NGN ATI PN Medical Surgical Online Practice A & B New Version Updated 2024-2025, Exams of Nursing

Download NGN ATI PN Medical Surgical Online Practice A & B New Version Updated 2024-2025 and more Exams Nursing in PDF only on Docsity! NGN ATI PN Medical Surgical Online Practice A & B New Version Updated 2024-2025 with All Questions and 100% Correct Answer A nurse is contributing to the plan of care for a client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? ------ --- Correct Answer ---------- Encourage weight-bearing exercises. r-Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis. A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? --------- Correct Answer ---------- Irregular borders A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ---------- Avoid stopping this medication suddenly. r-The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations. A nurse is reinforcing teaching with a client who is taking oxybutynin. The nurse should tell the client that the medication will have which of the following effects? a) Relaxes the muscles of the bladder b) Increases venous return to the heart c) Relaxes the muscles of the colon d) Increases tissue perfusion in the lungs --------- Correct Answer ---------- A. Relaxes the muscles of the bladder A nurse is reviewing the laboratory report of a client who has cancer and is experiencing anorexia. Which of the following laboratory values should indicate to the nurse that the client is experiencing malnutrition? a) Prealbumin 10.5 mg/dL b) Hematocrit 45% c) WBC count 6,000/mm3 d) BUN 15 mg/dL --------- Correct Answer ---------- A. Prealbumin 10.5 mg/dL A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls? a) Instructs the client to wear their own socks to the bathroom b) Keeps the client's bed in the low position c) Positions the bedside table close to the client d) Attaches the call light to the side rail of the client's bed --------- Correct Answer ---------- A. Instructs the client to wear their own socks to the bathroom A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement? a) Encourage the client to ambulate with a staff member. b) Isolate the client in their room. c) Apply bilateral wrist restraints to the client. d) Administer a prescribed oral dose of trazodone to the client. --------- Correct Answer -- -------- A. Encourage the client to ambulate with a staff member. A nurse is reinforcing teaching with a client who is to begin taking lansoprazole. Which of the following statements by the client indicates an understanding of the teaching? a) "I should chew the capsule thoroughly." b) "I should report episodes of diarrhea." c) "I should take the medication following a meal." d) "I should expect the medication to cause indigestion." --------- Correct Answer ---------- B. "I should report episodes of diarrhea." An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result? a) A client whose injection site has an elevated area measuring 15 mm (0.6 in) b) A client who injection site is scabbed c) A client whose injection site is firm and measures 3 mm (0.1 in) d) A client whose injection site is ecchymotic --------- Correct Answer ---------- A. A client whose injection site has an elevated area measuring 15 mm (0.6 in) A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take? a) Suction the client for 20 seconds with each pass. b) Apply suction pressure while inserting the catheter into the trachea. c) Sanitize around the stoma with povidone-iodine. d) Allow space for one finger to be placed under the tube ties. --------- Correct Answer --- ------- D. Allow space for one finger to be placed under the tube ties. The nurse should collect a sputum culture to identify the organism causing the client's infection. Antimicrobial sensitivities are obtained from the sputum culture to guide the provider in prescribing antibiotics. However, there is another prescription the nurse should implement first. The nurse should administer antibiotics to treat the infection. A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is suspected because it treats both gram-positive and gram-negative bacteria. After the results of the blood and sputum cultures are obtained, the provider will often change to a more specific antibiotic. However, there is another prescription the nurse should implement first. The nurse should obtain blood cultures to identify the organism causing the client's infection. Antimicrobial sensitivities obtained from the blood cultures will guide the provider in prescribing treatment. However, there is another prescription the nurse should implement first. A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? --------- Correct Answer -------- -- Stop the medication infusion. Rationale: The greatest risk to the client is injury from an allergic response to the medication. Therefore, the first action the nurse should take is to stop the medication infusion. -------------------- The nurse should notify the charge nurse about what has occurred. However, there is another action the nurse should take first. The nurse should administer a PRN dose of diphenhydramine to keep the allergic reaction from worsening. However, there is another action the nurse should take first. The nurse should follow facility policy when reporting an adverse reaction. However, there is another action the nurse should take first. A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After stopping the infusion, which of the following actions should the nurse take next? --- ------ Correct Answer ---------- Take the client's vital signs. Rationale: The first action the nurse should take when using the nursing process is to collect data from the client to determine what actions should be taken next. A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? --------- Correct Answer ---------- Creatinine 1.9 mg/dL Normal range is 0.7 to 1.3 Therefore the it's high and should be reported the the provider A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) --------- Correct Answer ---------- Ceftriaxone In exhibit 2 it says the patient is allergies: "penicillin reaction severe". A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? --------- Correct Answer ---------- Visitors must don a gown and gloves before entering client's room. ( This patient will be on a client on contact isolation precautions. Contact precautions requires visitors to put on a gown and gloves prior to entering the client's room to prevent MRSA from spreading) - Nurse should identify visitors of clients who are on airborne or droplet precautions should wear a mask within 3 feet of the client. -MRSA does not spread through the respiratory tract and does not need airborne or droplet precaution. -NO FRESH FLOWERS for patient on neutropenic precaution . A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? --------- Correct Answer ---------- Dysrhythmia RAT: When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia. A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? - -------- Correct Answer ---------- Keep a sheepskin pad between the client's extremity and the CPM machine. A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan? --------- Correct Answer ---------- Encourage abdominal breathing. r- the nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes. A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ---------- Avoid eating red meat for 3 days prior to the test. A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? --------- Correct Answer ---------- "You should have a pneumococcal immunizations every 10 years." A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an IN of 4. Available is phytonadione 10 mg/mL. How many ml should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) --------- Correct Answer ---------- 0.7 A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? --------- Correct Answer ---------- "I don't cross my legs anymore." RAT: Clients who have peripheral vascular disease should not cross their legs because it can impede circulation. A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? --------- Correct Answer ---------- Change the sheepskin liner weekly. Rationale: The nurse should provide instruction regarding the care and maintenance of the vest. The instruction should include changing the sheepskin liner either when soiled or at least once per week to prevent skin irritation. -------------------- The nurse should instruct the caregiver to clean the pin sites every day to decrease the risk for infection. The nurse should instruct the caregiver to never lift or reposition the client by pulling on the halo ring, which can cause further cervical injury. A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? --------- Correct Answer -------- -- Listen to soft music before sleeping. r- Listening to soft music can help the client to relax and reduces environmental stressors. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? --------- Correct Answer ---------- Keep the client in a side-lying position. RAT: The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity. A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? --------- Correct Answer ---------- Apply cold packs to the inamed joints. A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? --------- Correct Answer ---------- Determine the client's understanding of the procedure. r-When using the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should determine the client's understanding of the procedure to reinforce necessary teaching, which can help manage their anxiety. A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? --------- Correct Answer ---------- Dyspnea r-When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is dyspnea, which is a complication of the epidural infusion. Drag words from the choices below to fill in each blank in the following sentence. --------- Correct Answer ---------- Respiratory failure and hypovolemia A nurse is reinforcing teaching with an adolescent client regarding testicular self- examination. Which of the following statements by the client demonstrates an understanding of the teaching? --------- Correct Answer ---------- I understand that testicular cancer is painless. ( Clients should report a lump that is NOT painful bc testicular cancer is typically painless). - Perform a testicular self examination after a WARM shower - Perform testicular self exam MONTHLY - Clients should report pea- sized lump in the testes to the provider. A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? --------- Correct Answer ---------- Have a designated stethoscope in the client's room. Rationale: The nurse should designate equipment to leave in the client's room to avoid cross- contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room. A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? --------- Correct Answer -- -------- Minimize the time the head of the bed is elevated. r-The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area. A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? --------- Correct Answer ---------- The client stops the nurse and asks for pain medication. (Nurse should identify that a client who is in pain will not be able to concentrate which can interfere with his ability to learn.) -Nurse should identify that asking questions indicate active listening by the client and enhances learning. - Nurse should identify that clients learn . in different ways. Using multiple methods of teaching, including hands on practice and providing written materials enhances learning. - Nurse should identify that family members who are actively engaged in the teaching session and ask questions can enhance learning. A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? --------- Correct Answer ---------- Keep the skin dry and free of perspiration. RAT: The nurse should not leave moisture on the skin for prolonged periods of time because it can cause skin breakdown. A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) --------- Correct Answer ---------- Check the IV site. Stop the infusion. Withdraw the IV catheter. Elevate the affected arm. Notify the charge nurse. The nurse is reviewing the client's diagnostic results. Which of the following findings require follow up? Select all that apply. --------- Correct Answer ---------- PaCO2 WBC count Chest x-ray Oxygen saturation BUN The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. --------- Correct Answer ---------- • Client is short of breath and has a productive cough with yellow mucus • States, "I could barely breathe when I got up this morning and I had a throbbing headache" • Client is diaphoretic • Crackles heard in posterior lung A nurse is prioritizing care for the client. Complete the following sentence by using the lists of options. --------- Correct Answer --- ------- • At 1000, the nurse should first address the client's oxygen saturation , • followed by the client's heart rate The nurse is assisting with the plan of care for the client. For each potential provider prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. --------- Correct Answer -------- -- Cough and deep breathe every 2 hr is anticipated Obtain a sputum culture and sensitivity is anticipated Titrate oxygen to keep oxygen saturation greater than 90% is anticipated. Place client on a 1,500 mL fluid restriction is contraindicated Administer acetaminophen 500 mg PO every 6 hr PRN is anticipated. Administer famotidine 40 mg PO daily is nonessential. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention. --------- Correct Answer ---------- Temperature decreased sodium level to the provider before administering the medication because furosemide can cause hyponatremia. Which of the following actions should the nurse take? Select all that apply. --------- Correct Answer ---------- Instruct the client to splint their abdomen with a pillow when coughing plan to ambulate the client as soon as possible report the client's urinary output to the charge nurse monitor the client's pain level A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? --------- Correct Answer ---------- Mogs sx is a horizontal shaving of thin layers of the tumor A nurse is examining a client's IV site and notes a red line up their arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? --------- Correct Answer ---------- Thrombophlebitis Rationale: The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis. --------------------- swelling and cool skin at the IV site as indications of infiltration. swelling and bruising as indications of a hematoma that can develop by not holding enough pressure after discontinuing the IV. cramping at or above the insertion site and numbness as indications of venous spasms. A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? --------- Correct Answer ---------- Decreased shortness of breath. Rationale: The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion. ------------------ The nurse should expect the client's weight to decrease because of the increased excretion of fluid that is caused by improved cardiac output. The nurse should expect the client's heart rate to decrease because digoxin decreases the client's sympathetic nerve tone, which slows the heart rate. The nurse should expect the client to have an increase in urinary output because digoxin improves cardiac output and increases the client's renal blood flow through the kidneys, which results in an increased excretion of urine. A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? --------- Correct Answer ---------- Allow 30 min of rest before meals The nurse is collecting data on the client. For each client finding, click to specify if the finding is consistent with appendicitis, diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process. --------- Correct Answer ---------- • Blood in the stool - Diverticular disease & Crohn's disease • Pain in the right lower quadrant - appendicitis & Crohn's disease • Mucus in the stool - Crohn's disease • Nausea - appendicitis, diverticular disease, & Crohn's disease Complete the following sentence by using the lists of options. --------- Correct Answer --- ------- After reviewing the findings in the client's medical record, the nurse should first address the client's (1) abdominal distention, followed by the client's (2) acute pain Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. --- ------ Correct Answer ---------- Reduce the temperature in the clients room. Limit visitors Hyperthyroidism Increased temperature Weight daily The nurse is collecting data on the client. For each client finding, click to specify if the finding is consistent with appendicitis, diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process. --------- Correct Answer ---------- Blood in the stool - Diverticular disease Drag 1 condition and 1 client finding to fill in each blank in the following sentence. -------- - Correct Answer ---------- The nurse is caring for the client who has manifestations of peritonitis therefore, the priority finding for the nurse to report is laboratory values Peritonitis is correct. The client has manifestations of peritonitis, including rigid abdomen and elevated WBC count and ESR. Peritonitis is an inflammation and infection of the abdominal cavit that can occur when bacteria enter the peritoneum through a perforation in the bowel as a complication of Crohn's disease. Laboratory values is correct. The nurse should identify that the client's laboratory values is the priority to report when using the urgent vs. nonurgent priority framework. An elevated WBC count and a high neutrophil count indicates an infection, which is a manifestation of peritonitis. The nurse is contributing to the plan of care for the client who has peritonitis and Crohn's disease. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the client. --------- Correct Answer ---------- Obtain blood cultures - indicated obtain the client's vital signs every 15 min - indicated Administer a hypotonic IV solution - contraindicated insert a nasogastric tube - indicated The nurse is assisting with the care of the client who is preoperative for an exploratory laparotomy. Select the 4 actions the nurse should take. --------- Correct Answer ---------- Administer phenytoin with a sip of water on the day of surgery. Assist with the administration of gentamicin 100 mg IV. Assist with the administration of dextrose 5% in lactated Ringer's. Contact the wound, ostomy, and continence nurse. The nurse is reinforcing discharge teaching with the client. Which of the following client statements indicates an understanding of the teaching? Select all that apply. --------- Correct Answer ---------- • "I should schedule several rest periods throughout the day" • "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit". A nurse is caring for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? --- ------ Correct Answer ---------- Eat several, small-portioned meals daily. Clients who have difficulty eating because of pain or anorexia can usually tolerate small amounts of food at one time. Eating several small meals daily can increase the client's caloric intake. A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ---------- Increase fiber-rich foods. Rationale: The nurse should instruct the client to increase the amount of fiber-rich foods in their diet. Dried beans and brown rice are examples of fiber-rich foods. --------------- Instruct the client to increase their fluid intake to 2,000 mL/day to maintain soft stools. Insomnia is an adverse effect of methylphenidate. A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? --------- Correct Answer ---------- Combination oral contraceptives Rationale: The nurse should identify that combination oral contraceptives are contraindicated for this client because they increase estrogen levels, which can stimulate the growth of any remaining cancerous breast cells. --------------------------- The nurse should identify that the use of an intrauterine device requires the client to check the placement monthly and is not contraindicated for this client. The nurse should identify that the use of latex condoms is contraindicated for clients, or their partners, who are allergic to latex. However, it is not contraindicated for this client. The nurse should identify that prolonged use of a contraceptive sponge can increase the risk for toxic shock syndrome. However, it is not contraindicated for this client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. --- ------ Correct Answer ---------- Reduce the temperature in the clients room. Limit visitors Hyperthyroidism Increased temperature Weight daily A nurse is contributing to the plan of care for a client who has partial hearing loss. Which of the following interventions should the nurse include in the plan of care? --------- Correct Answer ---------- Face the client while speaking. r-The nurse should face the client, which allows the client to see who is speaking, read the nurse's lips, and obtain visual cues by observing facial expressions. A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? --------- Correct Answer ---------- Instruct the client to swish the medication in their mouth. A home health nurse is reinforcing teaching about preventing asthma attacks with a client who has asthma. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ---------- "Do not allow visitors to smoke cigarettes in your home." Rationale: The nurse should inform the client that cigarette smoke is a common allergen that can increase the risk for triggering an asthma attack. Therefore, the client should not allow anyone to smoke cigarettes in their home. -------------------------- The nurse should inform the client that carpet can hold mites and dust, which increases the risk for triggering an asthma attack. The nurse should inform the client that breathing cold air can cause bronchial constriction, which increases the risk for triggering an asthma attack. The nurse should inform the client that opening their windows during spring can increase their exposure to environmental allergens, which increases the risk for triggering an asthma attack. A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? --------- Correct Answer ---------- Administer an antiemetic to the client A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? --------- Correct Answer ---------- Hbg 11 g/dL A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? --------- Correct Answer ---------- "Consume foods low in sodium." A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? --------- Correct Answer ---------- "I will have my HbA1c checked twice per year." A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following foods should the nurse recommend? --------- Correct Answer ---------- Lemon juice RAT: The nurse should recommend that the client use lemon juice to flavor their food because it is low in sodium. A nurse is participating in a health fair for older adult clients. Which of the following vaccines should the nurse recommend for this age group? --------- Correct Answer ------- --- Herpes zoster The nurse should recommend the herpes zoster vaccine for adults who are 60 years of age and older. A nurse is reinforcing teaching with a client who is to begin using an insulin pump. Which of the following instructions should the nurse include? --------- Correct Answer ---- ------ "Use rapid-acting insulin in the infusion device." r-The nurse should instruct the client to use rapid-acting insulin with an insulin pump. A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for 2 days. Which of the following laboratory values should the nurse report to the provider? a) Potassium 4.0 mEq/L b) Lithium 0.9 mEq/L c) BUN 12 mg/dL d) Sodium 132 mEq/L --------- Correct Answer ---------- D. Sodium 132 mEq/L A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of the following actions should the nurse take? a) Cleanse the client's toothbrush with hydrogen peroxide. b) Instruct the client to use a disposable razor to shave. c) Decrease the client's protein intake. d) Encourage the client to eat unpasteurized dairy products. --------- Correct Answer ---------- A. Cleanse the client's toothbrush with hydrogen peroxide. A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first? a) Activate the fire alarm system. b) Use a fire extinguisher at the source of the smoke. c) Assist the client to a nearby common area. d) Close the doors to the room and to the bathroom. --------- Correct Answer ---------- C. Assist the client to a nearby common area. A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan? a) Apply foam handles to the client's eating utensils. b) Obtain a referral for physical therapy. c) Have an assistive personnel feed the client. b) Apply a motion sensor mat to the client's bed. c) Leave the television on in the client's room. d) Move the overbed table away from the bed. --------- Correct Answer ---------- B. Apply a motion sensor mat to the client's bed. A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of the following foods should the nurse encourage the client to eat? a) Cheese b) Pears c) Yogurt d) Eggs --------- Correct Answer ---------- B. Pears A nurse is reviewing the medical record of a client who reports his urine is red-orange. The nurse should identify which of the following medications can cause this adverse effect? a) Isoniazid b) Metoprolol c) Furosemide d) Rifampin --------- Correct Answer ---------- D. Rifampin A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse? a) "Encourage your partner to wake up to interact with family members." b) "Sitting quietly near the bedside can provide comfort and support." c) "I will call the provider to discuss your concerns." d) "I can ask the provider to prescribe a medication that will minimize drowsiness." ------- -- Correct Answer ---------- B. "Sitting quietly near the bedside can provide comfort and support." A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include? a) Drink fluids through a straw. b) Plan to shampoo hair in 1 week. c) Resume exercising in 10 days. d) Close mouth when sneezing. --------- Correct Answer ---------- B. Plan to shampoo hair in 1 week. A nurse is reinforcing discharge teaching about dietary changes with a client who has a new colostomy. Which of the following foods should the nurse recommend? a) Asparagus b) Bananas c) Grapes d) Broccoli --------- Correct Answer ---------- B. Bananas A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory results should the nurse report to the provider? a) Glycosylated hemoglobin 5.2% b) Urine positive for ketones c) Urine negative for bilirubin d) Fasting blood glucose 70 mg/dL --------- Correct Answer ---------- b. Urine positive for ketones A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider? a) Urinary output of 1,000 mL in 12 hr b) Potassium level 4.5 mEq/L c) PaCO2 55 mm Hg d) Chest x-ray showing cardiomegaly --------- Correct Answer ---------- C. PaCO2 55 mm Hg A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left food for 20 min." Which of the following actions should the nurse take? a) Complete Semmes-Weinstein monofilament testing following treatment. b) Apply the heating pad as prescribed by the provider. c) Clarify the prescription with the provider. d) Observe the skin 10 min after the start of treatment. --------- Correct Answer ---------- C. Clarify the prescription with the provider A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicates an understanding of the teaching? a) "I should clean around the stoma with moisturizing soap." b) "I should avoid broccoli and chewing gum." c) "I should decrease the amount of fresh fruit in my diet." d) "I should place an aspirin in the pouch to eliminate odor." --------- Correct Answer ---------- B. "I should avoid broccoli and chewing gum." A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image? a) Denies feelings of sadness about the ostomy b) Prefers not to look at the stoma site c) Accepts that seual activity will decrease d) Participates in performing ostomy care --------- Correct Answer ---------- D. Participates in performing ostomy care A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider? a) Ammonia 55 mcg/dL b) Bilirubin 1.0 mg/dL c) Platelets 60,000/mm3 d) Aspartate aminotransferase 34 units/L --------- Correct Answer ---------- C. Platelets 60,000/mm3 A nurse is assisting with the plan of care for a client who requires contact precautions. Which of the following interventions should the nurse include in the plan? a) Keep a stethoscope at the client's bedside for the duration of her hospital stay. b) Wear an N95 mask when entering the room. c) Use an alcohol swab to clean the temperature probe before removing it from the room. d) Remove personal protective equipment immediately after leaving the client's room. --------- Correct Answer ---------- A. Keep a stethoscope at the client's bedside for the duration of her hospital stay. A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take? a) Request a dosage increase of the apical heart rate is less than 60/min. b) Administer the medication with an antacid. c) Instruct the client to expect increased hair growth. d) Withhold the medication if the systolic blood pressure is less than 90 mm Hg. --------- Correct Answer ---------- D. Withhold the medication if the systolic blood pressure is less than 90 mm Hg. A nurse is reinforcing teaching about dietary modifications to help control blood pressure with a client who has hypertension. Which of the following food choices by the client indicates an understanding of the teaching? a) A ham sandwich on rye bread b) Broiled cod with broccoli c) Beef bouillon with crackers d) Pork sausage with sauteed peppers --------- Correct Answer ---------- B. Broiled cod with broccoli b) Hypotension c) Abdominal pain d) Arthralgia --------- Correct Answer ---------- C. Abdominal pain A nurse is collecting data from a client who began taking captopril 2 days ago. Which of the following findings should the nurse report to the provider immediately? a) Lip swelling b) Dizziness c) Joint aches d) Metallic taste --------- Correct Answer ---------- A. Lip swelling A nurse is caring for a client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take when assisting the client with feeding? a) Offer the client sticky foods such as peanut butter. b) Instruct the client to place their chin to their chest when swallowing. c) Place food on the affected side of the client's mouth. d) Position the client upright for 5 min after eating. --------- Correct Answer ---------- B. Instruct the client to place their chin to their chest when swallowing. A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter (PICC) line. Which of the following statements by the client indicates an understanding of the teaching? a) "I will wear an arm immobilizer to prevent dislodgement of this device." b) "I will monitor my temperature for fever while I have this device." c) "It's okay to get the device wet when I shower." d) "I should pull the dressing away from the insertion site when I change it." --------- Correct Answer ---------- B. "I will monitor my temperature for fever while I have this device." A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take? a) Replace the unit when the drainage chamber is full. b) Clamp the tube for 30 min every 8 hr. c) Pin the tubing to the client's bed sheets. d) Monitor for at least 150 mL of drainage every hour. --------- Correct Answer ---------- D. Monitor for at least 150 mL of drainage every hour. A nurse is collecting data from a client who is 2 days postoperative following a colon restriction. Which of the following indicates the need for nursing intervention? a) Mild abdominal pain when coughing 30 min after receiving pain medication b) Dark brown drainage in the NG tube c) Serosanguineous drainage on the wounddressing d) Oxygen saturation 95% --------- Correct Answer ---------- B. Dark brown drainage in the NG tube A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take? a) Provide the client with a small-handled adaptive utensil. b) Arrange for an assistive personnel to feed the client. c) Describe the food placement as though the plate were a clock. d) Discourage conversations during the client's mealtime. --------- Correct Answer ---------- C. Describe the food placement as though the plate were a clock. A nurse is reinforcing teaching with a client who is starting to take metformin extended release. Which of the following instructions should the nurse include in the instructions? a) Monitor blood glucose while taking this medication. b) Chew the medication before swallowing. c) Expect muscle pain while taking this medication. d) Take the medication with breakfast. --------- Correct Answer ---------- A. Monitor blood glucose while taking this medication. A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care? a) Advise the client about increased dry mouth. b) Check the client for increased hypopigmentation under the patch. c) Monitor the client for weight loss. d) Inform the client of the adverse effect of diarrhea. --------- Correct Answer ---------- B. Check the client for increased hypopigmentation under the patch. A nurse is receiving a change-of-shift report about the care of four clients. Which of the following clients should the nurse see first? a) A client who displays increased confusion over the past 4 hr b) A client who has a blood glucose level of 128 mg/dL c) A client who has a blood pressure of 138/88 mm Hg d) A client who reports a pain level of 4 on a scale of 0 to 10 --------- Correct Answer ---------- A. A client who displays increased confusion over the past 4 hr A nurse is assisting care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the following is the priority nursing action? a) Determine palpable pulse. b) Begin chest compressions. c) Perform immediate defibrillation. d) Provide pulmonary ventilation. --------- Correct Answer ---------- A. Determine palpable pulse. A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure? a) Tingling of the fingers b) Report of sore throat c) Serosanguineous drainage on the dressing d) Soreness at the incision site --------- Correct Answer ---------- A. Tingling of the fingers A nurse is reinforcing discharge teaching with a client who had an excisional biopsy of the left breast. Which of the following instructions should the nurse include? a) Refrain from wearing a bra for 10 days after surgery. b) Apply an ice pack to the incision site to treat discomfort. c) Expect numbness to last for up to 4 months. d) Use bandages to absorb bleeding at the incision site. --------- Correct Answer ---------- B. Apply an ice pack to the incision site to treat discomfort. A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect? a) Peripheral edema b) Decreased respirations c) Absent bowel sounds d) Polyuria --------- Correct Answer ---------- C. Absent bowel sounds A nurse is reinforcing teaching with a client about menopause. Which of the following statements by the client indicates an understanding of the teaching? a) "I will need hormone replacement therapy for the rest of my life." b) "I should expect to have an increased risk for breast cancer." c) "The use of black cohosh will decrease vaginal bleeding." d) "I should use a vaginal douche to prevent hypertension. Which of the following findings should the nurse identify as a contraindication to administering the medication? a) 2+ pedal edema b) Potassium 2.8 mEq/L c) Allergy to shellfish d) History of GERD --------- Correct Answer ---------- B. Potassium 2.8 mEq/L A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. Which of the following actions should the nurse take? a) Request a prescription for IV fluids. b) Ask the client's health care surrogate for permission to withhold nourishment. c) Provide regular oral care for the client with a moist swab. d) Explain the importance of oral hydration to the chest. --------- Correct Answer ---------- C. Provide regular oral care for the client with a moist swab. A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. Which of the following actions should the nurse take? a) Request a prescription for IV fluids. b) Ask the client's health care surrogate for permission to withhold nourishment. c) Provide regular oral care for the client with a moist swab. d) Explain the importance of oral hydration to the chest. --------- Correct Answer ---------- c) Provide regular oral care for the client with a moist swab. A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications? a) Check the client's blood pressure while the client lies supine, sits, and stands. b) Palpate the client's brachial pulses and compare bilaterally. c) Check for jugular vein distention while the client is supine. d) Palpate the client's pedal pulses and compare bilaterally. --------- Correct Answer ---------- D. Palpate the client's pedal pulses and compare bilaterally. A nurse is reinforcing teaching about food care with a client who has diabetes mellitus. Which of the following client statements indicates understanding of the teaching? a) "I should put lotion between my toes every day to prevent dryness and cracking." b) "I should apply a heating pad to my feet every night to help with circulation." c) "I should use my wrist to test the temperature of the water before bathing." d) "I should round the corners of my toenails with a nail file to prevent ingrown nails." --------- Correct Answer ---------- C. "I should use my wrist to test the temperature of the water before bathing." A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care? a) Dietitian b) Herbalist c) Occupational therapist d) Social worker --------- Correct Answer ---------- C. Occupational Therapist A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately? a) Difficulty speaking b) A change in pupil size c) Right-sided weakness d) Inability to follow direction --------- Correct Answer ---------- B. A change in pupil size A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take? a) Use safety pins to secure the pad in place. b) Fill the pad with sterile water. c) Apply the pad for 45 min at a time. d) Cover the pad prior to use. --------- Correct Answer ---------- D. Cover the pad prior to use. A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching? (Select all that apply.) a) High-fiber diet b) Physical inactivity c) History of diabetes mellitus d) Family history of colorectal cancer e) Age over 50 years --------- Correct Answer ---------- B. Physical inactivity D. Family history of colorectal cancer E. Age over 50 years A nurse is caring for an older adult client who has stomatitis due to poorly fitting dentures. Which of the following actions should the nurse take? a) Rinse the client's mouth twice daily with an alcohol-based mouthwash. b) Increase the client's fluid intake to 2,000 mL daily. c) Offer the client hot beverages to drink. d) Provide the client with a high-protein diet. --------- Correct Answer ---------- A. Rinse the client's mouth twice daily with an alcohol-based mouthwash. A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take? a) Loosen the ropes of the pulleys when repositioning the client in bed. b) Inspect the client's skin every 12 hr for signs of breakdown. c) Ensure the weights hang freely from the client's bed. d) Maintain 6.8 kg (15 lb) of weight for the client's skin traction. --------- Correct Answer ---------- C. Ensure the weights hang freely from the client's bed. A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection? a) WBC count 9,000/mm3 b) Changed mental status c) Temperature 37.3C (99.1F) d) Diminished reflexes --------- Correct Answer ---------- B. Changed mental status A nurse is preparing to assist with the administration of peritoneal dialysis to a client. In which order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) a) Record the client's vital signs. b) Measure the client's abdominal girth. c) Prime the client's catheter tubing with dialysate solution. d) Infuse dialysate solution into the client's peritoneal cavity. e) Open the client's drainage tubing after 10 min of dwell time. --------- Correct Answer ---------- A. Record the client's vital signs. B. Measure the client's abdominal girth. C. Prime the client's catheter tubing with dialysate solution. D. Infuse dialysate solution into the client's peritoneal cavity. received an opioid analgesic 1 hr ago and now reports a pain level of 2 on a scale of 0 to 10. Which of the following actions should the nurse take? a) Reposition the client. b) Administer an additional dose of pain medication. c) Maintain the client on bed rest. d) Apply a warm, moist compress to the incision area. --------- Correct Answer ---------- A. Reposition the client. A nurse is reinforcing teaching about immunizations with no older adult client. Which of the following instructions should the nurse include? a) "You should receive the live, attenuated influenza vaccine every other year." b) "You should receive the hepatitis A vaccine every 10 years." c) "You should receive the human papillomavirus vaccine." d) "You should receive one dose of the pneumococcal vaccine." --------- Correct Answer ---------- D. "You should receive one dose of the pneumococcal vaccine." A nurse is monitoring a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication that the client should receive diphenhydramine? a) Pulmonary congestion b) Urticaria c) Vomiting d) Jugular vein distention --------- Correct Answer ---------- B. Urticaria A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take? a) Apply restraints to the client. b) Insert a tongue blade into the client's mouth. c) Administer an IV bolus of lorazepam. d) Place the client in the prone position. --------- Correct Answer ---------- c) Administer an IV bolus of lorazepam A nurse is prioritizing care for four clients following a change-of-shift report. Which of the following clients should the nurse attend to first? a) A client who has diverticulitis and a temperature of 38.3C (100.9F) b) A client who has a prescription for a sputum specimen to be obtained before breakfast c) A client who sustained a head injury 2 days ago and has a decreased level of consciousness d) A client who has Alzheimer's disease and requires assistance to the bathroom --------- Correct Answer ---------- C. A client who sustained a head injury 2 days ago and has a decreased level of consciousness A nurse is reviewing the results for a client's facial occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result? a) The client consumed citrus juice 3 days before the test. b) The client has a history of breast cancer. c) The client takes ibuprofen for headaches. d) The client had a hemorrhoidectomy 1 year ago. --------- Correct Answer ---------- C. The client takes ibuprofen for headaches. A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching? a) "I will suction the mouth before inserting the suction catheter into the tracheostomy." b) "I will suction for less than 15 seconds while inserting the suction catheter." c) "I will set the suction pressure dial between 80 and 120." d) "I will wrap the suction catheters in a clean towel to be used again at a later time." ---- ----- Correct Answer ---------- C. "I will set the suction pressure dial between 80 and 120." A nurse is caring for a client who has Parkinson's disease. The client displays difficulty using utensils while eating at mealtime. For which of the following interdisciplinary team members should the nurse recommend a referral? a) Recreational therapist b) Occupational therapist c) Physical therapist d) Speech therapist --------- Correct Answer ---------- B. Occupational therapist A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) --------- Correct Answer ---------- 10 mL A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion? a) Hypertension b) Vomiting c) Distended neck veins d) Polyuria --------- Correct Answer ---------- B. Vomiting A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? a) Leave the television on. b) Install locks at the top of doors. c) Schedule alternate caregivers. d) Place throw rugs on the floor. --------- Correct Answer ---------- B. Install locks at top of doors. A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching? a) Avoid direct contact. b) Administer a broad-spectrum antibiotic. c) Place an airborne precautions. d) Isolate for 24 hr after lesions appear. --------- Correct Answer ---------- A. Avoid direct contact