ATI Medical Surgical Review Exam with Answers-133 Solved Questions

ATI Med-Surg proctored Exam
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home.
Which of the following instructions should the nurse include in the teaching?
a. Take temperature once a day.
b. Wash the armpits and genitals with a gentle cleanser daily.
c. Change the litter boxes while wearing gloves.
d. Wash dishes in warm water.
Answer: a. Take temperature once a day.
Rationale:
Monitoring temperature is important for individuals with HIV as fever can indicate infection
or other complications. Regular temperature checks allow for early detection of potential
issues, enabling prompt intervention and management.
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious
and tenacious secretions. Which of the following is an acceptable method for the nurse to use
to thin this client's secretions?
a. Provide humidified oxygen.
b. Perform chest physiotherapy prior to suctioning.
c. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
d. Hyperventilate the client with 100% oxygen before suctioning the airway..
Answer: a. Provide humidified oxygen.
Rationale:
Providing humidified oxygen helps to maintain moisture in the airway, which can help thin
secretions and facilitate their removal, thus reducing the risk of airway obstruction.
Following admission, a client with a vascular occlusion of the right lower extremity calls the
nurse and reports difficulty sleeping because of cold feet. Which of the following nursing
actions should the nurse take to promote the client's comfort?
a. Rub the client's feet briskly for several minutes.
b. Obtain a pair of slipper socks for the client.
c. Increase the client's oral fluid intake.
d. Place a moist heating pad under the client's feet.
Answer: b. Obtain a pair of slipper socks for the client.
Rationale:

Providing slipper socks helps to insulate the feet and maintain warmth, promoting comfort for
the client experiencing cold feet due to vascular occlusion.
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection
of the prostate (TURP). Which of the following is the priority finding for the nurse report to
the provider?
a. Emesis of 100 mL
b. Oral temperature of 37.5° C (99.5° F)
c. Thick, red-colored urine
d. Pain level of 4 on a 0 to 10 rating scale
Answer: c. Thick, red-colored urine
Rationale:
Thick, red-colored urine following a TURP procedure may indicate bleeding, which could
lead to hemorrhage or clot retention. It is a priority finding that requires immediate attention
from the provider.
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of the
following adverse effects of the hypothermia blanket?
a. Shivering
b. Infection
c. Burns
d. Hypervolemia
Answer: a. Shivering
Rationale:
Shivering is a common adverse effect of using a hypothermia blanket to reduce body
temperature. It indicates the body's attempt to generate heat in response to the cooling effect
of the blanket.
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus.
Which of the following statements by the client indicates an understanding of the teaching?
a. "I will carry a complex carbohydrate snack with me when I exercise."
b. "I should exercise first thing in the morning before eating breakfast."
c. "I should avoid injecting insulin into my thigh if I am going to go running."
d. "I will not exercise if my urine is positive for ketones."
Answer: d. "I will not exercise if my urine is positive for ketones."
Rationale:

Exercising when urine is positive for ketones can worsen ketoacidosis in individuals with
type 1 diabetes. It's important for the client to understand the importance of checking for
ketones and avoiding exercise if they are present.
A nurse notes a small section of bowel protruding from the abdominal incision of a client
who is postoperative. After calling for assistance, which of the following actions should the
nurse take first?
a. Cover the client's wound with a moist, sterile dressing.
b. Have the client lie supine with knees flexed.
c. Check the client's vital signs.
d. Inform the client about the need to return to surgery.
Answer: a. Cover the client's wound with a moist, sterile dressing.
Rationale:
Covering the protruding bowel with a moist, sterile dressing helps to protect it from further
injury or contamination while awaiting further interventions, such as surgical repair.
A nurse is collecting data from a client who has alcohol use disorder and is experiencing
metabolic acidosis. Which of the following manifestations should the nurse expect?
a. Cool, clammy skin.
b. Hyperventilation
c. Increased blood pressure
d. Bradycardia
Answer: b. Hyperventilation
Rationale:
Hyperventilation is a compensatory mechanism in metabolic acidosis, where the body
attempts to decrease carbon dioxide levels and increase pH by increasing respiratory rate and
depth.
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which
of the following should the nurse include in the teaching?
a. Avoid bending at the waist.
b. Remove the eye shield at bedtime.
c. Limit the use of laxatives if constipated.
d. Seeing flashes of light is an expected finding following extraction.
Answer: a. Avoid bending at the waist.
Rationale:

Avoiding bending at the waist helps to prevent increased intraocular pressure, which can be
detrimental to the healing process following cataract extraction.
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily.
The client refuses breakfast and reports nausea. Which of the following actions should the
nurse take first?
a. Suggest that the client rests before eating the meal.
b. Request a dietary consult.
c. Check the client's vital signs.
d. Request an order for an antiemetic.
Answer: c. Check the client's vital signs.
Rationale:
Nausea and anorexia can be signs of digoxin toxicity. Before taking any further actions, it is
essential for the nurse to assess the client's vital signs to determine if there are any indications
of digoxin toxicity, such as bradycardia or dysrhythmias.
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The
nurse suspects the client's wound is infected because the drainage from the dressing is yellow
and thick.
Which of the following findings should the nurse report as the type of drainage found?
a. Sanguineous
b. Serous
c. Serosanguineous
d. Purulent
Answer: d. Purulent
Rationale:
Purulent drainage, characterized by a yellow or greenish color and thick consistency,
indicates the presence of infection in the wound. It typically contains white blood cells,
indicating the body's immune response to infection.
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To
prevent postoperative complications which of the following actions should be reinforced
during the teaching?
a. Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
b. Place the client’s affected leg into the CPM machine with the machine in the flexed
position.
c. Place the client into a high Fowler’s position when initiating the CPM exercises.

d. Align the joints of the CPM machine with the knee gatch in the client’s bed.
Answer: a. Administer an opioid analgesic to the client 30 min prior to initiating CPM
exercises.
Rationale:
Administering an opioid analgesic prior to initiating Continuous Passive Motion (CPM)
exercises helps manage pain effectively, promoting client compliance with the exercises and
reducing the risk of complications such as muscle guarding or stiffness.
A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
a. Dyspnea
b. Barrel chest
c. Clubbing of the fingers
d. Shallow respirations
e. Bradycardia
Answer: a. Dyspnea
b. Barrel chest
c. Clubbing of the fingers
d. Shallow respirations
Rationale:
Emphysema is characterized by progressive shortness of breath (dyspnea), hyperinflation of
the lungs leading to a barrel chest appearance, clubbing of the fingers due to chronic hypoxia,
and shallow respirations due to impaired lung function. Bradycardia is not typically
associated with emphysema.
A nurse is caring for a client who sustained a basal skull fracture. When performing morning
hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client's
right nostril.
Which of the following actions should the nurse take first?
a. Take the client's temperature.
b. Place a dressing under the client's nose.
c. Notify the charge nurse.
d. Test the drainage for glucose
Answer: d. Test the drainage for glucose
Rationale:

Clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal
fluid (CSF) leak. Testing the drainage for glucose using a dipstick can help differentiate CSF
from nasal secretions, as CSF contains glucose while nasal secretions do not.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize
that the client is at risk for autonomic dysreflexia. Which of the following interventions
should the nurse take to prevent autonomic dysreflexia?
a. Monitor for elevated blood pressure.
b. Provide analgesia for headaches.
c. Prevent bladder distention.
d. Elevate the client's head.
Answer: c. Prevent bladder distention.
Rationale:
Bladder distention is a common trigger for autonomic dysreflexia in clients with spinal cord
injuries above the T-6 level. Preventing bladder distention through regular bladder emptying
or catheterization helps to reduce the risk of autonomic dysreflexia.
A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the
following findings should the nurse expect the client to report?
a. Hot flashes
b. Recurrent urinary tract infections
c. Blood in the stool
d. Abnormal vaginal bleeding
Answer: d. Abnormal vaginal bleeding
Rationale:
Abnormal vaginal bleeding, such as postmenopausal bleeding or intermenstrual bleeding, is a
common symptom of endometrial cancer. It often prompts women to seek medical
evaluation.
A nurse is caring for a client following an open reduction and internal fixation of a fractured
femur. Which of the following findings is the nurse's priority?
a. Altered level of consciousness
b. Oral temperature of 37.7° C (100° C)
c. Muscle spasms
d. Headache
Answer: a. Altered level of consciousness
Rationale:

An altered level of consciousness can indicate a serious complication such as hypovolemic
shock, fat embolism, or compartment syndrome, which require immediate intervention to
prevent further deterioration.
A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge
resection of the left lung and has a chest tube to suction. Which of the following is the
priority finding the nurse should report to the provider?
a. Abdomen is distended
b. Chest tube drainage of 70 mL in the last hour
c. Subcutaneous emphysema is noted to the left chest wall
d. Pain level of 6 on a 0 to 10 scale
Answer: a. Abdomen is distended
Rationale:
Abdominal distention following thoracic surgery could indicate a complication such as intraabdominal bleeding or organ perforation, which require immediate evaluation and
intervention to prevent further harm to the client.
A nurse is reinforcing discharge teaching with a client about how to care for a newly created
ileal conduit. Which of the following instructions should the nurse include in the teaching?
a. Change the ostomy pouch daily.
b. Empty the ostomy pouch when it is 2/3 full.
c. Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
d. Apply lotion to the peristomal skin when changing the ostomy pouch.
Answer: a. Change the ostomy pouch daily.
Rationale:
Changing the ostomy pouch daily helps to maintain skin integrity and prevent complications
such as skin breakdown or irritation around the stoma site.
A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland.
Which of the following actions should the nurse include in the plan?
a. Position the client supine while in bed.
b. Change the nasal drip pad as needed.
c. Encourage frequent brushing of teeth.
d. Encourage the client to cough every 2 hr following surgery.
Answer: b. Change the nasal drip pad as needed.
Rationale:

Following pituitary gland removal, the client may experience nasal drainage due to surgical
packing. Changing the nasal drip pad as needed helps to maintain cleanliness and prevent
infection or irritation of the nasal passages. Positioning, oral care, and coughing are not
specifically related to pituitary gland removal.
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily
following a myocardial infarction. The nurse should instruct the client that aspirin is
prescribed for clients who have coronary artery disease for which of the following effects?
a. To provide analgesia
b. To reduce inflammation
c. To prevent blood clotting
d. To prevent fever
Answer: c. To prevent blood clotting
Rationale:
Aspirin is commonly prescribed for clients with coronary artery disease to prevent blood clot
formation and reduce the risk of clot-related events, such as myocardial infarction or stroke.
It inhibits platelet aggregation, thus reducing the formation of blood clots in the arteries.
A nurse is collecting data from a client who has open-angle glaucoma. Which of the
following findings should the nurse expect?
a. Loss of peripheral vision
b. Headache
c. Halos around lights
d. Discomfort in the eyes
Answer: a. Loss of peripheral vision
Rationale:
Open-angle glaucoma is characterized by a gradual loss of peripheral vision. This occurs due
to increased intraocular pressure damaging the optic nerve fibers, resulting in peripheral
vision loss initially.
A nurse is collecting data from a client who has acute gastroenteritis. Which of the following
data collection findings should the nurse identify as the priority?
a. Weight loss of 3% of total body weight.
b. Blood glucose 150 mg/dL.
c. Potassium 2.5 mEq/L
d. Urine specific gravity 1.035
Answer: c. Potassium 2.5 mEq/L

Rationale:
Hypokalemia (low potassium levels) is a potentially life-threatening complication of acute
gastroenteritis due to fluid loss from vomiting and diarrhea. Potassium is essential for
maintaining normal cardiac and neuromuscular function, so severe hypokalemia requires
prompt intervention.
A nurse is reinforcing discharge teaching with a client who had a total abdominal
hysterectomy and a vaginal repair. Which of the following statements by the client indicates a
need for further teaching?
a. "I should increase my intake of protein and vitamin C."
b. "I will no longer have menstrual periods."
c. "Once I am able to resume sexual activity, I can use a water-based lubricant if I experience
discomfort."
d. "I will take a tub bath instead of a shower."
Answer: d. "I will take a tub bath instead of a shower."
Rationale:
After a total abdominal hysterectomy and vaginal repair, it's essential to avoid tub baths until
the healing process is complete to prevent infection. Showers are generally recommended
over baths during the initial recovery period.
A nurse is assisting with the care of a client who has a femur fracture and is in skeletal
traction. Which of the following actions should the nurse take?
a. Loosen the knots on the ropes if the client is experiencing pain.
b. Ensure the client’s weights are hanging freely from the bed.
c. Check the client’s bony prominences every 12 hr.
d. Cleanse the client’s pin sites with povidone-iodine.
Answer: b. Ensure the client’s weights are hanging freely from the bed.
Rationale:
In skeletal traction, the weights must hang freely to provide effective traction and prevent
complications such as contractures or nerve damage. The nurse should regularly assess and
ensure that the weights are properly positioned and hanging freely.
A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include?
a. Take this medication between meals.
b. Limit intake of Vitamin C while taking this medication.

c. Take this medication with milk.
d. Limit intake of whole grains while taking this medication.
Answer: a. Take this medication between meals.
Rationale:
Taking ferrous gluconate between meals enhances its absorption because it is better absorbed
in an acidic environment. However, it should be taken with food if gastrointestinal upset
occurs.
A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the
following interventions should the nurse recommend?
a. Apply topical antifungal agents.
b. Apply fresh ice packs every 4 hr.
c. Wash daily with an antibacterial soap.
d. Keep draining lesions uncovered to air dry.
Answer: c. Wash daily with an antibacterial soap.
Rationale:
Washing daily with an antibacterial soap helps to keep the affected area clean and reduce the
bacterial load, which is essential for managing cellulitis and preventing its spread.
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy
established. Which of the following instructions should the nurse include in the teaching?
a. Empty the pouch immediately after meals.
b. Change the entire appliance once a day.
c. Limit fluid intake.
d. Avoid medications in capsule or enteric form.
Answer: d. Avoid medications in capsule or enteric form.
Rationale:
Medications in capsule or enteric form may not dissolve completely in the small intestine
where the ileostomy empties, leading to potential blockages. It is advisable to use alternative
forms of medication, such as liquids or injections, whenever possible.
A nurse is caring for a client with severe burns to both lower extremities. The client is
scheduled for an escharotomy and wants to know what the procedure involves. Which of the
following statements is appropriate for the nurse to make?
a. "An escharotomy surgically removes dead tissue."
b. "A cannula will be inserted into the bone to infuse fluids and antibiotics."
c. "A piece of skin will be removed and grafted over the burned area."

d. "Large incisions will be made in the burned tissue to improve circulation."
Answer: d. "Large incisions will be made in the burned tissue to improve circulation."
Rationale:
An escharotomy involves making large incisions through the burned tissue to relieve pressure
caused by swelling and to improve circulation to the affected area. It is a surgical procedure
performed to prevent compartment syndrome and other complications associated with severe
burns.
A nurse is collecting data from a client who has a possible cataract. Which of the following
manifestations should the nurse expect the client to report?
a. Decreased color perception
b. Loss of peripheral vision
c. Bright flashes of light
d. Eyestrain
Answer: a. Decreased color perception
Rationale:
Cataracts commonly cause a gradual decrease in color perception as the lens becomes cloudy,
affecting the client's ability to distinguish between colors.
A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is
receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the
following interventions should the nurse include in the plan of care?
a. Measure abdominal girth daily.
b. Use sterile water to irrigate the nasogastric tube.
c. Maintain the client in Fowler’s position.
d. Moisten the client’s lips with lemon-glycerin swabs.
Answer: c. Maintain the client in Fowler’s position.
Rationale:
Keeping the client in Fowler’s position promotes optimal drainage of gastric contents into the
nasogastric tube, aiding in decompression of the intestines and relieving symptoms of
obstruction.
A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
a. Buffalo hump
b. Purple striations
c. Moon face

d. Tremors
e. obese extremities
Answer: a. Buffalo hump
b. Purple striations
c. Moon face
Rationale:
Cushing's syndrome is characterized by excess cortisol production, resulting in clinical
manifestations such as a buffalo hump (accumulation of fat between the shoulders), purple
striations (stretch marks), and a moon face (rounding and fullness of the face).
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the
following interventions should the nurse implement?
a. Provide diet high in protein
b. Provide ibuprofen for retroperitoneal discomfort
c. Monitor intake and output hourly
d. Encourage the client to consume at least 2 L of fluid daily.
Answer: c. Monitor intake and output hourly
Rationale:
During the oliguric phase of acute kidney injury, monitoring intake and output hourly is
essential for assessing renal function and fluid balance, as urine output is typically decreased.
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has
upper gastric pain. Which of the following statements should the nurse include in the
teaching?
a. "A flexible tube is introduced through the nose during the procedure."
b. "During the procedure you are in a sitting position."
c. “You will remain NPO for 8 hours before the procedure.”
d. “You will be awake while the procedure is performed”
Answer: c. “You will remain NPO for 8 hours before the procedure.”
Rationale:
Clients undergoing an esophagogastroduodenoscopy (EGD) typically need to remain NPO
for a specified period before the procedure to ensure the stomach is empty, reducing the risk
of aspiration during the examination.
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours
following a generalized tonic-clonic seizure. Which of the following descriptions should the
nurse use when documenting this finding in the medical record?

a. Aura phase
b. Presence of automatisms
c. Postictal phase
d. Presence of absence seizures
Answer: c. Postictal phase
Rationale:
The postictal phase refers to the period immediately following a seizure, characterized by
altered consciousness, drowsiness, confusion, and fatigue. Documenting this phase accurately
helps to communicate the client's condition and response to the seizure.
A nurse is reinforcing teaching with a client who reports right shoulder pain following a
laparoscopic cholecystectomy. Which of the following statements should the nurse make?
a. "The pain results from lying in one position too long during surgery."
b. "The pain occurs as a residual pain from cholecystitis."
c. "The pain will dissipate if you ambulate frequently."
d. "The pain is caused from the nitrous dioxide injected into the abdomen."
Answer: c. "The pain will dissipate if you ambulate frequently."
Rationale:
Shoulder pain following laparoscopic cholecystectomy is common due to irritation of the
diaphragm and phrenic nerve. Encouraging frequent ambulation helps to alleviate gas pain
and promote the resolution of shoulder discomfort.
A nurse is checking the suction control chamber of a client's chest tube and notes that there is
no bubbling in the suction control chamber. Which of the following actions should the nurse
take?
a. Notify the provider.
b. Verify that the suction regulator is on.
c. Continue to monitor the client because this is an expected finding.
d. Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Answer: b. Verify that the suction regulator is on.
Rationale:
Lack of bubbling in the suction control chamber may indicate inadequate suction. The nurse
should first verify that the suction regulator is properly set and functioning before taking
further action.
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)

a. Encourage fluid intake.
b. Monitor the puncture site for hematoma.
c. Insert a urinary catheter.
d. Elevate the client’s head of bed.
e. Apply a cervical collar to the client.
Answer: a. Encourage fluid intake.
b. Monitor the puncture site for hematoma.
Rationale:
Encouraging fluid intake helps prevent complications such as headache due to cerebrospinal
fluid loss. Monitoring the puncture site for hematoma is important to detect bleeding or
trauma at the site.
A nurse is assisting with the care of a client who is postoperative following surgical repair of
a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The
nurse should recognize which of the following is the priority action?
a. Relieve the client's pain.
b. Check the client’s pressure points for redness.
c. Provide oral hygiene
d. Prevent aspiration.
Answer: d. Prevent aspiration.
Rationale:
With the client's jaw wired shut, there is a risk of aspiration due to inability to open the
mouth. Preventing aspiration by keeping the client in a semi-Fowler's position and ensuring
that suction equipment is readily available takes priority to maintain airway patency and
prevent respiratory complications.
A nurse is collecting data from a client who has scleroderma. Which of the following findings
should the nurse expect?
a. A dry raised rash
b. Excessive salivation
c. Periorbital edema
d. Hardened skin
Answer: d. Hardened skin
Rationale:

Scleroderma is a connective tissue disorder characterized by the hardening and tightening of
the skin due to increased collagen production. This results in thickened, hardened skin
particularly affecting the fingers, hands, face, and other areas of the body.
A nurse is caring for an older adult client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
a. Instruct the client to tilt her head back when she swallows.
b. Place food on the left side of the client's mouth.
c. Add thickener to fluids.
d. Serve food at room temperature.
Answer: c. Add thickener to fluids.
Rationale:
Adding thickener to fluids helps to modify the consistency of liquids, making them easier for
the client with dysphagia to swallow safely and reducing the risk of aspiration.
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head,
neck, and chest. The nurse should recognize which of the following is the priority risk to the
client?
a. Airway obstruction
b. Infection
c. Fluid imbalance
d. Contractures
Answer: a. Airway obstruction
Rationale:
With burns to the head, neck, and chest, the priority risk is airway obstruction due to edema
or inhalation injury. Burns in these areas can cause swelling, which may compromise the
client's airway and lead to respiratory distress or failure.
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis
and is to start taking neostigmine. Which of the following instructions should the nurse
include in the teaching?
a. Take the medication 45 minutes before eating.
b. Expect diaphoresis as a side effect of the neostigmine.
c. If a medication dose is missed, wait until the next scheduled dose to take the medication.
d. Treat nasal rhinitis with an over-the-counter antihistamine.
Answer: a. Take the medication 45 minutes before eating.
Rationale:

Neostigmine, a cholinesterase inhibitor, improves muscle strength in myasthenia gravis by
increasing acetylcholine levels at the neuromuscular junction. Taking it before meals helps
improve swallowing and prevent aspiration due to muscle weakness during eating.
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection
of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse
notes there has not been any urinary output in the last hour. Which of the following actions
should the nurse perform first?
a. Notify the provider.
b. Administer a prescribed analgesic.
c. Offer oral fluids.
d. Determine the patency of the tubing.
Answer: d. Determine the patency of the tubing.
Rationale:
The absence of urinary output in a client with continuous bladder irrigation post-TURP could
indicate catheter blockage or clot formation. The nurse should first assess the patency of the
tubing to ensure proper drainage before taking further action.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear
about the procedure and asks the nurse if the biopsy will hurt. Which of the following
responses should the nurse make?
a. "You must be very worried about what the biopsy will show."
b. "You'll be asleep for the whole biopsy procedure and won't be aware of what’s happening."
c. "Your provider scheduled this, so she will want to know you still have questions about the
procedure."
d. "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."
Answer: d. "The biopsy can be uncomfortable, but we will try to keep you as comfortable as
possible."
Rationale:
Bone marrow biopsy involves inserting a needle into the bone to obtain a sample, which can
cause discomfort or pain. Assuring the client that discomfort will be managed and providing
support can help alleviate anxiety.
A nurse is assisting with planning care for a client recovering from a left-hemispheric stroke.
Which of the following interventions should the nurse include in the plan?
a. Control impulsive behavior.
b. Compensate for left visual field deficits.

c. Re-establish communication.
d. Improve left-side motor function.
Answer: c. Re-establish communication.
Rationale:
Left-hemispheric stroke often affects language and communication abilities due to damage to
the language centers located in the left hemisphere of the brain. Re-establishing
communication through speech therapy and other interventions is a priority in the care plan.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should
monitor the client for which of the following manifestations?
a. Hypotension
b. Polyphagia
c. Hyperglycemia
d. Bradycardia
Answer: a. Hypotension
Rationale:
Diabetes insipidus results in excessive urination and fluid loss, leading to dehydration and
electrolyte imbalances, which can manifest as hypotension.
A nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm Hg
Base excess -2
PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make
a. Metabolic acidosis
b. Respiratory acidosis
c. Metabolic alkalosis
d. Respiratory alkalosis
Answer: b. Respiratory acidosis
Rationale:
Respiratory acidosis is indicated by a low pH (45 mm Hg) due
to inadequate ventilation leading to retention of carbon dioxide. In this case, the low

respiratory rate contributes to hypoventilation and CO2 retention, resulting in respiratory
acidosis.
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The
nurse should recognize that which of the following statements by the client indicates a need
for further teaching?
a. "I will avoid crossing my legs at the knees."
b. "I will use a thermometer to check the temperature of my bath water."
c. "I will not go barefoot."
d. "I will wear stockings with elastic tops."
Answer: d. "I will wear stockings with elastic tops."
Rationale:
Elastic tops on stockings can impede circulation and exacerbate symptoms of peripheral
vascular disease. The client should wear loose-fitting, non-constrictive clothing to promote
circulation.
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's
disease. The client becomes agitated and combative when the nurse approaches him. Which
of the following actions should the nurse plan to take?
a. Turn the water on and ask the client to test the temperature.
b. Obtain assistance to place mitten restraints on the client.
c. Firmly tell the client that good hygiene is important.
d. Calmly ask the client if he would like to listen to some music.
Answer: d. Calmly ask the client if he would like to listen to some music.
Rationale:
Agitation and combativeness in clients with Alzheimer's disease can often be mitigated by
distraction or redirection. Offering music as a calming intervention can help to alleviate the
client's anxiety and facilitate hygiene care.
A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is
covered with soft, red tissue that bleeds easily. The nurse should recognize this is a
manifestation of which of the following?
a. Decreased perfusion
b. Infection
c. Granulation tissue
d. An inflammatory response
Answer: c. Granulation tissue

Rationale:
Granulation tissue is a normal part of the wound healing process characterized by soft, red
tissue that bleeds easily. It represents the proliferation of new blood vessels and connective
tissue in the wound bed.
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3.
Which of the following food items brought by the family should the nurse prohibit from
being given to the client?
a. Baked chicken
b. Bagels
c. A factory-sealed box of chocolates
d. Fresh fruit basket
Answer: d. Fresh fruit basket
Rationale:
Fresh fruits carry a risk of bacterial contamination, which can be dangerous for a client with a
low white blood cell count (leukopenia) due to the risk of infection. Foods that are more
likely to be contaminated should be avoided in immunocompromised clients.
A nurse is contributing to the plan of care for an older adult client who is postoperative
following a right hip arthroplasty. Which of the following interventions should the nurse
include in the plan?
a. Perform the client's personal care activities for her.
b. Limit the client’s fluid intake.
c. Monitor the Homan’s sign.
d. Maintain abduction of the right hip.
Answer: d. Maintain abduction of the right hip.
Rationale:
Maintaining abduction of the right hip helps prevent dislocation of the hip prosthesis
postoperatively. It's a crucial aspect of postoperative care to ensure proper healing and
prevent complications.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the
following actions should the nurse take first?
a. Establish IV access.
b. Feel for a carotid pulse.
c. Establish an open airway.
d. Auscultate for breath sounds.

Answer: b. Feel for a carotid pulse.
Rationale:
Assessing for a carotid pulse is the priority to determine if the client has a pulse. In the
absence of a pulse, immediate cardiopulmonary resuscitation (CPR) should be initiated to
restore circulation.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is
no longer certain he wants to have the procedure. Which of the following responses should
the nurse make?
a. "Why have you changed your mind about the surgery?"
b. "Bypass surgery must be very frightening for you."
c. "Your provider would not have scheduled the surgery unless you needed it."
d. "I will call your doctor and have him discuss your surgery with you."
Answer: b. "Bypass surgery must be very frightening for you."
Rationale:
Acknowledging the client's feelings and expressing empathy can help establish rapport and
trust. It also validates the client's concerns and opens the door for further discussion about the
surgery.
A nurse is caring for a client who is postoperative following foot surgery and is not to bear
weight on the operative foot. The nurse enters the room to discover the client hopped on one
foot to the bathroom, using an IV pole for support. Which of the following actions should the
nurse take?
a. Walk the client back to bed immediately and get the client a bedpan.
b. Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
c. Warn the client she might have to be restrained if she gets up without assistance.
d. Keep the bathroom door open to ensure the client is okay.
Answer: b. Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
Rationale:
It's important to provide alternative means of mobility for the client while adhering to weightbearing restrictions. Instructing the client to remain in the bathroom and obtaining a
wheelchair ensures safety and prevents further injury.
A nurse is assisting with the care of a client who is postoperative and has a closed wound
drainage system in place. Which of the following actions should the nurse take?
a. Fully recollapse the reservoir after emptying it.
b. Empty the reservoir once per day.

c. Replace the drainage plug after releasing hand pressure on the device.
d. Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
Answer: a. Fully recollapse the reservoir after emptying it.
Rationale:
Fully recollapsing the reservoir after emptying it helps maintain the negative pressure needed
for effective wound drainage. It ensures proper functioning of the closed drainage system and
prevents air from entering the wound.
A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the
following statements by the client indicates an understanding of the teaching?
a. "I will not eat fried foods."
b. "I will abstain from sexual intercourse."
c. "I will refrain from international travel."
d. "I will not order a salad in a restaurant."
Answer: b. "I will abstain from sexual intercourse."
Rationale:
Hepatitis A is primarily spread through the fecal-oral route, but sexual transmission can
occur. Abstaining from sexual intercourse helps prevent the spread of the virus to others.
Other options are also important, but abstaining from sexual intercourse directly addresses
one of the modes of transmission for hepatitis A.
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client
diagnosed with emphysema. Which of the following instructions should be included in the
teaching?
a. Rest in a supine position.
b. Consume a low-protein diet.
c. Breathe in through her nose and out through pursed lips.
d. Limit fluid intake throughout the day.
Answer: c. Breathe in through her nose and out through pursed lips.
Rationale:
Pursed lip breathing helps to create back pressure in the airways, which can prevent the
collapse of the small air sacs in the lungs (alveoli) and improve gas exchange in conditions
like emphysema.
A nurse is caring for a client who is postoperative and has a history Addison's disease. For
which of the following manifestations should the nurse monitor?
a. Hypernatremia

b. Hypotension
c. Bradycardia
d. Hypokalemia
Answer: b. Hypotension
Rationale:
Addison's disease is characterized by adrenal insufficiency, which can lead to decreased
production of aldosterone and cortisol. Hypotension is a common manifestation due to
decreased fluid volume and vascular tone.
A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is
to take hydroxyzine preoperatively. Which of the following effects of the medication should
the nurse include in the teaching? (Select all that apply.)
a. Decreasing anxiety
b. Controlling emesis
c. Relaxing skeletal muscles
d. Preventing surgical site infections
e. Reducing the amount of narcotics needed for pain relief
Answer: a. Decreasing anxiety, b. Controlling emesis, e. Reducing the amount of narcotics
needed for pain relief
Rationale:
Hydroxyzine is an antihistamine with anxiolytic (anxiety-reducing), antiemetic (anti-nausea),
and opioid-sparing effects. It is commonly used preoperatively to reduce anxiety, prevent
nausea and vomiting, and decrease the amount of opioids needed for pain relief.
A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The
nurse should reinforce to the client to take which of the following dietary supplements with
this medication?
a. Vitamin D
b. Vitamin A
c. Iron
d. Niacin
Answer: c. Iron
Rationale:
Epoetin alfa is a medication used to stimulate red blood cell production in patients with
anemia, often associated with chronic kidney disease or chemotherapy. Iron supplementation
is often recommended concurrently because iron is essential for red blood cell production.

A nurse is caring for a client after a radical neck dissection. To which of the following should
the nurse give priority in the immediate postoperative period?
a. Malnourishment related to NPO status and dysphagia
b. Impaired verbal communication related to the tracheostomy
c. High risk for infection related to surgical incisions
d. Ineffective airway clearance related to thick, copious secretions
Answer: d. Ineffective airway clearance related to thick, copious secretions
Rationale:
Ineffective airway clearance is a critical concern post-radical neck dissection due to potential
airway obstruction from swelling or secretions. Maintaining a clear airway is essential for
oxygenation and preventing respiratory compromise.
A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8
who is admitted for comprehensive rehabilitation. Which of the following long-term goals is
appropriate with regard to the client's mobility?
a. Walk with leg braces and crutches.
b. Drive an electric wheelchair with a hand-control device.
c. Drive an electric wheelchair equipped with a chin-control device.
d. Propel a wheelchair equipped with knobs on the wheels.
Answer: d. Propel a wheelchair equipped with knobs on the wheels.
Rationale:
Spinal cord injuries at level C8 typically result in quadriplegia with some arm movement.
Propelling a wheelchair with knobs on the wheels is a realistic long-term mobility goal for
these clients, allowing for independence in mobility.
A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the
following risk factors should the nurse identify as the leading cause of non-melanoma skin
cancer?
a. Exposure to environmental pollutants
b. Sun exposure.
c. History of viral illness
d. Scars from a severe burn
Answer: b. Sun exposure.
Rationale:

The primary risk factor for non-melanoma skin cancer, such as basal cell carcinoma and
squamous cell carcinoma, is prolonged exposure to ultraviolet (UV) radiation from the sun or
tanning beds.
Based on a client's recent history, a nurse suspects that a client is beginning menopause.
Which of the following questions should the nurse ask the client to help confirm the client is
experiencing manifestations of menopause?
a. "Do you sleep well at night?"
b. "Have you been experiencing chills?"
c. "Have you experienced increased hair growth?"
d. "When did you begin your menses?"
Answer: a. "Do you sleep well at night?"
Rationale:
Sleep disturbances, including difficulty falling asleep or staying asleep, are common
manifestations of menopause due to hormonal changes affecting sleep patterns.
A nurse is reinforcing teaching with a client about cancer prevention and plans to address the
importance of foods high in antioxidants. Which of the following foods should the nurse
include in the teaching?
a. Cottage cheese
b. Fresh berries
c. Bran cereal
d. Skim milk
Answer: b. Fresh berries
Rationale:
Fresh berries, such as blueberries, strawberries, and raspberries, are high in antioxidants,
which help neutralize harmful free radicals in the body and may reduce the risk of cancer
development.
A nurse is assisting with caring for a client who has a new concussion following a motorvehicle crash. The nurse should monitor the client for which of the following manifestations
of increased intracranial pressure?
a. Polyuria
b. Battle's sign
c. Nuchal rigidity
d. Lethargy
Answer: d. Lethargy

Rationale:
Lethargy, or decreased level of consciousness, can indicate increased intracranial pressure
following a concussion. Other signs of increased intracranial pressure include headache,
vomiting, changes in pupil size/reactivity, and changes in vital signs.
A nurse is reinforcing teaching about a tonometry examination with a client who has
manifestations of glaucoma. Which of the following statements should the nurse include in
the teaching?
a. "Tonometry is performed to evaluate peripheral vision."
b. "This test will diagnose the type of your glaucoma."
c. "Tonometry will allow inspection of the optic disc for signs of degeneration."
d. "This test will measure the intraocular pressure of the eye."
Answer: d. "This test will measure the intraocular pressure of the eye."
Rationale:
Tonometry is a diagnostic test used to measure the pressure inside the eye (intraocular
pressure), which is important for diagnosing and monitoring glaucoma, a condition
characterized by increased intraocular pressure.
A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a
kidney transplant. Which of the following laboratory findings should the nurse identify as the
most important to report to the provider?
a. Increase in serum glucose
b. Increase in serum creatinine
c. Decrease in white blood cell count
d. Decrease in platelets
Answer: b. Increase in serum creatinine
Rationale:
Cyclosporine is an immunosuppressant medication commonly used following organ
transplantation to prevent rejection. An increase in serum creatinine indicates impaired
kidney function, which can be a sign of nephrotoxicity from cyclosporine and requires
prompt medical attention.
A nurse is checking for paradoxical blood pressure on a client who has constrictive
pericarditis. Which of the following findings should the nurse expect?
a. Apical pulse rate different than the radial pulse rate
b. Increase in heart rate by 20% when standing
c. Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position

d. Drop in systolic BP more than 10 mm Hg on inspiration
Answer: d. Drop in systolic BP more than 10 mm Hg on inspiration
Rationale:
Paradoxical blood pressure, a classic sign of constrictive pericarditis, refers to a greater than
normal drop in systolic blood pressure during inspiration due to impaired filling of the
ventricles caused by the rigid pericardium.
A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client
entering the room of another client, who becomes upset and frightened. Which of the
following actions should the nurse take?
a. Attempt to determine what the client was looking for.
b. Explain the client’s Alzheimer’s diagnosis to the frightened client.
c. Reprimand the client for invading the other client's privacy.
d. Ask the client to apologize for his behavior.
Answer: a. Attempt to determine what the client was looking for.
Rationale:
In caring for clients with Alzheimer's disease, it's important to approach situations with
understanding and compassion. Attempting to determine the client's needs or intentions can
help address the behavior without causing further distress.
A nurse is caring for a client immediately following a cardiac catheterization with a femoral
artery approach. Which of the following actions should the nurse take?
a. Check pedal pulses every 15 min.
b. Perform passive range-of-motion for the affected extremity.
c. Remind the client not to turn from side to side.
d. Keep the client in high-Fowler's position for 6 hr.
Answer: a. Check pedal pulses every 15 min.
Rationale:
Checking pedal pulses every 15 minutes is essential following a cardiac catheterization with a
femoral artery approach to assess for adequate circulation to the lower extremities and detect
any signs of vascular compromise or hematoma formation.
A nurse is assisting with planning an immunization clinic for older adult clients. Which of the
following information should the nurse plan to include about influenza?
a. Individuals at high risk should receive the live influenza vaccine.
b. Immunization for influenza should be repeated every 10 years.
c. The composition of the influenza vaccine changes yearly.

d. The influenza vaccine is necessary only for clients who have never had influenza.
Answer: c. The composition of the influenza vaccine changes yearly.
Rationale:
The composition of the influenza vaccine is updated annually to provide protection against
the strains of influenza virus expected to circulate during the upcoming flu season.
A nurse is caring for an older adult client who has colon cancer. The client asks the nurse
several questions about his treatment plan. Which of the following actions should the nurse
take?
a. Tell the client to have a family member call the provider to ask what options he plans to
recommend.
b. Assure the client that the provider will tell him what is planned.
c. Help the client write down questions to ask his provider.
d. Provide the client with a pamphlet of information about cancer.
Answer: c. Help the client write down questions to ask his provider.
Rationale:
Encouraging the client to write down questions to ask his provider promotes active
involvement in his care and helps ensure that he receives the information he needs to make
informed decisions.
A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is
distressed over his mother's crying and condition. Which of the following responses should
the nurse make?
a. "If you just sit quietly with your mother, I'm sure she will calm down."
b. "I'll talk with your mother and see if I can comfort her."
c. "It must be hard to see your mother so ill and upset."
d. "Your mother's crying seems to bother you more than it does her."
Answer: c. "It must be hard to see your mother so ill and upset."
Rationale:
Expressing empathy validates the son's feelings and acknowledges the difficulty of the
situation without dismissing or minimizing his distress.
A nurse is reinforcing teaching with the family of a client who has primary dementia. Which
of the following manifestations of dementia should the nurse include in the teaching?
a. Temporary, reversible loss of brain function
b. Forgetfulness gradually progressing to disorientation
c. Sleeping more during the day than nighttime

d. Hyper vigilant behaviors
Answer: b. Forgetfulness gradually progressing to disorientation
Rationale:
Primary dementia, such as Alzheimer's disease, typically presents with progressive cognitive
decline, including forgetfulness that worsens over time and may lead to disorientation,
difficulty with memory, and impaired judgment.
A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the
following interventions should the nurse include in the plan?
a. Limit fluid intake.
b. Monitor client’s cardinal fields of vision.
c. Encourage ambulation.
d. Ensure the room is brightly lit.
Answer: b. Monitor client’s cardinal fields of vision.
Rationale:
Labyrinthitis, an inflammation of the inner ear, can cause symptoms such as vertigo, nausea,
and imbalance. Monitoring the client's cardinal fields of vision helps assess for nystagmus, a
characteristic eye movement associated with vertigo, aiding in the diagnosis and management
of labyrinthitis.
A nurse is contributing to the plan of care for a client who is admitted with a deep vein
thrombosis (DVT) of the left leg. Which of the following interventions should the nurse
include in the plan?
a. Apply ice to the extremity
b. Monitor platelet levels
c. Restrict oral fluids
d. Administer vasodilating medications
Answer: b. Monitor platelet levels
Rationale:
Deep vein thrombosis (DVT) involves the formation of a blood clot in a deep vein,
commonly in the legs. Monitoring platelet levels is important in DVT management to assess
for any clotting abnormalities or complications. While applying ice to the extremity might be
indicated for other conditions such as swelling or injury, it is not the priority intervention for
DVT. Restricting oral fluids and administering vasodilating medications are not directly
related to managing DVT.

A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a
close family contact tests positive. Which of the following measures should the nurse
anticipate preparing for this client?
a. Tuberculin skin test
b. Sputum culture for acid fast bacillus (AFB)
c. Bacille Calmette-Guérin (BCG) vaccine
d. Chest x-ray
Answer: d. Chest x-ray
Rationale:
When screening for tuberculosis (TB) after exposure, a chest x-ray is typically performed to
assess for any signs of active TB infection, such as lung abnormalities. Tuberculin skin test
may be used for screening but requires follow-up evaluation and is not the initial diagnostic
test. Sputum culture for acid fast bacillus (AFB) is done if TB is suspected based on chest xray findings or symptoms. Bacille Calmette-Guérin (BCG) vaccine is not typically
administered after exposure to TB.
A nurse is reviewing data for a client who has a head injury. Which of the following findings
should indicate to the nurse that the client might have diabetes insipidus?
a. Serum sodium 145 mEq/L
b. Urine specific gravity 1.028
c. Urine output 650 mL/hr
d. Blood glucose 198 mg/dL
Answer: c. Urine output 650 mL/hr
Rationale:
Diabetes insipidus (DI) is a condition characterized by excessive urine output (polyuria) and
thirst. A urine output of 650 mL/hr is significantly elevated and could indicate DI, especially
in the context of a head injury where damage to the pituitary gland may occur. The other
options are not indicative of DI. Serum sodium level may be elevated in DI due to
dehydration from excessive urination, but it is not specific to DI. Urine specific gravity and
blood glucose level are not directly related to DI.
A nurse is caring for a client who has recurrent kidney stones and a history of diabetes
mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should
collect additional data about which of the following statements made by the client?
a. "I took a laxative yesterday."
b. "I took my metformin before breakfast."

c. "I haven't had anything to eat or drink since last night."
d. "The last time I voided it was painful."
Answer: b. "I took my metformin before breakfast."
Rationale:
Metformin, a medication commonly used to treat diabetes mellitus, can interact with contrast
dye used in procedures such as intravenous pyelogram (IVP), potentially causing kidney
damage. Therefore, it is important for the nurse to collect additional data regarding the timing
of the client's last dose of metformin to ensure it is safe to proceed with the IVP. The other
statements are not directly related to the procedure or potential complications.
A nurse is collecting data from a client who is having an acute asthma exacerbation. When
auscultating the client's chest, the nurse should expect to hear which of the following sounds?
a. Expiratory wheeze
b. Pleural friction rub
c. Fine rales
d. Rhonchi
Answer: a. Expiratory wheeze
Rationale:
Expiratory wheezes are high-pitched, musical sounds heard during expiration and are
characteristic of airway obstruction, such as in an acute asthma exacerbation. Pleural friction
rub, fine rales, and rhonchi are not typically associated with asthma exacerbations.
A nurse is planning to change an abdominal dressing for a client who has an incision with a
drain. Which of the following actions should the nurse plan to take?
a. Remove the entire dressing at once.
b. Loosen the dressing by pulling the tape away from the wound.
c. Don clean gloves to remove the dressing.
d. Open sterile supplies before removing the dressing.
Answer: c. Don clean gloves to remove the dressing.
Rationale:
When changing a dressing for a client with an incision and drain, the nurse should first don
clean gloves to prevent contamination. The entire dressing should not be removed at once to
avoid exposing the wound unnecessarily. Loosening the dressing by pulling the tape away
from the wound may cause discomfort or disrupt the wound. Sterile supplies should be
opened after removing the dressing and cleansing the wound.

A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the
following positions should the nurse place the client for the procedure?
a. Prone with arms raised over the head.
b. Sitting, leaning forward over the bedside table.
c. High Fowler’s position
d. Side-lying with knees drawn up to the chest.
Answer: b. Sitting, leaning forward over the bedside table.
Rationale:
For a thoracentesis procedure, the client should be positioned sitting upright and leaning
forward over the bedside table to allow better access to the thoracic cavity and facilitate
needle insertion into the pleural space. This position also helps prevent injury to the
diaphragm and underlying organs. The other positions are not appropriate for thoracentesis.
A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following
reactions from the client should the nurse initially expect?
a. Denial
b. Bargaining
c. Acceptance
d. Anger
Answer: a. Denial
Rationale:
Denial is a common initial reaction to a new diagnosis of cancer, as the client may struggle to
accept the reality of the situation. It is a defense mechanism that allows the individual to cope
with overwhelming emotions and information. Bargaining, acceptance, and anger are other
stages of grief and adjustment that may occur later in the process.
A nurse is contributing to the plan of care for a client who is postoperative following
peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction
and closed-suction drains in place. Which of the following interventions should the nurse
include in the plan?
a. Irrigate the nasogastric tube with tap water.
b. Mark abdominal girth once daily.
c. Ambulate the client twice daily.
d. Place the client in a high Fowler’s position.
Answer: d. Place the client in a high Fowler’s position.
Rationale:

Placing the client in a high Fowler’s position helps promote drainage and prevent
complications such as aspiration. Irrigating the nasogastric tube with tap water
A nurse is caring for a client who is receiving hemodialysis. Which of the following client
measurements should the nurse compare before and after dialysis treatment to determine fluid
losses?
a. Neck vein distention
b. Blood pressure
c. Body weight
d. Abdominal girth
Answer: c. Body weight
Rationale:
Fluid removal is a primary goal of hemodialysis. Comparing the client's body weight before
and after dialysis sessions helps assess the effectiveness of fluid removal. Changes in body
weight reflect fluid loss or gain during the treatment. Neck vein distention, blood pressure,
and abdominal girth may provide additional information but are not specific measures for
assessing fluid losses during hemodialysis.
A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min
following the start of the transfusion, the nurse notes that the client is flushed and febrile, and
reports chills. To help confirm that the client is having an acute hemolytic transfusion
reaction, the nurse should observe for which of the following manifestations?
a. Urticaria
b. Muscle pain
c. Hypotension
d. Distended neck veins
Answer: c. Hypotension
Rationale:
Acute hemolytic transfusion reactions can lead to hypotension due to systemic vasodilation
and fluid shifts. Symptoms such as flushing, fever, and chills are common manifestations.
Urticaria may indicate an allergic reaction. Muscle pain may occur in other types of
transfusion reactions. Distended neck veins are more indicative of fluid overload.
A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The
nurse should recognize the client is experiencing which of the following conditions?
a. A continuous seizure state in which seizures occur in rapid succession
b. A sensory warning that a seizure is imminent

c. A period of sleepiness following the seizure during which arousal is difficult
d. A brief loss of consciousness accompanied by staring
Answer: b. A sensory warning that a seizure is imminent
Rationale:
An aura is a sensory warning experienced by some individuals with seizure disorders,
indicating that a seizure is about to occur. It serves as a signal to take precautions or seek
assistance before the seizure begins. The other options describe different types or phases of
seizures.
A nurse is caring for a client who just had cataract surgery. Which of the following comments
from the client should the nurse report to the provider?
a. "The bright light in this room is really bothering me."
b. "My eye really itches, but I'm trying not to rub it."
c. "It's really hard to see with a patch on one eye."
d. "I need something for the horrible pain in my eye."
Answer: d. "I need something for the horrible pain in my eye."
Rationale:
Severe pain following cataract surgery may indicate complications such as increased
intraocular pressure or inflammation. It is important to report significant pain promptly to the
provider for further evaluation and management. The other statements are common
experiences after cataract surgery and may not necessarily indicate complications.
A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if
there will be a lot of pain during the procedure. Which of the following responses should the
nurse make?
a. "You shouldn't feel any pain since the local area is anesthetized."
b. "Most clients report more discomfort from the preparation than from theprocedure itself."
c. "You may feel some cramping during the procedure."
d. "Don't worry; you won't remember anything about the procedure due to the effects of the
medication."
Answer: c. "You may feel some cramping during the procedure."
Rationale:
Cramping or discomfort during a colonoscopy is common due to the passage of the
endoscope through the colon. While sedation and local anesthesia may reduce discomfort, it
does not eliminate the possibility of cramping. Option a may not be entirely accurate as some
discomfort may still be felt despite local anesthesia. Option b addresses discomfort related to

preparation, not the procedure itself. Option d may be misleading as sedation may not entirely
erase memory or eliminate pain during the procedure.
A nurse caring for a client at risk for increased intracranial pressure is monitoring the client
for manifestations that indicate that the pressure is increasing. To do this, the nurse should
check the function of the third cranial nerve by performing which of the following datacollection activities?
a. Observing for facial asymmetry
b. Checking pupillary responses to light
c. Eliciting the gag reflex
d. Testing visual acuity
Answer: b. Checking pupillary responses to light
Rationale:
The function of the third cranial nerve (oculomotor nerve) involves controlling pupil size and
response to light. Changes in pupillary responses, such as unequal or non-reactive pupils, can
indicate increased intracranial pressure and compression of the cranial nerves. Observing for
facial asymmetry, eliciting the gag reflex, and testing visual acuity assess other aspects of
neurological function but are not specific to the third cranial nerve.
A nurse is caring for a client during the immediate postoperative period following thoracic
surgery. When administering an opioid analgesic for pain, the nurse should explain that the
medication should have which of the following effects?
a. Reducing anxiety
b. Increasing blood pressure
c. Increasing coughing
d. Increasing the client's respiratory rate
Answer: a. Reducing anxiety
Rationale:
Opioid analgesics primarily relieve pain and may also have sedative effects, which can help
reduce anxiety. They do not typically increase blood pressure or coughing. While opioids can
depress respiratory rate, proper dosing and monitoring help mitigate this risk.
A nurse is collecting data on a client who has hyperthyroidism. Which of the following
manifestations should the nurse expect the client to report?
a. Frequent mood changes
b. Constipation
c. Sensitivity to cold

d. Weight gain
Answer: a. Frequent mood changes
Rationale:
Hyperthyroidism is characterized by an overactive thyroid gland, leading to symptoms such
as increased metabolism, weight loss, heat intolerance, and frequent mood changes (such as
irritability or anxiety). Constipation, sensitivity to cold, and weight gain are more
characteristic of hypothyroidism.
A nurse is collecting data from a client who has skeletal traction. Which of the following
findings should the nurse identify as an indication of infection at the pin sites?
a. Serosanguineous drainage
b. Mild erythema
c. Warmth
d. Fever
Answer: d. Fever
Rationale:
Fever is a systemic response to infection and can indicate an infection at the pin sites of
skeletal traction. While serosanguineous drainage, mild erythema, and warmth may also be
present with infection, fever is a more reliable indicator of systemic inflammatory response.
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse
determines that teaching has been effective when the client identifies which of the following
manifestations of hypoglycemia? (Select all that apply.)
a. Polyuria
b. Blurry vision
c. Tachycardia
d. Polydipsia
e. Sweating
Answer: b. Blurry vision
c. Tachycardia
e. Sweating
Rationale:
Hypoglycemia is characterized by low blood glucose levels. Manifestations include blurry
vision, tachycardia, and sweating as the body responds to low glucose levels with
sympathetic nervous system activation. Polyuria and polydipsia are more characteristic of
hyperglycemia in diabetes mellitus.

A nurse is collecting data from a client who has an exacerbation of gout. Which of the
following findings should the nurse expect? (Select all that apply.)
a. Edema
b. Erythema
c. Tophi
d. Tight skin
e. Symmetrical joint pain
Answer: a. Edema
b. Erythema
c. Tophi
d. Tight skin
Rationale:
a. Edema is a common finding in gout exacerbations due to inflammation and fluid
accumulation in the affected joints.
b. Erythema, or redness, is typically present in the affected joints due to inflammation.
c. Tophi, which are deposits of uric acid crystals, may be visible as lumps under the skin in
chronic cases of gout.
d. Tight skin may occur due to swelling and inflammation in the affected areas.
A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a
complication of MG for which the nurse should monitor?
a. Respiratory difficulty
b. Confusion
c. Increased intracranial pressure
d. Joint pain
Answer: a. Respiratory difficulty
Rationale:
a. Respiratory difficulty is a serious complication of myasthenia gravis due to weakness of
the respiratory muscles, including the diaphragm.
b. Confusion is not typically associated with MG unless it is a result of respiratory
compromise or medication side effects.
c. Increased intracranial pressure is not a common complication of MG.
d. Joint pain is not directly related to MG.
A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis.
The nurse should recognize that which of the following actions is the priority?

a. Review stress factors that can cause disease exacerbation.
b. Evaluate fluid and electrolyte levels.
c. Provide emotional support.
d. Promote physical mobility.
Answer: b. Evaluate fluid and electrolyte levels.
Rationale:
b. During an acute exacerbation of ulcerative colitis, there is a risk of dehydration and
electrolyte imbalances due to diarrhea and inflammation of the colon. Therefore, assessing
fluid and electrolyte levels is a priority to prevent complications such as dehydration,
electrolyte abnormalities, and hypovolemic shock.
a. While stress can exacerbate symptoms of ulcerative colitis, addressing fluid and electrolyte
balance is more urgent.
c. Emotional support is important but may not be the priority during an acute exacerbation.
d. Promoting physical mobility is important for overall health but may not be the priority
during an acute exacerbation when the client may be debilitated by symptoms.
A nurse is reinforcing teaching about rifampin with a female client who has active
tuberculosis. Which of the following statements should the nurse include in the teaching?
a. "You should wear glasses instead of contacts while taking this medication."
b. "The medication causes amenorrhea if taken along with an oral contraceptive."
c. "A yellow tint to the skin is an expected reaction to the medication."
d. "Lifelong treatment with this medication is necessary."
Answer: a. "You should wear glasses instead of contacts while taking this medication."
Rationale:
a. Rifampin can cause discoloration of soft contact lenses, so wearing glasses is
recommended during treatment.
b. Rifampin can decrease the effectiveness of oral contraceptives, leading to breakthrough
bleeding or contraceptive failure, but it does not cause amenorrhea.
c. A yellow tint to the skin or eyes (jaundice) is a potential adverse effect of rifampin and
should be reported to the healthcare provider.
d. Rifampin is typically used for a specific duration of treatment rather than lifelong therapy
for tuberculosis.
A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following
a renal transplant. Which of the following statements by the client indicates an understanding
of the teaching?

a. "I will take this medication until my BUN returns to normal."
b. "This medication will help my new kidney make adequate urine."
c. "I will need to take this medication for the rest of my life."
d. "This medication will boost my immune system."
Answer: c. "I will need to take this medication for the rest of my life."
Rationale:
c. Cyclosporine is an immunosuppressant medication used to prevent organ rejection after
transplantation, and it is typically required for lifelong therapy to maintain the function of the
transplanted organ.
a. BUN (blood urea nitrogen) returning to normal is not directly related to the duration of
cyclosporine therapy.
b. Cyclosporine does not affect urine production directly.
d. Cyclosporine suppresses the immune system rather than boosting it.
A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by
mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for
with a client who is taking this medication?
a. Improved speech patterns
b. Increased bladder function.
c. Decreased tremors
d. Diminished drooling
Answer: c. Decreased tremors
Rationale:
c. Selegiline, a monoamine oxidase inhibitor (MAOI), can help reduce tremors, one of the
primary symptoms of Parkinson's disease.
a. Selegiline may not directly impact speech patterns.
b. Selegiline does not typically affect bladder function.
d. Diminished drooling is not a commonly monitored therapeutic outcome of selegiline.
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood
cells. The client develops itching and hives. Which of the following actions should the nurse
take first?
a. Obtain vital signs.
b. Stop the transfusion.
c. Notify the registered nurse.
d. Administer diphenhydramine.

Answer: b. Stop the transfusion.
Rationale:
b. Itching and hives are symptoms of a transfusion reaction, and the first action the nurse
should take is to stop the transfusion to prevent further complications.
a. While obtaining vital signs is important, stopping the transfusion takes precedence.
c. Notifying the registered nurse should be done after stopping the transfusion.
d. Administering diphenhydramine may be appropriate but should not precede stopping the
transfusion.
A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations
of Raynaud’s phenomenon. Which of the following statements should the nurse identify as an
indication that the client needs further teaching?
a. "I will keep my house at a cool temperature."
b. "I will try to anticipate and avoid stressful situations."
c. "I will complete the smoking cessation program I started."
d. "I will wear gloves when removing food from the freezer."
Answer: a. "I will keep my house at a cool temperature."
Rationale:
a. Raynaud's phenomenon is exacerbated by cold temperatures, so keeping the house at a cool
temperature could worsen symptoms.
b. Stress can trigger Raynaud's attacks, so avoiding stressful situations is a helpful preventive
measure.
c. Smoking can worsen symptoms of Raynaud's phenomenon, so completing a smoking
cessation program is beneficial.
d. Wearing gloves when handling cold objects can help prevent Raynaud's attacks by
protecting the hands from temperature changes.
A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start
taking ferrous sulfate twice a day. Which of the following statements by the client indicate an
understanding of the teaching?
a. "I will take the medication with orange juice."
b. "I should expect to have loose stools while taking this medication."
c. "I will have clay-colored stools while taking this medication."
d. "I should take the medication with milk."
Answer: a. "I will take the medication with orange juice."
Rationale:

a. Taking ferrous sulfate with orange juice can enhance iron absorption due to the vitamin C
content in the juice.
b. While gastrointestinal side effects such as constipation or diarrhea are common with iron
supplementation, loose stools are less common.
c. Clay-colored stools are not an expected side effect of ferrous sulfate.
d. Taking ferrous sulfate with milk can decrease iron absorption due to the calcium content in
milk.
A nurse is reinforcing teaching about pernicious anemia with a client following a total
gastrectomy. Which of the following dietary supplements should the nurse include in the
teaching as the treatment for pernicious anemia?
a. Vitamin B12
b. Vitamin C
c. Iron
d. Folate
Answer: a. Vitamin B12
Rationale:
a. Pernicious anemia is caused by a deficiency of intrinsic factor, which is necessary for the
absorption of vitamin B12. Therefore, vitamin B12 supplementation is the primary treatment.
b. Vitamin C is not typically used as a treatment for pernicious anemia.
c. Iron supplementation is used to treat iron deficiency anemia but is not effective for
pernicious anemia.
d. Folate supplementation may be necessary if there is a concurrent folate deficiency, but it
does not address the underlying cause of pernicious anemia.
A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a
prescription for lorazepam preoperatively. Which of the following statements by the client
should indicate to the nurse that the medication has been effective?
a. "My mouth is very dry."
b. "I feel very sleepy."
c. "I am not hungry any longer."
d. "My leg feels numb."
Answer: b. "I feel very sleepy."
Rationale:
Lorazepam is a benzodiazepine used preoperatively for anxiolysis and sedation. Feeling very
sleepy indicates that the medication has effectively induced sedation, which can help reduce

anxiety and promote relaxation before surgery. Dry mouth is a common side effect of
benzodiazepines, but it is not an indicator of the medication's effectiveness for preoperative
sedation. Loss of appetite or numbness in the leg are unrelated to the medication's action.
A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the
nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should
recognize this is a manifestation of which of the following conditions?
a. Xerostomia
b. Gingivitis
c. Candidiasis
d. Halitosis
Answer: c. Candidiasis
Rationale:
The white, creamy covering on the tongue and buccal membranes is characteristic of oral
candidiasis, commonly known as oral thrush, which is a fungal infection often seen in
immunocompromised individuals such as those with AIDS. Xerostomia refers to dry mouth,
not a white coating on the oral mucosa. Gingivitis is inflammation of the gums, typically
presenting as redness and swelling. Halitosis is bad breath, which may be associated with oral
infections but is not specific to candidiasis.
A nurse is caring for a client who is postoperative open reduction and internal fixation with
placement of a wound drain to repair a hip fracture. Which of the following actions should
the nurse take?
a. Empty the suction device every 4 hr.
b. Monitor circulation on the affected extremity every 2 hr for the first 12 hr.
c. Position the client’s hip so that it is internally rotated.
d. Encourage foot exercises every 4 hr.
Answer: a. Empty the suction device every 4 hr.
Rationale:
Emptying the suction device every 4 hours ensures optimal function and prevents overflow,
which could lead to potential complications such as dislodgement of the wound drain or
contamination of the surgical site. Monitoring circulation on the affected extremity,
positioning the hip, and encouraging foot exercises are important aspects of postoperative
care but are not specific to wound drain management.

A nurse is assisting with teaching a client who has a history of smoking about recognizing
early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and
report which of the following manifestations of laryngeal cancer?
a. Aphagia
b. Hoarseness
c. Tinnitus
d. Epistaxis
Answer: b. Hoarseness
Rationale:
Hoarseness is a common early manifestation of laryngeal cancer due to vocal cord
involvement. It is important for the client with a history of smoking to monitor for any
persistent changes in voice quality and report them promptly for further evaluation. Aphagia
refers to difficulty swallowing, which may occur in advanced stages of laryngeal cancer but is
not typically an early sign. Tinnitus is ringing in the ears and epistaxis is nosebleed, which are
not specific to laryngeal cancer.
A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which
of the following laboratory values should the nurse review to determine the client’s renal
function?
a. Antinuclear antibody
b. C-reactive protein
c. Erythrocyte sedimentation rate
d. Serum creatinine
Answer: d. Serum creatinine
Rationale:
Serum creatinine is a key laboratory value used to assess renal function. In clients with SLE,
renal involvement is common and can lead to nephritis or kidney damage, so monitoring
serum creatinine levels helps detect renal impairment. Antinuclear antibody, C-reactive
protein, and erythrocyte sedimentation rate are used to diagnose and monitor autoimmune
activity in SLE but do not directly assess renal function.
A nurse is collecting data from a client who has Cushing's syndrome. Which of the following
manifestations should the nurse expect?
a. Bruising
b. Weight loss
c. Hyperpigmentation

d. Double vision
Answer: a. Bruising
Rationale:
Cushing's syndrome is characterized by hypercortisolism, leading to manifestations such as
thinning of the skin, poor wound healing, and easy bruising. Weight gain, not loss, is typical
due to redistribution of fat to the face, trunk, and abdomen. Hyperpigmentation can occur due
to increased melanocyte-stimulating hormone (MSH) levels but is not specific to Cushing's
syndrome. Double vision is not a common manifestation of Cushing's syndrome.
A nurse is caring for a client who is postoperative and requesting something to drink. The
nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance
diet as tolerated." Which of the following actions should the nurse take first?
a. Offer the client apple juice.
b. Elevate the client’s head of bed.
c. Auscultate the client’s abdomen.
d. Order a lunch tray for the client.
Answer: c. Auscultate the client’s abdomen.
Rationale:
Auscultating the client's abdomen is the first priority to assess bowel sounds and ensure that
the gastrointestinal tract is functioning properly before advancing the diet. Offering clear
liquids or ordering a lunch tray can be done after confirming bowel function. Elevating the
client's head of bed may be necessary for comfort but is not the priority at this time.
A nurse is collecting data on a client who has a surgical wound healing by secondary
intention. Which of the following findings should the nurse report to the charge nurse?
a. The wound is tender to touch.
b. The wound has pink, shiny tissue with a granular appearance.
c. The wound has serosanguineous drainage.
d. The wound has a halo of erythema on the surrounding skin.
Answer: d. The wound has a halo of erythema on the surrounding skin.
Rationale:
A halo of erythema around the wound indicates possible infection and should be reported
promptly for further evaluation and management. Tenderness to touch, pink, shiny
granulation tissue, and serosanguineous drainage are common findings in a wound healing by
secondary intention and do not necessarily indicate infection.

A nurse is assisting with the care of a client who has multiple injuries following a motor
vehicle crash. The nurse should monitor for which of the following manifestations of a
pneumothorax?
a. Inspiratory stridor
b. Expiratory wheeze
c. Absence of breath sounds
d. Coarse crackles
Answer: c. Absence of breath sounds
Rationale:
Absence of breath sounds on auscultation over the affected lung area is a key manifestation of
a pneumothorax, indicating a loss of air in the pleural space. Inspiratory stridor and
expiratory wheeze are typically associated
A nurse is collecting data from a client who has right-sided heart failure. Which of the
following findings should the nurse expect?
a. Frothy sputum
b. Dyspnea
c. Orthopnea
d. Peripheral edema
Answer: d. Peripheral edema
Rationale:
Right-sided heart failure results in decreased cardiac output from the right ventricle, leading
to venous congestion. This venous congestion manifests as peripheral edema, particularly in
the lower extremities, as fluid accumulates due to impaired circulation. Therefore, peripheral
edema is a common finding in clients with right-sided heart failure.
A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer
and experiencing nausea. Which of the following actions should the nurse take?
a. Advise the client to lie down after meals.
b. Instruct the client to restrict food intake prior to treatment.
c. Provide the client with an antiemetic 2 hr prior to the chemotherapy.
d. Encourage the client to drink a carbonated beverage 1 hr before meals.
Answer: d. Encourage the client to drink a carbonated beverage 1 hr before meals.
Rationale:

d. Carbonated beverages can help alleviate nausea by settling the stomach and reducing
gastric distension. Encouraging the client to drink a carbonated beverage before meals may
help prevent or reduce nausea associated with chemotherapy.
a. Lying down after meals may worsen nausea in some individuals.
b. Restricting food intake prior to treatment may lead to increased nausea due to an empty
stomach.
c. While providing an antiemetic prior to chemotherapy is important, drinking a carbonated
beverage can complement antiemetic therapy to further alleviate nausea.
A nurse is assisting with the care of a client following a transurethral resection of the prostate
(TURP) and has an indwelling urinary catheter. Which of the following actions should the
nurse take?
a. Weigh the client weekly.
b. Irrigate the catheter as prescribed.
c. Instruct the client to report an urge to urinate.
d. Instruct the client to bear down as if to have a bowel movement every hour.
Answer: b. Irrigate the catheter as prescribed.
Rationale:
b. Irrigating the catheter as prescribed helps maintain patency and prevent obstruction, which
is essential for proper drainage of urine following a TURP.
a. While monitoring weight is important for assessing fluid balance, it is not directly related
to catheter care.
c. The client should not feel an urge to urinate with an indwelling urinary catheter in place.
d. Bearing down as if to have a bowel movement is not appropriate for a client with a urinary
catheter and could lead to complications such as displacement or dislodgment of the catheter.
A nurse is evaluating discharge instructions for a client following a right cataract extraction.
Which of the following client statements indicates the teaching is effective?
a. "I will take a stool softener until my eye is healed."
b. "I will expect to have moderately severe pain for 1-2 days."
c. "I will refrain from cooking for 1 week."
d. "I will bend at the waist to tie my shoes."
Answer: a. "I will take a stool softener until my eye is healed."
Rationale:

a. Taking a stool softener can help prevent straining during bowel movements, which is
important to avoid increasing intraocular pressure and potentially causing complications after
cataract surgery.
b. Moderately severe pain after cataract surgery would not be expected; this statement
indicates a need for further education.
c. Refraining from cooking for a week is not necessary after cataract surgery; this statement
indicates a need for further education.
d. Bending at the waist to tie shoes should be avoided to prevent increased intraocular
pressure; this statement indicates a need for further education.
A nurse is collecting data from a client who is 6 days post craniotomy for removal of an
intracerebral aneurysm. The nurse should monitor the client for which of the following
manifestations of increased intracranial pressure?
a. Decreased pedal pulses
b. Hypertension
c. Peripheral edema
d. Diarrhea
Answer: b. Hypertension
Rationale:
b. Hypertension can be a manifestation of increased intracranial pressure as the body tries to
maintain cerebral perfusion pressure.
a. Decreased pedal pulses are not typically associated with increased intracranial pressure.
c. Peripheral edema is not a direct manifestation of increased intracranial pressure.
d. Diarrhea is not typically associated with increased intracranial pressure.
A nurse is caring for a client who has COPD. Which of the following actions should the nurse
take?
a. Encourage the client to drink 8 glasses of water a day.
b. Instruct the client to cough every 4 hr.
c. Provide the client with a low-protein diet.
d. Advise the client to lie down after eating.
Answer: a. Encourage the client to drink 8 glasses of water a day.
Rationale:
a. Encouraging the client to drink adequate fluids helps thin mucus secretions, making them
easier to expectorate, which can help manage symptoms of COPD.

b. Coughing every 4 hours may not be effective in managing COPD symptoms and could
cause fatigue; this statement indicates a need for further education.
c. Protein is an important nutrient for maintaining muscle strength, which is particularly
important for clients with COPD; this statement indicates a need for further education.
d. Lying down after eating may exacerbate symptoms of COPD by increasing pressure on the
diaphragm and reducing lung capacity; this statement indicates a need for further education.
A nurse is caring for a client who was admitted with major burns to the head, neck, and chest.
Which of the following complications should the nurse identify as the greatest risk to the
client?
a. Hypothermia
b. Hyponatremia
c. Fluid imbalance
d. Airway obstruction
Answer: d. Airway obstruction
Rationale:
d. Airway obstruction is the greatest risk to the client due to potential swelling of the airway,
inhalation injury, or edema of the upper respiratory tract following burns to the head, neck,
and chest.
a. Hypothermia can occur due to loss of skin integrity and exposure, but it is not the greatest
risk.
b. Hyponatremia can occur due to fluid shifts and electrolyte imbalances, but it is not the
greatest risk.
c. Fluid imbalance is a concern, but airway obstruction poses a more immediate threat to the
client's life.
A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the
following client manifestations should the nurse identify as an indication of the development
of Lyme disease?
a. An expanding circular rash
b. Swollen, painful joints
c. Decreased level of consciousness
d. Necrosis at the site of the bite
Answer: a. An expanding circular rash
Rationale:

a. An expanding circular rash, known as erythema migrans, is a characteristic early sign of
Lyme disease that typically appears within 3 to 30 days after a tick bite.
b. Swollen, painful joints are more characteristic of later stages of Lyme disease.
c. Decreased level of consciousness and necrosis at the site of the bite are not typical
manifestations of Lyme disease.
A nurse is contributing to the plan of care for a client who is 12 hr postoperative following a
right radical mastectomy with closed suction drains present. The nurse should expect that the
client will be unable to perform which of the following activities with her right arm?
a. Combing her hair
b. Eating her breakfast
c. Buttoning her blouse
d. Tying her shoes
Answer: a. Combing her hair
Rationale:
Following a radical mastectomy, the client may have restricted movement and discomfort in
the affected arm due to surgical trauma and drainage tubes. Combing hair requires full range
of motion of the arm, which may not be possible immediately postoperatively.
A nurse in a provider’s office is collecting data for a 45-year-old client who is having
manifestations associated with perimenopause. Which of the following findings should the
nurse expect?
a. Report of urinary retention
b. Elevated blood pressure above 140/90
c. Report of dryness with vaginal intercourse
d. Elevated body temperature above 37.8° C (100° F)
Answer: c. Report of dryness with vaginal intercourse
Rationale:
Dryness with vaginal intercourse is a common symptom of perimenopause due to decreased
estrogen levels, which can result in vaginal atrophy and reduced lubrication. This symptom
can cause discomfort and pain during sexual activity, prompting the client to seek assistance
or intervention from healthcare providers.
A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a
regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the
following times?
a. On the same day every month

b. Prior to the beginning of menses
c. Three to seven days after menses stops
d. On the second day of menstruation
Answer: c. Three to seven days after menses stops
Rationale:
Performing breast self-examination (BSE) three to seven days after menses stops is
recommended for clients with regular menstrual cycles. During this time, breast tissue is least
likely to be affected by hormonal fluctuations, such as swelling and tenderness associated
with the menstrual cycle. This allows for a more consistent and accurate examination of the
breasts.
A nurse is caring for a client who has second- and third-degree burns and a prescription for a
high-calorie, high-protein diet. Which of the following menu choices should the nurse
recommend?
a. 1/2 cup whole-grain pasta with tomato sauce and pears
b. Turkey and cheese sandwich with scalloped potatoes
c. 1/2 cup black beans with a brownie
d. Roast beef with romaine lettuce salad
Answer: b. Turkey and cheese sandwich with scalloped potatoes
Rationale:
Clients with second- and third-degree burns require a high-calorie, high-protein diet to
support wound healing and metabolic demands. The menu choice of a turkey and cheese
sandwich with scalloped potatoes provides both protein and calories necessary for wound
healing.
A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram.
Which of the following should the nurse include in the teaching?
a. Omit your daily dose of aspirin.
b. Take a laxative the evening before the procedure.
c. Expect to be drowsy for 24 hr following the procedure.
d. You will feel cold chills after the dye has been injected.
Answer: b. Take a laxative the evening before the procedure.
Rationale:
Before an intravenous pyelogram, it is important to clear the intestines of fecal material to
enhance visualization of the urinary tract. Therefore, the nurse should instruct the client to
take a laxative the evening before the procedure.

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain.
Which of the following statements made by the client should the nurse identify as being
consistent with peptic ulcer disease?
a. "The pain is worse after I eat a meal high in fat."
b. "My pain is relieved by having a bowel movement."
c. "I feel so much better after eating."
d. "The pain radiates down to my lower back."
Answer: c. "I feel so much better after eating."
Rationale:
Clients with peptic ulcer disease often experience pain relief after eating, as food helps
neutralize stomach acid temporarily. This statement is consistent with the characteristics of
peptic ulcer disease.
A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the
following interventions should the nurse identify as the priority?
a. Promote the client’s expression of feelings about loss of self-care ability.
b. Encourage the client to recall positive life events.
c. Schedule pain medication on a routine basis.
d. Suggest ways the client can continue interacting with social contacts.
Answer: c. Schedule pain medication on a routine basis.
Rationale:
In caring for a client with a terminal illness, effective pain management is a priority to ensure
comfort and quality of life. Therefore, scheduling pain medication on a routine basis is the
priority intervention.
A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic
open-angle glaucoma. Which of the following statements by the client indicates an
understanding of the teaching?
a. "When my vision improves, I will be able to stop taking the eye drops."
b. "If I forget to take my eye drops, I should wait until the next time they are due."
c. "I should call the clinic before taking any over-the-counter medications."
d. "Every two years I will need to have my vision checked by an eye doctor."
Answer: c. "I should call the clinic before taking any over-the-counter medications."
Rationale:
Clients with chronic open-angle glaucoma need to avoid certain medications that can increase
intraocular pressure. Therefore, calling the clinic before taking any over-the-counter

medications indicates an understanding of the teaching about medication management for
glaucoma.