ATI CAPSTONE ADULT MEDICAL SURGICAL ASSESSMENT
CORRECT QNS & ANS COMPLETE A+ GUIDE
1. A nurse is caring for an adult client who asks about vaccinations against communicable
diseases. The nurse should inform the client that which of the following vaccines are available?
(Select all that apply)
A. Hepatitis A vaccine
B. Hepatitis B vaccine
C. Pneumococcal vaccine
D. Hepatitis C vaccine
E. Helicobacter pylori vaccine
Answer: A. Hepatitis A vaccine
B. Hepatitis B vaccine
C. Pneumococcal vaccine
Rationale: Adult vaccines currently available to prevent contracting communicable diseases
include those for hepatitis A & B influenza and pneumonia. No vaccine is currently available for
hep C/H.
2. A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the
following dietary modifications should the nurse include?
A. Provide a snack at bedtime
B. Choose decaffeinated coffee
C. Restrict intake of fried foods
D. Avoid drinking liquids with meals
Answer: C. Restrict intake of fried foods
Rationale: The nurse should instruct the client to avoid fried foods, spicy foods, and acidproducing foods, such as coffee and chocolate. Spicy foods, such as chili pepper, red pepper, and
black pepper can cause mucosal damage. The nurse should instruct the client to avoid
decaffeinated and caffeinated beverages and snacks at bedtime, which can stimulate gastric acid
secretion. A client with dumping syndrome, rather than peptic ulcer should avoid liquids with
meals
3. A nurse is caring for a client who is postoperative immediately following a
pheochromocytoma removal. Which of the following actions is the nurse’s priority?
A. Increase hydration
B. Monitor blood pressure
C. Measure urine output
D. Provide a calm environment
Answer: B. Monitor blood pressure
Rationale: The greatest risk to this client is injury from hypertension due to the release of
catecholamines during surgery or hypotension from the sudden loss of catecholamines after the
tumor has been removed. Therefore, the priority intervention the nurse should take is to monitor
the client's blood pressure
4. A nurse is caring for a client who is using a ventilator when the low-pressure ventilator alarm
sounds. Which of the following actions should the nurse take?
A. Suction secretions from the endotracheal tube
B. Check the ventilator tubing connections
C. Administer intravenous sedation and analgesia
D. Reassure the client and instruct them not to bite on the tube
Answer: B. Check the ventilator tubing connections
Rationale: A low-pressure alarm indicates a loss of volume due to a disconnection, cuff link or
tube displacement
5. A nurse is assessing a client who is receiving a blood transfusion. Which of the following
findings indicates the client might be experiencing a hemolytic transfusion reaction?
A. Hypertension
B. Report of urticaria
C. Distended neck veins
D. Report of chest pain
Answer: D. Report of chest pain
Rationale: Chest pain is a manifestation of a hemolytic transfusion reaction. Other
manifestations include headache, low back pain, and hypotension
6. A nurse is assessing a client who has right lower lobe pneumonia. Which of the following
findings should the nurse expect?
A. Dull percussion sounds
B. Increased anteroposterior chest diameter
C. Distended neck veins
D. Pitting edema
Answer: A. Dull percussion sounds
Rationale: The consolidation that occurs with pneumonia will result in dull chest percussion
over the involved lobes
7. A nurse is providing teaching to a newly licensed nurse about caring for a client who is
receiving a sealed radioactive implant. Which of the following information should the nurse
include in the teaching?
A. Place soiled linens in a lead container
B. Allow children who are over 10 years old to visit
C. Limit visitors to 1 hr per day
D. Wear a lead apron during care
Answer: D. Wear a lead apron during care
Rationale: The nurse should wear a lead apron at all times during care of a client who has a
sealed radioactive implant
8. A nurse is caring for a client who has a cervical spinal cord injury. Which of the following
interventions should the nurse include in the plan of care to prevent autonomic dysreflexia?
A. Monitor bowel movement regularity
B. Use a fan to promote air circulation to the client’s room
C. Tuck the top bedsheet tightly around the client’s torso
D. Monitor for cerebral spinal fluid leakage
Answer: A. Monitor bowel movement regularity
Rationale: Autonomic dysreflexia occurs secondary to the stimulation of the sympathetic
nervous system and inadequate compensatory response by the parasympathetic nervous system.
Common causes of autonomic dysreflexia include distended bladder, fecal impaction, cold stress,
tight clothing, and undiagnosed injury or illness. The nurse should monitor the client's bowel
movements to reduce the risk of fecal impaction which can lead to autonomic dysreflexia
9. A nurse is assessing a client who has tension pneumothorax following blunt chest trauma.
Which of the following findings should the nurse expect?
A. Tracheal deviation to the unaffected side
B. Pleural friction rub
C. Frothy, pink-tinged sputum
D. Increased breath sounds on the affected side
Answer: A. Tracheal deviation to the unaffected side
Rationale: Tracheal deviation to the unaffected side occurs with tension pneumothorax because
air fills the pleural space on the affected side pushing the trachea and great vessels to the
unaffected side
10. A nurse is providing instructions to a newly licensed nurse about NG intubation for a client
who is postoperative following a colectomy. Which of the following statements should the nurse
include?
A. “Tube drainage should be rust-colored.”
B. “Nutrition will be provided through the tube.”
C. “The tube decreases pressure within the stomach.”
D. “The tube should be irrigated with sterile water.”
Answer: C. “The tube decreases pressure within the stomach.”
Rationale: The purpose of the tube for the client immediately following a colectomy is to
promote rest and healing of the gastrointestinal tract by decompressing and draining abdominal
fluid
11. A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the
following information should the nurse include?
A. “Notify the provider if you experience a stinging sensation following administration.”
B. “Watch for a decreased heart rate while using this medication.”
C. “You can expect to develop a harmless darkening of the iris.”
D. “This medication can cause the lashes of the affected eye to lengthen.”
Answer: B. “Watch for a decreased heart rate while using this medication.”
Rationale: Timolol is a beta blocker medication applied topically for treatment of glaucoma. The
client should monitor their heart rate twice daily and notify the provider if it is consistently
below 58/min. Clients who have existing cardiac issues, such as sinus bradycardia and
atrioventricular heart block should not take this medication
12. A triage nurse finds a school-age child lying in the road following a school bus crash with
multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal
commands, and groans to painful stimuli. The nurse should assign the client which of the
following triage tags?
A. Red
B. Yellow
C. Green
D. Black
Answer: A. Red
Rationale: It indicates a life-threatening injury that requires immediate intervention. A client
who has a slow respiratory rate and a possible head injury requires immediate intervention.
Yellow tag is assigned to clients who can wait 30 min to 2 hr before receiving care. A green tag is
assigned to clients who have nonurgent injuries and can wait longer 2 hr before receiving care. A
black tag is assigned to clients whose injuries are severe and are not expected to survive
13. A nurse is caring for client who is postoperative following a below-the-knee amputation.
Which of the following actions should the nurse take?
A. Maintain a loose bandage on the residual limb
B. Turn the client from side to side once every 4 hr
C. Request a soft mattress for the client
D. Place the client prone for 20 min every 3 hr
Answer: D. Place the client prone for 20 min every 3 hr
Rationale: The nurse should place the client in a prone position for 20 to 30 mins every 3 to 4 hr
to reduce the risk for hip contractures
14. A nurse is assessing a client who has Gilliam-Barré syndrome. Which of the following
findings should the nurse report to the provider immediately?
A. Decreasing leg strength
B. Decreasing voice volume
C. Decrease deep tendon reflexes
D. Decrease sensation in the arms
Answer: B. Decreasing voice volume
Rationale: When using the airway, breathing, circulation approach to client care, the nurse
should determine that the priority finding is a decrease in voice volume. A decrease in voice
volume can indicate progressive ascending neuropathy towards the laryngeal area, which can
lead to respiratory compromise. The nurse should notify the provider of the finding immediately
15. A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which
of the following actions should the nurse take first?
A. Determined the time the last dose of pain medication was administered
B. Repositioned the client to assist with reduction of pain
C. Ask the client to describe the pain and rate it on a scale of 0 to 10
D. Check the clients medical record for type of PRN pain medication
Answer: C. Ask the client to describe the pain and rate it on a scale of 0 to 10
Rationale: The first action the nurse should take using the nursing process is to assess the client
by asking the client to describe and rate the pain. The nurse should use the clients self-report of
pain when possible to determine what type of pain intervention is indicated
16. A nurse is teaching a client who has angina pectoris about nitroglycerin sublingual tablets.
Which of the following statements should indicate to the nurse that the client understands the
teaching?
A. “I will keep the tablets in the original container”
B. “I should keep the container in my shirt or pants pocket”
C. “I should begin to feel relief within 20 minutes of taking the medication”
D. “I will drive myself to the emergency room if three nitroglycerin tablets do not relieve my
pain”
Answer: A. “I will keep the tablets in the original container”
Rationale: Nitroglycerin sublingual tablets should be kept in the original glass container or
especially made metal container because the tablets can lose their potency if they are exposed to
air or moisture
17. A nurse is assessing a client who has a herniated lumbar disc. Which of the following
findings should the nurse expect?
A. The client reports relief from pain when lying in the prone position
B. The client reports that her low-back pain radiates upward toward one scapula
C. The client reports tingling and a burning sensation in one foot
D. The client reports decreased pain when the affected leg is raised and straightened
Answer: C. The client reports tingling and a burning sensation in one foot
Rationale: Due to compression of the spinal column and nerve root, a herniated disk often
causes decreased sensation and paresthesia (numbness and tingling) in the leg on the side where
nerve compression occurs. Pain can travel down to the ankle or foot on that side of the body and
is often described as stabbing or burning
18. A nurse is assessing a client who is postoperative following a kidney transplant. Which of the
following findings indicates the client is experiencing a transplant rejection?
A. Polyurea
B. Hypothermia
C. Hypertension
D. Hypovolemia
Answer: C. Hypertension
Rationale: Hypertension is manifestation of kidney transplant rejection. Hyperacute rejection
occurs within 48 hr. An acute reaction can occur 1 week to 2 years postoperatively but is most
likely to occur within 2 weeks
19. A nurse is instructing a client’s caregiver on how to position the client before administering
tube feedings in the home. Which of the following statements by the caregiver demonstrates an
understanding of the teaching?
A. “I will allow him to assume a position of comfort”
B. “I will elevate the head of the bed 10 degrees”
C. “I will place him in a left side-lying position”
D. “I will sit him up in bed”
Answer: D. “I will sit him up in bed”
Rationale: to reduce the risk for aspiration of tube feeding, the client should sit up or lie with the
head of bed elevated 30 degrees to 45 degrees
20. A nurse is providing education regarding the prevention of urinary tract infections (UTIs) 2A
client who has a history of cystitis. Which of the following statements by the client indicates that
the teaching has been effective?
A. “I will limit my fluid intake to 1 liter per day to prevent frequency and urgency”
B. “I will empty my bladder every 2 to 3 hours throughout the day”
C. “I will use an antiseptic vaginal deodorant spray twice a day to reduce the bacterial growth”
D. “I will take a hot bath after sexual intercourse”
Answer: B. “I will empty my bladder every 2 to 3 hours throughout the day”
Rationale: The nurse should instruct the client to empty the bladder every 2 to 3 hrs to decrease
urinary stasis and reduce the presence of bacteria within the urethra. This can be achieved by
frequently emptying the bladder
21. A nurse is assessing a client who has a history of migraine headaches with aura and reports
feeling “a migraine coming on.” The nurse should expect the client to report which of the
following manifestations?
A. Visual disturbances
B. Photophobia
C. Nasal congestion
D. Phonophobia
Answer: A. Visual disturbances
Rationale: Common manifestations of migraine headaches with aura during the first, or
prodromal, phase are visual disturbances, such as zigzag, shimmering, or flashing lights and lines
or spots. The aura typically takes several minutes to manifest and usually disappears within an
hour
22. A nurse is receiving report on a group of clients. Which of the following clients should the
nurse assess first?
A. A client who has a chest tube and reports of pain level of 6 on a scale of 0 to 10
B. A client who received parenteral cephalosporin and reports urticaria and edema
C. A client who is being admitted with bilateral stage 3 pressure injuries on both heels
D. A client who has a systemic infection and an oral temperature of 39.1°C 102.4°F
Answer: B. A client who received parenteral cephalosporin and reports urticaria and edema
Rationale: The development of urticaria and edema indicates that this client is at greatest risk for
having an allergic reaction to the medication, which can lead to anaphylaxis and respiratory
compromise. Therefore, the nurse should assess this client first
23. A nurse is caring for a client who has renal failure. Which of the following arterial blood gas
(ABG) results should the nurse expect?
A. pH 7.25, HCO3- 20 mEq/L, PaCO2 35 mm Hg
B. pH 7.30, HCO3- 22 mEq/L, PaCO2 50 mm Hg
C. pH 7.50, HCO3- 32 mEq/L, PaCO2 45 mm Hg
D. pH 7.55, HCO3- 28 mEq/L, PaCO2 31 mm Hg
Answer: A. pH 7.25, HCO3- 20 mEq/L, PaCO2 35 mm Hg
Rationale: A client who has renal failure will manifest metabolic acidosis (low HCO3-, low pH)
related to an inability of the renal tubules to secrete hydrogen ions and a decrease in bicarbonate
levels. In response, the client's respiratory system attempts to compensate through
hyperventilation to reduce PaCO2. Expected reference ranges for ABG findings include the
following pH 7.35 to 7.45, HCO3- 22 to 26 mEq/L, PaCO2 35 to 45 mm Hg
24. A nurse is assessing a client who has Addison’s disease. Which of the following
manifestations should indicate to the nurse that the client is experiencing an Addisonian crisis?
A. Hypothermia
B. Increased deep tendon reflexes
C. Hypotension
D. Erythema of the neck and chest
Answer: C. Hypotension
Rationale: Severe hypotension is a manifestation of an Addisonian crisis. Aldosterone levels are
insufficient, causing increased sodium and water excretion and resulting in a deficiency in blood
volume
25. A nurse is caring for a client who has renal calculi. Which of the following prescriptions by
the provider is the priority action for the nurse to take?
A. Strain all urine
B. Schedule a retrograde pyelography
C. Monitor intake and output
D. Schedule a kidney ultrasound
Answer: C. Monitor intake and output
Rationale: The greatest risk to this client is injury from developing a urinary obstruction;
therefore, the priority intervention the nurse should take is to strictly monitor the client's I&O.
The nurse should encourage an increased fluid intake and monitor the client closely for oliguria
or anuria, which can indicate obstruction
26. A nurse is assessing a client who has tuberculosis and is taking rifampin. Which of the
following findings should the nurse report as an adverse effect of the medication?
A. Alopecia
B. Yellowing of the sclera
C. Report of Constipation
D. Report of insomnia
Answer: B. Yellowing of the sclera
Rationale: The nurse should contact the provider if the client develops jaundice or yellowing of
the sclera. These findings indicate liver toxicity and should be addressed
27. A nurse is assessing a client who has had a left hemisphere stroke. Which of the following
findings should the nurse expect?
A. Expressive aphasia
B. Poor impulse control
C. Left hemiparesis
D. Disorientation to place
Answer: A. Expressive aphasia
Rationale: The left side of the brain is the center for math, language, and analytical thinking.
Therefore, clients who have had a stroke on the left side of the brain can experience deficits such
as expressive aphasia, dyslexia, and agnosia
28. A nurse is providing teaching to a client who has a new onset of general herpes. Which of the
following statements should the nurse include in the teaching?
A. “You are contagious when lesions are healed.”
B. “This infection is spread through the air.”
C. “Stress can activate an outbreak.”
D. “Antiviral drugs will cure the infection.”
Answer: C. “Stress can activate an outbreak.”
Rationale: Viral shedding can occur when lesions are not present. The herpes simplex virus can
be spread during viral shedding. It is spread by skin-to-skin contact. Antiviral medications used
to treat herpes simplex virus type 2 do not cure the infection, but they can reduce the severity and
frequency of outbreaks. Dormant herpes simplex virus can be activated by stress, fever, sexual
activity, or malnutrition
29. A nurse is initiating a plan of care for a client who has COPD. Which of the following
interventions should the nurse include?
A. Request a prescription for an antibiotic
B. Educate the client on pursed lip breathing
C. Place the client in airborne precautions
D. Initiate a referral for gene therapy
Answer: B. Educate the client on pursed lip breathing
Rationale: Clients who have COPD should be taught breathing techniques to help manage
periods of dyspnea. Pursed lip breathing involves having the client breathe in through their nose
and out through their mouth while slowly pursing their lips as if they are whistling. It reduces air
trapping by prolonging exhalation and increasing airway pressure
30. A nurse is assessing a client following a hypophysectomy. Which of the following findings
indicates the client might be developing diabetes insipidus?
A. Urine ketones
B. Hyperglycemia
C. Halo or ring-shaped dressing drainage
D. Low urine specific gravity
Answer: D. Low urine specific gravity
Rationale: Clients who have had pituitary surgery are at increased risk for the development of
diabetes insipidus (lack of anti-diuretic hormone causes excess water excretion resulting in
decreased urine specific gravity)
31. A nurse is discussing risk factors for hepatitis A with a newly licensed nurse. Which of the
following clients should the nurse identify as being at an increased risk for hepatitis A?
A. A client who is hepatitis B positive
B. A client who had a kidney transplant in 1990
C. A client who has a history of intravenous street drug use
D. A client who has recently done volunteer work in a developing country
Answer: D. A client who has recently done volunteer work in a developing country
Rationale: Hepatitis A is most frequently acquired through infected water or food sources. These
conditions are often found in developing countries
32. A nurse is assessing a client who has a mild traumatic brain injury. The nurse should report
which of the following findings as a complication of this injury? Select all that apply
A. Bradycardia
B. Vomiting
C. Drainage from the ear
D. Unequal pupils Pruritus
Answer: A. Bradycardia
B. Vomiting
C. Drainage from the ear
D. Unequal pupils Pruritus
Rationale: Bradycardia, vomiting, and unequal pupils are manifestations of increased
intracranial pressure, which is a complication of a mild traumatic brain injury. It is a late
manifestation and a part of Cushing’s triad, which includes severe hypertension, a widened pulse
pressure, and bradycardia. The nurse should notify the provider immediately. Ear drainage can
consist of cerebral spinal fluid and is a manifestation of a possible basilar skull fracture, a
complication of a mild traumatic brain injury
33. A nurse is teaching a client who has a new diagnosis of polycystic kidney disease. Which of
the following statements should the nurse include in the teaching?
A. “Take aspirin as needed to reduce your pain”
B. “Reduce your dietary fiber intake”
C. “Apply dry heat to your abdomen when needed”
D. “Check your weight once per week”
Answer: C. “Apply dry heat to your abdomen when needed”
Rationale: The client should apply dry heat to the abdomen & flank area to reduce pain &
discomfort caused by distended kidneys / infected cysts. Other strategies to reduce pain include
deep breathing & guided imagery. Needle aspiration of cyst & antibiotic therapy can reduce pain
and treat infection
34. A nurse is teaching a client who has asthma about using a peak flow meter. When a yellow
zone meter reading appears, the nurse should instruct the client to take which of the following
actions?
A. Take another peak flow meter reading in 15 min
B. Take prescribed relief medication
C. Call for emergency transport to
D. A hospital Inhale through pursed lips
Answer: B. Take prescribed relief medication
Rationale: A peak flow rate in the yellow zone indicates that the client’s airflow is between 50%
- 80% of personal best. The client should take relief medication as prescribed & repeat the
reading in 1 to 2 min
35. A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy.
Which of the following actions should the nurse plan to take?
A. Review the clients Hgb level prior to administration
B. Use the Z track method when administering the medication
C. Shake the vial for 30 seconds prior to withdrawing the medication
D. Ensure the client is not taking iron supplements while on this medication
Answer: A. Review the clients Hgb level prior to administration
Rationale: The nurse should review the client's Hgb level prior to administration to ensure that
the client still requires the medication. This medication should not be given to clients who have a
Hgb level greater than 10 g/dL
36. A nurse is providing teaching to the caregivers of a client who has Alzheimer's disease.
Which of the following instructions should the nurse give? Select all that apply
A. Install safety locks and alarm systems
B. Place nightlights throughout the home
C. Replace carpeted flooring with tile
D. Establish a predictable daily routine for the client
E. Remind the client of scheduled activities 1 day in advance
Answer: A. Install safety locks and alarm systems
B. Place nightlights throughout the home
D. Establish a predictable daily routine for the client
Rationale: Clients who have Alzheimer's disease, especially in the later stages of the disease,
tend to wander. To keep the client safe at home, the family should be encouraged to install locks
on doors leading to the outside as well as alarms that will sound if the client wanders. Nightlights
should be placed to lead a pathway to the bathroom for the client at night. Nightlights should also
be placed in the client’s room, the hallway, and the bathroom to improve orientation & reduce the
risk of falls. Clients who have Alzheimer's disease function best when they are in familiar
surroundings & have an established routine. Tile flooring should be avoided due to risk of falling
37. A nurse is caring for a client who is postoperative and reports frequent leakage of small
amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The
nurse should identify these findings as which of the following forms of incontinence?
A. Stress
B. Urge
C. Functional
D. Overflow
Answer: D. Overflow
Rationale: Overflow incontinence is a condition that occurs when the pressure of urine in an
overfull bladder overcomes sphincter control. Manifestations can include leakage of small
amounts of urine frequently throughout the day & night, urinating frequently in sm amts & a
distended and palpable bladder. This condition is also known as reflex incontinence / underactive
bladder
38. A nurse is reviewing a client’s medical record prior to administering furosemide via IV bolus
to a client who has heart failure. For which of the following findings should the nurse withhold
the medication and notify the provider?
A. Hypokalemia
B. Hypernatremia
C. Hypoglycemia
D. Hypermagnesemia
Answer: A. Hypokalemia
Rationale: The nurse should identify that a client who has hypokalemia has a potassium level
below the expected reference range of 3.5 to 5 mEq/L. furosemide is a high ceiling loop diuretic
that increases renal excretion of potassium, which can result in generalized weakness and
irregular heartbeat. Therefore, the nurse should withhold the medication and notify the provider
39. A nurse is providing discharge teaching to a client who has multiple sclerosis. Which of the
following instructions should the nurse include in the teaching?
A. “It is important to engage in a strenuous aerobic exercise program to build strength &
endurance”
B. “It is important with this disease to relax muscles in a hot tub or spa”
C. “It is important to engage in social activity & volunteering to read to schoolchildren will keep
you active”
D. “It is important to develop a daily schedule that reduces fatigue & conserves energy”
Answer: D. “It is important to develop a daily schedule that reduces fatigue & conserves
energy”
Rationale: A client who has multiple sclerosis is at risk for fatigue. The client should develop a
daily schedule that allows for adequate time to complete planned activities in order to conserve
energy and reduce fatigue
40. A nurse is caring for a client who has the history of tonic clonic seizures. Which of the
following precautions should the nurse take? Select all that apply
A. Keep a suction apparatus at the bedside
B. Keep a padded tongue blade next to the bed
C. Keep the bed in the lowest position
D. Keep oxygen equipment at the bedside
E. Keep safety restraints near the bedside
Answer: A. Keep a suction apparatus at the bedside
C. Keep the bed in the lowest position
D. Keep oxygen equipment at the bedside
Rationale: The nurse should have suction equipment at the client's bedside to clear the client's
airway and reduce the risk of aspiration of secretions. Keeping the bed in the lowest position
reduces the risk of injury if the client falls out of bed during the seizure. The nurse should have
oxygen via nasal cannula or face mask available at the client's bedside to administer if needed for
hypoxia. Padded tongue blades can cause airway obstruction, chip teeth & result in aspiration of
tooth fragments. Restraining a client during seizure activity can result in injury & increase in
seizure activity
41. A nurse is caring for a client who has acute gastritis and is NPO. The client has a new
prescription to resume oral intake. Which of the following items should the nurse offer the
client?
A. Orange juice
B. Chicken broth
C. Apple sauce
D. Milk
Answer: C
Rationale: The nurse should begin with ice chips then introduce clear liquids such as gelatin and
add solid foods as tolerated. The nurse should monitor for manifestations of recurring gastritis.
The goal is to provide adequate nutrition while allowing for the mucosal barrier to heal. The
nurse should instruct the client to avoid gastric irritants such as dry pepper, alcohol, acidic foods
& caffeinated foods. The client should eliminate or limit any foods that cause discomfort
42. A nurse is reviewing laboratory reports for a client who is taking NSAIDs for rheumatoid
arthritis. Which of the following results should the nurse recognize as a possible adverse effect of
NSAID therapy?
A. Increased erythrocyte sedimentation rate
B. Elevated creatinine clearance
C. Increased serum potassium
D. Positive fecal occult blood test
Answer: D. Positive fecal occult blood test
Rationale: An adverse effect of NSAID therapy is gastrointestinal bleeding related to suppressed
platelet function. A positive fecal occult blood test indicating there is blood in the stool can be an
indication of this adverse effect
43. A nurse is providing teaching for a client who has Parkinson's disease and the new
prescription for selegiline. Which of the following statements should the nurse include?
A. “You might experience joint pain while taking this medication”
B. “The medication cannot be combined with other antiparkinsonian agents”
C. “Avoid eating aged cheeses or smoked meats while taking this medication”
D. “It will take up to 2 weeks for the medication to work”
Answer: C. “Avoid eating aged cheeses or smoked meats while taking this medication”
Rationale: The nurse should instruct the client to avoid foods that contain tyramine such as age
cheeses or smoked meats because these foods can trigger a hypertensive crisis in clients who
take MAOIs
44. A nurse is providing education to a client who is scheduled for a barium swallow. Which of
the following statements by the client indicates an understanding of the teaching?
A. “I should expect to experience diarrhea for several days after the test”
B. “I should limit my fluid intake for 6 hours after the procedure”
C. “I will remove my metal jewelry before coming in”
D. “I will eat a good breakfast for the morning of the test”
Answer: C. “I will remove my metal jewelry before coming in”
Rationale: The nurse should ask the client to remove all metal jewelry, which could interfere
with the films visualization results. A barium swallow is an X-ray that highlights abnormalities
of the gastrointestinal track. The nurse should instruct the client to increase fluid intake following
the procedure to assist in the elimination of the barium & prevent a bowel obstruction. The client
should also be instructed to take a cathartic laxative & report if they do not have a bowel
movement. The nurse should tell the client not to eat or drink after midnight before the procedure
to prevent interference with the films visualization results
45. A nurse is providing discharge teaching to a client who is postoperative following a total hip
arthroplasty. Which of the following statements by the client indicates an understanding of the
teaching?
A. “When I'm exercising, I'll include bent leg raises”
B. “I'll use my reaching device to help me pick up objects I drop on the floor”
C. “I can stop physical therapy when I quit using my walker”
D. “I'll sleep on my back with my knees close together”
Answer: B. “I'll use my reaching device to help me pick up objects I drop on the floor”
Rationale: To prevent dislocation, the client should avoid hip flexion of 90° or more. A reaching
device will reduce the risk of the client engaging in excessive hip flexion
46. A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken
from the iliac crest. Which of the following information should the nurse include?
A. “Avoid taking warm baths following the procedure.”
B. “You will lie on your back during the procedure”
C. “You will receive general anesthesia for the procedure”
D. “Take acetaminophen as prescribed for pain relief after the procedure”
Answer: D. “Take acetaminophen as prescribed for pain relief after the procedure”
Rationale: The nurse should instruct the client to take acetaminophen and to avoid NSAIDs,
such as aspirin following the procedure. NSAIDs can increase the risk for bleeding after a bone
marrow biopsy
47. A nurse is creating a plan of care for a client who has meningitis. Which of the following
interventions should the nurse include?
A. Initiate contact isolation precautions
B. Keep the client’s environment dark and quiet
C. Restrict the client’s fluid intake
D. Perform neurovascular assessments once a day
Answer: B. Keep the client’s environment dark and quiet
Rationale: The nurse should include in the plan to decrease the environmental stimuli for a
client who has meningitis, keeping the room dark & quiet. Clients who have meningitis often
have photophobia and phonophobia
48. A nurse is teaching strategies to prevent carpal tunnel syndrome to a group of office workers.
Which of the following instructions should the nurse include? Select all that apply
A. “Raise your chair height so that you lean over to type”
B. “Use a risk rest when working at a computer station”
C. “Stretch your fingers and wrists periodically while working”
D. “Position your keyboard at shoulder height”
E. Take breaks from repetitive activity”
Answer: B. “Use a risk rest when working at a computer station”
C. “Stretch your fingers and wrists periodically while working”
E. Take breaks from repetitive activity”
Rationale: A wrist rest and an ergonomic keyboard can reduce the risk for carpal tunnel
syndrome by keeping office workers’ wrist at a neutral position. Stretching fingers and wrists
frequently, taking frequent breaks from repetitive activities & alternating tasks to improve
circulation can increase circulation to offers workers’ fingers & reduce the risk for carpal tunnel
syndrome
49. A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is
the nurse’s priority?
A. Provide assistance with ambulation
B. Facilitate retention of facts by repeating instructions
C. Place the client in a darkened room
D. Speak slowly and clearly
Answer: A. Provide assistance with ambulation
Rationale: The greatest risk to this client is injury from falling due to manifestations of dizziness
and loss of balance related to the tumor; therefore, the priority action the nurse should take is to
assist the client with ambulation
50. A nurse is reviewing laboratory values for a client who has Cushing’s disease. Which of the
following values should the nurse expect?
A. Blood glucose 65 mg/Dl
B. Serum calcium 12.2 mg/Dl
C. Potassium 5 mEq/L
D. Sodium 150 mEq/L
Answer: D. Sodium 150 mEq/L
Rationale: Clients who have Cushing’s disease have hypernatremia due to mineral corticoid
excess. A sodium level of 150 mEq/L is above the expected reference range of 136 to 145 mEq/L
