A.
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?
A. Take temperature once a day.
B. Wash the armpits and genitals with a gentle cleanser daily.
C. Change the litter boxes while wearing gloves.
D. Wash dishes in warm water.
A.
A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report?
1) Frequent mood changes
2) Constipation
3) Sensitivity to cold
4) Weight gain
A.
A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
A.
A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side effect of the neostigmine.
3) If a medication dose is missed, wait until the next scheduled dose to take the medication.
4) Treat nasal rhinitis with an over-the-counter antihistamine.
A.
A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
A.
A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?
1) Fully recollapse the reservoir after emptying it.
2) Empty the reservoir once per day.
3) Replace the drainage plug after releasing hand pressure on the device.
4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
A.
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client’s secretions?
A. Provide humidified oxygen.
B. Perform chest physiotherapy prior to suctioning.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
D. Hyperventilate the client with 100% oxygen before suctioning the airway..
A.
A nurse is caring for a client who has Alzheimer’s disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take?
1) Attempt to determine what the client was looking for.
2) Explain the client’s Alzheimer’s diagnosis to the frightened client.
3) Reprimand the client for invading the other client’s privacy.
4) Ask the client to apologize for his behavior.
A.
A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?
1) Check pedal pulses every 15 min.
2) Perform passive range-of-motion for the affected extremity.
3) Remind the client not to turn from side to side.
4) Keep the client in high-Fowler’s position for 6 hr.
A.
A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client’s chest, the nurse should expect to hear which of the following sounds?
1) Expiratory wheeze
2) Pleural friction rub
3) Fine rales
4) Rhonchi
A.
A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect?
1) Denial
2) Bargaining
3) Acceptance
4) Anger
A.
A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?
1) Reducing anxiety
2) Increasing blood pressure
3) Increasing coughing
4) Increasing the client’s respiratory rate
A.
A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor?
1) Respiratory difficulty
2) Confusion
3) Increased intracranial pressure
4) Joint pain
A.
A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A.
A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching?
1) “You should wear glasses instead of contacts while taking this medication.”
2) “The medication causes amenorrhea if taken along with an oral contraceptive.”
3) “A yellow tint to the skin is an expected reaction to the medication.”
4) “Lifelong treatment with this medication is necessary.”
A.
A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud’s phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
1) “I will keep my house at a cool temperature.”
2) “I will try to anticipate and avoid stressful situations.”
3) “I will complete the smoking cessation program I started.”
4) “I will wear gloves when removing food from the freezer.”
A.
A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching?
1) “I will take the medication with orange juice.”
2) “I should expect to have loose stools while taking this medication.”
3) “I will have clay colored stools while taking this medication.”
4) “I should take the medication with milk.”
A.
A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia?
1) Vitamin B12
2) Vitamin C
3) Iron
4) Folate
A.
A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take?
1) Empty the suction device every 4 hr.
2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr.
3) Position the client’s hip so that it is internally rotated.
4) Encourage foot exercises every 4 hr.
A.
A nurse is collecting data from a client who has Cushing’s syndrome. Which of the following manifestations should the nurse expect?
1) Bruising
2) Weight loss
3) Hyperpigmentation
4) Double vision
A.
A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective?
1) “I will take a stool softener until my eye is healed.”
2) “I will expect to have moderately severe pain for 1-2 days.”
3) “I will refrain from cooking for 1 week.”
4) “I will bend at the waist to tie my shoes.”
A.
A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?
1) Encourage the client to drink 8 glasses of water a day.
2) Instruct the client to cough every 4 hr.
3) Provide the client with a low protein diet.
4) Advise the client to lie down after eating.
A.
A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease?
1) An expanding circular rash
2) Swollen, painful joints
3) Decreased level of consciousness
4) Necrosis at the site of the bite
A.
A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm?
1) Combing her hair
2) Eating her breakfast
3) Buttoning her blouse
4) Tying her shoes
A
A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
4) Eyestrain
A.
Based on a client’s recent history, a nurse suspects that a client is beginning menopause. Which of the following questions should the nurse ask the client to help confirm the client is experiencing manifestations of menopause?
1) “Do you sleep well at night?”
2) “Have you been experiencing chills?”
3) “Have you experienced increased hair growth?”
4) “When did you begin your menses?”
A.
A nurse in a provider’s office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A.
A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale
A.
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
2) Place the client’s affected leg into the CPM machine with the machine in the flexed position.
3) Place the client into a high Fowler’s position when initiating the CPM exercises.
4) Align the joints of the CPM machine with the knee gatch in the client’s bed.
A.
A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse’s priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache
A.
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?
A. Avoid bending at the waist.
B. Remove the eye shield at bedtime.
C. Limit the use of laxatives if constipated.
D. Seeing flashes of light is an expected finding following extraction.
A.
A nurse notes a small section of bowel protruding from the abdominal incision of a client who
is postoperative. After calling for assistance, which of the following actions should the nurse take first?
A. Cover the client’s wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client’s vital signs.
D. Inform the client about the need to return to surgery.
A.
A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?
1) Loss of peripheral vision
2) Headache
3) Halos around lights
4) Discomfort in the eyes
A.
A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?
1) Change the ostomy pouch daily.
2) Empty the ostomy pouch when it is 2/3 full.
3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
4) Apply lotion to the peristomal skin when changing the ostomy pouch.
A.
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia
A, B
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
A, B, C
A nurse is caring for a client who has Cushing’s syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
4) Tremors
5) Obese extremities
A, B, C, D
A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
A, B, C, D
A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
5) Symmetrical joint pain
A, B, E
A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.)
1) Decreasing anxiety 2) Controlling emesis
3) Relaxing skeletal muscles
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
A, D
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
B.
A nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?
1) Temporary, reversible loss of brain function
2) Forgetfulness gradually progressing to disorientation
3) Sleeping more during the day than nighttime
4) Hyper vigilant behaviors
B.
A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?
1) Prone with arms raised over the head.
2) Sitting, leaning forward over the bedside table.
3) High Fowler’s position
4) Side-lying with knees drawn up to the chest.
B.
A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client?
1) “I took a laxative yesterday.”
2) “I took my metformin before breakfast.”
3) “I haven’t had anything to eat or drink since last night.”
4) “The last time I voided it was painful.”
B.
A nurse is reviewing the laboratory results of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory findings should the nurse identify as the most important to report to the provider?
1) Increase in serum glucose
2) Increase in serum creatinine
3) Decrease in white blood cell count
4) Decrease in platelets
B.
A nurse is reinforcing teaching with a client about cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the teaching?
1) Cottage cheese 2) Fresh berries
3) Bran cereal
4) Skim milk
B.
A nurse is assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?
1) Position the client supine while in bed.
2) Change the nasal drip pad as needed.
3) Encourage frequent brushing of teeth.
4) Encourage the client to cough every 2 hr following surgery.
B.
A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?
1) Limit fluid intake..
2) Monitor client’s cardinal fields of vision.
3) Encourage ambulation.
4) Ensure the room is brightly lit.
B.
A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?
1) Review stress factors that can cause disease exacerbation.
2) Evaluate fluid and electrolyte levels.
3) Provide emotional support.
4) Promote physical mobility.
B.
A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions?
1) A continuous seizure state in which seizures occur in rapid succession
2) A sensory warning that a seizure is imminent
3) A period of sleepiness following the seizure during which arousal is difficult
4) A brief loss of consciousness accompanied by staring
B.
A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities?
1) Observing for facial asymmetry
2) Checking pupillary responses to light
3) Eliciting the gag reflex
4) Testing visual acuity
B.
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?
1) Obtain vital signs.
2) Stop the transfusion.
3) Notify the registered nurse.
4) Administer diphenhydramine.
B.
A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective?
1) “My mouth is very dry.”
2) “I feel very sleepy.”
3) “I am not hungry any longer.”
4) “My leg feels numb.”
B.
A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?
A. Cool, clammy skin.
B. Hyperventilation
C. Increased blood pressure
D. Bradycardia
B.
A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer?
1) Aphagia
2) Hoarseness
3) Tinnitus
4) Epistaxis
B.
A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take?
1) Weigh the client weekly.
2) Irrigate the catheter as prescribed.
3) Instruct the client to report an urge to urinate.
4) Instruct the client to bear down as if to have a bowel movement every hour.
B.
A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
1) Decreased pedal pulses
2) Hypertension
3) Peripheral edema
4) Diarrhea
B.
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort?
A. Rub the client’s feet briskly for several minutes.
B. Obtain a pair of slipper socks for the client.
C. Increase the client’s oral fluid intake.
D. Place a moist heating pad under the client’s feet.
B.
A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend?
1) ½ cup whole-grain pasta with tomato sauce and pears
2) Turkey and cheese sandwich with scalloped potatoes
3) ½ cup black beans with a brownie
4) Roast beef with romaine lettuce salad
B.
A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching?
1) Omit your daily dose of aspirin.
2) Take a laxative the evening before the procedure.
3) Expect to be drowsy for 24 hr following the procedure.
4) You will feel cold chills after the dye has been injected.
B.
A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer?
1) Exposure to environmental pollutants
2) Sun exposure.
3) History of viral illness
4) Scars from a severe burn
B.
A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?
1) Apply ice to the extremity
2) Monitor platelet levels
3) Restrict oral fluids
4) Administer vasodilating medications
B.
A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take?
1) Loosen the knots on the ropes if the client is experiencing pain. 2) Ensure the client’s weights are hanging freely from the bed.
3) Check the client’s bony prominences every 12 hr.
4) Cleanse the client’s pin sites with povidone-iodine.
B.
A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?
1) Walk the client back to bed immediately and get the client a bedpan.
2) Tell the client to remain in the bathroom after toileting and obtain a wheelchair.
3) Warn the client she might have to be restrained if she gets up without assistance.
4) Keep the bathroom door open to ensure the client is okay.
B.
A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actions should the nurse take first?
1) Establish IV access.
2) Feel for a carotid pulse.
3) Establish an open airway.
4) Auscultate for breath sounds.
B.
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
1) Metabolic acidosis
2) Respiratory acidosis
3) Metabolic alkalosis
4) Respiratory alkalosis
B.
A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?
1) “Why have you changed your mind about the surgery?”
2) “Bypass surgery must be very frightening for you.”
3) “Your provider would not have scheduled the surgery unless you needed it.”
4) “I will call your doctor and have him discuss your surgery with you.”
B.
A nurse is checking the suction control chamber of a client’s chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
1) Notify the provider.
2) Verify that the suction regulator is on.
3) Continue to monitor the client because this is an expected finding.
4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
B.
A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the following statements by the client indicates an understanding of the teaching?
1) “I will not eat fried foods.”
2) “I will abstain from sexual intercourse.”
3) “I will refrain from international travel.”
4) “I will not order a salad in a restaurant.”
B.
A nurse is caring for a client who is postoperative and has a history Addison’s disease. For which of the following manifestations should the nurse monitor?
1) Hypernatremia 2) Hypotension
3) Bradycardia
4) Hypokalemia
B, C, E
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.)
1) Polyuria
2) Blurry vision
3) Tachycardia
4) Polydipsia
5) Sweating
C.
A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching?
1) “I will take this medication until my BUN returns to normal.”
2) “This medication will help my new kidney make adequate urine.”
3) “I will need to take this medication for the rest of my life.”
4) “This medication will boost my immune system.”
C.
A nurse is caring for a client who has Parkinson’s disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication?
1) Improved speech patterns
2) Increased bladder function.
3) Decreased tremors
4) Diminished drooling
C.
A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic cholecystectomy. Which of the following statements should the nurse make?
1) “The pain results from lying in one position too long during surgery.”
2) “The pain occurs as a residual pain from cholecystitis.”
3) “The pain will dissipate if you ambulate frequently.”
4) “The pain is caused from the nitrous dioxide injected into the abdomen.”
C.
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client’s mouth.
3) Add thickener to fluids.
4) Serve food at room temperature.
C.
A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?
1) Weight loss of 3% of total body weight.
2) Blood glucose 150 mg/dL.
3) Potassium 2.5 mEq/L
4) Urine specific gravity 1.035
C
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
3) Check the client’s vital signs.
4) Request an order for an antiemetic.
C.
A nurse is collecting data from a client who has AIDS. When checking the client’s mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions?
1) Xerostomia
2) Gingivitis
3) Candidiasis
4) Halitosis
C.
A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function.
C.
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper
gastric pain. Which of the following statements should the nurse include in the teaching?
1) “A flexible tube is introduced through the nose during the procedure.”
2) “During the procedure you are in a sitting position.”
3) “You will remain NPO for 8 hours before the procedure.”
4) “You will be awake while the procedure is performed.”
C.
A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?
1) Aura phase
2) Presence of automatisms
3) Postictal phase
4) Presence of absence seizures
C.
A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client’s postoperative prescriptions, which include, “Clear liquids, advance diet as tolerated.” Which of the following actions should the nurse take first?
1) Offer the client apple juice.
2) Elevate the client’s head of bed.
3) Auscultate the client’s abdomen.
4) Order a lunch tray for the client.
C.
A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax?
1) Inspiratory stridor
2) Expiratory wheeze
3) Absence of breath sounds
4) Coarse crackles
C.
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?
1) Provide a diet high in protein.
2) Provide ibuprofen for retroperitoneal discomfort.
3) Monitor intake and output hourly
4) Encourage the client to consume at least 2 L of fluid daily.
C.
A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?
1) Measure abdominal girth daily.
2) Use sterile water to irrigate the nasogastric tube..
3) Maintain the client in Fowler’s position.
4) Moisten the client’s lips with lemon-glycerin swabs.
C.
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
C. Thick, red-colored urine
D. Pain level of 4 on a 0 to 10 rating scale
C.
A nurse in a provider’s office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect?
1) Report of urinary retention
2) Elevated blood pressure above 140/90
3) Report of dryness with vaginal intercourse
4) Elevated body temperature above 37.8° C (100° F)
C.
A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times?
1) On the same day every month
2) Prior to the beginning of menses
3) Three to seven days after menses stops
4) On the second day of menstruation
C.
A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?
1) “The pain is worse after I eat a meal high in fat.”
2) “My pain is relieved by having a bowel movement.”
3) “I feel so much better after eating.”
4) “The pain radiates down to my lower back.”
C.
A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority?
1) Promote the client’s expression of feelings about loss of self-care ability.
2) Encourage the client to recall positive life events.
3) Schedule pain medication on a routine basis.
4) Suggest ways the client can continue interacting with social contacts.
C.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
1) Monitor for elevated blood pressure.
2) Provide analgesia for headaches.
3) Prevent bladder distention.
4) Elevate the client’s head.
C.
A nurse is reinforcing teaching with a client who has a new prescription for epoetin alfa. The nurse should reinforce to the client to take which of the following dietary supplements with this medication?
1) Vitamin D
2) Vitamin A
3) Iron
4) Niacin
C.
A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?
1) “You shouldn’t feel any pain since the local area is anesthetized.”
2) “Most clients report more discomfort from the preparation than from the procedure itself.”
3) “You may feel some cramping during the procedure.”
4) “Don’t worry; you won’t remember anything about the procedure due to the effects of the medication.”
C.
A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take?
1) Remove the entire dressing at once.
2) Loosen the dressing by pulling the tape away from the wound.
3) Don clean gloves to remove the dressing.
4) Open sterile supplies before removing the dressing.
C.
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?
1) Rest in a supine position.
2) Consume a low-protein diet.
3) Breathe in through her nose and out through pursed lips.
4) Limit fluid intake throughout the day.
C.
A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?
1) To provide analgesia
2) To reduce inflammation
3) To prevent blood clotting
4) To prevent fever
C.
A nurse is assisting with planning an immunization clinic for older adult clients. Which of the following information should the nurse plan to include about influenza?
1) Individuals at high risk should receive the live influenza vaccine.
2) Immunization for influenza should be repeated every 10 years.
3) The composition of the influenza vaccine changes yearly.
4) The influenza vaccine is necessary only for clients who have never had influenza.
C.
A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take?
1) Tell the client to have a family member call the provider to ask what options he plans to recommend.
2) Assure the client that the provider will tell him what is planned.
3) Help the client write down questions to ask his provider.
4) Provide the client with a pamphlet of information about cancer.
C.
A nurse is caring for a client who has hemiplegia following a stroke. The client’s adult son is distressed over his mother’s crying and condition. Which of the following responses should the nurse make?
1) “If you just sit quietly with your mother, I’m sure she will calm down.”
2) “I’ll talk with your mother and see if I can comfort her.”
3) “It must be hard to see your mother so ill and upset.”
4) “Your mother’s crying seems to bother you more than it does her.”
C.
A nurse is reviewing the plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse recommend?
1) Apply topical antifungal agents.
2) Apply fresh ice packs every 4 hr.
3) Wash daily with an antibacterial soap.
4) Keep draining lesions uncovered to air dry.
C.
A nurse is reviewing data for a client who has a head injury. Which of the following findings should indicate to the nurse that the client might have diabetes insipidus?
1) Serum sodium 145 mEq/L
2) Urine specific gravity 1.028
3) Urine output 650 mL/hr
4) Blood glucose 198 mg/dL
C.
A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?
1) Decreased perfusion
2) Infection
3) Granulation tissue
4) An inflammatory response
C.
A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching?
1) “When my vision improves, I will be able to stop taking the eye drops.”
2) “If I forget to take my eye drops, I should wait until the next time they are due.”
3) “I should call the clinic before taking any over-the-counter medications.”
4) “Every two years I will need to have my vision checked by an eye doctor.”
C.
A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?
1) Urticaria
2) Muscle pain
3) Hypotension
4) Distended neck veins
C.
A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses?
1) Neck vein distention
2) Blood pressure
3) Body weight
4) Abdominal girth
D.
A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report?
1) Hot flashes
2) Recurrent urinary tract infections
3) Blood in the stool
4) Abnormal vaginal bleeding
D.
A nurse is contributing to the plan of care for a client who has a spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client’s mobility?
1) Walk with leg braces and crutches.
2) Drive an electric wheelchair with a hand-control device.
3) Drive an electric wheelchair equipped with a chin-control device.
4) Propel a wheelchair equipped with knobs on the wheels.
D.
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?
1) “I will avoid crossing my legs at the knees.”
2) “I will use a thermometer to check the temperature of my bath water.”
3) “I will not go barefoot.”
4) “I will wear stockings with elastic tops.”
D.
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching?
1) Empty the pouch immediately after meals.
2) Change the entire appliance once a day.
3) Limit fluid intake.
4) Avoid medications in capsule or enteric form.
D.
A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?
1) “An escharotomy surgically removes dead tissue.”
2) “A cannula will be inserted into the bone to infuse fluids and antibiotics.”
3) “A piece of skin will be removed and grafted over the burned area.”
4) “Large incisions will be made in the burned tissue to improve circulation.”
D.
A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
1) Polyuria
2) Battle’s sign
3) Nuchal rigidity
4) Lethargy
D.
A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching?
1) “Tonometry is performed to evaluate peripheral vision.”
2) “This test will diagnose the type of your glaucoma.”
3) “Tonometry will allow inspection of the optic disc for signs of degeneration.”
4) “This test will measure the intraocular pressure of the eye.”
D.
A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client’s right nostril.
Which of the following actions should the nurse take first?
1) Take the client’s temperature.
2) Place a dressing under the client’s nose.
3) Notify the charge nurse.
4) Test the drainage for glucose.
D.
A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?
1) Apical pulse rate different than the radial pulse rate
2) Increase in heart rate by 20% when standing
3) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position
4) Drop in systolic BP more than 10 mm Hg on inspiration
D.
A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client?
1) Hypothermia
2) Hyponatremia
3) Fluid imbalance
4) Airway obstruction
D.
A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
1) Serosanguineous drainage
2) Mild erythema
3) Warmth
4) Fever
D.
A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period?
1) Malnourishment related to NPO status and dysphagia
2) Impaired verbal communication related to the tracheostomy
3) High risk for infection related to surgical incisions
4) Ineffective airway clearance related to thick, copious secretions
D.
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will carry a complex carbohydrate snack with me when I exercise.”
B. “I should exercise first thing in the morning before eating breakfast.”
C. “I should avoid injecting insulin into my thigh if I am going to go running.”
D. “I will not exercise if my urine is positive for ketones.”
D.
A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take?
1) Advise the client to lie down after meals.
2) Instruct the client to restrict food intake prior to treatment.
3) Provide the client with an antiemetic 2 hr prior to the chemotherapy.
4) Encourage the client to drink a carbonated beverage 1 hr before meals.
D.
A nurse is preparing to provide morning hygiene care for a client who has Alzheimer’s disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take?
1) Turn the water on and ask the client to test the temperature.
2) Obtain assistance to place mitten restraints on the client.
3) Firmly tell the client that good hygiene is important.
4) Calmly ask the client if he would like to listen to some music.
D.
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
1) Frothy sputum
2) Dyspnea
3) Orthopnea
4) Peripheral edema
D.
A nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. Which of the following interventions should the nurse include in the plan?
1) Perform the client’s personal care activities for her.
2) Limit the client’s fluid intake.
3) Monitor the Homan’s sign.
4) Maintain abduction of the right hip.
D.
A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse?
1) The wound is tender to touch.
2) The wound has pink, shiny tissue with a granular appearance.
3) The wound has serosanguineous drainage.
4) The wound has a halo of erythema on the surrounding skin.
D.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make?
1) “You must be very worried about what the biopsy will show.”
2) “You’ll be asleep for the whole biopsy procedure and won’t be aware of what’s happening.”
3) “Your provider scheduled this, so she will want to know you still have questions about the procedure.”
4) “The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible.”
D.
A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a close family contact tests positive. Which of the following measures should the nurse anticipate preparing for this client?
1) Tuberculin skin test
2) Sputum culture for acid fast bacillus (AFB)
3) Bacille Calmette-Guérin (bCG) vaccine
4) Chest x-ray
D.
A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider?
1) “The bright light in this room is really bothering me.”
2) “My eye really itches, but I’m trying not to rub it.”
3) “It’s really hard to see with a patch on one eye.”
4) “I need something for the horrible pain in my eye.”
D.
A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client?
1) Baked chicken
2) Bagels
3) A factory-sealed box of chocolates
4) Fresh fruit basket
D.
A nurse is reinforcing discharge teaching with a client who had a total abdominal hysterectomy and a vaginal repair. Which of the following statements by the client indicates a need for further teaching?
1) “I should increase my intake of protein and vitamin C.”
2) “I will no longer have menstrual periods.”
3) “Once I am able to resume sexual activity, I can use a water-based lubricant if I experience discomfort.”
4) “I will take a tub bath instead of a shower.”
D.
A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize which of the following is the priority action?
1) Relieve the client’s pain.
2) Check the client’s pressure points for redness.
3) Provide oral hygiene.
4) Prevent aspiration.
D.
A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
D.
A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan?
1) Irrigate the nasogastric tube with tap water.
2) Mark abdominal girth once daily.
3) Ambulate the client twice daily.
4) Place the client in a high Fowler’s position.
D.
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client’s wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent
D.
A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the client’s renal function?
1) Antinuclear antibody
2) C-reactive protein
3) Erythrocyte sedimentation rate
4) Serum creatinine
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1. A client is admitted to the hospital with symptoms consistent with right hemisphere stroke. With
Neurovascular assessment requires immediate intervention by the nurse?
A. Pupillary changes to ipsilateral dilation
B. Orientation to person and place only.
C. Left Sided Facial dropping and dysphagia
D. Unequal bilateral hand grip strengths
2. Achieve maximum mobility and independence for a client multiple sclerosis (MS). Which intervention
is most important for the nurse to implement?
A. Provide a walker for ambulation
B. Frequently assist client to the bathroom
C. Apply alternating patches over the eyes
D. Teach strengthing exercises
3. The Nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations
should the nurse recommend the client to follow?
A. Limit oral Fluid intake to 500 mL per day
B. Restrict protein intake by including meats and other high protein foods
C. Increase intake of potassium-rich foods such as bananas or cantaloupe
D. Increase intake of high fiber foods, such as bran cereal.
4. The nurse Is caring for a client with herpes zoster who reports painful blisters that align from the back
along the chest curvature to the anterior chest. Which intervention is the highest priority for the nurse?
A. Place the client on contact precaution
B. Administer antiviral medication
C. Place wet compresses to ruptured vesicles
D. Administer narcotic analgesics
5. A young adult who suffered a severe brain injury in an automobile collision has been mechanically
ventilated for the past three days and has no spontaneous respiratory effort. After serial
electroencephalograms (EEG) reveal no brain activity, the healthcare provider discusses end-of-life
options with family who agree to discontinue life support. Which intervention should the nurse
implement?
A. Ask the family if they wish would remain at bedside during withdrawal
B. Request a living will be placed in the client’s medical record
C. Discuss the withdrawal procedure with the family and offer support
D. Turn off the mechanical ventilator and note the time of death
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6. Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with
an indwelling urinary catheter. Which instruction is most important for the nurse to include in the
discharge teaching plan?
A. Eliminate all the spicy food from your diet
B. Drinl 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
7. On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over
the bed railing. Previously he was oriented to person, place, and time on admission. Which intervention
should the nurse implement first?
A. Apply wrist restraints
B. Determine the clients blood pressure
C. Administer a mild sedative
D. Asses the client for pain
8. Acute soft-tissue injuries (I.e. sprains, strains) provide the nurse with a variety of teaching opportunities.
Which instruction should the nurse provide to a client with a soft-tissue injury?
A. Watch for shortness of breath which may indicate a fat embolus
B. Begin range of motion exercises within the first 24 hours
C. Apply Ice intermittently for the first 24 hours
D. After edema subsides, apply heat continuously
9. A male client is admitted to the rehabilitation unit following a cerebrovascular (CVA), which resulted in
paralysis of his right arm. When the nurse enters the room, he is struggling to put on a shirt, and he
curses at the nurse. What is the best response from the nurse?
A. “We will give you a class on dressing tomorrow”
B. This unit has a policy against staff harassment
C. Dressing must be a frustrating experience for you”
D. “It is important to dress the right arm first”
10. A client returns to unit following a craniotomy for removal of brain tumor and is obtunded but arouses
to painful stimuli. Which assessment is most important for the nurse to obtain?
A. Drainage on dressing
B. Last administration of analgesia
C. Body temperature
D. Serial blood pressure and pulse
11. An older client who is agitated, dyspneic, orthopneic, and using accessory muscle to breathe is admitted
for further treatment. Initialassessment indicates beats/minute and irregular, respirations 36
Med Surg Exam 2023
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breaths/minute, blood pressure 168/100 mmHg. Wheezes and crackles in alllung fields. An hour after
the administered mg IV, which assessment should the nurse obtain to determine the client’s response to
treatment? (Select all that apply)
A. Skin
B. Pain scale
C. Lung Sounds
D. Urinary output
E. Oxygen saturation
12. The nurse is caring for an older male client with impaired skin integrity to sheering forces and pressure
that is manifested as a draining stage 3 sacral ulcer. Which intervention is most important for the nurse
to implement?
A. Teach the family how to perform wound care
B. Encourage a diet high in protein
C. Ensure that IV fluids are administered as prescribed
D. Daily Range of motion exercise
13. While planning care for a client with carpal tunnel syndrome. The nurse identifies a collaborative
problem of pain. What is the etiology of this problem?
A. Compression of a nerve
B. Diminished blood flow
C. Ischemic tissue changes
D. Irritation of nerve endings
14. A young adult female visits the clinic for primary dysmenorrhea and tells the nurse that she started
taking a calcium supplement to reduce her menstrual cramps. But I quit taking calcium because it caused
constipation. The client to know what she does to relive her menstrual cramps. Which action should the
nurse implement first to address the client’s concern?
A. Encourage client to increase her dietary intake fiber
B. Question the client about her use of birth control pills
C. Ask her how much calcium she had been taking daily
D. Determine if she takes any over-the-counter analgesics
15. A client with a medical diagnosis of a ruptured cerebral aneurysm exhibits these symptoms no eye
opening, no sound vocalized, and flexion to pain (decorticate posturing). When calculating the Glasgow
Coma Scale score, Which value should the nurse document for this client?
A. 13
B. 9
Med Surg Exam 2023
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C. 3
D. 5
16. A client with acute myelogenic leukemia (AML) is admitted to chemotherapy (CT) using cytarabine and
the antitumor daunorubion . Which measures are most important for the nurse to implement during the
induction stage of chemotherapy?
A. Assessment for graft versus host disease
B. Precautions to prevent infection and bleeding
C. Administration of whole blood product
D. Scheduling of outpatient maintenance therapy
17. To reduce pulmonary complications for a client with Amyotrophic Lateral sclerosis (ALS). Which
intervention should the nurse implement? (Select allthat apply)
A. Perform chest physiotherapy
B. Establish a regular bladder routine
C. Initiate passives engage of motion exercises
D. Encourage use of incentive spirometer
E. Teach the client breathing exercises
18. A client with polycystic Kidney is admitted because of an abrupt onset of massive polyuria. The client is
pale, tachycardia and female. Which serum laboratory finding requires immediate intervention by the
nurse?
A. Sodium 184 mEq/L
B. Glucose 110 mg/dL
C. Calcium 9 mg/dL
D. HCO3 25 mEq/L
19. A client tells the nurse, “I just received good news about my tumor, I have a neoplasm, but it is benign.”.
How should the nurse respond?
A. Inform the healthcare provider that the client does not understand the test results
B. Ask the client if the diagnostic test indicates any secondary metastasis
C. Reinforce the clients joy and clarify the typical use of the team “neoplasm”
D. Explain to the client the seriousness of having neoplastic disease.
20. The Nurse is assessing a client diagnosed with medical diagnosis of a Bartholin cyst. Which physical
assessment technique should the nurse use to observe the cyst?
A. Listen for bowel sounds in all four quarters of the abdomen
B. Place the client in lithotomy position to perform a pelvic examination
C. Ask the client to lie flat and cough while the nurse visualizes the inguinal area
D. Expose the lesson to a woods lamp and observe for fluorescence
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21. The nurse is preparing to administer enoxaparin 90 mg subcutaneously daily to a client with pulmonary
embolism. The pharmacy provides a prefilled syringe labeled, “Enoxaparin 100 mg/1ML “How many
milliliters should the nurse administer?
22. While performing a neurovascular assessment distal to a client’s fracture site, the nurse determines that
the client’s pulse is present, regular, and full. Which nursing action should be taken next?
A. Notify the healthcare provider of assessment finding
B. Document the neurovascular assessment as normal
C. Discontinue elevating the client’s affected extremity.
D. Asses for color, feeling, discomfort, and movement
23. Magnesium hydroxide, 1.5 ounces P.O is prescribed for a client complaining of heartburn. After taking
the prescribed dose 3 times today, how many mL of magnesium hydroxide has the client ingested?
24. A client with renal calculus is complaining of severe right flank pain, nausea, and vomiting. Which
nursing problem has the highest priority?
A. Acute pain related to renal calculus
B. Impaired renal function to pain
C. Nutritional deficit related to nausea
D. Risk for aspiration related to vomiting
25. Which Technique should the nurse use when assessing for early signs of rheumatoid arthritis?
A. Palpate large joints for nodules
B. Palpate the lymph nodes
C. Observe the skin for lesions
D. Observe the clients’ fingers
26. A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Wich nursing
action has the highest priority in responding to the symptoms of this syndrome?
A. Identify potential sources of infection
B. Maintain intravenous therapy
C. Instruct the client to take analgesics on a regular schedule.
D. Encourage the client to verbalize anxiety and grief
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27. A client with Hepatitis A is complaining of weakness and chronic fatigue. Which intervention is most
important for the nurse to implement?
A. Provide liberal fluids for hydration and excretion of metabolic waste products
B. Place belongings with client reach so bed rest can be maintained
C. Encourage dietary selections that are high in essential vitamins and Iron
D. Ensure the client has scheduled rest periods every 4 to 6 hours during the day
28. A client who had a cast yesterday to the lower left arm comes to the clinic complaining of pain in the
cast arm. Which assessment finding is most important for the nurse to identify?
A. Presence of a pressure ulcer under the cast
B. Location of burning pain below the cast
C. Circulatory impairment distal to the cast
D.
29. The nurse review lab values of a female client with metastatic breast cancer and notes that the client’s
serum calcium level is 14 mg/dL. The client is weak, fatigued, and depressed. New prescriptions include
increasing the rate of intravenous fluids. Which action should the nurse take first?
A. Increase the intravenous fluids as prescribed.
B. Offer to provide privacy so the client can rest
C. Encourage verbalization of the clients’ feelings
D. Provide a nutritional supplement for a snack
30. A client with hypovolemic shock is admitted to the intensive care unit with an intraosseous (IO) vascular
access device placed in the right proximal tibia. The client has received two liters of normal saline and
one unit of packed red blood cells through the IO access device since admission. Which assessment
finding warrants immediate intervention by the nurse?
A. Client reports tenderness at intraosseous insertion site
B. Client verbalizes feeling tightness in right calf muscle.
C. IO Vascular access in lace greater than 24 hours
D. Sluggish intraosseous blood return when aspirated
31. A client has a neutrophil count of (ANC) of 500/mm3 (0.5 x 109/L) after completing chemotherapy.
Which intervention is most important for the nurse to implement?
A. Implement bleeding precaution
B. Review needs for pneumococcal vaccine
C. Asses Vital signs every 4 hours
D.
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32. Clients’ laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse
suspects that the client may have hyperthyroidism. Which symptom is most often associated with
hyperthyroidism?
A. Atrophied thyroid gland
B. Increased pulse rate
C. Periorbital edema
D. Diarrhea Stools
33. Prior to initiating peritoneal dialysis, which nursing action is most important for the nurse to implement?
A. Determine the client’s oxygen saturation
B. Obtain and record the clients’ vital signs
C. Ascultate the clients’ vital signs
D. Observe the amount and color of the client’s urine
34. The nurse is preparing to insert an indwelling catheter for a male client who has diabetes and a semirigid
penile implant. After placing the sterile drapes and prepping the meatus, the nurse notes that the client’s
penis is erect. Which action should the nurse implement?
A. Ask the client to deflate the implant
B. Talk to the client about his implant
C. Continue to insert the catheter
D. Wait until the erection subsides
35. Which finding should the nurse document as primary manifestation of osteoporosis in an older woman?
A. Loss of height over time
B. Decreased serum calcium level
C. Pain in the spine and neck
D. Abnormal cardiac status in the ECG
36. The nurse is conducting discharge teaching for a male client with a prescription for magnesium
hydroxide 15 mL one time per day. His home medication cup is ounces. How many ounces should he
take each dose?
A. 0.5 ounces
B. 0.05 ounces
C. 0.25 ounces
D. 1 ounce
37. Which change in lab values would indicate to the nurse that treatment for gout is successful?
Med Surg Exam 2023
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A. Increased Serum uric acid
B. Decreased serum purine
C. Increased serum purine
D. Decreased serum uric acid
38. A client with acute renal injury (AKI) weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/L)
is admitted to the hospital. Which prescribed medication should the nurse first administer?
A. Sevelamer one tablet PO
B. Calcium acetate one tablet PO
C. Sodium polystyrene sulfonate 15 grams PO
D. Epotin alfa, recombinant 2,500 Units SUBQ
39. Following the administration of intravenous regular insulin to a client diagnosed with hyperkalemia, the
nurse should expect which outcome to occur?
A. A temporary shift of potassium into the cells
B. An increase of potassium in the urinary output
C. An improvement in the cardiac conduction abnormalities
D. Excretion of potassium via bowel movement
40. An adult male who is insulin dependent diabetic. Is admitted to the hospital because of headaches. When
the client stiffens and begins to seize. Which intervention is most important for the nurse to implement?
A. Pad all side rails with available pillows and blankets
B. Determine the clients blood glucose level
C. Give the client a rapid form of glucose supplement
D. Obtain a suction set-up in the room
41. A young adult is burned when wearing a shirt that was splashed with lighter fluid and caught. The shirt
immediately without unbuttoning. What should the nurse implement first?
A. Assess range of motion
B. Monitor pulse intensity
C. Evaluate extremity sensation
D.
42. A female client returns to the clinic after being treated for chlamydia with azithromycin IM and reports
that she still has symptoms. The healthcare provider obtains a swab of the discharge from the cervix for
testing chlamydia. The client reports maintaining a monogamous relationship when laboratory results
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are positive for sexually transmitted infection. Which information should the nurse obtain to evaluate the
ineffective results of treatment?
A. Determine if the clients sexual partner received treatment for chlamydia
B. Ask the client if the complete course of antibiotics was completed
C. Confer with the healthcare provider about a different course of antibiotics
D. Inquire further about all sexual encounters and any other sexual activity
43. The nurse implements a change in the approach to the client care after gathering evidence of a new
approach. What should the nurse do first?
A. Engage staff in evidence-based practice
B. Consult with clinical nursing expert
C. Revise clinical practice guidelines
D. Evaluate effectiveness of the change
44. The Home Health nurse is caring for a client with Parkinson’s disease who is beginning to experience
swallowing difficulties. Which intervention should the nurse include for this client?
A. Teach the client to take his medication an hour before meals to enhance the swallowing reflex
B. Tell the client to lay on his left side to prevent his tongue from falling back in his mouth
C. Prepare the client and the family for the future need of a gastrostomy tube for feeding
D. Encourage the client and family to provide a semi-solid diet with thick liquids
45. A client with chronic cirrhosis has esophageal varices. it is most important for the nurse to monitor the
client for?
A. Hematemesis
B. Brown foamy urine
C. Anorexia
D. Clay colored stool
46. The intracranial pressure of a brain-injured client who is on a ventilator has increased from 15 mm Hg to
25 mm Hg within the last 30 minutes. The client is beginning to flex all extremities intermittently. Based
on these findings, which immediate action should the nurse take?
A. Draw stat arterial gases to the hypercapnia
B. Manually ventilate the client using and ambu bag
C. Asses the patency of the client’s artificial airway
D.
47. A young male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. Which
information should the nurse include in the teaching plan?
A. Epididymitis is a pre-cancerous condition
B. Avoid penile contact with rectal area
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C. Surgical intervention often indicated
D. Obtain an annual prostate digital exam
48. The ESR (sedimentation rate) of a client being treated with corticosteroids for rheumatoid arthritis has
decreased. Which explanation should the nurse provide the client to explain this change in lab values?
A. The treatment so far has not been effective
B. A value of 0 will indicate that that the client is cured
C. The client is most likely responding to treatment
D. The client disease is currently in a remission
49. A client has a prescription for a viscous compound containing lidocaine HCL and diphenhydramine to
relieve the discomfort of mucositis caused by radiation therapy. Which instructions should the nurse
provide the client about administration of this prescription?
A. Saturate a sterile dressing with the solution and pack the wound lightly
B. Dab the solution over the reddened areas and cover the site with occlusive dressing
C. Gently pat the solution on the sore areas, using cotton tipped applicators
D. Swish the solution around in the mouth, and swallow the remaining solution
50. A client admitted dehydration resulting from vomiting and diarrhea. The nurse knows that the client is at
greatest risk of developing which condition?
A. Bowel perforation
B. Papilledema
C. Tinnitus
D. Cardiac dysrhythmia
51. When the nurse begins discharge instructions for a client and her spouse, the client who had an above
the knee amputation for complications associated with diabetes, tells the nurse that she is not ready to go
home and wants to stay home in the hospital another day, which intervention is important for the nurse
to implement?
A. Explain the take home medications that can help the client manage her anxiety
B. Tell the spouse to wait outside the room so the nurse can interview the client alone
C. Ask the client what frightens her about leaving the hospital and returning home
D. Review the details of the home health care plan devised by the multidisciplinary team
52. The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which
intervention has the highest priority when providing care for the client?
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A. Obtain results of culture and sensitivity of CSF
B. Administer initial dose of broad-spectrum antibiotic
C. Instruct the client to force fluids hourly
D. Asses the client for symptoms of hyponatremia
53. While performing assisted range of motion exercises for a client with osteoarthritis, the nurse notes joint
crepitus. Which action should the nurse take?
A. Notify the healthcare provider of findings
B. Continue the range of motion exercises
C. Immobilize the extremity joint
D. Apply moist heat to the site
54. A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusion.
The client has a living will and the family is requesting hospice information. Which information should
the nurse provide regarding hospice? (Select all thatApply)
A. Can be provided within comfort of home
B. Provides comfort, dignity, and emotional support
C. Hospice services can be initiated prior to discharge
D. A living will become invalid when receiving hospice care
E. Family members can be involved in the plan of care