1. A client has an arteriovenous (AV) fistula in place in the right upper extremity for
hemodialysis treatments. When planning care for this client, which measure would the
nurse implement to promote client safety?
1 Use the right arm for blood pressure measurement.
2 Use the fistula for all venipunctures and intravenous infusions.
3 Ensure that small clamps are attached to the AV fistula dressing.
4 Assess the fistula for the presence of a bruit and thrill every 4 hours.
2. A client who experienced a fractured right ankle has a short leg cast applied in the
emergency department. During discharge teaching, which information would the nurse
provide to the client to prevent complications?
1. Trim the rough edges of the cast after it is dry.
2. Weight bearing on the right leg is allowed once the cast feels dry.
3. Expect burning and tingling sensations under the cast for 3 to 4 days.
4. Keep the right ankle elevated above the heart level with pillows for 24 hours.
3. During the postoperative period, the client who underwent a pelvic exenteration reports
pain in the calf area. What action would the nurse take?
1. Ask the client to walk and observe the gait.
2. Lightly massage the calf area to relieve the pain.
3. Check the calf area for temperature, color, and size.
4. Administer as needed (PRN) morphine sulfate as prescribed for postoperative pain.
4. The nurse, caring for a client with Buck's traction, is monitoring the client for complications of
the traction. Which assessment finding indicates a complication of this form of traction?
1. Weak pedal pulses
2. Drainage at the pin sites
3. Complaints of leg discomfort
4. Toes are warm and demonstrate a brisk capillary refill
5. The nurse is assessing the casted extremity of a client for signs of infection. Which finding is
indicative of the presence of an infection?
1 Dependent edema
2 Diminished distal pulse
3 Coolness and pallor of the skin
4 Presence of warm areas on the cast
6. A client with a diagnosis of diabetes mellitus has a blood glucose level of 644 mg/dL (35.8
mmol/L). The nurse interprets that this client is at risk of developing which type of acid-base
imbalance?
1 Metabolic acidosis
2 Metabolic alkalosis
3 Respiratory acidosis
4 Respiratory alkalosis
7. The nurse is ambulating a client for the first time after having abdominal surgery. What clinical
manifestations would indicate to the nurse that the client may be experiencing orthostatic
hypotension? Select all that apply.
1. Nausea
2. Dizziness
3. Bradycardia
4. Lightheadedness
5. Flushing of the face
8. The nurse is performing pin-site care on a client in skeletal traction. Which normal finding
would the nurse expect to note when assessing the pin sites?
1. Numbness at the pin sites
2. Warm skin around the pin sites
3. Clear drainage from the pin sites
4. Redness and swelling around the pin sites
9. The nurse, caring for a client who has been placed in Buck's extension traction while awaiting
surgical repair of a fractured femur, would perform a complete neurovascular assessment of the
affected extremity that includes which interventions? Select all that apply.
1 Vital signs
2 Bilateral lung sounds
3 Pulse in the affected extremity
4 Sensation in the affected leg
5 Skin color of the affected extremity
6 Capillary refill of the affected toes
10. The nurse prepares to transfer the client with a newly applied arm cast into the bed using
which method?
1 Placing ice on top of the cast
2 Supporting the cast with the fingertips only
3 Asking the client to support the cast during transfer
4 Using the palms of the hands and soft pillows to support the cast
11. The nurse is caring for a client who develops compartment syndrome as a result of a severely
fractured arm. When the client asks why this happens, how would the nurse respond?
1 A bone fragment has injured the nerve supply in the area.
2 An injured artery causes impaired arterial perfusion through the compartment.
3 Bleeding and swelling cause increased pressure in an area that cannot expand.
4 The fascia expands with injury, causing pressure on underlying nerves and
muscles.
12. The nurse plans care for a client diagnosed with end-stage renal disease (ESRD). Which
assessment findings does the nurse expect to note documented in the client's medical
record? Select all that apply.
1 Edema
2 Anemia
3 Polyuria
4 Bradycardia
5 Hypotension
6 Osteoporosis
13. A client has been admitted with a diagnosis of acute glomerulonephritis. During history
taking, the nurse would ask the client about a recent history of which event?
1 Bleeding ulcer
2 Myocardial infarction
3 Deep vein thrombosis
4 Streptococcal infection
14. Which important parameter would the nurse assess daily for a client diagnosed with
nephrotic syndrome?
1 Weight
2 Albumin levels
3 Activity tolerance
4 Blood urea nitrogen (BUN) level
15. A client is being admitted with a diagnosis of urolithiasis and ureteral colic. The nurse
expects to note which finding on pain assessment?
1 Dull and aching pain in the costovertebral area
2 Aching and cramplike pain throughout the abdomen
3 Pain that is sharp and radiating posteriorly to the spinal column
4 Pain that is excruciating, wavelike, and radiating toward the genitalia
16. The nurse performs a neurovascular assessment on a client with a newly applied cast. The
nurse would determine that there is a need for close observation and a need for follow-up if
which is noted?
1 Palpable pulses distal to the cast
2 Capillary refill greater than 6 seconds
3 Blanching of the nail bed when it is depressed
4 Sensation when the area distal to the cast is pinched
17. The nurse is assessing the respiratory status of a client with pleural effusion after a
thoracentesis has been performed. The nurse would become concerned with which assessment
finding?
1. Equal bilateral chest expansion
2. Respiratory rate of 22 breaths/min
3. Diminished breath sounds on the affected side
4. Few scattered wheezes, unchanged from baseline
18. A client diagnosed with urolithiasis is being evaluated to determine the type of calculi that
are present. The nurse would plan to keep which item available in the client's room to assist in
this process?
1 A urine strainer
2 A calorie count sheet
3 A vital signs graphic sheet
4 An intake and output record
19. The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD)
how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs
which action?
1 Loosens the abdominal muscles while breathing out
2 Breathes in and then holds the breath for 30 seconds
3 Inhales with puckered lips and exhales with the mouth open wide
4 Breathes so that expiration is two to three times as long as inspiration
20. The nurse performs an assessment on a client newly diagnosed with rheumatoid arthritis.
The nurse expects to note which early manifestations of the disease? Select all that apply.
1 Fatigue
2 Anorexia
3 Weakness
4 Low-grade fever
5 Joint deformities
6 Joint inflammation
21. The nurse sends a sputum specimen to the laboratory for culture from a client with
suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured.
How would the nurse correctly analyze these results?
1 The results are positive for active tuberculosis.
2 The results indicate a less virulent strain of tuberculosis.
3 The results are inconclusive until a repeat sputum specimen is sent.
4 The results are unreliable unless the client has also had a positive tuberculin
skin test (TST).
22. A client newly diagnosed with polycystic kidney disease asks the nurse to explain again what
the most serious complication of the disorder might be. The nurse would provide the client with
information concerning which condition?
1 Diabetes insipidus
2 End-stage renal disease (ESRD)
3 Chronic urinary tract infection (UTI)
4 Syndrome of inappropriate antidiuretic hormone (SIADH) secretion
23. The nurse is creating a plan of care for a client who has returned to the nursing unit after left
nephrectomy. Which assessments would the nurse include in the plan of care? Select all that
apply.
1 Pain level
2 Vital signs
3 Hourly urine output
4 Tolerance for food and fluid intake
5 Ability to cough and deep breathe
24. The nurse creates a care plan for a client receiving hemodialysis through an arteriovenous
(AV) fistula in the right arm. The nurse includes which interventions in the plan to protect the AV
fistula from injury? Select all that apply.
1 Assess pulses and circulation proximal to the fistula.
2 Palpate for thrills and auscultate for a bruit every 4 hours.
3 Check for bleeding and infection at hemodialysis needle insertion sites.
4 Avoid taking blood pressure or performing venipunctures in the extremity.
5 Instruct the client not to carry heavy objects or anything that compresses the
extremity.
6 Instruct the client not to sleep in a position that places her or his body weight
on top of the extremity.
25. A client experiencing calcium oxalate renal calculi is told to limit dietary intake of oxalate.
The nurse is confident that the teaching has been effective when the client includes which items
on a list of foods high in oxalate? Select all that apply.
1 Beets
2 Spinach
3 Rhubarb
4 Black tea
5 Cantaloupe
6 Watermelon
26. The nurse notes that a large number of clients reporting the presence of flulike symptoms
are being seen in the clinic. Which recommendations would the nurse provide to these
clients? Select all that apply.
1 Get plenty of rest.
2 Increase intake of liquids.
3 Get a flu shot immediately.
4 Take antipyretics for fever.
5 Consume a well-balanced diet.
27. A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8
weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder?
1 Thyroid cancer
2 Acute laryngitis
3 Laryngeal cancer
4 Bronchogenic cancer
28. The nurse is assigned to care for a client who is in traction. Which intervention by the nurse
would ensure a safe environment for the client?
1 Making sure that the knots are at the pulleys sites
2 Checking the weights to be sure that they are off the floor
3 Making sure that the head of the bed is kept at a 90-degree angle
4 Monitoring the weights to be sure that they are resting on a firm
surface
29. A client with a diagnosis of an acute respiratory infection and sinus tachycardia is admitted
to the hospital. The nurse would develop a plan of care for the client and include which
intervention?
1 Limiting oral and intravenous fluids
2 Measuring the client's pulse once each shift
3 Providing the client with short, frequent walks
4 Eliminating sources of caffeine from meal trays
30. The nurse has taught a client with a below-the-knee amputation about home care and about
monitoring for and preventing complications related to prosthesis and residual limb care. The
nurse determines that the client has understood the instructions if the client stated that which
action should be taken?
1 Wear a clean nylon sock over the residual limb every day.
2 Use a mirror to inspect all areas of the residual limb each day.
3 Toughen the skin of the residual limb by rubbing it with alcohol.
4 Prevent cracking of the skin of the residual limb by applying lotion
daily.
31. The nurse has given the client with a nephrostomy tube instructions to follow after hospital
discharge to prevent complications. The nurse determines that the client understands the
instructions if the client verbalizes the need to drink how many glasses of water per day?
1 1 to 3
2 6 to 8
3 10 to 12
4 14 to 16
32. The nurse is teaching a client who is preparing for discharge from the hospital after a total
hip arthroplasty. Which statement by the client indicates the need for further teaching?
1. "I need to avoid twisting my body when I am standing."
2. "I need to check my incision every day for signs of infection."
3. "I should not sit in one position for a prolonged period of time."
4. "I can cross my legs if it is more comfortable for me when I sit."
33. The clinic nurse instructs a client diagnosed with type 1 diabetes mellitus about preventing
diabetic ketoacidosis on days when the client is feeling ill. Which statement by the client
indicates the need for further teaching?
1 "I need to stop my insulin if I am vomiting."
2 "I need to call my doctor if I am ill for more than 24 hours."
3 "I need to eat 10 to 15 g of carbohydrates every 1 to 2 hours."
4 "I need to drink small quantities of fluid every 15 to 30 minutes."
34. The nurse is instructing a client with diabetes mellitus regarding hypoglycemia. Which
statement by the client indicates the need for further teaching?
1 "Hypoglycemia can occur at any time of the day or night."
2 "I should drink 6 to 8 ounces of milk if hypoglycemia occurs."
3 "If I feel sweaty or shaky, I might be experiencing hypoglycemia."
4 "If hypoglycemia occurs, I need to take my regular insulin as
prescribed."
35. A client has a history of urolithiasis related to hyperuricemia. To prevent the formation of
future stones, the nurse instructs the client to avoid which food?
1 Liver
2 Carrots
3 White rice
4 Skim milk
36. The nurse has conducted teaching, with a client who experienced pulmonary embolism,
about methods to prevent recurrence after discharge. Which client statement demonstrates
understanding of the teaching?
1 "I will limit the intake of fluids."
2 "I will sit down whenever possible."
3 "I am planning to continue to wear supportive stockings."
4 "I will cross my legs only at the ankle and not at the knees."
37. The home care nurse has given instructions to a client who was recently discharged from the
hospital regarding the care of an arterial ischemic leg ulcer. The nurse determines that there is
a need for further teaching if the client makes which statement?
1 "I should inspect my feet daily."
2 "I should wear shoes and socks."
3 "I should cut my toenails straight across."
4 "I should raise my legs above the level of my heart periodically."
38. A client diagnosed with type 2 diabetes mellitus is being discharged from the hospital after
an occurrence of hyperglycemic hyperosmolar state (HHS). The nurse creates a discharge
teaching plan for the client and identifies which intervention as a priority?
1 Exercise routines
2 Controlling dietary intake
3 Keeping follow-up appointments
4 Monitoring for signs/symptoms of dehydration
39. The nurse creates a plan of care for an older client diagnosed with diabetes mellitus. It is
important that the nurse plans to complete which action first?
1 Structure menus for adherence to diet.
2 Teach with videotapes showing insulin administration to ensure
competence.
3 Encourage dependence on others to prepare the client for the
chronicity of the disease.
4 Assess the client's ability to read label markings on syringes and blood
glucose monitoring equipment.
40. A client is diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse
places priority on teaching the client about modifications of which risk factor related to this
disorder?
1 Exposure to heat
2 Cigarette smoking
3 Diet low in vitamin C
4 Excessive water intake
41. The nurse is creating a teaching plan for the client diagnosed with Raynaud's disease. Which
instruction would the nurse include?
1 Daily cool baths will provide an analgesic effect.
2 A high-protein diet will minimize tissue malnutrition.
3 Vitamin K administration will prevent tendencies toward bleeding.
4 Keeping the hands and feet warm and dry will prevent
vasoconstriction.
42. The nurse teaches a client at risk for coronary artery disease about lifestyle changes needed
to reduce known risks. The nurse determines that the client understands these necessary lifestyle
changes if the client makes which statements? Select all that apply.
1 "I will attempt to stop smoking."
2 "I will be sure to include some exercise such as walking in my daily
activities."
3 "I will work at losing some weight so that my weight is at normal range
for my age."
4 "I will limit my sodium intake every day and avoid eating high-sodium
foods such as hot dogs."
5 "I will schedule regular doctor appointments for physical examinations
and monitoring my blood pressure."
6 "It is acceptable to eat red meat and cheese every day as I have been
doing, as long as I cut down on the butter."
43. The nurse is monitoring a client diagnosed with type 1 diabetes mellitus. Today's blood work
reveals a glycosylated hemoglobin level of 10%. The nurse creates a teaching plan based on the
understanding that this result indicates which finding?
1 A normal value that indicates that the client is managing blood
glucose control well
2 A value that does not offer information regarding the client's
management of the disease
3 A low value that indicates that the client is not managing blood
glucose control very well
4 A high value that indicates that the client is not managing blood
glucose control very well
44. The nurse is preparing a client diagnosed with pneumonia for discharge. Which statement by
the client should alert the nurse to the fact that the client needs further teaching before being
discharged?
1 "I will take all of my antibiotics, even if I do feel 100% better."
2 "You can toss out that incentive spirometer as soon as I leave for
home."
3 "I realize that it may be weeks before my usual sense of well-being
returns."
4 "It is a good idea for me to take a nap every afternoon for the next
couple of weeks."
45. The nurse is caring for a client diagnosed with type 1 diabetes mellitus. Because the client is
at risk for hypoglycemia, which instructions would the nurse teach the client to follow?
1 Keep glucose tablets handy.
2 Monitor the urine for acetone.
3 Report any feelings of drowsiness.
4 Omit the evening dose of NPH insulin if the client has been exercising.
46. The nurse teaches a client with hypertension to recognize the signs/symptoms that may
occur during periods of elevated blood pressure. The nurse determines that the client has
a need for further teaching if the client states that which sign/symptom is associated with this
condition?
1 Epistaxis
2 Dizziness
3 Blurred vision
4 A feeling of fullness in the head
47. A client has recently been diagnosed with polycystic kidney disease. The nurse has a series of
discussions with the client that are intended to help the client adjust to the disorder. Which
would the nurse plan to include as part of one of these discussions?
1 Ongoing fluid restriction
2 The need for genetic counseling
3 The risk of hypotensive episodes
4 Depression regarding massive edema
48. A client with arterial leg ulcers tells the nurse, "I'm so discouraged. I have had this pain for
more than a year now. The pain never seems to go away. I can't do anything, and I feel as
though I'll never get better." The nurse determines that which is the priority client concern?
1 Fatigue
2 Uneasiness
3 Chronic pain
4 An acute illness
49. A client diagnosed with diabetes mellitus requires the immediate amputation of a leg. The
client is very upset and states, "This is the doctor's fault! I did everything that I was told to do!"
When considering the grieving process, how would the nurse respond to the client's statement?
1 Notify the agency's risk management department.
2 Help the client consider alternatives to treatment.
3 Allow the client to use anger as a coping mechanism.
4 Ask the client to list all previous health care providers.
50. A client with a history of hypertension has been prescribed triamterene. The nurse provides
information to the client about the medication and instructs the client to avoid consuming
which fruit?
1 Pears
2 Apples
3 Bananas
4 Cranberries