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VERSION 11
CHAPTER 2
What are the five level system of triage?
Answer: Level 1: Resuscitation
Level 2: Emergent
Level 3: Urgent
Level 4: Less urgent
Level 5: Nonurgent
Resuscitation requires what?
Answer: Immediate treatment to prevent death
What is required for nonurgent triage (level 5)?
Answer: Non-life threatening condition requiring simple evaluation and care management
What is the standard precaution for primary survey during triage?
Answer: Gloves
Gowns
Eye protection
Face masks
Shoe covers
What is the ABCDE principle?
Answer: Airway/Cervical Spine → brain injury/death = 3-5 min. if airway not patent.
Breathing → assess presence & effectiveness of breathing.
Circulation
Disability
Exposure
How to implement airway for patients who is unresponsive without suspicious of trauma?
Answer: Airway opened → head tilt, chin lift maneuver

How to implement airway for patients who is unresponsive WITH suspicious trauma?
Answer: Airway opened → modified jaw thrust maneuver
How is the modified jaw thrust maneuver performed?
Answer: Nurse place both hands on either side of the client’s head. Locate the connection
between maxilla and mandible. Lift the jaw superiorly while maintaining alignment of the
cervical spine.
During triage, what mask is given to patient who are spontaneously breathing?
Answer: Non-breather mask with 100% O2 source
What does the breathing assessment include?
Answer: Auscultation of breath sounds
Observation of chest expansion and respiratory effort
Notation of rate and depth of respiration
Identification of chest trauma
Assessment of tracheal position
Assessment of JVD
How to assess for circulation?
Answer: Nurse assess HR, BP, peripheral pulses, and capillary refill for adequate perfusion.
What are the precursor to shock that nurses need to be aware of?
Answer: Cardiac arrest
Myocardial dysfunction
Haemorrhage
What are some interventions that is geared toward restoring effective circulation?
Answer: • CPR
• Assess for external bleeding.
• Haemorrhage control
• Obtain IV access using large-bore IV catheters inserted into the antecubital fossa of both
arms, unless there is obvious injury to the extremity.
• Infuse isotonic IV fluids such as Lactated Ringer’s & 0.9% NaCl &/or Blood products.

What is shock?
Answer: Body response to inadequate tissue perfusion and oxygenation. It manifests with an
increase HR, hypotension and result in tissue ischemia and necrosis.
What are some intervention that can alleviate shock?
Answer: • Administer oxygen
• Apply pressure to obvious bleeding
• Elevate lower extremities to shunt blood to vital organs
• Administer IV fluids and blood products
• Monitor VS
• Remain with client and provide reassurance and support for anxiety.
What is the D portion of the ABCDE protocol during triage?
Answer: Disability → quick assessment to determine clients LOC
Ex: AVPU (Alert, Response to Voice, Responsive to pain, Unresponsive), GCS
What is the E portion of the ABCDE protocol during triage?
Answer: Exposure
What is the primary concern during the exposure phase during triage?
Answer: Hypothermia → pt. core temperature 35 degree Celsius (95-degree F.) or less.
Why hypothermia for trauma patients? Exposure, un-warmed oxygen, cold IV fluids
What can hypothermia eventually lead to?
Answer: Coma, hypoxemia, and acidosis
What is a contraindication in the first 6-8 hours after the bite (poisoning)?
Answer: A. Ice
B. Tourniquets
C. Heparin
D. Corticosteroids
Antivenom is effective when?

Answer: Within 4-12 hour and is based on type and severity of a snake bite
What is considered cardiac emergency?
Answer: • Cardiac arrest
• V. Fib
• Pulseless V. tach.
• V. Asystole
• Pulseless electrical activity (PEA)
What is a cardiac arrest?
Answer: Sudden cessation of cardiac function causes most commonly by V. fib. or V. sys.
What is Ventricular fibrillation?
Answer: Fluttering of the ventricles causing LOC, pulselessness, no breathing. Requires
collaborative care to defibrillate immediately using ACLS protocol.
What is pulseless V. tach.?
Answer: • Irritable firing of ectopic ventricular beats at a rate of 140 to 180/min.
• Pt. overtime become unconscious and deteriorate into V. fib.
What is v. asystole?
Answer: • Complete absence of electrical activity and ventricular mvmt of heart.
• Pt. complete cardiac arrest → requires implementation of BLS/ACLS protocol.
What is pulseless electrical activity (PEA)?
Answer: Rhythm appears to have electrical activity but is not sufficient to stimulate effective
cardiac contractions and requires implementation of BLS/ACLS protocol
What are the most common causes of pulseless electrical activity?
Answer:

What is an Alpha-1 Receptor site?
Answer: Activation of receptors in the arterioles of skin, viscera, mucous membranes, veins
→ vasoconstriction
What is Beta-1 Receptor site?
Answer: • Heart stimulation leads to increased HR, increased myocardial contractility,
increased rate of conduction through the AV node
• Activation of receptors in the kidney → release of renin
What is a Beta-2 receptor site?
Answer: A. Bronchial stimulation → bronchodilation
B. Activation of receptors in uterine smooth muscle → relaxation
C. Activation of receptors in the liver → breakdown of glycogen into glucose
D. Skeletal muscle receptor activation → muscle contraction → tremors
What is a dopamine receptor site?
Answer: Activation of receptors in the kidney → renal blood vessels to dilate.
What is the AHA ACLS protocol for VF or pulseless VT?
Answer: Initiate CPR BLS
Defibrillate
IV access
Administer IV → antidysrhythmic medication → epi. & vasopressin
Amiodarone HCL
Lidocaine HCL

Magnesium Sulphate
What is the AHA ACLS protocol for pulseless electrical activity (PEA)?
Answer: • Initiate CPR
• IF shockable rhythm, defibrillate
• IV access
• Consider most common cause
• Administer epi. 1 mg IVP q3-5 min.
What is the AHA ACLS protocol for Asystole?
Answer: • Initiate CPR
• IV access
• Give epi. 1mg IVP q3-4 min.
• Consider reversible causes
What is the post-resuscitation medication therapy following a successful cardiac arrest?
Answer: IV meds → catecholamine adrenergic effect (can’t be taken by the oral route, do not
cross the BBB, short duration of action) → Epi., Dopamine, Dobutamine
What is the contraindication/precaution for catecholamine?
Answer: • Pregnancy Risk Category C
• Tachydysrhythmias
• Ventricular fibrillation
• Hyperthyroidism
• Angina
• Hx MI
• HTN
• DM
How to treat extravasation with a local injection?
Answer: Alpha-adrenergic blocking agent → Phentolamine
Chapter 3: Neurologic Diagnostic Procedure

What is cerebral angiography?
Answer: • Visualization of the cerebral blood vessels
• Hides the bones, tissues from the images
• Detect defects, narrowing, or obstruction of arteries or blood vessels in brain
• Iodine-based contrast dye injected into artery

What is the indication of cerebral angiography?
Answer: • Assess blood flow to within the brain
• Identify aneurysms
• Vascularity of tumours
• Blood clots
• Administer chemotherapy
Pre-procedure for cerebral angiography?
Answer: • NPO 4-6 before
• Hx bleed, anticoagulants
• Assess BUN/serum creatinine
• Mild sedative before, during
What is the intra-procedure for cerebral angiography?
Answer: Important to stay still.
What is a CT scan?
Answer: Cross sectional images of the cranial activity

When do we do a CT scan on a patient?
Answer: Identify tumors, infarctions, detect abnormalities, monitor response to treatment,
and guide needles used for biopsies.
Education for pt. who are about to undergo a CT scan.
Answer: • NPO 4-6 hour prior
• No jewellery
• Monitor for any allergic reaction to iodine, changes kidney function
What is an electroencephalography?
Answer: • Non-invasive procedure assesses the electrical activity of the brain and is used to
determine if there are abnormalities in brain wave patterns.
• Procedure 1 hour, no risk associated with this procedure.

What does Glasgow Coma Scale calculate?
Answer: • Eye opening
• Verbal
• Motor

• Low score = bad
• High score = good
• Total score correlate with the degree or level of coma.
A GCS score 13 indicates what?
Answer: Minor head trauma
What is the range for normal ICP?
Answer: 10-15 mm Hg
What are some complications and nursing actions need to be considered for ICP monitoring?
Answer: • Bleed/Infection
• Surgical aseptic technique
• Perform sterile dressing changes per facility protocol
• Drainage system closed
• Limit monitoring 3-5 days
• Irrigate system only as needed
What is the indication for LP (spinal tap)?
Answer: • Detect some diseases (MS, syphilis, meningitis) infection and malignancies.
• Reduce CSF pressure → instil contrast medium or air for diagnostic tests
• Administer medication or chemotherapy directly into spinal fluid
If headache persists after LP procedure, what would be done?
Answer: • Epidural blood patch to seal hole in the dura if the headache persists.
• Encourage pt. lie flat in bed & provide fluids.
What is an MRI?
• Cross-sectional images of the cranial activity
• Images obtained using magnets → results in no complication with radiation. Makes is safer
for women who are pregnant.

When will a patient need an MRI testing?
Answer: • Detect abnormalities, monitor response to tx, guide needles used for biopsies.
• Discriminates soft tissue from tumor or bone → effective in determining tumor size/blood
vessel location.
What will be let our patient know prior to MRI?
Answer: No jewellery, any metals such as pacemaker, artificial valves, IU devices, aneurysm
clips
What is PET/SPECT scans?
Answer: 3 dimensional images of the head. Static (vessels) Functional (brain activity)
Can help determine the presence of dementia by the inability of the brain to respond to the
tracer.

What needs to be considered when pt. is about to undergo a PET/SPECT scan?

Answer: Hx DM → hypoglycaemia or hyperglycaemia due to tracer is glucose based and
short acting ( 65 yrs. old with no previous immunized or have Hx of disease
What is MCV4?
Answer: • Neisseria meningitidis
• Ensure adolescents receive vaccine on schedule and before living residential setting in
college
• Others live in communal living such as military
• Initial dose → healthy children 11-12, booster administered at age 16
What are the risk factors of meningitis?
Answer: • No vaccine for viral meningitis → West Nile, mumps, measles, herpes
• Direct contamination of spinal fluid
• Immunosuppression
• Invasive procedure, skull fracture, penetrating wound
• Environment → crowded places
What would be expected to see with meningitis pt.?
Answer: • Bad, constant HA
• Nuchal rigidity (stiff neck)
• Photophobia
What are the physical assessment finding of meningitis pt.?
Answer: • Fever, chills, N, V, altered LOC, DTR, tachycardia, seizures, red macular rash,
• + Kernig’s sign → resistance w/ pain w/ extension of client’s leg from a flexed position
• + Brudzinski’s sign → flexion of knees/hips occurring w/ deliberate flexion of client neck

What are the laboratory tests for meningitis?
Answer: • Urine, throat, nose, blood culture and sensitivity
• CBC → elevated WBC
What are some diagnostic procedures for meningitis?
Answer: • CSF analysis → cloudy (bacterial) or clear (viral)
• Elevated WBC, protein, CSF pressure
• Decreased glucose (bacterial)
• CT scan/MRI → identify increased ICP and/or an abscess
What are some nursing care for meningitis?
Answer: • Isolate client as soon as meningitis suspected – Droplet precaution until antibiotics
have been administered for 24 hr and oral and nasal secretions are no longer infectious. →
standard precaution
• Report meningococcal infections to the public health department.
• Minimize exposure to bright light.
• Maintain at bed rest with the head of the bed elevated to 30 degree.

• Monitor for increased ICP
• TELL THE pt. to avoid coughing and sneezing which increase ICP.
• Seizure precaution
• Replace fluid/electrolytes
• Older adults → secondary complications = pneumonia
What are the medications for meningitis?
Answer: • Ceftriaxone or cefotaxime in combination with Vancomycin. → bacterial
• Phenytoin → anticonvulsants given if ICP increases or client experiences a seizure
• Acetaminophen/Ibuprofen →analgesics for HA and/or fever.
• Ciprofloxacin/ Rifampin /Ceftriaxone → prophylactic antibiotics given to ind. In close
contact with the pt.
What are some complications with meningitis?
Answer: • Increase ICP
• SIADH
• Septic emboli
What is a sign of increased ICP?
Answer: • Decreased level of consciousness
• Pupillary changes
• Impaired extraocular movements
What are some nursing interventions to reduce ICP?
Answer: • Positioning with head of the bed elevation at 30 degree
• Avoid cough and strain
• Mannitol can be administered via IV
What is a sign of SIADH?
Answer: • Dilute blood, concentrated urine
• Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a condition in which
the body makes too much antidiuretic hormone (ADH). This hormone helps the kidneys
control the amount of water your body loses through the urine. SIADH causes the body to
retain too much water

What are the nursing interventions for SIADH?
Answer: • Administer Demeclocycline & restrict fluid
• Monitor weight daily
Chapter 6: Seizures and Epilepsy
Are substance withdrawal or fever considering an epilepsy?
Answer: No
What are the risk factors for seizures?
Answer: • Genetic
• Acute febrile state → infants/children <2
• Head trauma
• Cerebral edema
• Abrupt cessation of antiepileptic drugs
• Infection
• Metabolic disorder → hypoglycaemia/hyponatremia
• Exposure to toxins
• Stroke
• Heart disease
• Brain tumor
• Hypoxia
• Acute substance withdrawal
• Fluid and electrolyte imbalance
What triggers seizure?
Answer: • Increase physical activity
• Excessive stress
• Hyperventilation
• Overwhelming fatigue
• Acute alcohol ingestion
• Excessive caffeine intake
• Exposure to flashing lights

• Substances such as cocaine, aerosols, inhaled glue products
What would you find with a patient who has a generalized seizure?
Answer: • Both cerebral hemisphere
• Begin with aura
What is tonic-clonic seizure?
Answer: • Begins for only few seconds
• Incontinence

What is tonic episode?
Answer: • Stiffening of muscles and loss of consciousness
• Breathing can stop
What is clonic episode?
Answer: • 1-2 min
• Breathing irregular
• Cyanosis
What is tonic seizure?
Answer: • ONLY tonic phase is experienced; <30 seconds
• Sudden loss consciousness
• Sudden increased muscle tone
• Loss of consciousness

• Autonomic manifestations
What is clonic seizure?
Answer: • Lasts several minutes
• Muscle contract and relax
• ONLY clonic phase
What is myoclonic seizure?
Answer: • Brief jerking, stiffening of extremities
• Lasts for seconds
What is atonic or akinetic seizure?
Answer: • Few seconds in which muscle tone is lost
• Period of confusion
• Loss of muscle tone → fall risk
What are the laboratory tests for seizure?
Answer: • Alcohol, illicit substance levels
• HIV testing
• Excessive toxins
What are some diagnostic procedure?
Answer: • EEG
• CAT
• PET
• CSF
What medication given for seizure pt.?
Answer: • Phenytoin, antiepileptic drugs
• Avoid oral contraceptives → decrease effectiveness
• Other medications→ on notes
What is another therapeutic procedure for partial seizure?
Answer: • Vagal nerve stimulator → L chest wall, electrode, general anaesthesia, intermittent

• Avoid MRI, Ultrasound, microwave ovens, shortwave radios
What is status epilepticus?
Answer: Repeated seizure activity within 30 min. time frame lasting more than 5 min.
What is the complication for status epilepticus?
Answer: Decreased oxygen levels, inability brain to normal function, assault neuronal tissue
Status epilepticus
Answer: Need immediate treatment to prevent further permanent loss of brain function.
What are the usual causes of Status Epilepticus?
Answer: • Substance withdrawal
• Sudden withdrawal from AEDS
• Head injury
• Cerebral edema
• Infection
• Metabolic disturbances
What are some nursing actions for Status epilepticus?
Answer: • Maintain airway
• Provide oxygen
• Establish IV access
• Perform ECG monitoring, pulse oximetry, ABG results
• Administer Diazepam or Lorazepam IVP followed by IV Phenytoin or Fos phenytoin
Chapter 7: Parkinson’s Disease
What is the Parkinson’s Disease?
Answer: Progressively debilitating disease that grossly affects motor function.
What are the 4 primary s/s of PD?
Answer: • Tremor
• Muscle Rigidity

• Bradykinesia (slow movement)
• Postural instability
Why do these s/s occur?
Answer: Overstimulation of the basal ganglia by acetylcholine occurs because degeneration
of the substantia nigra results in decreased dopamine production. Allows acetylcholine to
dominate making smooth, controlled movement difficult.

What is the tx of PD focused on?
Answer: Increase amount of dopamine or decrease the amount of Acetylcholine in a client’s
brain
What are the risk factors of PD?
Answer: • Onset s/s between age 40-70
• More common in men
• Genetic predisposition
• Exposure to environmental toxins
• Chronic use of antipsychotic medication
What would you expect to find in PD patients?
Answer: • Report of fatigue
• Report of decreased manual dexterity over time

What are some physical assessment findings PD?
Answer: • Stooped pressure
• Slow, shuffling, propulsive gait
• Slow, monotonous speech
• Tremors/pill-rolling tremor of fingers
• Muscle rigidity
• Bradykinesia/akinesia
• Masklike expression
• Autonomic s/s → orthostatic hypotension, flushing, diaphoresis
• Difficulty chewing and swallowing
What are the lab tests for PD?
Answer: No definitive diagnostic procedure
Dx made based manifestations, progression, ruling out other diseases
What are the types of food necessary for PD?
Answer: Semisolid foods and thickened liquids
What are the five stages of Parkinson’s disease involvement?
Answer: Stage 1: Unilateral shaking or tremor or one limb
Stage 2: Bilateral limb involvement occurs, making walking and balance difficult
Stage 3: Physical movements slow down significantly, affecting walking more.
Stage 4: Tremors can decrease but akinesia and rigidity make day-to-day tasks difficult
Stage 5: Client unable to stand or walk, is dependent for all care and might exhibit dementia
What are dopamine agonists?
Answer: • Bromocriptine
• Ropinirole
• Pramipexole
• Role: activate release of dopamine
What would the nurse need to monitor for pt. taking Bromocriptine, Ropinirole,
Pramipexole?
Answer: • Orthostatic hypotension

• Dyskinesia
• Hallucinations
What anticholinergic drugs use for PD pt.?
Answer: • Benztropine
• Trihexyphenidyl
• Role: help control tremors and rigidity
What are the SE of anticholinergic drugs?
Answer: • Dry mouth
• Constipation, Urinary retention
• Acute confusion
What are the MAO-B inhibitors such as Selegiline and Rasagiline?
Answer: Increase dopamine levels, reduce wearing off phenomenon when administered
concurrently with levodopa.
What to considered with Selegiline and Rasagiline?
Answer: • Avoid foods high in tyramine → hypertensive crisis
• Administered Meperidine and Fluoxetine
What are antivirals drugs?
Answer: • Amantadine
• Role: release dopamine and prevent its reuptake
What to consider when taking Amantadine?
Answer: Discoloration of skin, anxiety, confusion, anti-cholinergic effects
Chapter 8: Alzheimer’s Disease
What is Alzheimer’s Disease?
Answer: No reversible type of dementia that progressively develops over many years.
What is dementia?

Answer: Multiple cognitive deficits that impair memory and can affect language, motor
skills, and/or abstract thinking
What is the survival rate?
Answer: 10 years → some 20 years
What is the age system?
Answer: 60s/70s
Dx as early as 65
What presence of protein increase the risk of AD?
Answer: Apolipoprotein
What are some nursing care for AD pt.?
Answer: • Check skin weekly for breakdown
• Use calendar to assist with orientation
• Stimulate memory by repeating the clients last statement
What medications given to Dementia pt.?
Answer: • Antipsychotics
• Antidepressants
• Anxiolytics
What medications given to AD pt.?
Answer: • Temporarily slow course disease and DO NOT work for all clients.
• Donepezil → prevent breakdown of Ach → increase amt of Ach = increase nerve impulses
at the nerve sites.
• Cholinesterase → help slow this process
What nursing consideration to focus on AD?
Answer: • Observe for frequent stools or upset stomach
• Monitor for dizziness or headache
• Caution with asthma or COPD → worsen lung problems

What are alternative therapy for AD?
Answer: • Estrogen therapy for women → prevent AD → not useful decrease s/s
• Ginkgo biloba → increase memory and blood circulation

ATI Med-Surg proctored Exam
Version 12
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home.
Which of the following instructions should the nurse include in the teaching?
A. Take temperature once a day.
B. Wash the armpits and genitals with a gentle cleanser daily.
C. Change the litter boxes while wearing gloves.
D. Wash dishes in warm water.
Answer: A. Take temperature once a day.
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious
and tenacious secretions. Which of the following is an acceptable method for the nurse to use
to thin this client's secretions?
A. Provide humidified oxygen.
B. Perform chest physiotherapy prior to suctioning.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.
Answer: A. Provide humidified oxygen.
Following admission, a client with a vascular occlusion of the right lower extremity calls the
nurse and reports difficulty sleeping because of cold feet. Which of the following nursing
actions should the nurse take to promote the client's comfort?
A. Rub the client's feet briskly for several minutes.
B. Obtain a pair of slipper socks for the client.
C. Increase the client's oral fluid intake.
D. Place a moist heating pad under the client's feet.
Answer: B. Obtain a pair of slipper socks for the client.

A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection
of the prostate (TURP). Which of the following is the priority finding for the nurse report to
the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
C. Thick, red-coloured urine
D. Pain level of 4 on a 0 to 10 rating scale
Answer: C. Thick, red-coloured urine
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of the
following adverse effects of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia
Answer: A. Shivering
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus.
Which of the following statements by the client indicates an understanding of the teaching?
A. "I will carry a complex carbohydrate snack with me when I exercise."
B. "I should exercise first thing in the morning before eating breakfast."
C. "I should avoid injecting insulin into my thigh if I am going to go running."
D. "I will not exercise if my urine is positive for ketones."
Answer: D. "I will not exercise if my urine is positive for ketones."
A nurse notes a small section of bowel protruding from the abdominal incision of a client
who is postoperative. After calling for assistance, which of the following actions should the
nurse take first?
A. Cover the client's wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client's vital signs.
D. Inform the client about the need to return to surgery.
Answer: A. Cover the client's wound with a moist, sterile dressing.

A nurse is collecting data from a client who has alcohol use disorder and is experiencing
metabolic acidosis. Which of the following manifestations should the nurse expect?
A. Cool, clammy skin.
B. Hyperventilation
C. Increased blood pressure
D. Bradycardia
Answer: B. Hyperventilation
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which
of the following should the nurse include in the teaching?
A. Avoid bending at the waist.
B. Remove the eye shield at bedtime.
C. Limit the use of laxatives if constipated.
D. Seeing flashes of light is an expected finding following extraction.
Answer: A. Avoid bending at the waist.
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily.
The client refuses breakfast and reports nausea. Which of the following actions should the
nurse take first?
A. Suggest that the client rests before eating the meal.
B. Request a dietary consult.
C. Check the client's vital signs.
D. Request an order for an antiemetic.
Answer: C. Check the client's vital signs.
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The
nurse suspects the client's wound is infected because the drainage from the dressing is yellow
and thick. Which of the following findings should the nurse report as the type of drainage
found?
A. Sanguineous
B. Serous
C. Serosanguineous
D. Purulent

Answer: D. Purulent
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To
prevent postoperative complications which of the following actions should be reinforced
during the teaching?
A. Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
B. Place the client’s affected leg into the CPM machine with the machine in the flexed
position.
C. Place the client into a high Fowler’s position when initiating the CPM exercises.
D. Align the joints of the CPM machine with the knee gatch in the client’s bed.
Answer: A. Administer an opioid analgesic to the client 30 min prior to initiating CPM
exercises.
A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
A. Dyspnoea
B. Barrel chest
C. Clubbing of the fingers
D. Shallow respirations
E. Bradycardia
Answer: A. Dyspnoea
B. Barrel chest
C. Clubbing of the fingers
D. Shallow respirations
A nurse is caring for a client who sustained a basal skull fracture. When performing morning
hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's
right nostril. Which of the following actions should the nurse take first?
A. Take the client's temperature.
B. Place a dressing under the client's nose.
C. Notify the charge nurse.
D. Test the drainage for glucose.
Answer: D. Test the drainage for glucose.

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize
that the client is at risk for autonomic dysreflexia. Which of the following interventions
should the nurse take to prevent autonomic dysreflexia?
A. Monitor for elevated blood pressure.
B. Provide analgesia for headaches.
C. Prevent bladder distention.
D. Elevate the client's head.
Answer: C. Prevent bladder distention.
A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the
following findings should the nurse expect the client to report?
A. Hot flashes
B. Recurrent urinary tract infections
C. Blood in the stool
D. Abnormal vaginal bleeding
Answer: D. Abnormal vaginal bleeding
A nurse is caring for a client following an open reduction and internal fixation of a fractured
femur. Which of the following findings is the nurse's priority?
A. Altered level of consciousness
B. Oral temperature of 37.7° C (100° C)
C. Muscle spasms
D. Headache
Answer: A. Altered level of consciousness
A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge
resection of the left lung and has a chest tube to suction. Which of the following is the
priority finding the nurse should report to the provider?
A. Abdomen is distended
B. Chest tube drainage of 70 mL in the last hour
C. Subcutaneous emphysema is noted to the left chest wall
D. Pain level of 6 on a 0 to 10 scale
Answer: A. Abdomen is distended

A nurse is reinforcing discharge teaching with a client about how to care for a newly created
ileal conduit. Which of the following instructions should the nurse include in the teaching?
A. Change the ostomy pouch daily.
B. Empty the ostomy pouch when it is 2/3 full.
C. Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
D. Apply lotion to the peristomal skin when changing the ostomy pouch.
Answer: A. Change the ostomy pouch daily.
A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland.
Which of the following actions should the nurse include in the plan?
A. Position the client supine while in bed.
B. Change the nasal drip pad as needed.
C. Encourage frequent brushing of teeth.
D. Encourage the client to cough every 2 hr following surgery.
Answer: B. Change the nasal drip pad as needed.
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily
following a myocardial infarction. The nurse should instruct the client that aspirin is
prescribed for clients who have coronary artery disease for which of the following effects?
A. To provide analgesia
B. To reduce inflammation
C. To prevent blood clotting
D. To prevent fever
Answer: C. To prevent blood clotting
A nurse is collecting data from a client who has open-angle glaucoma. Which of the
following findings should the nurse expect?
A. Loss of peripheral vision
B. Headache
C. Halos around lights
D. Discomfort in the eyes
Answer: A. Loss of peripheral vision

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following
data collection findings should the nurse identify as the priority?
A. Weight loss of 3% of total body weight.
B. Blood glucose 150 mg/dL.
C. Potassium 2.5 mEq/L
D. Urine specific gravity 1.035
Answer: C. Potassium 2.5 mEq/L
A nurse is reinforcing discharge teaching with a client who had a total abdominal
hysterectomy and a vaginal repair. Which of the following statements by the client indicates a
need for further teaching?
A. "I should increase my intake of protein and vitamin C."
B. "I will no longer have menstrual periods."
C. "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience
discomfort."
D. "I will take a tub bath instead of a shower."
Answer: D. "I will take a tub bath instead of a shower."
A nurse is assisting with the care of a client who has a femur fracture and is in skeletal
traction. Which of the following actions should the nurse take?
A. Loosen the knots on the ropes if the client is experiencing pain.
B. Ensure the client’s weights are hanging freely from the bed.
C. Check the client’s bony prominences every 12 hr.
D. Cleanse the client’s pin sites with povidone-iodine.
Answer: B. Ensure the client’s weights are hanging freely from the bed.
A nurse in a provider’s office is reinforcing teaching with a client who has anaemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include?
A. Take this medication between meals.
B. Limit intake of Vitamin C while taking this medication.
C. Take this medication with milk.
D. Limit intake of whole grains while taking this medication.
Answer: A. Take this medication between meals.

A nurse in a provider’s office is reinforcing teaching with a client who has anaemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include?
A. Take this medication between meals.
B. Limit intake of Vitamin C while taking this medication.
C. Take this medication with milk.
D. Limit intake of whole grains while taking this medication.
Answer: A. Take this medication between meals.
A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the
following interventions should the nurse recommend?
A. Apply topical antifungal agents.
B. Apply fresh ice packs every 4 hr.
C. Wash daily with an antibacterial soap.
D. Keep draining lesions uncovered to air dry.
Answer: C. Wash daily with an antibacterial soap
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy
established. Which of the following instructions should the nurse include in the teaching?
A. Empty the pouch immediately after meals.
B. Change the entire appliance once a day.
C. Limit fluid intake.
D. Avoid medications in capsule or enteric form.
Answer: D. Avoid medications in capsule or enteric form.
A nurse is caring for a client with severe burns to both lower extremities. The client is
scheduled for an escharotomy and wants to know what the procedure involves. Which of the
following statements is appropriate for the nurse to make?
A. "An escharotomy surgically removes dead tissue."
B. "A cannula will be inserted into the bone to infuse fluids and antibiotics."
C. "A piece of skin will be removed and grafted over the burned area."
D. "Large incisions will be made in the burned tissue to improve circulation."
Answer: D. "Large incisions will be made in the burned tissue to improve circulation."

A nurse is collecting data from a client who has a possible cataract. Which of the following
manifestations should the nurse expect the client to report?
A. Decreased colour perception
B. Loss of peripheral vision
C. Bright flashes of light
D. Eyestrain
Answer: A. Decreased colour perception
A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is
receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the
following interventions should the nurse include in the plan of care?
A. Measure abdominal girth daily.
B. Use sterile water to irrigate the nasogastric tube.
C. Maintain the client in Fowler’s position.
D. Moisten the client’s lips with lemon-glycerine swabs.
Answer: C. Maintain the client in Fowler’s position.
A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
A. Buffalo hump
B. Purple striations
C. Moon face
D. Tremors
E. Obese extremities
Answer: A. Buffalo hump
B. Purple striations
C. Moon face
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the
following actions should the nurse take?
A. Provide a diet high in protein.
B. Provide ibuprofen for retroperitoneal discomfort.
C. Monitor intake and output hourly

D. Encourage the client to consume at least 2 L of fluid daily.
Answer: C. Monitor intake and output hourly
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has
upper gastric pain. Which of the following statements should the nurse include in the
teaching?
A. "A flexible tube is introduced through the nose during the procedure."
B. "During the procedure you are in a sitting position."
C. "You will remain NPO for 8 hours before the procedure."
D. "You will be awake while the procedure is performed."
Answer: C. "You will remain NPO for 8 hours before the procedure."
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours
following a generalized tonic-colonic seizure. Which of the following descriptions should the
nurse use when documenting this finding in the medical record?
A. Aura phase
B. Presence of automatisms
C. Postictal phase
D. Presence of absence seizures
Answer: C. Postictal phase
A nurse is reinforcing teaching with a client who reports right shoulder pain following a
laparoscopic cholecystectomy. Which of the following statements should the nurse make?
A. "The pain results from lying in one position too long during surgery."
B. "The pain occurs as a residual pain from cholecystitis."
C. "The pain will dissipate if you ambulate frequently."
D. "The pain is caused from the nitrous dioxide injected into the abdomen."
Answer: C. "The pain will dissipate if you ambulate frequently."
A nurse is checking the suction control chamber of a client's chest tube and notes that there is
no bubbling in the suction control chamber. Which of the following actions should the nurse
take?
A. Notify the provider.
B. Verify that the suction regulator is on.

C. Continue to monitor the client because this is an expected finding.
D. Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Answer: A. Notify the provider.
Rationale: The nurse should check for kinks and take other measures before notifying the
provider.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)
A. Encourage fluid intake.
B. Monitor the puncture site for hematoma.
C. Insert a urinary catheter.
D. Elevate the client’s head of bed.
E. Apply a cervical collar to the client.
Answer: A. Encourage fluid intake.
B. Monitor the puncture site for hematoma.
A nurse is assisting with the care of a client who is postoperative following surgical repair of
a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The
nurse should recognize which of the following is the priority action?
A. Relieve the client's pain.
B. Check the client’s pressure points for redness.
C. Provide oral hygiene.
D. Prevent aspiration.
Answer: D. Prevent aspiration.
A nurse is collecting data from a client who has scleroderma. Which of the following findings
should the nurse expect?
A. A dry raised rash
B. Excessive salivation
C. Periorbital edema
D. Hardened skin
Answer: D. Hardened skin

A nurse is caring for an older adult client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
A. Instruct the client to tilt her head back when she swallows.
B. Place food on the left side of the client's mouth.
C. Add thickener to fluids.
D. Serve food at room temperature.
Answer: C. Add thickener to fluids.
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head,
neck, and chest. The nurse should recognize which of the following is the priority risk to the
client?
A. Airway obstruction
B. Infection
C. Fluid imbalance
D. Contractures
Answer: A. Airway obstruction
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis
and is to start taking neostigmine. Which of the following instructions should the nurse
include in the teaching?
A. Take the medication 45 minutes before eating.
B. Expect diaphoresis as a side effect of the neostigmine.
C. If a medication dose is missed, wait until the next scheduled dose to take the medication.
D. Treat nasal rhinitis with an over-the-counter antihistamine.
Answer: A. Take the medication 45 minutes before eating.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection
of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse
notes there has not been any urinary output in the last hour. Which of the following actions
should the nurse perform first?
A. Notify the provider.
B. Administer a prescribed analgesic.
C. Offer oral fluids.
D. Determine the patency of the tubing.

Answer: A. Notify the provider.
D. Determine the patency of the tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear
about the procedure and asks the nurse if the biopsy will hurt. Which of the following
responses should the nurse make?
A. "You must be very worried about what the biopsy will show."
B. "You'll be asleep for the whole biopsy procedure and won't be aware of what’s happening."
C. "Your provider scheduled this, so she will want to know you still have questions about the
procedure."
D. "The biopsy can be uncomfortable, but we will try to keep you as comfortable as
possible."
Answer: D. "The biopsy can be uncomfortable, but we will try to keep you as comfortable as
possible."
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric
stroke. Which of the following interventions should the nurse include in the plan?
A. Control impulsive behavior.
B. Compensate for left visual field deficits.
C. Re-establish communication.
D. Improve left-side motor function.
Answer: C. Re-establish communication.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should
monitor the client for which of the following manifestations?
A. Hypotension
B. Polyphagia
C. Hyperglycaemia
D. Bradycardia
Answer: A. Hypotension
A nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH 7.22

PaCO2 68 mm Hg
Base excess -2
PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: B. Respiratory acidosis
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The
nurse should recognize that which of the following statements by the client indicates a need
for further teaching?
A. "I will avoid crossing my legs at the knees."
B. "I will use a thermometer to check the temperature of my bath water."
C. "I will not go barefoot."
D. "I will wear stockings with elastic tops."
Answer: D. "I will wear stockings with elastic tops."
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's
disease. The client becomes agitated and combative when the nurse approaches him. Which
of the following actions should the nurse plan to take?
A. Turn the water on and ask the client to test the temperature.
B. Obtain assistance to place mitten restraints on the client.
C. Firmly tell the client that good hygiene is important.
D. Calmly ask the client if he would like to listen to some music.
Answer: D. Calmly ask the client if he would like to listen to some music.
A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is
covered with soft, red tissue that bleeds easily. The nurse should recognize this is a
manifestation of which of the following?
A. Decreased perfusion

B. Infection
C. Granulation tissue
D. An inflammatory response
Answer: C. Granulation tissue
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3.
Which of the following food items brought by the family should the nurse prohibit from
being given to the client?
A. Baked chicken
B. Bagels
C. A factory-sealed box of chocolates
D. Fresh fruit basket
Answer: D. Fresh fruit basket
A nurse is contributing to the plan of care for an older adult client who is postoperative
following a right hip arthroplasty. Which of the following interventions should the nurse
include in the plan?
A. Perform the client's personal care activities for her.
B. Limit the client’s fluid intake.
C. Monitor the Homan’s sign.
D. Maintain abduction of the right hip.
Answer: D. Maintain abduction of the right hip.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the
following actions should the nurse take first?
A. Establish IV access.
B. Feel for a carotid pulse.
C. Establish an open airway.
D. Auscultate for breath sounds.
Answer: B. Feel for a carotid pulse.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is
no longer certain he wants to have the procedure. Which of the following responses should
the nurse make?

A. "Why have you changed your mind about the surgery?"
B. "Bypass surgery must be very frightening for you."
C. "Your provider would not have scheduled the surgery unless you needed it."
D. "I will call your doctor and have him discuss your surgery with you."
Answer: B. "Bypass surgery must be very frightening for you."
A nurse is caring for a client who is postoperative following foot surgery and is not to bear
weight on the operative foot. The nurse enters the room to discover the client hopped on one
foot to the bathroom, using an IV pole for support. Which of the following actions should the
nurse take?
A. Walk the client back to bed immediately and get the client a bedpan.
B. Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
C. Warn the client she might have to be restrained if she gets up without assistance.
D. Keep the bathroom door open to ensure the client is okay.
Answer: B. Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
A nurse is assisting with the care of a client who is postoperative and has a closed-wound
drainage system in place. Which of the following actions should the nurse take?
A. Fully recollapse the reservoir after emptying it.
B. Empty the reservoir once per day.
C. Replace the drainage plug after releasing hand pressure on the device.
D. Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
Answer: A. Fully recollapse the reservoir after emptying it.
A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will not eat fried foods."
B. "I will abstain from sexual intercourse."
C. "I will refrain from international travel."
D. "I will not order a salad in a restaurant."
Answer: B. "I will abstain from sexual intercourse."

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client
diagnosed with emphysema. Which of the following instructions should be included in the
teaching?
A. Rest in a supine position.
B. Consume a low-protein diet.
C. Breathe in through her nose and out through pursed lips.
D. Limit fluid intake throughout the day.
Answer: C. Breathe in through her nose and out through pursed lips.
A nurse is caring for a client who is postoperative and has a history Addison's disease. For
which of the following manifestations should the nurse monitor?
A. Hypernatremia
B. Hypotension
C. Bradycardia
D. Hypokalemia
Answer: B. Hypotension
A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is
to take hydroxyzine preoperatively. Which of the following effects of the medication should
the nurse include in the teaching? (Select all that apply.)
A. Decreasing anxiety
B. Controlling emesis
C. Relaxing skeletal muscles
D. Preventing surgical site infections
E. Reducing the amount of narcotics needed for pain relief
Answer: A. Decreasing anxiety
B. Controlling emesis
E. Reducing the amount of narcotics needed for pain relief
A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The
nurse should reinforce to the client to take which of the following dietary supplements with
this medication?
A. Vitamin D
B. Vitamin A

C. Iron
D. Niacin
Answer: C. Iron
A nurse is caring for a client after a radical neck dissection. To which of the following should
the nurse give priority in the immediate postoperative period?
A. Malnourishment related to NPO status and dysphagia
B. Impaired verbal communication related to the tracheostomy
C. High risk for infection related to surgical incisions
D. Ineffective airway clearance related to thick, copious secretions
Answer: D. Ineffective airway clearance related to thick, copious secretions
A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8
who is admitted for comprehensive rehabilitation. Which of the following long-term goals is
appropriate with regard to the client's mobility?
A. Walk with leg braces and crutches.
B. Drive an electric wheelchair with a hand-control device.
C. Drive an electric wheelchair equipped with a chin-control device.
D. Propel a wheelchair equipped with knobs on the wheels.
Answer: D. Propel a wheelchair equipped with knobs on the wheels.
A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the
following risk factors should the nurse identify as the leading cause of non-melanoma skin
cancer?
A. Exposure to environmental pollutants
B. Sun exposure.
C. History of viral illness
D. Scars from a severe burn
Answer: B. Sun exposure.
Based on a client's recent history, a nurse suspects that a client is beginning menopause.
Which of the following questions should the nurse ask the client to help confirm the client is
experiencing manifestations of menopause?
A. "Do you sleep well at night?"

B. "Have you been experiencing chills?"
C. "Have you experienced increased hair growth?"
D. "When did you begin your menses?"
Answer: A. "Do you sleep well at night?"
A nurse is reinforcing teaching with a client about cancer prevention and plans to address the
importance of foods high in antioxidants. Which of the following foods should the nurse
include in the teaching?
A. Cottage cheese
B. Fresh berries
C. Bran cereal
D. Skim milk
Answer: B. Fresh berries
A nurse is assisting with caring for a client who has a new concussion following a motorvehicle crash. The nurse should monitor the client for which of the following manifestations
of increased intracranial pressure?
A. Polyuria
B. Battle's sign
C. Nuchal rigidity
D. Lethargy
Answer: D. Lethargy
A nurse is reinforcing teaching about a tonometry examination with a client who has
manifestations of glaucoma. Which of the following statements should the nurse include in
the teaching?
A. "Tonometry is performed to evaluate peripheral vision."
B. "This test will diagnose the type of your glaucoma."
C. "Tonometry will allow inspection of the optic disc for signs of degeneration."
D. "This test will measure the intraocular pressure of the eye."
Answer: D. "This test will measure the intraocular pressure of the eye."

A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a
kidney transplant. Which of the following laboratory findings should the nurse identify as the
most important to report to the provider?
A. Increase in serum glucose
B. Increase in serum creatinine
C. Decrease in white blood cell count
D. Decrease in platelets
Answer: B. Increase in serum creatinine
72. A nurse is checking for paradoxical blood pressure on a client who has constrictive
pericarditis. Which of the following findings should the nurse expect?
A. Apical pulse rate different than the radial pulse rate
B. Increase in heart rate by 20% when standing
C. Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position
D. Drop in systolic BP more than 10 mm Hg on inspiration
Answer: D. Drop in systolic BP more than 10 mm Hg on inspiration
A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client
entering the room of another client, who becomes upset and frightened. Which of the
following actions should the nurse take?
A. Attempt to determine what the client was looking for.
B. Explain the client’s Alzheimer’s diagnosis to the frightened client.
C. Reprimand the client for invading the other client's privacy.
D. Ask the client to apologize for his behavior.
Answer: A. Attempt to determine what the client was looking for.
A nurse is caring for a client immediately following a cardiac catheterization with a femoral
artery approach. Which of the following actions should the nurse take?
A. Check pedal pulses every 15 min.
B. Perform passive range-of-motion for the affected extremity.
C. Remind the client not to turn from side to side.
D. Keep the client in high-Fowler's position for 6 hr.
Answer: A. Check pedal pulses every 15 min.

A nurse is assisting with planning an immunization clinic for older adult clients. Which of the
following information should the nurse plan to include about influenza?
A. Individuals at high risk should receive the live influenza vaccine.
B. Immunization for influenza should be repeated every 10 years.
C. The composition of the influenza vaccine changes yearly.
D. The influenza vaccine is necessary only for clients who have never had influenza.
Answer: C. The composition of the influenza vaccine changes yearly.
A nurse is caring for an older adult client who has colon cancer. The client asks the nurse
several questions about his treatment plan. Which of the following actions should the nurse
take?
A. Tell the client to have a family member call the provider to ask what options he plans to
recommend.
B. Assure the client that the provider will tell him what is planned.
C. Help the client write down questions to ask his provider.
D. Provide the client with a pamphlet of information about cancer.
Answer: C. Help the client write down questions to ask his provider.
A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is
distressed over his mother's crying and condition. Which of the following responses should
the nurse make?
A. "If you just sit quietly with your mother, I'm sure she will calm down."
B. "I'll talk with your mother and see if I can comfort her."
C. "It must be hard to see your mother so ill and upset."
D. "Your mother's crying seems to bother you more than it does her."
Answer: C. "It must be hard to see your mother so ill and upset."
A nurse is reinforcing teaching with the family of a client who has primary dementia. Which
of the following manifestations of dementia should the nurse include in the teaching?
A. Temporary, reversible loss of brain function
B. Forgetfulness gradually progressing to disorientation
C. Sleeping more during the day than nighttime
D. Hyper vigilant behaviours
Answer: B. Forgetfulness gradually progressing to disorientation

A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the
following interventions should the nurse include in the plan?
A. Limit fluid intake.
B. Monitor client’s cardinal fields of vision.
C. Encourage ambulation.
D. Ensure the room is brightly lit.
Answer: B. Monitor client’s cardinal fields of vision.
A nurse is contributing to the plan of care for a client who is admitted with a deep vein
thrombosis (DVT) of the left leg. Which of the following interventions should the nurse
include in the plan?
A. Apply ice to the extremity
B. Monitor platelet levels
C. Restrict oral fluids
D. Administer vasodilating medications
Answer: B. Monitor platelet levels
A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a
close family contact tests positive. Which of the following measures should the nurse
anticipate preparing for this client?
A. Tuberculin skin test
B. Sputum culture for acid fast bacillus (AFB)
C. Bacille Calmette-Guérin (BCG) vaccine
D. Chest x-ray
Answer: D. Chest x-ray
A nurse is reviewing data for a client who has a head injury. Which of the following findings
should indicate to the nurse that the client might have diabetes insipidus?
A. Serum sodium 145 mEq/L
B. Urine specific gravity 1.028
C. Urine output 650 mL/hr
D. Blood glucose 198 mg/dL
Answer: C. Urine output 650 mL/hr

A nurse is caring for a client who has recurrent kidney stones and a history of diabetes
mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should
collect additional data about which of the following statements made by the client?
A. "I took a laxative yesterday."
B. "I took my metformin before breakfast."
C. "I haven't had anything to eat or drink since last night."
D. "The last time I voided it was painful."
Answer: B. "I took my metformin before breakfast."
A nurse is collecting data from a client who is having an acute asthma exacerbation. When
auscultating the client's chest, the nurse should expect to hear which of the following sounds?
A. Expiratory wheeze
B. Pleural friction rub
C. Fine rales
D. Rhonchi
Answer: A. Expiratory wheeze
A nurse is planning to change an abdominal dressing for a client who has an incision with a
drain. Which of the following actions should the nurse plan to take?
A. Remove the entire dressing at once.
B. Loosen the dressing by pulling the tape away from the wound.
C. Don clean gloves to remove the dressing.
D. Open sterile supplies before removing the dressing.
Answer: C. Don clean gloves to remove the dressing.
A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the
following positions should the nurse place the client for the procedure?
A. Prone with arms raised over the head.
B. Sitting, leaning forward over the bedside table.
C. High Fowler’s position
D. Side-lying with knees drawn up to the chest.
Answer: B. Sitting, leaning forward over the bedside table.

A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following
reactions from the client should the nurse initially expect?
A. Denial
B. Bargaining
C. Acceptance
D. Anger
Answer: A. Denial
A nurse is contributing to the plan of care for a client who is postoperative following
peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction
and closed-suction drains in place. Which of the following interventions should the nurse
include in the plan?
A. Irrigate the nasogastric tube with tap water.
B. Mark abdominal girth once daily.
C. Ambulate the client twice daily.
D. Place the client in a high Fowler’s position.
Answer: D. Place the client in a high Fowler’s position.
A nurse is caring for a client who is receiving haemodialysis. Which of the following client
measurements should the nurse compare before and after dialysis treatment to determine fluid
losses?
A. Neck vein distention
B. Blood pressure
C. Body weight
D. Abdominal girth
Answer: C. Body weight
A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min
following the start of the transfusion, the nurse notes that the client is flushed and febrile, and
reports chills. To help confirm that the client is having an acute haemolytic transfusion
reaction, the nurse should observe for which of the following manifestations?
A. Urticaria
B. Muscle pain
C. Hypotension

D. Distended neck veins
Answer: C. Hypotension
A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The
nurse should recognize the client is experiencing which of the following conditions?
A. A continuous seizure state in which seizures occur in rapid succession
B. A sensory warning that a seizure is imminent
C. A period of sleepiness following the seizure during which arousal is difficult
D. A brief loss of consciousness accompanied by staring
Answer: B. A sensory warning that a seizure is imminent
A nurse is caring for a client who just had cataract surgery. Which of the following comments
from the client should the nurse report to the provider?
A. "The bright light in this room is really bothering me."
B. "My eye really itches, but I'm trying not to rub it."
C. "It's really hard to see with a patch on one eye."
D. "I need something for the horrible pain in my eye."
Answer: D. "I need something for the horrible pain in my eye."
A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if
there will be a lot of pain during the procedure. Which of the following responses should the
nurse make?
A. "You shouldn't feel any pain since the local area is anesthetized."
B. "Most clients report more discomfort from the preparation than from the procedure itself."
C. "You may feel some cramping during the procedure."
D. "Don't worry; you won't remember anything about the procedure due to the effects of the
medication."
Answer: C. "You may feel some cramping during the procedure."
A nurse caring for a client at risk for increased intracranial pressure is monitoring the client
for manifestations that indicate that the pressure is increasing. To do this, the nurse should
check the function of the third cranial nerve by performing which of the following datacollection activities?
A. Observing for facial asymmetry

B. Checking pupillary responses to light
C. Eliciting the gag reflex
D. Testing visual acuity
Answer: B. Checking pupillary responses to light
A nurse is caring for a client during the immediate postoperative period following thoracic
surgery. When administering an opioid analgesic for pain, the nurse should explain that the
medication should have which of the following effects?
A. Reducing anxiety
B. Increasing blood pressure
C. Increasing coughing
D. Increasing the client's respiratory rate
Answer: A. Reducing anxiety
A nurse is collecting data on a client who has hyperthyroidism. Which of the following
manifestations should the nurse expect the client to report?
A. Frequent mood changes
B. Constipation
C. Sensitivity to cold
D. Weight gain
Answer: A. Frequent mood changes
A nurse is collecting data from a client who has skeletal traction. Which of the following
findings should the nurse identify as an indication of infection at the pin sites?
A. Serosanguineous drainage
B. Mild erythema
C. Warmth
D. Fever
Answer: D. Fever
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse
determines that teaching has been effective when the client identifies which of the following
manifestations of hypoglycaemia? (Select all that apply.)
A. Polyuria

B. Blurry vision
C. Tachycardia
D. Polydipsia
E. Sweating
Answer: B. Blurry vision
C. Tachycardia
E. Sweating
A nurse is collecting data from a client who has an exacerbation of gout. Which of the
following findings should the nurse expect? (Select all that apply.)
A. Edema
B. Erythema
C. Tophi
D. Tight skin
E. Symmetrical joint pain
Answer: A. Edema
B. Erythema
C. Tophi
D. Tight skin
A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a
complication of MG for which the nurse should monitor?
A. Respiratory difficulty
B. Confusion
C. Increased intracranial pressure
D. Joint pain
Answer: A. Respiratory difficulty
A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis.
The nurse should recognize that which of the following actions is the priority?
A. Review stress factors that can cause disease exacerbation.
B. Evaluate fluid and electrolyte levels.
C. Provide emotional support.
D. Promote physical mobility.

Answer: B. Evaluate fluid and electrolyte levels.
A nurse is reinforcing teaching about rifampin with a female client who has active
tuberculosis. Which of the following statements should the nurse include in the teaching?
A. "You should wear glasses instead of contacts while taking this medication."
B. "The medication causes amenorrhea if taken along with an oral contraceptive."
C. "A yellow tint to the skin is an expected reaction to the medication."
D. "Lifelong treatment with this medication is necessary."
Answer: A. "You should wear glasses instead of contacts while taking this medication."
A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following
a renal transplant. Which of the following statements by the client indicates an understanding
of the teaching?
A. "I will take this medication until my BUN returns to normal."
B. "This medication will help my new kidney make adequate urine."
C. "I will need to take this medication for the rest of my life."
D. "This medication will boost my immune system."
Answer: C. "I will need to take this medication for the rest of my life."
A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by
mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for
with a client who is taking this medication?
A. Improved speech patterns
B. Increased bladder function.
C. Decreased tremors
D. Diminished drooling
Answer: C. Decreased tremors
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood
cells. The client develops itching and hives. Which of the following actions should the nurse
take first?
A. Obtain vital signs.
B. Stop the transfusion.
C. Notify the registered nurse.

D. Administer diphenhydramine.
Answer: B. Stop the transfusion.
A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations
of Raynaud’s phenomenon. Which of the following statements should the nurse identify as an
indication that the client needs further teaching?
A. "I will keep my house at a cool temperature."
B. "I will try to anticipate and avoid stressful situations."
C. "I will complete the smoking cessation program I started."
D. "I will wear gloves when removing food from the freezer."
Answer: A. "I will keep my house at a cool temperature."
A nurse is reinforcing teaching with a client who has iron deficiency anaemia and is to start
taking ferrous sulphate twice a day. Which of the following statements by the client indicate
an understanding of the teaching?
A. "I will take the medication with orange juice."
B. "I should expect to have loose stools while taking this medication."
C. "I will have clay coloured stools while taking this medication."
D. "I should take the medication with milk."
Answer: A. "I will take the medication with orange juice."
A nurse is reinforcing teaching about pernicious anaemia with a client following a total
gastrectomy. Which of the following dietary supplements should the nurse include in the
teaching as the treatment for pernicious anaemia?
A. Vitamin B12
B. Vitamin C
C. Iron
D. Folate
Answer: A. Vitamin B12
A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a
prescription for lorazepam preoperatively. Which of the following statements by the client
should indicate to the nurse that the medication has been effective?
A. "My mouth is very dry."

B. "I feel very sleepy."
C. "I am not hungry any longer."
D. "My leg feels numb."
Answer: B. "I feel very sleepy."
A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the
nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should
recognize this is a manifestation of which of the following conditions?
A. Xerostomia
B. Gingivitis
C. Candidiasis
D. Halitosis
Answer: C. Candidiasis
A nurse is caring for a client who is postoperative open reduction and internal fixation with
placement of a wound drain to repair a hip fracture. Which of the following actions should
the nurse take?
A. Empty the suction device every 4 hr.
B. Monitor circulation on the affected extremity every 2 hr for the first 12 hr.
C. Position the client’s hip so that it is internally rotated.
D. Encourage foot exercises every 4 hr.
Answer: A. Empty the suction device every 4 hr.
A nurse is assisting with teaching a client who has a history of smoking about recognizing
early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and
report which of the following manifestations of laryngeal cancer?
A. Aphagia
B. Hoarseness
C. Tinnitus
D. Epistaxis
Answer: B. Hoarseness

A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which
of the following laboratory values should the nurse review to determine the client’s renal
function?
A. Antinuclear antibody
B. C-reactive protein
C. Erythrocyte sedimentation rate
D. Serum creatinine
Answer: D. Serum creatinine
A nurse is collecting data from a client who has Cushing's syndrome. Which of the following
manifestations should the nurse expect?
A. Bruising
B. Weight loss
C. Hyperpigmentation
D. Double vision
Answer: A. Bruising
A nurse is caring for a client who is postoperative and requesting something to drink. The
nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance
diet as tolerated." Which of the following actions should the nurse take first?
A. Offer the client apple juice.
B. Elevate the client’s head of bed.
C. Auscultate the client’s abdomen.
D. Order a lunch tray for the client.
Answer: C. Auscultate the client’s abdomen.
A nurse is collecting data on a client who has a surgical wound healing by secondary
intention. Which of the following findings should the nurse report to the charge nurse?
A. The wound is tender to touch.
B. The wound has pink, shiny tissue with a granular appearance.
C. The wound has serosanguineous drainage.
D. The wound has a halo of erythema on the surrounding skin.
Answer: D. The wound has a halo of erythema on the surrounding skin.

A nurse is assisting with the care of a client who has multiple injuries following a motor
vehicle crash. The nurse should monitor for which of the following manifestations of a
pneumothorax?
A. Inspiratory stridor
B. Expiratory wheeze
C. Absence of breath sounds
D. Coarse crackles
Answer: C. Absence of breath sounds
A nurse is collecting data from a client who has right-sided heart failure. Which of the
following findings should the nurse expect?
A. Frothy sputum
B. Dyspnea
C. Orthopnoea
D. Peripheral edema
Answer: D. Peripheral edema
A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer
and experiencing nausea. Which of the following actions should the nurse take?
A. Advise the client to lie down after meals.
B. Instruct the client to restrict food intake prior to treatment.
C. Provide the client with an antiemetic 2 hr prior to the chemotherapy.
D. Encourage the client to drink a carbonated beverage 1 hr before meals.
Answer: D. Encourage the client to drink a carbonated beverage 1 hr before meals.
A nurse is assisting with the care of a client following a transurethral resection of the prostate
(TURP) and has an indwelling urinary catheter. Which of the following actions should the
nurse take?
A. Weigh the client weekly.
B. Irrigate the catheter as prescribed.
C. Instruct the client to report an urge to urinate.
D. Instruct the client to bear down as if to have a bowel movement every hour.
Answer: B. Irrigate the catheter as prescribed.

A nurse is evaluating discharge instructions for a client following a right cataract extraction.
Which of the following client statements indicates the teaching is effective?
A. "I will take a stool softener until my eye is healed."
B. "I will expect to have moderately severe pain for 1-2 days."
C. "I will refrain from cooking for 1 week."
D. "I will bend at the waist to tie my shoes."
Answer: A. "I will take a stool softener until my eye is healed."
A nurse is collecting data from a client who is 6 days post craniotomy for removal of an
intracerebral aneurysm. The nurse should monitor the client for which of the following
manifestations of increased intracranial pressure?
A. Decreased pedal pulses
B. Hypertension
C. Peripheral edema
D. Diarrhoea
Answer: B. Hypertension
A nurse is caring for a client who has COPD. Which of the following actions should the nurse
take?
A. Encourage the client to drink 8 glasses of water a day.
B. Instruct the client to cough every 4 hr.
C. Provide the client with a low protein diet.
D. Advise the client to lie down after eating.
Answer: A. Encourage the client to drink 8 glasses of water a day.
A nurse is caring for a client who was admitted with major burns to the head, neck, and chest.
Which of the following complications should the nurse identify as the greatest risk to the
client?
A. Hypothermia
B. Hyponatremia
C. Fluid imbalance
D. Airway obstruction
Answer: D. Airway obstruction

A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the
following client manifestations should the nurse identify as an indication of the development
of Lyme disease?
A. An expanding circular rash
B. Swollen, painful joints
C. Decreased level of consciousness
D. Necrosis at the site of the bite
Answer: A. An expanding circular rash
A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a
right radical mastectomy with closed suction drains present. The nurse should expect that the
client will be unable to perform which of the following activities with her right arm?
A. Combing her hair
B. Eating her breakfast
C. Buttoning her blouse
D. Tying her shoes
Answer: A. Combing her hair
A nurse in a provider’s office is collecting data for a 45-year-old client who is having
manifestations associated with perimenopause. Which of the following findings should the
nurse expect?
A. Report of urinary retention
B. Elevated blood pressure above 140/90
C. Report of dryness with vaginal intercourse
D. Elevated body temperature above 37.8° C (100° F)
Answer: C. Report of dryness with vaginal intercourse
A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a
regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the
following times?
A. On the same day every month
B. Prior to the beginning of menses
C. Three to seven days after menses stops
D. On the second day of menstruation

Answer: C. Three to seven days after menses stops
A nurse is caring for a client who has second- and third-degree burns and a prescription for a
high-calorie, high-protein diet. Which of the following menu choices should the nurse
recommend?
A. ½ cup whole-grain pasta with tomato sauce and pears
B. Turkey and cheese sandwich with scalloped potatoes
C. ½ cup black beans with a brownie
D. Roast beef with romaine lettuce salad
Answer: B. Turkey and cheese sandwich with scalloped potatoes
A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram.
Which of the following should the nurse include in the teaching?
A. Omit your daily dose of aspirin.
B. Take a laxative the evening before the procedure.
C. Expect to be drowsy for 24 hr following the procedure.
D. You will feel cold chills after the dye has been injected.
Answer: B. Take a laxative the evening before the procedure.
A nurse is collecting data from a client in the health clinic who is reporting epigastric pain.
Which of the following statements made by the client should the nurse identify as being
consistent with peptic ulcer disease?
A. "The pain is worse after I eat a meal high in fat."
B. "My pain is relieved by having a bowel movement."
C. "I feel so much better after eating."
D. "The pain radiates down to my lower back."
Answer: C. "I feel so much better after eating."
A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the
following interventions should the nurse identify as the priority?
A. Promote the client’s expression of feelings about loss of self-care ability.
B. Encourage the client to recall positive life events.
C. Schedule pain medication on a routine basis.
D. Suggest ways the client can continue interacting with social contacts.

Answer: C. Schedule pain medication on a routine basis.
A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic
open angle glaucoma. Which of the following statements by the client indicates an
understanding of the teaching?
A. "When my vision improves, I will be able to stop taking the eye drops."
B. "If I forget to take my eye drops, I should wait until the next time they are due."
C. "I should call the clinic before taking any over-the-counter medications."
D. "Every two years I will need to have my vision checked by an eye doctor."
Answer: C. "I should call the clinic before taking any over-the-counter medications."
VERSION 13
• Nurse is preparing to administer thrombolytic therapy to a client with ischemic stroke.
which is an appropriate nursing action?
Answer: Elevate HOB between 25-30 degrees
• Nurse is teaching about the use of an incentive spirometer. Which of the following
instructions should the nurse include in the teaching?
Answer: Holds breaths about 305 seconds before exhaling
• Nurse is assessing a client who is 12 hr post op following a colon resection. Which of the
following findings should the nurse report to the surgeon
Answer: Absent Bowel Sounds
• Nurse is caring for a client who has diabetes insipidus. Which of the following meds should
the nurse plan to administer?
Answer: Desmopressin
• Nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times
daily for 3 years. Which of the following tests should the nurse monitor?
Answer: Stool for occult blood
• A nurse in the ED is assessing a client. Which of the following actions should the nurse take
first?

Answer: Initiate Airborne Precautions
• 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?
Answer: Fentanyl
• Nurse is admitting a client who reports chest pain and has been places on a telemetry
monitor. Which of the following should the nurse analyse to determine whether the client is
experiencing a MI?
Answer: ST segment
• Nurse is teaching a client who has ovarian cancer about skin care following radiation
treatment. Which of the following should the nurse include?
Answer: Pat the skin on the radiation site to dry it
• A nurse is caring for a client receiving blood transfusion. Nurse observes client has
bounding peripheral pulse, HTN, distended jugular veins. The nurse should anticipate admin
which of the following meds?
Answer: Furosemide
• A nurse is assessing a client who is getting Magnesium Sulphate IV for Tx of
hypomagnesemia. Which of the following indicates effectiveness?
Answer: Apical Pulse 82
• Lumbar puncture positioning: Cannonball position while on one side or by having the client
stretch over an overbid table is sitting is preferred
Answer: Lateral recumbent position preferred.
• A nurse is reviewing ABG results: pH 7.42, PaCO2: 30; HCO3: 21. Indication for which of
the following conditions?
Answer: Uncompensated respiratory acidosis
• Nurse is preparing to administer daily meds to a client undergoing a procedure that requires
IV contrast dye. Which of the following meds should the nurse hold?

Answer: Metformin
• Nurse is caring for a client who is experiencing seizures secondary to meningitis. What
should be included in the plan of care? SATA!!
Answer: Have suction at bedside, Dim overhead lights
• Nurse is caring for pt who has a pressure ulcer with necrotic tissue and requires wet-to
damp dressing. Which of the following types of debridement should the nurse include in the
plan of care.
Answer: Mechanical
• Nurse is caring for a female with toxic shock. Which finding should nurse expect?
Answer: Generalized Rash
• Nurse is preparing to administer a med for a client through a non-tunnelled percutaneous
central catheter. Which of the following actions should the nurse take?
Answer: Flush catheter with 10mL of NS
• Nurse is caring for pt admitted with nausea, vomit, and possible bowel obstruction. NG tube
is placed and set to low intermittent suction. Which of the following findings should the nurse
report?
Answer: Distended and firm
• Nurse is reviewing the MAR of a pt with DI. Which of the following finding should the
nurse expect?
Answer: Urine specific gravity 1.001
• Nurse is caring for a pt who has hyperthyroidism and develops thyroid storm. Which of the
following instructions should the nurse give to the client regarding management of thyroid
storm?
Answer: You will need a cooling blanket to lower your body temperature
• Nurse is reviewing the MAR of a client who has acute gout. The nurse should expect an
increase in which of the lab values?

Answer: Uric Acid
• Nurse is preparing to administer peritoneal dialysis to a client. Which of the following
actions should the nurse take?
Answer: Hang drainage bag below the client’s abdomen
• Nurse in the Ed is caring for pt who has deep partial-thickness burns over 30% of his body,
including upper chest and abdomen. Which of the following actions is the nurse’s priority?
Answer: insert 18 gauge IV catheter
• Nurse is presenting an in-service about Parkinson’s disease. Which of the following
statements should nurse include int he teaching?
Answer: PD results from a decreased amount of dopamine in the client’s brain
• A nurse is caring for a client who has a serum sodium level of 150. Which action should the
nurse take?
Answer: Administer hypotonic IV fluids to the client
• Nurse is caring for a client who takes lisinopril for HTN. Which of the following client
statements indicates an adverse effect of the medication?
Answer: I have a nagging, dry cough. Heightened sense of taste
Nurse is proving discharge teaching to a client following a modified left radical mastectomy
with breast expander. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: I should expect less than 25mL of secretions per day
• Nurse is caring for a pt who has DM and has been following a treatment plan for 3 months.
Which lab values should nurse monitor to determine long-term glycaemic control?
Answer: Glycosylated Hgb level
• Nurse is providing discharge teaching to a client to has chronic UTI. Client has a
prescription for cipro. What should nurse include in teaching?
Answer: Drink 2 to 3 L of fluid per day

• A nurse is providing teaching to pt who has a DVT. Which of the following is a risk factor
for a DVT?
Answer: Oral Contraceptives
• Nurse is caring for pt with Cushing’s. Which of the following actions should the nurse take
first?
Answer: Got to Check the Exhibit Button
• Nurse is assessing pt with nephrotic syndrome. Which of the following findings should the
nurse expect?
Answer: Proteinuria
• Med math gtt/min:
Answer: 20 drops per min
• Right-sided heart failure. Which assessment finding should nurse expect?
Answer: Pitting Edema
• Newly inserted chest tube. Nurse should clarify which of the following orders?
Answer: Administer Morphine IV Bolus
• Nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of the
following instructions should the nurse include for the management for heart failure?
Answer: Obtain daily weight
• Nurse is providing discharge teaching to a client who has permanent pacemaker. Which of
the following statements by the client indicates understanding of the teaching?
Answer: I need to check my pulse rate every day for a full minute.
• 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? SATA!!
Answer: Influenza, Pneumococcal polysaccharide, Herpes Zoster

• Nurse is assessing a pt who is 4hr post op following an arterial revascularization of the left
femoral artery. Which of the following findings should the nurse report to the provider
immediately?
Answer: Pallor in the affected extremity
• Nurse is caring for an older adult client who has not been eating. Which of the following
findings indicates dehydration?
Answer: Diminished peripheral pulses
• Nurse is preparing to discharge a client who has a halo device and is reviewing new
prescriptions from the provider. The nurse should clarify which of the following prescriptions
with the provider?
Answer: May operate a motor vehicle when no longer taking analgesics
• Nurse is assessing for early signs of compartment syndrome for a client who has a short left
fiberglass cast. Which of the following can the nurse expect?
Answer: Intense Pain with Movement
• A nurse is caring for a client who is post op following coronary artery bypass surgery and
reports shortness of breath. The nurse administers oxygen at 3 L/mim and obtains arterial
blood gases 60 mins later. Which of the following lab values indicates positive response to
the oxygen therapy?
Answer: PaO2 90mmHg
• Nurse is performing cranial nerve assessment on a client following a head injury. Which of
the following findings has impaired function of the vestibulocochlear nerve?
Answer: Disequilibrium with movement
• 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?
Answer: GCS score changes from 14 to 9

• Nurse is caring for a client who presents to the ED after experiencing heat stroke. Which of
the following actions should the nurse take?
Answer: Administer Lactated Ringers or apply a cooling blanket
• Nurse is caring for a client who is taking furosemide. client has a potassium level of 3.1.
Which of the following should the nurse assess first?
Answer: Cardiovascular status
• 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?
Answer: Ask client to empty his bladder prior to the procedure
• Nurse is caring for a client who is 6hr post op thyroidectomy. The client reports tingling and
numbness in the hands. The nurse should identify this as a sign of which following electrolyte
imbalances?
Answer: Hypocalcaemia
• A nurse is assessing a client 15 minutes 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?
Answer: Hypotension
• Nurse in an ED is caring for a client who has sinus bradycardia. Which of the following
actions should the nurse take first?
Answer: Administer atropine to the client
• Nurse is caring for a client who has a prescription to discontinue a peripherally inserted
central catheter. Which of the following actions should the nurse take?
Answer: Apply slight pressure when resistance is met
• Nurse is assessing a client who has a 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?
Answer: Pull client up in bed

• Nurse is caring for a client who has a flail chest. Which of the following actions should the
nurse take?
Answer: Provide humidified oxygen
• 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?
Answer: Hypoxemia
• Nurse is caring for a client who is experiencing a seizure. Which of the following actions
should the nurse take first?
Answer: Lower client to the floor
• Nurse is teaching a client who is receiving TPN at home through a central line about
transparent dressing changes. Which of the following instructions should the nurse include in
the teaching?
Answer: Clean technique when doing dressing changes
• A Nurse is caring for a client in the ED who experienced a full-thickness burn injury to the
lower torso 1 hr ago. Which of the following findings should the nurse expect?
Answer: Hypotension
• Nurse in an ED is assessing a client who has cirrhosis of the liver. Which of the following is
a priority finding?
Answer: Mental Confusion
• A nurse is providing instructions about foot care for a client who has PAD. The nurse should
identify that which of the following statements by the client indicates an understanding of the
teaching?
Answer: I rest in my recliner with my feet elevated for about an hour every afternoon
A nurse is teaching a client who has a new prescription for alendronate to treat osteoporosis.
Which of the following should the nurse include in the teaching?
Answer: Sit upright for 30 min after taking the medication

• A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the
following statements should the nurse include in the teaching?
Answer: Exhale fully before bringing the inhaler to your lips
• A nurse is admitting a client to the ED 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?
Answer: Administer IV fluids to the client
• 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?
Answer:
Support bony prominences with pillows
• Nurse is reviewing the MAR 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 receiving
heparin?
Answer: Thrombocytopenia
• Nurse is caring for a client who has completed 10 daily cycles of TPN. Receiving adequate
TPN?
Answer: BUN level of 15
• Nurse s providing teaching to a client who is postop following partial glossectomy. Which
of the following indicates understanding of the teaching?
Answer: I will inspect my mouth once each week for sores
• Nurse is providing an ear irrigation for a client. Which of the following actions should the
nurse take?
Answer: Point the tip of the syringe toward the top of the ear canal
• Nurse is caring for a client who is receiving CBI following transurethral resection of the
prostate. Pt is experiencing sharp lower abdominal pain. Which of the following actions
should the nurse take first?

Answer: Check the client’s urine output.
• Nurse is providing teaching for a client who has DM about self admin of insulin. Which of
the following statements by the client indicates an understanding of the teaching?
Answer: I will draw up the regular insulin into the syringe first
• Nurse is caring for a pt who has SLE. During assessment which of the following should the
nurse expect to find?
Answer: Joint Inflammation
• Nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic
leukaemia. Which of the following actions should the nurse take?
Answer: Institute bleeding precautions.
• Nurse is caring for a client who is receiving TMP. Which of the following nursing actions
are appropriate?
Answer: Monitor serum blood glucose and obtain client’s daily weights.
• Nurse is caring for a client in DKA. Which of the following is the priority nursing
intervention?
Answer: Administer NS
• Nurse is reviewing the lab results of a female client who asks about acupuncture a treatment
for chemo. Which of the following lab results should the nurse identify as a contraindication
to receiving acupuncture?
Answer: ANC of 500
• A Nurse is caring for a client following a TKA. The client reports a pain level of 6 on a pain
scale of 0-10. What action should the nurse take?
Answer: Ice pack to the client’s knee
Nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the
following findings indicate hypokalaemia?
Answer: Muscle weakness

• A nurse at a long term care facility is assessing an older adult client. Which of the following
findings should the nurse find that the pt has a recall memory impairment?
Answer: Inability to state what he had for dinner last night
• An ICU nurse is planning care for a client who has ICP following a head injury. Which of
the following meds should the nurse plan to administer?
Answer: Mannitol
• Nurse of a med unit Is planning care for a group of clients. Which of the following clients
should the nurse attend to first?
Answer: Client who has thrombocytopenia and reports a nosebleed
• Nurse is planning to use nonpharmacological pain relief measures for an older adult client
who has several chronic back pain. Which of the following should the nurse use?
Answer: Clients who have difficulty with focus and concentration.
• A nurse is providing teaching to a client who is to start furosemide therapy for heart failure.
Which of the following understands a potential adverse effect of this medication?
Answer: I’m going to include cantaloupe in my diet
• Nurse is providing discharge teaching for a client who has HIV. Which of the following
information is the priority for the nurse to teach?
Answer: Describe your daily medication schedule
• Nurse is caring for a client who has an endotracheal tube. Which of the following actions
should the nurse take to verify tube placement?
Answer: Symmetry of chest expansion
• Nurse in the ED is caring for a client who is receiving treatment for excessive ingestion of
antacids. The Nurse should identify this client is at risk for which of the following acid base
imbalances?
Answer: Metabolic alkalosis

• Choveks sign picture hotspot?
Answer: Right in front of Ear
• Nurse is caring for a client who has advanced Liver disease.
Answer: Serum Ammonia
• Nurse is caring for a client who has a pneumothorax and a chest tube with a closed waterseal drainage system.
Answer: Clear the chest tube every 8 hours
• A nurse is reviewing clients ECG reading. Which of the following findings should the nurse
indicate has first degree heart block?
Answer: Prolonged PR intervals
• Obtain venous access, obtain the unit from the blood bank.
Answer: verify, initiate transfusion and stay with the client.
• A nurse is teaching a client who is to begin chemo about a PICC line. What should the nurse
include in the teaching?
Answer: We can draw samples from the PICC for diagnostic tests
• Nurse is assessing a client who has pyelonephritis and reports flank pain. Which of the
following actions should the nurse take?
Answer: Thump the area of tenderness directly with a closed fist
• Nurse is assessing a client who has acute kidney failure. Which of the following findings
should the nurse report to the provider?
Answer: Weight gain of 1.1kg
• A nurse is caring for an older client who is 72 hr postop following a total hyp arthroplasty.
The client requires a PRN med prior to ambulation. Which of the following meds should the
nurse anticipate administering?
Answer: Oxycodone

• Nurse is caring for a client who has Haemophilus influenza type B. Which of the following
types of isolation should ht ensure implement?
Answer: Droplet
Nurse is providing teaching to a client who has pulmonary TB. Which of the following
findings should the nurse include as an indication that the client is no longer infectious?
Answer: Negative sputum cultures for acid-fast bacillus
• Nurse is working in the ED 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?
Answer: Start an IV with large bore needle
• Nurse is caring for a client who has a central venous access device and notes the tubing has
become disconnected. Which of the following actions should the nurse take first?
Answer: Clamp the catheter
• Nurse is providing discharge teaching to a client who has an impaired immune system due
to chemotherapy. Which of the following things should the nurse include in the teaching?
Answer: Wash the perineal area two times each day with antimicrobial soap.
• A nurse assessing a pt. w. acute pancreatitis is getting TPN for 72hrs. what requires the
nurse to intervene?
Answer: crackles in lower lobes
• Which patient should the nurse obtain a BP on only the left extremity?
Answer: A cline w. right AV fistula
• The nurse is caring for a bed ridden client. Which suggests a complication to immobility?
Answer: blurred vision, polyuria, diarrhoea)
• HOTSPOT: where do you place the stethoscope to listen for a pericardial friction rub?
Lower
Answer: left box (apical pulse)

• A nurse is about to give a unit of packed RBC’s to a client on continuous IV of D5W. what
should the nurse do?
Answer: Begin an IV infusion of 0.9% NACL
• A client reports numbness and tingling of toes and a positive trousseaus sign. Which
electrolyte imbalance will the nurse suspect?
Answer: Hypocalcaemia
• What statement shows that the patient on isoniazid (INH) understands the teaching?
Answer: I will have my liver function tests tested.
• A nurse is planning care for a client on enoxaparin (lovanox, low molecular weight heparin)
which intervention should be included?
Answer: Monitor the PT levels
• A client just returned from surgery with an external fixator to the left tibia, which
assessment requires immediate intervention?
Answer: Capillary refill in the left toe is 6 seconds
• A community health nurse is reviewing home care instructions w. a client w. heart failure.
what is the priority topic to review?
Answer: daily sodium restrictions
• A nurse providing discharge teaching to a client after a modified left radical mastectomy
with breast expander. Which statement indicates understanding?
Answer: Wait 2 months before additional saline is added to the breast expander (not sure)
• A nurse is planning care for a pt. w. a chest drainage system. Which is appropriate to include
in the plan of care?
Answer: check for bubbling in the water seal chamber OR empty the collection chamber
q8hrs
• A nurse is assessing a client after the insertion of a central venous catheter. Which finding
indicates a pneumothorax?

Answer: Diminished breath sounds
• A nurse is taking a medication history from a client on naproxen for RA. Which med
increases the risk for bleeding?
Answer: Ibuprofen
• A nurse has a client on TPN via central line the current bag is nearly empty and a new bag is
unavailable. What should the nurse do?
Answer: Switch the infusion to 10% dextrose
A nurse is providing discharge teaching for a client w. a trach. Which statement indicates
understanding?
Answer: I’ll cut a slit in a clean gauze pad to use as a stoma dressing
• A nurse in the ED has a client w. liver cirrhosis. What is a priority finding?
Answer: Mental confusion (other options yellow sclera, spider angiomas, palmer erythema)
• A client has a new Arteriovenous graft in the right arm. Which should the nurse include in
the plan of care?
Answer: Palpate for a thrill
• A nurse completing discharge for a new AIDS PT. which shows understanding of teaching?
Answer: I will wear gloves and wash my hands when I change the litter box
• What should the nurse include in the teaching for a client on metoprolol?
Answer: Take a radial pulse before administration
• A client has a fib. What should the nurse expect to give?
Answer: Amiodarone
• A nurse is caring for a client with HF. Which should the nurse report t6o the provider?
Answer: Haematocrit 24%

• A nurse is teaching a client with graves’ disease about a thyroid storm, which should she
include?
Answer: Increased temperature (other manifestations: hypertension, tachycardia)
• A nurse is caring for a client who is 2 days’ post abdominal surgery and on opioids. Which
action will facilitate recovery?
Answer: Give analgesic before physical activities.
• A nurse teaching a client with a meter dose inhaler. Which should the nurse include?
Answer: Exhale fully before bringing the inhaler to your lips (ohhh nasty wit it)
• A nurse is caring for a client w. ulcerative colitis who was admitted for diarrhoea what will
you put on the breakfast tray?
Answer: Whole grain toast
• A nurse is caring for a client who developed third-degree heart block with a HR of 30/min.
what should the nurse do?
Answer: Prepare the client for a temporary pacing
• A nurse in the ED has a client with a MI. the client is placed on a heart monitor, which EKG
strip shows a MI?
Answer:(look for your QRS, the ST segment is elevated hence STEMI) ST segment is
relatively flat in a normal sinus
• Which indicates understand for a client with an ileostomy?
Answer: I will expect my stools to be loose
• A nurse is caring for a client with a bounding pulse, crackles, and pink frothy sputum. What
do these findings indicate?
Answer: Fluid volume excess
• A nurse is caring for a client 5 days’ post abdominal hysterectomy. Which indicates wound
dehiscence?
Answer: Increased serosanguinous drainage from the wound

• A nurse in the ED is caring for a client with hypovolemic shock. Which should the nurse do
first?
Answer: Administer IV therapy
• A nurse is caring for a pt. who had a total hip arthroplasty, which actions should the nurse
take?
Answer: Place two bed pillows between the legs when in bed
• A nurse is assessing a client w. malnutrition, what should be expected?
Answer: Cachexia
• SATA: a nurse is providing discharge teaching to a client with lupus, which statements
indicate understanding?
Answer:1) I will wear long sleeves when outdoors,
2) I will use NSAIDS to treat aches and pains
• A nurse is caring for a client w. myxoedema coma which finding indicates treatment is
effective?
Answer: Respiratory rate 18/min
• Which client requires a private room?
Answer: A client who reports fever, night sweats and cough for 2 days
• A nurse is caring for a female client w, toxic shock syndrome, which finding is expected?
Answer: Generalized rash
• What is an expected lab result for a client w. thrombocytopenia?
Answer: Platelets 70,000
• A nurse is assessing a client w. an AV fistula in the left arm, which finding indicates a
complication at the vascular access site?
Answer: Absence of a bruit
• A nurse is caring for a client w. right hemiplegia. The nurse notices a 3cm pink/red area on
both scapulae. Which action is appropriate?

Answer: Apply calcium alginate
• A nurse has a pt. who has acute pancreatitis and a PCA pump. Which action should the
nurse take?
Answer: Program the pump dosage parameters w. another nurse
• A nurse is providing instructions about foot care for a client with peripheral artery disease,
the nurse should identify which statement as understanding of the teaching?
Answer: I apply a lubricating lotion to the cracked areas on the soles of my feet q morning
• The nurse is teaching a client how to use a peak flow meter place the steps in order
Answer: • Stand upright
• Full your lungs with a deep breath
• Seal your lips around the mouth piece
• Exhale forcefully and quickly
• Record the highest of 3 consecutive blows
• A nurse is caring for a client after TURP. The client reports bladder spasms and the nurse
observes decreased output what should the nurse do?
Answer: Flush the catheter manually
• A nurse in the ED is caring for a client after an MI. what should the nurse do if the client
develops asystole?
Answer: Begin cardiopulmonary resuscitation
• A nurse Is administering packed RBC’s what is an appropriate action for the nurse to take?
Answer: Administer transfusion over a 4-hr period
• SATA: a nurse is teaching a group of young adults about hearing loss risk factors, which
should she include in the teaching?
Answer:1) chronic middle ear infections
2) perforation of the eardrum

• A nurse is giving daily meds to a client that will undergo a procedure at 1000 that requires
contrast dye which med to give at 0800 should be withheld?
Answer: Metoprolol
• A nurse is caring for a client post below the knee amputation and asks the purpose of the
bandage. What is an appropriate response?
Answer: Prevent excessive edema
• ABG’s: pH 7.30 (acidic) HCO3- 19 (low) PaO2 and PaCO2 are normal what condition
should the nurse expect?
Answer: Metabolic acidosis
• What position will you place a client in for a thoracentesis?
Answer: Upright on the edge of the bed leaning over the bedside table
• Client taking digoxin which statement indicates understanding?
Answer: I will report muscle weakness
• SATA: A nurse is caring for a client on TPN which actions are appropriate?
Answer: 1) verify the solution with another RN
2) obtain the clients weight daily
3) monitor blood glucose during the infusion (not sure)
• A nurse is planning care for a client following a cardiac cath. Which action should the nurse
take?
Answer: Maintain the affected extremity in extension
• COPD pt. which should the nurse expect?
Answer: Paco2 50 mm hg
• A nurse is teaching a client about type 1 diabetes sick day rules which shows
understanding?
Answer: I will check my urine for ketones if my blood sugar is above 24

Which client should the nurse assess first?
Answer: A client w. acute kidney injury and potassium is 6.5
• A nurse is reviewing meds w. a pt. w. angina which shows understanding?
Answer: I should lie down before taking isosorbide dinitrate
• A nurse is planning care for a pt. 12hr post kidney transplant which should the nurse do?
Answer: Asses urine output hourly
• Which should the nurse tach the diabetic pt. to prevent nephropathy?
Answer: Control HTN
• A nurse is caring for a pt. w. a sealed radiation implant which should the nurse do?
Answer: Limit family member limits to 30 mins. A day

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