Preview Extract
Med Surg – Proctored ATI Real Test Questions (125 Terms) with Correct
Answers and Rationales, Graded A+ Update 2023.
1. An older adult 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.
Rationale:
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase
in osmolarity, which is a manifestation of hypertonic dehydration.
2. 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.
3. 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-eight inch wider than the stoma."
Rationale:
The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than the stoma to
minimize irritation of the skin from exposure to urine.
4. 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 number of medications,
including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr
of levothyroxine administration.
5. 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.
6. 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.
7. 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
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.
8. 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
expect?
Answer: Administer an opioid analgesic to the client.
Rationale:
The nurse should expect a prescription for an opioid analgesic to promote comfort following a
rattlesnake bite.
9. 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?
(Click on the "Exhibit" button for additional information about the client).
Answer: Current medications
Rationale:
The nurse should review the client's medication record and identify medications, including ACE
inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that
can alter the allergy skin test results. These medications can diminish the client's reaction to the
allergens. The nurse should notify the provider and instruct the client to discontinue prednisone
for 2 weeks before allergy skin testing.
10. A nurse is a 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.
Rationale:
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to
enhance medication absorption and prevent hematoma formation.
11. A nurse is caring for a client who has a stage III pressure injury. Which if the following
findings contribute to delayed wound healing?
Answer: Urine output 25 mL/hr
Rationale:
Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can
delay wound healing.
12. 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 500kcal/L. The IV pump
should be set at how many mL/hr? (Rounding to the nearest whole number.)
Answer: 167mL/hr
Rationale:
To determine the rate at which the TPN should be infused, we first calculate the number of kcal
the client needs per hour. Since the client needs 2,000 kcal per day, we divide this by 24 to find
the kcal per hour:
2,000 kcal/24 hours = 83.33 kcal/hr
Next, we calculate how many milliliters (mL) of the TPN solution are needed to provide 83.33
kcal. The TPN solution has 500 kcal/L, so we divide 83.33 kcal by 500 kcal/L to find the volume
of solution needed per hour:
83.33 kcal/500 kcal/L = 0.16666 L/hr
Since there are 1,000 mL in 1 L, we multiply 0.16666 by 1,000 to convert liters to milliliters:
0.16666 L/hr × 1,000 mL/L = 166.66 mL/hr
Rounding to the nearest whole number, the IV pump should be set at approximately 167 mL/hr.
13. 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
fiber, low in fat, and low in refined carbohydrates. Brassica vegetables such as cabbage,
cauliflower, and broccoli, are high in fiber.
14. A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be
applied to her burn wounds. The nurse should evaluate the client for which of the following
laboratory findings?
Answer: Leukopenia
Rationale:
Transient leukopenia is an adverse effect of silver sulfadiazine.
15. A nurse is teaching a client with systemic erythematosus who has a new prescription for
prednisone. The nurse should instruct the client to monitor for which of the following adverse
effects of this medication?
Answer: Infection
Rationale:
The nurse should instruct the client to avoid contact with people who are ill and monitor for
manifestations of an infection such as a fever or a sore throat. Prednisone can suppress the
client's immune response and mask the manifestations of an infection.
16. A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy.
Which of the following statements indicates that the client understands the impact of the
surgery?
Answer: "I understand that I will have a permanent tracheostomy after the surgery."
Rationale:
With a partial laryngectomy, the tracheostomy is temporary. This client will have a total
laryngectomy, so the tracheostomy will be permanent.
17. A nurse is assessing a client who has systemic scleroderma. Which of the following findings
should the nurse expect?
Answer: Finger contractures
Rationale:
Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin,
blood vessels, and internal organs. There are 2 types of scleroderma: localized scleroderma,
which mainly affects the skin, and systemic scleroderma, which can affect internal organs.
Manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and
dry mucous membranes. With scleroderma the body produces and deposits too much collagen,
causing thickening and hardening. In addition to the client's skin and subcutaneous tissues
becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures
develop with advanced systemic scleroderma unless clients follow a regimen of range-of-motion
and muscle strengthening exercises.
18. A nurse is caring for a client who has tracheostomy and is receiving mechanical ventilation.
When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the
nurse?
Answer: A leak within the ventilator's circuitry
Rationale:
The low-pressure alarm means that either the ventilator tubing has come apart or the tubing
detached from the client. Low-pressure alarms are often the result of a malfunction or
displacement of connections somewhere between the endotracheal or tracheostomy tube and the
ventilator.
19. A nurse is monitoring a client following a thyroidectomy for the presence of
hypoparathyroidism. Which of the following findings should the nurse expect?
Answer: Involuntary muscle spasms
Rationale:
The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism,
which can occur if the parathyroid glands are damaged or removed during a thyroidectomy.
Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and
calcium deficiency.
20. A nurse is providing discharge teaching to client who has osteoarthritis. Which of the
following instructions should the nurse include?
Answer: "Rest frequently after periods of activity."
Rationale:
The joint pain in osteoarthritis is caused by deterioration of the synovial membranes and often
worsens after activity. Rest usually helps relieve the pain, so performing activities at a
comfortable pace with periods of rest is appropriate.
21. A nurse is teaching a client with arthritis who is experiencing joint pain that impairs mobility.
Which of the following instructions should the nurse include?
Answer: "Apply heat to your joints prior to exercising."
Rationale:
The nurse should instruct the client to apply heat to the joints prior to exercising to increase
mobility and reduce pain.
22. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has
just returned to the room following physical therapy. The nurse notes that the infusion pump for
the client's TPN is turned off. After restarting the infusion pump the nurse should monitor the
client for which of the following findings?
Answer: Diaphoresis
Rationale:
The nurse should recognize that this client has the potential to develop hypoglycemia due to the
sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations
of hypoglycemia can include weakness, anxiety, confusion, and hunger.
23. A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following
manifestations should the nurse expect?
Answer: Lower back discomfort
Rationale:
An abdominal aortic aneurysm involves widening, stretching, or ballooning of the aorta. Back
pain and abdominal pain indicate that the aneurysm is extending downward and pressing on
lumbar spinal nerve roots, causing pain.
24. A nurse is evaluating the laboratory values of a client who is in the resuscitation phase
following a major burn. Which of the following laboratory findings should the nurse expect?
Answer: Sodium 132 mEq/L
Rationale:
This laboratory finding is below the expected reference range. The nurse should anticipate a low
sodium level because sodium is trapped in interstitial space. The normal sodium level is 135-145
mEq/L
25. A nurse is assessing a client who is 1 week postoperative following a living donor kidney
transplant. Which of the following findings indicates the client is experiencing acute kidney
rejection?
Answer: Blood pressure 160/90 mmHg
Rationale:
Due to the kidney's role in fluid and blood pressure regulation, a client who is experiencing
rejection can have hypertension.
26. A nurse is caring for a client whom the respiratory therapist has just removed the
endotracheal tube. Which of the following actions should the nurse take first?
Answer: Evaluate the client for stridor
Rationale:
The first action the nurse should take using the nursing process is to assess the client. After
extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a
high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis.
Stridor reflects a narrowed airway and might require emergency reintubation.
27. A nurse is planning care for a client who has Cushing's syndrome due to chronic
corticosteroid use. Which of the following actions should the nurse include in the plan of care?
Answer: Check the client's urine specific gravity
Rationale:
The nurse should check the client's urine specific gravity to assess for fluid volume overload.
28. A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth.
Which of the following instructions should the nurse include in the teaching?
Answer: "You can suck on popsicles to numb your mouth."
Rationale:
The nurse should instruct the client to suck on popsicles or ice chips, which can numb the mouth.
29. A nurse is assessing a client who is postoperative following a transurethral resection of the
prostate (TURP) and has continuous bladder irrigation. The nurse notes no drainage in the
client's urinary drainage bag over 1 hour. Which of the following should the nurse take?
Answer: Irrigate the indwelling urinary catheter with a syringe.
Rationale:
No drainage in the urinary drainage bag indicates an obstruction. The nurse should gently irrigate
the indwelling urinary catheter as prescribed to clear the obstruction and allow urine and
irrigating fluid to drain.
30. A nurse is caring for a postmenopausal client who is concerned that she might have an
elevated risk of breast cancer. After conducting a risk assessment, the nurse should identify
which of the following factors as increasing the client's breast cancer risk? (Select all that apply)
Answer: • Increased breast density
• BMI of 32.
• Undergoing hormonal replacement therapy for 10 years
Rationale:
Women who have dense breast tissue are at an increased risk for developing breast cancer
because they have more connective and glandular breast tissue. Postmenopausal obesity
increases the risk for developing breast cancer. Hormone-related risks for developing breast
cancer include the long-term use of oral contraceptives or hormone replacement therapy, early
menarche, late menopause, and first pregnancy after 30 years of age.
31. A nurse is teaching a client with chronic kidney disease about predialysis dietary
recommendations. The nurse should recommend restricting the intake of which of the following
nutrients?
Answer: Protein
Rationale:
Dietary restrictions for clients who have chronic kidney disease vary based on the degree of
kidney function; however, most clients need protein limitations. Predialysis protein restriction
can help preserve some kidney function.
32. A nurse is providing teaching to a client who is preoperative prior to a transurethral resection
of the prostate (TURP). Which of the following client statements indicates an understanding of
the information?
Answer: "I will feel the urge to urinate following this procedure.
Rationale:
" After a TURP, the client will feel the urge to urinate. The nurse should reassure him that he will
receive analgesics to help relieve this discomfort.
33. A nurse is caring for client who is postoperative following a frontal craniotomy. The nurse
should place the client in which if the following positions?
Answer: Semi-fowler's
Rationale:
To prevent an increase in intracranial pressure, the nurse should position the client with his head
midline and the head of the bed elevated 30 degrees. This positioning permits blood flow to the
client's brain while allowing venous drainage, thereby decreasing the postoperative risk of
increased intracranial pressure.
34. A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2
L/min nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of
85%. Which of the following actions should the nurse take?
Answer: Increase the oxygen flow and request an arterial blood gas determination.
Rationale:
The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88%
and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with
ABG results and oxygen saturation via pulse oximetry measurements.
35. A nurse is assessing a client who has Graves disease. Which of the following findings should
the nurse expect the client to display?
Answer: Difficulty sleeping
Rationale:
A client who has Graves' disease can have difficulty sleeping and anxiety due to the
overproduction of thyroid hormone.
36. A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the
following findings should the nurse expect?
Answer: Prolonged QT intervals
Rationale:
Manifestations of hypocalcemia include tingling, numbness, seizures, prolonged QT intervals,
and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.
37. A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG).
Which of the following pieces of information should the nurse include?
Answer: Set an alarm to ensure medication dosages are taken on time
Rationale:
The nurse should instruct the client to take medication dosages on time to maintain a therapeutic
blood level. Dosages should not be missed or postponed because this can cause an exacerbation
of the disease.
38. A nurse is caring for a client who has receptive aphasia. Which of the following
communication problems should the nurse expect when assessing the client?
Answer: The client is unable to understand words or sentences they hear have receptive aphasia.
Rationale:
Receptive aphasia, also known as Wernicke's aphasia, is characterized by the inability to
comprehend spoken or written language. Therefore, when assessing a client with receptive
aphasia, the nurse should expect the client to have difficulty understanding words or sentences
they hear, as stated in the answer. This difficulty in comprehension can range from mild to
severe, affecting the individual's ability to understand conversations, instructions, and written
materials. It's essential for the nurse to be aware of this communication problem to provide
appropriate support and adapt communication strategies to meet the client's needs.
39. A nurse in a dermatology clinic is using the ABCDE method while screening several skin
lesions for skin cancer on a client. Which of the following findings should the nurse report to the
provider?
Answer: Color variation within a lesion
Rationale:
The C in the ABCDE method of screening for skin cancer stands for color variation within a
lesion. The E stands for evolving or changing in any feature of the lesion.
40. A nurse is caring for a client who has acute diverticulitis. While the client has active
inflammation, the nurse should instruct the client to include which of the following foods in her
diet?
Answer: White bread and plain yogurt
Rationale:
Because of the acute inflammation of diverticulitis, the client should maintain a diet very low in
fiber. The client can consume low-fiber foods like white bread, low-fat milk, yogurt with active
cultures, poached eggs and canned soft fruit.
41. A nurse is caring for a client with Addison's disease who has been admitted with muscle
weakness, dehydration, and nausea and vomiting for the past 2 days. Which of the following
prescribed medications should the nurse plan to administer?
Answer: Hydrocortisone
Rationale:
The nurse should identify that a client who has Addison's disease will require hydrocortisone to
assist with replacing cortisol levels. A client who has Addison's disease has adrenal corticoid
insufficiency, which is the inability of the pituitary to produce cortisol. Illness and stress can
require steroids like hydrocortisone to restore hormone levels.
42. A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBC's).
Which of the following findings should the nurse identify as an indication of an acute
intravascular hemolytic reaction.
Answer: Sudden oliguria
Rationale:
The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic
reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria
and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused
RBC's.
43. A nurse is preparing to administer packed RBC's to a client who is anemic. Which of the
following actions should the nurse take? (Select all that apply)
Answer: • Check to determine the packed RBC's are less than 1 week old
• Ask another nurse to check the packed RBC's label against the medical record
• Prime the transfusion tubing with 0.9% sodium chloride
Rationale:
The nurse should check to determine that the packed RBC's are less than 1 week old; if the blood
is older, the RBC's become fragile, break easily, and release potassium into the blood stream. In
addition, the nurse should ask another nurse to check the packed RBC's label against the medical
record for safety verification. The nurse should ensure that the client's complete name and
identification number match and that the blood group name and number are correct. If there is
any type of discrepancy, the nurse should not infuse the blood and should notify the blood bank.
Finally, the nurse should prime the transfusion tubing with 0.9% sodium chloride. Other
solutions such as Ringer's solutions such as Ringer's lactate and dextrose in water can cause
clotting or hemolysis of the packed RBC's.
44. A nurse is performing assessment of a client who has liver cirrhosis with abdominal
distention. Which of the following actions should the nurse take to asses for changes in the
client's abdominal distention?
Answer: Take serial measurements of the abdomen with a tape measure.
Rationale:
Measuring the abdomen is the most-effective way to assess for a change in abdominal distention
because it provides concrete, objective data that can be compared at various points in time to
monitor changes.
45. A nurse is preparing a client for an electromyogram (EMG). Which of the following
statements indicates that the client understands the preprocedure teaching?
Answer: "This test will help my doctor know if my nerves are working correctly."
Rationale:
An EMG shows electrical activity within the muscles during contraction. It is useful for
discriminating between muscular dysfunction and nerve dysfunction.
46. A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has
manifestations of bacterial meningitis. Which of the following findings should the nurse expect?
Answer: Elevated protein
Rationale:
An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination.
Manifestations of bacterial meningitis include increased protein in the cerebrospinal fluid.
47. A nurse is preparing an in-service presentation about the basics of hematology. Which of the
following factors provides a stimulus for the production of RBC's?
Answer: Tissue hypoxia
Rationale:
In response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the production
of erythrocytes (RBC's) in the bone marrow.
48. A nurse is caring for a client who has diabetes insipidus. For which of the following findings
should the nurse monitor?
Answer: Polyuria
Rationale:
Diabetes insipidus is characterized by increased thirst (polydipsia) and increased urination
(polyuria). A client who has diabetes insipidus will excrete large quantities of urine with a very
low specific gravity.
49. A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following
manifestations should the nurse expect?
Answer: Anorexia
Rationale:
Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from
the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify
an abnormal product.
50. A nurse in the emergency department is assessing a client for closed pneumothorax and
significant bruising of the left chest following a motor-vehicle crash. The client reports severe
left chest pain on inspiration. The nurse should assess the client for which of the following
manifestations of pneumothorax?
Answer: Absence of breath sounds
Rationale:
A client who has pneumothorax experiences severely diminished or absent breath sounds on the
affected side.
51. A nurse is planning care for a client who has syndrome of inappropriate antidiuretic hormone
secretion (SIADH) with mild manifestations. The nurse should expect the provider to prescribe
which of the following medications?
Answer: Tolvaptan
Rationale:
SIADH is a disorder of water intoxication due to the inappropriate continuous secretion of
antidiuretic hormone by the posterior pituitary gland, causing hypervolemia and hyponatremia.
Treatment of SIADH includes fluid restriction, sodium replacement with small amounts of 0.9 %
sodium chloride, and a vasopressin antagonist such as tolvaptan. Tolvaptan promotes the
excretion of water, which helps correct the fluid imbalance in clients who have SIADH.
52. A nurse is preparing an in-service presentation about the management of myocardial
infarction (MI). Death following MI is often a result of which of the following complications?
Answer: Dysrhythmias
Rationale:
According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the
most common cause of death following MI. Therefore, nurses should monitor client's ECG's
carefully for dysrhythmias and report and treat them immediately.
53. A nurse is recommending dietary modifications for a client who has GERD. The nurse should
suggest eliminating which of the following foods from the client's diet?
Answer: Orange and tomatoes
Rationale:
Symptoms of GERD worsen following the oral intake of substances that decrease lower
esophageal stricture (LES) pressure. These include alcohol, caffeine, nicotine, chocolate, fatty
foods, citrus fruits, tomatoes, and peppermint.
54. A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU
following endotracheal extubation. Which of the following findings should the nurse identify as
a possible manifestation of tracheal stenosis and report to the provider?
Answer: Increased coughing
Rationale:
The nurse should identify increased coughing as a manifestation of tracheal stenosis. Other
manifestations include an inability to cough up secretions and difficulty talking or breathing.
55. A nurse is teaching a client who had a vaginal hysterectomy with a bilateral oophorectomy.
Which of the following pieces of information should the nurse include in the teaching?
Answer: "Use a water based lubricant when having sexual intercourse."
Rationale:
Vaginal dryness is a manifestation of menopause after the ovaries are removed. The client may
require a water-based lubricant when having sexual intercourse.
56. A nurse is preparing a client for magnetic resonance imaging (MRI) of the spine. Which of
the following pieces of information should the nurse give the client prior to the procedure?
Answer: "You can have mild sedative before the procedure."
Rationale:
Some clients need mild sensation, especially when using an older closed MRI machine. Clients
can feel claustrophobic and anxious as they slowly pass through what seems like a tunnel.
57. A nurse is providing discharge teaching to a client who is postoperative following
rhinoplasty. Which of the following instructions should the nurse include?
Answer: "Lie on your back with your head elevated 30 degrees when resting."
Rationale:
The nurse should instruct the client to rest in the semi-fowler's position to prevent aspiration of
nasal secretions.
58. A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling
in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in
which of the following laboratory values can indicate arthritis?
Answer: Rheumatoid factor
Rationale:
An increase in the client's rheumatoid factor can indicate rheumatoid arthritis or other connective
tissue diseases.
59. A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the
following actions should the nurse teach the client to perform? (Select all that apply).
Answer: • Empty the bag when it is one-third to one-half full
• Cut the skin barrier opening a little larger than the ostomy
• Wash the peristomal skin with mild soap and water
Rationale:
Allowing the bag to become too full can cause leakage. The client should cut an opening that is
about 1/16 to 1/8 larger than the stoma to avoid applying any constricting pressure to the stoma.
The client should avoid moisturizing soaps because lubricants can affect adhesion of the
appliance.
60. A nurse is assessing a client who is postoperative following a craniotomy and has a urine
output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI).
Which of the following laboratory values should the nurse plan to obtain to assess for DI?
Answer: Specific gravity
Rationale:
Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of
cranial surgery, an infection, or a tumor. In this condition, an inadequate amount of antidiuretic
hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a
manifestation of diabetes insipidus.
61. A nurse is caring for a client who is postoperative following a urinary diversion to treat
bladder cancer. Which of the following interventions should the nurse include in the plan of
care?
Answer: Change the collection pouch in the early morning
Rationale:
The nurse should plan to change the urinary collection pouch in the early morning when urine
output is reduced.
62. A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4hr
ago. Which of the following actions should the nurse take?
Answer: Encourage the client to perform dorisflexion of the affected extremity every 2 hr.
Rationale:
The nurse should encourage the client to perform dorsiflexion of the affected extremity every 2
hours to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate
peroneal nerve damage. If this occurs, the nurse should notify the provider immediately.
63. A nurse in a provider's office is assessing a client's skin lesion. The nurse notes that the
lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should
document these findings as which of the following skin lesions?
Answer: Papules
Rationale:
A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm
in diameter. Papules are common lesions of warts and elevated moles.
64. A nurse is providing postoperative teaching about the management of dumping syndrome to a
client who had a partial gastrectomy. Which of the following instructions should the nurse
include in the teaching?
Answer: "Eat protein with each meal."
Rationale:
The nurse should instruct the client to eat meals that are high in protein and fat with low to
moderate carbohydrate content. Protein should be included in every meal because it delays
digestion, which helps reduce the manifestations of dumping syndrome.
65. A nurse is assessing a client who is unconscious. The client has a rhythmical breathing
pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods
of apnea. The nurse should document that the client is experiencing which of the following types
of respirations?
Answer: Cheyne-Stokes
Rationale:
Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods
of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased
intracranial pressure and can precede death.
66. A nurse is caring for client who has lung cancer that has metastasized. Which of the
following findings indicates the client is developing superior vena cava syndrome?
Answer: Facial edema
Rationale:
Superior vena cava syndrome is a medical emergency resulting from a partial occlusion of the
superior vena cava, leading to a decreased blood flow through the vein. Most cases of superior
vena cava syndrome are associated with cancers involving the client's upper chest (e.g.,
advanced lung and breast cancers and lymphoma). The earliest manifestations of superior vena
cava syndrome are facial and upper extremity edema. Death can result if the compression is not
corrected.
67. A nurse is caring for a client who is scheduled to receive peritoneal dialysis. Which of the
following actions should the nurse take?
Answer: Warm the dialysate solution prior to administration
Rationale:
The nurse should warm the dialysate solution prior to administration to prevent pain and
abdominal cramping.
68. A nurse is collecting a health history from a female client who is undergoing screening for
breast cancer. Which of the following factors increases the client's risk of developing breast
cancer?
Answer: Age over 50 years
Rationale:
A female client who is over 50 years of age has increased risk of developing breast cancer.
69. A nurse is caring for a client who is postoperative following vein ligation and stripping for
varicose veins. Which of the following actions should the nurse take?
Answer: Position the client supine with his legs elevated when in bed.
Rationale:
The nurse should elevate the client's legs above his heart to promote venous return by gravity.
During discharge teaching, the nurse should reinforce the importance of periodic positioning of
the legs above the heart.
70. A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a
joint following an injury. Which of the following actions should the nurse take?
Answer: Prepare for replacement of the missing clotting factor.
Rationale:
Hemophilia is a hereditary bleeding disorder in which blood clots slowly and abnormal bleeding
occurs. It is caused by a deficiency in the most common clotting factor, factor VIII (hemophilia
A). Aggressive factors replacement is initiated to prevent hemoarthrosis, which can result in a
long-term loss of range of motion in repeatedly affected joints.
71. A nurse is assessing the skin of a client who has frostbite. The client has small blisters that
contain blood, and the skin of the affected area does not blanch. The nurse should classify this
injury as which of the following?
Answer: Third-degree frostbite
Rationale:
When a client has third-degree frostbite, the skin of the affected area has small blisters that are
blood-filled, and the skin does not blanch.
72. A nurse is an acute care facility is preparing to admit a client who myasthenia gravis. Which
of the following supplies should the nurse place at the client's bedside?
Answer: Oral-nasal suction equipment
Rationale:
A client who has myasthenia gravis is at risk for aspiration due to progressive weakness of the
oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune
disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal
suction equipment at the bedside in the event of aspiration or respiratory distress.
73. A nurse is teaching a client who polycythemia vera about self-care measures. Which of the
following interventions should the nurse include?
Answer: "Elevate your legs when sitting."
Rationale:
Clients who have polycythemia vera should elevate their legs when seated to avoid venous
pooling with subsequent clot formation.
74. A nurse is assessing a client who has Addison's disease. Which of the following skin
manifestations should the nurse expect to find?
Answer: Bronze pigmentation of the skin
Rationale:
A client who has Addison's disease will have a darkening of the skin on both exposed and
unexposed parts of the body due to hormone deficiency caused by damage to the outer layer of
the adrenal gland (adrenal cortex).
75. An nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of
the following actions should the nurse include in the plan of care?
Answer: Tape all connections between the chest tube and drainage system
Rationale:
The nurse should tape all connections to ensure that the system is airtight and prevent the chest
tubing from accidentally disconnecting.
76. A nurse is preparing to provide self-care teaching to a client who is 4 days postoperative
following the creation of a colostomy and refuses to look at the stoma. Which of the following
actions should the nurse take?
Answer: Postpone any teaching with the client at this time
Rationale:
The nurse should postpone any teaching with the client this time and should encourage the client
to look at and touch the stoma before continuing to teach about self-care. Refusal to look at the
stoma indicates the client is in the denial stage of grief and might not be able to learn anything
further at this time about self-care of the colostomy.
77. A nurse is caring for client who has a traumatic brain injury and assumes a decerebate
posture in response to noxious stimuli. Which of the following reactions should the nurse
anticipate when drawing a blood sample?
Answer: The client rigidly extends his arms
Rationale:
A client who exhibits a decerebrate extends and pronates the 4 extremities and externally rotates
the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological
decline.
78. A nurse is caring for a client who has Meniere's disease. The nurse should identify that
Meniere's disease affects which structure of the ear?
Answer: Cochlea
Rationale:
Meniere's disease is a condition of the inner ear in which excess fluid distorts that inner ear canal
system. This distortion decreases hearing via dilation of the cochlear duct, leading to vertigo
from damage to the vestibular system.
79. A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding
through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following
findings requires interventions?
Answer: The head of the bed is elevated to 20 degrees.
Rationale:
The head of the bed should be elevated to at least 30 degrees (semi-Fowler's position) while the
tube feeding is administered. This position gravity to help the feeding move through the
digestive system an lessens the possibility of regurgitation.
80. A nurse is caring for a client who is receiving radiation therapy for mouth cancer and reports
a dry mouth. Which of the following dietary recommendations should the nurse provide?
Answer: Use gravies or sauces to soften food
Rationale:
The nurse should instruct the client to use gravies or sauces to soften foods and make them easier
to eat.
81. A nurse is caring for client who has a peripherally inserted central catheter (PICC) in place.
Which of the following actions should the nurse take when handling this central venous access
device? (Select all that apply).
Answer: • Flush the line with sterile 0.9% sodium chloride before and after medication
administration
• Access the PICC for blood sampling
• Perform a heparin flush of the line at least daily when not in use
Rationale:
The nurse should flush the line 10mL of sterile 0.9% sodium chloride solution before and after
administering medication through the PICC. The nurse should use a PICC to deliver fluids,
medications, and total parenteral nutrition to the client. The PICC is also used to obtain blood
samples, and the nurse should practice the appropriate technique to access and flush the line.
Ideally, blood samples should come from a 4 French lumen catheter or larger.
82. A nurse in the emergency department is caring for a client who has Addison's disease and
reports nausea, vomiting, diarrhea, and abdominal pain. To prevent an Addisonian crisis, the
nurse should prepare to administer which of the following medications?
Answer: Hydrocortisone
Rationale:
Addison's disease causes adrenal gland hypofunction and inadequate production of
glucocorticoids. Acute adrenal insufficiency is life-threatening and can lead to severe fluid and
electrolyte imbalances.
Without treatment, sodium levels fall, and potassium levels increase. Rapid infusion of IV fluids
such as 0.9% sodium chloride and IV administer of high dose corticosteroids such as
hydrocortisone are vital to correct the glucocorticoid deficiency.
83. A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions
and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations
of which of the following complications?
Answer: Respiratory obstruction
Rationale:
Intercostal retractions and a high-pitched inspiratory noise (i.e. stridor) are manifestations of an
airway obstruction caused by laryngospasm and edema. The nurse should notify the rapid
response team and plan to administer racemic epinephrine.
84. A nurse is providing discharge teaching to a client who is post-operative following a right
mastectomy for breast cancer. The client will be discharged with 2 Jackson-Pratt drains. Which
of the following pieces of information should the nurse include in the teaching?
Answer: "The drainage tubes often are removed at the same time as the stitches."
Rationale:
The nurse should instruct the client that the provider will remove the drainage tubes at the same
time the stitches are removed, usually within 7 to 10 days.
85. A nurse is caring for a client who is concerned about the possibility of contracting Lyme
disease after receiving a tick bite. For which of the following early manifestations of Lyme
disease should the nurse asses the client?
Answer: Progressive circular rash
Rationale:
Early Lyme disease is characterized by a fever, influenza-like manifestations, and erythema
migrans, which is distinct, progressive, circular or bullseye rash that often develops at the bite
site but can also develop at other sites such as the thighs and knees.
86. A nurse is caring for client who has a demand pacemaker inserted with a set rate of 72/min.
Which of the following findings should the nurse expect?
Answer: Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no
pacing spikes.
Rationale:
The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of
72/min because the client's intrinsic rate overrides the set rate of the pacemaker.
87. A nurse is caring for a client who has urolithiasis and requires further diagnostic testing after
an initial test indicated hypercalcemia. Which of the following structures controls calcium
concentration?
Answer: Parathyroid gland
Rationale:
The parathyroid gland secretes parathyroid hormones, which are substances that help the kidneys
reabsorb calcium and increase calcium absorption from the gastrointestinal tract.
88. A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the
right ankle. Which of the following should the nurse expect in the client's affected extremity?
Answer: Ankle swelling
Rationale:
The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency
due to poor venous return. Other manifestations can include brown pigmentation and cellulitis.
89. A nurse is providing teaching to a client who has a chronic cough and is scheduled for a
bronchoscopy. Which of the following client statements indicates an understanding of the
teaching?
Answer: "A tissue sample might be obtained during the procedure."
Rationale:
The nurse should inform the client that a tissue sample might be obtained during the procedure
for biopsy testing.
90. A nurse is caring for a client following a stroke. Which of the following actions should the
nurse take first?
Answer: Keep the client NPO
Rationale:
The first action the nurse should take when using the airway, breathing, and circulation (ABC)
approach to client care is to keep the client NPO due to the risk of aspiration as a result of the
stroke. The client should be screened for the ability to swallow and should not receive anything
by mouth until this has been completed. A client who has experienced a cerebrovascular accident
is at risk for dysphagia, which increases the change of life-threatening aspiration.
91. A nurse is checking the laboratory values of a client who has chronic kidney disease. The
nurse should expect elevations in which of the following values?
Answer: Potassium and magnesium
Rationale:
Clients who have chronic kidney disease have hyperkalemia, hyperphosphatemia, and
hypermagnesemia as well as elevations in serum creatinine and blood urea nitrogen.
92. A nurse is assessing the hematologic system of an older adult client. The nurse should report
which of the following findings to the provider as a possible indication of a hematologic
disorder?
Answer: Absence of hair on the legs
Rationale:
A progressive loss of hair is common with aging. However, thinning or absence of hair on the
extremities indicates poor arterial circulation to that area. The nurse should look for further
indications of arterial insufficiency and report these findings to the provider.
93. A nurse is caring for a group of clients on a medical-surgical unit. Which of the following
disorders should the nurse identify as increasing the client's metabolic needs? (Select all that
apply).
Answer: • COPD
• Cancer
• Parkinson's disease
• Major burns
Rationale:
Clients who have COPD develop hypermetabolism as a result of the increased amount of energy
used to breathe. Cancer can cause a number of metabolic changes, including hypermetabolism as
a result of the tumor growth. Clients who have Parkinson's disease develop hypermetabolism
because they burn calories due to muscular rigidity. Finally, clients who have major burns may
develop severe metabolic stress, which includes hypermetabolism and hypercatabolism.
94. A nurse is caring for a client with a hip fracture who has Buck's extension traction in place.
Which of the following pieces of information should the nurse give the client about this type of
traction? (Select all that apply).
Answer: • "You'll have considerably less pain with the traction in place."
• "The traction will help decrease muscle spasms."
• "The weights act as a pulling force to keep your leg and hip still."
Rationale:
Pain is usually more severe without the traction. Buck's extension traction uses weights to help
decrease muscle spasms. Typically, 2.3 to5.5 kg (5 to 10 lb) of force helps stabilize the hip and
legs preoperatively.
95. A nurse is assessing a client who is receiving a unit of whole blood. Which of the following
findings should the nurse identify as a manifestation of a hemolytic transfusion reaction?
Answer: Low back pain
Rationale:
Low back pain is a manifestation of hemolytic transfusion reaction. Other manifestations include
a headache, chest pain, tachypnea, tachycardia, and dark urine.
96. A nurse is providing postoperative discharge teaching to a client following panhysterectomy
for uterine cancer. Which of the following pieces of information should the nurse include in the
teaching?
Answer: "You might experience manifestations of menopause."
Rationale:
The nurse should inform the client that a panhysterectomy includes the removal of the uterus and
the ovaries, which might cause manifestations of menopause (e.g., hot flashes, night sweats, and
vaginal dryness).
97. A nurse in the emergency department is assessing a client who was in a motor vehicle crash 2
days ago and sustained fracture of his tibia, ulna, and several ribs. The client is not disoriented to
time and place and has SaO2 of 87%. The nurse notes generalized petechiae on the client's skin.
Which of the following complications should the nurse suspect?
Answer: Fat embolism syndrome
Rationale:
The nurse should identify the triad of neurological changes, petechial rash, and hypoxemia as
findings of fat embolism syndrome. Risk factors include multiple fractures and a fracture of a
long bone. Male clients are also at greater risk. The manifestations occur when far globules
occlude small blood vessels.
98. A nurse is providing discharge instructions to a client who is postoperative following surgical
excision of basal cell carcinoma. Which of the following findings should the nurse include as an
indication of a mole's potential malignancy?
Answer: Ulceration
Rationale:
Ulceration, bleeding and exudation are indications of mole's potential malignancy. Increasing
size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up
evaluation and the proper techniques for self-examination of the skin every month.
99. A nurse is assessing a provider with performing a paracentesis on a client. Which of the
following actions should the nurse take?
Answer: Ask the client to empty his bladder before the procedure.
Rationale:
The nurse should ask the client to empty his bladder before the procedure to prevent injury to the
bladder.
100. A nurse is collecting a health history from a client. Which of the following findings is the
highest risk factor for the client developing bladder cancer?
Answer: The client uses tobacco.
Rationale:
Tobacco use is one of the most significant risk factors for developing bladder cancer. Smoking
tobacco, whether cigarettes or other forms, exposes the body to carcinogens that can accumulate
in the bladder when excreted through urine. These carcinogens can damage the lining of the
bladder over time, increasing the risk of cancer development. Research indicates that smokers
are at least three times more likely to develop bladder cancer compared to non-smokers.
Therefore, when assessing a client's health history, a history of tobacco use stands out as a
critical risk factor for bladder cancer development. It's crucial for nurses to educate clients about
the risks of tobacco use and encourage smoking cessation to reduce the likelihood of bladder
cancer and other related health issues.
101. A nurse in a provider's office is reviewing the medical records of a group of clients. Which
of the following clients is at risk for iron deficiency? (Select all that apply).
Answer: • A client who is a vegetarian
• A client who is pregnant
• A toddler who is overweight
Rationale:
A client who is a vegetarian might require iron because the availability of iron in vegetable food
sources is limited. During pregnancy, maternal blood volume increases, and the fetus requires
additional iron. Therefore, the RDA of iron for clients who are pregnant is increased to 27 mg
per day. Toddlers who are overweight may get most of their calories from milk and foods that are
not considered healthy, which increases their risk for iron-deficiency anemia.
102. A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the
stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said
he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the
following purposes?
Answer: Prevents excessive pressure on suture lines
Rationale:
The NG tube remains in place after surgery to prevent pressure on suture lines postoperatively. It
drains the air and fluid that can cause pressure from inside the gastrointestinal (GI) tract. In
doing so, it also prevents vomiting and GI distention.
103. A nurse is reviewing laboratory values for an adult who has sickle cell anemia and a history
of receiving blood transfusions. For which of the following complications should the nurse
monitor?
Answer: Iron toxicity
Rationale:
A client who has received several blood transfusions is at risk of hemosiderosis, which is the
excess storage of iron in the body. Excessive iron can come from overuse of supplements or
from receiving frequent blood transfusions as in sickle cell anemia.
104. A nurse is planning care for a client who has cancer and has developed thrombocytopenia
following chemotherapy. Which of the following precautions should the nurse offer to minimize
the adverse effects of thrombocytopenia?
Answer: Remind the client to use an electric razor.
Rationale:
Thrombocytopenia is a decrease in the client's blood platelet count, which places the client at an
increased risk of bleeding due to the blood's inability to clot. Therefore, the nurse should institute
bleeding precautions, including the use of an electric razor.
105. A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following
manifestations should the nurse expect?
Answer: Swelling behind the affected ear
Rationale:
Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of
mastoiditis include swelling and pain behind the ear.
106. A nurse is caring for a client who has fulminant hepatic failure. Which of the following
procedures should the nurse anticipate for this client?
Answer: Liver transplant
Rationale:
Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the
development of hepatic encephalopathy within weeks of the onset of disease in a client without
prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities
such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently,
liver transplantation has become the treatment of choice for these clients.
107. A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The
client reports significant persistent nausea and muscle weakness. Which of the following
findings should the nurse expect?
Answer: Hyperkalemia
Rationale:
A client who has chronic kidney can have hyperkalemia, which is a potassium level greater than
5.0 mEq/L. The expected reference range for potassium is 3.5 to 5.0 mEq/L. Other
manifestations of hyperkalemia can include palpitations, dysrhythmias, nausea, and muscle
weakness.
108. A nurse is reviewing the medical history of a client who has presbyopia. With which of the
following activities should the nurse expect the client to have difficulty?
Answer: Reading the newspaper
Rationale:
With presbyopia, the lens is unable to change shape to focus on near objects. Presbyopia
develops with aging, beginning in middle age, and results from the decreased elasticity of the
lens.
109. A nurse is determining a client's risk of developing osteoporosis. The nurse should identify
which of the following as risk factors for bone loss? (Select all that apply).
Answer: • Small body frame
• Low vitamin D intake
• Smoking
Rationale:
Females have a higher risk of developing osteoporosis. Other risk factors include family history,
low body mass index, and a small body frame. Consuming inadequate levels of calcium and
vitamin D, smoking and ingesting high amounts of alcohol or caffeine also increase the risk of
developing osteoporosis.
110. A nurse is planning care for a client who has thrombocytopenia. Which of the following
interventions should the nurse include in the plan of care?
Answer: Measure the client's abdominal girth daily
Rationale:
The nurse should measure the client's abdominal girth daily to monitor for manifestations of
internal bleeding. A client who has reduced platelet count is at risk of bleeding due to delayed
clotting.
111. A nurse is providing teaching to a client who is preoperative for a renal biopsy. Which of the
following statements should the nurse make?
Answer: "You will need to be on bed rest following the procedure."
Rationale:
A renal biopsy involves a tissue biopsy through needle insertion into the lower lobe of the
kidney. The client should maintain bed rest in a supine position with a back roll for support for 2
to 24 hours following the procedure to reduce the risk of bleedings. The nurse can elevate the
head of the bed.
112. A nurse is examining the ECG of a client who is having an acute myocardial infarction. The
nurse should identify that the elevated ST segments on the ECG indicate which of the following
alterations?
Answer: Necrosis
Rationale:
ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG change
reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of
the artery.
113. A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the
following actions should the nurse take? (Select all that apply).
Answer: • Monitor vital signs every 2 hr
• Assess neurological status every 4 hr
• Keep the client's room darkened
Rationale:
The nurse should monitor the client's vital signs to assess for changes consistent with increased
intracranial pressure. In addition, the nurse should monitor the client's neurological status at least
every 4 hours or more frequently if the client's status indicates. The course of encephalitis is
unpredictable, so the client should be monitored closely for any indications of deteriorating
neurological functioning. The nurse should provide the client with a low-stimulation
environment to promote comfort and decrease agitation.
114. A nurse is teaching a client about the manifestations of an allergic reaction. The release of
histamine causes which of the following reactions?
Answer: Increased mucus secretion
Rationale:
The nurse should instruct the client that increased mucus secretion is a manifestation of
histamine release. Histamine is the neurotransmitter the body produces during an allergic
reaction.
115. A nurse is assessing a client who has urolithiasis and reports pain in his thigh. This finding
indicates the stone is in which of the following structures?
Answer: Ureter
Rationale:
When stones are in the ureters, pain radiates to the genitalia and to the thighs.
116. A nurse is preparing to test the function of cranial nerve X. Which of the following
assessment procedures should the nurse use?
Answer: Have the client open his mouth and say, "ahh"
Rationale:
The vagus or X nerve has both sensory and motor functions. To test the monitor function, the
nurse should have the client open his mouth and say, "ahh." The palate and the uvula should
move upward in response. The nurse should also assess the client's voice quality for hoarseness.
117. A nurse is assessing a client who is 85 years old. Which of the following findings should the
nurse identify as a manifestation of myocardial infarction?
Answer: Acute confusion
Rationale:
Acute confusion is a manifestation of myocardial infarction in clients age 65 or older. Other
manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness,
palpitations, and fatigue.
118. A nurse is preparing a client for discharge following a bronchoscopy. Which of the
following assessments is the nurse's monitoring priority?
Answer: Confirming the gag reflex
Rationale:
The greatest risk to the client's safety is aspiration resulting from a depressed gag reflex. The
nurse's priority is to make sure the client's gag reflex has returned before discharge so that the
client can maintain hydration and nutrition without risk.
119. A nurse is providing teaching to client who has anemia and a new prescription for epoetin
alfa. Which of the following pieces of information should the nurse include in the teaching?
Answer: Hypertension is a common adverse effect of this medication.
Rationale:
A common adverse effect of epoetin alfa is hypertension because of the rise in the production of
erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human
erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication
therapy. It increases and maintains the red blood cell level.
120. A nurse is caring for a client who is suspected to have tuberculosis. Which of the following
findings should the nurse expect?
Answer: Blood-streaked sputum
Rationale:
The nurse should expect blood-streaked sputum in a client who has tuberculosis. Sputum
cultures are used to diagnose pulmonary tuberculosis.
121. A nurse is caring for a client who is having possible myocardial infarction (MI). Which of
the following findings should the nurse identify as an associated manifestation of an MI?
Answer: Nausea
Rationale:
Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in
the jaw, shoulder, or abdomen.
122. A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks
ago. Which of the following findings should the nurse report to the provider immediately?
Answer: Abdominal pain in the left upper quadrant
Rationale:
When using the urgent vs nonurgent approach to client care, the nurse should determine that the
priority finding is left upper-quadrant pain, which can indicate an enlarged spleen. An enlarged
spleen can rupture, leading to internal hemorrhaging. The nurse should encourage the client to
refrain from engaging in strenuous activities until the splenomegaly is resolved.
123. A nurse is caring for a client who had thyroidectomy to treat hyperthyroidism caused by an
adenoma. Which of the following findings should the nurse report to the provider? (Select all
that apply).
Answer: • Tachycardia and hypertension
• Laryngeal stridor and hoarseness
• Positive Trousseau's sign
Rationale:
Tachycardia and hypertension are unexpected findings that can indicate the occurrence of thyroid
storm following removal of the thyroid gland, especially if the client was in a hyperthyroid state
prior to the surgery. Thyrotoxicity (thyroid storm) is life-threatening condition with a sudden
onset that includes tachycardia, a fever, sweating, restlessness, and tremors. Congestive heart
failure and pulmonary edema can develop rapidly and lead to death.
Laryngeal stridor and hoarseness are unexpected findings and can indicate swelling in the area of
the surgery or damage to the laryngeal nerve. This should be reported to the provider before
respiratory distress develops. A positive Trousseau's sign is an indication of hypocalcemia, which
is a complication of thyroid removal. This occurs when the parathyroid glands are also removed
and regulation of serum calcium is impaired.
124. A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which
of the following findings indicates that the nurse should suction the client's airway secretions?
Answer: The nurse auscultates coarse crackles in the lung fields.
Rationale:
The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see
secretions in the tracheostomy tube, and then suction the client's airway secretions.
125. A nurse is caring for a client who has a major burn injury and is experiencing third spacing.
Which of the following fluid or electrolyte imbalances should the nurse expect?
Answer: Elevated HCT
Rationale:
The nurse should expect a client who is experiencing third spacing resulting from a major burn
to have an elevated hematocrit level as blood volume is reduced by vascular dehydration.
