Practice Questions

Immune and Infection:

1. A nurse in a provider’s office is caring for an 18-year-old client who presents for a physical examination
and update of immunizations prior to traveling abroad for college. The client has no record of receiving
meningococcal, hepatitis B, tetanus, or measles, mumps, and rubella (MMR) vaccines since early
childhood. The client also reports not receiving the human papillomavirus (HPV) vaccine.
The client is alert and oriented ×3 and moves all extremities well. Respirations are even and unlabored, and
breath sounds are clear. The client reports a runny nose with clear drainage. Heart rate is regular with no
murmurs. Abdomen is soft with normoactive bowel sounds.
The nurse notes the following additional history:
 History of sickle cell disease
 History of throat swelling after consuming baker’s yeast
 Family history of hypertension and diabetes mellitus
The client is scheduled to receive the following vaccines over the next few weeks prior to travel: influenza,
meningococcal, hepatitis B, MMR, HPV, and diphtheria, tetanus, and pertussis (DTaP).
Vital signs are within normal limits:
 Temperature: 37.4°C (99.3°F)
 Blood pressure: 120/68 mm Hg
 Heart rate: 82/min
 Respiratory rate: 16/min
 Oxygen saturation: 100% on room air
The nurse is reviewing the client’s electronic medical record before scheduling vaccines. The nurse
should identify that the client is at risk for developing a reaction to which vaccine, and for what
reason?
A. HPV vaccine
B. DTaP vaccine
C. Hepatitis B vaccine
D. Meningococcal vaccine
E. Influenza vaccine
Due to the client’s:
A. Temperature
B. Nasal discharge
C. Family history
D. Allergy history
E. Medical history
Correct Answer:
C. Hepatitis B vaccine
D. Allergy history

2. A nurse is caring for a male client who was admitted with a diagnosis of lower gastrointestinal (GI)
bleeding after awakening with abdominal cramping and bloody stool. The client reports fatigue over the
last several weeks and describes abdominal fullness and a change in stool shape over the last several
months. He also reports unintentional weight loss of 9 kg (20 lb) over the past 3 months.
The client has a medical history of gastroesophageal reflux disorder (GERD), asthma, and atrial fibrillation.
On assessment, the client is alert and oriented. Respirations are even and unlabored, breath sounds are
clear, and bowel sounds are active. The abdomen is slightly distended and tender to palpation.
Vital signs:
 Temperature: 37°C (98.6°F)
 Blood pressure: 98/54 mm Hg
 Heart rate: 118/min
 Respiratory rate: 20/min
 Oxygen saturation: 98% on room air
Laboratory findings:
 Stool occult blood test: Positive
 Hemoglobin: 9.8 g/dL (low)
 Hematocrit: 30% (low)
The nurse is reviewing the client’s assessment findings. Which of the following findings are indicators
of colorectal cancer and should be reported to the provider?
Select all that apply.
A. Change in weight
B. Report of abdominal cramping
C. Heart rhythm
D. Occult blood results
E. Heart sounds
F. Recent stool patterns
Correct Answers:
A. Change in weight
B. Report of abdominal cramping
D. Occult blood results
F. Recent stool patterns
3. A nurse in a provider's office is caring for a client who reports stiffness of both hands upon awakening
every morning for the past several weeks. The client states, “The stiffness lasts until around lunch time then
seems to get a little better.” The client also reports daily fatigue and unintentional weight loss of 9 kg (20
lb). On physical exam, the second and third joints of the bilateral index and middle fingers are warm and
swollen.
The client reports a family history of hypertension, diabetes mellitus, and rheumatoid arthritis. The client
denies recent illnesses but reports smoking fewer than 10 cigarettes per month and drinking alcohol 1 to 2
times a month. BMI is calculated as 32.1 (height: 160 cm, weight: 82 kg). The client has not had a physical
exam in three years.
Vital signs:
 Temperature: 37.2° C (99° F)
  Blood pressure: 135/80 mm Hg
 Heart rate: 88/min
 Respiratory rate: 20/min
 Oxygen saturation: 95% on room air
The provider has prescribed methotrexate 7.5 mg by mouth once per week.
The nurse is providing teaching to the client about self-care. Which 4 statements should the nurse
include in the teaching?
Select 4 options.
A. “Taking a hot shower after waking up can help alleviate morning stiffness.”
B. “Applying cold packs to affected joints can provide relief from pain and swelling.”
C. “You can continue to drink alcoholic beverages while taking this medication.”
D. “You should have less joint swelling 4 to 6 weeks after starting the medication.”
E. “Losing weight will not help to decrease pain and joint swelling with this disease.”
F. “Acupuncture is a complementary therapy that can help to decrease pain.”
Correct Answers:
A. “Taking a hot shower after waking up can help alleviate morning stiffness.”
B. “Applying cold packs to affected joints can provide relief from pain and swelling.”
D. “You should have less joint swelling 4 to 6 weeks after starting the medication.”
F. “Acupuncture is a complementary therapy that can help to decrease pain.”

4. A nurse is providing teaching to a client who has Hodgkin's lymphoma and is undergoing external
radiation treatment. Which of the following instructions should the nurse include?
A. Use an antibacterial soap to cleanse the skin.
B. Wash the ink marking off when showering.
C. Rub the skin with a towel when drying.
D. Avoid direct sun exposure to the skin.
Correct Answer:
D. Avoid direct sun exposure to the skin.

5. A nurse is providing teaching to a client who has systemic lupus erythematosus (SLE). Which of the
following statements by the client indicates an understanding of the teaching?
A. "I should use a sunscreen with an SPF of at least 15."
B. "Long-term immunosuppressive therapy could cure this disease."
C. "I should wear gloves when it is cold outside."
D. "SLE should not affect my lungs or breathing."
Correct Answer:
C. "I should wear gloves when it is cold outside."
6. A nurse is educating a client who is scheduled for a kidney transplant. Which of the following information
about hyperacute rejection should the nurse include in the teaching?
A. Hyperacute rejection can occur during the first few weeks after the transplant.
B. If hyperacute rejection occurs, the kidney can become enlarged.
C. The organ will need to be removed if hyperacute rejection occurs.
D. Immunosuppressive therapy is given to reverse hyperacute rejection.
Correct Answer:
C. The organ will need to be removed if hyperacute rejection occurs.

7. A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect
that the client's diagnosis has progressed to AIDS?
A. Small, purple-colored skin lesions
B. Fever and diarrhea lasting longer than 1 month
C. Persistent, generalized lymphadenopathy
D. Anorexia and weight loss
Correct Answer:
A. Small, purple-colored skin lesions

8. A nurse is providing teaching to a group of clients regarding skin cancer prevention. Which of the following
risk factors should the nurse include in the teaching?
A. Psoriasis
B. Light skin pigmentation
C. History of frostbite
D. Immunodeficiency disorder
Correct Answer:
B. Light skin pigmentation

9. A nurse is providing teaching to a client who has an allergy to peanuts. Which of the following instructions
is the priority to include in the teaching?
A. Inform other health care professionals of the allergy.
B. Wear a medical identification tag.
C. Carry an emergency anaphylaxis kit.
D. Keep a food diary.
Correct Answer:
C. Carry an emergency anaphylaxis kit.
10. A nurse is caring for a client who has HIV. Which of the following laboratory findings should suggest to
the nurse that medication therapy is effective?
A. WBC count below the expected reference range
B. Lymphocyte count below the expected reference range
C. Decrease in viral load
D. Low CD4/CD8 ratio
Correct Answer:
C. Decrease in viral load

11. A nurse is reviewing the laboratory results for a client who has acute leukemia. Which of the following
results should the nurse expect?
A. Increased WBC count
B. Increased hemoglobin (Hgb)
C. Increased hematocrit (Hct)
D. Increased platelet count
Correct Answer:
A. Increased WBC count

12. A nurse is caring for four clients. Which of the following clients is at the greatest risk for developing
pneumonia?
A. A school-age child who has a history of asthma
B. A young adult client who is living in a college dormitory
C. A middle adult client who is using an incentive spirometer following surgery
D. An older adult client who has dysphagia
Correct Answer:
D. An older adult client who has dysphagia

13. A nurse is assessing a client who is taking clindamycin to treat acute pelvic inflammatory disease. The
nurse should report which of the following findings to the provider immediately?
A. Watery diarrhea
B. Vaginitis
C. Furry tongue
D. Nausea and vomiting
Correct Answer:
A. Watery diarrhea
14. A nurse is caring for a client who reports a skin change. Which of the following findings should the nurse
report to the provider?
A. An asymmetrical papule that is pigmented
B. A patch of silvery-white scales with a red epidermal base
C. A collection of irregular, dry papules that are black
D. An elevated red lesion that arises from a scar
Correct Answer:
A. An asymmetrical papule that is pigmented

15. A nurse is planning an education program about testicular cancer for a group of male adolescents. Which
of the following information should the nurse include?
A. Testicular cancer is more common in males who are older than 65.
B. Examine the testicles immediately after showering.
C. With early treatment, the survival rate is 50%.
D. Schedule an annual ultrasound to screen for testicular cancer.
Correct Answer:
B. Examine the testicles immediately after showering.

16. A nurse is providing discharge teaching to a client who has HIV. Which of the following statements by the
client indicates an understanding of the teaching?
A. "I will clean the bathroom surfaces with full-strength bleach."
B. "I should discard open beverages that have been unrefrigerated for 1 hr."
C. "I should wash laundry that is soiled with a body fluid in cool water."
D. "I will work in the garden for exercise."
Correct Answer:
B. "I should discard open beverages that have been unrefrigerated for 1 hr."

17. A nurse is caring for a client who has neutropenia. Which of the following actions should the nurse take?
A. Allow the client's 5-year-old grandchild to visit after school.
B. Give the client an apple with the skin on for an afternoon snack.
C. Allow the client's family to bring the client a bouquet of fresh flowers.
D. Provide the client with individually wrapped paper cups and plastic utensils.
Correct Answer:
D. Provide the client with individually wrapped paper cups and plastic utensils.
18. A nurse is planning discharge teaching for a client who is receiving chemotherapy and has bone marrow
suppression. Which of the following instructions should the nurse plan to include in the teaching?
A. "Take aspirin for minor aches and pains."
B. "Clean your toothbrush with warm water weekly."
C. "Bathe with an antimicrobial soap twice per day."
D. "Wear clothing that will minimize sun exposure."
Correct Answer:
C. "Bathe with an antimicrobial soap twice per day."

19. A nurse is caring for a client who has an elevated prostate-specific antigen (PSA) level. The nurse should
anticipate that the client will undergo which of the following diagnostic tests?
A. Palpation of testes
B. Human chorionic gonadotropin level
C. Digital rectal examination
D. Pelvic ultrasound
Correct Answer:
C. Digital rectal examination

20. A nurse in an emergency department is assessing a newly admitted client. Which of the following actions
places the client at an increased risk for contracting hepatitis B?
A. Residing in an institutional setting
B. Engaging in unprotected sexual intercourse
C. Working with hazardous chemical waste materials
D. Traveling to a foreign country
Correct Answer:
B. Engaging in unprotected sexual intercourse

21. A nurse is providing teaching to a client who has rheumatoid arthritis and reports persistent pain. Which
of the following responses should the nurse make?
A. "Take a cool bath in the evening."
B. "Exercise every other day."
C. "Use pillows to support your joints while in bed."
D. "Ask a friend or a family member to help with household chores."
Correct Answer:
D. "Ask a friend or a family member to help with household chores."
22. A nurse is caring for a client who is admitted with enlarged lymph nodes and a fever. To confirm a
diagnosis of bacterial pharyngitis, the nurse should anticipate which of the following diagnostic tests?
A. Indirect laryngoscopy
B. Chest x-ray
C. Throat culture
D. Monospot test
Correct Answer:
C. Throat culture

23. A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of
the following is the priority assessment finding?
A. Loss of body hair
B. Report of anorexia
C. Mucositis of the oral cavity
D. Erythema at the IV insertion site
Correct Answer:
D. Erythema at the IV insertion site

24. A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse
report to the provider immediately?
A. Negative blood culture
B. Left shift in WBC differential
C. Oxygen saturation 93%
D. Crackles heard on auscultation
Correct Answer:
B. Left shift in WBC differential

25. A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for
methotrexate. Which of the following client statements indicates an understanding of the teaching?
A. "I will avoid being in large crowds while taking this medication."
B. "I should expect symptoms to subside in 1 to 2 weeks after starting this medication."
C. "I will increase my intake of vitamin D while taking this medication."
D. "I should expect to experience constipation while taking this medication."
Correct Answer:
A. "I will avoid being in large crowds while taking this medication."
26. A nurse is reviewing the laboratory report for a client who has Hodgkin's lymphoma. Which of the
following findings should the nurse expect?
A. Overgrowth of B-lymphocyte plasma cells
B. Reed-Sternberg cells
C. Epstein-Barr virus
D. Overproduction of blast phase cells
Correct Answer:
B. Reed-Sternberg cells

27. A nurse is planning an education program for a group of high school teachers who will be taking students
on a hike. Which of the following information should the nurse include regarding Lyme disease?
A. "If bitten by a tick, you should be tested immediately."
B. "If you have a tick embedded in your skin, apply a lit match to remove it."
C. "You should wear dark-colored clothing to deter ticks from biting."
D. "If you develop pain and stiffness in your joints, you should see your doctor."
Correct Answer:
D. "If you develop pain and stiffness in your joints, you should see your doctor."

28. A nurse is planning care for a client who has leukemia and a platelet count of 48,000/mm³ (reference
range: 150,000 to 400,000/mm³). Which of the following interventions should the nurse include in the plan?
A. Provide the client with a diet that is low in vitamin K.
B. Place the client on contact precautions.
C. Administer subcutaneous epoetin alfa.
D. Test the client’s urine and stool for occult blood.
Correct Answer:
D. Test the client’s urine and stool for occult blood.

29. A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings
should the nurse expect?
(Select all that apply.)
A. Subcutaneous nodules
B. Decreased urine output
C. Renal calculi
D. Butterfly rash
E. Joint inflammation
Correct Answers:
B. Decreased urine output
D. Butterfly rash
E. Joint inflammation

30. A nurse is reviewing the client’s electronic medical record. The client is at risk for developing ____ and
____.
Client presentation includes:
 Diagnosed with systemic lupus erythematosus (SLE)
 Symptoms: fever, fatigue, intermittent chest pain, facial rash (malar), joint swelling, pericardial friction rub,
and cloudy, foamy urine
 Vital signs: T 38.9°C (102°F), BP 175/86, HR 124, RR 24, O2 sat 96%
Correct Answer:
Target 1: Pericarditis
Target 2: Nephritis

31. A nurse in a provider’s office is providing teaching to a client who has a recent diagnosis of rheumatoid
arthritis and has a new prescription for naproxen tablets. Which of the following statements by the client
requires further teaching?
A. "This medication will take 4 weeks for me to notice relief in my joints."
B. "I can take an antacid with this medication for indigestion."
C. "I can take this medication with aspirin."
D. "The naproxen goes down easier when I crush it and put it in applesauce."
Correct Answer:
C. "I can take this medication with aspirin."

32. A nurse is teaching a client who has human immunodeficiency virus (HIV) about the early manifestations
of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include
in the teaching?
A. "You can expect a persistent fever and swollen glands."
B. "You can expect an elevated white blood cell count."
C. "You can expect an increase in blood pressure and edema."
D. "You can expect weight gain."
Correct Answer:
A. "You can expect a persistent fever and swollen glands."
33. A nurse is providing discharge instructions to a client who is being treated for genital warts. Which of the
following statements indicates that the client understands how to prevent transmission of the sexually
transmitted infection (STI)?
A. "I will bring my sexual partner in for treatment."
B. "Now that I've had my first dose of medicine, I can resume sexual activity."
C. "Once I have been treated, it is no longer necessary to use condoms."
D. "Once treatment is completed and I am free of symptoms, I don't have to return to the clinic."
Correct Answer:
A. "I will bring my sexual partner in for treatment."

34. A nurse is teaching a client who has genital herpes about self-management. Which of the following
instructions should the nurse include in the teaching?
A. Use an alcohol-based soap to clean lesions.
B. Wear a condom during sexual activity when lesions are present.
C. Take a sitz bath once per day.
D. Apply a warm compress to the lesions.
Correct Answer:
D. Apply a warm compress to the lesions.

35. A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of
the following instructions should the nurse plan to include?
A. "Avoid the use of NSAIDs."
B. "Stop taking the corticosteroids when your symptoms resolve."
C. "Exposure to ultraviolet light will help control the skin rashes."
D. "Monitor your body temperature and report any elevations promptly."
Correct Answer:
D. "Monitor your body temperature and report any elevations promptly."

36. A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the
nurse expect?
A. Excessive salivation
B. Finger contractures
C. Periorbital edema
D. Alopecia
Correct Answer:
B. Finger contractures

37. A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after
receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess
the client?
A. A diffuse maculopapular rash
B. Dyspnea
C. Double vision
D. A progressive, circular rash
Correct Answer:
D. A progressive, circular rash

38. A nurse is teaching a client who has Raynaud's disease. Which of the following information should the
nurse include in the teaching?
A. Protect against the cold by wearing layers of clothing.
B. Begin an exercise program of 2-mile walks once per week.
C. Increase vitamin A in the diet.
D. Elevate the hands above heart level when resting.
Correct Answer:
A. Protect against the cold by wearing layers of clothing.

39. A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse,
"Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse give?
A. "That is your decision alone."
B. "I would if I were you."
C. "It sounds like you are unsure what to say to your partner."
D. "Your provider is required by law to notify your partner."
Correct Answer:
C. "It sounds like you are unsure what to say to your partner."

40. A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned about the skin
lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of the
following responses should the nurse give?
A. "Keep the lesions covered with a light sterile dressing when going outdoors."
B. "Rub lesions with a washcloth to dry after washing."
C. "Apply moisturizer after bathing the lesions with warm water."
D. "Apply antibiotic cream twice per day until scabs form on the lesions."
Correct Answer:
C. "Apply moisturizer after bathing the lesions with warm water."

41. A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at
home. Which of the following instructions should the nurse include in the teaching?
A. "Wash your genitalia using an antimicrobial soap."
B. "Rinse your dishes with cold water."
C. "Clean your toothbrush once per month."
D. "Incorporate raw fruits and vegetables into your diet."
Correct Answer:
A. "Wash your genitalia using an antimicrobial soap."

42. A nurse is teaching a client who has tested positive for an allergy to dust. The nurse should determine that
the client understands how to reduce her exposure to this allergen when she states which of the following?
A. "I will begin vacuuming once a week."
B. "Carpeting the entire house will be very expensive, but it will be worth it."
C. "I will apply a mattress cover to my bed."
D. "Installing curtains on the windows will help control the dust in the house."
Correct Answer:
C. "I will apply a mattress cover to my bed."

43. A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset
of manifestations. Which of the following statements by the client indicates an understanding of the teaching?
A. "I should limit my exposure to sunlight."
B. "I should avoid drinking alcohol."
C. "I should not smoke."
D. "I should limit intake of foods high in purine."
Correct Answer:
C. "I should not smoke."

44. A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I should take this medication with food."
B. "I need to take a B-complex vitamin while taking this medication."
C. "I can expect this medication to turn my skin orange."
D. "I can expect this medication to make my vision blurry."
Correct Answer:
C. "I can expect this medication to turn my skin orange."

45. A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary
tuberculosis, was placed on airborne precautions, and is scheduled for a chest x-ray. The nurse should
instruct the newly licensed nurse to take which of the following actions?
A. Have the client wear a surgical mask.
B. Wear a gown for protection from the client's infection.
C. Ask the radiology staff to perform a portable chest x-ray in the client’s room.
D. Place an N95 respirator on the client.
Correct Answer:
A. Have the client wear a surgical mask.

46. A nurse is caring for a client who is 2 days postoperative. Which of the following findings should alert the
nurse that the client is developing an infection?
A. Temperature 37.8° C (100° F)
B. Erythema at the incision site
C. WBC count 9,000/mm³
D. Pain reported as 6 on a scale of 0 to 10
Correct answer:
B. Erythema at the incision site

47. A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her
finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the
following laboratory tests can indicate arthritis?
A. Reticulocyte count
B. Rheumatoid factor
C. Direct Coombs' test
D. Platelet count
Correct answer:
B. Rheumatoid factor

48. A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse
should anticipate that the client's affected joints will require which of the following treatments?
A. An assistive device to use when the client is ambulating
B. Heat paraffin therapy applied to the client's joints
C. Gentle massage of the client’s hands
D. Active range-of-motion exercises on the client's affected joints
Correct answer:
B. Heat paraffin therapy applied to the client's joints

49. A nurse is teaching a client who has human immunodeficiency virus about how the virus is transmitted.
Which of the following statements should the nurse include the teaching?
A. "HIV can be transmitted as soon as a person develops manifestations."
B. "HIV can be transmitted to anyone who has had contact with the infected blood."
C. "HIV is transmitted through the respiratory route through droplets."
D. "HIV is transmitted only during the active phase of the virus."
Correct answer:
B. "HIV can be transmitted to anyone who has had contact with the infected blood."

50. A nurse is teaching an assistive personnel about standard precautions when caring for a client who has
vancomycin-resistant Enterococcus of the urine. Which of the following images of personal protective
equipment should the nurse recommend the AP to use when caring for this client?
A. Face mask
B. Gloves
C. Goggles
D. Shoe covers
Correct answer:
B. Gloves

51. A nurse is teaching a client about manifestations of an allergic reaction. The nurse should explain that
histamine release causes which of the following reactions?
A. Increased mucus secretion
B. Bronchial dilation
C. Bradycardia
D. Vertigo
Correct answer:
A. Increased mucus secretion
52. A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency
syndrome. Which of the following statements by the client's partner indicates the need for further teaching?
A. "I will dispose soiled tissues in separate plastic bags."
B. "I'll clean up blood spills immediately with hot water."
C. "I know that hand washing is an important preventive measure."
D. "I will wash soiled clothes in hot water."
Correct answer:
B. "I'll clean up blood spills immediately with hot water."

53. A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about
factors that can trigger an exacerbation of SLE. The nurse should determine that the client needs more
teaching when she identifies which of the following as a factor that can exacerbate SLE?
A. Exercise
B. Pregnancy
C. Infection
D. Sunlight
Correct answer:
A. Exercise

54. A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following
manifestations of the client's skin should the nurse expect?
A. Confluent, honey-colored, crusted lesions
B. Large, tender nodule located on a hair follicle
C. Unilateral, localized, nodular skin lesions
D. A fluid-filled vesicular rash in the genital region
Correct answer:
C. Unilateral, localized, nodular skin lesions

55. A nurse is preparing to administer a Mantoux skin test to a client. The nurse should inform the client that
the purpose of a Mantoux skin test using purified protein derivative (PPD) is to do which of the following
actions?
A. Identify if a client lacks immunity to tuberculosis.
B. Find out if a client has active tuberculosis.
C. Decrease the hypersensitivity of the client's reaction to PPD.
D. Identify if a client has been infected with mycobacterium tuberculosis.
Correct answer:
D. Identify if a client has been infected with mycobacterium tuberculosis

56. A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP).
Which of the following information should the nurse include in the teaching?
A. "PCP is sexually transmitted from person to person."
B. "You were most likely exposed to a contaminated surface, such as a drinking glass."
C. "PCP results from an impaired immune system."
D. "You may have contracted PCP from a family pet."
Correct answer:
C. "PCP results from an impaired immune system."

57. A nurse is caring for a client who had radioallergosorbent (RAST) testing completed due to seasonal allergies.
The nurse should anticipate an elevation in which of the following laboratory tests?
A. IgM (immunoglobulin M)
B. IgA (immunoglobulin A)
C. IgG (immunoglobulin G)
D. IgE (immunoglobulin E)
Correct answer:
D. IgE (immunoglobulin E)

58. A nurse is caring for a client who has human immunodeficiency virus. Which of the following types of
isolation should the nurse implement to prevent transmission of HIV?
A. Protective isolation
B. Droplet precautions
C. Standard precautions
D. Airborne precautions
Correct answer:
C. Standard precautions

59. A nurse is providing teaching to a client who has a diagnosis of Hepatitis A. Which of the following
statements by the client indicates an understanding of the teaching?
A. "I am unable to donate blood."
B. "I will need to get a booster shot of immune serum globulin every year."
C. "I should stop eating raw clams."
D. "I can get this disease by getting a tattoo.”
Correct answer:
C. "I should stop eating raw clams."

Renal & Urinary:

1. A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports
diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions
should the nurse take first?
A. Administer an analgesic to the client.
B. Check the client's electrolyte values.
C. Measure the client's weight.
D. Restrict the client's protein intake.
Correct answer:
B. Check the client's electrolyte values.

2. A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which of
the following nutrients should the nurse instruct the client to increase in her diet?
A. Calcium
B. Phosphorous
C. Potassium
D. Sodium
Correct answer:
A. Calcium

3. A nurse is teaching a client about the prostate-specific antigen (PSA) test. Which of the following
statements should the nurse make?
A. "You should fast for 8 hours after the PSA test."
B. "Annual PSA screening should begin at age 40."
C. "Expected PSA values will decrease as you get older."
D. "You should not ejaculate for 24 hours prior to the PSA test."
Correct answer:
D. "You should not ejaculate for 24 hours prior to the PSA test."

4. A nurse is caring for a client who has a diagnosis of renal calculi and reports severe flank pain. Which of
the following is the priority nursing action?
A. Relieve the client's pain.
B. Encourage the client to increase fluid intake.
C. Monitor the client's I&O.
D. Strain the client’s urine.
Correct answer:
A. Relieve the client's pain.

5. A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for
which of the following adverse effects?
A. Diarrhea
B. Increased serum albumin
C. Hypoglycemia
D. Peritonitis
Correct answer:
D. Peritonitis

6. A nurse is teaching a client who is preoperative for a cystoscopy. Which of the following statements should
the nurse make?
A. "You will need to keep the sutures clean after this procedure."
B. "You will be placed on your left side for this procedure."
C. "Expect to be on bed rest for 24 hours after this procedure."
D. "Expect to have pink-tinged urine after this procedure."
Correct answer:
D. "Expect to have pink-tinged urine after this procedure."

7. A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the
following statements should indicate to the nurse the need for additional teaching?
A. "I will empty my bladder every 4 hours."
B. "I will drink 2 liters of fluids per day."
C. "I will use a vaginal douche daily."
D. "I will wear cotton underwear."
Correct answer:
C. "I will use a vaginal douche daily."
8. A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis. Which of the
following findings should the nurse report to the provider?
A. WBC 6,000/mm³
B. Potassium 3.0 mEq/L
C. Clear, pale yellow drainage
D. Report of abdominal fullness
Correct answer:
B. Potassium 3.0 mEq/L

9. A nurse is teaching a client who has acute pyelonephritis. Which of the following instructions should the
nurse include in the teaching?
A. "You should complete the entire cycle of antibiotic therapy."
B. "You should maintain complete bed rest until manifestations decrease."
C. "You should drink 1,000 milliliters of fluid per day."
D. "You should use NSAIDs for pain."
Correct answer:
A. "You should complete the entire cycle of antibiotic therapy."

10. A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy (ESWL). The
nurse should identify that which of the following findings is the priority?
A. Dysrhythmias
B. Pink-tinged urine
C. Bruising on the flank area
D. Stone fragments in the urine
Correct answer:
A. Dysrhythmias

11. A nurse is teaching a newly licensed nurse about caring for a client who has a new left arteriovenous
fistula. Which of the following statements should the nurse make?
A. "Check the fistula site daily for a vibration."
B. "Instruct the client to restrict movement of his left arm."
C. "Avoid taking blood pressure on the client's left arm."
D. "Instruct the client to sleep on his left side."
Correct answer:
C. "Avoid taking blood pressure on the client's left arm."
12. A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which
of the following findings should indicate to the nurse that the client is experiencing acute kidney rejection?
A. Blood pressure 160/90 mm Hg
B. Creatinine 0.8 mg/dL
C. Sodium 137 mg/dL
D. Urinary output 100 mL/hr
Correct answer:
A. Blood pressure 160/90 mm Hg

13. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate
(TURP). After the nurse discontinues the client's urinary catheter, which of the following findings should the
nurse report to the provider?
A. Pink-tinged urine
B. Report of burning upon urination
C. Stress incontinence
D. Decreased urine output
Correct answer:
D. Decreased urine output

14. A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the client's dialysate
output is less than the input, and his abdomen is distended. Which of the following actions should the nurse
take?
A. Insert an indwelling urinary catheter.
B. Administer pain medication to the client.
C. Change the client’s position.
D. Place the drainage bag above the client’s abdomen.
Correct answer:
C. Change the client’s position.

15. A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements
should the nurse make?
A. "You will be NPO for 8 hours following the procedure."
B. "An allergy to shellfish is a contraindication to this procedure."
C. "You will need to be on bed rest following the procedure."
D. "A creatinine clearance is needed prior to the procedure."
Correct answer:
C. "You will need to be on bed rest following the procedure."

16. A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the
prostate (TURP). Which of the following statements indicates an understanding of the information?
A. "I will not need to have a urinary catheter following this procedure."
B. "I will expect my urine to be cloudy after having this procedure."
C. "At least I won't have leakage of urine after having this procedure."
D. "I will feel the urge to urinate following this procedure."
Correct answer:
D. "I will feel the urge to urinate following this procedure."

17. A nurse is teaching a client about urinary tract infections (UTIs). Which of the following manifestations
should the nurse include?
A. Weight gain
B. Back pain
C. Vaginal discharge
D. Muscle cramps
Correct answer:
B. Back pain

18. A nurse is teaching a newly licensed nurse about collecting a 24-hour urine specimen for creatinine
clearance. Which of the following instructions should the nurse include?
A. Include the first voided specimen at the start of the collection period.
B. Discard the last voided specimen at the end of the collection period.
C. Place signs in the bathroom as a reminder about the test in progress.
D. Instruct the client to increase exercise during the 24-hr period.
Correct answer:
C. Place signs in the bathroom as a reminder about the test in progress.

19. A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions
should the nurse include?
A. Limit fluid intake.
B. Limit caloric intake.
C. Eat a diet high in phosphorus.
D. Eat a diet high in protein.
Correct answer:
A. Limit fluid intake.

20. A nurse is assessing a client who was brought to the emergency department following a motor-vehicle
crash. The nurse should recognize that which of the following findings is a manifestation of bladder trauma?
A. Stress incontinence
B. Hematuria
C. Pyuria
D. Fever
Correct answer:
B. Hematuria

21. A nurse is caring for a male client.

Exhibit 1 – Nurses' Notes:
Day 1:
Client reports a 2-month history of difficulty starting urination and sensation that the bladder is not emptying
completely. Client reports dribbling after urinating and needs to urinate 2 to 3 times each night.
1 month later:
Client reports abdominal distention and discomfort and an increase in difficulty urinating over the past 8 hr. Client
states it is hard to start urinating and is unable to create a stream of urine. States, "The urine just dribbles out."
Exhibit 2 – Diagnostic Results:
Day 1 – Urodynamic pressure flow study:
Intravesical pressure when bladder is empty: 45 cm H₂O (normal: less than 40 cm H₂O)
Residual urine: 55 mL (normal: less than 30 mL)
WBC: 8,500/mm³ (normal: 5,000 to 10,000/mm³)
BUN: 17 mg/dL (normal: 10 to 20 mg/dL)
1 month later – Urodynamic pressure flow study:
Intravesical pressure when bladder is empty: 70 cm H₂O
Residual urine: 200 mL
WBC: 7,700/mm³
BUN: 18 mg/dL
Question:
Complete the following sentence by using the lists of options:
The client is at risk for _____ as evidenced by the client’s _____.
Answer Choices:
First drop-down menu (The client is at risk for):
 Bladder outlet obstruction
 Infection
 Chronic kidney disease
Second drop-down menu (as evidenced by the client’s):
 Urodynamic pressure flow study
 WBC
 BUN

Correct Completion:
The client is at risk for bladder outlet obstruction as evidenced by the client’s urodynamic pressure flow study.

22. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral
resection of the prostate. Upon detecting an output obstruction, which of the following actions should the
nurse take first?
A. Irrigate the catheter with 0.9% sodium chloride irrigation.
B. Notify the provider.
C. Check the irrigation tubing for kinks.
D. Provide PRN pain medication.
Correct Answer:
C. Check the irrigation tubing for kinks.

23. A nurse is caring for a postoperative client following arteriovenous (AV) fistula creation in the left arm.
Which of the following actions should the nurse take?
A. Measure blood pressure in the client's left arm every 4 hr.
B. Keep the client’s left arm in a dependent position.
C. Auscultate for bruits in the client's fistula every 4 hr.
D. Instruct the client to sleep on the affected side.
Correct Answer:
C. Auscultate for bruits in the client's fistula every 4 hr.

24. A nurse is caring for a female client who has acute kidney injury (AKI). Which of the following serum
laboratory findings is the highest priority for the nurse to report to the provider?
A. Potassium 5.9 mEq/L (3.5 to 5 mEq/L)
B. Calcium 8.8 mg/dL (9.0 to 10.5 mg/dL)
C. Creatinine 2.5 mg/dL (0.5 to 1.1 mg/dL)
D. BUN 27 mg/dL (10 to 20 mg/dL)
Correct Answer:
A. Potassium 5.9 mEq/L

25. A nurse is reviewing the medical records of four clients. The nurse should identify which of the following
disorders as a risk factor for chronic pyelonephritis?
A. Parkinson's disease
B. Diabetes mellitus
C. Peptic ulcer disease
D. Gallbladder disease
Correct Answer:
B. Diabetes mellitus

26. A nurse is planning education about cyclosporine for a client who had a kidney transplant 2 days ago.
Which of the following statements should the nurse plan to include?
A. "You might have hair loss due to the medication therapy you'll be taking."
B. "You will need to continue taking this medication to protect your new kidneys."
C. "Use an over-the-counter anti-inflammatory medication for aches and pains."
D. "Your risk for infection will increase if you stop taking this medication."
Correct Answer:
B. "You will need to continue taking this medication to protect your new kidneys."

27. A nurse is caring for a client following extracorporeal shock wave lithotripsy (ESWL) for the treatment of
calcium phosphate kidney stones. Which of the following actions should the nurse take?
A. Monitor the client’s urine for ketones.
B. Provide the client with an increased animal protein diet.
C. Limit the client’s fluid intake to 1.5 L per day.
D. Strain all of the client’s urine.
Correct Answer:
D. Strain all of the client’s urine.

28. A nurse is preparing to assess a client who received hemodialysis 1 hr ago. Which of the following
assessments should the nurse perform first?
A. Potassium level
B. Body weight
C. Creatinine level
D. Vital signs
Correct Answer:
D. Vital signs

29. A nurse is planning care for a client who is postoperative following a nephrectomy. Which of the following
assessments is the nurse's priority?
A. Bowel sounds
B. WBC count
C. Pain level
D. Blood pressure
Correct Answer:
D. Blood pressure

30. A nurse is teaching a client who has a new diagnosis of acute pyelonephritis. Which of the following
instructions should the nurse include in the teaching?
A. Drink up to 1,500 mL of fluid per day.
B. Avoid the use of NSAIDs for pain.
C. Check peripheral blood glucose levels twice per day.
D. Increase dietary protein intake.
Correct Answer:
B. Avoid the use of NSAIDs for pain.

31. A nurse is planning care for a client who has acute glomerulonephritis. The nurse should plan to provide
which of the following interventions?
A. Weigh the client daily.
B. Encourage the client to drink 2 to 3 L of fluid per day.
C. Instruct the client to ambulate every 2 hr.
D. Check the client's blood glucose level.
Correct Answer:
A. Weigh the client daily.
32. A nurse is teaching a client who has urge urinary incontinence about bladder retraining. Which of the
following instructions should the nurse include?
A. "If you are unable to urinate, sit on the toilet every 4 hours with water running in the sink."
B. "Increase the intervals between urination by 15 minutes per day when able to remain continent."
C. "Immediately empty your bladder when you have the urge to urinate."
D. "If you are unable to urinate, plan to self-catheterize every 3 to 4 hours."
Correct Answer:
B. "Increase the intervals between urination by 15 minutes per day when able to remain continent."

33. A nurse is reviewing the medical history of a client who has end-stage kidney disease. The nurse should identify
that which of the following factors in the client’s history is a contraindication for receiving hemodialysis?
A. History of hemophilia
B. Difficulty with ambulation
C. Decreased WBC count
D. Iodine allergy
Correct Answer:
A. History of hemophilia

34. A nurse is performing an admission assessment for a client who has severe chronic kidney disease (CKD).
Which of the following findings should the nurse expect?
A. Tachypnea
B. Hypotension
C. Exophthalmos
D. Insomnia
Correct Answer:
A. Tachypnea

35. A nurse is assessing a client who has chronic kidney disease and has completed the third peritoneal
dialysis (PD) treatment. Which of the following findings should the nurse report to the provider?
A. Greater outflow of dialysate than inflow
B. Weight loss
C. Cloudy dialysate effluent
D. Report of pain during inflow
Correct Answer:
C. Cloudy dialysate effluent
36. A nurse in a women's health clinic is caring for a client who reports urinary urgency and dysuria. Which
of the following additional findings should the nurse identify as an indication of a urinary tract infection
(UTI)?
A. Vaginal discharge
B. Pyuria
C. Glucosuria
D. Elevated creatine kinase-MB
Correct Answer:
B. Pyuria

37. A nurse is providing instructions for reducing the dietary intake of potassium to a client who has chronic
kidney disease. Which of the following client food selections indicates an understanding of the teaching?
A. 1 cup cubed cantaloupe
B. 1 cup boiled spinach
C. One medium baked potato
D. One large raw apple
Correct Answer:
D. One large raw apple

38. A nurse in an emergency department is caring for a client who reports costovertebral angle tenderness,
nausea, and vomiting. Which of the following laboratory values should the nurse report to the provider?
A. WBC count 15,000/mm³ (5,000 to 10,000/mm³)
B. BUN 20 mg/dL (10 to 20 mg/dL)
C. Urine pH of 4.2 (4.5 to 8)
D. Urine post-void residual of 50 mL
Correct Answer:
A. WBC count 15,000/mm³

39. A nurse is providing teaching to a male client who has a continent internal ileal reservoir following
surgery to treat bladder cancer. Which of the following client statements indicates an understanding of the
teaching?
A. "This should not affect my ability to function sexually."
B. "I should expect to gain some weight during the next few weeks."
C. "I will need to avoid foods that produce intestinal gas."
D. "I must insert a catheter through my stoma to drain the urine."
Correct Answer:
D. "I must insert a catheter through my stoma to drain the urine."

40. A nurse is monitoring a client following hemodialysis. The nurse should recognize that which of the
following factors places the client at risk for seizures?
A. Hypokalemia
B. A rapid increase of catecholamines
C. A rapid decrease in fluid
D. Hypercalcemia
Correct Answer:
C. A rapid decrease in fluid

41. A nurse is planning care for a client who has chronic kidney disease and a potassium level of 7.3 mEq/L.
Which of the following interventions should the nurse plan to take?
A. Initiate an IV infusion of lactated Ringer's solution.
B. Give spironolactone 50 mg PO BID.
C. Infuse regular insulin in dextrose 10% in water.
D. Administer supplemental phosphorus.
Correct Answer:
C. Infuse regular insulin in dextrose 10% in water.

42. A nurse is reviewing the laboratory report of a male client who has acute kidney injury (AKI). Which of
the following findings should the nurse expect? (Select all that apply.)
A. BUN 30 mg/dL (10 to 20 mg/dL)
B. Urine output 40 mL in the past 3 hr
C. Potassium 3.3 mEq/L (3.5 to 5 mEq/L)
D. Calcium 8.7 mg/dL (9.0 to 10.5 mg/dL)
E. Hematocrit 30% (42% to 52%)
Correct Answers:
A. BUN 30 mg/dL: Elevated due to reduced kidney function.
B. Urine output 40 mL in 3 hr: Indicates oliguria, a sign of AKI.
D. Calcium 8.7 mg/dL: Slightly low, which can occur in AKI.
E. Hematocrit 30%: Low, often seen in AKI due to decreased erythropoietin.

43. A nurse is obtaining a urine specimen for culture and sensitivity from a client who has manifestations of a
urinary tract infection. Which of the following actions should the nurse take?
A. Collect the client’s urine in a clean specimen container.
B. Instruct the client to start urinating then pass the container into the stream.
C. Obtain the client’s first morning urine on the following day.
D. Place the client’s urine specimen in a container with a preservative.
Correct Answer:
B. Instruct the client to start urinating then pass the container into the stream.

44. A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). Which of the following
statements by the client indicates an understanding of the teaching?
A. "I will consume foods that are high in protein."
B. "I will decrease my intake of foods that are high in phosphorus."
C. "I will limit my intake of foods that are high in iron."
D. "I will add salt to the foods I consume."
Correct Answer:
B. "I will decrease my intake of foods that are high in phosphorus."

45. A nurse is caring for a client who has nephrotic syndrome and has been taking prednisone for 3 days.
Which of the following findings should the nurse report to the provider as an adverse effect of prednisone?
A. Sore throat
B. Frequent stools
C. Hearing loss
D. Tremors
Correct Answer:
A. Sore throat

46. A nurse is performing an admission assessment of a client who has acute glomerulonephritis. The nurse
should expect which of the following findings?
A. Low blood pressure
B. Polyuria
C. Dark-colored urine
D. Weight loss
Correct Answer:
C. Dark-colored urine
47. A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to
monitor for signs of nephrotoxicity?
A. A client who is receiving gentamicin for the treatment of a wound infection
B. A client who is receiving digoxin for the treatment of heart failure
C. A client who is receiving methylprednisolone for the treatment of severe asthma
D. A client who is receiving propranolol for the treatment of hypertension
Correct Answer:
A. A client who is receiving gentamicin for the treatment of a wound infection

Hypertension:

1. Which finding indicates that hypertension is progressing to target organ damage?

A. Retinal blood vessel damage
B. Urine output of 60 mL over 2 hours
C. Blood urea nitrogen concentration of 12 mg/dL
D. Chest x-ray showing pneumonia
Correct Answer:
A. Retinal blood vessel damage

2. The nurse is caring for an older adult client who has come to the clinic for a yearly physical. When
assessing the client, the nurse notes the blood pressure (BP) is 140/93. The nurse knows that in older clients
what happens that may elevate the systolic BP?
A. Loss of arterial elasticity
B. Decrease in blood volume
C. Increase in calcium intake
D. Decrease in cardiac output
Correct Answer:
A. Loss of arterial elasticity

3. Which client statement indicates a good understanding of the nutritional modifications needed to manage
hypertension?
A. "A glass of red wine each day will lower my blood pressure."
B. "I should eliminate caffeine from my diet to lower my blood pressure."
C. "If I include less fat in my diet, I'll lower my blood pressure."
D. "Limiting my salt intake to 2 grams per day will improve my blood pressure."
Correct Answer:
D. "Limiting my salt intake to 2 grams per day will improve my blood pressure."

4. Which of the following client scenarios would be correct for the nurse to identify as a client with secondary
hypertension?
A. A client experiencing depression
B. A client diagnosed with kidney disease
C. A client of advanced age
D. A client with excessive alcohol intake
Correct Answer:
B. A client diagnosed with kidney disease

5. The nurse is caring for a client who has just received a diagnosis of hypertension. What lifestyle change(s)
should the nurse recommend to the client to decrease the consequences of hypertension? (Select all that
apply)
A. Restrict salt/sodium.
B. Manage stress effectively.
C. Adhere to an exercise plan.
D. Reduce caffeine intake.
E. Use smokeless tobacco.
Correct Answers:
A. Restrict salt/sodium.
B. Manage stress effectively.
C. Adhere to an exercise plan.

6. A client who is newly diagnosed with hypertension is going to be starting antihypertensive medicine. What
is one of the main things the client and the client's spouse should watch for?
A. Dizziness
B. Persistent cough
C. Blurred vision
D. Tremor
Correct Answer:
A. Dizziness
7. The nurse is conducting a service project for a local older adult community group on the topic of
hypertension. The nurse will relay that which risk factors and cardiovascular problems are related to
hypertension? (Select all that apply)
A. Smoking
B. Elevated high-density lipoprotein (HDL) cholesterol
C. Overweight/obesity
D. Age ≥65 in females
E. Decreased low-density lipoprotein (LDL) levels
Correct Answers:
A. Smoking
C. Overweight/obesity
D. Age ≥65 in females

8. A client with hypertension is waking up several times a night to urinate. The nurse knows that what
laboratory studies may indicate pathologic changes in the kidneys due to the hypertension? (Select all that
apply.)
A. Creatinine
B. Blood urea nitrogen (BUN)
C. Complete blood count (CBC)
D. Urine for culture and sensitivity
E. AST and ALT
Correct Answers:
A. Creatinine
B. Blood urea nitrogen (BUN)

9. When measuring blood pressure in each arm of a healthy adult, the nurse recognizes that the pressures
A. Must be equal in both arms
B. May vary 10 mm Hg or more between arms
C. Differ no more than 5 mm Hg between arms
D. May vary, with the higher pressure found in the left arm
Correct Answer:
C. Differ no more than 5 mm Hg between arms

10. The nurse assesses a client's blood pressure reading of 150/90 mm Hg along with several abnormal
laboratory results. What data supports the medical diagnosis of metabolic syndrome? (Select all that apply)
A. Increased serum creatinine levels
B. Insulin resistance
C. Abdominal obesity
D. Dyslipidemia
E. Blood pressure reading greater than 140/90 mm Hg
Correct Answers:
B. Insulin resistance
C. Abdominal obesity
D. Dyslipidemia
E. Blood pressure reading greater than 140/90 mm Hg

11. A nurse is caring for a client who has hypertension and diabetes mellitus. The client's blood pressure this
morning was 150/92 mm Hg. When the client asks the nurse what their blood pressure should be, what is the
nurse's most appropriate response?
A. "Your blood pressure is fine. Just keep doing what you're doing."
B. "The current recommendation is for everyone to have blood pressure of 140/90 mm Hg or lower."
C. "The lower the better. Blood pressure of 130/80 mm Hg is best for everyone."
D. "Clients with diabetes should have a lower blood pressure goal. You should strive for 120/80 mm Hg."
Correct Answer:
D. "Clients with diabetes should have a lower blood pressure goal. You should strive for 120/80 mm Hg."

12. The nurse is volunteering at a community blood pressure screening. A client, never diagnosed with
hypertension, presents with a blood pressure of 158/90 mm Hg. Which assessment question(s) is appropriate
for the nurse to ask? (Select all that apply.)
A. “Have you recently drunk a caffeinated beverage?”
B. “Did you have a beer after work?”
C. “Do you smoke?”
D. “Do you have a friend accompanying you?”
E. “Are you married and with children?”
Correct Answers:
A. “Have you recently drunk a caffeinated beverage?”
C. “Do you smoke?”

13. Papilledema is a fairly common symptom of elevated blood pressure. The best way to detect this condition
is through:
A. Ophthalmic examination
B. Using a sphygmomanometer
C. Laboratory tests
D. An MRI
Correct Answer:
A. Ophthalmic examination

14. A nurse is educating about lifestyle modifications for a group of clients with newly diagnosed
hypertension. While discussing dietary changes, which point would the nurse emphasize?
A. It takes 2 to 3 months for the taste buds to adapt to decreased salt intake.
B. The taste buds never adapt to decreased salt intake.
C. There is usually no need to change alcohol consumption for clients with hypertension.
D. A person with hypertension should never consume alcohol.
Correct Answer:
A. It takes 2 to 3 months for the taste buds to adapt to decreased salt intake.

15. A client hospitalized for treatment of hypertension is being prepared for discharge. Which teaching topic
should the nurse be sure to cover?
A. Maintaining a low-potassium diet
B. Skipping a medication dose if dizziness occurs
C. Maintaining a low-sodium diet
D. Receiving I.V. antihypertensive medications
Correct Answer:
C. Maintaining a low-sodium diet

16. A client is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The
client’s blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV nitroprusside. Upon
assessment, which finding requires immediate intervention by the nurse?
A. Numbness and weakness in the left arm
B. Nausea and severe headache
C. Chest pain score of 3 (on a scale of 1 to 10)
D. Urine output of 40 mL over the past hour
Correct Answer:
A. Numbness and weakness in the left arm
17. The nurse is administering medications on a medical-surgical unit. A client is ordered to receive 40 mg
oral nadolol for the treatment of hypertension. Before administering the medication, the nurse should
A. Check the client’s heart rate
B. Check the client’s serum K⁺ level
C. Check the client’s urine output
D. Weigh the client
Correct Answer:
A. Check the client’s heart rate

18. A nurse providing education about hypertension to a community group is discussing the high risk for
cardiovascular complications. What are risk factors for cardiovascular problems in clients with
hypertension? (Select all that apply)
A. Gallbladder disease
B. Smoking
C. Diabetes mellitus
D. Physical inactivity
E. Frequent upper respiratory infections
Correct Answers:
B. Smoking
C. Diabetes mellitus
D. Physical inactivity

19. Which diagnostic method is recommended to determine whether left ventricular hypertrophy has
occurred?
A. Echocardiography
B. Electrocardiography
C. Blood chemistry
D. Blood urea nitrogen
Correct Answer:
A. Echocardiography

20. A nurse working in the clinic is seeing a client who has just been prescribed a new medication for
hypertension. The client asks why hypertension is sometimes called the "silent killer." What is the best
response by the nurse?
A. "Hypertension often causes no symptoms."
B. "Hypertension often kills early in the disease process."
C. "Hypertension often causes no pain."
D. "Hypertension is difficult to diagnose."
Correct Answer:
A. "Hypertension often causes no symptoms."

21. A 77-year-old client presents to the local community center for a blood pressure (BP) screening; BP is
recorded as 180/90 mm Hg. The client has a history of hypertension but currently is not taking the prescribed
medications. Which question is most appropriate for the nurse to ask the client first?
A. “Are you having trouble paying for your medications?”
B. “Can you tell me the reasons you aren't taking your medications?”
C. “What medications are you prescribed?”
D. “Are you able to get to your pharmacy to pick up your medications?”
Correct Answer:
B. “Can you tell me the reasons you aren't taking your medications?”

22. The nurse is teaching a client about chronic untreated hypertension. What complication will the nurse
explain to the client?
A. Peripheral edema
B. Right-sided heart failure
C. Stroke
D. Pulmonary insufficiency
Correct Answer:
C. Stroke

23. A client is admitted to the emergency room with a blood pressure reading of 200/130 mm Hg. What are
this client's therapeutic goals? Select all that apply.
A. An immediate lowering of the blood pressure to a normotensive level within the first 30 minutes
B. Reduction of the mean blood pressure by 25% within the first hour
C. Achievement of a goal pressure of about 160/100 within 2 to 6 hours
D. Reduction to a target goal pressure over a period of days
Correct Answers:
B. Reduction of the mean blood pressure by 25% within the first hour
C. Achievement of a goal pressure of about 160/100 within 2 to 6 hours
D. Reduction to a target goal pressure over a period of days
24. A client is taking amiloride and lisinopril for the treatment of hypertension. What laboratory studies
should the nurse monitor while the client is taking these two medications together?
A. Magnesium level
B. Potassium level
C. Calcium level
D. Sodium level
Correct Answer:
B. Potassium level

25. Nurses should implement measures to relieve emotional stress for clients with hypertension because the
reduction of stress
A. Increases the production of neurotransmitters that constrict peripheral arterioles
B. Increases the resistance that the heart must overcome to eject blood
C. Increases blood volume and improves the potential for greater cardiac output
D. Decreases the production of neurotransmitters that constrict peripheral arterioles
Correct Answer:
D. Decreases the production of neurotransmitters that constrict peripheral arterioles

26. The nurse is performing an assessment on a client to determine the effects of hypertension on the heart
and blood vessels. What specific assessment data will assist in determining this complication? (Select all that
apply.)
A. Heart rate
B. Respiratory rate
C. Heart rhythm
D. Character of apical and peripheral pulses
E. Lung sounds
Correct Answers:
A. Heart rate
C. Heart rhythm
D. Character of apical and peripheral pulses

27. A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is
150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does
this client have?
A. Secondary
B. Pathologic
C. Malignant
D. Essential (primary)
Correct Answer:
D. Essential (primary)

28. Which statements are true when the nurse is measuring blood pressure (BP)? Select all that apply.
A. Using a BP cuff that is too small will give a higher BP measurement.
B. The client’s arm should be positioned at the level of the heart.
C. Using a BP cuff that is too large will give a higher BP measurement.
D. The client’s BP should be measured 1 hour before consuming alcohol.
E. The client should sit quietly while BP is being measured.
Correct Answers:
A. Using a BP cuff that is too small will give a higher BP measurement.
B. The client’s arm should be positioned at the level of the heart.
E. The client should sit quietly while BP is being measured.

29. A nurse is educating a client about monitoring blood pressure readings at home. What will the nurse be
sure to emphasize?
A. "Avoid smoking cigarettes for 8 hours prior to taking blood pressure."
B. "Sit quietly for 5 minutes prior to taking blood pressure."
C. "Sit with legs crossed when taking your blood pressure."
D. "Be sure the forearm is well supported above heart level while taking blood pressure."
Correct Answer:
B. "Sit quietly for 5 minutes prior to taking blood pressure."

30. A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. What will the
nurse specify about this client's target blood pressure?
A. 145/95 or lower
B. 130/80 or lower
C. 150/95 or lower
D. 125/85 or lower
Correct Answer:
B. 130/80 or lower
31. Which describes a situation in which blood pressure is severely elevated and there is evidence of actual or
probable target organ damage?
A. Hypertensive emergency
B. Hypertensive urgency
C. Primary hypertension
D. Secondary hypertension
Correct Answer:
A. Hypertensive emergency

32. Approximately what percentage of adults in the United States have hypertension?
A. 20%
B. 30%
C. 40%
D. 50%
Correct Answer:
D. 30%

33. When administering benazepril with spironolactone, the nurse should be aware that which electrolyte
imbalance may occur?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypocalcemia
Correct Answer:
A. Hyperkalemia

34. The nurse teaches the client which guidelines regarding lifestyle modifications for hypertension?
A. Reduce smoking to no more than four cigarettes per day
B. Limit aerobic physical activity to 15 minutes, three times per week
C. Stop alcohol intake
D. Maintain adequate dietary intake of fruits and vegetables
Correct Answer:
D. Maintain adequate dietary intake of fruits and vegetables
35. A 35-year-old client has been diagnosed with hypertension. The client is a stock broker, smokes daily, and has
diabetes. During a follow-up appointment, the client states that regular visits to the health care provider just to check
blood pressure (BP) are cumbersome and time consuming. Which aspect of client teaching would the nurse
recommend?
A. Purchasing a self-monitoring BP cuff
B. Discussing methods for stress reduction
C. Advising smoking cessation
D. Administering glycemic control
Correct Answer:
A. Purchasing a self-monitoring BP cuff

36. The nurse is performing an assessment on a client to determine the effects of hypertension on the heart
and blood vessels. What specific assessment data will assist in determining this complication? (Select all that
apply.)
A. Heart rate
B. Respiratory rate
C. Heart rhythm
D. Character of apical and peripheral pulses
E. Lung sounds
Correct Answers:
A. Heart rate
C. Heart rhythm
D. Character of apical and peripheral pulses
E. Lung sounds

37. When teaching a client about hypertension and lifestyle changes, what does the nurse emphasize should be
included in the diet?
A. Fresh fruits and vegetables
B. Chloride-containing foods
C. Whole milk and cheeses
D. A glass of red wine
Correct Answer:
A. Fresh fruits and vegetables

38. Management of hypertension includes three of the following four goals, depending on the primary and
secondary causes. Select all that apply.
A. Impairing the synthesis of norepinephrine
B. Modifying the rate of myocardial contraction
C. Increasing the force of cardiac output to overcome peripheral resistance
D. Decreasing renal absorption of sodium
Correct Answers:
A. Impairing the synthesis of norepinephrine
B. Modifying the rate of myocardial contraction
D. Decreasing renal absorption of sodium

39. Primary or essential hypertension accounts for about 95% of all hypertension diagnoses with an unknown
etiology. Secondary hypertension accompanies specific conditions that create hypertension as a result of tissue
damage. Which condition contributes to secondary hypertension?
A. Arterial vasoconstriction
B. Hepatic function
C. Calcium deficit
D. Acid-base imbalance
Correct Answer:
A. Arterial vasoconstriction

40. The nurse is teaching a client who is experiencing dizziness to rise slowly from a sitting or lying position.
What is the rationale for the teaching?
A. Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the
brain.
B. Gradual changes in position help reduce the blood pressure to resupply oxygen to the brain.
C. Gradual changes in position help reduce the heart’s work to resupply oxygen to the brain.
D. Gradual changes in position provide time for the heart to reduce its rate of contraction to resupply oxygen to the
brain.
Correct Answer:
A. Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the
brain.

41. A nurse is caring for a client who has hypertension and diabetes mellitus. The client's blood pressure this
morning was 150/92 mm Hg. When the client asks the nurse what their blood pressure should be, what is the
nurse's most appropriate response?
A. "Your blood pressure is fine. Just keep doing what you're doing."
B. "The current recommendation is for everyone to have blood pressure of 140/90 mm Hg or lower."
C. "The lower the better. Blood pressure of 130/80 mm Hg is best for everyone."
D. "Clients with diabetes should have a lower blood pressure goal. You should strive for 120/80 mm Hg."
Correct Answer:
D. "Clients with diabetes should have a lower blood pressure goal. You should strive for 120/80 mm Hg."

42. A client has severe coronary artery disease (CAD) and hypertension. Which medication order should the
nurse consult with the health care provider about that is contraindicated for a client with severe CAD?
A. Clonidine
B. Amiloride
C. Bumetanide
D. Methyldopa
Correct Answer:
A. Clonidine

43. A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. What will the
nurse specify about this client's target blood pressure?
A. 145/95 or lower
B. 130/80 or lower
C. 150/95 or lower
D. 125/85 or lower
Correct Answer:
B. 130/80 or lower

44. The nurse understands that an overall goal of hypertension management is that:
A. Keep the blood pressure low
B. There is no indication of target organ damage
C. There is no report of postural hypotension
D. There are no reports of sexual dysfunction
Correct Answer:
B. There is no indication of target organ damage

45. A client with a history of hypertension is receiving client education about structures that regulate arterial
pressure. Which structure is a component of that process?
A. Kidneys
B. Parasympathetic nervous system
C. Limbic system
D. Lungs
Correct Answer:
A. Kidneys

46. The nurse is evaluating the types of medications prescribed for a client’s hypertension. Which of the
following medication classifications establishes an action on vasoconstrictive hormones in the bloodstream?
A. Beta-blocker
B. ACE inhibitor
C. Loop diuretic
D. Calcium channel blocker
Correct Answer:
B. ACE inhibitor

47. The nurse is explaining the DASH diet to a client diagnosed with hypertension. The client inquires about
how many servings of fruit per day can be consumed on the diet. What is the nurse's best response?
A. 4 or 5 servings per day
B. 7 or 8 servings per day
C. 2 or 3 servings per day
D. 2 or fewer servings per day
Correct Answer:
A. 4 or 5 servings per day

48. The nurse is instructing a student on the proper technique for measuring blood pressure (BP). Which
student action indicates a need for further teaching?
A. Positions the arm at waist level
B. Palpates the systolic pressure before auscultating blood pressure
C. Centers the blood pressure cuff bladder directly over the brachial artery
D. Wraps the blood pressure cuff firmly around the arm
Correct Answer:
A. Positions the arm at waist level

49. Which of the following would be inconsistent with a hypertensive urgency?

A. Intracranial hemorrhage
B. Severe headache
C. Epistaxis
D. Anxiety
Correct Answer:
A. Intracranial hemorrhage

50. A nurse is providing education to a client about monitoring blood pressure readings at home. What
reminders will the nurse review with the client? Select all that apply.
A. Avoid smoking cigarettes for 1 hour prior to taking blood pressure.
B. Avoid talking during the measurement.
C. Sit with both feet on the ground during the measurement.
D. Ensure at least 5 minutes of quiet rest before measurements.
E. Be sure the forearm is well supported at heart level while taking blood pressure.
Correct Answer:
B. Avoid talking during the measurement.
C. Sit with both feet on the ground during the measurement.
D. Ensure at least 5 minutes of quiet rest before measurements.
E. Be sure the forearm is well supported at heart level while taking blood pressure.

Cardiovascular:

1. A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins.
Which of the following actions should the nurse take?
A. Position the client supine with his legs elevated when in bed
B. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr
C. Tell the client to sit with his legs dependent after ambulating
D. Instruct the client to wear knee-length socks for 2 weeks after surgery
Correct Answer:
A. Position the client supine with his legs elevated when in bed

2. A nurse is caring for a client who has heart failure and whose telemetry reading displays a flattening of the
T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG
change?
A. Potassium 2.8 mEq/L
B. Digoxin level 0.7 ng/mL
C. Hemoglobin 9.8 g/dL
D. Calcium 8.0 mg
Correct Answer:
A. Potassium 2.8 mEq/L

3. A nurse is reviewing a client’s repeat laboratory results 4 hr after administering fresh frozen plasma (FFP).
Which of the following laboratory results should the nurse review?
A. Prothrombin time
B. WBC count
C. Platelet count
D. Hematocrit
Correct Answer:
A. Prothrombin time

4. A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of
the following information should the nurse include in the teaching?
A. Hospitalization is required when administering each treatment.
B. The maximum effect of the medication will occur in 6 months.
C. Hypertension is a common adverse effect of this medication.
D. Blood transfusions are needed with each treatment.
Correct Answer:
C. Hypertension is a common adverse effect of this medication.

5. A nurse is completing an assessment for a client who has a history of unstable angina. Which of the
following findings should the nurse expect?
A. Chest pain is relieved soon after resting.
B. Nitroglycerin relieves chest pain.
C. Physical exertion does not precipitate chest pain.
D. Chest pain lasts longer than 15 min.
Correct Answer:
D. Chest pain lasts longer than 15 min.

6. A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the
following manifestations should the nurse expect? (Select all that apply.)
A. Jugular vein distension
B. Moist crackles
C. Postural hypotension
D. Increased heart rate
E. Fever
Correct Answer:
A. Jugular vein distension
B. Moist crackles
D. Increased heart rate

7. A nurse is monitoring a client who had a myocardial infarction. For which of the following complications
should the nurse monitor in the first 24 hr?
A. Infective endocarditis
B. Pericarditis
C. Ventricular dysrhythmias
D. Pulmonary emboli
Correct Answer:
C. Ventricular dysrhythmias

8. A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of the following
ECG abnormalities should the nurse recognize as atrial flutter?
A. P waves occurring at 0.16 seconds before each QRS complex
B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. An irregular ventricular rate of 125/min with a wide QRS pattern
Correct Answer:
B. Atrial rate of 300/min with QRS complex of 80/min

9. A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations
should the nurse expect?
A. Midsternal chest pain
B. Thrill
C. Pitting edema in lower extremities
D. Lower back discomfort
Correct Answer:
D. Lower back discomfort

10. A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload.
Which of the following findings should the nurse expect?
A. Weight gain 1 kg (2.2 lb) in 1 day
B. Pitting edema +1
C. Client report of nocturnal cough
D. B-Type Natriuretic Peptide (BNP) level of 100 pg/mL
Correct Answer:
A. Weight gain 1 kg (2.2 lb) in 1 day

11. A nurse is completing a medication history for a client who reports using fish oil as a dietary supplement.
Which of the following substances in fish oil should the nurse recognize as a health benefit to the client?
A. Omega-3 fatty acids
B. Antioxidants
C. Vitamins A, D, and C
D. Beta-carotene
Correct Answer:
A. Omega-3 fatty acids

12. A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should
the nurse expect?
A. Plethoric appearance of facial skin
B. Glossitis and weight loss
C. Jaundice with an enlarged liver
D. Petechiae and ecchymosis
Correct Answer:
D. Petechiae and ecchymosis

13. A nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. The
client’s vital signs are blood pressure 160/98 mm Hg, heart rate 102/min, respirations 22/min, and SpO₂ 95%.
Which of the following actions should the nurse take?
A. Administer antihypertensive medication for blood pressure.
B. Monitor that urinary output is 20 mL/hr.
C. Withhold pain medication to prepare for surgery.
D. Take vital signs every 2 hr.
Correct Answer:
A. Administer antihypertensive medication for blood pressure.

14. A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hr. Available
is a blood administration set that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to
deliver how many gtt/min?
Formula:

Correct Answer:
10 gtt/min

15. A nurse is assessing for cardiac tamponade on a client who had coronary artery bypass grafts. Which of
the following actions should the nurse take?
A. Check for hypertension
B. Auscultate for loud, bounding heart sounds
C. Auscultate blood pressure for pulsus paradoxus
D. Check for a pulse deficit
Correct Answer:
C. Auscultate blood pressure for pulsus paradoxus

16. A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse
should administer which of the following IV solutions?
A. 0.45% sodium chloride
B. Dextrose 5% in 0.9% sodium chloride
C. Dextrose 10% in water
D. 0.9% sodium chloride
Correct Answer:
D. 0.9% sodium chloride
17. A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse
should administer which of the following IV solutions?
A. 0.45% sodium chloride
B. Dextrose 5% in 0.9% sodium chloride
C. Dextrose 10% in water
D. 0.9% sodium chloride
Correct Answer:
D. 0.9% sodium chloride

18. A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral
arterial disease. Which of the following findings should the nurse expect?
A. Pitting edema
B. Areas of reddish-brown pigmentation
C. Dry, pale skin with minimal body hair
D. Sunburned appearance with desquamation
Correct Answer:
C. Dry, pale skin with minimal body hair

19. A nurse is providing teaching about lifestyle changes to a client who had a myocardial infarction and has a
new prescription for a beta blocker. Which of the following client statements indicates an understanding of
the teaching?
A. "I should eat foods high in saturated fat."
B. "Before taking my medication, I will count my radial pulse rate."
C. "I will exercise once per week for an hour at the health club."
D. "I will stop taking my medication when my blood pressure is within a normal range."
Correct Answer:
B. "Before taking my medication, I will count my radial pulse rate."

20. A nurse is caring for a client who has a demand pacemaker inserted with the rate set at 72/min. Which of
the following findings should the nurse expect?
A. Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes.
B. The client is experiencing premature ventricular complexes at 12/min.
C. Telemetry monitoring shows pacing spikes with no QRS complexes.
D. The client is experiencing hiccups.
Correct Answer:
A. Telemetry monitoring shows QRS complexes occurring at a rate of 74/min with no pacing spikes.

21. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the
nurse expect?
A. Decreased capillary refill
B. Dyspnea
C. Orthopnea
D. Dependent edema
Correct Answer:
D. Dependent edema

22. A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness
of breath on exertion. Which of the following conditions should the nurse expect?
A. Increased cardiac output
B. Increased pulmonary congestion
C. Decreased left atria pressure
D. Decreased pulmonary artery pressure
Correct Answer:
B. Increased pulmonary congestion

23. A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an
injury. Which of the following actions should the nurse take?
A. Obtain blood samples to test platelet function.
B. Prepare for replacement of the missing clotting factor.
C. Administer aspirin for the client’s pain.
D. Place the bleeding joint in the dependent position.
Correct Answer:
B. Prepare for replacement of the missing clotting factor.

24. A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse
expect?
A. Bradycardia with S-T segment depression
B. Relief of chest pain with deep inspiration
C. Dyspnea with hiccups
D. Chest pain that increases when sitting upright
Correct Answer:
C. Dyspnea with hiccups

25. A nurse is planning care for a client who has pernicious anemia. Which of the following interventions
should the nurse include in the plan?
A. Administer ferrous sulfate supplementation.
B. Increase dietary intake of folic acid.
C. Initiate weekly injections of vitamin B₁₂.
D. Initiate a blood transfusion.
Correct Answer:
C. Initiate weekly injections of vitamin B₁₂.

26. A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of
shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on
inspiration. Which of the following adventitious breath sounds should the nurse document?
A. Coarse crackles
B. Wheezes
C. Rhonchi
D. Friction rub
Correct Answer:
A. Coarse crackles

27. A nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty
(PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postprocedure
plan of care?

A. Instruct the client on a long-term cardiac conditioning program.

B. Administer scheduled doses of acetaminophen.

C. Check for peak laboratory markers of myocardial damage.

D. Monitor for bleeding.

Correct Answer:

D. Monitor for bleeding.

28. A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of
receiving blood transfusions. For which of the following complications should the nurse monitor?
A. Hypokalemia

B. Lead poisoning

C. Hypercalcemia

D. Iron toxicity

Correct Answer:

D. Iron toxicity

29. A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative.
Which of the following actions should the nurse take?

A. Continue to monitor for manifestations of a transfusion reaction.

B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution.

C. Continue the transfusion and repeat the type and crossmatch.

D. Prepare to administer a dose of diphenhydramine IV.

Correct Answer:

B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution.

30. A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) to a client who has anemia.
Which of the following actions should the nurse take first?

A. Hang an IV infusion of 0.9% sodium chloride with the blood.

B. Check the client’s identification number with the number on the blood.

C. Witness the informed consent.

D. Obtain pretransfusion vital signs.

Correct Answer:

C. Witness the informed consent.

31. A nurse is receiving report on a client on a medical floor.

Vital Signs (Exhibit 1 - Day 2, 1400):

Temperature: 37° C (98.6° F)

Heart rate: 118/min

Respiratory rate: 24/min

Blood pressure: 144/68 mm Hg

Oxygen saturation: 96% on 2L oxygen via nasal cannula

Laboratory Results (Exhibit 2 - Day 2, 0800):

Sodium: 140 mEq/L (Normal: 136–145 mEq/L)

Potassium: 3.7 mEq/L (Normal: 3.5–5 mEq/L)

Magnesium: 1.8 mEq/L (Normal: 1.3–2.1 mEq/L)

BUN: 18 mg/dL (Normal: 10–20 mg/dL)

BNP: 850 pg/mL (Elevated; Normal: <100 pg/mL)

Diagnostic Results (Exhibit 3):

Day 1, 1200: Chest x-ray shows bilateral pleural effusion

Day 1, 1600: Echocardiogram shows left ventricular hypertrophy, hypokinesis of the left ventricle, and an ejection
fraction of 45% (reduced).

SBAR Note (Exhibit 4 - Day 2, 1445):

S: Client presented to the ED with chest pain and shortness of breath.

B: Diagnosed with heart failure a year ago; history of hypertension and coronary artery disease.

A: Alert and oriented to person and place but confused to time. Respirations slightly labored, tachypneic respirations

Bibasilar crackles, pink frothy sputum, S3 gallop, sinus tachycardia, Jugular neck vein not distended, Weak
peripheral pulses, cool skin, and minimal clear urine output

R: Continue I&O. Monitor respiratory status.

Question:

For each assessment finding, click to specify if the assessment finding is consistent with left-sided heart failure
or right-sided heart failure.

Assessment Findings Left-sided Heart Failure Right-sided Heart Failure

Heart assessment (S3) ☑

Cough (hacking, pink sputum) ☑

Breath sounds (bibasilar crackles) ☑

BNP result (850 pg/mL) ☑ ☑

Neck vein assessment (not distended) ☑

32. A nurse in the emergency department is caring for a client who has chest pain.
Exhibit 1 – Vital Signs:
Time: 0200
Temperature: 37.5° C (99.5° F)
Blood pressure: 175/88 mm Hg
Heart rate: 125/min
Respiratory rate: 26/min
Oxygen saturation: 93% on room air

Exhibit 2 – Assessment:
Time: 0210
The client is alert and oriented to person, place, and time.
Reports chest pain radiating down the left arm for 40 minutes, unrelieved by rest.
Rates pain 9 out of 10.
Client appears short of breath, with labored respirations.
Skin is cool and clammy.
Tachypneic and tachycardic.
Clear bilateral breath sounds.
Heart tones regular.
Abdomen soft, nontender with active bowel sounds.
Palpable pulses.
Cardiac monitor shows sinus tachycardia.

Exhibit 3 – Diagnostic Results:

Time: 0218
12-lead EKG: ST elevation noted in leads II, III, and aVF (indicative of inferior myocardial infarction)
Question:
The nurse is planning care for the client who has chest pain. Specify the 4 anticipated prescriptions for this
client.

Correct Answers:
Oxygen
Morphine
Aspirin
Nitroglycerin

33. A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse
recognize as a potential complication?
A. Friction rub
B. Dependent rubor
C. Intermittent claudication
D. Cardiac murmur
Correct Answer:
D. Cardiac murmur

34. A nurse in an emergency department is caring for a client who had an anterior myocardial infarction. The
client’s history reveals they are 1 week postoperative following an open cholecystectomy. The nurse should
identify that which of the following interventions is contraindicated?
A. Administering IV morphine sulfate
B. Administering oxygen at 2 L/min via nasal cannula
C. Helping the client to the bedside commode
D. Assisting with thrombolytic therapy
Correct Answer:
D. Assisting with thrombolytic therapy

35. A nurse in an emergency department is assessing a client who has a bradydysrhythmia. Which of the
following findings should the nurse monitor for?
A. Confusion
B. Friction rub
C. Hypertension
D. Warm dry skin
Correct Answer:
A. Confusion

36. A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg.
The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse
take first?
A. Initiate seizure precautions.
B. Tell the client to report vision changes.
C. Elevate the head of the client’s bed.
D. Start a peripheral IV.
Correct Answer:
C. Elevate the head of the client’s bed
37. A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal
sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following
interventions?
A. Initiate chest compressions
B. Vagal stimulation
C. Administration of atropine IV
D. Defibrillation
Correct Answer:
B. Vagal stimulation

38. A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when
evaluating the point of maximal impulse (PMI).

Correct Answer:
D

39. A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the
following actions should the nurse take if the client’s aPTT is 96 seconds (30 to 40 seconds)?
A. Increase the heparin infusion flow rate by 2 mL/hr.
B. Continue to monitor the heparin infusion as prescribed.
C. Request a prothrombin time (PT).
D. Stop the heparin infusion.
Correct Answer:
D. Stop the heparin infusion.

40. A nurse is providing health teaching to a group of clients. Which of the following clients is at risk for
developing peripheral arterial disease?
A. A client who has hypothyroidism
B. A client who has diabetes mellitus
C. A client whose daily caloric intake consists of 25% fat
D. A client who consumes two 12-oz (0.35-L) bottles of beer a day
Correct Answer:
B. A client who has diabetes mellitus

41. A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. Which of the following
focused assessments should the nurse use to help differentiate between an arterial ulcer and a venous stasis
ulcer?
A. Explore the client’s family history of peripheral vascular disease.
B. Note the presence or absence of pain at the ulcer site.
C. Inquire about the presence or absence of claudication.
D. Ask if the client has had a recent infection.
Correct Answer:
C. Inquire about the presence or absence of claudication.

42. A nurse is planning a presentation for a group of clients who have hypertension. Which of the following
lifestyle modifications should the nurse include? (Select all that apply.)
A. Limited alcohol intake
B. Regular exercise program
C. Decreased magnesium intake
D. Reduced potassium intake
E. Tobacco cessation
Correct Answers:
A. Limited alcohol intake
B. Regular exercise program
E. Tobacco cessation

43. A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the
following findings should the nurse plan to monitor for and report to the provider immediately?
A. Slurred speech
B. Irregular pulse
C. Dependent edema
D. Persistent fatigue
Correct Answer:
A. Slurred speech

44. A nurse is caring for a client who is 8 hr postoperative following a coronary artery bypass graft (CABG).
Which of the following findings should the nurse report?
A. Mediastinal drainage 100 mL/hr
B. Blood pressure 160/80 mm Hg
C. Temperature 37.1° C (98.8° F)
D. Potassium 4.0 mEq/L (3.5 to 5.0 mEq/L)
Correct Answer:
B. Blood pressure 160/80 mm Hg

45. A nurse is assessing a female client who has a deep-vein thrombosis and is receiving warfarin. Which of
the following findings should indicate to the nurse that the medication is effective?
A. Hemoglobin 14 g/dL (12 to 16 g/dL)
B. Minimal bruising of extremities
C. Decreased blood pressure
D. INR 2.4 (2.0 to 3.0)
Correct Answer:
D. INR 2.4 (2.0 to 3.0)

46. A nurse is teaching a client who has a new prescription for an ACE inhibitor to treat hypertension. The
nurse should instruct the client to notify their provider if they experience which of the following adverse
effects of this medication?
A. Tendon pain
B. Persistent cough
C. Frequent urination
D. Constipation
Correct Answer:
B. Persistent cough

47. A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography
at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible
rescheduling?
A. "I'm still hungry after the bowl of cereal I ate at 7 a.m."
B. "I didn't take my heart pills this morning because the doctor told me not to."
C. "I have had chest pain a couple of times since I saw my doctor in the office last week."
D. "I smoked a cigarette this morning to calm my nerves about having this procedure."
Correct Answer:
D. "I smoked a cigarette this morning to calm my nerves about having this procedure."

48. A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client
statements indicates a potential complication of the insertion procedure?
A. "I can't get rid of these hiccups."
B. "I feel dizzy when I stand."
C. "My incision site stings."
D. "I have a headache."
Correct Answer:
A. "I can't get rid of these hiccups."

49. A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Which of the following
areas of the strip should the nurse examine to observe for atrial depolarization?

Correct Answer:
A

50. A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the
nurse expect?
A. Dyspnea on exertion
B. Tracheal deviation
C. Pericardial rub
D. Weight loss
Correct Answer:
A. Dyspnea on exertion
51. A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following
findings indicates effective treatment of the client’s condition?
A. Absence of adventitious breath sounds
B. Presence of a nonproductive cough
C. Decrease in respiratory rate at rest
D. SpO₂ 86% on room air
Correct Answer:
A. Absence of adventitious breath sounds

52. A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide.
The nurse should plan to monitor for which of the following adverse effects of the medication?
A. Shortness of breath
B. Lightheadedness
C. Dry cough
D. Metallic taste
Correct Answer:
B. Lightheadedness

53. A nurse is providing teaching to a client who is 2 days postoperative following a heart transplant. Which
of the following statements should the nurse include in the teaching?
A. "You might no longer be able to feel chest pain."
B. "Your level of activity intolerance will not change."
C. "After 6 months, you will no longer need to restrict your sodium intake."
D. "You will be able to stop taking immunosuppressants after 12 months."
Correct Answer:
A. "You might no longer be able to feel chest pain."

54. A nurse is caring for a client who was admitted for treatment of left-sided heart failure and is receiving
intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart
rate. Which of the following actions should the nurse take first?
A. Obtain the client’s current weight.
B. Review serum electrolyte values.
C. Determine the time of the last digoxin dose.
D. Check the client’s urine output.
Correct Answer:
B. Review serum electrolyte values.
55. A nurse is caring for a client who is 1 hr postoperative following an aortic aneurysm repair. Which of the
following findings can indicate shock and should be reported to the provider?
A. Serosanguineous drainage on dressing
B. Client reports 6 on a pain scale of 1–10 with coughing
C. Urine output of 20 mL/hr
D. Increase in temperature from 36.8° C (98.2° F) to 37.5° C (99.5° F)
Correct Answer:
C. Urine output of 20 mL/hr

56. A nurse is providing discharge teaching to a client who has a prescription for transdermal nitroglycerin
patches. Which of the following instructions should the nurse include in the teaching?
A. Apply the new patch to the same site as the previous patch.
B. Place the patch on an area of skin away from skin folds and joints.
C. Keep the patch on 24 hr per day.
D. Replace the patch at the onset of angina.
Correct Answer:
B. Place the patch on an area of skin away from skin folds and joints.

57. A nurse is providing discharge teaching to a client who has heart failure. The nurse should instruct the
client to report which of the following findings immediately to the provider?
A. Weight gain of 0.9 kg (2 lb) in 24 hr
B. Increase of 10 mm Hg in systolic blood pressure
C. Dyspnea with exertion
D. Dizziness when rising quickly
Correct Answer:
A. Weight gain of 0.9 kg (2 lb) in 24 hr

58. A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which
of the following client statements indicates a need for further clarification by the nurse?
A. "My arthritis is really bothering me because I haven't taken my aspirin in a week."
B. "My blood pressure shouldn't be high because I took my blood pressure medication this morning."
C. "I took my warfarin last night according to my usual schedule."
D. "I will check my blood sugar because I took a reduced dose of insulin this morning."
Correct Answer:
C. "I took my warfarin last night according to my usual schedule."
59. A nurse is caring for a client in the emergency department.
Vital Signs (0755):
Temperature: 37°C (98.6°F)
Blood pressure: 89/52 mm Hg
Heart rate: 144/min
Respiratory rate: 26/min
Oxygen saturation: 95% on room air
History and Physical (0830):
Client reports a history of smoking 1 pack per day for 40 years, diabetes mellitus, and obstructive sleep apnea.
Client drinks four beers each day. Reports family history of coronary artery disease. Client presents to the
emergency department with shortness of breath, palpitations, and dizziness. Client is alert and oriented to person,
place, and time. Heart sounds are irregular. Bilateral breath sounds are clear. Respirations are labored. Pulses are
palpable 2+ and irregular. Heart rhythm is irregular per EKG.

Diagnostic Results (0835):

12-lead EKG shows atrial fibrillation with a ventricular rate of 144.

Question:
The nurse is reviewing the client’s electronic medical record. The nurse should identify that the client is at the
greatest risk for developing _______ and _______.
Options:
Aortic stenosis
Stroke
Liver cirrhosis
Hypertension
Heart failure

Correct Answers:
Stroke and Heart failure

60. A nurse is caring for a client in a provider's office.

Vital Signs (0945):
Temperature: 37°C (98.6°F)
Heart rate: 110/min
Blood pressure: 172/92 mm Hg
Respiratory rate: 20/min
Oxygen saturation: 98% on room air

History and Physical (1000):

Client reports frequent headaches and dizziness. Smokes 1.5 to 2 packs of cigarettes per day for the past 20 years.
The client is alert and oriented to person, place, and time. No irregular heart tones auscultated. Respirations are even
and unlabored. Bilateral breath sounds are clear. Pulses are palpable at 3+. Skin is warm and dry.

Nurses' Notes:
1045: Client provided education on lifestyle modification regarding exercise, smoking cessation, DASH diet, weight
maintenance, and alcohol consumption.
1200: Client states:

"I understand that I need to eat 4 to 5 servings of vegetables a day. I am so glad I can still eat meat with every meal.
7 to 8 servings a day of grains will be difficult for me to eat. I will have to increase my consumption of nuts, seeds,
and dry beans to eat 4 to 5 servings weekly. I will not have any trouble with 2 to 3 servings of dairy per day. I
always drink whole milk with every meal and at bedtime."

Question:
The nurse provided dietary teaching to the client. Which of the following statements made by the client
indicate an understanding of the DASH diet? Select all that apply.
Correct Answers:
"I understand that I need to eat 4 to 5 servings of vegetables a day."
"7 to 8 servings a day of grains will be difficult for me to eat."
"I will have to increase my consumption of nuts, seeds, and dry beans to eat 4 to 5 servings weekly."
"I will not have any trouble with 2 to 3 servings of dairy per day."

Endocrine:

1. A nurse is caring for a client who is postoperative following a bilateral adrenalectomy. The nurse should
expect to administer glucocorticoids following the procedure to enhance which of the following therapeutic
effects?
A. Compensate for decrease in cortisol levels
B. Inhibit glucose metabolism
C. Act as a diuretic to maintain urine output
D. Decrease susceptibility to infection
Correct Answer:
A. Compensate for decrease in cortisol levels

2. A nurse is planning a community health screening for a group of clients who are at risk for type 2 diabetes
mellitus. Which of the following clients should the nurse include in the screening?
A. Men who smoke
B. Men and women who are obese
C. Women who have hepatitis
D. Men and women who consume high-protein and low-carbohydrate foods
Correct Answer:
B. Men and women who are obese

3. A nurse is providing teaching to a client who has type 1 diabetes mellitus about hypoglycemia. Which of the
following manifestations should the nurse include in the teaching?
A. Shakiness
B. Urinary frequency
C. Dry mucous membranes
D. Excess thirst
Correct Answer:
A. Shakiness

4. A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of
hyperglycemia. Which of the following findings should indicate to the nurse that the client has
hyperglycemia?
A. Hunger
B. Increased urination
C. Cold, clammy skin
D. Tremors
Correct Answer:
B. Increased urination

5. A nurse is preparing a 24-hour urine specimen for a client who is suspected to have pheochromocytoma.
Which of the following laboratory tests from the 24-hour urine specimen should the nurse use to determine
the client's condition?
A. Creatinine clearance
B. Vanillylmandelic acid (VMA)
C. 17-hydroxycorticosteroids (17-OHCS)
D. Protein
Correct Answer:
B. Vanillylmandelic acid (VMA)

6. A nurse is providing teaching to a client who has type 1 diabetes mellitus about exercise. Which of the
following statements should the nurse include in the teaching?
A. "You should exercise during a peak insulin time."
B. "Wear a medical alert identification tag when you exercise."
C. "Exercise can decrease the effects of insulin and cause the blood glucose levels to increase."
D. "You will get the most benefit from exercise when your glucose levels are higher than normal."
Correct Answer:
B. "Wear a medical alert identification tag when you exercise."

7. A nurse is caring for a client who is postoperative following a parathyroidectomy to treat

hyperparathyroidism. Which of the following laboratory values should the nurse expect to decrease as a
therapeutic effect of the procedure?
A. Calcium
B. Sodium
C. Potassium
D. Phosphorous
Correct Answer:
A. Calcium

8. A nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism caused by an adenoma.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
A. Tachycardia and hypertension
B. Respiratory rate 16/min
C. Negative Chvostek's sign
D. Laryngeal stridor and hoarseness
E. Positive Trousseau’s sign
Correct Answers:
A. Tachycardia and hypertension
D. Laryngeal stridor and hoarseness
E. Positive Trousseau’s sign
9. A nurse is planning care for a client who is experiencing the Somogyi effect and takes intermittent-acting
insulin. Which of the following actions should the nurse include in the plan?
A. Move the evening intermediate-acting insulin dose to 90 min before dinner.
B. Increase the client’s morning caloric intake.
C. Omit the client’s evening snack.
D. Monitor the client’s nighttime blood glucose levels.
Correct Answer:
D. Monitor the client’s nighttime blood glucose levels.

10. A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse
expect the client to display?
A. Constipation
B. Cold intolerance
C. Difficulty sleeping
D. Anorexia
Correct Answer:
C. Difficulty sleeping

11. A nurse is monitoring a client who has syndrome of inappropriate antidiuretic hormone secretion
(SIADH). Which of the following findings should the nurse expect?
A. Polyuria
B. Dehydration
C. Hyponatremia
D. Hyperthermia
Correct Answer:
C. Hyponatremia

12. A nurse is planning care for a client who has Cushing’s syndrome due to chronic corticosteroid use. Which
of the following actions should the nurse include in the plan of care?
A. Check the client’s blood glucose for hypoglycemia.
B. Check the client’s urine specific gravity.
C. Weigh the client weekly.
D. Insert an indwelling urinary catheter for the client.
Correct Answer:
B. Check the client’s urine specific gravity.

13. A nurse is caring for a client who has diabetes insipidus. For which of the following findings should the
nurse monitor?
A. Proteinuria
B. Oliguria
C. Polyuria
D. Glycosuria
Correct Answer:
C. Polyuria

14. A nurse is providing teaching to a client who has type 2 diabetes mellitus about the pathophysiology of the
disease. Which of the following statements by the client indicates an understanding of the teaching?
A. "My cells are resistant to the effects of insulin."
B. "My body breaks down sugars too efficiently."
C. "My pancreas does not produce insulin."
D. "My body produces antibodies against pancreatic beta cells."
Correct Answer:
A. "My cells are resistant to the effects of insulin."

15. A nurse is assessing a client who has manifestations of acromegaly. Which of the following findings should
the nurse expect?
A. Thinning of skeletal bone structure
B. Concave chest wall
C. High-pitched voice
D. Increased head size
Correct Answer:
D. Increased head size

16. A nurse is monitoring a client who has Graves' disease for the development of thyroid storm. The nurse
should report which of the following findings to the provider?
A. Constipation
B. Headache
C. Bradycardia
D. Hypertension
Correct Answer:
D. Hypertension

17. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. The nurse should
understand that which of the following laboratory values is consistent with diabetic ketoacidosis?
A. Blood glucose 30 mg/dL
B. Negative urine ketones
C. Blood pH 7.38
D. Bicarbonate level 12 mEq/L
Correct Answer:
D. Bicarbonate level 12 mEq/L

18. A nurse is checking laboratory values to determine if a client who has diabetes mellitus is adhering to the
treatment plan. Which of the following tests should the nurse use to make this determination?
A. Glycosylated hemoglobin levels
B. Urine sugar and acetone
C. Glucose tolerance test
D. Fasting serum glucose
Correct Answer:
A. Glycosylated hemoglobin levels

19. A nurse is assessing a client who has Addison’s disease. Which of the following skin manifestations should
the nurse expect to find?
A. Purple striae on the chest and abdomen
B. Butterfly rash across the bridge of the nose
C. Bronze pigmentation of skin
D. Jaundice of the face and sclera
Correct Answer:
C. Bronze pigmentation of skin

20. A nurse is providing teaching to a client who has Addison’s disease about healthy snack foods. Which of
the following food choices by the client indicates an understanding of the teaching?
A. Sliced bananas
B. Baked potato
C. Turkey and cheese sandwich
D. Plain yogurt with peaches
Correct Answer:
C. Turkey and cheese sandwich

Respiratory:

1. A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following
findings indicates that the nurse should suction the client’s airway secretions?
A. The client is unable to speak.
B. The client’s airway secretions were last suctioned 2 hr ago.
C. The client coughs and expectorates a large mucous plug.
D. The nurse auscultates coarse crackles in the lung fields.
Correct Answer:
D. The nurse auscultates coarse crackles in the lung fields.

2. A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the
following information should the nurse include?
A. "If the test is positive, it means you have an active case of tuberculosis."
B. "If the test is positive, you should have another tuberculin skin test in 3 weeks."
C. "You must return to the clinic to have the test read in 2 or 3 days."
D. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."
Correct Answer:
C. "You must return to the clinic to have the test read in 2 or 3 days."

3. A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of
the following instructions should the nurse include?
A. "Apply warm compresses to the face."
B. "Take aspirin 650 milligrams by mouth for mild pain."
C. "Close your mouth when sneezing."
D. "Lie on your back with your head elevated 30° when resting."
Correct Answer:
D. "Lie on your back with your head elevated 30° when resting."
4. A nurse is planning care for a client who has chronic obstructive pulmonary disease and is malnourished.
Which of the following recommendations to promote nutritional intake should the nurse include in the plan?
A. Eat high-calorie foods first.
B. Increase intake of water at meal times.
C. Perform active range-of-motion exercises before meals.
D. Keep saltine crackers nearby for snacking.
Correct Answer:
A. Eat high-calorie foods first.

5. A nurse in the emergency department is assessing a client for a closed pneumothorax and significant
bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on
inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax?
A. Absence of breath sounds
B. Expiratory wheezing
C. Inspiratory stridor
D. Rhonchi
Correct Answer:
A. Absence of breath sounds

6. A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the
following points should the nurse plan to discuss first?
A. How to eliminate environmental triggers that precipitate attacks
B. The client’s perception of the disease process and what might have triggered past attacks
C. The client’s medication regimen
D. Manifestations of respiratory infections
Correct Answer:
B. The client’s perception of the disease process and what might have triggered past attacks

7. A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify
that which of the following findings is an adverse effect of this medication?
A. Hallucinations
B. Pruritus
C. Hand and foot syndrome
D. Tinnitus
Correct Answer:
D. Tinnitus
8. A nurse is caring for an older adult client who has chronic obstructive pulmonary disease with pneumonia.
The nurse should monitor the client for which of the following acid-base imbalances?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
Correct Answer:
B. Respiratory acidosis

9. A nurse is preparing to assist a provider to withdraw arterial blood from a client’s radial artery for
measurement of ABG. Which of the following actions should the nurse plan to take?
A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen.
B. Apply ice to the site after obtaining the specimen.
C. Perform an Allen’s test prior to obtaining the specimen.
D. Release pressure applied to the puncture site 1 min after the needle is withdrawn.
Correct Answer:
C. Perform an Allen’s test prior to obtaining the specimen.

10. A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The
nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the
following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)?
A. Tympanic temperature 38° C (100.4° F)
B. PaO₂ 50 mm Hg
C. Rhonchi
D. Hypopnea
Correct Answer:
B. PaO₂ 50 mm Hg

11. A nurse in a provider’s office is assessing a client who states he was recently exposed to tuberculosis.
Which of the following findings is a clinical manifestation of pulmonary tuberculosis?
A. Pericardial friction rub
B. Weight gain
C. Night sweats
D. Cyanosis of the fingertips
Correct Answer:
C. Night sweats

12. A nurse in an urgent care clinical is collecting data from a client who reports exposure to anthrax. Which
of the following findings is an indication of the prodromal stage of inhalation anthrax?
A. Dry cough
B. Rhinitis
C. Sore throat
D. Swollen lymph nodes
Correct Answer:
A. Dry cough

13. A client is admitted to the emergency department following a motorcycle crash. The nurse notes a
crackling sensation upon palpation on the right side of the client’s chest. After notifying the provider, the
nurse should document this finding as which of the following?
A. Friction rub
B. Crackles
C. Crepitus
D. Tactile fremitus
Correct Answer:
C. Crepitus

14. A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive
pulmonary disease with emphysema. The nurse should explain that this breathing technique accomplishes
which of the following?
A. Increases oxygen intake
B. Promotes carbon dioxide elimination
C. Uses the intercostal muscles
D. Strengthens the diaphragm
Correct Answer:
B. Promotes carbon dioxide elimination

15. A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following
actions should the nurse include in the plan of care?
A. Clamp the chest tube if there is continuous bubbling in the water seal chamber.
B. Keep the chest tube drainage system at the level of the right atrium.
C. Tape all connections between the chest tube and drainage system.
D. Empty the collection chamber and record the amount of drainage every 8 hr.
Correct Answer:
C. Tape all connections between the chest tube and drainage system.

16. A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client
states, "I am afraid it will hurt to cough after the surgery." Which of the following statements by the nurse is
appropriate?
A. "After the surgeon removes the lung, you will not need to cough."
B. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough."
C. "Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little
pain."
D. "I will show you how to splint your incision while coughing."
Correct Answer:
D. "I will show you how to splint your incision while coughing."

17. A nurse is preparing a client for a thoracentesis. In which of the following positions should the nurse place the
client?
A. Lying flat on the affected side
B. Prone with the arms raised over the head
C. Supine with the head of the bed elevated
D. Sitting while leaning forward over the bedside table
Correct Answer:
D. Sitting while leaning forward over the bedside table

18. A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement
surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse
recognize as an indication of pulmonary embolism?
A. Sudden onset of dyspnea
B. Tracheal deviation
C. Bradycardia
D. Difficulty swallowing
Correct Answer:
A. Sudden onset of dyspnea

19. A nurse is providing teaching to a client about pulmonary function tests. Which of the following tests
measures the volume of air the lungs can hold at the end of maximum inhalation?
A. Total lung capacity
B. Vital lung capacity
C. Functional residual capacity
D. Residual volume
Correct Answer:
A. Total lung capacity

20. A nurse is teaching about daily chest physiotherapy with a client who has cystic fibrosis. The nurse should
instruct the client that which of the following is the purpose of the treatments?
A. To encourage deep breaths
B. To mobilize secretions in the airways
C. To dilate the bronchioles
D. To stimulate the cough reflex
Correct Answer:
B. To mobilize secretions in the airways

21. A nurse is caring for a client on a medical-surgical unit. The nurse should identify which of the following
findings are consistent with COPD?
Select all that apply.

Exhibit 1 – Vital Signs

1500:
Temperature 37° C (98.6° F)
Blood pressure 124/62 mm Hg
Heart rate 80/min
Respiratory rate 20/min
Oxygen saturation 89% on room air

1530:
Oxygen saturation 92% on 2 L/min via nasal cannula
Exhibit 2 – Nurses' Notes
1530:
Client is alert and oriented to person, place, and time. Client follows commands. Respirations are slightly labored.
Bilateral breath sounds coarse with rhonchi auscultated. Barrel chest is noted. The head of the bed is elevated.
Productive cough with thick sputum noted. Telemetry is in place. No abnormal heart sounds auscultated. Abdomen
soft with positive bowel sounds. Peripheral pulses are palpable. Skin is intact. Client reports recent weight loss of
4.5 kg (10 lb). BMI is 22.

Exhibit 3 – Diagnostic Results

Chest x-ray: Increased lung space. Hyperinflation of lungs noted.

Options:
Abdominal assessment
Chest assessment
Report regarding weight
Heart sounds
Lung sounds
Chest x-ray result

Correct Answers:
Chest assessment
Report regarding weight
Lung sounds
Chest x-ray result

22. A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is
the priority assessment finding?
A. Pallor
B. Insertion site pain
C. Persistent cough
D. Temperature 37.3° C (99.1° F)
Correct Answer:
C. Persistent cough

23. A nurse is assessing a client who is 4 hr postoperative following a total laryngectomy. Which of the
following findings is the priority for the nurse to report to the provider?
A. Bleeding at the surgical site
B. Decreased oxygen saturation
C. Urinary retention
D. Increased pain level
Correct Answer:
B. Decreased oxygen saturation

24. A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary
embolism?
A. A client who is 48 hr postoperative following a total hip arthroplasty
B. A client who is 8 hr postoperative following an open surgical appendectomy
C. A client who is 2 hr postoperative following an open reduction external fixation of the right radius
D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy
Correct Answer:
A. A client who is 48 hr postoperative following a total hip arthroplasty

25. A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma."
B. "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage."
C. "I should remove the old twill ties after the new ties are in place."
D. "I should apply suction while inserting the catheter into my tracheostomy tube."
Correct Answer:
C. "I should remove the old twill ties after the new ties are in place."

26. A nurse is planning care for a client who has asthma. Which of the following medications should the nurse
plan to administer during an acute asthma attack?
A. Cromolyn
B. Prednisone
C. Fluticasone/salmeterol
D. Albuterol
Correct Answer:
D. Albuterol

27. A nurse is assessing a client who has lung cancer. Which of the following manifestations should the nurse
expect?
A. Blood-tinged sputum
B. Decreased tactile fremitus
C. Resonance with percussion
D. Peripheral edema
Correct Answer:
A. Blood-tinged sputum

28. A nurse is assisting a provider who is performing a thoracentesis at the bedside of a client. Which of the
following actions should the nurse take? (Select all that apply.)
A. Wear goggles and a mask during the procedure.
B. Cleanse the procedure area with an antiseptic solution.
C. Instruct the client to take deep breaths during the procedure.
D. Position the client laterally on the affected side before the procedure.
E. Apply pressure to the site after the procedure.
Correct Answers:
A. Wear goggles and a mask during the procedure.
B. Cleanse the procedure area with an antiseptic solution.
E. Apply pressure to the site after the procedure.

29. A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following
adverse effects should the nurse monitor the client?
A. Hyperkalemia
B. Dyspnea
C. Tachycardia
D. Candidiasis
Correct Answer:
C. Tachycardia

30. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new
prescription for rifampin. Which of the following instructions should the nurse include?
A. "Ringing in the ears is an adverse effect of this medication."
B. "Have your skin test repeated in 4 months to show a positive result."
C. "Expect your urine and other secretions to be orange while taking this medication."
D. "Remember to take this medication with a sip of water just before your first bite of each meal."
Correct Answer:
C. "Expect your urine and other secretions to be orange while taking this medication."
31. A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items
should the nurse keep easily accessible for the client?
A. Extra drainage system
B. Suture removal set
C. Container of sterile water
D. Nonadherent pads
Correct Answer:
C. Container of sterile water

32. A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report
to the provider?
A. Rhonchi on inspiration
B. Elevated temperature
C. Barrel-shaped chest
D. Diminished breath sounds
Correct Answer:
B. Elevated temperature

33. A nurse is developing a plan of care for a client who has active tuberculosis. Which of the following
isolation precautions should the nurse include in the plan?
A. Airborne
B. Neutropenic
C. Contact
D. Droplet
Correct Answer:
A. Airborne

34. A nurse is caring for a newly admitted client who has emphysema. The nurse should place the client in
which of the following positions to promote effective breathing?
A. Lateral position with a pillow at the back and over the chest to support the arm
B. High-Fowler’s position with the arms supported on the overbed table
C. Semi-Fowler’s position with pillows supporting both arms
D. Supine position with the head of the bed elevated to 15°
Correct Answer:
B. High-Fowler’s position with the arms supported on the overbed table

35. A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast.
Which of the following client statements indicates an understanding of the teaching?
A. "I will monitor my heart rate every day while taking this medication."
B. "I will make sure I have this medication with me at all times."
C. "I will need to carefully rinse my mouth after I take this medication."
D. "I will take this medication every night even if I don't have symptoms."
Correct Answer:
D. "I will take this medication every night even if I don't have symptoms."

36. A nurse in an emergency department is caring for a client who is experiencing a pulmonary embolism.
Which of the following actions should the nurse take first?
A. Apply supplemental oxygen.
B. Increase the rate of IV fluids.
C. Administer pain medication.
D. Initiate cardiac monitoring.
Correct Answer:
A. Apply supplemental oxygen.

37. A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the
nurse's priority?
A. Provide a quiet environment.
B. Encourage use of incentive spirometry every 1 to 2 hr.
C. Obtain a blood sample for electrolyte study.
D. Administer heparin via continuous IV infusion.
Correct Answer:

D. Administer heparin via continuous IV infusion.

38. A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage
system in place following thoracic surgery with a newly licensed nurse. Which of the following statements by
the newly licensed nurse indicates an understanding of when to notify the provider?
A. "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration."
B. "I will notify the provider if there is continuous bubbling in the water seal chamber."
C. "I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery."
D. "I will notify the provider if there are several small, dark-red blood clots in the tubing."
Correct Answer:
B. "I will notify the provider if there is continuous bubbling in the water seal chamber."

39. A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should
the nurse include?
A. Schedule respiratory treatments following meals.
B. Have the client sit up in a chair for 2-hr periods three times per day.
C. Provide a diet that is high in calories and protein.
D. Combine activities to allow for longer rest periods between activities.
Correct Answer:
C. Provide a diet that is high in calories and protein.

40. A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four
clients. For which of the following clients should the nurse clarify the provider’s prescription?
A. A client who has epistaxis
B. A client who has amyotrophic lateral sclerosis
C. A client who has pneumonia
D. A client who has emphysema
Correct Answer:
A. A client who has epistaxis

41. A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following
findings is the priority to nurse report to the provider?
A. Decreased bowel sounds
B. Oxygen saturation 92%
C. Respiratory rate 22/min
D. Intercostal retractions
Correct Answer:
D. Intercostal retractions

42. A nurse is assessing a client who has bacterial pneumonia. Which of the following manifestations should
the nurse expect?
A. Decreased fremitus
B. SaO₂ 95% on room air
C. Temperature 38.8° C (101.8° F)
D. Bradypnea
Correct Answer:
C. Temperature 38.8° C (101.8° F)

43. A nurse working in an emergency department is caring for a client following an acute chest trauma.
Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension
pneumothorax?
A. Collapsed neck veins on the affected side
B. Collapsed neck veins on the unaffected side
C. Tracheal deviation to the affected side
D. Tracheal deviation to the unaffected side
Correct Answer:
D. Tracheal deviation to the unaffected side

44. A nurse in a provider’s office is assessing a client who has COPD. Which of the following findings is the
priority for the nurse to report to the provider?
A. Increased anterior-posterior chest diameter
B. Productive cough with green sputum
C. Clubbing of the fingers
D. Pursed-lip breathing with exertion
Correct Answer:
B. Productive cough with green sputum

45. A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery
devices should the nurse use to provide the client with the highest level of oxygen?
A. Nasal cannula
B. Non-rebreather mask
C. Simple face mask
D. Partial rebreather mask
Correct Answer:
B. Non-rebreather mask

46. A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. Which
of the following statements by a staff nurse indicates an understanding of the teaching?
A. "I will use clean technique when suctioning a client’s endotracheal tube."
B. "I will use a rotating motion when removing the suction catheter."
C. "I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube."
D. "I will suction a client’s endotracheal tube every 2 hours."
Correct Answer:
B. "I will use a rotating motion when removing the suction catheter."

47. A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds.
Which of the following situations should the nurse recognize as a possible cause of the alarm?
A. Excess secretions
B. Kinks in the tubing
C. Artificial airway cuff leak
D. Biting on the endotracheal tube
Correct Answer:
C. Artificial airway cuff leak

48. A nurse is caring for a client in the emergency department.

Exhibit 1 – Vital Signs (0800):

Temperature: 38.1° C (100.5° F)
Blood pressure: 144/68 mm Hg
Heart rate: 122/min
Respiratory rate: 24/min
Oxygen saturation: 96% on room air

Exhibit 2 – SBAR (0830):

S – Situation:
Client was diagnosed with bronchitis yesterday. Client states, “I get bronchitis 3 to 4 times per year.” Reports
dyspnea and coughing since early this morning and states, “My chest has been tight off and on throughout the
morning.”
B – Background:
30 pack-year history of smoking; quit 6 months ago. History of chronic bronchitis.
A – Assessment:
Alert and oriented
Non-productive cough
Labored respirations
Expiratory wheezing auscultated
No abnormal heart sounds
Peripheral pulses palpable
Diaphoretic
R – Recommendation:
Position client with head of bed elevated
Notify provider to see client

Exhibit 3 – Provider Prescriptions (0850):

Albuterol 90 mcg/inhalation: 2 inhalations every 4 hr PRN
Instruct on use of peak flow meter
Follow up with primary care provider

Exhibit 4 – Client Education (1000):

Client was instructed on:
How to use the peak flow meter
How to track manifestations
Repeating the reading three times
Recording the highest value in an asthma diary

The nurse is evaluating client understanding of the education on the peak flow meter.
For each client statement, indicate whether it reflects understanding or not:
"I should use the peak flow meter and my symptoms to determine the severity of my asthma." Understanding
"I will complete the process 3 times and then write down the highest number in my asthma diary." Understanding
"I will blow all the air out of my lungs before I place my mouth on the mouthpiece." Not Understanding
"I will make sure I am sitting down when I do this." Not Understanding
"I will start by moving the indicator on the flow meter to the bottom of the numbered scale." Understanding

Musculoskeletal:
1. A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While
transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the
following manifestations of dislocation of the hip prosthesis?
A. Bulging in the area over the surgical incision
B. Shortening of the right leg
C. Sensation of warmth over the surgical incision
D. Pallor following elevation of the right leg
Correct Answer:
B. Shortening of the right leg

2. A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath,
stabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing which of
the following complications?
A. Pneumonia
B. Pulmonary embolus
C. Tension pneumothorax
D. Tuberculosis
Correct Answer:
B. Pulmonary embolus

3. A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the
client has slid down toward the foot of the bed and the traction weight is resting on the floor. Which of the
following actions should the nurse take?
A. Remove the weight temporarily to reposition the client to the correct alignment in bed.
B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely.
C. Lift the rope off the pulley while the client rocks back and forth to reposition.
D. Lift the weight manually while another staff member moves the client up in bed.
Correct Answer:
B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely.

4. A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. Which
of the following statements by the client should the nurse identify as understanding of the teaching?
A. "I will wear a continuous movement machine on my knee for 24 hours a day."
B. "I should avoid taking NSAID medications for pain after surgery."
C. "I should wear elastic stockings on both of my legs."
D. "I will begin exercising my legs the day after surgery."
Correct Answer:
C. "I should wear elastic stockings on both of my legs."

5. A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly
licensed nurse. Which of the following information should the nurse include about osteoarthritis?
A. "Osteoarthritis is caused by autoimmune processes."
B. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate."
C. "Osteoarthritis affects other organ systems."
D. "Osteoarthritis can impair a joint on a single side of the body."
Correct Answer:
D. "Osteoarthritis can impair a joint on a single side of the body."

6. A nurse is assessing a client who is 24 hr postoperative following an above-the-elbow amputation. Which of

the following findings should the nurse identify as the priority?
A. Report of muscle spasms
B. Inability to get dressed without assistance
C. Report of feelings of anger
D. Refusal to look at the affected limb
Correct Answer:
A. Report of muscle spasms

7. A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate)
ankle sprain. Which of the following instructions should the nurse plan to give to the client?
A. Perform passive range-of-motion exercises of the ankle hourly.
B. Keep the affected extremity in a dependent position.
C. Wrap a loose dressing around the affected ankle.
D. Apply cold compresses to the extremity intermittently.
Correct Answer:
D. Apply cold compresses to the extremity intermittently.

8. A nurse is teaching a client who has a new prescription for alendronate for treatment of osteoporosis.
Which of the following statements by the client indicates understanding of the teaching?
A. "I will take the medication in the evening."
B. "I will drink a full glass of milk with the medication."
C. "I will take the medication at mealtime."
D. "I will sit upright after taking the medication."
Correct Answer:
D. "I will sit upright after taking the medication."

9. A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel.
Which of the following information should the nurse include?
A. "You will need to apply a cold pack to the site three times a day."
B. "Your provider might ask you to walk frequently to increase circulation to the area."
C. "You will need to limit consumption of high-protein foods."
D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."
Correct Answer:
D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

10. A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago
and sustained fractures to his tibia, ulna, and several ribs. The client is now disoriented to time and place, has
a SaO₂ of 87%, and the nurse notes generalized petechiae on the client’s skin. Which of the following
complications should the nurse suspect?
A. Hypovolemic shock
B. Fat embolism syndrome
C. Thrombophlebitis
D. Avascular bone necrosis
Correct Answer:
B. Fat embolism syndrome

11. A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription
to keep the affected arm adducted. Which of the following instructions should the nurse provide the client?
A. "Keep your arm bent at the elbow."
B. "Use a pillow to prop your shoulder up close to your ear."
C. "Hold your arm against the side of your body."
D. "Position your arm with the shoulder at a 90-degree angle."
Correct Answer:
C. "Hold your arm against the side of your body."

12. A nurse is reviewing the medical record of a female client. Which of the following findings should the
nurse identify as a risk factor for osteoporosis?
A. Decreased intake of phosphate-containing foods
B. Spending several hours in the sun daily
C. Increased estrogen levels
D. History of anorexia nervosa
Correct Answer:
D. History of anorexia nervosa

13. A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor
for and report which of the following findings as an indication of compartment syndrome?
A. Sensation of heat on the surface of the cast
B. Paresthesias of the extremity
C. Pruritus of the extremity
D. Musty odor noted from cast materials
Correct Answer:
B. Paresthesias of the extremity

14. A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The
client reports sensations of burning and crushing pain in the toes of the right foot. Which of the following
statements should the nurse make?
A. "This type of pain usually decreases over time as the limb becomes less sensitive."
B. "Try to look at the surgical wound as a reminder the limb is gone."
C. "Use a cold compress intermittently to decrease these pain sensations."
D. "Grief over the lost limb can sometimes cause denial that the limb is really gone."
Correct Answer:
A. "This type of pain usually decreases over time as the limb becomes less sensitive."

15. A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout.
The nurse should identify that which of the following medications can interact with probenecid?
A. Colchicine
B. Naproxen
C. Aspirin
D. Prednisone
Correct Answer:
C. Aspirin
16. A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now
reports itching under the cast. Which of the following actions should the nurse plan to take?
A. Use a hair dryer on a cool setting to blow air into the cast.
B. Ask the provider to bivalve the cast.
C. Provide the client with a sterile cotton swab to rub the affected skin.
D. Wrap the extremity with a dry heating pad.
Correct Answer:
A. Use a hair dryer on a cool setting to blow air into the cast.

17. A nurse is caring for a client who is postoperative following a total knee arthroplasty and is prescribed a
continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain."
Which of the following actions should the nurse take first?
A. Remind the client to push the button for the PCA device.
B. Discuss activities the client may use to distract from the pain.
C. Ask the client to describe the characteristics of the pain.
D. Pause the CPM machine briefly to apply a cold pack to the client's knee.
Correct Answer:
C. Ask the client to describe the characteristics of the pain

18. A nurse is providing discharge instructions for a client who is postoperative following inner maxillary
fixation with wiring. Which of the following information should the nurse include?
A. Cut the wiring if emesis occurs.
B. Consume three meals daily as part of a low-protein diet.
C. Swab the mouth with hydrogen peroxide if wiring produces oral irritation.
D. Resume a soft diet in 3 to 5 days.
Correct Answer:
A. Cut the wiring if emesis occurs.

19. A nurse is assessing a client who is 48 hr postoperative following open reduction and external fixation of a
fractured tibia. Which of the following findings should the nurse report to the provider?
A. Toes cold to the touch
B. Serous drainage from the pin sites
C. Blanching of the toenail beds with pressure
D. Pink tissue around the fixator insertion sites
Correct Answer:
A. Toes cold to the touch

20. A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis
(RA). Which of the following medications should the nurse identify as the treatment for this condition?
A. Misoprostol
B. Dantrolene
C. Celecoxib
D. Colchicine
Correct Answer:
C. Celecoxib

Gastrointestinal:

1. A nurse is caring for a client on a medical-surgical unit.

Day 1:
Client reports epigastric pain, bloating, and belching after eating that worsens when lying supine.
Scheduled for open surgical approach for Nissen fundoplication (NF).
Day 7 (Postoperative):
Client is postoperative following NF.
Bilateral breath sounds clear and present throughout.
Client is placed in a semi-Fowler’s position.
Abdomen soft, nondistended. Abdominal dressings dry and intact.
Nasogastric tube (NG) secured and placed to low intermittent suction.
Drainage from NG is dark brown drainage with small amount of old blood noted.

Day 9:
NG tube removed.
Client offered sips of clear liquids.
Coughing and hoarse voice after swallowing.
Client supports abdomen when coughing.
Client reports feeling of abdominal fullness and is unable to belch.

Vital Signs:
Day 1:
Temperature: 37.2°C (98.9°F)
Blood Pressure: 118/78 mm Hg
Heart Rate: 78/min
Respiratory Rate: 18/min
Oxygen Saturation: 95% on room air

Day 9:
Temperature: 38.3°C (100.9°F)
Blood Pressure: 108/68 mm Hg
Heart Rate: 102/min
Respiratory Rate: 24/min
Oxygen Saturation: 90% on room air

Based on the data provided, which of the following findings require follow-up?
A. Drainage from NG is dark brown with a small amount of old blood noted
B. Coughing and hoarse voice after swallowing
C. Client supports abdomen when coughing
D. Client reports abdominal fullness and is unable to belch
E. Oxygen saturation 90% on room air
Correct Answers:
B. Coughing and hoarse voice after swallowing
D. Client reports abdominal fullness and is unable to belch
E. Oxygen saturation 90% on room air

2. A nurse in the emergency department (ED) is caring for a male client who reports a sudden onset of severe mid-
epigastric pain that radiates to the back. The client also reports nausea, vomiting, recent weight loss, and consuming
4 to 5 beers daily. On assessment, the abdomen is soft and distended, with hypoactive bowel sounds in all four
quadrants. The client has daily formed stools.
Laboratory Results:
Amylase: 660 units/L (Normal: 30–220 units/L)
Lipase: 480 units/L (Normal: 0–160 units/L)
Hematocrit: 45% (Normal: 42%–52%)
Hemoglobin: 15 g/dL (Normal: 14–18 g/dL)
WBC: 16,000/mm³ (Normal: 5,000–10,000/mm³)
Fasting blood glucose: 200 mg/dL (Normal: 70–110 mg/dL)
Based on the assessment and laboratory findings, which condition is the client most likely experiencing?
Which two actions should the nurse take to address this condition, and which two parameters should the
nurse monitor to assess the client’s progress?
Correct Answer:
Condition: Pancreatitis
Actions: Prepare to insert a NG tube for the client; Prepare to administer insulin to the client
Parameters to Monitor: Amylase level; Jaundice

3. A nurse is caring for a client who has a new ileostomy. On Day 1, the client's ileostomy stoma is red. The ostomy
pouch is intact, and the skin surrounding the stomal barrier appears intact and the same color as the rest of the
abdomen. The stoma is draining moderate brown liquid stool. The client weighs 80 kg (176 lb). On Day 4 at 0800,
the ileostomy pouch was changed, and the stoma remains red. The skin around the stoma is inflamed and excoriated.
The client refuses to look at the stoma and expresses no interest in learning about stoma care. The stoma continues
to drain moderate brown liquid stool, and the client has been placed on a low-residue diet. By 1500, the client
reports abdominal cramping, and the abdomen is distended and firm. The client now weighs 78.2 kg (172 lb). Intake
and output records show urine intake of 2,500 mL and urine output of 650 mL over 24 hours on Day 4.

Question:
Which of the following Day 4 findings require immediate follow-up?

Correct Answers:
Skin around the stoma is inflamed and excoriated
Client reports abdominal cramping, abdomen is distended and firm
Urine output 650 mL/24 hr
Client will not look at stoma
Client says they’re not interested in learning about stoma care

4. A nurse is assessing a client who is postoperative following a gastrectomy. The nurse should identify which
of the following findings as an indication of abdominal distension?
A. Hiccups
B. Hypertension
C. Bradycardia
D. Chest pain
Correct Answer:
A. Hiccups

5. A nurse is assessing a client who has Crohn's disease. Which of the following findings should the nurse
expect?
A. Fatty diarrheal stools
B. Hyperkalemia
C. Weight gain
D. Sharp epigastric pain
Correct Answer:
A. Fatty diarrheal stools
6. A nurse is providing discharge teaching for a client who has GERD. Which of the following statements by
the client indicates an understanding of the teaching?
A. "I will decrease the number of carbonated beverages I drink."
B. "I will avoid drinking liquids for 30 minutes after taking a chewable antacid tablet."
C. "I will eat a snack before going to bed."
D. "I will lie down for at least 30 minutes after eating each meal."
Correct Answer:
A. "I will decrease the number of carbonated beverages I drink."

7. A nurse is admitting a client who has acute pancreatitis. Which of the following actions should the nurse
take first?
A. Insert a NG (nasogastric) tube for the client.
B. Prepare the client for intubation.
C. Identify the client’s current level of pain.
D. Instruct the client to remain NPO.
Correct Answer:
C. Identify the client’s current level of pain.
8. A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?
A. Bloody diarrhea
B. Board-like abdomen
C. Periumbilical cyanosis
D. Increased bowel sounds
Correct Answer:
B. Board-like abdomen

9. A nurse is caring for a client who has ulcerative colitis. The client has had several exacerbations over the
past 3 years. Which of the following instructions should the nurse include in the plan of care to minimize the
risk of further exacerbations? (Select all that apply.)
☑ Use progressive relaxation techniques.
☐ Increase dietary fiber intake.
☐ Drink two 8 oz (240 mL) glasses of milk per day.
☑ Arrange activities to allow for daily rest periods.
☑ Restrict intake of carbonated beverages.
Correct Answers:
 Use progressive relaxation techniques.
 Arrange activities to allow for daily rest periods.
 Restrict intake of carbonated beverages.

10. A nurse is providing discharge teaching for a client who has peptic ulcer disease and a new prescription
for once daily famotidine. Which of the following statements by the client indicates an understanding of the
teaching?
A. "I should take this medication at bedtime."
B. "I should expect this medication to discolor my stools."
C. "I will drink iced tea with my meals and snacks."
D. "I will monitor my blood glucose level regularly while taking this medication."
Correct Answer:
A. "I should take this medication at bedtime."
11. A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse
expect? (Select all that apply.)
☑ Oral temperature of 38.4° C (101.1° F)
☐ Decreased WBC count
☐ Bloody diarrhea
☑ Nausea and vomiting
☑ Right lower quadrant pain
Correct Answers:
 Oral temperature of 38.4° C (101.1° F)
 Nausea and vomiting
 Right lower quadrant pain

12. A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following
findings should the nurse expect?
A. Decreased blood glucose
B. Increased amylase
C. Increased calcium
D. Decreased bilirubin
Correct Answer:
B. Increased amylase

13. A nurse is caring for a client who has GERD and a new prescription for metoclopramide. The nurse
should plan to monitor for which of the following adverse effects?
A. Thrombocytopenia
B. Hearing loss
C. Hypersalivation
D. Ataxia
Correct Answer:
D. Ataxia

14. A nurse is providing discharge teaching for a client who has a new prescription for medications to treat
peptic ulcer disease. The nurse should inform the client that which of the following medications inhibits
gastric acid secretion?
A. Calcium carbonate
B. Famotidine
C. Aluminum hydroxide
D. Sucralfate
Correct Answer:
B. Famotidine

15. A nurse is providing dietary teaching for a client who is postoperative following a gastrectomy. Which of
the following foods should the nurse encourage the client to include in their diet to reduce the risk for
dumping syndrome?
A. Ice cream
B. Eggs
C. Grape juice
D. Honey
Correct Answer:
B. Eggs

16. A nurse is assessing a client who has acute hepatitis B. Which of the following findings should the nurse
expect?
A. Joint pain
B. Obstipation
C. Abdominal distention
D. Periumbilical discoloration
Correct Answer:
A. Joint pain

17. A nurse is teaching a client how to prepare for a colonoscopy. Which of the following instructions should
the nurse include in the teaching?
A. "You should stop consuming the liquid preparation solution if bloating or cramping occurs."
B. "Stop taking aspirin the day before the procedure."
C. "Drink clear liquids for 24 hr prior to the procedure, then nothing by mouth for 6 hr before the procedure."
D. "Drink the oral liquid preparation for bowel cleansing slowly the night before the procedure."
Correct Answer:
C. "Drink clear liquids for 24 hr prior to the procedure, then nothing by mouth for 6 hr before the procedure."

18. A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which of the following
findings should the nurse expect?
A. Increased alanine aminotransferase
B. Decreased serum carcinoembryonic antigen (CEA) level
C. Increased hematocrit
D. Decreased hemoglobin
Correct Answer:
D. Decreased hemoglobin

19. A nurse is caring for a client who has colorectal cancer and is receiving chemotherapy. The client asks the
nurse why blood is being drawn for a carcinoembryonic antigen (CEA) level. Which of the following
responses should the nurse make?
A. "The CEA determines the current stage of your colon cancer."
B. "The CEA determines the efficacy of your chemotherapy."
C. "The CEA determines if the neutrophil count is below the expected reference range."
D. "The CEA determines if you are experiencing occult bleeding from the gastrointestinal tract."
Correct Answer:
B. "The CEA determines the efficacy of your chemotherapy."

20. A nurse is assessing a client who has a duodenal ulcer. Which of the following findings should the nurse
expect?
A. The client states that the pain is in the upper epigastrium.
B. The client is malnourished.
C. The client states that ingesting food intensifies the pain.
D. The client reports that pain occurs during the night.
Correct Answer:
D. The client reports that pain occurs during the night.

21. A nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. Which of the following
laboratory findings should the nurse report to the provider?
A. Increased serum albumin level
B. Decreased lactate dehydrogenase (LDH) level
C. Decreased total bilirubin level
D. Increased ammonia level
Correct Answer:
D. Increased ammonia level

22. A nurse is providing discharge teaching for a client who has a new colostomy pouch and is concerned
about flatus and odor. Which of the following foods should the nurse recommend to the client?
A. Eggs
B. Fish
C. Yogurt
D. Broccoli
Correct Answer:
C. Yogurt

23. A nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. Which of
the following instructions should the nurse include in the teaching?
A. Notify the provider if bloating occurs.
B. Expect to have 2 to 3 soft stools per day.
C. Restrict carbohydrates in the diet.
D. Limit oral fluid intake to 1,000 mL per day of clear liquids.
Correct Answer:
B. Expect to have 2 to 3 soft stools per day.

24. A nurse is reviewing the prescriptions for a client who has Campylobacter enteritis. Which of the following
prescriptions should the nurse clarify with the provider?
A. 0.45% sodium chloride IV
B. Magnesium hydroxide
C. Ciprofloxacin
D. Potassium
Correct Answer:
B. Magnesium hydroxide

25. A nurse is providing dietary teaching for a client who has chronic pancreatitis. Which of the following
food selections by the client indicates an understanding of the teaching?
A. 8 oz (0.24 L) whole milk
B. One slice of beef bologna
C. 1 oz (28.3 g) cheddar
D. 8 oz (0.24 L) sliced banana
Correct Answer:
D. 8 oz (0.24 L) sliced banana
26. A nurse is providing dietary teaching for a client who has a new diagnosis of celiac disease. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I can return to my regular diet when I am free of symptoms."
B. "I will need to avoid taking vitamin supplements while on this diet."
C. "I will eat beans to ensure I get enough fiber in my diet."
D. "I need to avoid drinking liquids with my meals while on this diet."
Correct Answer:
C. "I will eat beans to ensure I get enough fiber in my diet."

27. A nurse is assessing a client who has upper gastrointestinal bleeding. Which of the following findings
should the nurse expect?
A. Bradycardia
B. Bounding peripheral pulses
C. Hypotension
D. Increased hematocrit levels
Correct Answer:
C. Hypotension

28. A nurse is providing discharge teaching for a client who has mild diverticulitis. Which of the following
statements by the client indicates an understanding of the teaching?
A. "I may experience right lower quadrant pain."
B. "I will remain active by working in my garden every day."
C. "I should eat foods that are low in fiber."
D. "I will take a mild laxative every day."
Correct Answer:
C. "I should eat foods that are low in fiber."

29. A nurse is assessing a client immediately following a paracentesis for the treatment of ascites. Which of the
following findings indicates the procedure was effective?
A. Presence of a fluid wave
B. Increased heart rate
C. Equal pre and postprocedure weights
D. Decreased shortness of breath
Correct Answer:
D. Decreased shortness of breath
30. A nurse is caring for a client in an endoscopy suite at a surgical center. The client presented with increased
difficulty swallowing and an unintentional 9 kg (20 lb) weight loss over the past 2 months. The client reported, "It
feels as if there is something caught in my throat." The provider scheduled the client for an
esophagogastroduodenoscopy (EGD) to evaluate the cause of the symptoms. Consent was obtained, and the client
was provided with pre-procedure instructions.
At 1200, the client underwent an EGD with a biopsy of an esophageal tumor.
At 1300, the post-procedure assessment revealed that the client was alert and oriented but had a hoarse voice. The
client also reported a sore throat, bloating, belching, continued difficulty swallowing, and upper gastric abdominal
pain.
Vital signs were monitored before and after the procedure:
 0800 Vital Signs:
 o Temperature: 37.2°C (98.9°F)

o BP: 118/78 mm Hg

o HR: 78/min

o RR: 18/min

o SpO₂: 95% on room air

 1300 Vital Signs:

o Temperature: 38.3°C (100.9°F)

o BP: 104/78 mm Hg

o HR: 106/min

o RR: 26/min

o SpO₂: 90% on room air

Question:
A nurse is assessing the client following the procedure. Which of the following findings should the nurse report to
the provider? (Select all that apply.)
 ☐ Voice quality
 ☐ Pain
 ☐ Swallowing ability
 ☐ Temperature
 ☐ Bloating
 ☐ Oxygen saturation
 ☐ Throat sensation
Correct Answers:
 Voice quality (hoarseness may indicate laryngeal nerve injury or edema)
 Swallowing ability (persistent dysphagia is concerning)
 Temperature (elevated post-procedure temperature suggests possible infection)
 Oxygen saturation (decreased SpO₂ may signal respiratory compromise or aspiration)

31. A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving
intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take
first?
A. Flush the tube with water.
B. Place the client in semi-Fowler’s position.
C. Cleanse the skin around the tube site.
D. Aspirate the tube for residual contents.
Correct Answer:
B. Place the client in semi-Fowler’s position.
32. A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The
nurse should identify that this procedure is used to do which of the following?
A. To visualize polyps in the colon
B. To detect an ulceration in the stomach
C. To identify an obstruction in the biliary tract
D. To determine the presence of free air in the abdomen
Correct Answer:
B. To detect an ulceration in the stomach

33. A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an
esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the
teaching?
A. "This procedure is performed to measure the presence of acid in your esophagus."
B. "This procedure can determine how well the lower part of your esophagus works."
C. "This procedure is performed while you are under general anesthesia."
D. "This procedure can determine if you have colon cancer."
Correct Answer:
B. "This procedure can determine how well the lower part of your esophagus works."

34. A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump
at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention
by the nurse?
A. A full pitcher of water is sitting on the client’s bedside table within the client’s reach.
B. The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding.
C. The client is lying on the right side with a visible dependent loop in the feeding tube.
D. The head of the bed is elevated 20°.
Correct Answer:
C. The client is lying on the right side with a visible dependent loop in the feeding tube

35. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just
returned to the room following physical therapy. The nurse notes that the infusion pump for the client’s TPN
is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the
following findings?
A. Hypertension
B. Excessive thirst
C. Fever
D. Diaphoresis
Correct Answer:
D. Diaphoresis

36. A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove
from the client’s meal tray?
A. Wheat toast
B. Tapioca pudding
C. Hard-boiled egg
D. Mashed potatoes
Correct Answer:
A. Wheat toast
37. A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy.
Which of the following laboratory findings should the nurse monitor prior to the procedure?
A. Prothrombin time
B. Serum lipase
C. Bilirubin
D. Calcium
Correct Answer:
A. Prothrombin time

38. A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following
manifestations should the nurse expect?
A. Increased blood pressure
B. Decreased heart rate
C. Yellowing of the skin
D. Boardlike abdomen
Correct Answer:
D. Boardlike abdomen

39. A nurse is caring for a client who has a history of cirrhosis and is admitted with manifestations of hepatic
encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to
determine the possibility of recent excessive alcohol use?
A. Gamma-glutamyl transferase (GGT)
B. Alkaline phosphatase (ALP)
C. Serum bilirubin
D. Alanine aminotransferase (ALT)
Correct Answer:
A. Gamma-glutamyl transferase (GGT)

40. A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks.
Which of the following foods should the nurse recommend?
A. Foods high in vitamin C
B. Foods low in fat
C. Foods high in fiber
D. Foods low in calories
Correct Answer:
C. Foods high in fiber

41. A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of
the following findings should the nurse expect?
A. Right shoulder pain
B. Urine output 20 mL/hr
C. Temperature 38.4° C (101.1° F)
D. Oxygen saturation 92%
Correct Answer:
A. Right shoulder pain

42. A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse
should anticipate a prescription for which of the following medications?
A. Famotidine
B. Esomeprazole
C. Vasopressin
D. Omeprazole
Correct Answer:
C. Vasopressin

43. A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations
should the nurse expect?
A. Jaundice
B. Anorexia
C. Dark urine
D. Pale feces
Correct Answer:
B. Anorexia

45. A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that
bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding?
A. Vanilla pudding
B. Apple juice
C. Diet ginger ale
D. Clear liquids
Correct Answer:
D. Clear liquids

46. A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which
of the following findings should the nurse identify as a likely cause of the client’s condition?
A. High-calorie diet
B. Prior gastrointestinal illnesses
C. Tobacco use
D. Alcohol use
Correct Answer:
D. Alcohol use

47. A community health nurse is planning an educational program about hepatitis A. When preparing the
materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis
A?
A. Children
B. Older adults
C. Women who are pregnant
D. Middle-aged men
Correct Answer:
A. Children

48. A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe
abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel
perforation has occurred?
A. Elevated blood pressure
B. Bowel sounds increased in frequency and pitch
C. Rigid abdomen
D. Emesis of undigested food
Correct Answer:
C. Rigid abdomen

49. A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should
the nurse anticipate for this client?
A. Endoscopic sclerotherapy
B. Liver lobectomy
C. Liver transplant
D. Transjugular intrahepatic portal-systemic shunt placement
Correct Answer:
C. Liver transplant

50. A nurse is preparing a community education program about hepatitis B. Which of the following
statements should the nurse include in the teaching?
A. "A hepatitis B immunization is recommended for those who travel, especially military personnel."
B. "A hepatitis B immunization is given to infants and children."
C. "Hepatitis B is acquired by eating foods that are contaminated during handling."
D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."
Correct Answer:
B. "A hepatitis B immunization is given to infants and children."

Oncolocy:

1. A nurse is admitting a client who has multiple myeloma and a white blood cell count of 2,200/mm³. Which
of the following foods should the nurse prohibit the family members from bringing to the client?
A. Fried chicken from a fast food restaurant
B. A case of canned nutritional supplements
C. A factory-sealed box of chocolates
D. A fresh fruit basket
Correct Answer:
D. A fresh fruit basket

2. A nurse is monitoring a client who has cancer and is receiving chemotherapy by peripheral IV infusion.
The client reports pain at the insertion site and the nurse notes fluid leaking around the catheter. Which of
the following actions should the nurse take first?
A. Take a photograph of the peripheral IV site.
B. Obtain and record the client’s vital signs.
C. Stop the infusion.
D. Identify all medications administered through the IV site for the past 24 hr.
Correct Answer:
C. Stop the infusion.

3. A nurse in an oncology clinic is assessing a client who has early stage Hodgkin's lymphoma. Which of the
following findings should the nurse expect?
A. Bone and joint pain
B. Enlarged lymph nodes
C. Intermittent hematuria
D. Productive cough
Correct Answer:
B. Enlarged lymph nodes

4. A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine
cancer. Which of the following information should the nurse include in the teaching?
A. "You will need to continue to use some form of birth control for 6 months."
B. "You might experience manifestations of menopause."
C. "Do not lift anything heavier than 15 pounds."
D. "Pain or burning on urination is an expected outcome of this surgery."
Correct Answer:
B. "You might experience manifestations of menopause."

5. A nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a
bone marrow transplant for leukemia. Which of the following information should the nurse include in the
teaching? (Select all that apply.)
A. "Take your temperature twice each day."
B. "You may return to school if you feel strong enough."
C. "It is important to always wear shoes."
D. "Clean your toothbrush weekly with isopropyl alcohol."
E. "Avoid using tampons."
Correct Answer:
A. "Take your temperature twice each day."
C. "It is important to always wear shoes."
E. "Avoid using tampons."

6. A nurse is providing teaching to a client who has cancer and is receiving external radiation therapy. Which
of the following statements by the client indicates an understanding of the teaching?
A. "I need to protect the area from sunlight."
B. "I'm going to apply a heating pad to the area after each treatment."
C. "I'll massage the area once per day."
D. "I'll wash the markings off after each therapy treatment."
Correct Answer:
A. "I need to protect the area from sunlight."

7. A nurse is obtaining a health history from a client who has cancer of the cervix. Which of the following
manifestations should the nurse expect?
A. Weight gain
B. Oliguria
C. Vaginal bleeding
D. Back pain
Correct Answer:
C. Vaginal bleeding

8. A nurse is providing discharge teaching to a client following open radical prostatectomy. The client is going
home with an indwelling urinary catheter. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will be able to take a tub bath in 1 week."
B. "I will change the catheter drainage bag once each week."
C. "I will use suppositories to prevent constipation."
D. "I will regain my bladder control once the catheter is removed."
Correct Answer:
B. "I will change the catheter drainage bag once each week."

9. A nurse is caring for a client who is postoperative following a urinary diversion to treat bladder cancer.
Which of the following interventions should the nurse include in the plan of care?
A. Empty the collection pouch when it is 2/3 full.
B. Expect urine outflow into pouch to begin 1 to 2 days following surgery.
C. Change the collection pouch in the early morning.
D. Place an aspirin in the collection pouch to control odor.
Correct Answer:
C. Change the collection pouch in the early morning.

10. A nurse is planning care for a client who has cancer and has developed thrombocytopenia following
chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of
thrombocytopenia?
A. Monitor visitors for manifestations of infection.
B. Remind the client to use an electric razor.
C. Encourage frequent rest periods.
D. Instruct the client to rinse mouth daily with normal saline.
Correct Answer:
B. Remind the client to use an electric razor.

11. A hospice nurse is providing education about palliative care to the partner of a client who has end-stage
liver cancer. Which of the following statements by the partner indicates an understanding of teaching?
A. "I will do my best to try to get him to eat something."
B. "I will lay him flat if his breathing becomes shallow."
C. "I will use an electric blanket to keep him warm."
D. "I will continue to talk to him even when he's sleeping."
Correct Answer:
D. "I will continue to talk to him even when he's sleeping."

12. A nurse is providing preoperative teaching for a client who has colorectal cancer and is to undergo
placement of a colostomy with a perineal wound. Which of the following statements by the client indicates an
understanding of the teaching?
A. "It will be a relief to not have any further rectal pain."
B. "I will need to sit on a rubber donut when I am out of bed in the chair."
C. "I can have only liquids for 2 days before the surgery."
D. "The colostomy will start working about 7 days after the surgery."
Correct Answer:
C. "I can have only liquids for 2 days before the surgery."

13. A nurse is collecting a health history from a client. Which of the following findings is the highest risk
factor for the client developing bladder cancer?
A. The client is a hairdresser.
B. The client uses tobacco.
C. The client is over 60 years of age.
D. The client has frequent urinary tract infections (UTIs).
Correct Answer:
B. The client uses tobacco.

14. A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following
adverse effects should the nurse anticipate from the chemotherapy?
A. Gingival hyperplasia
B. Hirsutism
C. Pancytopenia
D. Weight gain
Correct Answer:
C. Pancytopenia

15. A nurse is caring for a client who has testicular cancer and is experiencing peripheral neuropathy as an
adverse effect of chemotherapy. Which of the following client manifestations is an expected finding of
peripheral neuropathy?
A. Thinning of the scalp hair
B. Tingling of the hands and feet
C. Reduced ability to concentrate
D. Sores in the mucous membranes
Correct Answer:
B. Tingling of the hands and feet

16. A nurse is collecting a health history from a client. Which of the following findings is the highest risk
factor for the client developing skin cancer?
A. Age over 60
B. Genetic predisposition
C. Light-skinned race
D. Overexposure to sun light
Correct Answer:
D. Overexposure to sun light

17. A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings
indicates the client is developing superior vena cava syndrome?
A. Irregular cardiac rhythm
B. Numbness in the hands
C. Muscle cramps
D. Facial edema
Correct Answer:
D. Facial edema
A nurse is providing discharge teaching to a client who is postoperative following a right mastectomy for
breast cancer. The client will be discharged with two Jackson-Pratt drains. Which of the following
information should the nurse include in the teaching?
A. "Empty the drainage tubes once per day."
B. "Showering is permitted before the drainage tubes are removed."
C. "The drainage tubes often are removed at the same time as the stitches."
D. "Do not begin exercising the arm until the provider removes the drainage tubes."
Correct Answer:
C. "The drainage tubes often are removed at the same time as the stitches."
19. A nurse is collecting a health history from a female client who is undergoing screening for breast cancer.
Which of the following factors should the nurse identify for placing the client at the greatest risk for
developing breast cancer?
A. Obesity
B. Oral contraceptive use
C. Alcohol use
D. Over 50 years of age
Correct Answer:
D. Over 50 years of age

20. A nurse is caring for a client who has breast cancer and is receiving a combination of chemotherapy
medications. The client expresses confusion about the therapy. Which of the following explanations should the
nurse provide?
A. "The risk of renal toxicity is lessened when a combination of chemotherapy medications are used."
B. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed."
C. "The use of more chemotherapy medications will shorten the time you have to be in treatment."
D. "The combination of chemotherapy medications will eliminate the potential for bone marrow suppression."
Correct Answer:
B. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed."

Med-Surge Final:

1. A nurse in an emergency department is caring for a client who reports developing severe right eye pain
with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?
A. Instill proparacaine hydrochloride eyedrops.
B. Perform ocular irrigation of the right eye.
C. Place the client in a supine position with the head turned toward the affected side.
D. Ask the client about first aid performed at the scene.
Correct Answer:
D. Ask the client about first aid performed at the scene.

2. A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should
the nurse include in the client's plan of care?
A. Maintain the client's knees and hips in a flexed position.
B. Apply cold compresses to painful joints.
C. Withhold opioids until the crisis is resolved.
D. Encourage increased fluid intake.
Correct Answer:
D. Encourage increased fluid intake.

3. A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following
actions should the nurse take?
A. Have the client gently blow clots from the nose every 5 min.
B. Instruct the client to sit with his head hyperextended.
C. Apply ice compresses to the back of the client’s neck.
D. Apply lateral pressure to the client’s nose for 10 min.
Correct Answer:
D. Apply lateral pressure to the client’s nose for 10 min.
4. A nurse is performing an admission assessment for a client who has asthma and reports several food
allergies. Which of the following actions should the nurse take first?
A. Document the client’s food allergies on the medical record.
B. Ask the client to identify the specific food allergies.
C. Monitor the client for indications of anaphylaxis.
D. Have epinephrine available for administration.
Correct Answer:
B. Ask the client to identify the specific food allergies.

5. A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions
should the nurse take? (Select all that apply.)
A. Place the client on respiratory isolation.
B. Monitor vital signs every 2 hr.
C. Assess neurological status every 4 hr.
D. Maintain the client in a modified Trendelenburg position.
E. Keep the client’s room darkened.
Correct Answers:
B. Monitor vital signs every 2 hr.
C. Assess neurological status every 4 hr.
E. Keep the client’s room darkened.

6. A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should
the nurse take?
A. Cover the insertion site with a hydrocolloid dressing after removal.
B. Provide pain medication immediately after removal.
C. Instruct the client to perform the Valsalva maneuver during removal.
D. Delegate removal of the chest tube to a licensed practical nurse (LPN).
Correct Answer:
C. Instruct the client to perform the Valsalva maneuver during removal.

7. A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent
future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply.)
A. Take allopurinol as prescribed.
B. Exercise several times a week.
C. Limit intake of foods high in purine.
D. Decrease daily fluid intake.
E. Avoid citrus juices.
Correct Answers:
A. Take allopurinol as prescribed.
B. Exercise several times a week.
C. Limit intake of foods high in purine.

8. A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary
incontinence. Which of the following actions should the nurse include in the client's plan of care?
A. Offer the client a bedpan every 2 hr.
B. Limit the client's daily fluid intake until he is no longer incontinent.
C. Request a prescription for an indwelling urinary catheter from the client's provider.
D. Ambulate the client to the bathroom every 30 min.
Correct Answer:
A. Offer the client a bedpan every 2 hr.

9. A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions
should the nurse plan to take first?
A. Obtain sample menus from the dietitian to give to the client.
B. Ask the client to identify the types of foods she prefers.
C. Identify the recommended range for the client’s blood glucose level.
D. Discuss long-term complications that can result from nonadherence to the dietary plan.
Correct Answer:
B. Ask the client to identify the types of foods she prefers.

10. A nurse is providing postoperative care for a client who has two chest tubes in place following a
lobectomy. The client asks the nurse the reason for having two chest tubes. The nurse should inform the client
that the lower chest tube is placed for which of the following reasons?
A. Removing air from the pleural space
B. Creating access for irrigating the chest cavity
C. Evacuating secretions from the bronchioles and alveoli
D. Draining blood and fluid from the pleural space
Correct Answer:
D. Draining blood and fluid from the pleural space

11. A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive
brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I need to lie still in bed during my brachytherapy treatment."
B. "I will have an implant placed once a month during my brachytherapy treatment."
C. "I must stay at least 3 feet away from others between brachytherapy treatments."
D. "I should expect some blood in my urine after each brachytherapy treatment."
Correct Answer:
A. "I need to lie still in bed during my brachytherapy treatment."

12. A nurse in an emergency department is assessing a client who has extensive burns, including on her face.
Which of the following assessments should the nurse perform first?
A. Estimation of burn injury
B. Characteristics of the cough and sputum
C. Extent of peripheral edema
D. Amount of urine output
Correct Answer:
B. Characteristics of the cough and sputum

13. A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the
peritoneal fluid is not adequately draining. Which of the following actions should the nurse take?
A. Turn the client from side to side.
B. Elevate the height of the dialysate bag.
C. Lower the head of the client's bed.
D. Advance the catheter approximately 2.5 cm (1 in) further.
Correct Answer:
A. Turn the client from side to side

14. A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how
to prevent recurrence. Which of the following statements by the client indicates understanding of the
teaching?
A. "I will ask my provider to change my contraception to an intrauterine device."
B. "I will notify my doctor before I have dental procedures."
C. "I will avoid using antiseptic mouthwash during my oral care."
D. "I will wear a mask when I go out in public."
Correct Answer:
B. "I will notify my doctor before I have dental procedures."

15. A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which
of the following findings should the nurse expect?
A. Elevated blood pressure
B. Involuntary muscle spasms
C. Cold intolerance
D. Weight loss
Correct Answer:
B. Involuntary muscle spasms

16. A nurse in the emergency department is caring for a client who has fruity breath odor, dry mouth, and
extreme thirst. Which of the following assessments should the nurse make?
A. Blood glucose level
B. Pupillary reaction to light
C. Deep tendon reflexes
D. Liver function tests
Correct Answer:
A. Blood glucose level
17. A nurse is planning care for a client who has thrombophlebitis and a prescription to receive heparin via
continuous IV infusion. Which of the following actions should the nurse include in the plan of care?
A. Infuse the heparin using an electronic IV pump.
B. Administer vitamin K if the client has indications of hemorrhage.
C. Adjust the dosage of heparin based on the client’s PT levels.
D. Inform the client that the heparin will dissolve the thrombus.
Correct Answer:
A. Infuse the heparin using an electronic IV pump.

18. A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of
the prostate (TURP). Which of the following findings should the nurse report to the provider?
A. Output equal to the instilled irrigant
B. Report of bladder spasms
C. Viscous urinary output with clots
D. Report of a strong urge to urinate
Correct Answer:
C. Viscous urinary output with clots

19. A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to
initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse
take? (Select all that apply.)
A. Assess and document the client’s vital signs.
B. Restart the IV with a 22-gauge needle.
C. Verify with another nurse the blood type and Rh of the packed RBCs.
D. Hang a bag of lactated Ringer’s IV solution.
E. Change IV tubing to a set that has a filter.
Correct Answers:
A. Assess and document the client’s vital signs.
C. Verify with another nurse the blood type and Rh of the packed RBCs.
E. Change IV tubing to a set that has a filter.

20. A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a
standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the
teaching?
A. Remain NPO 6 to 8 hr prior to the EEG.
B. Take a sedative the night prior to the EEG.
C. Thoroughly shampoo hair prior to the EEG.
D. Sleep for at least 8 hr the night prior to the test.
Correct Answer:
C. Thoroughly shampoo hair prior to the EEG.

21. A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the
bedside. Which of the following actions should the nurse take first?
A. Provide oxygen.
B. Place the client in a side-lying position.
C. Provide privacy.
D. Lower the client to the floor.
Correct Answer:
D. Lower the client to the floor

22. A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis
of AIDS. Which of the following statements should the nurse include in the teaching?
A. "Your provider will prescribe one single antiretroviral medication at a time."
B. "You should take antiretroviral medications on a routine schedule."
C. "You should increase your intake of raw fruits and vegetables while taking antiretroviral medications."
D. "Your provider will prescribe antiretroviral therapy to kill the HIV virus."
Correct Answer:
B. "You should take antiretroviral medications on a routine schedule."

23. A nurse is teaching a client about transmission prevention of hepatitis A. The nurse should identify that
hepatitis A is transmitted by which of the following routes?
A. Maternal-fetal
B. Fecal-oral contamination
C. Genital sexual contact
D. Blood to blood
Correct Answer:
B. Fecal-oral contamination

24. A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus
erythematosus (SLE). Which of the following statements by the client indicates an understanding of the
teaching?
A. "I will need to take methotrexate even if I’m in remission."
B. "I'm thankful that this type of lupus only affects the skin."
C. "Each day I should apply a sunblock with a sun protection factor of 15."
D. "A mild fever is common with SLE and usually does not require medical intervention."
Correct Answer:
A. "I will need to take methotrexate even if I’m in remission."

25. A nurse is providing teaching to a client who has tuberculosis and prescriptions for rifampin and
ethambutol. The nurse should identify which of the following findings as an adverse effect of these
medications that the client should report to the provider?
A. Red-orange discoloration of urine
B. Unexpected weight gain
C. Ringing in the ears
D. Decreased visual acuity
Correct Answer:
D. Decreased visual acuity

26. A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight
management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which
of the following statements should the nurse make?
A. "You should try a little harder to stick to your diet."
B. "Why do you think you've gained 3 pounds this week?"
C. "Were there any issues last week that kept you from focusing on your diet?"
D. "You should put this week behind you and adhere to your diet from this point forward."
Correct Answer:
C. "Were there any issues last week that kept you from focusing on your diet?"

27. A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes
zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the following responses should
the nurse make?
A. "Adults receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox."
B. "Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant."
C. "A client who has herpes zoster is not contagious if blisters are present on the skin."
D. "Herpes zoster is not contagious to people who have had chickenpox."
Correct Answer:
D. "Herpes zoster is not contagious to people who have had chickenpox."

28. A community health nurse is teaching a group of clients about melanoma. Which of the following
characteristics of lesions associated with melanoma should the nurse include in the teaching?
A. One solid color
B. Symmetrical in shape
C. Less than 6 mm in diameter
D. An irregular border
Correct Answer:
D. An irregular border

29. A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I should check my heart rate at the same time each day."
B. "I don't have to take my antihypertensive medications now that I have a pacemaker."
C. "I should keep a pressure dressing over the generator until the incision is healed."
D. "I cannot stand in front of our new microwave oven when it is on."
Correct Answer:
A. "I should check my heart rate at the same time each day."

30. A nurse is preparing to care for a group of clients after receiving change-of-shift report. Which of the
following clients should the nurse assess first?
A. A client who has benign prostatic hyperplasia (BPH) and reports dysuria
B. A client who has ulcerative colitis and reports diarrhea
C. A client who has emphysema and reports dyspnea
D. A client who has esophageal cancer and reports painful swallowing
Correct Answer:
C. A client who has emphysema and reports dyspnea

31. A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy.
Which of the following statements by the client indicates a need for further teaching?
A. "I will use a soft toothbrush or foam swab for oral care."
 B. "I will use lemon and glycerine swabs after meals."
C. "I will remove my dentures except while eating."
D. "I will rinse my mouth frequently with hydrogen peroxide solution."
Correct Answer:
B. "I will use lemon and glycerine swabs after meals."
32. A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of
48,000/mm³. Which of the following interventions should the nurse include?
A. Avoid IM injections.
B. Assess the client for ecchymosis once per shift.
C. Do not allow the client to have visitors.
D. Encourage daily flossing between teeth.
Correct Answer:
A. Avoid IM injections.

33. A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48
mg/dL. Which of the following findings should the nurse expect?
A. Kussmaul respirations
B. Diaphoresis
C. Decreased skin turgor
D. Ketonuria
Correct Answer:
B. Diaphoresis

34. A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of
the following laboratory findings should the nurse identify as an increased risk for this disorder?
A. Cholesterol level 195 mg/dL
B. Elevated HDL levels
C. Elevated LDL levels
D. Triglyceride level 135 mg
Correct Answer:
C. Elevated LDL levels

35. A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate
the wound, which of the following actions should the nurse take first?
A. Obtain the prescribed irrigation solution.
B. Don personal protective equipment.
C. Check the client’s pain level.
D. Place a waterproof pad under the client’s extremity.
Correct Answer:
C. Check the client’s pain level.

36. A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The client
asks the nurse about the usual course of MS. Which of the following responses should the nurse make?
A. "Each client is different; we cannot predict what will happen."
B. "I can see that you are worried, but it’s too soon to predict what will happen."
C. "Acute episodes are usually followed by remissions, which can vary in duration."
D. "It’s too early to think about the future; let’s focus on the present and take one day at a time."
Correct Answer:
C. "Acute episodes are usually followed by remissions, which can vary in duration."
37. A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the
client for which of the following purposes?
A. Raising the bed linens off the client’s feet to prevent plantar flexion
B. Keeping the client’s heels off the bed to prevent pressure ulcers
C. Positioning the client off of the operative site while in bed
D. Preventing dislocation of the hip during position changes or movement
Correct Answer:
D. Preventing dislocation of the hip during position changes or movement

38. A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the
following meal selections by the client indicates an understanding of the teaching?
A. Chicken breast and corn on the cob
B. Shrimp and rice
C. Cheese omelet and turkey bacon
D. Liver and onions
Correct Answer:
A. Chicken breast and corn on the cob

39. A nurse is reviewing a client’s laboratory report. The client’s ABG levels are pH 7.5, PaCO₂ 32 mm Hg,
and HCO₃⁻ 24 mEq/L. The nurse should determine that the client has which of the following acid-base
imbalances?
A. Respiratory alkalosis
B. Metabolic acidosis
C. Respiratory acidosis
D. Metabolic alkalosis
Correct Answer:
A. Respiratory alkalosis

40. A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy.
Which of the following statements by the client indicates a need for further teaching?
A. "Because most of my colon is still intact and functioning, my stool will be formed."
B. "My stoma will appear large at first, but it will shrink over the next several weeks."
C. "My colostomy will begin to function 2 to 6 days after surgery."
D. "My diet will have to change to a soft diet after surgery."
Correct Answer:
D. "My diet will have to change to a soft diet after surgery."

41. A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. Which
of the following actions should the nurse take?
A. Elevate the residual limb on a soft pillow.
B. Assist the client to a prone position every 4 hr.
C. Reapply a bandage to the residual limb every 12 hr.
D. Apply dressings to the site in a proximal-to-distal direction.
Correct Answer:
B. Assist the client to a prone position every 4 hr.

42. A nurse is providing discharge teaching about improving gas exchange to a client who has emphysema.
Which of the following instructions should the nurse include in the teaching?
A. Use pursed-lip breathing during periods of dyspnea.
B. Limit fluid intake to 1,500 mL per day.
C. Practice chest breathing each day.
D. Wear home oxygen to maintain an SaO₂ of at least 94%.
Correct Answer:
A. Use pursed-lip breathing during periods of dyspnea.
43. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following
actions should the nurse take?
A. Administer 0.9% sodium chloride until TPN is available from the pharmacy.
B. Check the client’s capillary blood glucose level every 4 hr.
C. Obtain the client’s weight each week.
D. Change the IV tubing every 3 days.
Correct Answer:
B. Check the client’s capillary blood glucose level every 4 hr.

44. A nurse is teaching a client how to perform a breast self exam (BSE). The nurse should identify which of
the following findings as an indication of breast cancer?
A. Lumps that are mobile and tender upon palpation prior to a menstrual period
B. Multiple round masses that are tender and found in both breasts
C. Bilaterally darkened areolas
D. A nontender, hard lump that is palpated in one breast
Correct Answer:
D. A nontender, hard lump that is palpated in one breast

45. A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the
medication, which of the following actions should the nurse take?
A. Instruct the client to blink several times after instilling the medication.
B. Ask the client to look straight ahead during instillation of the medication.
C. Apply pressure to the puncta after instilling the medication.
D. Place each drop of the medication directly on to the client’s cornea.
Correct Answer:
C. Apply pressure to the puncta after instilling the medication.

46. A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the
following findings should the nurse identify as an indication of a basilar skull fracture?
A. A depressed fracture of the forehead
B. Clear fluid coming from the nares
C. Motor loss on one side of the body
D. Bleeding from the top of the scalp
Correct Answer:
B. Clear fluid coming from the nares

47. A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table.
Which of the following actions should the nurse take?
A. Recap the needle on the syringe.
B. Schedule a nurse to administer future injections for this client.
C. Explain to the client that the syringe should be disposed of in the bathroom trash can.
D. Place the syringe in a puncture-proof disposal container.
Correct Answer:
D. Place the syringe in a puncture-proof disposal container.

48. A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which
of the following personal protective equipment (PPE) should the nurse don prior to providing client care?
(Select all that apply.)

A. Gown
B. Gloves
 C. Mask
D. Hair cover
E. Goggles
Correct Answers:
A. Gown,
B. Gloves

49. A nurse is providing teaching to a client who has tuberculosis (TB) and a
prescription for isoniazid. Which of the following instructions should the nurse
include?
A. "It is necessary to take this medication for the rest of your life to prevent recurrence."
B. "Your provider will monitor your thyroid function while you are taking this medication."
C. "You should take this medication on an empty stomach."
D. "It is recommended to take this medication with an antacid."
Correct Answer:
C. "You should take this medication on an empty stomach."

50. A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the
following findings should the nurse report to the provider?
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg
Correct Answer:
C. Chest petechiae