ATI Proctored Exam Medical Surgical Form A
1. A nurse is preparing to administer thrombolytic therapy to a client who had an
ischemic stroke. Which of the following is an appropriate nursing action?
A. Start the therapy within 8 hrs. (within 6 hrs.)
B. Insert an indwelling urinary catheter after therapy begins
C. Monitor blood pressure every 30 minutes during infusion.
D. Elevate the head of the bed between 25 and 30 degrees
Answer: D. Elevate the head of the bed between 25 and 30 degrees
Rationale:
Elevating the head of the bed helps to promote venous drainage from the brain and
can reduce intracranial pressure, which is important after a stroke. Starting
thrombolytic therapy should ideally occur within 3 to 4.5 hours after symptom
onset, not 8 hours. Inserting an indwelling urinary catheter should be done
cautiously, as it increases the risk of infection. Monitoring blood pressure every 15
minutes is typically recommended during the infusion, rather than every 30
minutes.
2. A nurse is teaching a client about the use of an incentive spirometer. Which of
the following instructions should the nurse include in the teaching?
A. Place hands on the upper abdomen during inhalation.
B. Exhale slowly through pursed lips.
C. Hold breath about 3 to 5 seconds before exhaling.
D. Position the mouthpiece 2.5 cm (1 in) from the mouth.
Answer: C. Hold breath about 3 to 5 seconds before exhaling.
Rationale:
Holding the breath for a few seconds after inhalation helps to maximize lung
expansion and promote effective ventilation. Placing hands on the abdomen is not
recommended, as it can interfere with proper technique. Exhaling slowly through
pursed lips is generally a technique for preventing airway collapse but is not
specific to the use of an incentive spirometer. Positioning the mouthpiece 2.5 cm (1
in) from the mouth is not correct; it should be placed firmly in the mouth to ensure
a good seal.
3. A nurse is assessing a client who is 12 hr. postoperative following a colon
resection. Which of the following findings should the nurse report to the surgeon?
A. Heart rate 90/mm
B. Hgb 8.2 g/dL
C. Gastric ph of 3.0
D. Absent bowel sounds
Answer: D. Absent bowel sounds
Rationale:
• Recall that bowel sounds are altered in patients with obstruction; absent bowel
sounds imply total obstruction. QSEN: Safety (Book page 1143)
• Absent bowel sounds can indicate ileus or complications such as bowel
obstruction, which requires immediate reporting to the surgeon. A heart rate of 90
bpm is generally acceptable postoperatively. A haemoglobin level of 8.2 g/dL
indicates anaemia but may be expected depending on the extent of the surgery. A
gastric pH of 3.0 is normal; gastric secretions should be acidic. Therefore, absent
bowel sounds are the most concerning finding that warrants reporting.
4. A nurse is caring for a client who has diabetes insipidus. Which of the following
medications should the nurse plan to administer?
A. Regular Insulin
B. Furosemide
C. Desmopressin
D. Lithium Carbonate
Answer: C. Desmopressin
Rationale:
• Teach patients with diabetes insipidus the proper way to self-administer
desmopressin orally or by nasal spray.
• Management focuses on controlling symptoms with drug therapy.
• The most preferred drug is desmopressin acetate (DDAVP), a synthetic form of
vasopressin given orally, as a sublingual “melt,” or intranasally in a metered spray.
The frequency of dosing varies with patient responses. Teach patients that each
metered spray delivers 10 mcg and those with mild DI may need only one or two
doses in 24 hours.
• For more severe DI, one or two metered doses two or three times daily may be
needed.
5. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen
several times daily for 3 years. Which of the following test should the nurse
monitor?
A. Stool occult blood
B. Urine for white blood cells
C. Fasting blood glucose
D. Serum calcium
Answer: A. Stool occult blood
Rationale:
Assess for drug-related blood loss such as that caused by NSAIDs by checking the
stool for gross or occult blood. Older white women are the most likely to
experience GI bleeding as a result of taking these medications. (Book page 324)
6. A nurse in the emergency department is assessing a client. Which of the
following actions should the nurse take first? (Click on the “Exhibit” button for
additional information about the client. There are three tabs that contain separate
categories of data.)
A. Obtain a sputum sample for culture.
B. Prepare the client for a chest x-ray.
C. Initiate airborne precautions
D. Administer ondansetron.
Answer: C. Initiate airborne precautions
Rationale:
When assessing a client in the emergency department, the priority action is to
ensure the safety of the client and others. If there are indications that the client may
have a respiratory infection that can be transmitted through the air (such as
tuberculosis or COVID-19), initiating airborne precautions is critical. This helps
prevent the spread of potentially infectious agents to other patients and healthcare
staff.
7. A nurse is contacting the provider of a client who has cancer and is experiencing
breakthrough pain. Which of the following prescriptions should the nurse
anticipate?
A. Intravenous dexamethasone
B. Transmucosal fentanyl
C. Oral acetaminophen- not strong enough
D. Intramuscular meperidine
Answer: B. Transmucosal fentanyl
Rationale:
Fentanyl is a lipophilic (readily absorbed in fatty tissue) opioid and, as such, has a
fast onset and short duration of action. It is recommended opioid for patients with
end-organ failure because it has no clinically relevant metabolites. It also produces
fewer hemodynamic adverse effects than other opioids; therefore, it is often
preferred in patients who are hemodynamically unstable such as the critically ill.
(Book page 59)
8. A nurse is admitting a client who reports chest pain and has been placed on a
telemetry monitor. Which of the following should the nurse analyze to determine
whether the client is experiencing a myocardial infarction?
A. QRS duration
B. ST segment
C. T-wave
D. PR interval
Answer: B. ST segment
Rationale:
Examine the ST segment. The normal ST segment begins at the isoelectric line. ST
elevation or depression is significant if displacement is 1 mm (one small box) or
more above or below the line and is seen in two or more leads. ST elevation may
indicate problems such as myocardial infarction, pericarditis, and hyperkalaemia.
ST depression is associated with hypokalaemia, myocardial infarction, or
ventricular hypertrophy. (Book page 670)
9. A nurse is teaching a client who has ovarian cancer about skin care following
radiation treatment. Which of the following instructions should the nurse include?
A. Apply over the counter moisturizer to the radiation site
B. Cover the radiation site loosely with a gauze wrap before dressing
C. Use a soft washcloth to clean the area around the radiation site
D. Pat the skin on the radiation site to dry it.
Answer: D. Pat the skin on the radiation site to dry it.
Rationale:
Skin Protection During Radiation Therapy
• Wash the irradiated area gently each day with either water or a mild soap and
water as prescribed by your radiation therapy team.
• Use your hand rather than a washcloth when cleansing the therapy site to be
gentler.
• Rinse soap thoroughly from your skin.
• If ink or dye markings are present to identify exactly where the beam of radiation
is to be focused, take care not to remove them.
• Dry the irradiated area with patting rather than rubbing motions; use a clean, soft
towel or cloth.
• Use only powders, ointments, lotions, or creams that are prescribed by the
radiation oncology department on your skin at the radiation site.
• Wear soft clothing over the skin at the radiation site.
• Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the
skin at the radiation site.
• Avoid exposure of the irradiated area to the sun:
• Protect this area by wearing clothing over it.
• Try to go outdoors in the early morning or evening to avoid the more intense sun
rays.
• When outdoors, stay under awnings, umbrellas, and other forms of shade during
the times when the sun's rays are most intense (10 AM to 7 PM).
• Avoid heat exposure.
10. A nurse is caring for a client who is receiving a blood transfusion. The nurse
observes that the client has bounding peripheral pulses, hypertension, and
distended jugular veins. The nurse should anticipate administering which of the
following prescribed medications?
A. Acetaminophen
B. Furosemide
C. Diphenhydramine
D. Pantoprazole
Answer: B. Furosemide
Rationale:
The signs observed—bounding peripheral pulses, hypertension, and distended
jugular veins—suggest fluid overload, which can occur during a blood transfusion.
Furosemide, a loop diuretic, is used to help remove excess fluid from the body by
promoting urine output. Administering furosemide will help alleviate the
symptoms of fluid overload.
11. A nurse is assessing a client who is receiving magnesium sulfate IV for the
treatment of hypomagnesemia. Which of the following findings indicates
effectiveness of the medication?
A. Lungs clear
B. Hypoactive bowel sounds- Reduced motility, anorexia, nausea, constipation,
and abdominal distention are common. A paralytic ileus may occur when
hypomagnesemia is severe.
C. Blood pressure 90/50 mm Hg-hypomagnesemia causes hypertension, but this is
too low, abnormal
D. Apical pulse 82/min
Answer: D. Apical pulse 82/min
Rationale:
One aspect of the conduction problems is that, when serum magnesium levels are
low, intracellular potassium levels are also low. This changes the resting membrane
potential in cardiac muscle cells, slowing normal conduction and triggering ectopic
beats.
12. A nurse is preparing a client for a lumbar puncture. Which of the following
images indicates the position the nurse should assist the client into for this
procedure?
A. “Cannonball position on the side” picture #4 (ATI page 20)
B. Sitting and leaning forward
C. Prone position (lying flat on the stomach)
D. Supine position (lying flat on the back)
Answer: A. “Cannonball position on the side” picture #4 (ATI page 20)
Rationale:
The "cannonball position" helps to open the intervertebral spaces, facilitating the
insertion of the needle for a lumbar puncture. The client curls forward while lying
on their side, which is ideal for this procedure.
13. A nurse is reviewing a clients ABG results: pH 7.42, PaCO 2 30 mm Hg, and
HCO3 -21 mEq/L. The nurse should recognize these findings as an indication of
which of the following conditions?
A. Compensated respiratory alkalosis
B. Uncompensated respiratory acidosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: B. Uncompensated respiratory acidosis
Rationale:
The pH is normal, but the low HCO3 and low PaCO2 indicate that the body is not
adequately compensating for a primary respiratory acidosis condition.
14. A nurse is preparing to administer daily medications to a client who is
undergoing a procedure at 1000 that requires IV contrast dye. Which of the
following routine medications to give at 0800 should the nurse withhold?
A. Metoprolol
B. Metformin
C. Fluticasone
D. Valproic Acid
Answer: B. Metformin
Rationale:
Metformin should be withheld before a procedure requiring IV contrast due to the
risk of lactic acidosis and acute kidney injury, especially if renal function is
compromised.
15. A nurse is planning care for a client who is experiencing seizures secondary to
meningitis. Which of the following interventions should the nurse include in the
plan of care? (Select all that apply.)
A. Assist the client to ambulate every 4 hr.
B. Place a tongue blade at the bedside.
C. Have suction equipment at the bedside.
D. Dim the overhead lights.
E. Apply a warming blanket.
Answer: C. Have suction equipment at the bedside.
D. Dim the overhead lights.
Rationale:
Suction equipment is important for managing airway clearance during a seizure,
and dimming lights can help reduce sensory stimulation, which can trigger
seizures.
16. A nurse is caring for a client who has a pressure ulcer with necrotic tissue and
requires wet to damp dressing changes daily. Which of the following types of
debridement should the nurse include in the plan of care?
A. Enzymatic
B. Surgical
C. Autolytic
D. Mechanical
Answer: D. Mechanical
Rationale:
Mechanical debridement is suitable for removing necrotic tissue, especially when
wet to damp dressing changes are used, as it allows for the removal of non-viable
tissue.
17. A nurse is caring for a female who has toxic shock syndrome. Which of the
following findings should the nurse expect?
A. Elevated platelet count
B. Decreased total bilirubin
C. Generalized rash
D. Hypertension
Answer: C. Generalized rash
Rationale:
A generalized rash is a common manifestation of toxic shock syndrome, which is
caused by toxins produced by certain bacteria.
18. A nurse is preparing to administer a medication for a client though a nontunneled percutaneous central catheter. Which of the following actions should the
nurse take?
A. Close the inline clamp
B. Apply a local anaesthetic to the skin
C. Don sterile gloves
D. Flush the catheter with 10 mL of 0.9% sodium chloride.
Answer: D. Flush the catheter with 10 mL of 0.9% sodium chloride.
Rationale:
Flushing the catheter before administration ensures patency and helps prevent
infection.
19. A nurse is caring for a client who was admitted with nausea, vomiting, and a
possible bowel obstruction. An NG tube is placed and set to a low intermittent
suction. Which of the following findings should the nurse report to the provider?
A. The client reports being extremely thirst with a sore throat
B. The drainage is bright green in color with brown fecal material
C. The amount of drainage is gradually decreasing
D. The client’s abdomen becomes distended and firm.
Answer: D. The client’s abdomen becomes distended and firm.
Rationale:
Abdominal distension and firmness could indicate a bowel obstruction or other
complications that require immediate medical attention.
20. A nurse is reviewing the medical record of a client who has diabetes insipidus.
Which of the following findings should the nurse expect?
A. Elevated blood pressure
B. Hypothermia
C. Urine specific gravity 1.001
D. Bun 15 mg/d:
Answer: C. Urine specific gravity 1.001
Rationale:
A low urine specific gravity indicates dilute urine, which is characteristic of
diabetes insipidus due to insufficient antidiuretic hormone.
21. The nurse is caring for a client who has hyperthyroidism and develops thyroid
storm. Which of the following instructions should the nurse give to the client
regarding management of thyroid storm?
A. You will need to begin taking an ACE inhibition medication
B. You will need a pacemaker to increase your heart rate
C. You will need a cooling blanket to lower your body temperature
D. You will need additional thyroid supplementation
Answer: C. You will need a cooling blanket to lower your body temperature
Rationale:
Cooling measures are critical in managing the hyperthermia that occurs during a
thyroid storm.
22. The nurse is reviewing the medical record of a client who has acute gout. The
nurse should expect an increase in which of the following laboratory results?
A. Uric acid
B. Intrinsic factor
C. Creatinine kinase
D. Chloride level
Answer: A. Uric acid
Rationale:
Increased uric acid levels are a hallmark of gout, as it results from the
accumulation of urate crystals in the joints.
23. A nurse is preparing to administer peritoneal dialysis to a client. Which of the
following actions should the nurse take?
A. Use clean technique to access the catheter
B. Chill the dialysate before administration
C. Hang the drainage bag below the client’s abdomen
D. Place the client in high-Fowler’s position.
Answer: C. Hang the drainage bag below the client’s abdomen
Rationale:
Hanging the drainage bag lower than the abdomen facilitates gravity drainage
during peritoneal dialysis.
24. A nurse in the emergency department is caring for a client who has deep partial
thickness burns over 30% of his body, including his upper chest and abdomen.
Which of the following actions is the nurse priority?
A. Insert an 18-gauge IV catheter
B. Administer tetanus toxoid
C. Check the clients mouth for black particles
D. Remove the clients burned clothing.
Answer: A. Insert an 18-gauge IV catheter
C. Check the clients mouth for black particles
Rationale:
Establishing IV access is crucial for fluid resuscitation in burn victims. Checking
for black particles could indicate smoke inhalation and necessitate further
assessment and intervention.
25. A nurse is presenting an in-service program about Parkinson’s disease (PD).
Which of the following statements should the nurse include in teaching?
A. PD results form a decreased amount of dopamine in the client’s brain
B. PD causes clients to have an increased sympathetic nervous system response
C. PD results in the development of neurofibrillary tangles within the client’s brain
D. PD manifestations worsen due to the clients decreased production of
acetylcholine
Answer: A. PD results form a decreased amount of dopamine in the client’s brain
Rationale:
Parkinson's disease is characterized by a deficiency of dopamine due to the
degeneration of dopaminergic neurons.
26. A nurse is caring for a client who has a serum sodium level of 150 mEq/L.
Which of the following actions should the nurse take?
A. Increase sodium in the client’s diet
B. Administer hypotonic IV fluids to the client
C. Restrict the client’s oral fluid intake
D. Administer a beta blocker
Answer: B. Administer hypotonic IV fluids to the client
Rationale:
Administering hypotonic fluids can help to lower sodium levels by diluting serum
sodium concentrations.
27. A nurse is caring for a client who takes lisinopril for hypertension. Which of
the following client statements indicates an adverse effect of the medication?
A. I seem to be bruising more easily
B. I have a nagging, dry cough
C. I have a heightened sense of taste
D. I have to urinate frequently
Answer: B. I have a nagging, dry cough
Rationale:
A persistent dry cough is a common side effect of ACE inhibitors like lisinopril
due to increased bradykinin levels.
28. A nurse is providing discharge teaching to a client following a modified left
mastectomy with breast expander. Which of the following statements by the client
indicates an understanding of the teaching?
A. I will perform strength-building arm exercises using a 15-pound weight
B. I should expect less than 25 mL of secretions per day in the drainage devices
C. I will keep my left arm flexed at the elbow as much as possible
D. I will have to wait 2 months before additional saline can be added to my breast
expander
Answer: B. I should expect less than 25 mL of secretions per day in the drainage
devices
Rationale:
Expecting less than 25 mL of output suggests proper healing post-surgery.
29. A nurse is caring for a client who has diabetes mellitus and has been following
a treatment plan for 3 months. Which of the following laboratory results should the
nurse monitor to determine long-term glycaemic control?
A. Oral glucose tolerance test results
B. Fasting blood glucose level
C. Glycosylated haemoglobin level
D. Postprandial blood glucose level
Answer: C. Glycosylated haemoglobin level
Rationale:
The haemoglobin A1c level provides an average blood glucose level over the past
2-3 months, indicating long-term glycaemic control.
30. A nurse is providing discharge teaching to a client who has chronic urinary
tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice
daily. Which of the following instructions should the nurse include in the teaching?
A. Take a laxative to prevent constipation
B. Drink 2 to 3 L of fluids daily
C. Take an antacid 30 min before taking the medication
D. Monitor heart rate once daily
Answer: B. Drink 2 to 3 L of fluids daily
Rationale:
Increasing fluid intake helps prevent crystalluria, a potential side effect of
ciprofloxacin.
31. A nurse is providing teaching to a client who has a deep-vein thrombosis
(DVT). Which of the following findings should the nurse identify as a risk factor
for the development of DVTs?
A. NSAID use
B. Cirrhosis
C. Hypertension
D. Oral contraceptive use
Answer: D. Oral contraceptive use
Rationale:
Oral contraceptive use is a known risk factor for the development of DVT due to
the oestrogen component, which can increase the risk of clot formation. Other
factors like NSAID use, cirrhosis, and hypertension are not direct risk factors for
DVT compared to hormonal therapy.
32. A nurse is caring for client who has Cushing’s disease. Which of the following
actions should the nurse take first? (Click on the Exhibit button below for
additional information about the client. There are three tabs that contain separate
categories of data.)
A. Auscultate the client’s lung sounds
B. Check the client’s medication administration record for antihypertensive
medications
C. Determine the need for further glucose monitoring
D. Verify the client’s understanding of sodium restriction
Answer: C. Determine the need for further glucose monitoring
Rationale:
Clients with Cushing's disease often have elevated cortisol levels, which can lead
to increased blood glucose levels. Monitoring glucose is crucial, especially if the
client is experiencing symptoms of hyperglycemia. While checking lung sounds
and medication records are important, the priority is ensuring that blood glucose
levels are managed.
33. A nurse is assessing a client who has nephrotic syndrome. Which of the
following findings should the nurse expect?
A. Proteinuria
B. Hyperalbuminemia
C. Flank pain
D. Hypotension
Answer: A. Proteinuria
Rationale:
Nephrotic syndrome is characterized by significant proteinuria due to increased
permeability of the glomerular membrane. This condition leads to a loss of protein
in the urine, while hyperalbuminemia, flank pain, and hypotension are not typical
findings associated with nephrotic syndrome.
34. A nurse is preparing to administer a 250 mL IV bolus of dextrose 5% in water
to infuse over 2 hr. for a client. The drop factor is 10 gtt./mL. The nurse should set
the pump to administer how many gtt./min? (Round the answer to the nearest
whole number. Use a leading zero if it applies. Do not use a trailing zero.)
_____________ gtt./min (change 2 hours to minutes =
Answer: 120 minutes) 250 mL x 10 gtts/mL = 21 gtts/mL.
120 mins.
Rationale:
Setting the correct drip rate is crucial to ensure that the patient receives the
intended volume of fluid within the prescribed time frame. Incorrect rates could
lead to fluid overload or inadequate hydration.
35. A nurse is assessing a client who has right-sided heart failure. Which of the
following assessment findings should the nurse expect to find?
A. Poor skin turgor
B. Pitting edema
C. Oliguria
D. S3/S4 galloping heart sounds
Answer: B. Pitting edema
Rationale:
Right-sided heart failure leads to fluid accumulation in the body due to the heart's
inability to effectively pump blood returning from the body. This results in
symptoms such as pitting edema, particularly in the lower extremities. Poor skin
turgor and oliguria are more indicative of dehydration, while S3/S4 heart sounds
can occur in various types of heart failure but are not specific to right-sided heart
failure.
36. A nurse is caring for a client who has a newly inserted chest tube. The nurse
should clarify which of the following prescriptions with the provider?
A. Administer morphine 2 mg IV bolus every 3 hr. PRN for pain
B. Vigorously strip the chest tube twice daily
C. Notify the provider when tidaling creases
D. Assist the client out of bed 3 times daily
Answer: A. Administer morphine 2 mg IV bolus every 3 hr. PRN for pain
Rationale:
Stripping a chest tube can create negative pressure and potentially damage lung
tissue. Instead, gentle milking of the tube may be appropriate if needed, but this
should be clarified with the provider. Administering morphine, notifying the
provider of tidaling, and assisting the client out of bed are acceptable practices in
this scenario.
37. A nurse is teaching a client who is taking an ACE inhibitor for heart failure.
Which of the following instructions should the nurse include for home
management of heart failure?
A. Limit daily activity
B. Obtain daily weight
C. Monitor intake and output
D. Use a salt substitute
Answer: B. Obtain daily weight
Rationale:
Daily weight monitoring is crucial for clients with heart failure to detect fluid
retention early. Significant weight gain can indicate worsening heart failure. While
limiting activity, monitoring intake/output, and using salt substitutes may also be
relevant, obtaining daily weight is a direct measure of fluid status.
38. A nurse is providing discharge teaching to a client who has a permanent
pacemaker. Which of the following statements by the client indicates an
understanding of the teaching?
A. I need to check my pulse rate every day for a full minute
B. When a microwave oven I in use, I need to stay out of the room
C. I need to maintain pressure over the pacemaker site with an elastic bandage
D. The pacemaker will deliver a shock if I develop a dysrhythmia
Answer: D. The pacemaker will deliver a shock if I develop a dysrhythmia
Rationale:
Clients with pacemakers should regularly monitor their pulse to ensure the device
is functioning correctly. Staying out of the microwave's range is not necessary,
maintaining pressure on the site is not recommended, and while some pacemakers
do deliver shocks for certain dysrhythmias, many are designed primarily to pace
rather than shock.
39. A nurse in a clinic is providing preventive teaching to an older adult client
during a well visit. The nurse should instruct the client that which of the following
immunizations are recommended for healthy adults after age 60? (Select all that
apply.)
A. Influenza
B. Human Papillomavirus
C. Meningococcal
D. Herpes Zoster
E. Pneumococcal polysaccharide
Answer: A. Influenza
D. Herpes Zoster
E. Pneumococcal polysaccharide
Rationale:
Healthy adults over 60 should receive the annual influenza vaccine, the herpes
zoster vaccine to prevent shingles, and the pneumococcal polysaccharide vaccine
to reduce the risk of pneumonia. The human papillomavirus (HPV) vaccine is not
typically recommended for adults over 26.
40. A nurse is assessing a client who is 4 hr. postoperative following arterial
revascularization of the left femoral artery. Which of the following findings should
the nurse repot to the provider immediately?
A. Urine output 150 mL over 4 hr.
B. Pallor in the affected extremity
C. Bruising around the incisional site
D. Temperature of 37.9 C (100.2 F)
Answer: B. Pallor in the affected extremity
Rationale:
Pallor in the affected extremity indicates possible compromised blood flow, which
is a critical concern after arterial revascularization. This could suggest an arterial
occlusion or other serious complications that require immediate intervention. The
other findings (urine output, bruising, and mild temperature elevation) are not as
urgent.
41. A nurse is caring for an older adult who has not been eating. Which of the
following findings indicate dehydration?
A. Capillary refill of 2 seconds
B. Engorged neck veins
C. Crackles auscultated bilaterally
D. Diminished peripheral pulses (thready pulse)
Answer: D. Diminished peripheral pulses (thready pulse)
Rationale:
Diminished or thready peripheral pulses can indicate dehydration due to decreased
blood volume and perfusion. Other options, like capillary refill of 2 seconds and
engorged neck veins, suggest adequate hydration or fluid overload, while crackles
auscultated bilaterally may indicate fluid in the lungs, not dehydration.
42. A nurse is preparing to discharge a client who has a halo device and is
reviewing prescriptions from the provider. The nurse should clarify which of the
following prescriptions with the provider?
A. May place a small pillow under the head when sleeping
B. Take tub baths instead of showers
C. Increase intake of fiber-rich foods.
D. May operate a motor vehicle when no longer taking analgesics
Answer: D. May operate a motor vehicle when no longer taking analgesics
Rationale:
Operating a motor vehicle is not safe until the provider confirms the client is stable
and has good motor and cognitive function, not just after stopping analgesics. The
other options are generally acceptable for a client with a halo device.
43. A nurse is assessing for early signs of compartment syndrome for a client who
has a short leg fiberglass cast. Which of the following findings should the nurse
expect?
A. Bounding distal pulses
B. Intense pain with movement
C. Capillary refill less than 2 seconds
D. Erythema of the toes
Answer: B. Intense pain with movement
Rationale:
Intense pain with movement is a hallmark sign of compartment syndrome,
indicating increased pressure in the muscle compartments. Bounding distal pulses
and capillary refill of less than 2 seconds are not consistent with compartment
syndrome, and erythema of the toes is not specific.
44. A nurse is caring for a client who is postoperative following coronary artery
bypass surgery and reports shortness of breath. The nurse administers oxygen at 3
L/min and obtains arterial blood gases 60 min later. Which of the following
laboratory findings indicates a positive response to the oxygen therapy?
A. pH 7.32
B. PaCO2 34 mm Hg
C. PaO2 90 mm Hg
D. Bicarbonate 20 mEq/L
Answer: C. PaO2 90 mm Hg
Rationale:
A PaO2 of 90 mm Hg indicates adequate oxygenation and is a positive response to
oxygen therapy. The other lab values (pH, PaCO2, and bicarbonate) do not
specifically indicate improvement in oxygenation status.
45. A nurse is preforming a cranial nerve assessment on a client following a head
injury. Which of the following findings should the nurse expect if the client has
impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
A. Loss of peripheral vision
B. Deviation of the tongue from midline
C. Disequilibrium with movement
D. Inability to smell
Answer: C. Disequilibrium with movement
Rationale:
The vestibulocochlear nerve (cranial nerve VIII) is responsible for hearing and
balance. Impaired function would lead to issues with balance, resulting in
disequilibrium. The other findings pertain to different cranial nerves.
46. A nurse is caring for a client admitted with a skull fracture. Which of the
following assessment findings should be of greatest concern to the nurse?
A. Bilateral pupil diameter changes from 4 to 2 mm
B. Glasgow Coma Scale score changes from 14 to 9
C. Pulse pressure changes from 30 to 20 mm/hg
D. WBC count changes from 9,000 to 16,000/mm3
Answer: A. Bilateral pupil diameter changes from 4 to 2 mm
Rationale:
A decrease in the Glasgow Coma Scale score indicates a worsening level of
consciousness, which is critical in a client with a skull fracture. While bilateral
pupil changes can be concerning, the GCS change is a more direct indicator of
neurological status.
47. A nurse is caring for a client who presents to the emergency department after
experiencing a heat stroke. Which of the following actions should the nurse take?
A. Administer an antipyretic
B. Apply a cooling blanket
C. Assess axillary temperature every 15 min.
D. Administer lactated Ringer’s
Answer: B. Apply a cooling blanket
Rationale:
Applying a cooling blanket is the most immediate and effective action to reduce
body temperature in a heat stroke scenario. Antipyretics are not effective for heat
stroke, and monitoring axillary temperature is less critical than immediate cooling.
48. A nurse is caring for a client who is taking furosemide. The client has a
potassium level of 3.1 mEq/L. Which of the following should the nurse assess
first?
A. Muscle weakness
B. Urine output
C. Level of orientation
D. Cardiovascular status
Answer: D. Cardiovascular status
Rationale:
With a potassium level of 3.1 mEq/L (hypokalaemia), assessing cardiovascular
status is critical, as low potassium can lead to arrhythmias and other serious
cardiovascular issues. While muscle weakness is also a concern, the cardiovascular
system is the priority.
49. A nurse is caring for a client who is scheduled for an abdominal paracentesis.
The nurse should plan to take which of the following actions?
A. Administer a stool softener following the procedure
B. Instruct the client to take deep breaths and hold them during the procedure
C. Assist the client into the left lateral position during the procedure
D. Ask the client to empty his bladder prior to the procedure
Answer: D. Ask the client to empty his bladder prior to the procedure
Rationale:
Emptying the bladder reduces the risk of bladder injury during the paracentesis and
also helps to create more space for fluid removal. The other actions are not
standard pre-procedure interventions.
50. A nurse is caring for a client who is 6 hr. postoperative following a
thyroidectomy. The client reports tingling and numbness in the hands. The nurse
should identify this as a sign of which of the following electrolyte imbalances?
A. Hypernatremia
B. Hypocalcaemia
C. Hypermagnesemia
D. Hypokalaemia
Answer: B. Hypocalcaemia
Rationale:
Tingling and numbness in the hands can indicate hypocalcaemia, which is a
common complication after thyroid surgery due to potential damage to the
parathyroid glands. The other electrolyte imbalances do not typically present with
these symptoms.
51. A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of
packed RBCs. Which of the following findings is an indication of a haemolytic
transfusion reaction?
A. Hypotension
B. Hypothermia
C. Bradypnea
D. Bradycardia
Answer: A. Hypotension
Rationale:
Hypotension is a key indicator of a haemolytic transfusion reaction, which occurs
due to the destruction of red blood cells. Other symptoms can include fever, chills,
and back pain, but hypotension is particularly significant.
52. A nurse in an emergency department is caring for a client who has sinus
bradycardia. Which of the following actions should the nurse take first?
A. Administer atropine to the client
B. Initiate IV therapy for the client
C. Measure the client’s blood pressure
D. Prepare the client for temporary pacing
Answer: A. Administer atropine to the client
Rationale:
Atropine is the first-line treatment for symptomatic bradycardia, as it increases
heart rate. Other actions like measuring blood pressure or initiating IV therapy may
be important, but atropine directly addresses the underlying issue.
53. A nurse is caring for a client who has a prescription to discontinue a
peripherally inserted central catheter. Which of the following should the nurse
take?
A. Place a dry sterile dressing to the site after removal
B. Measure the catheter after removal
C. Apply slight pressure when resistance is met
D. Remove the catheter with one continuous motion
Answer: B. Measure the catheter after removal
Rationale:
Measuring the catheter after removal ensures that the entire catheter has been
extracted and no fragments remain in the vascular system. A dry sterile dressing is
appropriate after removal, but measuring is essential for safety.
54. A nurse is assessing a client who has skeletal traction for a femoral fracture.
The nurse notes that the weights are resting on the floor. Which of the following
actions should the nurse take?
A. Remove one of the weights
B. Increase the elevation of the effected extremity
C. Pull the client up in bed
D. Tie knots in the ropes near the pulleys to shorten them
Answer: C. Pull the client up in bed
Rationale:
If weights are resting on the floor, it indicates inadequate traction. Pulling the
client up in bed helps maintain proper alignment and ensures that the weights are
effective. Removing weights or tying knots would not be appropriate actions.
55. A nurse is caring for a client who has a flail chest. Which of the following
actions should the nurse take?
A. Implement fluid restriction
B. Administer antibiotic medication
C. Administer acetaminophen orally
D. Provide humidified oxygen
Answer: D. Provide humidified oxygen
Rationale:
Providing humidified oxygen helps improve oxygenation and is crucial for a client
with flail chest, which can lead to respiratory distress. Fluid restriction and
antibiotics may be indicated later, but immediate oxygen support is essential.
56. A nurse is teaching a group of newly licensed nurses about acute respiratory
failure. Which of the following manifestations should the nurse include in the
teaching?
A. Hypocarbia
B. Hypoxemia
C. Hyperventilation
D. Hypovolemia
Answer: B. Hypoxemia
Rationale:
Hypoxemia, or low oxygen levels in the blood, is a key manifestation of acute
respiratory failure. Hyperventilation may occur in some cases, but hypoxemia is a
direct indication of inadequate respiratory function.
57. A nurse is caring for a client who is experiencing a seizure. Which of the
following actions should the nurse take first?
A. Clear items from the client’s surrounding area.
B. Obtain the client’s vital signs
C. Loosen the client’s restrictive clothing
D. Lower the client to the floor
Answer: D. Lower the client to the floor
Rationale:
Lowering the client to the floor helps prevent injury during a seizure. Clearing the
area and loosening clothing are also important, but safety is the priority.
58. A nurse is teaching a client who is receiving total parenteral nutrition at home
through a central venous access device about transparent dressing changes. Which
of the following instructions should the nurse include in the teaching?
A. Use clean technique when changing the dressing
B. Wear a mask during the dressing change
C. Replace the extension tubing with each dressing change
D. Change the dressing every 48hr.
Answer: B. Wear a mask during the dressing change
Rationale:
Wearing a mask during the dressing change helps prevent infection by reducing
airborne pathogens. Clean technique is important but not as protective as wearing a
mask, especially in an immunocompromised client.
59. A nurse is caring for a client in the emergency department who experienced a
full-thickness burn injury to the lower torso 1 hour ago. Which of the following
findings should the nurse expect?
A. Decreased respiratory rate
B. Urinary diuresis
C. Hypotension
D. Bradycardia
Answer: A. Decreased respiratory rate
Rationale:
After a significant burn injury, respiratory function may be compromised, leading
to a decreased respiratory rate. Hypotension is also common, but the respiratory
rate change is a direct indication of the body’s response to trauma.
60. A nurse in an emergency department is assessing a client who has cirrhosis of
the liver. Which of the following is a priority finding?
A. Yellow sclera
B. Mental confusion
C. Palmar erythema
D. Spider angiomas
Answer: B. Mental confusion
Rationale:
Mental confusion may indicate hepatic encephalopathy, a serious complication of
liver failure that requires immediate attention. While yellow sclera (jaundice) is
concerning, mental status changes suggest a more acute need for intervention.
61. A nurse is providing instructions about foot care for a client who has peripheral
arterial disease. The nurse should identify that which of the following statements
by the client indicates an understanding of the teaching?
A. I apply a lubricating lotion to the cracked areas on the soles of my feet every
morning
B. I use my heating pad on a low setting to keep my feet warm
C. I soak my feet in hot water before trimming my toenails
D. I rest in my recliner with my feet elevated for about an hour every afternoon
Answer: D. I rest in my recliner with my feet elevated for about an hour every
afternoon
Rationale:
Elevating the feet helps reduce swelling and improves circulation. Other options,
like applying lotion to cracked areas, using heating pads, and soaking feet, can lead
to complications like burns or infections.
62. A nurse is teaching a client who has a new prescription for (alendronate to
treat) osteoporosis. Which of the following instructions should the nurse include in
the teaching?
A. Swallow the medication with 120 mL (4oz) of water
B. Sit upright for 30 min. after taking the medication
C. Take the medication with lunch
D. Take the medication with a vitamin E supplement
Answer: B. Sit upright for 30 min. after taking the medication
Rationale:
Sitting upright helps prevent oesophageal irritation, which can occur with
alendronate. Taking it with food or other supplements can interfere with
absorption, and it should be taken with a full glass of water, not just 120 mL.
63. A nurse is teaching a client about using a metered-dose rescue inhaler. Which
of the follow statement should the nurse include in the teaching?
A. Exhale fully before bringing the inhaler to your lips
B. Do not shake your inhaler before use
C. Use peroxide to clean the mouthpiece of your inhaler
D. Depress the canister after you exhale
Answer: A. Exhale fully before bringing the inhaler to your lips
Rationale:
Exhaling fully helps ensure that the inhaler delivers the medication effectively into
the lungs. Shaking the inhaler is typically recommended for proper dosing, and
cleaning with peroxide is not advised.
64. A nurse is admitting a client to the emergency department after a gunshot
wound to the abdomen. Which of the following actions should the nurse take to
help prevent the onset of acute kidney failure?
A. Imitate beta blocker therapy
B. Administer IV fluids to the client
C. Insert a urinary catheter
D. Prepare the client for an intravenous pyelogram
Answer: B. Administer IV fluids to the client
Rationale:
Administering IV fluids helps maintain renal perfusion and prevent acute kidney
failure, especially after trauma. Other options are not immediately relevant for
preventing kidney injury.
65. A nurse is completing an assessment of an older adult client and notes reddened
areas over the bony prominences, but the client’s skin is intact. Which of the
following interventions should the nurse include in the plan of care?
A. Massage the reddened areas three times daily
B. Turn and reposition the client every 4 hr.
C. Support bony prominences with pillows
D. Apply an occlusive dressing
Answer: C. Support bony prominences with pillows
Rationale:
Supporting bony prominences helps alleviate pressure and prevent pressure ulcers.
Massaging reddened areas can cause further damage, and turning every 4 hours
may not be frequent enough.
66. A nurse is reviewing the medical record of a client who is to undergo open
heart surgery. Which of the following findings should the nurse report to the
provider as a contraindication to receive heparin?
A. Thrombocytopenia
B. COPD
C. Thalassemia
D. Rheumatoid arthritis
Answer: A. Thrombocytopenia
Rationale:
Thrombocytopenia (low platelet count) is a contraindication for heparin due to the
increased risk of bleeding. COPD, thalassemia, and rheumatoid arthritis are not
direct contraindications.
67. A nurse is caring for a client who as completed 10 daily cycles of total
parenteral nutrition (TPN). Which of the following findings indicates that the client
is receiving adequate TPN supplementation?
A. Weight gain of 9.1 kg (20 lb.)
B. BUN level of 15 mg/dL
C. Improved mobility
D. Potassium level of 2.5 mEq/L
Answer: A. Weight gain of 9.1 kg (20 lb.)
Rationale:
Significant weight gain indicates that the client is receiving adequate nutrition from
TPN. A BUN level of 15 mg/dL is within normal limits, and a potassium level of
2.5 mEq/L indicates deficiency.
68. A nurse is providing teaching to a client who is postoperative following a
partial glossectomy. Which of the following statements by the client indicates an
understanding of the teaching?
A. I will inspect my mouth once each week for sores
B. I will drink orange juice to increase my vitamin C intake
C. I will consume canned soap whenever sores appear in my mouth
D. I will rinse my toothbrush with hydrogen peroxide and water after each use
Answer: A. I will inspect my mouth once each week for sores
Rationale:
Regular inspection of the mouth for sores is essential for early detection of
complications. Other statements indicate inadequate understanding of care,
especially regarding hydration and mouth care.
69. A nurse is preforming an ear irrigation for a client. Which of the following
actions should the nurse take?
A. Use cool fluid for irrigation
B. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal
C. Tilt the client’s head 45 degrees
D. Point the tip of the syringe toward the top of the ear canal
Answer: D. Point the tip of the syringe toward the top of the ear canal
Rationale:
Pointing the tip upward helps avoid damaging the eardrum and facilitates effective
irrigation. Cool fluids can cause discomfort, and the tip should not be inserted
deeply into the ear.
70. A nurse is caring for a client who is receiving continuous bladder irrigation
following a transurethral resection of the prostate (TURP). The client reports sharp
lower abdominal pain. Which of the following actions should the nurse take first?
A. Administer PRN pain medication
B. Check the client’s urine output
C. Reposition the client in bed
D. Increase the client’s fluid intake
Answer: B. Check the client’s urine output
Rationale:
Checking urine output is essential to assess for potential complications, such as
bladder spasms or clots. While pain medication and repositioning may be
necessary later, urine output is the priority to ensure proper irrigation and drainage.
71. A nurse is providing teaching for a client who has diabetes mellitus about the
self-administration of insulin. The client has prescriptions for regular and NPH
insulins. Which of the following statements by the client indicates an
understanding of the teaching?
A. I will store prefilled syringes in the refrigerator with the needle pointed
downward
B. I will shake the NPH vial vigorously before drawing up the insulin
C. I will draw up the regular insulin into the syringe first (clear before cloudy)
D. I will insert the needle at a 15-degree angle
Answer: C. I will draw up the regular insulin into the syringe first (clear before
cloudy)
Rationale:
This statement indicates understanding of the correct technique for mixing insulins.
Regular insulin is clear and should be drawn up before NPH, which is cloudy.
72. A nurse is caring for a client who has systemic lupus erythematous. During
assessment, which of the following should the nurse expect to find?
A. Esophagitis
B. Tophi
C. Bull eye lesions
D. Joint inflammation
Answer: D. Joint inflammation
Rationale:
Joint inflammation is a common symptom of SLE. Other options, like esophagitis
and tophi, are not characteristic of lupus, and bull's-eye lesions are more associated
with Lyme disease.
73. A nurse is monitoring an older adult client who has an exacerbation of chronic
lymphocytic leukaemia. The nurse notes petechiae on the client’s skin.
A. Institute bleeding precautions
B. Determine the client’s blood type
C. Avoid administering IV pain medication
D. Implement airborne precautions
Answer: A. Institute bleeding precautions
Rationale:
Petechiae indicate potential bleeding due to low platelet counts, so bleeding
precautions are necessary to prevent haemorrhage.
74. A nurse is caring for a client who is receiving TPN nutrition (TPN). Which of
the following actions are appropriate? (Select all that apply.)
A. Increase the rate of infusion if administration is delayed
B. Monitor serum blood glucose during infusion
C. Infuse 0.9% sodium chloride if the solution is not available
D. Verify the solution with another RN prior to infusion
E. Obtain the client’s daily weight
Answer: A. Increase the rate of infusion if administration is delayed
E. Obtain the client’s daily weight
Rationale:
Monitoring blood glucose is crucial during TPN, verifying the solution ensures
safety, and daily weights help assess nutritional status. Increasing the rate of
infusion if delayed is incorrect practice, and infusing saline if TPN is unavailable
could lead to complications.
75. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the
following is the priority intervention by the nurse?
A. Begin bicarbonate continuous IV infusion
B. Administer 0.9% sodium chloride
C. Check potassium levels
D. Initiate a continuous IV insulin infusion
Answer: B. Administer 0.9% sodium chloride
Rationale:
Administering IV fluids, like 0.9% sodium chloride, is the priority in DKA to
rehydrate and help correct electrolyte imbalances before insulin administration.
76. A nurse is reviewing the laboratory results of a female client who ask about
acupuncture as treatment for chemotherapy-induced nausea and vomiting. Which
of the following laboratory results should the nurse identify as a contraindication
to receiving acupuncture?
A. Haemoglobin 12 g/dL
B. C-reactive protein 0.7 mg/dL
C. Platelets 160,000/mm3
D. Absolute neutrophil count 500/mm3
Answer: D. Absolute neutrophil count 500/mm3
Rationale:
A low absolute neutrophil count indicates severe immunosuppression, making
acupuncture contraindicated due to the risk of infection.
77. A nurse is caring for a client following a total knee arthroplasty. The client
reports a pain level of 6 on a pain scale of 0 to 10. Which of the following
interventions should the nurse take?
A. Gently massage the area around the client’s incision
B. Apply an ice pack to the client’s knee
C. Perform range of motion exercises to the client’s knee
D. Place pillows under the client’s knee
Answer: B. Apply an ice pack to the client’s knee
Rationale:
Applying ice can help reduce swelling and alleviate pain post-surgery. Other
options may not provide immediate pain relief and could potentially cause
discomfort.
78. A nurse is assessing a client who has heart failure and is receiving a loop
diuretic. Which of the following findings indicates hypokalaemia?
A. Muscle weakness
B. Hypertension
C. Positive Chvostek sign
D. Oliguria
Answer: A. Muscle weakness
Rationale:
Muscle weakness is a common sign of hypokalaemia. Hypertension, positive
Chvostek sign, and oliguria are not specific indicators of low potassium levels.
79. A nurse at a long-term facility is assessing an older adult client. Which of the
following findings should the nurse identify as an indication that the client has a
recall memory impairment?
A. Inability to state his current age
B. Inability to name the members of his family
C. Inability to count backwards from 10
D. Inability to state what he had for dinner last night
Answer: D. Inability to state what he had for dinner last night
Rationale:
This reflects an issue with recent memory or recall memory. The other options
suggest more significant cognitive impairment.
80. A nurse on an intensive care unit is planning care for a client who has increased
intra cranial pressure following a head injury. Which of the following IV
medications should the nurse plan to administer?
A. Chlorpromazine
B. Mannitol
C. Dobutamine
D. Propranolol
Answer: B. Mannitol
Rationale:
Mannitol is an osmotic diuretic used to reduce intracranial pressure by drawing
fluid out of the brain. Other medications listed are not indicated for managing ICP.
81. A nurse on a medical unit is planning care for a group of clients. Which of the
following clients should the nurse see first?
A. A client who has left-sided paralysis and slurred speech from a prior stroke
B. A client who has multiple sclerosis and reports ataxia and vertigo
C. A client who has thrombocytopenia and reports a nosebleed
D. A client who has chronic obstruction pulmonary disease and an oxygen
saturation of 89%
Answer: C. A client who has thrombocytopenia and reports a nosebleed
Rationale:
This client is at high risk for bleeding due to low platelet count, and a nosebleed
can lead to significant blood loss, requiring immediate attention.
82. A home care nurse is planning to use nonpharmacological pain relief measures
for an older adult who has sever chronic back pain. Which of the following
guidelines should the nurse use?
A. Discontinue opioids before trying nonpharmacological methods of pain relief
B. Pain relief from the use of heat and cold continues for several hours after
removal of the stimulus
C. Use imagery with clients who have difficulty with focus and concentration
D. Distraction changes the client’s perception of pain, but does not affect the cause
Answer: C. Use imagery with clients who have difficulty with focus and
concentration
Rationale:
Imagery can be an effective method for pain relief, even for those who struggle
with focus. Other options do not align with best practices for managing chronic
pain.
83. A nurse is providing teaching to a client who is to start furosemide therapy for
heart failure. Which of the following statements indicates that the client
understands a potential adverse effect of this medication?
A. I’m going to include more cantaloupe in my diet
B. I will try to limit foods that contain salt
C. I will check my pulse before I take the medication
D. I’ll check my blood pressure, so it doesn’t get too high
Answer: A. I’m going to include more cantaloupe in my diet
Rationale:
Furosemide can cause potassium loss; therefore, increasing potassium-rich foods
like cantaloupe is appropriate. The other options do not directly address the
medication's side effects.
84. A nurse is providing discharge teaching for a client who has HIV. Which of the
following information is the priority for the nurse to review with the client?
A. Describe your daily medication schedule
B. Name a few things you will change about your diet
C. List some ways you can cope with the stress of your illness
D. Tell me why it’s important to have your CD4+ count checked
Answer: A. Describe your daily medication schedule
Rationale:
Adherence to the medication schedule is critical for managing HIV and preventing
complications. Other aspects are important but do not take precedence over
medication compliance.
85. A nurse is caring for a client who has an endotracheal tube. Which of the
following actions should the nurse take to verify the tube placement?
A. Deflate the cuff to check for tube placement
B. Place the clients head and neck in a flexed position
C. Document the tube length where it passes the chin
D. Observe for symmetry of chest expansion
Answer: D. Observe for symmetry of chest expansion
Rationale:
Symmetrical chest expansion indicates proper placement of the endotracheal tube.
The other options do not effectively confirm tube placement.
86. A nurse in an emergency department is caring for a client who is receiving
treatment for excessive ingestion of antacids. The nurse should identify that this
client is at risk for which of the following acid-base imbalances?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Answer: D. Metabolic alkalosis
Rationale:
Excessive antacid ingestion can lead to metabolic alkalosis due to increased
bicarbonate levels. Other options do not apply to this scenario.
87. A nurse is assessing a client for a positive Chvostek’s sign following a
thyroidectomy. Which of the following areas on the client’s head should the nurse
tap to assess the client for tetany? (You will find hot spots to select in the artwork
below. Select only the hot spot that corresponds to your answer.) (The cheek area)
A. Forehead
B. Cheek
C. Jaw
D. Neck
Answer: B. Cheek
Rationale:
• Tapping the cheek to assess for Chvostek's sign tests the facial nerve, with a
positive sign indicating hypocalcaemia, often seen after thyroid surgery.
• A positive Chvostek’s sign is indicated by twitching of the facial muscles when
the facial nerve is tapped, which typically occurs at the cheek area. This sign can
suggest hypocalcaemia, which may occur after a thyroidectomy if the parathyroid
glands are inadvertently damaged.
88. A nurse is caring for a client who has advance liver disease. Which of the
following laboratory results should the nurse monitor when assessing this client?
A. Phosphate level
B. Serum troponin
C. Serum ammonia
D. Glucose level
Answer: C. Serum ammonia
Rationale:
Elevated serum ammonia is a concern in advanced liver disease as the liver is less
able to detoxify ammonia, leading to hepatic encephalopathy.
89. A nurse is caring for a client who has a pneumothorax and a chest tube with the
closed water-seal drainage system. Which of the following actions should the nurse
take?
A. Strip or clear the chest tube every 8 hours
B. Change the chest tube site dressing every 24 hr.
C. Empty the system at least every 8 hours
D. Refill the water chamber if the fluid level is low
Answer: A. Strip or clear the chest tube every 8 hours
Rationale:
It's important to maintain the water seal in the drainage system. The other actions
could disrupt the system's function or are not recommended practices.
90. a nurse in an emergency department is reviewing a client’s ECG reading.
Which of the following finding should the nurse identify as an indication that the
client has first-degree heart block?
A. Prolonged PR intervals
B. More P waves than QRS complexes
C. Non discernible P waves
D. No correlation between P and QRS waves
Answer: A. Prolonged PR intervals
Rationale:
First-degree heart block is characterized by a prolonged PR interval on the ECG,
indicating delayed conduction through the AV node.
91. A nurse is preparing to administer a unit of packed RBCs to a client who is
anaemic. Identify a sequence of steps the nurse should follow. (Move the steps into
the box on the right, placing them in order of performance. Use all the steps.)
A. Verify blood compatibility with another nurse
B. Remain with the client for the first 15 to 30 minutes of the infusion
C. Obtain the unit of packed RBCs from the blood bank
D. Initiate transfusion of the unit of packed RBCs
E. Obtain venous assess using a 19-gauge needle
Answer: Correct Orders:
E. Obtain venous assess using a 19-gauge needle
C. Obtain the unit of packed RBCs from the blood bank
A. Verify blood compatibility with another nurse
D. Initiate transfusion of the unit of packed RBCs
B. Remain with the client for the first 15 to 30 minutes of the infusion
Rationale:
This order ensures proper preparation and monitoring during the transfusion.
92. A nurse is teaching a client who is to begin chemotherapy about a peripherally
inserted central catheter (PICC). Which of the following statement should the
nurse include in the teaching?
A. We can draw blood samples from the PICC for diagnostics test
B. We will replace the PICC every month
C. We will change the dressing daily
D. We can measure your blood pressure in either arm
Answer: A. We can draw blood samples from the PICC for diagnostics test
Rationale:
PICC lines are used for long-term venous access, allowing for both medication
administration and blood sampling. The other options are incorrect regarding the
management of PICCs.
93. A nurse is assessing a client who has pyelonephritis and reports flank pain.
Which of the following actions should the nurse take?
A. Auscultate for a bruit over the costovertebral area.
B. Assist the client to a sitting position
C. Thump the area of tenderness directly with a closed fist
D. Percuss the side of tenderness first
Answer: C. Thump the area of tenderness directly with a closed fist
Rationale:
This method, known as costovertebral angle (CVA) tenderness assessment, helps
identify kidney inflammation or infection.
94. A nurse is assessing a client who has acute kidney injury failure. Which of the
following findings should the nurse report to the provider?
A. Peripheral pulses 2+ bilaterally
B. Creatinine 0.8 mL/dL
C. Urine specific gravity 1.045
D. Weight gain 1.1 kg (2.4 lb.) in 24 hr.
Answer: D. Weight gain 1.1 kg (2.4 lb.) in 24 hr.
Rationale:
Sudden weight gain can indicate fluid retention, a concern in acute kidney injury
that should be reported.
95. A nurse is caring for an older adult client who is 72 hr. postoperative following
a total hip arthroplasty. The client requires a PRN medication prior to ambulation.
Which of the following medications should the nurse anticipate administering?
A. Naproxen
B. Meperidine
C. Indomethacin
D. Oxycodone
Answer: D. Oxycodone
Rationale:
Oxycodone is an opioid pain reliever appropriate for managing postoperative pain
prior to ambulation.
96. A nurse is caring for a client who has Haemophiles influenza type B. Which of
the following types of isolation should the nurse implement?
A. Droplet
B. Airborne
C. Protective
D. Contact
Answer: A. Droplet
Rationale:
Haemophilus influenza type B is transmitted via respiratory droplets, necessitating
droplet precautions.
97. A nurse is providing discharge teaching to a client who has pulmonary
tuberculosis. Which of the following finding should the nurse include as an
indication the client is no longer infectious?
A. Negative sputum cultures for acid-fast bacillus
B. Positive QuantiFERON-TB Gold test
C. Mantoux skin test revealing an induration of less than 1 mm
D. Client no longer coughing up blood-tinged sputum
Answer: A. Negative sputum cultures for acid-fast bacillus
Rationale:
A negative sputum culture indicates that the client is no longer infectious, which is
critical for public health.
98. A nurse is working in the emergency department is caring for a client who has a
burn injury. After securing the client’s airway, which of the following interventions
should the nurse take first?
A. Cleanse the client’s wounds
B. Administer analgesic medication
C. Start an IV with a large-bore needle
D. Increase the room temperature
Answer: C. Start an IV with a large-bore needle
Rationale:
Establishing IV access is critical for fluid resuscitation in burn patients, which is
often the priority after securing the airway.
99. A nurse is caring for a client who has a central venous access device and notes
the tubing has become disconnected. The client develops dyspnea and tachycardia.
Which of the following actions should the nurse take first?
A. Obtain ABG values
B. Perform an ECG
C. Turn the client to his left side
D. Clamp the catheter
Answer: D. Clamp the catheter
Rationale:
Clamping the catheter immediately prevents air from entering the bloodstream,
which could lead to an air embolism.
100. A nurse is providing discharge teaching to a client who has an impaired
immune system due to chemotherapy. Which of the following information should
the nurse include in the teaching?
A. Change your pet’s litter box daily
B. Wash your perineal area two times each day with antimicrobial soap
C. Change the water in your drinking glass every 4 hours
D. Wash your toothbrush in the dishwasher once a month
Answer: B. Wash your perineal area two times each day with antimicrobial soap
Rationale:
Maintaining hygiene is vital for clients with impaired immune systems to reduce
the risk of infection. The other options present potential health risks.
