Med-Surg ATI
CARDIOVASCULAR
1. A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) for a client who
has anemia. Which of the following actions should the nurse take first?
Witness the informed consent document
2. A nurse is teaching about a low-cholesterol diet to a client who had a myocardial
infarction. Which of the following meal selections by the client indicates an
understanding of the teaching?
Chicken breast and corn on the cob
3. A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse
should expect the client's provider to prescribe which of the following medications for this
client?
Vitamin B12
4. A nurse is 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.)
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
5. A nurse is monitoring a client who has heart failure related to mitral stenosis. The client
reports shortness of breath on exertion. Which of the following conditions should the
nurse expect?
Increased pulmonary congestion
6. 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?
Apply the defibrillator pads to the client's chest
7. A nurse is reviewing the laboratory findings of a client who has protein-calorie
malnutrition. Which of the following findings should the nurse expect?
Decreased albumin
8. A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client
who is receiving a transfusion of packed red blood cells (RBCs). Which of the following
interventions should the nurse use to prevent these manifestations with the client's next
transfusion?
Use a transfusion pump to regulate and maintain the transfusion at a slower rate
9. A nurse is assessing a client who has heart failure and is taking daily furosemide. The
client's apical pulse is weak and irregular. The nurse should identify these findings as
manifestations of which of the following electrolyte imbalances?
Hypokalemia
10. A nurse is providing teaching about lifestyle changes to a client who experienced a
myocardial infarction and has a new prescription for a beta blocker. Which of the
following client statements indicates an understanding of the teaching?
"Before taking my medication, I will count my radial pulse rate."
11. A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has
septic shock secondary to an untreated foot wound. Which of the following findings
should the nurse expect? (Select all that apply.)
Bleeding at the venipuncture site
Petechiae on the chest and arms
Abdominal distension
12. 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?
Substernal chest pain
13. 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?
"My coronary artery disease is a risk factor for heart failure."
14. A nurse is planning care for a client who has pernicious anemia. Which of the following
interventions should the nurse include in the plan?
Initiate weekly injections of vitamin B12
15. 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?
Apply pressure to the catheter removal site for 5 min
16. A nurse is teaching a client with heart disease about a low-cholesterol diet. Which of the
following client statements indicates the teaching was effective?
"I should remove the skin from poultry before eating it."
17. 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?
Peripheral vascular resistance increases.
18. A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of
the following findings indicates that the AAA is expanding?
Report of sudden, severe back pain
19. 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?
Ankle swelling
20. A nurse is assessing a client who has pericarditis. Which of the following manifestations
should the nurse expect?
Dyspnea with hiccups
21. A nurse is planning care for a client who has acute myelogenous leukemia and a platelet
count of 48,000/mm^3. Which of the following interventions should the nurse include?
Avoid IM injections
22. 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?
"Physical activity is good for me, but I need to avoid overexertion."
23. A nurse is assessing a client who has pernicious anemia. Which of the following findings
should the nurse expect?
Paresthesias in the hands and feet
24. 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?
"You'll feel a painful, pulling sensation when the doctor withdraws the marrow."
25. A nurse is reviewing the medical record of a client who has heart failure. Which of the
following findings should the nurse expect?
BNP of 200 pg/mL
26. A nurse is assessing a client who has late-stage heart failure and is experiencing fluid
volume overload. Which of the following findings should the nurse expect?
Weight gain of 1 kg (2.2 lb) in 1 day
27. A client who has thrombocytopenia asks the nurse why platelets are so important. Which
of the following responses should the nurse make?
“Platelets plug breaks in blood vessels”
28. A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of
blood, the nurse should administer which of the following IV solutions?
0.9 sodium chloride
29. A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and
a history of receiving blood transfusions. For which of the following complications should
the nurse monitor?
Iron toxicity
30. A nurse is completing an assessment for a client who has a history of unstable angina.
Which of the following findings should the nurse expect?
Chest pain lasts for longer than 15 min.
31. A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of
the following findings should the nurse expect?
Prolonged QT intervals
32. 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?
Measure the client abdominal girth daily
33. A nurse is assessing a client who has right-sided heart failure. Which of the following
findings should the nurse expect?
Dependent edema
34. A client who just learned that he has variant (Prinzmetal's) angina asks the nurse how
this type of angina compares with stable angina. Which of the following replies should
the nurse make?
"Variant angina can cause changes on your electrocardiogram."
35. A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute
myocardial infarction (MI). Which of the following indicators should the nurse identify to
confirm reperfusion?
Ventricular dysrhythmias
36. A nurse is assessing a client who had coronary artery bypass grafts for cardiac
tamponade. Which of the following actions should the nurse take?
Auscultate blood pressure for pulsus paradoxus
37. A 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?
Hyperkalemia
38. 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.)
Hardening along the blood vessel
Tenderness in the calf
Increased leg circumference
39. A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse expect?
Crackles in the lung bases
40. A nurse is examining the ECG of a client who has hyperkalemia. Which of the following
ECG changes should the nurse expect?
Elevated ST segments
41. A nurse is caring for a client who is postoperative following vein ligation and stripping for
varicose veins. Which of the following actions should the nurse take?
Position the client supine with his legs elevated when in bed
42. A nurse is caring for a client who has pernicious anemia. Which of the following factors
should the nurse identify with this condition?
Vitamin B12 deficiency
43. 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?
● Palpate the blood pressure and inflate the cuff above the systolic pressure.
● Deflate the cuff slowly and listen for the first audible sounds.
● Identify the first BP sounds audible on expiration and then on inspiration.
● Subtract the inspiratory pressure from the expiratory pressure.
● Inspect for jugular venous distention and notify the provider.
44. A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which
of the following ECG abnormalities should the nurse recognize as atrial flutter?
Atrial rate of 300/min with QRS complex of 80/min
45. A nurse is providing discharge teaching for a client who had a bone marrow transplant
and has thrombocytopenia. Which of the following statements indicates that the client
understands the precautions he must take at home?
"I’ll stick with soft foods for now."
46. A nurse is assessing a client who has isotonic dehydration. Which of the following
findings should the nurse expect?
Increased hematocrit level
47. A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the
following manifestations should the nurse expect?
Lower back discomfort
48. A nurse completing an assessment on a client. Which of the following findings should the
nurse identify as a risk factor for coronary artery disease?
Hypertension
Diabetes mellitus
Hyperlipidemia
Tobacco smoking
49. A nurse is teaching a client who has polycythemia vera about self-care measures. Which
of the following interventions should the nurse include?
"Elevate your legs when sitting."
50. A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood
type is O-negative. Which of the following actions should the nurse take?
Remove the unit of plasma immediately and start an IV infusion of normal saline solution
51. A nurse is reviewing the menu selections of a client who has heart failure and anticipates
discharge to home the following day. Which of the following lunch choices should the
nurse identify as an indication that the client understands his dietary instructions?
Turkey on whole-wheat bread
52. A nurse is reviewing the progress notes for a client who has heart failure. The provider
noted some improvement in the client's cardiac output. The nurse should understand
that cardiac output reflects which of the following physiologic parameters?
The heart rate times the stroke volume
53. A nurse is providing discharge teaching to a client who has a new permanent
pacemaker. Which of the following statements by the client indicates an understanding of
the teaching?
"I should check my heart rate at the same time each day."
54. A nurse is providing teaching for a client who has a prescription for a low-sodium diet to
manage hypertension. Which of the following statements by the client indicates an
understanding of the teaching?
"I can snack on fresh fruit."
55. A nurse is assessing a client who is receiving a unit of whole blood. Which of the
following findings should the nurse identify as a manifestation of a hemolytic transfusion
reaction?
Low back pain
56. A nurse is reviewing the laboratory results of a client who has end-stage renal disease
and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a
prescription for which of the following medications?
Erythropoietin
57. 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?
Hgb 6.5 g/dL
58. 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?
A solution of 5 mL heparin 1,000 units/mL has been prepared.
59. A nurse is caring for a client with heart failure whose telemetry reading displays a
flattening of the T wave. Which of the following laboratory results should the nurse
anticipate as the cause of this ECG change?
Potassium 2.8 mEq/L
60. A nurse is monitoring a client who had a myocardial infarction. For which of the following
complications should the nurse monitor in the first 24 hr?
Ventricular dysrhythmias
61. A nurse is caring for a client who is having a possible myocardial infarction (MI). Which
of the following findings should the nurse identify as an associated manifestation of an
MI?
Nausea
62. 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?
Acidosis
63. A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for
surgery. The client’s vital signs are blood pressure 160/98 mmHg, heart rate 102/min,
respirations 22/min, and SpO2 95%. Which of the following actions should the nurse
take?
Administer antihypertensive medication for blood pressure
64. 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?
Omega-3 fatty acids
65. A nurse is showing a client who has right-sided heart failure an illustration of the heart.
Which of the following blood vessels carry deoxygenated blood to the right atrium?
Superior vena cava
66. A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has
a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The
nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious
breath sounds should the nurse document?
Coarse crackles
67. A nurse is providing discharge teaching to an adult female client who has infective
endocarditis about how to prevent recurrence. Which of the following statements by the
client indicates an understanding of the teaching?
"I will notify my doctor before I have dental procedures."
68. A nurse is providing information to a client who is scheduled for an exercise
electrocardiography test. Which of the following client statements indicates an
understanding of the teaching?
"I will not drink coffee 4 hr prior to my test."
69. A nurse is assessing a client for manifestations of aplastic anemia. Which of the
following findings should the nurse expect?
Petechiae and ecchymosis
70. 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?
"Keep your cell phone 6 inches away from your pacemaker when making a call."
71. A nurse is teaching a client who has coronary artery disease about the difference
between angina pectoris and myocardial infarction (MI). Which of the following
manifestations should the nurse identify as indications of MI? (Select all that apply.)
A. Nausea and vomiting
B. Diaphoresis and dizziness
D. Anxiety and feelings of doom
72. 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?
Impaired circulation
73. A nurse is caring for a client who has a demand pacemaker inserted with a set rate of
72/min. Which of the following findings should the nurse expect?
Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no
pacing spikes
74. A nurse is teaching a client who has iron-deficiency anemia. The nurse should
encourage the client to increase consumption of which of the following foods?
Beef liver
75. 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?
"I should eliminate uncooked foods from my diet for now."
76. 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.)
Jugular vein distension
Moist crackles
Increased heart rate
77. A nurse is examining the ECG of a client who is having an acute myocardial infarction.
The nurse should identify that the elevated ST segments on the ECG indicate which of
the following alterations?
Necrosis
78. A nurse in a clinic is assessing the lower extremities and ankles of a client who has a
history of peripheral arterial disease. Which of the following findings should the nurse
expect?
Dry, pale skin with minimal body hair
79. A nurse is providing teaching to a client who has anemia and a new prescription for
epoetin alfa. Which of the following pieces of information should the nurse include in the
teaching?
Hypertension is a common adverse effect of this medication.
80. A nurse is reviewing a client’s repeat laboratory results 4 hr after administering fresh
frozen plasma (FFP). Which of the following laboratory results should the nurse review?
Prothrombin time
81. A nurse is teaching a client about dietary modifications to control blood pressure. Which
of the following food choices should the nurse identify as an indication that the client
understands the instructions?
Grilled chicken salad with fresh tomatoes
82. A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of
24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the
following actions should the nurse take? (Select all that apply.)
Assess and document the client's vital signs.
Verify with another nurse the blood type and Rh of the packed RBCs
Change IV tubing to a set that has a filter
83. A nurse is preparing a client for cardiac catheterization. Which of the following pieces of
information should the nurse give the client before the procedure? (Select all that apply.)
"You'll have to lie flat for several hours after the procedure."
"You'll receive medication to relax you before the procedure."
"You'll have to keep your leg straight after the procedure."
84. A nurse is teaching a client who has iron-deficiency anemia. The nurse should
encourage the client to increase her consumption of which of the following foods?
Lentils
85. 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?
Elevated Hct
86. While participating in a community health fair, a nurse is providing information to a client
who has a blood pressure of 150/90 mmHg during screening. Which of the following
actions should the nurse take?
Give the client a written record of his BP to bring to his provider
87. A nurse is planning care for a client who is having a percutaneous transluminal coronary
angioplasty (PTCA) with stent placement. Which of the following actions should the
nurse anticipate in the post-procedure plan of care?
Monitor for bleeding
88. 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?
Acute confusion
89. A nurse is caring for a client who is undergoing treatment for hypertension. Which of the
following statements indicates that the client is adhering to the treatment plan?
"I would never have believed I could get used to enjoying my food without salt."
90. A nurse in a provider's office is reviewing the medical records of a group of clients.
Which of the following clients is at risk for iron deficiency? (Select all that apply.)
A client who is a vegetarian
A client who is pregnant
A toddler who is overweight
91. A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the
following actions should the nurse take? (Select all that apply.)
Check to determine the packed RBCs are less than 1 week old
Ask another nurse to check the packed RBCs’ label against the medical record
Prime the transfusion tubing with 0.9% sodium chloride
92. 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?
Ample hydration
93. A nurse is caring for a client who has hemophilia. The client reports pain and swelling in
a joint following an injury. Which of the following actions should the nurse take?
Prepare for replacement of the missing clotting factor
94. A nurse is planning care for a client during a sickle cell crisis. Which of the following
interventions should the nurse include in the client's plan of care?
Encourage increased fluid intake
95. 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?
Epistaxis
96. A nurse is caring for an adult male client who is undergoing screening tests for
atherosclerosis. Which of the following laboratory findings should the nurse identify as an
increased risk for this disorder?
Elevated LDL levels
97. A nurse is teaching a client who has pernicious anemia. The nurse should encourage
the client to increase consumption of which of the following foods?
Eggs
98. A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which
of the following actions should the nurse take?
Apply lateral pressure to the client’s nose for 10 min
99. A nurse is preparing an in-service presentation about the management of myocardial
infarction (MI). Death following MI is often a result of which of the following
complications?
Dysrhythmias
100. 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?
Absence of hair on the legs
101. A nurse is caring for a client following a stroke. Which of the following actions should
the nurse take first?
Keep the client NPO
102. A nurse is assessing a client who is receiving a transfusion of packed red blood cells
(RBCs). Which of the following findings should the nurse identify as an indication of an
acute intravascular hemolytic reaction?
Sudden oliguria
103. A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client
over 4 hr. A blood administration set is available that delivers 10 gtt/mL. The nurse
should set the manual blood transfusion to deliver how many gtt/min?
10 gtt/min
104. A nurse is preparing an in-service presentation about the basics of hematology.
Which of the following factors provides a stimulus for the production of RBCs?
Tissue hypoxia
105. A nurse is completing dietary teaching with a client who has heart failure and is
prescribed a 2 g sodium diet. Which of the following statements by the client indicates an
understanding of the teaching?
"I can have yogurt as a dessert."
106. A nurse is caring for a client who reports calf pain. What is the first action the nurse
should take?
Check the affected extremity for warmth and redness
107. A nurse is administering a unit of packed red blood cells (RBCs) to a client who is
postoperative. The client reports itching and hives 30 min after the infusion begins.
Which of the following actions should the nurse take first?
Stop the infusion of blood
108. 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?
Stop the medication infusion
109. A nurse is examining the ECG of a client who has frequent premature ventricular
contractions (PVCs). Which of the following QRS changes should the nurse expect to
see on the client's ECG?
Much greater amplitude than the usual QRS complexes
110. A nurse is caring for a client who has scurvy. Which of the following vitamin
deficiencies should the nurse identify as the cause of this disease?
Vitamin C
111. 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?
Elevate the affected leg
112. A nurse is caring for a client who is undergoing conservative treatment for deep-vein
thrombosis. The client asks the nurse what will happen to the clot. Which of the following
responses should the nurse make?
"Your body has a process called fibrinolysis that will eventually dissolve the clot."
Dermatological
1. A nurse is teaching a group of young adult clients about health promotion techniques to
reduce the risk of skin cancer. Which of the following instructions should the nurse
include?
Avoid exposure to the midday sun
2. A nurse is planning care for a client who has been admitted for the treatment of a
malignant melanoma of the upper leg without metastasis. The nurse should plan to
prepare the client for which of the following procedures?
Surgical excision
3. A nurse is assessing the abdominal incision of a client who is 3 days postoperative. The
incision is slightly edematous and pink with crusting on the edges and is draining
serosanguineous fluid. Which of the following assessments describes the incision?
The incision is showing signs of healing without complications.
4. A nurse is caring for a client who has a large wound healing by secondary intention. The
nurse should inform the client that which of the following nutrients (in addition to protein)
promotes wound healing?
Vitamin C
5. A community health nurse is teaching a group of clients about melanoma. Which of the
following characteristics of lesions associated with melanoma should the nurse include in
the teaching?
Irregular border
6. A nurse is screening a client for skin cancer. When teaching the client about skin cancer
risk, which of the following risk factors should the nurse include?
Excessive exposure to ultraviolet light
7. A nurse is caring for a client who has regular occupational exposure to sunlight and
presents for evaluation of several skin lesions. Which of the following findings should
alert the nurse to the possibility of malignant melanoma?
An irregularly shaped brown lesion with light blue areas on the neck
8. A nurse is assessing a client who is bedridden and was admitted from home. The nurse
notes a shallow crater in the epidermis of the client’s sacral area. The nurse should
document that the client has a pressure ulcer at which of the following stages?
II
9. A nurse is teaching a client who has extensive deep partial- and full-thickness burns and
requires a topical antimicrobial medication. The goal of this medication therapy is to
reduce which of the following outcomes?
Bacterial growth
10. A nurse in a dermatology clinic is using the ABCDE method while screening several skin
lesions for skin cancer on a client. Which of the following findings should the nurse report
to the provider?
Color variation within a lesion
11. A nurse is conducting discharge teaching about foot care for a client who has diabetes
mellitus. Which of the following instructions should the nurse include?
Test water temperature with the wrist
12. A nurse is caring for a client whose wounds are covered with a heterograft dressing. In
response to the client’s questions about the dressing, the nurse explains that it is
obtained from which of the following sources?
Pig skin
13. A community health nurse is teaching a group of clients about malignant melanoma.
Which of the following traits places a client at risk for developing malignant melanoma?
Light skin
14. A nurse is caring for an adolescent client who has burn wounds on her face and hands.
Which of the following statements by the client indicates that she has adapted to her
changed body image?
"May I go with my family to the visitor’s lounge?"
15. A nurse is caring for a client who has a lesion on the back of his right hand. The client
asks the nurse which type of skin cancer is the most serious. Which of the following
responses by the nurse is appropriate?
Melanoma
16. A nurse is planning care for a client who has deep partial-thickness and full-thickness
thermal burns over 40% of his total body surface and is in the acute phase of burn injury.
Which of the following interventions should the nurse include in the plan?
Initiate range-of-motion exercises
17. A nurse in a provider’s office is assessing a client’s skin lesions. The nurse notes that
the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The
nurse should document these findings as which of the following skin lesions?
Papules
18. A nurse in an emergency department is assessing a client who has extensive burns,
including on her face. Which of the following assessments should the nurse perform
first?
Characteristics of the cough and sputum
19. A nurse is evaluating the laboratory values of a client who is in the resuscitation phase
following a major burn. Which of the following laboratory findings should the nurse
expect?
Sodium 132 mEq/L
20. A nurse is assessing the skin of a client who has frostbite. The client has small blisters
that contain blood, and the skin of the affected area does not blanch. The nurse should
classify this injury as which of the following?
Third-degree frostbite
21. A nurse in a provider’s office is caring for a client who has a new diagnosis of herpes
zoster. The nurse should anticipate a prescription for which of the following medications?
Acyclovir
22. A nurse is assessing a client who has a lesion on his skin. Which of the following
findings is a clinical manifestation of malignant melanoma?
Irregularly shaped lesion with blue tones
23. A nurse in the emergency department is caring for a client who has a snakebite on her
arm. Which of the following interventions should the nurse implement?
Immobilize the limb at the level of the heart
24. A nurse is teaching a group of clients about skin cancer. The nurse should explain that
basal cell carcinoma originates from which of the following tissues?
Epidermis
25. A nurse is caring for a client who has burn injuries on his trunk. The nurse is explaining
what to expect from the prescribed hydrotherapy. Which of the following statements by
the client indicates an understanding of the teaching?
"I will be on a special shower table."
26. A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be
applied to her burn wounds. The nurse should evaluate the client for which of the
following laboratory findings?
Leukopenia
27. A nurse is providing discharge instructions to a client who is postoperative following
surgical excision of a basal cell carcinoma. Which of the following findings should the
nurse include as an indication of a mole’s potential malignancy?
Ulceration
28. A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the
following wounds should the nurse expect to heal by primary intention?
Surgical incision
29. A nurse is caring for a client who has full-thickness burns covering 63% of her body and
smoke inhalation. Which of the following nursing actions is the top priority?
Monitor respiratory status.
30. A nurse is assessing a client who sustained superficial partial-thickness and deep
partial-thickness burns 72 hr ago. Which of the following findings should the nurse report
to the provider?
Temperature of 39.1°C (102.4°F)
31. A nurse is providing teaching to a client who is wheelchair-bound and his caregiver
about ways to reduce the risk of pressure ulcer formation. Which of the following
instructions should the nurse include?
"Shift your weight in the wheelchair every 15 min."
ENDOCRINE
1. A nurse is caring for a client who has urolithiasis and requires further diagnostic testing
after an initial test indicated hypercalcemia. Which of the following structures controls
calcium concentration?
Parathyroid gland
2. A nurse is caring for a client who is postoperative following a bilateral adrenalectomy.
The nurse should expect to administer glucocorticoids following the procedure to
enhance which of the following therapeutic effects?
Compensation for decreased cortisol levels
3. A nurse is monitoring a client who has syndrome of inappropriate antidiuretic hormone
secretion (SIADH). Which of the following findings should the nurse expect?
Hyponatremia
4. A nurse is planning care for a client who has Cushing's syndrome due to chronic
corticosteroid use. Which of the following actions should the nurse include in the plan of
care? Check the client’s urine specific gravity
5. A nurse in the emergency department is assessing a client who has pancreatitis. In
which of the following laboratory results should the nurse expect to see an elevation?
Amylase
6. A nurse is checking laboratory values to determine if a client with diabetes mellitus is
adhering to the treatment plan. Which of the following tests should the nurse use to
make this determination?
Glycosylated hemoglobin levels
7. A nurse is teaching a client who had a vaginal hysterectomy with a bilateral
oophorectomy. Which of the following pieces of information should the nurse include in
the teaching?
“Use a water-based lubricant when having sexual intercourse”
8. A nurse is planning care for a client who has syndrome of inappropriate antidiuretic
hormone secretion (SIADH) with mild manifestations. The nurse should expect the
provider to prescribe which of the following medications?
Tolvaptan
9. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following
findings should the nurse expect?
Kussmaul respirations
10. A nurse is providing teaching to a client who has type 2 diabetes mellitus. The client
states, "I eat pasta every day. I can't imagine giving it up." Which of the following
responses should the nurse provide?
"You don’t have to give up pasta; just adjust the amount you eat."
11. A nurse is caring for a client who has type 2 diabetes mellitus and is displaying
manifestations of hyperglycemia. Which of the following findings indicates the client has
hyperglycemia?
Increased urination
12. A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the
following actions should the nurse plan to take first?
Ask the client to identify the types of foods she prefers
13. A nurse is assessing a client who has manifestations of acromegaly. Which of the
following findings should the nurse expect?
Increased head size
14. A nurse is providing teaching to a client who has type 2 diabetes mellitus about the
pathophysiology of the disease. Which of the following statements by the client indicates
an understanding of the teaching?
"My cells are resistant to the effects of insulin."
15. A nurse is teaching a client who has hyperthyroidism about managing this disorder.
Which of the following recommendations should the nurse include?
Increase caloric intake with meals
16. A nurse is reviewing the laboratory results of a client who has diabetes mellitus. Which of
the following results indicates that the client’s diabetes is controlled?
Fasting blood glucose 95 mg/dL
17. A nurse is assessing a client who has Graves' disease. Which of the following findings
should the nurse expect the client to display?
Difficulty sleeping
18. A nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism caused by
an adenoma. Which of the following findings should the nurse report to the provider?
(Select all that apply.)
Tachycardia and hypertension
Laryngeal stridor and hoarseness
Positive Trousseau's sign
19. A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood
glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?
Diaphoresis
20. A nurse is caring for a client who is postoperative following a parathyroidectomy to treat
hyperparathyroidism. Which of the following laboratory values should the nurse expect to
decrease as a therapeutic effect of the procedure?
Calcium
21. A nurse is preparing a 24-hr urine specimen for a client who is suspected to have
pheochromocytoma. Which of the following laboratory tests from the 24-hr urine
specimen should the nurse use to determine the client’s condition?
Vanillylmandelic acid (VMA)
22. A nurse is monitoring a client who has Graves' disease for the development of thyroid
storm. The nurse should report which of the following findings to the provider?
Hypertension
23. A nurse is caring for a client who is scheduled to receive peritoneal dialysis. Which of the
following actions should the nurse take?
Warm the dialysate solution prior to administration
24. A nurse is assessing a client who is recovering from a thyroidectomy and has a harsh,
high-pitched respiratory sound. Which of the following actions should the nurse take?
Prepare for a tracheostomy
25. A nurse is conducting a home visit for an older adult client who has diabetes mellitus and
takes regular insulin subcutaneously before each meal. The client appears disoriented
and weak and has slurred speech. Which of the following conditions should the nurse
consider first when responding to these manifestations?
Hypoglycemia
26. A nurse is teaching a client who has type 2 diabetes mellitus about foot care. Which of
the following statements by the client indicates an understanding of the teaching?
"I'll be sure to wear cotton socks every day."
27. A nurse is planning care for a client who is experiencing the Somogyi effect and takes
intermittent-acting insulin. Which of the following actions should the nurse include in the
plan?
Monitor the client's nighttime blood glucose levels
28. A nurse is planning care for a client who has type 2 diabetes mellitus. Which of the
following interventions should the nurse include in the plan?
Encourage the client to control weight
29. A nurse is providing teaching to a client who has type 1 diabetes mellitus about
hypoglycemia. Which of the following manifestations should the nurse include in the
teaching?
Shakiness
30. A nurse is assessing a client who has Addison's disease. Which of the following findings
should the nurse expect?
Hypotension
31. A nurse is reviewing the laboratory reports of a client and notes an elevated
thyroid-stimulating hormone (TSH) level. Which of the following findings should the nurse
expect?
Bradycardia
32. A nurse is accepting a transfer from the postanesthesia care unit (PACU) of a client who
has had a subtotal thyroidectomy. Which of the following pieces of equipment should the
nurse have available at the bedside for this client?
Tracheostomy tray
33. A nurse in the emergency department is caring for a client who has a fruity breath odor,
a dry mouth, and extreme thirst. Which of the following assessments should the nurse
make?
Blood glucose level
34. A nurse is planning to administer fluids to a client who has 25% total body surface area
burns. The client has no prior medical history. Which of the following intravenous fluids is
contraindicated for this client?
0.45% sodium chloride
35. A nurse is monitoring a client following a thyroidectomy for the presence of
hypoparathyroidism. Which of the following findings should the nurse expect?
Involuntary muscle spasms
36. A nurse is assessing a client who has Addison’s disease. Which of the following skin
manifestations should the nurse expect to find?
Bronze pigmentation of the skin
37. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis.
Which of the following laboratory values is consistent with diabetic ketoacidosis?
Bicarbonate level 12 mEq/L
38. A nurse in the emergency department is caring for a client who has Addison’s disease
and reports nausea, vomiting, diarrhea, and abdominal pain. To prevent an Addisonian
crisis, the nurse should prepare to administer which of the following medications?
Hydrocortisone
39. A nurse is providing teaching about exercise to a client who has type 1 diabetes mellitus.
Which of the following statements should the nurse include?
”Wear a medical alert identification tag when you exercise."
40. A nurse is planning a community health screening for a group of clients who are at risk
for type 2 diabetes mellitus. Which of the following clients should the nurse include in the
screening?
Men and women who are obese
41. A nurse is providing teaching to a client who has Addison’s disease about healthy snack
foods. Which of the following food choices by the client indicates an understanding of the
teaching?
Turkey and cheese sandwich
42. A nurse is updating the plan of care for a client who is to receive total parenteral nutrition
(TPN). Which of the following actions should the nurse include in the plan? (Select all
that apply.)
Weigh the client daily
Obtain a serum blood glucose every 4 hr
Change the IV tubing every 24 hr
43. A nurse is teaching a client about the prostate-specific antigen (PSA) test. Which of the
following directions should the nurse provide?
"You should not ejaculate for 24 hours prior to the PSA test."
44. A nurse is providing teaching about food choices to a client who has diabetes mellitus.
Which of the following statements by the client indicates an understanding of the
teaching?
"I should replace white bread with whole-grain bread."
45. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a
central line. Which of the following actions should the nurse perform?
Weigh the client daily
46. A nurse is caring for a client with Addison's disease who has been admitted with muscle
weakness, dehydration, and nausea and vomiting for the past 2 days. Which of the
following prescribed medications should the nurse plan to administer?
Hydrocortisone
47. A nurse is caring for a client who has been diagnosed with an Addisonian crisis and has
a blood pressure of 74/42 mmHg. Which of the following prescriptions should the nurse
anticipate?
Hydrocortisone
48. A nurse is caring for a client who has diabetes insipidus. For which of the following
findings should the nurse monitor?
Polyuria
Gastrointestinal
1. A nurse is teaching a client who has cirrhosis of the liver and a history of alcohol
consumption. The nurse should explain that alcohol can cause liver cirrhosis through
which of the following actions?
Destroying liver cells that are later replaced with scar tissue
2. A nurse is completing a history and physical assessment for a client who has chronic
pancreatitis. Which of the following findings should the nurse identify as a likely cause of
the client’s condition?
Alcohol use
3. A nurse is teaching a group of clients about the functions of the liver and gallbladder.
Which of the following should the nurse include in the teaching as the purpose of bile?
Digesting fats
4. A nurse is recommending dietary modifications for a client who has GERD. The nurse
should suggest eliminating which of the following foods from the client's diet?
Oranges and tomatoes
5. A nurse is planning care for a client who has cholelithiasis. Which of the following
interventions should the nurse include in the plan?
Decrease the client's fat intake
6. A nurse is caring for a client from the Middle East who has celiac disease. Which of the
following actions should the nurse perform regarding the client's diet?
Determine the client's dietary preferences
7. A nurse is caring for a client who has recovered from acute diverticulitis. The nurse
should instruct the client to increase his intake of which of the following foods when the
inflammation subsides?
Cabbage and peaches
8. A nurse is developing a plan of care for a client who has gastroesophageal reflux
disease (GERD). The nurse should plan to monitor the client for which of the following
complications?
Aspiration
9. A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis
with abdominal distention. Which of the following actions should the nurse take to assess
for changes in the client's abdominal distention?
Take serial measurements of the abdomen with a tape measure
10. A nurse is caring for a client who is 4 hr postoperative following a laparoscopic
cholecystectomy. Which of the following findings should the nurse expect?
Right shoulder pain
11. A nurse is monitoring the laboratory results of a client who has end-stage liver failure.
Which of the following results should the nurse expect?
Increased prothrombin time
12. A nurse is preparing a community education program about hepatitis B. Which of the
following statements should the nurse include in the teaching?
"A hepatitis B immunization is given to infants and children."
13. A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest
with bathroom privileges. When the client asks the nurse why he has to say in bed,
which of the following responses should the nurse provide?
"Lying quietly in bed helps slow down the activity in your intestines."
14. A nurse is caring for a child who had her spleen removed following a bicycle accident.
The child's parent asks the nurse about the role of the spleen in the body. The nurse
should explain that the spleen performs which of the following functions?
Destroys old blood cells
15. A community health nurse is planning an educational program about hepatitis A. When
preparing the materials, the nurse should identify that which of the following groups is
most at risk for developing hepatitis A?
Children
16. A nurse is planning an in-service training session regarding nutrition. Which of the
following minerals should the nurse identify as involved in oxygen transportation?
Iron
17. A nurse is caring for a client who is 3 days postoperative following abdominal surgery.
The client states, "Something just popped when I coughed." Which of the following
actions should the nurse take first?
Cover the client's wound with a sterile, moist dressing
18. A nurse is caring for a client who is scheduled to undergo an
esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is
for which of the following reasons?
To detect an ulceration in the stomach
19. A nurse is caring for a client with a history of cirrhosis who has been admitted with
manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for
which of the following laboratory tests to determine the possibility of recent excessive
alcohol use?
Gamma-glutamyl transferase (GGT)
20. A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding
through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the
following findings requires intervention?
The head of the bed is elevated to 20°.
21. A nurse is teaching dietary-modification strategies to a client who has been newly
diagnosed with cirrhosis. Which of the following foods should the nurse recommend?
Grilled chicken
22. A nurse is planning an in-service training session for a group of nurses regarding the role
of enzymes in digestion. Which of the following enzymes plays a role in the digestion of
protein?
Pepsin
23. A nurse is assessing a client who has cholecystitis. Which of the following findings
should the nurse expect?
Blumberg's sign
24. A nurse is caring for a client who is 2 days postoperative following gastric surgery and
has an NG tube inserted. Which of the following findings should the nurse report to the
provider?
200 mL of bright red drainage from the NG tube
25. A nurse is caring for a client who has an indwelling urinary catheter. Which of the
following actions should the nurse take?
Empty the drainage bag when half-full of urine
26. A nurse is teaching a client who has a colostomy about ways to reduce flatus and odor.
Which of the following strategies should the nurse include?
Eat crackers and yogurt regularly
27. A nurse is caring for a client who has diverticulitis and a new prescription for a low-fiber
diet. Which of the following food items should the nurse remove from the client's meal
tray?
Coleslaw
28. A nurse is caring for a client who is postoperative following a laparotomy. The client has
an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following
findings indicates that the client is developing a postoperative complication?
Pulse oximetry of 85%
29. A nurse is providing postoperative teaching about the management of dumping
syndrome to a client who had a partial gastrectomy. Which of the following instructions
should the nurse include in the teaching?
"Eat protein with each meal."
30. A nurse is updating the plan of care for a client who has dumping syndrome. Which of
the following instructions should the nurse include?
Eat a source of protein with each meal
31. A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection
with colostomy. Which of the following statements by the client indicates a need for
further teaching? "I’ll have to consume a soft diet after surgery."
32. A nurse is caring for a client who has abdominal pain and possible pancreatitis. Which of
the following laboratory results should the nurse identify as an indication of pancreatitis?
Increased serum lipase level
33. A nurse is assessing a client who has a complete intestinal obstruction. Which of the
following findings should the nurse expect?
Hyperactive bowel sounds above the obstruction
34. A nurse is providing teaching to a client who has constipation. Which of the following
instructions should the nurse include?
Eat yogurt with live cultures
35. A nurse enters a client's room and notes smoke coming from a wastebasket in the
adjacent bathroom. Which of the following actions should the nurse take first?
Transport the client to an area away from the smoke
36. A nurse is caring for a client who has celiac disease. Which of the following foods should
the nurse remove from the client's meal tray?
Wheat toast
37. A nurse in the emergency department is caring for a client who has bleeding esophageal
varices. The nurse should anticipate a prescription for which of the following
medications?
Vasopressin
38. A nurse is providing teaching to the guardian of a child who has celiac disease. Which of
the following foods should the nurse instruct the guardian to omit from the child's diet?
Wheat bread
39. A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of
the following manifestations should the nurse expect?
Boardlike abdomen
40. A nurse is providing teaching about nutrients to a client. Which of the following
statements should the nurse include?
"Protein builds and repairs body tissue."
41. A nurse is caring for a client who has acute pancreatitis. Which of the following serum
laboratory values should return to the expected reference range within 72 hr of treatment
beginning?
Amylase
42. A nurse is providing preoperative teaching to a client who will undergo surgery to create
a temporary colostomy. The client asks the nurse about the difference between
colostomies and ileostomies. Which of the following responses should the nurse make?
"A colostomy is from the large intestine, and an ileostomy is from the small intestine."
43. A nurse is performing discharge teaching about ostomy care while at home for a client
who has a newly placed ileostomy. Which of the following instructions should the nurse
include in the teaching?
"Empty your ostomy pouch when it becomes half full."
44. A nurse in a provider's office is assessing a client who has GERD. When documenting
the client's history, the nurse should expect the client to report that symptoms worsen
with which of the following actions?
Bending over
45. A nurse in a provider's office is assessing a client who has GERD. The nurse should
expect the client to report which of the following manifestations? (Select all that apply.)
A. Regurgitation B. Nausea C. Belching D. Heartburn
46. A nurse is providing dietary teaching to a client who has ulcerative colitis. Which of the
following food selections by the client indicates an understanding of the teaching?
Roast chicken and white rice
47. A nurse is assessing a client who was admitted with a bowel obstruction. The client
reports severe abdominal pain. Which of the following findings indicates that a possible
bowel perforation has occurred?
Rigid abdomen
48. A nurse is caring for a client who is NPO and has an NG tube to suction. When the client
reports nausea, which of the following actions should the nurse take?
Irrigate the tube with normal saline solution
49. A nurse is obtaining a guaiac test from a client. This test is performed to detect which of
the following?
Blood in stool
50. A nurse is caring for a client who has acute diverticulitis. While the client has active
inflammation, the nurse should instruct the client to include which of the following foods
in her diet?
White bread and plain yogurt
51. A nurse is admitting a client who has cirrhosis. Which of the following prescriptions
should the nurse anticipate? (Select all that apply.) A. Obtain the client's PT and INR
measurements B. Administer lactulose 30 mL PO 4 times daily C. Obtain daily weight
and abdominal girth measurements D. Administer a daily multivitamin
52. A nurse is providing dietary teaching to a client who has dumping syndrome following
gastric bypass surgery 4 days ago. Which of the following recommendations should the
nurse include in the teaching?
Maintain a supine position after meals
53. A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The
nurse notes that bowel sounds are present. Which of the following foods should the
nurse provide at the initial feeding?
Clear liquids
54. A nurse is providing discharge teaching to the partner of a client who has a new
diagnosis of hepatitis A. Which of the following instructions should the nurse include in
the teaching?
"Encourage her to eat foods that are high in carbohydrates."
55. A nurse is caring for a client who has an acute exacerbation of Crohn's disease. Which
of the following actions should the nurse take?
Ensure bowel rest
56. A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of
the following actions should the nurse teach the client to perform? (Select all that apply.)
B. Empty the bag when it is one-third to one-half full C. Cut the skin barrier opening a
little larger than the ostomy D. Wash the peristomal skin with mild soap and water
57. A nurse is planning discharge teaching for a client who is postoperative following a
traditional open cholecystectomy. Which of the following learning needs of the client is
the nurse's priority?
Coughing and deep-breathing exercises
58. A nurse is caring for a client who has gastrointestinal bleeding. The provider suspects a
bleeding lesion in the colon. The initial approach to treatment likely will involve which of
the following procedures?
Colonoscopy
59. A nurse is presenting an in-service training session about nutrition. How many of the
amino acids must be obtained from dietary intake?
9
60. A nurse is caring for a client who has colitis and reported increased exacerbations due to
stress at work. Which of the following responses should the nurse make?
"Perhaps we should review your coping mechanisms and talk about other alternatives."
61. A nurse is caring for a client who has fulminant hepatic failure. Which of the following
procedures should the nurse anticipate for this client? Liver transplant
62. A nurse is teaching about secondary prevention actions for colorectal cancer for a health
fair for adults in the community. Which of the following topics should the nurse include?
Importance of colonoscopy screening starting at age 50 years old
63. A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the
following manifestations should the nurse include? (Select all that apply.)
B. Diaphoresis D. Palpitations E. Shakiness
64. A nurse is teaching a client with Barrett’s esophagus who is scheduled to undergo an
esophagogastroduodenoscopy (EGD). Which of the following statements should the
nurse include in the teaching?
"This procedure can determine how well the lower part of your esophagus works."
65. A nurse is assessing a client who is 12 hr postoperative following an open
cholecystectomy. Which of the following findings should the nurse report to the provider?
Indwelling urinary catheter output of 25 mL/hr
66. A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for
an esophagogastric balloon tamponade tube to treat bleeding esophageal varices.
Which of the following pieces of information should the nurse include in the teaching?
The client will be placed on mechanical ventilation prior to this procedure.
67. A nurse is assessing a client who has a bleeding duodenal ulcer. Which of the following
findings should the nurse expect?
Emesis with a coffee-ground appearance
68. A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the
stomach. The client tells the nurse in the PACU that he does not remember why the
surgeon said he had to have a tube in his nose. The nurse should explain that the NG
tube serves which of the following purposes?
Prevents excessive pressure on suture lines
69. A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG)
tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the
following actions should the nurse take first?
Place the client in the semi-Fowler’s position
70. A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected
malignancy. Which of the following laboratory findings should the nurse monitor prior to
the procedure?
Prothrombin time
71. A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy.
The client states she does not understand how she will be alright without her gallbladder.
The nurse should explain to the client that which of the following is the main function of
the gallbladder?
Storing bile
72. A nurse is assisting a provider with performing a paracentesis on a client. Which of the
following actions should the nurse take?
Ask the client to empty his bladder before the procedure
73. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and
has just returned to the room following physical therapy. The nurse notes that the
infusion pump for the client’s TPN is turned off. After restarting the infusion pump, the
nurse should monitor the client for which of the following findings?
Diaphoresis
74. A nurse is providing dietary teaching to a client who has diverticulitis about preventing
acute attacks. Which of the following foods should the nurse recommend?
Foods high in fiber
75. A nurse is assessing a client who is in the early stages of hepatitis A. Which of the
following manifestations should the nurse expect?
Anorexia
IMMUNE AND INFECTIOUS
1. A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the
following manifestations of the client's skin should the nurse expect?
Unilateral, localized, nodular skin lesions
2. A nurse is providing discharge teaching to a client who has a new diagnosis of systemic
lupus erythematosus (SLE). Which of the following statements by the client indicates an
understanding of the teaching?
"I will need to take methotrexate, even if I’m in remission."
3. A nurse is teaching a client who has genital herpes about self-management. Which of
the following instructions should the nurse include in the teaching?
Apply a warm compress to the lesions
4. A nurse is providing discharge teaching to the partner of a client who has acquired
immune deficiency syndrome (AIDS). Which of the following statements by the client’s
partner indicates a need for further teaching?
"I’ll clean up blood spills immediately with hot water."
5. A nurse is caring for a client who underwent radioallergosorbent (RAST) testing due to
seasonal allergies. The nurse should anticipate an elevation in which of the following
immunoglobulin laboratory values? IgE
6. A nurse is teaching a female client with a new diagnosis of systemic lupus
erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse
should determine that the client requires further teaching if she identifies which of the
following as an exacerbation factor?
Exercise
7. A nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hr ago.
The nurse finds 10 mm of induration with slight redness. Which of the following
conclusions should the nurse make?
The client had an exposure to tuberculosis.
8. A nurse is assessing a client who has Kaposi’s sarcoma. Which of the following findings
should the nurse expect?
Reddish-purple skin lesions
9. A nurse is assessing a 66-year-old client during a routine physical examination. This is
the client’s first clinic visit, and she does not have her medical records. When the nurse
asks if she has received the pneumococcal immunization, the client replies, “I am not
sure, but it’s been at least 5 years since I’ve had any immunizations.” Which of the
following responses should the nurse provide?
"Let’s go ahead and give you this immunization."
10. A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the
following statements by the client indicates an understanding of the teaching?
"I should stop eating raw clams.
11. A nurse is planning care for a client. Which of the following interventions should the
nurse include in the plan? (Click on "Exhibit NCLEX 2" under Resources on the
right-hand side for additional information about the client)
Restrict visitors
12. A nurse is reviewing the laboratory data of a client who reports manifestations
suggesting systemic lupus erythematosus (SLE). The nurse should expect an increase
in which of the following parameters for a client who has SLE?
Erythrocyte sedimentation rate (ESR)
13. A nurse is teaching a client who has human immunodeficiency virus (HIV) about the
early manifestations of acquired immune deficiency syndrome (AIDS). Which of the
following statements should the nurse include in the teaching?
"You can expect a persistent fever and swollen glands."
14. A nurse is providing discharge teaching to a client who has AIDS about preventing
infection while at home. Which of the following instructions should the nurse include in
the teaching?
"Wash your genitalia using an antimicrobial soap."
15. A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks
ago. Which of the following findings should the nurse report to the provider immediately?
Abdominal pain in the left upper quadrant
16. A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the
mouth. Which of the following instructions should the nurse include in the teaching?
"You can suck on popsicles to numb your mouth."
17. A nurse is preparing to administer a Mantoux skin test to a client. What is the purpose of
a Mantoux skin test using purified protein derivative (PPD)?
To identify if a client has been infected with Mycobacterium tuberculosis
18. A nurse is providing teaching about foot care to a client who has diabetes mellitus.
Which of the following pieces of information should the nurse include in the teaching?
"Wash your feet daily using lukewarm water and soap."
19. A nurse is teaching a client about preventing the transmission of hepatitis A. The nurse
should identify that hepatitis A is transmitted by which of the following routes?
Fecal-oral contamination
20. A nurse in a provider's office is teaching a client with a recent diagnosis of rheumatoid
arthritis who has a new prescription for naproxen tablets. Which of the following
statements by the client indicates the need for further teaching?
"I can take this medication with aspirin."
21. A nurse is reviewing the laboratory results for a client who reports bilateral pain and
swelling in her finger joints, with stiffness in the morning. The nurse should recognize
that an increase in which of the following laboratory values can indicate arthritis?
Rheumatoid factor
22. A nurse is teaching a client who has human immunodeficiency virus (HIV) about how the
virus is transmitted. Which of the following statements should the nurse include the
teaching?
"HIV can be transmitted to anyone who has had contact with infected blood."
23. A nurse is caring for a client who has human immunodeficiency virus (HIV). The client
asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following
statements should the nurse provide?
"It sounds like you are unsure what to say to your partner."
24. A nurse is monitoring a newly licensed nurse who is caring for a client. The client has
active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for
a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the
following actions?
Have the client wear a surgical mask.
25. A nurse is caring for client who has human immunodeficiency virus (HIV). Which of the
following types of isolation should the nurse implement to prevent the transmission of
HIV?
Standard precautions
26. A nurse is working with an assistive personnel (AP) who is assigned to bathe a client
with herpes zoster. The AP asks the nurse if herpes zoster is contagious. Which of the
following responses should the nurse make?
"Herpes zoster is not contagious to people who have had chickenpox."
27. A nurse is teaching a client who has tuberculosis about a new prescription for rifampin.
Which of the following statements by the client indicates an understanding of the
teaching?
"I can expect this medication to turn my skin orange."
28. A nurse is teaching a client who has AIDS about the transmission of Pneumocystis
jiroveci pneumonia (PCP). Which of the following pieces of information should the nurse
include in the teaching?
"PCP results from an impaired immune system."
29. A nurse is teaching a client who has Raynaud’s disease. Which of the following pieces of
information should the nurse include in the teaching?
Protect against the cold by wearing layers of clothing
30. A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid
arthritis. The nurse should anticipate that the client's affected joints will require which of
the following treatments?
Heat paraffin therapy applied to the client's joints
31. A nurse is caring for a client who is suspected to have tuberculosis. Which of the
following findings should the nurse expect?
Blood-streaked sputum
32. A nurse is teaching a client about the manifestations of an allergic reaction. The release
of histamine causes which of the following reactions?
Increased mucus secretion
33. A nurse is conducting dietary teaching for a client who has AIDS. Which of the following
instructions should the nurse include in the teaching?
Use a separate cutting board for poultry
34. A nurse is planning an educational program for a group of young adults about reducing
the risk of cervical cancer. Which of the following interventions should the nurse include?
Get the human papillomavirus (HPV) immunization
35. A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is
concerned about skin lesions on her face and neck. The client asks the nurse, "What
should I do about these spots?" Which of the following responses should the nurse give?
"Apply moisturizer after bathing the lesions with warm water."
36. A home health nurse is planning care for a client who is receiving chemotherapy and has
neutropenia. Which of the following foods should the nurse include in the client's plan of
care?
Baked chicken
37. A nurse is teaching a client with systemic lupus erythematosus who has a new
prescription for prednisone. The nurse should instruct the client to monitor for which of
the following adverse effects of this medication?
Infection
38. A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium
difficile infection. Which of the following interventions is the nurse’s priority?
Performing hand hygiene before and after contact with the client
39. A nurse is admitting a client who has manifestations that suggest tuberculosis. Which of
the following actions is the nurse’s priority?
Initiate airborne precautions
40. A nurse is providing discharge teaching to a client who has HIV. Which of the
instructions about infection prevention should the nurse include? (Select all that apply.)
A. Avoid large gatherings of people B. Clean toothbrush by running through the
dishwasher E. Avoid digging in the garden
41. A nurse is caring for a client who is 2 days postoperative. Which of the following findings
indicates that the client is developing an infection?
Erythema at the incision site
42. A nurse is planning discharge teaching for a client who has systemic lupus
erythematosus (SLE). Which of the following instructions should the nurse include?
"Monitor your body temperature and report any elevations promptly."
43. A nurse is teaching a client who tested positive for an allergy to dust. The nurse should
determine that the client understands how to reduce her exposure to this allergen
through which of the following statements?
"I will put a mattress cover on my bed."
44. A nurse is caring for a client with Clostridium difficile who has contact-isolation
precautions in place. Which of the following actions should the nurse perform?
Use dedicated equipment for the client.
45. A nurse is caring for a client who is concerned about the possibility of contracting Lyme
disease after receiving a tick bite. For which of the following early manifestations of
Lyme disease should the nurse assess the client?
Progressive circular rash
46. A nurse is teaching a client who was recently diagnosed with Raynaud’s disease about
preventing the onset of manifestations. Which of the following statements by the client
indicates an understanding of the teaching?
"I should not smoke."
47. A nurse is providing teaching to a client who has a new prescription for alprazolam.
Which of the following items is a priority for teaching?
"This medication can affect your ability to drive or handle mechanical equipment."
48. A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE)
and is scheduled to begin treatment for systemic manifestations. Which of the following
types of medications should the nurse plan to administer?
Corticosteroids
49. A nurse is providing discharge teaching about foot care to a client who has diabetic
neuropathy. Which of the following statements by the client demonstrates an
understanding of the teaching?
"I will wash my feet daily and apply lotion, except between my toes."
50. A nurse is caring for a male client who reports a thick urethral discharge. Which of the
following actions should the nurse take?
Obtain a urethral specimen for culture
51. A nurse is performing a preoperative assessment of a client about to undergo a
cholecystectomy. The nurse should identify a risk for a latex allergy when the client
reports an allergy to which of the following foods?
Bananas
52. A nurse is providing discharge instructions to a male client who is being treated for
genital warts. Which of the following statements indicates that the client understands
how to prevent the transmission of this sexually transmitted infection (STI)?
"I will bring my sexual partner for treatment."
53. A nurse is assessing a client who has systemic scleroderma. Which of the following
findings should the nurse expect?
Finger contractures
54. A nurse is planning care for a client who has AIDS and has developed stomatitis. Which
of the following interventions should the nurse include in the plan of care?
Avoid salty foods
ATI MED-SURG
Musculoskeletal
1. A nurse is discussing the plan of care with a client who has osteomyelitis of an open
wound on his heel. Which of the following information should nurse include?
“Your provider might prescribe a central catheter line for long-term antibiotic therapy.”
2. A nurse in an acute care clinic is talking with a client who reports that the osteoarthritis
pain in her knees is increasing each day. The client wants to discuss
non-pharmacological approaches to help relieve her pain. Which of the following
interventions should the nurse suggest?
A. Applying warm compresses to sore joints
3. A nurse is caring for a client who is 72 hr postoperative following an above-the-knee
amputation. Which of the following actions should the nurse take?
B. Assist the client into a prone position every 4 hr
4. A nurse is reviewing the medical record of a client who has a prescription for probenecid
to treat gout. The nurse should identify that which of the following medications can
interact with probenecid? C. Aspirin
5. A nurse is caring for a client who is in skeletal traction following a femur fracture. On
entering, the nurse finds that the client has slid toward the foot of the bed, and the
traction weight is resting on the floor. Which of the following actions should the nurse
take? B. Have the client use a trapeze to pull himself up while ensuring the weight hangs
freely
6. A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a
femur fracture. Which of the following actions should the nurse include in the client’s plan
of care? A. Offering the client a diet high in fluid and fiber
7. A nurse is preparing a client for discharge who is postoperative following a conventional
lumbar disk excision. Which of the following statements indicates that the client
understands the nurse’s instructions? C. "I'll use my heating pad if I feel any muscle
spasms in my back."
8. A nurse is providing teaching about disease management to a client who has
rheumatoid arthritis. Which of the following responses by the client indicates an
understanding of the teaching? C. "I will have handrails installed in my bathroom and
hall."
9. A nurse is assessing a client who is 48 hr postoperative following open reduction and
internal fixation of a fractured tibia. Which the following findings should the nurse report
to the provider? A. Toes that are cold to the touch
10. A nurse is teaching a client who has a new prescription for alendronate for the treatment
of osteoporosis. Which of the following statements by the client indicates an
understanding of the teaching? D. "I will sit upright after taking the medication."
11. A nurse is caring for a client who is postoperative following a lumbar disk excision.
Which of the following interventions should the nurse include in the client's plan of care?
Logroll the client in bed for care procedures
12. A nurse is caring for a client who is wearing a halo fixator. Which of the following
interventions should the nurse implement? (Select all that apply.)
A. Monitor the client's vital signs every 4 hr B. Monitor the client's pin sites for loosening
D. Check the client's skin to ensure the jacket is not applying pressure
13. A nurse is teaching a client with arthritis who is experiencing joint pain that impairs
mobility. Which of the following instructions should the nurse include? "
D. "Apply heat to your joints prior to exercising."
14. A nurse is assessing a client who has several risk factors for osteoporosis. Which of the
following findings indicates that the client requires further evaluation for this disorder?
Lower back pain
15. A nurse is teaching a client who had an amputation of the left lower leg 3 days ago.
Which of the following statements indicates that the client understands how to care for
the incision and his left upper leg?
"I will lie on my stomach for 30 min a few times a day."
16. A nurse is caring for a client who is 3 days postoperative following a below-the-knee
amputation. Which of the following actions should the nurse take? B. Rewrap the
residual limb with a bandage 3 times per day
17. A nurse is caring for a client immediately following application of a plaster cast. The
nurse should monitor for and report which of the following findings as an indication of
compartment syndrome? B. Paresthesias of the extremity
18. A home health nurse is performing an assessment on a client who is 1 week
postoperative following a total knee replacement. Which of the following statements by
the client indicates an understanding of the teaching? C. "I plan to use a walker to help
me get around."
19. A nurse is preparing a client for an electromyogram (EMG). Which of the following
statements indicates that the client understands the pre-procedure teaching? A. "This
test will help my doctor know if my nerves are working correctly."
20. A nurse is caring for a client who had a below-the-knee amputation for gangrene of the
right foot. The client reports sensations of burning and crushing pain in the toes of the
absent right foot. Which of the following statements should the nurse make? A. "This
type of pain usually decreases over time as the limb becomes less sensitive."
21. A nurse is assessing a client who has osteoarthritis. The client's medical record indicates
the presence of Heberden's nodes. Which of the following findings should the nurse
expect? D. Hard lumps over the joints of the fingers
22. A nurse is providing nutrition education to a client who has osteomalacia. The nurse
should identify that this condition is caused by a deficiency in which of the following
nutrients? C. Vitamin D
23. A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction
pillow on the client for which of the following purposes? D. To prevent dislocation of the
hip during position changes or movement
24. A nurse is preparing a community education program about reducing the risk of
osteoporosis. Which of the following pieces of information should the nurse include?. C.
Walking is the preferred mode of exercise to maintain strong bones.
25. A nurse is caring for a client who has a fractured right hip. Which of the following types of
traction should the nurse expect the client to have prior to hip arthroplasty surgery? D.
Buck's traction
26. A nurse is caring for a client who is postoperative following shoulder surgery. The client
has a prescription to keep the affected arm adducted. Which of the following instructions
should the nurse share with the client? C. "Hold your arm against the side of your body."
27. A nurse is providing discharge teaching for a client who had a left total hip arthroplasty.
Which of the following client statements indicates the teaching was effective? B. "I
should not cross my legs at the ankles or knees."
28. A nurse is providing discharge teaching to a client who has osteoarthritis. Which of the
following instructions should the nurse include? A. "Rest frequently after periods of
activity."
29. A nurse is caring for a client who is postoperative following a total knee arthroplasty and
has been prescribed a continuous passive motion (CPM) machine and PCA. The client
tells the nurse, "I am in so much pain." Which of the following actions should the nurse
take first? C. Ask the client to describe the characteristics of the pain
30. A nurse is providing post-procedural teaching to a client who had a diagnostic knee
arthroscopy. Which of the following statements indicates that the client understands the
nurse’s instructions? B. "I'll keep my leg elevated for the first day."
31. A nurse is preparing a client for magnetic resonance imaging (MRI) of the spine. Which
of the following pieces of information should the nurse give the client prior to the
procedure? A. "You can have a mild sedative before the procedure."
32. A nurse is teaching a client who is on bed rest about preventing complications. Which of
the following client statements indicates an understanding of the teaching? B. "I should
cough and deep-breathe every hour."
33. A nurse is caring for a client who has a pelvic fracture. The client reports sudden
shortness of breath, stabbing chest pain, and feelings of doom. This client is
experiencing which of the following complications? B. Pulmonary embolus
34. A nurse is caring for a client who has chronic phantom limb pain following an
above-knee amputation. Which of the following medication prescriptions should the
nurse verify with the provider? A. Meperidine
35. A nurse is providing preoperative teaching for a client who is scheduled for total knee
arthroplasty. Which of the following statements by the client indicates an understanding
of the teaching? C. "I should wear elastic stockings on both of my legs."
36. A nurse is teaching a group of clients at a senior center about the risk factors for
osteoporosis. Which of the following statements should the nurse include in the
teaching? A. "Extended periods of immobility increase your risk of osteoporosis."
37. A nurse is caring for a client who is scheduled to undergo surgery to repair an open hip
fracture. In which of the following positions should the nurse plan to place the client
postoperatively? C. With the leg on the affected side abducted
38. A nurse is assessing a client who has a fractured left femur and is in skeletal traction.
Which of the following findings should the nurse report to the provider? C. Chest
petechiae
39. A nurse is reviewing the medical record of a female client. Which of the following findings
should the nurse identify as a risk factor for osteoporosis? D. History of anorexia nervosa
40. A nurse is caring for a client who has osteoporosis and a new prescription for calcium
supplements. Which of the following foods should the nurse recommend to promote
calcium absorption? A. Fortified milk
41. A nurse in the emergency department is caring for a client who reports pain in her left leg
following a motor-vehicle crash. The client’s left leg has bruising, swelling, and
displacement of the bones. Which of the following actions should the nurse take first? C.
Check neurovascular status distal to the injury
42. A nurse is assessing a client's skeletal system. The nurse should be in which of the
following positions to screen the client for scoliosis? C. Standing behind the client, who is
bent over at the waist
43. A nurse is determining a client's risk of developing osteoporosis. The nurse should
identify which of the following as risk factors for bone loss? (Select all that apply.) A.
Small body frame D. Low vitamin D intake E. Smoking
44. A nurse is assessing a female client who reports severe joint pain. The nurse should
identify that which of the following factors places the client at risk for gout? C. Diuretic
use
45. A nurse is teaching a client who has a cast on his left arm to treat a forearm fracture.
Which of the following statements indicates that the client understands the teaching? A.
"I'll call the doctor's office if my fingers get colder on the arm with the cast."
46. A nurse is caring for a client who is 3 days postoperative following a right total hip
arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should
assess the client for which of the following manifestations of dislocation of the hip
prosthesis? B. Shortening of the right leg
47. A nurse is providing teaching for a client following a below-the-knee amputation. Which
of the following pieces of information should the nurse include in the teaching? A.
Instruct the client to lie prone while in bed
48. A nurse is preparing a client who is scheduled to have an arthroscopy the following day.
Which of the following statements indicates that the client understands the
pre-procedure teaching? B. "The doctor will be able to see if I have signs of rheumatoid
arthritis."
49. A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis
with a newly licensed nurse. Which of the following pieces of information should the
nurse include about osteoarthritis? D. "Osteoarthritis can impair a joint on a single side
of the body."
50. A nurse in the emergency department is assessing a client who was in a motor-vehicle
crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. The client is
now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalized
petechiae on the client’s skin. Which of the following complications should the nurse
suspect? B. Fat embolism syndrome
51. A nurse is preparing a client for a bone scan. Which of the following statements indicates
that the client understands the pre-procedure teaching? (Select all that apply.) B. "A
special camera will scan the bones in my entire body." D. "I'll have to drink a lot of water
to help get the radiation out of my body." E. "I understand the radiation is harmless, and I
don't have to worry about it."
52. A nurse is assessing a client who is 24 hr postoperative following an above-the-elbow
amputation. Which of the following findings should the nurse identify as the priority? A.
Client report of muscle spasms
53. A nurse is caring for a client who had a fiberglass cast placed on her left arm several
hours ago and now reports itching under the cast. Which of the following actions should
the nurse plan to take? A. Use a hair dryer on a cool setting to blow air into the cast
54. A nurse is performing medication reconciliation for a newly admitted client who has
rheumatoid arthritis (RA). Which of the following medications should the nurse identify as
the treatment for this condition? C. Celecoxib
55. A nurse in the emergency department is preparing to discharge a client following a
Grade II (moderate) ankle sprain. Which of the following instructions should the nurse
plan to give to the client? D. Apply cold compresses to the extremity intermittently
56. A nurse is teaching a client who has osteoporosis. Which of the following instructions
should the nurse include in the teaching? D. Perform weight-bearing exercises
57. A nurse is caring for a client with a hip fracture who has Buck's extension traction in
place. Which of the following pieces of information should the nurse give the client about
this type of traction? (Select all that apply.) A. "You'll have considerably less pain with the
traction in place." C. "The traction will help decrease muscle spasms." D. "The weights
act as a pulling force to keep your leg and hip still."
58. A nurse is providing discharge instructions for a client who is postoperative following
inner maxillary fixation with wiring. Which of the following pieces of information should
the nurse include? A. Cut the wiring if emesis occurs
59. A nurse is preparing an in-service presentation about the basics of bone injuries. Which
of the following types of fractures is especially common in children? D. Greenstick
60. A nurse is talking with an older adult client who has an elevated risk for osteoporosis
about strategies for preventing bone loss. Which of the following instructions should the
nurse provide? A. Begin a program of brisk walking
61. A nurse is preparing an in-service presentation about the basics of bone injuries. Which
of the following types of fractures results when a client's bone breaks into multiple
pieces? B. Comminuted
62. A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4
hr ago. Which of the following actions should the nurse take? ✔ B. Encourage the client
to perform dorsiflexion of the affected extremity every 2 hr
63. A nurse is planning care for a client following a total hip arthroplasty. Which of the
following interventions should the nurse include in the plan? C. Place a pillow between
the client's legs
64. A nurse is preparing a client who is postoperative following total hip arthroplasty for
discharge. Which of the following statements indicates that the client understands the
instructions? C. "I'll use a reacher to help me pick up anything I drop on the floor."
65. A nurse is caring for a client who has a depressed skull fracture of the bone that makes
up the larger part of the upper and side wall of the cranium. This fracture is located on
which of the following bones? C. Parietal
Neurosensory
1. A home health nurse is interviewing the adult of a child of a client who has
Alzheimer's disease. The child is the client's sole caregiver and reports feeling
fatigued and overwhelmed. Which of the following referrals should the nurse
make for the caregiver? Respite care
2. A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the
following manifestations should the nurse expect? A. Swelling behind the affected ear
3. A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following
findings should the nurse expect? C. Weakness of the lower extremities
4. A nurse is caring for a client who had a cerebrovascular accident (CVA). The client
appears alert and engaged during a visit but does not respond verbally to questions. The
nurse should document this as which of the following alterations? A. Expressive aphasia
5. A nurse is caring for a client who has a traumatic brain injury and assumes a
decerebrate posture in response to noxious stimuli. Which of the following reactions
should the nurse anticipate when drawing a blood sample? A. The client rigidly extends
his arms.
6. A nurse is preparing a client for an electroencephalogram (EEG). Which of the following
pieces of information should the nurse share with the client? B. "You'll begin by lying still
with your eyes closed."
7. A nurse is caring for a client during the first 72 hr following a cerebrovascular accident
(CVA). Which of the following actions should the nurse take? C. Elevate the head of the
bed 25° to 30° with the client in a neutral midline position
8. A nurse is providing teaching to the partner of a client who has a new diagnosis
of Parkinson's disease about degenerative complications. The nurse should
include in the teaching that which of the following manifestations is the priority?
Dysphagia
9. A nurse is assessing a client who is unconscious and has a rhythmical breathing
pattern of rapid deep respirations, followed by rapid shallow respirations,
alternating with periods of apnea. The nurse should document that the client is
experiencing which of the following types of respirations? Cheyne-Stokes
10. A nurse is caring for a client who has expressive aphasia following a stroke. The
nurse should identify that the stroke affected which of the following lobes of the
client's brain? C. Frontal
11. A nurse is triaging clients during a mass casualty event. Which of the following
labels should the nurse assign to a client who has a head injury with fixed, dilated
pupils? D. Black tag
12. A nurse is providing teaching to a client who has a new diagnosis of migraine
headaches about interventions to reduce pain at the onset of a migraine. What
instructions should the nurse include in the teaching? B. Darken the lights
13. A nurse is providing teaching to the family of a client who has stage II
Alzheimer's disease. What info should the nurse include in the teaching? D. Limit
choices offered to the client
14. A nurse is preparing a client for an electroencephalogram (EEG). When the client
asks the nurse what this test does, which of the following responses should the
nurse provide? D. "An EEG records the electrical activity of your brain cells."
15. A nurse is teaching a client who has a new diagnosis of primary open-angle
glaucoma (POAG). Which of the following pieces of information should the nurse
include in the teaching? (Select all that apply.) D. Driving can be dangerous due
to the loss of peripheral vision. E. Laser surgery can help reestablish the flow of
aqueous humor.
16. A nurse is caring for a client who experienced a traumatic brain injury. Which of
the following findings indicates the client is experiencing increased intracranial
pressure? C. Dilated pupils
17. A nurse is performing a neurological assessment for a client who has a brain
tumor. Which of the following findings should indicate cranial nerve involvement?
A. Dysphagia
18. A nurse is caring for a client who is postoperative following a frontal craniotomy.
The nurse should place the client in which of the following positions? C.
Semi-Fowler's
19. A nurse is caring for a client who is recovering from a recent stroke. Which of the
following assessments is the nurse's priority? A. The client's ability to clear oral
secretions
20. A nurse is caring for a client who has receptive aphasia. Which of the following
communication problems should the nurse expect when assessing the client?. C.
The client is unable to understand words or sentences she hears.
21. A nurse is assessing a client with a closed head injury who has received mannitol
for manifestations of increased intracranial pressure (ICP). Which of the following
findings indicates that the medication is having a therapeutic effect? A. The
client's serum osmolarity is 310 mOsm/L.
22. A nurse in the emergency department has assessed a client’s airway, breathing,
and circulation (ABC) following a head injury from a fall at work. Which of the
following actions is the priority for the nurse to perform next? D. Immobilize the
client's cervical spine
23. A nurse responds to a call from an assistive personnel that a client just had a
seizure and is unconscious. Which of the following assessments is the nurse’s
priority? C. Check airway patency
24. A nurse is assessing a client who reports an acute visual disturbance that he
describes as a "curtain" pulled over his visual field with occasional flashes of
light. The nurse should notify the provider that this client might have which of the
following disorders? C. Retinal detachment
25. A nurse is caring for a client who has a closed traumatic brain injury and is
experiencing increased intracranial pressure (ICP). This increase in ICP is due to
which of the following? C. Rigid skull containing cranial contents
26. A nurse is providing discharge teaching to a client who is postoperative following
cataract surgery and has an intraocular lens implant. Which of the following
statements by the client indicates an understanding of the instructions? B. "I will
avoid bending over."
27. A nurse is reviewing the medical history of a client who has presbyopia. With
which of the following activities should the nurse expect the client to have
difficulty? D. Reading the newspaper
28. A nurse is caring for a client who has had repeated middle ear infections. The
client reports that the provider said the infections are due to an obstruction of the
structure that connects the middle ear to the throat. The nurse should identify
that the provider was referring to which of the following structures? D. Eustachian
tube
29. A nurse is caring for a client who is experiencing autonomic dysreflexia due to a
C5 spinal cord injury. After checking the client's vital signs, which of the following
actions should the nurse perform next? B. Place the client in a high-Fowler's
position
30. A nurse in an emergency department is assessing a client who sustained a fall
off of a roof. Which of the following findings should the nurse identify as an
indication of a basilar skull fracture? B. Clear fluid coming from the nares
31. A nurse is caring for a client who has a left intracranial hemorrhage from a
stroke. Which of the following findings should the nurse expect? D. Right-sided
hemiplegia
32. A nurse is caring for a client who has moderate Alzheimer's disease. Which of
the following actions should the nurse take? A. Add gestures when speaking with
the client
33. A nurse is preparing a client who has a brain tumor for computed tomography
(CT). Which of the following factors affects the manner in which the nurse will
prepare the client for the scan? C. Development of hives when eating shrimp
34. A nurse is caring for a client who has Ménière's disease. The nurse should
identify that Ménière's disease affects which structure of the ear? B. Cochlea
35. An emergency room nurse is assessing a client who has a new traumatic brain
injury. The nurse observes extension of the client’s arms and legs, pronation of
the arms, and plantar flexion of the feet. Which of the following actions is the
nurse's priority? C. Provide supplemental oxygen
36. A nurse is providing teaching to a client who is scheduled for an
electroencephalogram in the morning. Which of the following pieces of
information should the nurse share? C. "Shampoo your hair before the procedure
and don’t use any styling products afterward."
37. A nurse is assessing a client who sustained a recent head injury. Which of the
following findings should the nurse recognize as a manifestation of increased
intracranial pressure? A. Widened pulse pressure
38. A nurse is providing teaching to a client who has a history of tonic-clonic seizures
and is scheduled for a standard electroencephalogram (EEG). Which of the
following instructions should the nurse include in the teaching? C. Thoroughly
shampoo her hair prior to the EEG
39. A nurse is providing teaching to the family of a client who has a new diagnosis of
amyotrophic lateral sclerosis (ALS). Which of the following findings is an early
manifestation of ALS? B. Weakness of the distal extremities
40. A nurse is reviewing the medical history of a client who is scheduled for a
magnetic resonance imaging (MRI) examination of the cervical vertebra. Which
of the following pieces of information in the client’s history is a contraindication to
this procedure? D. The client has a pacemaker.
41. A nurse is assessing a client who was admitted to the facility for observation
following a closed head injury. Which of the following is the priority assessment
the nurse should perform to determine a change in the client's neurological
status? C. Level of consciousness
42. A nurse is reviewing the medical record of a client who is experiencing tinnitus in
both ears. Which of the following pieces of information in the client's medical
record should the nurse identify as a risk factor for tinnitus?D. Sclerosis of the
ossicles
43. A nurse is assessing a client who has increased intracranial pressure and has
received intravenous mannitol. Which of the following findings indicates a
therapeutic effect of this medication? C. Increased urine output
44. A nurse is assessing a client who is postoperative following a craniotomy and
has a urine output of 600 mL/hr. The nurse suspects the client has
manifestations of diabetes insipidus (DI). Which of the following laboratory values
should the nurse plan to obtain to assess for DI? D. Specific gravity
45. A nurse is caring for a client who has dementia and is experiencing anxiety.
Which of the following actions should the nurse take? D. Redirect the client to a
different activity with a small group of people
46. A nurse is caring for a client who has encephalitis due to West Nile virus. Which
of the following actions should the nurse take? (Select all that apply.) B. Monitor
vital signs every 2 hr C. Assess neurological status every 4 hr E. Keep the
client’s room darkened
47. A nurse is providing discharge teaching to the family of a client who has a new
diagnosis of a seizure disorder. The nurse should instruct the client’s family to
take which of the following actions first in the event of a seizure? B. Protect the
client’s head
48. A nurse is preparing an older adult client who had a transient ischemic attack
(TIA) for discharge. The nurse should teach the client to monitor which of the
following parameters at home? B. Blood pressure
49. A nurse is assessing a client who has a new diagnosis of acute angle-closure
glaucoma. The nurse should anticipate the client to report which of the following
manifestations? C. Severe eye pain
50. A nurse is assessing a client who recently experienced a head injury. Which of
the following findings should the nurse identify as an indication of short-term
memory impairment? C. Inability to locate eyeglasses
51. A nurse is preparing to test the function of cranial nerve X. Which of the following
assessment procedures should the nurse use? A. Have the client open his mouth
and say, "aah"
52. A nurse is providing teaching to a client who has a new diagnosis of Menière’s
disease. Which of the following instructions should the nurse include in the
teaching? C. Avoid sudden movements
53. A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client
who has manifestations of bacterial meningitis. Which of the following findings
should the nurse expect? B. Elevated protein
54. A nurse in an acute care facility is preparing to admit a client who has
myasthenia gravis. Which of the following supplies should the nurse place at the
client’s bedside? C. Oral-nasal suction equipment
55. A nurse is teaching a client who has myopia about laser-assisted in situ
keratomileusis (LASIK) surgery. Which of the following is an adverse effect of
LASIK surgery? D. Dry eyes
56. A nurse asks a client to stand with her feet together and her eyes open. After a
few seconds, the nurse asks the client to close her eyes. If the client begins to
fall, the nurse should interpret this finding as a positive Romberg test, indicating
which of the following alterations? A. Cerebellar dysfunction
57. A nurse in the emergency department is caring for a group of clients who all have
an odor of alcohol on their breath and multiple injuries to the head and
extremities. Which of the following clients should the nurse assess first? A. A
client who is difficult to arouse and is unable to respond to questions
58. A nurse is providing teaching to a class about transient ischemic attacks (TIAs).
Which of the following pieces of information should the nurse include in the
teaching? D. A TIA can precede an ischemic stroke.
59. A nurse is providing discharge teaching to a client who is postoperative following
scleral buckling to repair a detached retina. Which of the following instructions
should the nurse include in the teaching? B. "You should avoid reading for 1
week."
60. A nurse is caring for a client who begins to have a generalized tonic-clonic
seizure while lying in bed. Which of the following actions should the nurse take?
B. Turn the client onto a side
61. A nurse names 3 objects for the client to remember, asks the client to repeat
them, and tells the client he will have to repeat them again in a few minutes. After
5 min, the nurse asks the client to name the objects. The nurse is using this
strategy to test which type of memory? C. Immediate
62. A nurse is assessing a client who has cataracts. Which of the following findings
should the nurse expect? B. Opacity visible behind the pupil
63. A nurse is caring for a client who has a brainstem injury. Which of the following
physiological functions should the nurse monitor? B. Respiratory effort
64. A nurse is walking along the unit when she sees smoke coming from the central
supply room. After activating the fire alarm, which of the following actions should
the nurse take? B. Turn off sources of oxygen near the fire.
65. A nurse is assessing an older adult client for physiological changes that can
occur with age. Which of the following findings should the nurse expect? B.
Decreased sense of taste
66. A nurse is teaching a client about computed tomography (CT) scanning of the
brain. Which of the following teaching points should the nurse include? A. "You'll
have to lie very still on a long, narrow table during the test."
67. During a neurological assessment, a nurse asks the client to name all of his
children, their ages, and their birth dates. Which of the following types of memory
is the nurse testing? A. Remote
68. A nurse is assessing a client who has a high-thoracic spinal cord injury. The
nurse should identify which of the following findings as a manifestation of
autonomic dysreflexia? D. Report of a headache
69. A nurse is planning care for a client following a stroke. Which of the following
interventions should the nurse identify as the priority in the client’s plan of care?
D. Monitor the client for increased intracranial pressure (ICP)
70. A nurse is assessing a client who has a head injury with a possible skull fracture.
Which of the following findings should the nurse identify as an indication that the
client might have a complication involving the eighth cranial nerve (CN VIII)? A.
Dizziness and hearing loss
71. A nurse is assessing a client who reports vision loss. The client describes the
loss as beginning with a "flash" of light followed by a "curtain" across the field of
vision. The nurse should identify that these manifestations indicate which of the
following eye disorders? B. Retinal detachment
72. A nurse is teaching a class of new parents about otitis media. Which of the
following manifestations should the nurse include in the teaching? D. Feeling of
fullness in the ear
73. A nurse is providing teaching to a client who has a new diagnosis of myasthenia
gravis (MG). Which of the following pieces of information should the nurse
include? D. Set an alarm to ensure medication dosages are taken on time
74. A nurse is caring for a client who has an impairment of cranial nerve II. Which of
the following actions should the nurse perform to promote the client's safety? C.
Provide an obstacle-free path for ambulation.
75. A nurse is teaching a client who has a new diagnosis of simple partial seizures
about auras. Which of the following statements by the client indicates an
understanding of the teaching? A. "An aura is a sensory warning that a seizure is
imminent."
76. A nurse is providing discharge teaching to a client who has had a transient
ischemic attack (TIA). Which of the following instructions should the nurse
include? A. Reduce dietary sodium
77. A nurse in a rehabilitation center is performing an assessment for a client who is
recovering from a left-hemisphere stroke. Which of the following findings should
the nurse expect? B. Difficulty with speech
78. A nurse in a clinic is providing teaching to an adolescent client who has recurrent
external otitis. Which of the following instructions should the nurse include in the
teaching? C. Instill a diluted alcohol solution into the ear after swimming
79. A nurse is providing teaching to a client who has a new diagnosis of multiple
sclerosis (MS). The client asks the nurse about the usual cause of MS. Which of
the following responses should the nurse make? C. "Acute episodes are usually
followed by remissions, which can vary in duration."
80. A nurse is caring for a client who has a cerebral lesion and develops
hyperthermia. Which of the following areas of the client’s brain is aected? D.
Hypothalamus
81. During a neurological assessment, a nurse asks how the client arrived at the
appointment and with whom. Which of the following types of memory is the nurse
testing? C. Recall
82. A nurse is caring for a client who has a hearing impairment. Which of the
following actions should the nurse take when communicating with the client? A.
Face the client when speaking
83. A nurse is providing preoperative teaching for a client who will undergo
laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following
pieces of information should the nurse include? A. "You might need glasses after
the surgery."
84. A nurse is caring for a client who has received sedation. When the nurse applies
nailbed pressure, the client withdraws his hand. The nurse should document this
response as indicating which of the following? B. Arousal
85. A charge nurse is observing a newly licensed nurse irrigate a client's ear, which
is impacted with cerumen. Which of the following actions requires the charge
nurse to intervene? B. Instilling 50 mL of fluid with each irrigation
Oncology
1. A nurse is preparing a plan of care for a client who is postoperative following a
modified radical mastectomy. Which of the following invasive devices should the
nurse expect the client to have?D. Jackson-Pratt drain
2. A nurse is caring for a client who recently had chemotherapy and now has
myelosuppression. Which of the following interventions should the nurse initiate?
(Select all that apply.) A. Prohibit visitors from bringing fresh flowers and plants
into the client's room. C. Ensure thorough cleaning of the client's room and
bathroom daily E. Use dedicated equipment such as stethoscopes.
3. A nurse is planning care for a client who is postoperative following a radical
mastectomy. Which of the following interventions should the nurse include in the
plan? C. Begin exercises with the client 1 day after the procedure
4. A nurse is providing teaching to a client who has cervical cancer and is
scheduled to receive brachytherapy in an ambulatory care clinic. Which of the
following statements by the client indicates an understanding of the teaching?
Check Answer ✔ A. "I need to lie still in bed during my brachytherapy treatment."
5. A nurse is teaching a client how to perform a breast self-examination (BSE). The
nurse should identify which of the following findings as an indication of breast
cancer? D. A nontender, hard lump that is palpated in a breast
6. A nurse is planning a presentation for a group of older adults at a community
center about risk factors for cancer. Which of the following factors increases the
risk of developing cancer aer age 60? D. Weakened immune responses
7. A nurse is providing teaching to a client who has cancer and is undergoing
external radiation treatment. Which of the following statements by the client
indicates an understanding of the teaching? D. "I should use my hand, instead of
a washcloth, to wash the areas being radiated."
8. A nurse in an oncology clinic is assessing a client who has early stage Hodgkin’s
lymphoma. Which of the following findings should the nurse expect? B. Enlarged
lymph node
9. A nurse is planning care for a client who has cancer and has developed
thrombocytopenia following chemotherapy. Which of the following precautions
should the nurse oer to minimize the adverse eects of thrombocytopenia? B.
Remind the client to use an electric razor
10. A nurse is providing teaching to a client with cancer who is receiving external
radiation therapy. Which of the following statements by the client indicates an
understanding of the teaching? Check Answer ✔ A. "I need to protect the area
from sunlight."
11. A nurse is caring for a client who is receiving radiation therapy for breast cancer
and reports a metallic taste in the mouth. Which of the following dietary
recommendations should the nurse share with the client? D. Offer mints
12. A nurse is obtaining a client’s health history who has cancer of the cervix. Which
of the following manifestations should the nurse expect? C. Vaginal bleeding
13. A nurse is caring for a client who has testicular cancer and is experiencing
peripheral neuropathy as an adverse eect of chemotherapy. Which of the
following client manifestations is an expected finding of peripheral neuropathy?
B. Tingling of the hands and feet
14. A nurse is caring for a client who will receive brachytherapy to treat uterine
cancer. The nurse should ensure the client understands that she will receive
which of the following interventions? D. Radioactive infusions or insertions into or
near the tumor
15. A nurse is caring for a client who has lung cancer that has metastasized. Which
of the following findings indicates the client is developing superior vena cava
syndrome? D. Facial edema
16. A nurse is caring for a client who has breast cancer and is receiving a
combination of chemotherapy medications. The client expresses confusion about
the therapy. Which of the following explanations should the nurse provide? B.
"The chemotherapy medications act at dierent stages of cell division so more
tumor cells are destroyed."
17. A nurse is providing preoperative teaching for a client with colorectal cancer who
is scheduled to undergo colostomy placement with a perineal wound. Which of
the following statements by the client indicates an understanding of the teaching?
C. "I can have only liquids for 2 days before the surgery."
18. A nurse is caring for a client whose surgeon informed him postoperatively that he
has a metastasizing malignant neoplasm in the colon. Which of the following
statements by the client should the nurse identify as an indication that the client
understands this information? Check Answer ✔ A. "I have cancer of the colon
that has begun to spread."
19. A charge nurse is observing a newly licensed nurse provide care for a client who
is receiving internal radiation therapy for the treatment of cervical cancer. For
which of the following actions by the newly licensed nurse should the charge
nurse intervene? C. Borrowing a dosimeter film badge from another nurse before
entering the client's room
20. A nurse is providing discharge teaching to a client who is post-operative following
a right mastectomy for breast cancer. The client will be discharged with 2
JacksonPratt drains. Which of the following pieces of information should the
nurse include in the teaching? C. "The drainage tubes oen are removed at the
same time as the stitches."
21. A nurse is teaching a client who has leukemia and has developed
thrombocytopenia. Which of the following instructions should the nurse include in
the teaching? C. "Use an electric razor when shaving."
22. A nurse is caring for a postmenopausal client who is concerned that she might
have an elevated risk of breast cancer. Aer conducting a risk assessment, the
nurse should identify which of the following factors as increasing the client's
breast cancer risk? (Select all that apply.) Check Answer A. Increased breast
density B. BMI of 32 D. Undergoing hormonal replacement therapy for 10 years
23. A nurse is providing discharge teaching to a client following an open radical
prostatectomy. The client is going home with an indwelling urinary catheter.
Which of the following statements by the client indicates an understanding of the
teaching? B. "I will change the catheter drainage bag once each week."
24. A hospice nurse is providing education about palliative care to the partner of a
client who has end-stage liver cancer. Which of the following statements by the
partner indicates an understanding of teaching? D. "I will continue to talk to him,
even when he’s sleeping."
25. A nurse is caring for a client who is receiving brachytherapy. Which of the
following measures should the nurse include in the client's plan of care? C. Keep
the door to the client's room closed.
26. A nurse is caring for a client who is postoperative following a urinary diversion to
treat bladder cancer. Which of the following interventions should the nurse
include in the plan of care? C. Change the collection pouch in the early morning
27. A nurse on an oncology unit is providing discharge teaching to an adolescent
female client who received a bone marrow transplant for leukemia. Which of the
following pieces of information should the nurse include in the teaching? (Select
all that apply.) A. "Take your temperature twice each day." C. "It is important to
wear shoes always." E. "Avoid using tampons."
28. A nurse is providing postoperative discharge teaching to a client following a
panhysterectomy for uterine cancer. Which of the following pieces of information
should the nurse include in the teaching? B. "You might experience
manifestations of menopause."
29. A nurse is admitting a client who has multiple myeloma and a white blood cell
count of 2,200/mm^3. Which of the following foods should the nurse prohibit the
family members from bringing to the client? D. A fresh fruit basket
30. A nurse is collecting a client’s health history. Which of the following findings is the
highest risk factor for the client developing skin cancer? D. Overexposure to
sunlight
31. A nurse is monitoring a client who has cancer and is receiving chemotherapy by
peripheral IV infusion. The client reports pain at the insertion site, and the nurse
notes fluid leaking around the catheter. Which of the following actions should the
nurse take first? C. Stop the infusion
32. A client who has stage II breast cancer asks the nurse about sites of metastasis
for this cancer. Which of the following responses should the nurse provide? D.
"Breast cancer tends to metastasize to the bones."
33. A nurse is caring for a client who is receiving radiation therapy for mouth cancer
and reports a dry mouth. Which of the following dietary recommendations should
the nurse provide? D. Use gravies or sauces to soften food
34. A nurse is collecting a health history from a female client who is undergoing
screening for breast cancer. Which of the following factors increases the client’s
risk of developing breast cancer? D. Age over 50 years
35. A nurse is caring for a client who is receiving chemotherapy to treat cancer.
Which of the following adverse eects should the nurse anticipate from the
chemotherapy? C. Pancytopenia
36. A nurse is providing teaching to a client who is receiving chemotherapy and has
developed neutropenia. Which of the following statements indicates that the
client needs further instructions? C. "I’m planning a large gathering of friends and
family for the holidays."
37. A nurse is planning a presentation at a community center about risk factors for
cancer. Which of the following types of cancer should the nurse include when
discussing familial clustering of specific types of cancer? B. Prostate
38. A nurse is talking with a group of women at a community center about the current
recommendations for early detection of breast cancer. The nurse should explain
which of the following options? C. Begin annual mammograms at age 40
39. A nurse is providing teaching to a client who has stomatitis due to chemotherapy
and radiation therapy. Which of the following statements by the client indicates a
need for further teaching? B. "I will use lemon and glycerin swabs aer meals."
40. A nurse is planning care for a client who is receiving chemotherapy and has a
protein deficiency. Which of the following interventions should the nurse include
in the plan of care? (Select all that apply.) Check Answer A. Mix powdered skim
milk into liquid milk C. Add a slice of cheese to hot vegetables E. Mix yogurt into
fresh fruit
41. A nurse is performing an admission assessment for a client who has colorectal
cancer. Which of the following manifestations should the nurse expect to find? B.
Abdominal cramps
42. A nurse is collecting a health history from a client. Which of the following findings
is the highest risk factor for the client developing bladder cancer? B. The client
uses tobacco.
Renal & Urinary
1. A nurse is teaching a client with chronic kidney disease about predialysis dietary
recommendations. The nurse should recommending restricting the intake of
which of the following nutrients? Check Answer ✔ A. Protein
2. A nurse is teaching a client who has chronic kidney disease (CKD). Which of the
following instructions should the nurse include? Check Answer ✔ A. Limit fluid
intake
3. A nurse is checking the laboratory values of a client who has chronic kidney
disease. The nurse should expect elevations in which of the following values?
Check Answer ✔ A. Potassium and magnesium
4. A nurse is assessing a client who is postoperative following a transurethral
resection of the prostate (TURP) and has continuous bladder irrigation. The
nurse notes no drainage in the client's urinary drainage bag over 1 hr. Which of
the following actions should the nurse take? C. Irrigate the indwelling urinary
catheter with a syringe
5. A nurse is teaching a newly licensed nurse about collecting a 24-hr urine
specimen for creatinine clearance. Which of the following instructions should the
nurse include? C. Place signs in the bathroom as a reminder about the test in
progress
6. A nurse is assessing a client who is receiving continuous ambulatory peritoneal
dialysis. Which of the following findings should the nurse report to the provider?
B. Potassium 3.0 mEq/L
7. A nurse is assessing a client who is postoperative following a transurethral
resection of the prostate (TURP). Aer the nurse discontinues the client’s urinary
catheter, which of the following findings should the nurse report to the provider?
D. Decreased urine output
8. A nurse is teaching a client about urinary tract infections (UTIs). Which of the
following manifestations should the nurse include? B. Back pain
9. A nurse is reviewing the laboratory report of a client who has chronic kidney
disease (CKD). The nurse finds the following laboratory test results: potassium
6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL.
Which finding is the priority for the nurse to report to the provider? B.
Hyperkalemia
10. A nurse is caring for a client who has a diagnosis of renal calculi and reports
severe flank pain. Which of the following is the priority nursing action? Check
Answer ✔ A. Relieve the client’s pain
11. A nurse is providing teaching to a young adult client who has a history of calcium
oxalate renal calculi. Which of the following instructions should the nurse
include? B. "Consume 1,000 mg of dietary calcium daily."
12. A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The
nurse observes that the peritoneal fluid is not adequately draining. Which of the
following actions should the nurse take? Check Answer ✔ A. Turn the client from
side to side
13. A nurse is reviewing the laboratory findings of a client who has chronic kidney
disease. The client reports significant persistent nausea and muscle weakness.
Which of the following findings should the nurse expect? D. Hyperkalemia
14. A nurse is providing teaching to a client who is preoperative for a renal biopsy.
Which of the following statements should the nurse make? C. "You will need to
be on bed rest following the procedure."
15. A nurse is providing dietary teaching to a client who has chronic renal failure.
Which of the following food choices by the client indicates an understanding of
the teaching? B. Grilled fish
16. A nurse is preparing an in-service program about the stages of acute kidney
injury (AKI). Which of the following pieces of information should the nurse include
about prerenal azotemia? B. Interference with renal perfusion causes prerenal
azotemia.
17. A nurse is conducting dietary teaching with a client who has a history of renal
calculi. Which of the following instructions should the nurse include in the
teaching? B. Drink 3.8 L (4 qt) of water throughout the da
18. A nurse is providing teaching to a client who is preoperative prior to a
transurethral resection of the prostate (TURP). Which of the following client
statements indicates an understanding of the information? D. "I will feel the urge
to urinate following this procedure."
19. A nurse is monitoring a client who is undergoing extracorporeal shockwave
lithotripsy (ESWL). The nurse should identify that which of the following findings
is the priority? Check Answer ✔ A. Dysrhythmias
20. A nurse is teaching a client who is preoperative for a cystoscopy. Which of the
following statements should the nurse make? D. "Expect to have pink-tinged
urine aer this procedure."
21. A nurse is assessing a client who was brought to the emergency department
following a motor-vehicle crash. Which of the following findings is a manifestation
of bladder trauma? B. Hematuria
22. A nurse is assessing a client who is 4 hr postoperative following a transurethral
resection of the prostate and has an indwelling urinary catheter in place. Which
of the following findings should the nurse expect? Check Answer ✔ A.
Blood-tinged urine in the drainage bag
23. A nurse is teaching a client who has a spinal cord injury to perform intermittent
urinary self-catheterization at home aer discharge. Which of the following
statements indicates that the client understands the procedure? D. "I will perform
intermittent self-catheterization every 2 to 3 hr
24. A nurse is caring for a client who has manifestations of acute tubular necrosis
(ATN) following a kidney transplantation. Which of the following interventions
should the nurse anticipate for this client? (Select all that apply.) Check Answer
A. Hemodialysis B. Biopsy C. Immunosuppression
25. nurse is caring for a client who has continuous bladder irrigation following a
transurethral resection of the prostate (TURP). Which of the following findings
should the nurse report to the provider? C. Viscous urinary output with clots
26. A female client who has recurrent cystitis asks the nurse about preventing future
episodes. For which of the following client statements should the nurse provide
further teaching? B. "I prefer taking tub baths to showering."
27. A nurse is teaching a client who has acute pyelonephritis. Which of the following
instructions should the nurse include in the teaching? Check Answer ✔ A. "You
should complete the entire cycle of antibiotic therapy."
28. A nurse is teaching a newly licensed nurse about caring for a client who has a
new le arteriovenous fistula. Which of the following statements should the nurse
make? C. "Avoid taking a blood pressure on the client’s le arm."
29. A nurse is caring for a client who has just returned from the surgical suite
following a right nephrectomy. Which of the following indicates that the client is
meeting a successful short-term goal following this procedure? C. Urinary output
is 35 to 50 mL/hr consistently
30. A nurse is assessing a client who has urolithiasis and reports pain in his thigh.
This finding indicates the stone is in which of the following structures? Check
Answer ✔ A. Ureter
31. A nurse is assessing a client who is receiving peritoneal dialysis. Which of the
following findings should the nurse report to the provider immediately? D. Cloudy
eluent
32. A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes
that the client's dialysate output is less than the input and that his abdomen is
distended. Which of the following actions should the nurse take? C. Change the
client’s position
33. A nurse is assessing a client who is receiving hemodialysis for the first time.
Which of the following findings indicates that the client is developing dialysis
disequilibrium syndrome (DDS)? C. Headache
34. A nurse is planning care for a client who had a stroke. The client has hemiplegia
and occasional urinary incontinence. Which of the following actions should the
nurse include in the client’s plan of care? Check Answer ✔ A. Oer the client a
bedpan every 2 hr
35. A nurse is assessing a client who is 1 week postoperative following a living donor
kidney transplant. Which of the following findings indicates the client is
experiencing acute kidney rejection? Check Answer ✔ A. Blood pressure 160/90
mmHg
36. A nurse is caring for a client who has chronic glomerulonephritis with oliguria. For
which of the following electrolyte imbalances should the nurse monitor? B.
Hyperkalemia
37. A nurse is providing teaching to a client who has a history of urinary tract
infections (UTIs). Which of the following client statements indicates the need for
additional teaching? C. "I will use a vaginal douche daily."
38. A nurse is caring for a client who is receiving peritoneal dialysis. The nurse
should monitor the client for which of the following adverse effects? D. Peritonitis
39. A nurse is preparing a client who is scheduled for an intravenous pyelogram
(IVP). Which of the following findings should the nurse report to the provider? B.
Vomiting and diarrhea for the last 6 hr
40. A nurse is assessing a client who has acute kidney injury (AKI). According to the
RIFLE classification system, which of the following findings indicates that the
client has end-stage kidney disease? D. No urine output without renal
replacement therapy for more than 3 months
41. A nurse is providing teaching to a client who has gout and urolithiasis. The client
asks how to prevent future uric acid stones. Which of the following suggestions
should the nurse provide? (Select all that apply.) Check Answer A. Take
allopurinol as prescribed B. Exercise several times a week C. Limit intake of
foods high in purine
42. A nurse is teaching a female client who has pyelonephritis about the disorder.
Which of the following pieces of information should the nurse include to help the
client prevent a recurrence? B. "Wipe from front to back aer defecation."
43. A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney
injury. The client reports diarrhea, a dull headache, palpitations, and muscle
tingling and weakness. Which of the following actions should the nurse take first?
B. Check the client’s electrolyte values
44. A nurse is providing dietary teaching a client who has late-stage chronic kidney
disease (CKD). Which of the following nutrients should the nurse instruct the
client to increase in her diet? Check Answer ✔ A. Calcium
45. A nurse is caring for a client who had a nephrostomy tube inserted 8 hours ago.
Which of the following actions should the nurse include in the client's plan of
care? C. Check the skin at the nephrostomy site for irritation from urine leakage.
Respiratory
1. A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy.
Which of the following is the purpose of these treatments? B. To mobilize
secretions in the airways
2. A nurse is providing instructions about pursed-lip breathing for a client who has
chronic obstructive pulmonary disease (COPD) with emphysema. This breathing
technique accomplishes which of the following? B. Promotes carbon dioxide
elimination
3. A nurse on a medical-surgical unit is caring for 4 clients. Which of the following
clients should the nurse monitor for crepitus? Check Answer ✔ A. A client who
has a chest tube following a pneumothorax
4. A nurse is preparing a client for thoracentesis. In which of the following positions
should the nurse place the client? D. Sitting while leaning forward over the
bedside table
5. A nurse is caring for a client who has chronic obstructive pulmonary disease
(COPD) and is experiencing shortness of breath. Which of the following actions
should the nurse perform first? D. Place the client in an upright position
6. A nurse is caring for a client immediately following extubation. Which of the
following manifestations indicates that the nurse should call the rapid response
team? Check Answer ✔ A. Stridor
7. A nurse is providing discharge teaching to a client who has emphysema. Which
of the following instructions should the nurse include? B. "Try to drink at least 2 to
3 liters of fluid per day."
8. A nurse is planning care for a client who has chronic obstructive pulmonary
disease (COPD) and is malnourished. Which of the following recommendations
to promote nutritional intake should the nurse include in the plan? Check Answer
✔ A. Eat high-calorie foods first
9. A nurse is preparing to administer cisplatin IV to a client who has lung cancer.
The nurse should identify that which of the following findings is an adverse effect
of this medication? D. Tinnitus
10. A nurse is providing teaching to a client who has a chronic cough and is
scheduled for a bronchoscopy. Which of the following client statements indicates
an understanding of the teaching? C. "A tissue sample might be obtained during
the procedure."
11. A nurse is developing a teaching plan for a client about preventing acute asthma
attacks. Which of the following points should the nurse plan to discuss first? B.
Addressing the client’s perception of the disease process and what might have
triggered past attacks ✔
12. A nurse is caring for a client who has a tracheostomy and is receiving
mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it
indicates which of the following to the nurse? B. A leak within the ventilator's
circuitry
13. A nurse is preparing to assist a provider with an arterial blood withdrawal from a
client’s radial artery for ABG measurement. Which of the following actions should
the nurse plan to take? C. Perform an Allen’s test prior to obtaining the specimen
14. A nurse in the PACU is assessing a newly admitted client and observes
intercostal retractions and a high-pitched inspiratory sound. The nurse should
identify these findings as manifestations of which of the following complications?
D. Respiratory obstruction
15. A nurse is assessing a client who has pharyngitis. Which of the following
findings is the nurse's priority to report to the provider? C. Inspiratory stridor
16. A nurse is caring for a client who has a chest tube. The nurse notes that the
chest tube has become disconnected from the chest drainage system. Which of
the following actions should the nurse take? D. Immerse the end of the chest
tube in a bottle of sterile water
17. A nurse is providing discharge instructions to a client who has a new
laryngectomy. The nurse should tell the client to be careful while bathing to
prevent which of the following complications? Check Answer ✔ A. Aspiration of
water
18. A nurse is assessing a client who has a positive tuberculin skin test. Which of the
following findings indicates that the client has active tuberculosis? C. Night
sweats
19. A client comes to the emergency department in severe respiratory distress
following left-sided blunt chest trauma. The nurse notes absent breath sounds on
the client’s left side and a tracheal shift to the right. For which of the following
procedures should the nurse prepare the client? ✔ D. Chest tube insertion
20. A nurse is planning care for a client who is postoperative following a hip
arthroplasty. In the client’s medical record, the nurse notes a history of chronic
obstructive pulmonary disease (COPD). Which of the following oxygen-delivery
methods should the nurse plan to use for this client? D. Nasal cannula
21. A nurse is caring for a client who is postoperative following a thoracic lobectomy.
The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the
other higher on the chest wall. When a family member asks why the client has 2
chest tubes, which of the following responses should the nurse make? C. "The
lower tube will drain blood, and the higher tube will remove air."
22. A nurse is caring for a client who is experiencing acute opioid toxicity. Which of
the following actions should the nurse identify as the priority? B. Ensure an
adequate airway
23. A nurse is caring for a client who is receiving mechanical ventilation and
develops acute respiratory distress. Which of the following actions should the
nurse take first? Check Answer ✔ A. Initiate bag-valve-mask ventilation
24. A nurse in an urgent care clinic is collecting data from a client who reports
exposure to anthrax. Which of the following findings is an indication of the
prodromal stage of inhalation anthrax? Check Answer ✔ A. Dry cough
25. A nurse is caring for a client who smokes cigarettes and has a new diagnosis of
emphysema. How should the nurse assist the client with smoking cessation?
Check Answer ✔ A. Discuss ways the client can reduce the number of cigarettes
smoked per day
26. A nurse is assisting a provider with a comprehensive physical examination of a
client. When the provider uses transillumination, the nurse should explain to the
client that this technique helps evaluate which of the following structures? B.
Maxillary sinuses
27. A client is admitted to the emergency department following a motorcycle crash.
The nurse notes a crackling sensation upon palpation of the right side of the
client's chest. Aer notifying the provider, the nurse should document this finding
as which of the following? C. Crepitus
28. A nurse is reviewing the laboratory results of a client who has metabolic
alkalosis. Which of the following laboratory values should the nurse expect? D.
pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg
29. A nurse on a medical-surgical unit is caring for a client who is postoperative
following a hip replacement surgery. The client reports feeling apprehensive and
restless. Which of the following findings should the nurse recognize as an
indication of pulmonary embolism? Check Answer ✔ A. Sudden onset of
dyspnea
30. A nurse is providing preoperative teaching to a client who is to undergo a
pneumonectomy. The client states, "I am afraid coughing will hurt aer the
surgery." Which of the following statements by the nurse is appropriate? D. "I will
show you how to splint your incision while coughing."
31. A nurse is caring for a client who had a le lower lobectomy to treat lung cancer.
Which of the following factors will have a significant impact on the plan of care for
this client? C. Lung cancer usually has metastasized before the client presents
with symptoms
32. A charge nurse receives notification of the admission of a client who is coughing
frequently and whose sputum is pink, frothy, and copious. The client has a history
of night sweats, anorexia, and weight loss. Which of the following actions should
the nurse take? (Select all that apply.) Check Answer A. Assign the client to a
private room with negative-pressure airflow C. Wear an N95 respirator when
entering the client's room
33. A nurse is providing postoperative care for a client who has 2 chest tubes in
place following a lobectomy. The client asks the nurse the reason for having 2
chest tubes. The nurse should inform the client that the lower chest tube is
placed for which of the following reasons? D. Draining blood and fluid from the
pleural space
34. A nurse in the emergency department is assessing a client for closed
pneumothorax and significant bruising of the le chest following a motor-vehicle
crash. The client reports severe le chest pain on inspiration. The nurse should
assess the client for which of the following manifestations of pneumothorax?
Check Answer ✔ A. Absence of breath sounds
35. A nurse is caring for a client who is extremely anxious and is hyperventilating.
The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L.
The nurse should identify that the client has which of the following acid-base
imbalances? C. Respiratory alkalosis
36. A nurse in a medical-surgical unit is assessing a client. The nurse should identify
that which of the following findings is a manifestation of a pulmonary embolism?
Check Answer ✔ A. Stabbing chest pain
37. A nurse is preparing a client for a bronchoscopy. Which of the following actions
should the nurse take? (Select all that apply.) Check Answer A. Explain that the
client will receive sedation and will not remember the procedure. B. Verify that
the client understands the purpose and nature of the procedure
38. A nurse is caring for an older adult client who has chronic obstructive pulmonary
disease (COPD) with pneumonia. The nurse should monitor the client for which
of the following acid-base imbalances? B. Respiratory acidosis
39. A nurse is caring for a client who has a tracheostomy with an inflated cu in place.
Which of the following findings indicates that the nurse should suction the client's
airway secretions? D. The nurse auscultates coarse crackles in the lung fields
40. A nurse is caring for a client following a right pleural thoracentesis. The nurse
measures a total of 35 mL of purulent drainage. Which of the following findings
should the nurse recognize as an indication of a tension pneumothorax? (Select
all that apply.) Check Answer A. Tracheal deviation to the left C. Absent breath
sounds on the right side D. Neck vein distention
41. A nurse is teaching breathing techniques to a client who has emphysema. Which
of the following statements indicates that the client understands the mechanics of
pursed-lip breathing? C. "When I breathe out through pursed lips, my airways
don't collapse between breaths."
42. A nurse is providing preoperative teaching to a client who will undergo a total
laryngectomy. Which of the following statements indicates that the client
understands the impact of the surgery? D. "I understand that I will have a
permanent tracheostomy aer the surgery."
43. A nurse is preparing a client for discharge following a bronchoscopy. Which of
the following assessments is the nurse's monitoring priority? D. Confirming the
gag reflex
44. A nurse is providing discharge teaching to a client who had a pulmonary
embolism. Which of the following statements indicates that the client understands
the information? C. "I'll call the doctor if I see any blood in my urine or stool."
45. A nurse is caring for a client who is postoperative following a rhinoplasty. Which
of the following findings should the nurse report to the surgeon? D. Frequent
swallowing
46. A nurse is caring for a client with pneumonia who is experiencing thick oral
secretions. Which of the following actions should the nurse take first? C.
Encourage deep-breathing and coughing
47. A nurse in a provider’s oice is assessing a client who states he was recently
exposed to tuberculosis. Which of the following findings is a clinical manifestation
of pulmonary tuberculosis? C. Night sweats
48. A nurse is providing discharge teaching about improving gas exchange for a
client who has emphysema. Which of the following instructions should the nurse
include in the teaching? Check Answer A. Use pursed-lip breathing during
periods of dyspnea
49. A nurse on a medical-surgical unit is assessing a client who recently transferred
from the ICU following endotracheal extubation. Which of the following findings
should the nurse identify as a possible manifestation of tracheal stenosis and
report to the provider? Check Answer ✔ A. Increased coughing
50. A nurse on a medical unit is caring for a client who aspirated gastric contents
prior to admission. The nurse administers 100% oxygen by nonrebreather mask
aer the client reports severe dyspnea. Which of the following findings is a clinical
manifestation of acute respiratory distress syndrome (ARDS)? B. PaO2 50
mmHg
51. A nurse in a clinic is providing teaching for a client who is scheduled to have a
tuberculin skin test. Which of the following pieces of information should the nurse
include? C. "You must return to the clinic to have the test read in 2 or 3 days
52. A nurse is providing teaching to a client about pulmonary function testing. Which
of the following tests measures the volume of air the lungs can hold at the end of
maximum inhalation? Check Answer ✔ A. Total lung capacity
53. A nurse is caring for a client who is scheduled to have his chest tube removed.
Which of the following actions should the nurse take? C. Instruct the client to
perform the Valsalva maneuver during removal
54. A nurse is caring for a client for whom the respiratory therapist has just removed
the endotracheal tube. Which of the following actions should the nurse take first?
C. Evaluate the client for stridor
55. A nurse is auscultating the lungs of a client who is having an acute asthma
attack. Which of the following sounds should the nurse expect to hear? D. Noisy
wheezing
56. A nurse is planning postoperative education for a client who will undergo a
radical neck dissection for cancer of the larynx. The nurse should include which
of the following topics? (Select all that apply.) Check Answer A. NPO status B.
Alternative methods of communication D. Changes in body image E. Swallowing
exercises
57. A nurse is assessing the respiratory status of a client who has COPD. Which of
the following manifestations should the nurse identify as an indication of
impending respiratory failure? C. Tachycardia
58. A nurse is planning care for a client following placement of a chest tube 1 hr ago.
Which of the following actions should the nurse include in the plan of care? C.
Tape all connections between the chest tube and drainage system
59. A nurse is providing preoperative teaching to a client who has lung cancer and
will undergo a pneumonectomy. Which of the following statements should the
nurse include? (Select all that apply.) Check Answer A. "You will have a chest
tube in place aer surgery." B. "We'll frequently help you turn, cough, and breathe
deeply after surgery." D. "We'll give you oxygen to support your breathing if you
need it."
60. A nurse is caring for a client who has a 20-year history of COPD and is receiving
oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen
saturation via pulse oximetry of 85%. Which of the following actions should the
nurse take? C. Increase the oxygen flow and request an arterial blood gas
determination
61. A nurse is providing discharge teaching to a client who is postoperative following
a rhinoplasty. Which of the following instructions should the nurse include? D.
"Lie on your back with your head elevated 30° when resting."