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TCIS PRACTICE TEST 2026 FULL SOLUTION VIEW
AHEAD
▶ The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first? a. assess for a blood return b. notify the physician c. document the finding d. stop the IV infusion. Answer: D Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein. ▶ A nurse is caring for an older adult client who lives alone. Which economic situation presents the most serious problem for this client? a. costs of creating a living will b. stock market fluctuations c. increased provider benefits d. social security as the basis of income. Answer: D Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic needs ▶ Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system wide. b. decreased tumor growth and longevity c. large tidal volumes and decreased lung capacity d. decreased carbohydrate, protein, and fat destruction. Answer: A
Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with pain or stress response. ▶ Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion? a. increasing the IV flow rate to 250 mL/hr b. applying oxygen by mask or nasal cannula c. placing the client in a high Fowler's position d. Measuring intake and output every four hours. Answer: A Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema. ▶ Which client is at greatest risk for dehydration? a. younger adult client on bedrest b. older adult client receiving hypotonic IV fluid c. older adult client with cognitive impairment d. younger adult client receiving hypertonic IV fluid. Answer: C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is
lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration. ▶ The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority? a. assess the client's respiratory rate, rhythm, and depth b. document findings and monitor the client c. measure the client's pulse and blood pressure d. call the health care provider. Answer: A In a client with hypokkalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life- threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement. ▶ The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you have Lasix 40 mg. How many tablets will you give the patient? a. 3 b. 1 c. 1 1/ d. 2 1/5. Answer: C 60/40 (desired/have) ▶ A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? a. a grilled cheese sandwich with tomato soup b. Chinese take-out, including steamed rice c. a chicken leg, one slice of bread with butter, and steamed carrots d. slices of ham and cheese on whole grain crackers. Answer: C Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments.
Foods lowest in sodium include fish, poultry, and fresh produce. The chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food - a category of foods often high in sodium. ▶ When a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain? a. inability to concentrate b. expressed hopelessness c. psychosocial withdrawal d. anger and hostility. Answer: A The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much more with acute pain, before any physiologic or behavioral adaptation has occurred. ▶ A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? A) Has had diabetes mellitus for 12 years B) Had abdominal surgery and has a nasogastric tube C) Just received 3 units of packed red blood cells D) Uses sodium-containing antacids frequently. Answer: C Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid. ▶ The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel? A) Assess level of consciousness. B) Evaluate the pulse oximetry reading. C) Assist the client with meals.
▶ An older adult client is in physical restraints. Which intervention by the nurse is the priority? A) Assess the client hourly while keeping the restraints in place. B) Assess the client once each shift, releasing the restraints for feeding. C) Assess the client twice each shift while keeping the restraints in place. D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.. Answer: D The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints. ▶ The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? A) Administer blood pressure medication. B) Administer a drug to lower the heart rate. C) Continue to assess for possible causes of elevated vital signs. D) Assess whether the client needs anti-arthritis medication.. Answer: C Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out. ▶ The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely not to be treated adequately for this problem? A) Middle-aged woman with a fractured arm B) Client with expressive aphasia
C) Younger adult with metastatic cancer D) Client who has undergone an appendectomy. Answer: B Populations at highest risk for inadequate pain treatment include older adults, minorities, and those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting. ▶ Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting? A) Cutaneous skin stimulation B) Imagery C) Radiofrequency ablation D) Hypnosis. Answer: B Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for imagery include being able to listen to music or other auditory stimuli. ▶ What interrelated constructs facilitate a nurse to become culturally competent? A) Cultural desire, self-awareness, cultural knowledge, and cultural skill B) Cultural desire, self-awareness, cultural knowledge, and cultural diversity C) Cultural desire, self-awareness, cultural knowledge, and cultural identity D) Cultural diversity, self-awareness, cultural skill, and cultural knowledge. Answer: A The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.
▶ A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia? A) Client taking digoxin (Lanoxin) B) Client who is NPO receiving intravenous D5W C) Client taking ibuprofen (Motrin) D) Client taking a sulfonamide antibiotic. Answer: B D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia. ▶ The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take? A) Assist with intubation. B) Monitor pain level. C) Administer oxygen. D) Administer naloxone (Narcan).. Answer: D A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms. ▶ Which action does the nurse teach a client to reduce the risk for dehydration? A) Avoiding the use of glycerin suppositories to manage constipation B) Maintaining a daily oral intake approximately equal to daily fluid loss C) Restricting sodium intake to no greater than 4 g/day D) Maintaining an oral intake of at least 1500 mL/day. Answer: B
Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation. ▶ A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition? A) 2.9 mEq/L B) 5.0 mEq/L C) 6.0 mEq/L D) 3.8 mEq/L. Answer: A Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations. ▶ The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n) A) rectal thermometer. B) tympanic membrane sensor. C) temporal thermometer scan. D) oral thermometer.. Answer: A The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment. ▶ A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which intervention will the nurse prepare for this client FIRST? A) Continuous arteriovenous rewarming
maintained on bedrest without adequate indication. Although family members are encouraged to visit, their presence around the clock is not necessary at this point. ▶ The nurse is caring for four clients. Which client assessment is the most indicative of having pain? A) Client stating that he is "anxious" B) Heart rate of 105 beats/min and restlessness C) Blood pressure 150/70 mm Hg and sleeping D) Postoperative client with a neck incision. Answer: B At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative. ▶ The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care? A) Prescribe aspirin for a client who presents with an acute myocardial infarction B) Insert a central line to give intravenous fluid to a dehydrated client. C) Use sterile technique when changing dressings on a new surgical site. D) Intubate a client whose oxygen saturation is 92%.. Answer: C The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician. ▶ Which is most indicative of pain in an older client who is confused? (Select all that apply). A) Screaming B) Decreased blood pressure C) Crying D) Decreased respirations
E) Facial grimace F) Restlessness. Answer: A,C,E,F No one scale has been found to be the best tool to use in pain assessment for adults with cognitive impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations. ▶ The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is: A) large for gestational age. B) well nourished. C) born at term. D) low birth weight.. Answer: D Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk. ▶ The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability? A) Healthy individual, college educated, travels frequently, can balance a checkbook B) Healthy individual, works out, reads well, cooks and cleans house C) Healthy individual, volunteers at church, works part time, takes care of family and house D) Healthy individual, works outside the home, uses a cane, well groomed. Answer: C Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.
▶ An emergency department (ED) nurse gives report on a client who is being transferred to the medical-surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact a sitter and behavioral health. This statement represents which part of the SBAR hand- off? A) Situation B) Recommendation C) Background D) Assessment. Answer: B The ED nurse is giving recommendations to the medical-surgical floor nurse about interventions to start for the client who is being transferred. No communication is provided in the SBAR report about the situation, background, or assessment. ▶ Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of: A) mixed pain syndrome. B) chronic pain. C) neuropathic pain. D) nociceptive pain.. Answer: D Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain. ▶ The new nurse is caring for a client with a high temperature. Which action should the nurse perform FIRST?
A) Obtaining a fan from central supply for the client's room B) Monitoring the client's temperature more often than ordered C) Sponging the client while monitoring for shivering D) Apply cool packs to the client's axillae and groin. Answer: D The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse pathogens. The other actions are appropriate. ▶ A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? A) The patient will demonstrate coping skills needed to manage hypertension. B) The patient will verbalize the side effects of treatment. C) The patient will select the type of learning materials they prefer. D) The patient will verbalize an understanding of the importance of following the regimen.. Answer: C Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient. ▶ When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of the family. A) development. B) function. C) structure. D) political views.. Answer: D An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure.
administration is appropriate in this situation of near pulmonary edema from ECV excess. ▶ The priority nursing intervention for a patient suspected to be hypothermic would be to: A) hydrate with intravenous (IV) fluids. B) remove wet clothes. C) assess vital signs. D) provide a warm blanket.. Answer: B The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy. ▶ The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates: A) slow capillary refill. B) red, sweaty skin. C) low pulse rate. D) decreased respirations.. Answer: B With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill. ▶ Why does the nurse always ask the client his or her pain level after taking routine vital signs? A) To follow McCaffery's guidelines on pain management B) To ensure that pain assessment occurs on a regular basis C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate. Answer: B Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management. ▶ The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? A) Examine dependent body areas. B) Notify the physician. C) Document the finding and continue to monitor. D) Assess turgor on the client's forehead.. Answer: D Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician. ▶ The nurse is assessing a client who has undergone a transurethral resection of the prostate (TURP). Which assessment finding requires immediate action by the nurse? A) Having the urge to void continuously while the catheter is inserted B) Passing small blood clots after catheter removal C) Having bright red drainage with multiple blood clots D) Experiencing urinary frequency after catheter removal. Answer: C A client who undergoes a TURP is at risk for bleeding during the first 24 hours after surgery. Passage of small blood clots and tissue debris, urinary frequency and leakage, and the urge to void continuously while the client still has the catheter inserted are all considered to be expected complications of the procedure. They will resolve as the client continues to recover and the catheter is removed. However, the presence of bright red blood with clots indicates arterial bleeding and should be reported to the provider.
