ATI MED SURG RETAKE EXAM: Ultimate Retake Guide EXAM QUESTIONS AND

WELL ELABORATED ANSWERS (2 VERSIONS)

A nurse is planning care for a client who is receiving mechanical ventilation. Which
mode of ventilation increases the effort of the client's respiratory muscles? (Select all
that apply)

A. Assist-control
B. Synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
D. Pressure support ventilation
E. Independent lung ventilation - CORRECT ANSWER B. Synchronized
intermittent mandatory ventilaiton
C. Continuous positive airway pressure
D. Pressure support ventilation

A nurse is caring for a client who is experiencing respiratory distress. Which of the
following are early clinical manifestations of hypoxemia? (Select all that apply)

A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevated blood pressure - CORRECT ANSWER B. Pale skin
E. Elevated blood pressure

A nurse is caring for a client that is receiving mechanical ventilation, which has been
placed on pressure support ventilation (PSV) mode. Which of the following statements
by the nurse demonstrates an understanding of PSV?

A. It keep the alveoli open and prevents atelectasis

B. It permits spontaneous ventilation to decrease the work of breathing
C. It is used with clients who have difficulty weaning from the ventilator
D. It delivers a preset ventilatory rate and tidal volume to the client - CORRECT
ANSWER B. PSV maintains a preset amount of pressure during spontaneous
ventilation to decrease the work of breathing

A provider is discharging a client who has a prescription for home oxygen therapy via
nasal cannula. Client and family teaching by the nurse should include which of the
following instructions? - CORRECT ANSWER 1. check the position of the cannula
frequently
2. report any nasal or difficulty breathing
3. post no smoking signs in a prominent location
A nurse is preparing to a perform endotracheal suctioning for a client. The nurse should
follow which guidelines? - CORRECT ANSWER 1. apply suction while withdrawing
the catheter
2. Use a new catheter for each suctioning attempt
3. Apply suctioning for 10-15 seconds

A nurse is caring for a client who has a tracheostomy. Which actions should the nurse
take when providing tracheostomy care? - CORRECT ANSWER 1. Apply the
oxygen source loosely if the SpO2 decreases during the procedure
2. use surgical asepsis to remove and clean the inner cannula
3. Clean the outer surfaces in a circular motion from the stoma site outward

Diagnostic and Therapeutic Procedures for Female Reproductive Disorders: Discharge

Instructions for Syphilis - CORRECT ANSWER disorder, diagnosis, and treatment,
including the need to comply with treatment prescribed medications, such as penicillin,
and the intended course of therapy depending on the stage of the disease possible
adverse effects of penicillin therapy, including headache, fever, chills, sweating,
malaise, and hypotension or hypertension (Jarisch-Herxheimer reaction)need to
complete the course of therapy even after symptoms subside importance of informing,
testing, and treating sexual partners need to refrain from sexual activity until treatment
is completed and follow-up VDRL or RPR test results are normal importance of repeat
serology testing at 3, 6, 9, and 12 months after treatment and again at 24 months if the
disease lasts longer than 1 year possible need for retreatment if clinical signs persist or
recur, a fourfold rise in titers occurs, or initially high titers fail to decrease fourfold by 6
months risks to the fetus if the patient is contemplating pregnancy and the need for all
pregnant patients to be screened at the first prenatal visit information for the patient and
sexual partners about human immunodeficiency virus infection importance of safer sex
practices, including the use of condoms.

As needed, obtain a physical or occupational therapy consultation. Refer the patient for
contact tracing. Refer the patient to a specialist if congenital syphilis is suspected.
Consult a social worker to determine home care needs.

Teaching after cervical biopsy - CORRECT ANSWER No tampons and avoid heavy
lifting for 2 weeks

Confirm syphilis diagnosis - CORRECT ANSWER FTA-A BS

Teaching prior to a Pap - CORRECT ANSWER Some bleeding may occur after
procedure

Stroke: Caring for a Client who has Left-Sided Hemiplegia (Ch. 15) - CORRECT
ANSWER -Stroke of the right cerebral hemisphere which is responsible for visual and
spatial awareness-altered perceptions of deficits-ignore left side of body; can't move or
feel affected side-loss of depth perceptions-poor impulse control and judgement-visual
changes

Teaching prior to mammogram - CORRECT ANSWER No deodorant prior to

procedure

Testing for HIV - CORRECT ANSWER Western blot assay confirms HIV diagnosis

A nurse should intervene if which of the following actions were observed?

A. A nurse moves all ambulatory clients into the hallways during a tornado warning.
B. A nurse discards an empty blood bag and tubing in the client's bedside trash can.
C. A nurse takes an infusion pump from the bedside of a client to the dirty utility room.
D. A nurse disposes a used needle and syringe in the biohazard box in the client's
room. - CORRECT ANSWER B. A nurse discards an empty blood bag and tubing
in the client's bedside trash can.

A nurse in a provider's office is reviewing the health record of a client who is being
evaluated for Grave's disease. Which of the following is an expected laboratory finding
for this client?

A. Decreased thyrotropin receptor antibodies

B. Decreased thyroid stimulating hormone
C. Decreased free thyroxine index
D. Decreased triiodothyronine - CORRECT ANSWER B. Decreased thyroid
stimulating hormone

A nurse is reviewing the clinical manifestations of hyperthyroidism with the client. Which
of the following findings should the nurse include? Select all that apply.

A. Anorexia
B. Heat intolerance
C. Constipation
D. Palpitations
E. Weight loss
F. Bradycardia - CORRECT ANSWER B. Heat intolerance
D. Palpitations
E. Weight loss

The nurse is preparing to receive a client from the PACU who is postoperative following
a thyroidectomy. The nurse should ensure that which of the following equipment is
available? Select all that apply.

A. Suction equipment
B. Humidified O2
C. Flashlight
D. Tracheostomy tray
E. Chest tube tray - CORRECT ANSWER A. Suction equipment
B. Humidified O2
D. Tracheostomy tray

A nurse in a provider's office is planning care for a client who has a new diagnosis of
Graves' disease and a new prescription for methimazole (Tapazole). Which of the
following should the nurse include in the plan of care?

A. Monitor CBC
B. Monitor triiodothyronine
C. Inform the client to increase consumption of shellfish
D. Advise the client to take the medication at the same time every day
E. Inform the client that an adverse effects of this medication is iodine toxicity -
CORRECT ANSWER A. Monitor CBC
B. Monitor triiodothyronine
D. Advise the client to take the medication at the same time every day

A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy.

Which of the following findings are indicative of a thyroid crisis? Select all that apply.

A. Bradycardia
B. Hypothermia
C. Dyspnea
D. Abdominal pain
E. Mental confusion - CORRECT ANSWER C. Dyspnea
D. Abdominal pain
E. Mental confusion

A client has requested pain medication. The nurse notes that morphine 5 mg is ordered
subcutaneously q3 to 4 hr. The medication is available in a pre filled syringe does of 10
mg/mL. The nurse knows that after giving the client 0.5 mL, the appropriate action is to

A. place the unused portion in the client's medication drawer.

B. dispose of the unused portion in the sharps container.
C. return the unused portion to the pharmacy.
D. have another nurse witness the disposal of the unused portion. - CORRECT
ANSWER D. have another nurse witness the disposal of the unused portion.

A nurse is orienting a newly licensed nurse on performing routine assessment of a client

who is receiving mechanical ventilation via a endotracheal tube. Which of the following
should the nurse include in the teaching?

A. Apply a vest restraint if self-extubation is attempted

B. Monitor ventilator settings every 8 hours
C. Document tube placement in centimeters at the angle of jaw
D. Assess breath sounds every 4 hours - CORRECT ANSWER D. Assess breath
sounds every 4 hours

A nurse is caring for a client who has dyspnea and is to receive oxygen continuously.
Which of the following oxygen devices should the nurse use to deliver a precise amount
of oxygen to the client?

A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask - CORRECT ANSWER B. Venturi mask

A nurse observes tachycardia, dyspnea, a cough and distended neck being in a client
who is receiving a transfusion of packed red blood cells (RBC's). Which of the following
interventions should the nurse use to prevent these manifestations with the client's next
transfusion? - CORRECT ANSWER Use a transfusion pump to regulate and maintain
the transfusion at a slower rate.

A nurse is providing discharge teaching for a client who has a newly inserted permanent
pacemaker. Which of the following instructions should the nurse include in the
teaching? - CORRECT ANSWER Keep your cell phone 6 inches away from your pace
maker when making a call.

A nurse is caring for an older adult client who had an acute myocardial infarction (MI).
When assessing this client the nurse should identify that older adults are prone to
complications of MI from Poor tissue perfusion because of which of the following age
related factors? - CORRECT ANSWER Peripheral vascular resistance increases

A nurse in caring for a client who has a peripherally inserted central catheter (PICC) in
place. Which of the following actions should the nurse take when handling this central
venous access device? select all that apply - CORRECT ANSWER Flush the line with
sterile 0.9% sodium chloride before and after medication administration
Access the PICC for blood sampling
Perform a heparin flush of the line at least daily when not in use

A nurse is caring for an adult male client who is undergoing screen testing for
atherosclerosis. Which of the following laboratory findings should the nurse identify as
an increased risk for this disorder? - CORRECT ANSWER Elevated LDL levels

A nurse is teaching a client who has coronary artery disease about eh difference
between angina pectoris and myocardial infarction. Which of the following
manifestations should the nurse identify as indications of MI? select all that apply -
CORRECT ANSWER nausea and vomiting
diaphoresis and dizziness
anxiety and feeling of doom

A nurse is teaching a client with heart disease about a lower cholesterol diet. Which of
the following client statements indicates the teaching was effective? - CORRECT
ANSWER I should remove the skin form sultry before eating it.

A nurse is planning care for a client who has thrombocytopenia. Which of the following
interventions should the nurse include in the plan of care? - CORRECT ANSWER
Measure the client's abdominal girth daily

A nurse is checking paradoxical blood pressure of a client who has a possible cardiac
tamponade. In what order should the nurse complete the following steps? - CORRECT
ANSWER 1. Palpate the blood pressure and inflate the cuff above the systolic pressure.
2. Deflate the cuff slowly and listen for the first audible sounds.
3. identify the first BP sounds audible on expiration and then on inspiration
4. Subtract the inspiratory pressure from the expiratory pressure
5. Inspect for jugular venous distention and notify the provider.

a nurse is completing dietary teaching who a client who has heart failure and is
prescribed a 2g sodium diet. Which of the following statements by the client indicates an
understanding of the teaching? - CORRECT ANSWER I can have yogurt as a dessert
rationale low in fat and sodium

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer
on the right ankle. Which of the following findings should the nurse expect in the client's
affected extremity? - CORRECT ANSWER Ankle swelling

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of

the following findings should the nurse expect? - CORRECT ANSWER Prolonged QT
intervals

A nurse is caring for a client who has pernicious anemia. Which of the following factors
should the nurse identify with this condition? - CORRECT ANSWER Vitamin B12
deficiency

A nurse is completing a medication history for a client who reports using fish oil as a
dietary supplement. Which of the following substances in fish oil should the nurse
recognize as a health benefit to the client? - CORRECT ANSWER Omega 3 fatty acids

A nurse is caring for a client who has an upper gastrointestinal bleed and an hematocrit
of 24%. Prior to initiating a transfusion of packed red blood cells (RBC), which of the
following actions should the nurse take? select all that apply - CORRECT ANSWER
Assess and document the client's vital signs
Verify with another nurse the blood type and Rh of the packed RBC's
Change IV tubing to a set that has a filter
A nurse is preparing to transfuse a unit of packed red blood cells (RBC's) for a client
who has anemia. Which of the following actions should the nurse take first? -
CORRECT ANSWER Witness the informed consent document

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of
the following statements indicates that the client understands the instructions? -
CORRECT ANSWER Physical activity is good for me, but I need to avoid overexertion

A nurse is preparing an in service presentation about assessing clients who are having
an acute myocardial infarction(MI). What is the most common assessment finding with
acute MI? - CORRECT ANSWER substernal chest pain

A nurse is caring for a client who has severely elevated blood pressure. Which of the
following findings should the nurse identify as a manifestation of hypertension? -
CORRECT ANSWER Epistaxis

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the
following manifestations should the nurse expect? - CORRECT ANSWER Lower back
discomfort

A charge nurse is observing a newly licensed nurse administer an IV medication to a

client who has an implanted venous access port. Which of the following observations
requires intervention by the charge nurse? - CORRECT ANSWER A solution of 5ml
heparin 1,000 units/mL has been prepared.

A nurse is preparing to administer packed RBC's to a client who is anemic. Which of the
following actions should the nurse take? select all that apply - CORRECT ANSWER
Check to determine the packaged RBC's are less than 1 week old
Ask another nurse to check the packaged RBC's label against the medical record
Prime the transfusion tubing with 0.9% sodium chloride

A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on
the toes. Which of the following findings of PVD is a risk factor for ulceration of the
extremities? - CORRECT ANSWER Impaired circulation

A nurse is teaching a 70 year old client about risk factors for heart failure. The client has
mild asthma, diabetes mellitus, and coronary artery disease. Which of the following
statements by the client indicates an understanding of the teaching? - CORRECT
ANSWER my coronary artery disease is a risk factor for heart failure

A nurse is preparing an in service presentation about the basics of hematology. Which

of the following factors provides a stimulus for the production fo RBC's? - CORRECT
ANSWER tissue hypoxia
rationale: the kidneys release erythropoietin, stimulates production of erythocytes in
bone marrow
A nurse is assessing a client who has deep vein thrombosis in her left calf. Which of the
following manifestations should the nurse expect to find? select all that apply -
CORRECT ANSWER hardening along the blood vessels
tenderness in the calf
increased leg circumference

The nurse is caring for a client who has emphysema and chronic respiratory acidosis.
The nurse should monitor the client for which of the following electrolyte imbalances? -
CORRECT ANSWER hyperkalemia
chronic respiratory acidosis can result in high potassium levels

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of
the following findings indicates that the AAA is expanding? - CORRECT ANSWER
Report of sudden, severe back pain

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

A nurse is assessing a client who has pericarditis. Which of the following manifestations
should the nurse expect? - CORRECT ANSWER Dyspnea with hiccups

A nurse is caring for a client who is hypovolemic shock. While waiting for a unit of bleed,
the nurse should administer which of the following IV solutions? - CORRECT ANSWER
0.9% sodium chloride

A nurse is preparing an automated external defibrillator (AED) for a client receiving CPR
after a cardiac arrest. Which of the following actions should the nurse perform first? -
CORRECT ANSWER apply the defibrillator pads to the clients chest

A nurse in a provider's office is review the medical records of a group of clients. Which
of the following clients is at risk for iron deficiency? select all that apply - CORRECT
ANSWER a client who is a vegetarian
a client who is pregnant
a toddler who is overweight

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for
enoxaparin. Which of the following actions should the nurse take? - CORRECT
ANSWER elevate the affected leg

A nurse is assessing a client who is receiving a transfusion of packed red blood cells
(RBC). Which of the following findings should the nurse identify as an indication of an
acute intravascular hemolytic reaction? - CORRECT ANSWER sudden oliguria
rationale: indication fo acute intravascular hemolytic reaction. AKI
A nurse is planning care for a client who has pernicious anemia. Which of the following
interventions should the nurse include in the plan? - CORRECT ANSWER initiate
weekly injections of vitamin B12

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and
dyspnea. Which of the following actions should the nurse take first? - CORRECT
ANSWER stop the medication infusion

A nurse is assessing the hematologic system of an older adult client. The nurse should
report which of the following findings to the provider as a possible indication of a
hematologic disorder? - CORRECT ANSWER Absence of hair on the legs
rationale: indicates poor arterial circulation to that area

A nurse is providing teaching about lifestyle changes to a client who experienced a

myocardial infarction and has a new perception for a beta block. Which of the following
client statements indicates an understanding of the teaching? - CORRECT ANSWER
Before taking my medication. I will count my radial pulse rate.

A nurse is caring for a client following a stroke. Which of the following actions should the
nurse take first? - CORRECT ANSWER Keep the client NPO

A nurse is planning care for a client during a sickle cell crisis. Which of the following
interventions should the nurse include in the clients plan of care? - CORRECT
ANSWER encourage increased fluid intake

A nurse is assessing a client who has fluid volume overload from a cardiovascular
disorder. Which of the following manifestations should the nurse expect? select all that
apply - CORRECT ANSWER jugular vein distension
moist crackles
increased heart rate

A nurse is caring for a client who has survey. Which of the following vitamin deficiencies
should the nurse identify as the cause of the disease? - CORRECT ANSWER Vitamin
C

A nurse is transfusing a unit of O negative fresh frozen plasma (FFP) to a client whose
blood type is B positive. Which of the following actions should the nurse take? -
CORRECT ANSWER Remove the unit of plasma immediately and start an IV infusion
of normal saline solution
rationale: can experience a hemolytic transfusion reaction.

A nurse is admitting a client who is in sickle cell crisis. Besides pain management which
of the following interventions should the nurse include in the client's plan of care? -
CORRECT ANSWER ample hydration
A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery.
For which of the following complications of the rewarming process should the nurse
monitor the client? - CORRECT ANSWER acidosis
rationale: metabolic acidosis associated with hypoxia can occur if a client is rewarmed
too quickly

A nurse is preparing a client for a bone marrow biopsy. Which of the following pieces of
information should the nurse include in preoperative teaching? - CORRECT ANSWER
You'll feel a painful, pulling sensation when the doctor withdraws the marrow.

A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever,
chills, fatigue, and pallor over the past week. When checking the client's laboratory
results, which of the following values should the nurse identify as contributing to the
client's fatigue and pallor? - CORRECT ANSWER Hgb 6.5 f/dL

A nurse is assessing a client who is 85 years old. Which of the following findings should
the nurse identify as a manifestation of myocardial infarction? - CORRECT ANSWER
acute confusion

A nurse is monitoring a client for repercussion following thrombolytic therapy to treat

acute myocardial infarction. Which of the following indicators should the nurse identify to
confirm reperfusion? - CORRECT ANSWER ventricular dysrhythmias
rationale: sign of reperfusion of the coronary artery

A nurse is caring for a client who has a platelet count of 50,000/mm^3. After
discontinuing the client's peripheral IV site, which of the following actions should the
nurse take? - CORRECT ANSWER apply pressure to the catheter removal site for 5
min

A nurse is providing discharge teaching to a client who has aplastic anemia. Which of
the following statements indicates that the client understands the instructions? -
CORRECT ANSWER I should eliminate uncooked foods from my diet for now.
rationale: to prevent infection

A nurse is caring for a client who has a major burn injury and is experiencing third
spacing. Which of the following fluid or electrolyte imbalances should the nurse expect?
- CORRECT ANSWER elevated HCT
rationale: expect an elevated hematocrit level, blood volume is reduced by vascular
dehydration.

A nurse is caring for a client who has a demand pacemaker inserted with a set rat of
72/min. Which of the following findings should the nurse expect? - CORRECT
ANSWER
A nurse is assessing a client who has a diagnosis on colon cancer which of the
following should the nurse expect?
a. Steatorrhea
b. Elevated hemoglobin
c. Hematochezia
d. Weight gain - CORRECT ANSWER Hematochezia

A nurse is assessing a client admitted with peripheral vascular disease. Which of the
following findings indicates a venous vascular disorder?

A. n ulcer at the tip of a toe

B. Hair loss distal to the client‟s calves
C. Leg pain at rest
D. Edema of the ankle - CORRECT ANSWER Edema of the ankle

A nurse is assessing a client who has pericarditis. In which of the following areas of the
client‟s chest should the nurse place the stethoscope to best hear a pericardial friction
rub?
(select HOT spot) - CORRECT ANSWER Lower left side of chest

A nurse is caring for a client who has a chest tube. The client asks why the fluid in the
water-seal chamber rises and falls. Which of the following statements should the nurse
make?

a. "This means your lung is fully expanded"

b. "This indicates a possible leak"
c. "Suction pressure that is too high causes this"
d. "Your breathing pattern causes this" - CORRECT ANSWER "Your breathing
pattern causes this"

A community health nurse is reviewing home care instructions with an older adult client
who has a new diagnosis of heart failure. Which of the following is the priority topic for
the nurse to review with the client?

a. Daily sodium restriction

b. Daily exercise routine
c. Changes in weight
d. Fluid intake record - CORRECT ANSWER Changes in weight

A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation
(TENS) unit. Which of the following statements should the nurse include?

a. "Apply lotion to the site prior to attaching the electrodes"

b. "This device requires access to a 220-volt outlet"
c. "This device delivers heat via electrodes that are attached to the affected area"
d. "Adjust the dial until you feel a ‟pins and needles" sensation" - CORRECT
ANSWER "Adjust the dial until you feel a ‟pins and needles‟ sensation"
A nurse is providing teaching to a client who is postoperative following a total hip
arthroplasty. Which of
the following statements should the nurse make?

a. "Use raised toilet seat to maintain your hips above the knees"
b. "Twist at the waist when standing from a seated position"
c. "Move your stronger leg first when using a walker"
d. "Apply a heating pad to the operative hip to decrease pain" - CORRECT ANSWER
"Use raised toilet seat to maintain your hips above the knees"

8. A nurse finds a client in bed, unresponsive and breathing. Which of the following
action should the nurse take first?

a. Establish IV access
b. Apply blood pressure cuff
c. Palpate for the client‟s carotid pulsed.
d. Initiate cardiac monitoring for the client - CORRECT ANSWER Palpate for the
client‟s carotid pulsed.

9. A nurse is caring for a patient who is experiencing a hypertensive crisis. Which of the
following actions should the nurse take?

a. Initiate IV dopamine infusion

b. Perform neurological assessments
c. Place the client supine
d. Begin an IV bolus of lactated ringer‟s - CORRECT ANSWER Perform
neurological assessments

A nurse is providing discharge teaching about blood sugar monitoring for a client who
has a new diagnosis of type 2 diabetes mellitus. The nurse should instruct the client to
obtain which of the following supplies?

a. Sterile lancets
b. Compression stockings
c. Hand mirror
d. Toenail clippers - CORRECT ANSWER Sterile lancets

A nurse is completing discharge teaching who has a peripherally inserted central

catheter (PICC) line in
the left arm. Which of the following instructions should the nurse include in the
teaching?

a. Do not elevate the arm above the level of the heart

b. Change the catheter dressing daily
c. Use 10-mL syringe to flush line
d. Clean the insertion site using 20- mL of hydrogen peroxide - CORRECT ANSWER
Use 10-mL syringe to flush line

A nurse is preparing naloxone 10 mcg/kg via IV bolus to a client who weights 220 lbs.
The amount available is 0.4 mg/mL. How many mL should the nurse administer? (round
to the nearest tenth) - CORRECT ANSWER 2.5 mL

A nurse is caring for a client who has a sealed radiation implant. Which of the following
actions should
the nurse take?

a. Remove soiled linens from the room after each change

b. Give the dosimeter badge to the oncoming nurse at the end of the shift
c. Apply a second pair of gloves before touching the client‟s implant if it dislodges
d. Limit family member visits to 30 min per day - CORRECT ANSWER Limit family
member visits to 30 min per day

14. A nurse is providing teaching to a client and his partner about performing peritoneal
dialysis at home. When discussing peritonitis, which of the following manifestations
should the nurse identify as the earliest indication of this complication?

a. Generalized abdominal pain

b. Cloudy effluent
c. Increased heart rate
d. Fever - CORRECT ANSWER Cloudy effluent

A nurse is caring for a client who is receiving a blood transfusion. The nurse observes
that the client has bounding peripheral pulses, hypertension, and distended jugular
veins. The nurse should anticipate administering which of the following prescribed
medications?

a. Pantoprazole
b. Acetaminophen
c. Furosemide
d. Diphenhydramine - CORRECT ANSWER Furosemide

A nurse is planning care for a client who has upper gastrointestinal bleeding due to a
peptic ulcer. Which of the following actions should the nurse plan to take?

a. Provide ketorolac for abdominal pain

b. Administer nitroprusside IV based on the client‟s weight
c. Insert a large bore nasogastric tube d. Ensure that the client has a 22-gauge IV line in
place - CORRECT ANSWER Insert a large bore nasogastric tube
A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3.
Which of the following actions should the nurse take?

a. Instruct client to avoid eating raw fruit

b. Move the client to a negative pressure room
c. Use contact isolation while providing care
d. Apply pressure to venipuncture sites for 10 min - CORRECT ANSWER Instruct
client to avoid eating raw fruit

A nurse is caring for a patient who has hypotension, cool and clammy skin, tachycardia
and tachypnea. Which of the following positions should the nurse place the client?

a. Reverse Trendelenburg
b. Feet elevated
c. Side lying
d. High-fowler‟s - CORRECT ANSWER Reverse Trendelenburg

A nurse is caring for a client who weights 190 lb and is receiving Total Parenteral
Nutrition. If the RDA Protein is 0.8g/kg of body weight, how many grams of protein
should the client receive daily (Round the answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing zero) - CORRECT ANSWER 69
grams

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 a catheter using a 10 mL syringe

b. Use clean technique when changing the dressing
c. Cleanse the site with Provo dine iodine
d. Change the dressing every 24 hours - CORRECT ANSWER Flush a catheter
using a 10 mL syringe

A nurse is reviewing the medical record of a client who is to undergo open heart
surgery. Which of the following findings should the nurse report to the provider as a
contradiction to receiving heparin?

a. Thalassemia
b. Rheumatoid arthritis
c. COPD
d. Thrombocytopenia - CORRECT ANSWER Thrombocytopenia

A nurse is caring for an older adult client who has dementia. Which of the following
question should the
nurse ask to assess the client's abstract thinking?
a. What is meant by saying "don't beat around the bush?"
b. What do you understand about your condition?
c. Can you count backwards from 100 in intervals of 7?
d. Can you state where you were born? - CORRECT ANSWER What is meant by
saying "don't beat around the bush?"

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. Apply an occlusive dressing

b. Turn and reposition the client every 4 hours
c. Support bony prominences with pillows
d. Massage Tourette in areas three times daily - CORRECT ANSWER Support
bony prominences with pillows

A nurse is reviewing a cardiac rhythm strip of a client who has atrial flutter. Which of the
following findings should the nurse expect?

a. Progressively longer PR durations

b. Undetectable p waves
c. Absent PR intervals with ventricular rate of 40 to 60 / minutes d)
d. Sawtooth pattern with atrial rate of 252 to 400 / minutes - CORRECT ANSWER
Sawtooth pattern with atrial rate of 252 to 400 / minutes

A nurse is caring for a client who is scheduled for an abdominal paracentesis. The
nurse should plan to take which of the following actions?

a. Administer a stool softener following the procedure

b. Ask the client to empty his bladder prior to the procedure
c. Instruct the client to take deep breaths and hold them during the procedure
d. Assist the client into the left lateral position during the procedure - CORRECT
ANSWER Ask the client to empty his bladder prior to the procedure

A nurse is assessing a client following the insertion of a central venous catheter. Which
of the following findings indicates a pneumothorax?

a. Diminished breath sounds

b. Itching over the incision
c. Distended neck veins
d. Irregular heart rate - CORRECT ANSWER Diminished breath sounds

A nurse is providing teaching to a client who is receiving opioids for pain management.
Which of the following information should the nurse include in the teaching?
a. Monitor urinary output for retention
b. avoid taking anti emetics with the medication
c. restrict fluid intake If you experience constipation
d. itching Indicates you are having an allergic reaction to the medication - CORRECT
ANSWER Monitor urinary output for retention

A nurse is providing discharge teaching for a client who has asthma and a new
prescription for a metered dose inhaler. Which of the following client statements
indicates an understanding of the teaching?

a. I should clean the cap of the inhaler once per week

b. I should shake the inhaler before I use it
c. I Should wait 15 seconds between puffs
d. I should inhale the medication quickly - CORRECT ANSWER I should shake the
inhaler before I use it

A nurse is providing preoperative teaching for a client who is having left-sided cardiac
catheterization. Which of the following information should the nurse include in the
teaching?

a. You should plan to remain in bed for 18 hours after the procedure
b. You will have blood pressure measurement every 5 minutes for the first two hours
after the
procedure
c. You will receive a general anesthetic during the procedure
d. You should expect warm sensation after the injection of the contrast dye during the
procedure - CORRECT ANSWER You should expect warm sensation after the
injection of the contrast dye during the procedure

A nurse is caring for a client who has anemia. Which of the following assessment
findings should the
nurse anticipate with the client's condition?

a. Bradycardia
b. Headache
c. Heat intolerance
d. Flushed skin color - CORRECT ANSWER Headache

31. A nurse is teaching a client who has a new prescription for Warfarin about foods that
affect the INR. The nurse should include in the teaching that which of the following
Foods interact with this medication?

a. Kale
b. Beef stew
c. Yogurt
d. Orange juice - CORRECT ANSWER Kale

A nurse is monitoring an older adult client who has an extrapolation of chronic

lymphocytic leukemia. The nurse notes petechia on the client's skin which of the
following actions should the nurse take?

a. Determine the client's blood type

b. Avoid administering IV pain medication
c. Implement airborne precautions
d. Institute bleeding precautions - CORRECT ANSWER Institute bleeding
precautions

A nurse is providing discharge teaching for a client who is receiving treatment for genital
herpes. Which of the following statements by the client indicates effectiveness of the
teaching?

a. I should expect to take my medication for three weeks

b. I should apply antibiotic ointment to the lesions
c. I should expect my lesions to resolve in 6 weeks
d. I should use natural skin condoms during sexual intercourse - CORRECT
ANSWER I should apply antibiotic ointment to the lesions

A nurse in an emergency department is preparing a client for emergency surgery. The

client's blood alcohol level is 180 mg / DL, which of the following action is the nurse‟s
priority?

a. Insert an NG Tube
b. Obtain consent for surgery
c. Apply anti-embolic stockings
d. Insert an indwelling urinary catheter - CORRECT ANSWER Insert an NG Tube

A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia.
Which of the following assessment findings supports this suspicion?

a. Cool, clammy skin

b. Kussmaul respirations
c. Acetone breath
d. Increased urine output - CORRECT ANSWER Cool, clammy skin

A nurse is caring for a client who is receiving radiation. The client reports nausea since
the therapy was initiated. Which of the following considerations should the nurse include
when finding the clients meals?

a. Offer hot beverages with meals

b. Offer a snack prior to radiation therapy
c. Offer highly seasoned foods
d. Offer frequent high carbohydrate meals - CORRECT ANSWER Offer frequent
high carbohydrate meals

A charge nurse receives a call from the house supervisor requesting room assignments
for four new clients. Based on the information diagnosis which of the following clients
requires a private room?

a. A client who reports having fever, night sweats, and cough for 2 days
b. An older adult client who was admitted with aspiration pneumonia
c. A client who has diabetes mellitus and is presenting with acute ketoacidosis
d. A client who has a compound fracture of the right femur - CORRECT ANSWER
A client who reports having fever, night sweats, and cough for 2 days

A nurse in an emergency department is assessing a client who has diabetic

ketoacidosis. Which of the following findings should the nurse expect? (select all the
apply)

a. Tremors
b. Reports of nausea and vomiting
c. Serum glucose 380 mg/dL
d. Serum pH 7.6
e. Fruity smelling breath - CORRECT ANSWER Reports of nausea and vomiting
Serum glucose 380 mg/dL
Fruity smelling breath

39. A nurse is planning a staff education session about hepatitis A. Which of the
following information should the nurse include?

a. Immunization for Hepatitis A is recommended prior to travel to high-risk areas

b. The incubation of hepatitis A is 5 to 10 days
c. Hepatitis A is transmitted is through blood-to-blood exposure
d. Clients who have Hepatitis A require a broad-spectrum antibiotic - CORRECT
ANSWER Immunization for Hepatitis A is recommended prior to travel to high-risk
areas

A nurse is caring for a client who has advanced liver disease. Which of the following
laboratory results should the nurse monitor when assessing this client?

a. Phosphate level
b. glucose level
c. serum troponin
d. Serum ammonia - CORRECT ANSWER Serum ammonia
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. Administer phenytoin IV bolus to the client

b. Provide the client oxygen at 6 L / min using a nasal cannula
c. Turn the client to the lateral position during seizure activity
d. Administer diazepam intravenously to the client - CORRECT ANSWER Turn the
client to the lateral position during seizure activity

A nurse is caring for a client who had a total hip arthroplasty. Which of the following
actions should the nurse take to prevent hip dislocation?

a. Elevate the knees higher than the hips when sitting

b. Remove the wedge device when turning
c. Encourage the client to lean forward when attempting to stand
d. Place two bed pillows between the legs when in bed - CORRECT ANSWER
Place two bed pillows between the legs when in bed

A nurse is caring for a client who is receiving Total parenteral Nutrition (TPN) The crane
infusion is almost complete and the new solution is not available which of the following
actions should the nurse take?

a. Infuse dextrose 10% in water

b. decrease that TPN infusion rate
c. disconnect and flush the IV access line
d. administer lactated ringers through the peripheral IV site - CORRECT ANSWER
Infuse dextrose 10% in water

A nurse is caring for a client who is 6 hours postoperative following application of an

external fixator for a tibial fracture. Which of the following actions should the nurse take?

a. Adjust the clamps on the fixator frame

b. Maintain the affected extremity in a dependent position
c. Palpate the dorsalis pedis pulsed.
d. Wrap sterile gauze on the sharp point of the pins - CORRECT ANSWER Palpate
the dorsalis pedis pulsed.

A nurse is caring for a client in the emergency department who experienced a full
thickness burn injury to the lower torso 1 hour ago. Which of the following findings
should the nurse expect?

a. Hypotension
b. Bradycardia
c. Decrease respiratory rate
d. Urinary diuresis - CORRECT ANSWER Hypotension
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. Limited client‟s fluid intake to 1500 ml / day
c. Administer aspirin if the client reports a headache
d. Encourage the client to change position slowly - CORRECT ANSWER
Encourage the client to change position slowly

A nurse is preparing to perform gastric lavage for a client who has bleeding gastric
ulcer. Which of the following equipment should the nurse plan to use for this procedure?
- CORRECT ANSWER nasogastric tube (wrapped)

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. Pulse pressure changes from 30 to 20 mmhg

b. bilateral pupil diameter changes from 4 to 2 mm
c. WBC count changes from 9,000 to 16,000 / mm 3
d. Glasgow Coma Scale score changes from 14 to 9 - CORRECT ANSWER
Glasgow Coma Scale score changes from 14 to 9

A nurse is caring for a client who has an indwelling urinary catheter. Which of the
following actions should the nurse take when performing a close intermittent irrigation?

a. Use a 3ml syringe to perform the catheter irrigation

b. Clamp the catheter above the specimen port
c. Place the client in Trendelenburg position
d. Inject the irrigation solution slowly into the catheter - CORRECT ANSWER Inject
the irrigation solution slowly into the catheter

50. A nurse is completing discharge teaching with a client who has a new diagnosis of
AIDS. Which of the following statements by the client indicates an understanding of the
teaching?

a. I will need to take my clothes to the dry cleaners to sterilize them

b. I will wipe up areas soiled with body fluids with alcohol and immediately disposed of
the trash
(should be cleaned with bleach not alcohol)
c. I will be sure to wear gloves and wash my hands when I change my cat's litter box
d. I will increase the amount of fresh fruits and vegetables I consume - CORRECT
ANSWER I will be sure to wear gloves and wash my hands when I change my cat's
litter box
A nurse is caring for a client who is post-operative following an endoscopy with
moderate (conscious) sedation. Which of the following assessment findings is the
nurse‟s priority?

a.Level of pain
b. Gag reflex
c. Warmth of extremities
d. Temperature - CORRECT ANSWER Gag reflex

Nurse is caring for an older adult client who is suspected of having septicemia. Which of
the following actions is the nurses priority?

a. Obtain a history to determine recent injuries

b. Obtain a broad-spectrum antibiotic for Rapid Administration
c. Obtain a WBC count with differential
d. Obtain a blood specimen for culture and sensitivity testing - CORRECT ANSWER
Obtain a blood specimen for culture and sensitivity testing

A nurse is caring for a client who has just undergone a total laryngectomy. Which of the
following findings is the nurse‟s priority for immediate intervention?

a. Blood-tinged secretions
b. Tachypnea
c. Fever
d. IV infiltration - CORRECT ANSWER Tachypnea

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. Administer IV fluids to the client

b. insert a urinary catheter
c. initiate beta-blocker therapy
d. prepare the client for an intravenous pyelogram - CORRECT ANSWER
Administer IV fluids to the client

A nurse is caring for a client who has just returned from surgery with an external fixator
to the left tibia. Which of the following assessment finding requires immediate
intervention by the nurse?

a. A client has 100 ml blood in the closed suction drain

b. The client's capillary refill in the left toe is 6 seconds
c. The client has an oral temperature of 38.3 C (100.9 Fahrenheit)
d. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site -
CORRECT ANSWER The client's capillary refill in the left toe is 6 seconds
56. A nurse is an emergency department is reviewing a client's ECG reading. Which of
the following
findings should the nurse identify as an indication that the client has a first-degree heart
block?

a. More P waves than QRS complexes

b. Prolonged PR intervals
c. Mon discernible P waves
d. No correlation between P and QRS waves - CORRECT ANSWER Prolonged PR
intervals

A nurse is reviewing the medication list of a client who is being admitted with diabetes
insipidus. Which of the following medication places the client at an increased risk for
developing diabetes insipidus?

a. Ranitidine
b. Atorvastatin
c. Propranolol
d. Lithium - CORRECT ANSWER Lithium

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. Place a plate guard on the client‟s meal tray

b. Position the bedside table on the client's left side
c. Remind the client to use a cane on his left side while ambulating d. Provide the client
with a short-handled reacher - CORRECT ANSWER Place a plate guard on the
client‟s meal tray

A nurse is administering potassium chloride via IV infusion to a client who has severe
hypokalemia. Which of the following actions should the nurse take?

a. Start the infusion at 30 mEq/hr - max rate is 10 mEq/hr

b. Assess the client for a positive Chvostek's sign
c. Monitor the client for adequate urine output
d. Check infusion site at least every 4 hours - CORRECT ANSWER Monitor the
client for adequate urine output

A nurse in the PACU is caring for a client. Which of the following assessment is the
nurse‟s priority?

a. Surgical site
b. Level of consciousness
c. Respiratory status
d. Pain level - CORRECT ANSWER Respiratory status

A nurse is reviewing the medical record of a client who is scheduled for a CT scan with
contrast media. Which of the following medication should the nurse instruct the client to
withhold for 48 hours following the procedure?

a. Carvedilol
b. Furosemide
c. Metformin
d. Clopidogrel - CORRECT ANSWER Metformin

Nurse is caring for a client who has pancreatitis and has been receiving total parenteral
nutrition. Which of the following Laboratory test should the nurse monitor for overall
nutritional status?

a. Creatinine
b. Prealbumin
c. Lipase
d. C-reactive protein - CORRECT ANSWER Prealbumin

A nurse is teaching a client who has endometriosis about the adverse effects of
leuprolide. Which of the following manifestations should the nurse include in the
teaching?

a. Pallor
b. Increased appetite
c. Bone loss
d. Hypoglycemia - CORRECT ANSWER Bone loss

64. A nurse is caring for a client who had an arterial revascularization of the right lower
extremity which of the following is the priority action the nurse should plan to take after
contacting the provider? (Click on the "exhibit" button for additional information about
the client)

a. Increase the Heparin infusion rate per protocol

b. Increase the insulin infusion rate per protocol
c. Start an IV fluid bolus of 0.9% sodium chloride 500 ml to infuse over 1 hour
d. Change the PCA timing of the patient control bolus every 15 minutes - CORRECT
ANSWER Start an IV fluid bolus of 0.9% sodium chloride 500 ml to infuse over 1 hour

65. A nurse is planning the discharge of a client who had an ischemic stroke. The nurse
should ensure that the client is discharged with which of the following types of
pharmacologic therapy?

a. Opioid analgesic
b. Anticonvulsant
c. Anti-thrombotic
d. Diuretic - CORRECT ANSWER Anti-thrombotic

A nurse is caring for a client who has a new colostomy the nurse notes that the client
appears withdrawn and looks away during ostomy care. Which of the following actions
should the nurse take?

a. Ask the client how they feel about the stoma

b. Make a referral for the client to see an ostomy nurse
c. Include the client‟s partner in stoma care education
d. Educate the client about expected stoma appearance - CORRECT ANSWER
Ask the client how they feel about the stoma

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. Administer proparacaine eye drops into the affected eye

b. Places strip of pH paper on to the cul-de-sac of the affected eye
c. Collect information about the irritant that caused an injury (assess first)
d. Instill 0.9% sodium chloride solution into the affected eye - CORRECT ANSWER
Collect information about the irritant that caused an injury (assess first)

A nurse is teaching a client who has AIDS and wishes to continue self-care at home
despite living alone. Which of the following actions by the nurse demonstrates client
advocacy?

a. Remind the client of the importance of the medication adherence

b. Initiate a referral for the client to a home health agency
c. Instruct the client to avoid eating raw vegetables
d. Tell the client to avoid places where there are large crowds of people - CORRECT
ANSWER Initiate a referral for the client to a home health agency

69. A nurse is assessing a client who has cirrhosis. Which of the following findings is the
priority for the nurse to report?

a. Alkaline phosphate 125 units /L

b. Clay-colored stools
c. Platelets 70,000 / mm3
d. Distended abdomen - CORRECT ANSWER Platelets 70,000 / mm3

A home health nurse is providing nutrition education for a client who has trigeminal
neuralgia. Which of the following foods should the nurse recommend?

a. Graham crackers
b. Iced coffee
c. Vanilla pudding
d. Vegetable soup - CORRECT ANSWER Vanilla pudding

A nurse is teaching about food choices to a client who has chronic kidney disease and
must limit potassium intake. Which of the following choices should the nurse
recommend as containing the least potassium?

a. Half cup non-fat yogurt

b. Two tablespoons of peanut butter
c. 1 Cup white riced.
d. One medium baked potato with skin - CORRECT ANSWER 1 Cup white riced.

A nurse is planning care for a client who has a full-thickness burns on the lower
extremities. Which of the following interventions should the nurse include?

a. Limit visitation time for client‟s children to 40 minutes per day

b. Clean the equipment in the client's room once per week
c. Provide a diet of fresh fruits and vegetable for the client
d. Apply new gloves when alternating between wound care sites - CORRECT
ANSWER Apply new gloves when alternating between wound care sites

A nurse is caring for a client who has cancer. The client tells the nurse, "I would prefer
to try vitamins and minerals instead of chemotherapy" which of the following responses
should the nurse make?

a. I have never heard of any holistic treatment that is effective

b. You should ask your provider about your plan
c. The best way to treat your cancer is chemotherapy
d. Tell me what you know about chemotherapy - CORRECT ANSWER Tell me
what you know about chemotherapy

A nurse is planning to teach a client whose provider has prescribed a low purine diet.
The nurse should plan to instruct the client that he can include which of the following
foods in his diet (select all that apply)

a. Sardines
b. Nuts
c. Apricot
d. Liver
e. Scallops - CORRECT ANSWER Nuts, Apricot

75. Nurse is caring for a client following a total knee arthroplasty. The client reports a
pain level of 6 on a paint scale of 0 to 10. Which of the following interventions should
the nurse take?
a. Place pillows under the client‟s knee
b. Gently massage the area around the client‟s incision
c. Apply an ice pack to the client‟s knee
d. Perform range of motion exercises to the client‟s knee - CORRECT ANSWER
Apply an ice pack to the client‟s knee

76. A nurse is caring for a client who has lower extremity fracture and a prescription for
crutches. Which of the following client statements indicates that the client is adapting to
their role change?

a. I will need to have my partner take over shopping for groceries and cooking the
meals for us
b. It's going to be difficult to tell my parents I can't take them to their appointments
anymore
c. I feel bad that I have to ask my partner to keep the house clean
d. These crutches will make it impossible to care for my child - CORRECT ANSWER
I will need to have my partner take over shopping for groceries and cooking the meals
for us

A nurse is assessing a client who is preoperative and reports an allergy to bananas.

The nurse should recognize that the client is at risk for an allergic cross-reactivity to
which of the following substances?

a. Adhesive tape
b. Latex
c. Anesthetics
d. Povidone iodine - CORRECT ANSWER Latex

A nurse on a medical unit is planning care for a group of clients. Which of the following
clients should
the nurse attend to first?

a. A client who has chronic obstructive pulmonary disease in oxygen saturation of 89%
b. A client who has left-sided paralysis and slurred speech from a prior stroke
c. A client who has thrombocytopenia and reports a nosebleed
d. A client who has multiple sclerosis and reports ataxia and vertigo - CORRECT
ANSWER A client who has thrombocytopenia and reports a nosebleed

A nurse is monitoring a client who is receiving two units packed RBC's. Which of the
following manifestation indicates a hemolytic transfusion reaction?

a. Back pain
b. Hypertension
c. Chills
d. Bradycardia - CORRECT ANSWER Chills

A nurse is teaching a client who has diabetes mellitus about foot care. Which of the
following instruction should the nurse include?

a. Use a heating pad to keep your feet warm at night

b. Wear loose-fitting slippers around the house
c. Where cotton rather than nylon socks
d. Wash your face twice per day with antibacterial soap and hot water - CORRECT
ANSWER Where cotton rather than nylon socks

A nurse is providing teaching to a client who has a deep vein thrombosis (DVT). Which
of the following findings should the nurse identify as a risk factor for the development of
the DVTs?

a. NSAID use
b. Hypertension
c. Oral contraceptive use
d. Cirrhosis - CORRECT ANSWER Oral contraceptive use

A nurse is administering furosemide 80 mg PO twice-daily to a client who has

pulmonary edema. Which of the following assessment findings indicates to the nurse
that the medication is effective?

a. Respiratory rate of 24/min

b. Adventitious breath sounds
c. Weight loss of 1.8 kg (4 lb) in the past 24 hours
d. Elevation in blood pressure - CORRECT ANSWER Weight loss of 1.8 kg (4 lb) in
the past 24 hours

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 contradiction for
receiving the medication?

a. Creatinine 0.8 mg/dL

b. Sodium 136 mEq/L
c. Potassium 3.2 mEq/L
d. BUN 18 mg/dL - CORRECT ANSWER Potassium 3.2 mEq/L

84. A nurse on an oncology unit is caring for a client who is receiving internal radiation
therapy. Which of the following actions should the nurse take?

a. Place the dosimeter film badge on a client's door

b. Wear a lead apron when providing client care
c. Leave the door to the client‟s room open
d. Allow visitors to hold the clients hand - CORRECT ANSWER Wear a lead apron
when providing client care

A nurse is caring for a client who has diabetes mellitus and has been following a
treatment plan for 3 months which of the following results should the nurse monitor to
determine long-term glycemic control?

a. Glycosylated hemoglobin level

b. fasting blood glucose level
c. oral glucose tolerance test results
d. post-prandial blood glucose level - CORRECT ANSWER Glycosylated
hemoglobin level

A nurse is reviewing the plan of care for a client who has a seizure disorder. Which of
the following interventions should the nurse anticipate including in the plan? (click on
the exhibit button for additional information about the client)

a. Place the client in a private room

b. Hold the client‟s phenytoin - therapeutic range is 10-20 mcg/mL
c. Check the client‟s stool for occult blood
d. Administer regular insulin to the client - CORRECT ANSWER Hold the client‟s
phenytoin - therapeutic range is 10-20 mcg/mL

A nurse is preparing to administer two units of packed RBCs to a client. Which of the
following actions should the nurse take?

a. Transfuse each unit of blood over five hours

b. Change the IV tubing after each unit of blood is transfused
c. Administer the blood through a 22-gauge intravenous catheter
d. Prime the tubing with 0.9% sodium chloride - CORRECT ANSWER Prime the
tubing with 0.9% sodium chloride

A nurse is caring for a client who has chronic renal failure. The client displays the
following ABG results: pH: 7.24 paCO2: 44 mm Hg, paO2: 84 mmHg, HCO3 : 18 mEq/
L base excess - 2 and O2 saturation 95% The nurse should include that the client has
which of the following acid-base balances ?

a. Metabolic alkalosis
b. Respiratory acidosis
c. Respiratory alkalosis
d. Metabolic acidosis - CORRECT ANSWER Metabolic acidosis

A nurse in a provider's office is teaching a client about the self-management of GERD

which of the following instruction should the nurse include?
a. Lie down 30 minutes after each meal
b. Sleep with the head of your bed elevated 6 inches
c. Increase your caloric intake by 250 calories per day
d. Eat A light meal 1 hour before bedtime - CORRECT ANSWER Sleep with the
head of your bed elevated 6 inches

A nurse is monitoring a client's heart rhythm following insertion of a permanent

pacemaker which of the following images should the nurse expect? - CORRECT
ANSWER upside down rhythm

A nurse is assessing a client who has heart failure which of the following client
statements should indicate to the nurse that the client needs a referral for cardiac
rehabilitation?

a. I hate how I feel all the time

b. I am too tired to brush my teeth
c. I Will Weight myself daily
d. I need to start eating a low sodium diet - CORRECT ANSWER I am too tired to
brush my teeth

A nurse is caring for a client who is receiving continuous bladder irrigation following a
transurethral resection of the prostate. The client reports bladder spasms and the nurse
observes decreased urinary output. Which of the following actions should the nurse
take?

a. Remove the indwelling urinary catheter

b. Decrease transaction of the catheter
c. Flush the catheter manually with 0.9% sodium chloride
d. Administer ibuprofen 400 mg for pain relief - CORRECT ANSWER Flush the
catheter manually with 0.9% sodium chloride

A nurse is discussing nutrition options with a client who has a new diagnosis of COPD.
Which of the following statements should the nurse take?

a. Plan to include high protein foods in each of your meals

b. Increase your intake of vegetables such as broccoli and brussels sprouts
c. Drink a glass of milk with each meal
d. Consume three large meals throughout the day - CORRECT ANSWER Plan to
include high protein foods in each of your meals

A nurse is teaching a client who has asthma about the use of a peak flow meter. After
setting the meter to the zero baseline, what is the sequence of steps the nurse should
instruct the client to take? Move the steps into the box of the right placing them in the
selected order of performance. Use all steps - CORRECT ANSWER 1) Stand
upright
2) Fill your lungs with a deep breath
3) Seal your lips around the mouthpiece
4) Exhale forcefully and quickly
5) Record the highest of three consecutive readings

95. A nurse is caring for a client who has bounding pulses, crackles on auscultation,
and pink frothy secretions when receiving suction. The nurse should recognize these
assessment findings us indicating which of the following?

a. Aspiration
b. Increased cardiac output
c. Pleural effusion
d. Fluid volume excess - CORRECT ANSWER Fluid volume excess

A nurse in a clinic is providing for preventive teaching to an older client during a Well
Visit. The nurse should instruct the client that which of the following immunizations are
recommended for healthy adults after age 60 (select all that apply)

a. Human papillomavirus
b. Pneumococcal polysaccharide
c. Meningococcal
d. Influenza
e. Herpes zoster - CORRECT ANSWER Influenza
Herpes zoster

A nurse is caring for a client who has a traumatic brain injury. The client, who has been
quiet and cooperative, becomes agitated and restless. Which of the following
assessment should the nurse perform first?

a. Blood pressure
b. Blood glucose
c. Urinary output
d. Motor responses - CORRECT ANSWER Motor responses

A nurse is preparing to administer piperacillin 3.375 grams by intermittent IV bolus every

6 hours. Available is piperacillin 3.375 grams in dextrose 5% in water 100 ml to infuse
over 30 minutes. The nurse should set the IV pump to deliver how many ml /hr? (round
the answer to the nearest whole number. Use a leading zero if it applies. Do not use a
trailing zero.) - CORRECT ANSWER 200 ml/hr

99. Nurse in the emergency department is caring for a client who was involved in an
explosion. Which of the following actions should the nurse plan to take first question
(click on the exhibit button for additional information about the client)

a. Initiate peripheral IV access

b. Obtain an ECG
c. Notify the rapid response team
d. Calculate the extent of burns using the rule of nines - CORRECT ANSWER
Notify the rapid response team

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

a. Oliguria
b. Poor skin turgor
c. Pitting edema
d. S3 - S4 Galloping heart sounds - CORRECT ANSWER Pitting edema