MedSurg 2023 proctored ATI exam
04 September 2024MedSurg 2023 proctored ATI
1. 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?
Take temperature once a day (Correct answer)
Avoid exposure to crowds
Limit fluid intake
Report changes in urine color
2. 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?
Administer acetylcysteine
Provide humidified oxygen (Correct answer)
Perform chest physiotherapy
Suction the airway every 15 minutes
3. 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?
Apply warm compresses
Obtain a pair of slipper socks for the client (Correct answer)
Elevate the feet
Administer pain medication
4. 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?
Output of 150 mL/hr
Thick, red-colored urine (Correct answer)
Reports of bladder spasms
Low-grade fever
5. 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?
Bradycardia
Shivering (Correct answer)
Hypotension
Tachycardia
6. 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?
“I will not exercise if my urine is positive for ketones.” (Correct answer)
“I will exercise at least 60 minutes a day.”
“I should avoid carbohydrates before exercising.”
“I should eat an extra snack before exercising.”
7. 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?
Apply a sterile dressing over the wound
Cover the client’s wound with a moist, sterile dressing (Correct answer)
Place the client in a low-Fowler’s position
Administer pain medication
8. 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?
Hypoventilation
Hyperventilation (Correct answer)
Bradycardia
Diaphoresis
9. A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?
Avoid bending at the waist (Correct answer)
Apply warm compresses to the affected eye
Avoid wearing an eye shield at night
Expect eye drainage for 2 weeks
10. 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?
Request an order for an antiemetic
Check the client’s vital signs (Correct answer)
Administer a dose of digoxin
Encourage the client to eat
11. 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?
Serous
Sanguineous
Purulent (Correct answer)
Serosanguineous
12. 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?
Encourage early ambulation
Administer an opioid analgesic to the client 30 minutes prior to initiating CPM exercises (Correct answer)
Limit fluid intake for 24 hours
Apply heat to the affected area every 4 hours
13. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)
Dyspnea (Correct answer)
Barrel chest (Correct answer)
Clubbing of the fingers (Correct answer)
Shallow respirations (Correct answer)
Increased appetite
14. 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 the client’s right nostril. Which of the following actions should the nurse take first?
Suction the nostril
Test the drainage for glucose (Correct answer)
Administer an antihistamine
Apply a nasal drip pad
15. 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?
Monitor for bradycardia
Prevent bladder distention (Correct answer)
Administer a muscle relaxant
Apply compression stockings
16. 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?
Pelvic pain
Abnormal vaginal bleeding (Correct answer)
Severe headaches
Lower back pain
17. 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?
Diminished peripheral pulses
Altered level of consciousness (Correct answer)
Swelling at the fracture site
Pain with movement
18. 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?
Bloody drainage in the chest tube
Abdomen is distended (Correct answer)
Pain at the chest tube insertion site
Minimal breath sounds
19. 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?
Apply powder to the stoma daily
Change the ostomy pouch daily (Correct answer)
Decrease fluid intake to reduce output
Irrigate the stoma with warm water
20. 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?
Monitor for hyperglycemia
Change the nasal drip pad as needed (Correct answer)
Apply ice packs to the incision site
Restrict fluid intake
21. 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?
To relieve pain
To reduce inflammation
To prevent blood clotting (Correct answer)
To lower cholesterol levels
22. A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?
Blurred vision
Loss of peripheral vision (Correct answer)
Eye redness
Halos around lights
23. 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?
Abdominal cramping
Potassium 2.5 mEq/L (Correct answer)
Diarrhea
Vomiting
24. A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching?
“I will avoid lifting heavy objects.”
“I will take a tub bath instead of a shower.” (Correct answer)
“I will follow up with my doctor next week.”
“I will monitor for signs of infection.”
25. 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?
Massage the affected leg
Ensure the client’s weights are hanging freely from the bed (Correct answer)
Remove traction during personal care
Apply warm compresses to the affected leg
26. 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?
Take this medication between meals (Correct answer)
Take this medication with a full glass of milk
Take this medication with a calcium supplement
Take this medication before bedtime
27. 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?
Apply heat to the affected area
Wash daily with an antibacterial soap (Correct answer)
Keep the affected leg elevated above the heart
Apply an ice pack to the affected area
28. 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?
Take fiber supplements daily
Avoid medications in capsule or enteric form (Correct answer)
Avoid foods that are high in carbohydrates
Change the appliance every 4 days
29. 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?
“We will remove the burned tissue to promote healing.”
“Large incisions will be made in the burned tissue to improve circulation.” (Correct answer)
“A skin graft will be placed over the burned area.”
“The procedure will help prevent infection.”
30. 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?
Double vision
Decreased color perception (Correct answer)
Severe eye pain
Halos around lights
31. 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?
Administer an antiemetic
Maintain the client in Fowler’s position (Correct answer)
Provide sips of water every hour
Encourage the client to ambulate frequently
32. 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.)
Buffalo hump (Correct answer)
Purple striations (Correct answer)
Moon face (Correct answer)
Weight loss
Increased skin elasticity
33. 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?
Monitor intake and output hourly (Correct answer)
Decrease fluid intake
Restrict protein intake
Increase sodium intake
34. 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?
“You will need to remain NPO for 24 hours after the procedure.”
“You will remain NPO for 8 hours before the procedure.” (Correct answer)
“You will need to avoid spicy foods after the procedure.”
“You will receive general anesthesia for this procedure.”
35. 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?
Seizure activity
Postictal phase (Correct answer)
Somnolence
Hyperactivity
36. 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?
“The pain is likely caused by your surgical position.”
“The pain will dissipate if you ambulate frequently.” (Correct answer)
“Apply heat to the affected area for relief.”
“Take an analgesic every 4 hours.”
37. 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?
Notify the provider (Correct answer)
Increase the suction pressure
Clamp the chest tube
Milk the chest tube tubing
38. 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.)
Encourage fluid intake (Correct answer)
Monitor the puncture site for hematoma (Correct answer)
Administer a sedative
Elevate the head of the bed
Monitor for urinary retention
39. 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?
Administer pain medication
Prevent aspiration (Correct answer)
Perform oral hygiene
Administer antiemetics
40. A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?
Skin breakdown
Hardened skin (Correct answer)
Alopecia
Blisters on the skin
41. 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?
Add thickener to fluids (Correct answer)
Feed the client while lying flat
Offer large sips of water
Administer a stimulant laxative
42. 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?
Airway obstruction (Correct answer)
Infection
Dehydration
Hypothermia
43. 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?
Take the medication 45 minutes before eating (Correct answer)
Take the medication with a full meal
Increase fluid intake
Take the medication every 6 hours
44. 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?
Administer a diuretic
Determine the patency of the tubing (Correct answer)
Increase the irrigation rate
Irrigate the catheter manually
45. 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?
“You will not feel any pain during the procedure.”
“The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible.” (Correct answer)
“You will be under anesthesia, so there is nothing to worry about.”
“The biopsy will only take a few minutes.”
46. 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?
Re-establish communication (Correct answer)
Encourage the client to use the left hand
Assist with range of motion exercises
Teach the client to use a cane for ambulation
47. 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?
Bradycardia
Hypotension (Correct answer)
Hyperglycemia
Weight gain
48. 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?
Metabolic acidosis
Respiratory acidosis (Correct answer)
Metabolic alkalosis
Respiratory alkalosis
49. 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?
“I will elevate my legs when sitting.”
“I will wear stockings with elastic tops.” (Correct answer)
“I will check my feet daily for sores.”
“I will keep my feet warm.”
50. 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?
Calmly ask the client if he would like to listen to some music (Correct answer)
Restrain the client
Administer an antipsychotic
Wait until the client falls asleep
51. 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?
Necrotic tissue
Granulation tissue (Correct answer)
Slough
Eschar
52. 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?
Cooked vegetables
Cheese
Fresh fruit basket (Correct answer)
Canned soup
53. 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?
Encourage the client to cross their legs at the ankles
Maintain abduction of the right hip (Correct answer)
Position the client on the right side
Perform passive range of motion exercises to the hip
54. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first?
Begin rescue breathing
Feel for a carotid pulse (Correct answer)
Call for assistance
Start chest compressions
55. 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?
“You don’t have to make a decision right now.”
“Let’s call the doctor to explain the procedure again.”
“Bypass surgery must be very frightening for you.” (Correct answer)
“You have the right to refuse the procedure.”
56. 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?
Help the client to the bed immediately
Tell the client to remain in the bathroom after toileting and obtain a wheelchair (Correct answer)
Report the incident to the provider
Provide the client with crutches for future use
57. 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?
Flush the drain with sterile saline
Fully recollapse the reservoir after emptying it (Correct answer)
Apply a warm compress to the drainage site
Change the dressing every 8 hours
58. 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?
“I can donate blood once my symptoms resolve.”
“I will take my medication with food to avoid nausea.”
“I will abstain from sexual intercourse.” (Correct answer)
“I can return to work in 1 week.”
59. 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?
Inhale deeply before exhaling quickly
Use a humidifier in your room
Breathe in through your nose and out through pursed lips (Correct answer)
Avoid exercise to conserve energy
60. 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?
Hyperglycemia
Hypotension (Correct answer)
Fluid retention
Weight gain
61. 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.)
Decreasing anxiety (Correct answer)
Reducing blood pressure
Controlling emesis (Correct answer)
Reducing the amount of narcotics needed for pain relief (Correct answer)
Promoting restlessness
62. 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?
Calcium
Magnesium
Iron (Correct answer)
Potassium
63. 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?
Maintaining the client in a supine position
Ineffective airway clearance related to thick, copious secretions (Correct answer)
Providing pain management
Assessing the surgical site for signs of infection
64. 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?
Walk without assistance
Propel a wheelchair equipped with knobs on the wheels (Correct answer)
Perform transfers independently
Use a mechanical lift for all transfers
65. A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer?
Sun exposure (Correct answer)
Smoking
Family history of cancer
Chemical exposure
66. 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?
“Do you have irregular menstrual periods?”
“Do you sleep well at night?” (Correct answer)
“Have you had any recent changes in your mood?”
“Do you experience headaches?”
67. 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?
Fresh berries (Correct answer)
Whole wheat bread
Chicken breast
White rice
68. 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?
Vomiting
Lethargy (Correct answer)
Fever
Hypotension
69. 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?
“This test will measure the clarity of your vision.”
“This test will measure the intraocular pressure of the eye.” (Correct answer)
“This test will assess for damage to your optic nerve.”
“This test will determine whether you have cataracts.”
70. 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?
Decrease in white blood cell count
Increase in potassium level
Increase in serum creatinine (Correct answer)
Decrease in hemoglobin level
71. A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?
Drop in systolic BP more than 10 mm Hg on inspiration (Correct answer)
Rise in diastolic BP more than 10 mm Hg on expiration
Elevated heart rate when standing
Irregular pulse rate during breathing
72. 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?
Escort the client back to their room
Attempt to determine what the client was looking for (Correct answer)
Administer an antianxiety medication
Provide one-on-one supervision
73. 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?
Assess the insertion site every 4 hours
Check pedal pulses every 15 minutes (Correct answer)
Position the client in Trendelenburg
Keep the client’s legs elevated
74. 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?
The composition of the influenza vaccine changes yearly (Correct answer)
The vaccine should be administered every 6 months
The vaccine is contraindicated for clients over 65
The vaccine is only required once in a lifetime
75. 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?
Explain all the details of the treatment plan
Help the client write down questions to ask his provider (Correct answer)
Provide educational pamphlets
Tell the client to wait for his provider’s explanation
76. 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?
“Your mother will recover soon.”
“It’s important that you remain calm.”
“Would you like to speak to a counselor?”
“It must be hard to see your mother so ill and upset.” (Correct answer)
77. 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?
Sudden memory loss
Forgetfulness gradually progressing to disorientation (Correct answer)
Hallucinations
Extreme mood swings
78. 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?
Assist with ambulation
Monitor the client’s cardinal fields of vision (Correct answer)
Encourage deep breathing exercises
Perform chest percussion
79. 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?
Perform range of motion exercises on the leg
Monitor platelet levels (Correct answer)
Apply ice to the leg
Massage the affected leg
80. 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?
Administer a TB vaccine
Obtain a sputum sample
Prepare for a chest x-ray (Correct answer)
Collect a stool sample
81. 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?
Increased urine specific gravity
Decreased thirst
Urine output 650 mL/hr (Correct answer)
Hypertension
82. 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?
“I have a shellfish allergy.”
“I drank plenty of fluids yesterday.”
“I took my metformin before breakfast.” (Correct answer)
“I haven’t eaten anything since last night.”
83. 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?
Crackles
Rhonchi
Expiratory wheeze (Correct answer)
Pleural friction rub
84. 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?
Use sterile gloves to remove the dressing
Don clean gloves to remove the dressing (Correct answer)
Apply a new dressing without washing hands
Pour sterile saline over the dressing
85. 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?
Sitting, leaning forward over the bedside table (Correct answer)
Lying flat with arms crossed
Side-lying with knees flexed
Supine with arms at the sides
86. 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?
Anger
Depression
Denial (Correct answer)
Acceptance
87. 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?
Place the client in the supine position
Place the client in a high Fowler’s position (Correct answer)
Perform range of motion exercises
Apply warm compresses to the abdomen
88. 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?
Blood pressure
Body weight (Correct answer)
Intake and output
Urine color
89. 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?
Increased blood pressure
Hypotension (Correct answer)
Bradycardia
Dry, warm skin
90. 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 sensory warning that a seizure is imminent (Correct answer)
A mild headache that signals a migraine
A temporary loss of consciousness
A feeling of dizziness before fainting
91. 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?
“I’m feeling a little drowsy from the medication.”
“I feel like my eye is itchy.”
“I need something for the horrible pain in my eye.” (Correct answer)
“The light is really bothering my eyes.”
92. 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?
“You won’t feel anything at all.”
“It depends on how sensitive your colon is.”
“You may feel some cramping during the procedure.” (Correct answer)
“You will be under general anesthesia.”
93. 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?
Checking visual acuity
Checking pupillary responses to light (Correct answer)
Asking the client to move the tongue from side to side
Testing hearing ability
94. 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?
Lowering the client’s blood pressure
Reducing anxiety (Correct answer)
Decreasing the client’s respiratory rate
Helping the client sleep
95. A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report?
Frequent mood changes (Correct answer)
Constipation
Weight gain
Decreased appetite
96. 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?
Redness at the pin sites
Fever (Correct answer)
Increased mobility of the joints
Mild discomfort
97. 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.)
Blurry vision (Correct answer)
Abdominal pain
Tachycardia (Correct answer)
Sweating (Correct answer)
Polyuria
98. 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.)
Diarrhea
Edema (Correct answer)
Erythema (Correct answer)
Tophi (Correct answer)
Tight skin (Correct answer)
99. 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?
Respiratory difficulty (Correct answer)
Muscle spasms
Joint pain
Increased heart rate
100. 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?
Administer antibiotics
Monitor bowel movements
Evaluate fluid and electrolyte levels (Correct answer)
Administer pain medication
101. 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?
“You should take the medication with food to avoid nausea.”
“You should avoid alcohol while taking this medication.”
“You should wear glasses instead of contacts while taking this medication.” (Correct answer)
“You will need to stop this medication after 2 weeks.”
102. 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?
“I will take this medication until my lab results are normal.”
“I will take this medication only when I feel sick.”
“I will need to take this medication for the rest of my life.” (Correct answer)
“I can stop this medication if I don’t experience any side effects.”
103. 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?
Decreased tremors (Correct answer)
Increased salivation
Decreased joint stiffness
Improved balance
104. 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?
Administer an antihistamine
Call the provider
Stop the transfusion (Correct answer)
Check the client’s temperature
105. 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?
“I will wear warm gloves when I go outside.”
“I will avoid smoking to help manage my symptoms.”
“I will use stress-relief techniques to help prevent attacks.”
“I will keep my house at a cool temperature.” (Correct answer)
106. 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 indicates an understanding of the teaching?
“I will take the medication with milk.”
“I will take the medication with orange juice.” (Correct answer)
“I will take the medication on an empty stomach.”
“I will avoid eating citrus fruits while taking this medication.”
107. 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?
Folic acid
Iron
Vitamin B12 (Correct answer)
Calcium
108. 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?
“I don’t feel like eating.”
“I feel very sleepy.” (Correct answer)
“I feel very thirsty.”
“I feel ready to go.”
109. 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?
Candidiasis (Correct answer)
Leukoplakia
Stomatitis
Herpes simplex
110. 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?
Change the wound dressing every 12 hours
Empty the suction device every 4 hours (Correct answer)
Apply warm compresses to the wound
Clamp the wound drain as needed
111. 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?
Hoarseness (Correct answer)
Difficulty swallowing
Shortness of breath
Persistent cough
112. 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?
BUN
Serum creatinine (Correct answer)
ALT
WBC count
113. A nurse is collecting data from a client who has Cushing’s syndrome. Which of the following manifestations should the nurse expect?
Weight loss
Bruising (Correct answer)
Increased muscle strength
Frequent urination
114. 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?
Ask the client what they would like to drink
Auscultate the client’s abdomen (Correct answer)
Offer the client a small amount of water
Measure the client’s urine output
115. 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?
The wound has a small amount of serous drainage
The wound edges are slightly red
The wound has a halo of erythema on the surrounding skin (Correct answer)
The wound bed is moist with granulation tissue
116. 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?
Absence of breath sounds (Correct answer)
Decreased respiratory rate
Hemoptysis
Bradycardia
117. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
Crackles in the lungs
Peripheral edema (Correct answer)
Dry, flaky skin
Weight loss
118. 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?
Encourage the client to drink a carbonated beverage 1 hour before meals (Correct answer)
Administer an antiemetic after meals
Offer the client a high-protein snack
Suggest the client eat a large meal before chemotherapy
119. 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?
Irrigate the catheter as prescribed (Correct answer)
Apply an external catheter
Empty the catheter bag every hour
Measure the client’s urine output every 30 minutes
120. 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?
“I will avoid reading for the next 3 days.”
“I will take a stool softener until my eye is healed.” (Correct answer)
“I can lift objects up to 20 pounds.”
“I can rub my eye if it starts itching.”
121. 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?
Tachycardia
Hypotension
Hypertension (Correct answer)
Increased appetite
122. A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?
Administer 100% oxygen via face mask
Encourage the client to drink 8 glasses of water a day (Correct answer)
Provide a high-carbohydrate diet
Limit fluid intake to prevent overload
123. 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?
Hypothermia
Airway obstruction (Correct answer)
Electrolyte imbalance
Infection
124. 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?
Joint pain
An expanding circular rash (Correct answer)
Difficulty breathing
Headache
125. 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?
Brushing her teeth
Combing her hair (Correct answer)
Writing her name
Eating a meal
126. 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?
Report of dryness with vaginal intercourse (Correct answer)
Irregular periods
Hair loss
Lower back pain
127. 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?
One week before menses
On the first day of menses
Three to seven days after menses stops (Correct answer)
On the last day of menses
128. 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?
Chicken salad
Turkey and cheese sandwich with scalloped potatoes (Correct answer)
Grilled cheese sandwich with a side of fruit
Low-fat yogurt with berries
129. 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?
“Take a laxative the evening before the procedure.” (Correct answer)
“Do not eat or drink anything for 12 hours before the procedure.”
“You may experience some discomfort during the procedure.”
“You will need to drink plenty of water after the procedure.”
130. 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?
“I feel so much better after eating.” (Correct answer)
“I feel bloated and gassy after meals.”
“My pain is worse when I lie down.”
“I have trouble swallowing food.”
131. 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?
Encourage family visits
Schedule pain medication on a routine basis (Correct answer)
Assist the client with activities of daily living
Provide emotional support
132. 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?
“I should call the clinic before taking any over-the-counter medications.” (Correct answer)
“I can stop using my eye drops once my vision improves.”
“I should avoid wearing contact lenses while taking my medication.”
“I should avoid reading for more than 30 minutes at a time.”
Â
