ATI MED SURG PROCTORED PRACTICE 2023-2025
04 September 2024ATI MED SURG PROCTORED PRACTICE 2023-2025
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. (Correct answer) - Monitoring temperature is crucial for early detection of infections.
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.
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. (Correct answer) - Humidified oxygen helps moisten secretions and makes them easier to expectorate.
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.
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. (Correct answer) - Slipper socks provide warmth and comfort without compromising circulation.
C) Increase the client’s oral fluid intake.
D) Place a moist heating pad under the client’s feet.
A nurse is caring for a client who is 4 hours postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse to report to the provider?
A) Emesis of 100 mL.
B) Oral temperature of 37.5°C (99.5°F).
C) Thick, red-colored urine. (Correct answer) - This may indicate bleeding, a common complication after TURP.
D) Pain level of 4 on a 0 to 10 rating scale.
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. (Correct answer) - Shivering is a common side effect and can raise body temperature.
B) Infection.
C) Burns.
D) Hypervolemia.
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.” (Correct answer) - Exercise can worsen the condition if ketones are present in the urine.
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. (Correct answer) - This action prevents the bowel from drying out and reduces the risk of infection.
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.
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. (Correct answer) - Hyperventilation occurs as the body attempts to blow off excess CO2.
C) Increased blood pressure.
D) Bradycardia.
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. (Correct answer) - Bending at the waist increases intraocular pressure and can affect healing.
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.
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. (Correct answer) - Nausea is a potential sign of digoxin toxicity; vital signs should be checked first.
D) Request an order for an antiemetic.
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 (Correct answer) - Purulent drainage is thick, yellow, and often indicates 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 minutes prior to initiating CPM exercises. (Correct answer) - Administering pain medication helps alleviate pain before starting 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.
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 (Correct answer) - Dyspnea or difficulty breathing is a common symptom of emphysema.
B) Barrel chest (Correct answer) - A barrel-shaped chest is characteristic of emphysema due to lung hyperinflation.
C) Clubbing of the fingers (Correct answer) - Clubbing occurs due to chronic low oxygen levels.
D) Shallow respirations (Correct answer) - People with emphysema often have shallow breathing.
E) Bradycardia
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.(Correct answer) - Clear drainage from the nose in a client with a skull fracture could be cerebrospinal fluid (CSF), and CSF contains glucose.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
A) Monitor for elevated blood pressure.
B) Provide analgesia for headaches.
C) Prevent bladder distention. (Correct answer) - Bladder distention is a common cause of autonomic dysreflexia and should be prevented.
D) Elevate the client’s head.
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 (Correct answer) - Abnormal vaginal bleeding, especially post-menopausal, is a common symptom of endometrial cancer.
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(Correct answer) - Altered LOC may indicate complications such as a fat embolism, which is life-threatening.
B) Oral temperature of 37.7°C (100°F)
C) Muscle spasms
D) Headache
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
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 (Correct answer) - Subcutaneous emphysema suggests air leakage from the lung, which could indicate complications that need immediate attention.
D) Pain level of 6 on a 0 to 10 scale
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 inch wider than the stoma. (Correct answer) - This ensures a proper fit without restricting the stoma.
D) Apply lotion to the peristomal skin when changing the ostomy pouch.
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.(Correct answer) - Frequent changing of the nasal drip pad is necessary to manage postoperative drainage.
C) Encourage frequent brushing of teeth.
D) Encourage the client to cough every 2 hours following surgery.
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 (Correct answer) - Aspirin has antiplatelet properties and helps prevent blood clots, which is crucial after a heart attack.
D) To prevent fever
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 (Correct answer) - Open-angle glaucoma typically causes a gradual loss of peripheral vision.
B) Headache
C) Halos around lights
D) Discomfort in the eyes
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 (Correct answer) - Hypokalemia (low potassium) is a serious issue and could lead to cardiac complications.
D) Urine specific gravity 1.035
A nurse is reinforcing discharge teaching with a client following 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.” (Correct answer) - Clients should avoid tub baths after surgery to prevent infection.
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. (Correct answer) - Traction must be maintained properly with the weights hanging freely to ensure the alignment and effectiveness of the treatment.
C) Check the client’s bony prominences every 12 hours.
D) Cleanse the client’s pin sites with povidone-iodine.
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.(Correct answer) - Ferrous gluconate is best absorbed when taken 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.
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 hours.
C) Wash daily with antibacterial soap.(Correct answer) - Antibacterial soap helps prevent infection and promote healing in cellulitis.
D) Keep draining lesions uncovered to air dry.
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. (Correct answer) - Capsules and enteric-coated medications may not dissolve properly in clients with an ileostomy.
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.” (Correct answer) - Escharotomy involves making large incisions to relieve pressure and improve circulation.
A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?
A) Decreased color perception (Correct answer) - Cataracts often cause a gradual decline in color perception.
B) Loss of peripheral vision
C) Bright flashes of light
D) Eyestrain
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.(Correct answer) - This helps to monitor for changes related to the obstruction and decompression.
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.
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 (Correct answer) - A common physical finding in Cushing’s syndrome.
B) Purple striations (Correct answer) - These occur due to skin thinning and stretching.
C) Moon face (Correct answer) - The face becomes round and swollen due to fat deposits.
D) Tremors
E) Obese extremities
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?
A) Provide a diet high in protein.
B) Provide ibuprofen for retroperitoneal discomfort.
C) Monitor intake and output hourly.(Correct answer) - Close monitoring of fluid balance is essential in acute kidney injury.
D) Encourage the client to consume at least 2 L of fluid daily.
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.” (Correct answer) - Fasting is necessary to reduce the risk of aspiration.
D) “You will be awake while the procedure is performed.”
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 (Correct answer) - The postictal phase is the recovery period following a seizure, where the client may be very sleepy.
D) Presence of absence seizures
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.” (Correct answer) - Ambulation helps dissipate the gas used during surgery, which can cause shoulder pain.
D) “The pain is caused from the nitrous dioxide injected into the abdomen.”
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.(Correct answer) - Bubbling should occur if the suction is functioning properly.
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.
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. (Correct answer) - Helps replenish lost fluid.
B) Monitor the puncture site for hematoma.(Correct answer) - Important to check for bleeding or complications.
C) Insert a urinary catheter.
D) Elevate the client’s head of bed.
E) Apply a cervical collar to the client.
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. (Correct answer) - The priority is ensuring the airway is clear and preventing aspiration.
A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?
A) A dry raised rash
B) Excessive salivation
C) Periorbital edema
D) Hardened skin (Correct answer) - Scleroderma typically causes thickening and hardening of the skin.
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?
A) Instruct the client to tilt her head back when she swallows.
B) Place food on the left side of the client’s mouth.
C) Add thickener to fluids. (Correct answer) - Adding a thickener to liquids can help prevent aspiration in a client with dysphagia.
D) Serve food at room temperature.
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 (Correct answer) - Burns to the face and neck can cause swelling that may obstruct the airway.
B) Infection
C) Fluid imbalance
D) Contractures
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. (Correct answer) - This ensures that the medication is effective in improving muscle strength during meals.
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.
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) Determine the patency of the tubing.(Correct answer) - The first action should be to assess the catheter for patency to ensure it is not blocked.
B) Notify the provider.
C) Administer a prescribed analgesic.
D) Offer oral fluids.
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.” (Correct answer) - This response addresses the client’s concern directly and provides reassurance.
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?
A) Control impulsive behavior.
B) Compensate for left visual field deficits.
C) Re-establish communication. (Correct answer) - A left-hemispheric stroke can affect language abilities, so focusing on re-establishing communication is essential.
D) Improve left-side motor function.
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 (Correct answer) - Diabetes insipidus causes excessive urination, which can lead to dehydration and hypotension.
B) Polyphagia
C) Hyperglycemia
D) Bradycardia
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 (Correct answer) - The elevated PaCO2 and decreased pH indicate respiratory acidosis.
C) Metabolic alkalosis
D) Respiratory alkalosis
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.” (Correct answer) - Elastic tops can constrict blood flow and should be avoided.
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. (Correct answer) - Calming the client with a distraction like music can help reduce agitation.
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 (Correct answer) - Granulation tissue is soft and red and indicates the wound is healing.
D) An inflammatory response
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 (Correct answer) - Fresh fruits can carry bacteria, which is dangerous for 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.(Correct answer) - This position prevents dislocation of the new hip joint.
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. (Correct answer) - Checking for a pulse is the first step in assessing the need for CPR.
C) Establish an open airway.
D) Auscultate for breath sounds.
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.” (Correct answer) - This response acknowledges the client’s feelings and opens the door for further discussion.
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.”
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. (Correct answer) - This action prioritizes safety by preventing further movement.
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.
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. (Correct answer) - This ensures the proper function of the drainage system.
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.
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.” (Correct answer) - Abstaining from sexual activity prevents the spread of hepatitis A, which is transmitted via the fecal-oral route.
C) “I will refrain from international travel.”
D) “I will not order a salad in a restaurant.”
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. (Correct answer) - Pursed-lip breathing helps improve gas exchange by keeping the airways open longer.
D) Limit fluid intake throughout the day.
A nurse is caring for a client who is postoperative and has a history of Addison’s disease. For which of the following manifestations should the nurse monitor?
A) Hypernatremia
B) Hypotension (Correct answer) - Clients with Addison’s disease are prone to low blood pressure due to decreased adrenal hormones.
C) Bradycardia
D) Hypokalemia
A nurse is reinforcing preoperative 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 (Correct answer) - Hydroxyzine is an anxiolytic.
B) Controlling emesis (Correct answer) - Hydroxyzine can help control nausea and vomiting.
C) Relaxing skeletal muscles
D) Preventing surgical site infections
E) Reducing the amount of narcotics needed for pain relief (Correct answer) - Hydroxyzine may reduce the need for higher doses of narcotics by providing sedation.
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 (Correct answer) - Iron is necessary to support red blood cell production, which epoetin alfa stimulates.
D) Niacin
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 (Correct answer) - Airway clearance is the priority to prevent respiratory complications.
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. (Correct answer) - Clients with a C8 injury retain the ability to use their arms and hands, making wheelchair propulsion possible.
A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors shoul the nurse identify as the leading cause of non-melanoma skin cancer?
A) Exposure to environmental pollutants
B) Sun exposure (Correct answer) - Ultraviolet radiation from the sun is the leading cause of skin cancer.
C) History of viral illness
D) Scars from a severe burn
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?"(Correct answer) - Difficulty sleeping and night sweats are common symptoms of menopause.
B) “Have you been experiencing chills?”
C) “Have you experienced increased hair growth?”
D) “When did you begin your menses?”
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 (Correct answer) - Berries are rich in antioxidants, which help protect the body against cancer-causing free radicals.
C) Bran cereal
D) Skim milk
A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle 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 (Correct answer) - Lethargy is an early sign of increased intracranial pressure.
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.” (Correct answer) - Tonometry measures the pressure inside the eye, which is elevated in glaucoma.
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(Correct answer) - An increase in serum creatinine indicates possible kidney damage or rejection.
C) Decrease in white blood cell count
D) Decrease in platelets
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 (Correct answer) - This is a hallmark sign of paradoxical pulse, often seen in constrictive pericarditis.
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. (Correct answer) - This action helps address the client’s needs and de-escalate the situation.
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.
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.(Correct answer) - Checking distal pulses ensures that blood flow is adequate following the procedure.
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.
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. (Correct answer) - The flu vaccine changes annually to match circulating strains.
D) The influenza vaccine is necessary only for clients who have never had influenza.
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. (Correct answer) - This encourages the client to take an active role in their care.
D) Provide the client with a pamphlet of information about cancer.
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.” (Correct answer) - This empathetic response acknowledges the son’s feelings.
D) “Your mother’s crying seems to bother you more than it does her.”
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 (Correct answer) - Dementia typically progresses from mild forgetfulness to severe disorientation.
C) Sleeping more during the day than nighttime
D) Hypervigilant behaviors
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. (Correct answer) - Monitoring eye movements helps assess for signs of vertigo or imbalance.
C) Encourage ambulation.
D) Ensure the room is brightly lit.
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 (Correct answer) - Monitoring platelet levels is crucial as the client may be on anticoagulants that affect clotting.
C) Restrict oral fluids
D) Administer vasodilating medications
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 (Correct answer) - The tuberculin skin test is commonly used for TB screening.
B) Sputum culture for acid-fast bacillus (AFB)
C) Bacille Calmette-Guérin (BCG) vaccine
D) Chest x-ray
A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus?
A) Serum sodium 145 mEq/L
B) Urine specific gravity 1.028
C) Urine output 650 mL/hr (Correct answer) - Excessive urine output is a key sign of diabetes insipidus.
D) Blood glucose 198 mg/dL
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.” (Correct answer) - Metformin can increase the risk of lactic acidosis when combined with contrast dye.
C) “I haven’t had anything to eat or drink since last night.”
D) “The last time I voided it was painful.”
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 (Correct answer) - Wheezing is common during an asthma exacerbation due to airway constriction.
B) Pleural friction rub
C) Fine rales
D) Rhonchi
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.(Correct answer) - Clean gloves should be used to avoid contamination when handling dressings.
D) Open sterile supplies before removing the dressing.
A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?
A) Prone with arms raised over the head.
B) Sitting, leaning forward over the bedside table. (Correct answer) - This position allows for better access to the pleural space.
C) High Fowler’s position
D) Side-lying with knees drawn up to the chest.
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 (Correct answer) - Denial is a common initial reaction to a new diagnosis of a serious illness.
B) Bargaining
C) Acceptance
D) Anger
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. (Correct answer) - High Fowler’s position aids in lung expansion and prevents aspiration.
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 (Correct answer) - Weight is the most accurate indicator of fluid loss during dialysis.
D) Abdominal girth
A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 minutes 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 (Correct answer) - Hypotension is a sign of a hemolytic transfusion reaction.
D) Distended neck veins
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 (Correct answer) - An aura often precedes a seizure and serves as a warning.
C) A period of sleepiness following the seizure during which arousal is difficult
D) A brief loss of consciousness accompanied by staring
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.” (Correct answer) - Severe pain after cataract surgery may indicate a complication and should be reported.
A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?
A) “You shouldn’t feel any pain since the local area is anesthetized.”
B) “Most clients report more discomfort from the preparation than from the procedure itself.”
C) “You may feel some cramping during the procedure.” (Correct answer) - Cramping may occur due to air being introduced into the colon during the procedure.
D) “Don’t worry; you won’t remember anything about the procedure due to the effects of the medication.”
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 data-collection activities?
A) Observing for facial asymmetry
B) Checking pupillary responses to light(Correct answer) - The third cranial nerve controls pupil response, and changes in response may indicate increased intracranial pressure.
C) Eliciting the gag reflex
D) Testing visual acuity
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 (Correct answer) - Opioid analgesics help reduce anxiety, which can exacerbate pain.
B) Increasing blood pressure
C) Increasing coughing
D) Increasing the client’s respiratory rate
A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect he client to report?
A) Frequent mood changes (Correct answer) - Hyperthyroidism can cause emotional instability and mood swings.
B) Constipation
C) Sensitivity to cold
D) Weight gain
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 (Correct answer) - Fever is a systemic sign of infection that should be monitored closely.
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 (Correct answer)
C) Tachycardia (Correct answer)
D) Polydipsia
E) Sweating (Correct answer)
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 (Correct answer)
B) Erythema (Correct answer)
C) Tophi (Correct answer)
D) Tight skin (Correct answer)
E) Symmetrical joint pain
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 (Correct answer) - MG can lead to muscle weakness, including respiratory muscles, posing a risk for respiratory failure.
B) Confusion
C) Increased intracranial pressure
D) Joint pain
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.(Correct answer) - Fluid and electrolyte imbalances are common and dangerous during exacerbations of ulcerative colitis.
C) Provide emotional support.
D) Promote physical mobility.
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.” (Correct answer) - Rifampin can cause bodily fluids to turn orange-red, which can stain contact lenses.
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.”
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.” (Correct answer) - Cyclosporine is a lifelong immunosuppressant therapy to prevent organ rejection.
D) “This medication will boost my immune system.”
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 (Correct answer) - Selegiline is used to reduce symptoms of Parkinson’s, including tremors.
D) Diminished drooling
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. (Correct answer) - The first step in addressing a transfusion reaction is to stop the transfusion to prevent further complications.
C) Notify the registered nurse.
D) Administer diphenhydramine.
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.” (Correct answer) - Clients with Raynaud’s phenomenon should avoid cold temperatures, so keeping the house cool is not advisable.
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.” (Correct answer) - Vitamin C enhances the absorption of iron.
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.”
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 (Correct answer) - Pernicious anemia is caused by a lack of intrinsic factor, necessary for B12 absorption.
B) Vitamin C
C) Iron
D) Folate
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."(Correct answer) - Lorazepam is a sedative, so sleepiness is expected after administration.
C) “I am not hungry any longer.”
D) “My leg feels numb.”
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 (Correct answer) - Candidiasis is a common fungal infection in immunocompromised clients, such as those with AIDS.
D) Halitosis
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. (Correct answer) - Circulation checks are essential in the first hours post-surgery to detect complications.
C) Position the client’s hip so that it is internally rotated.
D) Encourage foot exercises every 4 hr.
A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer?
A) Aphagia
B) Hoarseness (Correct answer) - Persistent hoarseness is an early symptom of laryngeal cancer.
C) Tinnitus
D) Epistaxis
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 (Correct answer) - Serum creatinine is a key indicator of kidney function and can detect renal involvement in SLE.
A nurse is collecting data from a client who has Cushing’s syndrome. Which of the following manifestations should the nurse expect?
A) Bruising (Correct answer) - Bruising is a common symptom due to the fragile skin and blood vessels associated with Cushing’s syndrome.
B) Weight loss
C) Hyperpigmentation
D) Double vision
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.(Correct answer) - Before advancing the diet, it’s important to assess for bowel sounds.
D) Order a lunch tray for the client.
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. (Correct answer) - Redness around the wound may indicate infection and should be reported.
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 (Correct answer) - The absence of breath sounds indicates a collapse of the lung due to pneumothorax.
D) Coarse crackles
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 (Correct answer) - Peripheral edema is a common sign of right-sided heart failure due to fluid backup in the systemic circulation.
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. (Correct answer) - Administering antiemetics before chemotherapy can help prevent nausea.
D) Encourage the client to drink a carbonated beverage 1 hr before meals.
A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take?
A) Weigh the client weekly.
B) Irrigate the catheter as prescribed.(Correct answer) - Irrigating the catheter is necessary to prevent clots from blocking the flow of urine.
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.
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.” (Correct answer) - Straining during a bowel movement can increase intraocular pressure, so stool softeners are recommended.
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.”
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 (Correct answer) - Hypertension is a common sign of increased intracranial pressure.
C) Peripheral edema
D) Diarrhea
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. (Correct answer) - Increasing fluid intake helps thin secretions, making them easier to expectorate.
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.
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 (Correct answer) - Burns to the face and neck can lead to airway obstruction, which is the most immediate and serious risk.
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 (Correct answer) - This rash, called erythema migrans, is a hallmark sign of Lyme disease.
B) Swollen, painful joints
C) Decreased level of consciousness
D) Necrosis at the site of the bite
A nurse is contributing to the plan of care for a client who is 12 hours 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 (Correct answer) - Combing hair involves significant arm movement, which may be restricted after a mastectomy.
B) Eating her breakfast
C) Buttoning her blouse
D) Tying her shoes
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 (Correct answer) - Vaginal dryness is a common symptom of perimenopause due to hormonal changes.
D) Elevated body temperature above 37.8°C (100°F)
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(Correct answer) - BSE should be performed after menses when the breasts are least likely to be swollen or tender.
D) On the second day of menstruation
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 (Correct answer) - This option provides both high calories and protein.
C) 1/2 cup black beans with a brownie
D) Roast beef with romaine lettuce salad
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. (Correct answer) - A laxative is often prescribed to clear the bowels for better visualization during 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.
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.” (Correct answer) - Peptic ulcer pain is often relieved temporarily by eating due to neutralization of stomach acid.
D) “The pain radiates down to my lower back.”
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. (Correct answer) - Pain management is the priority in terminal care to ensure comfort.
D) Suggest ways the client can continue interacting with social contacts.
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.” (Correct answer) - Certain medications can increase intraocular pressure and should be discussed with the provider.
D) “Every two years I will need to have my vision checked by an eye doctor.”
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