med surg ati proctored exam2024 version 1-100 Questions

04 September 2024

 

med surg ati proctored exam2024 version 1-100 Questions

  2. A nurse in an emergency department is preparing to perform an ocular irrigation for a client. Which of the following actions should the nurse plan to take?
  5. A nurse is preparing to administer lactated ringer’s via continuous IV infusion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the nurse set the IV pump to administer?
  8. A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?
  11. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
  14. A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take?
  17. A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change?
  20. A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
  23. A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client’s urinary output was 4,000 ml over the past 24 hours. The nurse should anticipate a prescription for which of the following IV medications?
  26. A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate?
  29. A nurse is taking an admission history from a client who reports Raynaud’s disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud’s?
  • a. Eating a strict vegetarian diet
  • b. A history of herpes zoster
  • c. Taking amiodipine for hypertension
  • d. Using a nicotine transdermal patch (Correct answer) Explanation: Nicotine is a vasoconstrictor and can trigger Raynaud’s disease symptoms
  2. A nurse is caring for a client who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first?
  • a. Perform an ECG
  • b. Obtain ABG values
  • c. Turn the client to his left side (Correct answer)
  • d. Clamp the catheter Explanation: Turning the client to the left side helps trap air in the right atrium and prevent an air embolism from reaching the lungs.
  2. A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client’s skin is intact. Which of the following interventions should the nurse include in the plan of care?
  • a. Turn and reposition the client every 4 hours
  • b. Apply an occlusive dressing
  • c. Support bony prominences with pillows (Correct answer)
  • d. Massage the reddened areas three times a day Explanation: Supporting bony prominences with pillows helps redistribute pressure and prevents skin breakdown.
  2. A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take?
  • a. Discuss recommendations for eating and swallowing techniques (Correct answer)
  • b. List strategies for family coping when dealing with possible role changes
  • c. Review the use of adaptive grooming devices to promote client independence
  • d. Give the client information about the local National Multiple Sclerosis Society Explanation: Ensuring safe eating and swallowing is the priority to prevent aspiration and ensure adequate nutrition.
  2. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? Exhibit
  • a. Obtain a sputum sample for culture
  • b. Administer ondansetron
  • c. Initiate airborne precautions (Correct answer)
  • d. Prepare the client for a chest x-ray Explanation: The client likely has a condition requiring airborne precautions, which should be implemented to prevent the spread of infection.
  2. A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client’s risk?
  • a. History of Crohn’s disease (Correct answer)
  • b. BMI of 24
  • c. Diet high in fiber
  • d. Age 46 years Explanation: A history of inflammatory bowel disease like Crohn’s increases the risk of colorectal cancer.
  2. A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, “I’m not sure I want to have a mastectomy.” Which of the following statements should the nurse make?
  • a. “I can give you a list of other people who had the same procedure”
  • b. “You will be cancer-free if you have the procedure”
  • c. “I can give you additional information about the procedure” (Correct answer)
  • d. “You should get a second opinion regarding the procedure” Explanation: Providing additional information supports informed decision-making.
  2. A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow.
  4. Obtain venous access using a 19-gauge needle (Correct answer)
  6. Obtain the unit of packed RBCs from the blood bank (Correct answer)
  8. Verify blood compatibility with another nurse (Correct answer)
  10. Initiate the transfusion of the unit of packed RBCs (Correct answer)
  12. Remain with the client for the first 15 to 30 minutes of the infusion (Correct answer) Explanation: These steps ensure safe blood transfusion by confirming compatibility and monitoring for reactions.
  14. A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?
  • a. “Rinse your mouth with hydrogen peroxide”
  • b. “Brush your teeth for 60 seconds twice daily”
  • c. “Wear your dentures only during meals”
  • d. “Floss your teeth following each meal” (Correct answer) Explanation: Flossing helps prevent infection in clients with mucositis, but it should be done carefully.
  2. A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open their eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse assign the client?
  • a. 5
  • b. 2
  • c. 13
  • d. 10 (Correct answer) Explanation: The score reflects the client’s response to painful stimuli and neurological function.
  2. A nurse is providing discharge teaching to a client who has heart failure and instructs them to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?
  • a. “I can season my foods with garlic and onion salts”
  • b. “I can have mayonnaise on my sandwiches”
  • c. “I can have a frozen fruit juice bar for dessert” (Correct answer)
  • d. “I can drink vegetable juice with a meal” Explanation: Frozen fruit juice bars are low in sodium and appropriate for clients on a restricted sodium diet.
  2. A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?
  • a. Instill 0.9% sodium chloride solution into the affected eye
  • b. Administer proparacaine eyedrops into the affected eye
  • c. Collect information about the irritant that caused the injury (Correct answer)
  • d. Remove any contact lenses Explanation: Identifying the chemical helps the nurse determine the appropriate treatment.
  2. A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately?
  • a. Rhonchi
  • b. SaO2 92%
  • c. Sore throat
  • d. Stridor (Correct answer) Explanation: Stridor is a sign of airway obstruction and requires immediate intervention.
  2. A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
  • a. Elevated serum calcium
  • b. Elevated blood glucose (Correct answer)
  • c. Decreased serum amylase
  • d. Decreased erythrocyte sedimentation rate Explanation: Pancreatitis can affect insulin production, leading to elevated blood glucose levels.
  2. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?
  • a. Hypothermia
  • b. Urine specific gravity 1.001 (<1.005) (Correct answer)
  • c. Elevated blood pressure
  • d. BUN 15 mg/dl Explanation: Diabetes insipidus causes excessive urination and diluted urine, reflected in low specific gravity.
  2. A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include?
  • a. Initiate a continuous IV heparin infusion (Correct answer)
  • b. Instruct the client to massage the lower extremities
  • c. Position the client on the left side
  • d. Measure vital signs every 4 hours Explanation: Heparin is used to prevent further clot formation and treat the embolism.

 

  2. A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
  • a. Avoid extremely hot or cold temperatures (Correct answer)
  • b. Limit fluids to 1.5 L per day
  • c. Limit alcohol intake to one drink per day
  • d. Avoid getting a flu vaccination Explanation: Temperature extremes can trigger sickle cell crises.
  2. A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first?
  • a. Obtain a blood specimen for type and crossmatch
  • b. Insert a large-bore IV catheter (Correct answer)
  • c. Administer IV therapy
  • d. Monitor urine output Explanation: Establishing IV access is the priority to begin fluid resuscitation in hypovolemic shock.
  2. A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
  • a. Dilated appearance of the graft
  • b. Absence of a bruit
  • c. Normotensive blood pressure
  • d. Palpable thrill (Correct answer) Explanation: A palpable thrill is a sign of proper blood flow through the AV graft.
  2. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia?
  • a. Oliguria
  • b. Hypertension
  • c. Muscle weakness (Correct answer)
  • d. Positive Chvostek’s sign (CHEEK) Explanation: Hypokalemia can cause muscle weakness and cramping.
  2. A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take?
  • a. Weigh the client once per week
  • b. Provide the client with a protein intake of 1g/kg/day
  • c. Maintain a daily count of the client’s calorie intake (Correct answer)
  • d. Place the client on a low-carb diet Explanation: Accurate calorie counting is essential to ensure adequate nutrition for wound healing.

 

  2. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?
  • a. “I will expect my stools to be loose” (Correct answer)
  • b. “I will eat a high fiber diet”
  • c. “I will take a laxative when I’m constipated”
  • d. “I will empty my bag when it is full” Explanation: Clients with ileostomies have loose stools due to the lack of colon involvement in waste formation.
  2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take?
  • a. Switch the infusion to a 10% dextrose solution (Correct answer)
  • b. Discontinue the infusion and flush the line
  • c. Decrease the rate of infusion to last until the new bag is available
  • d. Start an infusion of 0.45% sodium chloride solution Explanation: A dextrose solution helps prevent hypoglycemia when TPN is temporarily unavailable.

 

  2. A nurse is caring for a client who is 6 hours postoperative following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalances?
  • a. Hypocalcemia (Correct answer)
  • b. Hypokalemia
  • c. Hypermagnesemia
  • d. Hypernatremia Explanation: Tingling and numbness are classic signs of hypocalcemia, which can occur after thyroid surgery due to parathyroid gland injury.
  2. A nurse is caring for a client who is a caregiver for a relative who has a chronic disease. Which of the following statements indicates the client is adapting to the role change?
  • a. “I had to reschedule my doctor’s appointment last week”
  • b. “I have lunch with my friends once a week” (Correct answer)
  • c. “I’ve lost 15 pounds in the past 2 months”
  • d. “I need to get my blood pressure medicine refilled” Explanation: Maintaining social activities like having lunch with friends indicates adaptation to caregiving responsibilities.
  2. A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?
  • a. “I should withhold my metoprolol if my heart rate is above 100 bpm”
  • b. “I should take my daily aspirin on an empty stomach”
  • c. “I should lie down before taking a dose of isosorbide dinitrate (Correct answer)”
  • d. “I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four doses” Explanation: Lying down before taking isosorbide dinitrate helps prevent dizziness and hypotension, common side effects of nitrates.
  2. A nurse in the post-anesthesia care unit is assessing a client following an appendectomy and finds a 2-cm (3/4 in) area of blood on the postoperative dressing. Which of the following actions should the nurse take?
  • a. Apply pressure
  • b. Loosen the dressing
  • c. Circle the drainage (Correct answer)
  • d. Apply a new dressing Explanation: Circling the drainage allows the nurse to monitor any increase in the size of the blood spot and assess bleeding.
  2. A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement?
  • a. Empty water from the ventilator tubing daily (Correct answer)
  • b. Suction the client’s airway every 4 hours
  • c. Maintain the client in a supine position
  • d. Perform oral care every 2 hours Explanation: Emptying water from ventilator tubing prevents fluid from entering the client’s airway and reduces the risk of infection.
  2. A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?
  • a. Apply new gloves when alternating between wound care sites (Correct answer)
  • b. Provide a diet of fresh fruits and vegetables for the client
  • c. Limit visitation time for the client’s children to 40 minutes per day
  • d. Clean the equipment in the client’s room once per week Explanation: Applying new gloves between sites prevents cross-contamination and reduces the risk of infection.
  2. A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following adverse effects occurs?
  • a. Hair loss
  • b. Polyuria
  • c. Weight gain
  • d. Jaundice (Correct answer) Explanation: Jaundice indicates liver damage, a potential adverse effect of pyrazinamide.
  2. A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care?
  • a. Position the bedside table on the client’s left side
  • b. Place the plate guard on the client’s meal tray (Correct answer)
  • c. Provide the client with a short-handled reacher
  • d. Remind the client to use a cane on the left side while ambulating Explanation: A plate guard helps the client maintain independence in feeding, which is important for self-esteem and rehabilitation.
  2. A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?
  • a. Use a cool fluid for irrigation
  • b. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal
  • c. Tilt the client’s head 45 degrees
  • d. Point the tip of the syringe toward the top of the ear canal (Correct answer) Explanation: Pointing the syringe tip toward the top of the ear canal ensures safe and effective irrigation.
  2. A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
  • a. Ondansetron (Correct answer)
  • b. Sertraline
  • c. Methylprednisolone
  • d. Diphenhydramine Explanation: Ondansetron is an antiemetic commonly used to prevent nausea and vomiting caused by chemotherapy.
  2. A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?
  • a. Increase intake of fiber-rich foods
  • b. May place a small pillow under the head when sleeping
  • c. May operate a motor vehicle when no longer taking analgesics (Correct answer)
  • d. Take a tub bath instead of showers Explanation: Clients with a halo device should not drive due to limited neck mobility and the risk of accidents.
  2. A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching?
  • a. “You should wear an N95 respirator mask when you are at home”
  • b. “You will need to return in 2 weeks to provide a sputum specimen (Correct answer)”
  • c. “You can drink alcohol after the first 6 weeks of treatment”
  • d. “Your provider will discontinue your medications after 3 months of therapy” Explanation: Follow-up sputum tests are necessary to monitor the effectiveness of tuberculosis treatment.
  2. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
  • a. Flushed skin
  • b. Frothy sputum/Hacking cough (Correct answer)
  • c. Jugular vein distention
  • d. Bradycardia Explanation: Frothy sputum and coughing are signs of pulmonary congestion due to left-sided heart failure.
  2. A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following interventions should the nurse include in the plan?
  • a. Avoid using a topical salicylate cream
  • b. Administer acetaminophen for pain management (Correct answer)
  • c. Place a large pillow under the client’s knees when resting
  • d. Apply an ice pack directly to the client’s knees Explanation: Acetaminophen is the first-line treatment for mild to moderate pain associated with osteoarthritis.
  2. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse first take?
  • a. Increase the client’s fluid intake
  • b. Reposition the client in bed
  • c. Check the client’s urine output (Correct answer)
  • d. Administer PRN pain medication Explanation: Sharp abdominal pain may indicate an obstruction in the catheter or irrigation system, requiring immediate assessment of urine output.
  2. A nurse is caring for a client who has Parkinson’s disease and is prescribed a level 1 dysphagia diet. Which of the following items should the nurse remove from the client’s tray?
  • a. Vanilla milkshake
  • b. Peanut butter (Correct answer)
  • c. Chocolate pudding
  • d. Applesauce Explanation: Peanut butter is sticky and difficult to swallow, increasing the risk of choking in clients with dysphagia.
  2. A nurse in a provider’s office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include?
  • a. “Eat a light meal 1 hour before bedtime”
  • b. “Sleep with the head of your bed elevated 6 inches (Correct answer)”
  • c. “Increase your caloric intake by 250 calories per day”
  • d. “Lie down for 30 minutes after each meal” Explanation: Elevating the head of the bed helps prevent reflux during sleep by keeping stomach contents in place.
  2. A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
  • a. Client report of pain at the incision site
  • b. High-pitched sound on inspiration (Correct answer)
  • c. Hypoactive bowel sounds
  • d. Loose tracheal secretions Explanation: A high-pitched sound on inspiration (stridor) is a sign of airway obstruction, which is an emergency following thyroid surgery.

 

  2. A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?
  • a. “The elastic bandage will prevent a post-op wound infection”
  • b. “The elastic bandage will prevent excessive edema” (Correct answer)
  • c. “The elastic bandage will keep the sutures from loosening”
  • d. “The elastic bandage will keep you from seeing the surgical site” Explanation: The elastic bandage helps control swelling, which is essential for healing and preparing the limb for prosthesis.
  2. A nurse is planning care for a client who is 8 hours post-op following coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?
  • a. Examine the surgical incision for drainage
  • b. Auscultate breath sounds (Correct answer)
  • c. Palpate pulses distal to the graft donor site
  • d. Measure the client’s core body temperature Explanation: The priority is to assess for adequate airway and breathing post-surgery by checking breath sounds.
  2. A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?
  • a. “You will need cryotherapy for 1 to 2 weeks”
  • b. “You will need to take an antiviral medication for 6 months”
  • c. “You will need 3 follow-up blood tests within a 24-month period (Correct answer)”
  • d. “You will need to be monitored for 15 minutes after receiving each medication dose” Explanation: Follow-up blood tests are required to confirm that the syphilis infection is fully treated and to prevent complications.
  2. A nurse is caring for a client who has hypotension, cool clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
  • a. Reverse Trendelenburg
  • b. Feet elevated (Correct answer)
  • c. High Fowler’s
  • d. Side-lying Explanation: Elevating the client’s feet improves venous return and helps manage hypotension.
  2. A nurse is teaching a client how to use a quad cane for ambulation following a right-hemispheric stroke. Which of the following client actions indicates an understanding of the teaching?
  • a. Client takes a step before advancing the cane
  • b. Client holds the cane with the left hand (Correct answer)
  • c. Client moves the cane 2 feet ahead
  • d. Client advances the weaker leg forward first Explanation: The client should hold the cane on the opposite side of the affected leg to provide better support and balance.
  2. A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
  • a. “I’ll remove the soiled tracheostomy ties prior to cleansing my stoma”
  • b. “I’ll cut a slit in a clean gauze pad to use as a stoma dressing”
  • c. “I’ll insert the obturator after cleaning my stoma” (Correct answer)
  • d. “I’ll cleanse the cannula with half-strength hydrogen peroxide” Explanation: Inserting the obturator helps maintain the shape of the tracheostomy during cleaning.
  2. A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?
  • a. BUN 18 mg/dl
  • b. Creatinine 0.8 mg/dl
  • c. Potassium 3.2 mEq/L (Correct answer)
  • d. Sodium 136 mEq/L Explanation: Low potassium (hypokalemia) is a contraindication for furosemide because the drug can further reduce potassium levels.
  2. A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?
  • a. Bilateral pupil diameter changes from 4 to 2 mm
  • b. WBC count changes from 9,000 to 16,000/mm³
  • c. Pulse pressure changes from 30 to 20 mm Hg
  • d. Glasgow Coma Scale score changes from 14 to 9 (Correct answer) Explanation: A significant drop in the Glasgow Coma Scale score indicates a deterioration in neurological status, requiring immediate intervention.
  2. A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?
  • a. “I have a hard time with brushing my hair” (Correct answer)
  • b. “I would rather be in a wheelchair than use a walker to get around”
  • c. “I’ve been having problems with bladder control”
  • d. “I have difficulty swallowing food” Explanation: Occupational therapy helps clients maintain independence in performing daily activities like grooming.
  2. A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
  • a. “Secure the cap tightly over the needle before you discard it”
  • b. “Remove the needle from the syringe before you place it in the trash”
  • c. “You can discard needles in an empty bleach bottle with a lid (Correct answer)”
  • d. “Place your storage container in a recycle bin when it is full” Explanation: A sturdy, puncture-proof container like an empty bleach bottle is appropriate for safe needle disposal.
  2. A nurse is assessing a client who has an arteriovenous (AV) graft in the left forearm. Which of the following findings should indicate to the nurse a complication of vascular access?
  • a. 2+ left radial pulse
  • b. Absence of a bruit (Correct answer)
  • c. Presence of a palpable thrill
  • d. Dilated appearance of the AV site Explanation: The absence of a bruit indicates that blood is not flowing through the AV graft properly, which can signal a complication.
  2. A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
  • a. Familiarize themselves with commonly used sign language
  • b. Ask a family member to be present during the admission
  • c. Obtain a board that uses colored pictures as communication
  • d. Request an interpreter during the initial assessment (Correct answer) Explanation: Using an interpreter ensures effective communication with the client during admission.
  2. A nurse is planning care for a client who has an unrepaired intertrochanteric fracture and has Buck’s traction placed on the affected leg. Which of the following interventions should the nurse include?
  • a. Situate the client’s heel in the heel of the traction boot (Correct answer)
  • b. Apply weights of the traction to total 9.1 kg (20 lb)
  • c. Place the footplate against the foot of the bed
  • d. Remove the boot for skin inspection every 12 hours Explanation: Properly situating the client’s heel in the traction boot ensures the traction is effective and prevents skin breakdown.
  2. A nurse is caring for a client who sustained a spinal cord injury in a diving accident. Which of the following actions should the nurse take?
  • a. Assess the client’s neurological status every 8 hours
  • b. Monitor urine output hourly (Correct answer)
  • c. Provide the client with a low-fiber diet
  • d. Logroll the client every 4 hours Explanation: Hourly monitoring of urine output helps detect complications such as neurogenic bladder, which is common in spinal cord injuries.
  2. A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care?
  • a. Flush the catheter using a 10 ml syringe (Correct answer)
  • b. Change the dressing every 24 hours
  • c. Use clean technique when changing the dressing
  • d. Cleanse the site with povidone-iodine Explanation: Using a 10 ml syringe prevents excessive pressure in the catheter, reducing the risk of damage.
  2. A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first?
  • a. Check the color of the client’s skin (Correct answer)
  • b. Remove all of the client’s clothing
  • c. Administer an opioid analgesic
  • d. Prepare the client for peritoneal lavage Explanation: Assessing skin color helps determine circulation status and the presence of shock, which is a priority assessment.
  2. A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?
  • a. Check the client’s gag reflex (Correct answer)
  • b. Inform the client they might experience a low-grade fever
  • c. Instruct the client to report bleeding
  • d. Provide the client with sips of water Explanation: Assessing the gag reflex ensures that the client’s airway is safe before offering food or fluids.
  2. A nurse is developing a plan of care for a client who is returning from the PACU following a left below-the-knee amputation. Which of the following interventions should the nurse include in the plan?
  • a. Provide the client with a firm mattress (Correct answer)
  • b. Wrap the client’s residual limb with an elastic bandage in a distal-to-proximal direction
  • c. Place the client’s residual limb in a dependent position when possible
  • d. Keep the client in a supine position for 48 hours Explanation: A firm mattress prevents pressure sores and provides appropriate support for the client’s body.
  2. A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick-day rules. Which of the following statements by the client indicates an understanding of the teaching?
  • a. “I will monitor my blood glucose every 8 hours”
  • b. “I will consume 250 grams of carbs daily while I’m sick”
  • c. “I will not take my diabetes medications while I am sick”
  • d. “I will check urine for ketones if my blood glucose is greater than 240 mg/dl (Correct answer)” Explanation: Checking for ketones helps detect ketoacidosis, a serious complication of diabetes during illness.
  2. A nurse is reviewing ABG results for a client who has COPD. Which of the following findings should the nurse expect?
  • a. pH 7.38
  • b. PaO2 85 mm Hg
  • c. PaCO2 48 mm Hg (Correct answer)
  • d. HCO3- 25 mEq/L Explanation: Clients with COPD typically have increased PaCO2 due to chronic respiratory retention of carbon dioxide.
  2. A nurse is admitting a client to a medical unit following the placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse?
  • a. Sneezing
  • b. Hiccups (Correct answer)
  • c. Presence of a sharp spike prior to the QRS complex on the ECG
  • d. Presence of intrinsic P waves following a QRS complex on the ECG Explanation: Hiccups can indicate that the pacemaker is stimulating the diaphragm instead of the heart, which requires further evaluation.
  2. A nurse is caring for a client who experienced extensive burns to the arms and torso. Which of the following actions should the nurse take regarding the client’s oral nutritional intake?
  • a. Adhere to scheduled meal times three times daily
  • b. Encourage the client to eat as many calories as possible (Correct answer)
  • c. Limit the client’s fluid intake to 1,500 ml/day
  • d. Avoid the use of supplemental feedings throughout the day Explanation: Clients with extensive burns have increased caloric needs to promote healing and prevent malnutrition.
  2. A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?
  • a. Place pillows under the client’s knees
  • b. Apply compression stockings to the lower extremities (Correct answer)
  • c. Avoid use of anticoagulants
  • d. Discourage leg exercises while in bed Explanation: Compression stockings prevent deep vein thrombosis (DVT) and promote circulation post-surgery.
  2. A nurse is caring for a client who has a duodenal ulcer. Which of the following actions should the nurse take?
  • a. Restrict the client’s fluid intake to 1,000 ml/day
  • b. Infuse packed RBCs (Correct answer)
  • c. Administer the client’s naproxen prescription
  • d. Offer a snack before bedtime Explanation: Duodenal ulcers can cause bleeding, which may require the infusion of packed red blood cells to treat anemia.
  2. A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse’s priority?
  • a. “I can’t seem to get reading materials far enough away to see the words”
  • b. “I’m having more difficulty telling the difference between blues and greens”
  • c. “I’ve noticed that there is a gray ring around the colored part of my eye”
  • d. “In the last day, I have had a severe headache and pain around my right eye (Correct answer)” Explanation: A sudden severe headache with eye pain could indicate glaucoma or another serious condition requiring immediate attention.
  2. A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate?
  • a. BUN 8 mg/dl
  • b. Hgb 20 g/dl
  • c. Potassium 6.8 mEq/L (Correct answer)
  • d. Creatinine 0.4 mg/dl Explanation: Acute kidney injury can result in hyperkalemia, a dangerous electrolyte imbalance requiring immediate intervention.
  2. A nurse is planning care for an older adult client who has Meniere’s disease. Which of the following interventions should the nurse include in the plan?
  • a. Perform range-of-motion exercises to the client’s neck every 4 hours
  • b. Limit the client’s fluid intake to 1,500 ml/day
  • c. Encourage the client to change positions slowly (Correct answer)
  • d. Administer aspirin if the client reports a headache Explanation: Slow changes in position help reduce vertigo and dizziness, which are common symptoms of Meniere’s disease.
  2. A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations?
  • a. Upper left abdomen (Correct answer) Explanation: A transverse colostomy stoma is typically located in the upper left abdomen.
  2. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?
  • a. Initiate beta blocker therapy
  • b. Insert a urinary catheter
  • c. Prepare the client for an intravenous pyelogram
  • d. Administer IV fluids to the client (Correct answer) Explanation: Administering fluids helps maintain adequate perfusion and prevent acute kidney failure following trauma.
  2. A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take?
  • a. Administer through a 22-gauge IV catheter
  • b. Prime the IV tubing with 0.45% sodium chloride
  • c. Complete the transfusion within 2 hours (Correct answer)
  • d. Slow the transfusion rate if the client reports itching Explanation: Packed RBCs should be transfused within 2 to 4 hours to prevent complications such as bacterial growth.
  2. A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
  • a. Increase phosphorus intake
  • b. Decrease protein intake (Correct answer)
  • c. Increase potassium intake
  • d. Decrease carbohydrate intake Explanation: Clients with nephrotic syndrome are often advised to reduce protein intake to help manage kidney function.
  2. A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client’s abstract thinking?
  • a. “Can you count backwards from 100 in intervals of 7?”
  • b. “What is meant by the saying, don’t beat around the bush? (Correct answer)”
  • c. “What do you understand about your condition?”
  • d. “Can you tell me the state where you were born?” Explanation: Assessing abstract thinking involves asking the client to interpret sayings or metaphors.
  2. A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
  • a. Keep the soiled bed linens in the client’s room (Correct answer)
  • b. Instruct visitors to remain 3 feet from the client
  • c. Discard the radioactive device in the client’s trash can
  • d. Limit time for visitors to 2 hours per day Explanation: Soiled linens and other materials that may be contaminated with radiation should be kept in the client’s room for safety.
  2. A nurse is preparing a client for a lumbar puncture. Which of the following images indicates the position should the nurse assist the client into for this procedure?
  • a. Side-lying (Correct answer) Explanation: A fetal or side-lying position is required for a lumbar puncture to allow the doctor access to the spinal column.
  2. A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take?
  • a. Place long-handled forceps at the client’s bedside (Correct answer)
  • b. Attach a dosimeter badge to the client’s gown
  • c. Leave unused equipment in the client’s room until discharge
  • d. Move the client’s soiled linens to a designated container outside the room Explanation: Long-handled forceps should be available in case the radiation implant needs to be safely handled.
  2. A nurse is teaching a client who has Graves’ disease about recognizing the manifestations of a thyroid storm. Which of the following findings should the nurse include in the teaching?
  • a. Increased temperature (Correct answer)
  • b. Decreased heart rate
  • c. Hypotension
  • d. Lethargy Explanation: A thyroid storm is characterized by a high fever, tachycardia, and other signs of hypermetabolism.
  2. A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?
  • a. Serosanguineous drainage
  • b. Muscle twitching (Correct answer)
  • c. Client report of nausea
  • d. Client report of incisional pain Explanation: Muscle twitching may indicate hypocalcemia, a serious complication after thyroid surgery due to parathyroid injury.
  2. A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify that which of the following rhythms indicates bradycardia?
  • Pick the bradycardia strip (Correct answer) Explanation: Bradycardia is defined as a heart rate under 60 beats per minute, shown by a wider distance between QRS complexes.
  2. A nurse is caring for a client who is receiving epidural analgesics. Which of the following assessment findings is the nurse’s priority?
  • a. Bladder distention
  • b. Hypoactive bowel sounds
  • c. Hypotension (Correct answer)
  • d. Weakness in lower extremities Explanation: Hypotension is a common side effect of epidural analgesics and requires immediate intervention to maintain perfusion.
  2. A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse’s priority to include?
  • a. Turn the client to the lateral position during seizure activity (Correct answer)
  • b. Provide the client oxygen at 6 L/min using a nasal cannula
  • c. Administer phenytoin IV bolus to the client
  • d. Administer diazepam intravenously to the client Explanation: Turning the client to the lateral position helps prevent aspiration and maintain an open airway during seizures.
  2. A nurse is caring for a client following a below-the-knee amputation. The client states, “My life is over.” Which of the following responses should the nurse make?
  • a. “You are upset. We can talk about this later.”
  • b. “Would you like to meet with another client who is an amputee? (Correct answer)”
  • c. “Why do you think your life is over?”
  • d. “Most people can adjust following this surgery.” Explanation: Connecting the client with someone who has experienced a similar situation can provide emotional support and hope.
  2. A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after the age of 60? Select all that apply.
  • a. Herpes zoster (Correct answer)
  • b. Influenza (Correct answer)
  • c. Meningococcal
  • d. Human papillomavirus
  • e. Pneumococcal polysaccharide (Correct answer) Explanation: Older adults are at increased risk for shingles, influenza, and pneumonia, so these immunizations are recommended.
  2. A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
  • a. Turn off all lights in the client’s room at night
  • b. Place the client’s bed at the lowest height (Correct answer)
  • c. Request a prescription for a nightly sedative
  • d. Assist the client with toileting at least once every 4 hours Explanation: Lowering the bed helps prevent falls and keeps the client safe, especially at night when confusion can increase.
  2. A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings indicates that the client is experiencing hypoglycemia?
  • a. Abdominal cramping
  • b. Increased perspiration (Correct answer)
  • c. Dehydration
  • d. Fruity odor to breath Explanation: Increased perspiration, along with shakiness and dizziness, is a common sign of hypoglycemia.
  2. A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address?
  • a. Vomiting upon arousal (Correct answer)
  • b. Decreased body temperature
  • c. Indistinct, rambling speech
  • d. Piloerection of the skin Explanation: Vomiting increases the risk of aspiration, which is especially dangerous after anesthesia, making it the priority to address.
  2. A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?
  • a. Bradycardia
  • b. Hypotension
  • c. Loss of skin turgor
  • d. Weight gain (Correct answer) Explanation: Hypervolemia, or fluid overload, leads to weight gain due to excessive fluid retention.
  2. A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? Select all that apply.
  • a. Take a warm bubble bath daily
  • b. Void every 6 hours during the day
  • c. Drink low-fructose cranberry juice (Correct answer)
  • d. Wipe the perineal area from front to back after urinating (Correct answer)
  • e. Drink 3 L of fluids daily (Correct answer) Explanation: Cranberry juice can help prevent UTIs, and increased fluid intake, as well as proper hygiene, are key prevention strategies.
  2. A nurse is caring for a client following a cardiac catheterization who has hives and urticaria following administration of IV contrast dye. Which of the following medications should the nurse plan to administer?
  • a. Spironolactone
  • b. Desmopressin
  • c. Metoclopramide
  • d. Diphenhydramine (Correct answer) Explanation: Diphenhydramine is an antihistamine used to treat allergic reactions such as hives and urticaria.
  2. A home care nurse is planning to use nonpharmacological pain relief measures for an older adult client who has severe chronic back pain. Which of the following guidelines should the nurse use?
  • a. Discontinue opioids before trying nonpharmacological methods of pain relief
  • b. Use imagery with clients who have difficulty with focus and concentration
  • c. Distraction changes the client’s perception of pain but does not affect the cause (Correct answer)
  • d. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus Explanation: Distraction is effective for altering a client’s perception of pain, though it does not address the underlying cause.
  2. A nurse is caring for a female client who is receiving total parenteral nutrition (TPN) without fat emulsion. Which of the following findings should the nurse report?
  • a. Crackles in the bilateral lung bases (Correct answer)
  • b. Weight gain of 1.3 kg (3 lb) over the past 7 days
  • c. Triglyceride 110 mg/dL
  • d. Bowel sounds absent in lower quadrants Explanation: Crackles in the lungs may indicate fluid overload, a potential complication of TPN, and should be reported immediately.

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