Medical Surgical Exams: ATI Final Exam Test Bank
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is
the nurse's priority?
Answer: C. Tachycardia
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary
colic, which can lead to shock. The nurse should position the head of the client's bed flat and
report this finding immediately to the provider
A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney
disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands.
Which of the following medications should the nurse plan to administer?
Answer: D. Calcium carbonate
Rationale: Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis.
Often occurring late in the dialysis session, hypocalcemia can cause the client to experience
muscle cramping and tingling to extremities. The nurse should plan to administer a calcium
supplement, such as calcium carbonate, as a calcium replacement .
A nurse is providing teaching to a client who is receiving chemotherapy and has a new
prescription for epoetin alfa. Which of the following client statements indicates an
understanding of the teaching?
Answer: A. "I will monitor my blood pressure while taking this medication" Common side
effect of epoetin alfa is hypertension
Rationale: The client should monitor their blood pressure while taking this medication
because hypertension is a common adverse effect and can lead to hypertensive
encephalopathy.
A nurse is caring for a group of clients. The nurse should plan to make a referral to physical
therapy for which of the following clients?
Answer: A. A client who is receiving preoperative teaching for a right knee arthroplasty
Rationale: The nurse should make a referral to physical therapy for a client who is receiving
preoperative teaching for a knee arthroplasty so the client can begin understanding
postoperative exercises and physical restrictions
A nurse is providing teaching to a female client who has a history of urinary tract infections
(UTIs). Which of the following information should the nurse include in the teaching?
Answer: D. Take daily cranberry supplements
Rationale: The client should take cranberry supplements or drink low-fructose cranberry juice
because it contains compounds that adhere to the urinary tract wall, decreasing the risk for
developing a UTI
A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new
prescription for metformin. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: B. "I should take this medication with a meal."
Rationale: The client should take metformin with or immediately following meals to improve
absorption and to minimize gastrointestinal distress
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is
not available when the current infusion is nearly completed. Which of the following actions
should the nurse take?
Answer: C. Administer dextrose 10% in water until the new bag arrives
Rationale: TP solutions have a high concentration of dextrose. Therefore, if a TPN solution is
temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a
precipitous drop in the client's blood glucose level.
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 to avoid?
Answer: B. Aged cheese
Rationale: Foods that contain tyramine, such as aged cheese and sausage, can trigger
migraine
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the client to
withhold for 48 hr prior to cardioversion?
Answer: C. Digoxin
Rationale: There is an increased risk of ventricular arrhythmias developing in patients taking
digoxin during electrical cardioversion. Reduce dosage or withhold therapy for 1 to 2 days
before elective cardioversion
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications
can increase ventricular irritability and put the client at risk for ventricular fibrillation after
the synchronized countershock of cardioversion
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a
productive cough. Which of the following actions should the nurse take first?
Answer: D. Initiate airborne precautions
Rationale: This client is exhibiting manifestations of tuberculosis. The greatest risk in this
client situation is for other people in the facility to acquire an airborne disease from this
client. Therefore, the first action the nurse should take is to initiate airborne precautions
A nurse is caring for a client who has a stage III pressure injury. Which of the following
findings contributes to delayed wound healing?
Answer: D. Urine output 25 mL/hr
Rationale: Urinary output reflects fluid status. Inadequate urine output can indicate
dehydration, which can delay wound healing.
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation.
The client appears anxious and restless, and the high-pressure alarm is sounding. Which of
the following actions should the nurse take first?
Answer: C. Instruct the client to allow the machine to breathe for them.
Rationale: When providing client care, the nurse should first use the least restrictive
intervention. Therefore, the first action the nurse should take is to provide verbal instructions
and emotional support to help the client relax and allow the ventilator to work. Clients can
exhibit anxiety and restlessness when trying to "fight the ventilator."
A nurse is caring for a client who has hepatic encephalopathy that is being treated with
lactulose. The client is experiencing excessive stools. Which of the following findings is an
adverse effect of this medication?
Answer: A. Hypokalemia
Rationale: Lactulose works by stimulating the production of excess stools to rid the body of
excess ammonia. These excessive stools can result in hypokalemia and dehydration.
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea
for the past 3 days. Which of the following findings should indicate to the nurse that the client
is experiencing fluid volume deficit?
Answer: A. Heart rate 110/min
Rationale: A client who has a 3-day history of vomiting and diarrhea is likely to have fluid
volume deficit and an elevated heart rate.
A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory results to be below the expected reference range?
Answer: D. Calcium
Rationale: A client who has pancreatitis is expected to have decreased calcium and
magnesium levels due to fat necrosis.
A nurse is assessing a client who has Graves' disease. Which of the following images should
indicate to the nurse that the client has exophthalmos?
Answer: D. The nurse should identify an outward protrusion of the eyes is exophthalmos a
common finding of graves disease.
An overproduction of the thyroid hormone causes edema of the extraocular muscle and
increases fatty tissue behind the eye, which results in the eyes protruding outward.
Exophthalmos can cause the client to experience problems with vision, including focusing on
objects, as well as pressure on the optic nerve.
A nurse is caring for a client who was just admitted from the emergency department (ED).
Exhibit 1:
Nurses' Notes 0945:
Client is experiencing a sickle cell crisis. Client states that they began experiencing pain in
the lower extremities 3 days ago and is now experiencing pain in the chest, rating it as 4 on
scale of 0 to 10. Oxygen at 3 L/min via nasal cannula in place. Oral mucosa pink, no
cyanosis.
Pulses palpable in all four extremities, no peripheral edema noted.
Respirations even and slightly labored; lung sounds with slight wheezing in left upper lobe.
Abdomen soft and nontender, bowel sounds active in all four quadrants.
0.45% sodium chloride IV at 200 mL/hr infusing to left hand with no reports of pain or
swelling at the site.
1200:
Client is sitting up in high-Fowler's position and appears anxious. Client reports shortness of
breath and severe chest pain as 9 on a scale of 0 to 10. Client states that they have started
coughing and are expectorating pink-tinged mucus.
Lung sounds with increased wheezing in left lung and clear on the right side. Equal chest
expansion noted. Neck veins flat. No peripheral edema observed.
Exhibit 2:
Vital Signs
0945:
Blood pressure 132/88 mm
Hg Respiratory rate 22/min
Temperature 38° C (100° F)
Heart rate 98/min
SaO2 95% on 3 L/min via nasal cannula
1200:
Blood pressure 136/90 mm
Hg Respiratory rate 32/min
pneumonia
acute chest syndrome
right-sided heart failure
fluid volume overload
pneumothorax
Temperature 38.7° C (101.6° F)
Heart rate 110/min
SaO2 90% on 3 L/min via nasal cannula
Drag words from the choices below to fill in each blank in the following sentence. The
client is most likely experiencing and .
Word Choices
Answer: Fluid volume overload is incorrect. While the client is experiencing an increased
respiratory rate and shortness of breath, fluid volume overload typically includes moist
crackles on auscultation, pitting edema in dependent areas, neck vein distension, and
hypertension.
Right-sided heart failure is incorrect. While clients who have sickle-cell disease are at risk
for developing heart failure, the client does not have manifestations of rightsided heart
failure. Right-sided heart failure typically presents with signs of fluid volume overload, which
includes jugular vein distention, dependent edema, and blood pressure alterations.
Acute chest syndrome is correct. The client is most likely experiencing acute
chest syndrome, which can be caused by respiratory infections and debris from sickled cells.
The client is displaying manifestations of acute chest syndrome, which include cough,
shortness of breath, wheezing, tachypnea, fever, and chest pain.
Pneumonia is correct. The client is most likely experiencing pneumonia as evidenced by the
manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and
chest pain.
Pneumothorax is incorrect. While the client is experiencing increased respiratory distress, a
pneumothorax typically presents with reduced or absent breath sounds and unequal chest
expansion.
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the
following precautions should the nurse implement?
Answer: D. Ensure that the client has a patent IV.
Rationale: The nurse should ensure the client has IV access in the event that the client
requires medication to stop seizure activity.
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago.
Which of the following actions should the nurse take?
Answer: B. Check that one finger fits between the cast and the leg.
Rationale: To make sure the cast is not too tight, the nurse should be able to slide one finger
under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should
not be an issue 2 hr after application.
A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the
formation of a hematoma at the insertion site and a decreased pulse rate in the affected
extremity. Which of the following interventions is the nurse's priority?
Answer: B. Apply firm pressure to the insertion site
Rationale: The greatest risk to the client is bleeding. Therefore, the priority intervention is for
the nurse to apply firm pressure to the hematoma to stop the bleeding.
A nurse is assessing a male client for an that the client has an inguinal hernia?
Answer: C. Palpate the inguinal area to assess for any bulging or protrusions.
Rationale: The nurse should palpate this location to assess the client for an inguinal hernia.
An inguinal hernia forms from the peritoneum, which contains part of the intestine, and can
protrude into the scrotum in men.
A nurse is teaching a class about client rights. Which of the following instructions should the
nurse include?
Answer: A. A client should sign an informed consent before receiving a placebo during a
research trial.
Rationale: A nurse should ensure a client has provided informed consent before administering
a placebo. The nurse should not administer a placebo to a client who thinks it is an active
medication, because this action is a violation of client rights.
A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile
dysfunction, Which of the following statements should the nurse make?
Answer: D. "You will not be able to use sildenafil if you are taking nitroglycerin."
Rationale: The client should not use sildenafil when taking nitroglycerin because both
medications can cause vasodilation and lead to significant hypotension.
A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of
the following findings should the nurse identify as a manifestation of chronic
glomerulonephritis?
Answer: B. Hyperkalemia
Rationale: The nurse should identify that a client who has chronic glomerulonephritis can
experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased
excretion of potassium.
A nurse is assessing a client who has had a suspected stroke. The nurse should place the
priority on which of the following findings?
Answer: A. Dysphagia
Rationale: Dysphagia indicates that this client is at greatest risk for aspiration due to impaired
sensation and function within the oral cavity. Therefore, the nurse should place priority on
this finding.
A nurse is caring for a client who has a prescription for enalapril. The nurse should identify
which of the following findings as an adverse effect of the medication?
Answer: C. Orthostatic Hypotension
Rationale: The nurse should identify that dilation of arteries and veins causes orthostatic
hypotension, which is an adverse effect of enalapril.
A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago.
Which of the following findings should the nurse expect?
Answer: A. Stone fragments in the urine
Rationale: ESWL is an effort to break the calculi so that the fragments pass down the ureter,
into the bladder, and through the urethra during voiding. Following the procedure, the nurse
should strain the client's urine to confirm the passage of stones.
A nurse is caring for a client who is postoperative following abdominal surgery Exhibit 1:
Nurses' Notes 1100:
Client received from PACU; initial vital signs recorded. Client is drowsy, but arouses to
verbal stimuli. Oriented x3, moves all extremities. Normal sinus rhythm. Chest clear.
Dressing to abdomen intact, small amount of serosanguinous drainage noted and marked. No
bowel sounds x 4 quadrants. Indwelling urinary catheter in place, draining clear yellow urine.
Lactated Ringer's infusing at 100 mL/hr via IV catheter to right forearm.
1200:
Client reports nausea and pain as 8 on a scale of 0 to 10. Abdominal dressing intact, no
further drainage noted. Urine output 15 mL since arrival from PACU. Analgesic and
antiemetic administered as prescribed.
1230:
Client reports relief from nausea and pain as 4 on a scale of 0 to 10. SaO 2 96%. Repositioned
for comfort. Encouraged to turn, cough, and deep breathe.
1300:
No additional urine output since 1200.
A nurse is caring for a client who is postoperative. Which of the following actions should the
nurse take? Select all that apply.
A. Instruct the client to splint the abdomen with a pillow for coughing.
B. Report urinary output to the provider
C. Ask the client to rate their pain on a 0 to 10 pain scale
D. Apply oxygen via a face mask
E. Plan to ambulate the client as soon as possible
Answer: D. Apply oxygen via a face mask is incorrect. It is not necessary to place a face
mask on the client because their SaO2 is within the expected reference range of 95% to
100%.
Instruct the client to splint the abdomen with a pillow for coughing is correct. It is
important for the client to turn, cough, and deep breathe to reduce the risk for respiratory
complications. The nurse should instruct the client to splint the incision while performing
these actions to reduce the risk of complications to the surgical incision.
Plan to ambulate the client as soon as possible is correct. The nurse should plan to
ambulate the client as soon as possible to promote ventilation and decrease the risk of
thrombosis.
Report urinary output to the provider is correct. The client should produce at least 30 mL
of urine per hour. Therefore, the nurse should report this finding to the provider.
Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse should have
the client rate their pain prior to and following the administration of pain medication to
evaluate its effectiveness.
A nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: B. A nurse is providing teaching to a client who has chronic kidney disease and a
new prescription for erythropoietin. Which of the following statements by the client indicates
an understanding of the teaching?
Rationale: The goal of erythropoietin therapy is to increase the level of hematocrit in clients
who have anemia. When the medication is effective, the client should have a decrease in
fatigue and an improvement in activity tolerance.
A nurse is creating a plan of care for a client who has neutropenia as a result of
chemotherapy. Which of the following interventions should the nurse include in the plan?
Answer: A. Monitor the client's temperature every 4 hr.
Rationale: The nurse should monitor the temperature of a client who has neutropenia every 4
hr because the client's reduced amount of leukocytes greatly increases the client's risk for
infection.
A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of
the following client statements indicates the client is successfully coping with the change?
Answer: B. "I used to never worry about my feet. Now, I inspect my feet every day with a
mirror."
Rationale: This statement indicates that the client is successfully coping with the change
because the client is performing preventive foot care to reduce the risk for complications.
A nurse is planning care to decrease psychosocial health issues for a client who is starting
dialysis treatments for chronic kidney disease. Which of the following interventions should
the nurse include in the plan?
Answer: C. Tell the client that it is possible to return to similar previous levels of activity.
Rationale: The nurse should help the client develop realistic goals and activities to have a
productive life.
A nurse is providing teaching to an older adult client who has cancer and a new prescription
for an opioid analgesic for pain management. Which of the following information should the
nurse include in the teaching?
Answer: C. "You should void every 4 hours to decrease the risk of urinary retention."
Rationale: The nurse should instruct the client to void at least every 4 hr to decrease the risk
of urinary retention, which is an adverse effect of opioid analgesics.
A nurse is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
Answer: C. Demonstrate ways to deep breathe and cough.
Rationale: The nurse should demonstrate deep breathing and coughing exercises and explain
the importance of splinting the incision to reduce the risk for respiratory complications.
A nurse is caring for a client. Exhibit 1:
Nurses' Notes
1000:
Client is alert and oriented and reports not feeling well for a few days. Client is on continuous
ambulatory peritoneal dialysis (CAPD) and reports dialysate appeared cloudy this morning.
Reports abdominal pain as 4 on a scale of 0 to 10.
Bowel sounds active in all quadrants.
Peritoneal dialysis access site red, warm to touch, with a small amount of purulent drainage
noted on dressing.
1300:
Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly
distended, hypoactive bowel sounds. Client reports nausea. Reports pain as 6 on a scale of 0
to 10. Provider notified and updated with client condition and diagnostic results.
Exhibit 2:
Vital Signs
pneumonia
dysrhythmias
peritonitis
myxedema coma
1000:
Blood pressure 142/90 mm
Hg Respiratory rate 18/min
Temperature 38.3° C (101°F)
Heart rate 90/min
Oxygen saturation 96% on room air
Exhibit 3:
Diagnostic Results
1300:
WBC count 17,000/mm³ (5,000 to 10,000/ mm³)
Potassium 4.8 mEq/L (3.5 to 5.0 mEq/L)
Free thyroxine (Free T4) 1.4 ng/dL (0.8 to 2.8 ng/dL)
Thyroid stimulating hormone (TSH) 4.5 µU/mL (0.3 to 5 µU/ mL)
Platelet count 220,000/mm³ (150,000 to 400,000/mm³)
Abdominal x-ray result:
Fluid noted in the abdominal cavity and inflammation noted in the large intestines.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is experiencing manifestations of Condition due to Client Finding.
Condition
Client Finding
platelet count
potassium level
oxygen
saturation
Dropdown 1
Peritonitis is correct. The client is experiencing manifestations of peritonitis, such as
abdominal pain, cloudy dialysate, and an elevated white blood cell count.
Myxedema coma, hemorrhage, dysrhythmias and pneumonia are incorrect. The client
does not exhibit manifestations of any of these conditions based on assessment and laboratory
findings.
Dropdown 2
X-ray results are correct. The client’s abdominal x-ray shows fluid in the abdomen along
with inflammation, both of which are indications of peritonitis.
Thyroid level, platelet count, potassium level and oxygen saturation are incorrect. These
laboratory findings and the oxygen saturation are within the expected reference range and do
not indicate peritonitis.
A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after
hospitalization for heart failure. Based on the information in the client’s chart, which of the
following findings should the nurse report to the provider?
Exhibit 1:
Prescriptions
Digoxin 0.25 mg PO daily
Furosemide 40 mg
PO daily
Potassium chloride 20 mEq/L PO daily
Exhibit 2:
History and Physical
Discharge:
Weight 66.7 kg (147 lb)
SaO2 94% 2+ pedal edema
Heart rate 74/min
Current:
Weight 67.1 kg (148 lb)
SaO2 92%
1+ pedal edema
Heart rate 55/min
Exhibit 3:
Laboratory Results
Discharge:
Sodium 137 mEq/L
Potassium 4.2 mEq/L
Digoxin 1.2 ng/dL
Current:
Sodium 135 mEq/L
Potassium 4.1 mEq/L
Digoxin 1.8 ng/dL
Answer: B. Heart rate 55/min
Rationale: The client's heart rate of 55/min is a decrease from the client's baseline of 74/min,
and it can indicate the development of digoxin toxicity. The nurse should report this finding
to the provider.
A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place
which of the following items at the client's bedside?
Answer: A. Suction machine
Rationale: The nurse should ensure that a suction machine is at the bedside of a client who
has dysphagia to clear the client's airway as needed and reduce the risk for aspiration.
A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being
admitted to the hospital with pneumonia. Which of the following assessment findings is the
nurse's priority?
Answer: B. Increased respiratory secretions
Rationale: Using the airway, breathing, circulation approach to client care, the nurse should
determine that the priority assessment finding is increased respiratory secretions. These
secretions place the client at risk for aspiration pneumonia due to respiratory muscle
weakness caused by the ALS and the pneumonia.
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: B. 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.
A nurse is providing teaching to a client who has esophageal cancer and is to undergo
radiation therapy. Which of the following statements should the nurse identify as an
indication that the client understands the teaching?
Answer: B. “I will use my hands rather than a washcloth to clean the radiation area.”
Rationale: The client should gently wash the radiation area with their hands using warm water
and mild soap to protect the skin from further irritation.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of
the following laboratory values should the nurse report to the provider?
Answer: D. Hgb 8 g/dL
Rationale: The nurse should report an Hgb level of 8 g/dL, which is below the expected
reference range and is an indicator of postoperative hemorrhage or anemia.
A nurse is caring for a client.
Exhibit 1:
Nurses' Notes
Day 1
1000:
Client is short of breath and has a productive cough with yellow mucus. Client reports feeling
sick for the last few days and states, "I could barely breathe when I got up this morning and I
had a throbbing headache."
Client is alert and oriented to person, place, and time.
Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs.
Pedal pulses +2 bilaterally.
Client reports decreased appetite for the past 2 days.
Exhibit 2:
Diagnostic Results
Day 1
1000:
Sodium 150 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)
BUN 24 mg/dL (10 to 20 mg/dL)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
ABGs:
pH 7.25 (7.25 to 7.45)
PCO2 50 mm Hg (35 to 45 mm Hg)
HCO - 24 mEq/L (22 to 26 mEq/L)
Chest x-ray reveals increased opacity in the bilateral posterior lobes.
Exhibit 3:
Graphic Record
Day 1
1000:
Temperature 38.6° C (101.5° F)
Heart rate 98/min
Respiratory rate 24/min
Blood pressure 110/56 mm Hg
Oxygen saturation 88% on room air
The nurse is reviewing the client's diagnostic results. Which of the following findings
requires follow-up by the nurse?
Select all that apply.
Calcium level
WBC count
BUN level PCO2 level
HCO3 level
Oxygen saturation level
Chest x-ray
Answer: PCO2 level is correct. The client has an elevated PCO2 level, which indicates the
retention of carbon dioxide. Therefore, this finding requires follow-up by the nurse.
WBC count is correct. The client has an elevated WBC count, which indicates an infection.
Therefore, this finding requires follow-up by the nurse.
Chest x-ray is correct. The client's chest x-ray indicates increased opacity in the bilateral
posterior lobes, which is a manifestation of pneumonia. Therefore, this finding requires
follow- up by the nurse.
Oxygen saturation level is correct. The client's oxygen saturation is decreased, which is a
manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse.
Calcium level is incorrect. The client's calcium level is within the expected reference range.
Therefore, this finding does not require follow-up by the nurse.
HCO - level is incorrect. The client's HCO - level is within the expected reference range.
Therefore, this finding does not require follow-up by the nurse.
BUN level is correct. The client's BUN is elevated, which is a manifestation of dehydration
or kidney disease. Therefore, this finding requires follow-up by the nurse.
A nurse is caring for a client.
Exhibit 1:
Nurses' Notes
Day 1
1000:
Client is short of breath and has a productive cough with yellow mucus. Client reports feeling
sick for the last few days and states, "I could barely breathe when I got up this morning and I
had a throbbing headache."
Client is alert and oriented to person, place, and time.
Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs.
Pedal pulses +2 bilaterally.
Client reports decreased appetite for the past 2 days.
Exhibit 2:
Diagnostic Results
Day 1
1000:
Sodium 150 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)
BUN 24 mg/dL (10 to 20 mg/dL)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
ABGs:
pH 7.25 (7.25 to 7.45)
PCO2 50 mm Hg (35 to 45 mm Hg)
HCO - 24 mEq/L (22 to 26 mEq/L)
Chest x-ray reveals increased opacity in the bilateral posterior lobes.
Exhibit 3:
Graphic Record
Day 1
1000:
Temperature 38.6° C (101.5° F)
Heart rate 98/min
Respiratory rate 24/min
Blood pressure 110/56 mm Hg
Oxygen saturation 88% on room air
The nurse is reviewing the client's medical record.
Click to highlight the findings below that indicate that the client has a potential
problem. To deselect a finding, click on the finding again.
Nurses' Notes
Client is short of breath and has a productive cough with yellow mucus.
"I could barely breathe when I got up this morning and I had a throbbing headache.”
Capillary refill less than 2 seconds.
Client is diaphoretic.
Crackles heard in posterior lungs.
Pedal pulses +2 bilaterally.
Answer: Client is short of breath and has a productive cough with yellow mucus is
correct. Shortness of breath, along with a productive cough with yellow mucus,
indicates a potential problem.
"I could barely breathe when I got up this morning and I had a throbbing headache" is
correct. Difficulty breathing and a throbbing headache indicates a
potential problem.
Crackles heard in posterior lungs is correct. Crackles heard in the posterior lower lobes
indicate a potential problem.
Capillary refill less than 2 seconds is incorrect. A capillary refill less than 2 seconds is
within the expected reference range and indicates adequate perfusion.
Client is diaphoretic is correct. Diaphoresis is a manifestation of an elevated temperature or
hypoglycemia and indicates a potential problem.
Pedal pulses +2 bilaterally is incorrect. Pedal pulses +2 bilaterally is within the expected
reference range and indicates adequate perfusion.
A nurse is caring for a client.
Exhibit 1:
Nurses' Notes
Day 1 1000:
Client is short of breath and has a productive cough with yellow mucus. Client reports feeling
sick for the last few days and states, "I could barely breathe when I got up this morning and I
had a throbbing headache."
Client is alert and oriented to person, place, and time.
Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs.
Pedal pulses +2 bilaterally.
Client reports decreased appetite for the past 2 days.
Exhibit 2:
Diagnostic Results
Day 1 1000:
Sodium 150 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)
BUN 24 mg/dL (10 to 20 mg/dL)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
ABGs:
pH 7.25 (7.25 to 7.45)
PCO2 50 mm Hg (35 to 45 mm Hg)
HCO - 24 mEq/L (22 to 26 mEq/L)
Chest x-ray reveals increased opacity in the bilateral posterior lobes.
Exhibit 3:
Graphic Record
Day 1
1000:
Temperature 38.6° C
(101.5° F) Heart rate 98/min
Respiratory rate 24/min
Blood pressure 110/56 mm Hg
Oxygen saturation 88% on room air
A nurse is prioritizing client care.
Complete the following sentence by using the lists of options.
The nurse should first address the client's Select... , followed by the client's Select... .
Options 1:
Loss of appetite Oxygen saturation
BUN level
Option 2: Headache
Temperature
Heartrate
Dropdown 1
Answer: Oxygen saturation is correct. The first action the nurse should take when using the
airway, breathing, and circulation approach to client care is to address the client's oxygen
saturation. The client's oxygen saturation is 88%, which indicates hypoxemia and requires
supplemental oxygen.
Loss of appetite is incorrect. The nurse should address the client's loss of appetite, which is
a manifestation of an infection. However, there is another finding the nurse should address
first.
BUN level is incorrect. The nurse should address the client's BUN level because it is
elevated. However, there is another finding the nurse should address first.
Dropdown 2
Heart rate is incorrect. The nurse should address the client's elevated heart rate, which can
result in decreased cardiac output. However, there is another finding the nurse should address
first.
Temperature is correct. The nurse should next address the client's elevated temperature,
which is a manifestation of an infection. The client's elevated temperature can cause an
increase in other vital signs, such as heart rate.
Headache is incorrect. The nurse should address the client's headache, which is a
manifestation of an infection. However, there is another finding the nurse should address first.
A nurse is caring for a client. Exhibit 1:
Nurses' Notes
Day 1
1000:
Client is short of breath and has a productive cough with yellow mucus. Client reports feeling
sick for the last few days and states, "I could barely breathe when I got up this morning and I
had a throbbing headache." Client is alert and oriented to person, place, and time.
Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs.
Pedal pulses +2 bilaterally.
Client reports decreased appetite for the past 2 days.
Exhibit 2:
Diagnostic Results
Day 1
1000:
Sodium 150 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)
BUN 24 mg/dL (10 to 20 mg/dL)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
ABGs:
pH 7.25 (7.25 to 7.45)
PCO2 50 mm Hg (35 to 45 mm Hg)
HCO - 24 mEq/L (22 to 26 mEq/L)
Chest x-ray reveals increased opacity in the bilateral posterior lobes.
Exhibit 3:
Graphic Record
Day 1
1000:
Temperature 38.6° C (101.5° F)
Heart rate 98/min
Respiratory rate 24/min
Blood pressure 110/56 mm Hg
Oxygen saturation 88% on room air
For each potential provider's prescription, click to specify if the potential prescription is
anticipated, nonessential, or contraindicated for the client.
Answer: Cough and deep breathe every 2 hr is anticipated. The nurse should anticipate a
prescription for coughing and deep breathing to promote lung expansion and improve
impaired gas exchange.
Obtain a sputum culture and sensitivity is anticipated. The nurse should anticipate a
prescription for a sputum culture and sensitivity to determine the type of bacteria present and
to identify antibiotics to be prescribed.
Perform neurological checks every 2 hr is nonessential. The client is alert and oriented to
person, place, and time. Therefore, the nurse does not need to perform neurological checks
every 2 hr.
Administer oxygen at 3 L/min via nasal cannula is anticipated. The client's oxygen
saturation level is 88% on room air, which indicates hypoxemia. Therefore, the nurse should
administer oxygen at 3 L/min via nasal cannula.
Limit the client's fluid intake to 1,500 mL per day is contraindicated. The client has
manifestations of dehydration. Therefore, fluid restriction is contraindicated. Acetaminophen
500 mg PO every 6 hr as needed is anticipated. The nurse should anticipate a prescription
for acetaminophen to reduce the client's temperature and promote comfort.
Famotidine 40 mg PO daily is nonessential. Famotidine is a histamine2 antagonist that is
used in short-term therapy for the treatment of peptic ulcers. Therefore, the nurse does not
need to administer famotidine 40 mg PO daily.
A nurse is caring for a client.
Exhibit 1:
Nurses' Notes
Day 1
1000:
Client is short of breath and has a productive cough with yellow mucus. Client reports feeling
sick for the last few days and states, "I could barely breathe when I got up this morning and I
had a throbbing headache."
Client is alert and oriented to person, place, and time.
Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs.
Pedal pulses +2 bilaterally. Client reports decreased appetite for the past 2 days.
Day 3
0800:
Supplemental oxygen in use at 2 L/min via nasal cannula. Client reports difficulty coughing
up mucus. Encouraged the client to cough and deep breathe.
Exhibit 2:
Diagnostic Results
Day 1
1000:
Sodium 150 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)
BUN 24 mg/dL (10 to 20 mg/dL)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
ABGs:
pH 7.25 (7.25 to 7.45)
PCO2 50 mm Hg (35 to 45 mm Hg)
HCO - 24 mEq/L (22 to 26 mEq/L)
Chest x-ray reveals increased opacity in the bilateral posterior lobes.
Day 3
0800:
Sodium 146 mEq/L (136 to 145 mEq/L)
Potassium 5.4 mEq/L (3.5 to 5 mEq/L)
Calcium 9.2 mg/dL (7.6 to 10.4 mg/dL)
BUN 22 mg/dL (10 to 20 mg/dL)
WBC count 15,000/mm3 (5,000 to 10,000/mm3)
Sputum culture and sensitivity results indicate streptococcal pneumonia.
Exhibit 3:
Graphic Record
Day 1
1000:
Temperature 38.6° C (101.5° F)
Heart rate 98/min
Respiratory rate 24/min
Blood pressure 110/56 mm Hg
Oxygen saturation 88% on room air
Day 3
0800:
Temperature 38.6° C (101.5° F)
Heart rate 88/min
Respiratory rate 22/min
Blood pressure 132/62 mm Hg
Oxygen saturation 97% on 2 L/min of oxygen via nasal cannula
The nurse is reviewing the client's medical record.
Select the 3 findings that require nursing intervention.
Potassium level
Temperature Oxygen
Saturation
WBC Count
Heart rate
Answer: Temperature is correct. The nurse should identify that the client continues to have
a fever as a result of the body's immune system fighting the infection. Therefore, this finding
requires nursing intervention.
WBC count is correct. The nurse should identify that the client's WBC count remains
elevated, which indicates an infection. Therefore, this finding requires nursing intervention.
Heart rate is incorrect. The nurse should identify the client's heart rate is within the
expected reference range. Therefore, this finding does not require nursing intervention.
Potassium level is correct. The nurse should identify that the client's potassium level is
elevated, which places them at risk for cardiac dysrhythmias.
Therefore, this finding requires nursing intervention.
Oxygen saturation is incorrect. The nurse should identify the client's oxygen saturation has
improved and is within the expected reference range. Therefore, this finding does not require
nursing intervention.
A nurse is caring for a client.
Exhibit 1:
Nurses' Notes
Day 1
1000:
Client is short of breath and has a productive cough with yellow mucus. Client reports feeling
sick for the last few days and states, "I could barely breathe when I
got up this morning and I had a throbbing headache."
Client is alert and oriented to person, place, and time.
Capillary refill less than 2 seconds. Client is diaphoretic. Crackles heard in posterior lungs.
Pedal pulses +2 bilaterally. Client reports decreased appetite for the past 2 days.
Day 3
0800:
Supplemental oxygen in use at 2 L/min via nasal cannula. Client reports difficulty coughing
up mucus. Encouraged the client to cough and deep breathe.
Day 5
0800:
Client is alert and oriented to person, place, and time.
Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard
upon auscultation. Cough is productive with yellow mucus.
Exhibit 2:
Diagnostic Results
Day 1
1000:
Sodium 150 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEq/L (3.5 to 5 mEq/L)
Calcium 9.5 mg/dL (7.6 to 10.4 mg/dL)
BUN 24 mg/dL (10 to 20 mg/dL)
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
ABGs:
pH 7.25 (7.25 to 7.45)
PCO2 50 mm Hg (35 to 45 mm Hg)
HCO - 24 mEq/L (22 to 26 mEq/L)
Chest x-ray reveals increased opacity in the bilateral posterior lobes.
Day 3
0800:
Sodium 146 mEq/L (136 to 145 mEq/L)
Potassium 5.4 mEq/L (3.5 to 5 mEq/L)
Calcium 9.2 mg/dL (7.6 to 10.4 mg/dL)
BUN 22 mg/dL (10 to 20 mg/dL)
WBC count 15,000/mm3 (5,000 to 10,000/mm3)
Sputum culture and sensitivity results indicate streptococcal pneumonia.
Exhibit 3:
Graphic Record
Day 1
1000:
Temperature 38.6° C (101.5° F)
Heart rate 98/min
Respiratory rate 24/min
Blood pressure 110/56 mm
Hg Oxygen saturation 88% on room air
Day 3
0800:
Temperature 38.6° C (101.5° F)
Heart rate 88/min
Respiratory rate 22/min
Blood pressure 132/62 mm Hg
Oxygen saturation 97% on 2 L/min of oxygen via nasal cannula
Day 5
0800:
Heart rate 72/min
Respiratory rate 20/min
Blood pressure 128/56 mm Hg
Oxygen saturation 95% on room air
The nurse is reviewing the client's medical record from Day 5.
Click to highlight the findings below that indicate the client is improving. To deselect a
finding, click on the finding again.
Nurse's
Notes Day 5
0800:
Heart rate 72/min
Respiratory rate 20/min
Blood pressure 128/56 mm
Hg Oxygen saturation 95% on room air
Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard
upon auscultation.
Cough is productive with yellow mucus.
Answer: Heart rate is 72/min is correct. The client's heart rate, respiratory rate, and blood
pressure are within the expected reference ranges. Therefore, this finding indicates the client's
pulmonary and cardiovascular statuses are improving.
Respiratory rate is 20/min is correct. The client's heart rate, respiratory rate, and blood
pressure are within the expected reference ranges. Therefore, this finding indicates the client's
pulmonary and cardiovascular statuses are improving.
Blood pressure is 128/56 mm Hg is correct. The client's heart rate, respiratory rate, and
blood pressure are within the expected reference ranges. Therefore, this finding indicates the
client's pulmonary and cardiovascular statuses are improving.
Oxygen saturation is 95% on room air is correct. The client's oxygen
saturation is within the expected reference range and no longer requires supplemental oxygen.
Therefore, this finding indicates the client's pulmonary status is improving.
Lung sounds are diminished in the bilateral posterior bases with occasional crackles
heard upon auscultation is incorrect. The nurse should identify that the client's lungs
sounds are still diminished in the bilateral posterior bases with occasional crackles heard
upon auscultation due to the client's acute respiratory infection. Therefore, this finding
indicates the client's respiratory status is not improving.
Cough is productive with yellow mucus is incorrect. The client's cough is still productive
with yellow mucus due to the client's acute respiratory infection. Therefore, this finding
indicates the client's respiratory status is not improving.
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: D. Bradycardia
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.
A nurse is providing teaching to an older adult female client who has stress incontinence and
a BMI of 32, Which of the following statements by the client indicates an understanding of
the teaching?
Answer: B “I am dieting to lose weight”
Excess weight creates increased abdominal pressure that can result in stress incontinence.
A nurse is planning to provide discharge teaching for the family of an older adult client who
has hemianopsia and is at risk for falls. Which of the following instructions should the nurse
include?
Answer: C Remind the client to scan their complete range of vision during ambulation.
The nurse should instruct the family to remind a client who has hemianopsia, or blindness in
half of the visual field, to use visual scanning to look over their complete range of vision
during ambulation. This practice can accommodate for the loss of vision and help to reduce
the risk for falls.
A nurse in a provider's office is assessing a client who has migraine headaches and is taking
feverfew to prevent headaches. The nurse identify that which of the following client
medications interacts with feverfew?
Answer: C. Naproxen
Both naproxen and feverfew impair platelet aggregation and place the client at risk for
bleeding.
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
laboratory findings should the nurse expect?
Answer: B. BUN 32 mg/dL
DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client
who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the
excess glucose present in the urine.
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: C. Calcium
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.
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: A. History of asthma
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.
A nurse is caring for a client who is receiving dialysis treatment.
Exhibit 1:
Nurses' Notes
0530:
Client is awake and alert.
Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit.
Lung sounds clear upon auscultation; client denies shortness of breath. No peripheral edema
noted; capillary refill is less than 3 seconds; +2 bilateral pedal and radial pulses.
AVF access prepared and cannulated twice with no difficulty. Lines are taped and secured;
treatment is initiated.
0600:
Client is reading a book. Access is visible, and lines are secure. Client reports no discomfort
or pain.
0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly
confused.
Exhibit 2:
Vital Signs
0530:
Weight 88 kg (194 lb)
Temperature 37° C (98.6° F)
Heart rate 90/ min
Respiratory rate 20/ min
Blood pressure
• Sitting – 148/90 mm Hg
• Standing – 144/88 mm Hg
Oxygen saturation 98% on room air
0600:
Blood pressure 120/80 mm
Hg Heart rate 96/min
Respiratory rate 20/min
For each potential nursing intervention, click to specify if the intervention is indicated
or not indicated.
Answer: Perform a 12-lead ECG is not indicated. The client is not reporting chest pain;
therefore, a 12-lead ECG is not indicated at this time.
Place the client in Trendelenburg position is indicated. The client should be placed in the
Trendelenburg position to increase blood flow to the heart, improving cardiac output and
organ perfusion.
Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should
administer 200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's
blood pressure.
Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should administer
oxygen at 2 L/min via nasal cannula to increase the amount of oxygen carried in the blood.
Notify the provider immediately is indicated. The nurse should notify the provider
immediately as part of the nurse's role to provide an update on the client's condition.
Obtain the client's blood glucose level is not indicated. There is no indication that the
client is experiencing hypoglycemia; therefore, obtaining a blood glucose level is not
indicated.
A nurse is assessing a group of clients for indications of role changes. The nurse should
identify that which of the following clients is at risk for experiencing a role change?
Answer: D. A client who has multiple sclerosis and is experiencing progressive difficulty
ambulating
The nurse should identify that progression of a neurologic disease such as multiple sclerosis
can lead to a role change as the client becomes less independent.
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
Answer: D. Loosen restrictive clothing
The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.
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 500 kcal/L. The IV pump
should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing zero.)
Answer: 167 mL/hr
(1,000mL/1L)(1L/500 kcal)(2,000 kcal/1 day)(1 day/24 hr)
A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in the
plan of care to prevent a Pseudomonas aeruginosa infection?
Answer: B. Avoid placing plants or flowers in the client's room.
Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause
life-threatening complications. The nurse should ensure no one brings live plants or flowers
into the client's room.
A nurse in a provider's office is assessing a client who has hypertension and takes
propranolol. Which of the following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication?
Answer: A. Report of a night cough
The nurse should recognize that a night cough is an early indication of heart failure and report
this adverse reaction to the provider.
A nurse is preparing to administer a unit of packed RBCS to a client. Which of the following
actions should the nurse take?
Answer: A. Remain with the client for the first 15 min of the infusion.
The nurse should remain with the client for the first 15 to 30 min of the infusion because
hemolytic reactions usually occur during the infusion of the first 50 mL of blood.
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: C. "You should cut the opening of the skin barrier one-eighth inch wider than the
stoma." The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the
stoma to minimize irritation of the skin from exposure to urine.
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: C. Use a 30-mL syringe
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.
A nurse is teaching a young adult client how to perform testicular self-examination. Which of
the following instructions should the nurse include?
Answer: B. Roll each testicle between the thumb and fingers.
The nurse should instruct the client to roll each testicle horizontally between the thumbs and
fingers to feel for any lumps deep in the center of the testicle.
A nurse is providing discharge instructions to a client following an upper gastrointestinal
series with barium contrast. Which of the following information should the nurse provide?
Answer: A. Increase fluid intake
Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct
the client to increase fluid intake to facilitate the elimination of the barium used during the
test.
A nurse is caring for a client who is having a seizure. Which of the following interventions is
the nurse's priority?
Answer: C. Turn the client to the side
The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority
intervention the nurse should take is to place the client in a side-lying position to prevent
aspiration.
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter
placed. Which of the following findings indicates that the client is experiencing
increased intracranial pressure (ICP)? (Select all that apply.)
Flat jugular veins
A Glasgow Coma Scale score of 15 Sleepiness exhibited by the client Widening pulse
pressure Decerebrate posturing
Answer: Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically
distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye opening,
motor, and verbal response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client
from sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
A nurse is caring for a client in the emergency department (ED).
Exhibit 1:
Nurses' Notes
1000:
Client presents to the ED with visual disturbances, expressive aphasia, and numbness and
tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in
their vision, especially on the right side.
Client's partner states the client had some difficulty with finding words when speaking. Client
is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is
weaker than left. Client denies pain.
Exhibit 2:
Graphic Record
1000:
Temperature 36.8° C
(98.4° F) Heart rate 98/min
Respiratory rate 18/min
Blood pressure 134/75 mm Hg
Oxygen saturation 98% on room air
Exhibit 3:
History and Physical
History of mild anxiety and depression
History of high cholesterol, which is diet controlled
Family history of coronary artery disease, hyperlipidemia, epilepsy, and migraines
Select the 4 findings that require follow-up by the nurse. Expressive aphasia
Hand grasps
Blood Pressure
Tingling of the
lips Orientation
Visual disturbances
Pain
Answer: Visual disturbances is correct. Visual disturbances are manifestations of a
neurological event. Therefore, the nurse should follow-up on this finding.
Blood pressure is incorrect. The client's blood pressure is within the expected reference
range. Therefore, this finding does not require follow-up by the nurse.
Tingling of the lips is correct. Tingling in the face is a manifestation of a neurological event.
Therefore, the nurse should follow-up on this finding.
Orientation is incorrect. The client is alert and orientated x3, which is an expected finding.
Therefore, this finding does not require follow-up by the nurse.
Hand grasps is correct. The client's hand grasps are unequal, which could indicate a
neurological deficit. Therefore, this finding requires follow-up by the nurse.
Expressive aphasia is correct. Expressive aphasia is a manifestation of a neurological event.
Therefore, the nurse should follow-up on this finding.
Pain is incorrect. The client denies pain. Therefore, this finding does not require follow- up
by the nurse.
A nurse is caring for a client in the emergency department (ED).
Exhibit 1:
Nurses' Notes
1000:
Client presents to the ED with visual disturbances, expressive aphasia, and numbness and
tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in
their vision, especially on the right side.
Client's partner states the client had some difficulty with finding words when speaking. Client
is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is
weaker than left. Client denies pain.
Exhibit 2:
Graphic Record
1000:
Temperature 36.8° C
(98.4° F) Heart rate 98/min
Respiratory rate 18/min
Blood pressure 134/75 mm Hg
Oxygen saturation 98% on room air
Exhibit 3:
History and Physical
History of mild anxiety and depression
History of high cholesterol, which is diet controlled
Family history of coronary artery disease, hyperlipidemia, epilepsy, and migraines
For each finding below, click to specify if the finding is consistent with migraine, stroke,
or meningitis. Each finding can support more than one disease process.
Answer: Hand grasps is consistent with migraine, stroke, and meningitis. Unilateral
weakness can occur due to neurological vascular changes and inflammation that can be
present with migraine, stroke, and meningitis.
Numbness is consistent with migraine and stroke. Numbness and tingling of the lips and
tongue can occur with migraines due to neurological vascular changes and inflammation that
can be present. Numbness can also occur with middle cerebral artery strokes.
Aphasia is consistent with migraine and stroke. Aphasia can occur due to neurological
vascular changes and inflammation that can be present with a migraine and stroke.
Visual changes are consistent with migraine, stroke, and meningitis. Visual changes can
occur with migraine, stroke, and meningitis due to neurological vascular changes and
inflammation that can be present.
Family history is consistent with migraine and stroke. Family history is a risk factor
associated with migraine and stroke.
A nurse is caring for a client in the emergency department (ED).
Exhibit 1:
Nurses' Notes
1000:
Client presents to the ED with visual disturbances, expressive aphasia, and numbness and
tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in
their vision, especially on the right side.
Client's partner states the client had some difficulty with finding words when speaking. Client
is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is
weaker than left. Client denies pain.
1045:
Client states the flashing lights, numbness, and tingling in the lips have gone away. Client
states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is
requesting medication for pain that is 7 on a scale of 0 to 10.
Hand grasps are equal and strong bilaterally.
Exhibit 2:
Graphic Record
1000:
Temperature 36.8° C
(98.4° F) Heart rate 98/min
Respiratory rate 18/min
Blood pressure 134/75 mm Hg
Oxygen saturation 98% on room air
1045:
Temperature 36.8° C
(98.4° F) Heart rate 112/ min
Respiratory rate 22/min
Blood pressure 145/80 mm Hg
Oxygen saturation 98% on room air
Exhibit 3:
History and Physical
History of mild anxiety and depression
History of high cholesterol, which is diet controlled
Family history of coronary artery disease, hyperlipidemia, epilepsy, and migraines
Complete the following sentence by using the list of options.
The nurse should identify that the client is most likely
experiencing Select... and the nurse should address the client's
Select... .
Dropdown 1
Answer: A migraine is correct. The client is exhibiting manifestations of a migraine. The
client presented initially with neurological manifestations of flashing lights, aphasia,
unilateral weakness, and numbness of the lips. These findings are consistent with the first
phase, or aura phase, of a migraine. These changes resolved after an hour and were followed
by throbbing pain with nausea and vomiting.
A stroke is incorrect. A client who is experiencing a stroke will have neurological
manifestations; however, these changes would not resolve after 1 hr.
Meningitis is incorrect. A client who is experiencing meningitis will have neurological
manifestations; however, these changes would not resolve after 1 hr.
Dropdown 2
Blood pressure is incorrect. Although the client's blood pressure is mildly elevated, it does
not require intervention by the nurse.
Pain is correct. The client reports pain as 7 on a scale of 0 to 10, which indicates significant
discomfort. The nurse should address the client's pain level to promote comfort.
Neurological status is incorrect. The client's neurological changes have resolved. Therefore,
this finding does not require intervention by the nurse.
A nurse is caring for a client in the emergency department (ED).
Exhibit 1:
Nurses' Notes
1000:
Client presents to the ED with visual disturbances, expressive aphasia, and numbness and
tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in
their vision, especially on the right side.
Client's partner states the client had some difficulty with finding words when speaking. Client
is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is
weaker than left. Client denies pain.
1045:
Client states the flashing lights, numbness, and tingling in the lips have gone away. Client
states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is
requesting medication for pain that is 7 on a scale of 0 to 10.
Hand grasps are equal and strong bilaterally.
Exhibit 2:
Graphic Record
1000:
Temperature 36.8° C
(98.4° F) Heart rate 98/min
Respiratory rate 18/min
Blood pressure 134/75 mm Hg
Oxygen saturation 98% on room air
1045:
Temperature 36.8° C
(98.4° F)
Heart rate 112/ min
Respiratory rate 22/min
Blood pressure 145/80 mm Hg
Oxygen saturation 98% on room air
Exhibit 3:
History and Physical
History of mild anxiety and depression
History of high cholesterol, which is diet controlled
Family history of coronary artery disease, hyperlipidemia, epilepsy, and migraines A nurse is
caring for a client who has a migraine. Which of the following interventions should the
nurse anticipate?
Select all that apply.
Administer phenobarbital
Dim the lights in the client’s room Prepare to initiate fibrinolytic therapy Prepare the client
for a lumbar puncture Administer
sumatriptan
Place the client in seizure precautions
Answer: Administer sumatriptan is correct. The nurse should plan to administer a
medication, such as sumatriptan, to produce cerebral artery vasoconstriction and relieve the
client's manifestations.
Prepare the client for a lumbar puncture is incorrect. A lumbar puncture is indicated for
clients who are having manifestations of meningitis.
Administer phenobarbital is incorrect. Phenobarbital is indicated for clients who are
experiencing seizures.
Dim the lights in the client's room is correct. The nurse should plan to dim the lights in the
client's room to promote comfort because the client is experiencing photophobia.
Prepare to initiate fibrinolytic therapy is incorrect. The nurse should prepare to initiate
fibrinolytic therapy for clients who are experiencing a stroke. Fibrinolytic therapy is
administered during the acute phase of a stroke to decrease clot formation.
Place the client in seizure precautions is incorrect. The nurse should initiate seizure
precautions for clients who are at risk for a seizure.
A nurse is caring for a client in the emergency department (ED).
Exhibit 1:
Nurses' Notes
1000:
Client presents to the ED with visual disturbances, expressive aphasia, and numbness and
tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in
their vision, especially on the right side.
Client's partner states the client had some difficulty with finding words when speaking. Client
is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is
weaker than left. Client denies pain.
1045:
Client states the flashing lights, numbness, and tingling in the lips have gone away. Client
states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is
requesting medication for pain that is 7 on a scale of 0 to 10.
Hand grasps are equal and strong bilaterally.
Exhibit 2:
Graphic Record
1000:
Temperature 36.8° C
(98.4° F) Heart rate 98/min
Respiratory rate 18/min
Blood pressure 134/75 mm Hg
Oxygen saturation 98% on room air
1045:
Temperature 36.8° C (98.4° F)
Heart rate 112/ min
Respiratory rate 22/min
Blood pressure 145/80 mm Hg
Oxygen saturation 98% on room air
Exhibit 3:
History and Physical
History of mild anxiety and depression
History of high cholesterol, which is diet controlled
Family history of coronary artery disease, hyperlipidemia, epilepsy, and migraines
Drag one condition and one client finding to fill in each blank in the following sentence.
Following the administration of sumatriptan, the nurse should monitor for Select... due to the
risk of Select...
Dropdown 1
Answer: Dehydration is incorrect. Sumatriptan does not cause fluid loss, which could lead
to dehydration.
Chest pain is correct. The nurse should monitor the client for chest pain because sumatriptan
can cause coronary vasospasms.
Reflux is incorrect. Reflux is not an adverse effect of sumatriptan.
Dropdown 2
Peptic ulcer disease is incorrect. Peptic ulcer disease is not an adverse effect of sumatriptan.
Diuresis is incorrect. Fluid loss is not an adverse effect of sumatriptan.
Myocardial ischemia is correct. Sumatriptan can cause coronary vasospasms, which can
lead to myocardial ischemia.
The nurse is evaluating the client's understanding of discharge instructions. Which of
the following client statements indicates an understanding of the teaching?
Click to highlight the findings that indicate client understanding. To deselect a finding,
click on the finding again.
"Foods that contain tyramine might trigger my headaches." "I will keep a food and headache
diary." "I will place a cool cloth on my forehead when I experience a migraine." "I will take
the sumatriptan once every day." "I should stay awake until my headache is gone."
Answer: "Foods that contain tyramine might trigger my headaches" is correct.
Tyramine containing foods, such as aged cheeses, smoked sausage, pickles, and beer are
common triggers for migraines.
"I will keep a food and headache diary" is correct. The nurse should instruct the client to
keep a food and headache diary to identify migraine triggers.
"I will place a cool cloth on my forehead when I experience a migraine" is correct. The
nurse should instruct the client to lie down, dim the lights, and place a cool cloth on the
forehead to relieve migraine pain.
"I will take the sumatriptan once every day" is incorrect. Sumatriptan is not administered
to prevent a migraine, rather, it is used to treat an occurring migraine. The nurse should
instruct the client to take the sumatriptan only as needed for migraine pain.
"I should stay awake until my headache is gone" is incorrect. The nurse should instruct
the client to lie down, dim the lights, and place a cool cloth on the forehead to relieve
migraine pain. The client should be encouraged to sleep until the migraine is resolved.
A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin
subcutaneous. Which of the following actions should the nurse take?
Answer: Inject the medication into the anterolateral abdominal wall
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall
to enhance medication absorption and prevent hematoma formation.
A nurse is performing a dressing change for a client who is recovering from a hemicolectomy.
When removing the dressing. the nurse notes that a large part of the bowel is protruding
through the abdomen. Which of the following actions should the nurse take first?
Answer: Call for help
Evidence-based practice indicates that the nurse should first stay with the client and call for
assistance. The client will require emergency surgery and is at risk for shock; therefore, the
nurse should obtain immediate assistance.
A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis.
The nurse should give the AP which of the following instructions?
Answer: Wear a mask
Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear
a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun
receiving antibiotic therapy.
A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed
with food after a meal. Which of the following actions should the nurse take first?
Answer: Obtain vital signs
The first action the nurse should take using the nursing process is to assess the client's vital
signs. A client who has portal hypertension can develop esophageal varices, which are fragile
and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs
provides information about the client's condition that can contribute to decision making.
A nurse is caring for a client in the emergency department (ED).
Exhibit 1:
Physical Examination
Client presents to the ED with upper abdominal pain that radiates to the right shoulder. Client
rates pain as 7 on a scale of 0 to 10. Client also reports nausea, vomiting, and dyspepsia.
Client is awake, alert, and oriented x3. Lung sounds clear bilaterally, S1 and S2 heart tones
noted. All pulses palpable. Bowel sounds active in all 4 quadrants.
Exhibit 2:
Diagnostic Results
Aspartate aminotransferase (AST) 45 units/L (0 to 35 units/L)
Alanine aminotransferase (ALT) 39 international units/L (4 to 36 international units/L)
Total lactic dehydrogenase (LDH) 200 units/L (100 to 190 units/L)
WBC count 12,000/mm3 (5,000 to 10,000/ mm3)
Exhibit 3:
Vital Signs
Blood pressure 132/86 mm
Hg Heart rate 101/min
Respiratory rate 18/min
Temperature 37.2° C
(99.0° F) O2 saturation
97% on room air
Complete the diagram by dragging from the choices below to specify what condition the
client is most likely experiencing, 2 actions the nurse should take to address that
condition, and 2 parameters the nurse should monitor to assess the client's progress.
Monitor the client for a rigid, board-like abdomen.
Monitor for pain at McBurney's point.
Monitor the color of the client's stools. Monitor the client for rectal bleeding.
Monitor the client for dark urine.
Actions to Take
Potential Condition
Ulcerative
colitis
Appendicitis
Parameters to Monitor
The nurse should plan to administer an opioid analgesic, such as morphine, for acute pain.
Since the client is experiencing nausea and vomiting, the nurse should also ensure they are
NPO. The client is likely experiencing cholecystitis, which typically presents with nausea,
vomiting, upper abdominal pain that radiates to the right shoulder, fever, and dyspepsia. The
client also has elevated liver enzymes and a WBC count, which is consistent with
cholecystitis. Surgical management for cholecystitis might be indicated. The nurse should
monitor the client's stool and urine color because a biliary obstruction from gallstones may
cause claycolored stools and dark urine.
A nurse has received change-of-shift report for a group of clients. Which of the following
clients should the nurse assess first?
Answer: A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN
sublingual nitroglycerin tablet.
When using the stable vs. unstable approach to client care, the nurse should assess this client
first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual
nitroglycerin tablet could be unstable. This client might be experiencing angina or could be
having another MI.
A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for
omeprazole. The nurse should instruct the client that the medication provides relief by which
of the following actions?
Answer: Suppressing gastric acid production
Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by
suppressing gastric acid production.
A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus.
For which of the following adverse effects should the nurse monitor?
Answer: Respiratory paralysis
The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as
the adverse effects can impact the CNS, the cardiovascular system, and the respiratory
system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.
A nurse is caring for a client who is receiving morphine for daily dressing changes. The client
tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which
of the following actions should the nurse take?
Answer: Instruct the client on alternative therapies for pain reduction
The nurse should respect the client's concerns and offer nonpharmacologic alternatives to
pain management, such as relaxing activities and distraction.
A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the
following laboratory values should the nurse expect?
Answer: Elevated bilirubin level
Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the
hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the
client's degree of jaundice.
A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a
gastrectomy.
Exhibit 1:
Medical History
Since discharge, client reports several episodes of dizziness, "fast" heartbeat, and abdominal
cramping.
Client states, "I am afraid to eat."
Exhibit 2:
Medication Administration Record
Cyanocobalamin 100 mcg subcutaneous once a month Ferrous sulfate 65 mg PO every 8 hr
Exhibit 3:
Vital Signs 1200:
Temperature 36.4° C
(97.6° F) Heart rate 88/min
Respiratory rate 16/min
Blood pressure 146/76 mm Hg Oxygen saturation 96% on room air
A nurse is providing teaching for the client. Which of the following instructions should
the nurse include?
Select all that apply.
Avoid highly seasoned foods
Consume high-protein snacks Eat several small meals per day Avoid drinking fluids with
meals
Eat five servings of fresh fruit per day
Maintain a high carbohydrate intake.
Answer: Maintain a high carbohydrate intake is incorrect. Dumping syndrome requires a
low carbohydrate diet because of reactive hypoglycemia.
Eat five servings of fresh fruit per day is incorrect. The client should limit intake to three
servings of unsweetened cooked or canned fruit per day.
Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink
fluids 30 min before or after meals.
Eat several small meals per day is correct. The nurse should instruct the client to eat
several small, frequent meals instead of three large meals per day.
Consume high-protein snacks is correct. The client should eat snacks that are high in
protein and low in carbohydrates to prevent the gastric food boluses and reactive
hypoglycemia in dumping syndrome.
Avoid highly seasoned foods is correct. The nurse should instruct the client to avoid
excessive amounts of spices and salt.
A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following
assessment findings should the nurse expect?
Answer: Hypoactive bowel sounds
Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to
decreased peristalsis.
A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the
following is the priority assessment finding that the nurse should report to the provider?
Answer: Blood pressure 170/80 mm Hg
Using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at
risk for thyroid storm.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who
sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the
nurse expect?
Answer: Administer an opioid analgesic to the client.
The nurse should expect a prescription for an opioid analgesic to promote comfort following
a rattlesnake bite.
An older adult client is brought to an emergency department by a family member. Which of
the following assessment findings should cause the nurse to suspect that the client has
hypertonic dehydration?
Answer: Urine specific gravity 1.045
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.
A nurse is providing discharge instructions to a client who has a partial-thickness burn on the
hand. Which of the following instructions should the nurse include?
Answer: Wrap fingers with individual dressings
The nurse should instruct the client to wrap the fingers individually to allow for functional
use of the hand while healing occurs. The nurse should also instruct the client to perform
range-of-motion exercises to each finger every hour while awake to promote function of the
injured hand.
A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal
implant to treat endometrial cancer. Which of the following actions should the nurse include
in the client's plan of care?
Answer: Wear a lead apron while providing care to the client.
The nurse should wear a lead apron when providing direct care to provide protection from the
radiation source and not turn their back toward the client, because the apron only shields the
front of the body. The nurse should also wear a dosimeter film badge to measure radiation
exposure.
