RN Adult Medical Surgical Online Practice 2023 A

Question 1

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse’s priority?
1. Temperature 38.4 C (101.1 F)
2. Increased respiratory secretions
3. Fluid intake of 200 mL in the prior 8 hr
4. Limited range of motion

Answer 1

Increased respiratory secretions
CORRECT
Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. Clients who have ALS may experience respiratory muscle weakness and dysphagia, and excessive respiratory secretions can impair the ability to clear the airway, which increases the client’s risk for aspiration.

Question 2

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?
1. Obtain the client’s vital signs
2. Describe the blood transfusion procedure to the client
3. Check for the type and number of units of blood to administer.
4. Initiate a peripheral IV line

Answer 2

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

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.

Question 3

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?
1. Place a padded tongue blade at the client’s bedside
2. keep the side rails lowered on the client’s bed
3. Maintain the client’s bed at hip level o above
4. Ensure that the client has a patent IV.

Answer 3

Place a padded tongue blade at the client’s bedside.
INCORRECT
The nurse should never insert a padded tongue blade in the client’s mouth because it can cause injury or occlude the client’s airway.

Keep the side rails lowered on the client’s bed.
INCORRECT
The nurse should keep two or three side rails up on the client’s bed to prevent falls.

Maintain the client’s bed at hip level or above.
INCORRECT
The nurse should keep the client’s bed in the lowest position to prevent falls.

Ensure that the client has a patent IV.
CORRECT
The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.

Question 4

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?

1. Sedimentation rate
2. Hematocrit
3. Calcium
4. Acid phosphatase

Answer 4

Sedimentation rate
CORRECT
An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.

Hematocrit
INCORRECT
Hematocrit levels are not altered by inflammatory processes such as osteomyelitis.

Calcium
INCORRECT
A client who has a bone fracture can have an alteration in calcium levels due to bone remodeling, but alterations in calcium levels do not indicate an inflammatory process.

Acid phosphatase
INCORRECT
Acid phosphatase levels are altered in a client who has prostate disease. Phosphorus levels have an inverse relationship with calcium levels. Neither phosphorus nor acid phosphatase indicates an inflammatory disorder.

Question 5

A nurse is preparing to present a program about the prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.)

1. Follow a smoking cessation program.
2. Maintain an appropriate weight.
3. Eat a low-fat diet.
4. Increase fluid intake.
5. Decrease intake of complex carbohydrates.

Answer 5

Follow a smoking cessation program. (CORRECT)
Smoking cessation is an important lifestyle modification to prevent atherosclerosis.

Maintain an appropriate weight. (CORRECT)
Preventing obesity through diet and exercise can help to prevent atherosclerosis.

Eat a low-fat diet. (CORRECT)
Eating a low-fat diet decreases LDL cholesterol and can prevent atherosclerosis.

Increase fluid intake. (INCORRECT)
Increasing intake of fruits, vegetables, and grains can prevent atherosclerosis.

Decrease intake of complex carbohydrates. (INCORRECT)
Decreasing intake of simple sugars and sweetened foods and increasing complex carbohydrates, such as fiber, can reduce the risk of heart disease.

Question 6

A nurse is caring for a client who has a potassium level of 3 mEq/L (normal range: 3.5 to 5 mEq/L). Which of the following assessment findings should the nurse expect?

1. Positive Trousseau’s sign
2. 4+ deep tendon reflexes
3. Deep respirations
4. Hypoactive bowel sounds

Answer 6

Positive Trousseau’s sign:
INCORRECT
Trousseau’s sign is associated with hypocalcemia, not hypokalemia.

2+ deep tendon reflexes:
INCORRECT
Deep tendon reflexes may be normal or diminished in hypokalemia. A 2+ reflex is within the normal range.

Deep respirations:
INCORRECT
Hypokalemia can lead to shallow breathing due to muscle weakness, not deep respirations.

Hypoactive bowel sounds:
CORRECT
Hypokalemia can result in decreased gastrointestinal motility, leading to hypoactive or absent bowel sounds.

Question 7

A nurse is providing teaching for a female client who has recurrent urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching?

Take tub baths daily.
Drink at least 1 L of fluid daily.
Wear underwear made of nylon.
Void before and after intercourse.

Answer 7

Take tub baths daily. (INCORRECT)
The client should take showers instead of tub baths to prevent bacteria present in bath water from entering the urethra.

Drink at least 1 L of fluid daily. (INCORRECT)
The client should drink 2 to 3 L of fluid daily to keep her urine dilute and to flush bacteria out of the urinary tract.

Wear underwear made of nylon. (INCORRECT)
The nurse should encourage the client to wear underwear made of cotton, which provides improved airflow through the perineal area. Underwear made from nylon traps moisture and provides an opportunity for bacterial growth.

Void before and after intercourse. (CORRECT)
The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and helps prevent the occurrence of infection.

Question 8

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?

Obtain a sputum sample.
Administer antipyretics.
Provide hand hygiene education.
Initiate airborne precautions.

Answer 8

Obtain a sputum sample. (INCORRECT)
The nurse should obtain a sputum sample to identify the microorganisms that are causing the client’s illness. However, there is another action that the nurse should take first.

Administer antipyretics. (INCORRECT)
The nurse should administer antipyretics to treat the client’s fever. However, there is another action that the nurse should take first.

Provide hand hygiene education. (INCORRECT)
The nurse should provide hand hygiene education. However, there is another action that the nurse should take first.

Initiate airborne precautions. (CORRECT)
This client is exhibiting manifestations of tuberculosis. The greatest risk in this situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions.

Question 9

A nurse is providing teaching to a client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching?

“It is an expected effect to sleep through the day when taking this medication.”
“Your constipation will be lessened as you develop a tolerance to the medication.”
“You should void every 4 hours to decrease the risk of urinary retention.”
“If you experience ringing in your ears, your dose will need to be reduced.”

Answer 9

“It is an expected effect to sleep through the day when taking this medication.” (INCORRECT)
The nurse should instruct the client to report oversedation, which increases the risk for respiratory depression.

“Your constipation will be lessened as you develop a tolerance to the medication.” (INCORRECT)
The nurse should instruct the client that constipation is an adverse effect of opioid analgesics and can be managed by increasing intake of fiber.

“You should void every 4 hours to decrease the risk of urinary retention.” (CORRECT)
The nurse should instruct the client to void at least every hour to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.

“If you experience ringing in your ears, your dose will need to be reduced.” (INCORRECT)
Many medications, including aspirin and aminoglycosides, can cause ringing in the ears, but this is not an adverse effect of opioid analgesics.

Question 10

A nurse is providing teaching to a female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?

“Taking my daily progesterone should improve my symptoms.”
“A risk factor for my condition is obesity.”
“I should limit my daily fluid intake.”
“I will switch my morning cup of coffee to hot tea.”

Answer 10

“Taking my daily progesterone should improve my symptoms.” (INCORRECT)
Topical estrogen, not progesterone, can improve blood circulation to the perineal area and enhance the tone of the periurethral muscles for a client who has experienced menopause.

“A risk factor for my condition is obesity.” (CORRECT)
Excess weight creates increased abdominal pressure that can result in stress incontinence.

“I should limit my daily fluid intake.” (INCORRECT)
The client should maintain an adequate intake of water for proper kidney function and hydration.

“I will switch my morning cup of coffee to hot tea.” (INCORRECT)
A client who has stress incontinence should avoid caffeine intake because it is a bladder irritant. Many tea and coffee beverages contain caffeine.

Question 11

A nurse is assessing a group of clients for indications of role changes. The nurse should identify which of the following clients is at risk for experiencing a role change:

A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose.
A client who had a cholecystectomy and is starting on a modified-fat diet.
A client who has Crohn’s disease and is experiencing diarrhea three times a day.
A client who has multiple sclerosis and is experiencing progressive difficulty ambulating.

Answer 11

“A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose.” (INCORRECT)
The client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose can remain independent and active and is not at risk for experiencing a role change.

“A client who had a cholecystectomy and is starting on a modified-fat diet.” (INCORRECT)
The client who had a cholecystectomy with a diet change can remain independent and active and is not at risk for experiencing a role change.

“A client who has Crohn’s disease and is experiencing diarrhea three times a day.” (INCORRECT)
The client who has Crohn’s disease and is experiencing diarrhea can remain independent and active and is not at risk for experiencing a role change.

“A client who has multiple sclerosis and is experiencing progressive difficulty ambulating.” (CORRECT)
The nurse should identify that the progression of neurologic disease, such as multiple sclerosis, can lead to a role change as the client becomes less independent.

Question 12

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?

Temperature 37.2° C (99° F)
Blood pressure 100/70 mm Hg
Weight loss
Restlessness

Answer 12

Temperature 37.2° C (99° F) (INCORRECT)
An increased temperature is nonurgent because it is an expected finding for a client who has just completed dialysis. The increase is caused by the dialysis machine slightly warming the blood. Therefore, the nurse should identify another finding as the priority to report.

Blood pressure 100/70 mm Hg (INCORRECT)
A decrease in blood pressure is nonurgent because it is an expected finding for a client who has just completed dialysis. The decrease is a result of the removal of excess fluid from the client’s blood. Therefore, the nurse should identify another finding as the priority to report.

Weight loss (INCORRECT)
Weight loss is nonurgent because it is an expected finding for a client who has just completed dialysis. The weight loss is a result of the removal of excess fluid from the client’s blood. Therefore, the nurse should identify another finding as the priority to report.

Restlessness (CORRECT)
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 indicate that 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.

Question 13

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

“It’s like a curtain closed over my eye.”
“This sharp pain in my eye started 2 hours ago.”
“I’ve been having more and more difficulty seeing over the last few weeks.”
“I seem to have more problems seeing different colors.”

Answer 13

“It’s like a curtain closed over my eye.” (CORRECT)
A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.

“This sharp pain in my eye started 2 hours ago.” (INCORRECT)
Clients who have a retinal detachment may report seeing sudden flashes of light or floating dark spots, but retinal detachment is usually painless.

“I’ve been having more and more difficulty seeing over the last few weeks.” (INCORRECT)
Retinal detachment usually has a sudden onset rather than a gradual decline in vision over weeks.

“I seem to have more problems seeing different colors.” (INCORRECT)
Clients who have cataracts experience a loss in color perception. However, this is not a manifestation of retinal detachment.

Question 14

A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?

Monitor the client’s temperature every 4 hr.
Insert an indwelling urinary catheter for the client.
Request the client’s bathroom to be cleaned three times each week.
Place a box of latex gloves just outside the client’s room.

Answer 14

Monitor the client’s temperature every 4 hr. (CORRECT)
The nurse should monitor the temperature of a client who has neutropenia every 4 hours because the client’s reduced leukocyte count greatly increases the risk for infection.

Insert an indwelling urinary catheter for the client. (INCORRECT)
The nurse should avoid the insertion of an indwelling urinary catheter for a client who has neutropenia because it can significantly increase the risk of infection.

Request the client’s bathroom to be cleaned three times each week. (INCORRECT)
The nurse should ensure that the client’s room and bathroom are cleaned at least once each day, rather than three times each week, to decrease the client’s risk for infection.

Place a box of latex gloves just outside the client’s room. (INCORRECT)
The nurse should keep a dedicated box of disposable gloves inside the client’s room to decrease the risk of contamination, which can lead to infection.

Question 15

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse’s priority?

Loosen the clothing around the client’s neck.
Check the client’s pupillary response.
Turn the client to the side.
Move furniture away from the client.

Answer 15

Loosen the clothing around the client’s neck. (INCORRECT)
The nurse should loosen any restrictive clothing the client is wearing to prevent injury, but there is another action that is the priority in this situation.

Check the client’s pupillary response. (INCORRECT)
The nurse should perform neurologic checks after the seizure to monitor the client’s recovery, but this is not the immediate priority action.

Turn the client to the side. (CORRECT)
The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.

Move furniture away from the client. (INCORRECT)
The nurse should move furniture away from the client to prevent self-injury. However, this action is not the priority compared to ensuring the client’s airway is protected.

Question 16

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

PaCO₂ 56 mm Hg (35 to 45 mm Hg)
pH 7.50 (7.35 to 7.45)
HCO₃⁻ 18 mEq/L (21 to 28 mEq/L)
PaO₂ 130 mm Hg (80 to 100 mm Hg)

Answer 16

PaCO₂ 56 mm Hg (35 to 45 mm Hg) (CORRECT)
A client who has COPD retains PaCO₂ due to the weakening and collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange, causing the PaCO₂ to increase above the expected reference range.

pH 7.50 (7.35 to 7.45) (INCORRECT)
A client who has COPD typically will have a pH less than 7.35 due to poor gas exchange resulting from elevated PaCO₂ and HCO₃⁻ levels, along with low oxygen levels, for an extended period of time.

HCO₃⁻ 18 mEq/L (21 to 28 mEq/L) (INCORRECT)
A client who has COPD will generally have elevated HCO₃⁻ levels as a compensatory response from the kidneys due to chronic respiratory acidosis, leading to a retention of HCO₃⁻ in the blood and an increase in pH over time.

PaO₂ 130 mm Hg (80 to 100 mm Hg) (INCORRECT)
A client who has COPD typically has a low oxygen level due to the weakening and collapse of the alveolar sacs, which decreases the area available in the lungs for gas exchange. A PaO₂ of 130 mm Hg indicates hyperoxia, which is not typical in COPD patients.

Question 17

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?

Increase intake of foods containing calcium.
Alternate application of heat and cold to the affected joints.
Keep the affected extremities elevated.
Limit movement of the affected joints.

Answer 17

Increase intake of foods containing calcium. (INCORRECT)
While adequate calcium intake is important to prevent bone loss, this action does not directly reduce pain. The client should consume a balanced diet high in nutrients, such as protein, vitamins, and iron, to promote tissue repair.

Alternate application of heat and cold to the affected joints. (CORRECT)
The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. Cold applications can relieve joint swelling, while heat can decrease joint stiffness and pain.

Keep the affected extremities elevated. (INCORRECT)
Elevating the affected extremities does not relieve the painful inflammation caused by rheumatoid arthritis, which is an autoimmune inflammatory disease. Elevation can help manage pain in clients with peripheral vascular disease, but it is not effective for rheumatoid arthritis.

Limit movement of the affected joints. (INCORRECT)
Although exercising affected joints can be painful, regular exercise is important to prevent stiffness and maintain joint function.

Question 18

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Check laboratory values for recent hemoglobin and hematocrit levels.
Establish a peripheral IV line for possible transfusion.
Call the laboratory to obtain a stat platelet count.
Obtain vital signs.

Answer 18

Check laboratory values for recent hemoglobin and hematocrit levels. (INCORRECT)
While checking hemoglobin and hematocrit levels is important to assess the need for blood product replacement, there is another action the nurse should take first.

Establish a peripheral IV line for possible transfusion. (INCORRECT)
Although initiating a peripheral IV line for saline or blood administration is essential, there is another action the nurse should take first.

Call the laboratory to obtain a stat platelet count. (INCORRECT)
Checking for a low platelet count is crucial since it indicates potential problems with blood clotting. However, there is another priority action the nurse should take first.

Obtain vital signs. (CORRECT)
The first action the nurse should take using the nursing process is to assess the client’s vital signs. A client with portal hypertension can develop esophageal varices, which are fragile and can rupture, leading to significant blood loss and shock. Obtaining vital signs provides critical information about the client’s condition that aids in decision-making.

Question 19

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

Flush the line before administering antibiotics.
Position the client in Trendelenburg to obtain measurements.
Have the client bear down when readings are obtained.
Place a pressure bag around the flush solution.

Answer 19

Flush the line before administering antibiotics. (INCORRECT)
An arterial line is not appropriate access for administering antibiotics. The nurse should use the arterial line to obtain arterial blood gas samples and monitor hemodynamic pressures.

Position the client in Trendelenburg to obtain measurements. (INCORRECT)
The most appropriate positioning for a client while recording values from an arterial line is supine with the head of the bed elevated up to 60°.

Have the client bear down when readings are obtained. (INCORRECT)
Accurate readings from an arterial line cannot be obtained by having the client bear down since this action temporarily increases arterial pressure.

Place a pressure bag around the flush solution. (CORRECT)
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. This helps maintain a consistent flow of the flush solution into the arterial line.

Question 20

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse’s priority?

Moderate serosanguinous drainage on the dressing
Calcium 9.5 mg/dL (9 to 10.5 mg/dL)
Temperature 38.9° C (102° F)
Decreased bowel sounds

Answer 20

Moderate serosanguinous drainage on the dressing (INCORRECT)
Moderate serosanguinous drainage on the dressing is nonurgent because it is an expected finding for a client who is postoperative following a thyroidectomy. Therefore, there is another finding that is the nurse’s priority.

Calcium 9.5 mg/dL (9 to 10.5 mg/dL) (INCORRECT)
A serum calcium level of 9.5 mg/dL is nonurgent because it is within the expected reference range. The nurse should monitor the client for hypocalcemia following a thyroidectomy; however, there is another finding that is the nurse’s priority.

Temperature 38.9° C (102° F) (CORRECT)
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.

Decreased bowel sounds (INCORRECT)
Decreased bowel sounds are nonurgent because it is an expected finding for a client who is postoperative following a thyroidectomy due to general anesthesia. Therefore, there is another finding that is the nurse’s priority.

Question 21

A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?

Flex the foot every hour when awake.
Place a pillow under the knee when lying in bed.
Lower the leg when sitting in a chair.
Ensure the leg is abducted when resting in bed.

Answer 21

Flex the foot every hour when awake. (CORRECT)
The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.

Place a pillow under the knee when lying in bed. (INCORRECT)
The nurse should instruct the client to avoid placing pillows under the knee to prevent flexion contractures.

Lower the leg when sitting in a chair. (INCORRECT)
The nurse should instruct the client to elevate the leg when sitting in a chair to reduce edema and pain.

Ensure the leg is abducted when resting in bed. (INCORRECT)
The nurse should instruct the client to keep the operative leg in a neutral position when resting in bed to prevent dislocation of the knee.

Question 22

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?

“Ginkgo biloba relieves nausea for people who have vertigo.”
“Taking ginkgo biloba will help relieve your joint pain.”
“Ginkgo biloba can cause an increased risk for bleeding.”
“Taking ginkgo biloba decreases the risk of migraine headache.”

Answer 22

“Ginkgo biloba relieves nausea for people who have vertigo.” (INCORRECT)
Ginger root is a supplement that treats nausea caused by vertigo. Ginger root’s actions are similar to that of the antiemetic ondansetron in that both medications block serotonin receptors in the medulla.

“Taking ginkgo biloba will help relieve your joint pain.” (INCORRECT)
Glucosamine is a supplement that treats joint pain by reducing inflammation and promoting the body’s ability to make cartilage and synovial fluid.

“Ginkgo biloba can cause an increased risk for bleeding.” (CORRECT)
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.

“Taking ginkgo biloba decreases the risk of migraine headache.” (INCORRECT)
Feverfew decreases the risk of migraine headache, as well as the intensity of manifestations, when taken prophylactically. Its actions are not well understood, but it is known that feverfew can decrease platelet aggregation and can increase the risk for bleeding.

Question 23

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Insert a padded tongue blade.
Apply oxygen.
Restrain the client.
Loosen restrictive clothing.

Answer 23

Insert a padded tongue blade. (INCORRECT)
The nurse should not insert anything into the client’s mouth during the seizure. A tongue blade can create a choking hazard and cause injury to the client’s teeth and mouth.

Apply oxygen. (INCORRECT)
Clients who experience a tonic-clonic seizure can become hypoxic for brief intervals and may be offered oxygen in the postictal phase, but supplemental oxygen is not usually necessary.

Restrain the client. (INCORRECT)
The nurse should not restrain the client in any way during the seizure but should instead clear the area of objects close to the client to prevent injury.

Loosen restrictive clothing. (CORRECT)
The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.

Question 24

A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate?

Airbone
Droplet
Contact
Protective environment

Answer 24

Airborne (CORRECT)
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.

Droplet (INCORRECT)
Droplet precautions are required for clients who have infections due to micro-organisms that live in droplets but do not remain suspended in air for lengthy periods of time, such as influenza, rubella, pneumonia, streptococcal pharyngitis, pertussis, and mumps.

Contact (INCORRECT)
Contact precautions are required for clients who have infections that spread via direct contact or contact with the environment, such as vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, respiratory syncytial virus, scabies, and infections with Clostridium difficile.

Protective environment (INCORRECT)
Some clients who are immunocompromised require a protective environment.

Question 25

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?

Check the client’s blood glucose according to facility mealtimes.
Contact the provider to clarify the prescription.
Request for meals to be provided for the client.
Hold the prescription until the client is no longer NPO.

Answer 25

Check the client’s blood glucose according to facility mealtimes. (Incorrect)
Rationale: TPN contains a high amount of glucose, leading to the potential for hyperglycemia. The nurse should monitor blood glucose levels according to a scheduled protocol (e.g., every 6 hours) rather than mealtimes, especially since the client is NPO.

Contact the provider to clarify the prescription. (Correct)
Rationale: The client’s NPO status indicates that mealtimes are not applicable. Therefore, the nurse should clarify the prescription related to blood glucose monitoring or management.

Request for meals to be provided for the client. (Incorrect)
Rationale: An NPO status means that the client cannot have food or fluids by mouth. Meals cannot be reintroduced without a provider’s prescription, and there’s no indication that this client’s NPO status has changed.

Hold the prescription until the client is no longer NPO. (Incorrect)
Rationale: The nurse should continue to monitor blood glucose levels on a set schedule due to the glucose content in TPN, regardless of the client’s NPO status.

Question 26

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?

Keep the line open with 0.9% sodium chloride until the new bag arrives.
Administer dextrose 10% in water until the new bag arrives.
Flush the line and cap the port until the new bag arrives.
Decrease the infusion rate until the new bag arrives.

Answer 26

Keep the line open with 0.9% sodium chloride until the new bag arrives. (Incorrect)
Rationale: Infusing 0.9% sodium chloride can alter the client’s blood glucose levels, potentially causing harm.

Administer dextrose 10% in water until the new bag arrives. (Correct)
Rationale: TPN solutions contain high concentrations of dextrose. Administering dextrose 10% or 20% in water helps prevent a significant drop in the client’s blood glucose level.

Flush the line and cap the port until the new bag arrives. (Incorrect)
Rationale: The nurse should maintain an open IV line with an appropriate solution to avoid fluctuations in blood glucose levels.

Decrease the infusion rate until the new bag arrives. (Incorrect)
Rationale: Continuing to infuse IV fluids with the correct solution is necessary to prevent alterations in the client’s blood glucose levels.

Question 27

A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hours ago. Which of the following findings should the nurse expect?

Stone fragments in the urine
Fever
Decreased urine output
Bruising on the lower abdomen

Answer 27

Stone fragments in the urine (Correct)
Rationale: ESWL aims to break the calculi into fragments that can pass down the ureter, into the bladder, and through the urethra during voiding. After the procedure, the nurse should strain the client’s urine to confirm the passage of stones.

Fever following ESWL (Incorrect)
Rationale: Fever after ESWL can indicate a complication, possibly from micro-organisms associated with an underlying urinary tract infection or pyelonephritis.

Decreased urine output (Incorrect)
Rationale: A decrease in urine output following ESWL may indicate a complication caused by stone fragments obstructing urine flow.

Bruising on the lower abdomen (Incorrect)
Rationale: Bruising typically appears on the lower back or flank of the affected side due to the shock waves directed toward the body during the ESWL procedure.

Question 28

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 client who is taking potassium supplements, has a potassium level of 3.2 mEq/L (3.5 to 5 mEq/L), and reports constipation.
A client who has Alzheimer’s Disease (AD), has a room near the nurse’s station, and is agitated.
A client who is postoperative following abdominal surgery and reports feeling that something “popped” when they coughed.
A client who has a conductive hearing loss, speaks softly, and is scheduled for a cerumen removal.

Answer 28

A client who is taking potassium supplements, has a potassium level of 3.2 mEq/L (3.5 to 5 mEq/L), and reports constipation (Incorrect)
Rationale: A potassium level of 3.2 mEq/L is below the expected reference range, indicating hypokalemia. Constipation is an expected finding of hypokalemia. This client should continue taking the potassium supplements until manifestations of hypokalemia improve.

A client who has Alzheimer’s Disease (AD), has a room near the nurse’s station, and is agitated (Incorrect)
Rationale: Agitation is an expected finding for a client with moderate AD. This client should remain in a room near the nurse’s station so staff can frequently check on and intervene as needed.

A client who is postoperative following abdominal surgery and reports feeling that something “popped” when they coughed (Correct)
Rationale: A feeling of something popping or loosening with coughing may indicate wound dehiscence. This client will need revisions to the plan of care, including management of the dehiscence, prevention of evisceration, or possible surgical repair if evisceration occurs.

A client who has conductive hearing loss, speaks softly, and is scheduled for cerumen removal (Incorrect)
Rationale: Speaking softly is expected for a client with conductive hearing loss, and cerumen buildup is a causative factor. The client should proceed with the scheduled cerumen removal to determine if manifestations improve.

Question 29

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?

Metabolic alkalosis
Hyperkalemia
Increased hemoglobin
Hypophosphatemia

Answer 29

Metabolic alkalosis (Incorrect)
Rationale: A client who has chronic glomerulonephritis can experience metabolic acidosis due to bicarbonate loss and retention of hydrogen ions.

Hyperkalemia (Correct)
Rationale: The nurse should identify that a client with chronic glomerulonephritis can experience hyperkalemia due to kidney failure, which results in decreased excretion of potassium.

Increased hemoglobin (Incorrect)
Rationale: A client who has chronic glomerulonephritis can experience anemia as a result of decreased RBC production.

Hypophosphatemia (Incorrect)
Rationale: A client who has chronic glomerulonephritis can experience hyperphosphatemia due to decreased excretion of phosphorus through the kidneys.

Question 30

A nurse is teaching a class about client rights. Which of the following instructions should the nurse include?

A client should sign an informed consent before receiving a placebo during a research trial.
A client cannot refuse to sign a consent form for a life-saving treatment.
A client who has a mental illness is unable to give informed consent.
An unemancipated minor needs guardian consent for substance use disorder treatment.

Answer 30

A client should sign an informed consent before receiving a placebo during a research trial. (Correct)
Rationale: A nurse should ensure a client has provided informed consent before administering a placebo. Placebos should not be used outside of approved clinical research in which the client has consented to participate.

A client cannot refuse to sign a consent form for a life-saving treatment. (Incorrect)
Rationale: A client has the right to refuse consent even if the treatment might save their life.

A client who has a mental illness is unable to give informed consent. (Incorrect)
Rationale: A client who has a mental illness has the right to consent or refuse treatment, unless deemed incompetent by a court of law.

An unemancipated minor needs guardian consent for substance use disorder treatment. (Incorrect)
Rationale: An unemancipated minor has the right to consent to treatment for substance use disorder.

Question 31

Migraine vs stroke vs Meningitis

Family hx, hand grasps, aphasia, numbness, and visual changes

Answer 31

Hand grasps are consistent with migraine, stroke, and meningitis.
Unilateral weakness can occur due to neurological vascular changes and inflammation that can be present with migraines, strokes, and meningitis.

Numbness is consistent with migraines and strokes. Numbness and tingling of the lips and tongue can occur with migraines due to neurological vascular changes and inflammation that can be present. Numbness can also occur with middle cerebral artery strokes.

Aphasia is consistent with migraines and strokes. Aphasia can occur due to neurological vascular changes and inflammation that can be present with migraines and strokes.

Visual changes are consistent with migraines, strokes, and meningitis. Visual changes can occur with migraines, strokes, and meningitis due to neurological vascular changes and inflammation that can be present.

Family history is consistent with migraines and strokes. Family history is a risk factor associated with migraines and strokes.

Question 32

Proper use of Crutches

1. Shifts weight from the crutches to the unaffected leg
2. Brings the crutches and the affected leg up to the stair
3. Places body weight on the crutches
4. Advance the unaffected leg onto the stairs

Answer 32

The client should first place their body weight on the crutches. Next, they should advance the unaffected leg onto the stair. Third, they should shift their weight from the crutches to the unaffected leg. Lastly, they should bring the crutches and the affected leg up to the stair.

Question 33

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?

Decreased heart rate
Crackles heard on auscultation
Increased urinary output
Decreased deep tendon reflexes

Answer 33

Decreased heart rate (Incorrect)
Rationale: Tachycardia is an adverse effect of mannitol that the nurse should report.

Crackles heard on auscultation (Correct)
Rationale: 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 manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.

Increased urinary output (Incorrect)
Rationale: Mannitol is an osmotic diuretic and increased diuresis is a therapeutic effect.

Decreased deep tendon reflexes (Incorrect)
Rationale: A decrease in the deep tendon reflex response is an indication of hypercalcemia or hypermagnesemia. An adverse effect of mannitol is electrolyte loss.

Question 34

A nurse is assessing a client who has Graves’ disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

Answer 34

The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding in Graves’ disease. An overproduction of thyroid hormone causes edema of the extraocular muscles and increases fatty tissue behind the eye, resulting in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including difficulty focusing on objects, as well as pressure on the optic nerve.

Question 35

A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first?

Fluid

Analgesia

Antibiotics

Tetanus toxoid

Answer 35

Administer IV fluids to provide circulatory support (Correct)
Rationale: After establishing that the client’s airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support.

Administer analgesia to manage the client’s pain (Incorrect)
Rationale: The nurse should prepare to administer analgesia to manage the client’s pain. However, evidence-based practice indicates that another action is the priority.

Administer antibiotics to prevent infection (Incorrect)
Rationale: The nurse should prepare to administer antibiotics to prevent infection. However, evidence-based practice indicates that another action is the priority.

Administer tetanus toxoid (Incorrect)
Rationale: The nurse should prepare to administer tetanus toxoid. However, evidence-based practice indicates that another action is the priority.

Question 36

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?

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

“I will remove the markings on my skin after each radiation treatment.”

“I will avoid direct exposure to the sun.”

“I will rinse my mouth with a commercial mouthwash.”

Answer 36

“I will wear a badge to measure how much radiation I am receiving.”
INCORRECT
Health care providers who care for clients receiving radiation therapy should wear a dosimeter badge to measure radiation exposure. The client does not need to wear a badge.

“I will remove the markings on my skin after each radiation treatment.”
INCORRECT
The client should not remove the markings until the course of radiation is complete because radiation markings ensure consistent dose delivery to the target area.

“I will avoid direct exposure to the sun.”
CORRECT
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.

“I will rinse my mouth with a commercial mouthwash.”
INCORRECT
Head and neck radiation can damage the salivary glands and cause dry mouth, which predisposes the client to mucositis. The client should rinse the mouth with plain water or 0.9% sodium chloride.

Question 37

A nurse is caring for a client 1 hour following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse’s priority?

initiate oxygen at 2 L/min via nasal cannula.
Apply firm pressure to the insertion site.
Take the client’s vital signs.
Obtain a stat order for an aPTT.

Answer 37

Initiate oxygen at 2 L/min via nasal cannula. (INCORRECT)
The nurse can apply oxygen to promote adequate tissue oxygenation. However, another intervention is the priority.

Apply firm pressure to the insertion site. (CORRECT)
The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding.

Take the client’s vital signs. (INCORRECT)
The nurse should take the client’s vital signs to further determine the client’s status. However, another intervention is the priority.

Obtain a stat order for an aPTT. (INCORRECT)
The nurse can request laboratory data to provide information about the client’s coagulation status. However, another intervention is the priority.

Question 38

A nurse is caring for a client who is 4 hours postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

extremity cool upon palpation
serosanguineous drainage on the dressing
capillary refill of 2 seconds
client report of discomfort when moving toes

Answer 38

Extremity cool upon palpation. (CORRECT)
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.

Serosanguineous drainage on the dressing. (INCORRECT)
Serosanguineous, or blood-tinged, drainage on the dressing is an expected finding following surgery. Serosanguineous drainage is present the first few days following surgery as the wound heals.

Capillary refill of 2 seconds. (INCORRECT)
A capillary refill of 2 seconds is within the expected reference range and indicates the client has adequate arterial blood flow. A delay in capillary refill can indicate an early manifestation of acute compartment syndrome.

Client report of discomfort when moving toes. (INCORRECT)
A report of discomfort when moving toes is an expected finding following surgery. However, a report of increased pain at the surgical site when moving can indicate an early manifestation of acute compartment syndrome.

Question 39

A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client’s plan of care?

collect and place the client’s urine or feces in a biohazard bag.
Limit the client’s ambulation to their own room.
Wear a lead apron while providing care to the client.
Limit each visitor to 1 hr per day.

Answer 39

Collect and place the client’s urine or feces in a biohazard bag. (INCORRECT)
With sealed implants, the client’s excretions are not radioactive. Standard precautions require gloves when handling body fluids or waste, but there are no special precautions required for this client’s excreta.

Limit the client’s ambulation to their own room. (INCORRECT)
Not only does the client require bedrest in a private room while the radiation implant is in place, but the nurse must also discourage the client from any excessive movements while in bed to prevent dislodging the implant.

Wear a lead apron while providing care to the client. (CORRECT)
The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure.

Limit each visitor to 1 hr per day. (INCORRECT)
The nurse should limit each of the client’s visitors to 30 min per day and instruct them to remain at least 1.8 m (6 ft) from the client at all times.

Question 40

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?

After 1 week of medication, TB is no longer communicable.
Dispose of contaminated tissues in a paper bag.
Airborne precautions are necessary in the home.
Family members in the household should undergo TB testing.

Answer 40

After 1 week of medication, TB is no longer communicable. (INCORRECT)
The nurse should inform the client that they are no longer contagious after 2 to 3 weeks of continuous medication therapy or following three consecutive negative sputum cultures, which are typically obtained every 2 to 4 weeks.

Dispose of contaminated tissues in a paper bag. (INCORRECT)
This is a highly communicable disease that is spread through aerosolization when the client sneezes, coughs, or laughs. The nurse should instruct the client to cover their mouth when sneezing or coughing and to place contaminated tissues in a plastic bag for disposal.

Airborne precautions are necessary in the home. (INCORRECT)
Airborne precautions are not necessary because household members have already been exposed to TB. However, the nurse should instruct the client to wear a mask when they are in public.

Family members in the household should undergo TB testing. (CORRECT)
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.

Question 41

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following findings indicates that the client is experiencing a complication?

The client reports that the sequential compression devices (SCDs) are uncomfortable.
The client reports pain at the surgical site as 4 on a scale of 0 to 10.
The client’s surgical site dressing has required changing twice in 2 hours due to drainage.
The client needs assistance with a walker when ambulating in the room.

Answer 41

The client reports that the sequential compression devices (SCD) are uncomfortable. (INCORRECT)
SCDs can often feel bulky and uncomfortable to clients; however, the nurse should encourage the client to wear them to prevent DVTs and promote circulation.

The client reports pain at the surgical site as 4 on a scale of 0 to 10. (INCORRECT)
Moderate pain is an expected finding after a total hip arthroplasty and does not indicate a complication. The nurse should provide pain management as prescribed.

The client’s surgical site dressing has required changing twice in 2 hr due to drainage. (CORRECT)
Frequent dressing changes after surgery may indicate poor clotting and increased bleeding.

The client needs assistance with a walker when ambulating in the room. (INCORRECT)
Clients are encouraged to use ambulatory aids following a total hip arthroplasty to promote safe ambulation.

Question 42

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Heart rate 110/min
Blood pressure 138/90 mm Hg
Urine specific gravity 1.001 (1.005 to 1.030)
Sodium 120 mEq/L (135 to 145 mEq/L)

Answer 42

Heart rate 110/min. (CORRECT)
A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate.

Blood pressure 138/90 mm Hg. (INCORRECT)
A blood pressure of 138/90 mm Hg is within the expected reference range. A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and hypotension.

Urine specific gravity 1.001 (1.005 to 1.030). (INCORRECT)
Urine specific gravity measures the concentration of particles in urine. Therefore, a client who has a 3-day history of vomiting and diarrhea is at risk for fluid loss from emesis and stool, which can lead to dehydration, and the urine specific gravity will be elevated to reflect concentrated urine. This measurement is below the expected reference range and more indicative of overhydration.

BUN 8 mg/dL (10 to 20 mg/dL). (INCORRECT)
A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit, resulting in a BUN greater than 20 mg/dL.

Question 43

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?

Neutralizing gastric acid
Reducing the growth of ulcer-causing bacteria
Coating the stomach lining
Suppressing gastric acid production

Answer 43

Neutralizing gastric acid. (INCORRECT)
Antacids, such as aluminum hydroxide, neutralize gastric acid.

Reducing the growth of ulcer-causing bacteria. (INCORRECT)
Antibiotics, such as amoxicillin, reduce the growth of the ulcer-causing bacteria Helicobacter pylori.

Coating the stomach lining. (INCORRECT)
Anti-ulcer medications, such as sucralfate, coat the stomach lining and adhere to the ulcer site.

Suppressing gastric acid production. (CORRECT)
Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production.

Question 44

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?

Teach the importance of a clear liquid diet after discharge.
Tell the client to remove the incisional adhesive strips 3 days after discharge.
Demonstrate ways to deep breathe and cough.
Instruct the client to maintain bed rest for 48 hr.

Answer 44

Teach the importance of a clear liquid diet after discharge. (INCORRECT)
The nurse should teach the client to advance to solid foods with the return of peristalsis, which usually occurs within 1 to 2 days after surgery, and to introduce foods high in fat one at a time to determine tolerance.

Tell the client to remove the incisional adhesive strips 3 days after discharge. (INCORRECT)
The nurse should tell the client that the incisional adhesive strips will begin to fall off 7 to 10 days after application and that the provider might remove the adhesive strips during that timeframe.

Demonstrate ways to deep breathe and cough. (CORRECT)
The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.

Instruct the client to maintain bed rest for 48 hours. (INCORRECT)
The nurse should instruct the client to ambulate as soon as possible to prevent postoperative complications, such as deep-vein thrombosis or pneumonia.

Question 45

A nurse is assessing a client while suctioning the client’s tracheostomy tube. Which of the following findings should indicate to the nurse that the client is experiencing hypoxia?

The client starts to cough.
The client’s heart rate increases.
The client is diaphoretic.
The client’s blood pressure decreases.

Answer 45

The client starts to cough. (INCORRECT)
The nurse should expect the client to cough during suctioning of a tracheostomy due to bronchial stimulation.

The client’s heart rate increases. (CORRECT)
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.

The client is diaphoretic. (INCORRECT)
Diaphoresis is not associated with suction-induced hypoxia. However, long-term hypoxia can lead to diaphoresis.

The client’s blood pressure decreases. (INCORRECT)
A client’s blood pressure can increase initially with hypoxia. If this occurs, the nurse should stop suctioning and manually oxygenate the client. Long-term hypoxia can lead to a decrease in blood pressure and shock.

Question 46

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?

Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
pH 7.28 (7.35 to 7.45)
Glucose 272 mg/dL (74 to 106 mg/dL)
HCO3 14 mEq/L (21 to 28 mEq/L)

Answer 46

Potassium 3.2 mEq/L (3.5 to 5 mEq/L) (INCORRECT)
The potassium level of a client who has DKA might be below, at, or above the expected reference range. A potassium level of 3.2 mEq/L does not indicate improvement in the client’s status.

pH 7.28 (7.35 to 7.45) (INCORRECT)
A pH of 7.28 is an expected finding of DKA and does not indicate improved client status.

Glucose 272 mg/dL (74 to 106 mg/dL) (CORRECT)
A glucose reading less than 300 mg/dL indicates improvement in the client’s status.

HCO₃ 12 mEq/L (21 to 28 mEq/L) (INCORRECT)
An HCO₃ level of 12 mEq/L is an expected finding of DKA and does not indicate an improvement in the client’s status.

Question 47

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Maintain adduction of the client’s legs.
Encourage range of motion of the hip up to a 120° angle.
Place a pillow between the client’s legs.
Keep the client’s hip internally rotated.

Answer 47

Maintain adduction of the client’s legs. (INCORRECT)
The nurse should assist the client to maintain their legs in abduction.

Encourage range of motion of the hip up to a 120° angle. (INCORRECT)
The client should not flex their hip greater than 90° to prevent hip dislocation.

Place a pillow between the client’s legs. (CORRECT)
The nurse should place a pillow between the client’s legs to prevent hip dislocation.

Keep the client’s hip internally rotated. (INCORRECT)
The nurse should not keep the client’s hip internally rotated, as this can lead to hip dislocation.

Question 48

A nurse in a provider’s office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Report of a night cough
Report of tinnitus
Report of excessive tearing
Report of increased salivation

Answer 48

Report of a night cough. (CORRECT)
The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider.

Report of tinnitus. (INCORRECT)
Propranolol is a nonselective beta-adrenergic antagonist that has sensory effects, including dry eyes and vision changes. However, tinnitus is not an adverse effect of propranolol.

Report of excessive tearing. (INCORRECT)
Propranolol is a nonselective beta-adrenergic antagonist that can affect the heart, the lungs, and the eyes. Ophthalmic adverse effects include blurred vision and dry eyes.

Report of increased salivation. (INCORRECT)
Propranolol is a nonselective beta-adrenergic antagonist that has several gastrointestinal effects, such as dry mouth, abdominal cramping, constipation, and diarrhea.

Question 49

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?

“Older adult clients might require up to 6 grams of acetaminophen over 24 hours for effective pain control.”
“Ibuprofen can cause gastrointestinal bleeding in older adult clients.”
“Meperidine is the medication of choice for older adult clients experiencing severe pain.”
“Older adult clients taking oxycodone are at risk for diarrhea.”

Answer 49

“Older adult clients might require up to 6 grams of acetaminophen over 24 hours for effective pain control.” (INCORRECT)
Acetaminophen is used for the relief of mild to moderate pain but has a maximum dose limit of 4 g per 24 hr for adults. A reduced dosage of 3 g per 24 hr is recommended for older adult clients.

“Ibuprofen can cause gastrointestinal bleeding in older adult clients.” (CORRECT)
A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.

“Meperidine is the medication of choice for older adult clients experiencing severe pain.” (INCORRECT)
Meperidine is contraindicated for older adult clients experiencing pain. The potential accumulation of the toxic metabolite normeperidine can result in CNS toxicities.

“Older adult clients taking oxycodone are at risk for diarrhea.” (INCORRECT)
Oxycodone is an opioid analgesic that slows intestinal motility in all age groups and increases the risk for constipation. The nurse should closely monitor older adult clients who are taking oxycodone for constipation and initiate a bowel regimen to minimize the constipating effects of the medication.

Question 50

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?

Obtaining vital signs
Placing the client in Fowler’s position
Administering epinephrine
Initiating an IV infusion of 0.9% sodium chloride

Answer 50

“Obtaining vital signs.” (INCORRECT)
The nurse should obtain the client’s vital signs to determine the status of the condition. However, evidence-based practice indicates that the nurse should take a different action.

“Placing the client in Fowler’s position.” (INCORRECT)
The nurse should place the client in Fowler’s position to promote lung expansion after determining the client is not hypotensive. However, evidence-based practice indicates that the nurse should take a different action first.

“Administering epinephrine.” (CORRECT)
Evidence-based practice indicates that the priority intervention is for the nurse to administer epinephrine quickly to dilate the bronchioles and prevent circulatory shock.

“Initiating an IV infusion of 0.9% sodium chloride.” (INCORRECT)
The nurse should initiate an IV infusion of 0.9% sodium chloride to maintain IV access and prevent circulatory collapse. However, evidence-based practice indicates that the nurse should take a different action first.

Question 51

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take?

Apply a wet-to-dry gauze dressing.
Irrigate with hydrogen peroxide solution.
Use a 30-mL syringe.
Attach a 24-gauge angiocatheter to the syringe.

Answer 51

“Apply a wet-to-dry gauze dressing.” (INCORRECT)
The nurse should not apply wet-to-dry dressings to clean, granulating wounds as they interrupt viable, healing tissues when they are removed. Appropriate dressings for a wound that is developing granulation tissue include a hydrocolloid dressing and a transparent film dressing.

“Irrigate with hydrogen peroxide solution.” (INCORRECT)
The nurse should use hydrogen peroxide to clean contaminated surfaces. However, hydrogen peroxide should not be used on a pressure injury wound because it destroys newly granulated tissue. Instead, the nurse should use solutions specifically designed as wound cleansers or 0.9% sodium chloride irrigation to irrigate the wound.

“Use a 30-mL to 60-mL syringe.” (CORRECT)
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

“Attach a 24-gauge angiocatheter to the syringe.” (INCORRECT)
The nurse should use an 18- or 19-gauge catheter that will apply the appropriate irrigation pressure. A 24-gauge angiocatheter delivers solutions at a higher pressure than necessary for irrigation and can potentially damage the developing granulation tissues.

Question 52

A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan?

Remind the client that dialysis treatments are not difficult to incorporate into daily life.
Inform the client that dialysis will result in a cure.
Tell the client that it is possible to return to similar previous levels of activity.
Begin health promotion teaching during the first dialysis treatment.

Answer 52

“Remind the client that dialysis treatments are not difficult to incorporate into daily life.” (INCORRECT)
The nurse should inform the client of the difficulty of incorporating dialysis into daily life to allow the client to develop realistic expectations.

“Inform the client that dialysis will result in a cure.” (INCORRECT)
The nurse should inform the client that dialysis is not a cure and is a lifelong management for chronic kidney disease.

“Tell the client that it is possible to return to similar previous levels of activity.” (CORRECT)
The nurse should help the client develop realistic goals and activities to have a productive life.

“Begin health promotion teaching during the first dialysis treatment.” (INCORRECT)
The nurse should begin health and lifestyle teaching in the first weeks after starting the dialysis treatment once the client feels better physically and emotionally.

Question 53

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted at the lung bases. Which of the following actions should the nurse anticipate taking?

Administer an antihistamine.

Slow the infusion rate.

Give the client a corticosteroid.

Elevate the client’s lower extremities.

Answer 53

“Administer an antihistamine.” (INCORRECT)
Antihistamines can manage an allergic transfusion reaction. Manifestations of an allergic reaction to a blood product include hives and itching.

“Slow the infusion rate.” (CORRECT)
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.

“Give the client a corticosteroid.” (INCORRECT)
Corticosteroids are prescribed to manage a septic or allergic transfusion reaction. If sepsis is suspected, the nurse should send the remainder of the blood product and the blood tubing to the laboratory for testing.

“Elevate the client’s lower extremities.” (INCORRECT)
The nurse should elevate the head of the client’s bed and lower the client’s legs to manage the client’s manifestations. The nurse should apply oxygen and anticipate a prescription for a diuretic or morphine.

Question 54

A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings indicates a potential complication?

The client’s urinary output has increased.

The client reports back pain.

The client’s urine color is red-tinged.

The client’s tube requires irrigation.

Answer 54

“The client’s urinary output has increased.” (INCORRECT)
The nurse should notify the provider if there is a decrease in urinary output, which can indicate impaired renal function or dysfunction of the nephrostomy tube.

“The client reports back pain.” (CORRECT)
The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged.

“The client’s urine color is red-tinged.” (INCORRECT)
Red-tinged urine is an expected finding for the first 12 to 24 hours following a nephrostomy tube insertion.

“The client’s tube requires irrigation.” (INCORRECT)
The nurse should identify this finding as expected after a nephrostomy tube insertion.

Question 55

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make?

“You should accept your body image change before discharge.”
“It is important for you to look at the incisional site when the dressings are removed.”
“I will refer you to community resources that can provide support.”
“The scar will remain red and raised for many years after surgery.”

Answer 55

“You should accept your body image change before discharge.”
INCORRECT
The nurse should explain that acceptance of the changed body image is individualized and usually occurs over a period of time.

“It is important for you to look at the incisional site when the dressings are removed.”
INCORRECT
The nurse should encourage the client to look at the incision when the client is ready.

“I will refer you to community resources that can provide support.”
CORRECT
The nurse should provide the client with support resources, including community programs, to assist with body image acceptance.

“The scar will remain red and raised for many years after surgery.”
INCORRECT
The nurse should tell the client that the redness and raised area will begin to decrease within the first few months after surgery.

Question 56

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?

Flex the affected arm when ambulating.
Numbness can occur along the inside of the affected arm.
Begin active range-of-motion exercises 1 day after surgery.
Dress in clothing that fits snugly.

Answer 56

Flex the affected arm when ambulating.
INCORRECT
The nurse should instruct the client to stand upright and avoid flexing the affected arm when ambulating to reduce the risk of elbow contracture.

Numbness can occur along the inside of the affected arm.
CORRECT
The nurse should inform the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury.

Begin active range-of-motion exercises 1 day after surgery.
INCORRECT
The nurse should instruct the client to begin active range-of-motion exercises 1 week after surgery to improve mobility without stressing the incision.

Dress in clothing that fits snugly.
INCORRECT
The nurse should recommend wearing loose-fitting clothing to avoid placing stress on the incision.

Question 57

A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend?

Add full-fat yogurt to the diet.
Add cabbage to the diet.
Replace butter with coconut oil.
Replace shellfish with red meat.

Answer 57

Add full-fat yogurt to the diet.
INCORRECT
To help reduce the risk for colorectal cancer, the client should consume a diet low in fat and refined carbohydrates. Full-fat yogurt contains fat, and many yogurt products also contain refined sugar.

Add cabbage to the diet.
CORRECT
A diet high in fiber, low in fat, and low in refined carbohydrates helps reduce the risk for colorectal cancer. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.

Replace butter with coconut oil.
INCORRECT
To reduce the risk for colorectal cancer, the client should follow a low-fat diet. Coconut oil, with 100 g of fat per 100 g, contains more fat than butter, which has 81 g of fat per 100 g.

Replace shellfish with red meat.
INCORRECT
Red meat is high in fat and should be avoided to reduce the risk for colorectal cancer. Lower-fat protein sources, such as shellfish and skinless poultry, are recommended.

Question 58

A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?

Dysphagia
Aphasia
Ataxia
Hemianopsia

Answer 58

Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding.
CORRECT

Aphasia indicates that the client is at risk for communication impairment. However, another finding is the priority.
INCORRECT

Ataxia indicates that the client is at risk for injury from falling. However, another finding is the priority.
INCORRECT

Hemianopsia indicates that the client is at risk for injury when ambulating. However, another finding is the priority.
INCORRECT

Question 59

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?

Set the wall suction to 80 to 100 mm Hg.
Compress the drain reservoir after emptying.
Allow the drainage to collect on a sterile gauze dressing.
Position the drain below the bed to promote drainage.

Answer 59

Set the wall suction to 80 to 100 mm Hg.
INCORRECT
Wall suction settings typically depend on the provider’s orders and the type of procedure performed; however, closed-suction drains generally do not require wall suction.

Compress the drain reservoir after emptying.
CORRECT
Compressing the drain reservoir after emptying helps create negative pressure, which facilitates drainage from the surgical site.

Allow the drainage to collect on a sterile gauze dressing.
INCORRECT
The purpose of a closed-suction drain is to collect drainage in the reservoir, not on a dressing.

Position the drain below the bed to promote drainage.
INCORRECT
The drain should be positioned below the surgical site (not necessarily below the bed) to promote proper drainage. However, positioning it below the bed may not be ideal.

Question 60

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?

Discontinuing the treatments is your choice if it is your wish to do so.
Your child is named as your health care surrogate. I will ask them if you can stop the treatments.
I will call your spiritual advisor to come in so you can discuss this with them.
Next time you have an oncology appointment, you should ask the oncologist.

Answer 60

“Discontinuing the treatments is your choice if it is your wish to do so.”
CORRECT
The nurse should recognize the client’s right to refuse treatments and inform them of this right. The nurse should advocate for the client and offer to contact the provider on their behalf.

“Your child is named as your health care surrogate. I will ask them if you can stop the treatments.”
INCORRECT
The individual named in the health care proxy is appointed to make decisions for the client when they are unable to do so. The client is still able to express their wishes; therefore, the health care surrogate does not need to participate at this time.

“I will call your spiritual advisor to come in so you can discuss this with them.”
INCORRECT
The nurse should not contact a spiritual advisor unless the client requests this, as it would violate the client’s right to privacy.

“Next time you have an oncology appointment, you should ask the oncologist.”
INCORRECT
The client should not have to wait until a later time to discuss their treatment plan with the oncologist. The client has the right to refuse treatments at any time, and the nurse should address this matter immediately.

Question 61

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?

“Wear an eye patch over one eye.”
“Make sure to have a staff member walk on your stronger side.”
“Scan the environment by turning your head from side to side.”
“Make sure to look at your feet while walking.”

Answer 61

“Wear an eye patch over one eye.”
INCORRECT
This intervention is useful for clients who have diplopia but is not a recommendation for clients with homonymous hemianopsia.

“Make sure to have a staff member walk on your stronger side.”
INCORRECT
During ambulation, the nurse should walk next to the client’s weaker side and be prepared to assist them. The use of a gait belt can add additional safety during ambulation.

“Scan the environment by turning your head from side to side.”
CORRECT
Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning the head from side to side helps enlarge the client’s visual field and is useful during mealtimes.

“Make sure to look at your feet while walking.”
INCORRECT
The nurse should encourage the client to look forward while ambulating, not at their feet. Looking at their feet can increase the risk of falls.

Question 62

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

“I will monitor my blood pressure while taking this medication.”
“I should take a vitamin D supplement to increase the effectiveness of the medication.”
“I should inform the provider if I experience an increased appetite while taking this medication.”
“I will decrease the amount of protein in my diet while taking this medication.”

Answer 62

“I will monitor my blood pressure while taking this medication.”
CORRECT
The client should monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy.

“I should take a vitamin D supplement to increase the effectiveness of the medication.”
INCORRECT
The client requires adequate intake of iron, folic acid, and vitamin B1 while taking this medication because they are essential for the production of erythrocytes.

“I should inform the provider if I experience an increased appetite while taking this medication.”
INCORRECT
Increased appetite is not an adverse effect of epoetin alfa. Adverse effects include seizures, heart failure, myocardial infarction, stroke, thrombolytic events, and hypertension.

“I will decrease the amount of protein in my diet while taking this medication.”
INCORRECT
The client should increase their protein intake while receiving chemotherapy to decrease the risk of infection.

Question 63

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?

Increase fluid intake.
Take an over-the-counter antidiarrheal medication.
Expect black, tarry stools.
Follow a low-fiber diet.

Answer 63

“Increase fluid intake.”
CORRECT
Increasing fluid intake will help prevent constipation. The nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.

“Take an over-the-counter antidiarrheal medication.”
INCORRECT
Taking an over-the-counter antidiarrheal following an upper gastrointestinal series would slow the elimination of the barium. The nurse should instruct the client to take a laxative instead.

“Expect black, tarry stools.”
INCORRECT
The client should expect stools to appear chalky white until the barium is completely eliminated, which typically takes between 24 and 72 hours. Black, tarry stools indicate gastrointestinal bleeding.

“Follow a low-fiber diet.”
INCORRECT
A low-fiber diet, used to treat diarrhea, does not facilitate the elimination of the barium. The nurse should recommend an increase in fiber intake instead.

Question 64

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?

“You will have an implant placed twice each month for the duration of the treatment.”
“You should remain at least 6 feet away from others between treatments.”
“You should expect to have blood in your urine for a few days after treatment.”
“You will need to stay still in the bed during each treatment session.”

Answer 64

“You will have an implant placed twice each month for the duration of the treatment.”
INCORRECT
The nurse should instruct the client that there will likely be between two and five treatments, once or twice each week.

“You should remain at least 6 feet away from others between treatments.”
INCORRECT
The nurse should instruct the client that there is no excreted radiation between treatments, so there are no restrictions regarding contact with others.

“You should expect to have blood in your urine for a few days after treatment.”
INCORRECT
The nurse should instruct the client that blood in the urine is an adverse effect of brachytherapy and is not an expected finding; the client should report this finding to the provider immediately.

“You will need to stay still in the bed during each treatment session.”
CORRECT
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.

Question 65

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?

“I will monitor my blood sugar carefully because the medication increases the secretion of insulin.”
“I should take this medication with a meal.”
“I can expect to gain weight while taking this medication.”
“While taking this medication, I will experience flushing of my skin.”

Answer 65

“I will monitor my blood sugar carefully because the medication increases the secretion of insulin.”
INCORRECT
Metformin decreases the amount of glucose produced in the liver and increases tissue sensitivity to insulin, rather than increasing insulin secretion.

“I should take this medication with a meal.”
CORRECT
The client should take metformin with or immediately following meals to improve absorption and minimize gastrointestinal distress.

“I can expect to gain weight while taking this medication.”
INCORRECT
Typically, clients may lose weight when beginning to take metformin due to nausea and vomiting.

“While taking this medication, I will experience flushing of my skin.”
INCORRECT
Flushing of the skin is not an adverse effect of metformin.

Question 66

A nurse is reviewing the laboratory results of a client who has a history of aplastic anemia. Which of the following findings indicates that the client is experiencing pancytopenia?

RBC count 6.3 million/mm³ (4.7 to 6.1 million/mm³ male)
WBC count 2,000/mm³ (5,000 to 10,000/mm³)
Platelets 450,000/mm³ (150,000 to 400,000/mm³)
Potassium 3.3 mEq/L (3.5 to 5 mEq/L)

Answer 66

“RBC count 6.3 million/mm³ (4.7 to 6.1 million/mm³ male).”
INCORRECT
An increased RBC count is not a manifestation of pancytopenia.

“WBC count 2,000/mm³ (5,000 to 10,000/mm³).”
CORRECT
A decreased WBC count, or leukopenia, is a manifestation of pancytopenia. Pancytopenia occurs when there is a decreased RBC count, decreased WBC count, and decreased platelets.

“Platelets 450,000/mm³ (150,000 to 400,000/mm³).”
INCORRECT
An increased platelet count is not a manifestation of pancytopenia. A decreased platelet count, or thrombocytopenia, is a component of pancytopenia.

“Potassium 3.3 mEq/L (3.5 to 5 mEq/L).”
INCORRECT
A decreased potassium level is not a manifestation of pancytopenia.

Question 67

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?

Check the client’s neurologic status.
Document the client’s statements.
Prepare the client for a CT scan.
Teach the client about using safety precautions for falls.

Answer 67

“Check the client’s neurologic status.”
CORRECT
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.

“Document the client’s statements.”
INCORRECT
The nurse should document the client’s statements to provide a complete history of the accident. However, there is another action that the nurse should take first.

“Prepare the client for a CT scan.”
INCORRECT
The nurse should prepare the client for a CT scan if the provider prescribes it. However, there is another action that the nurse should take first.

“Teach the client about using safety precautions for falls.”
INCORRECT
The nurse should teach the client fall precautions to promote safety. However, there is another action that the nurse should take first.

Question 68

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first?

Cover the wound with a sterile, saline-moistened dressing.
Place the client in a supine position.
Measure vital signs.
Call for help.

Answer 68

“Place the client in a supine position.”
INCORRECT
The nurse should place the client in a supine position to promote blood flow to the vital organs. However, evidence-based practice indicates that another action is the priority.

“Measure vital signs.”
INCORRECT
The nurse should measure the client’s vital signs to monitor for complications. However, evidence-based practice indicates that another action is the priority.

“Cover the wound with a sterile, saline-moistened dressing.”
INCORRECT
The nurse should cover the wound with a sterile, saline-moistened dressing to protect the organs. However, evidence-based practice indicates that another action is the priority.

“Call for help.”
CORRECT
Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock, so obtaining immediate assistance is essential.

Question 69

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

Constipation
Insomnia
Tachycardia
Diaphoresis

Answer 69

“Constipation.”
CORRECT
A client who has hypothyroidism can experience constipation due to the decrease in 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 of constipation.

“Insomnia.”
INCORRECT
A client who has hypothyroidism can have somnolence due to the decrease in metabolism related to the decreased secretion of thyroid hormone.

“Tachycardia.”
INCORRECT
A client who has hypothyroidism can have bradycardia due to a decrease in cardiac function related to the decreased secretion of thyroid hormone.

“Diaphoresis.”
INCORRECT
The thyroid hormone controls metabolic functions in the body. A client who has hypothyroidism is more likely to have dry, scaly skin due to the decreased secretion of thyroid hormone.