Preview Extract
ATI PN Med Surge Predictor Exam| Questions and Answers | Latest 2023
2024
1. A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While
taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions
should the nurse take?
Answer: Withhold the dose.
Rationale:
Digoxin is a medication used to treat heart conditions but can cause toxicity, especially with
lower heart rates. A heart rate of 58/min is below the normal range (60-100/min). Withholding
the dose is appropriate to prevent potential digoxin toxicity.
2. A nurse is caring for a client who has neutropenia. Which of the following nursing
interventions should the nurse implement?
Answer: Limit visitors to healthy adults.
Rationale:
Neutropenia is a condition characterized by a low level of neutrophils, a type of white blood cell
important for fighting infections. Limiting visitors to healthy adults helps reduce the risk of
exposing the client to infections that could be harmful due to their weakened immune system.
3. A nurse is caring for a client who has an intestinal obstruction and reports a new onset of
nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV
infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first?
Answer: Check for kinks in the NG tube.
Rationale:
Nausea in a client with an intestinal obstruction could indicate a worsening condition, such as an
increase in the obstruction or development of complications like ischemia. Checking for kinks in
the NG tube ensures proper functioning of the tube and suction, which can help relieve the
obstruction and prevent further complications.
4. A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the
following information should the nurse recommend to include in the pamphlet?
Answer: Women have a higher risk of contracting STIs than men.
Rationale:
Including information about the higher risk of STIs in women helps raise awareness and
promote preventive measures among the target audience. Women are often more vulnerable to
STIs due to physiological factors, making this information relevant and important for women's
health.
5. A nurse is reinforcing teaching with a client who is postoperative following a cemented total
hip arthroplasty. Which of the following instructions should the nurse include?
Answer: Maintain hip flexion to 90 degrees or less when sitting.
Rationale:
Maintaining hip flexion to 90 degrees or less helps prevent dislocation of the hip prosthesis,
which is a common complication after hip arthroplasty. This position reduces stress on the hip
joint and supports proper healing, promoting successful recovery from the surgery.
6. A nurse is preparing a client for a cardiac catheterization. Which of the following actions
should the nurse take first?
Answer: Verify the client has given informed consent.
Rationale:
Verifying informed consent is the first step to ensure the client understands the procedure, its
risks, benefits, and alternatives. This ensures the client's autonomy and legal protection for the
healthcare provider.
7. A nurse is caring for an adult client who has age-related macular degeneration. Which of the
following findings should the nurse expect?
Answer: Distorted central vision of the eyes.
Rationale:
Age-related macular degeneration affects the macula, leading to central vision distortion. This
condition is common in older adults and can significantly impact visual acuity and quality of
life.
8. A nurse is planning care for a group of clients after receiving change-of-shift report. Which of
the following clients should the nurse plan to see first?
Answer: A client who is dehydrated, has mental confusion, and was found getting out of bed
several times during the night.
Rationale:
Dehydration, mental confusion, and frequent attempts to get out of bed can indicate a serious
issue such as electrolyte imbalance, infection, or medication side effects. Addressing these needs
promptly is essential to prevent further complications.
9. A nurse is collecting data from a client who is receiving sumatriptan. Which of the following
is an expected outcome?
Answer: Diminished headache.
Rationale:
Sumatriptan is a medication used to treat migraines by constricting blood vessels in the brain.
The expected outcome of sumatriptan therapy is a reduction or elimination of the headache
associated with the migraine episode.
10. A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of
90%. Which of the following actions should the nurse take?
Answer: Administer oxygen via nasal cannula.
Rationale:
Oxygen saturation of 90% indicates hypoxemia, which requires supplemental oxygen therapy to
improve oxygenation and prevent further complications. Administering oxygen via nasal
cannula is a common and effective intervention to increase oxygen levels in the blood.
11. A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery.
Which of the following findings requires immediate attention from the nurse?
Answer: Oxygen saturation of 88%
Rationale:
Oxygen saturation of 88% indicates hypoxemia, which is below the normal range (95-100%).
This requires immediate attention to ensure adequate oxygenation and prevent complications
such as tissue hypoxia and organ dysfunction.
12. A nurse is caring for a client following a gastrectomy. Which of the following actions should
the nurse take to decrease episodes of dumping syndrome?
Answer: Place the client in the supine position after meals
Rationale:
Placing the client in a supine position after meals can help decrease episodes of dumping
syndrome by slowing gastric emptying. This position helps to reduce the rapid entry of food into
the small intestine, which is a contributing factor to dumping syndrome.
13. A nurse is assisting with the care of a client who had a stroke and is unable to speak. The
nurse should identify that the client's injury occurred in which of the following lobes of the
brain?
Answer: Frontal lobe
Rationale:
The frontal lobe is responsible for speech production (Broca's area). Damage to this area can
result in expressive aphasia, which is the inability to produce language despite comprehension.
14. A home health nurse is caring for a client who has COPD. The client tells the nurse that he
becomes short of breath while eating despite the use of home oxygen. Which of the following
instructions should the nurse include?
Answer: Drink beverages at the end of meals
Rationale:
Drinking beverages at the end of meals can help reduce the risk of shortness of breath while
eating for a client with COPD. Consuming liquids during meals can increase the feeling of
fullness and contribute to shortness of breath.
15. A nurse is reinforcing teaching with a client who has chronic kidney disease about disease
management. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: I will limit my daily intake of protein
Rationale:
Limiting daily protein intake is an important aspect of managing chronic kidney disease.
Excessive protein consumption can increase the workload on the kidneys, leading to further
damage.
16. A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the
following actions should the nurse take to reduce the client's confusion?
Answer: Encourage reminiscence of past experiences
Rationale:
Encouraging reminiscence of past experiences can help reduce confusion in clients with
dementia by providing a familiar and comforting context. It can also help maintain cognitive
function and improve overall well-being.
17. A nurse is caring for a client who has Cushing's syndrome and expresses concern regarding
body image changes. Which of the following should the nurse recognize as a physical change
caused by this disease?
Answer: Truncal obesity
Rationale:
Truncal obesity, or the accumulation of fat in the trunk and face while limbs remain thin, is a
common physical change seen in clients with Cushing's syndrome due to excess cortisol
production.
18. A nurse is delegating the task of repositioning a client who is in skeletal traction to an
assistive personnel (AP). Which of the following instructions should the nurse give the AP?
Answer: Allow the weights to hang freely
Rationale:
Allowing the weights to hang freely is important in maintaining proper alignment and
effectiveness of skeletal traction. Traction should not be interrupted to prevent complications
such as fractures or misalignment.
19. A nurse is contributing to the plan of care for a client who has a head injury and is at risk for
increased intracranial pressure (ICP). Which of the following actions should the nurse include in
the plan?
Answer: Use a turn sheet to reposition the client
Rationale:
Using a turn sheet to reposition the client can help reduce the risk of increased ICP by
minimizing movement and avoiding sudden changes in position, which can increase intracranial
pressure.
20. A nurse is preparing to administer an influenza vaccine to a client. Which of the following
statements by the client should cause the nurse to postpone administration of the vaccine?
Answer: I had a low fever this morning
Rationale:
Administration of the influenza vaccine should be postponed if the client has a fever. Fever can
be a sign of infection, and administering the vaccine during an acute illness can reduce its
effectiveness.
21. A nurse is repositioning a client who has lower back pain. Which of the following positions
is appropriate for the client?
Answer: Semi-Fowler's with knees flexed
Rationale:
Semi-Fowler's position with knees flexed can help alleviate lower back pain by reducing
pressure on the spine and promoting a more comfortable posture.
22. A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes.
Which of the following information should the nurse include in the teaching?
Answer: The virus can be transmitted without lesions present
Rationale:
It's important for the client to understand that genital herpes can be transmitted even when there
are no visible lesions. This is known as viral shedding, and it can occur at any time.
23. A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM)
machine with a client who is scheduled for a total knee arthroplasty. Which of the following
information should the nurse include in the teaching?
Answer: Your knee is flexed and extended as prescribed by your provider, The machine is
padded with sheepskin
Rationale:
Continuous passive motion (CPM) machines are used to help prevent stiffness and improve
range of motion after knee surgery. The client should follow the prescribed flexion and
extension schedule to avoid overexertion or injury. Padding the machine with sheepskin can help
increase comfort during use.
24. A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the
following instructions should the nurse include in the teaching?
Answer: Take calcium supplements with meals
Rationale:
Taking calcium supplements with meals can help enhance absorption. This is particularly
important for older adults with osteoporosis, as they are at higher risk for calcium deficiency and
fractures.
25. A nurse is reviewing the medication record of a client who is taking digoxin. Which of the
following medications should the nurse identify as increasing the risk for the client to develop
digoxin toxicity?
Answer: Furosemide
Rationale:
Furosemide, a loop diuretic, can cause hypokalemia (low potassium levels), which increases the
risk of digoxin toxicity. Digoxin toxicity can lead to serious cardiac arrhythmias and other
complications.
26. A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4
kg (100 lb). Which of the following statements by the client indicates an understanding of the
teaching?
Answer: "I should give my shot in my belly tissue."
Rationale:
Injecting insulin into the abdomen is a common and appropriate site for insulin injections. The
abdomen has a good blood supply, which helps insulin to be absorbed quickly and consistently.
27. A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve
replacement. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: "I will notify my dentist about this procedure."
Rationale:
Clients with mechanical heart valves are at increased risk for endocarditis, a serious infection of
the heart lining. It is important for these clients to inform their healthcare providers, including
dentists, about their valve replacement to receive appropriate antibiotic prophylaxis before
certain procedures.
28. A nurse is reviewing the medical record for an older adult who is experiencing nausea and
vomiting. Based on the client data, which of the following actions should the nurse take?
Answer: Notify the charge nurse of the client's BUN level.
Rationale:
Elevated blood urea nitrogen (BUN) levels can indicate dehydration, which may be a concern
for an older adult experiencing nausea and vomiting. Notifying the charge nurse can help ensure
appropriate interventions, such as fluid replacement therapy, are initiated promptly.
29. A nurse is providing information regarding transmission-based precautions for a client who
has Clostridium difficile to an assistive personnel (AP). Which of the following instructions
should the nurse include? (Select all)
Answer: Provide the client with disposable utensils and dishes for meals, Leave blood pressure
equipment in the client's room, Clean contaminated surfaces with a bleach solution.
Rationale:
Clostridium difficile is a highly contagious bacterium that can cause severe diarrhea.
Transmission-based precautions, including using disposable utensils and dishes, leaving
equipment in the client's room, and cleaning contaminated surfaces with a bleach solution, are
necessary to prevent the spread of infection.
30. A nurse is admitting a client who is suspected of having active tuberculosis (TB). Which of
the following actions should the nurse take first?
Answer: Institute airborne precautions.
Rationale:
Airborne precautions are necessary for clients suspected of having active TB to prevent the
transmission of Mycobacterium tuberculosis through the air. Instituting these precautions first
helps protect healthcare workers and other clients from exposure.
31. A nurse is caring for a client who is postoperative and has a Jackson-pratt drain. Which of
the following actions should the nurse take?
Answer: Compress the bulb reservoir and then close the drainage valve.
Rationale:
Compressing the bulb reservoir of a Jackson-Pratt drain creates negative pressure, allowing the
drain to function properly. After compressing the bulb, the drainage valve should be closed to
prevent fluid from leaking out.
32. A nurse is reinforcing teaching with the parent of a toddler who has type I diabetes mellitus
and whose prescription has been changed from regular insulin to lispro insulin. Which of the
following information should the nurse include in the teaching?
Answer: Lispro should be given before eating.
Rationale:
Lispro insulin is a rapid-acting insulin that should be administered just before meals to control
postprandial blood sugar levels effectively.
33. A nurse is reinforcing teaching with a client who has microcytic anemia and is prescribed a
daily iron supplement. The nurse tells the client to consume foods containing vitamin C when
taking the supplement to enhance iron absorption. Which of the following client food choices
indicates an understanding of the teaching?
Answer: 1 cup boiled broccoli
Rationale:
Broccoli is high in vitamin C, which can enhance the absorption of iron from the supplement.
Consuming foods rich in vitamin C along with iron supplements can help improve iron levels in
clients with microcytic anemia.
34. A nurse is assisting with the development of a plan of care to manage pain for a client who
has herpes zoster with lesions on the lower extremities. Which of the following interventions
should the nurse include in the plan of care?
Answer: Keep bed linens off of the affected areas.
Rationale:
Keeping bed linens off of the affected areas can help reduce irritation and pain caused by contact
with the lesions. It also promotes air circulation, which can aid in healing.
35. A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should
recommend which of the following foods as the best source of fiber?
Answer: 1/2 cup cooked kidney beans
Rationale:
Kidney beans are an excellent source of dietary fiber. Consuming foods high in fiber can help
improve digestion and promote overall gastrointestinal health.
36. A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is
receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following
findings should indicate to the nurse that the client's therapeutic regimen is effective?
Answer: Decrease in exertional dyspnea
Rationale:
Exertional dyspnea is a common symptom of pneumonia. A decrease in exertional dyspnea
indicates that the client's pneumonia is improving, which suggests that the antibiotic therapy and
albuterol nebulizer treatments are effective.
37. A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the
cast. Which of the following actions should the nurse take?
Answer: Blow cool air into the cast using a blow dryer on a cool setting
Rationale:
Intense itching under a cast is common and can be relieved by blowing cool air into the cast.
This helps to alleviate the itching sensation without compromising the integrity of the cast.
38. A nurse is caring for a client who has just returned to the unit following a bronchoscopy.
Which of the following findings should the nurse report to the provider?
Answer: Diminished breath sounds
Rationale:
Diminished breath sounds could indicate a complication such as pneumothorax, which is a
serious condition that requires immediate intervention. The nurse should report this finding to
the provider for further evaluation and management.
39. A nurse is caring for a client who has been taking enalapril. The nurse should monitor the
client for which of the following adverse effects?
Answer: Cough
Rationale:
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor, and a common adverse effect is
a persistent, dry cough. This cough is thought to be related to the accumulation of bradykinin
and is a common reason for discontinuation of ACE inhibitors.
40. A nurse is caring for a client who begins to have a seizure while ambulating in the hall.
Identify the sequence of actions the nurse should follow.
Answer: Lower the client to the floor, Place a pad beneath the client's head to protect the client
from injury, Loosen the clothing around the client's neck, Time the length of the client's seizure,
Reorient and reassure the client
Rationale:
These actions follow the standard protocol for managing a client experiencing a seizure.
Lowering the client to the floor prevents injury from falling. Placing a pad beneath the client's
head protects the head from injury. Loosening the clothing around the neck prevents
constriction. Timing the length of the seizure helps in determining when to seek further medical
attention. Reorienting and reassuring the client after the seizure helps them regain consciousness
and reduces anxiety.
41. A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB)
and a prescription for isoniazid and rifampin. Which of the following information should the
nurse include in the teaching?
Answer: Household family members should be tested for TB.
Rationale:
Tuberculosis (TB) is a contagious disease caused by Mycobacterium tuberculosis. It is important
to test household family members for TB to determine if they have been infected and to prevent
the spread of the disease.
42. A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a
statin medication to lower cholesterol levels. Which of the following instructions should the
nurse include in the teaching?
Answer: Add oily fish to your diet twice weekly.
Rationale:
Oily fish, such as salmon or mackerel, are rich in omega-3 fatty acids, which can help lower
cholesterol levels and reduce the risk of coronary artery disease. Including oily fish in the diet is
a beneficial dietary modification for clients with this condition.
43. A nurse is reinforcing teaching with a client who has diabetes mellitus and a new
prescription for regular and NPH insulin. Which of the following instructions on preparing the
insulins should the nurse include?
Answer: Withdraw the regular insulin before withdrawing the NPH insulin.
Rationale:
When mixing regular and NPH insulin, the regular insulin should be withdrawn first to prevent
contamination of the regular insulin vial with the cloudy NPH insulin. This sequence helps
ensure accurate dosing and prevents medication errors.
44. A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis.
Which of the following instructions should the nurse include to promote comfort?
Answer: Sleep on a firm mattress.
Rationale:
Sleeping on a firm mattress can help support the joints and reduce pressure on them, which can
help alleviate discomfort associated with osteoarthritis. A firm mattress provides better support
for the spine and joints compared to a softer mattress.
45. A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke.
Which of the following actions should the nurse include in the plan?
Answer: Use simple verbal cues when directing tasks.
Rationale:
Clients who have had a left hemispheric stroke may have difficulty with language and
communication (aphasia). Using simple verbal cues can help the client understand instructions
and improve communication, promoting independence in completing tasks.
46. A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the
following laboratory results indicates the client is experiencing a myocardial infarction?
Answer: Elevated troponin
Rationale:
Troponin is a protein released into the bloodstream when there is damage to the heart muscle,
such as during a myocardial infarction (heart attack). Elevated troponin levels indicate
myocardial injury and are used as a diagnostic marker for myocardial infarction.
47. A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the
following statements by the client indicates an understanding of the teaching?
Answer: The medication should be taken before I eat breakfast every morning.
Rationale:
Levothyroxine is a thyroid hormone replacement medication that should be taken on an empty
stomach, preferably in the morning before breakfast, to ensure optimal absorption. Taking it
with food or certain medications can interfere with absorption.
48. A nurse is contributing to the plan of care to promote a restful night's sleep for a client who
has Alzheimer's disease. Which of the following interventions should the nurse include in the
plan?
Answer: Offer a small snack at bedtime.
Rationale:
Offering a small snack at bedtime can help prevent hunger and promote sleep in clients with
Alzheimer's disease. It is important to offer a healthy snack that is low in sugar and caffeine to
avoid disruptions in sleep patterns.
49. A nurse is reviewing the medical record of a client who is postoperative. Which of the
following findings should the nurse identify as a complication of surgery?
Answer: WBC count of 15,000/mm3
Rationale:
An elevated white blood cell (WBC) count can indicate an inflammatory response to infection or
another complication following surgery. Monitoring the WBC count helps detect and manage
postoperative complications early.
50. A nurse is changing the dressing for a client who has an abdominal incision and a Hemovac
drain. Which of the following actions should the nurse take?
Answer: Cleanse the drainage plug with alcohol swabs.
Rationale:
Cleaning the drainage plug with alcohol swabs helps prevent infection at the drain site. It is
important to maintain aseptic technique when caring for the drain to reduce the risk of
complications.
51. A nurse is reviewing the medication administration record of a client who has osteoarthritis.
Which of the following analgesic prescriptions should the nurse expect to administer when the
client reports pain?
Answer: Acetaminophen
Rationale:
Acetaminophen is a commonly used analgesic for the management of mild to moderate pain
associated with osteoarthritis. It is often preferred over nonsteroidal anti-inflammatory drugs
(NSAIDs) due to its lower risk of gastrointestinal side effects.
52. A nurse is reinforcing teaching with a client who has asthma and a new prescription for a
corticosteroid. Which of the following findings should the nurse include as an adverse effect of
the medication?
Answer: Frequent colds
Rationale:
Corticosteroids can suppress the immune system, making individuals more susceptible to
infections such as colds. Educating the client about this potential adverse effect is important for
monitoring and early intervention.
53. A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for
calcitonin. Which of the following statements should the nurse make to describe the effect of
calcitonin in treating osteoporosis?
Answer: Calcitonin will slow the breakdown of bone in your body.
Rationale:
Calcitonin is a hormone that helps regulate calcium and bone metabolism. It inhibits osteoclast
activity, which slows down the breakdown of bone. This can help prevent further bone loss in
clients with osteoporosis.
54. A nurse is assisting with an educational program for clients who have been newly diagnosed
with diabetes mellitus. Which of the following instructions should the nurse include in the
program regarding insulin?
Answer: Opened insulin can be stored on a cool countertop away from light.
Rationale:
Opened insulin vials or pens can be stored at room temperature (between 59-86°F or 15-30°C)
for up to 28 days. Storing insulin in the refrigerator can cause it to thicken and become less
effective, so it is important to store it at room temperature.
55. A nurse is caring for a client who is suspected of having a myocardial infarction. Which of
the following actions should the nurse take to prepare the client for an ECG?
Answer: Cleanse the client's skin prior to electrode placement.
Rationale:
Cleaning the client's skin removes oils and debris, ensuring good electrode contact for accurate
ECG readings. It also helps reduce the risk of skin irritation or infection.
56. A nurse is reinforcing teaching with a client who has circulatory compromise in the lower
extremities due to peripheral vascular disease. Which of the following actions should the nurse
take?
Answer: Educate the client about choosing low-fat, low-cholesterol foods.
Rationale:
Peripheral vascular disease (PVD) is often associated with atherosclerosis, which can be
exacerbated by high-fat, high-cholesterol diets. Educating the client about choosing low-fat,
low-cholesterol foods can help reduce further progression of the disease and improve
circulation.
57. A nurse is caring for a client who is postoperative following a transurethral resection of the
prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased
output from the urethral catheter. Which of the following provider prescriptions should the nurse
expect?
Answer: Irrigate the urethral catheter with 0.9% sodium chloride.
Rationale:
Decreased output from the urethral catheter following a TURP may indicate clot formation
obstructing the catheter. Irrigating the catheter with 0.9% sodium chloride can help dislodge and
remove clots, restoring proper drainage.
58. A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic
cholecystectomy. Which of the following actions should the nurse take first?
Answer: Obtain the client's blood pressure.
Rationale:
Before assisting the client out of bed, it is important to assess their vital signs, including blood
pressure, to ensure they are stable and not at risk for orthostatic hypotension or other
complications related to the surgery.
59. A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis (TB)
about transmission of the disease. Which of the following client statements indicates an
understanding of the teaching?
Answer: "I inhaled the infected droplets that were in the air."
Rationale:
Tuberculosis (TB) is primarily spread through the air when an infected individual coughs,
sneezes, or speaks, releasing infectious droplets. Inhaling these droplets is the primary mode of
transmission for TB.
60. A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the
following findings should the nurse expect?
Answer: Muscle spasticity is a manifestation of multiple sclerosis.
Rationale:
Muscle spasticity, or stiffness and involuntary muscle contractions, is a common symptom of
multiple sclerosis (MS). It occurs due to damage to the nerves that control muscle movement,
leading to disrupted signals and muscle dysfunction.
61. A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was
precipitated by the client not taking her medication for several days. The nurse should identify
that withdrawal from which of the following medications potentiated the adrenal crisis?
Answer: Prednisone
Rationale:
Prednisone is a corticosteroid medication that is commonly used to treat conditions such as
adrenal insufficiency. Abrupt withdrawal of prednisone can lead to adrenal crisis, as the body
may not be able to produce enough cortisol to meet its needs, especially during times of stress.
62. A nurse is caring for a client following thyroidectomy. Which of the following findings
should alert the nurse to the possibility of parathyroid gland injury?
Answer: Muscle twitching
Rationale:
The parathyroid glands are located near the thyroid gland and are responsible for regulating
calcium levels in the body. Injury to the parathyroid glands during thyroidectomy can lead to
hypocalcemia, which can manifest as muscle twitching due to irritability of the nerves and
muscles.
63. A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot.
Which of the following actions should the nurse take first?
Answer: Check incisional dressing
Rationale:
After an amputation, it is important to monitor the incisional dressing for any signs of bleeding,
infection, or other complications. Checking the incisional dressing is the first priority to ensure
the wound is healing properly and to prevent complications.
64. A nurse is caring for a client who has a new cast on her forearm and reports severe pain in
the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with
sluggish capillary refill. Which of the following fracture complications should the nurse suspect?
Answer: Compartment Syndrome
Rationale:
Compartment syndrome is a serious complication that can occur when there is increased
pressure within a closed muscle compartment, such as within a cast. This increased pressure can
lead to decreased blood flow, resulting in severe pain, numbness, tingling, and changes in skin
color and temperature.
65. A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new
diagnosis of COPD. The nurse should identify which of the following client statements indicates
an understanding of the teaching?
Answer: "Pursed-lip breathing works best for activities like walking up stairs"
Rationale:
Pursed-lip breathing is a breathing technique that can help improve airflow and reduce shortness
of breath in clients with COPD. It is particularly helpful during activities that require increased
exertion, such as walking up stairs, as it can help reduce the work of breathing and improve
oxygenation.
66. A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative
following a total hip arthroplasty. Which of the following interventions should the nurse
contribute to the plan of care?
Answer: Keep an abduction pillow beneath the client's legs.
Rationale:
After a total hip arthroplasty, it is important to maintain proper positioning to prevent dislocation
of the hip prosthesis. Keeping an abduction pillow between the client's legs helps maintain
proper alignment and prevents the legs from crossing, which could strain the hip joint.
67. A nurse is collecting data from an older adult client who has several concerns. Which of the
following concerns should the nurse recognize as a normal change associated with aging?
Answer: "My food tastes bland even after I add seasoning."
Rationale:
Changes in taste and smell perception are common in older adults and are often related to
changes in the sense organs or decreased sensitivity of taste buds. This can lead to a perception
of blandness in foods even when seasoning is added.
68. A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the
following findings should the nurse anticipate?
Answer: Elevated serum amylase level
Rationale:
Acute pancreatitis is characterized by inflammation of the pancreas, which can cause the release
of pancreatic enzymes, including amylase, into the bloodstream. Elevated serum amylase levels
are a common finding in acute pancreatitis and are used to help diagnose the condition.
69. A nurse is collecting data from a client who has an obstructive pulmonary disorder. The
nurse should document the sound as which of the following?
Answer: Wheezes
Rationale:
Wheezes are high-pitched, musical sounds heard on expiration that are characteristic of
obstructive pulmonary disorders such as asthma or chronic obstructive pulmonary disease
(COPD). Wheezes occur due to narrowing of the airways, which causes turbulent airflow.
70. A nurse is caring for a client who has restricted movement of the chest due to a burn injury.
The nurse should anticipate preparing the client for which of the following procedures?
Answer: Escharotomy
Rationale:
Escharotomy is a surgical procedure performed to release the constricting tissue (eschar) that
forms over a burn injury. This procedure is done to improve chest wall movement and prevent
respiratory compromise in clients with restrictive chest burns.
71. A nurse is caring for 4 clients. Which of the following conditions should the nurse identify as
a risk for developing vascular disease?
Answer: Diabetes mellitus
Rationale:
Diabetes mellitus is a significant risk factor for developing vascular disease, including
peripheral arterial disease (PAD) and coronary artery disease (CAD). The high levels of glucose
in the blood can damage blood vessels over time, leading to atherosclerosis and an increased risk
of vascular complications.
72. A nurse caring for a client who has end-stage liver disease and just underwent an abdominal
paracentesis. For which of the following manifestations should the nurse monitor as an adverse
effect of the procedure?
Answer: Decreased blood pressure
Rationale:
Abdominal paracentesis is a procedure used to remove fluid from the abdominal cavity. One of
the potential complications of this procedure is hypotension, or decreased blood pressure, which
can occur due to the rapid removal of a large volume of fluid. Monitoring for signs of
hypotension is important to prevent further complications.
73. A nurse is caring for a female client who is being treated for dehydration due to nausea and
vomiting. Which of the following findings should the nurse report to the provider?
Answer: Heart rate 120/min
Rationale:
A heart rate of 120/min is above the normal range and could indicate dehydration or another
underlying issue. It is important to report this finding to the provider for further evaluation and
management.
74. A nurse is contributing to the plan of care for a client who had a cerebrovascular accident
(CVA). For which of the following interdisciplinary team members should the nurse recommend
a referral prior to initiating oral intake for the client?
Answer: Speech-language pathologist
Rationale:
Following a CVA, many clients experience dysphagia, or difficulty swallowing, which can lead
to aspiration and other complications. A speech-language pathologist can assess the client's
swallowing function and recommend appropriate interventions to ensure safe oral intake.
75. A nurse is reinforcing teaching to a client about preventing osteoporosis. Which of the
following client statements indicates an understanding of the teaching?
Answer: "I will limit my coffee intake"
Rationale:
Limiting caffeine intake, including coffee, can help prevent osteoporosis. Caffeine can interfere
with calcium absorption, which is important for maintaining bone health. Limiting caffeine
intake can help ensure that the body absorbs an adequate amount of calcium from the diet.
76. A nurse is reinforcing discharge teaching a client who has Crohn's disease. Which of the
following statements should the nurse include in the teaching?
Answer: "Maintain a low-residue diet"
Rationale:
A low-residue diet is often recommended for clients with Crohn's disease to reduce the
frequency and volume of bowel movements, minimize abdominal pain, and decrease the risk of
intestinal blockages. This diet includes foods that are easily digestible and low in fiber.
77. A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is
having difficulty with urination. Which of the following responses should the nurse make?
Answer: "The tumor causes obstruction of urine from the urethra."
Rationale:
Prostate cancer can cause difficulty with urination due to the enlargement of the prostate gland,
which can obstruct the flow of urine through the urethra. This obstruction can lead to symptoms
such as urinary hesitancy, dribbling, and incomplete emptying of the bladder.
78. A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of
the following interventions should the nurse include?
Answer: Place the client in a negative-pressure airflow room
Rationale:
Placing the client in a negative-pressure airflow room helps prevent the spread of TB by
containing the infectious particles within the room. This measure is important to protect other
clients and healthcare workers from exposure to TB.
79. A nurse is reinforcing teaching with a client about testicular self-examination. Which of the
following instructions should the nurse include in the teaching?
Answer: Perform testicular self-examination after taking a warm shower
Rationale:
Performing testicular self-examination after taking a warm shower can help relax the scrotal
skin and make it easier to detect any abnormalities, such as lumps or swelling, in the testicles.
This is an important screening technique for early detection of testicular cancer.
80. A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports
increased pain at the site of the fracture. Which of the following actions should the nurse take?
Answer: Reposition the client
Rationale:
Repositioning the client can help alleviate pressure on the fractured hip, which may reduce pain.
It is important to ensure that the client is positioned correctly in traction to maintain alignment
and prevent complications.
81. A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client indicates a
therapeutic response of the medication?
Answer: I have gained 3 pounds since my last appointment.
Rationale:
Weight gain can indicate a therapeutic response to methimazole in a client with
hyperthyroidism. Hyperthyroidism often causes weight loss, so weight gain can suggest that the
medication is helping to normalize the client's metabolism.
82. A nurse is collecting data from a client who has 30% body surface area partial-thickness and
full-thickness burns. Which of the following findings indicates that fluid resuscitation is
adequate?
Answer: Urine output is 50 mL/hr.
Rationale:
Adequate urine output is an important indicator of fluid resuscitation in clients with burns. A
urine output of at least 0.5 mL/kg/hr or approximately 30 mL/hr in an adult indicates that the
kidneys are perfused adequately and are functioning properly.
83. A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the
following statements should indicate to the nurse that the client understands the teaching?
Answer: "I will feel vibrations on my leg from the cast cutter."
Rationale:
Feeling vibrations from the cast cutter is a normal sensation during cast removal. This statement
indicates that the client understands what to expect during the procedure and is prepared for it.
84. A nurse is contributing to the plan of care for a client who has pericarditis. In which of the
following positions should the nurse plan to place the client to decrease pain?
Answer: Upright, leaning forward
Rationale:
Placing the client in an upright position, leaning forward can help decrease pain associated with
pericarditis by reducing pressure on the pericardium and minimizing friction between the
inflamed pericardial layers.
85. A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2
cal/mL. How many calories will the client receive in 12 hrs? (Round the answer to the nearest
whole number)
Answer: Step 1: What is the unit of measurement the nurse should calculate? Calories
Step 2: What is the volume the nurse should infuse? 60 mL/hr x 12 hr = 720 mL
Step 3: What is the total infusion time? 12 hrs
Step 4: Should the nurse convert the units of measurement? No
Step 5: Set up an equation and solve for x.
720 x 1.2 cal/mL = calories
721 x = 864 cal
Step 6: Round if necessary.
Step 7: Reassess to determine if the amount to administer makes sense.
Rationale:
To calculate the total calories, you first determine the total volume infused over 12 hours, which
is 720 mL. Then, you multiply this by the caloric content per milliliter (1.2 cal/mL) to find the
total calories: 720 mL x 1.2 cal/mL = 864 calories. This calculation ensures that the client
receives the correct amount of calories over the specified time period.
86. A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is
receiving chemotherapy. The nurse should identify which of the following statements by the
client indicates an understanding of the teaching?
Answer: "I drink bottled water."
Rationale:
Drinking bottled water reduces the risk of exposure to harmful bacteria or contaminants that
may be present in tap water, which can pose a greater risk to individuals with weakened immune
systems, such as those undergoing chemotherapy for leukemia.
87. A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving
chemotherapy. Which of the following statements should the nurse include in the teaching?
Answer: "You should place your toothbrush in hydrogen peroxide overnight."
Rationale:
Placing the toothbrush in hydrogen peroxide overnight can help reduce the risk of bacterial
contamination and infection, which is important for clients with leukemia who are at an
increased risk of infection due to chemotherapy-induced immunosuppression.
88. A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about
glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse
include in the teaching?
Answer: HbA1c results measure glucose control for the prior 3 months.
Rationale:
HbA1c testing provides an average of the blood glucose levels over the past 3 months, reflecting
the effectiveness of diabetes management during that time. This test is important for monitoring
long-term glucose control and assessing the risk of diabetes-related complications.
