ATI Medical Surgical Proctored Exam With NGN Version 8-10 With Answers-193 Solved Questions

VERSION 8
ATI MED SURG REMEDIATION COMPLTE SOLUTION
A nurse is caring for a client following a bone marrow biopsy. What information should the
nurse include in the discharge education?
Answer: • Teach the client to report excessive bleeding and evidence of infection to the
provider.
• Teach the client to check the biopsy site daily. Keep the dressing clean, dry, and intact.
• If sutures are in place, remind the client to return in 7-10 days to have them removed.
What dietary education should the nurse provide to a client diagnosed with a hiatal hernia?
Answer: • Avoid eating immediately prior to going to bed.
• Avoid foods and beverages that decrease LES pressure (fatty and fried foods, chocolate,
coffee, peppermint, spicy foods, tomatoes, citrus fruits, and alcohol).
A nurse is caring for a client with chronic gastritis. Provide three (3) dietary
recommendations the nurse should include in client education?
Answer: • Assist the client in identifying foods that are triggers.
• Provide small, frequent meals and encourage the client to eat slowly.
• Advise the client to avoid alcohol, caffeine, and foods that can cause gastric irritation.
A nurse is caring for a client who has been admitted with renal calculi. List three (3)
interventions the nurse will take in the management of renal calculi.
Answer: • Strain all urine to check for passage of the calculus and save the calculus for
laboratory analysis.
• Encourage increased oral intake to 3L/day unless contraindicated.
• Encourage ambulation to promote passage of calculus.
Define the following types of urinary incontinence: Stress, urge, overflow, reflex, functional,
total.
Answer: • Stress: loss of small amounts of urine from increased abdominal pressure without
bladder muscle contraction with laughing, sneezing, or lifting.
• Urge: inability to stop urine flow long enough to reach the bathroom due to an overactive
detrusor muscle with increased bladder pressure.

• Overflow: urinary retention from bladder overdistention and frequent loss of small amounts
of urine due to obstruction of the urinary outlet or an impaired detrusor muscle.
• Reflex: involuntary loss of moderate amount of urine usually without warning due to
hyperreflexia of the detrusor muscle, usually from spinal cord dysfunction.
• Functional: loss of urine due to factors that interfere with responding to the need to urinate,
such as cognitive, mobility, and environmental barriers.
• Total: unpredictable, involuntary loss of urine that generally does not respond to treatment.
A nurse is caring for a client with pneumonia. What are three (3) physical assessment
findings that are noted with the development of pneumonia?
Answer: • Pleuritic chest pain (sharp)
• Sputum production (yellow-tinged)
• Dull percussion over areas of consolidation
• Decreased oxygen saturation levels
A nurse is caring for a client scheduled for a liver biopsy. What nursing actions should be
taken before, during and after this procedure?
Answer: • Inform client that biopsy through venous route reduces the risk of haemorrhage.
• Position the client to the right side for 1-2 hours to ensure haemostasis.
• Monitor for haemorrhage (coagulation studies, frank bleeding).
A nurse is caring for a client with colorectal cancer who is scheduled for a colectomy. What
preoperative and post-operative education should be provided to this client?
Answer:
• Preoperative:
• Educate the client regarding preoperative diet (clear liquids several days prior to
surgery).
• Instruct the client to complete bowel prep with cathartics.
• Inform client of the administration of antibiotics (neomycin, metronidazole) to
eradicate intestinal flora.
• Post-operative:
• Teach client regarding turning and deep breathing.

• Educate the client regarding the care of the incision, activity limits, and ostomy care,
if applicable.
• Provide information regarding management of postoperative complications,
including incontinence or sexual dysfunction (most likely to occur with AP resection).
A nurse is caring for a client with Cushing’s disease. Would the nurse expect this client’s
plasma cortisol levels to be increased or decreased?
Answer: Increased
A client is diagnosed with Addisonian Crisis. List the lab values that will be affected by this
disease process.
Answer:
• Serum electrolytes
• Potassium: increased
• Sodium: decreased
• Calcium: increased
• BUN: increased
• Creatinine: increased
• Serum glucose: normal to decreased
• Serum cortisol: decreased
• ACTH stimulation test: ACTH is infused, and the cortisol response is measured 30 minutes
and 1 hour after the injection. With primary adrenal insufficiency, plasma cortisol levels do
not rise. With secondary adrenal insufficiency, plasma cortisol levels are decreased.
What are the manifestations of diabetic ketoacidosis?
Answer: • Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• GI effects: nausea, vomiting, abdominal pain
• Blurred vision
• Headache
• Weakness
• Orthostatic hypotension

• Fruity Odor of breath
• Kussmaul respirations
• Metabolic acidosis
• Mental status changes
A nurse is caring for a client undergoing a clonidine suppression test to identify a
pheochromocytoma. If a client has a pheochromocytoma and is administered clonidine, what
will the outcome be?
Answer: • If a client does not have a pheochromocytoma, clonidine suppresses
catecholamines release and decreases the level of catecholamines (decreases blood pressure).
• If the client has a pheochromocytoma, the clonidine has no effect (no decreased blood
pressure).
A nurse is caring for a client who underwent a kidney transplant. List the cause,
manifestations and treatment for the following types of transplant rejection: Hyperacute,
Acute, Chronic.
Answer:
• Hyperacute (occurs within 48 hours after surgery)
• Cause: an antibody-mediated response causing small blood clots to form in the
transplanted kidney that occlude vessels and result in massive cellular destruction.
This process is not reversible.
• Manifestations: fever, hypertension, pain at the transplant site
• Treatment: immediate removal of the donor kidney
• Acute (occurs within 1 week to 2 years after surgery)
• Cause: an antibody mediated response causing vasculitis in the donor kidney, and
cellular destruction starts with inflammation that causes lysis of the donor kidney.
• Manifestations: oliguria, anuria, low-grade fever, hypertension, tenderness over
transplanted kidney, lethargy, azotaemia, and fluid retention
• Treatment: involves increased doses of immunosuppressive medications
• Chronic (occurs gradually over months to years)
• Causes: blood vessel injury from overgrowth of the smooth muscles of the blood
vessels causing fibrotic tissue to replace normal tissue resulting in a nonfunctioning
donor kidney.

• Manifestations: gradual return of azotaemia, fluid retention, electrolyte imbalance,
and fatigue
• Treatment: conservative (monitor kidney status, continue immunosuppressive
therapy) until dialysis is required.
What are some common complications related to internal pacemaker insertion?
Answer: • Infection or hematoma at insertion site
• Pneumothorax or haemothorax
• Arrhythmias3
To remember right sided versus left side heart failure symptoms (HEAD/CHOP)
Right sided (HEAD)
H- Hepatomegaly
E- Edema (Bipedal)
A- Ascites
D- Distended Neck Vein
Left sided (CHOP)
C- Cough
H- Haemoptysis
O- Orthopnoea
P- Pulmonary Congestion (crackles/ rales)
To remember signs and symptoms of Cushing's:
Remember the mnemonic: “STRESSED” (remember there is too much of the STRESS
hormone CORTISOL)
Skin fragile
Truncal obesity with small arms
Rounded face (appears like moon), Reproductive issues amenorrhea and ED in male(due to
adrenal cortex’s role in secreting sex hormones)
Ecchymosis, Elevated blood pressure
Striae on the extremities and abdomen (Purplish)
Sugar extremely high (hyperglycaemia)
Excessive body hair especially in women…and Hirsutism (women starting to have male
characteristics), Electrolytes imbalance: hypokalaemia
Dorsocervical fat pad (Buffalo hump), Depression

To remember signs and symptoms of Addison's:
Remember the phrase: “Low STEROID Hormones” (remember you have low production of
aldosterone & cortisol which are STEROID hormones)
Sodium & Sugar low (due to low levels of cortisol which is responsible for retention sodium
and increases blood glucose), Salt cravings
Tired and muscle weakness
Electrolyte imbalance of high Potassium and high Calcium
Reproductive changes…irregular menstrual cycle and ED in men low blood pressure (at risk
for vascular collapse)….aldosterone plays a role in regulating BP
Increased pigmentation of the skin (hyperpigmentation of the skin) Diarrhoea and nausea,
Depression
Also, quick note on Hepatitis - the way that I remember the routes of transmission.... If it has
a VOWEL (A or E) it comes from the BOWEL- - all others are blood transmission.
Thyroid disorders and analogy with Tigger and Eeyore (silly, but it works)
Tigger has hyperthyroidism: bouncing around (tremors, excitability. Nervousness,
irritability)--> weight loss as he is always moving, tachycardic as he never stops moving,
everything is heightened: sweating, more frequent bowel movements, increased appetite,
can't sleep, fatigued, increased sensitivity to heat
Eeyore has hypothyroidism: everything is slowing down: constipation, weight gain, puffy
face, slowed heart rate, depression, increased sensitivity to cold
Lab Value Review
While lab values vary slightly according to the source, knowing an average range for the
following common lab tests will be very helpful when answering questions.
Sodium 136-145 mEq/L
Potassium 3.5-5.0 mEq/L
Total Calcium 9.0-10.5 mg/dL
Magnesium 1.3-2.1 mEq/dL
Phosphorus 3.0 – 4.5 mg/dL
Chloride 98-106 mEq/L
BUN 10-20 mg/dL
Glucose 70-105 mg/dL

HgbA1c 4-6%
WBC 5,000-10,000/mm3
RBC Men 4.7-6.1 million/uL, Women 4.2-5.4 million/uL
Haemoglobin Men 14-18 g/dL, Women 12-16 g/dL
Haematocrit Men 42-52%, Women 37-47% Platelet 150,000-400,000/mm3
pH 7.35-7.45 pC02 35 to 45 mm Hg p02 80-100 mm Hg
HCO3 21-28 mEq/L
Normal PT = 11-12.5 sec, Normal INR = 0.8-1.1 (Therapeutic INR 2-3)
Normal PTT = 30-40 sec (Therapeutic PTT 45-80 sec)
Digoxin 0.8 to 2.0 ng/mL
Lithium 0.4 to 1.4 mEq/L
Phenobarbital 10-40 mcg/mL
Dilantin 10-20 mcg/mL
Theophylline 10-20 mcg/mL
Version 9
ATI MED-SURG PART A
A nurse is reinforcing discharge teaching about wound care with a family member of a client
who is postoperative. Which of the following should the nurse include in the teaching?
A. Administer an analgesic following wound care. (The nurse should remind the family
member to administer an analgesic prior to wound care to prevent discomfort.)
B. Irrigate the wound with povidone iodine. (The nurse should remind the family member to
irrigate the wound with 0.9% sodium chloride.)
C. Cleanse the wound with a cotton-tipped applicator. (The nurse should remind the family
member to avoid using a cotton-tipped applicator to cleanse the wound because the fibres can
become embedded in the wound, cause infection, and delay wound healing.)
D. Report purulent drainage to the provider. (The nurse should remind the family member to
report signs of infection, including purulent drainage.)
Answer: D. Report purulent drainage to the provider. (The nurse should remind the family
member to report signs of infection, including purulent drainage.)
A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which
of the following findings should the nurse expect?

A. Flaccid neck (The nurse should recognize that nuchal rigidity, rather than a flaccid neck, is
a manifestation of meningitis.)
B. Stooped posture with shuffling gait (The nurse should recognize that a stooped posture
with shuffling gait is a manifestation of Parkinson's disease, not a manifestation of
meningitis.)
C. Red macular rash (The nurse should expect to find a red macular rash, sometimes called a
petechial rash, which is a manifestation of meningococcal meningitis.)
D. Masklike facial expression (The nurse should recognize that a masklike expression is a
manifestation of Parkinson's disease, not a manifestation of meningitis.)
Answer: C. Red macular rash (The nurse should expect to find a red macular rash,
sometimes called a petechial rash, which is a manifestation of meningococcal meningitis.)
A nurse is contributing to the plan of care for an older adult client who is at risk for
osteoporosis. Which of the following interventions should the nurse include to prevent bone
loss?
A. Increase fluid intake. (Fluid intake is beneficial for general health and wellness, and it
helps to treat some disorders. Caffeine and alcohol intake can increase the client's risk of
developing osteoporosis. However, fluid intake does not prevent bone loss.)
B. Encourage range-of-motion exercises. (Range-of-motion exercises are beneficial for
general health and wellness, and they help to maintain flexibility and prevent contractures.
However, range-of-motion exercises do not prevent bone loss.)
C. Massage bony prominences. (Massaging bony prominences should be avoided because it
can traumatize deep tissues.)
D. Encourage weight-bearing exercises. (Weight-bearing exercises, such as walking, can
maintain bone mass by reducing bone demineralization, thus helping to prevent
osteoporosis.)
Answer: D. Encourage weight-bearing exercises. (Weight-bearing exercises, such as
walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent
osteoporosis.)
A nurse is collecting data from a client and notices several skin lesion. Which of the
following findings should the nurse report as possible melanoma?
A. Scaly patches (The nurse should report scaly patches as possible basal or squamous cell
carcinoma.

B. Silvery white plaques (The nurse should report silvery white plaques as possible
psoriasis.)
C. Irregular borders (The nurse should report irregular borders of a skin lesion to the provider
because it can indicate malignant melanoma.)
D. Raised edges (The nurse should report raised edges of a skin lesion as possible basal cell
carcinoma.)
Answer: C. Irregular borders (The nurse should report irregular borders of a skin lesion to
the provider because it can indicate malignant melanoma.)
A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following
a partial gastrectomy for ulcers. Which of the following information should the nurse include
in the teaching?
A. Avoid liquids at mealtimes. (The nurse should remind the client to avoid drinking liquids
at mealtimes to prevent the food from emptying into the small bowel too quickly.)
B. Exclude eating starchy vegetables. (The nurse should remind the client to include starchy
vegetables in the meal plan to slow gastric emptying.)
C. Avoid eating high-protein meals. (The nurse should remind the client to eat high protein
meals to help slow gastric emptying.)
D. Plan to increase intake of sweetened fruits. (The nurse should remind the client to exclude
sweetened fruits from the diet to help slow gastric emptying.)
Answer: A. Avoid liquids at mealtimes. (The nurse should remind the client to avoid
drinking liquids at mealtimes to prevent the food from emptying into the small bowel too
quickly.)
A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of
the following laboratory levels should the nurse review prior to the procedure?
A. Albumin (Albumin levels determine the amount of protein the liver produces in the body
and is an indication of hepatic function and nutritional status. However, it is not impacted by
contrast media used for cardiac catheterization. Therefore, the nurse does not need to review
this laboratory level prior to a cardiac catheterization.)
B. Phosphorus (Phosphorus is an electrolyte that combines with calcium to maintain bone
health and is involved as an energy source in metabolism. However, it is not impacted by
contrast media used for cardiac catheterization. Therefore, the nurse does not need to review
this laboratory level prior to a cardiac catheterization.)

C. TSH (TSH levels determine thyroid function. However, it is not impacted by contrast
media used for cardiac catheterization. Therefore, the nurse does not need to review this
laboratory level prior to a cardiac catheterization.)
D. BUN (BUN levels indicate kidney function. Contrast media used during cardiac
catheterization can cause renal failure. The nurse should review this laboratory level to
determine if the client can tolerate the IV contrast dye during the procedure.)
Answer: D. BUN (BUN levels indicate kidney function. Contrast media used during cardiac
catheterization can cause renal failure. The nurse should review this laboratory level to
determine if the client can tolerate the IV contrast dye during the procedure.)
A nurse is reinforcing glycosylated haemoglobin (HbA1c) testing with a client who has
diabetes mellitus. Which of the following statements indicates that the client understands the
teaching?
A. "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates."
(The nurse should remind the client that carbohydrate consumption is not required for HbA1c
testing.)
B. "The HbA1c test can help detect the presence of ketones in my body." (The nurse should
remind the client that urine testing can detect ketone bodies.)
C. "I will have my HbA1c checked twice per year." (An HbA1c test provides the client's
average glucose level for the preceding 3 months. The nurse should instruct the client to have
her HbA1c tested twice yearly to manage her glucose.)
D. "I will plan to fast before I have my HbA1c tested." (The nurse should remind the client
that fasting is not required for HbA1C testing.)
Answer: C. "I will have my HbA1c checked twice per year." (An HbA1c test provides the
client's average glucose level for the preceding 3 months. The nurse should instruct the client
to have her HbA1c tested twice yearly to manage her glucose.)
A nurse is examining a client’s IV site and notes a red line up his arm. The client reports a
throbbing, burning pain at the IV site. The nurse should identify that the client’s
manifestations indicate which of the following complications of IV therapy?
A. Thrombophlebitis (The nurse should identify pain, warmth, and a red streak up the arm as
indications of thrombophlebitis.)
B. Infiltration (The nurse should identify swelling and cool skin at the IV site as indications
of infiltration.)

C. Hematoma (The nurse should identify swelling and bruising as indications of a hematoma
that can develop by not holding enough pressure after discontinuing the IV.)
D. Venous spasms (The nurse should identify cramping at or above the insertion site and
numbness as indications of venous spasms.)
Answer: A. Thrombophlebitis (The nurse should identify pain, warmth, and a red streak up
the arm as indications of thrombophlebitis.)
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following should the nurse include in the teaching?
A. Increase intake of fibre-rich foods. (The nurse should instruct the client to increase the
amount of fibre-rich foods in his diet. Dried beans and brown rice are examples of fibre-rich
foods.)
B. Take a laxative every morning. (The nurse should instruct the client to initially take a
laxative in the evening to stimulate the evacuation of stool. However, the nurse should
instruct the client to use laxatives sparingly.)
C. Maintain a fluid intake of 1200 mL per day. (The nurse should instruct the client to
increase his fluid intake to 2,000 mL per day to maintain soft stools.)
D. Limit activity to preserve energy. (The nurse should instruct the client to increase activity
to stimulate the evacuation of stool.)
Answer: A. Increase intake of fibre-rich foods. (The nurse should instruct the client to
increase the amount of fibre-rich foods in his diet. Dried beans and brown rice are examples
of fibre-rich foods.)
A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the
following actions should the nurse take?
A. Position pillows between the bony prominences. (The nurse should use positioning
devices to keep bony prominences from being in direct contact with each other, which will
prevent skin breakdown and pressure ulcer development.)
B. Check for incontinence every 3 hr. (The nurse should check the client for incontinence at
least every 2 hr to prevent skin breakdown.)
C. Massage reddened areas of the skin. (The nurse should avoid massaging reddened areas of
the skin, which can lead to the formation of a pressure ulcer by damaging underlying tissue.)

D. Elevate the head of the bed to 45°. (The nurse should avoid elevating the head of the bed
to an angle greater than 30°. An angle greater than 30° can cause shearing of the skin, which
leads to tissue injury and pressure ulcer development.)
Answer: A. Position pillows between the bony prominences. (The nurse should use
positioning devices to keep bony prominences from being in direct contact with each other,
which will prevent skin breakdown and pressure ulcer development.)
A nurse is contributing to the plan of care for a client who has peripheral arterial disease
(PAD) of the lower extremities. Which of the following interventions should the nurse
include?
A. Place moist heat pads on the extremities. (The nurse should avoid applying heat to the
client's extremities to prevent injury due to decreased sensation.)
B. Perform manual massage of the affected extremities. (The nurse should avoid massaging
the client's lower extremities if the client is having pain from ischemia. A warm environment
and keeping the client warm will help with circulation to the extremities and decrease pain
through vasodilation.)
C. Dangle the extremities off the side of the bed. (The nurse should include in the plan of care
to have the client dangle the lower extremities off the side of the bed to aid in reducing pain
by increasing arterial blood flow. The client should not raise the lower extremities above the
level of the heart when resting in bed because it impairs arterial blood flow.)
D. Apply support stockings before getting out of bed. (The nurse should avoid applying
support stockings to the lower extremities because support stockings interfere with the
arterial blood flow to the lower extremities.)
Answer: C. Dangle the extremities off the side of the bed. (The nurse should include in the
plan of care to have the client dangle the lower extremities off the side of the bed to aid in
reducing pain by increasing arterial blood flow. The client should not raise the lower
extremities above the level of the heart when resting in bed because it impairs arterial blood
flow.)
A nurse is caring for a client who has meningococcal pneumonia. Which of the following
personal protective equipment should the nurse use?
A. Gown (The nurse should wear a gown when caring for a client who requires contact
precautions.)

B. Mask (The nurse should identify that a client who has Meningococcal pneumonia requires
droplet precautions, which include wearing a mask when providing care within 3 feet of the
client.)
C. Sterile gloves (The performance of sterile dressing changes or tracheostomy care requires
the nurse to wear sterile gloves. However, clean gloves are used to provide medical aseptic
care.)
D. Protective eyewear A nurse should wear protective eyewear when there is a risk for
splashing, such as during the irrigation of a wound.)
Answer: B. Mask (The nurse should identify that a client who has Meningococcal
pneumonia requires droplet precautions, which include wearing a mask when providing care
within 3 feet of the client.)
A nurse is assisting with the care of a client who has a cardiac catheterization via the right
femoral artery. Which of the following actions should the nurse take to prevent post
procedure complications (Select all that apply?)
A. Should wait at least 2 hours after eating before going to bed." (The client should wait to lie
down or go to bed at least 2 hr after eating to minimize reflux.)
B. "I should eat three meals a day without eating snacks between meals." (The client should
eat four to six small meals per day rather than three large meals to minimize bloating and
abdominal distention.)
C. "I should season my food with garlic." (The client should avoid spicy foods, including
garlic, to minimize reflux.)
D. "I should drink my liquids through a straw." (The client should avoid drinking through a
straw, which can promote belching and reflux.)
Answer: A. Should wait at least 2 hours after eating before going to bed." (The client should
wait to lie down or go to bed at least 2 hr after eating to minimize reflux.)
A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the
following findings should the nurse recognize as the priority?
A. Pruritus (The nurse should identify pruritus as an adverse effect of an epidural infusion.
However, another finding is the priority.)
B. Nausea (The nurse should identify nausea as an adverse effect of an epidural infusion.
However, another finding is the priority.)

C. Urinary retention (The nurse should identify urinary retention as an adverse effect of an
epidural infusion. However, another finding is the priority.
D. Dyspnea (When using the airway, breathing, circulation approach to client care, the nurse
should determine that the priority finding is dyspnea, which is a complication of the epidural
infusion.)
Answer: D. Dyspnea (When using the airway, breathing, circulation approach to client care,
the nurse should determine that the priority finding is dyspnea, which is a complication of the
epidural infusion.)
A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client.
Which of the understanding of the teaching?
A. I should wait at least 2 hours after eating before going to bed." (The client should wait to
lie down or go to bed at least 2 hr after eating to minimize reflux.)
B. "I should eat three meals a day without eating snacks between meals." (The client should
eat four to six small meals per day rather than three large meals to minimize bloating and
abdominal distention.)
C. "I should season my food with garlic." (The client should avoid spicy foods, including
garlic, to minimize reflux.)
D. "I should drink my liquids through a straw." (The client should avoid drinking through a
straw, which can promote belching and reflux.)
Answer: A. I should wait at least 2 hours after eating before going to bed." (The client should
wait to lie down or go to bed at least 2 hr after eating to minimize reflux.)
A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the
following information should the nurse include in the teaching?
A. This type of insulin should be given at the same time every day." (Insulin glargine is
released in the body over a 24 hr period. The nurse should instruct the client to administer the
insulin at the same time each day to maintain consistent serum levels for optimal therapeutic
effect.)
B. "This insulin can be mixed with short-acting insulin in a single syringe." (The nurse
should remind the client that insulin glargine should not be mixed with any other insulin.)
C. "This type of insulin can be used in a pump." (The nurse should inform the client insulin
glargine is a long-acting insulin that is administered once daily at the same time and is not to
be administered intravenously.)

D. "This insulin has an increased risk for hypoglycaemia." (The nurse should inform the
client that insulin glargine has a low risk for hypoglycaemia because serum levels of the
insulin do not peak and remain consistent over time.)
Answer: A. This type of insulin should be given at the same time every day." (Insulin
glargine is released in the body over a 24 hr period. The nurse should instruct the client to
administer the insulin at the same time each day to maintain consistent serum levels for
optimal therapeutic effect.)
A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an
INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer?
(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing
zero.)
Answer: Ratio and Proportion
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the dose the nurse should administer? Dose to administer = Desired 7 mg
Step 3: What is the dose available? Dose available = Have 10 mg
Step 4: Should the nurse convert the units of measurement? No
Step 5: What is the quantity of the dose available? 1 mL
Step 6: Set up an equation and solve for X.
Have/Quantity = Desired/X
10 mg/1 mL = 7 mg/X mL
X = 0.7
Step 7: Round if necessary.
Step 8: Reassess to determine whether the amount to administer makes sense. If there are 10
mg/mL and the provider prescribed 7 mg, it makes sense to administer 0.7 mL. The nurse
should administer phytonadione 0.7 mL subcutaneously.
Desired Over Have
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the dose the nurse should administer? Dose to administer = Desired 7 mg
Step 3: What is the dose available? Dose available = Have 10 mg
Step 4: Should the nurse convert the units of measurement? No
Step 5: What is the quantity of the dose available? 1 mL
Step 6: Set up an equation and solve for X.
Desired x Quantity/Have = X

7 mg x 1 mL/10 mg = X mL
0.7 = X
Step 7: Round if necessary.
Step 8: Reassess to determine whether the amount to administer makes sense. If there are 10
mg/mL and the provider prescribed 7 mg, it makes sense to administer 0.7 mL. The nurse
should administer phytonadione 0.7 mL subcutaneously.
Dimensional Analysis
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the quantity of the dose available? 1 mL
Step 3: What is the dose available? Dose available = Have 10 mg
Step 4: What is the dose the nurse should administer? Dose to administer = Desired 7 mg
Step 5: Should the nurse convert the units of measurement? No
Step 6: Set up an equation and solve for X.
X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/
X mL = 1 mL/10 mg x 7 mg/
X = 0.7
Step 7: Round if necessary.
Step 8: Reassess to determine whether the amount to administer makes sense. If there are 10
mg/mL and the provider prescribed 7 mg, it makes sense to administer 0.7 mL. The nurse
should administer phytonadione 0.7 mL subcutaneously.
A nurse is reinforcing teaching with an adolescent client regarding testicular selfexamination. Which of the following statements by the client demonstrates an understanding
of the teaching?
A. “I will perform the exam before I shower.” (Clients should perform a testicular selfexamination after a warm shower.)
B. “I will check my testicles every 6 months.” (Clients should perform a testicular selfexamination monthly.)
C. "I understand that testicular cancer is painless." (Clients should report a lump that is not
painful because testicular cancer is typically painless.)
D. "I understand that pea-sized lumps are normal." (Clients should report pea-sized lumps in
the testes to a provider.)
Answer: C. "I understand that testicular cancer is painless." (Clients should report a lump
that is not painful because testicular cancer is typically painless.)

A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which
of the following interventions should the nurse identify as the priority?
A. Determine the client's understanding of the procedure. (Using the nursing process, the first
action the nurse should take is to collect data from the client. Therefore, the nurse should
determine the client's understanding of the procedure to provide necessary teaching, which
can help manage his anxiety.)
B. Encourage the client to express his feelings. (Encouraging the client to express his feelings
can reduce anxiety. However, this is not the first action the nurse should take.)
C. Allow the client's family to stay with him. (Allowing the client's family to stay with him
can reduce anxiety. However, this is not the first action the nurse should take.)
D. Provide music as a distraction. (Providing music as a distraction can reduce anxiety.
However, this is not the first action the nurse should take.)
Answer: A. Determine the client's understanding of the procedure. (Using the nursing
process, the first action the nurse should take is to collect data from the client. Therefore, the
nurse should determine the client's understanding of the procedure to provide necessary
teaching, which can help manage his anxiety.)
A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty.
Which of the following factors should the nurse identify as an indication that a barrier to
learning might be present?
A. The client asks questions each time the nurse stops talking. (The nurse should identify that
asking questions indicates active listening by the client and enhances learning.)
B. The client stops the nurse and asks for pain medication. (The nurse should identify that a
client who is in pain will not be able to concentrate, which can interfere with his ability to
learn.)
C. While the nurse is speaking, the client refers to the written materials. (The nurse should
identify that clients learn in different ways. Using multiple methods of teaching, including
hands-on practice and providing written materials, enhances learning.)
D. A family member who is present asks the client to repeat important points. (The nurse
should identify that family member who are actively engaged in the teaching session and ask
questions can enhance learning.)

Answer: B. The client stops the nurse and asks for pain medication. (The nurse should
identify that a client who is in pain will not be able to concentrate, which can interfere with
his ability to learn.)
A nurse is reinforcing discharge instructions with a client who is postoperative following a
right hip arthroplasty. Which of the following statements should the nurse make?
A. You may cross your legs in 60 days." (The nurse should instruct the client to wait 90 days
before crossing her legs. Crossing her legs early in the postoperative period can result in
dislocation of the replacement hip.)
B. "Avoid lying on your operative side." (The nurse should inform the client that she may lie
on her operative side with a pillow between her legs. This will not injure the suture site or
cause dislocation of the replacement hip.)
C. "Avoid bending your hips more than 90 degrees." (The nurse should instruct the client to
avoid bending her hips more than 90° to prevent dislocation of the replacement hip.)
D. "You may sleep on a soft mattress." (The nurse should instruct the client to sleep on a firm
mattress to avoid potential dislocation of the replacement hip.)
Answer: C. "Avoid bending your hips more than 90 degrees." (The nurse should instruct the
client to avoid bending her hips more than 90° to prevent dislocation of the replacement hip.)
A nurse is caring for a client who has a compound fracture of the femur and was placed in
balanced suspension skeletal traction 4 days ago. Which of the following actions should the
nurse take?
A. Perform pin site care daily. (The nurse should perform pin site care daily with
chlorhexidine solution or use a solution according to facility protocol. The nurse should also
monitor the pin sites for manifestations of infection.)
B. Remove the overbed trapeze.(The nurse should ensure the client has an overbed trapeze to
aid in lifting the upper body off the bed when necessary and to help prevent skin breakdown
of the heels and elbows with client repositioning.)
C. Remove the boot every 2 hr. (The nurse should identify that balanced suspension skeletal
traction is managed through the use of pins, pulleys, weights, and frames and that the client
does not wear a boot.)
D. Keep the weights on a stable, flat surface. (The nurse should ensure the weights hang
freely at all times.)

Answer: A. Perform pin site care daily. (The nurse should perform pin site care daily with
chlorhexidine solution or use a solution according to facility protocol. The nurse should also
monitor the pin sites for manifestations of infection.)
A nurse is assisting the charge nurse with developing an in-service about caring for clients
who have internal sealed radiation implants. Which of the following information should the
nurse include?
A. Restrict the time pregnant women are allowed in the client's room to 15 min. (Pregnant
women and children should not be allowed to visit a client who is receiving internal radiation
therapy because of the risk for exposure to radiation emissions.)
B. Pick up a radiation implant with a double-gloved hand if it becomes dislodged. (The nurse
should use forceps to pick up a radiation implant if it becomes dislodged.
C. Limit time spent in the client's room to 2 hr during an 8 hr shift. (The nurse should limit
time spent in the client's room to 30 min during an 8 hr shift.)
D. Dispose of radiation implants in a lead container. (Lead impairs the emission of radiation.
Therefore, the nurse should dispose of radiation implants in a lead container in accordance
with facility protocol.)
Answer: D. Dispose of radiation implants in a lead container. (Lead impairs the emission of
radiation. Therefore, the nurse should dispose of radiation implants in a lead container in
accordance with facility protocol.)
A nurse in a long-term care facility is collecting data from a client who reports fullness in the
rectum and abdominal cramping. Which of the following findings should indicates to the
nurse that the client might have a fecal impaction?
A. Halitosis (Halitosis, or bad breath, is associated with the ingestion of certain foods and
medications, and it can also be an indication of infection.)
B. Haemorrhoids (Haemorrhoids indicate that the client is straining when defecating.
However, the presence of haemorrhoids does not indicate fecal impaction.)
C. Rebound tenderness (Rebound tenderness is an indication of appendicitis. A client who has
a fecal impaction can experience abdominal cramping and distention.)
D. Small liquid stools (Small liquid stools can be the result of fecal material being expelled
around an impaction.)
Answer: D. Small liquid stools (Small liquid stools can be the result of fecal material being
expelled around an impaction.)

A nurse is providing discharge teaching for the family of a client who has Parkinson’s
disease. Which of the following information should the nurse include in the teaching?
A. Place the client on a low-calorie diet to prevent weight gain. (The nurse should instruct the
client's family to provide the client with extra calories and protein to prevent unintentional
weight loss from expenditure of energy due to tremors, dyskinesia, and difficulty
swallowing.)
B. Remind the client to avoid watching her feet when walking. (The nurse should instruct the
client's family to frequently remind the client to maintain correct posture and prevent falls by
not watching her feet when walking.)
C. Use small area rugs in the client's home for traction. (The nurse should instruct the client's
family to avoid using area rugs in the client's home because her foot may drag or be stiff and
catch on an area rug, which can cause a fall.)
D. Instruct the client to take tub baths instead of showers. (The nurse should instruct the
family to encourage the client to take walk-in, sit-down showers, because skeletal muscle
rigidity can cause difficulty in moving, coordination, and balance, which increases the risk of
a fall.)
Answer: B. Remind the client to avoid watching her feet when walking. (The nurse should
instruct the client's family to frequently remind the client to maintain correct posture and
prevent falls by not watching her feet when walking.)
A home health nurse is reinforcing teaching with a client about preventing complications of
peripheral vascular disease. Which of the following statements indicates that client is
adhering to the nurse’s instructions?
A. "I apply rubbing alcohol to my feet every day to prevent infection." (Rubbing alcohol has
a drying effect on skin and can increase cracking, allowing an entry point for infection. The
client should apply lotions that do not contain alcohol.)
B. "I will wear clean, knee-high wool socks every day to help improve my circulation."
(Wool socks can result in perspiration, which puts the client at risk for developing a fungal
infection. The client should use light-weight socks to promote arterial blood flow.)
C. "I use hot water bottles to keep my feet warm at night." (Clients who have peripheral
vascular disease have decreased sensation of the affected extremities. Therefore, they are
unable to detect the temperature of the water bottle, which increases the risk for burns.)

D. "I don't cross my legs anymore." (Clients who have peripheral vascular disease should not
cross their legs because it can impede circulation
Answer: D. "I don't cross my legs anymore." (Clients who have peripheral vascular disease
should not cross their legs because it can impede circulation
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an
IV contrast agent. Which of the following laboratory findings should the nurse report to the
provider prior to the procedure?
A. Sodium 136 mEq/L (Sodium 136 mEq/L is within the expected reference range.
Therefore, the nurse does not need to report this finding to the provider before the client has a
CT scan with an IV contrast agent.)
B. Potassium 4.8 mEq/L (Potassium 4.8 mEq/L is within the expected reference range.
Therefore, the nurse does not need to report this finding to the provider before the client has a
CT scan with an IV contrast agent.)
C. Creatinine 1.9 mg/dL (Creatinine 1.9 mg/dL is not within the expected reference range.
Therefore, the nurse should report the finding to the provider before the client has a CT scan
with an IV contrast agent. This finding places the client at risk for developing contrastinduced nephropathy.)
D. Calcium 10 mg/dL (Calcium 10 mg/dL is within the expected reference range. Therefore,
the nurse does not need to report this finding to the provider before the client has a CT scan
with an IV contrast agent.)
Answer: C. Creatinine 1.9 mg/dL (Creatinine 1.9 mg/dL is not within the expected reference
range. Therefore, the nurse should report the finding to the provider before the client has a
CT scan with an IV contrast agent. This finding places the client at risk for developing
contrast-induced nephropathy.)
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA)
infections in a surgical wound. Which of the following information should the nurse plan to
share with visitors?
A. Visitors should call prior to visiting the client. (Visitors do not need to make arrangements
prior to visiting a client who is on contact isolation precautions, but visitors should receive
assistance before entering the client's room.)
B. Visitors must don a gown and gloves prior to entering the client's room. (The nurse should
provide teaching to the visitors regarding the infection control measures for a client who is on

contact isolation precautions. Contact precautions require visitors to put on a gown and
gloves prior to entering the room of a client who has MRSA to prevent the spread of
infection.)
C. Visitors need to wear a mask when in close proximity to the client. (The nurse should
identify that visitors of clients who are on airborne or droplet precautions should wear a mask
when within 3 feet of the client. However, MRSA is not spread through the respiratory tract
and does not require airborne or droplet precautions.)
D. Visitors may not bring fresh flowers into the client's room. (The nurse should identify that
fresh flowers are contraindicated for a client who is on neutropenic precautions. However,
they are not contraindicated for a client who has MRSA.)
Answer: B. Visitors must don a gown and gloves prior to entering the client's room. (The
nurse should provide teaching to the visitors regarding the infection control measures for a
client who is on contact isolation precautions. Contact precautions require visitors to put on a
gown and gloves prior to entering the room of a client who has MRSA to prevent the spread
of infection.)
A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular
disease. Which of the following images indicates the type of cooking fat the nurse should
recommend the client use when preparing meals?

A. Butter is high in saturated fat, which contributes to the development of cardiovascular
disease. It should be used sparingly or avoided.

B. Coconut oil is high in saturated fat, which contributes to the development of
cardiovascular disease. It should be used sparingly or avoided.

C. The nurse should instruct the client who has cardiovascular disease to consume foods
which contain primarily monounsaturated and polyunsaturated fats, such as olive oil or other
vegetable oils, rather than foods that are high in saturated fat. The nurse should reinforce that
oils high in monounsaturated fats help decrease the client's cardiovascular risk by lowering
LDL cholesterol and triglyceride levels.

D. Shortening is high in saturated fat, which contributes to the development of cardiovascular
disease. It should be used sparingly or avoided.

Answer: C. The nurse should instruct the client who has cardiovascular disease to consume
foods which contain primarily monounsaturated and polyunsaturated fats, such as olive oil or
other vegetable oils, rather than foods that are high in saturated fat. The nurse should
reinforce that oils high in monounsaturated fats help decrease the client's cardiovascular risk
by lowering LDL cholesterol and triglyceride levels.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for
hydrochlorothiazide. Which of the following findings should the nurse instruct the client to
report to the provider?
A. Onset of nausea (The nurse should instruct the client to report a new onset of nausea,
which can be an indication of hyponatremia or hypokalaemia resulting from the diuretic
effects of the hydrochlorothiazide.
B. Increased urinary output (The nurse should remind the client that an increase in urinary
output is a desired effect of hydrochlorothiazide.)
C. Weight loss of 0.9 kg (2 lb) per week (The nurse should remind the client to report weight
gain of 0.9 kg (2 lb) or more per week to the provider.)
D. Missed dose of the medication (The nurse should instruct the client to take a missed dose
of the medication as soon as the client remembers. However, the client should not take a
double-dose of the medication.)
Answer: A. Onset of nausea (The nurse should instruct the client to report a new onset of
nausea, which can be an indication of hyponatremia or hypokalaemia resulting from the
diuretic effects of the hydrochlorothiazide.
A nurse is preparing to suction a client who has a tracheostomy. Which of the following
actions should the nurse take first?
A. Insert the suction catheter into the tracheostomy. (The nurse should insert the catheter tip
into the tracheostomy during inspiration until it meets resistance, then pull back 2.5 cm (1 in).
However, evidence-based practice indicates that there is another action the nurse should take
first.)
B. Rinse the catheter with sterile 0.9% sodium chloride. (The nurse should rinse or flush the
catheter with 0.9% sodium chloride to clear the catheter of secretions before repeating the
suctioning procedure. However, evidence-based practice indicates that there is another action
the nurse should take first.)

C. Ventilate with 100% oxygen. (According to evidence-based practice, the nurse should
ventilate the client with 100% oxygen before suctioning to prevent hypoxemia when
removing air and debris from the upper airway.)
D. Occlude the vent on the catheter for 10 seconds. (The nurse should occlude the vent on the
catheter for 10 to 15 seconds while removing the catheter during suctioning. However,
evidence-based practice indicates that there is another action the nurse should take first.)
Answer: C. Ventilate with 100% oxygen. (According to evidence-based practice, the nurse
should ventilate the client with 100% oxygen before suctioning to prevent hypoxemia when
removing air and debris from the upper airway.)
A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how
to improve the taste of bland food. Which of the following should the nurse recommend?
A. Ketchup (The nurse should not recommend ketchup to the client because it is high in
sodium.)
B. Mayonnaise (The nurse should not recommend mayonnaise to the client because it is high
in sodium.)
C. Soy sauce (The nurse should not recommend soy sauce to the client because it is high in
sodium.)
D. Lemon juice (The nurse should recommend that the client use lemon juice to flavour his
food because it is low in sodium.)
Answer: D. Lemon juice (The nurse should recommend that the client use lemon juice to
flavour his food because it is low in sodium.)
A nurse is reviewing the medical record of a client who has a prescription for morphine.
Which of the following findings should the nurse reports to the provider?
A. Urinary retention (The nurse should recognize that administering morphine to the client
can cause urinary retention. Therefore, the nurse should report this finding to the provider.)
B. Administration of celecoxib 24 hr ago (Celecoxib is not a contraindication to morphine
administration.)
C. History of immunosuppression (A history of immunosuppression is not a contraindication
to morphine administration.)
D. Administration of levothyroxine 12 hr ago (Levothyroxine is not a contraindication to
morphine administration.)

Answer: A. Urinary retention (The nurse should recognize that administering morphine to
the client can cause urinary retention. Therefore, the nurse should report this finding to the
provider.)
A nurse is caring for a client who is 13 days postoperative following a total right hip
arthroplasty. Which of the following actions should the nurse take?
A. Use a traction boot to keep the client's right leg internally rotated. (The nurse should not
apply any type of traction boot or allow the client's leg to rotate internally or externally
because it can cause a dislocation of the affected hip.)
B. Have the client sit in a reclining chair when out of bed. (The nurse should provide a chair
that does not allow the client to recline because a reclining chair increases the risk of the
client flexing at the hips beyond 90° when moving to a standing position.)
C. Maintain abduction of the client's right leg while in bed. (The nurse should maintain
abduction of the client's right leg to prevent dislocation of the affected hip by placing an
abductor pillow between the client's legs when resting in bed.)
D. Encourage the client to perform passive range-of-motion exercises. (The nurse should
encourage the client to stand at the bedside on the day of surgery and, if prescribed by the
provider, to walk using a walker. Passive range-of-motion exercises require flexion and
extension of the joints and are not recommended 3 days following surgery.)
Answer: C. Maintain abduction of the client's right leg while in bed. (The nurse should
maintain abduction of the client's right leg to prevent dislocation of the affected hip by
placing an abductor pillow between the client's legs when resting in bed.)
A nurse is monitoring a client who is taking acarbose. Which of the following findings should
the nurse identify as an adverse effect of the medication?
A. Polyuria (Polyuria is an adverse effect of furosemide.)
B. Abdominal cramps (Acarbose affects the gastrointestinal system. Therefore, the nurse
should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhoea as
adverse effects of this medication.)
C. Renal insufficiency (Long-term and high-dose use of acarbose can cause liver dysfunction,
not renal insufficiency.)
D. Insomnia (Insomnia is an adverse effect of methylphenidate.)

Answer: B. Abdominal cramps (Acarbose affects the gastrointestinal system. Therefore, the
nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and
diarrhoea as adverse effects of this medication.)
A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is
receiving epoetin alfa. The nurse should identify that which of the following laboratory
values indicates the treatment is effective?
A. BUN 40 mg/dL (Clients who have chronic kidney failure will demonstrate elevated BUN
levels, but this does not measure the effectiveness of epoetin alfa.)
B. Hgb 11 g/Dl (Epoetin alfa stimulates the production of erythropoietin and red blood cells,
resulting in increased haemoglobin levels. Therefore, a haemoglobin level of 11 g/dL
indicates the epoetin alfa treatment is effective.)
C. Urine specific gravity 1.035 (Clients who have chronic kidney failure will demonstrate
concentrated urine and elevated specific gravity, but this does not measure the effectiveness
of epoetin alfa.)
D. Blood glucose 105 mg/dL (Epoetin alfa does not affect blood glucose levels.)
Answer: B. Hgb 11 g/Dl (Epoetin alfa stimulates the production of erythropoietin and red
blood cells, resulting in increased haemoglobin levels. Therefore, a haemoglobin level of 11
g/dL indicates the epoetin alfa treatment is effective.)
A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the
following actions should the nurse take when communicating with the client?
A. Rephrase client instructions when not understood. (When communicating with a client
who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions
when they are not understood.)
B. Cup hands around the mouth and direct speech toward the client. (When communicating
with a client who has hearing loss, the nurse should keep hands away from the mouth to
promote lip reading.)
C. Accentuate vowel sounds by using a higher pitch when speaking. (When communicating
with a client who has hearing loss, the nurse should speak in a lower tone of voice and use a
lower pitch. Higher pitched sounds can impede hearing by accentuating vowel sounds and
concealing consonants.)

D. Sit to the side of the client and speak instructions into her best ear. (When communicating
with a client who has hearing loss, the nurse should sit or stand facing the client on the same
level so that the nurse's mouth and lips can be seen for lip reading.)
Answer: A. Rephrase client instructions when not understood. (When communicating with a
client who has hearing loss, the nurse should rephrase, rather than repeat, discharge
instructions when they are not understood.)
A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The
client is exhibiting hypotension, tachycardia, and tachypnoea. The nurse should recognize
that these findings indicate which of the following complications?
A. Wound infection (Manifestations of a wound infection include fever, inflammation of the
incision, and foul-smelling drainage. Hypotension, tachycardia, and tachypnoea do not
indicate a wound infection in a client who is 1 day postoperative.)
B. Pulmonary embolism (Manifestations of a pulmonary embolism include hypotension,
tachycardia, and tachypnoea.)
C. Thrombophlebitis (Thrombophlebitis is the inflammation of a blood vessel, which can lead
to a thrombus formation. Hypotension, tachycardia, and tachypnoea do not indicate
thrombophlebitis.)
D. Paralytic ileus (Paralytic ileus is the absence of bowel peristalsis, or movement.
Hypotension, tachycardia, and tachypnoea do not indicate a paralytic ileus.)
Answer: B. Pulmonary embolism (Manifestations of a pulmonary embolism include
hypotension, tachycardia, and tachypnoea.)
A nurse is monitoring a client who recently had a cast placed on the right lower extremity for
a bone fracture. Which of the following findings should the nurse recognize as abnormal?
A. Report of a dull, throbbing pain (Dull, throbbing pain is an expected finding for a client
who has a bone fracture.
B. Extremities that are cool bilaterally) (Cool, bilateral extremities are an indication of the
client's overall body temperature and general circulatory status and are an expected finding.)
C. Capillary refill of 3 seconds in the nail beds of the toes (A capillary refill of 3 seconds in
the nail beds of the toes is slowed but still within the expected reference range after
application of a cast.)

D. Lack of sensation between the first and second toes (Lack of sensation between the toes
indicates peripheral nerve impairment and is an abnormal finding that can indicate the client
has compartment syndrome. The nurse should notify the provider immediately.)
Answer: D. Lack of sensation between the first and second toes (Lack of sensation between
the toes indicates peripheral nerve impairment and is an abnormal finding that can indicate
the client has compartment syndrome. The nurse should notify the provider immediately.)
A nurse is caring for a client who has a history of breast cancer. The client asks the nurse
about birth control. Which of the following methods of birth control is contraindicated for
this client?
A. Intrauterine device (The nurse should identify that the use of an intrauterine device
requires the client to check the placement monthly and is not contraindicated for this client.)
B. Latex condom (The nurse should identify that the use of latex condoms is contraindicated
for clients, or their partners, who are allergic to latex. However, it is not contraindicated for
this client.)
C. Combination oral contraceptives (The nurse should identify that combination oral
contraceptives are contraindicated for this client because they increase estrogen levels, which
can stimulate the growth of any remaining cancerous breast cells.)
D. Contraceptive sponge (The nurse should identify that prolonged use of a contraceptive
sponge can increase the risk for toxic shock syndrome. However, it is not contraindicated for
this client.)
Answer: C. Combination oral contraceptives (The nurse should identify that combination
oral contraceptives are contraindicated for this client because they increase estrogen levels,
which can stimulate the growth of any remaining cancerous breast cells.)
A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of
the following outcome from the medication should the nurse expect?
A. Increased weight (The nurse should expect the client's weight to decrease because of the
increased excretion of fluid that is caused by improved cardiac output.)
B. Increased heart rate (The nurse should expect the client's heart rate to decrease because
digoxin decreases the client's sympathetic nerve tone, which slows the heart rate.)
C. Decreased urinary output (The nurse should expect the client to have an increase in urinary
output because digoxin improves cardiac output and increases the client's renal blood flow
through the kidneys, which results in an increased excretion of urine.)

D. Decreased shortness of breath (The nurse should expect the client to have decreased
shortness of breath. Digoxin increases the contractility of the heart, which decreases
pulmonary congestion.)
Answer: D. Decreased shortness of breath (The nurse should expect the client to have
decreased shortness of breath. Digoxin increases the contractility of the heart, which
decreases pulmonary congestion.)
A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE)
and is to begin taking methylprednisolone orally. Which of the following statements should
the nurse include in the teaching?
A. "Take the medication on an empty stomach." (The client should take glucocorticoids with
food to prevent gastrointestinal upset and bleeding.)
B. "Limit contact with large groups of people." (Glucocorticoids cause immunosuppression
and may mask infection. The client should limit contact with sources of possible infections,
such as large groups of people.)
C. "Avoid taking over-the-counter calcium supplements." (Clients who take glucocorticoids
are at risk for osteoporosis, so they should take additional vitamin D and calcium
supplements.)
D. "Follow a low-protein diet." (It is not necessary for a client who has SLE and is taking a
glucocorticoid to restrict protein intake.)
Answer: B. "Limit contact with large groups of people." (Glucocorticoids cause
immunosuppression and may mask infection. The client should limit contact with sources of
possible infections, such as large groups of people.)
A nurse is caring for a client who is 24 hr. postoperative following abdominal surgery and has
an NG tube. Which of the following actions should the nurse plan to take to decrease the risk
of postoperative complications?
A. Offer sips of water to the client following oral care. (The nurse should provide frequent
oral care and the use of moistened oral swabs to alleviate dry mucous membranes. However,
oral fluids are contraindicated for a client who had abdominal surgery and has an NG tube.)
B. Massage the client's lower extremities with lotion every 2 hr. (The nurse should monitor
the client's lower extremities for tenderness, warmth, or redness. However, massaging the
client's lower extremities is contraindicated because, if there is a blood clot formation in the a
lower extremity, it can loosen the clot and cause a pulmonary embolism.

C. Encourage the client to use an incentive spirometer every hour while awake. (The nurse
should assist the client to use the incentive spirometer in addition to coughing and deep
breathing every hour while awake for the first 24 hr postoperatively and at least every 2 hr
while awake thereafter. An incentive spirometer will inflate the client's alveoli and improve
ventilation to prevent postoperative pneumonia.)
D. Place one or two pillows beneath the client's knees while he is in bed. (The nurse should
elevate the foot of the bed slightly and apply prescribed compression stockings or sequential
compression devices to promote venous return. However, pillows beneath the client's knees
can create pressure and decrease venous return in the lower extremities, which can lead to
thrombosis.)
Answer: C. Encourage the client to use an incentive spirometer every hour while awake.
(The nurse should assist the client to use the incentive spirometer in addition to coughing and
deep breathing every hour while awake for the first 24 hr postoperatively and at least every 2
hr while awake thereafter. An incentive spirometer will inflate the client's alveoli and
improve ventilation to prevent postoperative pneumonia.)
A nurse is reinforcing teaching with a client who has multiple sclerosis and a new
prescription for baclofen. Which of the following instructions should the nurse include in the
teaching?
A. Consume a low-purine diet. (The nurse should recommend a low-purine diet for a client
who has gout and a prescription for colchicine.)
B. Avoid stopping this medication suddenly. (The nurse should instruct the client to avoid
stopping baclofen suddenly because it can result in adverse reactions, including seizures,
paranoia, and hallucinations.)
C. Use chamomile tea to alleviate insomnia. (The nurse should instruct the client to avoid
chamomile because it can interact with baclofen to increase CNS depression.)
D. Take this medication on an empty stomach. (The nurse should instruct the client to take
baclofen with milk or food to minimize gastric upset.)
Answer: B. Avoid stopping this medication suddenly. (The nurse should instruct the client to
avoid stopping baclofen suddenly because it can result in adverse reactions, including
seizures, paranoia, and hallucinations.)

A nurse reviewing the laboratory results of a client who has type 2 diabetes mellitus. The
nurse should identify that which of the following laboratory values indicates the client is at
risk for delayed wound healing?
A. HbA1c 6% (This laboratory value indicates glycaemic control and does not indicate that
the client is at risk for delayed wound healing. The nurse should identify that elevated HbA1c
levels can increase the risk for delayed wound healing.)
B. Prealbumin 12 mg/dL (This laboratory value is below the expected reference range,
indicating that the client's protein status is inadequate and that he is at risk for delayed wound
healing due to malnutrition.)
C. WBC 8,000/mm3 (This laboratory value is within the expected reference range and
indicates immune function. The nurse should identify that an elevated WBC count increases
the risk for delayed wound healing.)
D. Creatinine 0.8 mg/dL (This laboratory value is within the expected reference range and
indicates adequate kidney function. The nurse should identify that the client who is diabetic is
at increased risk for the development of renal failure, which can increase the risk for infection
and delayed wound healing.)
Answer: B. Prealbumin 12 mg/dL (This laboratory value is below the expected reference
range, indicating that the client's protein status is inadequate and that he is at risk for delayed
wound healing due to malnutrition.)
A nurse is assisting with the discharge planning for a client who is postoperative following a
total hip arthroplasty. Which of the following instructions should the nurse include in the
discharge plan?
A. Expect decreased sensation for the first postoperative week. (The nurse should instruct the
client to report decreased sensation in the affected foot or leg because this can indicate
neurovascular compromise.)
B. Avoid lying on the operative side. (The nurse should instruct the client that lying on the
operative side is allowed but the client should place pillows between the legs to prevent
dislocation of the hip.)
C. Obtain a raised toilet seat. (The nurse should instruct the client to use a raised toilet seat to
avoid flexing the hip more than 90°, which increases the risk for dislocation.)
D. Cross legs at the ankles. (The nurse should instruct the client to avoid crossing her legs to
prevent dislocation of the hip.)

Answer: C. Obtain a raised toilet seat. (The nurse should instruct the client to use a raised
toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation.)
A nurse is preparing to move a client’s NG tube. Which of the following interventions should
the nurse take to decrease the risk of aspiration?
A. Instil 10 mL of air through the NG tube. (The nurse should instil 50 mL of air through the
NG tube to remove mucus and gastric secretions from the tube and to prevent aspiration of
these secretions.)
B. Place the client in the supine position. (The nurse should place the client in a sitting
position to prevent the risk of aspiration.)
C. Irrigate the NG tube. (The nurse should identify that irrigating the NG tube before removal
can put the client at risk for aspiration and should be avoided.)
D. Pinch the NG tube. (The nurse should pinch the NG tube to prevent secretions from
draining into the client's throat, which can cause aspiration.)
Answer: D. Pinch the NG tube. (The nurse should pinch the NG tube to prevent secretions
from draining into the client's throat, which can cause aspiration.)
A nurse is collecting data from a client who has chronic kidney disease with hyperkalaemia.
Which of the following findings should the nurse expect related to hyperkalaemia?
A. Polyuria (Polyuria is a manifestation of hypokalaemia.)
B. Constipation (Constipation is a manifestation of hypokalaemia.)
C. Anorexia (Anorexia is a manifestation of hypokalaemia.)
D. Bradycardia (The client who has hyperkalaemia can have an irregular, slow heart rate,
known as bradycardia.)
Answer: D. Bradycardia (The client who has hyperkalaemia can have an irregular, slow heart
rate, known as bradycardia.)
A nurse is reinforcing teaching with a client who has asthma. Which of the following client
statements indicate an understanding of the use of budesonide and albuterol inhalers? (Select
all that apply.)
A. "I should expect to feel sleepy after using my albuterol inhaler" (The client should
recognize that albuterol stimulates the sympathetic nervous system, which can cause
nervousness and insomnia, along with increased heart rate and blood pressure.)

B. "I never forget to rinse my mouth after using my budesonide inhaler. (The client should
rinse his mouth after using a budesonide inhaler to reduce the risk for oral fungal infection.)
C. "Between office visits, I keep a record of how many times I use my albuterol inhaler" (The
client should record the number of times that he uses his albuterol inhaler. This information
can assist the provider to determine the effectiveness of the medication.)
D. "I use my albuterol inhaler before I go swimming" (The client should use the albuterol
inhaler before exercise to prevent exercise-induced bronchospasms.)
E. "I should use my budesonide inhaler before using my albuterol inhaler" (The client should
first use the albuterol inhaler, a bronchodilator, to open the airway and enhance the absorption
of the budesonide, which is an inhaled corticosteroid.)
Answer: B. "I never forget to rinse my mouth after using my budesonide inhaler. (The client
should rinse his mouth after using a budesonide inhaler to reduce the risk for oral fungal
infection.)
C. "Between office visits, I keep a record of how many times I use my albuterol inhaler" (The
client should record the number of times that he uses his albuterol inhaler. This information
can assist the provider to determine the effectiveness of the medication.)
D. "I use my albuterol inhaler before I go swimming" (The client should use the albuterol
inhaler before exercise to prevent exercise-induced bronchospasms.)
A nurse is caring for a client and administers penicillin IM. the client begins exhibiting hives
and has severe difficulty breathing. After establishing a patent airway, which of the following
actions should the nurse take next?
A. Administer epinephrine. (The greatest risk to the client is death from anaphylaxis.
Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal
edema.)
B. Monitor the client's vital signs. (The nurse should monitor the client's vital signs during the
crisis to detect a decrease in blood pressure and an increase in respiratory effort. However,
there is another action the nurse should take first.)
C. Monitor the client's oxygen saturation level. (The nurse should monitor the client's oxygen
saturation level to ensure respiratory support. However, there is another action the nurse
should take first.)
D. Administer an antihistamine. (The nurse should administer an antihistamine to treat the
hives and reduce the histamine release. However, there is another action the nurse should take
first.)

Answer: A. Administer epinephrine. (The greatest risk to the client is death from
anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms
and laryngeal edema.)
A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the
following statements by the client indicates an understanding of the disease process?
A. "I should call my doctor if I get a headache." (Headaches are not a complication of mitral
valve disease.)
B. "I may develop gastric reflux." (Mitral valve disease does not cause gastric reflux.)
C. "I may develop excessive bruising." (A provider may prescribe anticoagulants to prevent
thrombus formation on the valve, which can cause excessive bruising for a client who has
mitral valve disease. However, excessive bruising is not a direct result of the disease.)
D. "I should call my doctor if my ankles swell." (Swelling of the ankles can indicate heart
failure. The client should report this finding to the provider.)
Answer: D. "I should call my doctor if my ankles swell." (Swelling of the ankles can indicate
heart failure. The client should report this finding to the provider.)
A nurse is monitoring an older adult client who has a history of an enlarged prostate and is
experiencing suprapubic discomfort. Which of the following actions should the nurse take
first?
A. Administer doxazosin. (The nurse may need to administer doxazosin to relax the smooth
muscle of the bladder to increase urine flow. However, the nurse should use a less restrictive
intervention first.)
B. Palpate the abdomen. (When providing client care, the nurse should first use the least
restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the
client has a distended bladder from urinary retention.)
C. Insert an indwelling urinary catheter. (The nurse may need to insert an indwelling urinary
catheter for a distended bladder. However, the nurse should use a less restrictive intervention
first.)
D. Notify the primary care provider. (The nurse may need to notify the primary care provider
if the client has a distended bladder. However, the nurse should use a less restrictive
intervention first.)

Answer: B. Palpate the abdomen. (When providing client care, the nurse should first use the
least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if
the client has a distended bladder from urinary retention.)
A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary
disease (COPD) and is dyspneic. Which of the following interventions should the nurse
include in the plan?
A. Encourage abdominal breathing. (The nurse should encourage abdominal breathing, which
reduces the workload on the accessory muscles of respiration during dyspneic episodes.)
B. Direct the client to inhale with pursed lips. (The nurse should direct the client to exhale
using pursed-lip breathing during dyspneic episodes to maintain positive airway pressure.)
C. Set the oxygen therapy at 5 L/min. (The nurse should set the oxygen therapy between 1 to
3 L/min to prevent the client's urge to breathe from decreasing during dyspneic episodes.
D. Instruct the client to lean back when coughing. (The nurse should instruct the client to lean
forward and repeatedly "huff" followed by relaxed breathing to clear secretions during
dyspneic episodes.)
Answer: A. Encourage abdominal breathing. (The nurse should encourage abdominal
breathing, which reduces the workload on the accessory muscles of respiration during
dyspneic episodes.)
A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the
following provider prescriptions should the nurse implement first?
A. Collect a sputum culture. (The nurse should collect a sputum culture to identify the
organism causing the client's infection. Antimicrobial sensitivities are obtained from the
sputum culture to guide the provider in prescribing antibiotics. However, there is another
prescription the nurse should implement first.)
B. Administer ceftriaxone by intermittent IV bolus. (The nurse should administer antibiotics
to treat the infection. A broad spectrum antibiotic, such as ceftriaxone, is administered when
sepsis is suspected because it treats both gram-positive and negative bacteria. After the results
of the blood and sputum cultures are obtained, the provider will often change to a more
specific antibiotic. However, there is another prescription the nurse should implement first.)
C. Initiate oxygen at 4 L/min via nasal cannula. (When using the airway, breathing,
circulation approach to client care, the first action the nurse should take is to initiate oxygen.
Clients who have manifestations of sepsis are often hypoxic, tachypnoeic, or have a PaCO2

level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's
oxygen saturation levels at 95% or greater, which will maximize the ability of the
haemoglobin to support the oxygen needs of the body.)
D. Obtain blood cultures. (The nurse should obtain blood cultures to identify the organism
causing the client's infection. Antimicrobial sensitivities obtained from the blood cultures will
guide the provider in prescribing treatment. However, there is another prescription the nurse
should implement first.)
Answer: C. Initiate oxygen at 4 L/min via nasal cannula. (When using the airway, breathing,
circulation approach to client care, the first action the nurse should take is to initiate oxygen.
Clients who have manifestations of sepsis are often hypoxic, tachypnoeic, or have a PaCO2
level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's
oxygen saturation levels at 95% or greater, which will maximize the ability of the
haemoglobin to support the oxygen needs of the body.)
A nurse is caring for a client who has terminal pancreatic cancer. The client states, “I don’t
think I can go on any longer.” Which of the following responses should the nurse make?
A. "Can I get you something for the pain?" (The nurse should monitor the client's pain level
and provide analgesics as needed. However, this response changes the subject, does not
acknowledge the client's feelings, and is a barrier to a continued trusting relationship.)
B. "You should talk about this with your family." (This response is an example of giving
common advice and is dismissive of the client's feelings, which are barriers to a trusting
relationship and open communication.)
C. "Tomorrow will be a better day." (This response is an example of false reassurance and is
dismissive of the client's feelings, provides false hope, and does not promote open
communication.)
D. "Tell me more about the way you are feeling." (The nurse is establishing a trusting
relationship by seeking clarification and encouraging the client to verbalize feelings.)
Answer: D. "Tell me more about the way you are feeling." (The nurse is establishing a
trusting relationship by seeking clarification and encouraging the client to verbalize feelings.)
A nurse is collecting data from a 55-year old female client who reports vaginal dryness and
hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of
the following should the nurse recognize as a contraindication to HRT?

A. Five-year history of menopause manifestations (The nurse should identify that
manifestations of menopause can last for 10 years or more and HRT is not contraindicated for
a client whose menopause manifestations began 5 years ago.)
B. History of treatment for blood clots (Estrogen increases the risk of blood clots.
Therefore, a woman who has a history of blood clots should not receive HRT.)
C. Topiramate use for migraine headaches (The nurse should identify that the use of
topiramate to treat migraine headaches can cause decreased absorption of estrogen when used
as a contraceptive. However, topiramate is not a contraindication to HRT.)
D. Increased serum cholesterol levels (The nurse should identify that one of the benefits of
HRT is a decrease in LDL and an increase in HDL levels. Therefore, HRT is not
contraindicated for a client who has increased serum cholesterol levels.)
Answer: B. History of treatment for blood clots (Estrogen increases the risk of blood clots.
Therefore, a woman who has a history of blood clots should not receive HRT.)
A nurse in an oncology clinic is reinforcing teaching is reinforcing teaching about Mohs
surgery with a client who has skin cancer. Which for the following information should the
nurse include in the teaching?
A. Mohs surgery is a horizontal shaving of thin layers of the tumour. (Mohs surgery is
performed to treat basal and squamous cell carcinoma. The procedure, which involves a
horizontal shaving of thin layers of a tumour, has a high treatment rate.)
B. Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. (Cryosurgery, rather
than Mohs surgery, uses liquid nitrogen to destroy cancerous tissue.)
C. Mohs surgery is the preferred treatment for melanoma skin cancer. (Mohs surgery is the
preferred treatment for basal and squamous cell carcinoma. The preferred treatment for
melanoma is a wide, full thickness surgical excision.)
D. Mohs surgery is a palliative treatment for metastatic skin cancer. (Radiation, rather than
Mohs surgery, can be used as a palliative treatment for metastatic skin cancer.)
Answer: A. Mohs surgery is a horizontal shaving of thin layers of the tumour. (Mohs surgery
is performed to treat basal and squamous cell carcinoma. The procedure, which involves a
horizontal shaving of thin layers of a tumour, has a high treatment rate.)
A nurse I performing ECG on a client who is scheduled for surgery the following morning. In
which of the following locations should the nurse place the V1 electrode? (You will find hot
spots to select in the artwork below. Select only the hot spot that corresponds to your answer)

A. A is incorrect. The nurse should identify that the Right Arm (RA) electrode should be
positioned just below the right clavicle.
B. B is incorrect. The nurse should identify that the Left Arm (LA) electrode should be
positioned just below the left clavicle.
C. C is correct. The nurse should identify that the V1 electrode should be placed in the 4th
intercostal space just to the right of the sternum. Correct placement of the electrodes is vital
in obtaining accurate information about the electrical activity of the heart.
D. D is incorrect. The nurse should identify that the V2 electrode should be placed in the 4th
intercostal space just to the left of the sternum.
Answer: C. C is correct. The nurse should identify that the V1 electrode should be placed in
the 4th intercostal space just to the right of the sternum. Correct placement of the electrodes
is vital in obtaining accurate information about the electrical activity of the heart.
A nurse is collecting data from a client who has hypokalaemia. Which of the following
findings should the nurse identify as the priority?
A. Muscle weakness (The nurse should address muscle weakness to prevent injury for a
client who has hypokalaemia. However, another finding is the priority.)
B. Dysrhythmia (When using the airway, breathing, circulation approach to client care, the
nurse should identify that the priority finding for a client who has hypokalaemia is
dysrhythmia.)
C. Abdominal pain (The nurse should address abdominal pain to promote comfort for a client
who has hypokalaemia. However, another finding is the priority.)
D. Lethargy (The nurse should address lethargy for a client who has hypokalaemia to prevent
injury. However, another finding is the priority.)

Answer: B. Dysrhythmia (When using the airway, breathing, circulation approach to client
care, the nurse should identify that the priority finding for a client who has hypokalaemia is
dysrhythmia.)
A nurse is caring for an older adult client who has reddened area over the sacrum. Which of
the following actions should the nurse take?
A. Minimize the time the head of the bed is elevated. (The nurse should minimize the time
the head of the bed is elevated to reduce pressure on the sacral area.)
B. Apply a sterile gauze dressing to the site. (The nurse should collect further data before
determining what type of dressing is needed. For a stage I pressure injury, skin preparation
can be applied to preserve the integrity of the skin and prevent further direct injury.
Alternatively, a dressing such as a hydrocolloid or transparent dressing can be applied.
However, gauze dressings are not used in the treatment of a stage I pressure injury.)
C. Massage the site with moisturizing lotion. (The nurse should not massage nor apply
moisturizing lotion to a reddened area because it can cause further skin injury.)
D. Place a donut-shaped cushion under the client's sacral area. (The nurse should not place a
donut-type device under the client's sacral area because it can contribute to the development
of a pressure injury.)
Answer: A. Minimize the time the head of the bed is elevated. (The nurse should minimize
the time the head of the bed is elevated to reduce pressure on the sacral area.)
A nurse is caring for a client who is in Buck’s traction. Which of the following interventions
should the nurse perform to reduce skin breakdown?
A. Keep the skin dry and free of perspiration. (The nurse should not leave moisture on the
skin for prolonged periods of time because it can cause skin breakdown.)
B. Use hot water and antibacterial soap to bathe the client. (The nurse should bathe the client
in tepid water and use mild soap to prevent skin breakdown.)
C. Massage the skin over bony prominences to promote circulation. (The nurse should not
massage bony prominences because it can cause skin damage.)
D. Limit the use of moisturizers on the skin over bony prominences. (The nurse should
moisturize skin that is intact to help prevent cracks and breaks in the skin.)
Answer: A. Keep the skin dry and free of perspiration. (The nurse should not leave moisture
on the skin for prolonged periods of time because it can cause skin breakdown.)

A nurse is contributing to the plan of care for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infections and is on contract isolation precautions.
Which of the following actions should the nurse take?
A. Keep the door of the client's room closed at all times. ()The nurse should keep the door of
a client's room closed at all times if the client requires airborne precautions.
B. Remove gloves after leaving the client's room. (The nurse should remove gloves before
leaving the client's room.)
C. Wear a mask when working within 1 m (3 feet) of the client. (The nurse should wear a
mask when working within 1 m (3 feet) of a client who requires droplet precautions.)
D. Have a designated stethoscope in the client's room. (The nurse should designate equipment
to leave in the client's room to avoid cross-contamination. The designated equipment should
be disposed of or decontaminated before leaving the client's room.)
Answer: D. Have a designated stethoscope in the client's room. (The nurse should designate
equipment to leave in the client's room to avoid cross-contamination. The designated
equipment should be disposed of or decontaminated before leaving the client's room.)
A nurse is caring for a client who has a prescription for phenazopyridine. Which of the
following findings should the nurse identify as a therapeutic effect of the medication?
A. Reduces bacteria in the urinary tract (Bacteria in the urinary tract is reduced with the use
of an antimicrobial medication, such as Fosfomycin.)
B. Suppresses urge to void (The urge to void is suppressed with the use of an antispasmodic
for urinary incontinence, such as oxybutynin.)
C. Prevents nerve stimulation to the bladder muscle (Nerve stimulation to the bladder muscle
is prevented with the use of an antispasmodic, such as hyoscyamine.)
D. Decreases pain during urination (Phenazopyridine reduces pain and burning during
urination by exerting an aesthetic effect on the mucosa of the urinary tract.)
Answer: D. Decreases pain during urination (Phenazopyridine reduces pain and burning
during urination by exerting an aesthetic effect on the mucosa of the urinary tract.)
A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the
following instructions should the nurse include?
A. "You can take acetaminophen for pain." (The nurse should instruct the client to avoid
taking any over-the-counter medications, including acetaminophen, which is toxic to the
liver.)

B. "Consume a diet high in animal protein." (The nurse should instruct the client to increase
vegetable proteins and reduce animal proteins in the diet to limit the development of
encephalopathy.)
C. "Sleep lying flat on your back." (The nurse should instruct the client to elevate the head of
the bed while sleeping to prevent shortness of breath from the pressure of ascites or
hydrothorax.)
D. "Consume foods low in sodium." (The nurse should instruct the client to consume foods
low in sodium to reduce the development of edema and ascites.)
Answer: D. "Consume foods low in sodium." (The nurse should instruct the client to
consume foods low in sodium to reduce the development of edema and ascites.)
A nurse is planning to implement droplet precautions for a client who has manifestations of
pertussis. Which of the following interventions should the nurse include when contributing to
the plan of care?
A. Apply a mask on the client if transport is needed. (The nurse should apply a mask to the
client who has manifestations of pertussis during transport to prevent exposure to others.)
B. Wear a mask when working within 4 feet of the client. (The nurse should wear a surgical
mask when working within 1 m (3 feet) of the client who has manifestations of pertussis.)
C. Don a gown when visiting with the client. (The nurse should wear a gown when providing
direct care to a client if there is potential for soiling clothes during contact. However, it is not
required for the care of the client who requires droplet precautions; unwarranted use of the
gown increases costs.)
D. Wear an N95 mask when entering the client's room. (The nurse should wear an N95 mask
when caring for a client who has been placed on airborne precautions, such a client who has
tuberculosis.)
Answer: A. Apply a mask on the client if transport is needed. (The nurse should apply a
mask to the client who has manifestations of pertussis during transport to prevent exposure to
others.)
A nurse is assisting a client who reports difficulty falling asleep. Which of the following
activities should the nurse recommend to promote sleep?
A. Get out of bed if unable to fall asleep within 60 min. (The client should get out of bed after
30 min if unable to fall asleep.)

B. Take a brisk walk before sleeping. (The client should avoid stimulating activities, such as
exercise, before bedtime.)
C. Listen to soft music before sleeping. (Listening to soft music can help the client to relax
and reduces environmental stressors.)
D. Drink adequate amounts of fluids before sleeping. (The client should reduce fluids 2 to 4
hr before sleep. Drinking fluids before bedtime can cause the client to wake up during the
night to use the bathroom.)
Answer: C. Listen to soft music before sleeping. (Listening to soft music can help the client
to relax and reduces environmental stressors.)
A nurse is caring for a client who has an acute ischemic stroke 1 day ago. Which of the
following actions should the nurse take to reduce the risk for aspiration?
A. Allow for 30 min of rest before meals. (The nurse should allow the client to rest for
30 min before meals to prevent aspiration.)
B. Provide a straw for drinking liquids. (The nurse should provide a cup for drinking liquids,
rather than a straw.)
C. Serve foods at room temperature. 9The nurse should serve foods that are cold or heated. It
is more difficult for the client to swallow food that is lukewarm or at room temperature.)
D. Place 2 tsp of food in the client's mouth at a time. (The nurse should place only 1 tsp of
food in the client's mouth at a time.)
Answer: A. Allow for 30 min of rest before meals. (The nurse should allow the client to rest
for 30 min before meals to prevent aspiration.)
A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min
ago by the RN. The client reports dyspnoea and urticaria. Which of the following actions
should the nurse perform first?
A. Count the client's respiratory rate. (The nurse should take the client's vital signs, which
includes counting the client's respiratory rate. However, evidence-based practice indicates
that the nurse should take a different action first.)
B. Ask the client if chest pain is present. (The nurse should inquire about the presence of
chest pain and other manifestations to determine the severity of the reaction. However,
evidence-based practice indicates that the nurse should take a different action first.)

C. Stop the infusion. (Evidence-based practice indicates the nurse should stop the infusion of
the blood product as soon as manifestations occur because they can indicate a transfusion
reaction.)
D. Administer an antihistamine. (The nurse should administer antihistamines when allergic
transfusion manifestations are present. However, evidence-based practice indicates that the
nurse should take a different action first.)
Answer: C. Stop the infusion. (Evidence-based practice indicates the nurse should stop the
infusion of the blood product as soon as manifestations occur because they can indicate a
transfusion reaction.)
A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a
halo vest in place. Which of the following safety precautions should the nurse include in the
teaching?
A. Clean the pin sites every 72 hr. (The nurse should instruct the family to clean the pin sites
every day to decrease the risk for infection.)
B. Use the halo ring to reposition the client when in bed. (The nurse should instruct the
family to never lift or reposition the client by pulling on the halo ring, which can cause
further cervical injury.)
C. Change the sheepskin liner weekly. (The nurse should provide instruction regarding the
care and maintenance of the vest. The instruction should include changing the sheepskin liner
when soiled, or at least once per week, to prevent skin irritation.)
D. Tighten the traction bar as needed. (The nurse should instruct the family to call a provider
if the pins or traction bar is loose. The pin sites or traction bar supports should not be
manipulated in any way because it could cause injury to the client.)
Answer: C. Change the sheepskin liner weekly. (The nurse should provide instruction
regarding the care and maintenance of the vest. The instruction should include changing the
sheepskin liner when soiled, or at least once per week, to prevent skin irritation.)
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel
obstruction in the descending colon. When listening in the left upper quadrant, the nurse
should identify this sound as which of the following? (Click on the audio button to listen to
the clip.)
A. Hyperactive bowel sounds (A mechanical bowel obstruction prevents a portion or all of
the bowel contents from moving forward through the bowel. The nurse should expect to

auscultate high-pitched, hyperactive bowel sounds above the point of the intestinal
obstruction as the intestines attempt to propel the blockage forward.
B. Friction rub (The nurse should expect to auscultate a pericardial friction rub, a highpitched scratchy sound over the heart, for a client who has pericarditis.)
C. Normal bowel sounds (When auscultating normal bowel sounds, the nurse should expect
to hear 5 to 35 gurgles and clicks in 1 min.)
D. Abdominal bruit (When auscultating an abdominal bruit, the nurse should expect to hear a
whooshing sound that indicates impaired blood flow through an artery.)
Answer: A. Hyperactive bowel sounds (A mechanical bowel obstruction prevents a portion
or all of the bowel contents from moving forward through the bowel. The nurse should expect
to auscultate high-pitched, hyperactive bowel sounds above the point of the intestinal
obstruction as the intestines attempt to propel the blockage forward.
A nurse is reinforcing teaching with a client a client who has gonorrhoea. Which for the
following information should the nurse include?
A. "Your partner will not require treatment for this infection." (The nurse should inform the
client that sexual partners will require treatment to prevent the risk of reoccurrence of the
infection.)
B. "You can resume sexual activity as soon as you begin treatment." (The nurse should
instruct the client to abstain from sexual contact until treatment is completed and cultures are
negative.)
C. "You are at risk for infertility with this infection, regardless of treatment." (The nurse
should inform the client that there is a risk for infertility as a result of this infection.)
D. "You will not be at further risk for this infection following treatment." (The nurse should
inform the client that immunity does not occur with this infection and that reoccurrence is
possible.)
Answer: C. "You are at risk for infertility with this infection, regardless of treatment." (The
nurse should inform the client that there is a risk for infertility as a result of this infection.)
A nurse is assisting in the plan of care regarding bowel retraining for a client who has
cervical spinal cord injury. Which of the following interventions should the nurse plan to
implement first?

A. Determine the client's daily elimination habits. (The first action the nurse should take
using the nursing process is to collect data on the client's daily bowel elimination habits to
establish a routine defecation time.)
B. Administer a suppository to the client 30 min prior to defecation time. (The nurse should
administer a suppository to the client 30 min prior to defecation time to stimulate bowel
elimination. However, there is another action the nurse should take first.)
C. Offer the client 4 oz of warm prune juice to promote elimination. (The nurse should offer
the client warm prune juice to stimulate peristalsis to promote elimination.
However, there is another action the nurse should take first.)
D. Provide dietary bulk to the client to ease the passage of stool. (The nurse should provide
dietary bulk to the client to ease the passage of stool and stimulate bowel elimination.
However, there is another action the nurse should take first.)
Answer: A. Determine the client's daily elimination habits. (The first action the nurse should
take using the nursing process is to collect data on the client's daily bowel elimination habits
to establish a routine defecation time.)
A nurse is contributing to the plan of care for a client who was admitted to the neurological
unit following a stroke 3 hr. ago. Which of the following interventions should the nurse
identify as the priority?
A. Encourage the client to participate in self-care. (The nurse should encourage the client to
complete self-care to the extent that he is able. Self-care promotes mobility of the joints and
increases the client's feelings of independence and self-esteem.
However, there is another intervention that is the priority.)
B. Assist the client with active range-of-motion exercises. (The nurse should assist the client
with active range-of-motion exercises and should provide passive range-of motion exercises
to the client's affected side to maintain joint mobility and improve muscle strength. However,
there is another intervention that is the priority.)
C. Keep the client in a side-lying position. (The greatest risk to the client following a stroke is
aspiration. The nurse should position the client in a lateral, or side-lying position, which will
allow any secretions to drain out of the mouth, decreasing the risk for aspiration.
Additionally, the nurse should have suction available in the event that any secretions are
present in the oral cavity.)

D. Maintain the client's body alignment. (The nurse should keep the client's body in
alignment to maintain joint function and prevent skin breakdown caused by pressure on bony
prominences. However, there is another intervention that is the priority.)
Answer: C. Keep the client in a side-lying position. (The greatest risk to the client following
a stroke is aspiration. The nurse should position the client in a lateral, or side-lying position,
which will allow any secretions to drain out of the mouth, decreasing the risk for aspiration.
Additionally, the nurse should have suction available in the event that any secretions are
present in the oral cavity.)
A nurse is preparing to administer furosemide to a client who has heart failure. Which of the
following findings should the nurse report before administering the medication?
A. Elevated sodium (The nurse should report a decreased sodium level to the provider before
administering the medication because furosemide can cause hyponatremia.)
B. Elevated blood pressure (The nurse should expect the client who has heart failure to have
an elevated blood pressure and does not need to report this finding to the provider before
administering the medication. Furosemide is a diuretic that should help to lower the client's
blood pressure.)
C. Decreased potassium (The nurse should notify the provider immediately of a decreased
potassium level because potassium is lost when a diuretic such as furosemide is administered,
which can cause hypokalaemia.)
D. Decreased urine output (The nurse should expect the client who has heart failure to have a
decreased urine output and does not need to report this finding to the provider before
administering the medication. Furosemide is a diuretic, which should cause an increase in
urine output for a client who has heart failure.)
Answer: C. Decreased potassium (The nurse should notify the provider immediately of a
decreased potassium level because potassium is lost when a diuretic such as furosemide is
administered, which can cause hypokalaemia.)
A nurse observes a client who is lying in bed experiencing a tonic-colonic seizure. Which of
the following actions should the nurse take?
A. Lower the side rails of the client's bed. (The nurse should leave the bed rails up to prevent
the client from falling out of bed, which can cause injury.
B. Apply wrist restraints to the client. (The nurse should not apply restraints that can place the
client at risk for a fracture injury

C. Position the client in the semi-Fowler's position. (The nurse should place the client in a
lateral position to allow for the drainage of oral secretions and to maintain an open airway.)
D. Loosen clothing around the client's neck. (The nurse should loosen clothing around the
client's neck to maintain an open airway and prevent aspiration.)
Answer: D. Loosen clothing around the client's neck. (The nurse should loosen clothing
around the client's neck to maintain an open airway and prevent aspiration.)
A nurse is reinforcing teaching about joint protection with a client who has an acute
exacerbation of rheumatoid arthritis. Which of the following information should the nurse
include in the teaching?
A. Apply cold packs to the inflamed joints. (The nurse should instruct the client to use both
warm and cold packs on inflamed joints to decrease pain.)
B. Participate in high-impact exercise. (The nurse should instruct the client to participate in
low-impact aerobic exercises, which will not inflame the client's joints.)
C. Carry a hand purse rather than a shoulder bag. (The nurse should instruct the client to
carry a shoulder bag, which places the stress on larger muscles.)
D. Sleep on a soft foam mattress. (The nurse should instruct the client to sleep on a firm
mattress to support the joints.)
Answer: A. Apply cold packs to the inflamed joints. (The nurse should instruct the client to
use both warm and cold packs on inflamed joints to decrease pain.)
A nurse is participating in a health fair for older adult clients. Which for the following
immunizations should the nurse recommend for this age group?
A. Meningococcal (The nurse should recommend the meningococcal immunization to college
students and military recruits living in shared housing.)
B. Herpes zoster (The nurse should recommend the herpes zoster immunization for adults 60
years of age and older.)
C. Human papillomavirus (HPV) (The nurse should recommend the HPV immunization for
clients who are 9 to 26 years old.)
D. Measles, mumps, and rubella (MMR) (The nurse should recommend the MMR
immunization to clients who were born after 1956.)
Answer: B. Herpes zoster (The nurse should recommend the herpes zoster immunization for
adults 60 years of age and older.)

A nurse is caring for a client who has difficulty swallowing. Which of the following actions
should the nurse implement to prevent aspiration?
A. Provide small, frequent meals. (Providing small, frequent meals can improve the client's
nutritional intake, but it does not decrease the risk for aspiration.)
B. Tell the client to extend his neck when swallowing. (The client should tilt his neck forward
while swallowing to decrease the risk for aspiration.)
C. Provide mouth care before meals. (Mouth care can enhance the client's sense of taste, but
it does not decrease the risk for aspiration.)
D. Give the client liquids with increased viscosity. (Thickened liquids are easier for the client
to swallow and can prevent aspiration.)
Answer: D. Give the client liquids with increased viscosity. (Thickened liquids are easier for
the client to swallow and can prevent aspiration.)
A nurse is contributing to the plan of care for a client who has a new prescription for nystatin
suspension for oral candidiasis. Which of the following interventions should the nurse
include in the plan?
A. Use a commercial mouthwash before taking the medication. (The client should avoid
commercial mouthwashes while the mouth infection is present because using mouthwash can
increase pain and does not contribute to treatment of the infection.)
B. Instruct the client to swish the medication in her mouth. (The nurse should instruct the
client to place half the dose in each side of her mouth, swish the medication, and then
swallow. This action will allow the medication to coat the entire oral mucosa and treat the
fungal infection.)
C. Discontinue the medication as soon as the lesions are healed. (The client should continue
nystatin for two days after the lesions have healed.)
D. Combine the medication with applesauce. (The client should not mix nystatin with food
because it will alter the absorption of the medication and prevent adequate coating of the oral
lesions.)
Answer: B. Instruct the client to swish the medication in her mouth. (The nurse should
instruct the client to place half the dose in each side of her mouth, swish the medication, and
then swallow. This action will allow the medication to coat the entire oral mucosa and treat
the fungal infection.)

A nurse is collecting data from a client who has hypothyroidism. Which of the following
manifestations should the nurse anticipate?
A. Blurred vision (The nurse should identify that blurred vision is a manifestation of
hyperthyroidism.)
B. Insomnia (The nurse should identify that insomnia is a manifestation of hyperthyroidism
that is caused by an increase in the client's metabolic rate.)
C. Bradycardia (The nurse should identify that bradycardia is a manifestation of
hypothyroidism that is caused by a decrease in the client's metabolic rate.)
D. Weight loss (The nurse should identify that weight loss is a manifestation of
hyperthyroidism caused by an increase in the client's metabolic rate.)
Answer: C. Bradycardia (The nurse should identify that bradycardia is a manifestation of
hypothyroidism that is caused by a decrease in the client's metabolic rate.)
A nurse is discussing health screening guidelines with an older adult client. Which of the
following statements should the nurse include?
A. "You should have a screening for glaucoma every 5 years." (The nurse should remind the
client to have a screening for glaucoma every 2 to 3 years along with an annual visual acuity
exam. )
B. "You should have a physical examination every other year." (The nurse should remind the
client to have a physical examination every year.)
C. "You should have your hearing checked every 2 years." (The nurse should remind the
client to have her hearing checked every year.)
D. "You should have a pneumococcal immunization every 10 years." (The nurse should
remind the client to have a pneumococcal immunization at age 65 and every 10 years
thereafter to protect her from acquiring pneumonia.)
Answer: D. "You should have a pneumococcal immunization every 10 years." (The nurse
should remind the client to have a pneumococcal immunization at age 65 and every 10 years
thereafter to protect her from acquiring pneumonia.)
A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by
continuous IV infusion. The client reports pain and swelling at the IV site. In which order
should the nurse perform the following steps? (Move the steps into the box on the right,
placing them in order of performance. Use all the steps.)

Notify the charge nurse
Stop the infusion.
Elevate the affected arm.
Withdraw the IV catheter.
Check the IV site.
Answer:
Notify the charge nurse

Check the IV site.

Stop the infusion.

Stop the infusion.

Elevate the affected arm.

Withdraw the IV catheter.

Withdraw the IV catheter.

Elevate the affected arm.

Check the IV site.

Notify the charge nurse

The first action the nurse should take using the nursing process is to check the IV site for
infiltration. If infiltration is found, the next step is to stop the infusion to prevent vein and
tissue damage. Once the infusion is stopped, the nurse should remove the IV catheter. Then,
the nurse should elevate the affected extremity to decrease swelling and notify the charge
nurse.
A nurse is contributing to the plan of care for a client who is postoperative following a total
knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of
the following interventions should the nurse recommend for the plan of care?
A. Store the CPM machine on the floor when it is not in use. (The nurse should avoid placing
the CPM machine on the floor, as this exposes it to potential contamination, which can
increase the client's risk for infection.)
B. Keep a sheepskin pad between the client's extremity and the CPM. (The nurse should plan
to keep a sheepskin pad between the client's extremity and the CPM machine to protect the
client's skin. The nurse should check the client's skin condition frequently while the client is
using the CPM.)
C. Check the cycle and range-of-motion settings at least every 12 hr. (The nurse should plan
to check the settings of the CPM machine at least every 8 hr.)

D. Align the frame joint of the CPM with the middle of the client's calf. (The nurse should
plan to align the frame joint of the CPM with the client's knee joint to provide appropriate
flexion and extension.)
Answer: B. Keep a sheepskin pad between the client's extremity and the CPM. (The nurse
should plan to keep a sheepskin pad between the client's extremity and the CPM machine to
protect the client's skin. The nurse should check the client's skin condition frequently while
the client is using the CPM.)
A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse
observes ecchymosis around the umbilicus. The nurse should identify that this is a
manifestation of which of the following?
A. Cirrhosis of the liver (A client who has cirrhosis of the liver can have a manifestation of
bluish varicose veins that radiate from the umbilicus, which can indicate portal hypertension.
However, cirrhosis of the liver does not cause ecchymosis around the umbilicus.)
B. Hypermotility of the bowel (A client who has hypermotility of the bowel can exhibit
diarrhoea as a manifestation, not ecchymosis around the umbilicus.)
C. Intra-abdominal bleeding (Ecchymosis around the umbilicus is a sign of intraabdominal
bleeding, which is a finding consistent with pancreatitis.)
D. Acute cholecystitis (A client who has acute cholecystitis has an inflammation of the
gallbladder that can indicate gallstones, but acute cholecystitis does not cause ecchymosis
around the umbilicus.)
Answer: C. Intra-abdominal bleeding (Ecchymosis around the umbilicus is a sign of
intraabdominal bleeding, which is a finding consistent with pancreatitis.)
A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has
a loss of appetite because she has sores in her mouth and that food no longer tastes good.
Which of the following suggestions to the client should the nurse make?
A. Drink water before and after each bite. (The nurse should suggest that the client add gravy,
broth, or sauces to foods to increase the moisture content of the food. Drinking water before
and after each bite can lead to early satiety, which might cause the client to consume less
food.)
B. Consume foods that are served hot rather than cold. (Cold foods are usually tolerated
better by a client who is receiving chemotherapy because they emit less Odor.)

C. Rinse with a glycerine-based mouthwash before meals. (Clients who have sores in their
mouths or mucositis should rinse with a solution of water and 0.9% sodium chloride, or with
water and baking soda. Using a glycerine- or alcohol-based mouthwash can lead to irritation
and burning of the oral mucosa.)
D. Eat several, small-portioned meals daily. (Clients who have difficulty eating because of
pain or anorexia can usually tolerate small amounts of food at one time. Eating several small
meals daily can increase the client's caloric intake.)
Answer: D. Eat several, small-portioned meals daily. (Clients who have difficulty eating
because of pain or anorexia can usually tolerate small amounts of food at one time. Eating
several small meals daily can increase the client's caloric intake.)
A nurse is contributing to the plan of care for a client who is having difficulty eating
following a stroke. Which of the following interventions should the nurse plan to implement
first?
A. Collaborate with a dietitian. (The nurse should collaborate with the dietician to evaluate
the client's nutritional status and incorporate the client's food likes and dislikes into the meal
plan. However, there is another intervention the nurse should plan to implement first.)
B. Provide nutritional supplements. (The nurse should provide nutritional supplements as
needed to ensure the client's nutritional needs are being met. However, there is another
intervention the nurse should plan to implement first.)
C. Recommend a referral for a speech language pathologist. (The greatest risk to the client
following a stroke is injury from aspiration. Therefore, the first intervention the nurse should
include in the plan of care is to recommend a referral for a speech language pathologist. A
speech language pathologist can conduct a swallow study to determine the client's risk for
aspiration, provide teaching to the client regarding swallowing techniques, and recommend
the consistency of foods and liquids.)
D. Inform assistive personnel about proper positioning. (The nurse should provide instruction
to assistive personnel regarding proper positioning of the client during mealtimes. The client
should be positioned upright during meals to help prevent aspiration and facilitate swallowing
and should remain in this position for at least 45 min after eating. However, there is another
intervention the nurse should plan to implement first.)
Answer: C. Recommend a referral for a speech language pathologist. (The greatest risk to the
client following a stroke is injury from aspiration. Therefore, the first intervention the nurse
should include in the plan of care is to recommend a referral for a speech language

pathologist. A speech language pathologist can conduct a swallow study to determine the
client's risk for aspiration, provide teaching to the client regarding swallowing techniques,
and recommend the consistency of foods and liquids.)
Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the
nurse, “I’m glad they took my blood because I’m really hungry. All I’ve had since midnight is
water and some juice.” Which of the following actions should the nurse take?
A. Offer the client breakfast then repeat the FBS request. (An FBS test requires the client to
have no food or juice for at least 8 hr. The result of the FBS test would be invalid after the
client had breakfast.)
B. Reschedule the FBS test for early the next morning. (An FBS test requires the client to
have no food or juice for at least 8 hr. The result of the FBS test would be invalid because the
client drank juice during the fasting time period. The nurse should reinforce with the client to
only drink water and have no food or other beverages for 8 hr before the phlebotomist obtains
the blood specimen.)
C. Request that the phlebotomist obtain another specimen. (The client had juice within the
past 8 hr. The nurse should request that the phlebotomist obtain another specimen when the
client has ingested no food or other beverages for 8 hr.)
D. Ask the laboratory technician to repeat the test on the same specimen. (Repeating the test
on the same specimen will yield the same result, which will also be invalid.)
Answer: B. Reschedule the FBS test for early the next morning. (An FBS test requires the
client to have no food or juice for at least 8 hr. The result of the FBS test would be invalid
because the client drank juice during the fasting time period. The nurse should reinforce with
the client to only drink water and have no food or other beverages for 8 hr before the
phlebotomist obtains the blood specimen.)
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking
dantrolene to manage muscle spasms. Which of the following interventions should he nurse
include?
A. Apply hot packs to the client's muscles. (The nurse should avoid exposing the client's
muscles to extreme temperatures because it decreases muscle strength.)
B. Schedule physical therapy in the afternoon. (The nurse should schedule physical therapy
and other activities in the morning when the client's strength is at its peak.
Fatigue increases in the afternoon.)

C. Encourage the client to complete ADLs. The nurse should encourage the client to complete
ADLs and provide assistance as needed. Performing self-care increases the client's
independence, strength, and level of functioning.)
D. Administer valerian to promote sleep. (The nurse should instruct the client to avoid using
valerian to promote sleep because this herbal supplement can increase CNS depression when
taken with dantrolene.)
Answer: C. Encourage the client to complete ADLs. The nurse should encourage the client to
complete ADLs and provide assistance as needed. Performing self-care increases the client's
independence, strength, and level of functioning.)
A nurse is preparing to administer scheduled medications to a client. Which of the following
prescriptions should the nurse verify with the provider? (Click on the “Exhibit” button for
additional information about the client. There are three tabs that contain separate categories
of data.)

A. Ceftriaxone (Clients who have a severe sensitivity to penicillin can have a cross sensitivity
reaction to ceftriaxone, a cephalosporin. Therefore, the nurse should contact the provider to
clarify the prescription.)
B. Diltiazem (The nurse should administer diltiazem because the client's heart rate and blood
pressure are within the expected reference ranges.)
C. Pioglitazone. (The nurse should administer pioglitazone because the client's blood glucose
level is within the expected reference range.)

D. Hydrocodone 5 mg/acetaminophen 500 mg (The nurse should administer hydrocodone
and acetaminophen to manage the client's pain because the client's respiratory rate is within
the expected reference range.)
Answer: A. Ceftriaxone (Clients who have a severe sensitivity to penicillin can have a cross
sensitivity reaction to ceftriaxone, a cephalosporin. Therefore, the nurse should contact the
provider to clarify the prescription.)
A nurse is caring for a client who is postoperative and is receiving an IV infusion of
cefazolin. Ten minutes after beginning the infusion, the client reports intense itching.
Which of the following actions should the nurse take first?
A. Stop the medication infusion. (The greatest risk to the client is injury from an allergic
response to the medication. Therefore, the priority action the nurse should take is to stop the
medication infusion.)
B. Notify the charge nurse. (The nurse should notify the charge nurse about what has
occurred. However, there is another action the nurse should take first.)
C. Administer a PRN dose of diphenhydramine. (The nurse should administer a PRN dose of
diphenhydramine to keep the allergic reaction from worsening. However, there is another
action the nurse should take first.)
D. Follow facility policy for appropriate reporting of the adverse reaction. (The nurse should
follow facility policy when reporting an adverse reaction. However, there is another action
the nurse should take first.)
Answer: A. Stop the medication infusion. (The greatest risk to the client is injury from an
allergic response to the medication. Therefore, the priority action the nurse should take is to
stop the medication infusion.)
Version 10
ATI MED-SURG PART B
A nurse is reinforcing teaching with an older adult client who has osteoporosis.
Which of the following instructions should the nurse in the teaching?
A. "Place throw rugs on wooden floors at home."
B. "Supplement your diet with vitamin E."
C. "Swim laps for 20 minutes twice per week."

D. "Take calcium supplements with meals." (The nurse should instruct the client to take
calcium carbonate supplements with or following meals to increase absorption and
effectiveness.)
Answer: D. "Take calcium supplements with meals." (The nurse should instruct the client to
take calcium carbonate supplements with or following meals to increase absorption and
effectiveness.)
A nurse is reviewing the medication record of a client who is taking digoxin. Which of the
following medications should the nurse identify as increasing the risk for the client to develop
digoxin toxicity?
A. Potassium chloride
B. Famotidine
C. Levothyroxine
D. Furosemide (The nurse should identify that loop diuretics, such as furosemide, increase
the urinary excretion of potassium, which can lead to hypokalaemia. Hypokalaemia increases
the risk for the development of digoxin toxicity.)
Answer: D. Furosemide (The nurse should identify that loop diuretics, such as furosemide,
increase the urinary excretion of potassium, which can lead to hypokalaemia. Hypokalaemia
increases the risk for the development of digoxin toxicity.)
A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4
kg (100 lb.). Which of the following statements by the client indicates an understanding of
the teaching?
A. "I should insert the needle at a 90-degree angle."
B. "I should give my shot in my belly tissue." (Clients who have low body weights can have
very little subcutaneous tissue. Therefore, the nurse should instruct the client to administer
the medication in the upper abdomen for proper absorption.)
C. "I will pull back on the syringe plunger to look for blood before I push the medication in."
D. "I will use the side of my hand to pull my skin to the side prior to administering the
insulin."
Answer: B. "I should give my shot in my belly tissue." (Clients who have low body weights
can have very little subcutaneous tissue. Therefore, the nurse should instruct the client to
administer the medication in the upper abdomen for proper absorption.)

A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve
replacement. Which of the following statements by the client indicates an understanding of
the teaching?
A. "I will notify my dentist about this procedure." (The nurse should instruct the client to
notify his dentist about the mechanical mitral valve replacement before any procedures so
antibiotic therapy can be initiated to reduce the risk of endocardial infection.)
B. "I will take an enteric-coated aspirin daily."
C. "I will use a firm-bristled toothbrush."
D. "I will weigh myself once a week."
Answer: A. "I will notify my dentist about this procedure." (The nurse should instruct the
client to notify his dentist about the mechanical mitral valve replacement before any
procedures so antibiotic therapy can be initiated to reduce the risk of endocardial infection.)
A nurse is reviewing the medical record for an older adult client who is experiencing nausea
and vomiting. Based on the client data, which of the following actions should the nurse take?
(Click on the “Exhibit” button for additional client information. There are three tabs that
contain separate categories of data.)
View the Exhibit

A. Encourage the client to ambulate.
B. Administer an antipyretic medication.

C. Notify the charge nurse of the client's BUN level (The client's BUN level is above the
expected reference range of 10 to 20 mg/dL, which indicates dehydration and impaired renal
function. The nurse should notify the charge nurse of this finding and anticipate interventions
to restore the client's fluid volume.)
D. Keep the temperature in the client's room warm.
Answer: C. Notify the charge nurse of the client's BUN level (The client's BUN level is
above the expected reference range of 10 to 20 mg/dL, which indicates dehydration and
impaired renal function. The nurse should notify the charge nurse of this finding and
anticipate interventions to restore the client's fluid volume.)
A nurse is providing information regarding transmission-based precautions for a client who
has Clostridium difficile to an assistive personnel (AP). Which of the following instructions
should the nurse include? (Select all that apply).
A. "Provide the client with disposable utensils and dishes for meals." (Clients who have C.
difficile require contact precautions, which include using disposable utensils and dishes
during meals to prevent exposure to contaminants by others.)
B. "Leave blood pressure equipment in the client's room." (When using contact precautions,
the health care staff should dedicate equipment to single-client use to prevent transmission of
the pathogen.)
C. "Clean contaminated surfaces with a bleach solution." (The health care staff should use a
bleach solution to clean equipment to prevent transmission of the pathogen.)
D. "Use an alcohol-based hand sanitizer after client care."
E. "Wear a face mask when in the client's room."
Answer: A. "Provide the client with disposable utensils and dishes for meals." (Clients who
have C. difficile require contact precautions, which include using disposable utensils and
dishes during meals to prevent exposure to contaminants by others.)
B. "Leave blood pressure equipment in the client's room." (When using contact precautions,
the health care staff should dedicate equipment to single-client use to prevent transmission of
the pathogen.)
C. "Clean contaminated surfaces with a bleach solution." (The health care staff should use a
bleach solution to clean equipment to prevent transmission of the pathogen.)
A nurse is admitting a client who is suspected having active tuberculosis (TB). Which of the
following actions should the nurse take first? (chap. 20)

A. Administer antituberculosis medication.
B. Institute airborne precautions. (The greatest risk from this client is transmitting TB to staff
and other clients. Therefore, the first action the nurse should take is to implement airborne
precautions.)
C. Obtain sputum cultures.
D. Auscultate breath sounds.
Answer: B. Institute airborne precautions. (The greatest risk from this client is transmitting
TB to staff and other clients. Therefore, the first action the nurse should take is to implement
airborne precautions.)
A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain.
Which of the following actions should the nurse take?
A. Fill the bulb reservoir with 0.9% sodium chloride.
B. Allow the Jackson-Pratt drain to hang freely.
C. Cut a slit in a gauze sponge and apply it around the tubing insertion site.
D. Compress the bulb reservoir and then close the drainage valve. (The nurse should fully
compress the bulb reservoir and then replace the valve plug using aseptic technique to
establish suction after emptying or activating a Jackson-Pratt drain.)
Answer: D. Compress the bulb reservoir and then close the drainage valve. (The nurse
should fully compress the bulb reservoir and then replace the valve plug using aseptic
technique to establish suction after emptying or activating a Jackson-Pratt drain.)
A nurse is reinforcing teaching with the parent of a toddler who has type I diabetes mellitus
and whose prescription has been changed from regular insulin to lispro insulin. Which of the
following information should the nurse include in the teaching?
A. Lispro is given once a day.
B. Lispro should be given before eating. (Lispro insulin should be given around mealtime,
within 15 min before or after eating.)
C. Lispro cannot be given with other insulin.
D. Lispro does not cause hypoglycaemia.
Answer: B. Lispro should be given before eating. (Lispro insulin should be given around
mealtime, within 15 min before or after eating.)

A nurse is reinforcing teaching with a client who has microcytic anaemia and is prescribed a
daily iron supplement. The nurse tells the client to consume foods containing vitamin C when
taking the supplement to enhance iron absorption. Which of the following client food choices
indicates an understanding of the teaching?
A. 1 cup cooked brown rice
B. 1 cup boiled broccoli (The nurse should determine that choosing boiled broccoli indicates
an understanding of the teaching because 1 cup contains 101 mg of vitamin C per serving.)
C. 1 cup cottage cheese
D. 1 cup cooked kidney beans
Answer: B. 1 cup boiled broccoli (The nurse should determine that choosing boiled broccoli
indicates an understanding of the teaching because 1 cup contains 101 mg of vitamin C per
serving.)
A nurse is assisting with the development of a plan of care to manage pain for a client who
has herpes zoster with lesions on the lower extremities. Which of the following interventions
should the nurse include in the plan of care?
A. Keep bed linens off of the affected areas. (The nurse should keep bed linens off of the
affected areas using a bed cradle, which will relieve pain caused by the linens rubbing against
the lesions.)
B. Position a heat lamp over the lower extremities.
C. Apply warm, moist compresses to the affected areas.
D. Initiate droplet isolation precautions.
Answer: A. Keep bed linens off of the affected areas. (The nurse should keep bed linens off
of the affected areas using a bed cradle, which will relieve pain caused by the linens rubbing
against the lesions.)
A nurse is reinforcing teaching with a client about increasing dietary fibre. The nurse should
recommend which of the following foods as the best source of fibre?
A. ½ cup cooked kidney beans (The nurse should recommend kidney beans as the best source
of fibre because ½ cup contains 6.5 g of fibre per serving.)
B. ½ cup raw cauliflower
C. 1 cup cucumber with peel
D. 1 cup parboiled brown rice

Answer: A. ½ cup cooked kidney beans (The nurse should recommend kidney beans as the
best source of fibre because ½ cup contains 6.5 g of fibre per serving.)
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is
receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following
findings should indicate to the nurse that the client’s therapeutic regimen is effective?
A. Adventitious lung sounds
B. Decrease in exertional dyspnea (A decrease in exertional dyspnea indicates the antibiotics
are resolving the infection and the albuterol treatments are facilitating effective ventilation.
Therefore, the nurse should evaluate the therapeutic regimen as effective for the client.)
C. Respiratory rate of 26/min while sitting in a chair
D. Elevation of the head of the bed is required to sleep
Answer: B. Decrease in exertional dyspnea (A decrease in exertional dyspnea indicates the
antibiotics are resolving the infection and the albuterol treatments are facilitating effective
ventilation. Therefore, the nurse should evaluate the therapeutic regimen as effective for the
client.)
A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the
cast. Which of the following actions should the nurse take?
A. Blow cool air into the cast using a blow dryer on a cool setting. (Using a blow dryer on a
cool setting to blow cold air into the cast is an effective way to relieve the client's itching
without damaging the skin.)
B. Obtain a prescription for pregabalin.
C. Ask the provider to bivalve the cast.
D. Provide the client with a tongue blade to rub the skin under the cast.
Answer: A. Blow cool air into the cast using a blow dryer on a cool setting. (Using a blow
dryer on a cool setting to blow cold air into the cast is an effective way to relieve the client's
itching without damaging the skin.)
A nurse is preparing to insert a double-lumen gastric (Salem) sump tube for a client who has
peptic disease and has developed gastrointestinal bleeding. Which of the following images
indicates the tube that the nurse should select?
A.

In a double-lumen gastric (Salem) sump tube, the clear portion of the tube allows for
aspiration of stomach contents. The blue portion of the tube, or the "pig tail", vents the tube
to the atmosphere, which prevents the tube from becoming lodged against the wall of the
stomach and protects the stomach from damage.
B.

This image shows a percutaneous endoscopic gastrostomy (PEG) feeding tube. A provider
inserts a PEG feeding tube surgically through the abdomen and into the stomach to allow for
longer-term medication administration and tube feedings.
C.

This image shows a Levin tube. It is a single-lumen nasogastric tube which facilitates gastric
decompression. Damage to the gastric mucosa can occur during aspiration of stomach
contents with this tube.
d).

This image shows a Sengstacke-Blakemore tube. The provider prescribes this tube in the
treatment of bleeding esophageal varices.

Answer: A. In a double-lumen gastric (Salem) sump tube, the clear portion of the tube allows
for aspiration of stomach contents. The blue portion of the tube, or the "pig tail", vents the
tube to the atmosphere, which prevents the tube from becoming lodged against the wall of the
stomach and protects the stomach from damage.
A nurse is caring for a client who has just returned to the unit following a bronchoscopy.
Which of the following findings should the nurse report to the provider?
A. Absent gag reflex
B. Blood-tinged mucus
C. Diminished breath sounds (Diminished breath sounds might indicate a pneumothorax or
laryngeal edema. The nurse should report this finding to the provider for further evaluation of
the client.)
D. Oxygen saturation 95%
Answer: C. Diminished breath sounds (Diminished breath sounds might indicate a
pneumothorax or laryngeal edema. The nurse should report this finding to the provider for
further evaluation of the client.)
A nurse is caring for a client who has been taking enalapril. The nurse should monitor the
client for which of the following adverse effects?
A. Bradycardia
B. Tremors
C. Cough (Enalapril is an ACE inhibitor, which can cause a dry, nonproductive cough.
Therefore, the nurse should monitor the client for this adverse effect.)
D. Hyperglycemia
Answer: C. Cough (Enalapril is an ACE inhibitor, which can cause a dry, nonproductive
cough. Therefore, the nurse should monitor the client for this adverse effect.)
A nurse is preparing a client for a cardiac catheterization. Which of the following actions
should the nurse take first?
A. Verify the client has given informed consent. (The greatest risk to the client in this
situation is performing an unauthorized invasive procedure. Therefore, the first action the
nurse should take is to verify that the client has given informed consent. If documentation of
informed consent is not on the client's medical record, the nurse should withhold medications,
which can alter the client’s consciousness until consent is obtained.)

B. Administer preoperative medication.
C. Mark the location of the pedal pulses.
D. Have the client void.
Answer: A. Verify the client has given informed consent. (The greatest risk to the client in
this situation is performing an unauthorized invasive procedure. Therefore, the first action the
nurse should take is to verify that the client has given informed consent. If documentation of
informed consent is not on the client's medical record, the nurse should withhold medications,
which can alter the client’s consciousness until consent is obtained.)
A nurse is caring for an adult client who has age-related macular degeneration.
Which of the following findings should the nurse expect?
A. Seeing halos around artificial lights
B. Distorted central vision of the eyes (Macular degeneration results in a distortion and
blurring of central vision. The client might completely lose central vision and view a dark
spot in the centre.)
C. Coloured spots before the visual fields
D. Spontaneous tearing of the eyes
Answer: B. Distorted central vision of the eyes (Macular degeneration results in a distortion
and blurring of central vision. The client might completely lose central vision and view a dark
spot in the centre.)
A nurse is planning care for a group of clients after receiving change-of-shift report. Which of
the following clients should the nurse plan to see first?
A. A client who had a colectomy 2 days ago and has a nasogastric tube, Jackson-Pratt drain,
and indwelling urinary catheter
B. A client who is dehydrated, has mental confusion, and was found getting out of bed several
times during the night (When using the urgent vs. nonurgent approach to client care, the nurse
determines to first see the client who has mental confusion and is getting out of bed without
assistance. The client is experiencing manifestations of dehydration that can cause injury due
to falls. Therefore, the nurse should see this client first.)
C. A client who had a right lower lobe lobectomy 4 days ago and has a chest tube set to
continuous suction
D. A client who has pneumonia and an oral temperature of 38.7º C (101.7º F)

Answer: B. A client who is dehydrated, has mental confusion, and was found getting out of
bed several times during the night (When using the urgent vs. nonurgent approach to client
care, the nurse determines to first see the client who has mental confusion and is getting out
of bed without assistance. The client is experiencing manifestations of dehydration that can
cause injury due to falls. Therefore, the nurse should see this client first.)
A nurse is collecting data from a client who is receiving sumatriptan. Which of the following
is an outcome?
A. Reduced cough
B. Diminished headache (Sumatriptan is a vascular headache suppressant prescribed for relief
of migraines or cluster headaches. Therefore, the nurse should monitor the client for a
diminished headache as an expected outcome of the medication.)
C. Relaxed muscles
D. Decreased peripheral edema
Answer: B. Diminished headache (Sumatriptan is a vascular headache suppressant
prescribed for relief of migraines or cluster headaches. Therefore, the nurse should monitor
the client for a diminished headache as an expected outcome of the medication.)
A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of
90%. Which of the following actions should the nurse take?
A. Prepare for intubation of the client.
B. Administer opioid medication.
C. Administer oxygen via nasal cannula. (The nurse should administer oxygen via nasal
cannula to a client who reports shortness of breath and has an oxygen saturation below the
expected reference range. The nurse should continue to monitor the client and adjust the
oxygen flow rate as needed.)
D. Place the client in low-Fowler's position
Answer: C. Administer oxygen via nasal cannula. (The nurse should administer oxygen via
nasal cannula to a client who reports shortness of breath and has an oxygen saturation below
the expected reference range. The nurse should continue to monitor the client and adjust the
oxygen flow rate as needed.)

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While
taking the client’s apical pulse, the nurse notes a rate of 58/min. which of the following
actions should the nurse takes?
A. Give the dose as prescribed.
B. Use a different route to administer the medication.
C. Administer half of the prescribed dose.
D. Withhold the dose. (The nurse should withhold the digoxin dose for an apical pulse less
than 60/min and notify the provider. Digoxin slows the heart rate, so administering the dose
can cause harm to the client.)
Answer: D. Withhold the dose. (The nurse should withhold the digoxin dose for an apical
pulse less than 60/min and notify the provider. Digoxin slows the heart rate, so administering
the dose can cause harm to the client.)
A nurse is caring for a client who has neutropenia. Which of the following nursing
interventions should the nurse implement?
A. Offer the client fresh fruits and vegetables.
B. Monitor the client's platelet count daily.
C. Limit visitors to healthy adults. (The nurse should limit visitors to healthy adults to
minimize the client's risk of exposure to infection.)
D. Apply firm pressure to injection sites.
Answer: C. Limit visitors to healthy adults. (The nurse should limit visitors to healthy adults
to minimize the client's risk of exposure to infection.)
A nurse is caring for client who has an intestinal obstruction and reports a new onset of
nausea. The client has an NG tube set at low intermittent suction and is receiving continuous
IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take
first?
A. Check for kinks in the NG tube. (The first action the nurse should take when using the
nursing process is to collect data from the client. Therefore, the priority action is to check the
NG tube to determine if the tube is kinked, which can interfere with the suctioning function
and result in nausea.)
B. Increase the IV fluid rate.
C. Provide ice chips.
D. Administer an antiemetic.

Answer: A. Check for kinks in the NG tube. (The first action the nurse should take when
using the nursing process is to collect data from the client. Therefore, the priority action is to
check the NG tube to determine if the tube is kinked, which can interfere with the suctioning
function and result in nausea.)
A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the
following information should the nurse recommend to include in the pamphlet?
A. The number of sexual partners does not affect the risk for STIs.
B. Oral contraceptive use decreases the risk for STIs.
C. Men seek treatment for STIs later than women.
D. Women have a higher risk of contracting STIs than men. (The nurse should include that
oral contraceptive use, prolonged contact with male secretions, and increased cervical
permeability during hormone fluctuations increase a woman's risk of acquiring STIs.)
Answer: D. Women have a higher risk of contracting STIs than men. (The nurse should
include that oral contraceptive use, prolonged contact with male secretions, and increased
cervical permeability during hormone fluctuations increase a woman's risk of acquiring
STIs.)
A nurse is reinforcing teaching with a client who is postoperative following a cemented total
hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
A. Avoid weight-bearing until healing of the hip incision is complete.
B. Cross legs intermittently several times a day.
C. Lean forward to change positions when sitting in a chair.
D. Maintain hip flexion to 90° or less when sitting. (A client who has had a cemented total
hip arthroplasty should maintain hip flexion to 90° or less when sitting to prevent hip
dislocation.)
Answer: D. Maintain hip flexion to 90° or less when sitting. (A client who has had a
cemented total hip arthroplasty should maintain hip flexion to 90° or less when sitting to
prevent hip dislocation.)
A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery.
Which of the following findings requires immediate attention from the nurse?
A. Reported pain level of 6 on a scale of 0 to 10
B. Urinary output of 110 mL in the past 4 hr

C. Temperature of 38.0º C (100.4º F)
D. Oxygen saturation of 88% (When using the airway, breathing, circulation approach to
client care, the nurse determines that the finding that requires immediate attention is an
oxygen saturation of 88%. This finding is below the expected reference range of 95% to
100% and requires intervention to restore oxygenation to the client's tissues.)
Answer: D. Oxygen saturation of 88% (When using the airway, breathing, circulation
approach to client care, the nurse determines that the finding that requires immediate
attention is an oxygen saturation of 88%. This finding is below the expected reference range
of 95% to 100% and requires intervention to restore oxygenation to the client's tissues.)
A nurse is caring for a client following a gastrectomy. Which of the following actions should
the nurse take to decrease episodes of dumping syndrome?
A. Place the client in the supine position after meals. (The nurse should encourage the client
to lie in the supine position for a short time following meals to decrease rapid gastric
emptying.)
B. Administer pancreatic enzymes before meals.
C. Encourage the client to drink 240 mL (8 oz) of fluids with meals.
D. Offer the client three meals daily.
Answer: A. Place the client in the supine position after meals. (The nurse should encourage
the client to lie in the supine position for a short time following meals to decrease rapid
gastric emptying.)
A nurse is assisting with the care of a client who has a stroke and is unable to speak. The
nurse should identify that the client’s injury occurred in which of the following lobes of the
brain? (You will find hot spots to select in the artwork below. Select only the hot spot that
corresponds to your answer.)

A. A is correct. Injury to the frontal lobe can result in alterations to motor function or
voluntary movement. This involves the ability to speak and the ability to move purposefully.
B. B is incorrect. The nurse should identify that injury to the parietal lobe results in
alterations to higher-level activities, such as writing, and processing sensory information,
such as proprioception, pain, temperature, touch, and pressure.
C. C is incorrect. The nurse should identify that injury to the occipital lobe results in
alterations in visual perception and the ability to track movement of an object. Injuries to this
area can result in an inability to recognize objects, faces, or the written word.
D. D is incorrect. The nurse should identify that injury to the temporal lobe results in
alterations in the ability to understand the spoken language and impaired short term memory.
Answer: A. A is correct. Injury to the frontal lobe can result in alterations to motor function
or voluntary movement. This involves the ability to speak and the ability to move
purposefully.
A home health nurse is caring for a client who has COPD. The client tells the nurse that he
becomes short of breath while eating despite the use of home oxygen.
Which of the following instructions should the nurse include?
A. Limit protein in daily meal plan.
B. Use a bronchodilator 1 hr before meals.
C. Drink beverages at the end of meals. (Lie down for 1 hr after meals. The client should
drink beverages at the end of meals, rather than during meals, to prevent shortness of breath
while eating. This also prevents early satiety and promotes adequate nutrient intake during
the meal)
D. Lie down for 1 hr. after meals.

Answer: C. Drink beverages at the end of meals. (Lie down for 1 hr after meals. The client
should drink beverages at the end of meals, rather than during meals, to prevent shortness of
breath while eating. This also prevents early satiety and promotes adequate nutrient intake
during the meal)
A nurse is reinforcing teaching with a client who has chronic kidney disease about
management. Which of the following statements by the client indicates an understanding of
the teaching?
A. "I will add a banana to my morning cereal."
B. "I will decrease my intake of carbohydrates."
C. "I will limit my daily intake of protein." (The client should decrease his intake of protein
to slow the progression of kidney failure. Therefore, the nurse should identify this statement
as an understanding of the teaching.)
D. "I will season my foods with a salt substitute."
Answer: C. "I will limit my daily intake of protein." (The client should decrease his intake of
protein to slow the progression of kidney failure. Therefore, the nurse should identify this
statement as an understanding of the teaching.)
A nurse is caring for a client who has dementia due to Alzheimer’s disease.
Which of the following actions should the nurse take to reduce the client’s confusion?
A. Restrict visitors to three at a time.
B. Avoid touching the client during care.
C. Encourage reminiscence of past experiences. (The nurse should encourage reminiscence of
past experiences to reduce the client's confusion.)
D. Give the client multiple options for daily events.
Answer: C. Encourage reminiscence of past experiences. (The nurse should encourage
reminiscence of past experiences to reduce the client's confusion.)
A nurse is caring for a client who has Cushing’s syndrome and expresses concern regarding
body image changes. Which of the following should the nurse recognize as a physical change
caused by this disease?
A. Bronze skin
B. Truncal obesity (Truncal obesity is a manifestation of Cushing's syndrome that occurs due
to a redistribution of fat. The client also usually has fatty tissue edema between the scapula,

also known as "buffalo hump". The nurse should use therapeutic communication techniques
to investigate the client's body image concerns.)
C. Lordosis
D. Exophthalmos
Answer: B. Truncal obesity (Truncal obesity is a manifestation of Cushing's syndrome that
occurs due to a redistribution of fat. The client also usually has fatty tissue edema between
the scapula, also known as "buffalo hump". The nurse should use therapeutic communication
techniques to investigate the client's body image concerns.)
A nurse is delegating the task of repositioning a client who is in skeletal traction to an
assistant personnel (AP). Which of the following instructions should the nurse give the AP?
A. Allow the weights to hang freely. (The nurse should instruct the AP to allow the weights to
hang freely and to refrain from bumping the weights. Skeletal traction maintains alignment of
fractured bones through the use of counterweights. If these weights rest on the floor or
another object, they do not maintain the counterbalance necessary to maintain the alignment
of the fracture, which can result in client injury or pain.)
B. Release the tension of the ropes.
C. Remove the weights when rewrapping bandages.
D. Manually lift the weights when moving the client up in bed.
Answer: A. Allow the weights to hang freely. (The nurse should instruct the AP to allow the
weights to hang freely and to refrain from bumping the weights. Skeletal traction maintains
alignment of fractured bones through the use of counterweights. If these weights rest on the
floor or another object, they do not maintain the counterbalance necessary to maintain the
alignment of the fracture, which can result in client injury or pain.)
A nurse is contributing to the plan of care for a client who has a head injury and is at risk for
increased intracranial pressure (ICP). Which of the following actions should the nurse include
in the plan?
A. Measure rectal temperature every 4 hr.
B. Remind the client to cough as needed.
C. Use a turn sheet to reposition the client. (The nurse should change the client's position
slowly to prevent sudden increases in ICP. The use of a turn sheet to reposition the client
provides the nurse with the ability to better control the client's movement and alignment. The

nurse should instruct the client to exhale during the position change to prevent an increase in
ICP.)
D. Apply wrist restraints.
Answer: C. Use a turn sheet to reposition the client. (The nurse should change the client's
position slowly to prevent sudden increases in ICP. The use of a turn sheet to reposition the
client provides the nurse with the ability to better control the client's movement and
alignment. The nurse should instruct the client to exhale during the position change to
prevent an increase in ICP.)
A nurse is preparing to administer an influenza vaccine to a client. Which of the following
statements by the client should cause the nurse to postpone administration of the vaccine?
A. "I am allergic to shrimp."
B. "I am allergic to latex balloons."
C. "I had a tuberculosis skin test 2 days ago."
D. "I had a low fever this morning." (Clients who have a febrile illness should not receive the
influenza vaccine.)
Answer: D. "I had a low fever this morning." (Clients who have a febrile illness should not
receive the influenza vaccine.)
A nurse is repositioning a client who has lower back pain. Which of the following position is
appropriate for the client?
A. Semi-Fowler's with knees flexed (Sitting in semi-Fowler's position with the head of bed
elevated 15° to 45° and flexing the knees will help relax the lumbar area of the client's back
and relieve pressure on the nerves.)
B. Orthopneic
C. Dorsal recumbent
D. Prone with legs straight
Answer: A. Semi-Fowler's with knees flexed (Sitting in semi-Fowler's position with the head
of bed elevated 15° to 45° and flexing the knees will help relax the lumbar area of the client's
back and relieve pressure on the nerves.)
A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes.
Which of the following information should the nurse include in the teaching?
A. "Use condoms when lesions are present."

B. "Look for lesions that have a wart-like appearance."
C. "The virus can be transmitted without lesions present." (The nurse should inform the client
that viral shedding and spreading of the infection can occur even when lesions are not
present)
D. "The lesions resolve in 2 weeks and usually do not recur."
Answer: C. "The virus can be transmitted without lesions present." (The nurse should inform
the client that viral shedding and spreading of the infection can occur even when lesions are
not present)
A nurse is reinforcing teaching regarding the use of a continuous passive motion motion
(CPM) machine with a client who is schedules for a total knee arthroplasty. Which of the
following information should the nurse include in the teaching? (Select all that apply.)
A. "Your knee is flexed and extended as prescribed by your provider." (The provider will give
specific instructions concerning the CPM flexion and extension motion each day.)
B. "The machine is padded with sheep skin." (Padding the CPM machine with sheep skin
prevents injury to pressure points on the extremity.)
C. "You might have the head of the bed elevated to 45 degrees while using this machine."
D. "To use the machine, you must pedal as if you are riding a bike."
E. "We will store the CPM machine on the floor under the bed when not in use."
Answer: A. "Your knee is flexed and extended as prescribed by your provider." (The
provider will give specific instructions concerning the CPM flexion and extension motion
each day.)
A nurse is caring for a client who begins to have a seizure while ambulating in the hall.
Identify the sequence of actions the nurse should follow. (Move the steps the nurse should
take into the box on the right, placing them in order of performance. Use all the steps.)
Reorient and reassure the client.
Lower the client to the floor
Time the length of the client’s
seizure.
Place a pad beneath the client’s head.
Loosen the clothing around the client’s
neck.
Answer:

Reorient and reassure the client.
Lower the client to the floor
Time the length of the client’s
seizure.
Place a pad beneath the client’s head.
Loosen the clothing around the client’s
neck.

Lower the client to the floor
Place a pad beneath the client’s head.
Loosen the clothing around the client’s
neck.
Time the length of the client’s
seizure.
Reorient and reassure the client.

First, the nurse should lower the client to the floor to prevent the client from falling. Second,
the nurse should place a pad beneath the client's head to protect the client from injury. Third,
the nurse should loosen clothing around the client's neck to allow for easier ventilation.
Fourth, the nurse should note the time the seizure began for accurate reporting. Fifth, the
nurse should reorient and reassure the client because confusion and embarrassment are
common following a seizure.
A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB)
and a prescription for isoniazid and rifampin. Which of the following information should the
nurse include in the teaching?
A. Weekly sputum cultures will be needed.
B. Household family members should be tested for TB. (The nurse should instruct the client
that family members or others who have been in close contact with the client should schedule
testing for TB.)
C. TB is no longer contagious after 2 to 3 days of medication therapy.
D. Family members should wear N95 masks when in contact with the client.
Answer: B. Household family members should be tested for TB. (The nurse should instruct
the client that family members or others who have been in close contact with the client should
schedule testing for TB.)
A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a
statin medication to lower cholesterol levels. Which of the following instructions should the
nurse include in the teaching?
A. "Maintain fat intake of 40 percent of total calories."
B. "Have your white blood cell count checked."
C. "Sustain an HDL level of 25 milligrams per deciliter."

D. "Add oily fish to your diet twice weekly." (The nurse should reinforce teaching about
dietary changes to manage coronary artery disease, such as eating fish that are rich in omega3 fatty acids, like tuna, mackerel, or salmon, twice weekly or taking a fish oil supplement
daily.)
Answer: D. "Add oily fish to your diet twice weekly." (The nurse should reinforce teaching
about dietary changes to manage coronary artery disease, such as eating fish that are rich in
omega-3 fatty acids, like tuna, mackerel, or salmon, twice weekly or taking a fish oil
supplement daily.)
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription
for regular and NPH insulin. Which of the following instructions on preparing the insulin
should the nurse include?
A. Withdraw both types of insulin and then add 0.2 mL of air to the syringe. (The nurse
should instruct the client to draw air into the syringe prior to withdrawing the insulins. No
additional air should be added to the syringe after withdrawing the insulins.)
B. Gently shake the NPH insulin prior to withdrawing the dose. (The nurse should instruct
the client to gently rotate the vial of NPH insulin to mix it prior to withdrawing the dose.)
C. Withdraw the regular insulin before withdrawing the NPH insulin. (The nurse should
instruct the client to withdraw the regular insulin before withdrawing the NPH insulin. This
will protect the regular insulin from contamination with the NPH insulin.)
D. Inject air into the NPH vial after withdrawing regular insulin. (The nurse should instruct
the client to inject air into both insulin vials before withdrawing either medication.)
Answer: C. Withdraw the regular insulin before withdrawing the NPH insulin. (The nurse
should instruct the client to withdraw the regular insulin before withdrawing the NPH insulin.
This will protect the regular insulin from contamination with the NPH insulin.)
A nurse in an orthopaedic clinic is reinforcing teaching with a client who has osteoarthritis.
Which of the following instructions should the nurse include to promote comfort?
A. Sleep on a firm mattress. (A firm mattress or a bed board helps the client maintain joint
alignment while sleeping.)
B. Try jogging in place when joints feel stiff.
C. Use a soft chair or recliner for sitting.
D. Apply ice packs to painful joints.

Answer: A. Sleep on a firm mattress. (A firm mattress or a bed board helps the client
maintain joint alignment while sleeping.)
A nurse is assisting in the plan of care for a client who has a recent left hemispheric stroke.
Which of the following actions should the nurse include in the plan?
A. Observe for impulsive behavior.
B. Approach the client from the right side.
C. Use simple verbal cues when directing tasks. (The nurse should expect a client who
experiences a left hemispheric stroke to manifest some degree of expressive and/or receptive
aphasia. Using simple verbal cues will assist the client in understanding spoken
communication.)
D. Place the client in low-Fowler's position during meals.
Answer: C. Use simple verbal cues when directing tasks. (The nurse should expect a client
who experiences a left hemispheric stroke to manifest some degree of expressive and/or
receptive aphasia. Using simple verbal cues will assist the client in understanding spoken
communication.)
A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the
following laboratory results indicates the client is experiencing a myocardial infarction?
A. Decreased lipase
B. Decreased erythrocyte sedimentation rate (ESR)
C. Elevated creatinine
D. Elevated troponin (Laboratory evaluation of troponin is used specifically to detect cardiac
muscle injury. Therefore, the nurse should identify an elevated troponin level as an indication
that the client is experiencing a myocardial infarction.)
Answer: D. Elevated troponin (Laboratory evaluation of troponin is used specifically to
detect cardiac muscle injury. Therefore, the nurse should identify an elevated troponin level
as an indication that the client is experiencing a myocardial infarction.)
A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will need to take the medication until my thyroid function returns to normal."

B. "The medication should be taken before I eat breakfast every morning." (The nurse should
instruct the client to take levothyroxine at the same time each day, preferably 1 hr. before
breakfast.)
C. "The medication might lower my blood sugar."
D. "I will take the medication with an antacid if it gives me heartburn."
Answer: B. "The medication should be taken before I eat breakfast every morning." (The
nurse should instruct the client to take levothyroxine at the same time each day, preferably 1
hr. before breakfast.)
A nurse is contributing to the plan of care to promote a restful night's sleep for a client who
has Alzheimer’s disease. Which of the following interventions should the nurse include in the
plan?
A. Encourage stimulating activities after dinner.
B. Encourage a late afternoon nap.
C. Offer a small snack at bedtime. (The nurse should offer the client a small snack of
carbohydrates or a glass of milk as part of the bedtime routine, which can help the client relax
and prepare for sleep.)
D. Offer hot chocolate at bedtime.
Answer: C. Offer a small snack at bedtime. (The nurse should offer the client a small snack
of carbohydrates or a glass of milk as part of the bedtime routine, which can help the client
relax and prepare for sleep.)
A nurse is reviewing medical record of a client who is postoperative. Which of the following
findings should the nurse identify as a complication of surgery?
A. Serous drainage from the incision
B. WBC count of 15,000/mm3 (The nurse should monitor laboratory findings for indications
of a postoperative complication. This WBC count is above the expected reference range and
indicates the presence of infection.)
C. Temperature of 37.2° C (99° F)
D. Urine output of 400 mL over the past 8 hr.
Answer: B. WBC count of 15,000/mm3 (The nurse should monitor laboratory findings for
indications of a postoperative complication. This WBC count is above the expected reference
range and indicates the presence of infection.)

A nurse is changing the dressing for a client who has an abdominal incision and a Hemovac
drain. Which of the following actions should the nurse take?
A. Secure the drainage tube to the client's bedding.
B. Wear sterile gloves to empty the drainage system.
C. Cut an absorbent gauze dressing to fit around the drainage tube.
D. Cleanse the drainage plug with alcohol swabs. (The nurse should cleanse the drain
opening and plug with alcohol swabs to remove excess drainage and discourage pathogens
from entering the drainage system.)
Answer: D. Cleanse the drainage plug with alcohol swabs. (The nurse should cleanse the
drain opening and plug with alcohol swabs to remove excess drainage and discourage
pathogens from entering the drainage system.)
A nurse is reviewing the medication administration record of a client who has osteoarthritis.
Which of the following analgesic prescriptions should the nurse expert to administer when
the client reports pain?
A. Methotrexate
B. Acetaminophen (Acetaminophen is a nonopioid analgesic that is a good choice for a client
who has osteoarthritis because its adverse effects are less toxic than many other analgesics.
However, clients should be advised that an overdose of acetaminophen can cause liver
damage.)
C. Gabapentin
D. Etanercept
Answer: B. Acetaminophen (Acetaminophen is a nonopioid analgesic that is a good choice
for a client who has osteoarthritis because its adverse effects are less toxic than many other
analgesics. However, clients should be advised that an overdose of acetaminophen can cause
liver damage.)
A nurse is reinforcing teaching with a client who has asthma and a new prescription for a
corticosteroid. Which of the following findings should the nurse include as an adverse effect
of the medication?
A. Frequent colds (The nurse should inform the client that corticosteroids can increase
susceptibility to infection by suppressing the immune response. The nurse should instruct the
client about infection prevention measures to implement while taking a corticosteroid.)
B. Vitamin deficiency

C. Increased urination
D. Orthostatic hypotension
Answer: A. Frequent colds (The nurse should inform the client that corticosteroids can
increase susceptibility to infection by suppressing the immune response. The nurse should
instruct the client about infection prevention measures to implement while taking a
corticosteroid.)
A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for
calcitonin. Which of the following statements should the nurse make to describe the effect the
calcitonin in treating osteoporosis?
A. "Calcitonin will slow the breakdown of bone in your body." (Calcitonin inhibits osteoclast
activity, therefore minimizing bone loss. The medication helps to preserve bone for a client
who has osteoporosis.)
B. "Calcitonin will increase the level of cortisol in your blood."
C. "Calcitonin will decrease the amount of calcium you are losing in your urine."
D. "Calcitonin will increase the blood flow to your skeletal muscles."
Answer: A. "Calcitonin will slow the breakdown of bone in your body." (Calcitonin inhibits
osteoclast activity, therefore minimizing bone loss. The medication helps to preserve bone for
a client who has osteoporosis.)
A nurse is assisting with an educational program for clients who have newly diagnosed with
diabetes mellitus. Which of the following instructions should the nurse include in the
program regarding insulin?
A. Store unopened insulin vials in the freezer for up to 1 month.
B. Opened insulin can be stored on a cool countertop away from light. (The nurse should
inform the clients that opened insulin vials do not require refrigeration, but can be placed in a
cool location for up to 4 weeks, out of direct sunlight.)
C. Roll discoloured insulin gently to mix it before use.
D. Use refrigerated insulin immediately after removing it from the refrigerator.
Answer: B. Opened insulin can be stored on a cool countertop away from light. (The nurse
should inform the clients that opened insulin vials do not require refrigeration, but can be
placed in a cool location for up to 4 weeks, out of direct sunlight.)

A nurse is caring for a client who is suspected of having myocardial infarction. Which of the
following actions should the nurse take to prepare the client for an ECG?
A. Position the client in Sims' position before electrode placement. (The nurse should place
the client in a supine position to prepare the procedure.)
B. Ensure that each electrode is dry before application. (The nurse should expect the
electrodes to be relubricated so they will adhere to the client's skin and provide clear signal
transmission and an adequate ECG reading.)
C. Cleanse the client's skin prior to electrode placement. (The nurse should cleanse the
client's skin prior to electrode placement to improve electrode conduction.)
D. Place the electrodes on the client's abdomen and back. (The nurse should place the
electrodes on the client's chest and limbs.)
Answer: C. Cleanse the client's skin prior to electrode placement. (The nurse should cleanse
the client's skin prior to electrode placement to improve electrode conduction.)
A nurse is contributing to the plan of care for a client who has just transferred to the medicalsurgical unit from the PACU following a right total knee arthroplasty.
Which of the following interventions should the nurse include in the plan?
A. Massage both lower extremities to promote comfort. (The nurse should never massage the
extremities, because doing so could dislodge a blood clot, causing a pulmonary embolus.)
B. Begin the client on a regular diet when the gag reflex returns. (The nurse should only offer
the client ice chips or sips of water when the gag reflex returns to determine how well the
client will tolerate PO intake. The provider will advance the client's diet when bowel sounds
are present.)
C. Encourage the client to use the incentive spirometer every 4 hr while awake. (The nurse
should have the client use the incentive spirometer once per hr while awake during the first
24 hr postoperative to prevent respiratory complications.)
D. Assist the client to change positions at least every 2 hr. (The nurse should assist the client
to change positions at least every 2 hr to promote return of respiratory function following
anaesthesia and prevent atelectasis and pneumonia.)
Answer: D. Assist the client to change positions at least every 2 hr. (The nurse should assist
the client to change positions at least every 2 hr to promote return of respiratory function
following anaesthesia and prevent atelectasis and pneumonia.)

A nurse is reinforcing teaching with a client who has circulatory compromise in the lower
extremities due to peripheral vascular disease. Which of the following actions should the
nurse take?
A. Educate the client about choosing low-fat, low-cholesterol foods. (The nurse should
educate the client about a low-fat, low-cholesterol diet, which is prescribed for clients who
have atherosclerosis. This diet can also aid in weight reduction, which can improve activity
tolerance.)
B. Have the client flex hips and knees when lying in bed. (The nurse should have the client
avoid flexing the hips and knees because it can further impede the peripheral blood flow.)
C. Encourage the client to wear elastic support hose during the day time. (The nurse should
instruct the client to avoid the use of elastic support hose because they can reduce circulation
to the skin.)
D. Instruct the client to use an electric heating pad. (The nurse should instruct the client to
avoid the use of electric heating pads due to an increased risk of burns from decreased
sensation of the extremities.)
Answer: A. Educate the client about choosing low-fat, low-cholesterol foods. (The nurse
should educate the client about a low-fat, low-cholesterol diet, which is prescribed for clients
who have atherosclerosis. This diet can also aid in weight reduction, which can improve
activity tolerance.)
A nurse is caring for a client who is postoperative following a transurethral resection of the
prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased
output from the urethral catheter. Which of the following provider prescriptions should the
nurse expect?
A. Clamp the urethral catheter for 30 min. (Applying a clamp to the urethral catheter will
prevent drainage from the bladder and increase the risk of bladder trauma.)
B. Place the urethral catheter drainage bag at the client's heart level. (Placing the urethral
catheter drainage bag at the client's heart level will slow bladder output and increase the risk
for infection.)
C. Slow the bladder irrigation flow rate. (Slowing the bladder irrigation flow rate will
increase the risk of clotting in the tubing and disrupt the irrigation output.)
D. Irrigate the urethral catheter with 0.9% sodium chloride. (The nurse should expect a
prescription to irrigate the urethral catheter because this will clear the tubing of any blood
clots or tissue pieces and allow for a better flow.)

Answer: D. Irrigate the urethral catheter with 0.9% sodium chloride. (The nurse should
expect a prescription to irrigate the urethral catheter because this will clear the tubing of any
blood clots or tissue pieces and allow for a better flow.)
A nurse is preparing to assist a client out of bed 4 hr. following a laparoscopic
cholecystectomy. Which of the following actions should the nurse take first?
A. Place the client in Fowler's position. (The nurse should place the client in Fowler's
position, which raises the client's head to prevent vertigo and facilitate movement out of bed.
However, there is another action the nurse should take first.)
B. Obtain the client's blood pressure. (The greatest risk to the client is postural hypotension
due to decreased blood volume following surgery. Therefore, the first action the nurse should
take is to obtain the client's baseline blood pressure to determine whether it is safe to have the
client get out of bed.)
C. Dangle the client's legs at the bedside. (The nurse should assist the client to dangle his legs
at the bedside to prevent vertigo and decrease the client's risk of falling.
However, there is another action the nurse should take first.)
D. Apply non-skid slippers. (The nurse should apply non-skid slippers to prevent the client
from falling when out of bed. However, there is another action the nurse should take first.)
Answer: B. Obtain the client's blood pressure. (The greatest risk to the client is postural
hypotension due to decreased blood volume following surgery. Therefore, the first action the
nurse should take is to obtain the client's baseline blood pressure to determine whether it is
safe to have the client get out of bed.)
A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis (TB)
about transmission of the disease. Which of the following client statements indicates an
understanding of the teaching?
A. "I inhaled the infected droplets that were in the air." (TB is spread by airborne
transmission. Therefore, the nurse should identify this statement as an understanding of the
teaching.)
B. "I must have touched someone who had TB." (The nurse should reinforce that TB is not
spread by direct contact.)
C. "I probably caught this disease from a mosquito bite." (The nurse should reinforce that TB
is not spread by vectors, such as mosquitos.)

D. "I developed TB from having unprotected sex." (The nurse should reinforce that TB is not
spread by having unprotected sex.)
Answer: A. "I inhaled the infected droplets that were in the air." (TB is spread by airborne
transmission. Therefore, the nurse should identify this statement as an understanding of the
teaching.)
A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the following
findings should the nurse expect?
A. Muscle spasticity (Muscle spasticity is a manifestation of multiple sclerosis.)
B. Tremors at rest (Tremors at rest is a manifestation of Parkinson's disease.)
C. Ptosis (Ptosis is a manifestation of myasthenia gravis.)
D. Ascending paralysis (Ascending paralysis is a manifestation of Guillain-Barré syndrome.)
Answer: B. Tremors at rest (Tremors at rest is a manifestation of Parkinson's disease.)
A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was
precipitated by the client not taking her medication for several days. The nurse should
identify that withdrawal from which of the following medications potentiated the adrenal
crisis?
A. Metoprolol (Metoprolol is a beta-adrenergic antagonist used to treat hypertension.
Discontinuation of this medication does not cause an adrenal crisis.)
B. Methimazole (Methimazole is an antithyroid hormone used to treat hyperthyroidism.
Discontinuation of this medication does not cause an adrenal crisis.)
C. Furosemide (Furosemide is a high-ceiling loop diuretic used to treat heart failure.
Discontinuation of this medication does not cause an adrenal crisis.)
D. Prednisone (Prednisone is administered to replace glucocorticoids, which are deficient in
adrenocortical insufficiency. Abrupt withdrawal of the medication can lead to an adrenal
crisis.)
Answer: D. Prednisone (Prednisone is administered to replace glucocorticoids, which are
deficient in adrenocortical insufficiency. Abrupt withdrawal of the medication can lead to an
adrenal crisis.)
A nurse is caring for a client following a thyroidectomy. Which of the following findings
should alert the nurse to the possibility of parathyroid gland injury?
A. Anorexia (Anorexia is not an indication of a parathyroid gland injury.)

B. Hoarseness (A client might experience hoarseness following a thyroidectomy, which can
result from intubation during surgery. Persistent hoarseness can also indicate damage to the
vocal cords. However, hoarseness is not an indication of parathyroid gland injury.)
C. Muscle twitching (A common complication of a thyroidectomy is parathyroid gland injury,
leading to hypocalcaemia. Clients experiencing hypocalcaemia can have twitching,
numbness, and tingling of fingers, toes, and around the mouth.)
D. Blurred vision (Blurred vision is not an indication of a parathyroid gland injury but can be
an adverse effect of some medications or an indication of hyperglycaemia.)
Answer: C. Muscle twitching (A common complication of a thyroidectomy is parathyroid
gland injury, leading to hypocalcaemia. Clients experiencing hypocalcaemia can have
twitching, numbness, and tingling of fingers, toes, and around the mouth.)
A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot.
Which of the following actions should the nurse take first?
A. Obtain the client's temperature. (The nurse should obtain the client's temperature to
monitor for hyperthermia, which can indicate an infection, or hypothermia following
anaesthesia administration. However, there is another action the nurse should take first)
B. Observe for phantom pain. (The nurse should observe the client for phantom pain to
promote prompt pain treatment and relief. However, there is another action the nurse should
take first.)
C. Measure urinary output. (The nurse should measure the client's urinary output to monitor
for fluid imbalance. However, there is another action the nurse should take first.)
D. Check the incisional dressing. (The greatest risk to the client is haemorrhage following an
amputation of the lower extremity. Therefore, the first action the nurse should take is to check
the client's incisional dressing for excessive bleeding.)
Answer: D. Check the incisional dressing. (The greatest risk to the client is haemorrhage
following an amputation of the lower extremity. Therefore, the first action the nurse should
take is to check the client's incisional dressing for excessive bleeding.)
A nurse is caring for a client who has a new cast on her left forearm and report severe pain in
the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with
sluggish capillary refill. Which of the following fracture complication should the nurse
suspect?

A. Compartment syndrome (Compartment syndrome is a complication that involves
increased pressure within a compartment (an area that supports blood vessels, bones, and
nerves) leading to circulatory compromise to the limb. The pressure can be caused externally
by a cast that is too tight or internally by the inflammation or edema from the injury.
Circulatory impairment causes pallor and paraesthesia of the extremities and a delay in
capillary refill, and without immediate treatment, can cause nerve damage and necrosis.)
B. Fat embolism (A bone fracture can result in globules of fat migrating from the bone
marrow into the circulation. Depending on where these globules travel, the nurse should
expect manifestations of a blockage to the brain or lungs. Fat embolus usually occur in the
long bones, pelvis, or ribs.)
C. Deep-vein thrombosis (The nurse should expect pain with possible tenderness, redness,
and warmth of the extremity for a client who has a deep-vein thrombosis
(DVT). DVTs usually occur in the iliac or femoral veins.)
D. Osteomyelitis (Osteomyelitis occurs when pathogens enter the blood stream from the
wound of an open fracture, causing bone infection. The nurse should expect manifestations of
severe pain and tenderness at the site and systemic manifestations of infection, such as fever,
chills, headache, and malaise.)
Answer: A. Compartment syndrome (Compartment syndrome is a complication that involves
increased pressure within a compartment (an area that supports blood vessels, bones, and
nerves) leading to circulatory compromise to the limb. The pressure can be caused externally
by a cast that is too tight or internally by the inflammation or edema from the injury.
Circulatory impairment causes pallor and paraesthesia of the extremities and a delay in
capillary refill, and without immediate treatment, can cause nerve damage and necrosis.)
A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new
diagnosis of COPD. The nurse should identify which of the following client statements
indicates an understanding of the teaching?
A. "I should perform pursed-lip breathing exercises before going to bed." (The nurse should
reinforce with the client that the use of pursed-lip breathing can help reduce fatigue during
times of activity. However, there is no indication that pursed-lip breathing exercises are
beneficial to the client before going to bed.)
B. "When I'm fatigued, I should inhale slowly through pursed lips." (The nurse should
reinforce with the client that the use of pursed-lip breathing can help reduce fatigue.

However, pursed-lip breathing involves exhaling slowly through pursed lips to keep the
airways open.)
C. "Pursed-lip breathing works best for activities like walking up stairs." (The nurse should
acknowledge that performing pursed-lip breathing during times of activity, such as walking
upstairs, helps increase airway pressure and reduce the amount of trapped air in the lungs.
This breathing technique helps eliminate excess carbon dioxide that clients who have COPD
might retain.)
D. "I will exhale through my nose after breathing in through pursed lips." (The nurse should
reinforce with the client that the use of pursed-lip breathing can improve dyspnoea with
activity. However, pursed-lip breathing involves exhaling through pursed-lips after breathing
in through the nose.)
Answer: C. "Pursed-lip breathing works best for activities like walking up stairs." (The nurse
should acknowledge that performing pursed-lip breathing during times of activity, such as
walking upstairs, helps increase airway pressure and reduce the amount of trapped air in the
lungs. This breathing technique helps eliminate excess carbon dioxide that clients who have
COPD might retain.)
A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative
following a total hip arthroplasty. Which of the following interventions should the nurse
contribute to the plan of care?
A. Check neurovascular status on the extremity every 8 hr. (The nurse should check the
neurovascular status on the extremity every 2 to 4 hr.)
B. Have the client perform incentive spirometry every 4 hr. (The nurse should have the client
perform incentive spirometry every 2 hr as well as deep breathing and coughing every 2 hr to
prevent atelectasis.)
C. Keep an abduction pillow between the client's legs. (The nurse should keep an abduction
pillow or a splint between the client's legs to prevent hip dislocation after surgery.)
D. Maintain the client on bed rest until the third postoperative day. (The nurse should
encourage and assist the client to get out of bed as soon as possible after the surgery.)
Answer: C. Keep an abduction pillow between the client's legs. (The nurse should keep an
abduction pillow or a splint between the client's legs to prevent hip dislocation after surgery.)
A nurse is collecting data from an older adult client who has several concerns. Which of the
following concerns should the nurse recognize as a normal change associated with aging?

A. "I sweat more than I used to." (Perspiration decreases in older adult clients as sweat glands
produce less sweat. Increased sweating could indicate a disorder in the endocrine system.)
B. "Sometimes I can't remember my kids' names." (Older adult clients usually retain longterm memory better than short-term memory. An inability to remember family members'
names is not a normal part of the aging process and might indicate deteriorating cognitive
function.)
C. "I seem to have more loose stools than I used to." (Constipation is common in older adult
clients because peristalsis decreases with age. Diarrhoea can indicate a disorder in the
gastrointestinal system.)
D. "My food tastes bland even after I add seasoning."(As clients’ age, their sense of smell
decreases, causing a secondary decrease in taste.)
Answer: D. "My food tastes bland even after I add seasoning."(As clients’ age, their sense of
smell decreases, causing a secondary decrease in taste.)
A nurse is reviewing the medical record of a client who has acute pancreatitis.
Which of the following findings should the nurse anticipate?
A. Elevated serum amylase level (The nurse should anticipate an elevation in the client's
serum amylase level due to injury of the pancreatic cells.)
B. Hypertension (The nurse should expect a client who has acute pancreatitis to have
hypotension as a result of third spacing and fluids shifts.)
C. Bradycardia (The nurse should expect a client who has acute pancreatitis to have
tachycardia as a result of the inflammatory response and pain associated with the illness.)
D. Decreased leukocyte count (The nurse should expect a client who has acute pancreatitis to
have an elevated white blood cell count due to the inflammation and necrosis of the
pancreas.)
Answer: A. Elevated serum amylase level (The nurse should anticipate an elevation in the
client's serum amylase level due to injury of the pancreatic cells.)
A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse
should document the sound as which of the following? (Click on the audio button to listen to
the clip)
A. Pleural friction rub (The nurse should expect to hear a pleural friction rub, which is a dry,
grating sound during respirations, when auscultating the lungs of a client who has pleurisy.)

B. Wheezes (The nurse should identify the breath sound auscultated as wheezes. These are
high-pitched, musical sounds that occur as air passes through narrowed airways, such as
when a client is experiencing an asthma attack.)
C. Vesicular (The nurse should expect to hear vesicular breath sounds when auscultating the
periphery of a lung field of a client who is without pulmonary illness or disease. These
sounds are soft, low-pitched blowing sounds that occur as air passes through the smaller
airways.)
D. Crackles (The nurse should expect to hear crackles, which are crackling or bubbling
sounds heard during inspiration, when auscultating the lungs of a client who has fluid
overload. Crackles can be termed fine, medium, or coarse, and are an indication of air passing
through fluid or mucus. Crackles do not tend to clear with coughing.)
Answer: B. Wheezes (The nurse should identify the breath sound auscultated as wheezes.
These are high-pitched, musical sounds that occur as air passes through narrowed airways,
such as when a client is experiencing an asthma attack.)
A nurse is caring for a client who has restricted movement of the chest due to a burn injury.
The nurse should anticipate preparing the client for which of the following procedures?
A. Fasciotomy (A fasciotomy is used to treat compartment syndrome for clients following
traumatic musculoskeletal injury.)
B. Escharotomy (The nurse should anticipate a prescription for an escharotomy to relieve
constriction of the client's chest due to a burn injury. Following removal of the eschar, chest
wall movement will be possible and the client's oxygenation should improve.)
C. Skin grafting (Skin grafting is used to promote wound healing for clients who have large
wounds, like burn injuries.)
D. Hyperbaric oxygen therapy (Hyperbaric oxygen therapy involves high pressure oxygen
therapy and is part of treatment for life-threatening wound infections.)
Answer: B. Escharotomy (The nurse should anticipate a prescription for an escharotomy to
relieve constriction of the client's chest due to a burn injury. Following removal of the eschar,
chest wall movement will be possible and the client's oxygenation should improve.)
A nurse is caring for four clients. Which of the following conditions should the nurse identify
as a risk for developing vascular disease?

A. Rheumatoid arthritis (Clients who have rheumatoid arthritis are at increased risk for iron
deficiency anaemia. However, rheumatoid arthritis does not increase the client's risk of
developing vascular disease.)
B. Diabetes mellitus (Clients who have diabetes mellitus are at increased risk for developing
cardiovascular and peripheral vascular disease due to the changes in the microvasculature
resulting from elevated levels of glucose.)
C. Myasthenia gravis (Clients who have myasthenia gravis are at increased risk for
pneumonia due to aspiration resulting from muscle weakness. However, myasthenia gravis
does not increase the client's risk of developing vascular disease.)
D. Crohn's disease (Clients who have Crohn's disease are at increased risk for malabsorption,
malnutrition, and eventually colon cancer resulting from repeated damage to the intestinal
mucosa. However, Crohn's disease does not increase the client's risk of developing vascular
disease.)
Answer: B. Diabetes mellitus (Clients who have diabetes mellitus are at increased risk for
developing cardiovascular and peripheral vascular disease due to the changes in the
microvasculature resulting from elevated levels of glucose.)
A nurse is caring for a client who has end-stage liver disease and just underwent an
abdominal paracentesis. For which of the following manifestations should the nurse monitor
as an adverse effect of the procedure?
A. Changes in the client's sputum (The nurse should expect changes in the client's sputum as
an adverse effect following a bronchoscopy.)
B. Decreased blood pressure (Following an abdominal paracentesis, the nurse should monitor
the client for a decrease in blood pressure. This finding indicates hypovolemia as a result of
excess fluid withdrawal. Depending on the amount of fluid withdrawn, hypovolemia can lead
to shock.)
C. Changes in neurological status (The nurse should monitor for changes in the client's
neurological status as an adverse effect following a lumbar puncture.)
D. Increased urinary output (Following an abdominal paracentesis, the nurse should monitor
the client for a decrease in urinary output. This finding can indicate hypovolemia as a result
of excess fluid withdrawal.
Answer: B. Decreased blood pressure (Following an abdominal paracentesis, the nurse
should monitor the client for a decrease in blood pressure. This finding indicates

hypovolemia as a result of excess fluid withdrawal. Depending on the amount of fluid
withdrawn, hypovolemia can lead to shock.)
A nurse is caring for a female client who is being treated for dehydration due to due to nausea
and vomiting. Which of the following findings should the nurse report to the provider?
A. Haemoglobin 13 g/dL (The client's haemoglobin level is within the expected reference
range.)
B. Blood pressure 110/55 mm Hg (The client's blood pressure is within the expected
reference range.)
C. Heart rate 120/min (The client's heart rate of 120/min is above the expected reference
range and indicates the client's dehydration has not resolved. Therefore, the nurse should
report this finding to the provider to obtain additional prescriptions for fluid replacement.)
D. Potassium 3.6 mEq/L (The client's potassium level is within the expected reference range.)
Answer: C. Heart rate 120/min (The client's heart rate of 120/min is above the expected
reference range and indicates the client's dehydration has not resolved. Therefore, the nurse
should report this finding to the provider to obtain additional prescriptions for fluid
replacement.)
A nurse is contributing to the plan of care for a client who had a cerebrovascular accident
(CVA). For which of the following interdisciplinary team members should the nurse
recommend a referral prior to initiating oral intake for the client?
A. Occupational therapist (The nurse should recommend a referral for an occupational
therapist to assist the client with activities of daily living. An occupational therapist will help
develop the client's self-care skills, taking into consideration any impaired functions the client
might have as a result of the CVA.)
B. Speech-language pathologist (The nurse should recommend a referral for a speech
language pathologist to evaluate the client's ability to safely swallow. A client who has had a
CVA is at increased risk for dysphagia and aspiration of fluids, food, and medications. The
speech-language pathologist should conduct a swallowing study to determine the client's risk
for aspiration and provide teaching to the client regarding swallowing techniques.)
C. Physical therapist (The nurse should recommend a referral for a physical therapist to assist
with the client's mobility needs. A client who has had a CVA can experience paralysis or
muscle weakness. The physical therapist will help the client safely manage mobility needs,
such as changing positions, transferring from bed to chair, and ambulating.)

D. Case manager (The nurse should recommend a referral for a case manager to coordinate
resources the client might need. The case manager will help the client, family members or
caregivers, and health care team members to identify needs and ensure the client receives
appropriate services across the care continuum.)
Answer: B. Speech-language pathologist (The nurse should recommend a referral for a
speech language pathologist to evaluate the client's ability to safely swallow. A client who has
had a CVA is at increased risk for dysphagia and aspiration of fluids, food, and medications.
The speech-language pathologist should conduct a swallowing study to determine the client's
risk for aspiration and provide teaching to the client regarding swallowing techniques.)
A nurse is reinforcing teaching to a client about preventing osteoporosis. Which of the
following client statements indicates an understanding of the teaching?
A. "I will eat more bananas." (The nurse should recommend a diet high in calcium for a client
who is at risk for osteoporosis. A medium banana is low in calcium, containing only 6 mg.
Low-fat cheese, yogurt, and calcium-fortified orange juice are better options for ensuring the
client receives an adequate amount of calcium.)
B. "I will walk for 20 minutes 3 days a week." (The nurse should recommend the client walk
20 min or more 5 days per week or 30 min 3 days per week. Weight-bearing exercises, such
as walking, can help prevent the development of osteoporosis.)
C. "I will limit my coffee intake." (Coffee contains caffeine, which can cause excretion of
calcium through diuretic effects. Clients often drink caffeinated beverages instead of
beverages that contain calcium, and caffeine might interfere with the absorption of Vitamin
D. Therefore, the nurse should identify this statement as an indication that the client
understands the teaching.)
D. "I will take a calcium supplement at bed time." (The nurse should inform the client that
supplementing the diet with calcium can help prevent the development of osteoporosis and
limit fractures. However, the client should take calcium supplements in divided doses
throughout the day.)
Answer: C. "I will limit my coffee intake." (Coffee contains caffeine, which can cause
excretion of calcium through diuretic effects. Clients often drink caffeinated beverages
instead of beverages that contain calcium, and caffeine might interfere with the absorption of
Vitamin D. Therefore, the nurse should identify this statement as an indication that the client
understands the teaching.)

A nurse is reinforcing discharge teaching with a client who has Crohn’s disease. Which of the
following statements should the nurse include in the teaching?
A. "Increase your intake of dietary fat." (The nurse should instruct the client to decrease
dietary fat because it can exacerbate the manifestations of Crohn's disease.)
B. "Maintain a low-residue diet." (The nurse should instruct the client to maintain a lowfibre, low-residue diet, which helps control pain and inflammation in the small intestine and
reduces episodes of diarrhoea.)
C. "Avoid taking antidiarrheal medications." (The nurse should instruct the client to take
antidiarrheal medications as prescribed by the provider to relieve abdominal cramping and
loose stools.)
D. "Plan to weigh yourself weekly." (The nurse should instruct the client to weigh himself
daily because diarrhoea can lead to dehydration and nutritional deficits, causing weight loss.)
Answer: B. "Maintain a low-residue diet." (The nurse should instruct the client to maintain a
low-fibre, low-residue diet, which helps control pain and inflammation in the small intestine
and reduces episodes of diarrhoea.)
A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is
having difficulty with urination. Which of the following responses should the nurse make?
A. "The kidneys' ability to filter urine is decreased." (Prostate cancer does not affect the
function of the kidneys.)
B. "The tumour causes obstruction of urine from the urethra." (As a prostate tumour grows, it
compresses the urethra, resulting in obstructed urine flow.)
C. "The cancer results in hormonal changes, which affect urination." (Prostate cancer does
not affect hormonal changes. However, hormone therapy is one of the treatment options for
prostate cancer.)
D. "The protein-specific antigen in your blood is decreased." (An increased protein specific
antigen is a diagnostic finding of prostate cancer.)
Answer: B. "The tumour causes obstruction of urine from the urethra." (As a prostate tumour
grows, it compresses the urethra, resulting in obstructed urine flow.)
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of
the following interventions should he nurse include?
A. Place a "no visitors" sign on the client's door. (Clients who have TB can have visitors.
However, visitors should follow transmission precautions.)

B. Have the client wear an N95 respiratory mask during transport. (The nurse should place a
surgical mask on the client when transporting her outside of the room to prevent the
transmission of micro-organisms.)
C. Initiate droplet precautions for the client. (The nurse should implement droplet precautions
for a client who has rubella or pertussis.
D. Place the client in a negative-pressure airflow room. (The nurse should place the client in a
negative-pressure airflow room to filter the air and prevent the transmission of microorganisms.)
Answer: D. Place the client in a negative-pressure airflow room. (The nurse should place the
client in a negative-pressure airflow room to filter the air and prevent the transmission of
micro-organisms.)
A nurse is reinforcing teaching with a client about testicular self-examination. Which of the
following instructions should the nurse include in the teaching?
A. "Perform testicular self-examination after taking a warm shower." The nurse should
instruct the client to perform testicular self-examination after taking a warm shower or bath.
This causes relaxation of the scrotal skin, which allows for better palpation of the testes.)
B. "Examine both testicles at the same time." (The nurse should instruct the client to examine
each testicle individually to feel for any lumps or abnormalities.)
C. "Use the palm of your hand to palpate for abnormalities." (The nurse should instruct the
client to use the thumbs and fingers of both hands when palpating each testicle.)
D. "Perform testicular self-examination every 6 months." (The nurse should instruct the client
to perform testicular self-examination monthly on approximately the same day of each
month)
Answer: A. "Perform testicular self-examination after taking a warm shower." The nurse
should instruct the client to perform testicular self-examination after taking a warm shower or
bath. This causes relaxation of the scrotal skin, which allows for better palpation of the
testes.)
A nurse is caring for a client who is in Buck’s traction for a fractured hip. The client reports
increased pain at the sited of the fracture. Which of the following actions should the nurse
take?

A. Massage the area. (The nurse should avoid massaging the areas, because it might increase
the client's pain. The nurse should monitor the bony prominences of a client in traction to
detect findings of tissue breakdown or impaired circulation.)
B. Remove the weights. (The nurse should not remove the weights unless there is a
prescription to do so)
C. Loosen the ropes. (The nurse should not loosen the ropes because this can affect the
weight applied to the traction.)
D. Reposition the client. (When the client's body is out of alignment with the traction, muscle
spasms develop, causing increased pain. Therefore, the nurse should reposition the client,
ensuring there is a straight line from the client's hip to the traction rope and pulley, evaluate
the client's response, and provide other interventions as needed.)
Answer: D. Reposition the client. (When the client's body is out of alignment with the
traction, muscle spasms develop, causing increased pain. Therefore, the nurse should
reposition the client, ensuring there is a straight line from the client's hip to the traction rope
and pulley, evaluate the client's response, and provide other interventions as needed.)
A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been
taking methimazole for 4 weeks. Which of the following statements by the client indicates a
therapeutic response of the medication?
A. "I have been sleeping less since I started the medication." (The nurse should expect the
client to report improved sleeping patterns after 4 weeks of methimazole therapy.)
B. "I have gained 3 pounds since my last appointment." (Hyperthyroidism can cause weight
loss. Therefore, the nurse should identify weight gain as an indication that the methimazole
therapy has been effective.)
C. "My bowel movements have become more frequent." (The nurse should expect the client
to report regular bowel movements and absence of diarrhoea after 4 weeks of methimazole
therapy.)
D. "I urinate more often than before." (The nurse should expect the client to report urinating
less frequently after 4 weeks of methimazole therapy.)
Answer: B. "I have gained 3 pounds since my last appointment." (Hyperthyroidism can
cause weight loss. Therefore, the nurse should identify weight gain as an indication that the
methimazole therapy has been effective.)

A nurse is collecting data from a client who has 30% body surface area partial thickness and
full-thickness burns. Which of the following findings indicates that fluid resuscitation is
adequate?
A. Granulation tissue is present. (The nurse should monitor the client's wounds because
infection is a complication of burns. The presence of granulation tissue is an indicator used to
monitor the effectiveness of wound therapy.)
B. Urine output is 50 mL/hr. (The nurse should closely monitor the client's urinary output as
an indicator of effective fluid resuscitation. A urinary output greater than
30 to 50 mL/hr indicates that fluid resuscitation is adequate.)
C. Lung sounds are clear. (The nurse should monitor the client's lung sounds because
pneumonia is a complication of burns. Clear lung sounds only indicate that the client has not
had excessive fluid replacement, not whether fluid resuscitation was adequate.)
D. Oxygen saturation level is 95%. (The nurse should monitor the client's oxygen saturation
level because respiratory problems are a complication of burns. An oxygen saturation within
the expected reference range indicates adequate perfusion of oxygen to the tissues.)
Answer: B. Urine output is 50 mL/hr. (The nurse should closely monitor the client's urinary
output as an indicator of effective fluid resuscitation. A urinary output greater than
30 to 50 mL/hr indicates that fluid resuscitation is adequate.)
A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the
following statements should indicate to the nurse that the client understands the teaching?
A. "I will scrub the skin to remove the old skin flakes." (Scrubbing the skin can damage its
deeper layers. The client should use a gentle technique, such as soaking the skin or applying
moisturizing lotion, to remove dry, scaly flakes.)
B. "I can expect to my leg to be swollen after the cast is removed." (The nurse should instruct
the client that the leg might appear atrophied following cast removal due to disuse of the
muscles.)
C. "I can go back to my usual activities as soon as the cast is off." (The client should resume
activities gradually to avoid placing unnecessary stress on the healing bone.)
D. "I will feel vibrations on my leg from the cast cutter."(The client will feel heat and
vibrations from the cast cutter on the affected extremity. The nurse should assure the client
that cast removal should not cause any pain.)

Answer: D. "I will feel vibrations on my leg from the cast cutter."(The client will feel heat
and vibrations from the cast cutter on the affected extremity. The nurse should assure the
client that cast removal should not cause any pain.)
A nurse is contributing to the plan of care for a client who has pericarditis. In which of the
following positions should the nurse plan to place the client to decrease plan?
A. Semi-Fowler's (The nurse should place a client in Semi-Fowler's position to facilitate
breathing as part of management of peritonitis.)
B. Supine with lower extremities elevated (The nurse should place a client who is in shock in
the supine position with lower extremities elevated or modified Trendelenburg position, to
increase the venous return to the heart.)
C. Upright, leaning forward (The nurse should plan to place a client who has pericarditis in
an upright position, leaning forward, to facilitate breathing and decrease pain.)
D. Side-lying with knees bent (The nurse should place a client in side-lying position with
knees bent to assist in decreasing the pain related to a unilateral or sensory motor deficit on
one side of the body.)
Answer: C. Upright, leaning forward (The nurse should plan to place a client who has
pericarditis in an upright position, leaning forward, to facilitate breathing and decrease pain.)
A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2
cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest
whole number. Use a leading zero if applicable. Do not use a trailing zero.)
Answer: Follow these steps to calculate the calorie intake:
Step 1: What is the unit of measurement the nurse should calculate? calories
Step 2: What is the volume the nurse should infuse? 60 mL/hr x 12 hr = 720 mL
Step 3: What is the total infusion time? 12 hr
Step 4: Should the nurse convert the units of measurement? No
Step 5: Set up an equation and solve for X.
720 mL x 1.2 cal/mL = calories
X = 864 cal
Step 6: Round if necessary.
Step 7: Reassess to determine if the amount to administer makes sense. If the provider
prescribed 60 mL to infuse over 12 hr, it makes sense to administer 720 mL/12 hr. If there are

1.2 cal/mL, it makes sense that the total number of calories the nurse will deliver in 12 hr is
864.
A nurse is reinforcing teaching about nutrition choices with a client who has leukaemia and is
receiving chemotherapy. The nurse should identify that which of the following statements by
the client indicates an understanding of the teaching?
A. "I drink bottled water." (To avoid exposure to bacteria, clients who have cancer and are
receiving chemotherapy should be sure that drinking water is safe. Drinking fresh, bottled
water limits exposure to bacteria.)
B. "I eat at a salad bar for lunch." (Clients who have cancer and are receiving chemotherapy
are at risk for leukopenia. The nurse should recommend the client avoid salad bars and
buffets because of the risk of exposure to bacteria.)
C. "I like to eat steak cooked medium." (Clients who have cancer and are receiving
chemotherapy should cook foods that can contain bacteria, such as meat, to the well-done
stage to prevent infection.)
D. "I put plenty of pepper on my soft-boiled eggs." (Clients who have cancer and are
receiving chemotherapy should avoid undercooked eggs and pepper because of the risk of
exposure to bacteria.)
Answer: A. "I drink bottled water." (To avoid exposure to bacteria, clients who have cancer
and are receiving chemotherapy should be sure that drinking water is safe. Drinking fresh,
bottled water limits exposure to bacteria.)