2023 ATI Medical Surgical Practice Exam Set 4-6 With Answers-470 Solved Questions

Med Surg ATI Med Test Bank QUESTIONS AN CORRECT ANSWERS
VERIFIED 2023 UPDATE
Set 4
1. A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse expect?
A. Bradycardia
B. Flushed skin
C. Frothy sputum
D. Jugular vein distention
Answer: C. Frothy sputum
2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal
pelvis. Identify the area where the nurse should expect the client to have referred pain. (Find
“hot spots” in the artwork)
A. Right lower quadrant
B. Periumbilical area
C. Left lower back, flank, and radiating to the groin
D. Left upper quadrant

Answer: C. Left lower back, flank, and radiating to the groin
3. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in
the dialysate flow rate. Which of the following actions should the nurse take? (Select all the
apply.)
A. Monitor the access site for drainage.
B. Strip the catheter tubing
C. Measure the amount of the dialysate outflow
D. Raise the client to high fowlers position - pg.370: encourage client to lie Supine with head
slightly elevated during CCPD and APD treatment.
E. Position the client to her other side.
Answer: A. Monitor the access site for drainage.
C. Measure the amount of the dialysate outflow
E. Position the client to her other side.
4. A nurse is providing discharge teaching to a client who has an impaired immune system
due to chemotherapy. Which of the following information should the nurse include in the
teaching?

A. Wash you’re perineal area two times each day with antimicrobial soap.
B. Change your pet’s litter box daily.
C. Change the water in your drinking glass every 4 hrs.
D. Wash your toothbrush in the dishwasher once each month.
Answer: A. Wash you’re perineal area two times each day with antimicrobial soap.
5. A nurse is planning to insert an indwelling catheter for a female client. Which of the
following actions should the nurse plan to take?
A. Collect urine specimen from the drainage bag 1 hr after insertion
B. Raise the head of the bed to 45 degrees prior to insertion
C. Secure the catheter to the client's inner thigh
D. Attach the bag to the rail of the bed
Answer: C. Secure the catheter to the client's inner thigh
6. A nurse is providing teaching for a client who has age-related macular degeneration. Which
of the following information should the nurse include in the teaching?
A. A possible cause of this problem is long-term lack of dietary protein.
B. You probably have a Detachment of your retina.
C. You probably have noticed a decline in your central vision.
D. The doctor can perform surgery to correct the start paying the folds in your retina.
Answer: C. You probably have noticed a decline in your central vision.
7. A nurse is assessing a client who has cirrhosis. Which of the following findings is the
priority for the nurse to report? – Expected Findings: fatigue, Wt. loss, Abdo. Pain, Abdo.
Distention, pruritus.
A. Platelets 70,000/mm3
B. Distended abdomen
C. Alkaline phosphatase 125 units/L
D. Clay coloured stools
Answer: A. Platelets 70,000/mm3
8. A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a
client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk
of which of the following adverse effects?

A. Hyperglycaemia – if unavailable, do not attempt to catch up by increasing the infusion rate
because client can develop Hyperglycaemia.
B. Diarrhoea
C. Constipation
D. Hypoglycaemia - sudden abruption of infusing rate can cause hypoglycaemia.
Answer: D. Hypoglycaemia - sudden abruption of infusing rate can cause hypoglycaemia.
9. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the
following actions should the nurse plan to take?
A. Administer the unit of packed RBC’s over 1 hr.
B. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion.
C. Initiate venous access with a 21-gauge needle.
D. Use Y tubing with 0.9% sodium chloride when administering the transfusion.
Answer: D. Use Y tubing with 0.9% sodium chloride when administering the transfusion.
10. A nurse is caring for a female who has toxic shock syndrome. Which of the following
findings should the nurse expect?
A. Elevated platelet count
B. Generalized rash
C. Whole body rash
D. Decreased total bilirubin
E. Hypertension
Answer: B. Generalized rash
11. A nurse is providing discharge teaching to an older adult client who had an exacerbation
of COPD. The client is to start fluticasone by metered-dose inhaler. Which of the following
instructions should the nurse include?
A. Use fluticasone as needed for shortness of breath.
B. Limit fluid intake to 1 L per day.
C. Obtain a yearly influenza immunization.
D. Assist use of pursed-lip breathing.
Answer: D. Assist use of pursed-lip breathing.

12. A nurse is providing discharge teaching to an older adult client following a left total hip
arthroplasty. Which of the following instructions should the nurse include in the teaching?
A. “You can cross your legs at the ankles when sitting down.”
B. “Clean the incision daily with hydrogen peroxide.”
C. “Install a raised toilet seat in your bathroom.”
D. “You should use an incentive spirometer every 8 hrs.”
Answer: C. “Install a raised toilet seat in your bathroom.”
13. A nurse is caring for a client who is postoperative following a femur fracture. Which of
the following findings should the nurse report to the provider immediately?
A. The client reports shortness of breath – sign of surgical complication
B. The client has a temperature of 38.1 C (100.5F)
C. The client’s incision is red and warm
D. The client reports incision pain
Answer: A. The client reports shortness of breath – sign of surgical complication
14. A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of
the following is an appropriate nursing action?
A. Place the client in a protective environment
B. Obtain a stool specimen with gloves
C. Clean surfaces with chlorhexidine-bleach
D. Wash hands with alcohol-based hand rub.
Answer: A. Place the client in a protective environment
15. A nurse is setting up a sterile field before performing a dressing change on client who is
postoperative. Which of the following actions should the nurse plan to take to maintain the
sterile field? (Select all the apply.)
A. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap
B. Select a work surface at the nurse’s waist level
C. Apply sterile gloves before opening the pack
D. Open the first flap of the sterile package toward the nurse's body
E. Place a surgical pack with a sterile drape on the work surface.
Answer: A. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap
B. Select a work surface at the nurse’s waist level

E. Place a surgical pack with a sterile drape on the work surface.
16. A nurse is caring for a client who has acute appendicitis. Which of the findings is the
priority to the provider?
A. Nausea
B. Flank pain
C. Fever
D. Rigid abdomen
Answer: D. Rigid abdomen
17. A nurse is caring for a client who is receiving radiation. The client reports nauseas since
the therapy was initiated. Which of the following considerations should the nurse include
when planning the client’s meals?
A. Offer frequent, high-carbohydrate meals
B. Offer highly seasoned foods
C. Offer a snack prior to radiation therapy
D. Offer hot beverages with meals
Answer: A. Offer frequent, high-carbohydrate meals
18. A nurse is caring for a client who is receiving mechanical ventilation. Which of the
following interventions should the nurse implement?
A. Empty water from the ventilator tubing daily.
B. Suction the client’s airway every 4 hr.
C. Maintain the client in supine position.
D. Perform oral care every 2 hr.
Answer: A. Empty water from the ventilator tubing daily.
19. A nurse in an emergency department is assessing a client who has cirrhosis of the liver.
Which of the following is a priority finding?
A. Palmar erythema
B. Spider angiomas
C. Yellow Sclera
D. Mental Confusion
Answer: D. Mental Confusion

20. A nurse is preparing to administer bumetanide to a client who has heart failure. Which of
the following assessment findings should indicate effectiveness of the medication?
A. Bowel sounds present in 4 quadrants on auscultation
B. Alert and oriented to time place and person
C. Lung sounds clear
D. Apical pulse 80/min and regular
Answer: C. Lung sounds clear
21. A nurse is caring for a client who has active tuberculosis. Which of the following
interventions should the nurse include in the plan of care?
A. Perform chest percussion twice daily
B. Wear a high-efficiency particulate air mask
C. Initiate droplet precautions
D. Obtain daily sputum specimen
Answer: B. Wear a high-efficiency particulate air mask
22. A nurse is caring for a client who has hypertension and has a new prescription for
lisinopril. The nurse should consult with the provider about which of the following
medication in the client's medication administration record?
A. Potassium chloride
B. Levothyroxine
C. Acetaminophen
D. Metformin
Answer: D. Metformin
23. A nurse is planning care for a client who is 1 day postoperative following an open
cholecystectomy. Which of the following interventions should the nurse include in the plan or
care?
A. Avoid use of anticoagulants
B. Place pillow under client knees
C. Discourage leg exercises while in bed
D. Apply compression stocking in lower extremities
Answer: D. Apply compression stocking in lower extremities

24. What interferes with warfarin therapy?
A. Potatoes
B. Oranges
C. Bananas
D. Cauliflower
Answer: D. Cauliflower
25. A nurse is administering furosemide 80 to a client with pulmonary edema. Which of the
following assessment findings indicates the nurse that the medication is effective?
A. Elevation in BP
B. Adventitious breath sounds
C. Weight loss of 1.8 kg (4lb) in the past 24 hr
D. Respiratory rate of 24/min
Answer: C. Weight loss of 1.8 kg (4lb) in the past 24 hr
26. A nurse is caring for a client who has Cushing’s disease. Which of the following findings
should the nurse expect?
A. Weight loss
B. Hyponatremia
C. Hyperglycemia
D. Hypercalcemia
Answer: C. Hyperglycemia
27. A nurse is monitoring a client who has receiving 2 units packed RBCs. Which of the
following manifestations indicates a haemolytic transfusion reaction?
A. Back pain
B. Bradycardia
C. Hypertension
D. Chills
Answer: A. Back pain

28. A PACU nurse is monitoring the drainage from a client’s NG tube following abdominal
surgery. Which of the following findings in the first postoperative hour should the nurse
report to the provider?
A. 75 mL of greenish yellow drainage
B. 100 mL of red drainage
C. 200 mL of brown drainage – purulent
D. 150 mL of serosanguineous drainage
Answer: C. 200 mL of brown drainage – purulent
29. A nurse is performing an admission assessment on a client who has severe chronic kidney
disease. Which of the following findings should the nurse expect?
A. Lethargy
B. Potassium 4.0 mEq/L
C. Hypotension
D. Serum creatinine 0.9 mg/Dl
Answer: A. Lethargy
30. A nurse is teaching a client who has hypothyroidism. Which of the following information
should the nurse include in the teaching? (Select all the apply.)
A. You will take medication for this condition for several months
B. You will need to eat a high-fibre diet to prevent complications of this condition
C. You might notice that you perspire more with this condition
D. We will perform laboratory tests to monitor the effect of your medication
E. This condition can cause you to gain weight.
Answer: B. You will need to eat a high-fibre diet to prevent complications of this condition
D. We will perform laboratory tests to monitor the effect of your medication
E. This condition can cause you to gain weight.
31. A nurse is caring for a client who is receiving mechanical ventilation when the lowpressure alarm sounds on the ventilator. Which of the following actions should the nurse
take?
A. Empty water from the client’s ventilator tubing
B. Evaluate the client for a cuff leak
C. Suction the client’s airway

D. Increase the client’s ventilator flow rate
Answer: B. Evaluate the client for a cuff leak
32. A nurse is reviewing laboratory results for four client who are scheduled for surgery.
Which of the following laboratory values should the nurse report to the surgeon?
A. INR of 1.6
B. Platelets 95,000/mm3
C. Hct 42%
D. WBC 8,000/mm3
Answer: B. Platelets 95,000/mm3
33. A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of the
following findings should the nurse identify as an indication that the medication is effective?
A. Increased potassium level
B. Decreased blood pressure
C. Increased heart rate
D. Decreased urinary output
Answer: B. Decreased blood pressure
34. A nurse is providing teaching to a client following a liver biopsy 1 hour ago. Which of the
following positions should the nurse instruct the client to maintain after the procedure?
A. Prone
B. Supine
C. Right lateral
D. Left lateral
Answer: C. Right lateral
35. A nurse is providing discharge teaching to a client following a modified left radical
mastectomy with breast expander. Which of the following statements by the client indicates
an understanding of the teaching?
A. “I will have to wait 2 months before additional saline can be added to my breast expander”
B. “I will perform strength building arm exercises using a 15-pound weight”
C. “I should expect less than 25 ml of secretions per day in the drainage devices”
D. “I will keep my left arm flexed at the elbow as much as possible”

Answer: C. “I should expect less than 25 ml of secretions per day in the drainage devices”
36. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the
following instructions should the nurse include?
A. “Wash your feet twice per day with antibacterial soap and hot water”
B. “Wear loose fitting slippers around the house”
C. “Wear cotton rather than nylon sock”
D. “Use a heating pad to keep your feet warm at night”
Answer: C. “Wear cotton rather than nylon sock”
37. A nurse is caring for a client following the placement of a transverse colostomy. Which of
the following findings indicates a possible complication?
A. Client reports pain of 6 on scale from 0 to 10
B. Heart rate 110/min
C. Bowel sounds hypoactive d.
D. Stoma appears dry
Answer: D. Stoma appears dry
38. A nurse is counseling a client who has a family history of hypertension about reducing
high risk for high blood pressure. Which of the following strategies should the nurse
recommend?
A. Engage is isometric exercises for 15 min daily
B. Maintain a body mass index between 31 and 34 less than 30
C. Lower total cholesterol level <200 mg/dL
D. Increase dietary potassium intake
Answer: C. Lower total cholesterol level <200 mg/dL
39. A nurse in the PACU is assessing a client who is postoperative following general
anaesthesia. Which of the following findings is the priority to address?
A. Piloerection of the skin
B. Vomiting upon arousal
C. Decreased body temperature
D. Indistinct, rambling speech
Answer: C. Decreased body temperature

40. A nurse is providing discharge teaching to the partner of a client who has a linear incision
site following an open cholecystectomy. Which of the following wound care instructions
should the nurse include?
A. Change the dressing four times per day
B. Use sterile gloves when performing the dressing change
C. Clean from the incision to the surrounding skin
D. Apply tincture of benzoin prior to removing the dressing
Answer: C. Clean from the incision to the surrounding skin
41. A nurse is preparing to administer vancomycin IV bolus to a client who has pneumonia.
Which of the following clinical manifestations should the nurse instruct the client to monitor
for and report?
A. Pallor of the extremities
B. Taste of metal in the mouth
C. Halo of light around objects
D. Ringing in the ears
Answer: D. Ringing in the ears
42. A nurse is caring for a client who has pancreatitis and has been receiving total parenteral
nutrition. Which of the following laboratory tests should the nurse monitor for overall
nutritional status?
A. Prealbumin
B. Creative protein
C. Creatinine
D. Lipase
Answer: A. Prealbumin
43. A charge nurse is called to a client’s room after a staff nurse reports a client has had a
wound evisceration. Which of the following actions should the charge nurse take?
A. Attempt to reinsert the protruding viscera
B. Obtain bottles of warm, sterile 0.9% sodium chloride solution
C. Place the client in left lateral recumbent position- low fowlers hips knees bent
D. Apply a firm pressure dressing across the client’s abdomen

Answer: B. Obtain bottles of warm, sterile 0.9% sodium chloride solution
44. A nurse is caring for four clients. Which of the following clients is at risk for developing
metabolic alkalosis?
A. A client who is receiving continuous gastric suctioning
B. A client who has aspiration pneumonia
C. A client who is experiencing an opioid overdose
D. A client who has uncontrolled diabetes mellitus
Answer: A. A client who is receiving continuous gastric suctioning
45. A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for
developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of
the following electrolytes because it can increase the risk for digoxin toxicity?
A. Calcium
B. Potassium -Digoxin toxicity can occur in the presence of hypokalaemia
C. Magnesium
D. Phosphatase
Answer: B. Potassium -Digoxin toxicity can occur in the presence of hypokalaemia
46. A nurse is assessing the abdominal wound of a client who is 3 days postoperative
following a colon resection. Which of the following findings should the nurse report to the
provider?
A. Erythema
B. Ecchymotic skin
C. Drainage
D. Edema
Answer: A. Erythema
47. A nurse is completing an admission assessment for a client. The nurse should expect the
provider to prescribe which of the following medications for the client? EXHIBIT:
Temperature (98.3 F), HR (100/min), RR (20/min), BP (152/94mmHg)
A. Atorvastatin
B. Allopurinol
C. Metoprolol

D. levothyroxine
Answer: C. Metoprolol
48. A nurse is assessing a client who is near the end of life following a head injury. The client
has alternating periods of rapid breathing and apnea. The nurse should document this finding
as which of the following respiratory patterns?
A. Biot’s respirations
B. Hypo ventilatory respirations
C. Kussmaul respirations
D. Cheyne-Stokes respirations
Answer: D. Cheyne-Stokes respirations
49. A nurse is administering a unit of packed RBCs to a client and notes that there are several
small clots floating in the IV bag. Which of the following actions should the nurse take?
A. Inject 5,000 units of heparin into the unit of packed RBCs
B. Place the unit of packed RBCs in a warming unit for 5 min
C. Return the unit of packed RBCs to the blood bank
D. Dilute the unit of packed RBCs using 50 mL of Lactated Ringer’s
Answer: C. Return the unit of packed RBCs to the blood bank
50. A nurse in a provider’s office is teaching a client about the self-management of GERD.
Which of the following instructions should the nurse include?
A “Eat a light meal 1 hour before bedtime”
B. “Lie down for 30 minutes after each meal”
C. “Increase your caloric intake by 250 calories per day”
D. “Sleep with the head of your bed elevated 6 inches”
Answer: D. “Sleep with the head of your bed elevated 6 inches”
51. A nurse is reviewing a client’s ECG rhythm strip. Which of the following components
should the nurse use to measure impulse conduction from the SA node through the AV node?
A. ST segment
B. QRS complex
C. PP interval
D. PR interval

Answer: D. PR interval
D. PR interval
52. A nurse is caring for a client who has pulmonary edema. The client’s ABGs are pH 7.22,
PaCO2 60mm Hg, and HCO3 26 mEq/L. The nurse should identify that the client is
experiencing which of the following acid- base imbalances?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D Metabolic acidosis
Answer: A. Respiratory acidosis
53. A nurse is teaching a client about self-administration of nitro-glycerine sublingual for the
treatment of angina pectoris. Which of the following statements should the nurse identify as
an indication that the client understands the teaching?
A. I should avoid repeating the dose if I get a headache
B. I should lie down when I take this medication
C. I should store the medication in a pill box
D. I should take the medication 1 hour before exercise
Answer: B. I should lie down when I take this medication
54. A nurse is caring for a client who has had a subtotal thyroidectomy? Which of the
following findings is the highest priority finding?
A. Haemorrhage
B. Decreased urine output
C. Stridor
D. Hypoglycaemia
Answer: A. Haemorrhage
55. A nurse is providing teaching to a client and his partner about performing peritoneal
dialysis at home. When discussing peritonitis, which of the following manifestations should
the nurse identify as the earliest indication of this complication?
A. Generalized abdominal pain
B. Cloudy effluent

C. Fever
D. Increased heart rate
Answer: C. Fever
56. A nurse is caring for a client who is receiving enteral nutrition. Which of the following
interventions by the nurse will prevent aspiration?
A. Check the gastric pH following bolus feedings
B. Place the client in supine position before initiating feedings
C. Instruct the client to perform the Valsalva maneuver after feedings
D. Measure residual volume prior to bolus feedings
Answer: D. Measure residual volume prior to bolus feedings
57. 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 plan to take to help prevent of
acute kidney failure?
A. Administer 0.9% sodium chloride IV at 25 mL/hr.
B. Administer a calcium channel blocker
C. Administer 500 mL IV fluid bonus
D. Administer oral rehydration solution
Answer: C. Administer 500 mL IV fluid bonus
58. A nurse is providing instructions about foot care for a client who has peripheral arterial
disease. The nurse should identify that which of the following statements by the client
indicates an understanding of the teaching?
A. I rest in my recliner with my feet elevated for about an hour every afternoon
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 apply a lubricating lotion to the cracked areas on the soles of my feet every morning
Answer: A. I rest in my recliner with my feet elevated for about an hour every afternoon
59. A nurse is caring for client who has COPD and reports dyspnea. The nurse should place
the client in which of the following positions
A. Lithotomy
B. Prone

C. Fowler’s
D. Trendelenburg
Answer: C. Fowler’s
60. Client has a pressure ulcer. Which indicates wound healing?
A. Light yellow exudate
B. Wound tissue firm to palpation
C. Dry brown eschar
D. Dark red granulation tissue
Answer: D. Dark red granulation tissue
61. STEPS to use of a peak flow meter (order form 1-5)
A. “Stand upright”
B. “Seal your lips around the mouth piece”
C. “Fill your lungs with a deep breath”
D. “Exhale forcefully and quickly”
E. “Record the highest of three consecutive readings”
Answer: A. “Stand upright”
C. “Fill your lungs with a deep breath”
B. “Seal your lips around the mouth piece”
D. “Exhale forcefully and quickly”
E. “Record the highest of three consecutive readings”
62. A nurse is caring for a client who has a PICC line in her left forearm. The client is
receiving an antibiotic via intermittent IV bolus every 12hr. Which of the following actions
should the nurse take in managing the client’s PICC line?
A. Maintain a continuous IV infusion through the PICC line
B. Access the catheter using a non-coring needle
C. Change the transparent membrane dressing daily- Usually q7days
D. Flush the catheter with a 0.9% sodium chloride solution after each use
Answer: D. Flush the catheter with a 0.9% sodium chloride solution after each use
63. A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the
following statements should the nurse include in the teaching?

A. Use peroxide to clean the mouthpiece of your inhaler
B. Exhale fully before bringing the inhaler to your lips
C. Depress the chatheter after you inhale
D. Do not shake your inhaler before use
Answer: B. Exhale fully before bringing the inhaler to your lips
64. A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia.
Which of the following assessment findings supports this suspicion?
A. Cool, clammy skin
B. Increased urine output
C. Kussmaul respirations
D. Acetone breath
Answer: A. Cool, clammy skin
65. Client, who is 6 hr postoperative following application of an external fixator for a tibial
fracture. Which of the following actions should the nurse take?
A. Palpate the dorsalis pedis pulse.
B. Maintain the affected extremity in a dependent position
C. Wrap sterile gauze on the short point of the pins
D. Adjust the clamps on the fixator flame
Answer: A. Palpate the dorsalis pedis pulse.
66. A nurse is preparing an in-service presentation about the use of automated external
defibrillators (AEDs). Which of the following instructions should the nurse include in the
teaching?
A. “Perform CPR while the AED is analysing”
B. “Position the client on a flat surface”
C. “Set the AED to 80 joules”
D. “Use an AED for a client who has A-fib”
Answer: B. “Position the client on a flat surface”
67. Serum sodium level of 120 mEq/L. Which of the followings findings should the nurse
expect?
A. Hyperreflexia

B. Decreased bowel sounds
C. Confusion
D. Increase CVP
Answer: C. Confusion
68. A nurse in an emergency dept is caring for a client who has abdominal pain. The client
reports a 3-day history of low-grade fever with the chest congestion. Which of the following
prescriptions should the nurse initiate first?(exhibit)
A. Sputum for culture and sensitivity
B. Regular insulin at 0.1 unit/kg/hr by continuous IV infusion
C. Ceftriaxone 1g by intermittent IV bolus every 12 hr
D. 0.9% sodium chloride at 500 mL/hr by continuous IV infusion
Answer: C. Ceftriaxone 1g by intermittent IV bolus every 12 hr
69. Pt. taking isoniazid and rifampin, which understands?
A. “I will be finished with this medication regimen in 3 months”
B. “I should check the whites of my eyes while taking these medications” – hepatotoxicity
C. “I should take my mediation with an antacid if it upsets my stomach”
D. “I will no longer be infectious after two consecutive negative sputum specimens”
Answer: B. “I should check the whites of my eyes while taking these medications” –
hepatotoxicity
70. The use of incentive spirometer.
A. Position the mouthpiece 2.5cm (1 in) from the mouth
B. Place hands on the upper abdomen during inhalation
C. Hold breaths about 3-5 secs before exhaling
D. Exhale slowly through purse lips
Answer: C. Hold breaths about 3-5 secs before exhaling
71. Pt. who is in septic shock. Which lab findings indicate the patient is developing “multiple
organ dysfunction syndrome”?
A. Arterial hypoxemia – MODS Complication
B. Decreased liver enzymes
C. Decreased BUN

D. Hypoglycemia
Answer: A. Arterial hypoxemia – MODS Complication
72. A nurse is reviewing a client’s laboratory values and notes a potassium level of 2.8
mEq/Which of the following findings should the nurse expect?
A. Hypoactive Bowel sounds
B. Decreased BP
C. Irregular pulse
D. Exaggerated reflexes
Answer: C. Irregular pulse
73. A nurse is caring for a client who is admitted to the medical-surgical unit with a seizure
disorder. Which of the following interventions should the nurse include in the plan of care?
A. Teach assistive personnel how to apply restraints
B. Keep the side rails in a down position
C. Keep a padded tongue blade at the client’s bedside
D. Maintain peripheral IV access.
Answer: D. Maintain peripheral IV access.
74. A nurse is collecting a medical history from an older adult client who has hypertension
and new prescription of nadolol Which of the following findings should the nurse report to
the provider?
A. cataracts
B. GERD
C. Asthma
D. Hypothyroidism
Answer: C. Asthma
75. A nurse is preparing a client for a Lumbar puncture. Which of the following images
indicates the position the nurse should assess the client into for this procedure?
Answer: fetal position (sitting forward on the table)

76. A nurse is caring for a client who has diabetes mellitus. The client’s ABG are ph 7.14,
PaO2 90 mmHg, PaCO2 35 mmHg, and HCO3-4 mEq/L. The nurse should identify that the
client has which of the following acid-base imbalances?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Metabolic acidosis
Answer: D. Metabolic acidosis
77. A nurse is planning care for a client who has developed nephrotic syndrome. Which of the
following dietary recommendations should the nurse include?
A. Increased Phosphorus intake
B. Increased Potassium intake
C. Decrease protein intake
D. Decreased carbohydrate intake.
Answer: C. Decrease protein intake
78. A nurse is planning care for a client who has new diagnosis of acute pancreatitis. Which
of the ff interventions should the nurse include in the plan of care?
A. Administer antihypertensive meds
B. Maintain the client on NPO status
C. Place client in supine position
D. Monitor the client for hypercalcemia
Answer: B. Maintain the client on NPO status
79. A nurse is assessing a client who has increased intracranial pressure. The nurse should
recognize that which of the following is the first sign of deteriorating neurological status?
A. Altered level of consciousness
B. Pupillary constriction
C. Decorticate posturing
D. Cheyne-stokes respirations
Answer: A. Altered level of consciousness

80. A nurse is obtaining a medication history from a client who is to start therapy with
naproxen for rheumatoid arthritis. Which of the following medications places the client at
risk for bleeding?
A. Captopril
B. Ibuprofen
C. Digoxin
D. Phenytoin
Answer: B. Ibuprofen
81. A nurse is caring for an older adult client who is suspected of having septicaemia. Which
of the following actions is the nurse’s priority?
A. Obtain a WBC count with differential
B. Obtain a history to determine recent injuries.
C. Obtain a blood specimen of culture and sensitivity testing
D. Obtain a broad-spectrum antibiotic for rapid administration.
Answer: C. Obtain a blood specimen of culture and sensitivity testing
82. A nurse is assessing a client following a kidney biopsy. Which of the following findings
should the nurse identify as an indication that the client is experiencing internal bleeding?
A. Bradycardia
B. Polyuria
C. Flank Pain
D. Increase Blood Pressure
Answer: C. Flank Pain
83. A nurse is caring for a client who has diabetes insipidus and has had a urinary output of
3,000 ml in the past 12 hr. which of the following medications should the nurse expect to
administer to the client?
A. Dopamine
B. Desmopressin acetate
C. Furosemide.
D. Spironolactone
Answer: B. Desmopressin acetate

84. A nurse is admitting a client to a medical unit following placement of a permanent
pacemaker. Which of the following findings requires further assessment by the nurse?
A. Sneezing
B. Presence of a sharp spike prior to the QRS complex on the ECG
C. Hiccups
D. Presence of intrinsic P waves following a QRS complex on the ECG
Answer: C. Hiccups
85. A nurse is caring for a client receiving TPN who weighs 160Lb. If the RDA of protein
is0.8g/kg of body weight. How many g of protein should the client receive?
Answer: (160/2.2) x 0.8 = 58g
86. A nurse is caring for a client who has an arteriovenous graft. Which of the following
findings indicates adequate circulation of the graft?
A. Dilated appearance of the graft
B. Normotensive blood pressure
C. Absence of a bruit
D. Palpable thrill
Answer: D. Palpable thrill
87. A nurse is providing discharge teaching for a client who is receiving treatment for genital
herpes. Which of the following indicates effective of the teaching?
A. I should expect my lesions to resolve in 6 weeks
B. I should expect to take my medication for 3 weeks
C. I should use natural skin condoms during sex.
D. I should apply antibiotic ointment to lesions.
Answer: A. I should expect my lesions to resolve in 6 weeks
88. A nurse is caring for a client who has a history of chemotherapy-included nauseas and
vomiting. Which of the following medications should the nurse administer prior to
chemotherapy?
A. Ondansetron
B. Sertraline
C. Diphenhydramine

D. Methylprednisolone
Answer: A. Ondansetron
89. A nurse is preparing to administer daily medications to a client who is undergoing
procedure at 1000 that req IV contrast dye. Which of the following routine meds to give at
0800 should the nurse withhold?
A. Metoprolol
B. Metformin -risk for lactic acidosis from contrast dye with iodine
C. Fluticasone
D. Valproic Acid
Answer: B. Metformin -risk for lactic acidosis from contrast dye with iodine
90. A nurse is preparing to assist with the insertion of a non-tunnelled central venous catheter
fora client who is malnourished. Which of the following actions should the nurse plan to
take?
A. Confirm the correct position of the line by obtaining a blood sample. – Xray confirms
placement.
B. Instruct the client to cough as the catheter is inserted. – cough may shift vessels.
DANGER
C. Place the head of the client’s bed lower than the foot.
D. Cleanse the site with a hydrogen peroxide solution. – must clean with chlorhexidine
Answer: C. Place the head of the client’s bed lower than the foot.
91. A nurse is caring for a client who has hypervolemia. Which of the following is an
expected assessment finding?
A. Hypotension
B. Weight gain - S/S: weight gain, hypertension, tachycardia
C. Bradycardia
D. Loss of skin turgor
Answer: B. Weight gain - S/S: weight gain, hypertension, tachycardia
92. A nurse is reviewing discharge teaching with a client with a client who has a new
prescription for warfarin. Which of the following client statements indicates an understanding
of the teaching?

A. “I know the medication increases my risk for blood clots.”
B. “I should avoid taking ibuprofen while taking this medication.”
C. “I will increase green leafy vegetables in my diet.”
D. “I will return in 1 month to have my blood tested.”
Answer: B. “I should avoid taking ibuprofen while taking this medication.”
93. A nurse is caring for a client who has glaucoma. Which of the following findings should
the nurse expect?
A. The client reports loss of peripheral vision.
B. The client’s eyes are watery t
C. The client’s pupils are constricted.
D. The client reports dark floaters in the affected eye.
Answer: A. The client reports loss of peripheral vision.
94. A nurse is planning care for a client who has left-sided hemiplegia following a stroke.
Which of the following actions should the nurse include in the plan of care?
A. Remind the client to use a cane on his left side while ambulating.
B. Provide the client with a short-handled Reacher.
C. Position the bedside table on the client’s left side.
D. Place a plate guard on the client’s meal tray.
Answer: C. Position the bedside table on the client’s left side.
95. A nurse in the emergency department is evaluating a young client for bacterial meningitis.
Which of the following actions should the nurse take as a part of the focused assessment?
A. Run a tongue blade on the outside of the client’s sole and note any flaring of the toes
B. Tap the client’s facial nerve and note any fecal twitching
C. Strike the client’s patellar tendon with a percussion hammer and note any increase in
response
D. Gently elevate the client’s head and note any nuchal rigidity
Answer: D. Gently elevate the client’s head and note any nuchal rigidity
96. A nurse is planning to flush an implanted port for a client who is receiving chemotherapy.
Which of the following supplies should the nurse plan to use?
A. A short peripheral catheter

B. A winged infusion needle
C. A non-coring needle
D. A large-bore needle
Answer: C. A non-coring needle
97. A nurse is providing discharge teaching to a client who has heart failure and instructs him
to limit sodium intake to 2 g per day. Which of the following statements by the client
indicates an understanding of the teaching?
A. “I can have mayonnaise on my sandwiches.”
B. “I can drink vegetable juice with a meal.” 3
C. “I can season my foods with garlic and onion salts.”
D. “I can have a frozen fruit juice bar for dessert.”
Answer: D. “I can have a frozen fruit juice bar for dessert.”

Set 5
1. A nurse is caring for a client who is having a seizure. Which of the following Interventions
in the nurse’s priority?
Answer: Turn the client to the side
2. A nurse is caring for a group of clients. The nurse should plan to make are ferral to
physical therapy for which of the following clients?
Answer: A client who is receiving preoperative teaching for a right knew arthroplasty
3. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing.
The nurse should postpone the testing and report to the provider which of the following
findings?
Answer: Current medications
4. A home health nurse is assigned to a client who was recently discharged from rehabilitation
centre after experiencing a right-hemispheric stroke. Which of the following neurologic
deficits should the nurse expect to find when assessing the client? (SATA)
A. Visual spatial deficits

B. Left hemianopsia
C. One-sided neglect
Answer: A. Visual spatial deficits
B. Left hemianopsia
C. One-sided neglect
Rationale:
A. Visual spatial deficits is correct. Visual spatial deficits and loss of depth perception occur
secondary to a right-hemispheric stroke.
B. Left hemianopsia is correct. Left hemianopsia, or blindness in the left half of the visual
field, occurs secondary to a right-hemispheric stroke.
C. One-sided neglect is correct. One-sided neglect, or an unawareness of the affected side,
occurs secondary to a right-hemispheric stroke.
5. A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty.
Which of the following actions should the nurse take?
Answer: Place a pillow between the client’s legs
6. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place
which of the following items at the client’s bedside table?
Answer: Suction machine
7. A nurse is planning teaching for a client who has bladder cancer and is to undergo a
cutaneous diversion procedure to establish a ureterostomy. Which of the following statements
should the nurse include in the teaching?
Answer: You should cut the opening of the skin barrier one-eighth inch wider than the stoma
(1/8)
8. A nurse in an emergency department is caring for a client who reports vomiting and
diarrhoea for the past 3 days. Which of the following findings should indicate to the nurse
that the client is experiencing fluid volume deficit?
Answer: Heart rate 110 (sign of dehydration)

9. A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal
implant to treat endometrial cancer. Which of the following actions should the nurse include
in the client’s plan of care?
Answer: Wear a lead apron while providing care to the client
10. A nurse is planning to provide discharge teaching for the family of an older adult client
who has hemianopsia and is at risk for falls. Which of the following instructions should the
nurse include?
Answer: Remind the client to scan their complete range of vision during ambulation
11. A nurse is planning care to decrease psychosocial health issues for a client who is starting
dialysis treatments for chronic kidney disease. Which of the following interventions should
the nurse include in the plan?
Answer: Tell the client that it is possible to return to similar previous levels of activity
12. A nurse is caring for a client who has a closed head injury and has an intraventricular
catheter placed. Which of the following findings indicate that the client is experiencing
increased intracranial pressure? (SATA)
A. Sleepiness exhibited by the client
B. Widening pulse pressure
C. Decerebrate posturing
Answer: A. Sleepiness exhibited by the client
B. Widening pulse pressure
C. Decerebrate posturing
13. An older adult client is brought to an emergency department by a family member. Which
of the following assessment findings should cause the nurse to suspect that the client has
hypertonic dehydration?
Answer: Urine specific gravity 1.045
14. A nurse is caring for client who has a prescription for enalapril. The nurse should identify
which of the following findings as an adverse effect of the medication?
Answer: Orthostatic hypotension

15. 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?
Answer: You will not be able to use sildenafil if you are taking nitro-glycerine.
16. A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in the
plan of care to prevent a pseudomonas aeruginosa infection?
Answer: Avoid placing plants or flowers in the client’s room
17. A nurse is teaching a class about client rights. Which of the following instructions should
the nurse include?
Answer: A client should sign an informed consent before receiving a placebo during a
research trial.
18. A nurse is caring for a client who is receiving morphine for daily dressing changes. The
client tells the nurse, “I don’t want any more morphine because I don’t want to get addicted”.
Which of the following actions should the nurse take?
Answer: Instruct the client on alternative therapies for pain reduction
19. A nurse is preparing a client who has supraventricular tachycardia for elective
cardioversion. Which of the following prescribed medications should the nurse instruct the
client to withhold for 48hr prior to cardioversion?
Answer: Digoxin
Rationale:
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medication
scan increase ventricular irritability and put the client at risk for ventricular fibrillation after
the synchronized countershock of cardioversion.
20. A nurse is caring for a client 1 hr following a cardiac cath. The nurse notes the formation
of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which
of the following interventions is the nurse’s priority?
Answer: Apply firm pressure to the insertion site

21. A nurse is assessing a client who has Graves’ disease. Which of the following images
should indicate to the nurse that the client has exophthalmos?
Answer:

Rationale:
The nurse should identify an outward protrusion of the eyes as exophthalmos, a common
finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the
extraocular muscle and increases fatty tissue behind the eye, which results in the eyes
protruding outward. Exophthalmos can cause the client to experience problems with vision,
including focusing on objects, as well as pressure on the optic nerve.
22. A nurse is caring for a client who has a stage III pressure injury. Which of the following
findings contributes to delayed wound healing?
Answer: Urine output 25ml/hr. (normal 30ml/hr.)
Rationale:
Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which
can delay wound healing.
23. A nurse is providing teaching to a client who is receiving chemo and has a new
prescription for epoetin alfa. Which of the following statements indicated an understanding of
the teaching?
Answer: I will monitor my blood pressure while taking this medication
Rationale:

The client should monitor their blood pressure while taking this medication because
hypertension is a common adverse effect and can lead to hypertensive encephalopathy.
24. A nurse is providing discharge instructions to a client following an upper gastrointestinal
series with barium contrast. Which of the following information should the nurse provide?
Answer: Increase fluid intake
Rationale:
Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct
the client to increase fluid intake to facilitate the elimination of the barium used during the
test.
25. A nurse is assessing a client who has acute cholecystitis. Which of the following findings
is the nurse’s priority?
Answer: Tachycardia
Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can
lead to shock. The nurse should position the head of the client's bed flat and report this
finding immediately to the provider.
26. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend?
Answer: Add cabbage to the diet
Rationale:
To help reduce the risk for colorectal cancer, the client should consume a diet that is high in
fibre, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage,
cauliflower, and broccoli, are high in fibre.
27. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation.
The client appears anxious and restless, and the high-pressure alarm is sounding. Which of
the following actions should the nurse take first?
Answer: Instruct the client to allow the machine to breathe for them
Rationale:

When providing client care, the nurse should first use the least restrictive intervention.
Therefore, the first action the nurse should take is to provide verbal instructions and
emotional support to help the client relax and allow the ventilator to work. Clients can exhibit
anxiety and restlessness when trying to "fight the ventilator."
28. A nurse is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
Answer: Demonstrate ways to deep breath and cough
29. Nurse and assistive personnel are caring for a client who has bacterial meningitis. The
nurse should give the AP which of the following instructions?
Answer: Wear a mask
Rationale:
Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear
a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun
receiving antibiotic therapy.
30. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the
following actions should the nurse take?
Answer: Remain with the client for the first 15 min of the infusion
31. 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?
Answer: I am taking this medication to increase my energy level
Rationale:
The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have
anemia. When the medication is effective, the client should have a decrease in fatigue and an
improvement in activity tolerance.
32. A nurse is caring for a client who has hepatic encephalopathy that is being treating with
lactulose. The client is experiencing excessive stools. Which of the following findings is an
adverse effect of this medication?
Answer: Hypokalaemia

Rationale:
Lactulose works by stimulating the production of excess stools to rid the body of excess
ammonia. These excessive stools can result in hypokalemia and dehydration.
33. 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?
Answer: I am dieting to lose weight
34. A nurse is caring for a client who has type 1 diabetes mellitus and has acute bronchitis for
the past 3 days. Which of the following statements should the nurse include when instructing
the client?
Answer: Take your insulin even if you are unable to eat your regular diet
35. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin
subQ. Which of the following action should the nurse take?
Answer: Inject the medication into the anterolateral abdominal wall.
36. A nurse is caring for a client who is undergoing haemodialysis to treat end-stage kidney
disease. The client reports muscle cramps and a tingling sensation in their hands. Which of
the following medications should the nurse plan to administer?
Answer: Calcium Carbonate
Rationale:
Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring
late in the dialysis session, hypocalcaemia can cause the client to experience muscle
cramping and tingling to extremities. The nurse should plan to administer a calcium
supplement, such as calcium carbonate, as a calcium replacement.
37. A nurse is assessing a client following the administration of magnesium sulphate 1g IV
bolus. For which of the following adverse effects should the nurse monitor?
Answer: Respiratory paralysis
Rationale:

The nurse should monitor a client who is receiving magnesium sulphate via IV bolus closely
as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory
system. Respiratory paralysis is a life- threatening adverse effect of magnesium sulphate.
38. A nurse is caring for a client who has diabetic ketoacidosis. Which of the following lab
findings should the nurse expect?
Answer: BUN 32
39. A nurse is providing teaching to a client who has irritable bowel syndrome. Which of the
following instructions should the nurse include in the teaching?
Answer: Increase fibre intake to at least 30g per day
40. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory results to be below the expected reference range?
Answer: Calcium
Rationale:
A client who has pancreatitis is expected to have decreased calcium and magnesium levels
due to fat necrosis.
41. A nurse is assessing a client who had extracorporeal shock wave lithotripsy 6hr ago.
Which of the following findings should the nurse expect?
Answer: Stone fragments in the urine
Rationale:
ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the
bladder, and through the urethra during voiding. Following the procedure, the nurse should
strain the client's urine to confirm the passage of stones.
42. A nurse is creating a plan of care for a client who has neutropenia as a result of
chemotherapy. Which of the following interventions should the nurse include in the plan?
Answer: Monitor the client’s temperature every 4 hr
Rationale:
The nurse should monitor the temperature of a client who has neutropenia every 4 hr because
the client's reduced amount of leukocytes greatly increases the client's risk for infection.

43. A nurse is assessing a group of clients for indications of role changes. The nurse should
identify that which of the following clients is at risk for experiencing a role change?
Answer: A client who has MS and is experiencing progressive difficulty ambulating
Rationale:
The nurse should identify that progression of a neurologic disease such as multiple sclerosis
can lead to a role change as the client becomes less independent.
44. A nurse in a provider’s office is assessing a client who has migraine headaches and is
taking feverfew to prevent headaches. The nurse should identify that which of the following
client medications interacts with feverfew?
Answer: Naproxen
Rationale:
Both naproxen and feverfew impair platelet aggregation and place the client at risk for
bleeding
45. A nurse is conducting an admission history for a client who is to undergo a CT scan with
an IV contrast agent. The nurse should identify that which of the following findings requires
further assessment?
Answer: History of asthma
Rationale:
A client who has a history of asthma has a greater risk of reacting to the contrast dye used
during the procedure. Other conditions that can result in a reaction to contrast media include
allergies to foods, such as shellfish, eggs, milk, and chocolate.
46. A nurse has received change-of-shift report for a group of clients. Which of the following
clients should the nurse assess first?
Answer: A client who had a myocardial infarction 4 days ago and is asking for a PRN
sublingual nitro tabs.
Rationale:
When using the stable vs. unstable approach to client care, the nurse should assess this client
first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual
nitro-glycerine tablet could be unstable. This client might be experiencing angina or could be
having another MI.

47. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a
productive cough. Which of the following actions should the nurse take first?
Answer: Initiate airborne precautions
Rationale:
This client is exhibiting manifestations of tuberculosis. The greatest risk in this client
situation is for other people in the facility to acquire an airborne disease from this client.
Therefore, the first action the nurse should take is to initiate airborne precautions.
48. A nurse is caring for a client who has a new prescription for total parental nutrition. The
client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should
be set at how many mL/hr?
Answer: 167
X = 4,000 mL
mL/hr = 24 hr
X mL/hr = 166.67
Step 6: Round if necessary. 166.67 = 167 mL/hr
49. A nurse is an emergency department is caring for a client who has full thickness burns
over 20% of their total body surface area. After ensuring a patent airway and administering
oxygen, which of the following items should the nurse prepare to administer first?
Answer: IV fluids
Rationale:
After establishing that the client's airway is secure and administering oxygen, evidence-based
practice indicates that the nurse should prepare to administer IV fluids to provide circulatory
support.
50. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a
pressure injury. Which of the following actions should the nurse take?
Answer: Use a 30mL syringe
Rationale:
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver
the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain
healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

51. A nurse is providing teaching for a female client who has recurrent UTI. Which of the
following info should the nurse include in the teaching?
Answer: Void before and after intercourse
52. A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon
assessing the client, the nurse observes the following findings: HR 200 B/P 78.40 RR 30.
Which of the following actions should the nurse take?
Answer: Perform synchronized cardioversion
Rationale:
The nurse should perform synchronized cardioversion for a client who has supra ventricular
tachycardia.
53. A nurse is providing teaching to an older adult client who has cancer and a new
prescription for an opioid analgesic for pain management. Which of the following
information should the nurse include in the teaching?
Answer: You should void every 4 hours to decrease the risk of urinary retention
54. A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of
the following precautions should the nurse implement?
Answer: Ensure that the client has a patent IV
Rationale:
The nurse should ensure the client has IV access in the event that the client requires
medication to stop seizure activity.
55. 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?
Answer: Suppressing gastric acid production
Rationale:
Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by
suppressing gastric acid production.

56. A nurse is caring for client who has bilateral pneumonia and an SaO 2 of 85%.The client
has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the
following actions should the nurse take first?
Answer: Place the client in high-Fowlers position
Rationale:
The greatest risk to this client is injury from airway obstruction. Therefore, the priority
intervention the nurse should take is to move the client into high-Fowler's position. HighFowler's position facilitates lung expansion and improves ventilation and gas exchange.
57. A nurse is assessing a male client for an inguinal hernia. Which of the following areas
should the nurse palpate to verify that the client has an inguinal hernia?
A. The nurse should palpate this location to assess the client for a femoral hernia.
B. The nurse should palpate this location to assess the client for an umbilical hernia.
C. The nurse should palpate this location to assess the client for an inguinal hernia.
Answer: C. The nurse should palpate this location to assess the client for an inguinal hernia.
Rationale:
A is incorrect. The nurse should palpate this location to assess the client for a femoral hernia.
A femoral hernia is composed of fat and forms in the femoral canal, which, as a result,
enlarges and pulls on the peritoneum and sometimes the bladder.
B is incorrect. The nurse should palpate this location to assess the client for an umbilical
hernia. This type of hernia can be congenital or acquired as a result of pregnancy or obesity
and places increased pressure on the abdominal wall.
C is correct. The nurse should palpate this location to assess the client for an inguinal hernia.
An inguinal hernia forms from the peritoneum, which contains part of the intestine, and can
protrude into the scrotum in men.
58. A nurse in an emergency department is caring for a client who is experiencing a thyroid
storm. Which of the following manifestations should the nurse expect? SATA
A. Fever
B. Nonpitting edema
C. Hypertension
D. Tachycardia
E. Hypoglycemia
Answer: A. Fever

C. Hypertension
D. Tachycardia
Rationale:
A. Fever is correct. The nurse should expect the client to have a fever because of the
excessive thyroid hormone release.
B. Nonpitting edema is incorrect. Nonpitting edema is a manifestation of myxedema coma, a
complication of hypothyroidism.
C. Hypertension is correct. The nurse should expect one of the early manifestations of thyroid
storm to include systolic hypertension because of the excessive thyroid hormone release.
D. Tachycardia is correct. The nurse should expect the client to have tachycardia because of
the excessive thyroid hormone release.
E. Hypoglycemia is incorrect. Hypoglycemia is a manifestation of myxedema coma,
acomplication of hypothyroidism.
59. A nurse is performing a dressing change for a client who is recovering from a
hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is
protruding through the abdomen. Which of the following actions should the nurse take first?
Answer: Call for help
Rationale:
Evidence-based practice indicates that the nurse should first stay with the client and call for
assistance. The client will require emergency surgery and is at risk for shock; therefore, the
nurse should obtain immediate assistance.
60. A nurse is providing discharge instructions to a client who has a partial thickness burn on
the hand. Which of the following instructions should the nurse include?
Answer: Wrap fingers with individual dressings
Rationale:
The nurse should instruct the client to wrap the fingers individually to allow for functional
use of the hand while healing occurs. The nurse should also instruct the client to perform
range-of-motion exercises to each finger every hour while awake to promote function of the
injured hand.
61. A nurse is caring for a client who has HIV. Which of the following findings indicates a
positive response to the prescribed HIV treatment?

Answer: Decreased viral load
62. 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?
Answer: Administer dextrose in 10% water until the new bag arrives
Rationale:
TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is
temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid
a precipitous drop in the client's blood glucose level.
63. A nurse is assessing a client who has had a suspected stroke. The nurse should place
priority on which of the following findings?
Answer: Dysphagia
Rationale:
Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation
and function within the oral cavity. Therefore, the nurse should place priority on this finding.
64. A nurse in a provider’s office is assessing a client who has hypertension and takes
propranolol. Which of the following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication?
Answer: Report of a night cough
Rationale:
The nurse should recognize that a night cough is an early indication of heart failure and report
this adverse reaction to the provider.
65. A nurse in an emergency department is assessing a client who has a detached retina.
Which of the following should the nurse expect the client to report?
Answer: It’s like a curtain closed over my eye
Rationale:
A retinal detachment is the separation of the retina from the epithelium. It can occur because
of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment
typically report the sensation of a curtain being pulled over part of the visual field.

66. A nurse is providing teaching to a female client who has a history of UTI. Which of the
following information should the nurse include in the teaching?
Answer: Daily cranberry supplements
Rationale:
The client should take cranberry supplements or drink low-fructose cranberry juice because it
contains compounds that adhere to the urinary tract wall, decreasing the risk for developing
aUTI.
67. A nurse in an emergency department is reviewing the provider’s prescriptions for a client
who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should
the nurse suspect?
Answer: Administer an opioid analgesic to the client
68. A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of
the following findings should the nurse identify as a manifestation of chronic
glomerulonephritis?
Answer: Hyperkalemia
Rationale:
The nurse should identify that a client who has chronic glomerulonephritis can experience
hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of
potassium.
69. A nurse in a community clinic is caring for a client who reports an increase in the
frequency of migraine headaches. To help reduce the risk for migraine headaches, which of
the following foods should the nurse recommend the client avoid?
Answer: Aged cheese
Rationale:
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine
headaches.
70. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago.
Which of the following actions should the nurse take?
Answer: Check that one finger fits between the cast and the leg
Rationale:

To make sure the cast is not too tight, the nurse should be able to slide one finger under the
cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an
issue 2 hr after application.
71. A nurse is caring for a client who has viral pneumonia. The client’s pulse ox readings
have fluctuated between 79% and 88% for the last 3o min. Which of the following oxygen
delivery systems should the nurse initiate to provide the highest concentration of oxygen?
Answer: Nonrebreather mask
Rationale:
The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the
client. A client who has an unstable respiratory status should receive oxygen via a
nonrebreather mask.
72. 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?
Answer: Blood pressure 170/80
Rationale:
Using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at
risk for thyroid storm.
73. A nurse is teaching a young adult client how to perform testicular self-exams. Which of
the following instructions should the nurse include?
Answer: Roll each testicle between the thumb and fingers
74. A nurse is caring for a client who has a potassium level 3. Which of the following
assessment findings should the nurse expect?
Answer: Hypoactive bowel sounds
Rationale:
Hypokalaemia decreases smooth muscle contraction in the gastrointestinal tract leading to
decreased peristalsis.
75. A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following
lab values should the nurse expect?

Answer: Elevated bilirubin level
Rationale:
Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the
haemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the
client's degree of jaundice.
76. A nurse is providing discharge teaching to a client who has heart failure and anew
prescription for a potassium-sparing diuretic. Which of the following information should the
nurse include in the teaching?
Answer: Try to walk at least 3x per week for exercise
77. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes militias. Which
of the following client statements indicates the client is successfully coping with the change?
Answer: I used to never worry about my feet. Now I inspect my feet every day with a mirror
78. A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following supplements
can interfere with the effectiveness of the medication?
Answer: Calcium
Rationale:
Calcium limits the development of osteoporosis in clients who are postmenopausal and works
as an antacid. Calcium supplements can interfere with the metabolism of a n
79. A nurse is providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statements should the nurse identify as an
indication that the client understands the teaching?
Answer: I will use my hands rather than a washcloth to clean the radiation area
Rationale:
The client should gently wash the radiation area with their hands using warm water and mild
soap to protect the skin from further irritation.
80. A nurse is performing a cardiac assessment for a client who had a MI 2 days ago. Which
of the following actions should the nurse take first after hearing the following sound?
Answer: Listen with the client on their left side

Rationale:
When providing nursing care, the nurse should first use the least invasive intervention.
Therefore, after auscultating a murmur, the first action the nurse should take is to place the
client on their left side and listen to the heart again so that the murmur can be heard more
clearly.
81. A nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client understands the
teaching?
Answer: I will wear clean graduated compression stockings everyday
82. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
Answer: Loosen restrictive clothing
Rationale:
The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.
83. A nurse is caring for a client who presents to a clinic for a 1 week follow up visit after
hospitalization for a heart failure. Based on the information in the client’s chart, which of the
following findings should the nurse report to the provider?
Answer: Heart rate 55
84. A nurse is providing instructions to a client who has type 2 DM and a new prescription for
metformin. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: I should take this medication with a meal
85. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing’s triad?
Answer: Bradycardia
Rationale:
A client who has increased intracranial pressure from a traumatic brain injury can develop
bradycardia, which is one component of Cushing's triad. The other components of Cushing’s
Triad are severe hypertension and a widened pulse pressure.

86. A nurse is providing dietary teaching to a client who is postoperative following a
thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to
include which of the following foods that has the greatest amount of calcium in her diet?
Answer: 12 Almonds
Rationale:
The nurse should determine that almonds are the best source of calcium to recommend
because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which
regulate calcium in the body, can result in hypocalcaemia.
87. A nurse is caring for a client who has portal hypertension. The client is vomiting blood
missed with food after a meal. Which of the following actions should the nurse take first?
Answer: Obtain vital signs
Rationale:
The first action the nurse should take using the nursing process is to assess the client's vital
signs. A client who has portal hypertension can develop esophageal varices, which are
fragileand can rupture, resulting in large amounts of blood loss and shock. Obtaining vital
signs provides information about the client's condition that can contribute to decision making.
88. A nurse is caring for a client who is postoperative following a total hip arthoplasty. Which
of the following lab values should the nurse report to the provider?
Answer: Hgb 8 g/dL
Rationale:
The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range
and is an indicator of postoperative hemorrhage or anaemia.
89. A nurse is caring for a client who has amyotrophic lateral sclerosis and is being admitted
to the hospital with pneumonia. Which of the following assessment findings is the nurse’s
priority?
Answer: Increased respiratory secretions
Rationale:
Using the airway, breathing, circulation approach to client care, the nurse should determine
that the priority assessment finding is increased respiratory secretions. These secretions place

the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the
ALS and the pneumonia.
90. A nurse is caring for a client who has a leg cast and is returning demonstration on the
proper use of crutches while climbing stairs. Identify the sequence the client should follow
when demonstrating crutch use.
Answer: Places body weight on crutches
Advances the unaffected leg onto the stair
Shifts weight from the crutches to the unaffected leg Brings the crutches and the affected leg
up to the stair
91. A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend?
Answer: Add cabbage to the diet
92. A home health nurse is assigned to a client who was recently discharged from a
rehabilitation centre after experiencing a right-hemispheric stroke. Which of the following
neurologic deficits should the nurse expect to find when assessing the client?
Answer: Visual spatial deficits
Left hemianopsia
One-sided neglect
93. A nurse is caring for a client who has viral pneumonia. The client’s pulse oximeter
readings have fluctuated between 79% and 88% for the last 30 min.
Answer: Nonrebreather mask
94. A nurse is caring for a client who has bilateral pneumonia and an SaO 2 of 85%. The client
has dyspnea with a productive cough and is using accessory muscles to breathe.
Answer: Place the client in high- Fowler’s position
95. A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in the
plan of care to prevent a Pseudomonas aeruginosa infection?
Answer: Avoid placing plants or flowers in the client’s room

96. An older adult client is brought to an emergency department by a family member. Which
of the following assessment findings should cause the nurse to suspect that the client has
hypertonic dehydration?
Answer: Urine specific gravity 1.045
97. A nurse in an emergency department is reviewing the provider’s prescription for a client
who sustained a rattlesnake bite to the lower leg.
Answer: Administer an opioid analgesic to the client
98. A nurse is assessing a client who has had a suspected stroke. The nurse should place the
priority on which of the following findings?
Answer: Dysphagia
99. A nurse is teaching a young adult client how to perform testicular self- examination.
Which of the following instructions should the nurse include?
Answer: Roll each testicle between the thumb and fingers
100. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new
prescription for metformin. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: I should take this medication with a meal
101. A nurse is teaching a client who has venous insufficiency about self-care. Which of the
following statements should the nurse identify as an indication that the client understands the
teaching?
Answer: “I will wear clean graduated compression stockings every day.”
102. A nurse is assessing a client who has acute cholecystitis. Which of the following
findings is the nurse’s priority?
Answer: Tachycardia

103. A nurse is reviewing the health record of a client who is scheduled for allergy skin
testing. The nurse should postpone the testing and report to the provider which of the
following findings?
Answer: Current medications
104. A nurse is caring for a group of clients. The nurse should plan to make a referral to
physical therapy for which of the following clients?
Answer: A client who is receiving preoperative teaching for a right knee arthroplasty
105. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which for the
following laboratory findings should the nurse expect?
Answer: BUN 32 mg/dL
106. A nurse is planning teaching for a client who has bladder cancer and is to undergo
acutaneous diversion procedure to establish a ureterostomy. Which of the following
statements should the nurse include in the teaching?
Answer: “You should cut the opening of the skin barrier one-eight inch wider than the
stoma”
107. A nurse is providing teaching for a female client who has recurrent urinary tract
infections. Which of the following information should the nurse include in the teaching?
Answer: Void before and after intercourse.
108. A nurse and an assistive personnel (AP) are caring for a client who has bacterial
meningitis. The nurse should give the AP which of the following instructions?
Answer: Wear a mask
109. A nurse is caring for a client who is 12 hr postoperative following a total hip
arthroplasty. Which of the following actions should the nurse take?
Answer: Place a pillow between the client’s legs.
110. A nurse in a provider’s office is assessing a client who has migraine headaches and is
taking feverfew to prevent headaches. The nurse should identify that which of the following
client medications interacts with feverfew?

Answer: Naproxen
111. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory results to be below the expected reference range?
Answer: Calcium
112. A nurse is providing discharge instructions to a client following an upper gastrointestinal
series with barium contrast. Which of the following information should the nurse provide?
Answer: Increase fluid intake
113. A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr
ago. Which of the following findings should the nurse expect?
Answer: Stone fragments in the urine
114. A nurse is assessing a group of clients for indications of role changes. The nurse should
identify that which of the following clients is at risk for experiencing a role change?
Answer: A client who has multiple sclerosis and is experiencing progressive difficulty
ambulating.
115. 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?
Answer: Blood pressure 170/80 mm Hg
116. A nurse is providing discharge instructions to a client who has a partial-thickness burn
on the hand. Which of the following instructions should the nurse include?
Answer: Wrap fingers with individual dressings
117. A nurse is providing teaching to a client who is receiving chemotherapy and has a new
prescription for epoetin alfa. Which of the following client statements indicates an
understanding of the teaching?
Answer: I will monitor my blood pressure while taking this medication.

118. A nurse is providing discharge teaching to a client who has heart failure and a new
prescription for a potassium-sparing diuretic. Which of the following information should the
nurse include in the teaching?
Answer: Try to walk at least three times per week for exercise
119. A nurse is caring for a client who has HIV. Which of the following findings indicates a
positive response to the prescribed HIV treatment?
Answer: Decreased viral load
120. A nurse is caring for a client who is postoperative following a total hip arthroplasty.
Which of the following laboratory values should the nurse report to the provider?
Answer: HgB 8 g/dL
121. A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago.
Answer: Check that one finger fits between the cast and the leg
122. A nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin.
Answer: “I am taking this medication to increase my energy level.”
123. A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney
disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands.
Answer: Calcium carbonate
124. A nurse in a community clinic is caring for a client who reports an increase in the
frequency of migraine headaches. To help reduce the risk for migraine headaches, which of
the following foods should the nurse recommend the client avoid?
Answer: Aged cheese
125. A nurse is providing teaching to a female client who has a history of urinary tract
infections (UTIs).
Answer: Take daily cranberry supplements.

126. A nurse is performing a dressing change for a client who is recovering from a
hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is
protruding through the abdomen.
Answer: Call for help
127. A nurse is preparing to administer a unit of packed RBCs to a client.
Answer: Remain with the client for the first 15 min of infusion.
128. A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus.
Which of the following client statements indicates the client is successfully coping with the
change?
Answer: “I used to never worry about my feet. Now, I inspect my feet every day with a
mirror.”
129. A nurse is caring for a client who has a closed head injury and has an intraventricular
catheter placed. Which of the following findings indicates that the client is experiencing
increased intracranial pressure (ICP)? (Select all that apply)
A. Sleepiness exhibited by the client
B. Widening pulse pressure
C. Decerebrate posturing
Answer: A. Sleepiness exhibited by the client
B. Widening pulse pressure
C. Decerebrate posturing
130. A nurse is planning to provide discharge teaching for the family of an older adult client
who has hemianopsia and is at risk for falls.
Answer: Remind the client to scan their complete range of vision during ambulation
131. A nurse in an emergency department is caring for a client who reports vomiting and
diarrhoea for the past 3 days. Which of the following findings should indicate to the nurse
that the client is experiencing fluid volume deficit?
Answer: Heart rate 110/min

132. A nurse is caring for a client who is on bed rest and has a new prescription for
enoxaparin subcutaneous. Which of the following actions should the nurse take?
Answer: Inject the medication into the anterolateral abdominal wall.
133. 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?
Answer: “You will not be able to use sildenafil if you are taking nitro-glycerine.”
134. A nurse in an emergency department is assessing a client who has a detached retina.
Which of the following should the nurse expect the client to report?
Answer: “It’s like a curtain closed over my eye.”
135. A nurse is providing teaching to an older adult client who has cancer and a new
prescription for an opioid analgesic for pain management. Which of the following
information should the nurse include in the teaching?
Answer: “You should void every 4 hours to decrease the risk of urinary retention.”
136. A nurse is assessing a client following the administration of magnesium sulphate 1 g IV
bolus. For which of the following adverse effects should the nurse monitor?
Answer: Respiratory paralysis
137. A nurse is assessing a male client for an inguinal hernia. Which of the following areas
should the nurse palpate to verify that the client has an inguinal hernia?
Answer: bottom left side
138. A nurse is caring for a client who has type 1 diabetes mellitus and has had acute
bronchitis for the past 3 days. Which of the following statements should the nurse include
when instructing the client?
Answer: “Take insulin even if you are unable to eat your regular diet.”
139. A nurse has received change-of-shift report for a group of clients. Which of the
following clients should the nurse assess first?
Answer: A client who had a myocardial infarction (MI) 4 days ago is asking for a PRN
sublingual nitro-glycerine tablet.

140. A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being
admitted to the hospital with pneumonia. Which of the following assessment findings is the
nurse’s priority?
Answer: Increased respiratory secretions
141. A nurse is creating a plan of care for a client who has neutropenia as a result of
chemotherapy. Which of the following interventions should the nurse include in the plan?
Answer: Monitor the client’s temperature every 4 hr.
142. A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following supplements
can interfere with the effectiveness of the medication?
Answer: Calcium
143. A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a
productive cough. Which of the following actions should the nurse take first?
Answer: Initiate airborne precautions
144. A nurse in an acute care facility is caring for a client who is at risk for seizures.
Which of the following precautions should the nurse implement?
Answer: Ensure that the client has a patent IV.
145. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new
bags not available when the current infusion is nearly completed. Which of the following
actions should the nurse take?
Answer: Administer dextrose 10% in water until the new bag arrives.
146. A nurse is providing dietary teaching to a client who is postoperative following a
thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to
include which of the following foods that has the greatest amount of calcium in her diet?
Answer: 12 almonds

147. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
Answer: Loosen restrictive clothing
148. A nurse is performing a cardiac assessment for a client who had a myocardial infarction
3days ago. Which of the following actions should the nurse take first after hearing the
following sound? (Click on the audio button to listen to the clip)
Answer: Listen with the client on their left side
149. 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?
Answer: Suppressing gastric acid production
150. A nurse is conducting an admission history for a client who is to undergo a CT scan with
an IV contrast agent. The nurse should identify that which of the following findings requires
further assessment?
Answer: History of asthma
151. A nurse is caring for a client who has portal hypertension. The client is vomiting blood
mixed with food after a meal. Which of the following actions should the nurse take first?
Answer: Obtain vital signs
152. A nurse is planning care for a client who is undergoing brachytherapy via a sealed
vaginal implant to treat endometrial cancer. Which of the following actions should the nurse
include in the client’s plan of care?
Answer: Wear a lead apron while providing care to the client.
153. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the
following assessment findings should the nurse expect?
Answer: Hypoactive bowel sounds
154. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing’s triad?

Answer: Bradycardia
155. A nurse is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
Answer: Demonstrate ways to deep breath and cough
156. A nurse is caring for a client who has a leg cast and is returning demonstration on the
proper use of crutches while climbing stairs. Identify the sequence the client should follow
when demonstrating crutch use.
A. Places body weight on the crutches
B. advance the unaffected leg onto the stair
C. shifts weight from the crutches to the unaffected leg
D. bring crutches and the affected leg up to the stair
Answer: A. Places body weight on the crutches
B. advance the unaffected leg onto the stair
C. shifts weight from the crutches to the unaffected leg
D. bring crutches and the affected leg up to the stair
157. A nurse in an emergency department is caring for a client who is experiencing a thyroid
storm. Which of the following manifestations should the nurse expect? (Select all that apply)
A. Fever
B. Hypertension
C. Tachycardia
Answer: A. Fever
B. Hypertension
C. Tachycardia
158. 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?
Answer: Orthostatic hypotension
159. 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?
Answer: Increase fibre intake to at least 30g per day

160. A nurse is caring for a client who has a stage III pressure injury. Which of the following
findings contributes to delayed wound healing?
Answer: Urine output 25 mL/hr
161. A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon
assessing the client, the nurse observes the following findings: heart rate 200/min, blood
pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should
the nurse take?
Answer: Perform synchronized cardioversion
162. A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after
hospitalization for heart failure. Based on the information in the client’s chart, which of the
following findings should the nurse report to the provider? (Click on the Exhibit button for
additional information about the client. There are three tabs that contain separate categories
of data.)
Answer: Heart rate 55/min
163. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has
a pressure injury. Which of the following actions should the nurse take?
Answer: Use a 30-mL syringe
164. A nurse is caring for a client who has a new prescription for total parenteral nutrition
(TPN) The client is to receive 2,000 kcal per day. The TPN solution has 5000 kcal/L. The IV
pump should be set at how many mL/hr?
Answer: 167
165. A nurse is caring for a client who is receiving morphine for daily dressing changes. The
client tells the nurse, “I don’t want any more morphine because I don’t want to get addicted.”
Which of the following actions should the nurse take?
Answer: Instruct the client on alternative therapies for pain reduction

166. A nurse is planning care to decrease psychosocial health issues for a client who is
starting dialysis treatments for chronic kidney disease. Which of the following interventions
should the nurse include in the plan?
Answer: Tell the client that it is possible to return to similar previous levels of activity.
167. A nurse in a provider’s office is assessing a client who has hypertension and takes
propranolol. Which of the following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication?
Answer: Report of a night cough
168. A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the
following laboratory values should the nurse expect?
Answer: Elevated bilirubin level
169. A nurse is preparing a client who has supraventricular tachycardia for elective
cardioversion. Which of the following prescribed medications should the nurse instruct the
client to withhold for 48 hrs prior to cardioversion?
Answer: Digoxin
170. 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?
Answer: I am dieting to lose weight
171. A nurse is assessing a client who has Grave’s disease. Which of the following images
should indicate to the nurse that the client has exophthalmos?
Answer: Picture D [Bulging eyes (super wide and big)]
172. A nurse is caring for a client has who has chronic glomerulonephritis with oliguria.
Which of the following findings should the nurse identify as a manifestation of chronic
glomerulonephritis?
Answer: Hyperkalemia

173. A nurse in an emergency department is caring for a client who has full-thickness burns
over 20% of their total body surface area. After ensuring a patent airway and administering
oxygen, which of the following items should the nurse prepare to administer first?
Answer: IV fluids
174. A nurse is caring for a client who is having a seizure. Which of the following
interventions is the nurse’s priority?
Answer: Turn the client to the side
175. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the
formation of a hematoma at the insertion site and a decreased pulse rate in the affected
extremity. Which of the following interventions is the nurse’s priority?
Answer: Apply firm pressure to the insertion site
176. A nurse is providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statement should the nurse identify as an indication
that the client understands the teaching?
Answer: “I will use my hands rather than a washcloth to clean the radiation area.”
177. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place
which of the following items at the client’s bedside?
Answer: Suction machine
178. A nurse is teaching a class about client rights. Which of the following instructions
should the nurse include?
Answer: A client should sign an informed consent before receiving a placebo during a
research trial.

Set 6
1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki
disease. Which of the following interventions should the nurse include in the plan of care?
A. Give acetaminophen to control the child’s fever
B. Monitor the client’s cardiac status

C. Administer antibiotics via intermittent IV bolus for 24 hrs.
D. Provide stimulation with children of the same age in the play room
Answer: B. Monitor the client’s cardiac status
2. A nurse observes a client on the psychiatric unit muttering and standing near a window.
The client states, “The voices are telling me to jump.” Which of the following is an
appropriate response by the nurse?
A. “Do you recognize the voices as belonging to anyone you know?”
B. “I understand the voices are frightening you, but I do not hear any voices.”
C. “That can’t be true. The only voices in this room are yours and mine.”
D. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.”
Answer: B. “I understand the voices are frightening you, but I do not hear any voices.”
3. A nurse is caring for a client who is preparing his advance directives. Which of the
following statements by the client indicates an understanding of advance directives? (Select
all that apply.)
A. “I need an attorney to witness my signature on the advance directives.” (nurse witnesses
it)
B. “I have the right to refuse treatment.”
C. “My doctor will need to approve my advance directives.” (just needs to write a
prescription)
D. “My health care proxy can make medical decisions for me.”
E. “I can’t change my advance directives once submitted.” (yes, you can)
Answer: B. “I have the right to refuse treatment.”
D. “My health care proxy can make medical decisions for me.”
4. A client who is pregnant voices her concern that her 3-year-old son will feel left out once
the newborn arrives. Which of the following statements by the nurse is appropriate?
A. “Offer your son a gift when the baby receives one.” (Provide a gift from the infant to give
the sibling)
B. “Teach your son to change the baby’s diapers.” (Allow older siblings to help in providing
care for the infant)
C. “Tell your son to kiss the baby.” (Let the sibling be one of the first to see the infant)

D. “Move your son to a toddler bed when the baby arrives. (do this weeks prior to baby’s
arrival)
Answer: C. “Tell your son to kiss the baby.” (Let the sibling be one of the first to see the
infant)
5. A nurse is teaching a client who has nephrotic syndrome about dietary management. Which
of the following instructions should the nurse include in the teaching?
A. Limit total daily sodium intake to 4 to 5 grams
B. Obtain most calories from complex carbohydrates (for CKD)
C. Consume a high-protein diet (High protein, high potassium, low sodium)
D. Avoid intake of soy products.
Answer: B. Obtain most calories from complex carbohydrates (for CKD)
C. Consume a high-protein diet (High protein, high potassium, low sodium)
6. A nurse is interviewing an adolescent client who has a history of physical aggression due to
anger management issues. Which of the following is an appropriate question by the nurse?
A. “Did you think about removing yourself from the situation when you became angry?”
B. “Why do you get angry when things don’t go your way?”
C. “How do you think others feel when you express anger?”
D. “What are you thinking about when you express anger?” (assessing the underlying issue of
aggression)
Answer: D. “What are you thinking about when you express anger?” (assessing the
underlying issue of aggression)
7. A nurse is planning care for a client who has a sealed radiation implant and is to remain in
the hospital for 1 week. Which of the following should the nurse include in the plan of care?
A. Wear a dosimeter film badge while in the client’s room.
B. Ensure family members remain at least 3 feet from the client (should be at least 6ft)
C. Limit each of the client’s visitors to 1 hrs. per day. (should be 30 minutes)
D. Remove dirty linens from the room after double bagging
Answer: A. Wear a dosimeter film badge while in the client’s room.
8. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the
following actions should the nurse plan to take?

A. Sit at or below the client’s eye level during feedings (Observe for aspiration and pocketing
of food in the cheeks or other areas of the mouth)
B. Talk with the client during her feeding
C. Discourage the client from coughing during feedings (encourage pt. to cough to prevent
aspiration)
D. Instruct the client to lift her chin when swallowing (tuck chin)
Answer: A. Sit at or below the client’s eye level during feedings (Observe for aspiration and
pocketing of food in the cheeks or other areas of the mouth)
9. A nurse is caring for a preschool child who is dehydrated. Which of the following
assessment findings indicates moderate dehydration?
A. Bradypnea
B. Oliguria
C. Diaphoresis
D. Excessive tears
Answer: B. Oliguria
10. A nurse is providing teaching to a parent of a child who has varicella. Which of the
following statements should the nurse include in the teaching?
A. “Your child can return to school after a negative titer result.”
B. “Your child can return to school 24 hours after beginning antibiotics.”
C. “Your child can return to school once the lesions have crusted over.”
D. “Your child can return to school once the fever has subsided.”
Answer: C. “Your child can return to school once the lesions have crusted over.”
11. A nurse is providing information for a client who has a new prescription for simvastatin.
For which of the following should the nurse instruct the client to monitor and report to the
provider?
A. Muscle weakness- rhabdomyolysis
B. Edema
C. Weight loss
D. Fever
Answer: A. Muscle weakness- rhabdomyolysis

12. A nurse on a medical-surgical unit is receiving report on four clients. Which of the
following clients should the nurse assess first?
A. A client who is receiving warfarin and has an INR of 3.3
B. A client who had an NG tube inserted 6 hrs. ago and has abdominal distention
C. A client who is 4 hrs. postoperative following a thyroidectomy and reports fullness in the
back of the throat (edema can lead to resp. distress)
D. A client who has acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL
Answer: C. A client who is 4 hrs. postoperative following a thyroidectomy and reports
fullness in the back of the throat (edema can lead to resp. distress)
13. A nurse is receiving report on four postpartum clients. Which of the following clients
should the nurse plan to attend to first?
A. A client who reports changing her perineal pad every 2 hrs.
B. A client who reports abdominal pain during breastfeeding
C. A client who has a urine output of 250 mL in 6 hrs.
D. A client who has hyporeflexia while receiving magnesium sulphate
Answer: D. A client who has hyporeflexia while receiving magnesium sulphate
14. A nurse is providing nutritional teaching regarding appropriate food choices to a client
who has a new diagnosis of uric acid calculi. Which of the following should the nurse include
in the teaching?
A. Roast beef
B. Chicken breast
C. Low-fat yogurt (avoid purine foods [organ meats & shellfish] & poultry)
D. Tuna fish
Answer: C. Low-fat yogurt (avoid purine foods [organ meats & shellfish] & poultry)
15. A nurse in the emergency department is caring for a client who has a full-thickness burn
of the thorax and upper torso. After securing the client’s airway, which of the following is the
nurse’s priority intervention?
A. Preventing infection
B. Offering emotional support
C. Providing pain management
D. Initiating IV fluid resuscitation

Answer: D. Initiating IV fluid resuscitation
16. A nurse is caring for a client who will undergo a procedure. The client states she does not
want the provider to discuss the results with her partner. Which of the following is an
appropriate response for the nurse to make?
A. “The provider will be tactful when talking to your partner.”
B. “You have the right to decide who receives information.”
C. “Is there a reason you don’t want your partner to know about your procedure?”
D. “Your partner can be a great source of support for you at this time.”
Answer: B. “You have the right to decide who receives information.”
17. A nurse is providing teaching about dietary recommendations to the parents of a schoolage child who has acute kidney injury. Which of the following recommendations should the
nurse include in the teaching?
A. Provide low-calcium foods
B. Provide high-phosphorus foods
C. Provide low-potassium foods
D. Provide high-sodium foods
Answer: C. Provide low-potassium foods
18. A nurse is planning care for a school-age child who is 4 hrs. postoperative following
perforated appendicitis. Which of the following actions should the nurse include in the plan
of care?
A. Apply a warm compress to the operative site every 4 hrs.
B. Offer small amounts of clear liquids 6 hrs. following surgery
C. Give cromolyn nebulized solution every 8 hrs.
D. Administer analgesics on a scheduled basis for the first 24 hrs.
Answer: D. Administer analgesics on a scheduled basis for the first 24 hrs.
19. A nurse is assessing a client who is 8 hrs. postpartum and has been unable to void. Which
of the following actions should the nurse take first?
A. Pour warm water over the client’s perineum
B. Offer the client a Sitz-bath
C. Insert a sterile catheter

D. Administer an analgesic
Answer: A. Pour warm water over the client’s perineum
20. A nurse is providing nutritional teaching for an older adult client who has seizure disorder
and a new prescription for phenytoin. Which of the following statements by the nurse is
appropriate?
A. “Limit foods that contain folic acid while taking this medication.”
B. “You should expect a change in the colour of your stool while taking this medication.”
C. “Increase your intake of vitamin D while taking this medication.” - phenytoin
complication (bone pain and weakness)
D. “Plan to take this medication with antacids.”
Answer: C. “Increase your intake of vitamin D while taking this medication.” - phenytoin
complication (bone pain and weakness)
21. A nurse is assessing a client who sustained fractures to both legs in a motor-vehicle crash.
Which of the following findings indicates the client is experiencing a fat embolism?
A. Petechiae on the chest and abdomen
B. Decreased pedal pulses
C. Pain unrelieved by opioid analgesics
D. Crepitus at the knee joint
Answer: A. Petechiae on the chest and abdomen
22. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which
of the following information should the nurse include in the teaching?
A. “You will have a Doppler transducer applied to your abdomen during the test.”
B. “You should massage one of your nipples to stimulate contractions of your uterus.”
C. “You will need blood work before and after the test.”
D. “You should avoid eating or drinking for 4 hrs. before the test.”
Answer: A. “You will have a Doppler transducer applied to your abdomen during the test.”
23. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and
has had recent weight loss. Which of the following is the priority admission data for the nurse
to obtain?
A. Changes in appetite

B. Daily fluid intake
C. Swallowing ability - aspirations precautions
D. Prescribed medications
Answer: C. Swallowing ability - aspirations precautions
24. A nurse is providing discharge teaching for a client who has myelosuppression following
chemotherapy treatment. Which of the following statements should the nurse include in the
teaching?
A. “Eat a diet rich in fresh fruits and vegetables.”
B. “Wear disposable gloves under gardening gloves while working with house plants.”
C. “Children may visit as long as they’ve recently received a live influenza vaccination.”
D. “Check your temperature weekly.”
Answer: B. “Wear disposable gloves under gardening gloves while working with house
plants.”
25. A nurse is caring for a client who has undergone a modified radical mastectomy. The
client has a closed-suction drain. Which of the following actions should the nurse take?
A. Maintain the client in supine position for the first 24 hrs.
B. Secure the drain to the bedding
C. Reset the vacuum by compressing the container
D. Position the affected extremity below the level of the client’s heart
Answer: C. Reset the vacuum by compressing the container
26. A nurse is providing discharge instructions to a client who is 1-day postoperative vertical
banded gastroplasty for morbid obesity. Which of the following statements demonstrates an
understanding for the dietary teaching?
A. “It should take me 30 to 60 minutes to eat a meal”
B. “I will be limited to pureed foods for the next 6 months.” (weeks)
C. “I should eat three meals per day.”
D. “Vomiting is common and I will have to learn to live with it.”
Answer: A. “It should take me 30 to 60 minutes to eat a meal”
Rationale:
Serve to restrict and decrease food intake helps to promote wt. loss

27. A home health nurse is visiting a client whose partner states that she is overwhelmed by
caring for him. When suggesting respite care, which of the following explanations should the
nurse provide?
A. “Respite care offers financial resources to help care for your husband.”
B. “Respite care includes volunteers who will perform household tasks.”
C. “Respite care provides clinicians to work with you in caring for your husband.”
D. “Respite care allows for time away from caring for your husband.”
Answer: D. “Respite care allows for time away from caring for your husband.”
28. A nurse is collecting a specimen for urinalysis and culture from a client who has an
indwelling urinary catheter. Which of the following actions should the nurse take during
collection?
A. Obtain the urinalysis specimen before the culture specimen.
B. Collect 2 mL or urine for each specimen.
C. Drain the specimen from the drainage bag.
D. Clamp the catheter distal to the injection port.
Answer: D. Clamp the catheter distal to the injection port.
29. A nurse is caring for four clients. Which of the following clients should the nurse care for
first?
A. A client who has hypothyroidism and is stuporous
B. A client who has a burn requiring a sterile dressing change
C. A client who received a chemotherapy treatment and reports nausea
D. A client who had an appendectomy 2 days ago and has diminished bowel sounds
Answer: A. A client who has hypothyroidism and is stuporous
30. A nurse is caring for a client who states he recently purchased lavender oil to use when he
gets the flu. The nurse should recognize which of the following findings as a potential
contraindication to using lavender?
A. The client has a history of alcohol use disorder
B. The client has a history of
C. The client takes Vitamin C daily
D. The client takes furosemide twice daily
Answer: B. The client has a history of

D. The client takes furosemide twice daily
31. A nurse is providing discharge teaching to a client following a total hip arthroplasty.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I won’t cross my legs when I sit in a chair.”
B. “I don’t need to use a walker when walking around my house.”
C. “I will stay in bed for 3 days after returning home before starting leg exercises.”
D. “I will bend over at my hips to tie my shoes.” bend at your knees
Answer: A. “I won’t cross my legs when I sit in a chair.”
32. A nurse is assessing a client who is experiencing a pulmonary embolism. Which of the
following manifestations should the nurse expect?
A. Hypertension
B. Dyspnea -confirmed
C. Bradycardia
D. Frothy sputum
Answer: B. Dyspnea -confirmed
33. A nurse is performing a neurological examination on a client as part of a complete
physical assessment. The nurse determines that cranial nerve XI is intact when the client
performs which of the following actions?
A. Shrugs his shoulders
B. Frowns symmetrically
C. Sticks his tongue out
D. Identifies a sour taste cra
Answer: A. Shrugs his shoulders
34. A nurse is preparing to administer lactated Ringer’s 500 mL IV to infuse over 4 hrs. The
drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion
to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading
zero if applicable. Do not use a trailing zero.)
Answer: 31 gtt/min
4 x 60 = 240mins
500/240 = 2.08 x 15 gtt = 31.25 or 31

35. A nurse is teaching an adolescent who has type 1 diabetes mellitus. Which of the
following goals should the nurse include in the teaching?
A. HbA1c level greater than 8%
B. HbA1c level less than 7%
C. Blood glucose level less than 60 mg/dL before breakfast
D. Blood glucose level greater than 200 mg/dL at bedtime
Answer: B. HbA1c level less than 7%
36. A nurse is caring for a client who develops a lower left leg deep-vein thrombosis
following surgery. Which of the following actions should the nurse take?
A. Apply warm, moist compresses to the affected extremity
B. Check for the presence of a Homan’s sign
C. Form a 5 cm (2 in) cuff at the top of the ant embolism stocking
D. Massage the left lower extremity
Answer: A. Apply warm, moist compresses to the affected extremity
37. A nurse working in an acute care mental health facility is assessing a client who has
schizophrenia. Which of the following findings should the nurse expect?
A. Euphoric mood
B. All-or-nothing thinking
C. Hypochondriasis
D. Disorganized speech
Answer: D. Disorganized speech
38. A nurse is developing a nutritional care plan for a client who has COPD with severe
dyspnea. To promote intake, which of the following instructions is appropriate to include in
the plan of care?
A. Administer a bronchodilator after meals
B. Ambulate the client before each meal
C. Offer the client three large meals each day
D. Limit fluid intake with meals
Answer: D. Limit fluid intake with meals

39. A nurse is caring for four clients who are scheduled for surgery the same day. Which of
the following laboratory values indicates the need for intervention before surgery?
A. WBC 9,800/mm3
B. Creatinine 0.9 mg/dL < 1.0 is normal
C. Fasting blood glucose 108 mg/dL
D. Potassium level 5.2 mEq/L REPEAT - 3.5 - 5.0 mEq =
Answer: D. Potassium level 5.2 mEq/L REPEAT - 3.5 - 5.0 mEq =
40. A nurse in a long-term care facility is managing the care of an older adult client who has
difficulty swallowing and occasional choking during meals. The nurse should initiate a
referral to which of the following members of the interprofessional care team?
A. Social worker
B. Respiratory therapist
C. Speech-language pathologist
D. Occupational therapist
Answer: C. Speech-language pathologist
41. A nurse in an oncology clinic receives a call from the partner of a client who has
pancreatic cancer. The partner tells the nurse that she is able to manage the client’s physical
care, but she doesn’t want to leave him home alone while she travels for work. Which of the
following referrals should the nurse make?
A. Community outreach center
B. Respite care
C. Skilled nursing facility
D. Restorative care
Answer: A. Community outreach center
42. A nurse is caring for a client who has deep-vein thrombosis of the left lower extremity.
Which of the following actions should the nurse take? (Click on the “Exhibit” button below
for additional client information. There are three tabs that contain separate categories of data.)
A. Massage the affected extremity every 4 hrs.
B. Administer acetaminophen
C. Withhold heparin IV infusion - not enough info
D. Position the client with the affected extremity lower than the heart

Answer: C. Withhold heparin IV infusion - not enough info
43. A nurse preceptor is working with a newly licensed nurse to care for a client who has
vancomycin-resistant enterococci (VRE). Which of the following actions by the newly
licensed nurse requires the nurse preceptor to intervene?
A. Taking a blood pressure machine out of the client’s room to use on another client
B. Cleaning her hands with alcohol-based antiseptic after delivering a meal to the client
C. Instructing the client to dispose of soiled facial tissues in the wastebasket in his room
D. Wiping a client’s over bed table with hydrogen peroxide following a dressing change
Answer: A. Taking a blood pressure machine out of the client’s room to use on another client
44. A nurse in a health clinic is developing written material to teach adult clients how to
manage their blood pressure. Which of the following strategies should the nurse use in
creating the material?
A. Create material using a 12-point font size
B. Type information in capital letters
C. Use words with one or two syllables
D. Write information at a seventh-grade reading level
Answer: D. Write information at a seventh-grade reading level
45. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation.
Which of the following actions the nurse take?
A. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate
B. Place the client in a side-lying position prior to assessing the fetal heart rate
C. Perform Leopold maneuvers prior to auscultating the fetal heart rate
D. Measure the fundal height to determine the placement of the ultrasound stethoscope
Answer: A. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal
heart rate
46. A nurse in a mental health facility received change-of-shift report on four clients. Which
of the following clients should the nurse plan to assess first?
A. A client placed in restraints due to aggressive behavior
B. A client who received a PRN dose of haloperidol 2 hrs. ago for increased anxiety
C. A newly admitted client who has a history of 4.5 (10 lbs.) weight loss in the past 2 months

D. A client who will be receiving his first ECT treatment today
Answer: A. A client placed in restraints due to aggressive behavior
47. A nurse is admitting a client who has a history of atrial fibrillation. The nurse should
recognize that atrial fibrillation places the client at risk for which of the following?
A. Pulmonary emboli
B. Cardiac tamponade
C. Hemothorax
D. Widened pulse pressure
Answer: A. Pulmonary emboli
48. A nurse is teaching a client who is trying to conceive. Which of the following should the
nurse instruct the client to increase in her diet to prevent a neural tube defect?
A. Iron
B. Calcium
C. Folate
D. Zinc
Answer: C. Folate
49. A nurse is caring for a client who is not ambulatory. Which of the following interventions
is appropriate to prevent contracture?
A. Place a towel roll under the client’s neck
B. Align a trochanter wedge between the client’s legs
C. Apply an orthotic to the client’s footD. Position a pillow under the client’s knees
Answer: C. Apply an orthotic to the client’s foot50. A nurse is caring for a client who has a thoracic spine injury. Which of the following
actions is appropriate for the nurse to take when turning the client?
A. Apply an immobilizing collar on the client prior to movement
B. Instruct the client to keep his arms at his side when altering positions
C. Place a pillow under the client’s knees when changing positions
D. Use a sheet when repositioning the client onto his side
Answer: A. Apply an immobilizing collar on the client prior to movement

51. A nurse is teaching a client about a variety of stress management techniques. Which of the
following instructions by the nurse is appropriate?
A. “Tighten your muscles before relaxing them when using muscle relaxation techniques.”
B. “Imagine a situation that has been stimulating for you when practicing guided imagery.”
C. “Talk to someone who you admire as the first step in using mindfulness techniques to
relax.”
D. “Breathe in through your mouth and out through your nose when using deep breathing
exercises.”
Answer: A. “Tighten your muscles before relaxing them when using muscle relaxation
techniques.”
52. A nurse is caring for a client who is incontinent and has a stage II pressure ulcer on her
coccyx. Which of the following interventions should the nurse implement?
A. Reposition the client every 3 hrs.
B. Use two facility personnel to slide the client up in bed
C. Position the client laterally at 30 degrees
D. Apply lotion to the skin every 4 hrs.
Answer: C. Position the client laterally at 30 degrees
53. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the
following clients should the nurse see first?
A. A client who has preeclampsia and reports a persistent headache
B. A client who has pregestational diabetes mellitus and an HbA1c of 6.2%
C. A client who is at 28 weeks of gestation and reports leukorrhea
D. A client who is at 36 weeks of gestation with a biophysical profile score of 8
Answer: A. A client who has preeclampsia and reports a persistent headache
54. A nurse is preparing to obtain a blood sample from a client who has a central venous
catheter. Which of the following actions should the nurse take? (Select all that apply)
A. Assess catheter patency
B. Flush the catheter with 0.9% sodium chloride after obtaining the blood sample
C. Cleanse the port with alcohol
D. Aspirate the blood sample with large bore needle

E. Apply a tourniquet above the catheter insertion site
Answer: A. Assess catheter patency
B. Flush the catheter with 0.9% sodium chloride after obtaining the blood sample
C. Cleanse the port with alcohol
55. A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of
the following responses by the client is the priority for the nurse to evaluate?
A. “I don’t understand why I am getting this antibiotic.”
B. “My arm burns each time that medication is running.”
C. “My throat feels tight.” anaphylactic shock?
D. “This medication bag is still full.”
Answer: C. “My throat feels tight.” anaphylactic shock?
56. A nurse is caring for a client who has schizoaffective disorder and tells the nurse, “I’m the
prince of peace and my enemies are coming to take me to another world.” Which of the
following responses should the nurse make?
A. “Why do you think people will come for you?”
B. “Let’s take a walk around the unit together.”
C. “The staff and I will protect you from them.”
D. “You are not the prince of peace. Your name is John.”
Answer: B. “Let’s take a walk around the unit together.”
D. “You are not the prince of peace. Your name is John.”
57. A nurse is caring for a client following a stroke. The client has right-sided weakness and
facial drooping. Which of the following nursing actions is the priority?
A. Perform range-of-motion exercises to the client’s extremities
B. Place the client’s right hand in a supination position
C. Maintain an NPO status for the client
D. Change the client’s position every 2 hrs.
Answer: C. Maintain an NPO status for the client
58. A charge nurse is providing information to a group of nurses on the unit about risk factor
for hypoglycemia in newborns. Which of the following risk factors should the charge nurse
include in the information?(Select all that apply)

A. Anemia
B. Infection
C. Maternal diabetes
D. Prematurity
E. Polycythemia
Answer: B. Infection
C. Maternal diabetes
D. Prematurity
59. A nurse is providing an in-service about client evacuation during a fire. Which of the
following clients should the nurse instruct the staff to evacuate first?
A. A client who has a fracture and is in balance suspension traction
B. A client who uses a wheelchair and is confused
C. A client who is bedridden and wears a hearing aid
D. A client who is ambulatory and receiving oxygen
Answer: D. A client who is ambulatory and receiving oxygen
60. A nurse is providing discharge instructions for a client who has a new prescription for
clopidogrel following a cardiac catheterization. Which of the following instructions should
the nurse include?
A. “Your stools will become black and tarry”
B. “Take NSAIDs for pain every 6 hours”
C. “Plan to discontinue the medication 7 days before any surgery.”
D. “Take medication twice daily with acetaminophen.”
Answer: C. “Plan to discontinue the medication 7 days before any surgery.”
61. A nurse is an outpatient mental health facility is providing teaching to a group of
adolescents. Which of the following statements by a client indicates an understanding of the
teaching?
A. “I will limit my alcohol use to one drink daily while taking disulfiram.”
B. “I will avoid foods containing tyramine while taking fluoxetine.”
C. “I will take my lithium on an empty stomach.”
D. “I will take the sustained-release methylphenidate every morning.”
Answer: D. “I will take the sustained-release methylphenidate every morning.”

62. A nurse is planning care for a client who has stage II Parkinson’s disease. Which of the
following actions should the nurse include in the plan of care?
A. Offer clear liquids with in between meals
B. Offer high-calorie nutrition supplements
C. Encourage the client to concentrate on looking at his feet while walking
D. Encourage the client to participate in small muscle dexterity activities
Answer: B. Offer high-calorie nutrition supplements
63. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2
diabetes mellitus. The nurse should report which of the following conditions is a
contraindication to the use of metformin?
A. Renal insufficiency
B. Gluten intolerance
C. Seizure disorder
D. Polycystic ovary syndrome
Answer: A. Renal insufficiency
64. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is
an appropriate action for the nurse to take?
A. Obtain a 12 F catheter
B. Apply EMLA cream prior to the procedure
C. Discard the first 10 mL of urine
D. Don sterile gloves prior to the procedure
Answer: D. Don sterile gloves prior to the procedure
65. A charge nurse is teaching a newly licensed nurse about clients designating a healthcare
proxy in situations that require a durable power of attorney for health care (DPAHC). Which
of the following information should the charge nurse include?
A. “The proxy should make healthcare decisions for the client regardless of the client’s
ability to do so.”
B. “The proxy can make treatment decisions if the client is under anaesthesia.”
C. “The proxy can make financial decisions if the need arises.”
D. “The proxy should manage legal issues for the client.”

Answer: B. “The proxy can make treatment decisions if the client is under anaesthesia.”
66. A nurse is providing teaching to a client who is receiving misoprostol for induction of
labor. Which of the following statements the nurse include in the teaching?
A. “You will have oxytocin initiated within 3 hours of administration of the medication.”
B. “You will have intermittent fetal monitoring while you receive the medication.”
C. “You will lie on your side for 30 minutes after the medication is inserted.”
D. “You will have a urinary catheter inserted prior to the placement of the medication.”
Answer: B. “You will have intermittent fetal monitoring while you receive the medication.”
67. A nurse is assessing a client who is at 24 weeks of gestation during a routine prenatal
exam. Which of the following finding should the nurse report to the provider?
A. Bleeding gums
B. White vaginal discharge
C. Fundal height of 26 cm
D. Periorbital edema
Answer: D. Periorbital edema
68. A nurse is caring for a client who has lung cancer and has a sealed radiation implant.
Which of the following actions should the nurse take? (Select all that apply)
A. Close the door to the client’s room
B. Limit visitors to 30 minutes per day
C. Wear a lead apron when providing care
D. Place the client in a semi-private room " private
E. Instruct visitors who are pregnant to remain 3 feet from the client " 6 feet
Answer: A. Close the door to the client’s room
B. Limit visitors to 30 minutes per day
C. Wear a lead apron when providing care
69. A nurse is planning care for a child who has increased intracranial pressure with a
decrease in level of consciousness. Which of the following interventions should the nurse
include in the plan of care?
A. Perform neurological checks every 4 hrs.
B. Perform active range-of-motion exercises

C. Maintain the head at a midline position
D. Suction the airway frequently
Answer: C. Maintain the head at a midline position
70. A charge nurse is orienting a newly licensed nurse to the telemetry unit. Which of the
following should the charge nurse identify as purpose of telemetry monitoring?
A. To measure cardiac perfusion
B. To identify valve insufficiency
C. To measure cardiac output
D. To identify dysrhythmias
Answer: D. To identify dysrhythmias
71. At her first prenatal visit a client asks the nurse when she will most likely deliver. If her
last menstrual period began on March 31, when is the estimated date of delivery (EDD)?
A. December 24
B. January 7 - 3 month + 7 days
C. December 31
D. January 3
Answer: B. January 7 - 3 month + 7 days
72. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict
about overtime requirements. Which of the following strategies should the charge nurse use
to promote effective negotiation?
A. Focus on how the conflict occurred
B. Attempt to understand both sides of the issue
C. Identify solutions prior to negotiation
D. Personalize the conflict
Answer: B. Attempt to understand both sides of the issue
73. A public health nurse is managing four projects for the community. Which of the
following activities should the nurse identify as a primary prevention strategy?
A. Providing crisis intervention through a mobile counseling unit
B. Conducting mental health screenings at the local community center
C. Teaching parenting skills to expectant mothers and their partners

D. Referring individuals who have mental health disorders to day treatment programs
Answer: C. Teaching parenting skills to expectant mothers and their partners
74. A nurse is caring for an infant who is in contact isolation and received a blood
transfusion. Which of the following actions is appropriate for the nurse to take to provide
cost-effective care?
A. Return unopened equipment to the supply center
B. Stock the room with a 2-day supply of disposable diapers
C. Bring in formula as needed
D. Leave the unused infusion pump in the room until discharge
Answer: D. Leave the unused infusion pump in the room until discharge
75. A nurse in a provider’s office is caring for a client who asks about using acupuncture to
manage his osteoarthritis pain. The nurse should identify which of the following conditions as
a contraindication for receiving this treatment?
A. Herpes zoster
B. Hypertension
C. Obesity
D. Hypothyroidism
Answer: A. Herpes zoster
76. A nurse manager observes two staff nurses reviewing the computer records of a client
who is not under their care. Which of the following actions should the nurse manager take
first?
A. Instruct the nurses to close the client’s computer record
B. Request the nurses present an in-service on client confidentiality
C. Place documentation of the nurses’ actions in the personnel file
D. Advise the nurses to read the facility’s confidentiality policy
Answer: A. Instruct the nurses to close the client’s computer record
77. A nurse is teaching a client who is to start a new prescription for carbidopa-levodopa.
Which of the following instructions should the nurse include?
A. Monitor for hyperglycaemia
B. Take with a protein snack

C. Change positions slowly - orthostatic hypotension
D. Report dark-coloured urine
Answer: C. Change positions slowly - orthostatic hypotension
78. A nurse is teaching a group of newly licensed nurses about caring for a client who has a
Clostridium difficile infection. Which of the following instructions should the nurse include
in the teaching?
A. Wipe the stethoscope with alcohol after leaving the client’s room
B. Place the client in a room with negative airflow
C. Wear a gown while providing personal hygiene
D. Apply a mask when providing care
Answer: C. Wear a gown while providing personal hygiene
79. A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The client asks
the nurse about using saw palmetto to relieve the symptoms of BPH. The nurse should
instruct the client that which of the following medications interacts adversely with saw
palmetto?
A. Metoprolol
B. Clopidogrel - saw palmetto interacts with antiplatelet/anticoagulant medications
C. Ipratropium
D. Zolpidem
Answer: B. Clopidogrel - saw palmetto interacts with antiplatelet/anticoagulant medications
80. A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing
treatment prescribed by a wound care consultant. For which of the following findings should
the nurse contact the consultant to revise the plan of care?
A. Weight loss of 5% in 10 days " Risk for development of pressure ulcer: Recent weight
loss- lost 5% of total body weight or 4.5 kg (10lb) practice ass
B. Appearance of pink tissue under eschar
C. Hgb 15 g/dL
D. Albumin level 4.0 g/dL
Answer: A. Weight loss of 5% in 10 days " Risk for development of pressure ulcer: Recent
weight loss- lost 5% of total body weight or 4.5 kg (10lb) practice ass

81. A nurse is providing preoperative teaching to an older adult female client who is
scheduled for a laminectomy and uses supplements. Which of the following supplements
should the nurse identify as increasing the client’s risk for hypotension during surgery?
A. Soy
B. Black cohosh
C. Probiotics
D. Flaxseed
Answer: B. Black cohosh
82. A nurse is planning care for a client who is scheduled to receive a peripherally inserted
central catheter in the arm. Which of the following interventions is appropriate for the nurse
to include in the plan of care?
A. Measure the arm circumference above the insertion site daily
B. Schedule an MRI post procedure to verify placement
C. Administer sedation for the procedure
D. Use gauze to secure an arm board to the involved extremity
Answer: A. Measure the arm circumference above the insertion site daily
83. A nurse is assessing a client who has fine hair, exophthalmos, and reports intolerance to
heat. Which of the following endocrine disorders is associated with these findings?
A. Hyperthyroidism
B. Hyperparathyroidism
C. Hypoparathyroidism
D. Hypothyroidism
Answer: A. Hyperthyroidism
84. A nurse is providing discharge teaching for a client who has a prescription for captopril.
Which of the following adverse effects should the nurse instruct the client to report to the
provider?
A. Alopecia
B. Headache
C. Sore throat
D. Hypoglycaemia
Answer: C. Sore throat

85. A nurse is receiving report on four clients. Which of the following clients should the nurse
assess first?
A. A client who has chronic kidney disease with cloudy dialysate outflow
B. A client who has an ilial conduit and mucus in the pouch
C. A client who had a transurethral resection of the prostate with red-tinged urine in the bag
D. A client who has an arteriovenous fistula that vibrates when palpated
Answer: A. A client who has chronic kidney disease with cloudy dialysate outflow
86. A nurse is caring for a group of clients. Which of the following clients should the nurse
assess first?
A. A client who has heart failure and reports shortness of breath while ambulating
B. A client who had an open cholecystectomy and has green drainage from the T-tube
C. A client who has benign prostatic hyperplasia and is unable to urinate
D. A client who has abdominal pain and is vomiting coffee-ground emesis
Answer: D. A client who has abdominal pain and is vomiting coffee-ground emesis
87. A nurse is caring for a client who has Crohn’s disease. Which of the following diagnostic
procedures should the nurse plan to teach the client regarding pernicious anaemia?
A. Schilling test
B. D-dimer test
C. Oral glucose tolerance test
D. Thyroid scan
Answer: A. Schilling test
88. A nurse is reviewing the medical record of a client who has tuberculosis and a new
prescription for rifampin. The nurse should notify the provider for which of the following
findings?
A. Irregular heart rate
B. Elevated blood glucose level
C. History of alcohol use disorder
D. Allergy to cephalosporins
Answer: C. History of alcohol use disorder

89. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence
the nurse should follow to perform suctioning. (Move the steps into the box on the right,
placing them in the selected order of performance)
A. Turn on the suction and set the pressure
B. Don sterile gloves
C. Insert the catheter during the client’s inspiration
D. Apply suction while rotating the catheter
E. Rinse the catheter to remove secretions
Answer: A. Turn on the suction and set the pressure
B. Don sterile gloves
C. Insert the catheter during the client’s inspiration
D. Apply suction while rotating the catheter
E. Rinse the catheter to remove secretions
90. A nurse is admitting a client who is to undergo paracentesis for removal of ascetic fluid.
Which of the following actions should the nurse take?
A. Ensure the client has a full bladder just prior to the procedure
B. Weigh the client before and after the procedure
C. Administer a low-volume hypertonic enema the night before the procedure
D. Place the client in a side-lying position for the procedure
Answer: B. Weigh the client before and after the procedure
91. A nurse is caring for a child who has sickle cell anaemia and is experiencing Vasoocclusive crisis. Which of the following actions should the nurse include in the place of care?
A. Give aspirin to reduce pain
B. Start a 24-hr urine collection
C. Encourage ambulation
D. Initiate IV fluid replacement
Answer: D. Initiate IV fluid replacement
92. A nurse manager is planning an in-service program for newly licensed nurses. The nurse
manager should instruct to perform medication reconciliation in which of the following
situations?
A. When a client has a new prescription for an enteral feeding

B. When a client is referred to physical therapy
C. When a client returns to the unit after surgery
D. When a client has completed haemodialysis treatment
Answer: C. When a client returns to the unit after surgery
93. A nurse manager is planning a staff in-service to address advocacy in client care. The
nurse should promote which of the following practices during the in-service? (Select all that
apply)
A. Honouring family requests to withhold medical information
B. Addressing client needs when providing resources
C. Encouraging clients to seek further information from the provider
D. Promoting health care access
E. Making decisions about health care on clients’ behalf
Answer: B. Addressing client needs when providing resources
C. Encouraging clients to seek further information from the provider
D. Promoting health care access
94. A nurse is caring for a client who is in labor and has received an epidural. Which of the
following actions should the nurse take?
A. Decrease the maintenance infusion rate of IV fluid
B. Have protamine sulphate available at the bed ide
C. Monitor the client for hypertension
D. Reposition the client side-to-side each hour
Answer: D. Reposition the client side-to-side each hour
95. A nurse is caring for a client who has a new prescription for clozapine. Which of the
following should the nurse recognize as an adverse effect of this medication?
A. Hypoglycemia
B. diarrheal
C. Agranulocytosis
D. Urinary frequency
Answer: C. Agranulocytosis

96. A nurse in the emergency department is interviewing a client immediately following a
sexual assault. Which of the following actions should the nurse take first?
A. Determine the client’s current anxiety level
B. Report the client’s assault to the authorities
C. Initiate a referral for client counseling
D. Request the client’s permission to contact a family member
Answer: A. Determine the client’s current anxiety level
97. A charge nurse is teaching a newly licensed nurse regarding herpes simplex virus (HSV)
during pregnancy. Which of the following statements by the newly licensed nurse indicates
an understanding of the teaching?
A. “The laboratory will test the cord blood to determine if the newborn has contracted HSV.”
B. “The client should avoid acyclovir during pregnancy due to risk to the fetus.”
C. “The client should have a caesarean birth if any active lesions are present.”
D. “The client should avoid breastfeeding until the lesions are healed.”
Answer: C. “The client should have a caesarean birth if any active lesions are present.”
98. A nurse is providing instruction to a client who is to start therapy with acarbose(antidiabetic). Which of the following statements by the client indicates an understanding of the
teaching?
A. “I should take this medication even if I miss a meal.”
B. “I may experience insomnia while taking this medication.”
C. “I may lose weight while taking this medication.”
D. “I should take this medication with the first bite of each meal.”
Answer: D. “I should take this medication with the first bite of each meal.”
99. A charge nurse is admitting four clients to an acute care unit. Which of the following
clients should the nurse place near the nurses’ station?
A. A client who has an open wound
B. A client who has orthostatic hypotension- risk for falls patient = put them in sight of the
nurses for OTC monitoring
C. A client who is on fluid restriction
D. A client who is in Buck’s traction

Answer: B. A client who has orthostatic hypotension- risk for falls patient = put them in sight
of the nurses for OTC monitoring
100. A nurse is preparing information about skin care for a client who has cancer of the
prostate and is receiving radiation therapy. Which of the following should the nurse include in
the information?
A. Clean the perineal area using a washcloth
B. Dry the perineal area by using a patting motion
C. Wear snug-fitting underwear
D. Apply heat packs to the affected area as needed
Answer: B. Dry the perineal area by using a patting motion
101. A nurse is planning care for a group of clients and is working with one licensed practical
nurse (LPN) and one assistive personnel (AP). Which of the following actions should the
nurse take first to manage her time effectively?
A. Schedule daily activities
B. Develop an hourly time frame for tasks
C. Determine goals of the day
D. Delegate tasks to the AP
Answer: C. Determine goals of the day
102. A nurse is caring for four clients. Which of the following client data should the nurse
report to the provider?
A. A client who is 4 hrs. postoperative and has a heart rate of 98/min
B. A client who has a total of 110mL of serosanguineous fluid from a Jackson-Pratt drain
within the first 24 hrs. following surgery
C. A client who has a prescription for chemotherapy and an absolute neutrophil count of
75/mm - immunosuppressed
D. A client who has pleurisy and reports pain of a 6 on a scale of 0 to 10 when coughing
Answer: C. A client who has a prescription for chemotherapy and an absolute neutrophil
count of 75/mm - immunosuppressed

103. A nurse is caring for a client who has a prescription for a peripheral IV catheter. After
puncturing the skin with the vascular access device and noting a blood return in the flashback
chamber, which of the following actions should the nurse perform next?
A. Advance the catheter into the vein
B. Flush the catheter with saline
C. Retract the stylet
D. Release the tourniquet
Answer: A. Advance the catheter into the vein
104. A nurse is caring for a client who is in active labor. The nurse should notify the provider
for which of the following findings?
A. Three uterine contractions within 10 min
B. Baseline FHR 115/min
C. Prolonged decelerations- ABSENT or LATE DECELS are always priority - this may lead
to c section emergency
D. Moderate variability in the FHR
Answer: C. Prolonged decelerations- ABSENT or LATE DECELS are always priority - this
may lead to c section emergency
105. A nurse is providing discharge instructions to the parents of a child who is postoperative
following a tonsillectomy. Which of the following instructions should the nurse include in the
teaching?
A. “You should use a warm-moist vaporizer.”
B. “Encourage your child to eat ice cream to promote comfort for his throat.”
C. “You should call your provider if your child has an increase in swallowing.” - bleeding
D. “Encourage your child to blow his nose frequently to clear secretions.”
Answer: C. “You should call your provider if your child has an increase in swallowing.” bleeding
106. A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in
the community. Which of the following actions should the nurse plan to take?
A. Recommend to the provider specific acute care clients for discharge
B. Determine the medical needs of incoming clients through the emergency department
C. Act as a liaison between the facility and the media

D. Call in additional medical-surgical unit nursing care staff
Answer: B. Determine the medical needs of incoming clients through the emergency
department
107. A home health nurse is caring for a child who has Lyme disease. Which of the following
is an appropriate action for the nurse to take?
A. Ensure the state health department has been notified - national notifiable disease
B. Administer antitoxin
C. Educate the family to avoid sharing personal belongings
D. Assess for skin necrosis
Answer: A. Ensure the state health department has been notified - national notifiable disease
108. A surgeon is obtaining informed consent from a client. When a nurse witnesses the client
sign the consent form, which of the following legal requirements is the nurse confirming?
A. The client knows he may no longer refuse the procedure
B. The client agreed to the procedure voluntarily
C. The nurse explained the risks and benefits of the surgery
D. The nurse explained the surgical procedure in detail
Answer: B. The client agreed to the procedure voluntarily
109. A nurse is caring for a client who is experiencing mild anxiety. Which of the following
findings should the nurse expect?
A. Heightened perceptual field
B. Rapid speech
C. Purposeless activity
D. Feelings of dread
Answer: A. Heightened perceptual field
110. A nurse in the emergency department is caring for an adolescent who has acute
appendicitis and reports pain at McBurney’s point. The nurse should identify which of the
following areas as McBurney’s point? (You will find “Hot Spots” to select in the artwork
below. Select only the hot spot that corresponds to your answer.)

A. Leftmost circle (Yellow circle)
B. Central square above the pelvis
C. Central square below the belly button
D. Rightmost circle (Marked with an "X")
Answer: A. Leftmost circle (Yellow circle)
111. A nurse working with the state health department is reviewing medical records for four
clients. Which of the following infectious diseases is a national notifiable disease?
A. Hepatitis B
B. Human papillomavirus
C. Molluscum contagiosum
D. Bacterial vaginosis
Answer: A. Hepatitis B
112. A nurse is verifying informed consent for surgery from a client who does not speak the
same language as the nurse. Which of the following resources should the nurse use to
facilitate communication?
A. The client’s family member
B. A language application on an electronic device
C. A bilingual staff member
D. A medical interpreter
Answer: D. A medical interpreter

113. A nurse is planning to delegate the fasting blood glucose testing for a client who has
diabetes mellitus to an assistive personnel (AP). Which of the following actions should the
nurse take?
A. Have the AP check the medical record for prior blood glucose test results
B. Determine if the AP has the skills to perform the test
C. Help the AP perform the blood glucose test
D. Assign the AP to ask the client if he has taken his antidiabetic medication today
Answer: B. Determine if the AP has the skills to perform the test
114. A home care nurse is making a follow-up visit with a client who has COPD and is using
a compressed oxygen system in his home. Which of the following actions should the nurse
take?
A. Store the oxygen tank wrench in a locked cabinet
B. Have the client store smaller tanks under his bed
C. Ensure that the client is checking the gauge weekly
D. Place the oxygen tank away from curtains or drapes
Answer: D. Place the oxygen tank away from curtains or drapes
115. A nurse in an acute mental health facility is assessing a client who is experiencing
auditory command hallucinations. Which of the following questions should the nurse ask
first?
A. “Do the voices cause you to feel anxious?”
B. “Can you tune out the voices by listening to music?”
C. What are the voices telling you to do?”
D. “Are you also seeing unusual persons or things?
Answer: C. What are the voices telling you to do?”
116. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging
(MRI) scan. Which of the following statements is appropriate to include in the teaching?
A. “You should not have this procedure if you have a tattoo.”
B. “The nurse will ask you to remove any transdermal patches prior to the procedure.”
C. “You should not have this procedure if you are allergic to iodine.” - contrast media may be
used
D. “The nurse will ask you to wear protective eyewear during this procedure.”

Answer: C. “You should not have this procedure if you are allergic to iodine.” - contrast
media may be used
117. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the
following tasks is appropriate for the nurse to delegate to an AP?
A. Administering oral fluids to a client who has dysphagia
B. Documenting the report of pain for a client who is postoperative
C. Applying a condom catheter for a client who has a spinal cord injury
D. Reviewing active range-of-motion exercises with a client who had a stroke
Answer: C. Applying a condom catheter for a client who has a spinal cord injury
118. A client who is having suicidal thoughts tells the nurse, “It just does not seem worth it
anymore. Why not end my misery?” Which of the following responses by the nurse is
appropriate?
A. “You can trust me and tell me what you are thinking.”
B. “I need to know what you mean by misery.”
C. “Why do you think your life is not worth it anymore?”
D. “Do you have a plan to end your life?” – SAFETY
Answer: D. “Do you have a plan to end your life?” – SAFETY
119. A nurse is providing teaching to a client who has a new prescription for omeprazole.
Which of the following adverse effects should the nurse include as a possible risk of longterm therapy?
A. Constipation
B. Lung cancer
C. Tinnitus
D. Osteoporosis
Answer: D. Osteoporosis
120. A mental health nurse is caring for a client who recently attempted suicide. The client
states, “I wish I was dead.” Which of the following is an appropriate response by the nurse?
A. “Suicide is not the answer to your problems.”
B. “Don’t worry. Everything will be just fine.”
C. “You seem like you’re feeling hopeless.”

D. “Did you take your medications today?”
Answer: C. “You seem like you’re feeling hopeless.”
121. A charge nurse is concerned about a recent increase in facility-acquired infections.
Which of the following actions should the nurse take first?
A. Schedule nursing staff training for infection control procedures
B. Revise the current policy for catheter care
C. Identify possible precipitating factors related to the infections
D. Meet with providers to discuss measures to decrease the infections
Answer: C. Identify possible precipitating factors related to the infections
Rationale:
Assess first by Identifying.
122. A nurse receives change-of-shift report on four clients. Based on the shift information,
which of the following clients should the nurse plan to assess first?
A. A client who had a hip arthroplasty reports pain and erythema in his calf
B. A client who had a barium enema 2 days ago and reports constipation
C. A client who has anorexia and peripheral edema
D. A client who had Addison’s disease with a blood glucose level of 75 mg/dL (low sugar
level expected for Addison’s)
Answer: A. A client who had a hip arthroplasty reports pain and erythema in his calf
Rationale:
Clinical Manifestation of Post thrombotic Syndrome, specially seen after surgery such as
Arthroplasty.
123. A nurse is assessing a client who is prescribed valproic acid. Which of the following
laboratory tests should the nurse monitor?
A. Arterial blood gas
B. Serum creatinine
C. Serum potassium
D. Liver function test
Answer: D. Liver function test
Rationale:
Valproic Acid risk for Hepatotoxicity on Practice Q

124. A nurse is caring for a client who has a vented NG tube set to low intermittent suction
and has vomited. Which of the following actions should the nurse perform first?
A. Replace the NG tube
B. Evaluate functioning of the suction device
C. Provide oral hygiene care
D. Administer an antiemetic medication
Answer: B. Evaluate functioning of the suction device
Rationale:
Assess and maintain function of NG tube
125. A nurse in a clinic is reviewing the health history of a client during her first prenatal
visit. Which of the following findings indicates a risk for diabetes mellitus?
A. Delivery of a low birth-weight infant
B. Previous miscarriage
C. BMI of 28
D. 1-hr oral glucose tolerance test of 132 mg/dL (140 mg/dL is considered DM per OB ATI
Book)
Answer: C. BMI of 28
Rationale:
Risk factor of DM is Obesity.
126. A nurse is preparing to administer medications to a group of clients using a portable
medication cart. Which of the following actions should the nurse take?
A. Lock the medication cart prior to entering each client’s room
B. Place controlled substances in the client’s drawers of the medication cart before leaving
the medication room (they can take it from the drawer)
C. Prepare each client’s medications and place in client drawers prior to beginning
medication administration
D. Contact the pharmacy to restock the medication cart when the cart if empty
Answer: A. Lock the medication cart prior to entering each client’s room
Rationale:
To prevent loss of medication patient might take it if they have access to it.

127. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor.
The client’s contractions are occurring every 45 seconds with a 90 second duration and the
fetal heart rate is 170 to 180/min. Which of the following actions should the nurse take?
A. Discontinue the oxytocin infusion
B. Increase the oxytocin infusion
C. Maintain the oxytocin infusion
D. Decrease the oxytocin infusion
Answer: A. Discontinue the oxytocin infusion
Rationale:
Discontinue if uterine hyper stimulation occurs with contraction frequency more often than
every 2 min, contraction duration longer than 90 seconds, contraction intensity results with
pressures greater than 90 mm Hg as shown by IUPC, uterine resting tone greater than 20 mm
Hg between contractions showing no relaxation of uterus between contractions.
128. A school nurse is performing scoliosis screenings. The nurse should recognize which of
the following clinical manifestations as an indication of scoliosis?
A. Limited range-of-motion of hips
B. Exaggerated curvature of sacrum
C. Mild pain in the hip region
D. Uneven shoulder and pelvic heights
Answer: D. Uneven shoulder and pelvic heights
Rationale:
Scoliosis is Lateral Curvature of the Spine which can be seen as uneven shoulder and pelvic
heights.
129. A nurse is reviewing laboratory results for a client prior to administering zidovudine.
Which of the following laboratory values should the nurse monitor?
A. Serum potassium
B. WBC count
C. Blood glucose
D. Serum albumin
Answer: B. WBC count
Rationale:
Zidovudine is a NRTI which causes suppress bone marrow.

130. A nurse is planning care for a client who has cancer and is about to receive low dose
brachytherapy via a vaginal implant applicator. Which of the following interventions should
the nurse include in the plan of care?
A. Maintenance of NPO status until therapy is complete
B. Removal of vaginal packing
C. Ambulation four times daily (Activity is Restricted to prevent dislodgement)
D. Insertion of an indwelling urinary catheter
Answer: D. Insertion of an indwelling urinary catheter
Rationale:
The client who has cervical cancer will have a vaginal radiation implant. A catheter is needed
to prevent displacement of the implant during ambulation.
131. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an
assistive personnel (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists
and feed you.” The nurse should intervene and explain to the AP that this statement
constitutes which of the following torts?
A. Malpractice
B. Battery
C. Assault- verbal
D. Negligence
Answer: C. Assault- verbal
132. While performing a routine assessment, a nurse notices fraying on the electrical cord of
a client’s continuous passive motion (CPM) device. Which of the following actions should
the nurse take first?
A. Ensure the device inspection sticker is current
B. Report the defect to the equipment maintenance staff
C. Remove the device from the room
D. Initiate a requisition for a replacement CPM device
Answer: C. Remove the device from the room
133. A nurse is planning to teach a client about ways to prevent recurrent urinary tract
infections. Which of the following instructions should the nurse plan to include?

A. Void after intercourse- confirm
B. Drink orange juice
C. Soak in a hot tub
D. Wear nylon underwear
Answer: A. Void after intercourse- confirm
134. A nurse is caring for a client who is alert and oriented and is receiving continuous ECG
monitoring. The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and
an increased heart rate. The nurse should identify the cardiac rhythm as which of the
following?
A. Second-degree heart block
B. Ventricular asystole
C. Atrial fibrillation- confirm
D. Sinus tachycardia
Answer: C. Atrial fibrillation- confirm
135. A nurse is caring for a client who has severe hypertension and is to receive nitroprusside
via continuous IV infusion. Which of the following actions should the nurse take?
A. Keep calcium gluconate at the bedside
B. Monitor blood pressure every hour
C. Cover the IV bag with opaque material- protect IV container and tubing from light
D. Use an in-line filter
Answer: C. Cover the IV bag with opaque material- protect IV container and tubing from
light
136. A nurse is teaching a parent of a child about pediculosis capitis. Which of the following
should be included in the teaching?
A. “Lice can be transmitted by pets.”
B. “The eggs live off the host’s blood supply.”
C. “Lice survive up to 48 hours on surfaces.”
D. “Applying mayonnaise on your child’s head will remove the lice.”- avoid home remedies
Answer: C. “Lice survive up to 48 hours on surfaces.”

137. A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran.
Which of the following statements by the client indicates an understanding of the teaching?
(direct thrombin inhibitor, for stroke clients who have atrial fibrillation, DVT)
A. “I can crush the medication and mix with applesauce.”- must be taken whole
B. “I can store the medication in the refrigerator.”
C. “I should replace any unused medication every 6 months.”- container should be used in 30
days
D. “I should keep the medication in the original container.”
Answer: D. “I should keep the medication in the original container.”
138. A charge nurse is selecting clients for discharge to prepare to receive victims from a
local disaster. Which of the following clients should the nurse recommend for discharge?
A. A client who has hemiplegia and is to undergo an annual colonoscopy
B. A client who has a BUN 105 mg/dL following a CT scan with contrast
C. A client who reports vomiting and is under observation following a head injury
D. A client who has shortness of breath and a B-type natriuretic peptide 230 mg/mL
Answer: A. A client who has hemiplegia and is to undergo an annual colonoscopy
139. A nurse is admitting an older adult client who is transferring from another facility. The
nurse notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of
the following actions should the nurse take to address suspicions of elder abuse?
A. Privately interview the client about her condition
B. Contact the family regarding the client’s condition
C. Inform the transferring agency of the client’s condition
D. Notify risk management
Answer: A. Privately interview the client about her condition
140. A nurse in the emergency department is admitting a client who reports ingesting 30
diazepam tablets 20 minutes ago. The client has a respiratory rate of 10/min and is lethargic.
After securing the client’s airway, which of the following actions should the nurse take next?
A. Evaluate the client for potential suicidal ideation
B. Administer flumazenil to the client ! Reverse Sedative Effects; Lorazepam
C. Assist the client with ingestion of activated charcoal
D. Perform gastric lavage for the client

Answer: B. Administer flumazenil to the client ! Reverse Sedative Effects; Lorazepam
141. A nurse is providing teaching to a client who has a new prescription for methotrexate.
For which of the following adverse effects should the nurse instruct the client to monitor and
report to the provider?
A. Muscle pain
B. Pedal edema
C. Insomnia
D. Petechiae- monitor for bleeding
Answer: D. Petechiae- monitor for bleeding
142. A nurse is orienting a newly licensed nurse while caring for clients who are in labor.
Which of the following pain management strategies by the newly licensed nurse requires
intervention?
A. Using effleurage on a client’s lower abdomen
B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomenfor back pain
C. Instructing a client’s partner how to apply counter pressure to the client’s sacral spine for
30 minutes
D. Encouraging a client to use jet hydrotherapy on her lower back for 1 hrs.
Answer: B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s
abdomen- for back pain
143. A nurse is performing assessments on infants in the newborn nursery. Which of the
following findings should the nurse report to the provider?
A. A 16-hr-old infant whose blood glucose is 45 mg/dL
B. A 2-day-old infant who has a small amount of blood-tinged vaginal discharge
C. A 16-hr-old infant who has yet to pass a meconium stool
D. A 2-day-old infant who has a respiratory rate of 70/min
Answer: D. A 2-day-old infant who has a respiratory rate of 70/min
144. A nurse is verifying a record of informed consent for a client who is scheduled for
surgery. Which of the following actions should the nurse take?
A. Explain the procedure to the client before verifying informed consent

B. Inform the client about the condition that requires treatment
C. Confirm the client’s signature is authentic
D. Provide information on the informed consent form about the benefits of the surgery
Answer: C. Confirm the client’s signature is authentic
145. A nurse is providing teaching for a child prescribed ferrous sulphate. Which of the
following instructions should the nurse include?
A. Take at bedtime
B. Take with a glass of orange juice- vitamin C always goes with iron
C. Take with a glass of milk
D. Take with meals
Answer: B. Take with a glass of orange juice- vitamin C always goes with iron
146. A nurse is teaching a client about taking omeprazole. Which of the following statements
by the client indicates an understanding of the teaching?
A. “I will open the capsule and mix the medication with applesauce.”
B. “I will take a laxative if I become constipated.”
C. “I will take it 30 minutes before meals. “properly absorbed”
D. “I will take it as needed for ulcer pain every 4 hours.”
Answer: C. “I will take it 30 minutes before meals. “properly absorbed”
147. A nurse is preparing to administer heparin IV bolus to a client. The prescription is for
175 units/kg. The client weighs 167.2 lbs. How many units should the nurse plan to
administer? (Round the answer to the nearest whole number. Use a leading zero if applicable.
Do not use a trailing zero.)
Answer: 13,300 units
167.2 / 2.2 = 76 kg
175 units x 76kg = 13,300 units
148. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving
because the facility policy prohibits smoking inside. Which of the following actions should
the nurse take?
A. Notify security to monitor the facility’s exits
B. Inform the client of the risks involved if she leaves

C. Call the provider for a discharge prescription
D. Place the client in seclusion
Answer: B. Inform the client of the risks involved if she leaves
149. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the
following food choices is appropriate for this client?
A. Canned barley soup
B. Wheat crackers
C. Potato pancakes Repeat No To Brow Highlight Yellow
D. White flour tortillas
Answer: C. Potato pancakes Repeat No To Brow Highlight Yellow
150. A nurse is caring for a client who requires seclusion to prevent harm to others on the
unit. Which of the following is an appropriate action for the nurse to take?
A. Assess the client’s behavior once every hour
B. Document the client’s behavior prior to being placed in seclusion
C. Discuss with the client his inappropriate behavior prior to seclusion
D. Offer fluids every 2 hrs.
Answer: B. Document the client’s behavior prior to being placed in seclusion
151. A nurse is providing teaching for a client who is undergoing radiation therapy and has
stomatitis. Which of the following responses by the client indicates an understanding of the
teaching?
A. “I should limit my intake of dairy products to prevent nausea.”
B. “I should use a soft-bristle toothbrush to clean my teeth after meals.”
C. “I should moisten my lips with lemon-glycerin swabs.”
D. “I should gargle with an alcohol-based mouthwash to kill germs.”
Answer: B. “I should use a soft-bristle toothbrush to clean my teeth after meals.”
152. A nurse is caring for a client who is postoperative and has a new prescription for
hydromorphone. Which of the following actions should the nurse take?
A. Withhold the medication if the client does not appear to be in pain
B. Withhold the medication if the client has a fever

C. Count the current number of unit doses available in the medication dispensing system !
narcotics
D. Document administration of the medication upon removal from the medication dispensing
system
Answer: C. Count the current number of unit doses available in the medication dispensing
system ! narcotics
153. A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled
for surgery for a fractured femur of the right leg. Which of the following interventions should
the nurse delegate to an assistive personnel?
A. Remind the client to use the incentive spirometer
B. Check the client’s pedal pulse on the right leg ASSESS
C. Ask the client to describe her pain ASSESS
D. Observe the position of the suspended weight ASSESS
Answer: A. Remind the client to use the incentive spirometer
154. A wound care nurse is planning care for an older adult client who has a pressure ulcer on
his coccyx. Which of the following resources should the nurse reference when including
evidence-based practices in the treatment plan?
A. A diagnosis-related group (DRG)
B. The State Nurse Practice Act
C. A clinical practice guideline
D. The current Institute of Medicine (IOM) report
Answer: C. A clinical practice guideline
155. A nurse on an inpatient mental health unit is leading a group session and a member of
the group is dominating the discussion. Which of the following actions should the nurse take?
A. Ask the client why he is being disruptive
B. Request that the client leave the group session
C. Remind the group that everyone should have equal time to contribute
D. Encourage other group members to ignore the client’s behavior
Answer: C. Remind the group that everyone should have equal time to contribute

156. A nurse is reviewing the laboratory results of a client who has severe malnutrition and is
receiving total enteral nutrition. Which of the following results should the nurse report to the
provider?
A. Serum phosphorus 3.3 mg/dL
B. Serum sodium 128 mEq/L
C. Serum calcium 9.2 mg/dL
D. Serum potassium 3.9 mEq/L
Answer: B. Serum sodium 128 mEq/L
157. A nurse is caring for an adolescent who has hyperthermia. Which of the following is an
appropriate action for the nurse to take?
A. Cover the adolescent with a thermal blanket
B. Initiate seizure precautions
C. Administer oral acetaminophen B na yan kalerki.
D. Submerge the adolescent’s feet in ice water
Answer: B. Initiate seizure precautions
158. A nurse is caring for a female client who tells the nurse she is taking valerian to relieve
her menstrual cramps. The client’s nurse should instruct the client to avoid the use of this
herbal product due to which of the following medications?
A. Alprazolam
B. Oral contraceptives
C. Levothyroxine
D. Calcium carbonate
Answer: A. Alprazolam
159. A nurse is reviewing laboratory findings of a client who is to receive a dose of
enoxaparin. For which of the following laboratory values should the nurse withhold the dose
and notify the provider?
A. BUN 25 mg/dL
B. Urine specific gravity 1.035
C. Platelets 80,000/mm3
D. WBC 15,000/mm3
Answer: C. Platelets 80,000/mm3

160. A nurse is providing prenatal teaching about iron to a client who follows a vegetarian
diet. The nurse should recommend that the client consume which of the following foods to
enhance the absorption of nonheme iron?
A. Orange slices vitamin C goes with iron in combo
B. Boiled eggs
C. Mixed nuts
D. Cheddar cheese
Answer: A. Orange slices vitamin C goes with iron in combo
161. A nurse is admitting a client who is 1 week postpartum with excessive vaginal bleeding.
The nurse does not speak the same language as the client. The client’s partner and 1-year-old
child are accompanying her. Which of the following actions should the nurse take to gather
the client’s admission data?
A. Ask a nursing student who speaks the same language as the client to translate
B. Request a female interpreter through the facility
C. Have the client’s child translate
D. Allow the client’s partner to translate
Answer: B. Request a female interpreter through the facility
162. A nurse is preparing to apply a transdermal nicotine patch on a client. Which of the
following actions should the nurse take?
A. Remove the previous patch and place it in a tissue
B. Shave hairy areas of skin prior to application
C. Apply the patch within 1 hrs. of removing it from the protective pouch
D. Wear gloves to apply the patch to the client’s skin
Answer: D. Wear gloves to apply the patch to the client’s skin
163. A nurse is reviewing a laboratory values. Which of the following should the nurse
review to evaluate the nutritional status?
A. Serum sodium
B. Serum albumin protein
C. Troponin level heart stroke
D. Erythrocyte sedimentation rate

Answer: B. Serum albumin protein
164. A nurse is assessing the pupils of a client who has a head injury. Which of the following
images indicates that the client has increased intracranial pressure?
A.

B.

C.

D.

Answer:
D.

165. A nurse is assessing a client who is 2 hrs. postpartum for uterine atony. Which of the
following actions should the nurse take?
A. Encourage the client to empty her bladder.
B. Measure the client’s vital signs.
C. Perform fundal massage.
D. Administer oxygen at 2 L/min via nasal cannula.

Answer: C. Perform fundal massage.
166. A nurse is planning discharge teaching about cord care for the parents of a newborn.
Which of the following instructions should the nurse plan to include in the teaching?
A. Clean the cord with hydrogen peroxide daily.
B. Cover the cord with a sterile gauze dressing.
C. Keep the cord dry until it falls off.
D. Give the newborn a tub bath daily until the cord falls off.
Answer: C. Keep the cord dry until it falls off.
167. A nurse is teaching an adolescent who has type 1 diabetes mellitus and his parents how
to dispose of his insulin syringes and needles at home. Which of the following instructions is
appropriate?
A. Recap the needles and wrap them and the syringes in paper towels
B. Seal the needles in zipper-lock plastic bags and place them in a metal trash can
C. Place the needles in an aluminium coffee can and store them on a high shelf
D. Place the needles in a plastic container and then pour alcohol into the container
Answer: C. Place the needles in an aluminium coffee can and store them on a high shelf
168. A nurse is reviewing the medication administration record of a client who has
rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which
of the following medications places the client at risk for delayed wound healing?
A. Digoxin
B. Prednisone
C. Morphine
D. Omeprazole
Answer: B. Prednisone
169. A nurse is administering an analgesic to a client who has a chest tube. The provider is
preparing to discontinue the chest tube before the medication has taken effect. Which of the
following actions should the nurse take first?
A. Instruct the client about the steps of the procedure
B. Document the sequence of events as they occur
C. Inform the provider of the time of the last dose of pain medication

D. Provide nonpharmacological pain management interventions
Answer: C. Inform the provider of the time of the last dose of pain medication
170. A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving
monitoring for following findings should the nurse monitor?
A. Weight loss
B. Bradycardia
C. Bulging fontanel
D. Distended jugular vein
Answer: A. Weight loss
171. A nurse is assessing a client who has antisocial personality disorder. Which of the
following characteristics should the nurse expect?
A. Lack of remorse
B. Needs continued reassurance
C. Sensitive to criticism
D. Exaggerated expression of emotion
Answer: A. Lack of remorse
172. A nurse in a surgical suite is planning care for a client who requires surgery and has a
latex sensitivity. Which of the following strategies is appropriate for this client?
A. Schedule the client as the last surgery of the day
B. Remove stopcocks from IV tubing
C. Tape stockinet over monitoring devices and cords
D. Disinfect and powder any latex products before use
Answer: B. Remove stopcocks from IV tubing
173. A nurse is planning care for a client who is returning to the unit following open gastric
bypass surgery. Which of the following interventions should the nurse include in the client’s
plan of care?
A. Provide 60 mL (2 oz.) of fluid intake every 5 min
B. Measure and compare abdominal girth daily
C. Ambulate the client 48 hrs. after the procedure
D. Provide a soft diet on the first postoperative day

Answer: B. Measure and compare abdominal girth daily
174. A nurse on a medical-surgical unit is receiving report on four clients. Which of the
following clients should the nurse assess first?
A. A client who is 2 days postoperative following placement of an ascending colostomy and
has shreds of bloody mucus in the bag
B. A client who is receiving a blood transfusion and reports low-back pain
C. A client who is scheduled for chemotherapy and has an RBC of 4 million/mm3
D. A client who is 24 hrs. postoperative following a transurethral resection of the prostate and
has small blood clots in the drainage tubing
Answer: B. A client who is receiving a blood transfusion and reports low-back pain
175. A nurse is assessing a client who has been taking oral contraceptives for the past 6
months. Which of the following findings should the nurse immediately report to the provider?
A. Breast tenderness
B. Frequent nausea
C. Persistent headache - migraine headaches; report to MD
D. Weight gain 2.3 (5 lbs.)
Answer: C. Persistent headache - migraine headaches; report to MD
176. A nurse is providing teaching to a client who is to undergo a cardiac catheterization.
Which of the following findings is expected during the procedure?
A. Numbness and tingling of the extremities
B. Increased salivation
C. Headache
D. Sensation of skin warmth - dye is injected
Answer: D. Sensation of skin warmth - dye is injected
177. A nurse is caring for a client who has AIDS and is receiving antiretroviral treatment.
Which of the following laboratory findings indicates that the client is responding to the
treatment?
A. Decreased plasma HIV RNA
B. Negative ELISA test
C. Decreased CD4+ cell count - should increase when responding to TX

D. Positive Western blot test
Answer: A. Decreased plasma HIV RNA
178. A nurse is assessing a client who has a chest tube with a water seal drainage system.
Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an
explanation for the tidaling?
A. The lung has re-expanded
B. There is a loop of tubing below the drainage system
C. The system is working properly
D. The tubing is partially obstructed by clots
Answer: C. The system is working properly
179. A nurse is caring for a client who has a new diagnosis of diabetes mellitus and states, “I
will never be able to give myself insulin shots.” Which of the following is an appropriate
response by the nurse?
A. “Don’t you think you will change your mind about the injections?”
B. “Many people give themselves injections every day.”
C. “Would you tell me more about how you are feeling?”
D. “Let’s talk about the changes you will need to make in your lifestyle.”
Answer: C. “Would you tell me more about how you are feeling?”
180. A nurse is caring for a client recovering from a cerebrovascular accident in a
rehabilitation facility. The client tells the nurse, “I am sick of being in here, and I want to go
home.” Which of the following is an appropriate therapeutic response?
A. “You should call your partner to discuss this.”
B. “You are making progress in your treatment plan.”.
C. “It must be very frustrating for you to be here.”
D. “Maybe you should discuss your discharge plans with your provider.”
Answer: C “It must be very frustrating for you to be here.”
181. A nurse on a medical-surgical unit is receiving report on four clients. Which of the
following clients should the nurse assess first?
A. A client who is 2 days postoperative following placement of an ascending colostomy and
has shreds of bloody mucus in the bag

B. A client who is receiving a blood transfusion and reports low back pain
C. A client who is scheduled for chemotherapy and has an RBC of 4 million/mm3
D. A client who is 24 hrs. postoperative following a transurethral resection of the prostate and
has small blood clots in the drainage tubing
Answer: B. A client who is receiving a blood transfusion and reports low back pain
182. A nurse is assessing a client who has been taking oral contraceptives for the past 6
months. Which of the following findings should the nurse immediately report to the provider?
A. Breast tenderness
B. Frequent nausea
C. Persistent headache
D. Weight gain 2.3 (5 lbs.)
Answer: C. Persistent headache
183. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which
of the following interventions should the nurse perform?
A. Position the head of bed at 30° during feeding PREVENT ASPIRATION
B. Mix the client’s medications with the tube feedings
C. Give 100 mL of water with every feeding
D. Obtain gastric residuals every 24 hrs.
Answer: A. Position the head of bed at 30° during feeding PREVENT ASPIRATION
184. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to
an assistive personnel?
A. Assess effectiveness of antiemetic medication
B. Provide discharge instructions
C. Perform chest compressions during cardiac resuscitation
D. Perform a dressing change for a new amputee
Answer: C. Perform chest compressions during cardiac resuscitation
185. A nurse is assessing a client who is receiving magnesium sulphate for preeclampsia
which of the following is the nurse’s priority?
A. Urinary output 35 ml/hrs. at least 30 ml
B. 2+ deep tendon reflexes – normal

C. 3+ pedal ed ema 10/min
D. Respiratory rate
Answer: D. Respiratory rate
186. A nurse is caring for a client who is at 32 weeks of gestation and has a history of cardiac
disease. Into which of the following positions should the nurse place the client to best
promote optimal cardiac output?
A. High fowlers
B. Standing
C. Left-lateral
D. Supine
Answer: C. Left-lateral
187. A nurse is assessing a client who has type 1 diabetes Mellitus and a blood glucose level
of 32mg/dl. Which of the following should the nurse expect?
A. Blurred vision
B. Hot, dry skin
C. Deep respirations
D. Bradycardia
Answer: A. Blurred vision
188. A nurse is reviewing a client’s cardiac rhythm strips and notes a constant P-R interval of
0.35 seconds. Which of the following dysrhythmias is the client displaying?
A. Atrial fibrillation
B. Complete heart lock
C. First degree atrioventricular block
D. Premature atrial complexes
Answer: C. First degree atrioventricular block
189. A nurse is providing discharge teaching to a client who has hyperlipidemia and is to start
treatment with atorvastatin. The nurse should instruct the client to avoid taking the
medication with which of the following?
A. Caffeinated beverages
B. Green leafy vegetables

C. Aged cheese
D. Grape fruit.
Answer: d. Grape fruit.
190. A nurse is evaluating a client’s understanding of food nutrition labels. Which of the
following statements by the client indicate an understanding of the teaching?
A. The ingredient with the greatest weight appears first
B. Food manufacturers provide nutrition information voluntarily
C. Item serving size is consistent from one manufacturer to the next
D. The daily values relate to a 1,500-calorie diet
Answer: B. Food manufacturers provide nutrition information voluntarily
191. A nurse is planning care for a child who has neutropenia due to leukaemia. Which of the
following interventions should the nurse include in the plan?
A. Screen the child’s visitors for active infections
B. Initiate a low protein diet for the child
C. Prepare the child for a platelet transfusion
D. Monitor the child for indications of active bleeding
Answer: A. Screen the child’s visitors for active infections
192. The nurse is reviewing laboratory values for a client who has bipolar disorder and takes
lithium carbonate. Which of the following values should the nurse report to the provider?
A. Thyroxine tT4 2.8 mcg/dl
B. Sodium 137
C. Lithium 1.0
D. WBC 5,600
Answer: A. Thyroxine tT4 2.8 mcg/dl
193. A nurse is preparing to administer cefpodoxime 10 mg/kg/day PO divided equally every
12 hrs. to a child who 66lbs. available is cefpodoxime 20 mg/ml oral solution. How many ml
should the nurse administer per dose?
Answer: 66lbs/2.2= 30kg; 300mg/day PO.
300/20 = 15mL oral solution per day
Q is bid so 15ml/2 = 7.5Ml

194. A nurse is caring for a client who has a prescription for lactated ringers IV 4080 ml/24
hr. the nurse should set the IV infusion pump to deliver many ml/hrs. to administer half the
total volume in the first 8hr?
Answer: 255
195. A nurse is caring for a client who speaks a different language than the nurse and is using
an interpreter. Which of the following actions should the nurse take when working with the
interpreter?
A. Speak in a normal voice at a natural pace
B. Direct statements to the interpreter - put this send it before changing
C. Use gestures when speaking with the client
D. Pause in the middle of sentence.
Answer: A. Speak in a normal voice at a natural pace