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ATI Med Surg B, RN Adult Med Surg A,
ATI MED SURG, ATI A, ATI B, ATI C/2023/2024
Part I
A nurse is providing teaching to a client who has a new prescription for psyllium. Which of
the following information should the nurse include in the teaching?
a) Take the medication with meals
b) Mix the medication with a full glass of water
c) Chew the medication thoroughly
d) Take the medication at bedtime
Answer: b)
Rationale:
Psyllium is a bulk-forming laxative that works by absorbing liquid in the intestines to form a
bulky, softer stool that is easier to pass. It is crucial for the client to drink a sufficient amount
of water after taking psyllium to ensure that the medication works effectively and to prevent
the risk of choking or blockage in the esophagus or intestines. Mixing the medication with
water helps to properly hydrate the psyllium and prevent it from swelling and causing
complications.
A nurse is caring for a client who has DKA. Which of the following findings should indicate
to the nurse that the client's condition is improving?
a) Blood pH 7.20
b) Serum bicarbonate 10 mEq/L
c) Glucose 272 mg/dL
d) Serum potassium 3.5 mEq/L
Answer: c)
Rationale:
In diabetic ketoacidosis (DKA), hyperglycemia is a key feature. As the client's condition
improves and treatment is effective, the glucose level will begin to decrease. A glucose level
of 272 mg/dL indicates a significant improvement from higher levels commonly seen in
DKA.
A nurse is admitting a client who has active TB. Which of the following types of transmission
precautions should the nurse initiate?

a) Contact
b) Droplet
c) Airborne
d) Standard
Answer: c)
Rationale:
Tuberculosis (TB) is transmitted via airborne droplet nuclei. Airborne precautions are
necessary to prevent the spread of TB to others. These precautions include placing the client
in a negative pressure room and wearing an N95 respirator mask when entering the room.
A nurse is providing teaching to a client who has asthma about the use of a metered-dose
inhaler. The nurse should identify that which of the following client actions indicates an
understanding of the teaching?
a) Exhaling forcefully after inhalation
b) Inhaling slowly and deeply through the mouthpiece
c) Not shaking the inhaler before use
d) Holding breath for 10 secs after inhaling
Answer: d)
Rationale:
Holding the breath for 10 seconds after inhaling the medication allows for better absorption
of the medication into the lungs. This technique helps ensure that the medication reaches the
lower airways where it is needed to relieve asthma symptoms.
A nurse is assessing a client who is at risk for the development of pernicious anemia resulting
from peptic ulcer disease. Which of the following images depicts a condition caused by
pernicious anemia?
a) Image of pallor
b) Image of petechiae
c) Image of jaundice
d) Image of a smooth red tongue
Answer: d)
Rationale:
Pernicious anemia is a type of anemia caused by a deficiency of vitamin B12, which is
essential for the production of red blood cells. One of the characteristic signs of pernicious

anemia is glossitis, which presents as a smooth, red, and swollen tongue. This condition is
often seen in individuals with pernicious anemia resulting from malabsorption of vitamin B12
due to conditions such as peptic ulcer disease.
A nurse on a medsurg unit is reviewing the medical record of an older adult client who is
receiving IV fluid therapy. Which of the following client information should indicate to the
nurse that the client requires re-evaluation of the IV therapy prescription?
a) Blood pressure
b) BUN
c) Temperature
d) Heart rate
Answer: b)
Rationale:
Blood urea nitrogen (BUN) levels can indicate the hydration status and kidney function of a
client receiving IV fluid therapy. Elevated BUN levels may indicate dehydration or impaired
kidney function, which could require a re-evaluation of the IV fluid therapy prescription.
Monitoring BUN levels helps ensure that the client is receiving the appropriate amount and
type of IV fluids.
A nurse is assessing a client following the completion of hemodialysis. Which of the
following findings is the nurse's priority to report to the provider?
a) Dry skin
b) Restlessness
c) Decreased blood pressure
d) Muscle cramps
Answer: b)
Rationale:
Restlessness can be a sign of several complications following hemodialysis, including
hypotension, electrolyte imbalances, or inadequate dialysis. It is important for the nurse to
report restlessness promptly to the provider for further evaluation and intervention.
A nurse is receiving report on a client who is postop following an open repair of Zenker's
diverticulum. The nurse should anticipate the surgical incision to be in which of the following
locations?

a) Neck
b) Abdomen
c) Chest
d) Back
Answer: a)
Rationale:
Zenker's diverticulum is typically repaired through an incision in the neck to access the area
of the diverticulum near the pharynx. This approach allows for direct access to the surgical
site and is associated with better outcomes compared to other approaches. Placing the
incision in the neck also minimizes the risk of complications associated with other areas of
the body, such as the chest or abdomen.
A nurse is teaching a group of newly licensed nurses about pain management for older adult
clients. Which of the following statements by a newly licensed nurse indicates an
understanding of the teaching?
a) Acetaminophen is the preferred analgesic for older adult clients
b) Morphine is contraindicated in older adult clients
c) Older adult clients should avoid all NSAIDs for pain management
d) Ibuprofen can cause gastrointestinal bleeding in older adult clients
Answer: d)
Rationale:
Older adult clients are more susceptible to gastrointestinal bleeding from nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen. Understanding the risks associated with
NSAIDs in older adults is essential for safe pain management.
A nurse is planning a health promotional presentation for a group of African American clients
at a community center. Which of the following disorders presents the greatest risk to this
group?
a) Diabetes
b) Hypertension
c) Sickle cell anemia
d) Breast cancer
Answer: b)
Rationale:

Hypertension, or high blood pressure, is more prevalent among African Americans and can
lead to serious complications such as heart disease, stroke, and kidney failure.
A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount
available is oral solution 125 mg/5mL. How many mL should the nurse administer?
a) 15 mL
b) 20 mL
c) 24 mL
d) 30 mL
Answer: c)
Rationale:
To calculate the amount to administer, divide the total dose by the concentration of the
solution: 600 mg / 125 mg/5 mL = 24 mL
A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The
nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions
should the nurse take?
a) Document that depolarization has occurred
b) Prepare to change the pacemaker settings
c) Administer atropine as prescribed
d) Increase the pacemaker's output
Answer: a)
Rationale:
A pacemaker artifact followed by a QRS complex indicates that the pacemaker is functioning
correctly and has successfully stimulated depolarization of the heart. Documenting this
finding is appropriate.
A nurse is providing discharge instructions to a client who has active TB. Which of the
following information should the nurse include in the instructions?
a) Sputum specimens are necessary every 2 to 4 weeks until there are 3 negative cultures
b) Avoid contact with pregnant women and children
c) Take the medication with meals to reduce gastrointestinal upset
d) Return to the healthcare provider in 6 months for a follow-up chest X-ray
Answer: a)

Rationale:
Monitoring sputum cultures is important to ensure that the TB infection is responding to
treatment and to prevent the spread of the disease to others.
A nurse is providing preop teaching for a client who is scheduled for a mastectomy. Which of
the following statements should the nurse make?
a) "I will refer you to community resources that can provide support"
b) "You will be able to resume your normal activities immediately after surgery"
c) "You will need to avoid using your arm on the affected side for 4 to 6 weeks"
d) "You will need to stop taking your pain medication 24 hours before surgery"
Answer: a)
Rationale:
Mastectomy can have a significant emotional impact on clients, and it is important to provide
support resources to help them cope with the changes.
A nurse is assessing a client who is postop following a TURP and notes clots in the client's
indwelling urinary catheter and a decrease in urinary output. Which of the following actions
should the nurse take?
a) Irrigate the indwelling urinary catheter
b) Administer intravenous fluids
c) Encourage the client to drink more fluids
d) Document the findings as expected
Answer: a)
Rationale:
Clots in the urinary catheter can obstruct urine flow and lead to urinary retention. Irrigating
the catheter can help clear the obstruction and restore urinary output.
A nurse is assessing a client who has peripheral arterial disease. Which of the following
findings should the nurse expect?
a) Hair loss on the lower legs
b) Warm skin on the lower extremities
c) Pitting edema in the lower legs
d) Thickened, discolored toenails
Answer: a)

Rationale:
Peripheral arterial disease can lead to poor circulation in the lower extremities, resulting in
symptoms such as hair loss, cool skin, and decreased or absent pulses.
A nurse is planning discharge teaching for a client who has an external fixation device for a
fracture of the lower extremity. Which of the following instructions should the nurse include
in the plan of care?
a) Use crutches with rubber tips
b) Apply lotion to the pins daily
c) Remove the device for bathing
d) Avoid weight-bearing on the affected leg
Answer: a)
Rationale:
Using crutches with rubber tips can help prevent slipping and falling while walking with an
external fixation device.
A nurse is reviewing the lab results of a client who has aplastic anemia. Which of the
following findings indicates a potential complication?
a) Hemoglobin 12 g/dL
b) Platelet count 150,000/mm3
c) WBC count 2,000/mm3
d) RBC count 4.5 million/mm3
Answer: c)
Rationale:
Aplastic anemia is characterized by a deficiency of all types of blood cells, including white
blood cells (WBCs). A low WBC count can increase the risk of infection, which is a potential
complication of this condition.
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations
should the nurse expect?
a) Heat intolerance
b) Weight loss
c) Diarrhea
d) Constipation

Answer: d)
Rationale:
Hypothyroidism is characterized by a decreased production of thyroid hormone, which can
lead to a slowing down of the digestive system. Constipation is a common manifestation of
hypothyroidism due to decreased gastrointestinal motility.
A nurse is caring for a client who is receiving TPN and is NPO. When reviewing the chart,
the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the
following actions should the nurse take?
a) Administer the capillary blood glucose test before meals and at bedtime
b) Discontinue the capillary blood glucose monitoring
c) Contact the provider to clarify the prescription
d) Perform the capillary blood glucose test after meals and at bedtime
Answer: c)
Rationale:
The prescription for capillary blood glucose testing AC (before meals) and HS (at bedtime)
may be unnecessary for a client who is NPO and receiving total parenteral nutrition (TPN).
The nurse should clarify with the provider if this prescription is still appropriate.
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the
following nonpharmacological interventions should the nurse suggest to the client to reduce
pain?
a) Limit physical activity to prevent joint damage
b) Apply heat continuously to the affected joints
c) Use a firm mattress for sleeping
d) Alternate application of heat and cold to the affected joints
Answer: d)
Rationale:
Heat can help relax muscles and improve blood flow, while cold can reduce inflammation
and numb the area, providing pain relief. Alternating between heat and cold can help reduce
pain and stiffness in the joints associated with rheumatoid arthritis.
A nurse is caring for a client who is 8 hr postop following a total hip arthroplasty. The client
is unable to void on the bedpan. Which of the following actions should the nurse take first?

a) Insert an indwelling urinary catheter
b) Assist the client to a chair to void
c) Scan the bladder with a portable ultrasound
d) Encourage the client to drink more fluids
Answer: c)
Rationale:
Scanning the bladder with a portable ultrasound can help determine if the client has urinary
retention. If urinary retention is confirmed, further interventions, such as intermittent
catheterization, may be necessary.
A nurse is providing postop teaching for a client who had a total knee arthroplasty. Which if
the following instruction should the nurse include?
a) Elevate the leg above the level of the heart
b) Avoid flexing the knee
c) Flex the foot every hour when awake
d) Avoid applying ice to the knee
Answer: c)
Rationale:
Flexing the foot helps maintain circulation and prevents blood clots in the lower extremities
after knee arthroplasty.
A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the
client that which of the following medications can increase their risk for developing
osteoporosis?
a) Alendronate
b) Calcium supplements
c) Prednisone
d) Vitamin D supplements
Answer: c)
Rationale:
Prednisone and other corticosteroids can increase the risk of osteoporosis by decreasing bone
formation and increasing bone resorption.

A nurse is planning care for a client who is having a modified radical mastectomy of the right
breast. Which of the following interventions should the nurse include in the plan of care?
a) Instruct the client that the drain will be removed when there is 25 mL of output or less over
a 24-hour period
b) Encourage the client to elevate the right arm above the level of the heart
c) Apply ice packs to the incision site
d) Instruct the client to avoid using the right arm for 48 hours
Answer: a)
Rationale:
Drain removal criteria help ensure that the client no longer requires drainage and reduces the
risk of infection.
A nurse is assessing a client's hydration status. Which of the following findings indicates
fluid volume overload?
a) Decreased skin turgor
b) Dry mucous membranes
c) Distended neck veins
d) Hypotension
Answer: c)
Rationale:
Distended neck veins can indicate increased central venous pressure, which is a sign of fluid
volume overload.
A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To
reduce the risk of falls when ambulating, the nurse should provide which of the following
instructions to the client?
a) Keep your gaze fixed straight ahead
b) Scan the environment by turning your head from side to side
c) Use a cane to feel for obstacles
d) Walk with a wide base of support
Answer: b)
Rationale:
Scanning the environment helps the client compensate for the visual field deficit and detect
obstacles or hazards that may lead to falls.

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks
ago. The nurse should recognize that an unexpected finding for which of the following lab
values is a manifestation of osteomyelitis and should be reported to the provider?
a) Hemoglobin
b) Platelet count
c) WBC count
d) Sedimentation rate
Answer: d)
Rationale:
An elevated sedimentation rate (ESR) can indicate inflammation, which is a common finding
in osteomyelitis. Monitoring ESR can help assess the response to treatment and detect
complications.
A nurse is caring for a client who has a positive culture for MRSA. Which of the following
actions should the nurse take?
a) Bathe the client using chlorhexidine solution
b) Apply antibiotic ointment to the nares
c) Wear a gown and gloves when entering the client's room
d) Initiate contact precautions
Answer: a)
Rationale:
Chlorhexidine is an antiseptic that can help reduce the spread of MRSA. Bathing the client
with chlorhexidine can help decrease the bacterial load on the skin and reduce the risk of
infection transmission.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings
should the nurse expect?
a) High urine specific gravity
b) Low urine specific gravity
c) Polyuria
d) Polydipsia
Answer: b)
Rationale:

Diabetes insipidus is characterized by the inability of the kidneys to concentrate urine,
leading to the excretion of large amounts of dilute urine with a low specific gravity.
A nurse is assessing a client who has advanced lung cancer and is receiving palliative care.
The client has just undergone thoracentesis. The nurse should expect a reduction in which of
the following common manifestations of advanced cancer?
a) Dyspnea
b) Cough
c) Chest pain
d) Hemoptysis
Answer: a)
Rationale:
Thoracentesis can help remove excess fluid from the pleural space, which can reduce
pressure on the lungs and improve breathing, leading to a reduction in dyspnea.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted in the lung bases. Which of the following actions
should the nurse anticipate taking?
a) Slow the infusion rate
b) Stop the transfusion
c) Administer diuretics
d) Obtain a new blood product
Answer: a)
Rationale:
Restlessness, dyspnea, and crackles can be signs of transfusion-related acute lung injury
(TRALI), which is a serious complication of blood transfusion. Slowing the infusion rate can
help reduce the severity of the reaction.
A nurse is assessing a client who is postop following a thyroidectomy. Which of the
following findings is the nurse's priority?
a) Temperature 102°F
b) Incisional pain
c) Hoarseness
d) Tingling in the fingers

Answer: a)
Rationale:
A temperature of 102°F can indicate infection, which is a serious complication following
thyroid surgery. Infection can lead to further complications if not promptly treated.
A nurse is providing education to a client who has TB and their family. Which of the
following information should the nurse include in the teaching?
a) Family members in the household should undergo TB testing
b) The client should wear a mask at all times
c) The client should not leave the house until treatment is completed
d) Household items should be disposed of
Answer: a)
Rationale:
TB is contagious and can spread to others in close contact with the infected individual.
Testing household members can help identify and treat latent TB infection, reducing the risk
of active TB disease.
A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago.
Which of the following manifestations indicates that the client is experiencing autonomic
dysreflexia (AD)?
a) Heart rate 52 bpm
b) Blood pressure 180/100 mmHg
c) Respiratory rate 18 breaths/min
d) Skin warm and dry
Answer: b)
Rationale:
Autonomic dysreflexia is characterized by a sudden increase in blood pressure, often
accompanied by other signs such as bradycardia, flushing, and headache.
A nurse is caring for a client who has an arterial line. Which of the following actions should
the nurse take?
a) Place a pressure bag around the flush solution
b) Position the client's arm above the level of the heart
c) Flush the arterial line with heparin solution

d) Change the arterial line dressing daily
Answer: a)
Rationale:
Placing a pressure bag around the flush solution can help maintain the pressure needed to
keep the arterial line patent and prevent clot formation.
A nurse is providing teaching to a client who has AIDS. Which of the following statements
by the client indicates an understanding of the teaching?
a) "I will take my temperature once a day"
b) "I will avoid using condoms during sexual activity"
c) "I will stop taking my antiretroviral medications when I feel better"
d) "I will avoid close contact with family members"
Answer: a)
Rationale:
Monitoring temperature is important for clients with AIDS, as fever can be a sign of infection
or disease progression.
A nurse is planning care for an older adult client who has dementia. Which of the following
interventions should the nurse include in the plan of care?
a) Encourage the client to use memory aids, such as a calendar or planner
b) Place personal items, such as pictures, at the client's bedside
c) Provide complex instructions to challenge the client's cognitive abilities
d) Limit physical activity to prevent fatigue
Answer: b)
Rationale:
Placing personal items at the client's bedside can help provide familiarity and comfort, which
can be soothing for clients with dementia.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement.
Which of the following statements should the nurse make?
a) "Ginkgo biloba can cause an increased risk for bleeding"
b) "Ginkgo biloba can improve memory and cognitive function"
c) "Ginkgo biloba can interact with certain medications, such as blood thinners"
d) "Ginkgo biloba is safe to take with any other herbal supplements"

Answer: a)
Rationale:
Ginkgo biloba can increase the risk of bleeding, especially when taken with blood thinners or
other medications that affect blood clotting. Clients should be cautious when taking ginkgo
biloba, especially before surgery or if they have a bleeding disorder.
A nurse is obtaining a medication history from a client who is scheduled to undergo cataract
surgery. The nurse should recognize that which of the following client meds is a
contraindication for the surgery and notify the provider?
a) Ibuprofen
b) Acetaminophen
c) Warfarin
d) Prednisone
Answer: c)
Rationale:
Warfarin is a blood thinner, which can increase the risk of bleeding during surgery, including
cataract surgery. It is a contraindication for the surgery due to the potential for increased
bleeding.
A PACU nurse is assessing a client who is postop following a right nephrectomy. The client's
initial vital signs were heart rate 80/min, BP 130/70, RR 16/min, and temp 96.8°F. which of
the following vital sign changes should alert the nurse that the client might be hemorrhaging?
a) Heart rate 110/min
b) Blood pressure 140/80
c) Respiratory rate 20/min
d) Temperature 98.6°F
Answer: a)
Rationale:
An increase in heart rate can be a sign of hemorrhage, as the body tries to compensate for
decreased blood volume by pumping more blood. The other vital signs are within normal
range.

A nurse is reviewing the lab results of a client who has AIDS and is taking amphotericin B for
a fungal infection. The nurse should identify that which of the following values is an
indication of an adverse effect of the medication?
a) WBC 8,000/mm³
b) Hemoglobin 12 g/dL
c) Platelets 250,000/mm³
d) BUN 34 mg/dL
Answer: d)
Rationale:
An elevated blood urea nitrogen (BUN) level can indicate kidney damage, which is a
potential adverse effect of amphotericin B. Monitoring kidney function is important during
treatment with this medication.
A nurse is providing teaching to a client who has anemia and a new prescription for an oral
iron supplement. Which of the following statements by the client indicates an understanding
of the teaching?
a) "I will take the iron supplement with milk."
b) "I will eat more high-fiber foods."
c) "I will take the iron supplement on an empty stomach."
d) "I will take the iron supplement with my morning coffee."
Answer: b)
Rationale:
Iron supplements can cause constipation, so increasing intake of high-fiber foods can help
prevent this side effect.
A nurse is caring for a client who has increased ICP and is receiving mannitol via continuous
IV infusion. Which of the following findings should the nurse report to the provider as an
adverse effect of this medication?
a) Decreased urine output
b) Increased blood pressure
c) Increased level of consciousness
d) Crackles heard on auscultation
Answer: d)
Rationale:

Mannitol is a diuretic used to reduce increased intracranial pressure (ICP). Crackles on
auscultation could indicate fluid overload, which is an adverse effect of mannitol.
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer.
Which of the following interventions should the nurse include in the plan of care?
a) Administering IM injections in the unaffected arm
b) Limiting time spent in the client's room
c) Keeping a lead-lined container in the client's room
d) Allowing visitors of any age to visit the client
Answer: c)
Rationale:
Keeping a lead-lined container in the client's room is necessary to safely contain the radiation
source and protect others from exposure.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the
following results should the nurse expect?
a) pH 7.50
b) PaCO2 56 mmHg
c) PaO2 95 mmHg
d) HCO3 22 mEq/L
Answer: b)
Rationale:
In advanced COPD, the respiratory drive is often impaired, leading to retention of carbon
dioxide (CO2) and an elevated PaCO2 level.
A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the
greater trochanter of his left hip. Which of the following instructions should the nurse include
in the teaching?
a) Apply heat to the area for 20 minutes twice a day
b) Change positions every hour
c) Massage the area with lotion
d) Keep the area open to air
Answer: b)
Rationale:

Changing positions regularly helps relieve pressure on the affected area and promotes healing
of pressure injuries.
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the
following findings should the nurse identify as the priority?
a) Nausea and vomiting
b) Report of sore throat
c) Hair loss
d) Fatigue
Answer: b)
Rationale:
A sore throat can indicate an infection, which can be more serious in a client receiving
chemotherapy due to their compromised immune system.
A nurse is providing education to a client who is at risk for osteoporosis. Which of the
following instructions should the nurse include?
a) Limit weight-bearing exercises
b) Take calcium supplements with meals
c) Avoid sun exposure
d) Walk for 30 minutes 4 times a week
Answer: d)
Rationale:
Weight-bearing exercises, like walking, can help strengthen bones and reduce the risk of
osteoporosis.
A nurse is providing teaching to a client who has hypertension and a new prescription for
verapamil. Which of the following information should the nurse include in the teaching?
a) Increase fiber intake to avoid constipation
b) Avoid foods high in vitamin K
c) Take the medication with grapefruit juice
d) Increase intake of foods high in potassium
Answer: a)
Rationale:
Verapamil can cause constipation, so increasing fiber intake can help prevent this side effect.

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube.
The nurse should recognize that which of the following complications is associated with
long-term mechanical ventilation?
a) Hypotension
b) Pulmonary embolism
c) Stress ulcers
d) Pneumothorax
Answer: c)
Rationale:
Stress ulcers can develop in clients receiving long-term mechanical ventilation due to factors
such as decreased blood flow to the GI tract and increased gastric acid production.
A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing
continuous telemetry monitoring. Which of the following statements by the client reflects an
understanding of the teaching?
a) "This identifies if the pacemaker cells of my heart are working properly."
b) "This measures the electrical activity of my heart over time."
c) "This records the pressure inside my heart chambers."
d) "This evaluates the blood flow through my coronary arteries."
Answer: b)
Rationale:
Continuous telemetry monitoring measures the electrical activity of the heart over time to
detect any abnormalities or dysrhythmias.
A nurse is caring for a client who is 4 hr postop following an open reduction internal fixation
of the right ankle. Which of the following assessment findings should the nurse report to the
provider?
a) Capillary refill of 2 seconds
b) Extremity cool upon palpation
c) Pain level of 6 on a scale of 0 to 10
d) Incision site intact without drainage
Answer: b)
Rationale:

A cool extremity could indicate decreased blood flow, possibly due to compartment
syndrome, which is a serious complication that requires immediate intervention.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial
fibrillation. Which of the values should the nurse identify as a desired outcome for this
therapy?
a) INR 1.5
b) INR 2.5
c) INR 3.5
d) INR 4.5
Answer: b)
Rationale:
The therapeutic range for INR (International Normalized Ratio) in clients taking warfarin for
atrial fibrillation is typically between 2.0 and 3.0. An INR of 2.5 falls within this range.
A nurse is providing discharge teaching to a client who is to self-administer heparin
subcutaneously. Which of the following statements by the client indicates an understanding of
the teaching?
a) "I will take a hot bath before administering the heparin."
b) "I will use an electric razor to shave."
c) "I will massage the injection site after administering the heparin."
d) "I will aspirate for blood after inserting the needle."
Answer: b)
Rationale:
Using an electric razor can help prevent cuts or nicks that can lead to bleeding, which is a
concern when taking heparin, an anticoagulant.
A nurse is providing teaching to a client who has a severe form of stage II Lyme disease.
Which of the following statements made by the client reflects an understanding of the
teaching?
a) "My joints ache because I have Lyme disease."
b) "I should avoid using insect repellent."
c) "I can stop taking antibiotics once my symptoms improve."
d) "Lyme disease is caused by a virus."

Answer: a)
Rationale:
Joint pain is a common symptom of Lyme disease, especially in its later stages.
A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic
reaction. After ensuring a patent airway, which of the following nursing interventions is the
priority?
a) Administering epinephrine
b) Applying oxygen via face mask
c) Assessing blood pressure
d) Placing the client in a supine position
Answer: a)
Rationale:
Epinephrine is the first-line treatment for anaphylaxis and should be administered promptly to
help reverse the allergic reaction.
A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription
for gentamicin. Which of the following findings from the client's medical record should
indicate to the nurse the need to withhold the medication and notify the provider?
a) Blood glucose level
b) Serum creatinine
c) White blood cell count
d) Platelet count
Answer: b)
Rationale:
Gentamicin can be nephrotoxic, so an elevated serum creatinine level could indicate potential
kidney damage and the need to withhold the medication and notify the provider.
A nurse is providing discharge instructions to a client who has laryngeal cancer and is
receiving radiation therapy. Which of the following statements by the client indicates an
understanding of the teaching?
a) "I will avoid direct exposure to the sun."
b) "I will drink carbonated beverages to soothe my throat."
c) "I will use a heating pad on my neck for pain."

d) "I will apply lotion to the radiation site."
Answer: a)
Rationale:
Avoiding direct exposure to the sun can help prevent skin irritation and damage to the
radiation site.
A nurse is planning care for a client who is postop following a laparotomy and has a closedsuction drain. Which of the following actions should the nurse take to manage the drain?
a) Milk the tubing every 4 hours
b) Keep the drainage container below the level of the incision
c) Compress the drain reservoir after emptying
d) Clamp the drain for 1 hour before and after meals
Answer: c)
Rationale:
Compressing the drain reservoir after emptying helps maintain suction and prevent air from
entering the drain.
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the
following findings should the nurse report to the provider?
a) The client reports back pain
b) The nephrostomy tube is draining clear urine
c) The client has a temperature of 99.8°F (37.7°C)
d) The drainage bag is secured below the level of the kidney
Answer: a)
Rationale:
Back pain could indicate a complication such as obstruction or infection of the nephrostomy
tube and should be reported to the provider for further evaluation.
A nurse is evaluating the plan of care for 4 clients after 2 days of hospitalization. The nurse
should identify the need to revise the plan for which of the following clients?
a) A client who is postop following abdominal surgery and reports feeling that something
"popped" when they coughed
b) A client who has a stage III pressure injury and reports increased pain at the wound site
c) A client who is receiving IV fluids and has crackles in the lung bases

d) A client who is postop following a total knee arthroplasty and has mild swelling in the
affected leg
Answer: a)
Rationale:
The client's report of feeling that something "popped" when they coughed could indicate a
surgical complication such as an incisional hernia, which would require immediate evaluation
and possible revision of the plan of care.
A nurse is caring for a client following extubation of an endotracheal tube (ET tube) 10
minutes ago. Which of the following findings should the nurse report to the provider
immediately?
a) Hoarseness
b) Mild cough
c) Stridor
d) Sore throat
Answer: c)
Rationale:
Stridor is a high-pitched, crowing sound that indicates upper airway obstruction and requires
immediate intervention to ensure adequate oxygenation.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system.
Which of the following findings is an indication of lung re-expansion?
a) Continuous bubbling in the water seal chamber
b) Absence of fluctuation in the water seal chamber
c) Bubbling in the suction control chamber
d) Bubbling in the water seal chamber has ceased
Answer: d)
Rationale:
Ceasing of bubbling in the water seal chamber indicates that the lung has re-expanded and
there is no longer air escaping from the pleural space into the drainage system.
A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the
following findings should indicate to the nurse the client is experiencing hypoxia?
a) The client's heart rate increases

b) The client's blood pressure decreases
c) The client's respiratory rate decreases
d) The client's skin becomes warm and flushed
Answer: a)
Rationale:
An increased heart rate can be a compensatory mechanism in response to hypoxia, as the
body tries to increase oxygen delivery to tissues.
A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has
become cyanotic. Which of the following actions should the nurse take? (Select all that
apply)
a) Prepare to suction the client's airway
b) Loosen restrictive clothing
c) Restrain the client's limbs
d) Place a tongue depressor in the client's mouth
e) Administer lorazepam (Ativan) per protocol
Answer: a)
b) Loosen restrictive clothing
Rationale:
Suctioning the airway can help clear any secretions or vomitus that may obstruct the airway
during a seizure. Loosening restrictive clothing can improve ventilation and circulation.
A nurse is providing discharge teaching about infection prevention to a client who has AIDS.
Which of the following statements by the client indicates understanding of the teaching?
a) "I will no longer floss my teeth after brushing"
b) "I will wash my hands frequently with soap and water"
c) "I will avoid eating raw fruits and vegetables"
d) "I will stop taking my antiretroviral medications"
Answer: b)
Rationale:
Handwashing is an important infection prevention measure for clients with AIDS, as it helps
reduce the risk of transmitting infections.

A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for
a kidney transplant. Which of the following information should the nurse provide?
a) Peritoneal dialysis is an option for long-term management
b) A kidney transplant is a cure for end-stage kidney disease
c) Hemodialysis is sometimes required following surgery
d) A kidney transplant can be performed without the need for immunosuppressant
medications
Answer: c)
Rationale:
Following a kidney transplant, some clients may require hemodialysis temporarily until the
transplanted kidney starts functioning properly.
A nurse is caring for an older adult client who has dementia and requires acute care for a
respiratory infection. The client is agitated and is attempting to remove their catheter. Which
of the following actions should the nurse take to avoid restraining the client?
a) Use a soft wrist restraint
b) Apply a vest restraint
c) Keep the client occupied with a manual activity
d) Administer a sedative medication
Answer: c)
Rationale:
Keeping the client occupied with a manual activity can help redirect their behavior and
reduce agitation without the need for restraints.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the
following interventions should the nurse include in the plan?
a) Encourage the client to take deep breaths after the procedure
b) Instruct the client to lie on the affected side during the procedure
c) Position the client in high Fowler's position during the procedure
d) Apply a warm compress to the puncture site after the procedure
Answer: a)
Rationale:
Deep breathing can help re-expand the lung and promote lung expansion after the procedure.

A nurse is preparing to present a program about prevention of atherosclerosis at a health fair.
Which of the following recommendations should the nurse plan to include? (Select all that
apply)
a) Follow a smoking cessation program
b) Maintain an appropriate weight
c) Eat a low-fat diet
d) Increase intake of red meat
e) Engage in regular physical activity
Answer: a)
b) Maintain an appropriate weight
c) Eat a low-fat diet
Rationale:
Smoking cessation, maintaining a healthy weight, and eating a low-fat diet are all
recommendations for preventing atherosclerosis and cardiovascular disease. Reducing red
meat intake and engaging in regular physical activity are also important for overall
cardiovascular health.
A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for
brachytherapy. Which of the following instructions should the nurse include?
a) You will need to stay in the bed during each treatment session
b) You can walk around during treatment to help pass the time
c) You should avoid eating or drinking before each treatment
d) You will need to wear a lead apron during treatment
Answer: a)
Rationale:
During brachytherapy, the radioactive source is placed inside or next to the tumor. It's
important for the client to remain still in bed to ensure accurate placement of the radioactive
material and to minimize the radiation exposure to surrounding tissues.
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of
the following actions should the nurse take first?
a) Check for the type and number of units of blood to administer
b) Obtain the client's vital signs
c) Ensure informed consent has been obtained

d) Verify the client's identity
Answer: a)
Rationale:
Before administering a blood transfusion, the nurse should verify the type and number of
units of blood to be administered to ensure compatibility and prevent transfusion reactions.
A nurse is reviewing the lab findings of a client who developed chest pain 6 hr ago. The nurse
should identify which of the following findings as an indication of a MI?
a) Troponin
b) BNP
c) D-dimer
d) Creatinine
Answer: a)
Rationale:
Troponin is a cardiac enzyme released into the bloodstream when there is damage to the heart
muscle, such as during a myocardial infarction (MI). Elevated troponin levels indicate
myocardial injury and are used as a diagnostic marker for MI.
A nurse is performing a preop assessment for a client. The nurse should identify that an
allergy to which of the following foods can indicate a latex allergy?
a) Avocados
b) Strawberries
c) Bananas
d) Tomatoes
Answer: a)
Rationale:
Avocados, along with certain other foods like bananas, chestnuts, and kiwis, contain proteins
that are similar to those found in latex. Individuals with a latex allergy may also experience
allergic reactions to these foods, known as latex-fruit syndrome.
A nurse in an emergency department is assessing an older adult client who has a fractured
wrist following a fall. During the assessment, the client states, "Last week I crashed my car
because my vision suddenly became blurry." Which of the following actions is the nurse's
priority?

a) Check the client's neuro status
b) Assess the client's wrist for swelling and tenderness
c) Perform a complete physical examination
d) Review the client's medication list
Answer: a)
Rationale:
The client's statement about blurry vision and a recent car crash raises concerns about
possible neurological issues, such as a transient ischemic attack (TIA) or stroke. Checking the
client's neurological status is the priority to assess for any signs of neurological deficits that
may require immediate intervention.
A nurse is teaching a family about the care of a parent who has a new diagnosis of
Alzheimer's disease. Which of the following information should the nurse include in the
teaching?
a) Create complete outfits and allow the client to select one each day
b) Limit the client's choices to reduce confusion
c) Encourage the client to change clothes multiple times a day
d) Remove all clothing choices to simplify dressing
Answer: a)
Rationale:
Providing complete outfits and allowing the client to choose one each day can help maintain
the client's dignity and independence in dressing while also reducing confusion and
frustration.
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of
the following findings should the nurse identify as a manifestation of the condition?
a) Pain that increases with passive movement
b) Warmth and redness over the casted area
c) Capillary refill of less than 3 seconds
d) Swelling that decreases with elevation
Answer: a)
Rationale:

Compartment syndrome is characterized by increased pressure within a muscle compartment,
leading to pain that worsens with passive movement due to restricted blood flow and tissue
perfusion.
A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the client to notify the provider? (Select all that apply)
a) Calf pain
b) Numbness in the arms
c) Intense headache
d) Mood swings
e) Weight gain
Answer: a)
b) Numbness in the arms,
c) Intense headache
Rationale:
Hormone replacement therapy can increase the risk of certain adverse effects, including calf
pain (which could indicate a blood clot), numbness in the arms (which could indicate a
neurological issue), and intense headache (which could indicate increased blood pressure or
other serious issues).
A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify
which of the following sounds the nurse should document in the client's medical record by
listening to the audio clip.
a) Pericardial friction rub
b) S3 gallop
c) Opening snap
d) Murmur
Answer: a)
Rationale:
Pericardial friction rub is a rubbing or grating sound heard on auscultation of the heart and is
often associated with pericarditis, which can cause substernal precordial pain.

A nurse is providing teaching to a client who has a recent diagnosis of constipationpredominant IBS. Which of the following instructions should the nurse include in the
teaching?
a) Consume at least 30 g of fiber daily
b) Avoid high-fiber foods
c) Limit fluid intake
d) Avoid physical activity
Answer: a)
Rationale:
Increasing dietary fiber can help alleviate constipation in clients with constipationpredominant irritable bowel syndrome (IBS). Fiber helps add bulk to the stool and can
improve bowel movements.
A nurse is providing discharge teaching to a client who is postop following a modified radical
mastectomy. Which of the following instructions should the nurse include?
a) Apply heat packs to the affected area for 30 minutes every hour.
b) Elevate the affected arm above heart level when sitting or lying down.
c) Perform shoulder exercises to improve flexibility.
d) Numbness can occur along the inside of the affected arm.
Answer: d)
Rationale:
This instruction is important because it prepares the client for a potential side effect of the
surgery, helping them understand what to expect and how to manage it.
A nurse is administering packed RBCs to a client. Which of the following assessment
findings indicates a hemolytic transfusion reaction?
a) Increased blood pressure and flushed skin.
b) Low back pain and apprehension.
c) Decreased heart rate and increased urine output.
d) Elevated temperature and chills.
Answer: b)
Rationale:

Low back pain and apprehension are signs of a hemolytic transfusion reaction, indicating that
the body is reacting to the transfusion in a potentially harmful way, which requires immediate
intervention.
A nurse is teaching a client about the use of TENS for the management of bone cancer pain.
The nurse should explain that applying a TENS unit to the painful area has which of the
following effects?
a) A burning sensation intensifying the pain.
b) A freezing sensation numbing the area.
c) A tingling sensation replacing the pain.
d) A stinging sensation alleviating the pain.
Answer: c)
Rationale:
TENS works by stimulating the nerves with electrical impulses, which can help reduce the
perception of pain by creating a tingling sensation that overrides the pain signals.
A nurse is caring for a client who has breast cancer and tells the nurse they would like to have
acupuncture because it provides greater relief than pain medication. Which of the following
statements should the nurse make?
a) Acupuncture is not a scientifically proven treatment.
b) I will schedule you for an acupuncture session tomorrow.
c) I can speak to the provider about incorporating acupuncture into your treatment plan.
d) Acupuncture is only effective for certain types of pain.
Answer: c)
Rationale:
This response acknowledges the client's preference for acupuncture and offers to explore its
integration into their treatment plan, ensuring the client feels heard and understood.
A nurse is caring for a client who has DKA. Which of the following should the nurse plan to
administer?
a) Glucagon subcutaneously.
b) Regular insulin 20 units IV bolus.
c) Metformin orally.
d) Lispro insulin subcutaneously.

Answer: b)
Rationale:
In DKA, insulin is given intravenously to rapidly lower blood sugar levels and correct
acidosis. Regular insulin is the preferred choice for this purpose.
A nurse is reviewing the medical record of a client who has SLE. Which of the following
findings should the nurse expect?
a) Increased white blood cell count
b) Elevated liver enzymes
c) Decreased platelet count
d) Facial butterfly rash
Answer: d)
Rationale:
SLE (Systemic Lupus Erythematosus) is characterized by various symptoms, including a
facial butterfly rash. This rash typically appears on the cheeks and bridge of the nose, often in
a butterfly shape. While other laboratory findings can be associated with SLE, the facial rash
is a hallmark sign.
A nurse is planning care for a client who is postop following a parathyroidectomy. Which of
the following actions should the nurse identify as the priority?
a) Administer pain medication
b) Monitor serum calcium levels
c) Keep the head of the bed elevated
d) Place a tracheostomy tray at the bedside
Answer: d)
Rationale:
Following a parathyroidectomy, there is a risk of injury to the recurrent laryngeal nerve,
which can lead to airway compromise. Placing a tracheostomy tray at the bedside ensures that
emergency airway management equipment is readily available in case of respiratory distress,
making it the priority action.
A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I
could stop these treatments. I am ready to die." Which of the following statements should the
nurse make?

a) "You shouldn't give up hope. Let's talk about this some more."
b) "I understand how you feel. Let's discuss your options."
c) "You should keep fighting. There might be other treatments."
d) "Discontinuing with the treatments is your choice if it is your wish to do so."
Answer: d)
Rationale:
When a client expresses a desire to stop treatment and is ready to die, it is important to
respect their autonomy and wishes. Option d acknowledges the client's autonomy and
supports their decision-making process, which is essential in end-of-life care.
A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into
shock. Identify the sequence of actions the nurse should take.
a) Administer oxygen
b) Initiate IV therapy
c) Insert an NG tube
d) Administer ranitidine
Answer: The correct sequence of actions is:
1) Administer oxygen
2) Initiate IV therapy
3) Insert an NG tube
4) Administer ranitidine
Rationale:
Oxygen should be administered first to ensure adequate oxygenation to tissues. IV therapy is
then initiated to restore fluid volume. Inserting an NG tube can help decompress the stomach
and reduce the risk of aspiration. Administering ranitidine can help reduce gastric acid
secretion and promote healing.
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of
the following actions should the nurse take first?
a) Check for the type and number of units of blood to administer
b) Obtain the client's baseline vital signs
c) Ensure the blood is the correct type for the client
d) Verify the client's identification
Answer: a)

Rationale:
Checking for the type and number of units of blood to administer is the first step in ensuring
that the correct blood product is given to the right patient in the right amount, reducing the
risk of transfusion reactions or errors.
a nurse is providing teaching to an older adult female client who has stress incontinence and a
BMI of 32. Which of the following statements by the client indicates an understanding of the
teaching?
a) "I will limit my fluid intake to reduce leakage."
b) "I am dieting to lose weight."
c) "I will perform Kegel exercises daily."
d) "I will use absorbent pads to manage leakage."
Answer: b)
Rationale:
A BMI of 32 indicates obesity, which can contribute to stress incontinence. Weight loss can
help reduce symptoms by reducing pressure on the bladder. The other options are also
important aspects of managing stress incontinence, but weight loss is particularly relevant
given the client's BMI.
A nurse is providing instructions to a client who has type 2 diabetes and a new prescription of
metformin. Which of the following statements by the client indicates an understanding of the
teaching?
a) I should take this medication with a meal
b) I should take this medication on an empty stomach
c) I should take this medication only when I feel unwell
d) I should take this medication at bedtime
Answer: a)
Rationale:
Taking metformin with a meal helps reduce gastrointestinal side effects.
a nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin. Which of the following statements by the client indicates an
understanding of the teaching?
a) I am taking this medication to increase my energy level

b) I am taking this medication to lower my blood pressure
c) I am taking this medication to improve my kidney function
d) I am taking this medication to lower my blood sugar
Answer: a)
Rationale:
Erythropoietin is used to treat anemia by stimulating red blood cell production, which can
help increase energy levels in clients with chronic kidney disease.
a nurse is caring for a client who has a prescription for enalapril. The nurse should identify
which of the following findings as an adverse effect of the medication?
a) Orthostatic hypotension
b) Bradycardia
c) Hyperkalemia
d) Increased urinary output
Answer: a)
Rationale:
Enalapril, an ACE inhibitor, can cause orthostatic hypotension, which is a sudden drop in
blood pressure when standing up.
a nurse is caring for a client who has hypothyroidism. which of the following manifestations
should the nurse expect?
a) Constipation
b) Heat intolerance
c) Weight loss
d) Tachycardia
Answer: a)
Rationale:
Hypothyroidism can slow down the digestive system, leading to constipation.
a charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA.
which of the following statements by the new nurse indicates an understanding of the
teaching?
a) I will leave assessment equipment in the room to use on this patient
b) I will wear gloves when entering the room

c) I will use standard precautions when caring for this patient
d) I will wear a mask when providing care to this patient
Answer: a)
Rationale:
Leaving assessment equipment in the room reduces the risk of spreading MRSA to other
patients.
a nurse is providing teaching to a client who has irritable bowel syndrome (IBS). which of the
following instructions should the nurse include in the teaching?
a) Increase fiber intake to at least 30 g/day
b) Avoid dairy products
c) Limit fluid intake
d) Eat large meals to prevent frequent snacking
Answer: a)
Rationale:
Increasing fiber intake can help regulate bowel movements in clients with IBS.
a nurse is caring for a client who has a positive culture for C. diff. which of the following
actions should the nurse take?
a) Implement contact precautions for the client
b) Implement droplet precautions for the client
c) Implement airborne precautions for the client
d) Implement standard precautions for the client
Answer: a)
Rationale:
Contact precautions are used for C. diff. to prevent the spread of the bacteria through contact
with contaminated surfaces or objects.
a nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the
following is the priority assessment finding that the nurse should report to the provider?
a) BP 170/80
b) Weight gain
c) Bradycardia
d) Intolerance to heat

Answer: a)
Rationale:
A blood pressure of 170/80 is elevated and could indicate complications of hyperthyroidism,
such as hypertension.
a nurse is planning care for a client who is scheduled for a thoracentesis. which of the
following interventions should the nurse include in the plan?
a) Encourage the client to take deep breaths after the procedure
b) Place the client in a supine position during the procedure
c) Apply a warm compress to the puncture site after the procedure
d) Instruct the client to avoid coughing during the procedure
Answer: a)
Rationale:
Deep breathing can help re-expand the lung and prevent complications after a thoracentesis.
a nurse is assessing a client who has had a suspected cerebrovascular accident. the nurse
should place the priority on which of the following findings?
a) Dysphagia
b) Aphasia
c) Hemiparesis
d) Confusion
Answer: a)
Rationale:
Dysphagia can lead to aspiration and is a priority finding to address in a client who has had a
stroke.
a nurse is reviewing the ABG results of a client who has advanced COPD. which of the
following results should the nurse expect?
a) PaO2 90 mm Hg
b) PaCO2 56 mm Hg
c) pH 7.45
d) HCO3 28 mEq/L
Answer: b)
Rationale:

In advanced COPD, the client often retains carbon dioxide (CO2), leading to an increased
PaCO2 level.
a nurse is providing discharge instructions to a client who has laryngeal cancer and is
receiving radiation treatment. which of the following statements by the client indicates an
understanding of the teaching?
a) I will avoid direct exposure to the sun
b) I will use a heating pad on my neck for pain
c) I will stop taking my prescribed pain medication
d) I will avoid wearing loose-fitting clothing around my neck
Answer: a)
Rationale:
Radiation treatment can make the skin more sensitive to the sun, so avoiding direct exposure
is important to prevent skin damage.
a nurse is assessing for compartment syndrome in a client who has a short leg cast. which of
the following findings should the nurse identify as a manifestation of this condition?
a) Pallor of the affected extremity
b) Weak pedal pulses
c) Cool skin temperature
d) Pain that increases with passive movement
Answer: d)
Rationale:
Increased pain with passive movement is a classic sign of compartment syndrome due to
increased pressure within the compartment.
a nurse is providing teaching to a client who has a gastric ulcer and a new prescription for
omeprazole. the nurse should instruct the client that the medication provides relief by which
of the following actions?
a) Neutralizing gastric acid
b) Promoting gastric emptying
c) Protecting the stomach lining
d) Suppressing gastric acid production
Answer: d)

Rationale:
Omeprazole is a proton pump inhibitor that reduces gastric acid production, which can help
heal gastric ulcers.
a nurse is assessing a client who has peripheral arterial disease. which of the following
findings should the nurse expect?
a) Hair loss on the lower legs
b) Thickened, discolored toenails
c) Cool skin temperature
d) Dependent rubor
Answer: a)
Rationale:
Hair loss on the lower legs is a common finding in clients with peripheral arterial disease due
to poor blood flow to the extremities.
a nurse is assessing a client following the completion of hemodialysis. which of the following
findings is the nurse's priority to report to the provider?
a) Restlessness
b) Bradycardia
c) Increased urine output
d) Increased blood pressure
Answer: a)
Rationale:
Restlessness can be a sign of complications such as hypotension or electrolyte imbalances
following hemodialysis and should be reported to the provider.
a nurse is reviewing the medical record of a client who has osteomyelitis and a prescription of
gentamicin. which of the following findings from the client's medical record should indicate
to the nurse the need to withhold the medication?
a) Serum creatinine
b) Blood glucose level
c) Platelet count
d) White blood cell count
Answer: a)

Rationale:
Gentamicin is nephrotoxic, so an elevated serum creatinine level would indicate renal
impairment and the need to withhold the medication.
a nurse is reviewing the medical record of a client who has SLE. which of the following
findings should the nurse expect?
a) Facial butterfly rash
b) Clubbing of the fingers
c) Bradycardia
d) Increased appetite
Answer: a)
Rationale:
A facial butterfly rash is a classic sign of systemic lupus erythematosus (SLE).
a nurse is providing teaching to a client who has a new prescription for psyllium. which of the
following information should the nurse include in the teaching?
a) Take the medication on an empty stomach
b) Take the medication with a full glass of milk
c) Drink 240 mL of water after administration
d) Chew the medication thoroughly before swallowing
Answer: c)
Rationale:
Psyllium is a bulk-forming laxative that should be taken with plenty of water to prevent
esophageal obstruction.
a nurse in a provider's office is assessing a client who has migraine headaches and is taking
feverfew to prevent her headaches. the nurse should identify that which of the following
client medications interacts with feverfew?
a) Naproxen
b) Acetaminophen
c) Diphenhydramine
d) Metoprolol
Answer: a)
Rationale:

Feverfew may increase the risk of bleeding when taken with nonsteroidal anti-inflammatory
drugs (NSAIDs) like naproxen.
a nurse in a provider's office is caring for a client who requests sildenafil to treat erectile
dysfunction. which of the following statements should the nurse make?
a) You will not be able to use sildenafil if you are taking nitroglycerin
b) You should take sildenafil with a high-fat meal
c) Sildenafil can be taken with any other medications
d) Sildenafil is safe to take with alcohol
Answer: a)
Rationale:
Sildenafil should not be taken with nitroglycerin or other nitrate medications due to the risk
of severe hypotension.
a nurse is caring for a client who is receiving TPN. a new bag is not available when the
current infusion is nearly completed. which of the following actions should the nurse take?
a) Administer dextrose 10% in water until the new bag arrives
b) Increase the rate of the current infusion
c) Discontinue the current infusion until the new bag arrives
d) Switch the client to oral nutrition until the new bag arrives
Answer: a)
Rationale:
Administering dextrose 10% in water can prevent hypoglycemia until the new TPN bag is
available.
a nurse is providing discharge teaching to a client who has HF and a new prescription for a
potassium sparing diuretic. which of the following information should the nurse include in
the teaching?
a) Try to walk at least 3 times per week for exercise
b) Avoid foods high in potassium
c) Monitor weight once per week
d) Take the medication on an empty stomach
Answer: a)
Rationale:

Regular exercise can help improve heart function and manage symptoms of heart failure.
a nurse is planning care for a client who is postop following a laparotomy and has a closedsuction drain. which of the following actions should the nurse take to manage the drain?
a) Compress the drain reservoir after emptying
b) Clamp the drain while emptying
c) Remove the drain when output is less than 10 mL/day
d) Empty the drain every 8 hours
Answer: a)
Rationale:
Compressing the drain reservoir helps create suction and maintain drainage.
a nurse in an emergency department is admitting a client who reports dyspnea and SOB.
which of the following actions is the priority for the nurse to perform prior to administering
oxygen?
a) Determine if the client has a history of COPD
b) Check the client's oxygen saturation
c) Assess the client's respiratory rate and effort
d) Obtain a chest x-ray
Answer: a)
Rationale:
Administering oxygen to a client with COPD can cause respiratory depression due to
decreased respiratory drive in response to elevated PaO2 levels (known as "hypoxic drive").
It is important to assess for COPD before administering oxygen.
a nurse is obtaining a medication history from a client who is scheduled to undergo cataract
surgery. the nurse should recognize that which of the following client medications is a
contraindication for the surgery and notify the provider?
a) Warfarin
b) Aspirin
c) Acetaminophen
d) Ibuprofen
Answer: a)
Rationale:

Warfarin is an anticoagulant that can increase the risk of bleeding during surgery and is
typically discontinued prior to surgery.
a nurse is caring for a client following extubation of her endotracheal tube 10 min ago. which
of the following findings should the nurse report to the provider immediately?
a) Stridor
b) Hoarseness
c) Coughing
d) Mild dyspnea
Answer: a)
Rationale:
Stridor is a high-pitched, noisy breathing sound that can indicate airway obstruction and
requires immediate attention.
a nurse is providing dietary teaching to a client who is postop following a thyroidectomy with
removal of the parathyroid glands. the nurse should instruct the client to include which of the
following foods to increase calcium in the diet?
a) 12 almonds
b) 1 cup of milk
c) 1 cup of orange juice
d) 1 medium banana
Answer: a)
Rationale:
Almonds are a good source of calcium and can help increase calcium intake in clients with
hypoparathyroidism following thyroidectomy.
a nurse is preparing to assist with the insertion of a non tunneled percutaneous central venous
catheter into a subclavian vein. the nurse should plan to place the client in which of the
following positions?
a) Trendelenburg
b) Supine with the head turned to the side
c) High Fowler's
d) Trendelenburg with the head turned to the side
Answer: c)

Rationale:
Placing the client in a high Fowler's position helps distend the veins and facilitate insertion of
the central venous catheter.
teaching to a client with HTN and new medication verapamil. what juice should client avoid?
a) Orange juice
b) Grapefruit juice
c) Apple juice
d) Cranberry juice
Answer: b)
Rationale:
Grapefruit juice can interact with verapamil and increase the risk of side effects.
client experiencing an anaphylactic reaction, after patent airway, which is the priority nursing
intervention?
a) Apply oxygen via face mask
b) Administer epinephrine
c) Administer antihistamines
d) Elevate the legs
Answer: a)
Rationale:
Ensuring adequate oxygenation is a priority in managing anaphylactic reactions to prevent
hypoxia.
client had nephrostomy tube inserted 12hrs ago. what should the nurse report to the provider?
a) Client reports back pain
b) Drainage from the nephrostomy tube is pink-tinged
c) Client's temperature is 99.5°F (37.5°C)
d) Client's urine output is 30 mL/hr
Answer: a)
Rationale:
Back pain could indicate a complication such as obstruction or infection, which should be
reported to the provider for further evaluation.

teaching to perimenopausal and has hormone replacement therapy. adverse effects to notify
provider?
a) Calf pain, numbness in arms, and intense headache
b) Mild headache
c) Mild fatigue
d) Slight dizziness
Answer: a)
Rationale:
These symptoms could indicate serious side effects of hormone replacement therapy, such as
blood clots or stroke, and should be reported to the provider immediately.
older adult with cancer and a new prescription of opioid analgesic. which info should the
nurse include in teaching?
a) You should increase your fiber intake to prevent constipation
b) You should decrease your fluid intake to avoid fluid overload
c) You should take the medication on an empty stomach for better absorption
d) You should take the medication with grapefruit juice to enhance its effects
Answer: a)
Rationale:
Opioid analgesics can cause constipation, so increasing fiber intake can help prevent this side
effect.
a nurse is providing med teaching to a group with seizure disorders. instruction about
phenytoin?
a) Phenytoin decreases the effectiveness of oral contraceptives
b) Phenytoin should be taken on an empty stomach
c) Phenytoin can cause drowsiness and dizziness
d) Phenytoin should be stopped abruptly
Answer: a)
Rationale:
Phenytoin can reduce the effectiveness of hormonal contraceptives, so alternative forms of
contraception should be used.

a nurse is caring for client with supraventricular tachycardia. which action should nurse take
next?
a) Perform synchronized cardioversion
b) Administer adenosine
c) Perform Valsalva maneuver
d) Assess for signs of hypoxia
Answer: a)
Rationale:
Synchronized cardioversion is often used to treat supraventricular tachycardia by delivering a
synchronized electrical shock to the heart to restore normal rhythm.
change of shift report with four clients. client with greatest risk of developing infection?
a) COPD and receiving steroid therapy
b) Diabetes mellitus and history of foot ulcers
c) Hypertension controlled with medication
d) History of allergic rhinitis
Answer: a)
Rationale:
Steroid therapy can suppress the immune system, increasing the risk of infection, especially
in clients with underlying respiratory conditions like COPD.
teach with self-administration of heparin?
a) Use electric razor
b) Avoid foods high in vitamin K
c) Monitor for signs of bleeding
d) Inject the medication into the muscle
Answer: a)
Rationale:
Using an electric razor can help prevent cuts and bleeding, which can be more difficult to
control when taking anticoagulant medications like heparin.
client having a seizure, nurse priority?
a) Turn client on the side
b) Administer oxygen

c) Insert an oral airway
d) Restrain the client's limbs
Answer: a)
Rationale:
Turning the client on the side helps prevent aspiration and ensures a clear airway during the
seizure.
female client with hx of UTI, nurse include in teaching?
a) Clean perineum front to back
b) Take a tub bath daily
c) Use scented feminine hygiene products
d) Drink less than 1 liter of water per day
Answer: a)
Rationale:
Cleaning from front to back helps prevent the spread of bacteria from the anus to the urethra,
reducing the risk of UTIs.
cardiac assessment with MI 2 days ago. action after hearing this sound?
a) Listen with the client on the left side
b) Listen with the client on the right side
c) Listen with the client in the supine position
d) Listen with the client in the sitting position
Answer: a)
Rationale:
Listening with the client on the left side allows for optimal auscultation of the heart sounds,
including any abnormal sounds that may indicate complications following an MI.
client on bed rest and enoxaparin sub cut, actions nurse take?
a) Administer med at the same time each day
b) Assist with ambulation as tolerated
c) Encourage increased fluid intake
d) Monitor for signs of bleeding
Answer: a)
Rationale:

Enoxaparin should be administered at the same time each day to maintain consistent
therapeutic levels and reduce the risk of complications.
postop following parathyroidectomy. priority action?
a) Place a trach tray at bedside
b) Monitor serum calcium levels
c) Assess for signs of hypocalcemia
d) Administer calcium supplements
Answer: b)
Rationale:
Monitoring serum calcium levels is a priority after a parathyroidectomy to assess for
hypocalcemia, which can occur due to the removal of the parathyroid glands.
pt with arterial line, following actions should nurse take?
a) Place a pressure bag around the flush solution
b) Flush the line with normal saline every 4 hours
c) Change the dressing daily
d) Remove the line if the site is red and warm
Answer: a)
Rationale:
Placing a pressure bag around the flush solution helps maintain adequate pressure in the
arterial line, preventing clot formation and ensuring accurate readings.
teaching client about a fib and purpose of wearing a holter monitor. info should nurse include
in the teaching?
a) This device can detect when you have an irregular HR
b) This device will help you monitor your blood pressure
c) This device will track your physical activity
d) This device will monitor your oxygen saturation levels
Answer: a)
Rationale:
A Holter monitor is used to record the heart's electrical activity over a period of time, helping
to detect and diagnose irregular heart rhythms such as atrial fibrillation (a fib).

client with DKA, client condition improving?
a) Glucose 272
b) Serum potassium 3.0 mEq/L
c) Serum bicarbonate 15 mEq/L
d) Arterial pH 7.32
Answer: d)
Rationale:
An arterial pH of 7.32 indicates that the client's acidosis is improving, as DKA is
characterized by metabolic acidosis.
stroke on right hemisphere. nurse expect?
a) Impulsive behavior
b) Difficulty with spatial awareness
c) Difficulty with language comprehension
d) Weakness on the right side of the body
Answer: a)
Rationale:
A stroke on the right hemisphere of the brain can result in impulsive behavior due to changes
in judgment and inhibition.
client who has external fixation device for fracture. instruction for nurse plan of care?
a) Use crutches with rubber tips
b) Apply a heating pad to the affected area
c) Remove the fixation device daily
d) Monitor for signs of infection
Answer: a)
Rationale:
Using crutches with rubber tips can help prevent slips and falls while ambulating with an
external fixation device.
receiving mechanical ventilation via trach tube. nurse recognizes complications with longterm mechanical ventilation?
a) Stress ulcers
b) Pneumothorax

c) Pulmonary embolism
d) Laryngeal edema
Answer: a)
Rationale:
Stress ulcers are a common complication of long-term mechanical ventilation, especially in
critically ill patients, due to factors such as decreased mucosal blood flow and increased
gastric acid secretion.
teaching about asthma use of metered-dose inhaler. understand teaching?
a) Holding breath for 10 secs after inhaling
b) Exhaling into the inhaler before inhaling
c) Inhaling through the nose while using the inhaler
d) Using the inhaler only when symptoms are severe
Answer: a)
Rationale:
Holding the breath for 10 seconds after inhaling helps ensure that the medication reaches
deep into the lungs for optimal effectiveness.
graves disease, picture with exophthalmos?
a) Big eyes, last picture
b) Small eyes, first picture
c) Normal eyes, second picture
d) Closed eyes, third picture
Answer: a)
Rationale:
Exophthalmos, or bulging eyes, is a common feature of Graves' disease, which is
characterized by hyperthyroidism.
leg cast and demonstration w/crutches on climbing stairs. identify steps
a) Body weight on crutches, advance unaffected leg onto stair, shift weight from crutch to
unaffected, bring crutches and affected leg up to the stair
b) Body weight on unaffected leg, advance affected leg onto stair, shift weight from stair to
affected leg, bring crutches and unaffected leg up to the stair

c) Body weight on crutches, advance affected leg onto stair, shift weight from crutch to
affected leg, bring crutches and unaffected leg up to the stair
d) Body weight on unaffected leg, advance unaffected leg onto stair, shift weight from stair to
unaffected leg, bring crutches and affected leg up to the stair
Answer: a)
Rationale:
This sequence ensures proper weight-bearing and stability while climbing stairs with
crutches.
older adult with fractured wrist following fall. last week, I crashed my car because my vision
suddenly became blurry.
a) Check for neuro status
b) Assess for signs of increased intracranial pressure
c) Perform a vision test
d) Document the statement and continue monitoring
Answer: a)
Rationale:
Sudden blurry vision could indicate a neurological issue, so checking the client's neurological
status is the priority to assess for any potential problems.
performing dressing change recovering from hemicolectomy. large part of bowel is
protruding, action take first?
a) Call for help
b) Push the bowel back in
c) Cover the protruding bowel with a sterile, saline-soaked dressing
d) Assess the client's vital signs
Answer: a)
Rationale:
In this situation, the nurse should call for assistance from other healthcare providers to help
manage the situation safely.
older adult about osteoporosis prevention. meds increase risk for developing osteoporosis?
a) Fludrocortisone
b) Metoprolol

c) Lisinopril
d) Atorvastatin
Answer: a)
Rationale:
Fludrocortisone, a corticosteroid, can increase the risk of osteoporosis due to its effects on
bone density.
client having modified radical mastectomy of right breast. intervention for plan of care?
a) Instruct the client that the drain is removed when there is 25mL of output or less over a
24hr period
b) Apply a warm compress to the drain site
c) Encourage the client to sleep on the affected side
d) Administer pain medication as needed
Answer: a)
Rationale:
This instruction helps the client understand when the drain can be removed, based on the
amount of drainage.
client with anemia and a prescription for an oral iron supplement. which of the following
statements by teaching?
a) I will eat more high fiber foods
b) I will take the iron supplement with meals
c) I will take the iron supplement with milk
d) I will take the iron supplement with my calcium supplement
Answer: a)
Rationale:
High fiber foods can interfere with the absorption of iron, so it is important to take iron
supplements on an empty stomach for better absorption.
program about prevention of atherosclerosis at health fair. recommendations plan to include?
a) Follow smoking cessation, maintain appropriate weight, eat low-fat diet
b) Increase saturated fat intake, avoid exercise, smoke regularly
c) Consume high amounts of red meat, avoid fruits and vegetables, maintain sedentary
lifestyle

d) Avoid all fats, consume high amounts of sugar, avoid physical activity
Answer: a)
Rationale:
These recommendations are key components of preventing atherosclerosis and reducing the
risk of cardiovascular disease.
TPN 2000kcal per day. 500kcal/L; mL/hr
a) 167
b) 200
c) 250
d) 334
Answer: c)
Rationale:
To calculate the mL/hr for TPN, divide the total kcal by the kcal per liter of TPN solution. In
this case, 2000 kcal ÷ 500 kcal/L = 4 L. Since there are 24 hours in a day, the rate would be 4
L ÷ 24 hr = 250 mL/hr.
client with chronic glomerulonephritis with oliguria. manifestation?
a) Hyperkalemia
b) Hypokalemia
c) Hyponatremia
d) Hypocalcemia
Answer: a)
Rationale:
Oliguria, or decreased urine output, can lead to the retention of potassium, resulting in
hyperkalemia.
reviewing lab results with aplastic anemia. potential complication?
a) WBC 2,000/mm3
b) Hgb 12 g/dL
c) Platelets 250,000/mm3
d) RBC 4.5 million/mm3
Answer: a)
Rationale:

Aplastic anemia is characterized by pancytopenia, which includes a decrease in all blood cell
types, including white blood cells (WBCs). A low WBC count can increase the risk of
infection, which is a potential complication of this condition.
ED with full-thickness burns over 20% of total body surface. administer first after patent
airway and administer O2?
a) IV fluids
b) Antibiotics
c) Pain medication
d) Burn dressing
Answer: a)
Rationale:
In the initial management of severe burns, fluid resuscitation is crucial to maintain adequate
circulation and prevent hypovolemic shock.
client with UTI and prescription ciprofloxacin. instructions?
a) Avoid taking magnesium-containing antacids with this med
b) Take the med on an empty stomach
c) Crush the med before taking it
d) Take the med with dairy products
Answer: a)
Rationale:
Ciprofloxacin can interact with magnesium-containing antacids, reducing its absorption and
effectiveness. It's important to take these medications at least 2 hours apart.
teaching with AIDS. understanding of teaching?
a) I will take my temp once a day
b) I will avoid crowds and sick individuals
c) I will take my medication with grapefruit juice
d) I will stop taking my medication if I feel better
Answer: b)
Rationale:
People with AIDS have compromised immune systems, so avoiding crowds and sick
individuals can help reduce the risk of infections.

compound fracture 3 weeks ago, unexpected finding lab value of manifestation of
osteomyelitis and report to provider?
a) Sedimentation rate
b) Hemoglobin level
c) Serum electrolytes
d) Blood glucose level
Answer: a)
Rationale:
An elevated sedimentation rate (ESR) can be an indicator of inflammation, including
osteomyelitis. This finding should be reported to the provider for further evaluation.
bilateral pneumonia, client is dyspneic with productive cough. action nurse take first?
a) Place the client in high-fowlers position
b) Administer oxygen therapy
c) Initiate IV antibiotic therapy
d) Collect a sputum sample for culture
Answer: a)
Rationale:
Placing the client in high-fowlers position helps improve ventilation and oxygenation in
patients with respiratory distress.
client who is hypokalemia. manifestations?
a) Decreased peristalsis
b) Hyperreflexia
c) Muscle weakness
d) Bradycardia
Answer: c)
Rationale:
Hypokalemia can lead to muscle weakness due to the effects of potassium on muscle
function.
client with suctioning the client's trach tube. indication for hypoxia?
a) The client's heart rate increases

b) The client's skin becomes pale
c) The client's oxygen saturation decreases
d) The client's respiratory rate decreases
Answer: c)
Rationale:
A decrease in oxygen saturation indicates hypoxia, which can occur during suctioning due to
the temporary interruption of airflow.
med hx who undergo allergy testing. nurse should discontinue which med before testing?
a) Prednisone
b) Acetaminophen
c) Diphenhydramine
d) Ranitidine
Answer: a)
Rationale:
Prednisone, a corticosteroid, can suppress the immune response and affect the results of
allergy testing. It should be discontinued before testing as per the healthcare provider's
instructions.
client with type 1 DM and new prescription for insulin lispro. understands teaching?
a) I will need to take the lispro instead of my other prescribed insulin
b) I will need to take the lispro in addition to my other prescribed insulin
c) I will need to take the lispro with meals only
d) I will need to take the lispro at bedtime only
Answer: b)
Rationale:
Insulin lispro is a rapid-acting insulin used to control blood sugar levels. It is often taken with
meals to manage postprandial glucose levels.
client postop total hip arthroplasty. lab value should nurse report?
a) Hgb 8g/dL
b) WBC 9,000/mm3
c) Platelets 250,000/mm3
d) Blood glucose 120 mg/dL

Answer: a)
Rationale:
A hemoglobin (Hgb) level of 8g/dL is below the normal range and may indicate anemia,
which could be a concern postoperatively, especially after total hip arthroplasty.
checking ECG rhythm strip for client has temp pacemaker. spike followed by QRS complex.
Action take first?
a) Document the depolarization has occurred
b) Increase the pacemaker output
c) Notify the healthcare provider
d) Administer atropine
Answer: a)
Rationale:
A spike followed by a QRS complex indicates that the pacemaker is functioning correctly,
and documenting this observation is the appropriate action.
ED client reports vomiting and diarrhea past 3 days. findings client experience fluid volume
deficit?
a) HR 110/min
b) BP 130/80 mmHg
c) Urine output 50 mL/hr
d) Respiratory rate 16/min
Answer: a)
Rationale:
A heart rate of 110/min is consistent with compensatory mechanisms in response to fluid
volume deficit, as the body tries to maintain adequate circulation.
PACU nurse client postop right nephrectomy. VS changes alert nurse client might be
hemorrhaging?
a) HR 110/min
b) BP 130/80 mmHg
c) Urine output 50 mL/hr
d) Respiratory rate 16/min
Answer: a)

Rationale:
An elevated heart rate (tachycardia) can be a sign of hemorrhage or inadequate fluid volume
after surgery, especially following a nephrectomy.
ED planning care for flail chest on right side in motor vehicle crash. action plan to take?
a) Prepare the client for positive pressure ventilation
b) Administer oxygen at 2 L/min
c) Apply a chest tube to the affected side
d) Encourage deep breathing exercises
Answer: a)
Rationale:
Flail chest, a serious chest injury, may require positive pressure ventilation to support
respiratory function and improve oxygenation.
providing discharge w patient with active TB, nurse teach?
a) Sputum specimens are necessary every 2-4 wks until there are three neg cultures
b) Isolation precautions are not necessary once treatment begins
c) TB is not contagious after 2 wks of treatment
d) TB medications are only needed for 2 weeks
Answer: a)
Rationale:
Active TB requires a prolonged treatment regimen, and monitoring sputum cultures is
necessary to ensure treatment effectiveness and to prevent the spread of infection.
client who is 12hr postop following total hip arthroplasty. action nurse take?
a) Place a pillow between the client's legs
b) Assist the client with ambulation
c) Administer IV pain medication
d) Perform passive range of motion exercises
Answer: a)
Rationale:
Placing a pillow between the client's legs helps maintain proper hip alignment and prevents
dislocation of the new hip prosthesis.

reviewing lab results w client has acute leukemia. expected finding?
a) Increased WBC count
b) Decreased platelet count
c) Decreased hemoglobin level
d) Increased blood glucose level
Answer: a)
Rationale:
Acute leukemia is characterized by an increased number of immature white blood cells
(WBCs) in the blood. This results in a high WBC count.
client has venous insufficiency about self-care. client understands teaching?
a) I will wear tight socks to help with circulation
b) I will avoid elevating my legs when sitting
c) I will wear clean graduated compression stockings every day
d) I will apply heating pads to my legs for comfort
Answer: c)
Rationale:
Graduated compression stockings help improve circulation and reduce swelling in the legs,
which is beneficial for managing venous insufficiency.
client has end stage kidney disease about organ donation. nurse include in teaching?
a) The client who receives a kidney from a deceased donor has a lower rate of transplant
rejection
b) The client who receives a kidney from a live donor has a higher rate of transplant rejection
c) The client who receives a kidney from a live donor has a lower rate of transplant rejection
d) The client who receives a kidney from a deceased donor has a higher rate of transplant
rejection
Answer: c)
Rationale:
Kidneys from live donors tend to have better outcomes, including lower rates of rejection,
compared to kidneys from deceased donors.
client is exhibiting manifestations of a febrile reaction while receiving blood transfusion.
meds should nurse administer?

a) Acetaminophen
b) Diphenhydramine
c) Furosemide
d) Epinephrine
Answer: a)
Rationale:
Acetaminophen is commonly used to reduce fever, which is a common manifestation of a
febrile reaction to a blood transfusion.
client receiving plasmapheresis through venous access site. action nurse take?
a) Check electrolyte levels before and after therapy
b) Apply a warm compress to the access site
c) Monitor for signs of infection at the access site
d) Elevate the extremity with the access site
Answer: a)
Rationale:
Plasmapheresis can affect electrolyte levels, so it is important to monitor these levels before
and after the procedure to ensure they remain within normal limits.
client at client for a 1 week follow up visit after HF. nurse report to provider?
a) BP 130/80 mmHg
b) HR 55/min
c) Weight gain of 2 pounds
d) Respiratory rate of 18/min
Answer: c)
Rationale:
Weight gain can be a sign of fluid retention, which is important to monitor closely in patients
with heart failure.
preop teaching for client with scheduled for open cholecystectomy, action nurse take?
a) Teach how to change a dressing
b) Demonstrate ways to deep breathe and cough
c) Instruct on how to use an incentive spirometer
d) Review the importance of ambulating after surgery

Answer: b)
Rationale:
Deep breathing and coughing exercises help prevent postoperative complications such as
pneumonia.
acute care facility caring for client at risk for seizures. precautions nurse implement?
a) Ensure that the client has a patent IV
b) Administer antiepileptic medication
c) Provide a quiet environment with minimal stimulation
d) Encourage the client to drink plenty of fluids
Answer: c)
Rationale:
Seizure precautions include creating an environment that is conducive to preventing
overstimulation, which can trigger seizures in susceptible individuals.
client has bladder cancer and undergo cutaneous diversion procedure to establish ureterstomy.
nurse include in teaching?
a) Empty the pouch when it is one-third full
b) Change the pouch every 3-5 days
c) Cut the opening of the skin barrier 1/8 inch wider than the stoma
d) Keep the skin around the stoma moist with lotion
Answer: c)
Rationale:
Ensuring the correct size of the opening in the skin barrier helps prevent leakage and skin
irritation.
client is 8hr postop total hip arthroplasty, client unable to void on bedpan. action nurse take
first?
a) Scan bladder with portable ultrasound
b) Catheterize the client
c) Encourage the client to drink more fluids
d) Assist the client to a bedside commode
Answer: a)
Rationale:

Scanning the bladder with ultrasound can determine if the client needs to be catheterized due
to urinary retention.
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home.
Which of the following instructions should the nurse include in the teaching?
a) Take temperature once a day.
b) Wash the armpits and genitals with a gentle cleanser daily.
c) Change the litter boxes while wearing gloves.
d) Wash dishes in warm water.
Answer: a)
Rationale:
Monitoring temperature is important for detecting early signs of infection, which can be more
serious for individuals with HIV due to their compromised immune system. Washing dishes
in warm water, while a good hygiene practice, is not specific to the care needs of a client with
HIV.
A nurse is caring for a client who is postoperative following a tracheostomy and has copious
and tenacious secretions. Which of the following is an acceptable method for the nurse to use
to thin this client's secretions?
a) Provide humidified oxygen.
b) Perform chest physiotherapy prior to suctioning.
c) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
d) Hyperventilate the client with 100% oxygen before suctioning the airway.
Answer: a)
Rationale:
Providing humidified oxygen can help moisten and thin secretions, making them easier to
remove. Chest physiotherapy, while beneficial for some patients, may not be suitable for all
and should be done under the guidance of a healthcare provider. Prelubricating the suction
catheter tip with sterile saline is important for preventing trauma to the airway during
suctioning. Hyperventilating the client with 100% oxygen is not a standard practice and can
lead to adverse effects.

Following admission, a client with a vascular occlusion of the right lower extremity calls the
nurse and reports difficulty sleeping because of cold feet. Which of the following nursing
actions should the nurse take to promote the client's comfort?
a) Rub the client's feet briskly for several minutes.
b) Obtain a pair of slipper socks for the client.
c) Increase the client's oral fluid intake.
d) Place a moist heating pad under the client's feet.
Answer: b)
Rationale:
Providing slipper socks can help keep the client's feet warm and promote comfort. Rubbing
the client's feet briskly may not be appropriate and could potentially cause discomfort or
injury. Increasing oral fluid intake is important for overall hydration but may not directly
address the client's immediate concern. Placing a moist heating pad under the client's feet can
pose a risk of burns, especially if the client has reduced sensation due to vascular occlusion.
A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of
the prostate (TURP). Which of the following is the priority finding for the nurse to report to
the provider?
a) Emesis of 100 mL
b) Oral temperature of 37.5° C (99.5° F)
c) Thick, red-colored urine
d) Pain level of 4 on a 0 to 10 rating scale
Answer: c)
Rationale:
Thick, red-colored urine could indicate bleeding, which is a potential complication following
a TURP and requires immediate attention. Emesis of 100 mL, an oral temperature of 37.5° C
(99.5° F), and a pain level of 4 are important to note but are not as urgent as the potential sign
of bleeding.
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of the
following adverse effects of the hypothermia blanket?
a) Shivering
b) Infection

c) Burns
d) Hypervolemia
Answer: a)
Rationale:
Shivering is a common adverse effect of hypothermia blankets, as the body attempts to
generate heat in response to the cooling effects of the blanket. Infection, burns, and
hypervolemia are potential complications of using a hypothermia blanket but are less
common than shivering.
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus.
Which of the following statements by the client indicates an understanding of the teaching?
a) "I will carry a complex carbohydrate snack with me when I exercise."
b) "I should exercise first thing in the morning before eating breakfast."
c) "I should avoid injecting insulin into my thigh if I am going to go running."
d) "I will not exercise if my urine is positive for ketones."
Answer: d)
Rationale:
Exercising when urine is positive for ketones can increase the risk of ketoacidosis, a serious
complication of diabetes. The other statements are not incorrect but do not address the
immediate concern related to ketones in the urine.
A nurse notes a small section of bowel protruding from the abdominal incision of a client
who is postoperative. After calling for assistance, which of the following actions should the
nurse take first?
a) Cover the client's wound with a moist, sterile dressing.
b) Have the client lie supine with knees flexed.
c) Check the client's vital signs.
d) Inform the client about the need to return to surgery.
Answer: a)
Rationale:
Covering the protruding bowel with a moist, sterile dressing helps prevent infection and
keeps the area moist, which is important for the viability of the tissue. Checking vital signs
and informing the client about the need for further surgery are important actions but are not
as immediate as covering the exposed bowel.

A nurse is collecting data from a client who has alcohol use disorder and is experiencing
metabolic acidosis. Which of the following manifestations should the nurse expect?
a) Cool, clammy skin.
b) Hyperventilation.
c) Increased blood pressure.
d) Bradycardia.
Answer: b)
Rationale:
Metabolic acidosis can lead to compensatory hyperventilation as the body tries to decrease
carbon dioxide levels and increase pH. Cool, clammy skin, increased blood pressure, and
bradycardia are not typically associated with metabolic acidosis.
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which
of the following should the nurse include in the teaching?
a) Avoid bending at the waist.
b) Remove the eye shield at bedtime.
c) Limit the use of laxatives if constipated.
d) Seeing flashes of light is an expected finding following extraction.
Answer: a)
Rationale:
Bending at the waist can increase intraocular pressure, which can be harmful after cataract
surgery. The other statements are not correct or relevant to postoperative care after cataract
extraction.
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily.
The client refuses breakfast and reports nausea. Which of the following actions should the
nurse take first?
a) Suggest that the client rests before eating the meal.
b) Request a dietary consult.
c) Check the client's vital signs.
d) Request an order for an antiemetic.
Answer: c)
Rationale:

Nausea and anorexia are common signs of digoxin toxicity, which can lead to serious
dysrhythmias. Therefore, the nurse's priority is to assess the client's vital signs to determine if
there are any signs of toxicity. Resting before eating, requesting a dietary consult, and
administering an antiemetic may be appropriate interventions but are not as immediate as
assessing for toxicity.
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The
nurse suspects the client's wound is infected because the drainage from the dressing is yellow
and thick. Which of the following findings should the nurse report as the type of drainage
found?
a) Sanguineous.
b) Serous.
c) Serosanguineous.
d) Purulent.
Answer: d)
Rationale:
Purulent drainage is thick, yellow, green, or brown and can indicate infection. Sanguineous
drainage is bright red and indicates fresh bleeding. Serous drainage is thin and watery.
Serosanguineous drainage is a mixture of blood and serum and is typically pink or bloodtinged.
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To
prevent postoperative complications, which of the following actions should be reinforced
during the teaching?
a) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
b) Place the client's affected leg into the CPM machine with the machine in the flexed
position.
c) Place the client into a high Fowler's position when initiating the CPM exercises.
d) Align the joints of the CPM machine with the knee gatch in the client's bed.
Answer: a)
Rationale:
Administering an opioid analgesic prior to initiating continuous passive motion (CPM)
exercises can help manage pain and improve the client's tolerance to the exercises. Placing
the client's affected leg into the CPM machine with the machine in the flexed position,

placing the client into a high Fowler's position, and aligning the joints of the CPM machine
with the knee gatch in the client's bed are not directly related to preventing postoperative
complications.
A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
a) Dyspnea.
b) Barrel chest.
c) Clubbing of the fingers.
d) Shallow respirations.
e) Bradycardia.
Answer: a)
b) Barrel chest,
c) Clubbing of the fingers,
d) Shallow respirations.
Rationale:
Emphysema is a type of chronic obstructive pulmonary disease (COPD) characterized by
dyspnea, barrel chest (due to hyperinflation of the lungs), clubbing of the fingers (in
advanced cases), and shallow respirations. Bradycardia is not typically associated with
emphysema.
A nurse is caring for a client who sustained a basal skull fracture. When performing morning
hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's
right nostril. Which of the following actions should the nurse take first?
a) Take the client's temperature.
b) Place a dressing under the client's nose.
c) Notify the charge nurse.
d) Test the drainage for glucose.
Answer: d)
Rationale:
Clear drainage from the nose following a basal skull fracture, especially if it is cerebrospinal
fluid (CSF), can indicate a basal skull fracture with a CSF leak. Testing the drainage for
glucose can help differentiate between CSF and other types of fluid. Taking the client's

temperature, placing a dressing under the client's nose, and notifying the charge nurse are
important actions but are not as immediate as testing the drainage for glucose.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize
that the client is at risk for autonomic dysreflexia. Which of the following interventions
should the nurse take to prevent autonomic dysreflexia?
a) Monitor for elevated blood pressure.
b) Provide analgesia for headaches.
c) Prevent bladder distention.
d) Elevate the client's head.
Answer: c)
Rationale:
Autonomic dysreflexia is a potentially life-threatening condition that can occur in clients with
spinal cord injuries at or above T-6. It is often triggered by a stimulus below the level of
injury, such as bladder distention. Preventing bladder distention by ensuring regular bladder
emptying is an important intervention to prevent autonomic dysreflexia. Monitoring for
elevated blood pressure, providing analgesia for headaches, and elevating the client's head are
important interventions but are not specific to preventing autonomic dysreflexia.
A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the
following findings should the nurse expect the client to report?
a) Hot flashes.
b) Recurrent urinary tract infections.
c) Blood in the stool.
d) Abnormal vaginal bleeding.
Answer: d)
Rationale:
Abnormal vaginal bleeding, such as postmenopausal bleeding or irregular bleeding, is a
common symptom of endometrial cancer. Hot flashes are more commonly associated with
menopause. Recurrent urinary tract infections and blood in the stool are not typically
associated with endometrial cancer.
A nurse is caring for a client following an open reduction and internal fixation of a fractured
femur. Which of the following findings is the nurse's priority?

a) Altered level of consciousness.
b) Oral temperature of 37.7°C (100°F).
c) Muscle spasms.
d) Headache.
Answer: a)
Rationale:
An altered level of consciousness can indicate a serious complication, such as hemorrhage or
infection, and should be assessed and addressed immediately. While an oral temperature of
37.7°C (100°F) may indicate a mild fever, it is not the priority over an altered level of
consciousness. Muscle spasms and headache may be expected postoperatively but are not as
urgent as an altered level of consciousness.
A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge
resection of the left lung and has a chest tube to suction. Which of the following is the
priority finding the nurse should report to the provider?
a) Abdomen is distended.
b) Chest tube drainage of 70 mL in the last hour.
c) Subcutaneous emphysema is noted to the left chest wall.
d) Pain level of 6 on a 0 to 10 scale.
Answer: a)
Rationale:
Abdominal distention can indicate a potential complication, such as a diaphragmatic injury or
abdominal bleeding, which requires immediate attention. While chest tube drainage and
subcutaneous emphysema are important to monitor, they are not as immediately concerning
as abdominal distention. Pain is important to address but is not as urgent as the potential
complications indicated by abdominal distention.
A nurse is reinforcing discharge teaching with a client about how to care for a newly created
ileal conduit. Which of the following instructions should the nurse include in the teaching?
a) Change the ostomy pouch daily.
b) Empty the ostomy pouch when it is 2/3 full.
c) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
d) Apply lotion to the peristomal skin when changing the ostomy pouch.
Answer: a)

Rationale:
Changing the ostomy pouch daily helps maintain skin integrity and prevents irritation and
infection. Emptying the ostomy pouch when it is 2/3 full is correct, but changing the pouch
daily is also important. Trimming the opening of the ostomy seal and applying lotion to the
peristomal skin are not necessary for caring for a newly created ileal conduit.
A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland.
Which of the following actions should the nurse include in the plan?
a) Position the client supine while in bed.
b) Change the nasal drip pad as needed.
c) Encourage frequent brushing of teeth.
d) Encourage the client to cough every 2 hr following surgery.
Answer: b)
Rationale:
Following removal of the pituitary gland, the client may experience nasal drainage, which
should be managed by changing the nasal drip pad as needed to maintain cleanliness and
prevent infection. Positioning the client supine while in bed is not specific to the care of a
client following pituitary gland removal. Encouraging frequent brushing of teeth is important
to prevent infection but is not specific to pituitary gland removal. Encouraging the client to
cough every 2 hours following surgery is not typically indicated and could potentially
increase intracranial pressure.
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily
following a myocardial infarction. The nurse should instruct the client that aspirin is
prescribed for clients who have coronary artery disease for which of the following effects?
a) To provide analgesia.
b) To reduce inflammation.
c) To prevent blood clotting.
d) To prevent fever.
Answer: c)
Rationale:
Aspirin is often prescribed to reduce the risk of blood clot formation in individuals with
coronary artery disease, including those who have had a myocardial infarction. It is not
typically prescribed for analgesia, reducing inflammation, or preventing fever in this context.

A nurse is collecting data from a client who has open-angle glaucoma. Which of the
following findings should the nurse expect?
a) Loss of peripheral vision.
b) Headache.
c) Halos around lights.
d) Discomfort in the eyes.
Answer: a)
Rationale:
Open-angle glaucoma is characterized by a gradual loss of peripheral vision. Headache, halos
around lights, and discomfort in the eyes are not typically associated with open-angle
glaucoma.
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) Weight loss of 3% of total body weight.
b) Blood glucose 150 mg/dL.
c) Potassium 2.5 mEq/L.
d) Urine specific gravity 1.035.
Answer: c)
Rationale:
Hypokalemia (low potassium level) can be a serious complication of acute gastroenteritis and
can lead to cardiac dysrhythmias. Therefore, it is the priority finding that the nurse should
address. While weight loss, blood glucose level, and urine specific gravity are important to
assess, they are not as immediately life-threatening as a low potassium level.
A nurse is reinforcing discharge teaching with a client who had a total abdominal
hysterectomy and a vaginal repair. Which of the following statements by the client indicates a
need for further teaching?
a) "I should increase my intake of protein and vitamin C."
b) "I will no longer have menstrual periods."
c) "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience
discomfort."
d) "I will take a tub bath instead of a shower."

Answer: d)
Rationale:
Taking a tub bath instead of a shower is not recommended after a total abdominal
hysterectomy and vaginal repair, as it can increase the risk of infection. The client should be
advised to avoid tub baths and to stick to showers until cleared by their healthcare provider.
Statements about increasing protein and vitamin C intake, no longer having menstrual
periods, and using a water-based lubricant are all appropriate and do not indicate a need for
further teaching.
A nurse is assisting with the care of a client who has a femur fracture and is in skeletal
traction. Which of the following actions should the nurse take?
a) Loosen the knots on the ropes if the client is experiencing pain.
b) Ensure the client's weights are hanging freely from the bed.
c) Check the client's bony prominences every 12 hr.
d) Cleanse the client's pin sites with povidone-iodine.
Answer: b)
Rationale:
Ensuring that the client's weights are hanging freely from the bed is important to maintain the
traction's effectiveness. Loosening the knots on the ropes can compromise the traction.
Checking the client's bony prominences every 12 hours is important to prevent pressure
ulcers but is not specific to skeletal traction. Cleansing the client's pin sites with povidoneiodine is important for pin site care but is not the priority action related to skeletal traction.
A nurse in a provider's office is reinforcing teaching with a client who has anemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include?
a) Take this medication between meals.
b) Limit intake of Vitamin C while taking this medication.
c) Take this medication with milk.
d) Limit intake of whole grains while taking this medication.
Answer: a)
Rationale:
Taking ferrous gluconate between meals can enhance its absorption, as certain foods can
inhibit iron absorption. Limiting Vitamin C intake is actually recommended, as Vitamin C can

enhance iron absorption. Taking iron supplements with milk is not recommended, as calcium
can inhibit iron absorption. Limiting whole grain intake is not necessary unless the client has
been advised otherwise by their healthcare provider.
A nurse in a provider's office is reinforcing teaching with a client who has anemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include?
a) Take this medication between meals.
b) Limit intake of Vitamin C while taking this medication.
c) Take this medication with milk.
d) Limit intake of whole grains while taking this medication.
Answer: a)
Rationale:
Taking ferrous gluconate between meals helps to enhance its absorption. This is because
certain foods, especially those high in fiber or containing minerals like calcium, can interfere
with the absorption of iron supplements. Taking it between meals helps to avoid this
interference and maximize the absorption of iron.
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) Apply topical antifungal agents.
b) Apply fresh ice packs every 4 hours.
c) Wash daily with an antibacterial soap.
d) Keep draining lesions uncovered to air dry.
Answer: c)
Rationale:
Washing daily with an antibacterial soap can help prevent the spread of infection and promote
healing in clients with cellulitis. Applying topical antifungal agents is not appropriate for
cellulitis, as it is a bacterial infection, not a fungal infection. Applying fresh ice packs may
provide comfort but does not address the underlying infection. Keeping draining lesions
uncovered to air dry can increase the risk of infection and is not recommended.
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy
established. Which of the following instructions should the nurse include in the teaching?

a) Empty the pouch immediately after meals.
b) Change the entire appliance once a day.
c) Limit fluid intake.
d) Avoid medications in capsule or enteric form.
Answer: d)
Rationale:
Clients with an ileostomy should avoid medications in capsule or enteric form, as these
formulations may not dissolve properly in the digestive tract and may be excreted whole in
the ileostomy output. Emptying the pouch immediately after meals is not necessary unless it
becomes full or uncomfortable. Changing the entire appliance once a day may be too
frequent, as appliances can often be worn for several days before needing to be changed.
Limiting fluid intake is not necessary unless advised by a healthcare provider.
A nurse is caring for a client with severe burns to both lower extremities. The client is
scheduled for an escharotomy and wants to know what the procedure involves. Which of the
following statements is appropriate for the nurse to make?
a) "An escharotomy surgically removes dead tissue."
b) "A cannula will be inserted into the bone to infuse fluids and antibiotics."
c) "A piece of skin will be removed and grafted over the burned area."
d) "Large incisions will be made in the burned tissue to improve circulation."
Answer: d)
Rationale:
An escharotomy involves making large incisions through the eschar (dead tissue) in order to
relieve pressure and improve circulation to the underlying tissues. This procedure is
performed to prevent compartment syndrome, which can occur when swelling within the
tissues is restricted by the surrounding eschar. Surgically removing dead tissue
(debridement), inserting a cannula into the bone, and skin grafting are other procedures that
may be performed but are not specifically related to an escharotomy.
A nurse is collecting data from a client who has a possible cataract. Which of the following
manifestations should the nurse expect the client to report?
a) Decreased color perception
b) Loss of peripheral vision
c) Bright flashes of light

d) Eyestrain
Answer: a)
Rationale:
A cataract causes the lens of the eye to become cloudy, which can result in decreased color
perception. Loss of peripheral vision is more indicative of conditions such as glaucoma.
Bright flashes of light may occur with retinal detachment. Eyestrain is a nonspecific symptom
that can occur with various eye conditions but is not specific to cataracts.
A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is
receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the
following interventions should the nurse include in the plan of care?
a) Measure abdominal girth daily.
b) Use sterile water to irrigate the nasogastric tube.
c) Maintain the client in Fowler's position.
d) Moisten the client's lips with lemon-glycerin swabs.
Answer: c)
Rationale:
Maintaining the client in Fowler's position (sitting upright) helps promote the passage of gas
and fluids through the obstructed area. Measuring abdominal girth is important for assessing
for abdominal distention but is not specific to the care of a client with an intestinal
obstruction. Using sterile water to irrigate the nasogastric tube is not necessary; normal saline
is typically used. Moisten the client's lips with lemon-glycerin swabs is important for oral
care but is not specific to the care of a client with an intestinal obstruction.
A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a) Buffalo hump
b) Purple striations
c) Moon face
d) Tremors
e) Obese extremities
Answer: a)
b) Purple striations,
c) Moon face

Rationale:
Cushing's syndrome is characterized by excess cortisol production, which can lead to the
development of a buffalo hump (fat accumulation between the shoulders), purple striations
(stretch marks), and a moon face (rounding and reddening of the face). Tremors and obese
extremities are not typically associated with Cushing's syndrome.
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the
following actions should the nurse take?
a) Provide a diet high in protein.
b) Provide ibuprofen for retroperitoneal discomfort.
c) Monitor intake and output hourly.
d) Encourage the client to consume at least 2 L of fluid daily.
Answer: c)
Rationale:
In the oliguric phase of acute kidney injury, the client's urine output is significantly reduced,
so it is important to monitor intake and output hourly to assess kidney function and fluid
balance. Providing a diet high in protein is not recommended, as excessive protein intake can
increase the workload on the kidneys. Ibuprofen is contraindicated in acute kidney injury, as
it can further impair kidney function. Encouraging the client to consume at least 2 L of fluid
daily may be inappropriate, as fluid restriction is often necessary in the oliguric phase to
prevent fluid overload.
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has
upper gastric pain. Which of the following statements should the nurse include in the
teaching?
a) "A flexible tube is introduced through the nose during the procedure."
b) "During the procedure you are in a sitting position."
c) "You will remain NPO for 8 hours before the procedure."
d) "You will be awake while the procedure is performed."
Answer: c)
Rationale:
Clients undergoing an esophagogastroduodenoscopy (EGD) are typically instructed to remain
NPO (nothing by mouth) for a certain period before the procedure to ensure the stomach is
empty, which allows for better visualization during the procedure. A flexible tube is indeed

introduced through the mouth, not the nose, during an EGD. Clients are usually lying down
during the procedure, not sitting. Sedation or anesthesia is often used during an EGD, so
clients are typically not awake during the procedure.
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours
following a generalized tonic-clonic seizure. Which of the following descriptions should the
nurse use when documenting this finding in the medical record?
a) Aura phase
b) Presence of automatisms
c) Postictal phase
d) Presence of absence seizures
Answer: c)
Rationale:
The postictal phase refers to the period following a seizure, during which the client may be
difficult to arouse, confused, sleepy, or experience other neurological symptoms. This phase
is important to document as it provides information about the client's condition following the
seizure.
A nurse is reinforcing teaching with a client who reports right shoulder pain following a
laparoscopic cholecystectomy. Which of the following statements should the nurse make?
a) "The pain results from lying in one position too long during surgery."
b) "The pain occurs as a residual pain from cholecystitis."
c) "The pain will dissipate if you ambulate frequently."
d) "The pain is caused from the nitrous dioxide injected into the abdomen."
Answer: c)
Rationale:
Shoulder pain following a laparoscopic cholecystectomy is a common side effect due to the
irritation of the diaphragm and phrenic nerve from the carbon dioxide used during surgery.
Ambulation can help dissipate this pain by promoting the reabsorption of the carbon dioxide.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)
a) Encourage fluid intake.
b) Monitor the puncture site for hematoma.

c) Insert a urinary catheter.
d) Elevate the client's head of bed.
e) Apply a cervical collar to the client.
Answer: a)
b) Monitor the puncture site for hematoma
Rationale:
After a lumbar puncture, it is important to encourage fluid intake to prevent dehydration and
help replenish cerebrospinal fluid. Monitoring the puncture site for hematoma is important to
detect any bleeding or swelling at the site.
A nurse is checking the suction control chamber of a client's chest tube and notes that there is
no bubbling in the suction control chamber. Which of the following actions should the nurse
take?
a) Notify the provider.
b) Verify that the suction regulator is on.
c) Continue to monitor the client because this is an expected finding.
d) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Answer: b)
Rationale:
The absence of bubbling in the suction control chamber may indicate that the suction is not
properly set or that there is an issue with the suction device. The nurse should first verify that
the suction regulator is on and set appropriately before notifying the provider.
A nurse is assisting with the care of a client who is postoperative following surgical repair of
a fractured mandible. The client's jaw is wired shut to repair and stabilize the fracture. The
nurse should recognize which of the following is the priority action?
a) Relieve the client's pain.
b) Check the client's pressure points for redness.
c) Provide oral hygiene.
d) Prevent aspiration.
Answer: d)
Rationale:

With the client's jaw wired shut, there is a risk of aspiration if the client vomits or has
difficulty swallowing. Therefore, preventing aspiration is the priority action to ensure the
client's safety.
A nurse is collecting data from a client who has scleroderma. Which of the following findings
should the nurse expect?
a) A dry raised rash
b) Excessive salivation
c) Periorbital edema
d) Hardened skin
Answer: d)
Rationale:
Scleroderma is a connective tissue disorder that causes the skin and other tissues to become
hard and thick. This results in hardened skin, which is a hallmark symptom of the condition.
A nurse is caring for an older adult client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
a) Instruct the client to tilt her head back when she swallows.
b) Place food on the left side of the client's mouth.
c) Add thickener to fluids.
d) Serve food at room temperature.
Answer: c)
Rationale:
Dysphagia is difficulty swallowing, which can increase the risk of aspiration. Thickening
fluids can help prevent aspiration and make swallowing easier for the client.
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head,
neck, and chest. The nurse should recognize which of the following is the priority risk to the
client?
a) Airway obstruction
b) Infection
c) Fluid imbalance
d) Contractures
Answer: a)

Rationale:
Burns to the head, neck, and chest can cause swelling that may compromise the airway.
Airway obstruction is a life-threatening complication that requires immediate intervention.
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis
and is to start taking neostigmine. Which of the following instructions should the nurse
include in the teaching?
a) Take the medication 45 minutes before eating.
b) Expect diaphoresis as a side effect of the neostigmine.
c) If a medication dose is missed, wait until the next scheduled dose to take the medication.
d) Treat nasal rhinitis with an over-the-counter antihistamine.
Answer: a)
Rationale:
Neostigmine is a cholinesterase inhibitor used to treat myasthenia gravis. Taking the
medication before meals can help improve muscle strength and reduce symptoms of the
condition.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection
of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse
notes there has not been any urinary output in the last hour. Which of the following actions
should the nurse perform first?
a) Notify the provider.
b) Administer a prescribed analgesic.
c) Offer oral fluids.
d) Determine the patency of the tubing.
Answer: d)
Rationale:
Lack of urinary output in a client with continuous irrigation of a urinary catheter may indicate
a blockage in the tubing. The nurse should first check the tubing for patency to ensure that
urine can flow freely.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear
about the procedure and asks the nurse if the biopsy will hurt. Which of the following
responses should the nurse make?

a) "You must be very worried about what the biopsy will show."
b) "You'll be asleep for the whole biopsy procedure and won't be aware of what's happening."
c) "Your provider scheduled this, so she will want to know you still have questions about the
procedure."
d) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."
Answer: d)
Rationale:
It is important for the nurse to acknowledge the client's fear and provide reassurance that
efforts will be made to keep them comfortable during the procedure.
A nurse is assisting with planning care for a client who is recovering from a left hemispheric
stroke. Which of the following interventions should the nurse include in the plan?
a) Control impulsive behavior.
b) Compensate for left visual field deficits.
c) Re-establish communication.
d) Improve left-side motor function.
Answer: c)
Rationale:
Clients recovering from a left hemisphere stroke often experience communication difficulties
due to damage to language centers in the brain. Re-establishing communication is a key
intervention in their care.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should
monitor the client for which of the following manifestations?
a) Hypotension
b) Polyphagia
c) Hyperglycemia
d) Bradycardia
Answer: a)
Rationale:
Diabetes insipidus is characterized by excessive thirst and excretion of large amounts of
diluted urine, which can lead to dehydration and hypotension.

A nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm Hg
Base excess -2
PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
a) Metabolic acidosis
b) Respiratory acidosis
c) Metabolic alkalosis
d) Respiratory alkalosis
Answer: b)
Rationale:
The pH is low (acidosis) and the PaCO2 is elevated, indicating respiratory acidosis. This
occurs due to inadequate ventilation, leading to retention of carbon dioxide.
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The
nurse should recognize that which of the following statements by the client indicates a need
for further teaching?
a) "I will avoid crossing my legs at the knees."
b) "I will use a thermometer to check the temperature of my bath water."
c) "I will not go barefoot."
d) "I will wear stockings with elastic tops."
Answer: d)
Rationale:
Elastic tops on stockings can impede circulation, which is contraindicated in clients with
PVD. The client should wear loose-fitting clothing to avoid constriction.
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's
disease. The client becomes agitated and combative when the nurse approaches him. Which
of the following actions should the nurse plan to take?
a) Turn the water on and ask the client to test the temperature.

b) Obtain assistance to place mitten restraints on the client.
c) Firmly tell the client that good hygiene is important.
d) Calmly ask the client if he would like to listen to some music.
Answer: d)
Rationale:
Providing a calming and soothing environment, such as offering music, can help reduce
agitation in clients with Alzheimer's disease.
A nurse is collecting data on a client's wound. The nurse observes that the wound surface is
covered with soft, red tissue that bleeds easily. The nurse should recognize this is a
manifestation of which of the following?
a) Decreased perfusion
b) Infection
c) Granulation tissue
d) An inflammatory response
Answer: c)
Rationale:
Granulation tissue is soft, red, and bleeds easily. It is a sign of healing in a wound.
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3.
Which of the following food items brought by the family should the nurse prohibit from
being given to the client?
a) Baked chicken
b) Bagels
c) A factory-sealed box of chocolates
d) Fresh fruit basket
Answer: d)
Rationale:
Fresh fruits can harbor bacteria, which can be harmful to a client with a low WBC count. It is
important to avoid fresh fruits and vegetables that cannot be peeled or cooked before eating.
A nurse is contributing to the plan of care for an older adult client who is postoperative
following a right hip arthroplasty. Which of the following interventions should the nurse
include in the plan?

a) Perform the client's personal care activities for her.
b) Limit the client's fluid intake.
c) Monitor the Homan's sign.
d) Maintain abduction of the right hip.
Answer: d)
Rationale:
Maintaining abduction of the hip helps prevent dislocation after hip arthroplasty.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the
following actions should the nurse take first?
a) Establish IV access.
b) Feel for a carotid pulse.
c) Establish an open airway.
d) Auscultate for breath sounds.
Answer: b)
Rationale:
Assessing for a carotid pulse is the first step in determining if the client has a pulse. If a pulse
is absent, immediate cardiopulmonary resuscitation (CPR) should be initiated.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is
no longer certain he wants to have the procedure. Which of the following responses should
the nurse make?
a) "Why have you changed your mind about the surgery?"
b) "Bypass surgery must be very frightening for you."
c) "Your provider would not have scheduled the surgery unless you needed it."
d) "I will call your doctor and have him discuss your surgery with you."
Answer: b)
Rationale:
This response acknowledges the client's feelings and shows empathy, which can help build
trust and rapport. It opens up the conversation for further discussion about the client's
concerns.
A nurse is caring for a client who is postoperative following foot surgery and is not to bear
weight on the operative foot. The nurse enters the room to discover the client hopped on one

foot to the bathroom, using an IV pole for support. Which of the following actions should the
nurse take?
a) Walk the client back to bed immediately and get the client a bedpan.
b) Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
c) Warn the client she might have to be restrained if she gets up without assistance.
d) Keep the bathroom door open to ensure the client is okay.
Answer: b)
Rationale:
This response addresses the immediate safety concern and provides a solution to prevent
further injury. It also helps the client maintain dignity and independence.
A nurse is assisting with the care of a client who is postoperative and has a closed-wound
drainage system in place. Which of the following actions should the nurse take?
a) Fully recollapse the reservoir after emptying it.
b) Empty the reservoir once per day.
c) Replace the drainage plug after releasing hand pressure on the device.
d) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
Answer: a)
Rationale:
Fully recollapsing the reservoir ensures proper functioning of the closed-wound drainage
system by maintaining the appropriate suction. This prevents air from entering the system,
which could lead to ineffective drainage.
A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the
following statements by the client indicates an understanding of the teaching?
a) "I will not eat fried foods."
b) "I will abstain from sexual intercourse."
c) "I will refrain from international travel."
d) "I will not order a salad in a restaurant."
Answer: b)
Rationale:
Hepatitis A is primarily transmitted through the fecal-oral route, so avoiding sexual
intercourse can help prevent the spread of the virus to others.

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client
diagnosed with emphysema. Which of the following instructions should be included in the
teaching?
a) Rest in a supine position.
b) Consume a low-protein diet.
c) Breathe in through her nose and out through pursed lips.
d) Limit fluid intake throughout the day.
Answer: c)
Rationale:
Pursed lip breathing helps improve gas exchange by keeping the airways open longer,
allowing for more effective exhalation and preventing air trapping in the lungs, which is
common in emphysema.
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) Hypernatremia
b) Hypotension
c) Bradycardia
d) Hypokalemia
Answer: b)
Rationale:
Addison's disease is characterized by adrenal insufficiency, which can lead to decreased
levels of aldosterone and cortisol. This can result in hypotension due to decreased fluid
volume and vasodilation.
A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is
to take hydroxyzine preoperatively. Which of the following effects of the medication should
the nurse include in the teaching? (Select all that apply.)
a) Decreasing anxiety
b) Controlling emesis
c) Relaxing skeletal muscles
d) Preventing surgical site infections
e) Reducing the amount of narcotics needed for pain relief
Answer: a)

b) Controlling emesis,
e) Reducing the amount of narcotics needed for pain relief
Rationale:
Hydroxyzine is an antihistamine with anxiolytic (anxiety-reducing), antiemetic (antivomiting), and analgesic-sparing effects. It can help reduce anxiety, control nausea and
vomiting, and reduce the need for opioids for pain relief.
A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The
nurse should reinforce to the client to take which of the following dietary supplements with
this medication?
a) Vitamin D
b) Vitamin A
c) Iron
d) Niacin
Answer: c)
Rationale:
Epoetin alfa is a medication used to stimulate red blood cell production in patients with
anemia, often associated with chronic kidney disease or chemotherapy. Iron supplementation
is often recommended with epoetin alfa to support the increased red blood cell production.
A nurse is caring for a client after a radical neck dissection. To which of the following should
the nurse give priority in the immediate postoperative period?
a) Malnourishment related to NPO status and dysphagia
b) Impaired verbal communication related to the tracheostomy
c) High risk for infection related to surgical incisions
d) Ineffective airway clearance related to thick, copious secretions
Answer: d)
Rationale:
In the immediate postoperative period after a radical neck dissection, maintaining a clear
airway is a priority to prevent respiratory complications. Thick, copious secretions can
obstruct the airway and lead to respiratory distress.

A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8
who is admitted for comprehensive rehabilitation. Which of the following long-term goals is
appropriate with regard to the client's mobility?
a) Walk with leg braces and crutches.
b) Drive an electric wheelchair with a hand-control device.
c) Drive an electric wheelchair equipped with a chin-control device.
d) Propel a wheelchair equipped with knobs on the wheels.
Answer: d)
Rationale:
A spinal cord injury at level C8 typically results in tetraplegia (paralysis of all four limbs),
making walking with leg braces and crutches unlikely. Driving an electric wheelchair with
hand or chin control may be more feasible for mobility. However, propelling a wheelchair
equipped with knobs on the wheels is a realistic long-term goal for the client's mobility.
A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the
following risk factors should the nurse identify as the leading cause of non-melanoma skin
cancer?
a) Exposure to environmental pollutants
b) Sun exposure.
c) History of viral illness
d) Scars from a severe burn
Answer: b)
Rationale:
Sun exposure, specifically to ultraviolet (UV) radiation, is the leading cause of nonmelanoma skin cancer. UV radiation from the sun can damage the DNA in skin cells, leading
to the development of skin cancer over time.
Based on a client's recent history, a nurse suspects that a client is beginning menopause.
Which of the following questions should the nurse ask the client to help confirm the client is
experiencing
manifestations of menopause?
a) "Do you sleep well at night?"
b) "Have you been experiencing chills?"
c) "Have you experienced increased hair growth?"

d) "When did you begin your menses?"
Answer: a)
Rationale:
Changes in sleep patterns, such as insomnia or disrupted sleep, are common symptoms of
menopause. Asking about sleep quality can help confirm if the client is experiencing
menopausal symptoms related to sleep disturbances.
A nurse is reinforcing teaching with a client about cancer prevention and plans to address the
importance of foods high in antioxidants. Which of the following foods should the nurse
include in the teaching?
a) Cottage cheese
b) Fresh berries
c) Bran cereal
d) Skim milk
Answer: b)
Rationale:
Fresh berries, such as blueberries, strawberries, and raspberries, are high in antioxidants,
which are substances that can help prevent or delay cell damage. Antioxidants can help
protect cells from damage that can lead to cancer.
A nurse is assisting with caring for a client who has a new concussion following a motorvehicle crash. The nurse should monitor the client for which of the following manifestations
of increased intracranial pressure?
a) Polyuria
b) Battle's sign
c) Nuchal rigidity
d) Lethargy
Answer: d)
Rationale:
Lethargy, or excessive drowsiness or fatigue, can be a manifestation of increased intracranial
pressure following a concussion. Other signs of increased intracranial pressure include severe
headache, vomiting, changes in vision, and confusion.

A nurse is reinforcing teaching about a tonometry examination with a client who has
manifestations of glaucoma. Which of the following statements should the nurse include in
the teaching?
a) "Tonometry is performed to evaluate peripheral vision."
b) "This test will diagnose the type of your glaucoma."
c) "Tonometry will allow inspection of the optic disc for signs of degeneration."
d) "This test will measure the intraocular pressure of the eye."
Answer: d)
Rationale:
Tonometry is a test used to measure the pressure inside the eye, known as intraocular
pressure. Elevated intraocular pressure is a key risk factor for glaucoma, so this test is
important in diagnosing and monitoring the condition.
A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a
kidney transplant. Which of the following laboratory findings should the nurse identify as the
most important to report to the provider?
a) Increase in serum glucose
b) Increase in serum creatinine
c) Decrease in white blood cell count
d) Decrease in platelets
Answer: b)
Rationale:
An increase in serum creatinine can indicate kidney dysfunction, which is a critical concern
in a client who has had a kidney transplant and is taking immunosuppressant medications like
cyclosporine. It could indicate potential rejection or other kidney-related issues that need
immediate attention.
A nurse is checking for paradoxical blood pressure on a client who has constrictive
pericarditis. Which of the following findings should the nurse expect?
a) Apical pulse rate different than the radial pulse rate
b) Increase in heart rate by 20% when standing
c) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position
d) Drop in systolic BP more than 10 mm Hg on inspiration
Answer: d)

Rationale:
Paradoxical blood pressure, a characteristic of constrictive pericarditis, is defined as a drop in
systolic blood pressure of more than 10 mm Hg on inspiration. This occurs due to the
inability of the heart to expand fully during inspiration, leading to decreased cardiac output
and blood pressure.
A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client
entering the room of another client, who becomes upset and frightened. Which of the
following actions should the nurse take?
a) Attempt to determine what the client was looking for.
b) Explain the client's Alzheimer's diagnosis to the frightened client.
c) Reprimand the client for invading the other client's privacy.
d) Ask the client to apologize for his behavior.
Answer: a)
Rationale:
It's important to approach the situation calmly and try to redirect the client with Alzheimer's
disease rather than reprimand or explain their condition to another client. Understanding the
client's behavior can help the nurse address their needs and prevent further distress to others.
A nurse is caring for a client immediately following a cardiac catheterization with a femoral
artery approach. Which of the following actions should the nurse take?
a) Check pedal pulses every 15 min.
b) Perform passive range-of-motion for the affected extremity.
c) Remind the client not to turn from side to side.
d) Keep the client in high-Fowler's position for 6 hr.
Answer: a)
Rationale:
Checking pedal pulses is essential after a cardiac catheterization to assess for adequate
circulation in the affected extremity. This helps monitor for complications such as thrombosis
or arterial occlusion.
A nurse is assisting with planning an immunization clinic for older adult clients. Which of the
following information should the nurse plan to include about influenza?
a) Individuals at high risk should receive the live influenza vaccine.

b) Immunization for influenza should be repeated every 10 years.
c) The composition of the influenza vaccine changes yearly.
d) The influenza vaccine is necessary only for clients who have never had influenza.
Answer: c)
Rationale:
The composition of the influenza vaccine is updated annually to match the strains of
influenza virus expected to circulate during the flu season. This is because the influenza virus
can mutate and change over time, requiring a new vaccine formulation each year to provide
optimal protection.
A nurse is caring for an older adult client who has colon cancer. The client asks the nurse
several questions about his treatment plan. Which of the following actions should the nurse
take?
a) Tell the client to have a family member call the provider to ask what options he plans to
recommend.
b) Assure the client that the provider will tell him what is planned.
c) Help the client write down questions to ask his provider.
d) Provide the client with a pamphlet of information about cancer
Answer: c)
Rationale:
Assisting the client in writing down questions can help him remember important topics to
discuss with his provider and feel more empowered in his healthcare decisions.
A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is
distressed over his mother's crying and condition. Which of the following responses should
the nurse make?
a) "If you just sit quietly with your mother, I'm sure she will calm down."
b) "I'll talk with your mother and see if I can comfort her."
c) "It must be hard to see your mother so ill and upset."
d) "Your mother's crying seems to bother you more than it does her."
Answer: c)
Rationale:
This response acknowledges the son's feelings and offers empathy, which can help validate
his emotions and provide support.

A nurse is reinforcing teaching with the family of a client who has primary dementia. Which
of the following manifestations of dementia should the nurse include in the teaching?
a) Temporary, reversible loss of brain function
b) Forgetfulness gradually progressing to disorientation
c) Sleeping more during the day than nighttime
d) Hyper vigilant behaviors
Answer: b)
Rationale:
Dementia is characterized by a gradual decline in memory and cognitive function, eventually
leading to disorientation and other cognitive impairments.

Document Details

  • Subject: Nursing
  • Exam Authority: ATI
  • Semester/Year: 2023

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