Here are questions 41 through 100, rewritten with the correct answers indicated:

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41. **A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take?**

\- a. Encourage the client to drink fluids before swallowing food.

\- b. \*\*Offer the client food on the unaffected side of their mouth.\*\* (Correct answer)

\- c. Place the client in a supine position for meals.

\- d. Encourage the client to drink thin liquids.

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42. **A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take first?**

\- a. \*\*Verify the client’s identity.\*\* (Correct answer)

\- b. Obtain the client’s vital signs.

\- c. Prime the infusion tubing with normal saline.

\- d. Obtain the blood product from the blood bank.

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43. **A nurse is providing teaching to a client who has a new prescription for digoxin. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I will increase my intake of foods high in sodium.”

\- b. “I will take my pulse before taking the medication.” (Correct answer)

\- c. “I should drink plenty of water while taking this medication.”

\- d. “I will take this medication with antacids.”

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44. **A nurse is caring for a client who has a prescription for acetaminophen 650 mg every 4 hours PRN for pain. The client has been receiving 650 mg every 4 hours for the past 24 hours. Which of the following findings should the nurse report to the provider?**

\- a. Temperature of 37.2°C (99°F)

\- b. \*\*Difficulty waking the client\*\* (Correct answer)

\- c. BP 118/76 mm Hg

\- d. Pain level 5 on a scale of 0 to 10

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45. **A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?**

\- a. Shave the area around the insertion site.

\- b. \*\*Lift the penis perpendicular to the client’s body.\*\* (Correct answer)

\- c. Retract the foreskin before cleansing.

\- d. Hold the penis at a 45° angle when inserting the catheter.

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46. **A nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which of the following actions should the nurse take?**

\- a. \*\*Clamp the NG tube for 30 minutes after medication administration.\*\* (Correct answer)

\- b. Administer the medication through a syringe with a 16-gauge needle.

\- c. Flush the tube with 10 mL of water before and after medication administration.

\- d. Place the client in a supine position.

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47. **A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse notes that the client’s bowel sounds are present. Which of the following actions should the nurse take?**

\- a. \*\*Encourage the client to ambulate.\*\* (Correct answer)

\- b. Notify the surgeon.

\- c. Administer a stool softener.

\- d. Keep the client NPO.

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48. **A nurse is teaching a client who has a new diagnosis of type 2 diabetes mellitus about foot care. Which of the following instructions should the nurse include?**

\- a. \*\*Wear shoes that are fitted properly.\*\* (Correct answer)

\- b. Soak the feet in hot water daily.

\- c. Apply lotion between the toes.

\- d. Cut the toenails at an angle.

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49. **A nurse is caring for a client who has a prescription for a fluid restriction of 1,000 mL/day. Which of the following actions should the nurse take?**

\- a. Provide the client with a pitcher of water at the beginning of each shift.

\- b. \*\*Offer the client 120 mL of fluid every 4 hours.\*\* (Correct answer)

\- c. Place the client on NPO status.

\- d. Measure the client's urine specific gravity.

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50. **A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?**

\- a. Crackles in the lungs

\- b. \*\*Jugular vein distention\*\* (Correct answer)

\- c. Decreased capillary refill

\- d. Decreased urinary output

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51. **A nurse is teaching a client who has a new diagnosis of hypertension about lifestyle changes to manage the condition. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I will eat a high-protein diet.”

\- b. “I will limit my intake of foods high in potassium.”

\- c. \*\*“I will reduce my sodium intake.”\*\* (Correct answer)

\- d. “I will increase my fluid intake.”

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52. **A nurse is caring for a client who has COPD and is receiving oxygen therapy. Which of the following actions should the nurse take?**

\- a. \*\*Use a venturi mask to deliver a precise oxygen concentration.\*\* (Correct answer)

\- b. Administer oxygen at 6 L/min via nasal cannula.

\- c. Encourage the client to use pursed-lip breathing.

\- d. Discontinue the oxygen therapy during meals.

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53. **A nurse is assessing a client who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?**

\- a. Hypertension

\- b. \*\*Muscle spasms\*\* (Correct answer)

\- c. Decreased deep tendon reflexes

\- d. Constipation

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54. **A nurse is teaching a client who has a new prescription for metoprolol. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I will take my pulse before taking this medication.” (Correct answer)

\- b. “I should take this medication on an empty stomach.”

\- c. “I will avoid eating grapefruit while taking this medication.”

\- d. “I should expect to feel nervous while taking this medication.”

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55. **A nurse is caring for a client who is postoperative following a hip replacement. Which of the following actions should the nurse take to prevent complications?**

\- a. \*\*Encourage the client to perform isometric exercises.\*\* (Correct answer)

\- b. Place a pillow under the client’s knees.

\- c. Elevate the client’s legs above heart level.

\- d. Apply ice packs to the client’s legs.

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56. **A nurse is teaching a client who has heart failure about dietary changes. Which of the following foods should the nurse recommend the client avoid?**

\- a. \*\*Canned soups\*\* (Correct answer)

\- b. Fresh fruit

\- c. Whole grains

\- d. Lean meats

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57. **A nurse is caring for a client who has a nasogastric tube in place for gastric decompression. Which of the following actions should the nurse take?**

\- a. \*\*Maintain the client in a semi-Fowler’s position.\*\* (Correct answer)

\- b. Measure the tube from the tip of the nose to the earlobe to the xiphoid process.

\- c. Advance the tube 2.5 cm (1 in) if resistance is met.

\- d. Secure the tube to the client’s gown.

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58. **A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?**

\- a. Flush the tube with water.

\- b. \*\*Aspirate the tube for residual contents.\*\* (Correct answer)

\- c. Elevate the head of the bed.

\- d. Warm the feeding solution.

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59. **A nurse is caring for a client who has had a cerebrovascular accident (CVA) and is experiencing aphasia. Which of the following actions should the nurse take?**

\- a. \*\*Use pictures to communicate.\*\* (Correct answer)

\- b. Speak louder to the client.

\- c. Discourage the client from using gestures.

\- d. Limit communication to short, simple sentences.

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60. **A nurse is planning care for a client who has a new prescription for enoxaparin. Which of the following actions should the nurse take?**

\- a. \*\*Administer the medication into the client's abdomen.\*\* (Correct answer)

\- b. Massage the injection site after administering the medication.

\- c. Aspirate before injecting the medication.

\- d. Use a 21-gauge needle to administer the medication.

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61. **A nurse is caring for a client who has deep vein thrombosis (DVT). Which of the following actions should the nurse take?**

\- a. \*\*Elevate the affected extremity.\*\* (Correct answer)

\- b. Apply ice to the affected extremity.

\- c. Encourage the client to ambulate.

\- d. Massage the affected extremity.

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62. **A nurse is providing teaching to a client who has a new prescription for furosemide. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I will increase my intake of potassium-rich foods.” (Correct answer)

\- b. “I will limit my intake of fluids while taking

this medication.”

\- c. “I should take this medication before bedtime.”

\- d. “I should expect my urine to be orange in color.”

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63. **A nurse is preparing to insert an IV catheter for a client who is dehydrated. Which of the following actions should the nurse take?**

\- a. \*\*Apply a tourniquet above the intended insertion site.\*\* (Correct answer)

\- b. Shave the hair around the intended insertion site.

\- c. Insert the catheter at a 45° angle.

\- d. Place the arm in a dependent position.

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64. **A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take?**

\- a. \*\*Log roll the client when turning.\*\* (Correct answer)

\- b. Place pillows under the client's knees.

\- c. Elevate the head of the bed to 45°.

\- d. Encourage the client to ambulate on the day of surgery.

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65. **A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about ways to improve gas exchange. Which of the following instructions should the nurse include?**

\- a. \*\*“Pursed-lip breathing can help you control your breathing.”\*\* (Correct answer)

\- b. “You should limit your fluid intake to 1 liter per day.”

\- c. “Lie flat on your back to help with breathing.”

\- d. “Use oxygen at a rate of 8 L/min.”

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66. **A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?**

\- a. Administer a diuretic.

\- b. \*\*Provide oral hygiene every 2 hours.\*\* (Correct answer)

\- c. Restrict fluid intake.

\- d. Encourage the client to increase sodium intake.

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67. **A nurse is providing teaching to a client who has gastroesophageal reflux disease (GERD). Which of the following instructions should the nurse include?**

\- a. “You should avoid lying down for 30 minutes after meals.”

\- b. \*\*“You should eat four to six small meals each day.”\*\* (Correct answer)

\- c. “You should increase your intake of citrus fruits.”

\- d. “You should avoid drinking fluids between meals.”

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68. **A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?**

\- a. \*\*Edema in the affected extremity\*\* (Correct answer)

\- b. Diminished pedal pulses

\- c. Thin, shiny skin

\- d. Hair loss on the legs

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69. **A nurse is teaching a client who has a new prescription for lisinopril. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I will increase my intake of foods high in sodium.”

\- b. “I will take this medication with food.”

\- c. \*\*“I should notify my provider if I develop a persistent cough.”\*\* (Correct answer)

\- d. “I should expect to gain weight while taking this medication.”

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70. **A nurse is caring for a client who has a urinary tract infection (UTI). Which of the following findings should the nurse expect?**

\- a. \*\*Urinary frequency\*\* (Correct answer)

\- b. Hematuria

\- c. Oliguria

\- d. Proteinuria

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71. **A nurse is teaching a client who has hypertension about dietary modifications. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I will eat a diet high in saturated fat.”

\- b. “I will limit my intake of foods high in potassium.”

\- c. \*\*“I will reduce my sodium intake.”\*\* (Correct answer)

\- d. “I will increase my fluid intake.”

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72. **A nurse is providing teaching to a client who has a new diagnosis of peptic ulcer disease (PUD). Which of the following instructions should the nurse include?**

\- a. “You should take ibuprofen for pain relief.”

\- b. \*\*“You should avoid eating spicy foods.”\*\* (Correct answer)

\- c. “You should increase your intake of dairy products.”

\- d. “You should drink alcohol in moderation.”

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73. **A nurse is assessing a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following findings should the nurse expect?**

\- a. Decreased pedal pulse in the left foot.

\- b. \*\*Warmth and redness of the affected area.\*\* (Correct answer)

\- c. Cyanosis of the toes on the left foot.

\- d. Numbness and tingling of the left leg.

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74. **A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?**

\- a. \*\*Elevate the head of the bed to at least 30°.\*\* (Correct answer)

\- b. Measure the residual feeding volume every 8 hours.

\- c. Flush the tube with 5 mL of water every 4 hours.

\- d. Administer the feeding solution at room temperature.

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75. **A nurse is teaching a client who has a new prescription for simvastatin. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I should take this medication in the morning.”

\- b. “I will avoid drinking grapefruit juice while taking this medication.” (Correct answer)

\- c. “I will limit my intake of dairy products.”

\- d. “I should increase my intake of foods high in vitamin K.”

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76. **A nurse is assessing a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse expect?**

\- a. Hyperactive bowel sounds

\- b. \*\*Weak, irregular pulse\*\* (Correct answer)

\- c. Dry mucous membranes

\- d. Increased deep tendon reflexes

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77. **A nurse is caring for a client who has a prescription for a blood transfusion. Which of the following actions should the nurse take?**

\- a. \*\*Remain with the client during the first 15 minutes of the transfusion.\*\* (Correct answer)

\- b. Infuse the blood at a rate of 150 mL/hr.

\- c. Prime the infusion tubing with dextrose 5% in water.

\- d. Administer the transfusion through a 22-gauge IV catheter.

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78. **A nurse is caring for a client who has a new prescription for warfarin. Which of the following laboratory tests should the nurse monitor?**

\- a. Activated partial thromboplastin time (aPTT)

\- b. Fibrinogen level

\- c. Platelet count

\- d. \*\*International normalized ratio (INR)\*\* (Correct answer)

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79. **A nurse is providing teaching to a client who has a new prescription for levothyroxine. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I will take this medication with food.”

\- b. “I should avoid foods high in fiber.”

\- c. “I will take this medication in the evening.”

\- d. \*\*“I should take this medication on an empty stomach.”\*\* (Correct answer)

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80. **A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client reports nausea and vomiting. Which of the following actions should the nurse take first?**

\- a. Administer an antiemetic medication.

\- b. \*\*Auscultate the client’s bowel sounds.\*\* (Correct answer)

\- c. Place the client in a supine position.

\- d. Encourage the client to take deep breaths.

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81. **A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?**

\- a. \*\*Discard the first voiding.\*\* (Correct answer)

\- b. Keep the urine specimen at room temperature.

\- c. Instruct the client to drink 1 L of fluid during the collection.

\- d. Obtain the urine specimen from the urinary catheter bag.

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82. **A nurse is caring for a client who has dehydration. Which of the following laboratory values should the nurse expect?**

\- a. \*\*Elevated hematocrit\*\* (Correct answer)

\- b. Decreased serum sodium

\- c. Decreased BUN

\- d. Elevated WBC count

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83. **A nurse is teaching a client who has a new prescription for spironolactone. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I will increase my intake of foods high in potassium.”

\- b. “I will use a salt substitute while taking this medication.”

\- c. \*\*“I will limit my intake of foods high in potassium.”\*\* (Correct answer)

\- d. “I will avoid foods high in sodium.”

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84. **A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?**

\- a. Jugular vein distention

\- b. Peripheral edema

\- c. \*\*Crackles in the lungs\*\* (Correct answer)

\- d. Enlarg

ed liver

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85. **A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?**

\- a. Clamp the chest tube while ambulating the client.

\- b. \*\*Keep the chest tube drainage system below the level of the client’s chest.\*\* (Correct answer)

\- c. Milk the chest tube to promote drainage.

\- d. Empty the chest tube drainage system every 8 hours.

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86. **A nurse is preparing to administer a controlled substance. Which of the following actions should the nurse take?**

\- a. \*\*Count the available doses of the medication.\*\* (Correct answer)

\- b. Administer the medication within 2 hours of the scheduled time.

\- c. Discard any unused portion of the medication.

\- d. Report any errors to the pharmacy.

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87. **A nurse is teaching a client who has a new prescription for nitroglycerin. Which of the following client statements indicates an understanding of the teaching?**

\- a. “I will take the medication with meals.”

\- b. \*\*“I will lie down after taking this medication.”\*\* (Correct answer)

\- c. “I will take this medication at bedtime.”

\- d. “I will avoid drinking grapefruit juice while taking this medication.”

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88. **A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect?**

\- a. Hypoactive bowel sounds

\- b. Hypertension

\- c. \*\*Positive Chvostek’s sign\*\* (Correct answer)

\- d. Hyperactive deep tendon reflexes

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89. **A nurse is caring for a client who is receiving a blood transfusion and reports itching. Which of the following actions should the nurse take?**

\- a. Administer acetaminophen.

\- b. \*\*Stop the infusion.\*\* (Correct answer)

\- c. Decrease the infusion rate.

\- d. Flush the IV tubing with normal saline.

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90. **A nurse is caring for a client who has diabetes mellitus and is receiving insulin. Which of the following findings should indicate to the nurse that the client is experiencing hypoglycemia?**

\- a. Kussmaul respirations

\- b. \*\*Diaphoresis\*\* (Correct answer)

\- c. Bradycardia

\- d. Flushing

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91. A nurse is preparing to administer medication to a client who has a nasogastric tube for enteral feedings. Which of the following actions should the nurse take?

\- a. Administer all medications at the same time.

\- b. \*\*Flush the nasogastric tube before and after each medication.\*\* (Correct answer)

\- c. Administer the medications with the feeding.

\- d. Dilute the medications with sterile water.

92. A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

\- a. “I will increase my intake of foods high in vitamin K.”

\- b. “I will take the medication with meals.”

\- c. “I will avoid drinking grapefruit juice while taking this medication.”

\- d. \*\*“I will use an electric razor when shaving.”\*\* (Correct answer)

93. A nurse is assessing a client who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?

\- a. Hypertension

\- b. \*\*Muscle spasms\*\* (Correct answer)

\- c. Decreased deep tendon reflexes

\- d. Constipation

94.A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

\- a. Clamp the catheter for 30 minutes every 2 hours.

\- b. Empty the catheter bag when it is 3/4 full.

\- c. \*\*Keep the catheter bag below the level of the bladder.\*\* (Correct answer)

\- d. Cleanse the catheter with alcohol daily.

95. A nurse is teaching a client who has a new diagnosis of hypertension about lifestyle changes to manage the condition. Which of the following client statements indicates an understanding of the teaching?

\- a. “I will eat a high-protein diet.”

\- b. “I will limit my intake of foods high in potassium.”

\- c. \*\*“I will reduce my sodium intake.”\*\* (Correct answer)

\- d. “I will increase my fluid intake.”

96. A nurse is providing teaching to a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include?

\- a. \*\*Trim toenails straight across.\*\* (Correct answer)

\- b. Soak feet daily.

\- c. Apply lotion between the toes.

\- d. Use a heating pad to warm the feet.

97. A nurse is preparing to administer medication through a nasogastric tube that is connected to suction. Which of the following actions should the nurse take?

\- a. \*\*Clamp the NG tube for 30 minutes after medication administration.\*\* (Correct answer)

\- b. Administer the medication through a syringe with a 16-gauge needle.

\- c. Flush the tube with 10 mL of water before and after medication administration.

\- d. Place the client in a supine position.

98. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

\- a. \*\*Jugular vein distention\*\* (Correct answer)

\- b. Crackles in the lungs

\- c. Decreased capillary refill

\- d. Decreased urinary output

99. A nurse is teaching a client who has a new diagnosis of hypertension about dietary modifications. Which of the following client statements indicates an understanding of the teaching?

\- a. “I will eat a diet high in saturated fat.”

\- b. “I will limit my intake of foods high in potassium.”

\- c. \*\*“I will reduce my sodium intake.”\*\* (Correct answer)

\- d. “I will increase my fluid intake.”

100. A nurse is caring for a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

\- a. \*\*Edema in the affected extremity\*\* (Correct answer)

\- b. Diminished pedal pulses

\- c. Thin, shiny skin

\- d. Hair loss on the legs