ATI Med Surg Proctored Exam Practice Qs & As
1. A nurse is caring for a client who experienced a traumatic head
injury and has an intraventricular catheter (Ventriculostomy) for
ICP monitoring. The nurse should monitor the client for which of
the following complications related to the ventriculostomy?:
a. Headache
b. Infection
c. Aphasia
d. Hypertension: b. Infection
Monitor for infection and use strict asepsis to avoid life-threatening
meningitis.
2. A nurse is providing education to a client who is to undergo an EEG
the next day. Which of the following info should the nurse include in
the teaching?
a. "Do not wash your hair the morning of the procedure."
b. "Try and stay awake most of the night prior to the procedure."
c. "The procedure will take approximately 15 mins."
d. "You will need to lie flat for 4 hours after the procedure.": b. "Try
and stay awake most of the night prior to the procedure."
Tell the client to remain awake to provide cranial stress and increase the
possibility of abnormal electrical activity
3. A nurse is caring for a client who is postprocedural following a
lumbar puncture and reports a throbbing headache when sitting
upright. Which of the following actions should the nurse take? SATA.
a. Use the GCS scale to assess the client
b. Assist the client into a supine position
c. Administer an opioid analgesic
d. Encourage the client to increase PO fluid intake
e. Instruct the client to perform coughing and deep breathing: B, D
4. 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 irrigate b. Client reports bladder
spasms
c. Viscous urinary output with clots
d. Reports of strong urge to urinate: c. Viscous urinary output with clots
Urine that is bright red with clots is an indication of arterial bleeding.
5. A nurse is monitoring the ECG of a client who has hypocalcemia.
Which of the following findings should the nurse expect?
a. Flattened T waves
b. Prolonged QT intervals
c. Shortened QT intervalsd Widened QRS complexes: b. Prolonged QT
intervals
Manifestations of hypocalcemia include tingling, numbness, tetany,
seizures, prolonged QT intervals, and laryngospasm.
6. A nurse is preparing a client who has a brain tumor for a CT scan.
Which of the following factors affects the manner in which the nurse
will prepare the client for the scan?
a. No food or fluids consumed for 4 hours
b. Difficulty recalling recent events
c. Development of hives while eating shrimp
d. Paresthesia in both hands: c. Development of hives while eating shrimp
Shellfish allergy is contraindication of use of contrast media during a CT
scan.
7. A nurse is preparing an in-service program about the stages of
acute kidney injury. Which of the following pieces of info should the
nurse include about prerenal azotemia?
a. Prerenal azotemia begins prior to the onset of symptoms
b. Interference with renal perfusion causes renal azotemia
c. Prerenal azotemia is irreversible, even in early stages
d. Infections and tumors cause prerenal azotemia: b. Interference with
renal perfusion causes prerenal azotemia.
Prerenal = interference with renal perfusion, such as from heart failure or
hypovolemic shock.
8. A nurse is teaching a client who has CAD about the difference
between angina pectoris and MI. Which of the following should the
nurse identify as indications of MI? SATA.
a. N/V
b. Diaphoresis and dizziness
c. Chest and left arm pain that subsides with rest
d. Anxiety and feelings of doom
e. Bounding pulse and bradypnea: A, B, D
9. A nurse is reviewing the lab results of a lumbar puncture for a
client who has manifestations of bacterial meningitis. Which of the
following findings should the nurse expect?
a. Elevated glucose
b. Elevated protein
c. Presence of RBCs
d. Presence of D-dimer: b. Elevated protein
Manifestations of bacterial meningitis include increase protein in the CSF,
decreased glucose. RBCs can indicate bleeding, however, WBCs are what
indicates bacterial meningitis.
10. A nurse is providing teaching to a client who has a new diagnosis
of myasthenia gravis (MG). Which of the following pieces of
information should the nurse include?
A. Use enemas to treat constipation caused by daily medications
B. Take a hot bath when muscles ache
C. Eat a low-calorie diet
D. Set an alarm to ensure medication dosages are taken on time: D. Set
an alarm to ensure medication dosages are taken on time
The nurse should instruct the client to take medication dosages on time to
maintain a therapeutic blood level. Dosages should not be missed or
postponed because this can cause an exacerbation of the disease.
11. A nurse is teaching a client who has a new diagnosis of primary
open-angle glaucoma (POAG). Which of the following pieces of
information should the nurse include in the teaching? (Select all that
apply.)
A. Lost vision can improve with eye drops.
B. Administer eye drops as needed for vision loss.
C. Glasses will be necessary to correct the accompanying presbyopia.
D. Driving can be dangerous due to the loss of peripheral vision.
E. Laser surgery can help reestablish the flow of aqueous humor.: D.
Driving can be dangerous due to the loss of peripheral vision.
E. Laser surgery can help reestablish the flow of aqueous humor.
12. 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: C. Chest petechiae
The nurse should identify chest petechiae as an indication of fat
embolism syndrome. Clients who have fractures of the long bones such
as the femur are at increased risk of fat emboli. Fat emboli typically
occur 12 to 48 hours after the injury when fat droplets from the marrow
enter into the systemic circulation and are deposited in the lungs. The
nurse should immediately notify the provider because the client could
progress to acute respiratory failure.
13. A nurse is assessing a client who has Kaposi's sarcoma. Which of
the following findings should the nurse expect?
A. Nonproductive cough, fever, and shortness of breath
B. Lesions on the retina that produce blurred vision
C. Onset of progressive dementia
D. Reddish-purple skin lesions: D. Reddish-purple skin lesions
Kaposi's sarcoma is commonly associated with AIDS and manifests as
hyperpigmented multicentric lesions that can be firm, flat, raised, or
nodular. Following a biopsy, the lesions are treated with radiation and/or
chemotherapy.
14. 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 for longer than 15 min.: D. Chest pain lasts for longer
than 15 min.
A client who has unstable angina will have chest pain lasting longer than
15 minutes. This is due to reduced blood flow in a coronary artery from
atherosclerotic plaque and thrombus formation causing partial arterial
obstruction or from an artery spasm.
Incorrect Answers:
A. A client who has unstable angina will have chest pain even while
resting because of insufficient blood flow to the coronary arteries and a
decreased oxygen supply.
Chest pain at rest is a condition called variant
(Prinzmetal's) angina and is caused by an arterial spasm.
B. A client who has unstable angina will have minimal, if any, relief of
chest pain with nitroglycerin.
C. A client who has unstable angina will report chest pain or discomfort
with exertion, which can limit the client's activity.
15. A nurse is assessing a client with a closed head injury who has
received mannitol for manifestations of increased intracranial
pressure (ICP). Which of the following findings indicates that the
medication is having a therapeutic effect?
A. The client's serum osmolarity is 310 mOsm/L.
B. The client's pupils are dilated.
C. The client's heart rate is 56/min.
D. The client is restless.: A. The client's serum osmolarity is 310 mOsm/L.
Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing
water out of the brain tissue. A serum osmolarity of 310 mOsm/L is
desired. A decrease in cerebral edema should result in a decrease in ICP.
16. A nurse is planning care for a client who has AIDS and has
developed stomatitis. Which of the following interventions should
the nurse include in the plan of care?
A. Rinse the mouth with chlorhexidine solution every 2 hr
B. Limit fluid intake with meals
C. Provide oral hygiene with a firm-bristled toothbrush after each meal
D. Avoid salty foods: D. Avoid salty foods
Stomatitis is an inflammation of the mucosa of the mouth, usually with
ulcerations. Foods that are spicy, acidic, or salty should be avoided to
prevent further irritation and damage to the oral mucosa.
17. A nurse is caring for a client who had a left lower lobectomy to
treat lung cancer. Which of the following factors will have a
significant impact on the plan of care for this client?
A. The client will need intensive smoking-cessation education.
B. After surgery, the prognosis for clients with lung cancer is usually
good.C. Lung cancer usually has metastasized before the client
presents with symptoms.
D. Oxygen therapy is ineffective following a lobectomy.: C. Lung
cancer usually has metastasized before the client presents with symptoms.
The nurse should be aware that lung cancer is usually at an advanced stage
before the client has any manifestations. This has implications for both
short-term and long-term care options for the client.
18. A nurse is examining the ECG of a client who has hyperkalemia.
Which of the following ECG changes should the nurse expect?
A. Elevated ST segments
B. Absent P waves
C. Depressed ST segments
D. Varying PP intervals: A. Elevated ST segments
Elevated ST segments can indicate hyperkalemia and pericarditis.
19. A nurse is caring for a client during the first 72 hr following a
cerebrovascular accident (CVA). Which of the following actions
should the nurse take?
A. Turn the client's head to the side with the head of the bed elevated
60°
B. Place the head of the bed flat with pillows under the client's neck
and feetC. Elevate the head of the bed 25° to 30° with the client in a
neutral midline position
D. Position the client in a dorsal recumbent position with pillows
under the head and knees:
20. A nurse is caring for a client who is taking streptomycin. Which
of the following medications increases the client's risk of developing
ototoxicity when taken with streptomycin?
A. Cefoxitin
B. Furosemide
C. Naproxen
D. Amphotericin B: B. Furosemide
Furosemide, a high-ceiling (loop) diuretic, increases the risk of
developing ototoxicity when taken with streptomycin, an aminoglycoside.
21. A nurse is preparing to administer an IM injection for a client.
Which of the following factors should the nurse identify as a potential
contraindication to administering the medication via the IM route?
A. The medication is a depot preparation.
B. The client is taking an anticoagulant.
C. The medication is a particulate suspension.
D. The client has been vomiting.: B. The client is taking an anticoagulant.
Because of the risk of bleeding from the injection site, anticoagulant
therapy (e.g. warfarin) is a contraindication to receiving medications via
the IM route.
22. A nurse is caring for a client with Clostridium difficile who has
contact-isolation precautions in place. Which of the following actions
should the nurse perform?
A. Instruct visitors to maintain a distance of at least 1 m (3 ft) from
the client.
B . Wash hands with antimicrobial soap after leaving the client's
room. C. Use dedicated equipment for the client.
D. Keep the doors to the client's room closed at all times.: C. Use
dedicated equipment for the client.
The nurse should use dedicated equipment that is left in the room for a
client who has contact-isolation precautions in place.
Incorrect Answers:
A. The nurse should instruct visitors to maintain a distance of at least 1
m (3 ft) from a client who has droplet-isolation precautions in place.
B. The nurse should wash hands with antimicrobial soap before leaving
the room of a client who has contact-isolation precautions in place.
D. The nurse should keep the doors to the client's room closed at all times
when airborne-isolation precautions are in place.
23. A nurse is assessing a client who sustained superficial partialthickness
and
deep
partial-thickness
burns 72
hr ago.
Which
of the
following
findings
should
the
nurse
report
to
the
provider?
A. Edema in the burned extremities
B. Severe pain at the burn sites
C. Urine output of 30 mL/hr
D. Temperature of 39.1°C (102.4°F): D. Temperature of 39.1°C (102.4°F)
An elevated temperature is an indication of infection, and the nurse should
report this finding to the provider. Sepsis is a critical finding following a
major burn injury. Initially, burn wounds are relatively pathogen-free. On
approximately the third day following the injury, early colonization of the
wound surface by gram-negative organisms changes to predominantly
gram-positive opportunistic organisms.
24. An emergency room nurse is assessing a client who has a new
traumatic brain injury. The nurse observes extension of the client's
arms and legs, pronation of the arms, and plantar flexion of the feet.
Which of the following actions is the nurse's priority?
A. Monitor urinary output
B. Administer an osmotic diuretic
C. Provide supplemental oxygen
D. Initiate seizure precautions: C. Provide supplemental oxygen
The first action the nurse should take when using the airway, breathing,
and circulation (ABC) approach to client care is to provide supplemental
oxygen. The client might require an artificial airway and mechanical
ventilation because these findings indicate decerebrate positioning,
which is associated with brainstem injury and can lead to brain
herniation and death.
25. A nurse is teaching a client who has persistent cancer pain about
the adverse effects of opioids. Which of the following statements
should the nurse include in the teaching?
A. "Opioids do not relieve pain without causing severe adverse effects."
B. "Physical dependence is not the same as addiction."
C. "Tolerance typically means that the medication will no longer be
effective."D. "The most common adverse effect is respiratory
depression with prolonged use.": B. "Physical dependence is not the
same as addiction."
The nurse should explain that physical dependence can occur in all clients
who take opioids, and the client may develop abstinence syndrome if the
opioid is abruptly withdrawn. Physical dependence is not the same as
addiction, but it can result in addiction. Addiction results when the opioid
is continued despite physical or psychological harm.
26. A nurse is preparing a client who is scheduled to have an
arthroscopy the following day. Which of the following statements
indicates that the client understands the pre-procedure teaching?
A. "I have to keep my leg straight throughout the whole procedure."
B. "The doctor will be able to see if I have signs of rheumatoid arthritis."
C. "I should expect to stay overnight until I can walk around."
D. "I'll have a scar that will be about an inch long.": B. "The doctor will
be able to see if I have signs of rheumatoid arthritis."
An arthroscopy helps with diagnosing musculoskeletal disorders such as
rheumatoid arthritis, osteoarthritis, and internal joint injuries.
27. A nurse is caring for a client who has manifestations of acute
tubular necrosis (ATN) following a kidney transplantation. Which of
the following interventions should the nurse anticipate for this client?
(Select all that apply.)
A. Hemodialysis
B. Biopsy
C. Immunosuppression
D. Balloon angioplasty
E. Surgical repair: A, B, C
Clients who develop ATN after transplantation surgery might need
dialysis until they have an adequate urine output and their BUN and
creatinine levels stabilize. Because the development of ATN after
transplantation surgery mimics the symptoms of rejection of the
transplanted kidney, clients have to undergo a biopsy to determine the
correct diagnosis. Immunosuppressive medication therapy is essential
after kidney transplantation to protect the new kidney.
28. A nurse is providing teaching to a client who is scheduled for a
sigmoid colon resection with colostomy. Which of the following
statements by the client indicates a need for further teaching?
A. "Because most of my colon is still intact and functioning, my stool will
be formed."
B. "My stoma will appear large at first, but it will shrink over the next
several weeks."
C. "My colostomy will begin to function in 2 to 6 days after surgery."
D. "I'll have to consume a soft diet after surgery.": D. "I'll have to
consume a soft diet after surgery."
The nurse should identify that this statement requires further teaching.
After surgery, the client quickly returns to a regular diet, and there are no
food restrictions unless the client chooses to decrease the intake of foods
that increase gas or odor.
29. A nurse is caring for a client who is 2 days postoperative. Which
of the following findings indicates that the client is developing an
infection?
A. Temperature 37.8°C (100°F)
B. Erythema at the incision site
C. WBC count 9,000/mm^3
D. Pain reported as 6 on a scale of 0 to 10: B. Erythema at the incision site
Redness at the incision site is an initial sign of a wound infection and
requires intervention by the nurse.
30. A nurse is caring for a client who had a cerebrovascular accident
(CVA). The client appears alert and engaged during a visit but does
not respond verbally to questions. The nurse should document this as
which of the following alterations?
A. Expressive aphasia
B. Dysarthria
C. Receptive aphasia
D. Dysphagia: A. Expressive aphasia
A client who has expressive aphasia understands speech but has difficulty
speaking and writing. This typically occurs as a result of a lesion at
Broca's area of the frontal lobe.
31. A nurse is teaching a female client with a new diagnosis of systemic
lupus erythematosus (SLE) about factors that can trigger an
exacerbation of SLE. The nurse should determine that the client
requires further teaching if she identifies which of the following as an
exacerbation factor?
A. Exercise
B. Pregnancy
C. Infection
D. Sunlight: A. Exercise
SLE is a chronic autoimmune disease that develops when the immune
system becomes hyperactive and attacks healthy body tissue. This attack
results in generalized inflammation and creates manifestations associated
with the specific involved tissues. Most clients who have SLE can follow
an exercise program to increase their cellular aerobic capacity and
improve immune function, and the client should follow a program with
her provider's assistance. This client needs additional teaching about the
importance of exercise to keep her muscles and joints active.
32. 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: B. Diaphoresis
A client who has a blood glucose level below 70 mg/dL will exhibit
manifestations of hypoglycemia. Expected findings associated with
hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness,
and confusion.
33. A nurse is caring for a client who has a major burn injury and is
experiencing third spacing. Which of the following fluid or electrolyte
imbalances should the nurse expect?
A. Hypokalemia
B. Hypernatremia
C. Elevated Hct
D. Decreased Hgb: C. Elevated Hct
The nurse should expect a client who is experiencing third spacing
resulting from a major burn to have an elevated hematocrit level as
blood volume is reduced by vascular dehydration.
Incorrect Answers:
A. The nurse should expect the client to have hyperkalemia as a result
of potassium being leaked from cellular injury.
B. The nurse should expect the client to have hyponatremia once
sodium leaks into the interstitial space, causing decreased levels in the
blood.
D. The nurse should expect the client to have an increased hemoglobin
level as blood volume is reduced by vascular dehydration.
34. A nurse is examining the ECG of a client who has frequent
premature ventricular contractions (PVCs). Which of the following
QRS changes should the nurse expect to see on the client's ECG?
A. Narrower than usual QRS complexes
B. Much greater amplitude than the usual QRS complexes
C. Same polarity as the usual QRS complexes
D. Immediate resumption of the usual rhythm: B. Much greater amplitude
than the usual QRS complexes
The QRS complexes unusually have greater amplitude in height and depth
in clients with PVCs.
35. A nurse is caring for a client who is experiencing autonomic
dysreflexia due to a C5 spinal cord injury. After checking the
client's vital signs, which of the following actions should the nurse
perform next?
A. Administer nifedipine
B. Place the client in a high-Fowler's position
C. Check for urinary retention
D. Check for a fecal impaction: B. Place the client in a high-Fowler's
position
According to evidence-based practice, the nurse should first place the
client in a high-Fowler's position to decrease the client's blood pressure
and reduce the risk of end-organ damage from the sudden rise in blood
pressure.
36. A nurse is monitoring a client for reperfusion following
thrombolytic therapy to treat acute myocardial infarction (MI).
Which of the following indicators should the nurse identify to confirm
reperfusion?
A. Ventricular dysrhythmias
B. Appearance of Q waves
C. Elevated ST segments
D. Recurrence of chest pain: A. Ventricular dysrhythmias
The appearance of ventricular dysrhythmias following thrombolytic
therapy is a sign of reperfusion of the coronary artery.
37. A nurse is teaching a newly licensed nurse about caring for a client
who is scheduled for an esophagogastric balloon tamponade tube to
treat bleeding esophageal varices. Which of the following pieces of
information should the nurse include in the teaching?
A. The client will be placed on mechanical ventilation prior to this
procedure.
B. The tube will be inserted into the client's trachea.
C. The client will receive a bowel preparation with cathartics prior to
this procedure.
D. The tube allows the application of a ligation band to the bleeding
varices.: A. The client will be placed on mechanical ventilation prior to
this procedure.
The client will require intubation and mechanical ventilation prior to this
procedure to protect the airway.
38. A nurse is preparing an in-service presentation about the
management of myocardial infarction (MI). Death following MI is
often a result of which of the following complications?
A. Cardiogenic shock
B. Dysrhythmias
C. Heart failure
D. Pulmonary edema: B. Dysrhythmias
According to evidence-based practice, dysrhythmias (specifically
ventricular fibrillation) are the most common cause of death following
MI. Therefore, nurses should monitor clients' ECGs carefully for
dysrhythmias and report and treat them immediately.
39. A nurse is teaching a client who has polycythemia vera about selfcare
measures.
Which
of
the
following
interventions
should
the
nurse
include?
A. "Drink at least 1 liter of fluid each day."
B. "Continuously wear support hose."
C. "Elevate your legs when sitting."
D. "Use dental floss daily.": C. "Elevate your legs when sitting."
Clients who have polycythemia vera should elevate their legs when seated
to avoid venous pooling with subsequent clot formation.
40. A nurse is planning care for a client who has thrombocytopenia.
Which of the following interventions should the nurse include in the
plan of care?
A. Restrict fluids to 1,000 mL per day
B. Measure the client's abdominal girth daily
C. Check IV sites every 4 hr for bleeding
D. Administer an enema as needed for constipation: B. Measure the
client's abdominal girth daily
The nurse should measure the client's abdominal girth daily to monitor for
manifestations of internal bleeding. A client who has a reduced platelet
count is at risk of bleeding due to delayed clotting.
41. A nurse is assessing for disseminated intravascular coagulation
(DIC) in a client who has septic shock secondary to an untreated foot
wound. Which of the following findings should the nurse expect?
(Select all that apply.)
A. Bradycardia
B. Bleeding at the venipuncture site
C. Petechiae on the chest and arms
D. Flushed, dry skin
E. Abdominal distension: B C E
The formation of large amounts of microemboli in the circulation depletes
the body's platelets and clotting factors. As a result, uncontrollable
bleeding can occur, as manifested by bleeding at the venipuncture site,
petechiae on the chest and arms, and bleeding in the abdominal cavity
resulting in abdominal distension due to internal bleeding.
42. A nurse is caring for a semiconscious client who had a smallbore
NG
tube
placed
yesterday
for
the
administration
of enteral
feeding.
Which
of
the
following
methods
should
the
nurse
use to
verify
correct
tube
placement?
(Select
all
that
apply.)
A. Auscultate injected air
B. Verify the initial X-ray examination
C. Measure the length of the exposed tube
D. Determine the pH of aspirated fluid
E. Check the aspirated fluid for glucose: B. Verify the initial X-ray
examination
C. Measure the length of the exposed tube
D. Determine the pH of aspirated fluid
43. A nurse is teaching a client who is postoperative how to use a floworiented
incentive spirometer. Which of the following instructions
should the nurse include?
A. Blow into the spirometer to elevate the balls in the device
B. Cough deeply after each use
C. Clean the mouthpiece with an alcohol swab after each use
D. Use the spirometer every 8 hr: B. Cough deeply after each use
Proper use of the incentive spirometer loosens secretions in the client's
lungs. The client should cough deeply to facilitate the removal of
secretions from his lungs.
A. The nurse should instruct the client to inhale deeply to elevate the balls
in the device.
C. The nurse should instruct the client to clean the mouthpiece with
water and dry it after each use.
D. The nurse should instruct the client to use the spirometer several
times every hour while awake.
44. A nurse is talking with a group of women at a community center
about the current recommendations for early detection of breast
cancer. The nurse should explain which of the following options?
A. Begin monthly breast self-examinations at age 40
B. Have a clinical breast examination each year after age 30
C. Begin annual mammograms at age 40
D. Have breast magnetic resonance imaging every 5 years after age 50:
C. Begin annual mammograms at age 40
Women should begin performing monthly breast self-examinations at 20
years of age. From 20 to 39 years of age, women should undergo a
breast examination by a health care provider every 3 years. Women
older than 40 years of age should have annual breast examinations by a
health care provider and an annual mammogram. 45. A nurse is
preparing a client for a bronchoscopy. Which of the following
actions should the nurse take? (Select all that apply.)
A. Explain that the client will receive sedation and will not remember
the procedure.
B. Verify that the client understands the purpose and nature of the
procedure.
C. Offer the client sips of clear liquids until 1 hr before the test.
D. Obtain a pre-procedural sputum specimen.
E. Instruct the client to keep his neck in a neutral position.: A. Explain
that the client will receive sedation and will not remember the procedure.
B. Verify that the client understands the purpose and nature of the
procedure.
For a bronchoscopy, clients typically receive premedication with a
benzodiazepine or an opioid to ensure sedation and amnesia. The client
will have signed a consent form, so the nurse should verify that the
provider explained the procedure and that the client understands it.
46. A nurse is assessing a client who has peripheral vascular disease
and a venous ulcer on the right ankle. Which of the following
findings should the nurse expect in the client's affected extremity?
A. Absent pedal pulses
B. Ankle swelling
C. Hair loss
D. Skin atrophy: B. Ankle swelling
The nurse should identify that swelling of the ankle is a manifestation of
venous insufficiency due to poor venous return. Other manifestations
can include brown pigmentations and cellulitis.
47. A nurse in an emergency department is assessing a client who
sustained a fall off of a roof. Which of the following findings should
the nurse identify as an indication of a basilar skull fracture?
A. Depressed fracture of the forehead
B. Clear fluid coming from the nares
C. Motor loss on one side of the body
D. Bleeding from the top of the scalp: B. Clear fluid coming from the nares
Cerebrospinal fluid manifests as a clear fluid coming from the nares or
ears, indicating a basilar skull fracture.
48. 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: C. Polyuria
49. A client is being discharged home with oxygen therapy delivered
through a nasal cannula. Which of the following instructions should
the nurse provide to the client and family members?
A. Use battery-operated equipment for personal care.
B. Apply mineral oil to protect the facial skin from irritation.
C. Remove the television set from the client's bedroom.
D. Wear cotton clothing to avoid static electricity.: D. Wear cotton
clothing to avoid static electricity.
The use of cotton clothing will limit the buildup of static electricity.
Oxygen is a highly combustible gas. The use of oxygen in high
concentrations has great combustion potential and readily fuels fire.
Although it will not spontaneously burn or cause an explosion, it can
easily cause a fire in a client's room if it contacts a spark.
50. A nurse is removing personal protective equipment (PPE) after
performing a procedure for a client who requires isolation
precautions. Which of the following items of PPE should the nurse
remove first?
A. Gloves
B. Gown
C. Eyewear
D. Mask:
51. 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 N-95 respirator on the client.: A. Have the
client wear a surgical mask.
52. A nurse is assessing a client who has cholecystitis. Which of the
following findings should the nurse expect?
A. Blumberg's sign
B. Ascites
C. Gastrointestinal bleeding
D. Kehr's sign: A. Blumberg's sign
The nurse should expect to find rebound tenderness (Blumberg's sign) in
a client who has cholecystitis. This response can be an indication of
peritoneal inflammation.
:B. The nurse should expect to find ascites in a client who has chronic
pancreatitis or pancreatic cancer.
C. The nurse should expect to find gastrointestinal bleeding in a client
who has pancreatic cancer.
D. The nurse should expect to find a positive Kehr's sign in a client who
has liver trauma.
53. A nurse is implementing cold therapy for a client who has an ankle
sprain. Which of the following actions should the nurse take?
A. Apply a cold pack to the edematous area
B. Check capillary refill before applying an ice pack to the affected area
C. Half-fill an ice pack with crushed ice
D. Apply an ice pack for 60 min intervals: B. Check capillary refill before
applying an ice pack to the affected area
The nurse should check the affected area for adequate circulation by
assessing pulses and capillary refill because a cold pack applied to an
area of impaired circulation can further decrease the blood supply to the
area.
54. A nurse is caring for a client following a stroke. Which of the
following actions should the nurse take first?
A. Obtain coagulation laboratory studies from the client
B. Apply pneumatic compression boots to the client
C. Request a referral for a speech-language pathologist
D. Keep the client NPO: D. Keep the client NPO
The first action the nurse should take when using the airway, breathing,
and circulation (ABC) approach to client care is to keep the client NPO
due to the risk of aspiration as a result of the stroke. The client should be
screened for the ability to swallow and should not receive anything by
mouth until this has been completed. A client who has experienced a
cerebrovascular accident is at risk for dysphagia, which increases the
change of life-threating aspiration.
55. 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.":
A. "I should check my heart rate at the same time each day."
The nurse should instruct the client to check the heart rate at the same time
each day and to document the rate in a log for reporting to the provider.
Incorrect Answers:
B. A pacemaker maintains a regular heart rate but is not intended to lower
blood pressure or control hypertension.
C. The client should avoid applying pressure over the generator.
D. New microwaves are equipped with shielding that protects a person who
has a pacemaker from interference. Hence, standing in front of a new
microwave oven is not contraindicated. The client should avoid being in
close proximity to older microwaves that do not have this shielding.
56. 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 the semi-Fowler's position
C. Cleanse the skin around the tube site
D. Aspirate the tube for residual contents: B. Place the client in the semiFowler's
position
The nurse should apply the ABC priority-setting framework, which
emphasizes the basic core of human functioning: having an open airway,
being able to breathe in adequate amounts of oxygen, and circulating
oxygen to the body's organs via the blood. An alteration in any of these
areas can indicate a threat to life and is the nurse's priority concern. When
applying the ABC priority-setting framework, airway is always the
highest priority because the airway must be clear for oxygen exchange to
occur. Breathing is the second priority because adequate ventilatory effort
is essential for oxygen exchange to occur. Circulation is the third priority
because the delivery of oxygen to critical organs only occurs if the heart
and blood vessels are capable of efficiently carrying oxygen to them.
57. A nurse is teaching a client how to perform range-of-motion
exercises of the wrist. To perform adduction, which of the following
instructions should the nurse include?
A. "With your palm facing down, move your wrist sideways toward your
thumb."
B. "Move your palm toward the inner part of your forearm."
C. "With your palm facing down, move your wrist sideways toward your
little finger."
D. "Bring the back of your hand as far back toward the wrist as you
can.": a. "With your palm facing down, move your wrist sideways toward
your thumb."
This motion describes adducting the wrist. The client should be able to
move her wrist 30º to 50º with this motion.
58. A nurse is caring for a client who is NPO and has an NG tube to
suction. When the client reports nausea, which of the following
actions should the nurse take?
A. Irrigate the tube with normal saline solution
B. Provide oral hygiene
C. Clamp the tube for 30 min
D. Increase the amount of suction: A. Irrigate the tube with normal saline
solution
When a client with an NG tube develops nausea, the nurse should first
attempt to irrigate the tube to determine patency. If the tube is not patent,
gastric pressure cannot decrease, and the steady or increasing pressure
can cause nausea.
Incorrect Answers:
B. Although oral hygiene is an appropriate comfort measure for a client who
is NPO, it will not eliminate the client's nausea.
C. Clamping the NG tube will likely worsen the client's nausea.
D. Increasing the suction can either be ineffective or increase the risk of
tissue injury.
59. A nurse is assessing a client who is 12 hr postoperative following
an open cholecystectomy. Which of the following findings should the
nurse report to the provider?
A. Hypoactive bowel sounds
B. Indwelling urinary catheter output of 25 mL/hr
C. Heart rate of 96/min
D. Serous drainage at the surgical incision site: B. Indwelling urinary
catheter output of 25 mL/hr
The nurse should report a urinary output of