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ATI COMPREHENSIVE PREDICTOR REVISION GUIDE 2021 500+ Correct Questions & Answers
ATI COMPREHENSIVE PREDICTOR REVISION GUIDE 2021
500+ Correct Questions & Answers
1. 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 suspect? Oncology
A. Bone and joint pain
B. Enlarged lymph nodes
C. Intermittent hematuria
D. Productive cough
2. 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? Dermatology
A. Immobilize the limb at the level of the heart
B. Apply a tourniquet to the affected limb
C. Use a sterile scapula to incise the wound
D. Apply ice to the skin over the snakebite wound
3. 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?
A. "After taking this medication for 4 weeks, I’ll start to notice relief in my joints."
B. "I can take an antacid with this medication for
indigestion." C. "I can take this medication with aspirin."
D. "The naproxen goes down easier when I crush it and put it in applesauce.”
4. 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? Hematology
A. Hospitalization is required when administering each treatment.
B. The maximum effect of the medication will occur in 6 months.
C. Hypertension is a common adverse effect of this medication.
D. Blood transfusions are needed with each treatment.
5. A nurse is teaching a client who has acute pyelonephritis. Which of the following
instructions should the nurse include in the teaching? Renal & Urinary
A. “You should complete the entire cycle of antibiotic therapy.”
B. “You should maintain complete bed rest until manifestations decrease.”
C. “You should drink 1,000 mL of fluid per day.”
D. “You should avoid using NSAIDs for pain.”
6. A nurse is assessing a client who has a bleeding duodenal ulcer. Which of the following
findings should the nurse expect? Gastrointestinal
A. Emesis with a coffee-ground appearance
B. Increased blood pressure
C. Decreased heart rate
D. Bright green stools
7. 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? Neurosensory
A. Sensory dysfunction
B. Weakness of the distal extremities
C. Decreased vision
D. Altered temperature regulation
8. 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? Neurosensory
A. A TIA can cause irreversible hemiparesis.
B. A TIA can be the result of cerebral bleeding.
C. A TIA can cause cerebral edema.
D. A TIA can precede an ischemic stroke.
9. 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? Fluids, Electrolytes Imbalance
A. Hypokalemia
B. Hypernatremia
C. Elevated Hct
D. Decreased Hgb
10. 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?
A. Turn the client from side to side
B. Elevate the height of the dialysate bag
C. Lower the head of the client’s bed
D. Advance the catheter approximately 2.5 cm (1 in) further
11.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? Endocrine
A. "You should exercise during a peak insulin time."
B. "Wear a medical alert identification tag when you exercise."
C. "Exercise can decrease the effects of insulin and cause your blood glucose levels to increase."
D. "You will get the most benefit from exercise when your glucose levels are higher than normal.
12. 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? Oncology
A. Chemotherapy via a central venous access device
B. Radiation to the tumor from an external source
C. Precise delivery of high-dose radiation after tumor imaging
D. Radioactive infusions or insertions into or near the tumor
13. 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.
After notifying the provider, the nurse should document this finding as which of the
following? Respiratory
A. Friction rub
B. Crackles
C. Crepitus
D. Tactile fremitus
14. A nurse in the emergency department is assessing a client for closed pneumothorax and
significant bruising of the left chest following a motor-vehicle crash. The client reports
severe left chest pain on inspiration. The nurse should assess the client for which of the
following manifestations of pneumothorax? Respiratory
A. Absence of breath sounds
B. Expiratory wheezing
C. Inspiratory stridor
D. Rhonchi
15. 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?
Gastrointestinal
A. Oranges and tomatoes
B. Carrots and bananas
C. Potatoes and squash
D. Whole wheat and beans
16. A nurse is caring for a client who is recovering at home after inpatient treatment for
burn injuries. To increase the protein density of the client's meals, which of the
following recommendations should the nurse make to the client's caregiver? Nutrition
A. Use sour cream instead of plain yogurt
B. Add honey to cooked cereals
C. Use salad dressing in place of mayonnaise
D. Add chopped hard-boiled eggs to soups and casseroles
17. A nurse is caring for a client who has type 2 diabetes mellitus and is displaying
manifestations of hyperglycemia. Which of the following findings should indicate to
the nurse that the client has hyperglycemia? Endocrine
A. Hunger
B. Increased urination
C. Cold, clammy skin
D. Tremors
18. 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? Oncology
A. Basal cell carcinoma
B. Melanoma
C. Actinic keratosis
D. Squamous cell carcinoma
19. 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 agerelated factors? Cardiovascular
A. Peripheral vascular resistance increases.
B. The sensitivity of blood pressure-adjusting baroreceptors increases.
C. Blood is hypercoagulable and clots more quickly.
D. Cardiac medications are less effective.
20. 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?
A. Cabbage
B. Oatmeal
C. Milk
D. Bananas
21. 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."
B. "Try to look at the surgical wound as a reminder the limb is gone."
C. "Use a cold compress intermittently to decrease these pain sensations."
D. "Grief over the lost limb can sometimes cause denial that the limb is really gone."
22. 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? Immune & Infection
A. "During this illness, she may take acetaminophen for fevers or discomfort."
B. "Encourage her to eat foods that are high in carbohydrates."
C. "The provider will prescribe a medication to help her liver heal faster."
D. "Have her perform moderate exercise to restore her strength more quickly
23. 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?
A. Stridor
B. Coughing
C. Hoarseness
D. Extensive oral secretions
24. 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? Musculoskeletal
A. "Engage your joints in resistance exercises."
B. "Avoid using assistive devices when walking."
C. "Perform passive exercises."
D. "Apply heat to your joints prior to exercising
25. 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.)
A. Bradycardia
B. Diaphoresis
C. Deep, rapid respirations
D. Palpitations
E. Shakiness
26. 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
B. Speak in a loud voice
C. Use a normal rate when speaking
D. Avoid hand motions
27. 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?
Renal &Urinary
A. Include the first voided specimen at the start of the collection period
B. Discard the last voided specimen at the end of the collection period
C. Place signs in the bathroom as a reminder about the test in progress
D. Instruct the client to increase exercise during the 24-hr period
28. 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?
Nutrition
A. Cornflakes
B. Reduced-fat milk
C. Canned fruits
D. Wheat bread
29. 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?
A. Rhinitis
B. Air hunger
C. Night
sweats
D. Weight gain
30. 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? Vaginal dryness manifestation
A. "Plan to use some type of birth control for up to 6 weeks after
surgery." B. "Use a water-based lubricant when having sexual
intercourse."
C. "Expect to have an increase in bloody vaginal drainage during the first 10 days after surgery."
D. "Plan to start some type of aerobic exercise such as swimming within a week after surgery
31. 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? Immune & Infection
A. "I will need to take methotrexate even if I'm in remission."
B. "I'm thankful that this type of lupus only affects the skin."
C. "Each day I should apply a sunblock with a sun protection factor of 15."
D. "A mild fever is common with SLE and usually does not require medical intervention."
32. 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
follow findings should the nurse recognize as an indication of a pulmonary embolism
(PE)? Respiratory
A. Sudden onset of dyspnea
B. Tracheal deviation
C. Bradycardia
D. Difficulty swallowing
33. 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?
A. Offer the client a bedpan every 2 hr
B. Limit the client’s daily fluid intake until he is no longer incontinent
C. Request a prescription for an indwelling urinary catheter from the client’s provider
D. Ambulate the client to the bathroom every 30 min
34. 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?
A. Hang an IV infusion of 0.9% sodium chloride with the blood
B. Compare the client’s identification number with the number on the blood
C. Witness the informed consent document
D. Obtain pretransfusion vital signs
35. 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?
A. "An EEG measures the electric signals to your brain from hearing, sight, and touch."
B. "An EEG measures the electrical activity in your muscles."
C. "An EEG identifies the magnetic fields produced by electrical activity in your
brain." D. "An EEG records the electrical activity of your brain cells."
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."
B. "Prolonged periods of sun exposure increase your risk of osteoporosis."
C. "Eating a diet high in protein can reduce your risk of osteoporosis."
D. "Corticosteroid therapy will reduce your risk of osteoporosis."
37. 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?
A. "I should check my heart rate at the same time each day."
B. "I don't have to take my antihypertensive medications now that I have a pacemaker."
C. "I should keep a pressure dressing over the generator until the incision is healed."
D. "I cannot stand in front of our new microwave oven when it is on."
38. 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?
A. Elevated glucose
B. Elevated protein
C. Presence of RBCs
D. Presence of
D-dimer
39. 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 nonpharmacological
approaches to help relieve her pain. Which of the following interventions should the nurse
suggest?
A. Applying warm compresses to sore joints
B. Decreasing the daily intake of dietary protein
C. Keeping joints in extension during rest periods
D. Limiting sleep to 6 to 7 hr per night
40. 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? Shock
A. 0.45% sodium chloride
B. Dextrose 5% in 0.9% sodium chloride
C. Dextrose 10% in water
D. 0.9% sodium chloride
41. 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?
A. Metered-dose inhaler
B. Continuous passive motion machine
C. Oral-nasal suction equipment
D. External defibrillator pads
42. 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?
A. Rinse the mouth with chlorhexidine solution every 2 hr
B. Limit fluid intake with meals
C. Provide oral hygiene with a firm bristled toothbrush after each meal
D. Avoid salty foods
43. A nurse is teaching a class of new parents about otitis media. Which of the following
manifestations should the nurse include in the teaching?
A. High-pitched sound heard in the ear
B. Intermittent rapid eye movement
C. Itching of the external canal
D. Feeling of fullness in the ear
44. A nurse is reviewing the dietary choices of a client who has chronic pancreatitis. Which
of the following food items should the nurse suggest removing from the client's menu for
the following day?
A. White rice
B. Broiled cod
C. Ice cream
D. Canned peaches
45. A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which
of the following factors will have a significant impact on the plan of care for this client?
A. The client will need intensive smoking-cessation education.
B. After surgery, the prognosis for clients with lung cancer is usually good.
C. Lung cancer usually has metastasized before the client presents with symptoms.
D. Oxygen therapy is ineffective following a lobectomy.
46. 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?
A. The client has a new tattoo.
B. The client is unable to sit upright.
C. The client has a history of peripheral vascular disease.
D. The client has a pacemaker.
47. 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?
A. "You need to conserve energy at this time."
B. "Lying quietly in bed helps slow down the activity in your intestines."
C. "Staying in bed promotes the rest and comfort you need."
D. "Staying in bed will help prevent injury and minimize your fall risk."
48. 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? Fluids & Electrolytes Imbalance
A. Hypocalcemia
B. Hyperkalemia
C. Anemia
D. Hypoalbuminemia
49. 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?
A. High-calorie diet
B. Prior gastrointestinal illnesses
C. Tobacco use
D. Alcohol use
50. 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?
A. "Keep the lesions covered with a light sterile dressing when going outdoors."
B. "Rub lesions with a washcloth to dry after washing."
C. "Apply moisturizer after bathing the lesions with warm water."
D. "Apply antibiotic cream twice per day until scabs form on the lesions."
51. 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)?
A. "I will bring my sexual partner for treatment."
B. "Now that I’ve had my first dose of medicine, I can resume sexual activity."
C. "Once I have been treated, I don’t have to use condoms anymore."
D. "Once treatment is complete and I am free of symptoms, I don't have to return to the clinic."
52. 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?
A. Decreased blood glucose
B. Decreased bronchospasms
C. Increased urine output
D. Increased temperature
53. 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."
B. "The doctor will be able to fix the problem with my arm during this procedure."
C. "I cannot eat or drink for at least 10 hr before I have this procedure."
D. "I will get enough sedation to put me to sleep for this procedure."
54. 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
B. Dysarthria
C. Receptive aphasia
D. Dysphagia
55. 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?
A. Sudden hemoptysis
B. Acute diarrhea
C. Frontal headache
D. Acute confusion
56. 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?
A. "May I go with my family to the visitor’s lounge?"
B. "I’ll see my friends when I get home."
C. "My dad is coming to visit. Can you fix my hair for me?"
D. "I told my cousins I’m in protective isolation."
57. A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which
of the following is the purpose of these treatments?
A. To encourage deep breaths
B. To mobilize secretions in the airways
C. To dilate the bronchioles
D. To stimulate the cough reflex
58. 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."
B. "You'll have to lie still on your back for 15 to 20 min."
C. "You can't have this test if you’ve had cataract surgery."
D. "Your exposure to radiation will be minimal."
59. 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?
A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen
B. Apply ice to the site after obtaining the specimen
C. Perform an Allen’s test prior to obtaining the specimen
D. Release the pressure applied to the puncture site 1 min after the needle is withdrawn
60. 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?
A. No food or fluids consumed for 4 hr
B. Difficulty recalling recent events
C. Development of hives when eating shrimp
D. Paresthesias in both hands
61. 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.)
A. Tachycardia and hypertension
B. Respiratory rate 16/min
C. Negative Chvostek’s sign
D. Laryngeal stridor and hoarseness
E. Positive Trousseau's sign
62. A nurse is preparing a community education program about hepatitis B. Which of the
following statements should the nurse include in the teaching?
A. "A hepatitis B immunization is recommended for those who travel, especially military
personnel."
B. "A hepatitis B immunization is given to infants and children."
C. "Hepatitis B is acquired by eating foods that are contaminated during handling."
D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."
63. 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?
A. Digesting fats
B. Producing chyme
C. Stimulating gastric acid secretion
D. Providing energy
64. 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?
A. Initiate bag-valve-mask ventilation
B. Provide the client with a communication board
C. Obtain a blood sample for ABG analysis
D. Document the ventilator settings
65. 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?
A. Remove the weight temporarily to reposition the client to the correct alignment in bed
B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely
C. Lift the rope off the pulley while the client rocks back and forth to reposition himself
D. Lift the weight manually while another staff member moves the client up in bed
66. 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?
A. Aspiration
B. Infection
C. Anemia
D. Weight loss
67. 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?
A. Elevate the residual limb on a soft pillow
B. Assist the client into a prone position every 4 hr
C. Re-apply a bandage to the residual limb every 12 hr
D. Apply dressings to the site in a proximal-to-distal direction
68. 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?
A. Maintain IV access with 0.9% sodium
chloride B. Stop the infusion of blood
C. Send the blood container and tubing to the blood bank
D. Obtain a urine sample
69. 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?
A. Sphenoid
B. Occipital
C. Parietal
D. Frontal
70. 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?
A. Blood glucose
B. Blood pressure
C. Daily weight
D. Sensation in the feet
71. 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?
A. "This procedure is performed to measure the presence of acid in your esophagus."
B. "This procedure can determine how well the lower part of your esophagus works."
C. "This procedure is performed while you are under general anesthesia."
D. "This procedure can determine if you have colon cancer."
72. 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?
A. Multiple floaters
B. Flashes of light in front of the eye
C. Severe eye pain
D. Double vision
73. 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?
A. "I can use a heating pad on my feet to keep them warm."
B. "I can go barefoot as long as I stay inside the house."
C. "I will wash my feet daily and apply lotion, except between my toes."
D. "I will trim my toenails every morning by rounding the corners."
74. 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)?
A. Elevated BUN
B. Bradycardia
C. Headache
D. Temperature 39.2°C (102.5°F)
75. 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?
A. Check the client's blood glucose for hypoglycemia
B. Check the client's urine specific gravity
C. Weigh the client weekly
D. Insert an indwelling urinary catheter for the client
76. 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?
A. Turn the client's head to the side with the head of the bed elevated 60°
B. Place the head of the bed flat with pillows under the client's neck and feet
C. Elevate the head of the bed 25° to 30° with the client in a neutral midline position
D. Position the client in a dorsal recumbent position with pillows under the head and knees
77. 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?
A. "I’ll keep an antibacterial hand gel in my purse."
B. "My partner will have to take care of the cat’s litter boxes for a while."
C. "I’m planning a large gathering of friends and family for the holidays."
D. "I will eat canned fruits and vegetables."
78. 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.)
A. Weigh the client daily
B. Obtain a serum blood glucose every 4 hr
C. Apply a new dressing to the client's IV site every 5
days D. Change the IV tubing every 24 hr
E. Infuse the TPN through a peripheral IV site
79. 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.
B. The client's pupils are dilated.
C. The client's heart rate is 56/min.
D. The client is restless
80. 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?
A. "Let’s discuss this with your doctor; giving up daily pasta may not be necessary."
B. "Is there another favorite dish you can substitute?"
C. "You don’t have to give up pasta; just adjust the amount you eat."
D. "You can use no-added-salt tomato products on your pasta."
81. 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? Perioperative
A. Simple face mask
B. Nonrebreather mask
C. Bag-valve-mask device
D. Nasal cannula
82. 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?
A. "Exertion often brings on pain."
B. "Variant angina occurs randomly at various times."
C. "Variant angina can cause changes on your electrocardiogram."
D. "Reducing your cholesterol can help you experience less pain."
83. 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?
A. Insert an oral airway
B. Turn the client onto a side
C. Restrict movement of the client's limbs
D. Place a pillow under the client's head
84. A nurse is caring for a client who has a large wound healing by secondary intention. The
nurse should inform the client that, in addition to protein, which of the following nutrients
promotes wound healing?
A. Vitamin B1
B. Calcium
C. Vitamin C
D. Potassium
85. 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
B. Occipital lobe dysfunction
C. Increased intraocular pressure
D. Macular degeneration
86. 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?
A. Clamp the chest tube if there is continuous bubbling in the water seal chamber
B. Keep the chest tube drainage system at the level of the right atrium
C. Tape all connections between the chest tube and drainage system
D. Empty the collection chamber and record the amount of drainage every 8 hr
87. 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?
A. "I am unable to donate blood."
B. "I will need to get a booster shot of immune serum globulin every year."
C. "I should stop eating raw clams."
D. "I can develop this disease by getting a tattoo.”
88. 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?
A. "I’ll stick with soft foods for now."
B. "My family will be bringing me fresh flowers today."
C. "I'll use a new disposable razor each day."
D. "I’ll blow my nose more often to avoid nosebleeds."
89. 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?
A. "You’ll feel some mild electrical sensations like static electricity during the procedure."
B. "Do not eat or drink anything except water after midnight."
C. "Shampoo your hair before the procedure and don’t use any styling products afterward."
D. "It’s common to have temporary short-term memory loss after the procedure."
90. 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.)
A. Use a 5 mL syringe to flush the line
B. Cleanse the insertion site with half-strength hydrogen peroxide
C. Flush the line with sterile 0.9% sodium chloride before and after medication
administration D. Access the PICC for blood sampling
E. Perform a heparin flush of the line at least daily when not in use
91. 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?
A. Pneumonia
B. Pulmonary embolus
C. Tension pneumothorax
D. Tuberculosis
92. A nurse is monitoring a client following a thyroidectomy for the presence of
hypoparathyroidism. Which of the following findings should the nurse expect?
A. Elevated blood pressure
B. Involuntary muscle spasms
C. Cold intolerance
D. Weight loss
93. 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?
A. Press the analyze button on the machine
B. Stop CPR and move away from the client
C. Push the charge button to prepare to shock
D. Apply the defibrillator pads to the client's chest
94. 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?
A. Estimation of burn injury
B. Characteristics of the cough and sputum
C. Extent of peripheral edema
D. Amount of urine output
95. 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.)
A. Jugular vein distension
B. Moist crackles
C. Postural hypotension
D. Increased heart rate
E. Fever
96. Nurse is providing discharge teaching to a client who is postoperative following
a rhinoplasty. Which of the following instructions should the nurse include?
A. Apply warm compresses to the face
B. Take aspirin 650 mg by mouth for mild pain
C. Close your mouth when sneezing
D. Lie on your back with your head elevated 30 degree when resting
97. 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
B. Sensory
C. Immediate
D. Recall
98. 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? Fluids & Electrolytes Imbalance
A. <0.5 mL/kg of urine output for 12 hr
B. No urine output for 12 hr
C. No urine output without renal replacement therapy for 4 to 12 weeks
D. No urine output without renal replacement therapy for more than 3 months
99. 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?
A. Vitamin A
B. Vitamin B3
C. Vitamin C
D. Vitamin D
100. A nurse is assessing a client who has Addison’s disease. Which of the following skin
manifestations should the nurse expect to find?
A. Purple striae on the chest and abdomen
B. Butterfly rash across the bridge of the nose
C. Bronze pigmentation of the skin
D. Jaundice of the face and sclera
101. 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?
A. Temperature 37.8°C (100°F)
B. Erythema at the incision site
C. WBC count 9,000/mm^3
D. Pain reported as 6 on a scale of 0 to 10
102. 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?
A. Soft-boiled eggs
B. Brie cheese made with unpasteurized milk
C. Cold deli-meat sandwiches
D. Baked chicken
103. 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?
A. "Empty the drainage tubes once per day."
B. "Showering is permitted before the drainage tubes are removed."
C. "The drainage tubes often are removed at the same time as the stitches."
D. "Do not begin exercising your arm until the provider removes the drainage tubes."
104. 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?
A. Finding the bathroom in the dark
B. Driving at night
C. Seeing numbers on highway signs
D. Reading the newspaper
105. 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?
A."I should take this medication with food."
B."I need to take a B-complex vitamin while using this
medication." C."I can expect this medication to turn my skin
orange."
D."I can expect this medication to make my vision blurry."
106. 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?
A. Elevate the affected leg
B. Place the client on bed rest
C. Massage the affected leg
D. Administer aspirin for discomfort
107. 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"
B. Ask the client to identify the scent of coffee
C. Use a tongue blade to provoke a gag reflex
D. Have the client smile and raise his eyebrows
108. 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?
A. White bread and plain yogurt
B. Shredded wheat cereal and blueberries
C. Broccoli and kidney beans
D. Oatmeal and fresh pears
109. A nurse is assessing a client who has Addison's disease. Which of the following
findings should the nurse expect?
A. Hypotension
B. Weight gain
C. Sugar craving
D. Pale skin tone
110. A nurse is caring for a client who has a platelet count 50,000/mm^3. After
discontinuing the client's peripheral IV site, which of the following actions should the
nurse take?
A. Apply warm compress
B. Apply pressure to the catheter removal site for 5 min
C. place the affected arm in a dependent position
D. Clean the insertion site with alcohol
111.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?
A. Depressed fracture of the forehead
B. Clear fluid coming from the nares
C. Motor loss on one side of the body
D. Bleeding from the top of the scalp
112.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?
A. Keep the client's legs flat with the knees extended
B. Encourage the client to sit up in a chair for as long as
possible C. Logroll the client in bed for care procedures
D. Expect urinary retention for the first postoperative day
113.A nurse is assessing a client who has a complete intestinal obstruction. Which of the
following findings should the nurse expect?
A. Absence of bowel sounds in all 4 abdominal quadrants
B. Passage of blood-tinged liquid stool
C. Presence of flatus
D. Hyperactive bowel sounds above the obstruction
114.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.)
A. Insert a 23-gauge angiocatheter with an IV adaptor
B. Check to determine the packed RBCs are less than 1 week old
C. Administer the packed RBCs over a 6-hr period
D. Ask another nurse to check the packed RBCs’ label against the medical record
E. Prime the transfusion tubing with 0.9% sodium chloride
115.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?
A. Question the client's coworkers about the mechanism of injury
B. Check the client's pupils for equality and reaction to light
C. Measure the client's alertness using the Glasgow Coma Scale
D. Immobilize the client's cervical spine
116.A nurse is caring for a male client who reports a thick urethral discharge. Which of the
following actions should the nurse take?
A. Contact the client's sexual partners
B. Obtain a urethral specimen for culture
C. Prepare to administer penicillin to the client
D. Obtain blood for a rapid plasma reagin test
117.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?
A. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min
B. Prepare the client for possible endotracheal intubation and mechanical
ventilation C. Increase the oxygen flow and request an arterial blood gas
determination
D. Position the client supine and administer an antianxiety medication
118.A nurse is reviewing the medical record of a client who has heart failure. Which of the
following findings should the nurse expect? (Click on "Exhibit NCLEX 3" under
Resources on the right-hand side for additional information about the client) Fluids &
Electrolytes Imbalance
A. BNP of 200 pg/mL
B. Bradycardia
C. Fluid restriction of 3 L per day
D. 4 g sodium diet
119.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?
A. Onion soup and salad
B. Vegetarian wrap with potato chips
C. Grilled chicken salad with fresh tomatoes
D. Chicken bouillon and crackers
120. 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?
A. Wheezing
B. Bradypnea
C. Tachycardia
D. Diaphoresis
121. 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?
A. Narrower than usual QRS complexes
B. Much greater amplitude than the usual QRS complexes
C. Same polarity as the usual QRS complexes
D. Immediate resumption of the usual rhythm
122. 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?
A. Exploratory laparotomy
B. Double-contrast barium enema
C. Magnetic resonance imaging
D. Colonoscopy
123. 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. "A colostomy drains stool, and an ileostomy drains urine."
B. "A colostomy is temporary, and an ileostomy is permanent."
C. "A colostomy is from the large intestine, and an ileostomy is from the small intestine."
D. "An ileostomy requires dietary restrictions, while a colostomy does not."
124. 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?
A. Warm the unit of blood to room temperature before administering it
B. Administer acetaminophen prior to the blood transfusion
C. Give an antihistamine prior to the transfusion
D. Use a transfusion pump to regulate and maintain the transfusion at a slower rate
125. 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?
A. Obtain blood samples to test platelet function
B. Prepare for replacement of the missing clotting factor
C. Administer aspirin for the client's pain
D. Place the bleeding joint in the dependent position
126. 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?
A. Rifampin
B. Loperamide
C. Hydrocortisone
D. Spironolactone
127. A nurse is assessing a client who has Graves' disease. Which of the following findings
should the nurse expect the client to display?
A. Constipation
B. Cold intolerance
C. Difficulty sleeping
D. Anorexia
128. 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?
A. Platelet count
B. RBC count
C. Hct
D. Erythrocyte sedimentation rate (ESR)
129. 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?
A. Grilled chicken
B. Potato soup
C. Fish sticks
D. Baked ham
130. 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?
A. Producing bile
B. Adding digestive enzymes to bile
C. Storing bile
D. Eliminating bile
131. 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?
A. "Drink fruit punch or juice with every meal."
B. "Consume 1,000 mg of dietary calcium daily."
C. "Take 1 g of a vitamin C supplement daily."
D. "Increase your daily bran intake."
132. 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?
A. "I should eat foods that are high in saturated fat."
B. "Before taking my medication, I will count my radial pulse rate."
C. "I will exercise once a week for an hour at the health club."
D. "I will stop taking my medication when my blood pressure is within a normal range."
133. A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of
the following manifestations should the nurse expect?
A. Increased blood pressure
B. Decreased heart rate
C. Yellowing of the skin
D. Boardlike abdomen
134. 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
B. Tachycardia
C. Periorbital edema
D. Decrease in urine output
135. 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?
A. "I should limit my exposure to sunlight."
B. "I should avoid drinking alcohol."
C. "I should not smoke."
D. "I should limit of intake of foods that are high in purine."
136. 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?
A. Curettage
B. External radiation therapy
C. Regional chemotherapy
D. Surgical excision
137. 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?
A. Fried chicken from a fast food restaurant
B. A case of canned nutritional supplements
C. A factory-sealed box of chocolates
D. A fresh fruit basket
138. 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
B. Encouraging active range of motion of the affected leg
C. Removing the weights prior to repositioning the client
D. Inspecting pin sites every 24 hr for drainage
139. A nurse is assessing a client who is in the early stages of hepatitis A. Which of
the following manifestations should the nurse expect?
A. Jaundice
B. Anorexia
C. Dark urine
D. Pale feces
140. 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?
A. Hypovolemic shock
B. Fat embolism syndrome
C. Thrombophlebitis
D. Avascular bone necrosis
141. 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?
A. Right shoulder pain
B. Urine output 20 mL/hr
C. Temperature 38.4°C (101.1°F)
D. Oxygen saturation 92%
142. 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?
A. Eat high-calorie foods first
B. Increase intake of water at meal times
C. Perform active range-of-motion exercises before meals
D. Keep saltine crackers nearby for snacking
143. 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?
A. Increases oxygen intake
B. Promotes carbon dioxide elimination
C. Uses the intercostal muscles
D. Strengthens the diaphragm
144. 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?
A. Corticosteroids
B. Antimalarials
C. Antidepressants
D. Opioids
145. 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?
A. Necrosis
B. Hypokalemia
C. Hypomagnesemia
D. Insufficiency
146. 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?
A. Place unused equipment between the fire doors.
B. Turn off sources of oxygen near the fire.
C. Place rolled blankets at the base of the fire.
D. Keep the doors to the unit and client rooms open
147. 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.)
A. "I will have to drink a radioactive solution before the test begins."
B. "A special camera will scan the bones in my entire body."
C. "There will be better absorption of the radiation by healthy bone."
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."
148. 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?
A. The percentage of blood the ventricles pump during each beat
B. The amount of blood the left ventricle pumps during each beat
C. The amount of blood in the left ventricle at the end of diastole
D. The heart rate times the stroke volume
149. 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
preprocedure teaching? Perioperative
A. "I have to keep my leg straight throughout the whole procedure."
B. "The doctor will be able to see if I have signs of rheumatoid arthritis."
C. "I should expect to stay overnight until I can walk around."
D. "I'll have a scar that will be about an inch long
150. A nurse is assessing a client who had coronary artery bypass grafts for cardiac
tamponade. Which of the following actions should the nurse take?
A. Check for hypertension
B. Auscultate for loud, bounding heart sounds
C. Auscultate blood pressure for pulsus paradoxus
D. Check for a pulse deficit
151. 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?
A. Maintains fluid balance
B. Regulates calcium in the blood
C. Destroys old blood cells
D. Produces prothrombin
152. 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?
A. Severe hypertension
B. Low body temperature
C. Sudden oliguria
D. Decreased respirations
153. 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?
A. Instruct the client to cough
B. Administer oxygen via face
mask C. Evaluate the client for
stridor
D. Keep the client in a semi- to high-Fowler's position
154. 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?
A. An assistive device when the client is ambulating
B. Heat paraffin therapy applied to the client's joints
C. Gentle massage of the client's hands
D. Active range-of-motion exercises on the client’s affected joints
155. 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?
A. "I need to lie still in bed during my brachytherapy treatment."
B. "I will have an implant placed once a month during my brachytherapy treatment."
C. "I must stay at least 3 feet away from others between brachytherapy treatments."
D. "I should expect some blood in my urine after each brachytherapy treatment."
156. 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?
A. To visualize polyps in the colon
B. To detect an ulceration in the stomach
C. To identify an obstruction in the biliary tract
D. To determine the presence of free air in the abdomen
157. 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?
A. "Move between the bed and the wheelchair once every 2 hr."
B. "Make sure that your caregiver massages your skin daily."
C. "Use a rubber ring when sitting on the bedside."
D. "Shift your weight in the wheelchair every 15 min."
158. 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?
A. "Not having any more rectal pain will be a relief."
B. "I will need to sit on a rubber donut when I am in the
chair." C. "I can have only liquids for 2 days before the
surgery."
D. "The colostomy will start working about 7 days after the surgery."
159. 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?
A. Remain NPO 6 to 8 hr prior to the EEG
B. Take a sedative the night prior to the EEG
C. Thoroughly shampoo her hair prior to the EEG
D. Sleep for at least 8 hr during the night prior to the test
160. 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?
A. Skin
B. Prostate
C. Bone
D. Bladder
161. 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?
A. Aspiration of water
B. Infection of the stoma
C. Bleeding around the stoma
D. Skin breakdown around the stoma
162. 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."
B. "Perform your exercises only on days that you feel good."
C. "Perform your exercises after applying cold packs to your joints."
D. "Place a large pillow under your knees when lying down."
163. 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?
A. Omega-3 fatty acids
B. Antioxidants
C. Vitamins A, D, and C
D. Beta-carotene
164. 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?
A. Leg cramps with exercise
B. Stress incontinence
C. Abdominal
distention D. Lower
back pain
165. 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?
A. Insert an indwelling urinary catheter
B. Administer pain medication to the client
C. Change the client’s position
D. Place the drainage bag above the client’s abdomen
166. 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?
A. Cucumbers and tomatoes
B. Cabbage and peaches
C. Strawberries and corn
D. Figs and nuts
167. 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?
A. Maintain the client’s knees and hips in a flexed position
B. Apply cold compresses to painful joints
C. Withhold opioids until the crisis is resolved
D. Encourage increased fluid intake
169. 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?
A. Stabbing chest pain
B. Calf tenderness
C. Elevated temperature
D. Bradycardia
170. 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?
A. Cadaver skin
B. Pig skin
C. Amniotic membranes
D. Beef collagen
171. 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?
A. Confluent, honey-colored, crusted lesions
B. A large, tender nodule located on a hair follicle
C. Unilateral, localized, nodular skin lesions
D. A fluid-filled vesicular rash in the genital region
172. 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?
A. Initiate range-of-motion exercises
B. Use clean technique to provide wound care
C. Place the client on a low-protein diet
D. Maintain the client on bed rest
173. 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?
A. Protect against the cold by wearing layers of clothing
B. Begin an exercise program of 2- mile walks once per week
C. Increase vitamin A in the diet
D. Elevate the hands above heart level when resting
174. 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?
A. Apply a broad-spectrum sunscreen 5 min before sun exposure
B. Wear a sun visor instead of a hat when outside in the sun
C. Avoid exposure to the midday sun
D. Use a tanning booth instead of sunbathing outdoors
175. 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? A. Administer antihypertensive medication for blood pressure
B. Monitor to ensure the client’s urinary output is 20 mL/hr
C. Withhold pain medication to prepare the client for surgery
D. Take the client’s vital signs every 2 hr
176. A nurse is reviewing the laboratory results of a client who has metabolic alkalosis.
Which of the following laboratory values should the nurse expect? Fluid, Electrolyte &
Balance
A. pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mmHg
B. pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mmHg
C. pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mmHg
D. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg
177. A nurse is caring for a client who has a brainstem injury. Which of the following
physiological functions should the nurse monitor?
A. Understanding speech
B. Respiratory effort
C. Decision-making ability
D. Temperature control
178. 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?
A. "HIV can be transmitted as soon as a person develops manifestations."
B. "HIV can be transmitted to anyone who has had contact with infected blood."
C. "HIV is transmitted through the respiratory route via droplets."
D. "HIV is transmitted only during the active phase of the virus."
179. 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?
A. "Because most of my colon is still intact and functioning, my stool will be formed."
B. "My stoma will appear large at first, but it will shrink over the next several weeks."
C. "My colostomy will begin to function in 2 to 6 days after
surgery." D. "I’ll have to consume a soft diet after surgery."
180. A nurse is assisting a provider with performing a paracentesis on a client. Which of the
following actions should the nurse take?
A. Ask the client to empty his bladder before the procedure
B. Place the client leaning forward over the bedside table for the procedure
C. Inform the client he will be sedated during the procedure
D. Instruct the client to fast for 6 hr prior to the procedure
181. A nurse is providing teaching to the family of a client who has stage II Alzheimer’s
disease (AD). Which of the following pieces of information should the nurse include in
the teaching?
A. Place abstract pictures on the wall in the client’s room
B. Provide music for the client using headphones
C. Reorient the client to reality frequently
D. Limit choices offered to the client
182. 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?
A. Increased coughing
B. Diaphragmatic breathing
C. Hemoptysis
D. Kussmaul respirations
183. 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?
A. Remote
B. Immediate
C. Recall
D. Past
184. 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?
A. "I should perform range-ofmotion exercises once per day."
B. "I should cough and deep-breathe every hour."
C. "I should change my position every 4 hours."
D. "I should perform foot and ankle pumps every 3 hours."
185. A nurse is providing preoperative teaching to a client who is to undergo a
pneumonectomy. The client states, "I am afraid coughing will hurt after the
surgery." Which of the following statements by the nurse is appropriate?
A. "After the surgeon removes the lung, you will not need to cough."
B. "I'll make sure you get a cough suppressant to keep you from straining the incision when you
cough."
C. "Don’t worry. You will have a pump that delivers pain medication as needed, so you will
have very little pain."
D. "I will show you how to splint your incision while coughing."
186. 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? Perioperative
A. "You will need to continue to use some form of birth control for 6 months."
B. "You might experience manifestations of menopause."
C. "Do not lift anything heavier than 15 lb."
D. "Pain or burning with urination is an expected outcome of this surgery."
187. A nurse is caring for a client who is suspected to have tuberculosis. Which of the
following findings should the nurse expect?
A. Recent weight gain
B. High fever
C. Rhinitis
D. Blood-streaked sputum
188. 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?
A. Calcium
B. Potassium
C. Iodine
D. Hydrocortisone
189. 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?
A. Close the door to the client's room
B. Attempt to extinguish the fire
C. Activate the facility's fire alarm system
D. Transport the client to an area away from the smoke
190. 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. A dressing is not applied to the port site after use.
B. A 22-gauge non-coring needle is used to access the port.
C. Blood return is noted prior to administering the medication.
D. A solution of 5 mL heparin 1,000 units/mL has been
prepared.
191. 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?
A. Diffuse maculopapular rash
B. Dyspnea C. Double
vision D. Progressive
circular rash
192. 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?
A. Prothrombin time
B. WBC count
C. Platelet count
D. Hematocrit
193. 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? Fluids, Electrolytes
Imbalances
A. Hypokalemia
B. Hypophosphatemia
C. Hypercalcemia
D. Hypermagnesemia
194. 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?
A. "My diabetes will not increase my risk of heart failure."
B. "My asthma makes it more likely for me to have heart failure."
C. "My age does not increase my risk of heart failure."
D. "My coronary artery disease is a risk factor for heart failure."
195. A nurse is caring for a client who has fulminant hepatic failure. Which of the following
procedures should the nurse anticipate for this client?
A. Endoscopic sclerotherapy
B. Liver lobectomy
C. Liver transplant
D. Transjugular intrahepatic portalsystemic shunt placement
196. 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?
A. "I will begin vacuuming once a week."
B. "Carpeting the entire house will be very expensive, but it will be worth
it." C. "I will put a mattress cover on my bed."
D. "Installing curtains on the windows will help control the dust in my house."
197. A nurse is planning discharge teaching for a client who has systemic lupus
erythematosus (SLE). Which of the following instructions should the nurse
include?
A. "Avoid the use of NSAIDs."
B. "Stop taking the corticosteroids when your symptoms resolve."
C. "Exposure to ultraviolet light will help control the skin rashes."
D. "Monitor your body temperature and report any elevations promptly."
198. 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?
A. Cardiac monitor
B. Defibrillator
C. Thoracotomy tray
D. Tracheostomy
tray
199. A nurse is assessing a client who has Kaposi’s sarcoma. Which of the following findings
should the nurse expect?
A. Nonproductive cough, fever, and shortness of breath
B. Lesions on the retina that produce blurred vision
C. Onset of progressive dementia
D. Reddish-purple skin lesions
200. 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. Which of
the following instructions should the nurse include in the teaching?
A. "Place a warm compress on your forehead."
B. "Darken the lights."
C. "Light a scented candle."
D. "Drink a caffeinated beverage."
201. A nurse is planning care for a client who has pernicious anemia. Which of the
following interventions should the nurse include in the plan?
A. Administer ferrous sulfate supplementation
B. Increase dietary intake of folic acid
C. Initiate weekly injections of vitamin B12
D. Initiate a blood transfusion
203. 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?
A. Protective isolation
B. Droplet precautions
C. Standard precautions
D. Airborne precautions
204. 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?
A. Avoid IM injections
B. Assess the client for ecchymosis once per shift
C. Do not allow the client to have visitors
D. Encourage daily flossing between teeth
205. 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?
A. Tracheostomy placement
B. Thoracentesis C.
CT scan of the chest
D. Chest tube insertion
206. A nurse is providing teaching to a client who is preoperative for a renal biopsy. Which
of the following statements should the nurse make?
A. "You will be NPO for 8 hr following the procedure."
B. "An allergy to shellfish is a contraindication to this procedure."
C. "You will need to be on bed rest following the procedure."
D. "A creatinine clearance is needed prior to the procedure."
207. 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."
B. "You may drive home after the procedure."
C. "Continue to wear your contact lenses until the day of the surgery."
D. "Expect complete healing and
208. 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?
A. IV
B. I
C. III
D. II
209. 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?
A. Glaucoma
B. Retinal detachment
C. Macular degeneration
D. Cataracts
211. 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?
A. Compensation for decreased cortisol levels
B. Inhibition of glucose metabolism
C. Diuretic action to maintain urine output
D. Decreased susceptibility to infection
212. 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?
A. Prothrombin time
B. Serum lipase
C. Bilirubin
D. Calcium
213. A nurse in a provider’s office is assessing a client who states he was recently exposed to
tuberculosis. Which of the following findings is a clinical manifestation of pulmonary
tuberculosis?
A. Pericardial friction rub
B. Weight gain
C. Night
sweats
D. Cyanosis of the fingertips
214. 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?
A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no
pacing spikes
B. Premature ventricular complexes at 12/min
C. Telemetry monitoring showing pacing spikes with no QRS complexes
D. Hiccups
215. A nurse is teaching a client who has osteoporosis. Which of the following instructions
should the nurse include in the teaching?
A. Reduce dietary protein intake
B. Apply ice to painful areas
C. Increase calcium intake to 900 mg per day
D. Perform weight-bearing exercises
216. 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?
A. Perform passive range-of-motion exercises of the ankle hourly
B. Keep the affected extremity in a dependent position
C. Wrap a loose dressing around the affected ankle
D. Apply cold compresses to the extremity intermittently
217. 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?
A. Reorient the client
B. Protect the client’s head
C. Loosen constrictive clothing
D. Turn the client onto his side
219. 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? (Select all that apply.)
A. Hypothyroidism
B. Hypertension
C. Diabetes mellitus
D. Hyperlipidemia
E. Tobacco smoking
220. A nurse is conducting dietary teaching for a client who has AIDS. Which of
the following instructions should the nurse include in the teaching?
A. Discard leftovers after 8 hr
B. Use a separate cutting board for poultry
C. Thaw frozen foods at room temperature
D. Store cold foods at 10°C (50°F) or less
221. 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?
A. The client cannot name simple objects or formulate sentences or phrases.
B. The client has difficulty articulating correctly due to muscle weakness of the mouth
and tongue.
C. The client is unable to understand words or sentences she hears.
D. The client speaks words that substitute for those she intends to say.
222. 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? (Move the
steps into the box on the right, placing them in the order of performance. Use all the
steps.)
1- Palpate the blood pressure and inflate the cuff above the systolic pressure.
2- Deflate the cuff slowly and listen for the first audible sounds.
4- Subtract the inspiratory pressure from the expiratory pressure.
3- Inspect for jugular venous distention and notify the provider.
5- Identify the first BP sounds audible on expiration and then on inspiration.
223. 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?
A. "I need to stay active to prevent blood clots in my legs."
B. "If I have a bad headache, I can take aspirin to get rid of it."
C. "I should eliminate uncooked foods from my diet for now."
D. "I should eat more iron-fortified cereal to strengthen my blood."
224. A nurse is caring for a client who has chronic phantom limb pain following an aboveknee amputation. Which of the following medication prescriptions should the nurse
verify with the provider?
A. Meperidine
B. Amitriptyline
C. Gabapentin
D. Propranolol
225. 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
B. Ask the provider to bivalve the cast
C. Provide the client with a sterile cotton swab to rub the affected skin
D. Wrap the extremity with a dry heating pad
226. 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?
A. Restrict fluids to 1,000 mL per day
B. Measure the client's abdominal girth daily
C. Check IV sites every 4 hr for bleeding
D. Administer an enema as needed for constipation
227. 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?
A. Chicken breast and corn on the cob
B. Shrimp and rice
C. Cheese omelet and turkey bacon
D. Liver and onions
228. 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?
A. "PCP is sexually transmitted from person to person."
B. "You were most likely exposed to a contaminated surface such as a drinking glass."
C. "PCP results from an impaired immune system."
D. "You might have contracted PCP from a family pet."
229. 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?
A. Wear nylon socks with shoes every day
B. Trim toenails by rounding the edges of the nail
C. Apply lotion between the toes after bathing
D. Test water temperature with the wrist (diabetic pte have peripheral nerve damage)
230. 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?
A. Men who smoke
B. Men and women who are obese
C. Women who have hepatitis
D. Men and women who consume high-protein and low-carbohydrate foods
231. 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
B. Ensure the client sleeps on a soft mattress
C. Pull up the residual limb while in bed
D. Keep the residual limb exposed to air to heal
232. A nurse is preparing to administer codeine 30 mg PO every 4 hr PRN to a client for pain.
The amount available is codeine oral solution 15 mg/5 mL. How many mL should the nurse
plan to administer per dose? (Fill in the blank with the numeric value only, round the answer
to the nearest whole number, and use a leading zero if applicable. Do not use a trailing
zero.) Ans: 10 mL
233. 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?
A. Excessive airway secretions
B. A leak within the ventilator's circuitry
C. Decreased lung compliance
D. The client coughing or attempting to talk
234. 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?
A. Diarrhea
B. Increased serum albumin
C. Hypoglycemia
D. Peritonitis
235. 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?
A. A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper
right shoulder
B. Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose
C. A raised, circumscribed lesion on the face that contains yellow-white purulent material
D. An irregularly shaped brown lesion with light blue areas on the neck
236. 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?
A. Hyponatremia
B. Leukopenia
C. Hyperchloremia
D. Elevated BUN
237. 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
B. The client's ability to communicate verbally
C. The client's ability to move all extremities
D. The client's ability to remain continent of urine
238. A nurse is assessing a client who has pericarditis. Which of the following
manifestations should the nurse expect?
A. Bradycardia with ST-segment depression
B. Relief of chest pain with deep inspiration
C. Dyspnea with hiccups
D. Chest pain that increases when sitting upright
239. 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? Perioperative
A. "I should expect swelling of the affected leg for several weeks."
B. "I should not cross my legs at the ankles or knees."
C. "I will inspect my hip incision every other day for redness."
D. "I can bend over at the hip to pick up objects."
240. 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?
A. Discuss ways the client can reduce the number of cigarettes smoked per day
B. Suggest the client switch from smoking cigarettes to smoking a pipe
C. Inform the client that treatment will be ineffective if smoking continues
D. Discourage the use of nicotine gum
241. 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?
A. Impacted
B. Depressed
C. Compound
D. Greenstick
242. 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.)
A. NPO status
B. Alternative methods of communication
C. Endotracheal intubation
D. Changes in body image
E. Swallowing exercises
243. A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of
the following adverse effects should the nurse anticipate from the chemotherapy?
A. Gingival hyperplasia
B. Hirsutism
C. Pancytopenia
D. Weight gain
244. 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?
A. First-degree frostbite
B. Second-degree frostbite
C. Third-degree frostbite
D. Fourth-degree frostbite
245. 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
B. Weakness of a side of the tongue
C. Facial droop and asymmetrical smile
D. Loss of the same visual field in both eyes
246. 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?
A. "You can expect a persistent fever and swollen glands."
B. "You can expect an elevated white blood cell count."
C. "You can expect increased blood pressure and edema."
D. "You can expect weight gain."
247. 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?
A. The incision is showing early signs of infection.
B. The incision is showing early signs of dehiscence.
C. The incision is showing signs of healing without complications.
D. The incision is showing signs of developing a fistula.
248. 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?
A. Eustachian tube
B. Cochlea
C. Perichondrium
D. Eardrum
249. 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?
A. Constipation
B. Headache
C. Bradycardia
D. Hypertension
250. 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?
A. Wheat toast
B. Tapioca pudding
C. Hard-boiled egg
D. Mashed potatoes
251. 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? Fluids & Electrolytes Imbalance
A. Acidosis
B. Infection
C. Hypertension
D. Cardiac tamponade
252. 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?
A. Zinc
B. Iron
C. Phosphorus
D. Magnesium
253. A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse expect?
A. Pitting peripheral edema
B. Crackles in the lung bases (Left-sided heart failure precipitates pulmonary congestion and
edema, causing crackles in the lungs)
C. Jugular vein distention
D. Hepatomegaly
254. 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? Fluids & Electrolytes Imbalance
A. Hypernatremia
B. Hypomagnesemia
C. Hypercalcemia
D. Hyperkalemia
255. 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)?
A. To identify if a client lacks immunity to tuberculosis
B. To find out if a client has active tuberculosis
C. To decrease the hypersensitivity of the client's reaction to PPD
D. To identify if a client has been infected with Mycobacterium tuberculosis
256. 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?
A. Papules
B. Macules
C. Wheals
D. Vesicles
257. 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?
A. "I will dispose of soiled tissues in separate plastic bags."
B. "I’ll clean up blood spills immediately with hot water."
C. "I know that handwashing is an important preventive measure."
D. "I will wash soiled clothes in hot water."
258. 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?
A. Decreased lactate dehydrogenase
B. Increased serum albumin
C. Decreased serum ammonia
D. Increased prothrombin time
259. 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?
A. Stress incontinence
B. Hematuria
C. Pyuria
D. Fever
260. 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?
A. Insufficient skin care
B. Dehydration
C. Immobility
D. Impaired circulation
261. 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?
A. Gamma-glutamyl transferase (GGT)
B. Alkaline phosphatase (ALP)
C. Serum bilirubin
D. Alanine aminotransferase (ALT)
262. A nurse is assessing a client who is postoperative following a transurethral resection of
the prostate (TURP). After the nurse discontinues the client’s urinary catheter, which of the
following findings should the nurse report to the provider?
A. Pink-tinged urine
B. Report of burning upon urination
C. Stress incontinence
D. Decreased urine output
263. A nurse responds to a call from assistive personnel that a client just had a seizure and is
unconscious. Which of the following assessments is the nurse’s priority?
A. Measure the client’s vital signs
B. Perform a neurological
examination C. Check airway patency
D. Assess the client for injuries
264. 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?
A. The client requests pain medication upon arrival from surgery.
B. A chest X-ray shows consolidation in the right lower lobe.
C. Urinary output is 35 to 50 mL/hr consistently.
D. The client has slight abdominal distention
265. 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?
A. Soft blowing
B. Loud bubbling
C. Dry grating
D. Noisy wheezing
266. 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?
A. With the leg on the affected side adducted
B. With the hip externally rotated on the affected side
C. With the leg on the affected side abducted
D. With the hip flexed to 90° on the affected side
267. A nurse is teaching a client who has polycythemia vera about self-care measures.
Which of the following interventions should the nurse include?
A. "Drink at least 1 liter of fluid each day."
B. "Continuously wear support hose."
C. "Elevate your legs when sitting."
D. "Use dental floss daily."
268. 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?
A. Famotidine
B. Esomeprazole
C. Vasopressin
D. Omeprazole
269. 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?
A. Cataracts
B. Angle-closure glaucoma
C. Retinal detachment
D. Macular degeneration
270. 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?
A. Confusion
B. Arousal
C. Orientation
D.Attention
271. 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? Perioperative
A. Calcium
B. Sodium
C. Potassium
D. Phosphorous
272. A nurse is caring for a client who has pernicious anemia. Which of the following
factors should the nurse identify with this condition?
A. Iron deficiency
B. Hemolytic blood loss
C. Folic acid deficiency
D. Vitamin B12
deficiency
273. A nurse is planning care for a client who has cholelithiasis. Which of the following
interventions should the nurse include in the plan?
A. Restrict the client's fluid intake
B. Restrict the client's calcium
intake C. Decrease the client's fat
intake
D. Decrease the client's potassium intake
274. 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? Fluids &
Electrolytes Imbalance
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
275. 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?
A. Elevated blood pressure
B. Bowel sounds increased in frequency and pitch
C. Rigid abdomen
D. Emesis of undigested food
276. 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?
A. Age over 60
B. Genetic predisposition
C. Light-skinned race
D. Overexposure to sunlight
277. 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?
A. "Each client is different; we cannot predict what will happen."
B. "I can see that you are worried, but it’s too soon to predict what will happen."
C. "Acute episodes are usually followed by remissions, which can vary in duration."
D. "It’s too early to think about the future; let’s focus on the present and take each day as it
comes."
278. 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?
A. Get the human papillomavirus (HPV) immunization
B. Avoid the use of tampons on a routine basis
C. Avoid drinking alcohol
D. Get a Papanicolaou test every year starting at age 30
279. 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?
A. IgM
B. IgA
C. IgG
D. IgE
280. A nurse is preparing a client for thoracentesis. In which of the following positions
should the nurse place the client?
A. Lying flat on the affected side
B. Prone with the arms raised over the head
C. Supine with the head of the bed elevated
D. Sitting while leaning forward over the bedside table
281. 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? Fluids
& Electrolytes Imbalance
A. WBC 6,000/mm^3
B. Potassium 3.0 mEq/L
C. Clear, pale yellow drainage
D. Report of abdominal fullness
282. 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?
A. "You will need to apply a cold pack to the site 3 times a day."
B. "Your provider might ask you to walk frequently to increase circulation to the area."
C. "You will need to limit your consumption of high-protein foods."
D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."
283. 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.)
A. Tracheal deviation to the left
B. Temperature of 38.8°C (102°F)
C. Absent breath sounds on the right side
D. Neck vein distention
E. Bradypnea
284. 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?
A. Inability to remember current age
B. Inability to count backward
C. Inability to locate eyeglasses
D. Inability to recall names of family members
285. 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?
A. "Osteoarthritis is caused by autoimmune processes."
B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate."
C. "Osteoarthritis affects other organ systems."
D. "Osteoarthritis can impair a joint on a single side of the body."
286. A nurse is caring for a client who is scheduled to receive peritoneal dialysis. Which of
the following actions should the nurse take?
A. Warm the dialysate solution prior to administration
B. Cleanse the catheter site using a back and forth motion, beginning at the end of the
catheter and moving inward
C. Place the drainage bag at the level of the client's chest
D. Apply clean gloves and cleanse the client's catheter site with cold water
287. 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?
A. Zoster vaccine
B. Acyclovir
C. Amoxicillin
D. Infliximab
288. 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?
A. Coarse crackles
B. Wheezes
C. Rhonchi
D. Friction rub
289. 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?
A. Provide foods prepared according to kosher dietary law
B. Ask the kitchen to prepare grits to meet the client’s dietary need for grains
C. Determine the client's dietary preferences
D. Prepare a diet tray that includes vegetable and barley soup
290. 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 after the client
reports severe dyspnea. Which of the following findings is a clinical manifestation of acute
respiratory distress syndrome (ARDS)? Fluids & Electrolytes Imbalance
A. Tympanic temperature 38°C (100.4°F)
B. PaO2 50 mmHg
C. Rhonchi
D. Hypopnea
291. 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?
A. One solid color
B. Symmetrical shape
C. <6 mm in diameter
D. Irregular border
292. 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?
A. Avoid sun exposure.
B. Take a calcium supplement once each day if at risk for
osteoporosis. C. Walking is the preferred mode of exercise to maintain
strong bones.
D. Caffeine intake minimizes the risk of developing osteoporosis.
293. 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?
A. Sensation of heat on the surface of the cast
B. Paresthesias of the extremity
C. Pruritus of the extremity
D. Musty odor noted from cast materials
294. 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.)
A. "You will have a chest tube in place after surgery."
B. "We'll frequently help you turn, cough, and breathe deeply after surgery."
C. "You will have to remain in bed for about 2 days after the surgery."
D. "We'll give you oxygen to support your breathing if you need it."
E. "You should expect pain for the first few days after surgery.
295. A nurse is planning care for a client who is postoperative following a gastrectomy.
Which of the following strategies should the nurse include to help prevent dumping
syndrome?
A. Have the client drink plenty of water with meals
B. Eliminate simple sugars and sugar alcohols from the client's diet Sugar, honey, and sugar
alcohols (e.g. sorbitol and xylitol) increase hypertonicity and propel food through the intestines
faster than food without sweeteners.
C. Limit the client’s intake to 2 meals per day
D. Offer the client meals that are low in protein or protein-free
296. 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?
A. "I should try to drink at least 2 liters of fluid per day."
B. “I can still fly out to visit my sister in Colorado for a while."
C. "Physical activity is good for me, but I need to avoid overexertion."
D. "I can still go skiing during the cold winter months."
297. 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?
A. Battle’s sign
B. Periorbital edema
C. Dilated pupils
D. Halo sign
298. A nurse is assessing a client who has cholecystitis. Which of the following findings
should the nurse expect?
A. Blumberg's sign
B. Ascites
C. Gastrointestinal bleeding
D. Kehr's sign
299. 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?
A. Dry the ear canal with a cotton swab after swimming
B. Apply an ice pack to the ear to relieve pain
C. Instill a diluted alcohol solution into the ear after swimming
D. Irrigate the ear with cool tap water to clean
300. 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?
A. "That is your decision alone."
B. "I would if I were you."
C. "It sounds like you are unsure what to say to your partner."
D. "Your provider is required by law to notify your partner."
301. 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?
A. P waves occurring at 0.16 seconds before each QRS
complex B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. Irregular ventricular rate of 125/min with a wide QRS pattern
302. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the
following findings should the nurse expect?
A. Urine negative for ketones
B. Distended neck veins
C. Kussmaul respirations
D. Elevated blood pressure
303. 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?
A. "If the test is positive, it means you have an active case of tuberculosis."
B. "If the test is positive, you should have another tuberculin skin test in 3 weeks."
C. "You must return to the clinic to have the test read in 2 or 3 days."
D. "A nurse will use a small lancet to scratch the skin of your forearm before applying the
tuberculin substance."
304. 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?
A. Oval window
B. Auricle
C. Tympanic membrane
D. Eustachian tube
305. 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?
A. "You can expect your vision to return immediately after the procedure."
B. "You should avoid reading for 1 week."
C. "You can remove eye shields when you’re sleeping."
D. "You should not lift objects
306. 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?
A. Encourage the client to control weight
B. Inspect the client's feet once each week
C. Restrict the client's activity
D. Apply moisturizer between the client's toes
307. 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?
A. Ferrous sulfate
B. Epoetin alfa
C. Vitamin B12
D. Folic acid
308. A nurse is caring for a postmenopausal client who is concerned that she might have an
elevated risk of breast cancer. After 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.)
A. Increased breast density
B. BMI of 32
C. Having given birth to 5 children
D. Undergoing hormonal replacement therapy for 10 years
E. Having 1–2 alcoholic drinks per week
309. 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?
A. Elevate the client's feet and legs
B. Administer epinephrine
C. Infuse 0.9% sodium chloride
D. Stop the medication infusion
310. 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?
A. Monitor the client's arterial blood gas results
B. Instruct the client to perform controlled coughing
C. Teach the client how to use pursed-lip breathing
D. Place the client in an upright position
311.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?
A. Infective endocarditis
B. Pericarditis
C. Ventricular dysrhythmias
D. Pulmonary emboli
312. A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which
of the following findings should the nurse expect? Fluid & Electrolytes Imbalance
A. Flattened T waves
B. Prolonged QT intervals
C. Shortened QT intervals
D. Widened QRS complexes
313. 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?
A. "I should use powder inside my limb sock to keep it cool."
B. "I will lie on my stomach for 30 min a few times a day."
C. "I should expect some drainage with a strong odor because I had gangrene."
D. "I will keep elevating my leg on 2 pillows to keep the swelling down."
314. 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? Perioperative
A. "I'll use alcohol pads to clean my incision each day."
B. "When I'm doing my exercises, I'll include bent-leg raises."
C. "I'll use a reacher to help me pick up anything I drop on the floor."
D. "When I can walk without my walker, I can stop attending physical therapy."
315. 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?
A. Hematuria
B. Abdominal cramps
C. Weight gain
D. Polycythemia
316. 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?
A. Increased cardiac output
B. Increased pulmonary congestion
C. Decreased left atrial pressure
D. Decreased pulmonary artery pressure
317. 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?
A. "I will apply moisturizer between my toes."
B. "I will soak my feet daily."
C. "I'll be sure to wear cotton socks every day."
D. "I'll use a heating pad to warm my feet."
317. 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
B. Decrease dietary potassium
C. Restrict intake of insoluble fiber
D. Limit alcohol intake to ≤3 servings per day
318. 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?
A. Hypertension
B. Excessive thirst
C. Fever
D. Diaphoresis
319. 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?
A. Turkey on whole-wheat bread
B. Hamburger and french fries
C. Frankfurter on a white roll
D. Macaroni and cheese
320. A nurse is preparing a client for an electroencephalogram (EEG). Which of the
following pieces of information should the nurse share with the client?
A. "Expect the test to take about 3 hr."
B. "You'll begin by lying still with your eyes closed."
C. "You'll sleep for the duration of the procedure."
D. "Expect some mild electrical shocks during the test.
321. 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?
A. Relieve the client’s pain
B. Encourage the client to increase fluid intake
C. Monitor the client’s intake and output (I&O)
D. Strain the client’s urine
322. A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of
the following findings indicates that the AAA is expanding?
A. Increased BP and decreased pulse rate
B. Jugular vein distention and peripheral edema
C. Report of sudden, severe back pain
D. Report of retrosternal chest pain radiating to the left arm
323. 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?
A. Instruct visitors to maintain a distance of at least 1 m (3 ft) from the client.
B. Wash hands with antimicrobial soap after leaving the client's
room. C. Use dedicated equipment for the client.
D. Keep the doors to the client's room closed at all times.
324. 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?
A. Removing air from the pleural space
B. Creating access for irrigating the chest cavity
C. Evacuating secretions from the bronchioles and alveoli
D. Draining blood and fluid from the pleural space
325. 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.) Shock
A. Bradycardia
B. Bleeding at the venipuncture site
C. Petechiae on the chest and arms
D. Flushed, dry skin
E. Abdominal distension
327. 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?
A. Perimenopause
B. Migraine headaches
C. Diuretic use
D. Irritable bowel syndrome
328. 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?
A. Amylase
B. Potassium
C. Calcium
D. Hematocrit
329. 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?
A. "I will be able to take a tub bath in 1 week."
B. "I will change the catheter drainage bag once each week."
C. "I will use suppositories to prevent constipation."
D. "I will regain my bladder control once the catheter is removed."
330. A nurse is admitting a client who has manifestations that suggest tuberculosis. Which
of the following actions is the nurse’s priority?
A. Initiate airborne precautions
B. Administer antimicrobial therapy
C. Tell the client that the infection will be communicable for 2–3 weeks from the start of
medication therapy
D. Teach the client about the manifestations of tuberculosis
331. 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
C. Change pet litter boxes with disposable gloves
D. Consume fresh fruit and raw
vegetables E. Avoid digging in the garden
332. 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."
B. "You may return to school if you feel strong enough."
C. "It is important to wear shoes always."
D. "Clean your toothbrush weekly with isopropyl alcohol."
E. "Avoid using tampons."
333. 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?
A. "I can snack on fresh fruit."
B. "I can continue to eat lunchmeat sandwiches."
C. "I can have cottage cheese with my meals."
D. "Canned soup is a good lunch option."
334. 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?
A. Colchicine
B. Naproxen
C. Aspirin
D. Prednisone
335. 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?
A. Place the client on a soft mattress
B. Rewrap the residual limb with a bandage 3 times per day
C. Assist the client into a prone position for 20 min every 8 hr daily
D. Turn the client every 4 hr while in bed
336. 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. A client who is
postmenopausal B. A client who
is a vegetarian
C. A middle adult male
client D. A client who is
pregnant
E. A toddler who is overweight
337. 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?
A. Insert a large-bore IV catheter
B. Ensure an adequate airway
C. Obtain an accurate medication history
D. Prepare to administer an antagonist
338. A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following
findings should the nurse expect?
A. Tonic-clonic seizures
B. Report of a severe headache
C. Weakness of the lower extremities
D. Decreased level of consciousness
339. 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? Perioperative
A. Remind the client to push the button for the PCA device
B. Discuss activities the client may use to distract from the pain
C. Ask the client to describe the characteristics of the pain
D. Pause the CPM machine briefly to apply a cold pack to the client’s knee
340. 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?
A. Eliminating environmental triggers that precipitate attacks
B. Addressing the client’s perception of the disease process and what might have triggered past
attacks
C. Overviewing the client’s medication regimen
D. Explaining manifestations of respiratory infections
341. 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?
A. Cover the insertion site with a hydrocolloid dressing after removal
B. Provide pain medication immediately after removal
C. Instruct the client to perform the Valsalva maneuver during removal
D. Delegate removal of the chest tube to a licensed practical nurse (LPN)
342. 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?
A. Ensure bowel rest
B. Offer sparkling water frequently
C. Administer a stool softener
D. Offer plain warm tea frequently
343. A nurse is providing teaching to a client who has constipation. Which of the following
instructions should the nurse include?
A. Use bismuth subsalicylate regularly
B. Consume a low-fiber diet
C. Eat yogurt with live cultures
D. Use bisacodyl suppositories regularly
344. 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?
A. Reduced left-sided motor function
B. Difficulty with speech
C. Impulsive behavior
D. Neglect of the left side of the body
345. A nurse is caring for a client who has an indwelling urinary catheter. Which of the
following actions should the nurse take?
A. Place the drainage bag on the client's abdomen when transferring from a bed to cart
B. Empty the drainage bag when half-full of urine
C. Rest the drainage bag on the floor when closing the drainage spigot during emptying
D. Disconnect the drainage bag when obtaining a urine specimen
346. A home health nurse is interviewing the adult 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?
A. Attorney
B. Physical
therapy C. Respite
care
D. Occupational therapy
347. 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?
A. "Adults receive natural immunity to herpes zoster from casual exposure to children who have
had chickenpox."
B. "Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant."
C. "A client who has herpes zoster is not contagious if blisters are present on the skin."
D. "Herpes zoster is not contagious to people who have had chickenpox."
348. 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?
A. "I would never have believed I could get used to enjoying my food without salt."
B. "My blood pressure device at home usually shows about 156 over 98 or so."
C. "I make sure I take my blood pressure medicine when I have headaches."
D. "My blood pressure pills are very expensive. Could I take a cheaper medication?
349. 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?
A. The client is a hairdresser.
B. The client uses tobacco.
C. The client is over 60 years of age.
D. The client has frequent urinary tract infections (UTIs).
350. A nurse is teaching a client with chronic kidney disease about predialysis dietary
recommendations. The nurse should recommend restricting the intake of which of
the following nutrients?
A. Protein
B. Carbohydrates
C. Calcium
D. Monounsaturated fats
351. A nurse is caring for a client who has a tracheostomy with an inflated cuff in place.
Which of the following findings indicates that the nurse should suction the client's
airway secretions?
A. The client is unable to speak.
B. The client's airway secretions were last suctioned 2 hr ago.
C. The client coughs and expectorates a large mucous plug.
D. The nurse auscultates coarse crackles in the lung fields.
352. 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? Perioperative
A. Cover the client's wound with a sterile, moist dressing
B. Flex the client's knees
C. Reassure the client
D. Instruct the client to avoid coughing
353. 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?
A. Dry cough
B. Rhinitis
C. Sore throat
D. Swollen lymph nodes
354. 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?
A. "Limit flossing your teeth to once a week."
B. "Gently blow your nose if needed."
C. "Use an electric razor when shaving."
D. "Wear shoes that have a soft sole."
355. 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?
A. Allergy to egg products
B. Vomiting and diarrhea for the last 6 hr
C. Serum potassium of 3.6 mEq/L
D. Serum creatinine of 1.2 mg/dL
356. 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?
A. Remote
B. Sensory
C. Immediate
D. Recall
357. 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?
A. "Empty your ostomy pouch when it becomes half full."
B. "Place an aspirin in the ostomy pouch to eliminate odor."
C. "Change the ostomy appliance every week."
D. "Cleanse the site around the stoma with hydrogen peroxide and water."
357. 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?
A. "This medication can affect your ability to drive or handle mechanical equipment."
B. "You should avoid drinking beverages that contain caffeine with this medication."
C. "You should avoid taking antacids within 2 hours of this medication."
D. "This medication should be taken with or shortly after meals."
358. 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.)
A. Assign the client to a private room with negative-pressure airflow.
B. Add contact precautions to the client's plan of care.
C. Wear an N95 respirator when entering the client's room.
D. Ensure the client's environment provides 4 exchanges of fresh air per minute.
E. Institute protective environment precautions as soon as the client arrives on the unit.
359. 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?
A. Symmetric shape
B. Border regularity
C. Color variation within a lesion
D. Diameter >4 mm
360. A nurse is providing teaching about nutrients to a client. Which of the following
statements should the nurse include?
A. "Carbohydrates transport nutrients throughout the body."
B. "Fats prevent ketosis."
C. "Protein builds and repairs body tissue."
D. "Carbohydrates help regulate body temperature."
361. A nurse is assessing a client who is unconscious. The client 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?
A. Orthopnea
B. Cheyne-Stokes
C. Paradoxical
D. Kussmaul
362. 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?
A. Vital signs
B. Body posture
C. Level of consciousness
D. Examination of pupils
361. 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?
A. Lentils
B. Avocados
C. Cabbage
D. Broccoli
362. 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? Perioperative
A. "Keep your arm bent at the elbow."
B. "Use a pillow to prop your shoulder up close to your ear."
C. "Hold your arm against the side of your body."
D. "Position your arm with the shoulder at a 90° angle."
363. 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? Fluids &Electrolytes
Imbalance
A. Administer an analgesic to the client
B. Check the client’s electrolyte values
C. Measure the client’s weight
D. Restrict
364. 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? Perioperative
A. Prevents excessive pressure on suture lines
B. Allows gastric lavage after surgery
C. Allows early postoperative feeding
D. Facilitates obtaining gastric specimens for testing
365. 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?
A. Avoid bearing down
B. Increase caffeine intake
C. Avoid sudden movements
D. Increase sodium intake
366. 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?
A. Stair-climbing
B. Bending over
C. Sitting
D. Walking
367. 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?
A. Pitting edema
B. Areas of reddish-brown pigmentation
C. Dry, pale skin with minimal body
hair
D. Sunburned appearance with desquamation
368. 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?
A. Avoid foods containing protein
B. Drink liquids during each meal
C. Eat foods that contain simple sugars
D. Maintain a supine position after meals
369. A nurse is examining the ECG of a client who has hyperkalemia. Which of the
following ECG changes should the nurse expect?
A. Elevated ST segments
B. Absent P waves
C. Depressed ST segments
D. Varying PP intervals
369. 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?
A. Cardiogenic shock
B. Dysrhythmias
C. Heart failure
D. Pulmonary edema
370. 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?
A. A full pitcher of water is sitting on the client’s bedside table within the client's reach.
B. The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding.
C. The client is lying on the right side with a visible dependent loop in the feeding
tube. D. The head of the bed is elevated to 20°.
371. 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
E. Weight loss
372. A nurse is providing teaching about degenerative complications to the partner of a
client who has a new diagnosis of Parkinson’s disease. Which of the following
manifestations is the priority?
A. Dysphagia
B. Emotional lability
C. Impaired speech
D. Self-care dependency
373. 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? Perioperative
A. "I should have no problem climbing stairs when I get home."
B. "I'll wait about 3 weeks before I return to my usual activities."
C. "I'll use my heating pad if I feel any muscle spasms in my
back."
D. "I can go back to driving in about 2 weeks or so."
374. 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?
A. Eat with metal utensils
B. Limit coffee
C. Avoid citrus foods
D. Offer mints
375. 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.)
A. Lost vision can improve with eye drops.
B. Administer eye drops as needed for vision loss.
C. Glasses will be necessary to correct the accompanying presbyopia.
D. Driving can be dangerous due to the loss of peripheral vision.
E. Laser surgery can help reestablish the flow of aqueous humor.
376. 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? Fluids & Electrolytes Imbalance
A. Pancreas
B. Thyroid gland
C. Anterior pituitary gland
D. Parathyroid gland
377. 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?
A. Decreased white blood cell (WBC) count
B. Increased albumin level
C. Increased serum lipase level
D. Decreased blood glucose level
378. 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
B. A client who has slurred speech and exhibits anger
C. A client who reports nausea and vomiting
D. A client who is uncooperative and has uncoordinated movements
379. 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? Perioperative
A. Cut the wiring if emesis occurs
B. Consume 3 meals daily as part of a low-protein diet
C. Swab the mouth with hydrogen peroxide if wiring produces oral irritation
D. Resume a soft diet in 3 to 5 days
380. 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
B. Positive Babinski sign
C. Decreased deep-tendon reflexes
D. Ataxia
381. 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? Perioperative
A. Toes that are cold to the touch
B. Serous drainage from the pin sites
C. Blanching of the toenail beds with pressure
D. Pink tissue around the fixator insertion sites
382. 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?
A. "I will take the medication in the evening."
B. "I will drink a full glass of milk with the medication."
C. "I will take the medication at mealtime."
D. "I will sit upright after taking the medication."
383. A nurse is assessing a client who has isotonic dehydration. Which of the following
findings should the nurse expect?
A. Increased hematocrit level
B. Bradycardia
C. Distended neck veins
D. Decreased urine specific gravity
384. 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?
A. Aldolase
B. Lipase
C. Amylase
D. Lactic dehydrogenase
385. A hospice nurse is providing education about palliative care to the partner of a client
who has endstage liver cancer. Which of the following statements by the partner
indicates an understanding of teaching?
A. "I will do my best to try to get him to eat something."
B. "I will lay him flat if his breathing becomes shallow."
C. "I will use an electric blanket to keep him warm."
D. "I will continue to talk to him, even when he’s sleeping."
386. 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?
A. Ventricular dysrhythmias
B. Appearance of Q waves
C. Elevated ST segments
D. Recurrence of chest pain
387. 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?
A. Leaving soiled linens in a container in the client’s room
B. Instructing visitors to remain 2 m (6 feet) away from the client
C. Borrowing a dosimeter film badge from another nurse before entering the client's room
D. Removing an extra IV pole from the client's room to be used for another client
388. 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?
A. Vertigo
B. Epistaxis
C. Exophthalmos
D. Spondylolisthesis
389. A nurse is monitoring a client who has syndrome of inappropriate antidiuretic
hormone secretion (SIADH). Which of the following findings should the nurse
expect? Fluids & Electrolytes Imbalance
A. Polyuria
B. Dehydration
C. Hyponatremia
D. Hyperthermia
390. 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 offer to minimize the adverse effects of thrombocytopenia?
A. Monitor visitors for manifestations of infection
B. Remind the client to use an electric razor
C. Encourage frequent rest periods
D. Instruct the client to rinse mouth daily with normal saline
391. 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? Perioperative
A. Position the client supine with his legs elevated when in bed
B. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr
C. Tell the client to sit with his legs dependent after ambulating
D. Instruct the client to wear knee-length socks for 2 weeks after surgery
392. 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?
A. Decreased cerebral perfusion
B. Leakage of cerebral spinal fluid
C. Rigid skull containing cranial contents
D. Brain herniated into the brainstem
393. 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.)
A. Mix powdered skim milk into liquid milk
B. Add a raw egg to fruit smoothies
C. Add a slice of cheese to hot vegetables
D. Add honey to hot tea
E. Mix yogurt into fresh fruit
394. 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?
A. Ureter
B. Bladder
C. Renal pelvis
D. Renal tubules
395. 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?
A. Balanced skeletal traction
B. Pelvic belt
C. Pelvic sling
D. Buck's traction
396. 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?
A. HbA1c 8.5%
B. Postprandial blood glucose 190 mg/dL
C. Casual blood glucose 205 mg/dL
D. Fasting blood glucose 95 mg/dL
397. 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?
A. Foods high in vitamin C
B. Foods low in fat
C. Foods high in fiber
D. Foods low in calories
398. 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?
A. "I will ask my provider to change my contraception to an intrauterine device."
B. "I will notify my doctor before I have dental procedures."
C. "I will avoid using antiseptic mouthwash for oral care."
D. "I will wear a mask when I go out in public."
399. 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?
A. Reticulocyte count
B. Rheumatoid factor
C. Direct Coombs’ test
D. Platelet count
400. 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.)
A. Place the client in respiratory isolation
B. Monitor vital signs every 2 hr
C. Assess neurological status every 4 hr
D. Maintain the client in a modified Trendelenburg position
E. Keep the client’s room darkened
401. 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?
A. Trendelenburg
B. Prone
C. Semi-Fowler's
D. Sims'
402. 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?
A. Blood-tinged urine in the drainage bag
B. Catheter tubing coiled at the client's side
C. Client report of severe bladder spams
D. Urinary output of 20 mL/hr
403. 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?
A. Exercise
B. Pregnancy
C. Infection
D. Sunlight
404. 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."
B. "If I have any itching under the cast, I'll try to reach the area with a cotton swab."
C. "If my fingers swell, I should put a heating pad on them and rest."
D. "If I have any tingling under my cast, I'll know I need to move my fingers more."
404. 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
B. Ripe bananas
C. Steamed broccoli
D. Green leafy vegetables
405. A nurse is caring for a group of clients on a medical-surgical unit. Which of the
following disorders should the nurse identify as increasing the client’s metabolic
needs? (Select all that apply.)
A. COPD
B. Hypothyroidism
C. Cancer
D. Parkinson's disease
E. Major burns
406. 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?
A. "I'll expect a little leg swelling since I won't be that active for a while."
B. "I'll see the doctor every week to change my vena cava
filter." C. "I'll call the doctor if I see any blood in my urine or
stool."
D. "I'll have to take the blood thinner for a few more days."
407. 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 righthand side for additional information about the client)
A. Advance diet to soft
B. Perform active and passive range-of-motion (ROM) exercises twice daily
C. Apply compression garments 23 hr
daily D. Restrict visitors
408. A nurse is caring for a client who reports calf pain. What is the first action the nurse
should take?
A. Notify the provider
B. Elevate the affected extremity
C. Check the affected extremity for warmth and redness
D. Prepare to administer unfractionated heparin
409. 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?
A. Eggs
B. Squash
C. Kale
D. Tofu
410. A 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?
A. Output equal to the instilled irrigant
B. Client report of bladder spasms
C. Viscous urinary output with
clots
D. Client report of a strong urge to urinate
411. 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?
A. Use an alcohol-based soap to clean lesions
B. Wear a condom during sexual activity when lesions are present
C. Take a sitz bath once per day
D. Apply a warm compress to the lesions
412. 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?
A. "Request a provider's prescription when traveling to alert airport security."
B. "Stand at least 3 feet away while using a microwave."
C. "Keep your cell phone 6 inches away from your pacemaker when making a call."
D. "Avoid showering for the first 2 weeks following surgery."
413. 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?
A. "I drink at least 2 L of fluid per day."
B. "I prefer taking tub baths to showering."
C. "I urinate before and after sexual relations."
D. "I wipe from front to back after urinating."
414. 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?
A. Move the evening intermediate-acting insulin dose to 90 min before dinner
B. Increase the client's morning caloric intake
C. Omit the client’s evening snack
D. Monitor the client's nighttime blood glucose levels
414. 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?
A. Magnesium 2.0 mEq/L
B. Hgb 6.5 g/dL
C. WBC count 9.6/mm3
D. Creatinine 0.8 mg/dL
415. A nurse is providing discharge teaching to a client who has emphysema. Which of the
following instructions should the nurse include?
A. "Be sure to take cough medicine to avoid coughing."
B. "Try to drink at least 2 to 3 liters of fluid per day."
C. "Try to reduce your smoking to 2 cigarettes per day."
D. "Be sure to eat 3 full meals each day."
416. 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?
A. Misoprostol
B. Dantrolene
C. Celecoxib
D. Colchicine
417. A nurse is presenting an in-service training session about nutrition. How many of the
amino acids must be obtained from dietary intake?
A. 6
B. 9
C. 11
D. 15
418. 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?
A. Hallucinations
B. Pruritus
C. Hand and foot syndrome
D. Tinnitus
419. 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?
A. Administer nifedipine
B. Place the client in a highFowler's position
C. Check for urinary retention
D. Check for a fecal impaction
420. 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?
A. Percuss the abdomen for tympanic sounds
B. Inspect the contour of the abdominal wall
C. Instruct the client to report increased abdominal discomfort
D. Take serial measurements of the abdomen with a tape
measure
421. 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?
A. Red tag
B. Yellow tag
C. Green tag
D. Black tag
422. 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?
A. "Wear nylon socks with shoes."
B. "Wear flip flops instead of going barefoot when outside."
C. "Apply moisturizing cream between your toes."
D. "Wash your feet daily using lukewarm water and soap
423. 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?
A. "The risk of renal toxicity is lessened when a combination of chemotherapy medications is
used."
B. "The chemotherapy medications act at different stages of cell division so more tumor cells are
destroyed."
C. "The use of more chemotherapy medications will shorten the time you have to be in
treatment."
D. "The combination of chemotherapy medications will eliminate the potential for bone marrow
suppression."
424. 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?
A. Canned soup
B. Grilled fish
C. Pastrami
D. Peanut butter
425. 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?
A. Desmopressin
B. Hydrocortisone
C. Dopamine
D. Furosemide
426. 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?
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg
427. A nurse is reviewing the laboratory findings of a client who has protein-calorie
malnutrition. Which of the following findings should the nurse expect?
A. Decreased albumin
B. Elevated hemoglobin
C. Elevated lymphocytes
D. Decreased cortisol
428. 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?
A. "You can suck on popsicles to numb your mouth."
B. "Season food with spices instead of salt."
C. "Avoid the use of a straw to drink liquids."
D. "Eat foods at hot temperatures."
429. 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.)
A. Take allopurinol as prescribed
B. Exercise several times a week
C. Limit intake of foods high in purine
D. Decrease daily fluid intake
E. Avoid citrus juices
430. 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?
A. Beef liver
B. Oranges
C. Turnips
D. Whole milk
431. 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."
B. "You'll have the traction in place for a week or so."
C. "The traction will help decrease muscle spasms."
D. "The weights act as a pulling force to keep your leg and hip still."
E. "We have to make sure the weights are just barely touching the floor."
432. 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?
A. "I will not need to have a urinary catheter following this procedure.”
B. "I will expect my urine to be cloudy after having this procedure."
C. "At least I won’t have leakage of urine after having this
procedure." D. "I will feel the urge to urinate following this
procedure."
433. 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? Perioperative
A. Rest the arm on the affected side on the bed when the client is sleeping
B. Instruct the client to keep the affected arm flexed when ambulating
C. Begin exercises with the client 1 day after the procedure
D. Maintain the client on bed rest for 2 days after the procedure
434. A nurse is teaching a client who is preoperative for a cystoscopy. Which of the
following statements should the nurse make? Perioperative
A. "You will need to keep the sutures clean after this procedure."
B. "You will be placed on your left side for this procedure."
C. "Expect to be on bed rest for 24 hr after this procedure."
D. "Expect to have pink-tinged urine after this procedure."
435. 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?
A. Venous stasis
B. Thrombocytopenia
C. Inflammation
D. Tissue
hypoxia
436. 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?
A. "I'll inhale slowly through pursed lips to help me breathe better."
B. "When I do my pursed-lip breathing, I'll lie down first."
C. "When I breathe out through pursed lips, my airways don't collapse between breaths."
D. "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises."
437. 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?
A. Dyspnea
B. Pain in the shoulder and left arm
C. Substernal chest pain
D. Palpitations
438. A nurse is preparing a client for a bronchoscopy. Which of the following actions should
the nurse take? (Select all that apply.)
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.
C. Offer the client sips of clear liquids until 1 hr before the test.
D. Obtain a pre-procedural sputum specimen.
E. Instruct the client to keep his neck in a neutral position.
439. 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?
A. "I will wear a continuous movement machine on my knee for 24 hr a day."
B. "I should avoid taking NSAID medications for pain after
surgery." C. "I should wear elastic stockings on both of my legs."
D. "I will begin exercising my legs the day after surgery."
440. 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?
A. Irrigate the tube with normal saline solution
B. Provide oral hygiene
C. Clamp the tube for 30 min
D. Increase the amount of suction
441. 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?
A. Increased saliva production
B. Decreased sense of taste
C. Increased sense of smell
D. Decreased chest wall rigidity
442. 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?
A. Monitor urinary output
B. Administer an osmotic diuretic
C. Provide supplemental oxygen
D. Initiate seizure precautions
443. 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 postprocedure plan of care?
A. Instruct the client about a longterm cardiac conditioning program
B. Administer scheduled doses of acetaminophen
C. Check for peak laboratory markers of myocardial
damage D. Monitor for bleeding
444. A nurse is teaching a client who has chronic kidney disease (CKD). Which of the
following instructions should the nurse include?
A. Limit fluid intake
B. Limit caloric intake
C. Eat a diet high in phosphorus
D. Eat a diet high in protein
445. 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
C. Hold the halo device when turning the client
D. Check the client's skin to ensure the jacket is not applying pressure
E. Adjust the screws holding the client's halo device in place to ensure a proper fit
446. 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?
A. Use enemas to treat constipation caused by daily medications
B. Take a hot bath when muscles ache
C. Eat a low-calorie diet
D. Set an alarm to ensure medication dosages are taken on time
447. 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? Fluids & Electrolytes Imbalance
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
448. 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?
A. Pallor
B. Jaundice
C. Absence of hair on the legs
D. Poor nailbed capillary refill
449. 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?
A. Hyperextend the client’s neck
B. Prepare for a tracheostomy
C. Lower the head of the bed
D. Administer morphine
450. 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?
A. Eat crackers and yogurt regularly
B. Chew minty gum throughout the day
C. Drink orange juice every day
D. Put an aspirin in the pouch
451. 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.)
A. Hemodialysis
B. Biopsy
C. Immunosuppression
D. Balloon angioplasty
E. Surgical repair
452. 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.)
A. Hardening along the blood vessel
B. Absence of a peripheral pulse
C. Tenderness in the calf
D. Cool skin on the leg
E. Increased leg circumference
453. 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?
A. "I will contact the social worker so you can discuss career alternatives."
B. "Have you thought about discussing the possibility of a part-time assignment with
your employer?"
C. "Why don't you ask your employer to relieve you of some work until you are stronger?"
D. "Perhaps we should review your coping mechanisms and talk about other alternatives."
454. 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?
A. Shakiness
B. Urinary frequency
C. Dry mucous membranes
D. Excess thirst
455. 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?
A. "I need to protect the area from sunlight."
B. "I’m going to apply a heating pad to the area after each treatment."
C. "I’ll massage the area once per day."
D. "I’ll wash off the markings after each therapy treatment."
456. 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.)
A. Assess and document the client's vital signs
B. Restart the IV with a 22-gauge needle
C. Verify with another nurse the blood type and Rh of the packed RBCs
D. Hang a bag of lactated Ringer's IV
solution E. Change IV tubing to a set that has
a filter
457. 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?
A. Give the client a written record of his BP to bring to his provider
B. Encourage the client to go to the nearest emergency department
C. Instruct the client to follow-up with a provider within 6 months
D. Explain to the client that he is not at risk unless he has manifestations of hypertension
458. 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?
A. "I can keep my dentures in during the procedure."
B. "I am allowed only clear liquids prior to the procedure."
C. "A tissue sample might be obtained during the procedure."
D. "A signed consent form is not required for this procedure."
459. 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?
A. Lymph nodes
B. Maxillary sinuses
C. Intercostal spaces
D. Salivary glands
460. A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the
following manifestations should the nurse expect?
A. Midsternal chest pain
B. Thrill
C. Pitting edema in lower
extremities D. Lower back
discomfort
461. 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? Perioperative
A. Instruct the client to attempt to void around the indwelling urinary catheter
B. Increase the rate of irrigation fluid instillation
C. Irrigate the indwelling urinary catheter with a syringe
D. Prepare to administer a diuretic
462. 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?
A. Creatinine clearance
B. Vanillylmandelic acid (VMA)
C. 17-hydroxycorticosteroids (17- OHCS)
D. Protein
463. 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?
A. Total lung capacity
B. Vital lung capacity
C. Functional residual capacity
D. Residual volume
464. A nurse is teaching a client who has hyperthyroidism about managing this disorder.
Which of the following recommendations should the nurse include?
A. Reduce total hours of sleep
B. Keep the immediate environment warm
C. Increase caloric intake with meals
D. Gradually increase activity
465. 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?
A. "I will need to eliminate sweet desserts from my diet."
B. "I should avoid using sucralose in my coffee."
C. "I should consume alcohol between meals in moderation."
D. "I should replace white bread with whole-grain bread."
466. 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?
A. Continue to monitor for manifestations of a transfusion reaction
B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution
C. Continue the transfusion and repeat the type and crossmatch
D. Prepare to administer a dose of diphenhydramine IV
467. A nurse is caring for a client who has testicular cancer and is experiencing peripheral
neuropathy as an adverse effect of chemotherapy. Which of the following client
manifestations is an expected finding of peripheral neuropathy?
A. Thinning of the scalp hair
B. Tingling of the hands and feet
C. Reduced ability to concentrate
D. Sores in mucous membranes
468. A nurse is teaching a client about the prostate-specific antigen (PSA) test. Which of the
following directions should the nurse provide?
A. "You should fast for 8 hours after the PSA test."
B. "Annual PSA screening should begin at age 40."
C. "Expected PSA values will decrease as you get older."
D. "You should not ejaculate for 24 hours prior to the PSA test."
469. 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?
A. Blood urea nitrogen (BUN)
B. Blood glucose
C. Urine ketones
D. Specific gravity
470. 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?
A. Visualizing the eardrum before irrigating
B. Instilling 50 mL of fluid with each irrigation
C. Using firm, continuous pressure while irrigating
D. Warming the irrigation fluid to at least 37°C (98°F)
471. 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?
A. Cholesterol level 195 mg/dL
B. Elevated HDL
levels C. Elevated LDL
levels
D. Triglyceride level 135 mg
472. 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? Perioperative
A. "I will sleep on the affected side."
B. "I will avoid bending over."
C. "I will restrict caffeine in my diet."
D. "I will take aspirin to relieve my pain."
473. 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?
A. Bradycardia
B. Paresthesia
C. Hypertension
D. Low back pain
474. A nurse is updating the plan of care for a client who has dumping syndrome. Which of
the following instructions should the nurse include?
A. Consume beverages with meals
B. Eat 3 large meals per day
C. Include high-fiber foods in the diet
D. Eat a source of protein with each meal
475. A nurse is teaching a client who has a spinal cord injury to perform intermittent
urinary self-catheterization at home after discharge. Which of the following
statements indicates that the client understands the procedure?
A. "I’ll drink less water so I don’t have to catheterize myself too often."
B. "I must use sterile technique for each of the catheterizations."
C. "I should stop the catheterization when I have removed 150 mL of
urine." D. "I will perform intermittent self-catheterization every 2 to 3 hr."
476. 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?
A. Decreased intake of phosphate-containing foods
B. Spending several hours in the sun daily
C. Increased estrogen levels
D. History of anorexia nervosa
477. 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?
A. Empty the collection pouch when it is 2/3 full
B. Expect urine outflow into pouch to begin 1 to 2 days after surgery
C. Change the collection pouch in the early morning
D. Place an aspirin in the collection pouch to control odor
478. 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?
A. Potassium 2.8 mEq/L
B. Digoxin level 0.7 ng/mL
C. Hemoglobin 9.8 g/dL
D. Calcium 8.0 mg
479. 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.) A. "You'll have to lie flat for several hours after the procedure."
B. "You'll receive medication to relax you before the procedure."
C. "You'll feel a cool sensation after the injection of the dye."
D. "You'll have to keep your leg straight after the procedure."
E. "You'll have to limit the amount of fluid you drink for the first 24 hr."
480. 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?
A. "I will not drink coffee 4 hr prior to my test."
B. "I can eat a light meal 1 hr prior to the test."
C. "I can have a cigarette up to 30 min prior to the test."
D. "I will take my heart medication on the day of the test."
481. A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the
following characteristics places the infant at a higher risk of electrolyte imbalances
compared to an adult client? Fluids & Electrolytes Imbalance
A. Less extracellular fluid
B. Reduced body surface area
C. Longer intestinal tract
D. Decreased rate of metabolism
482. A nurse in a clinic is assessing a client who is at 13 weeks of gestation and has
hyperemesis gravidarum. Which of the following findings should the nurse identify as
the priority?
A. Blood pressure 90/52 mmHg
B. Ketones 2+
C. Specific gravity 1.035
D. Sodium 130 mEq/L
483. 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?
A. Change the tubing every 12 hr
B. Check the client's blood glucose every 8 hr
C. Apply a new dressing to the IV site every 76
hr D. Weigh the client daily
484. A nurse is caring for a client who has chronic glomerulonephritis with oliguria. For
which of the following electrolyte imbalances should the nurse monitor?
A. Hypercalcemia
B. Hyperkalemia
C. Hypomagnesemia
D. Hypophosphatemia
485. 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?
A. Children
B. Older adults
C. Women who are pregnant
D. Middle-aged men
486. 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 after age 60?
A. High-protein diet
B. Insufficient calcium intake
C. Declining muscle mass
D. Weakened immune responses
487. 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? Fluids & Electrolytes Imbalance
A. Calcium
B. Phosphorous
C. Potassium
D. Sodium
488. 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?
A. Sliced bananas
B. Baked potato
C. Turkey and cheese sandwich
D. Plain yogurt with peaches
489. 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? Fluids & Electrolytes Imbalance
A. "I should use salt sparingly while cooking."
B. "I can have yogurt as a dessert."
C. "I should use baking soda when I bake."
D. "I should use canned vegetables instead of frozen."
490. 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? Perioperative/ Fluids & Electrolytes Imbalance
A. Blood pressure 160/90 mmHg
B. Creatinine 0.8 mg/dL
C. Sodium 137 mg/dL
D. Urinary output 100 mL/hr
491. 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? Fluids & Electrolytes Imbalance
A. Hemoglobin 10 g/dL
B. Sodium 132 mEq/L This laboratory finding is below the expected reference range. The
nurse should anticipate a low sodium level because sodium is trapped in interstitial space.
C. Albumin 3.6 g/dL
D. Potassium 4.0 mEq/dL
492. 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? Fluids &
Electrolytes Imbalance
A. Potassium and magnesium
B. Calcium and bicarbonate
C. Hemoglobin and hematocrit
D. Arterial pH and PaCO2
493. A nurse in the emergency department is caring for a client who has abdominal trauma.
Which of the following assessment findings should the nurse identify as an indication of
hypovolemic shock? Shock
A. Warm, dry skin
B. Increased urinary output
C. Tachycardia
D. Bradypnea
494. A nurse is caring for a client with dehydration who has developed hypovolemic shock.
Which of the following laboratory values should the nurse expect for this client? Shock
A. BUN 18 mg/dL
B. Capillary refill 1.5 sec
C. Hct 55%
D. Urine specific gravity 1.001
495. A nurse is caring for a client who is 48 hr postoperative following a small bowel
resection. The client reports gas pains in the periumbilical area. The nurse should plan
care based on which of the following factors contributing to this postoperative
complication? Perioperative
A. Blood loss
B. NPO status after surgery
C. Nasogastric tube suctioning
D. Impaired peristalsis of the intestines
496. A nurse is planning care for a toddler who has acute gastroenteritis and was recently
admitted. Which of the following should the nurse plan to provide for the child? Fluids
& Electrolytes Imbalance
A. Oral rehydration solution
B. Bananas or applesauce
C. Chicken or beef broth
D. Hypertonic IV solution
497. A nurse is reviewing the laboratory data of a client who has a fever and watery
diarrhea. Which of the following results should the nurse report to the provider? Fluids
& Electrolytes Imbalance
A. Calcium 9.5 mg/dL
B. Sodium 150 mEq/L A sodium level of 150 mEq/L is greater than the expected reference
range of 135 to 145 mEq/L. This client is at risk for dehydration due to diarrhea. Hypernatremia
is a manifestation of dehydration, and the nurse should report this finding to the provider.
C. Potassium 4 mEq/L
D. Magnesium 1.5 mEq/L
498. A nurse is monitoring a client's laboratory results. Which of the following results
should the nurse report to the provider? Fluids & Electrolytes Imbalance
A. Sodium 140 mEq/L
B. Potassium 3.0 mEq/L
C. Chloride 100 mEq/L
D. Magnesium 2.0 mEq/L
499. A nurse is caring for a client who is postoperative following a vaginal hysterectomy
and asks for a drink. Her postoperative diet prescription states “clear liquids; advance
diet as tolerated.” Which of the following responses should the nurse make?
A. "Lunch trays should be here within the hour."
B. "I am going to listen to your abdomen."
C. "I'll get you some water to drink."
D. "Let’s wait a bit so you don’t feel sick."
500. A nurse is teaching a client who is postoperative about the importance of turning,
coughing, and breathing deeply. Which of the following statements should the nurse
identify as an indication that the client understands the instructions?
A. "If I do this often, I won't experience muscle wasting."
B. "If I do this often, I won't get pneumonia."
C. "If I do this often, I won't get constipation."
D. "If I do this often, I won't have a fast heartbeat."
501. A nurse is assessing a client who is postoperative. Which of the following findings
should the nurse identify as an indication that the client is experiencing pain?
Perioperative
A. Diarrhea
B. Pupillary constriction
C. Flushing
D. Grimacing
502. 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? Perioperative
A. "You'll receive heavy sedation, so you might even sleep during the procedure."
B. "You'll have to lie on your back throughout the procedure."
C. "You'll feel a painful, pulling sensation when the doctor withdraws the marrow."
D. "Expect the procedure to take about an hour."
503. 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? Perioperative
A. "I'm not going to be able to cough for a while after the surgery."
B. "After I recover from the anesthesia, I'll be able to eat regular food again."
C. "After the surgery, my voice will gradually return but might be weak."
D. "I understand that I will have a permanent tracheostomy after the surgery."
504. A nurse is teaching a group of unit nurses about the experiences of clients who are
having surgery. In which phase of care is the client transferred to the surgical suite
table before being transferred to the PACU? Perioperative
A. Preoperative
B. Postoperative
C. Intraoperative
D. Admission
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| Version | 2022 |
| Category | ATI |
| Included files | |
| Authors | vaites |
| Pages | 77 |
| Tags | ATI COMPREHENSIVE PREDICTOR REVISION GUIDE 2021 500+ Correct Questions & Answers |
| Comments | 0 |
| Sales | 0 |
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