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ATI Med Surg Exams Combined
Nursing (Jomo Kenyatta University of Agriculture and Technology)
A nurse is caring for a client who is having a seizure. Which of the following interventions in the
nurse’s priority?
Answer: Turn the client to the side
A nurse is caring for a group of clients. The nurse should plan to make a referral to physical
therapy for which of the following clients?
Answer: A client who is receiving preoperative teaching for a right knew arthroplasty
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The
nurse should postpone the testing and report to the provider which of the following findings?
Answer: Current medications
A home health nurse is assigned to a client who was recently discharged from a rehabilitation
center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits
should the nurse expect to find when assessing the client? (SATA)
Answer: Visual spatial deficits
Left hemianopsia
One-sided neglect
A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which
of the following actions should the nurse take?
Answer: Place a pillow between the client’s legs
A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which
of the following items at the client’s bedside table?
Answer: Suction machine

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous
diversion procedure to establish a ureterostomy. Which of the following statements should the
nurse include in the teaching?
Answer: You should cut the opening of the skin barrier one-eighth inch wider than the
stoma
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: Heart rate 110
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
A nurse is planning to provide discharge teaching for the family of an older adult client who has
hemianopsia and is at risk for falls. Which of the following instructions should the nurse include?
Answer: Remind the client to scan their complete range of vision during ambulation
A nurse is planning care to decrease psychosocial health issues for a client who is starting
dialysis treatments for chronic kidney disease. Which of the following interventions should the
nurse include in the plan?
Answer: Tell the client that it is possible to return to similar previous levels of activity
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter
placed. Which of the following findings indicate that the client is experiencing increased
intracranial pressure? (SATA)
Answer: Sleepiness exhibited by the client
Widening pulse pressure
Decerebrate posturing

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 nurse is caring for client who has a prescription for enalapril. The nurse should identify which
of the following findings as an adverse effect of the medication?
Answer: Orthostatic hypotension
A nurse in a provider’s office is caring for a client who requests sildenafil to treat erectile
dysfunction. Which of the following statements should the nurse make?
Answer: You will not be able to use sildenafil if you are taking nitro
A nurse is planning care for a client who has extensive burn injuries and is
immunocompromised. Which of the following precautions should the nurse include in the plan
of care to prevent a pseudomonas aeruginosa infection?
Answer: Avoid placing plants or flowers in the clients room
A nurse is teaching a class about client rights. Which of the following instructions should the
nurse include?
Answer: A client should sign an informed consent before receiving a placebo during a
research trial
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

A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the client to withhold
for 48hr prior to cardioversion?
Answer: Dig
A nurse is caring for a client 1 hr following a cardiac cath. The nurse notes the formation of a
hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the
following interventions is the nurse’s priority?
Answer: Apply firm pressure to the insertion site
A nurse is assessing a client who has Graves’ disease. Which of the following images should
indicate to the nurse that the client has?

Answer: exophthalmos
A nurse is caring for a client who has a stage III pressure injury. Which of the following
findings contributes to delayed wound healing?
Answer: Urine output 25ml/hr
A nurse is providing teaching to a client who is receiving chemo and has a new prescription for
epoetin alfa. Which of the following statements indicated an understanding of the teaching?
Answer: I will monitor my blood pressure while taking this medication
A nurse is providing discharge instructions to a client following an upper gastrointestinal series
with barium contrast. Which of the following information should the nurse provide?
Answer: Increase fluid intake
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the
nurses priority?

Answer: Tachycardia
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this
risk, which of the following dietary alterations should the nurse recommend?
Answer: Add cabbage to the diet
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The
client appears anxious and restless, and the high-pressure alarm is sounding. Which of the
following actions should the nurse take first?
Answer: Instruct the client to allow the machine to breathe for them
A nurse is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
Answer: Demonstrate ways to deep breathe and cough
A nurse and an assistive personnel are caring for a client who has bacterial meningitis. The nurse
should give the AP which of the following instructions?
Answer: Wear a mask
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following
actions should the nurse take?
Answer: Remain with the client for the first 15 min of the infusion
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription
for erythropoietin. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: I am taking this medication to increase my energy level
A nurse is caring for a client who has hepatic encephalopathy that is being treating with
lactulose. The client is experiencing excessive stools. Which of the following findings is an
adverse effect of this medication?

Answer: Hypokalemia
A nurse is providing teaching to an older adult female client who has stress incontinence and a
BMI of 32. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: I am dieting to lose weight
A nurse is caring for a client who has type 1 diabetes mellitus and has acute bronchitis for the
past 3 days. Which of the following statements should the nurse include when instructing the
client?
Answer: Take your insulin even if you are unable to eat your regular diet
A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subQ.
Which of the following action should the nurse take?
Answer: Inject the medication into the anterolateral abdominal wall.
A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease.
The client reports muscle cramps and a tingling sensation in their hands. Which of the following
medications should the nurse plan to administer?
Answer: Calcium Carbonate
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
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following lab findings
should the nurse expect?
Answer: BUN 32
A nurse is providing teaching to a client who has irritable bowel syndrome. Which of the
following instructions should the nurse include in the teaching?

Answer: Increase fiber intake to at least 30g per day
A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory results to be below the expected reference range?
Answer: Calcium
A nurse is assessing a client who had extracorporeal shock wave lithotripsy 6 hr ago. Which of
the following findings should the nurse expect?
Answer: Stone fragments in the urine
A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy.
Which of the following interventions should the nurse include in the plan?
Answer: Monitor the client’s temperature every 4 hr
A nurse is assessing a group of clients for indications of role changes. The nurse should identify
that which of the following clients is at risk for experiencing a role change?
Answer: A client who has MS and is experiencing progressive difficulty ambulating
A nurse in a provider’s office is assessing a client who has migraine headaches and is taking
feverfew to prevent headaches. The nurse should identify that which of the following client
medications interacts with feverfew?
Answer: Naproxen
A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV
contrast agent. The nurse should identify that which of the following findings requires further
assessment?
Answer: History of asthma
A nurse has received change-of-shift report for a group of clients. Which of the following clients
should the nurse assess first?

Answer: A client who had a myocardial infarction 4 days ago and is asking for a PRN
sublingual nitro tabs.
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive
cough. Which of the following actions should the nurse take first?
Answer: Initiate airborne precautions
A nurse is an emergency department is caring for a client who has full-thickness burns over 20%
of their total body surface area. After ensuring a patent airway and administering oxygen, which
of the following items should the nurse prepare to administer first?
Answer: IV fluids
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a
pressure injury. Which of the following actions should the nurse take?
Answer: Use a 30mL syringe
A nurse is providing teaching for a female client who has recurrent UTI. Which of the following
info should the nurse include in the teaching?
Answer: Void before and after intercourse
A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing
the client, the nurse observes the following findings: HR 200 B/P 78.40 RR 30. Which of the
following actions should the nurse take?
Answer: Perform synchronized cardioversion
A nurse is providing teaching to an older adult client who has cancer and a new prescription for
an opioid analgesic for pain management. Which of the following information should the nurse
include in the teaching?
Answer: You should void every 4 hours to decrease the risk of urinary retention

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the
following precautions should the nurse implement?
Answer: Ensure that the client has a patent IV
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
A nurse is caring for client who has bilateral pneumonia and an SaO2 of 85%. The client has
dyspnea with a productive cough and is using accessory muscles to breathe. Which of the
following actions should the nurse take first?
Answer: Place the client in high-Fowlers position
A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the
nurse palpate to verify that the client has an inguinal hernia?
a) Above the pubic symphysis
b) Mid-abdomen
c) Inguinal area
d) Upper thigh
Answer: c) Inguinal area
A nurse in an emergency department is caring for a client who is experiencing a thyroid storm.
Which of the following manifestations should the nurse expect? (SATA)
Answer: Fever
Hypertension
Tachycardia
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
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
A nurse is caring for a client who has HIV. Which of the following findings indicates a positive
response to the prescribed HIV treatment?
Answer: Decreased viral load
A nurse is assessing a client who has had a suspected stroke. The nurse should place priority on
which of the following findings?
Answer: Dysphagia
A nurse in a provider’s office is assessing a client who has hypertension and takes propanalol.
Which of the following findings should indicate to the nurse that the client is experiencing an
adverse reaction to this medication?
Answer: Report of a night cough
A nurse in an emergency department is assessing a client who has a detached retina. Which of
the following should the nurse expect the client to report?
Answer: Its like a curtain closed over my eye
A nurse is providing teaching to a female client who has a history of UTI. Which of the
following information should the nurse include in the teaching?
Answer: Daily cranberry supplements
A nurse in an emergency department is reviewing the provider’s prescriptions for a client who
sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the
nurse suspect?
Answer: Administer an opioid analgesic to the client

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the
following findings should the nurse identify as a manifestation of chronic glomerulonephritis?
Answer: Hyperkalemia
A nurse in a community clinic is caring for a client who reports an increase in the frequency of
migraine headaches. To help reduce the risk for migraine headaches, which of the following
foods should the nurse recommend the client avoid?
Answer: Aged cheese
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of
the following actions should the nurse take?
Answer: Check that one finger fits between the cast and the leg
A nurse is caring for a client who has viral pneumonia. The client’s pulse ox readings have
fluctuated between 79% and 88% for the last 3o min. Which of the following oxygen delivery
systems should the nurse initiate to provide the highest concentration of oxygen?
Answer: Nonrebreather mask
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
A nurse is teaching a young adult client how to perform testicular self-exams. Which of the
following instructions should the nurse include?
Answer: Roll each testicle between the thumb and fingers
A nurse is caring for a client who has a potassium level 3. Which of the following assessment
findings should the nurse expect?
Answer: Hypoactive bowel sounds

A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following lab
values should the nurse expect?
Answer: Elevated bilirubin level
A nurse is providing discharge teaching to a client who has heart failure and a new prescription
for a potassium-sparing diuretic. Which of the following information should the nurse include in
the teaching?
Answer: Try to walk at least 3x per week for exercise
A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitius. Which of the
following client statements indicates the client is successfully coping with the change?
Answer: I used to never worry about my feet. Now I inspect my feet everyday with a
mirror
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine.
The nurse should instruct the client that which of the following supplements can interfere with
the effectiveness of the medication?
Answer: Calcium
A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation
therapy. Which of the following statements should the nurse identify as an indication that the
client understands the teaching?
Answer: I will use my hands rather than a washcloth to clean the radiation area
A nurse is performing a cardiac assessment for a client who had a MI 2 days ago. Which of the
following actions should the nurse take first after hearing the following sound?
Answer: Listen with the client on their left side
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following
statements should the nurse identify as an indication that the client understands the teaching?
Answer: I will wear clean graduated compression stockings everyday

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following
actions should the nurse take?
Answer: Loosen restrictive clothing
A nurse is caring for a client who presents to a clinic for a 1 week follow up visit after
hospitalization for a heart failure. Based on the information in the client’s chart, which of the
following findings should the nurse report to the provider?
Answer: Heart rate 55
A nurse is providing instructions to a client who has type 2 DM and a new prescription for
metformin. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: I should take this medication with a meal
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following
findings should the nurse identify as a component of Cushing’s triad?
Answer: Bradycardia
A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy
with removal of the parathyroid glands. The nurse should instruct the client to include which of
the following foods that has the greatest amount of calcium in her diet?
Answer: 12 Almonds
A nurse is caring for a client who has portal hypertension. The client is vomiting blood missed
with food after a meal. Which of the following actions should the nurse take first?
Answer: Obtain vital signs
A nurse is caring for a client who is postoperative following a total hip arthoplasty. Which of the
following lab values should the nurse report to the provider?
Answer: Hgb 8 g/dL

A nurse is caring for a client who has amyotrophic lateral sclerosis and is being admitted to the
hospital with pneumonia. Which of the following assessment findings is the nurse’s priority?
Answer: Increased respiratory secretions
A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use
of crutches while climbing stairs. Identify the sequence the client should follow when
demonstrating crutch use.
Answer: Places body weight on crutches, Advances the unaffected leg onto the stair, Shifts
weight from the crutches to the unaffected leg, Brings the crutches and the affected leg up
to the stair
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE).
Which of the following findings should the nurse expect.
Answer: Facial butterfly rash
A nurse is caring for a client who is receiving plasmapheresis through a venous access site.
Which of the following action should the nurse take?
Answer: Check electrolyte levels before and after therapy.
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: The last one (That has the eyes bugging out).
A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days
ago. Which of the following actions should the nurse take first after hearing the following sound?
Answer: Listen with the client on his left side.
A nurse is providing teaching to an older adult female client who has stress incontinence and a
BMI of 32. Which of the following statement by the client indicates an understanding of the
teaching.

Answer: "I am dieting to lose weight."
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the
following results should the nurse expect?
Answer: PsCO2 56
A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following adverse effects should the nurse
instruct the client to notify the provider?
Answer: Calf pain
Numbness in the arms
Intense headache
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription
for erythropoietin. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: "I am taking this medication to increase my energy level."
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following
statements should the nurse identify as an indication that the client understands the teaching?"
Answer: "I will wear clean graduated compression stockings every day."
A nurse is preparing the present a program about prevention of atherosclerosis at a health fair.
Which of the following recommendations should the nurse plan to include?
Answer: Follow a smoking cessation program.
Maintain an appropriate weight.
Eat a low-fat diet.
A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which
of the following actions should the nurse take?
Answer: Place a pillow between the client's legs.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the
following actions should the nurse take first?
Answer: Check for the type and number of units of blood to administer.
A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron
supplement. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: "I will eat more high-fiber foods."
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of
the following laboratory values should the nurse report to the provider?
Answer: Hgb 8 g/dL
A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use
of crutches while climbing stairs. Identify the sequence the client should follow when
demonstration crutch use.
Answer: Places body weight on the crutches.
Advances the unaffected leg onto the stair.
Shifts weight form the crutches to the unaffected leg.
Brings the crutches and the affected leg up to the stair.
A nurse is caring for client who is on bed rest and has a new prescription for enoxaparin
subcutaneous. Which of the following action should the nurse take?
Answer: Administer the medication at the same time each day.
A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the
following findings indicates a potential complication?
Answer: WBC 2,000/mm3

A nurse in an emergency department is admitting a client who reports dyspnea and shortness of
breath. Which of the following actions is the priority for the nurse to perform prior to
administering oxygen?
Answer: Determine if the client has a history of COPD.
A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile
dysfunction. Which of the following statements should the nurse make?
Answer: "You will not be able to use sildenafil if you are taking nitroglycerin."
A nurse in a provider's office is providing teaching to a client who has a urinary tract infection
and a new prescription for ciprofloxacin. Which of the following instructions should the nurse
include?
Answer: "Avoid taking magnesium-containing antacids with this medication."
A nurse is caring for a client who is receiving TPN. A new bag is not available when the current
infusion is nearly completes. Which of the following action should the nurse take?
Answer: Administer dextrose 10% in water until the new bag arrives.
A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago.
The nurse should recognize that an unexpected finding for which of the following laboratory
values is a manifestation of osteomyelitis and should be reported to the provider?
Answer: Sedimentation rate
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations
should the nurse expect?
Answer: Constipation
A nurse is providing discharge to a client who is to self-administer heparin subcutaneously.
Which of the following responses by the client indicates an understanding of the teaching?
Answer: "I will use an electric razor to shave."

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic
reaction. After ensuring a patent airway, which of the following nursing interventions is the
priority?
Answer: Applying oxygen via face mask
A nurse is assessing a male client for an inguinal hernia. Which of following areas should the
nurse palpate to verify that the client has an inguinal hernia?
Answer: Above the pubic bone and near the inguinal ligament
A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse
notes a spike (pacemaker artifact) followed by a QRS complex. Which of the following actions
should the nurse take?
Answer: Document that depolarization has occurred.
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The
client is unable to void on the bedpan. Which of the following actions should the nurse take first?
Answer: Scan the bladder with a portable ultrasound.
A nurse an acute care facility is caring for a client who is at risk for seizures. Which of the
following precautions should the nurse implement?
Answer: Ensure that the client has a patent IV.
A nurse is caring for 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
A nurse is reviewing the medication history of client who is to undergo allergy testing. The nurse
should instruct the client to discontinue which of the following medications before the testing?
Answer: Prednisone

A nurse is caring for a client who has an arterial line. Which of the following actions should the
nurse take?
Answer: Place a pressure bag around the flush solution.
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
A nurse is caring for a client who has a new prescription for 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?
Answer: 167 mL/hr
A nurse is caring for a client following extubation of her endotracheal tube 10 min ago. Which of
the following findings should the nurse report to the provider immediately?
Answer: Stridor
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the
following findings should the nurse report to the provider?
Answer: The client reports back pain.
A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the
following findings should indicate to the nurse the client is experiencing hypoxia?
Answer: The client's heart rate increases.
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous
diversion procedure to establish an ureterostomy. Which of the following statements should the
nurse include in the teaching?
Answer: "Cut the opening of the skin barrier 1/8-inch wider than the stoma."

A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a Holter
monitor. Which of the following information should the nurse include in the teaching?
Answer: "This device can detect when you have an irregular heart rate."
A nurse is providing discharge teaching to a client who has heart failure and a new prescription
for a potassium-sparing diuretic. Which of the following information should the nurse include in
the teaching?
Answer: Try to walk at least three times per week for exercise.
A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the
following findings should the nurse identify as a manifestation of chronic glomerulonephritis?
Answer: Hyperkalemia
A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client is
dyspneic with a productive cough and is using accessory muscles to breathe. Which of the
following actions should the nurse take first?
Answer: Place the client in high-fowlers position.
A nurse is providing teaching to a client who has AIDS. Which of the following statements by
the client indicates an understanding to the teaching?
Answer: "I will take my temperature once a day."
A nurse is assessing a client who has peripheral arterial disease. Which of the following findings
should the nurse expect?
Answer: Hair loss on the lower legs
A nurse is providing teaching to an older adult client who as cancer and a new prescription for an
opioid analgesic for pain management. Which of the following information should the nurse
include in the teaching?
Answer: "You should increase your fiber intake to prevent constipation."

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following
interventions should the nurse include in the plan?
Answer: Encourage the client to take deep breaths after the procedure.
A nurse is caring for a client who has a prescription for enalapril. The nurse should identify
which of the following findings as an adverse effect of the medication?
Answer: Orthostatic hypotension
A charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA.
Which of the following statements by the new nurse indicates an understanding of the teaching?
Answer: "I will leave assessment equipment in the room to use on this client."
A nurse is caring for a client who recently had a stroke of the right hemisphere. Which of the
following manifestations should the nurse expect?
Answer: Impulsive behavior
A nurse is caring for a client who is exhibiting manifestations of a febrile reaction while
receiving a blood transfusion. Which of the following medications should the nurse administer?
Answer: Acetaminophen
A nurse is assessing a client who has hypokalemia. Which of the following manifestations should
the nurse expect?
Answer: Decreased peristalsis
A nurse is caring for client who is experiencing supraventricular tachycardia. Upon assessing the
client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm
Hg, and respiratory rate 30/min. Which of the following actions should then nurse take?
Answer: Perform synchronized cardioversion.

A nurse providing dietary teaching to a client who is postoperative following a thryoidectomy
with removal of the parathyroid glands. The nurse should instruct the client to include which of
the following foods that has the greatest amount of calcium in her diet?
Answer: 12 almonds
A nurse is caring for a client who has DKA. Which of the following findings should indicate to
the nurse that the client's condition is improving?
Answer: Glucose 272 mg/dL
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.
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?
Answer: Heart rate 55/min
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of
the following findings should the nurse identify as a manifestation of this condition?
Answer: Pain that increases with passive movement
A nurse is planning care for a client who is postoperative following a laparotomy and has a
closed-suction drain. Which of the following actions should the nurse take to manage the drain?
Answer: Compress the drain reservoir after emptying.
A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The
client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate
16/min, and temperature 36C. Which of the following vital sign changes should alert the nurse
that the client might be hemorrhaging?

Answer: Heart rate 110/min
A nurse is assessing a client following the completion of hemodialysis. Which of the following
findings is the nurse's priority to report to the provider?
Answer: Restlessness
A nurse is caring for a client who is having a seizure. Which of the following interventions is the
nurse's priority?
Answer: Turn the client to the side.
A nurse is obtaining a medication history from a client who is scheduled to undergo cataract
surgery. The nurse should recognize that which of the following client medications is a
contraindication for the surgery and notify the provider?
Answer: Warfarin
Rationale:
because it is an anticoagulant which increases the client's risk for bleeding and is contraindicated
for a client scheduled for I or Central Nervous System since surgery
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: Clean the perineum form front to back.
A nurse is assessing a client who has had a suspected cerebrovascular accident. The nurse should
place the priority on which of the following findings?
Answer: Dysphagia
A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which
of the following actions should the nurse identify as the priority?
Answer: Place a tracheostomy tray at the bedside.

A nurse is providing teaching to a client who has type 2 diabetes mellitus and a new prescription
for insulin lispro. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: "I will need to take the lispro in addition to my other prescribed insulin."
A nurse is providing medication teaching to a group of clients who have seizure disorders. Which
of the following information should the nurse include about phenytoin?
Answer: Phenytoin decreases the effectiveness of oral contraceptives.
Rationale:
because it stimulates the synthesis of hepatic enzymes which can decrease the activity of other
medications including oral contraceptives
A nurse is providing discharge teaching to a client who has active TB. Which of the following
information should the nurse include in the instructions.?
Answer: Sputum specimens are necessary every 2 to 4 weeks until there are three negative
cultures.
A nurse is planning care for a client who his having a modified radical mastectomy of the right
breast. Which of the following interventions should the nurse include in the plan of care?
Answer: Instruct the client that the drain is removed when there is 25 mL of output or less
over a 24-hr period.
Another similar questions – Flex the affected arm when ambulating at home
A nurse is providing teaching to a client who has hypertension and a new prescription for
verapamil. Which of the following juices should the nurse instruct the client to avoid?
Answer: Grapefruit
A nurse is providing teaching to a client who has asthma about the use of a metered-dose
inhaler. The nurse should identify that which of the following client actions indicates an
understanding of the teaching?
Answer: Holding breath for 10 seconds after inhaling

A nurse is providing instructions to a client who has type 2 DM and a new prescription for
metformin. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: "I should take this medication with a meal."
A nurse is providing teaching to a client who has IBS. Which of the following instructions
should the nurse include in the teaching?
Answer: Increase fiber intake to at least 30g per day.
A nurse in an emergency department is assessing an older adult client who has a fractured wrist
following a fall. During the assessment, the client states, "Last week I crashed my car because
my vision suddenly became blurry." Which of the following actions is the nurse's priority?
Answer: Check the client's neurologic status.
A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the
following information should the nurse include in the teaching?
Answer: Drink 240 mL of water after administration.
A nurse on a med-surg unit is receiving change-of-shift report on four clients. Which of the
following clients should the nurse identify as having the greatest risk for developing an
infection?
Answer: A client who has COPD and is receiving steroid therapy
A nurse is planning discharge teaching for a client who has an external fixation device for a
fracture of the lower extremity. Which of the following instructions should the nurse include in
the plan of care?
Answer: Use crutches with rubber tips.

A nurse in an emergency department is caring for a client who has full-thickness burns over 20%
of his total body surface area. After ensuring a patent airway and administering oxygen, which of
the following items should the nurse prepare to administer first?
Answer: IV fluids
A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for
gentamicin. Which of the following findings from the client's medical record should indicate to
the nurse the need to withhold the medication and notify the provider?
Answer: Serum creatinine.
A nurse is reviewing the lab results of a client who has a new diagnosis of acute leukemia. Which
of the following findings should the nurse identify as an expected finding?
Answer: Increased WBC count
A nurse is an emergency department is caring for a client who report 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: Heart rate 110/min
A nurse is providing preoperative teaching for a client who his scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
Answer: Demonstrate ways to deep breathe and cough.
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube.
The nurse should recognize that which of the following complications is associated with longterm mechanical ventilation?
Answer: Stress ulcers b/c of the elevated levels of hydrochloric acid in the stomach
A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving
radiation treatment. Which of the following statements by the client indicates an understanding
of the teaching?

Answer: "I will avoid direct exposure to the sun."
A nurse is caring for a client who has a positive culture for C-diff. Which of the following action
should the nurse take?
Answer: Implement contact precautions for the client.
A nurse in a provider's office is assessing a client who has migraine headaches and is taking
feverfew to prevent her headaches. The nurse should identify that which of the following client
medications interacts with feverfew?
Answer: Naproxen
A nurse in an emergency department is planning care for a client who has a flail chest on the
right side following a motor-vehicle crash. Which of the following actions should the nurse plan
to take?
Answer: Prepare the client for positive pressure ventilation.
A nurse is preparing to assist with the insertion of a non-tunneled percutaneous central venous
catheter into a client's subclavian vein. The nurse should plan to place the client in which of the
following positions?
Answer: Trendelenburg
A nurse is teaching an older adult client about osteoporosis prevention. The nurse should instruct
the client that which of the following medications can increase her risk for developing
osteoporosis?
Answer: Fludocortisone / Prednisone
A nurse is teaching a client who has end-stage kidney disease about organ donation. Which of the
following information should the nurse include in the teaching?
Answer: The client who receives a kidney form a live donor has a lower rate of transplant
rejection.

A nurse is providing teaching to a client who has a prescription for
trimethoprim/sulfamethoxazole. Which of the following instructions should the nurse include in
the teaching?
Answer: Drink 8 to 10 glasses of water daily
A nurse at an urgent care clinic is collecting a history from a female client who has a urinary tract
infection. The nurse should identify that which of the following client statements indicates a
contraindication for administering this medication?
Answer: I have tendonitis, so I haven't been able to exercise.
A nurse is teaching a client who has an upper respiratory infection about guaifenesin. Which of
the following statements should the nurse include in the teaching?
Answer: Increase your fluid intake to at least 2 liters each day while taking this medication.
A nurse is reviewing the medical record of a client who has schizophrenia and a prescription for
clozapine. Which of the following laboratory tests should the nurse review before administering
the medication?
Answer: Total cholesterol
A nurse is developing a plan for a client who has a new prescription for simvastrin. Which of the
following instructions should the nurse include in the teaching plan? (SATA)
Answer: report muscle pain to the provider // avoid taking the medication with grapefruit
juice // expect therapy with this medication to be lifelong
A nurse is caring for a client who has heart failure and is receiving an IV infusion of dopamine.
Which of the following findings indicates that the medication is effective?
Answer: Increased cardiac output
A nurse is caring for a client who is taking acetazolamide for chronic open-angle glaucoma. For
which of the following adverse effects should the nurse instruct the client to monitor and report?
Answer: Tingling fingers

A nurse is teaching a client who is starting to take amitriptyline. Which of the following findings
should the nurse include in the teaching as an adverse effect of the medication?
Answer: urinary retention
A nurse is monitoring a client who is receiving amphotericin B intermittent IV bolus for the
treatment of histoplasmosis. Which of the following findings should the nurse identify as an
adverse reaction to the medication?
Oliguria
A nurse is preparing to administer a scheduled antibiotic at 0800 to a client and discovers the
antibiotic is not present in the client's medication drawer. The nurse should identify that
administration of the medication can occur at which of the following time periods without
requiring an incident report?
Answer: 0830
A nurse in an emergency department is caring for a client who has heroin toxicity. The client is
unresponsive with pinpoint pupils and a respiratory rate of 6/min. Which of the following
medications should the nurse plan to administer?
Answer: Naloxone
A nurse is planning discharge teaching for a client who has a prescription for furosemide. The
nurse should plan to include which of the following statements in the teaching?
Answer: "Drink a glass of milk with each dose of medication."
A nurse is caring for a client who reports lethargy and myalgia after taking clozapine for 6
months. Which of the following actions should the nurse plan to take?
Answer: Obtain WBC with absolute neutrophil count
A nurse is teaching a client who is to start taking diltiazem. The nurse should instruct the client
to report which of the following findings as an adverse effect of the medication?

Answer: Shortness of breath
A nurse is providing teaching to a client who has a new prescription for phenytoin. Which of the
following statements by the client indicates an understanding of the teaching?
Answer: "I should let my dentist know I'm taking this medication."
A circulating nurse is planning care for a client who is scheduled for surgery and has a latex
allergy. Which of the following actions should the nurse include in the plan of care?
Answer: Place monitoring cords and tubes in a stockinet
A nurse is providing teaching about insulin glargine to a client who has type 1 diabetes mellitus.
Which of the following information should the nurse include in the instructions?
Answer: Do not mix this medication in a syringe with other insulin
A nurse in an emergency department is caring for a client whose family reports the client has
taken large amounts of diazepam. Which of the following medications should the nurse
anticipate administering?
Answer: Flumazenil
A nurse is caring for a client who is in labor. The client is receiving oxytocin by continuous IV
infusion with a maintenance IV solution. The external FHR monitor indicates late decelerations.
Which of the following actions should the nurse take first?
Answer: Turn the client to a side-lying position
A nurse is reviewing the medication list of a client who wants to begin taking oral
contraceptives. The nurse should identify that which of the following medications will interfere
with the effectiveness of oral contraceptives?
Answer: Carbamazepine
A nurse is teaching a client who is starting to take ketorolac. Which of the following information
should the nurse include in the teaching?

Answer: "Check for bruising while taking this medication."
A nurse is preparing to teach a client who is to start a new prescription for extended release
verapamil. Which of the following instructions should the nurse plan to include?
Answer: Change positions slowly; Notify HCP if see rash (SJS); constipation side effect
also;
A nurse is providing teaching to a client about the use of ethinyl estradiol/norelgestromin. The
nurse should identify that which of the following statements by the client indicates an
understanding of the teaching?
Answer: "I will fold the sticky sides of the old patch together before disposing it."
A nurse is monitoring for adverse effects of hydrochlorothiazide after administering the
medication to an older adult client who has heart failure. Which of the following findings should
the nurse identify as an adverse effect of the medication?
Answer: orthostatic hypotension
A nurse is caring for a client who is receiving long-term treatment for systemic lupus
erythematosus with prednisone. The nurse should inform the client to expect to undergo which of
the following diagnostic tests to monitor for long-term complications of prednisone?
Answer: Bone density scan
A nurse is teaching a client who is to start taking temazepam. Which of the following
instructions should the nurse include?
Answer: Plan to withdraw from the medication gradually
A nurse is assessing a client who has myasthenia gravis and is taking neostigmine. Which of the
following findings should indicate to the nurse the client is experiencing an adverse effect?
Answer: Miosis

A nurse is providing discharge instruction to a client who it so self-administer insulin at home.
Which of the following client statements should indicate to the nurse that the teaching is
effective?
Answer: "I will store my unopened bottles of insulin in the refrigerator."
A nurse in a provider's office is assessing a client who has been taking aspirin daily for the past
year. For which of the following findings should the nurse notify the provider immediately?
Answer: Hyperventilation
A nurse is caring for a client who has diabetes mellitus and is taking glyburide. The client reports
feeling confused and anxious. Which of the following actions should the nurse take first?
Answer: Perform capillary blood glucose test
A nurse is preparing to administer amoxicillin 250 mg PO to a school-age child. The amount
available is amoxicillin oral suspension 200 mg/5 ml. How many ml should the nurse administer
per dose?
Answer: 6.3 mL
A nurse is assessing a client who has received atropine eye drops during an eye examination.
Which of the following findings should the nurse expect as an adverse effect of the medication?
Answer: blurred vision
A nurse is caring for the mother of a newborn. The mother asks the nurse when her newborn
should receive his first diphtheria, tetanus, and pertussis vaccine (DTaP). The nurse should
instruct the mother that her newborn should receive the immunization at which of the following
ages?
Answer: 2 months
A nurse is administering cefotetan via intermittent IV bolus to a client who suddenly develops
dyspnea and widespread hives. Which of the following actions should the nurse take first?
Answer: Discontinue the medication IV infusion

A nurse is teaching a client about cyclobenzaprine. Which of the following client statements
should indicate to the nurse that the teaching is effective?
Answer: "I will taper off the medication before discontinuing it."
A nurse is preparing to administer to a client 0.9% sodium chloride 1,000 ml IV over 8 hr. The
drop factor of the manual IV tubing is 15 gtt/ml. The nurse should set the manual IV infusion to
deliver how many gtt/min?
Answer: 31 gtt/min
A nurse is teaching a client who is to start taking ranitidine for peptic ulcer disease. Which of the
following client statements should the nurse identify as understanding of the teaching?
Answer: "I know smoking makes ranitidine less effective."
A nurse is teaching about zolpidem with a client who has insomnia. The nurse should identify
that which of the following client statements indicates an understanding of the teaching?
Answer: "I will use this medication for a short period of time."
A nurse is caring for a client who is taking atenolol. Which of the following findings should
indicate to the nurse that the medication is effective?
Answer: The client has a decrease in blood pressure
A nurse is providing teaching to a client who is starting to take lisinopril. Which of the following
findings is an adverse effect that the nurse should instruct the client to monitor and report to the
provider?
Answer: dry cough
A nurse administers ceftazidime to a client who has a severe penicillin allergy. The nurse should
identify which of the following client findings as an indication that she should complete an
incident report?
Answer: The client reports shortness of breath

A nurse is caring for a 20-year-old female client who has a prescription for isotretinoin for severe
nodulocystic acne vulgaris. Before the client can obtain a refill, the nurse should advice the client
that which of the following tests is required?
Answer: Pregnancy test
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the
following should the nurse document as a therapeutic outcome?
Answer: Decrease in flexor and extensor spasticity
A nurse is preparing to administer medication to a client who has gout. The nurse discovers that
an error was made during the previous shift and the client received atenolol instead of
allopurinol. Which of the following actions should the nurse take first?
Answer: Obtain the client's blood pressure
A nurse is providing teaching to client who has a prescription for a MAOI inhibitor. Which of the
following foods should the nurse instruct the client to avoid while taking this medication?
Answer: smoked sausage
A nurse is providing discharge teaching about handling medication to a client who is to continue
taking oral transmucosal fentanyl raspberry-flavored lozenges on a stick. Which of the following
information should the nurse include in the teaching?
Answer: Store unused medication sticks in a storage container
A nurse is providing teaching to a client who is to start taking sumatriptan. Which of the
following adverse effects should the nurse instruct the client to monitor for and report to the
provider?
Answer: Chest pressure

A nurse is caring for a client who is receiving end-of-life care and has a prescription for fentanyl
patches. Which of the following information regarding the adverse effects of fentanyl should the
nurse plan to give to the client and family?
Answer: Take a stool softener on a daily basis
A nurse is providing teaching for a client who has multiple sclerosis and a new prescription for
methylprednisone. Which of the following instructions should the nurse include (SATA)?
Answer: Blood glucose levels will be monitored during therapy //
Avoid contact with people who have known infections //
Grapefruit juice can increase the effects of the medication
A nurse is providing teaching for a patient who has a new prescription for ferrous sulfate. The
nurse should instruct the client to take the medication with which of the following to promote
absorption?
Answer: orange juice
A nurse is caring for a client who has cancer and is taking oral morphine and docusate sodium.
The nurse should instruct the client that taking to docusate sodium on a daily basis can minimize
which of the following adverse effects of morphine?
Answer: constipation
A nurse is teaching about self-administration of transdermal medication with a male client who
has a new prescription for nitroglycerin. The nurse should identify that which of the following
statements by the client indicates understanding of the teachings?
Answer: "I will remove the patch after 14 hours."
A nurse is providing teaching to a client who is to start treatment for asthma with
beclomethasone and albuterol inhalers. Which of the following instructions should the nurse
include in the teaching?
Answer: Rinse you mouth after inhaling the beclomethasone

A nurse is reviewing the medical record of a client who has hypertension. The nurse should
identify which of the following findings as a contraindication to receiving propranolol?
Answer: asthma
A nurse is reviewing the prescriptions of a client who has tuberculosis. The nurse should identify
that which of the following medications are used to treat tuberculosis (SATA)?
Answer: Rifampin // Isoniazid
A nurse is providing teaching about adverse effects of clindamycin to a client. Which of the
following findings should the nurse instruct the client to report to the provider?
Answer: watery diarrhea
A nurse is preparing to administer heparin subcutaneously to a client. Which of the following
actions should the nurse plan to take?
Answer: Administer the medication outside the 5-cm (2 in) radius of the umbilicus
A nurse is caring for a client who has pneumonia. The client tells the nurse that she is pregnant
and that she has not told her provider yet. The nurse should identify that pregnancy is a
contraindication to receiving which of the following medications?
Answer: Doxycycline
A nurse is caring for a client who is recovering from a deep vein thrombosis and is to start taking
warfarin. For which of the following findings should the nurse monitor as an adverse effect of
warfarin?
Answer: Bleeding gums
A nurse is caring for a client who has sickle cell anemia and is taking hydroxyurea. Which of the
following findings should the nurse report to the provider (SATA)?
Answer: Hemoglobin 7.0 g/dl
Platelets 70,000/mm3
Potassium 5.2 meq/l

A nurse is planning care for a client who has hypertension and is to start taking metoprolol.
which of the following interventions should the nurse include in the plan of care?
Answer: Determine apical pulse prior to administering
A nurse is assessing a client who is taking amitriptyline for depression. Which of the following
findings should the nurse identify as an adverse effect of the medication?
Answer: Dry Mouth
A nurse is teaching about neural tube defects to a client who is planning a pregnancy. Which of
the following vitamins should the nurse instruct the client to start taking before becoming
pregnant?
Answer: folic acid
A nurse is preparing to mix and administer dantrolene via IV bolus to a client who has developed
malignant hyperthermia during therapy. Which of the following actions should the nurse take?
Answer: Reconstitute the initial dose with 60 mL of sterile water without a bacteriostatic
agent.
A nurse is caring for a client who has heart failure and is prescribed enalapril. The nurse should
monitor the client for which of the following findings as an adverse effect of the medication?
Answer: hyperkalemia
A nurse is providing care for a client who is postoperative following an open cholecystectomy
with the placement of a closed suction drain and is receiving morphine via patient controlled
analgesia for pain. Which of the following assessments is the nurse's priority?
Answer: respiratory rate
A nurse is teaching a client about warfarin. The client asks if she can take aspirin while taking
the warfarin. Which of the following responses should the nurse make?
Answer: aspirin will increase the risk of bleeding

A nurse is caring for a client who is receiving heparin therapy via continuous IV infusion to treat
a pulmonary embolism. Which of the following findings should the nurse identify as an adverse
effect of the medication and report to the provider?
Answer: blood in the urine
A nurse is teaching a client who has tuberculosis about the adverse effects of isoniazid. The nurse
should instruct the client to report to the provider which of the following finding as an adverse
effect of the medication?
Answer: yellowish skin tones
A nurse is providing teaching to a client who is taking bupropion as an aid to quit smoking.
which of the following finding should the nurse identify as an adverse effect of the medication?
Answer: insomnia
A nurse is teaching about a new prescription for ciprofloxacin to an older adult client who has a
urinary tract infection. The nurse should identify which of the following statements as an
indication that the client understands the teaching?
Answer: "I will report any signs of tendon pain or swelling"
A nurse is preparing to administer a new prescription of amoxicillin/clavulanic to a client. The
client tells the nurse that he is allergic to penicillin. Which of the following actions should the
nurse take first?
Answer: Withhold the medication
A nurse is precepting a newly licensed nurse who is caring for four clients. The nurse should
complete an incident report for which of the following actions by the newly licensed nurse?
Answer: administers isosorbide mononitrate to a client who has a BP 82/60 mm Hg

A nurse is reviewing the health history of a client who has diabetes mellitus and will begin taking
insulin. Which of the following dings should the nurse identify as a fact that might cause the
client to have difficulty safely self administering insulin?
Answer: macular degeneration
A nurse is teaching a client who is to begin taking tamoxifen for the treatment of breast cancer.
Which of the following adverse effects should the nurse include in the teaching?
Answer: hot flashes
A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for
ranitidine. which of the following instructions should the nurse include?
Answer: report the yellowing of the skin
A nurse is collecting a medication history from a client who has a new prescription for lithium.
The nurse should identify that the client should discontinue which of the following over-thecounter medications?
Answer: ibuprofen
A nurse is preparing to administer dextrose 5% in water (D5W) 400 mL IV to infuse over 1 hr.
The drop factor of the manual IV tubing is 15gtt/mL. The nurse should set the manual IV
infusion to deliver how many gatt/min?
Answer: 100 gtt/min
A nurse is providing teaching to a client who is to start therapy with digoxin. For which of the
following adverse effects should the nurse instruct the client to monitor and report to the
provider?
Answer: Yellow-tinged vision
A nurse in the emergency department is caring for a client who has myasthenia gravis and is in a
cholinergic crisis. Which of the following medications should the nurse plan to administer?
Answer: atropine

A nurse is teaching a group of unit nurses about medication reconciliation. Which of the
following information should the nurse include in the teaching?
Answer: A transition in care requires the nurse to conduct medication reconciliation.
A nurse is caring for a client who is receiving cefazolin IV. The nurse should identify that which
of the following medications can potentiate nephrotoxicity if administered concurrently?
Answer: Gentamicin
A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should
identify which of the following findings as the best indication the morphine has been effective?
Answer: The client rates the pain at a 3 on a scale from 0 to 10
A nurse is providing teaching to a client who has a prescription for ergotamine sublingual to treat
migraine headaches. Which of the following information should the nurse include in her
instructions?
Answer: take one tablet at the onset of a migraine
A nurse is planning care for a client who is prescribed metoclopramide following bowel surgery.
For which of the following adverse effects should the nurse monitor?
Answer: sedation
A nurse is teaching a client who is starting to take diltiazem. Which of the following statements
should the nurse identify as an indication that the client understands the teaching?
Answer: "I will check my heart rate before I take the medication"
A nurse is caring for a client who recently began taking oral amoxicillin/clavulanate and reports
urticaria. Which of the following actions should the nurse take?
Answer: request a change in the type of the antibiotic

A nurse is providing teaching to a client who has depression and has a new prescription for
fluoxetine. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: "I should take acetaminophen instead of ibuprofen for my headaches while taking
this medication."
A nurse is caring for a client who is receiving oprelvekin. Which of the following findings
should the nurse document to indicate the effectiveness of the therapy?
Answer: increased platelet count
A nurse is caring for a client who is taking atorvastatin for hyperlipidemia. Which of the
following client laboratory values should the nurse monitor?
Answer: creatinine kinase
A nurse is instructing a client on the application of nitroglycerin transdermal patches. Which
of the following statements by the client indicates an understanding of the teaching?
Answer: "I will take the patch off right after my evening meal."
A nurse has administered 2 doses of betamethasone to a client in preterm labor. After delivery
of the newborn, the nurse understands the medication was effective when she observes which of
the following?
Answer: The newborn has normal respiratory pattern
A nurse is preparing to administer Ciprofloxacin 15mg/kg PO every 12 hr to a child who weighs
44lbs. how many mg should the nurse administer per dose?
Answer: 300 mg
A nurse is planning care for a clienct who is receiving mannitol via continuous IV infusion. The
nurse should monitor the client for which of the following adverse effects?
Answer: bibasilar crackles

A nurse is teaching a client about the use of risedronate for the treatment of osteoporosis. The
nurse should identify which of the following statements as an indication that the client
understands the teaching?
Answer: "I should sit up for 30 minutes after taking the risedronate."
A nurse is assessing a client who is receiving epoetin alfa to treat anemia. Which of the
following findings should the nurse monitor?
Answer: Increased blood pressure
A nurse at a clinic is providing follow-up care to a client who is taking fluoxetine for depression.
Which of the following findings should the nurse identify as an adverse effect of the medication?
Answer: sexual dysfunction
A nurse on the acute care unit is caring for a client who is receiving gentamicin IV. The nurse
should report which of the following findings to the provider as an adverse effect of the
medication?
Answer: tinnitus
A nurse is planning to teach about the use of a spacer to a child who has a new prescription for a
fluticasone inhaler to treat chronic asthma. the nurse should include that the spacer deceases the
risk for which of the following adverse effect of the medication?
Answer: oral candidias
A nurse is teaching a client who is taking allopurinol for the treatment of gout. Which of the
following information should the nurse include in the teaching?
Answer: rink 2 L of water daily
A nurse is providing teaching to a client who has a peptic ulcer disease and is to start a new
prescription for sucralfate. Which of the following actions of sucralfate should the nurse include
in the teaching?
Answer: forms a protective barrier over ulcers

A nurse is teaching a client who has a new prescription for docusate sodium about the
medications mechanism of action. Which of the following information should the nurse include
in the teaching?
Answer: Docusate sodium reduces the surface tension of the stool to change three
consistency
A nurse is providing discharge instructions to a client who has heart failure and a new
prescription for captopril. Which of the following client statements indicates an understanding of
the teaching?
Answer: "I should tell my provider if a I develop a sore throat."
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes
the client has anxiety, hypotension, and dyspnea. Which of the following medications should the
nurse administer first?
Answer: epinephrine
A nurse is providing teaching to a client who is to begin taking oxybutynin for urinary
incontinence. The nurse should instruct the client to report which of the following findings as an
adverse effect of the medication?
Answer: dry mouth // blurred vision // dry eyes
A nurse is teaching a client who is to start taking hydrocodone with acetaminophen tablets for
pain. Which of the following information should the nurse include in the teaching?
Answer: decreased respirations might occur
A nurse is planning to teach about inhalant medications to a client who has a new diagnosis of
exercise induced asthma. which of the following medications should the nurse plan to instruct
the client o use prior to physical activity?
Answer: Cromolyn

A nurse in a clinic is caring for a client who is taking aspirin for the treatment of arthritis. The
nurse should identify which of the following findings as an indication that the client is beginning
to exhibit salicylism?
Answer: tinnitus
A nurse is reviewing laboratory results for a client who is to receive a dose of ceftazadime via
intermittent IV bolus. Which of the following laboratory finding is the priority for the nurse
to report to the provider before administering the medication?
Answer: creatinine 2.6 mg/dL
A nurse is caring for a client who is receiving haloperidol. The nurse should observe for which
of the following findings as an adverse effect of the medication?
Answer: akathisia
A nurse is preparing to administer 0.9% sodium chloride (NaCl) 1,500 mL to infuse over 8 hr to
a client who is postoperative. The nurse should set the IV pump to deliver how many mL/hr?
Answer: 188 ml/hr
A nurse is caring for a client who is experiencing acute alcohol withdrawal. For which of the
following client outcomes should the nurse administer chlordiazepoxide?
Answer: Prevent delirium tremens
A nurse is reviewing laboratory results for a client who is receiving heparin via continuous IV
infusion for deep-vein thrombosis. The nurse should discontinue the medication infusion for
which of the following client findings?
Answer: platelets 96,000/mm3
A nurse is providing discharge teaching to a a client who has a new prescription for furosemide
twice daily. The nurse should include which of the following instructions in the teaching?
Answer: Increase intake of potassium-rich foods // Monitor for muscle weakness // Dangle
legs for side of bed before standing

A nurse is providing teaching for a client who has multiple sclerosis and a new prescription for
methylprednisolone. Which of the following instructions should the nurse include?
Answer: Blood glucose levels will need to be monitored during therapy // avoid contact with
persons who have known infections // grapefruit juice can increase the blood levels of the
medication
A nurse is caring for a client who has acute acetaminophen toxicity. The nurse should
anticipate administering which of the following medications?
Answer: acetylcysteine
A nurse is caring for a client in the emergency department following a diazepam overdose.
Which of the following medications should the nurse anticipate administering to the client?
Answer: flumazenil
A nurse is providing follow up care to a client who is taking lisinopril. Which of the following
manifestations should the nurse instruct the client to report as an adverse effect of lisinopril?
Answer: persistent cough
A nurse is administering donepezil to a client who has Alzheimer's disease. Which of the
following findings should the nurse report to the provider immediately?
Answer: dyspnea
A nurse is assessing a client who is taking propylthiouracil for the treatment of Graves disease.
Which of the following findings should the nurse identify as an indication of the medication has
been effective?
Answer: Increase focus
A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The
nurse should identify which of the following findings as an indication of a myocardial
infarction(MI)?

Answer: Troponin 8 ng/mL
A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin
B for a fungal infection. The nurse should identify that which of the following values is an
indication of an adverse effect of the medication?
Answer: BUN 34 mg/dl
The nurse is reinforcing teaching on positioning for a patient after a right total knee replacement.
Which patient statement indicated a correct understanding of the teaching?
Answer: “Suspine with pillow under right knee”
A patient with a fractured pelvis and a left acetabular fracture is prescribed bedrest. When the
patient asks to toilet, which measure would be appropriate?
Answer: “Ask patient to lift straight up using a trapeze mounted above the bed and slide a
bedpan underneath from the right side.”
The nurse is caring for a patient with gout. Which laboratory value should the nurse review
which indicates that the treatment plan is effective?
Answer: Uric Acid 7.9 mg/dL
Preoperative Interventions for mastectomy.
Answer: Ensure to teach for presence of one or more surgical drainages
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement.
Which of the following statements should the nurse make?
Answer: "Ginkgo biloba can cause an increased risk for bleeding." -decreases platelet
aggregation
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer.
Which of the following interventions should the nurse include in the plan of care?
Answer: Keep a lead-lined container in the client's room

A nurse is receiving report on a client who is postoperative following an open repair of Zenker's
Diverticulum. The nurse should anticipate the surgical incision to be in which of the following
locations?
Answer: Throat
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus.
Which of the following findings should the nurse expect?
Answer: Facial butterfly rash.
A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a
kidney transplant. Which of the following information should the nurse provide?
Answer: Hemodialysis is sometimes needed following surgery.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system.
Which of the following findings is an indication of lung re-expansion?
Answer: Bubbling in the water seal chamber has ceased-- bubbling in the water seal
chamber ceases when the lung re-expands
A nurse is administering packed RBC's to a client. Which of the following assessment findings
indicates a hemolytic transfusion reaction?
Answer: Low back pain and apprehension --creates a systemic inflammatory response
A nurse is planning care for a client who is post-operative following a laparotomy and has a
closed suction drain which of the following actions should the nurse take to manage the drain?
Answer: Compress the drain Reservoir after emptying
Rationale:
because it creates a vacuum that draws fluid out of the room through the drain and into the
reservoir

A nurse is providing discharge instructions to a client who has laryngeal cancer and received is
receiving radiation treatment which of the following statements by the client indicates an
understanding of the teaching?
Answer: I will avoid direct exposure to the Sun
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
should the nurse plan to administer?
Answer: Regular insulin 20 units IV bolus-- regular insulin is a fast-acting insulin that can be
effective within 10 minutes of IV administration
A nurse is assessing a client following the completion of hemodialysis which of the following
findings is the nurses priority to report to the provider?
Answer: Restlessness
A nurse in an emergency department is assessing an older adult client who has a fractured wrist
following a fall during the assessment the client states last week I crashed my car because my
vision suddenly became blurry which of the following actions is the nurses priority
Answer: Check the clients neurologic status because the first action you should take is to
assess the client
A nurse is planning care for a client who is scheduled for a thoracentesis which of the following
interventions should the nurse include in the plan?
Answer: Encourage the client to take deep breaths after the procedure to read expand the lung
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following
nonpharmacological interventions should the nurse suggest to the client to reduce pain?
Answer: Alternate application of heat and cold to the affected joints-- the cold can relieve
joint swelling and heat can decrease joint stiffness
A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into
shock. Identify the sequence of actions the nurse should take.

Answer: Step 1: Administer oxygen via nonrebreather mask
Step 2: Initiate IV therapy with a large bore catheter
Step 3: Insert and NG tube
Step 4: Administer ranitidine
A nurse is providing teaching to a client who has a severe form of stage II lyme disease. Which
of the following statements made by the client reflects an understanding of the teaching?
Answer: My joints ache because I have Lyme disease-- this is stage I, if left untreated leads to
stage II and III
A nurse is caring for a client who is 4 hour postoperative following an open reduction internal
fixation of the right ankle. Which of the following assessment findings should the nurse report to
the provider?
Answer: Extremity cool upon palpation
Rationale:
reduced circulation, cool temp, paresthesia of the extremity, these can indicate the client is at risk
for developing compartment syndrome
A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing
continuous telemetry monitoring. Which of the following statements by the client reflects an
understanding of the teaching?
Answer: This identifies if the pacemaker cells of my heart are working properly
A nurse is providing discharge instructions to a client who has active tuberculosis which of the
following information should the nurse include in the instructions?
Answer: Sputum specimens are necessary every 2 to 4 weeks
Rationale:
until there are three negative cultures after three negative sputum cultures the client is no longer
considered infectious

A nurse is providing education to a client who has tuberculosis, and his family. Which of the
following information should the nurse include in the teaching?
Answer: Family members in the household should undergo TB testing
A nurse is caring for a client who has had a cerebrovascular accident. Which of the following
findings indicates that the client has homonymous hemianopsia?
Answer: The client has to turn her head to see the entire visual field—
Rationale:
homonymous hemianopsia is blindness in the same visual field of both eyes caused by damage to
the optic tract or occipital lobe
A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for
Gentamicin which of the following findings from the client's medical record should indicate to
the nurse the need to withhold the medication and notify the provider?
Answer: Serum creatinine
A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless,
dyspneic, and has crackles noted to the lung bases. Which of the following actions should the
nurse anticipate taking?
Answer: Slow the infusion rate-- crackles in the lungs are manifestations of circulatory
overload
A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago.
Which of the following manifestations indicates that the client is experiencing autonomic
dysreflexia (AD)?
Answer: Heart rate 52/min--AD can exhibit bradycardia, severe headache and flushing
A nurse is performing a perioperative assessment for a client. The nurse should identify that an
allergy to which of the following foods can indicate a latex allergy?
Answer: Avocados

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When
reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and
HS. Which of the following actions should the nurse take?
Answer: Contact the PCP to clarify the prescription-- meals don't pertain to client due to
NPO status, the nurse should monitor glucose on a set schedule
A nurse is assessing a client who is postoperative following a transurethral resection of the
prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in
urinary output. Which of the following actions should the nurse take?
Answer: Irrigate the indwelling urinary catheter-- this should remove clots obstructing the
urine flow
A nurse is providing teaching to a client who takes ginkgo biloba as a herbal supplement. Which
of the following statements should the nurse make?
Answer: Ginko biloba can cause an increased risk for bleeding-- ginko biloba increases
blood flow and is effective in decreasing the pain associated with peripheral artery disease, it
also decreases platelet aggregation which increases risk for bleeding

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