decorticate posturing. Which of the
followings should the nurse expect to observe?
A) Plantar flexion of the legs
B) Flexion of the arms and extension of the legs
C) Extension of the arms and flexion of the legs
D) Abnormal body positioning with the head turned to one side
Answer: B) Flexion of the arms and extension of the legs
A nurse is collecting data from a client who is to have an intravenous pyelogram (IVP).
Which of the following data is a contraindication to this procedure?
A) Client has an allergy to shellfish
B) Client has a history of hypertension
C) Client has a history of kidney stones
D) Client has a family history of diabetes mellitus
Answer: A) Client has an allergy to shellfish
A nurse is reinforcing discharge teaching with an older adult client who has peripheral artery
disease (PAD) which of the following instructions should the nurse include in the teaching?
A) Adjust the thermostat so that the environment is warm
B) Apply heating pads to the legs to improve circulation
C) Sit with the legs crossed to promote comfort
D) Wear tight socks to prevent swelling
Answer: A) Adjust the thermostat so that the environment is warm
A nurse is caring for a client who has acute dehydration is receiving IV fluids. Which of the
following laboratory values indicates to the nurse that the current treatment regimen is
effective?
A) Urine specific gravity 1.020
B) Hemoglobin 16 g/dL
C) Blood urea nitrogen (BUN) 25 mg/dL
D) Hematocrit 52%
Answer: A) Urine specific gravity 1.020
A nurse on a medical-surgical unit is checking the bowel sounds of a client who has epilepsy.
The client begins to experience a tonic-clonic seizure. Identify the sequence of steps the nurse
should follow. (Move the steps into the box on the right
A. Remain with the client and call for
B. help Place the client in the lateral
C. position Check the client for injuries
D. Reorient and reassure the client
A nurse is reinforcing teaching about the frequency of breast self-examination (BSE) with a
young adult client. Which of the following statements by the client indicates an
understanding of the teaching?
A) The best day to perform BSE is 7 days after the menstrual cycle begins
B) BSE should be performed at least once a year
C) BSE should be done only when symptoms such as pain or lumps are felt
D) BSE should be performed every week, regardless of the menstrual cycle
Answer: A) The best day to perform BSE is 7 days after the menstrual cycle begins
A nurse is reviewing the admission prescriptions for a client who has benign prostatic
hyperplasia. Which of the following medications should the nurse expect to administer?
A) Silodosin
B) Ibuprofen
C) Furosemide
D) Atenolol
Answer: A) Silodosin
A nurse is collecting data from a client who has herpes zoster (shingles) which of the
following is an expected finding?
A) Painful vesicles following a nerve pathway
B) Swelling of the lymph nodes in the axillary region
C) A rash that appears symmetrically on both sides of the body
D) Lesions that appear on the face, including the mouth and eyes
Answer: A) Painful vesicles following a nerve pathway
A nurse is caring for a client who has a gastrointestinal (GI) bleed. Which of the following
findings is the priority for the nurse to report to the provider?
A) Urine output of 50 mL in 2 hours
B) Hemoglobin of 10 g/dL
C) Abdominal pain 6/10
D) Heart rate of 110 bpm
Answer: A) Urine output of 50 mL in 2 hours
A nurse is collecting data from a client who has a hip fracture. Which of the following
findings should the nurse expect when checking the extremity?
A) Muscle spasms
B) Increased pulse rate in the affected leg
C) Decreased skin temperature in the affected leg
D) Increased range of motion in the affected hip
Answer: A) Muscle spasms
A nurse is reviewing HIPAA with a newly licensed nurse. Which of the following statements
by the newly licensed nurse indicates a need for further instruction?
A) Information about a client can be disclosed to family members at any time
B) A client's health information can be shared with other healthcare providers involved in the
client's care
C) A client's health information can be shared for billing purposes
D) A client has the right to access their medical records
Answer: A) Information about a client can be disclosed to family members at any time
A nurse collecting data from a client who has manifestations of appendicitis. Where would
the nurse palpate to monitor for pain at McBurney’s point? (You will find hot spots to select
in the artwork below. Select only the hot spot that corresponds to your answer.)
A) Left lower abdomen
B) Right upper abdomen
C) Right lower abdomen
D) Left upper abdomen
Answer: C) Right lower abdomen
A nurse is assisting in planning care for a client who has cystitis. Which of the following
interventions should be included in the plan of care?
A) Instruct the client to avoid drinking caffeinated beverages.
B) Encourage the client to take baths in hot water.
C) Suggest the client decrease fluid intake to reduce bladder frequency.
D) Advise the client to wear tight-fitting clothing to prevent infection.
Answer: A) Instruct the client to avoid drinking caffeinated beverages.
A nurse is evaluating client laboratory findings. The nurse should identify that an increase in
a client’s prostate-specific antigen (PSA) level can indicate which of the following
conditions?
A) Prostatitis
B) Cystitis
C) Epididymitis
D) Testicular cancer
Answer: A) Prostatitis
A nurse is reinforcing dietary instructions with a client who has chronic kidney disease.
Which of the following information should the nurse include?
A) Reduce intake of foods high in potassium
B) Increase intake of foods high in protein
C) Increase intake of foods high in phosphorus
D) Limit intake of fluids to 1 liter per day
Answer: A) Reduce intake of foods high in potassium
A nurse is monitoring a client who reports having chills and back pain during a blood
transfusion. Which of the following actions should the nurse take first?
A) Stop the transfusion
B) Increase the rate of the transfusion
C) Administer an antihistamine
D) Notify the blood bank
Answer: A) Stop the transfusion
A nurse is reviewing discharge instructions with a client who has pruritus following treatment
for scabies. Which of the following instructions should the nurse include?
A) Wear loose fitting clothing while you are experiencing itching.
B) Take a warm bath to relieve itching.
C) Apply an alcohol-based lotion to the affected areas.
D) Wash the bedding and clothing in hot water after each treatment.
Answer: A) Wear loose fitting clothing while you are experiencing itching.
A nurse is collecting data from a client who fell at home and reported a brief loss of
consciousness. Which of the following findings should the immediately report to the charge
nurse
A) Small drops of clear fluid in left ear
B) Mild headache
C) Bruising on left knee
D) Sensitivity to light
Answer: A) Small drops of clear fluid in left ear
A nurse is reinforcing teaching with a client who is scheduled for a CT scan of the head with
contrast. Which of the following statements by the client should the nurse identify as
understanding of the teaching?
A) "I can take medication up to 2 hours before the procedure."
B) "I should avoid taking any medication before the procedure."
C) "I need to fast for 12 hours before the CT scan."
D) "I will need to drink a contrast solution before the CT scan."
Answer: A) "I can take medication up to 2 hours before the procedure."
The nurse is caring for a client on the third day following abdominal surgery and assesses the
absence of bowel sounds, abdominal distention, and the client passing no flatus. These
findings indicated the client is experiencing which of the following postoperative
complications?
A) Paralytic ileus
B) Small bowel obstruction
C) Gastrointestinal hemorrhage
D) Wound infection
Answer: A) Paralytic ileus
A nurse is caring for a client who has a cerebral aneurysm. Which following actions should
the nurse take?
A) Monitor vital signs at least once each hour
B) Encourage the client to cough and deep breathe every hour
C) Administer anticoagulants as prescribed
D) Position the client with the head of the bed flat
Answer: A) Monitor vital signs at least once each hour
A nurse is contributing to the plan of care of a client who has increased intracranial pressure
following a closed-head injury. Which of the following interventions should the nurse
recommend?
A) Elevate the head of the bed
B) Keep the head of the bed flat
C) Place the client in a side-lying position with the head turned to the right
D) Allow the client to lie on their back with their head turned to the left
Answer: A) Elevate the head of the bed
A nurse is reinforcing dietary teaching with a client who has GERD. Which of the following
food choices by the client indicates an understanding of the teaching?
A) Baked turkey breast
B) Fried chicken
C) Spaghetti with marinara sauce
D) Chocolate cake
Answer: A) Baked turkey breast
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about selfcare
during illness. Which of the following instructions should the nurse include in the teaching?
A) Administer your usual daily dose of insulin
B) Skip insulin doses until your blood glucose returns to normal
C) Drink only water to stay hydrated
D) Eat only foods that are low in carbohydrates
Answer: A) Administer your usual daily dose of insulin
A nurse is assisting with triaging clients after a mass casualty event. Which of the following
clients should the nurse attend to first?
A) A client who has severe respiratory stridor and a deviated trachea
B) A client with a large open wound to the abdomen and stable vital signs
C) A client with a compound fracture and mild bleeding
D) A client who is alert but has a superficial burn on the arm
Answer: A) A client who has severe respiratory stridor and a deviated trachea
A nurse is reviewing the medical record of a client who has osteoarthritis which of the
following findings should the nurse expect?
A) Stiffness of the joints
B) Decreased muscle tone
C) Warmth and redness around the joints
D) Morning stiffness lasting several hours
Answer: A) Stiffness of the joints
A nurse is collecting data on a client who has hyperthyroidism. Which of the following
manifestations should the nurse expect the client to report?
A) Frequent mood changes
B) Weight gain
C) Cold intolerance
D) Slow heart rate
Answer: A) Frequent mood changes
A nurse is assisting with menu selections for a client who has recovered from the acute phase
of diverticulitis. Which of the following foods should the nurse recommend?
A) Bean soup with steamed broccoli
B) White rice with plain grilled chicken
C) Mashed potatoes with buttered bread
D) Creamed spinach with soft scrambled eggs
Answer: A) Bean soup with steamed broccoli
A nurse is checking the laboratory tests for a client who has glomerulonephritis. The nurse
should expect to find an increase in which of the following test results?
A) BUN (Blood Urea Nitrogen)
B) Sodium
C) Potassium
D) Hemoglobin
Answer: A) BUN (Blood Urea Nitrogen)
A nurse is reinforcing teaching with an older adult client who has been newly diagnosed with
a heart murmur. Which of the following statements should the nurse make?
A) This indicates turbulent blood flow through a valve
B) This is a sign of a heart attack
C) This will cause chest pain with exertion
D) This will eventually lead to heart failure
Answer: A) This indicates turbulent blood flow through a valve
A nurse is collecting data from a client who has a traumatic head injured which of the
following findings should the nurse report to the provider immediately?
A) Sudden sleepiness
B) Mild headache
C) Slight nausea
D) Irritability
Answer: A) Sudden sleepiness
A nurse is reviewing the laboratory results of a group of clients which of the following
laboratory findings should the nurse report to the provider?
A) Hemoglobin of 6.2 g/dL in a client who is receiving chemotherapy
B) Hemoglobin of 11.5 g/dL in a client who is receiving chemotherapy
C) Hemoglobin of 8.2 g/dL in a client who is receiving chemotherapy
D) Hemoglobin of 14.2 g/dL in a client who is receiving chemotherapy
Answer: A) Hemoglobin of 6.2 g/dL in a client who is receiving chemotherapy
A nurse is caring for a client who is scheduled for a Tensilon challenge test to check for
myasthenia gravis. Which of the following findings should the nurse identify as a positive
result?
A) Muscle strength becomes temporarily stronger
B) Muscle strength becomes temporarily weaker
C) Increased heart rate and blood pressure
D) Increased muscle twitching and spasms
Answer: A) Muscle strength becomes temporarily stronger
A nurse is caring for a client who has acute kidney injury. The client’s ABGS are:
Ph: 7.26
PaCO2: 30 mm
HgHCO3: 14 mEq/L
Which of the following acid-imbalances should the nurse identify the client is experiencing?
A) Metabolic acidosis
B) Respiratory acidosis
C) Metabolic alkalosis
D) Respiratory alkalosis
Answer: A) Metabolic acidosis
A nurse is collecting data from a client who has Cushing’s syndrome. Which of the following
findings should the nurse expect?
A) Hyperpigmentation
B) Moon face
C) Hypoglycemia
D) Weight loss
Answer: B) Moon face
A nurse in a clinic is caring for a client who is postmenopausal and has risk factors for
osteoporosis. The nurse anticipates the client will be prescribed which of the following
medications?
A) Raloxifene hydrochloride
B) Levothyroxine
C) Metformin
D) Alendronate sodium
Answer: A) Raloxifene hydrochloride
A nurse is preparing to administer medications to four clients. Which of the following clients
should the nurse administer medication to first?
A) A client who has a potassium level of 5.8 mEq/L that is to receive sodium polystyrene
sulfonate
B) A client who has a blood pressure of 120/80 mm Hg and is to receive an antihypertensive
medication
C) A client who has a blood glucose level of 90 mg/dL and is to receive insulin
D) A client who has a heart rate of 110 beats/min and is to receive a beta-blocker
Answer: A) A client who has a potassium level of 5.8 mEq/L that is to receive sodium
polystyrene sulfonate
A nurse is reinforcing dietary teaching to a client who is at risk for osteoporosis about
increasing her calcium intake. Which of the following foods should the nurse recommend the
client consume frequently?
A) Collards
B) Oranges
C) Apples
D) Carrots
Answer: A) Collards
A nurse is contributing to a plan of care for a client who has Hepatitis B which of the
following should the nurse include in the plan?
A) Limit activity
B) Increase protein intake
C) Encourage heavy alcohol consumption
D) Restrict fluid intake
Answer: A) Limit activity
A nurse is caring for a client who has a diagnosis of acute glomerulonephritis. Which of the
following should be reported immediately to the provider?
A) Blood Pressure 162/90 mm Hg
B) Urine output 30 mL/hr
C) Serum creatinine 1.5 mg/dL
D) Temperature 99.8°F (37.7°C)
Answer: A) Blood Pressure 162/90 mm Hg
A nurse is reinforcing teaching about ileostomy care with a client. The nurse should
recognize which of the following statements by the client indicates a need for further
teaching?
A) "I will be certain to take enteric-coated medication."
B) "I will drink plenty of fluids every day."
C) "I should empty the pouch when it is about one-third full."
D) "I will avoid eating foods that may cause blockages, like nuts and popcorn."
Answer: A) "I will be certain to take enteric-coated medication."
A nurse is caring for a client who enters an ambulatory clinic bleeding profusely from a deep
laceration on his left lower forearm. After donning gloves, which of the following actions
should the nurse take first?
A) Apply pressure directly over the wound
B) Elevate the left arm above the level of the heart
C) Apply a tourniquet above the injury site
D) Cleanse the wound with sterile saline
Answer: A) Apply pressure directly over the wound
A nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. the arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm
Hg Base excess
-2 PaO2 78 mm
Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
A) Respiratory Acidosis
B) Metabolic Acidosis
C) Respiratory Alkalosis
D) Metabolic Alkalosis
Answer: A) Respiratory Acidosis
A nurse is contributing to the plan of care for a client following a lumbar puncture. Which of
the following interventions should the nurse include?
A) Encourage oral fluids
B) Instruct the client to sit upright for 1 hour after the procedure
C) Apply cold compresses to the puncture site
D) Encourage the client to remain flat in bed for several hours
Answer: A) Encourage oral fluids
A nurse is caring for a client who is immunocompromised which of the following actions
should the nurse take first?
A) Perform hand hygiene before and after care
B) Wear a mask when interacting with the client
C) Isolate the client in a private room
D) Administer prescribed antibiotics as ordered
Answer: A) Perform hand hygiene before and after care
A school nurse is reinforcing teaching to a group of teenage clients about prevention of
sexually transmitted infections (STIs). Which of the following practices is the most effective
form of protection to include in the teaching?
A) The use of latex condoms
B) The use of withdrawal method
C) The use of spermicides
D) The use of oral contraceptives
Answer: A) The use of latex condoms
A nurse is caring for a client who has dysphagia following a stroke which of the following is
the priority action for the nurse to take when feeding the client?
A) Place the client in the upright position
B) Offer small bites of food
C) Encourage the client to swallow after each bite
D) Give the client thin liquids to drink
Answer: A) Place the client in the upright position
A nurse is reviewing the urinalysis results of a client who reports urinary frequency and
burning. Which of the following findings should the nurse report to the provider?
A) Microscopic hematuria
B) Leukocytes
C) Specific gravity of 1.020
D) Proteinuria
Answer: A) Microscopic hematuria
A nurse is caring for a client who has developed a Clostridium Difficile infection following
antibiotic therapy. Which of the following actions should the nurse take?
A) Disinfect equipment with bleach solution
B) Place the client on a standard medical-surgical unit
C) Use alcohol-based hand sanitizer for hand hygiene
D) Encourage the client to eat foods that are high in fiber
Answer: A) Disinfect equipment with bleach solution
A nurse is caring for a client who has a large wound that has a vacuum-assisted closure
device placed over it which of the following findings by the nurse indicates healing of the
wound?
A) Granulation tissue on the surface of the wound
B) Presence of eschar covering the wound
C) Pale, dry tissue around the wound edges
D) Increased pain at the wound site
Answer: A) Granulation tissue on the surface of the wound
A nurse is caring for a client who recently had a permanent pacemaker placed. The nurse is
reinforcing teaching following the initial pacemaker check. Which of the following
statements by the client indicates understanding?
A) I will let my dentist know that I have a pacemaker
B) I can use a microwave without any concerns
C) I need to avoid lifting heavy objects for at least 6 months
D) I should check my pulse every hour to monitor pacemaker function
Answer: A) I will let my dentist know that I have a pacemaker
A nurse is reinforcing discharge teaching about self-administered peritoneal dialysis with a
client. Which of the following statements by the client indicates an understanding of the
teaching?
A) The amount of the liquid output should be greater than what was put in
B) I should stop the procedure if I feel any discomfort during the exchange
C) The dialysis fluid should remain clear when it is drained
D) I should increase the amount of dialysis fluid if I don’t feel like I am getting enough
dialysis
Answer: A) The amount of the liquid output should be greater than what was put in
A nurse is collecting data from a client who has peripheral arterial disease (PAD) which of
the following findings should the nurse expect
A) Intermittent claudication
B) Edema in the lower extremities
C) Positive Homans' sign
D) Warm, flushed skin in the lower extremities
Answer: A) Intermittent claudication
A nurse is reinforcing teaching with a client following surgery who has antiembolism
stockings in place. Which of the following information should the nurse include in the
teaching?
A) The stockings prevent venous stasis
B) The stockings reduce blood pressure in the legs
C) The stockings eliminate the need for ambulation
D) The stockings prevent arterial insufficiency
Answer: A) The stockings prevent venous stasis
A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/ min
via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which
of the following actions is the nurse priority at this time?
A) Evaluate the client’s respiratory status
B) Increase the oxygen flow to 4 L/min
C) Call the provider for a change in medication
D) Encourage the client to take deep breaths
Answer: A) Evaluate the client’s respiratory status
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH) and a sodium level of 123 mEq/L which of the following actions should the nurse
take?
A) Restrict oral fluids to 800 to 1000 mL/day
B) Increase oral sodium intake to 4-6 grams/day
C) Administer a diuretic as prescribed
D) Encourage the client to drink electrolyte-rich beverages
Answer: A) Restrict oral fluids to 800 to 1000 mL/day
A nurse is reinforcing discharge teaching to a client who will be performing intermittent selfcatheterizations. Which of the following statement should the nurse include in the teaching?
A) Advance the catheter 5 cm (2 in) after urine begins to flow
B) Use sterile water to lubricate the catheter before insertion
C) Insert the catheter while standing if unable to perform the procedure lying down
D) Reuse the catheter after cleaning it thoroughly
Answer: A) Advance the catheter 5 cm (2 in) after urine begins to flow
A client arrives for initial evaluation following a diagnosis of systemic lupus erythematosus
(SLE) the nurse understands that which of the following is a classic cutaneous manifestation
of SLE?
A) Butterfly rash on face
B) Hyperpigmentation on the chest
C) Petechiae on the legs
D) Shiny, smooth, tight skin over the joints
Answer: A) Butterfly rash on face
A nurse is reinforcing discharge teaching with a client who has undergone a transurethral
resection of the prostate (TRUP) which of the following statements should the nurse include
in the teaching
A) Increase fluid intake if urine becomes blood tinged
B) Avoid drinking fluids with caffeine
C) Limit activity to prevent straining
D) Take stool softeners to prevent constipation
Answer: A) Increase fluid intake if urine becomes blood tinged
A nurse at an urgent care center is reinforcing information with a new employee about the
difference between sprains and strains. Which of the following examples should the nurse
include as a cause of sprain injury?
A) Twisting a ligament while walking
B) Overstretching a tendon during exercise
C) Pulling a muscle while lifting a heavy object
D) Tearing a tendon while running
Answer: A) Twisting a ligament while walking
A nurse is monitoring a client following a hemodialysis treatment through an arteriovenous
(AV) fistula. Which of the following findings should the nurse report to the provider
A) Headache, restlessness
B) Hypotension, dizziness
C) Decreased urine output
D) Fatigue, nausea
Answer: A) Headache, restlessness
A nurse is collecting a data for a female client who has genital herpes which of the following
findings should the nurse expect
A) Dysuria
B) Polyuria
C) Hematuria
D) Pyuria
Answer: A) Dysuria
A charge nurse is observing a nurse who is caring for a client who has continuous skeletal
traction of a lower extremity. For which of the following actions should the charge nurse
intervene?
A) Removes the traction weights for a brief period each day
B) Ensures the client is in proper alignment in the bed
C) Monitors for skin breakdown under the traction apparatus
D) Performs range of motion exercises on the unaffected limb
Answer: A) Removes the traction weights for a brief period each day
A nurse is reinforcing teaching to a female client who has risk factors for stroke. Which of the
following statements by the client indicates an understanding of the teaching?
A) Managing my cholesterol will reduce my chances of having a stroke
B) I will need to increase my salt intake to lower my blood pressure
C) Drinking more than two alcoholic drinks per day is safe as long as I exercise regularly
D) I will stop taking my medications once I feel better to prevent side effects
Answer: A) Managing my cholesterol will reduce my chances of having a stroke
A nurse is assisting with teaching a newly licensed nurse about parenteral nutrition (PN)
which of the following information should the nurse include in the teaching?
A) Reduce the rate of the solution gradually to discontinue
B) The solution should be discontinued immediately to prevent infection
C) The PN solution can be stopped abruptly after 24 hours
D) The solution should be discontinued if the patient shows signs of infection
Answer: A) Reduce the rate of the solution gradually to discontinue
Upon inspection of a client’s skin, a nurse identifies a stage 3 pressure ulcer on the sacrum.
Which of the following statement by the nurse describes a stage 3 pressure ulcer
A) "The ulcer involves full-thickness skin loss, and the base of the wound may have visible
muscle or bone."
B) "The ulcer involves full-thickness skin loss, and the base of the wound may have visible
fat."
C) "The ulcer is characterized by partial-thickness skin loss with exposed dermis."
D) "The ulcer involves a shallow crater with intact skin over the wound."
Answer: B) "The ulcer involves full-thickness skin loss, and the base of the wound may have
visible fat."
A nurse is reinforcing teaching about cast care with a client who has a long-leg fiberglass cast
on the right tibia. Which of the following instructions should the nurse include in the teaching
A) Report any worsening or unrelieved pain
B) Use a hair dryer on a cool setting to dry the cast if it gets wet
C) Apply lotion or powder inside the cast to keep the skin dry
D) Lift the leg by the toes to avoid putting pressure on the cast
Answer: A) Report any worsening or unrelieved pain
A nurse is assisting in planning care for a client who has a head injury and is in a halo traction
device. which of the following actions should the nurse recommend for the plan of care?
A) Monitor the client for elevated temperature
B) Ensure the client wears the halo vest at all times, including during meals
C) Check the pin sites for signs of infection every 8 hours
D) Encourage the client to perform range-of-motion exercises on the neck to prevent stiffness
Answer: A) Monitor the client for elevated temperature
A nurse in a clinic is collecting data from a client who reports wrist pain caused by carpal
tunnel syndrome. The nurse should expect which of the following findings
A) Positive Phalen’s sign
B) Negative Tinel's sign
C) Numbness in the little finger
D) Pain in the wrist that is relieved by wrist extension
Answer: A) Positive Phalen’s sign
A nurse is reviewing the laboratory results for a male adult client who is at risk for peripheral
arterial disease from atherosclerosis. The nurse should identify that which of the following
results places the client at risk
A) LDL 172 mg/dL
B) HDL 45 mg/dL
C) Total cholesterol 180 mg/dL
D) Triglycerides 120 mg/dL
Answer: A) LDL 172 mg/dL
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the
following should the nurse do after noticing a rise in the water seal with client inspiration?
A) Continue to monitor the client
B) Increase the suction pressure
C) Check for an air leak
D) Clamp the chest tube
Answer: A) Continue to monitor the client
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following
of the findings should the nurse expect?
A) Oliguria
B) Increased urine output
C) Warm, dry skin
D) Increased capillary refill time
Answer: A) Oliguria
A nurse is caring with the plan of care for a client who is scheduled a transurethral resection
of the prostate. Which of the following intervention should the nurse include in the plan of
care
A) Inform the client to expect insertion of a large indwelling urinary catheter following
surgery
B) Encourage the client to limit fluid intake to avoid bladder distension
C) Advise the client to avoid deep breathing exercises postoperatively
D) Instruct the client to expect a continuous bladder irrigation (CBI) following surgery
Answer: D) Instruct the client to expect a continuous bladder irrigation (CBI) following
surgery
A nurse in a provider’s office is reinforcing teaching with a client who has risk factor for
atherosclerosis. The nurse should help the client identify which of the following as treatment
goals
A) Maintain blood pressure at less than 140/90 mm Hg
B) Maintain blood pressure at less than 120/80 mm Hg
C) Maintain blood pressure at less than 160/100 mm Hg
D) Maintain blood pressure at less than 150/90 mm Hg
Answer: A) Maintain blood pressure at less than 140/90 mm Hg
A nurse is assisting with the care of a client who has partial-thickness and full-thickness
burns to his upper torse and face. Which of the following actions should the nurse take to
prevent infection?
A) Change gloves between sites when providing wound care to multiple wounds
B) Apply a hydrocolloid dressing to all burn wounds
C) Perform wound cleaning using hydrogen peroxide
D) Administer oral antibiotics as prophylaxis for infection
Answer: A) Change gloves between sites when providing wound care to multiple wounds
A nurse at a health fair is collecting data form a group of clients. Which of the following
clients is at risk for developing an obesity-related disease?
A) A female client who has a BMI of 32 and a waist circumference of 102 cm (40 in)
B) A male client who has a BMI of 24 and a waist circumference of 85 cm (33 in)
C) A female client who has a BMI of 22 and a waist circumference of 75 cm (30 in)
D) A male client who has a BMI of 28 and a waist circumference of 90 cm (35 in)
Answer: A) A female client who has a BMI of 32 and a waist circumference of 102 cm (40
in)
A nurse is collecting data from a client who is African American has cholecystitis which of
the following areas should the nurse inspect to monitor for the presence of jaundice?
A) Head palate
B) Sclera of the eyes
C) Nail beds
D) Palms of the hands
Answer: B) Sclera of the eyes
A nurse is caring for a group of clients on an adult medical-surgical unit. Which of the
following clients should the nurse identify as having the highest risk for aspiration?
A) A client receiving enteral feedings through an NG tube
B) A client with chronic obstructive pulmonary disease (COPD)
C) A client who is alert and oriented with a history of hypertension
D) A client with a recent stroke who has impaired swallowing
Answer: A) A client receiving enteral feedings through an NG tube
A nurse is reinforcing teaching with a client who has rheumatoid arthritis (RA) about selfcare
techniques which of the following strategies should the nurse include in the teaching
A) Avoid exercising joints that are swollen
B) Perform stretching exercises only after the joints have cooled
C) Apply cold compresses to joints before exercise
D) Engage in low-impact exercises to maintain joint mobility
Answer: D) Engage in low-impact exercises to maintain joint mobility
A nurse is reinforcing preoperative teaching with a client who is scheduled to have hip
arthroplasty. Which of the following information should the nurse provided in the teaching
A) Bending the hip within 90 degrees is allowed
B) Crossing the legs at the knees is allowed
C) Placing the foot on the opposite knee is allowed
D) Adducting the hip is allowed
Answer: C) Placing the foot on the opposite knee is allowed
A nurse is caring for a client who is receiving peritoneal dialysis the nurse should monitor the
client for which of the following manifestations of peritonitis
A) Nausea and vomiting
B) Fever and chills
C) Diarrhea and abdominal cramping
D) Decreased urine output
Answer: B) Fever and chills
A nurse is collecting data from a client while changing his ileostomy pouch. Which of the
following data should the nurse report immediately
A) The stoma is pale in color
B) The stoma is slightly swollen
C) The stoma is bleeding slightly
D) The stoma has a small amount of mucus discharge
Answer: A) The stoma is pale in color
A nurse is collecting data from a client following a bee sting which of the following findings
can indicate an anaphylactic reaction to the venom
A) Urticaria
B) Erythema at the sting site
C) Local swelling and pain
D) Mild headache
Answer: A) Urticaria
A nurse is collecting a health history form a client which of the following client data should
the nurse identify as a risk factor for contracting hepatitis C
A) Presence of multiple tattoos
B) History of regular exercise
C) Family history of high blood pressure
D) Consuming a vegetarian diet
Answer: A) Presence of multiple tattoos
A nurse is assisting with the care of a newly admitted client who has acute osteomyelitis
which of the following interventions is the priority for the nurse to implement
A) Administering antibiotic therapy
B) Providing pain management
C) Preparing the client for surgery
D) Monitoring for signs of sepsis
Answer: A) Administering antibiotic therapy
A nurse is collecting data from a client who has right-sided heart failure. Which of the
following findings should the nurse expect
A) Hepatomegaly
B) Dyspnea on exertion
C) Orthopnea
D) Pulmonary edema
Answer: A) Hepatomegaly
A nurse is planning care for several clients and is considering the clients risk for stroke.
Which of the following conditions places the client at risk for an ischemic embolic stroke?
A) A client who has chronic atrial fibrillation
B) A client who has hypertension
C) A client who has diabetes mellitus
D) A client who has hyperlipidemia
Answer: A) A client who has chronic atrial fibrillation
A nurse is caring for a client who is postoperative and has a history Addison’s disease. For
which of the following manifestations should the nurse monitor?
A) Hypotension
B) Hyperglycemia
C) Tachycardia
D) Hyperkalemia
Answer: A) Hypotension
A nurse is collecting data from a male client who has been exposed to syphilis and has genital
chancre. Which of the following prescriptions should the nurse anticipate when notifying the
provider of these findings
A) Venereal Disease Research Laboratory (VDRL) test
B) Rapid Plasma Reagin (RPR) test
C) Chlamydia trachomatis culture
D) Human Immunodeficiency Virus (HIV) test
Answer: A) Venereal Disease Research Laboratory (VDRL) test
A nurse is caring for a client who develops a pulmonary embolism which of the following
interventions is the priority for the nurse to take?
A) Begin oxygen therapy
B) Administer anticoagulant therapy
C) Obtain a chest X-ray
D) Assess the client's vital signs
Answer: A) Begin oxygen therapy
A nurse is assisting with the care of a client following a left femoral cardiac angiography. The
nurse should place a sandbag on the client over which of the following areas (you will find
hot spots to select in the artwork below select only the hot spot that corresponds to your
answer)
A) Left groin area
B) Left thigh
C) Right groin area
D) Right femoral area
Answer: A) Left groin area
A nurse is assisting with the plan of care for a client who has a cerebral aneurysm. The nurse
should plan to monitor the client for which of the following early indications of increased
intracranial pressure
A) Disorientation to time and place
B) Bradycardia
C) Hemiparesis (weakness on one side of the body)
D) Increased blood pressure with widening pulse pressure
Answer: A) Disorientation to time and place
A nurse is monitoring a client who received desmopressin (DDAVP) to treat diabetes
insipidus. Which of the following findings indicates effectiveness of the medication?
A) Urine specific gravity 1.015
B) Urine output of 500 mL over 8 hours
C) Serum sodium level of 155 mEq/L
D) Urine output of 3 L in 12 hours
Answer: A) Urine specific gravity 1.015
A nurse is reinforcing health screening education with a group of clients. The nurse should
recognize that which of the following clients has the greatest risk for hypertension?
A) A client who is African American
B) A client who is 30 years old
C) A client who has a family history of hypertension
D) A client who is obese
Answer: A) A client who is African American
A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis.
The nurse should recognize that which of the following actions is the priority
A) Evaluate fluid and electrolyte levels
B) Administer corticosteroids as prescribed
C) Provide a high-fiber diet
D) Monitor for signs of infection
Answer: A) Evaluate fluid and electrolyte levels
A nurse in a health clinic is reinforcing teaching to a newly licensed nurse about vaginal yeast
infections. Which of the following information should the nurse include in the teaching
A) Vaginal yeast infections present as a thick, white discharge
B) Vaginal yeast infections present as a thin, clear discharge
C) Vaginal yeast infections are usually associated with greenish discharge
D) Vaginal yeast infections are most commonly caused by bacteria
Answer: A) Vaginal yeast infections present as a thick, white discharge
A nurse is assisting with the plane of care for a client who has thrombocytopenia. Which of
the following interventions should the nurse include in the plan of care?
A) Monitor level of consciousness every 4 hours
B) Administer aspirin as prescribed
C) Encourage the client to ambulate frequently
D) Apply pressure to any puncture sites for at least 5 minutes
Answer: A) Monitor level of consciousness every 4 hours
A nurse is reviewing the medical record of a client who hyperthyroidism (Graves’ disease)
which of the following serum laboratory findings should the nurse expect to be below the
expected reference range?
A) Thyroid stimulating hormone (TSH) level
B) T3 (triiodothyronine) level
C) T4 (thyroxine) level
D) Thyroglobulin level
Answer: A) Thyroid stimulating hormone (TSH) level
A nurse is assisting with the care of a client who has hypocalcemia. For which of the
following signs should the nurse monitor?
A) Chvostek’s sign
B) Trousseau’s sign
C) Brudzinski’s sign
D) Kernig’s sign
Answer: A) Chvostek’s sign
A nurse is contributing to the care plan for a client who has developed deep-vein thrombosis.
Which of the following interventions should the nurse include?
A) Elevate the affected extremity when the client is resting
B) Massage the affected extremity to promote circulation
C) Apply a warm compress to the affected area
D) Encourage the client to remain on bed rest until the clot resolves
Answer: A) Elevate the affected extremity when the client is resting
A nurse is reinforcing teaching about pernicious anemia with a client following a total
gastrectomy. Which of the following dietary supplements should the nurse include in the
teaching as the treatment for pernicious anemia?
A) Vitamin B12
B) Iron
C) Folic acid
D) Vitamin C
Answer: A) Vitamin B12
A nurse is assisting with the care of a client who has multiple facial injuries which of the
following equipment should the nurse place at the client’s bedside?
A) Suction catheter
B) Oxygen mask
C) Chest tube kit
D) Defibrillator
Answer: A) Suction catheter
The nurse is collecting data form an older adult female client who has chronic
hypothyroidism which of the following findings should the nurse report to the provider
immediately?
A) Decreased level of consciousness
B) Increased appetite
C) Dry skin
D) Weight gain
Answer: A) Decreased level of consciousness
A nurse is planning care for a client who is to receive a unit of packed RBSs within which of
the following time spans must the nurse complete the infusion
A) 2 hours
B) 4 hours
C) 6 hours
D) 8 hours
Answer: B) 4 hours
A nurse is assisting in the care of a client who is to receive a blood transfusion. Prior to the
transfusion which of the following staff members should the nurse select to assist her in
checking the blood
A) Oncology nurse
B) Phlebotomist
C) Licensed practical nurse (LPN)
D) Registered nurse (RN)
Answer: D) Registered nurse (RN)
A nurse is reinforcing teaching about the Mediterranean diet with a client who is at risk for
hypertension. Which of the following statements by the client indicates a need for further
teaching
A) "I will limit my intake of red meat to two times per week."
B) "I will include olive oil as the primary fat in my diet."
C) "I will focus on eating more fruits and vegetables."
D) "I will consume whole grains instead of refined grains."
Answer: A) "I will limit my intake of red meat to two times per week."
A nurse is caring for a client who is conscious and has an airway obstruction which of the
following actions should the nurse take
A) Begin the Heimlich maneuver
B) Encourage the client to cough forcefully
C) Perform a head-tilt, chin-lift maneuver
D) Insert an oral airway
Answer: B) Encourage the client to cough forcefully
A nurse is collecting data from a client who has pneumonia and is experiencing acute
respiratory acidosis. Which of the following manifestations should the nurse expect to find?
A) Decreased level of consciousness
B) Hypotension
C) Tachypnea
D) Hypertension
Answer: A) Decreased level of consciousness
A nurse is reinforcing teaching with a client who has anew diagnosis of gout the client asks
the nurse how she got the disorder. Which of the following information should the nurse
include in the teaching?
A) Intra-articular urate crystal deposits cause inflammation
B) Gout is caused by a bacterial infection in the joints
C) It is caused by a deficiency in vitamin D
D) Gout is caused by excessive calcium buildup in the joints
Answer: A) Intra-articular urate crystal deposits cause inflammation
A nurse is assisting with the care of a client who 1 day postoperative following a
thyroidectomy and reports sever muscle spasms of the lower extremities. Which of the
following actions should the nurse take?
A) Determine the client’s calcium level
B) Administer a muscle relaxant
C) Assess the surgical site for bleeding
D) Encourage the client to walk around
Answer: A) Determine the client’s calcium level
A nurse is a provider’s office is reviewing the health histories of four clients for which of the
following clients should the nurse anticipate scheduling a colonoscopy
A) 32-year-old who has a sister who died of colon cancer
B) 45-year-old who is experiencing occasional abdominal bloating
C) 50-year-old with a family history of hypertension
D) 60-year-old who has a history of smoking for 30 years
Answer: A) 32-year-old who has a sister who died of colon cancer
A nurse is reviewing the arterial blood gas (ABG) results of a client. The client’s
ABGs are: pH: 7.6
PaCO2: 40 mm
Hg HCO3 32 mEq/L
Which of the following acid base conditions should the nurse identify the client is
experiencing
A) Metabolic Alkalosis
B) Respiratory Alkalosis
C) Metabolic Acidosis
D) Respiratory Acidosis
Answer: A) Metabolic Alkalosis
A nurse is monitoring a client who is dehydrated which of the following laboratory findings
should the nurse report to the provider
A) BUN 25 mg/dL
B) Potassium 3.9 mEq/L
C) Hemoglobin 13.5 g/dL
D) Sodium 137 mEq/L
Answer: A) BUN 25 mg/dL
