ATI ADULT MEDICAL SURGICAL NGN TEST BANK
2023 / ATI MED SURG WITH NGN LATEST UPDATE
2023/A+ GRADE ASSURED
A nurse is assessing a patient who is 12hr postoperative following a colon resection. Which of
the following findings should the nurse report to the surgeon?
a. Heart rate 90/min
b. Absent bowel sounds
c. Hgb 8.2 g/dl
d. Gastric pH of 3.0 (normal 0-4)
Answer: c. Hgb 8.2 g/dl
A nurse is caring for a patient who has diabetes insipidus. Which of the following medications
should the nurse plan to administer?
a. Desmopressin
b. Regular insulin
c. Furosemide
d. Lithium carbonate
Answer: a. Desmopressin
A nurse is admitting a patient who has arthritic pain and reports taking ibuprofen several times
daily for 3 years. Which of the following test should the nurse monitor?
a. Fasting blood glucose
b. Stool for occult blood
c. Urine for white blood cells
d. Serum calcium
Answer: b. Stool for occult blood
A nurse in the emergency department is assessing a patient. Which of the following actions
should the nurse take first (Click on the "Exhibit" button for additional information about the
patient. There are three tabs that contain separate categories of data.
a. Obtain a sputum sample for culture
b. Prepare the patient for a chest x-ray
c. Initiate airborne precautions
d. Administer ondansertron.
Answer: c. Initiate airborne precautions
A nurse is contacting the provider for a patient who has cancer and is experiencing breakthrough
pain. Which of the following prescriptions should the nurse anticipate?
a. Transmucosal fentanyl
b. Intramuscular meperidine
c. Oral acetaminophen
d. Intravenous dexamethasone
Answer: a. Transmucosal fentanyl
A nurse is admitting a patient who reports chest pain and has been placed on a telemetry monitor.
Which of the following should the nurse analyze to determine whether the patient is experiencing
a myocardial infarction?
a. PR interval
b. QRS duration
c. T wave
d. ST segment
Answer: d. ST segment
A nurse is teaching a patient who has ovarian cancer about skin care following radiation
treatment. Which of the following instructions should the nurse include?
a. Pat the skin on the radiation site to dry it
b. Apply OTC moisturizer to the radiation site
c. Cover the radiation site loosely with a gauze wrap before dressing
d. Use a soft washcloth to clean the area around the radiation site
Answer: a. Pat the skin on the radiation site to dry it
A nurse is caring for a patient who is receiving a blood transfusion. The nurse observes that the
patient has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse
should anticipate administering which of the following prescribed medications?
a. Diphenhydramine
b. Acetaminophen
c. Pantoprazole
d. Furosemide
Answer: d. Furosemide
A nurse is assessing a patient who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the medication?
a. Lungs clear
b. Apical pulse 82/min
c. Hyperactive bowel sounds
d. Blood pressure 90/50 mm Hg
Answer: b. Apical pulse 82/min
A nurse is reviewing a patient's ABG results pH 7.42, PaCO2 30 mm Hg, and HCO3 21 mEq/L.
The nurse should recognize these findings as indication of which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Compensated respiratory alkalosis
d. Uncompensated respiratory acidosis
Answer: c. Compensated respiratory alkalosis
A nurse is caring for a patient who has a deep partial thickness burns over 15% of her body
which of the following labs should the nurse expect during the first 24 hours
a. Decreased BUN
b. Hypoglycemia
c. Hypoalbuminemia
d. Decreased Hematocrit
Answer: c. Hypoalbuminemia
A nurse is caring for a patient who has dumping syndrome following a gastrectomy, which of the
following actions should the nurse take ?
a. Offer the patient high carbohydrate meal options
b. Provide the patient with four full meals a day
c. Encourage the patient to drink at least 360 ml of fluids with meals
d. Have the patient lie down for 30 minutes after meals
Answer: d. Have the patient lie down for 30 minutes after meals
A nurse is teaching a group of young adult patients about risk factors for hearing loss. Which of
the following factors should the nurse include in the teaching? Select all that apply:
a. Born with a high weight
b. Chronic infections of the middle ear
c. Use a loop diuretic
d. Perforation of the ear drum
e. Frequent exposure to low volume noise
Answer: a. Born with a high weight
c. Use a loop diuretic
d. Perforation of the ear drum
A nurse is preparing to administer fresh frozen plasma to a patient . Which of the following
actions should the nurse take?
a. Administer the plasma immediately after thawing
b. Transfuse the plasma over 4 hour
c. Hold the transfusion if the patient is actively bleeding
d. Administer the transfusion through a 24 gauge saline lock
Answer: a. Administer the plasma immediately after thawing
A nurse is assessing a patients who reports numbness and tingling of his toes and exhibits a
positive TROUSSEAU. Which of the following electrolyte imbalance should the nurse suspect?
a. Hypoatremia
b. Hyperchloremia
c. Hypermagnesemia
d. Hypocalcemia
Answer: d. Hypocalcemia
A home health nurse is teaching a patient how to care for a peripherally central catheter in his
right arm. Which of the following statements should the nurse include in the teaching?
a. Change the transparent dressing over the insertion site every 48 hours
b. Clean the insertion site with mild soap and water
c. Measure your right arm circumference once weekly
d. Use a 10 milliliter syringe when flushing the catheter
Answer: d. Use a 10 milliliter syringe when flushing the catheter
A nurse is caring for a patient who has a central venous access device. Which of the following
assessment findings should the nurse report to the provider?
a. RBC count of 4.7 million/mm3
b. BUN 22 mg/dl
c. WBC count of 16,000/mm3
d. Blood glucose of 120 mg/dl
Answer: c. WBC count of 16,000/mm3
A nurse is providing dietary teaching to a patient who has chronic kidney disease and a decreased
glomerular filtration rate. Which of the following statements by the patient indicates an
understanding of the teaching?
a. I will spread my protein allowances over the entire day
b. I should increase my intake of canned salmon to three times per week
c. I will season my food with lemon pepper rather than salt
d. I should limit my intake of hard cheese to 3 ounces each day
Answer: a. I will spread my protein allowances over the entire day
A nurse is caring for a patient who has a PICC. The patient is receiving an antibiotic via
intermittent IV bolus. Which of the following actions should the nurse take?
a. Administer 20 ml of 0.9 sodium chloride after each dose of medication
b. Flush the catheter using a 5 ml syringe
c. Verify the placement with an x ray prior to the initial dose
d. Change the transparent membranes dressing daily
Answer: c. Verify the placement with an x ray prior to the initial dose
A nurse is teaching a patient using a metered dose rescue inhaler. Which of the following
statements should the nurse include in the teaching?
a. Do not shake your inhaler before use
b. Exhale fully before bringing the inhaler to your lips
c. Depress the canister after you inhale
d. Use peroxide to clean the mouthpiece if your inhaler
Answer: b. Exhale fully before bringing the inhaler to your lips
A nurse is assessing the pain status of a group of patients. Which of the following findings
indicate a patient is experiencing referred pain?
a. A patient who has angina reports substernal chest pain
b. A patient who has pancreatitis reports pain in the left shoulder
c. A patient who is postoperative reports incisional pain
d. A patient who has peritonitis reports generalized abdominal pain
Answer: b. A patient who has pancreatitis reports pain in the left shoulder
A nurse is caring for a patient who has just returned from surgery with an external fixator to the
left tibia. Which of the following assessments findings requires immediate intervention by the
nurse?
a. The patient reports a pain level of 7 on a scale from 0 -10 at the operative site.
b. The patients capillary refill in the left toe is 6 seconds
c. The patient has an oral temperature of 38.3 (100.9 F)
d. The patient has 100 ml of blood in the closed suction drained.
Answer: b. The patients capillary refill in the left toe is 6 seconds
A nurse is assessing a patient who has acute pancreatitis and has been receiving TPN for the past
72 hours. Which of the following findings requires the nurse to intervene?
a. Right upper quadrant pain
b. Capillary blood glucose level of 164 mg/dl
c. WBC count 13,000/mm3
d. Crackle in bilateral lower lobes
Answer: d. Crackle in bilateral lower lobes
A nurse is caring for a patient who has hypotension, cool and clammy skin, tachycardia, and
tachypnea. In which of the following positions should the nurse place the patient?
a. Reverse Trendelenburg
b. Side Lying
c. High Fowlers
d. Feet elevated
Answer: d. Feet elevated
A nurse is caring for a patient who has tuberculosis and is taking rifampin. The patient reports
that her saliva has turned red-orange in color. Which of the following responses should the nurse
make?
a. "This finding may indicate possible medication toxicity"
b. "Your provider will prescribe a different medication regimen"
c. "This is an expected adverse effect of this medication"
d. "You will need to increase your fluid intake to resolve this problem"
Answer: c. "This is an expected adverse effect of this medication"
A nurse is preparing to administer a unit of packed RBCs for a patient who is receiving a
continuous IV infusion of 5% dextrose in water. Which of the following actions should the nurse
take?
a. Administer the unit through secondary IV tubing
b. Verify the blood product with an assistive personnel
c. Begin an IV infusion of 0.9% sodium chloride
d. Insert another 22-gauge IV catheter
Answer: c. Begin an IV infusion of 0.9% sodium chloride
A nurse is planning care for a patient who is 12 hr post-operative following a kidney transplant.
Which of the following actions should the nurse include in the plan of care?
a. Check the patient's blood pressure every 8 hr
b. Administer opioids PO
c. Assess urine output hourly
d. Monitor for hypokalemia as a manifestation of acute rejection
Answer: c. Assess urine output hourly
A nurse in an emergency department is assessing a patient who has cirrhosis of the liver. Which
of the following is a priority finding?
a. Yellow sclera
b. Mental confusion
c. Palmar erythema
d. Spider angiomas
Answer: b. Mental confusion
A nurse is obtaining a medication history from a patient who is to start therapy with naproxen for
rheumatoid arthritis. Which of the following medications places the patient at risk for bleeding?
a. Captopril
b. Ibuprofen
c. Digoxin
d. Phenytoin
Answer: b. Ibuprofen
A nurse is caring for a patient in diabetic ketoacidosis (DKA). Which of the following is the
priority intervention by the nurse?
a. Administer 0.9% sodium chloride
b. Check potassium levels
c. Initiate a continuous IV insulin infusion
d. Begin bicarbonate continuous IV infusion
Answer: a. Administer 0.9% sodium chloride
A nurse is assessing the extremities of a patient who has Raynaud's disease. Which of the
following findings should the nurse expect?
a. Blanching of the hands
b. Hyperactive reflexes
c. Calf pain with foot dorsiflexion
d. Vitiligo on affected extremities
Answer: a. Blanching of the hands
A nurse is caring for a group of patients. The nurse should obtain a blood pressure reading using
only the left extremity from which of the following patients?
a. A patient who has a peripherally inserted central catheter in the left arm
b. A patient who has left-sided Bell's palsy
c. A patient who has a right upper extremity arteriovenous fistula
d. A patient who has right-sided weakness due to Parkinson's disease
Answer: c. A patient who has a right upper extremity arteriovenous fistula
A nurse is providing teaching to a patient who has DVT. Which of the following findings should
the nurse identify as a risk factor for the development of DVTs?
a. Hypertension
b. Cirrhosis
c. NSAIDS use
d. Oral Contraceptive Use
Answer: d. Oral Contraceptive Use
A nurse is caring for patient who has Cushing's disease. Which of the following actions should
the nurse take first? (Click Exhibit button for additional information)
a. Check the patient's medication administration record for antihypertensive medication.
b. Verify the patient's understanding of sodium restriction.
c. Auscultate the patient's lung sound
d. Determine the need for further glucose monitoring
Answer: d. Determine the need for further glucose monitoring
A nurse is assessing a patient who has nephrotic syndrome. Which of the findings should the
nurse expect?
a. Proteinuria
b. Flank pain
c. Hyperalbuminemia
d. Hypotension
Answer: a. Proteinuria
A nurse is assessing a patient who has right-sided heart failure. Which of the following
assessment findings should the nurse expect to find?
a. Oliguria
b. S3/S4 galloping heart sounds
c. Poor skin turgor
d. Pitting edema
Answer: d. Pitting edema
A nurse is caring for a patient who has newly inserted chest tube. The nurse should clarify which
of the following prescriptions with the provider?
a. Notify the provider when tidaling ceases.
b. Assisting the patient out of bed three times daily.
c. Vigorously strip the chest tube twice daily.
d. Administer morphine 2 mg IV bolus every 3 hr PRN for pain.
Answer: c. Vigorously strip the chest tube twice daily.
A nurse is teaching a patient who is taking an ACE inhibitor for heart failure. Which of the
following instructions should the nurse include for home management of heart failure?
a. Obtain daily weight.
b. Use of salt substitute.
c. Monitor I and O.
d. Limit daily activity.
Answer: a. Obtain daily weight.
A nurse is providing discharge teaching to a patient who has a permanent pacemaker. Which of
the following statements by the patient indicates an understanding of the teaching?
a. I need to maintain pressure over the pacemaker site with an elastic bandage.
b. I need to check my pulse rate every day for a full minute.
c. The pacemaker will deliver shock if I develop a dysrhythmia
d. When a microwave oven is in use, I need to stay out of the room.
Answer: b. I need to check my pulse rate every day for a full minute.
A nurse in a clinic is providing preventive teaching to an older adult patient during well visit.
The nurse should instruct the patient that which of the following immunization are recommended
for healthy adults after age 60? select all that apply:
a. Herpes Zoster
b. Influenza
c. HPV
d. Meningococcal
e. Pneumococcal Polysaccharide
Answer: a. Herpes Zoster
b. Influenza
e. Pneumococcal Polysaccharide
A nurse is assessing a patient who is 4hr postoperative following arterial revascularization of the
left femoral artery. Which of the following findings should the nurse report immediately?
a. Bruising around the incision site
b. Pallor in the affected extremity
c. Urine output 150mL over 4hr
d. Temperature of 37.9 (100.2)
Answer: b. Pallor in the affected extremity
A nurse is caring for an older adult patient who has not been eating. Which of the following
findings indicates dehydration?
a. Crackles auscultated bilaterally
b. Capillary refill of 2 seconds
c. Dimiminished peripheral pulses
d. Engorged neck veins
Answer: c. Dimiminished peripheral pulses
A nurse is preparing to discharge a patient who has a halo device and is reviewing new
prescriptions from the provider. The nurse should clarify which of the following prescriptions
with the provider?
a. Increase intake of fiber rich foods
b. May operate a motor vehicle when no longer taking analgesics
c. Take tub baths instead of showers
d. May place a small pillow under the head when sleeping
Answer: b. May operate a motor vehicle when no longer taking analgesics
A nurse is assessing for early signs of compartment syndrome for a patient who has a short leg
fiberglass cast. Which of the following findings should the nurse expect?
a. Bounding distal pulses
b. Capillary refill less than 2 seconds
c. Erythema of the toes
d. Intense pain with movement
Answer: d. Intense pain with movement
A nurse is caring for a patient who is postoperative following CABG and reports shortness of
breath. The nurse administers oxygen at 3L/min and obtains arterial blood gases 60 min later.
Which of the following lab findings indicates a positive response to the oxygen therapy?
a. PaCO2 34 mmHg
b. Bicarbonate 20 mEq/L
c. PaO2 90 mmHg
d. Ph 7.32
Answer: c. PaO2 90 mmHg
A nurse is performing a cranial nerve assessment on a patient following a head injury. Which of
the following findings should the nurse expect if the patient has impaired function of the
vestibulocochlear (VIII)?
a. Loss of the peripheral vision
b. Disequilibrium with movement
c. Deviation of the tongue from midline
d. Inability to smell
Answer: b. Disequilibrium with movement
A nurse is caring for a patient admitted with a skull fracture. Which of the following assessment
findings should be of greatest concern to the nurse?
a. Glasgow coma scale score changes from 14 to 9
b. Bilateral pupil diameter changes from 4 to 2 mm
c. Pulse pressure changes from 30 to 20 mm Hg
d. WBC count changes from 9000 to 16,000 mm3
Answer: a. Glasgow coma scale score changes from 14 to 9
A nurse is caring for a patient who is taking furosemide. The patient has a potassium level of 3.1
mEq/L. Which of the following should the nurse assess first?
a. Urine output
b. Level of orientation
c. Cardiovascular status
d. Muscle weakness
Answer: c. Cardiovascular status
A nurse is caring for a patient who is scheduled for an abdominal paracentesis. The nurse should
plan to take which of the following actions?
a. Instruct the patient to take deep breaths and hold them during the procedure
b. Administer a stool softener following the procedure
c. Ask the patient to empty his bladder prior to the procedure
d. Assist the patient into the left lateral position during the procedure
Answer: c. Ask the patient to empty his bladder prior to the procedure
A nurse is caring for a patient who is 6 hours postoperatively following a thyroidectomy. The
patient reports tingling and numbness in the hands. The nurse should identify this as a sign of
which of following electrolytes imbalances?
a. Hyperatremia
b. Hypermagnesemia
c. Hypokalemia
d. Hypocalcemia
Answer: d. Hypocalcemia
A nurse is assessing a patient 15 min after the start of a transfusion of 1 unit of packed RBC's.
Which of the following findings is an indication of a hemolytic transfusion reaction?
a. Hypotension
b. Bradypnea
c. Bradycardia
d. Hypothermia
Answer: a. Hypotension
A nurse in an emergency department is caring for a patient who has sinus bradycardia. Which of
the following actions should the nurse take first?
a. Prepare the patient for temporary pacing.
b. Initiate IV fluid therapy for the patient
c. Measure the patient's blood pressure
d. Administer atropine to the patient
Answer: b. Initiate IV fluid therapy for the patient
A nurse is caring for a patient who has a prescription to discontinue a PICC. Which of the
following actions should the nurse take?
a. Apply slight pressure when resistance is met
b. Measure the catheter after removal
c. Remove the catheter with one continuous motion
d. Place a dry sterile dressing to the site after removal
Answer: d. Place a dry sterile dressing to the site after removal
A nurse is caring for a patient who has a flail chest. Which of the following actions should the
nurse take?
a. Provide humidified oxygen
b. Implement fluid restriction
c. Administer antibiotic medication
d. Administer acetaminophen orally
Answer: a. Provide humidified oxygen
A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which of the
following manifestations should the nurse include in the teaching?
a. Hypoxemia
b. Hyperventilation
c. Hypocarbia
d. Hypervolemia
Answer: a. Hypoxemia
A nurse is caring for a patient who is experiencing a seizure. Which of the following actions
should the nurse take first?
a. Obtain the patient's vital signs
b. Clear items from the patient's surrounding area
c. Loosen the patient's restrictive clothing
d. Lower the patient to the floor
Answer: d. Lower the patient to the floor
A nurse is teaching a patient who is receiving total parenteral nutrition at home through a central
venous access device about transparent dressing changes. Which of the following instructions
should the nurse include in the teaching?
a. Change the dressing every 48 hr
b. Replace the extension tubing with each dressing change
c. Use clean technique when changing the dressing
d. Wear a mask during dressing change
Answer: d. Wear a mask during dressing change
A nurse is caring for a patient in the emergency department who experienced a full- thickness
burn injury to the lower torso 1 hr ago. Which of the following findings should the nurse expect?
a. Decreased respiratory rate
b. Hypotension
c. Bradycardia
d. Urinary diuresis
Answer: b. Hypotension
A nurse is providing instructions about foot care for a patient who has a peripheral arterial
disease. The nurse should identify which of the following statements by the patient indicates an
understanding of the teaching?
a. "I apply a lubricating lotion to the cracked areas on the soles of my feet every morning"
b. "I use my heating pad on a low setting to keep my feet warm."
c. "I soak my feet in hot water before trimming my toenails"
d. "I rest in my recliner with my feet elevated for about an hour every afternoon"
Answer: d. "I rest in my recliner with my feet elevated for about an hour every afternoon"
A nurse is teaching a patient who has a new prescription for alendronate to treat osteoporosis.
Which of the following instructions should the nurse include in the teaching?
a. Swallow the medication with 120mL (4 oz) of water
b. Take the medication with a vitamin E supplement
c. Sit upright for 30 min after taking the medication
d. Take the medication with lunch
Answer: c. Sit upright for 30 min after taking the medication
A nurse is admitting a patient to the emergency department after a gunshot wound to the
abdomen. Which of the following actions should the nurse take to help prevent the onset of acute
kidney failure?
a. Initiate beta blocker therapy
b. Insert a urinary catheter
c. Prepare the patient for intravenous pyelogram
d. Administer IV fluids to the patient
Answer: d. Administer IV fluids to the patient
A nurse is completing an assessment of an older adult patient and notes redness areas over the
bony prominences, but the patient's skin is intact. Which of the following interventions should
the nurse include in the plan of care?
a. Apply an occlusive dressing
b. Manage the redness areas three times daily
c. Support bony prominences with pillows
d. Turn and reposition the patient every 4 hr.
Answer: c. Support bony prominences with pillows
A nurse is caring for a patient who has completed 10 daily cycles of Total parenteral Nutrition
(TPN). Which of the following findings indicates that the patient is receiving adequate TPN
supplementation.
a. Improved Mobility
b. Weight gain of 9.1 kilograms to 20 pounds
c. Potassium level of 2.5 meq/l
d. BUN level of 15 mg/dL
Answer: b. Weight gain of 9.1 kilograms to 20 pounds
A nurse is providing teaching to a patient who is post-operative following a partial glossectomy.
Which of the following statements by the patient indicates an understanding of the teaching?
a. I will consume can soup whenever sores appear in my mouth
b. I will drink orange juice to increase my vitamin C intake
c. I will rinse my toothbrush with hydrogen peroxide and water after each use
d. I will inspect my mouth once each week for sores.
Answer: c. I will rinse my toothbrush with hydrogen peroxide and water after each use
A nurse is performing an ear irrigation for a patient. Which of the actions should the nurse take?
a. tilt the patient's head 45 degrees
b. Insert the tip of the syringe to .5 centimeters 1 inch into the ear canal
c. Point the tip of the syringe toward the top of the ear canal
d. Use cool fluid for irrigation
Answer: c. Point the tip of the syringe toward the top of the ear canal
A nurse is caring for a patient who is receiving continuous bladder irrigation following a
transurethral resection of the prostate (TURP). The patient reports sharp lower abdominal pain.
Which of the following actions should the nurse take first?
a. Check the patient's urine output
b. Reposition the patient in bed
c. Increase the patient's fluid intake
d. administer PRN pain medication
Answer: a. Check the patient's urine output
A nurse is providing teaching for a patient who has diabetes mellitus about the selfadministration of insulin. The patient has prescriptions for regular and NPH insulin. Which of the
following statements by the patient indicates an understanding of the teaching?
a. I will draw up regular insulin into the syringe first
b. I will insert the needle at a 15 degree angle
c. I will store prefilled syringes in the refrigerator with the needle pointing downward
d. I will shake the NPH vial vigorously before drawing up the insulin
Answer: a. I will draw up regular insulin into the syringe first
A nurse is caring for a patient who is receiving Total parenteral Nutrition (TPN). which of the
following nursing actions are appropriate? (Select all the apply)
a. Obtain the patient's weight daily
b. Increase the rate of infusion if Administration is delayed
c. Monitor serum blood glucose during infusion
d. In to use 0.9% sodium chloride if the solution is not available
e. Verify the solution with another RN prior to infusion
Answer: e. Verify the solution with another RN prior to infusion
A nurse is caring for a patient in DKA. Which of the following is the priority intervention by the
nurse?
a. Check potassium levels
b. Administer 0.9% sodium chloride
c. Begin bicarbonate continuous IV infusion
d. Initiate continuous IV insulin infusion
Answer: b. Administer 0.9% sodium chloride
A nurse is reviewing the laboratory results of a female patient who asked about acupuncture
treatment for chemotherapy-induced nausea and vomiting. Which of the following laboratory
results is an indication to receiving acupuncture?
a. Absolute neutrophil count 500/mm3
b. C-reactive protein 0.7 mg/dl
c. platelets 160,000/mm3
d. Hemoglobin 12/dl
Answer: a. Absolute neutrophil count 500/mm3
A nurse is caring for a patient following a total knee arthroplasty. The patient reports a pain level
of 6 on a Pain Scale of 0 to 10. which of the following should the nurse take?
a. Gently massage the area around the patients incision
b. Place pillows under the patient's knee
c. Apply an ice pack to the patient's knee
d. Perform range of motion exercises to the patient's knee
Answer: c. Apply an ice pack to the patient's knee
A nurse is Assessing a patient who has heart failure and is receiving a loop diuretic. Which of the
following findings indicates hypokalemia?
a. Hypertension
b. positive chvostek's sign
c. Muscle weakness
d. Oliguria
Answer: c. Muscle weakness
A nurse at a long-term care facility is assessing an older adult patient. Which of the following
findings should the nurse identify as an indication that the patient has recall memory
impairment?
a. Inability to state what he had for dinner last night
b. Inability to Name the members of his family
c. Inability to count backwards from 10
d. Inability to state his current age
Answer: a. Inability to state what he had for dinner last night
A nurse on an intensive care unit is planning care for a patient who has increased intracranial
pressure following a head injury. Which of the following IV medications should the nurse plan to
administer?
a. Chlorpromazine
b. Dobutamine
c. Mannitol
d. Propanol
Answer: c. Mannitol
A nurse on a medical unit is planning care for a group of patients. Which of the following
patients should the nurse attend to First?
a. A patient who has thrombocytopenia and reports and nosebleed
b. A patient who has chronic obstruction pulmonary disease and oxygen saturation of 89%
c. A patient who has multiple sclerosis and Ataxia and vertigo
d. A patient who has left-sided paralysis and slurred speech from a prior stroke
Answer: a. A patient who has thrombocytopenia and reports and nosebleed
A home care nurse is planning to use non pharmacological pain relief measures for an older
patient who has severe chronic back pain. Which of the following guidelines should the nurse
use?
a. Use imagery with patients who have difficulty with focus and concentration
b. Pain relief from the use of heat and cold continues for several hours after removal of the
stimulus
c. Discontinue opioids before trying non pharmacological methods of pain relief
d. Distraction changes the patient's perception of pain but does not affect the cause
Answer: d. Distraction changes the patient's perception of pain but does not affect the cause
A nurse is caring for a patient who has pneumothorax and a chest tube with closed water seal
drainage system. Which of the following actions should the nurse take?
a. Strip or clear the chest tube every 8 hours
b. Refill the water chamber if the fluid is low
c. Empty the system at least every 8 hr
d. Change the chest to site dressing every 24 hour
Answer: b. Refill the water chamber if the fluid is low
A nurse is in an emergency department is reviewing a patient's ECG reading. which of the
following findings should the nurse identify as an indication that the patient has first degree heart
block?
a. Prolonged PR intervals
b. More p waves than QRS complexes
c. Non discernible p waves
d. No correlation between p and QRS waves
Answer: a. Prolonged PR intervals
A nurse is preparing to administer a unit of packed rbc's to a patient who is anemic. Identify the
sequence of steps the nurse should follow.
a. Obtain venous access using a 19 gauge needle
b. Obtain the unit of packed rbc's from Blood Bank align
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed rbc's
e. Remain with the patient for the first 15 to 30 minutes of the infusion
Answer: b. Obtain the unit of packed rbc's from Blood Bank align
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed rbc's
e. Remain with the patient for the first 15 to 30 minutes of the infusion
A nurse is teaching a patient who is to begin chemotherapy about peripherally inserted Central
catheter. which of the following statements should the nurse include in the teaching?
a. We will replace the PICC every month
b. We can draw blood samples from the PICC for diagnostic test
c. We will change the dressing daily
d. We can measure your blood pressure in either arm
Answer: b. We can draw blood samples from the PICC for diagnostic test
A nurse is assessing a patient who has Pyelonephritis and reports flank pain. which of the
following actions should the nurse take?
a. Assist the patient to a sitting position
b. Percuss the side of tenderness first
c. Auscultate for a bruit over the coastal vertebral area
d. Thump the area of tenderness directly with a closed fist
Answer: a. Assist the patient to a sitting position
A nurse is assessing a patient who has acute kidney failure. Which of the following findings
should the nurse report to the provider?
a. Peripheral pulses 2 + bilaterally
b. Weight gain 1.1 kilogram to 2.4 pound in 24-hour
c. Urine specific gravity 1.045
d. Creatinine 0.8 milliliter
Answer: b. Weight gain 1.1 kilogram to 2.4 pound in 24-hour
A nurse is caring for an older adult patient who is 72 hour postoperative following a total hip
arthroplasty. the patient requires a PRN medication prior to ambulation. Which of the following
medications should the nurse anticipate administering?
a. Indomethacin
b. Meperidine
c. Naproxen
d. Oxycodone
Answer: c. Naproxen
A nurse is caring for a patient who has Haemophilus Influenzae type B. which of the following
types of isolation should the nurse implement?
a. Droplet
b. Contact
c. Airborne
d. Protective
Answer: a. Droplet
A nurse is providing discharge teaching to a patient who has pulmonary tuberculosis. Which of
the following findings should the nurse include as an indication the patient is no longer
infectious?
a. Mantoux skin test reveals and induration of less than 1mm
b. patient no longer coughing up blood tinged sputum
c. Positive quantiferon TB gold test
d. Negative sputum culture for acid fast bacillus
Answer: d. Negative sputum culture for acid fast bacillus
A nurse working in the emergency department is caring for a patient who has a burn injury. After
securing the patient's Airway which of the following interventions should the nurse take first?
a. Cleanse the patient wound
b. Administer Analgesic medication
c. Increase the room temperature
d. Start an IV with a large bore needle
Answer: d. Start an IV with a large bore needle
A nurse is caring for a patient who has a central venous access device and notes the tubing has
become disconnected. The patient develops dyspnea and tachycardia. Which of the following
actions should the nurse take first?
a. Obtain ABG values
b. Perform an ECG
c. turn the patient to his left side
d. Clamp the catheter
Answer: d. Clamp the catheter
A nurse is providing discharge teaching to a patient who has impaired immune system due to
chemotherapy. Which of the following information should the nurse include in the teaching?
a. Wash your perineal area 2 times each day with antimicrobial soap
b. Change the water in your drinking glass every 4 hours
c. Wash your toothbrush in the dishwasher once each month
d. Change your pet litter box daily
Answer: a. Wash your perineal area 2 times each day with antimicrobial soap
A nurse is caring for a patient who has advanced liver disease. Which of the following laboratory
results should the nurse monitor when assessing the patient?
a. Serum Ammonia
b. Glucose level
c. Phosphate level
d. Serum troponin
Answer: a. Serum Ammonia
A nurse is caring for a patient who has admitted with nausea, vomiting, and a possible bowel
obstruction. An NG tube is placed and set to low intermittent suction. Which of the following
findings should the nurse report to the provider?
a. The patient reports being extremely thirsty with a sore throat
b. The amount of drainage is gradually decreasing
c. The patient's abdomen becomes distended and firm
d. The drainage is bright green in color with brown fecal material
Answer: c. The patient's abdomen becomes distended and firm
A nurse is caring for a patient who takes Lisinopril for HTN. Which of the following patient
statements indicates an adverse effect of the medication?
a. I have a heightened sense of taste
b. I have a nagging, dry cough
c. I have to urinate frequently
d. I seem to be bruising more easily
Answer: b. I have a nagging, dry cough
A nurse is caring for a patient who has an endotracheal tube. Which of the following actions
should the nurse take to verify tube placement?
a. Deflate the cuff to check the tube placement
b. Place the patient's head and neck in a flexed position
c. Observe for symmetry of chest expansion
d. Document the tube length where it passes the chin
Answer: c. Observe for symmetry of chest expansion
A nurse is providing discharge teaching to a patient who has chronic urinary tract infections. The
patient has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following
instructions should the nurse include in the teaching?
a. Take a laxative to prevent constipations
b. Take an antacid 30 min before taking the medication
c. Monitor heart rate once daily
d. Drink 2 to 3 L of fluid daily
Answer: d. Drink 2 to 3 L of fluid daily
A nurse is caring for a patient who presents to the emergency department after experiencing a
heat stroke. Which of the following actions should the nurse take?
a. Apply a cooling blanket.
b. Assess axillary temperature every 15 min.
c. Administer an antipyretic
d. Administer lactated Ringers.
Answer: a. Apply a cooling blanket.
A nurse is presenting an in-service program about Parkinson's disease (PD). Which of the
following statements should the nurse include in the teaching?
a. PD cause patients to have an increased sympathetic nervous system response
b. PD results in the development of neurofibrillary tangles within the patient's brain
c. PD results from a decreased amount of dopamine in the patient's brain
d. PD manifestations worse due to the patients decreased production of acetylcholine.
Answer: c. PD results from a decreased amount of dopamine in the patient's brain
A nurse is reviewing the medical record of a patient who is to undergo open heart surgery. Which
of the following findings should the nurse report to the provider as a contraindication to
receiving heparin?
a. Thrombocytopenia
b. Thalassemia
c. Rheumatoid arthritis
d. COPD
Answer: a. Thrombocytopenia
A nurse is assessing a patient who has skeletal traction for a femoral fracture. The nurse notes
that the weights are resting on the floor. Which of the following actions should the nurse take?
a. Pull the patient up in bed
b. Tie knots in the ropes near the pulleys to shorten them - ensure that pulley ropes are free of
knots
c. Increase the elevation of the affected extremity
d. Remove one of the weights
Answer: a. Pull the patient up in bed
A nurse is reviewing a medical record of a patient who has acute gout. The nurse expects an
increase in which of the following laboratory results?
a. Intrinsic factor
b. Chloride level
c. Uric acid
d. Creatinine kinase
Answer: c. Uric acid
A nurse is providing teaching to a patient who is to start furosemide therapy for heart failure.
Which of the following statements indicates that the patient understands a potential adverse
effect of this medication?
a. "I will check my pulse before I take this medication."
b. "I'll check my blood pressure so it doesn't get too high."
c. "I'm going to include more cantaloupe in my diet."
d. "I will try to limit foods that contain salt."
Answer: c. "I'm going to include more cantaloupe in my diet."
