1. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the

following instructions should the nurse include?

a. Flex the foot every hour when awake.

b. Place a pillow under the knee when lying in bed.

c. Lower the leg when sitting in a chair.

d. Ensure the leg is abducted when resting in bed.

The nurse should instruct the client to flex the foot every hour to reduce the risk for

thromboembolism and promote venous return.

2. A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of

the following findings is an indication of lung re-expansion?

a. The chest tube is draining serosanguineous fluid at 65 mL/hr.

b. The client tolerates gentle milking of the tubing.

c. Bubbling in the water seal chamber has ceased.

d. There is tidaling in the water seal chamber.

Bubbling in the water seal chamber ceases when the lung re-expands.

3. A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation.

Which of the following values should the nurse identify as a desired outcome for this therapy?

a. INR 1

b. INR 2.5

c. aPTT 45 seconds

d. aPTT 90 seconds

Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or

pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must

be monitored to ensure the anticoagulation is within the therapeutic range and prevent

hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation).

An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial

fibrillation.

4. A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater

trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?

a. Clean the wound daily with an antiseptic.

b. Use a donut-shaped pillow when sitting in a chair.

c. Change position every hour.

d. Massage the area two times daily.

Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse should

also instruct the client to limit the angle of the hips when in a lateral position to no more than

30°. This positioning prevents direct pressure on the trochanter.

5. A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is

the nurse’s priority to report to the provider?

a. Temperature 37.2° C (99° F)

b. Blood pressure 100/70 mm Hg

c. Weight loss

d. Restlessness

Using the urgent vs. nonurgent approach to client care, the nurse should determine that the

priority finding to report to the provider is restlessness, which can be an indication the client is

experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal

of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other

manifestations include nausea, vomiting, fatigue, and headache.

6. A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is

unable to void on the bedpan. Which of the following actions should the nurse take first?

a. Document the client's intake and output.

b. Scan the bladder with a portable ultrasound.

c. Pour warm water over the client's perineum.

d. Perform a straight catheterization.

The first action the nurse should take using the nursing process is to assess the client.

Scanning the bladder with a portable ultrasound device will determine the amount of urine in the

bladder.

7. A nurse is planning a health promotional presentation for a group of African American clients at a

community center. Which of the following disorders presents the greatest risk to this group of clients?

a. Multiple sclerosis

b. Skin cancer

c. Urolithiasis

d. Hypertension

When using the safety/risk reduction approach to client care, the nurse should determine that

the disorder with the greatest risk for this group of clients is hypertension. The prevalence of

hypertension is highest among African American clients, followed by Caucasian clients, and

then Hispanic clients.

8. A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse

that the client’s condition is improving?

a. Potassium 3.5 mEq/L

b. pH 7.28

c. Glucose 272 mg/dL

d. HCO3- 14 mEq/L

A glucose reading less than 300 mg/dL indicates improvement in the client's status.

9. A nurse is caring for a client following extubation of an endotracheal tube 10 minutes ago. Which of the

following findings should the nurse report to the provider immediately?

a. Stridor

b. Oral secretions

c. Hoarseness

d. Sore throat

Using the urgent vs. nonurgent approach to client care, the nurse should determine that the

priority finding is stridor. Stridor can indicate a narrowing airway or possible obstruction caused

by edema or laryngeal spasms. The nurse should report the finding immediately and implement

an intervention.

10. A nurse is caring for a client who had a nephrostomy tube inserted 12 hrs ago. Which of the following

findings should the nurse report to the provider?

a. The client's urinary output has increased.

b. The client reports back pain.

c. The client's urine color is red tinged.

d. The client's BUN is 18 mg/dL.

The nurse should notify the provider if the client reports back pain, which can indicate that the

nephrostomy tube is dislodged or clogged.

11. A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission

precautions should the nurse initiate?

a. Airborne

b. Droplet

c. Contact

d. Protective environment

Airborne precautions are required for clients who have infections due to micro-organisms that

can remain suspended in air for lengthy periods of time, such as tuberculosis, measles,

varicella, and disseminated varicella zoster.

12. A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the

following interventions should the nurse include in the plan of care?

a. Keep a lead-lined container in the client's room.

b. Limit each visitor to 1 hr per day.

c. Place a dosimeter badge on the client.

d. Remove soiled linens from the client's room each day.

The nurse should keep a lead-lined container and forceps in the client's room in case of

accidental dislodgement of the implant.

13. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following

findings is the nurse’s priority?

a. Moderate serosanguinous drainage on the dressing

b. Calcium 9.5 mg/dL

c. Temperature 38.9° C (102° F)

d. Decreased bowel sounds

When using the urgent vs. nonurgent approach to client care, the nurse should determine that

the priority finding is an elevated temperature. An elevated temperature is a manifestation of

excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The

nurse should report this finding immediately to the provider because it can lead to seizures and

coma.

14. A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of

the following statements by the client indicates understanding of the teaching?

a. "I will eat a salad at least once each day to increase my intake of vitamin K."

b. "I can work in my flower garden as long as I wear gardening gloves to cover my skin."

c. "I will no longer floss my teeth after brushing my teeth."

d. "I can sip on a glass of juice for at least 2 hours before I should discard it."

The nurse should instruct the client to avoid flossing teeth to prevent gum inflammation, which

could create the opportunity for infection.

15. A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil.

Which of the following information should the nurse include in the teaching?

a. "Take this medication on an empty stomach."

b. "Eczema is an immediate expected adverse effect of this medication."

c. "Increase fiber intake to avoid constipation."

d. "Monitor your blood pressure monthly."

The nurse should instruct the client that constipation is an adverse effect of verapamil. The

client should increase fiber intake to promote regular bowel function.

16. A nurse is providing education to a client who is at risk for osteoporosis. Which of the following

instructions should the nurse include?

a. Begin taking glucosamine supplements.

b. Walk for 30 min four times per week.

c. Jog for 15 min two times per week.

d. Avoid taking over-the-counter calcium supplements.

Weight-bearing exercises promote bone mass. Therefore, walking can help the client prevent

osteoporosis.

17. A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone

replacement therapy. For which of the following adverse effects should the nurse instruct the client to

notify the provider? (Select all that apply.)

a. Night sweats

b. Calf pain

c. Vaginal dryness

d. Numbness in the arms

e. Intense headache

Calf pain is an indication of deep-vein thrombosis. The client should report this finding to the

provider immediately. Numbness in the arms can indicate a cerebrovascular accident, which is

an adverse effect of hormone replacement therapy. The client should report this finding to the

provider immediately. An intense headache can indicate a cerebrovascular accident, which is an

adverse effect of hormone replacement therapy. The client should report this finding to the

provider immediately.

18. A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should

identify the need to revise the plan for which of the following clients?

a. A client who is taking potassium supplements, has a potassium level of 3.2 mEq/L, and reports

constipation

b. A client who has Alzheimer's Disease (AD), has a room near the nurse's station, and is agitated

c. A client who is postoperative following abdominal surgery and reports feeling that something

"popped" when they coughed

d. A client who has a conductive hearing loss, speaks softly, and is scheduled for a cerumen

removal

A feeling of something popping or loosening with coughing might indicate a wound dehiscence.

This client will need to have revisions to the plan of care, which can include management of the

dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one

occurs.

19. A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the

nurse expect?

a. Constipation

b. Insomnia

c. Tachycardia

d. Diaphoresis

A client who has hypothyroidism can experience constipation due to the decrease in the client's

metabolism, resulting in slow motility of the gastrointestinal tract. The nurse should instruct the

client to increase fiber and fluid intake to reduce the risk for constipation.

20. A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the

following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)?

a. Temperature 38.9° C (102° F)

b. Systolic blood pressure 70 mm Hg

c. Heart rate 52/min

d. Respiratory rate 8/min

A client who is experiencing AD will exhibit multiple manifestations, including bradycardia,

severe headache, and flushing.

21. A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse

take?

a. Flush the line before administering antibiotics.

b. Position the client in Trendelenburg to obtain measurements.

c. Have the client bear down when readings are obtained.

d. Place a pressure bag around the flush solution.

The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride

because the pressure from an artery is greater than that of the line.

22. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for

gentamicin. Which of the following findings from the client’s medical record should indicate to the nurse

the need to withhold the medication and notify the provider?

a. WBC count 13,700/mm3

b. Temperature 38.4° C (101.1° F)

c. Blood pressure 155/98 mm Hg

d. Serum creatinine 2.1 mg/dL

A client who has an elevated serum creatinine level should not receive gentamicin because the

medication is nephrotoxic.

23. A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral

solution 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest

whole number. Use a leading zero if it applies. Do not use a trailing zero.)

a. 24 mL PO

24. A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the

following statements should the nurse make?

a. "You should accept your body image change before discharge."

b. "It is important for you to look at the incisional site when the dressings are removed."

c. "I will refer you to community resources that can provide support."

d. "The scar will remain red and raised for many years after surgery."

The nurse should provide the client with support resources, including community programs, to

assist the client with acceptance of body image changes.

25. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following

interventions should the nurse include in the plan?

a. Encourage the client to take deep breaths after the procedure.

b. Assist the client to hold their arms up during the procedure.

c. Instruct the client to remain NPO after midnight prior to the procedure.

d. Keep the client on bed rest for 8 hr following the procedure.

After a thoracentesis, the client should deep breathe to re-expand the lung.

26. A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving

radiation therapy. Which of the following statements by the client indicates an understanding of the

teaching?

a. "I will wear a badge to measure how much radiation I am receiving."

b. "I will remove the markings on my skin after each radiation treatment."

c. "I will avoid direct exposure to the sun."

d. "I will rinse my mouth with a commercial mouthwash."

The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after

completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage.

27. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following

nonpharmacological interventions should the nurse suggest to the client to reduce pain?

a. Increase intake of foods containing calcium.

b. Alternate application of heat and cold to the affected joints.

c. Keep the affected extremities elevated.

d. Limit movement of the affected joints.

The nurse should instruct the client to alternate heat and cold applications to decrease joint

inflammation and pain. The application of cold can relieve joint swelling and the application of

heat can decrease joint stiffness and pain.

28. A nurse is assessing a client’s hydration status. Which of the following findings indicates fluid volume

overload?

a. Warm, moist skin

b. Distended neck veins

c. Dark amber, odiferous urine

d. Orthostatic hypotension

The nurse should identify distended neck and hand veins as indicators of fluid volume overload.

29. A nurse is planning care for a client who is having modified radical mastectomy of the right breast.

Which of the following interventions should the nurse include in the plan of care?

a. Instruct the client that the drain will be removed when there is 25 mL of output or less over a

24-hr period.

b. Assist the client to start arm exercises 48 hr after surgery.

c. Maintain the right arm in an extended position at the client's side when in bed.

d. Place the client in a supine position for the first 24 hr after surgery.

The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after

surgery and will be removed when there is 25 mL of output or less in a 24-hr period.

30. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse

should recognize which of the following complications is associated with long-term mechanical

ventilation?

a. Elevated blood pressure

b. Dehydration

c. Stress ulcers

d. Hypernatremia

Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by

elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic

infection and require pharmacological treatment.

31. A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the

nurse expect?

a. Low urine specific gravity

b. Hypertension

c. Bounding peripheral pulses

d. Hyperglycemia

An expected finding for a client who has diabetes insipidus is a urine specific gravity between

1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration

in antidiuretic hormone release or the kidneys' responsiveness to the hormone.

32. A nurse is assessing for compartment syndrome in a client who has a short leg cast. WHich of the

following findings should the nurse identify as a manifestation of this condition?

a. Bounding pedal pulse

b. Capillary refill less than 2 seconds

c. Pain that increases with passive movement

d. Areas of warmth on the cast

The nurse should identify that a client who has compartment syndrome experiences pain that

increases with passive movement. Compartment syndrome results from a decrease in blood

flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is

too tight.

33. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate

(TURP) and notes clots in the client’s indwelling urinary catheter and a decrease in urinary output.

Which of the following actions should the nurse take?

a. Remove the client's indwelling urinary catheter.

b. Irrigate the indwelling urinary catheter.

c. Clamp the indwelling urinary catheter.

d. Apply traction to the indwelling urinary catheter.

The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the

urine flow.

34. A nurse is assessing a client while suctioning the client’s tracheostomy tube. Which of the following

findings should indicate to the nurse the client is experiencing hypoxia?

a. The client starts to cough.

b. The client's heart rate increases.

c. The client is diaphoretic.

d. The client's blood pressure decreases.

Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the

nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen.

The nurse should instruct the client to take three or four deep breaths prior to suctioning to

reduce the risk for hypoxia.

35. A nurse is providing discharge teaching to a client who is postoperative following a modified radical

mastectomy. Which of the following instructions should the nurse include?

a. Flex the affected arm when ambulating.

b. Numbness can occur along the inside of the affected arm.

c. Begin active range-of-motion exercises 1 day after surgery.

d. Dress in clothing that fits snugly.

The nurse should instruct the client that numbness can occur near the incision and along the

inside of the affected arm due to nerve injury.

36. A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hours ago. The

nurse should identify which of the following findings as an indication of a myocardial infarction (MI)?

a. Creatine kinase (CK-MB) 85 units/L

b. High-density lipoprotein (HDL) 65 mg/dL

c. Alanine aminotransferase (ALT) 28 units/L

d. Troponin I 8 ng/mL

Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle

contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The

client's laboratory value is above the expected reference range for troponin I, indicating an MI

has occurred.

37. A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of

the lower extremity. Which of the following instructions should the nurse include in the plan of care?

a. Secure the straps firmly around the boot.

b. Remove the device before showering.

c. Use crutches with rubber tips.

d. Adjust the screws to maintain alignment.

Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls.

38. A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following

findings should the nurse identify as the priority?

a. Report of sore throat

b. Report of memory loss

c. Alopecia

d. Mucositis

When using the urgent vs. nonurgent approach to client care, the nurse should determine that

the priority finding is a report of a sore throat, which could be a manifestation of an infection.

The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead

to sepsis.

39. A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron

supplement. Which of the following statements by the client indicates an understanding of the

teaching?

a. "I will take my iron with a glass of milk."

b. "I will take an antacid with my iron."

c. "I will limit my intake of red meat."

d. "I will eat more high-fiber foods."

The client should eat high-fiber foods to help prevent constipation, which is a common adverse

effect of oral iron supplements.

40. A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates

a hemolytic transfusion reaction?

a. Anorexia and jaundice

b. Bronchospasm and urticaria

c. Hypertension and bounding pulse

d. Low back pain and apprehension

Hemolytic transfusion reactions result from the infusion of incompatible blood products and

create a systemic inflammatory response. Manifestations include low back pain, hypotension,

tachycardia, and apprehension.

41. A nurse is providing discharge teaching to a client who is self-administering heparin subcutaneously.

Which of the following statements by the client indicates an understanding of the teaching?

a. "I can expect to have blood in my urine during the first week of injections."

b. "I will floss my teeth after each meal."

c. "I will gently massage the site after I inject my medication."

d. "I will use an electric razor to shave."

Heparin is an anticoagulant that places the client at the risk for bleeding. Therefore, the nurse

should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the

skin.

42. A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that

which of the following medications can increase their risk for developing osteoporosis?

a. Conjugated estrogens

b. Enalapril

c. Prednisone

d. Colchicine

The nurse should instruct the client that prednisone can increase the risk for developing

osteoporosis due to suppression of bone formation, and an increase in bone resorption by

osteoclasts. Prednisone can also reduce intestinal absorption of calcium.

43. A nurse is teaching a group of newly licensed nurses about pain management for older adult clients.

Which of the following statements by a newly licensed nurse indicates an understanding of the

teaching?

a. "Older adult clients might require up to 6 grams of acetaminophen over 24 hours for effective

pain control."

b. "Ibuprofen can cause gastrointestinal bleeding in older adult clients."

c. "Meperidine is the medication of choice for older adult clients experiencing severe pain."

d. "Older adult clients taking oxycodone are at risk for diarrhea."

A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have

an increased risk for gastrointestinal toxicity and bleeding.

44. A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer’s

disease. Which of the following information should the nurse include in the teaching?

a. Position tabletop clocks with multi-colored backgrounds throughout the home.

b. Explain how to complete a task while having the client do the task.

c. Place a calendar on the wall with days and weeks included.

d. Create complete outfits and allow the client to select one each day.

The family should place completed outfits on hangers and allow the client to select which one to

wear each day.

45. A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney

transplant. Which of the following information should the nurse provide?

a. Kidney donation must come from a living donor.

b. Immunosuppressive therapy is necessary until the donated kidney begins producing urine.

c. Hemodialysis is sometimes required following surgery.

d. Kidney transplant recipients can resume their regular diet following surgery.

When a kidney comes from a deceased donor, it might not function immediately, requiring the

recipient to continue hemodialysis postoperatively.

46. A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The

nurse recognizes that an unexpected finding for which of the following laboratory values is a

manifestation of osteomyelitis and should be reported to the provider?

a. Sedimentation rate

b. Hematocrit

c. Calcium

d. Acid phosphatase

An increased sedimentation rate occurs when a client has any type of inflammatory process,

such as osteomyelitis.

47. A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of

the right ankle. Which of the following assessment findings should the nurse report to the provider?

a. Extremity cool upon palpation

b. Serosanguineous drainage on the dressing

c. Capillary refill of 2 seconds

d. Client report of discomfort when moving toes

The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or

paresthesia of the client's extremity. These findings can indicate that the client is at risk for

developing acute compartment syndrome.

48. A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the

management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful

area has which of the following effects?

a. Electrically generated feelings of heat

b. Cryotherapy for painful areas

c. A tingling sensation replacing the pain

d. Realignment of energy flow through meridians

A TENS unit applies small electric currents to the painful area, with the client increasing the

current until the “pins and needles” sensation overrides the pain.

49. A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the

risk of falls when ambulating, the nurse should provide which of the following instructions to the client?

a. "Wear an eye patch over one eye."

b. "Make sure to have a staff member walk on your stronger side."

c. "Scan the environment by turning your head from side to side."

d. "Make sure to look at your feet while walking."

Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head

from side to side helps enlarge a client's visual field. This technique is also useful for the client

during mealtimes.

50. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following

results should the nurse expect?

a. PaCO2 56 mm Hg

b. pH 7.38

c. HCO3- 24 mEq/L

d. PaO2 90 mm Hg

A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar

sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to

increase above the expected reference range.

51. A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should

the nurse expect?

a. Painless ulcerations on the ankles

b. Hair loss on the lower legs

c. No extremity pain when resting

d. Rubor with elevation of the extremity

The nurse should expect a client who has peripheral arterial disease to have hair loss on the

lower legs as a result of impaired arterial circulation affecting follicular growth.

52. A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy

to which of the following foods can indicate a latex allergy?

a. Shellfish

b. Peanuts

c. Avocados

d. Eggs

Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex.

Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or

sensitivity.

53. A nurse is planning care for a client who is postoperative following a laparotomy and has a

closed-suction drain. Which of the following actions should the nurse take to manage the drain?

a. Set the wall suction to 80 to 100 mm Hg.

b. Compress the drain reservoir after emptying.

c. Allow the drainage to collect on a sterile gauze dressing.

d. Position the drain below the bed to promote drainage.

Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the

drain, and into the reservoir.

54. A nurse is caring for a client who has terminal cancer. The client tells the nurse, “I wish I could stop

these treatments. I am ready to die.” Which of the following statements should the nurse make?

a. "Discontinuing with the treatments is your choice if it is your wish to do so."

b. "Your daughter is named as your health care surrogate. I will ask her if you can stop them."

c. "I will call your spiritual advisor to come in, so you can discuss this with them."

d. "Next time you have an oncology appointment, you should ask the oncologist."

The nurse should recognize the client's right to refuse the treatments and inform the client of

this right. The nurse should advocate for the client and offer to contact the provider for the client.

55. A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory

infection. The client is agitated and is attempting to remove their IV catheter. Which of the following

actions should the nurse take to avoid restraining the client?

a. Check on the client every 2 hr.

b. Provide a quiet environment with no distractions.

c. Turn on the television in the client's room.

d. Keep the client occupied with a manual activity.

The nurse should provide the client with a manual activity such as a puzzle or an art project.

This can help to distract the client from the IV catheter.

56. A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have

acupuncture because it provides greater relief than pain medication. Which of the following statements

should the nurse make?

a. "Acupuncture is not an approved treatment for cancer pain."

b. "I can speak to the provider about incorporating acupuncture into your treatment plan."

c. "I will ask the provider to prescribe a stronger medication to help ease your pain."

d. "I can contact a family member or spiritual advisor for you to speak with."

The nurse should serve as an advocate for the client by acting on behalf of the client and

offering to speak with the provider. The client has the right to make choices and decisions about

their treatment and the nurse should support these decisions and assist the client to carry them

out.

57. A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery.

The nurse should recognize which of the following client medications is a contraindication for the

surgery and notify the provider?

a. Hydrocodone

b. Bupropion

c. Lactulose

d. Warfarin

Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is

contraindicated for a client scheduled for eye or central nervous system surgery.

58. A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following

findings indicates a potential complication?

a. RBC count 5.2 million/mm3

b. WBC count 2,000/mm3

c. Platelets 380,000/mm3

d. Potassium 4 mEq/L

A WBC count of 2,000/mm3 is below the expected reference range and indicates a risk for

severe immunosuppression.

59. A nurse in an emergency department is assessing an older adult client who has a fractured wrist

following a fall. During the assessment, the client states, “Last week I crashed my car because my

vision suddenly became blurry.” Which of the following actions is the nurse’s priority?

a. Check the client's neurologic status.

b. Document the client's statements.

c. Prepare the client for a CT scan.

d. Teach the client about using safety precautions for falls.

The first action the nurse should take using the nursing process is to assess the client.

Therefore, the nurse should first check the neurologic status of the client.

60. A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following

information should the nurse include in the teaching?

a. Drink 240 mL (8 oz) of water after administration.

b. Expect results in 4 to 6 hr.

c. Take this medication before meals to increase appetite.

d. Reduce dietary fiber intake to improve medication absorption.

The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid.

61. A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of

the following recommendations should the nurse plan to include? (Select all that apply.)

a. Follow a smoking cessation program.

b. Maintain an appropriate weight.

c. Eat a low-fat diet.

d. Increase fluid intake.

e. Decrease intake of complex carbohydrates.

Smoking cessation is an important lifestyle modification to prevent atherosclerosis.Preventing

obesity through diet and exercise can help to prevent atherosclerosis. Eating a low-fat diet

decreases LDL cholesterol and can prevent atherosclerosis.

62. A nurse is teaching a client who has cardiac dysrhythmia about the purpose of undergoing continuous

telemetry monitoring. Which of the following statements by the client reflects an understanding of the

teaching?

a. "This measures how much blood my heart is pumping."

b. "This identifies if I have a defective heart valve."

c. "This identifies if the pacemaker cells of my heart are working properly."

d. "This measures the blood circulating to my heart muscle."

Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical

impulse through the heart muscle.

63. A nurse is planning care for an older adult client who has dementia. Which of the following interventions

should the nurse include in the plan of care?

a. Explain procedures as they occur to the client.

b. Place personal items, such as pictures, at the client's bedside.

c. Orient the client to their location once a shift.

d. Encourage the family members to remain home until the client has adjusted.

The nurse should plan to have the family bring personal items such as pictures to place at the

client's bedside for cognitive support.

64. A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client

has just undergone thoracentesis. The nurse should expect a reduction in which of the following

common manifestations of advanced cancer?

a. Dyspnea

b. Hemoptysis

c. Mucus production

d. Dysphagia

Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the

client's breathing and improve comfort.

65. A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the

following actions should the nurse identify as the priority?

a. Use pillows to support the client's head and neck.

b. Offer opioid medication.

c. Place a tracheostomy tray at the bedside.

d. Place the client in semi-Fowler's position.

The priority action the nurse should take when using the airway, breathing, circulation approach

to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction.

66. A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After

ensuring a patent airway, which of the following nursing interventions is the priority?

a. Applying oxygen via face mask

b. Placing the client in Fowler's position

c. Administering epinephrine

d. Initiating an IV infusion of 0.9% sodium chloride

Evidence-based practice indicates that the priority intervention is for the nurse to apply oxygen.

The nurse should use a high-flow nonrebreather mask to deliver oxygen at 90% to 100%.

67. A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE).

Which of the following findings should the nurse expect?

a. Facial butterfly rash

b. Bradycardia

c. Esophagitis

d. Interstitial fibrosis

A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the client's cheeks

and nose and can disappear during times of remission.

68. A nurse on a med-srug unit is reviewing the medical record of an older adult client who is receiving IV

fluid therapy. Which of the following client information should indicate to the nurse that the client

requires re-evaluation of the IV therapy prescription?

a. Blood pressure 118/68 mm Hg

b. Prescribed medications

c. O2 saturation 96%

d. BUN 29 mg/dL

The client's Hct and BUN levels indicate dehydration and require an increase in the IV fluid

infusion rate.

69. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the

nurse plan to administer?

a. 240 mL (8 oz) of orange juice

b. 1 ampule of 50% dextrose IV bolus

c. NPH insulin 60 units subcutaneous

d. Regular insulin 20 units IV bolus

DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic

acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration,

correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a

fast-acting insulin that can be effective within 10 min when administered intravenously.

70. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a

fungal infection. The nurse should identify which of the following values is an indication of an adverse

effect of the medication?

a. Potassium 4.8 mEq/L

b. Magnesium 1.7 mEq/L

c. BUN 34 mg/dL

d. Hematocrit 45%

Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal

impairment. The nurse should notify the provider of this result.

71. A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The

nurse should identify that which of the following client actions indicates an understanding of the

teaching?

a. Breathing in rapidly while administering the medication

b. Washing the plastic case and cap of the inhaler in the dishwasher

c. Holding breath for 10 seconds after inhaling

d. Waiting 15 seconds between puffs, if two puffs are required

The client should hold their breath for 10 seconds after inhaling so the medication can move

deep into the airways.

72. A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from

peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?

a. A

b. B

c. C

d. D

This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red

tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.

73. A nurse is receiving a report on a client who is postoperative following an open repair of Zenker’s

diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations?

a. A

b. B

c. C

d. D

Zenker's diverticulum, or pharyngeal pouch, is a herniation of the esophagus occurring through

the cricopharyngeal muscle in the midline of the neck. Repair of the diverticulum is

accomplished through an open incision in the client's neck.

74. A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the

following information should the nurse include in the instructions?

a. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures.

b. The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy.

c. Family members should follow airborne precautions at home.

d. A follow-up tuberculosis skin test is necessary in 2 months.

After three negative sputum cultures, the client is no longer considered infectious.

75. A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the

following actions should the nurse take first?

a. Obtain the client's vital signs.

b. Describe the blood transfusion procedure to the client.

c. Check for the type and number of units of blood to administer.

d. Initiate a peripheral IV line.

According to evidence-based practice, the nurse should first confirm that the type and number

of units of blood to administer matches what is indicated in the client's medication administration

record.

76. A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless,

dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse

anticipate taking?

a. Administer an antihistamine.

b. Slow the infusion rate.

c. Give the client a corticosteroid.

d. Elevate the client's lower extremities.

Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations

of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability

to breathe, place the client in an upright position, and notify the provider. The provider might

prescribe a diuretic to alleviate the fluid overload.

77. A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for

brachytherapy. Which of the following instructions should the nurse include?

a. "You will have an implant placed twice each month for the duration of the treatment."

b. "You should remain at least 6 feet away from others between treatments."

c. "You should expect to have blood in your urine for a few days after treatment."

d. "You will need to stay still in the bed during each treatment session."

The nurse should instruct the client that they will need to remain on bed rest with very limited

movement because excessive movement can cause the radioactive source to become

dislodged.

78. A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the

following statements should the nurse make?

a. "Ginkgo biloba relieves nausea for people who have vertigo."

b. "Taking ginkgo biloba will help relieve your joint pain."

c. "Ginkgo biloba can cause an increased risk for bleeding."

d. "Taking ginkgo biloba decreases the risk of migraine headache."

Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with

peripheral artery disease. The supplement also decreases platelet aggregation, which in turn

increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such

as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.

79. A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock.

Identify the sequence of actions the nurse should take.

a. Using the airway, breathing, circulation approach to client care, the first action the nurse should

take is to administer oxygen. The nurse should then initiate IV therapy to support circulation by

expanding the client's intravascular fluid volume. Next, the nurse should insert an NG tube to

monitor the rate of bleeding and prevent gastric dilatation. Finally, to prevent a stress ulcer, the

nurse can administer ranitidine when the client is no longer bleeding.

80. A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client

indicates an understanding of the teaching?

a. "I should clean my toothbrush in the dishwasher once a month."

b. "I should eat more fresh fruit and vegetables."

c. "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes."

d. "I will take my temperature once a day."

A client who has AIDS is immunocompromised and is at risk for infection. The client should

check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is

an early manifestation of an infection.

81. A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has become cyanotic.

Which of the following actions should the nurse take? (Select all that apply.)

a. Restrain the client.

b. Prepare to suction the client's airway.

c. Insert a tongue blade in the client's mouth.

d. Raise the head of the client's bed to a semi-Fowler's position.

e. Loosen restrictive clothing on the client.

The client's airway can become obstructed and the nurse may need to suction to clear the

client's airway after the seizure. The nurse should loosen restrictive clothing so the client is able

to move freely during the seizure.

82. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When

reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS.

Which of the following actions should the nurse take?

a. Check the client's blood glucose according to facility mealtimes.

b. Contact the provider to clarify the prescription.

c. Request for meals to be provided for the client.

d. Hold the prescription until the client is no longer NPO.

Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the

client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the

prescription requires clarification.

83. A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes

a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take?

a. Document that depolarization has occurred.

b. Increase the pacemaker's voltage.

c. Decrease the pacemaker's sensitivity.

d. Check the placement of the ECG leads.

When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on

the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates

pacemaker capture or depolarization.

84. A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the

following statements made by the client reflects an understanding of the teaching?

a. "I will need to take antibiotics for 1 year."

b. "My partner will need to take an antiviral medication."

c. "My joints ache because I have Lyme disease."

d. "I bruise easily because I have Lyme disease."

Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs

in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms

continue throughout stage II and, by stage III, become chronic. Other chronic complications

include memory problems and fatigue.

85. A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant

irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching?

a. Take a calcium antacid before meals and at bedtime.

b. Consume at least 30 g of fiber daily.

c. Take a stimulant laxative daily.

d. Consume no more than 1,000 mL of water per day.

Irritable bowel syndrome is a gastrointestinal disorder characterized by abdominal pain,

bloating, and either constipation or diarrhea or a mixture of both. Consuming a diet high in

dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

86. A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client’s

vital signs were HR 80/min, BP 130/70 mmHg, RR 16/min, and T 36 C (96.8 F). Which of the following

vital sign changes should alert the nurse that the client might be hemorrhaging?

a. Heart rate 110/min

b. Blood pressure 160/70 mm Hg

c. Respiratory rate 14/min

d. Temperature 38.4° C (101.1° F)

One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline,

which occurs to compensate for blood loss.

87. A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus

(MRSA). Which of the following actions should the nurse take?

a. Obtain a sputum specimen to determine if there is colonization.

b. Bathe the client using chlorhexidine solution.

c. Place the client in droplet isolation.

d. Restrict visits from the client's friends and family.

The nurse should bathe the client using chlorhexidine solution because it reduces the risk of

transmission of MRSA to other areas of the body.

88. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via

continuous IV infusion. Which of the following findings should the nurse report to the provider as an

adverse effect of this medication?

a. Decreased heart rate

b. Crackles heard on auscultation

c. Increased urinary output

d. Decreased deep tendon reflexes

Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus

increasing urinary output. With the exception of the brain, mannitol can leave the vascular

system at the capillary site, which can result in edema. The nurse should identify crackles as a

manifestation of pulmonary edema and notify the provider. Other manifestations include

dyspnea and decreased oxygen saturation.

89. A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the

following information should the nurse include in the teaching?

a. After 1 week of medication, TB is no longer communicable.

b. Dispose of contaminated tissues in a paper bag.

c. Airborne precautions are necessary in the home.

d. Family members in the household should undergo TB testing.

Family members who live in the same household with the client have been exposed to TB.

Therefore, the nurse should recommend TB screening to foster early detection and treatment of

TB.

90. A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of

the following sounds the nurse should document in the client’s medical record by listening to the audio

clip.

a. Murmur

b. S4

c. Pericardial friction rub

d. Ventricular gallop

The nurse is hearing a pericardial friction rub, which is a scratchy, high-pitched sound

associated with infection, inflammation, or infiltration and can be a manifestation of pericarditis.

A pericardial friction rub is best heard with the diaphragm of the stethoscope.