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HESI RN MEDICAL SURGICAL EXAM
PACK 2024/2025 QUESTIONS AND
ANSWERS

1
...
When she attempts to talk, she slurs her speech and
appears very frightened
...
A carotid bruit
B
...
hyperreflexic deep tendon relexes
...
Decreased bowel sounds - CORRECT ANSWER A) A carotid bruit
...
Rationale: the carotid artery (artery to the brain) is narrowed in clients with a
brain attack
...
Usually the blood pressure is hypertensive
...

Bowel sounds are not indicative of a brain attack
...
Which clinical manifestation further supports an assessment of a left-sided brain
attack?
A) Visual field deficit on the left side
...

C) Paresthesia of the left side
...

D) Global aphasia
...

Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as
well as difficulty reading and writing
...
Aphasia
may occur secondary to any brain injury involving the left hemisphere
...

4
...

C) Premedicate the client to decrease pain prior to having the procedure
...
- CORRECT
ANSWER B) Explain that the client will not be able to move her head throughout the
CT scan
...
Allergies to iodine is important if contrast dye is being used
for the CT scan
...
Providing

an explanation of relaxation exercises prior to the procedure is a worthwhile intervention
to decrease anxiety but is not of highest priority
...
A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT
for a patient
...

B) Allergy to shell fish
...

D) History of atrial fibrillation
...

The magnetic field generated by the MRI is so strong that metal-containing items are
strongly attracted to the magnet
...
Elevated blood pressure, an allergy to shell fish,
and a history of atrial fibrillation would not affect the MRI
...
A client's daughter is sitting by her mother's bedside who was recently
transferred to the Intermediate Care Unit
...
The healthcare provider told me my mother is in serious condition
and they are going to run several tests
...
What
happened to my mother?" What is the best response by the nurse?
A) "I am sorry, but according to the Health Insurance Portability and Accounting Act
(HIPAA), I cannot give you any information
...
"
C) "How do you feel about what the healthcare provider said?"
D) "I will call the healthcare provider so he/she can talk to you about your mother's
serious condition
...
"
Rationale: The nurse can discuss what a diagnosis means
...
The nurse has the knowledge, and the responsibility, to explain
Nancy's condition to Gail
...

What is the normal range for cardiac output? - CORRECT ANSWER The normal
range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8
L/min
...
A client was admitted with the diagnosis of a brain attack
...
Why would this client not be a candidate for for
thrombolytic therapy? - CORRECT ANSWER Thrombolytic therapy is
contraindicated in clients with symptom onset longer than 3 hours prior to

admission
...
Using plate guards and other assistive devices will encourage
independence in a client with a self-care deficit
...
Which condition is considered a non-modifiable risk factor for a brain attack?
A) High cholesterol levels
...

C) History of atrial fibrillation
...
- CORRECT ANSWER D) Advanced age
...
Nonmodifiable means the client cannot do anything to change the risk factor
...

9
...

Which nursing intervention would the nurse implement to address this condition?
A) Turn Nancy every two hours and perform active range of motion exercises
...

C) Speak slowly and clearly to assist Nancy in forming sounds to words
...
- CORRECT ANSWER B) Place the objects Nancy needs for activities of daily
living on the left side of the table
...
This results in the client neglecting that side of the body, so it is
beneficial to place objects on that side
...
Speaking slowly and clearly would address the client's verbal
deficits due to aphasia
...

Turning the client every 2 hours and performing active range of motion exercises would
address the client's risk for immobility due to paralysis
...
A physical therapist (PT) places a gait belt on a client and is assisting them with
ambulation from the bed to the chair
...
The PT carefully allows them to fall back to the bed
and notifies the primary nurse
...

B) PT reported client complained of dizziness when getting out of bed, and gait belt was
used to allow client to fall back onto the bed
...

D) Client had difficulty ambulating from the bed to the chair when accompanied by the
PT, variance report completed
...

Rationale: This documentation provides the factual data of the events that occurred
...
C) Not all the pertinent facts are included in this documentation
...

11
...
30; PCO2, 60 mm Hg; PO2, 80 mm Hg;
bicarbonate, 24 mEq/L; and O2 saturation, 96%
...

B) Administer oxygen by nasal cannula
...

D) Inform the charge nurse that no changes in therapy are needed
...

Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest
expansion secondary to anesthesia
...
O2 is not indicated because Po2 and oxygen saturation are within the
normal range
...
Post anesthesia, the client will need interventions as described in A above or
may progress to a state of somnolence and unresponsiveness
...
The nurse is providing dietary instructions to a 68-year-old client who is at high
risk for development of coronary heart disease (CHD)
...

C) Decrease plant stanols and sterols to less than 2 grams/day
...
- CORRECT ANSWER
B) Increase intake of soluble fiber to 10 to 25 grams per day
...
Cholesterol
intake (A) should be limited to 180 mg/day or less
...
Saturated fat (D) intake should be limited to 7% of total
daily calories
...
A splint is prescribed for nighttime use by a client with rheumatoid arthritis
...

B) Avoidance of joint trauma
...

D) Improvement in joint strength
...

Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent
deformities (A) caused by muscle spasms and contractures
...

(C) is usually treated with medications, particularly those classified as non-steroidal
antiinflammatory drugs (NSAIDs)
...

14
...
Which
additional history should the nurse obtain that is consistent with the client's
complaints?
A) Frequent urinary tract infections
...

C) Premenstrual syndrome
...
- CORRECT ANSWER B) Inability to get pregnant
...
A history of infertility (B) is another
common finding associated with endometriosis
...

15
...
Which finding should the nurse conclude as an early symptom
of renal insufficiency?
A) Dyspnea
...

C) Confusion
...
- CORRECT ANSWER B) Nocturia
...
In the early stage of renal
insufficiency, polyuria results from the inability of the kidneys to concentrate urine and
contribute to nocturia (B)
...

16
...
In determining the possible cause of the
bradycardia, the nurse assesses the client's medication record
...

B) Captopril (Capoten)
...

D) Dobutamine (Dobutrex)
...

Rationale: Inderal (A) is a beta adrenergic blocking agent, which causes decreased
heart rate and decreased contractility
...
(D) is a sympathomimetic, direct acting cardiac stimulant,
which would increase the heart rate
...
A client has been taking oral corticosteroids for the past five days because of
seasonal allergies
...

B) Serum glucose of 115 mg/dl
...

D) Excessive hunger
...

Rationale: Steroids cause immunosuppression, and a purulent sputum (C) is an
indication of infection, so this symptom is of greatest concern
...
(B) may remain normal, borderline, or increase while
taking oral steroids
...
A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture
reports to the nurse that she feels substernal tightness and pressure across her
chest
...

B) Nasogastric lavage with cool saline
...

D) Prepare for endotracheal intubation
...

Rationale: Vasopressin is used to promote vasoconstriction, thereby reducing bleeding
...
(B) will not

resolve the cardiac problem
...
Endotracheal intubation may
be needed if respiratory distress occurs (D)
...
A client with gastroesophageal reflux disease (GERD) has been experiencing
severe reflux during sleep
...

B) Decreasing caffeine intake
...

D) Raising the head of the bed on blocks
...

20
...
(A, B and C) may be effective recommendations but raising the head of
the bed is more effective for relief during sleep
...

B) Dependent edema, fever
...

D) Hypernatremia, tachypnea
...

Rationale: SIADH occurs when the posterior pituitary gland releases too much ADH,
causing water retention, a urine output of less than 20 ml/hour, and dilutional
hyponatremia
...
(B) is not associated with
SIADH
...
The increase in plasma volume causes an
increase in the glomerular filtration rate that inhibits the release of rennin and
aldosterone, which results in an increased sodium loss in urine, leading to greater
hyponatremia, not (D)
...
The nurse is planning care for a client with newly diagnosed diabetes mellitus
that requires insulin
...

B) Intelligence and developmental level
of the client
...


D) Financial resources available for the equipment
...

Rationale: If a client is incapable or does not want to learn, it is unlikely that learning will
occur, so motivation is the first factor the nurse should assess before teaching (C)
...
(B and D) are factors to consider, but not as
vital as (C)
...
The nurse is caring for a client who has taken a large quantity of furosemide
(Lasix) to promote weight loss
...
31 - CORRECT ANSWER B) HCO3 of 34 mEq/L
Rationale: Diuretics (non-potassium sparing) cause metabolic alkalosis
...
C) PCO2 of 56 mm Hg: CO2 retention results from hypoventilation,
which is not consistent with diuretic use
...
31: This pH is acidotic; diuretics
promote metabolic alkalosis
...
The nurse is preparing a teaching plan for a client who is newly diagnosed with
Type 1 diabetes mellitus
...

B) Polyuria, polydipsia, polyphagia
...

D) Fruity breath, tachypnea, chest pain
...

Rationale: Sweating, dizziness, and trembling are signs of hypoglycemic reactions
related to the release of epinephrine as a compensatory response to the low blood
sugar (A)
...

Which reaction should the nurse identify in a client who is responding to stimulation of
the sympathetic nervous system?
A) Pupil constriction
...

C) Bronchial constriction
...
- CORRECT ANSWER B) Increased heart rate
...
(A, C, and D) are responses of the
parasympathetic nervous system
...
Which client should the nurse recognize as most likely to experience sleep
apnea?
A) Middle-aged female who takes a diuretic nightly
...

C) Adolescent female with a history of tonsillectomy
...
- CORRECT ANSWER
B) Obese older male client with a short, thick neck
...
With
obstructive sleep apnea, the client is often obese or has a short, thick neck as in (B)
...

25
...
A) Blood glucose levels must be checked
several times a day
...
C) Eating regularly is a way to achieve acid-base balance but is not the
goal itself
...
After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to
draw blood samples to determine peak and trough levels
...

B) One hour before and one hour after the next dose
...

D) 30 minutes before and 30 minutes after the next dose
...


Rationale: Peak drug serum levels are achieved 30 minutes after IV administration of
aminoglycosides
...
(A, B, and D) are not as good a time to draw the trough as (C)
...

27
...
The nurse provides oxygen and anticipates which of these physician
orders?
A) Administration of IV sodium bicarbonate
B) Computed tomography (CT) of the chest, stat
C) Intubation and mechanical ventilation
D) Administration of concentrated potassium chloride solution - CORRECT ANSWER
C) Intubation and mechanical ventilation
Rationale: Support with mechanical ventilation may be needed for clients who cannot
keep their oxygen saturation at 90% or who have respiratory muscle fatigue
...
B)
Although the underlying reason for this client's hypoxemia may eventually require a
diagnostic study, the priority is to restore oxygenation
...
Signs of hypoxemia and work of breathing are present,
requiring correction with intubation and mechanical ventilation
...
A male client receives a local anesthetic during surgery
...
Which
action should the nurse take?
A) Determine the client is anxious and allow him to sleep
...

C) Review the client's pre-operative history for alcohol abuse
...
- CORRECT ANSWER
B) Evaluate his blood pressure, pulse, and respiratory status
...
The client's anxiety (A), a history
of alcohol abuse (D), or local anesthesia (D) are unrelated to the client's sudden onset
of slurred speech
...
When providing discharge teaching for a client with osteoporosis, the nurse
should reinforce which home care activity?
A) A diet low in phosphates
...


C) Exercise regimen, including swimming
...
- CORRECT ANSWER D) Elimination of
hazards to home safety
...
A low
phosphorus diet is not recommended in the treatment of osteoporosis (A)
...
Weight-bearing exercise is most beneficial for
clients with osteoporosis
...

30
...

What should be the correct interpretation if the nurse hears the spoken words
"99" very clearly through the stethoscope?
A) This is a normal auscultatory finding
...

C) May indicate pneumonia
...
- CORRECT ANSWER C) May indicate
pneumonia
...
Normally,
the spoken word is not well transmitted through lung tissue, and is heard as a muffled or
unclear transmission of the spoken word
...
g
...
When lung tissue is filled with more air than normal, the voice
sounds are absent or very diminished (e
...
, pneumothorax, severe emphysema) (B and
D)
...
The nurse recognizes that
Kussmaul respirations are consistent with which situation?
A) Client receiving mechanical ventilation
B) Use of hydrochlorothiazide
C) Aspirin overdose
D) Administration of sodium bicarbonate - CORRECT ANSWER C) Aspirin overdose
Rationale: If acidosis is metabolic in origin, the rate and depth of breathing increase as
the hydrogen ion level rises; this is known as Kussmaul respirations
...
A)
Mechanical ventilation is used to correct hypoxemia and hypercapnia (elevated Pco2)
...
D) Sodium bicarbonate is used in the
treatment of metabolic acidosis; administration of this buffer may cause metabolic
alkalosis
...

B) There are fewer healthcare providers to choose from than in an HMO plan
...

D) An individual can become a member of a PPO without belonging to a group
...

Rationale: The financial advantage of (C) is the feature of a PPO that is most relevant to
the average consumer
...
In return, the insurance company receives a large pool of clients for their
facilities
...

A client has taken steroids for 12 years to help manage chronic obstructive pulmonary
disease (COPD)
...

B) blood pressure, both standing and sitting
...

D) skin color and turgor
...

Rationale: It is very important to check the client's temperature (C)
...
Clients with COPD who are on
maintenance doses of corticosteroids are particularly predisposed to infection
...
Assessment of skin
color and turgor is less important (D)
...
Which information should the nurse
include? (Select all that apply
...

B) Wash the diaphragm with an alcohol solution
...

D) Do not leave the diaphragm in place longer than 8 hours after intercourse
...

F) Replace the old diaphragm every 3 months
...


Rationale: The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent
pregnancy but should not remain for longer than 8 hours (D) to avoid the risk of TSS
...
(A) increases
the risk of pregnancy, and (B) can reduce the integrity of the barrier contraceptive but
neither prevents the risk of TSS
...
(F) is not necessary
...
According to the Health Belief Model, which event is most
likely to increase the client's willingness to become compliant with the prescribed diet?
A) He visits his diabetic brother who just had surgery to amputate an infected foot
...

C) He comments on the community service announcements about preventing
complications associated with diabetes
...
- CORRECT ANSWER A) He visits his diabetic brother who just had
surgery to amputate an infected foot
...
(B, C,
and D) may influence his behavior but do not have the personal impact of (A)
...
What action should the nurse implement?
A) Determine if the client has also experienced breast tenderness and weight gain
...

C) Advise the client to notify the healthcare provider for immediate medical attention
...
CORRECT ANSWER C) Advise the client to notify the healthcare provider for
immediate medical attention
...
(A) are symptoms of oral
contraceptive use, but are of less immediacy than (C)
...
By not seeking immediate attention, (D) is potentially
dangerous to the client
...

Which assessment is most important for the nurse to obtain?
A) Amount of weight gain or weight loss during the previous year
...

C) Skin pigmentation and hair texture for evidence of hormonal changes
...
- CORRECT
ANSWER B) An accurate menstrual cycle diary for the past 6 to 12 months
...
(A and C) may
be partially related to hormonal fluctuations but are not indicators for using the calendar
method
...

The nurse knows that lab values sometimes vary for the older client
...

B) Increased serum bilirubin, slightly increased liver enzymes
...

D) Decreased serum sodium, an increased urine specific gravity
...

Rationale: In older adults, the protein found in urine slightly rises probably as a result of
kidney changes or subclinical urinary tract infections
...
The specific gravity declines by age 80 from 1
...
024
...

B) History of white nipple discharge
...

D) Excessive diaphoresis occurs at night
...

Rationale: Postmenopausal vaginal bleeding (C) may be an indication of endometrial
cancer, which should be reported to the healthcare provider
...
Up to 80% of women experience (B),
depending on sexual stimulation or hormonal levels, and is no longer recommended as
a reportable symptom when discovered during breast self-exam (BSE)
...


The nurse is assisting a client out of bed for the first time after surgery
...

B) Encourage deep breathing prior to standing
...

D) Allow the client to sit with the bed in a high Fowler's position
...

Rationale: The first step is to raise the head of the bed to a high Fowler's position (D),
which allow venous return to compensate from lying flat and vasodilating effects of
perioperative drugs
...

The nurse is receiving report from surgery about a client with a penrose drain who is to
be admitted to the postoperative unit
...

B) If the family would prefer a private or semi-private room
...

D) If the client's wound is infected
...

Rationale: Penrose drains provide a sinus tract or opening and are often used to
provide drainage of an abscess
...
To avoid contamination of another
postoperative client, it is most important to place an infected client in a private room (D)
...
Although (B) is information that should be
considered, it does not have the priority of (D)
...

A patient admitted for a head injusry develops dry skin and urine output of 600 mL/hr
...
The nurse should assess for low specific gravity and elevated
serum osmolarity
...

-Notifying the physician is appropriate after the nurse has gathered additional data
...
Which of the following assessment findings should the nurse
expect if this treatment is effective?
a) Increased response to stimuli
b) decreased urine output
c) respiration rate of 12
d) Increased blood pressure - CORRECT ANSWER a) Increased response to stimuli
rationale: Dexamethasone (Decadron) is a corticosteroid that reduces inflammation in
the brain
...

-Decadron has little effect on blood pressure, respiration rate, and urine output
...
How should the nurse assess the client for possible dependent edema?
A) Compress the flank and upper buttocks
...

C) Gently palpate the lower abdomen
...
- CORRECT ANSWER A) Compress the flank
and upper buttocks
...
(B) provides data about ascites
(fluid collection in the abdomen), rather than dependent edema, and (C) provides data
about abdominal distention
...

A male client with chronic atrial fibrillation and a slow ventricular response is scheduled
for surgical placement of a permanent pacemaker
...
How should the nurse explain the action of a synchronous
pacemaker?
A) Ventricular irritability is prevented by the constant rate setting of pacemaker
...

C) An impulse is fired every second to maintain a heart rate of 60 beats per minute
...
CORRECT ANSWER D) An electrical stimulus is discharged when no ventricular
response is sensed
...
Pacing

modes that are synchronous (impulse generated on demand or as needed according to
the patient's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of
the myocardium stimulating it to contract when no ventricular depolarization is sensed
(D)
...

The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who
is sitting in a chair at the bedside has an oral temperature of 97
...
Which intervention
should the nurse implement?
A) Document the temperature reading on the vital sign graphic sheet
...

C) Instruct the UAP to take the client's temperature again in 30 minutes
...
- CORRECT ANSWER
A) Document the temperature reading on the vital sign graphic sheet
...
2° F (orally) is a common finding in elderly
clients, so the nurse should document the findings (A) and continue with the plan of
care
...

The nurse is completing the health assessment of a 79-year-old male client who denies
any significant health problems
...

B) Dilated superficial veins on both legs
...

D) Yellowish discoloration of the sclerae
...

Rationale: Jaundice, a yellowish discoloration of the sclerae (D), may indicate liver
damage and requires further assessment
...

Which finding should the nurse report to the healthcare provider for a client with a
circumferential extremity burn?
A) Full thickness burns rather than partial thickness
...

C) Slow capillary refill in the digits with absent distal pulse points
...
- CORRECT
ANSWER C) Slow capillary refill in the digits with absent distal pulse points
Rationale: A circumferential burn can form an eschar that results from burn exudate
fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue
...
Although eschar formation occurs more readily over full thickness burns
(A), the circumferential location of the burn is most likely to constrict underlying
structures
...
(D) may be related to the depth of
the burn
...
What technique should
the nurse perform next in the abdominal examination?
A) Percussion
...

C) Deep palpation
...
- CORRECT ANSWER B) Auscultation
...

A client who has just tested positive for human immunodeficiency virus (HIV) does not
appear to hear what the nurse is saying during post-test counseling
...

B) Teach the client about the medications that are available for treatment
...

D) Discuss retesting to verify the results, which will ensure continuing contact
...

Rationale: Encouraging retesting (D) supports hope and gives the client time to cope
with the diagnosis
...

The nurse hears short, high-pitched sounds just before the end of inspiration in the right
and left lower lobes when auscultating a client's lungs
...

B) Crackles in the right and left lower lobes
...

D) Pleural friction rub in the right and left lower lobes
...


Rationale: Fine crackles (B) are short, high-pitched sounds heard just before the end of
inspiration that are the result of rapid equalization of pressure when collapsed alveoli or
terminal bronchioles suddenly snap open
...
Although (C) describes an adventitious lung
sound, this documentation is vague
...

A client asks the nurse about the purpose of beginning chemotherapy (CT) because the
tumor is still very small
...

B) Collateral circulation increases as the tumor grows
...

D) The cell count of the tumor reduces by half with each dose
...

Rationale: Initiating chemotherapy while the tumor is small provides a better chance of
eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with
each dose
...

The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving
chemotherapy
...
What action
should the nurse implement?
A) Encourage fluids to 3000 ml/day
...

C) Provide oral hygiene every 2 hours
...
- CORRECT ANSWER B) Check stools for occult
blood
...
A client with thrombocytopenia should be
assessed frequently for occult bleeding in the emesis, sputum, feces (B), urine,
nasogastric secretions, or wounds
...
(C) may cause increased bleeding in a client with
thromobcytopenia
...

The nurse is caring for a client with end stage liver disease who is being assessed for
the presence of asterixis
...

B) Extend the arm, dorsiflex the wrist, and extend the fingers
...

D) Extend arms with both legs adducted to shoulder width
...

Rationale: Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often
seen frequently in hepatic encephalopathy
...
(A, C, and D) do not illicit axterixis
...

What action should the nurse implement?
A) Notify the surgeon
...

C) Secure a colostomy pouch over the stoma
...
- CORRECT ANSWER A) Notify
the surgeon
...
If the stoma becomes dry, firm, flaccid, or is
dark red or purple, the stoma is ischemic, and the surgeon should be notified
immediately (A)
...

What assessment finding should the nurse identify that indicates a client with an acute
asthma exacerbation is beginning to improve after treatment?
A) Wheezing becomes louder
...

C) Vesicular breath sounds decrease
...
- CORRECT ANSWER A) Wheezing becomes
louder
...
If the client is successfully responding to bronchodilators and respiratory
treatments, wheezing becomes louder (A) as air flow increases in the airways
...
Vesicular sounds are soft, low-pitched, gentle, rustling sounds
heard over lung fields (C) and is not an indicator of improvement during asthma
treatment
...

A client is admitted to the emergency department after being lost for four days while
hiking in a national forest
...
Which
additional assessment should the nurse make?

A) Body mass index
...

C) Thought processes and speech
...
- CORRECT ANSWER D) Exposure
to cold environmental temperatures
...
Prolonged exposure to cold
environmental temperatures (D) stimulates the hypothalamus to secrete thyrotropinreleasing hormone, which increases anterior pituitary serum release of TSH
...
Tenting of the skin (B) is indicative of dehydration
...

Which method elicits the most accurate information during a physical assessment of an
older client?
A) Ask the client to recount one's health history
...

C) Review the past medical record for medications
...
- CORRECT ANSWER D) Use
reliable assessment tools for older adults
...
(A and B) are subjective and may vary in reliability
based on the client's memory and caregiver's current involvement
...

The nurse obtains a client's history that includes right mastectomy and radiation therapy
for cancer of the breast 10 years ago
...

B) Myocardial infarction
...

D) Pathologic fracture of two ribs on the right chest
...

* The ribs lie in the radiation pathway and lose density over time, becoming thin and
brittle, so the occurence of two right-sided ribs with pathological fractures resulting

without evidence of trauma (D) is related to radiation damage
...

Three weeks after discharge for an acute myocardial infarction (MI), a client returns to
the cardiac center for follow-up
...
He states, I guess we will never have sex again after
this
...

B) Sexual activity can be resumed whenever you and your wife feel like it because the
sexual response is more emotional rather than physical
...

D) Sexual activity is similar in cardiac workload and energy expenditure as climbin CORRECT ANSWER D) Sexual activity is similar in cardiac workload and energy
expenditure as climbing two flights of stairs and may be resumed like other activities
...
(A, B, and C) do not provide the best factual information to
reduce the client's anxiety and misconceptions
...
The client's radial pulse rate is 104
beats/minute
...

B) Count the brachial pulse rate
...

D) Assess for a carotid bruit
...

* Elderly clients who take antihypertensive medications often experience side effects,
such as hypotension, which causes tachycardia, a compensatory mechanism to
maintain adequate cardiac output, so the client's blood pressure (C) should be
determined
...

The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a
history of allergic rhinitis
...

B) Increase fluid intake while taking an antihistamine or decongestant
...

D) Ophthalmic lubricating drops may be used for eye dryness due to allergy
medications
...

* OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine,
which can cause adrenergic side effects, such as increased intraocular pressure, so a
client with glaucoma should avoid using these OTC medications (C)
...
(B and D) may provide symptomatic relief for other side effects,
such as dry mouth or eye dryness related to common agents used for allergic rhinits
...

B) Remove fluid from the intrapleural space
...

D) Relieve empyema after pneumonectomy
...

* Instillation of a sclerosing agent to create pleurodesis (adherence of the parietal and
visceral pleura) is aimed at preventing the formation of pleural effusion fluid (A)
...
(C) is achieved by surgical resection
...

A female client with type 2 diabetes mellitus reports dysuria
...

B) Bounding pulse at 100 beats/minute
...

D) Small vesicular perineal lesions
...

* Elevated fingerstick glucose levels (C) spill glucose in the urine and provide a medium
for bacterial growth
...

A nurse is preparing a teaching plan for a client who is post-menopausal
...

B) Use only low fat milk products
...


D) Bicycle for at least 3 miles every day
...

* Weight bearing on the skeletal system stimulates bone formation, so recommending
weight resistance exercises (C) is most important in the prevention of osteoporosis in
post-menopausal women
...

A young adult female reports that she is experiencing a lack of appetite, hypersomnia,
stress incontinence, and heart palpitations
...

B) Anorexia
...

D) Stress incontinence
...

* Characteristic features of premenstrual syndrome include heart palpitations (A),
sleeplessness, increased appetite and food cravings, and oliguria or enuresis
...

A nurse is preparing to insert an IV catheter after applying an eutectic mixture of
lidocaine and prilocaine (EMLA), a topical anesthetic cream
...

B) Cover the skin with a gauze dressing after applying the cream
...

D) Use the smallest amount of cream necessary to numb the skin surface
...

* Topical anesthetic creams, such as EMLA, should be applied to the puncture site at
least 60 minutes to 2 hours before the insertion of an IV catheter (C)
...

A 26-year-old male client with Hodgkin's disease is scheduled to undergo radiation
therapy
...
What information should the nurse provide?
A) The radiation therapy causes the inability to have an erection
...

C) Permanent sterility occurs in male clients who receive radiation
...
- CORRECT ANSWER
C) Permanent sterility occurs in male clients who receive radiation
...
Radiotherapy often results in permanent aspermia, or sterility (C)
...

The nurse is preparing discharge instructions for a client who is going home with a
surgical wound on the coccyx that is healing by second intention
...

B) Risk for infection
...

D) Risk for deficient fluid volume
...

* A wound healing by second intention is an open wound that is at risk for infection (B)
...

Risk for deficient fluid volume (D) requires a significant amount of wound draining,
which is not evident
...

The nurse is preparing an adult client for an upper gastrointestinal (UGI) series
...

B) A nasogastric tube (NGT) is inserted to instill the barium
...

D) Nothing by mouth is allowed for 6 to 8 hours before the study
...

* The client should be NPO for at least 6 hours before the UGI (D)
...
A NGT is not needed to instill the barium (B) unless the client is unable
to swallow
...

A client is admitted to the hospital with a traumatic brain injury after his head violently
struck a brick wall during a gang fight
...

B) Serosanguineous nasal drainage
...

D) Dizziness, nausea and transient confusion
...

* Any nasal discharge should be evaluated (B) to determine the presence of cerebral
spinal fluid which indicates a tear in the dura making the client susceptible to meningitis
...
Pain is

expected and can be treated after further assessment of the presence of nasal
discharge (C)
...

When planning care for a client with right renal calculi, which nursing diagnosis has the
highest priority?
A) Acute pain related to movement of the stone
...

C) Risk for infection related to urinary stasis
...
CORRECT ANSWER A) Acute pain related to movement of the stone
...
Impaired urinary elimination (B), risk for
infection (C), and knowledge deficit (D) are components of the plan of care with less
immediacy than management of the etiology of the client's pain
...

B) Maintain sterile technique
...

D) Drink 500 ml of fluid within 2 hours of catheterization
...

* The average interval between catheterizations for adults is every 3 to 4 hours (A)
...
(C and D) are
not indicated before self-catheterization
...
Which items should the nurse
remove from the client? (Select all that apply
...

B) Hearing aid
...

D) Left leg brace
...

F) Partial dentures
...
Hearing aids (B), contact lenses (E), and partial dentures

(F) are removed to prevent damage, loss or misplacement, or injury during surgery
...

A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0
...
Which conclusion regarding this lab data is accurate?
A) Probable prostatitis
...

C) The presence of cancer cells
...
- CORRECT ANSWER Correct Answer(s): B
* Clients with a PSA density less than 0
...
(A, C, and D) are incorrect interpretations of the test results
...

Which information should the nurse include in the teaching plan? (Select all that apply
...

B) Report inflammation of the incision site or the affected arm
...

D) Avoid lifting more than 4
...
- CORRECT
ANSWER Correct Answer(s): B, D
* Part of the client's teaching plan should include reporting evidence of inflammation at
the incision or of the affected arm (B), and to avoid lifting or reaching (D), which places
the client at risk for injury to the extremity that may have compromised lymphatic
drainage
...
Activity
that decreases circulation (C) in the affected arm, such as carrying a handbag over the
shoulder, wearing tight clothing, or tight jewelry, should be avoided
...

B) Chlamydia trachomatis
...

D) Human papillomavirus
...
Although STIs (A, B, and C) place the
client at risk for exposure to HPV, these are likely to place the client at risk for pelvic
inflammatory disease, infertility sequela, and painful reoccurrence
...
What action should the nurse
implement next?

A) Inform the healthcare provider
...

C) Give a sublingual nitroglycerin tablet
...
- CORRECT ANSWER Correct Answer(s): C
* After a percutaneous transluminal coronary angioplasty (PTCA), a client who
experiences acute chest pain may be experiencing cardiac ischemia related to
restenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery
...
Then, (A, B, and D) are implemented
...
Which
assessment should the nurse expect to identify?
A) An absence of lung sounds on the affected side
...

C) A deviation of the trachea toward the side opposite the pneumothorax
...
- CORRECT
ANSWER Correct Answer(s): C
* Tension pneumothorax is caused by rapid accumulation of air in the pleural space,
causing severely high intrapleural pressure
...

(A, B, and D) are not demonstrated with a tension pneumothorax
...
What information should the nurse provide?
A) A uniformly enlarged prostate is benign prostatic hypertrophy that occurs with aging
...

C) An infection is usually present when the prostate indents when a finger is pressed on
it
...
CORRECT ANSWER Correct Answer(s): D
* PSA levels are prescribed to screen for prostatic cancer which is often detected by
DRE and manifested as small, hard, or stony, irregularly-shaped nodules on the surface
of the prostate (D)
...

What is the primary nursing diagnosis for a client with asymptomatic primary syphilis?

A) Acute pain
...

C) Sexual dysfunction
...
- CORRECT ANSWER Correct Answer(s): D
An asymptomatic client with primary syphilis is most likely unaware of this disease, so to
prevent transmission to others and recurrence in the client, the priority nursing
diagnosis is deficient knowledge (D)
...
Although the client is at risk for injury (B) and sexual
dysfunction (C) related to complications, teaching the client about transmission and
treatment is instrumental in preventing the progression to systemic secondary or tertiary
syphilis
...
What is the most significant desired
outcome for this client?
A) Free from injury of drug side effects
...

C) Adequate oxygenation
...
- CORRECT ANSWER Correct Answer(s): B
* MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary
process
...
Drug schedules and side
effects (A) remain a life long management problem
...
Skin integrity (D)
is dependent upon resolution of diarrhea, which is not as significant as optimal nutrition
...
Which action should the nurse include in the client's plan of care?
A) Increase fluid intake
...

C) Assist the client in coping with hot flashes
...
- CORRECT ANSWER
Correct Answer(s): C
* Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so (C) should
be included in the plan of care
...


A client in the preoperative holding area receives a prescription for midazolam (Versed)
IV
...
Which action should the nurse implement?
A) Give the drug and allow the client to read and sign the consent form
...

C) Withhold the drug until the client validates understanding of the surgical procedure
and signs the consent form
...
- CORRECT ANSWER Correct Answer(s): C
* Midazolam, a benzodiazepine sedative, is commonly used for conscious-sedation
intraoperatively and interferes with the client's cognition and level of consciousness, so
the consent form should be signed before the drug is administered (C)
...
If indicated, (D) may need to be
implemented but should be determined before the client arrives to the preoperative
area
...
What
assessment finding is most important for the nurse to identify?
A) Increased anxiety since the transfusion began
...

C) Complaints of feeling cold
...
- CORRECT ANSWER Correct Answer(s): D
* The most common type of reaction is a febrile, nonhemolytic blood transfusion
reaction related to leukocyte incompatibility, which causes chills, fever, headache, and
flushing (D)
...
Drowsiness (B) is an
expected symptom after diphenhydramine administration
...

A 48-year-old client with endometrial cancer is being discharged after a total
hysterectomy and bilateral salpingo-oophorectomy
...

B) I can't wait to go on the cruise that I have planned for this summer
...

D) I have asked my daughter to stay with me next week after I am discharged
...
The client's knowledge about
reproduction (A), a positive outlook with plans for the future (B), and her anticipated
need for assistance and support during recovery (D) indicate she understands the
present status of her recovery
...
The pain is greater with passive movement of the limb
than with active movement by the client
...

B) Fat embolism syndrome
...

D) Aseptic ischemic necrosis
...
The signs do not indicate (B, C, or D)
...
The client complains of
feeling distended and has sharp, cramping gas pains
...

B) Withhold all oral fluid and food
...

D) Administer the prescribed morphine sulfate
...
Peristalsis is stimulated and distention minimized by
implementing early and frequent ambulation (C)
...
Although pain
management should be implemented (D), another analgesic prescription may be
needed because morphine reduces intestinal motility and contributes to the client's gas
pains
...

The nurse determines the client's lower abdomen is distended and assesses dullness to
percussion
...

B) Document the finding as the only action
...


D) Insert a rectal tube for the passage of flatus
...
To provide additional data supporting bladder distention, the
last time the client voided (C) should be determined next
...
(A and D) are
not priority actions based on the client's abdominal findings
...
The nurse should recognize these
symptoms as characteristic of what reaction?
A) A mild allergic reaction
...

C) An anaphylactic transfusion reaction
...
- CORRECT ANSWER Correct
Answer(s): B
* Symptoms of a febrile reaction (B) include sudden chills, fever, headache, flushing and
muscle pain
...
An anaphylactic reaction (C) exhibits an
exaggerated allergic response that progresses to shock and possible cardiac arrest
...

A client with a recent history of blood in his stools is scheduled for a
proctosigmoidoscopy
...
)
A) Obtain consent for the procedure
...

C) Begin fast the morning of the procedure
...

E) Provide a clear-liquid diet 48 hours before the procedure
...
Preoperative sedation is not the norm for this procedure (B), although some
healthcare providers administer a mild tranquilizer
...
The nurse should communicate
which information?
A) Low impact exercise, walking, swimming and water aerobics
...

C) Circuit training alternating with frequent rest periods
...
- CORRECT ANSWER Correct Answer(s): A
* Low impact exercises such as walking or swimming (A), that do not cause further
harm to damaged joints, are most beneficial to clients with osteoarthritis
...

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH)
...

B) Active tuberculosis infection
...

D) Tricyclic antidepressant therapy
...
(B, C, and D)
are also possible causes, but secondary to CNS trauma or disease
...
What
information is best for the nurse to provide? (Select all that apply
...

B) Smoking can decrease the quantity and quality of sperm
...

D) Cessation of smoking improves general health and fertility
...
- CORRECT ANSWER
Correct Answer(s): B, C, D
* Use of tobacco, alcohol, and marijuana may affect sperm counts (B)
...
A minimum of two analyses
should be performed several weeks apart to assess male fertility, not (E)
...


Which finding should the nurse identify as an indication of carbon monoxide poisoning
in a client who experienced a burn injury during a house fire?
A) Pulse oximetry reading of 80%
...

C) Cherry red color to the mucous membranes
...
- CORRECT ANSWER Correct
Answer(s): C
The saturation of hemoglobin molecules with carbon monoxide and the subsequent
vasodilation induce a cherry red color of the mucous membranes (C) in a client who
experienced a burn injury during a house fire
...
Mouth breathing during the fire allows the inhalation of
soot that is seen as particles in the client's sputum (D)
...
What
instruction should the nurse provide the client to reduce the risk of spreading the
infection to other areas of the client's urinary tract?
A) Wear a condom when having sexual intercourse
...

C) Empty the bladder completely with each voiding
...
- CORRECT ANSWER
Correct Answer(s): D
* The prostate is not easily penetrated by antibiotics and can serve as a reservoir for
microorganisms, which can infect other areas of the genitourinary tract
...
(A, B, and C) do not reduce the risk of spreading the infection
internally
...
Which statement indicates that the client understands
his post-operative care and prognosis?
A) I should continue to perform testicular self-examination (TSE) monthly on my
remaining testicle
...

C) I should always use a condom because I am at increased risk for acquiring a
sexually transmitted disease
...
- CORRECT ANSWER Correct Answer(s): A

* Although testicular cancer protocols, such as surgery, radiation, or chemotherapy,
focus on the primary site of testicular cancer, these treatments do not reduce the risk of
testicular cancer in the remaining testicle, so early recognition is the best prevention
...

Although an athletic support (B) protects the testicle from trauma, it does not address
the client's understanding of self-care
...
Although the client's sons should learn
TSE (D), the client should continue TSE himself
...
Which finding is most important for the nurse to further
assess?
A) Upper chest subcutaneous emphysema
...

C) Constant air bubbling in the suction-control chamber
...
- CORRECT ANSWER Correct Answer(s):
A
* Subcutaneous emphysema (A) is a complication and indicates air is leaking beneath
the skin
...
Pain at the insertion site is an expected finding (D) and the
prescribed analgesia should be given to assist the client to breathe deeply and facilitate
lung expansion
...
What is the best response for the nurse to provide?
A) Tell your friends and family so that they can help you
...
I will give you some names
...

D) Start adoption proceedings immediately since obtaining an infant is very difficult
...
Although talking about feelings may unburden the
couple of negative feelings, infertility is a major stressor that affects the couple's
relationships, so discussion with family and friends (A) should be minimal
...
Giving an opinion about adoption (D) is not therapeutic nor supportive of the
psychosocial needs
...
Which information has the greatest priority for this
client?
A) Prognosis after treatment is excellent
...

C) The stoma should never be covered after this type of surgery
...
- CORRECT
ANSWER Correct Answer(s): D
* Radical neck dissection is the removal of lymphatic drainage channels and nodes,
sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular
area
...
(A, B, and C) are included, but the
client's concern for (D) is the priority
...

B) There is a possibility of long bone pain
...

D) A low-residue diet may be ordered to reduce the likelihood of diarrhea
...
(B, C, and D) are not
found in this situation
...

B) Administer an oral anti-diabetic agent
...

D) Withhold insulin while the client is NPO
...
A client with type 1 DM
who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin
(A)
...

In planning care for a client with an acute stroke resulting in right-sided hemiplegia,
which positioning should the nurse should use to maintain optimal functioning?
A) Mid-Fowler's with knees supported
...

C) Sim's position alternated with right lateral position q2 hours
...
- CORRECT
ANSWER Correct Answer(s): D
* After an acute stroke, a positioning and turning schedule that minimizes lying on the
affected side, which can impair circulation and cause pain, and includes the prone
position (D) to help prevent flexion contractures of the hips, prepares the client for
optimal functioning and ambulating
...

Which intervention should the nurse implement that best confirms placement of an
endotracheal tube (ET) tube?
A) Use an end-tital CO2 detector
...

C) Obtain pulse oximeter reading
...
- CORRECT ANSWER Correct Answer(s): A
* The end-tital carbon dioxide detector indicates the presence of CO2 by a color change
or a number (A), which is evidence that the ET is in the trachea, not the esophagus
...

A female client with hyperesthesia on the oncology unit is using a transcutaneous
electrical nerve stimulation (TENS) unit for chronic pain
...

B) Ask the client about her past experience with chronic pain
...

D) Evaluate the client's ability to adjust the voltage to control pain
...
The PN can collect data about the client's pain (A, B, and C)
...
The client asks the nurse to explain how a PEG
tube differs from a gastrostomy tube (GT)
...


B) Location of the tubes
...

D) Procedure for feedings
...
GT insertion involves making an incision in the wall of the abdomen and
suturing the tube to the gastric wall
...
(B, C, and D) identify commonalities
...
What should the nurse
implement?
A) Reposition the catheter drainage tubing
...

C) Irrigate the catheter
...
- CORRECT ANSWER Correct Answer(s): C
* Obstruction urinary flow after a TURP is most often due to blood clots, and sterile
irrigation should be implemented to remove the clots that are blocking the catheter (C)
...
(D) is not necessary
...
Which assessment finding requires
immediate action by the nurse?
A) Radiating abdominal pain with left lower quadrant palpation
...

C) Rebound tenderness with abdominal palpation
...
- CORRECT ANSWER Correct Answer(s):
D
* Immediate action is indicated for intraperitoneal hemorrhage which causes
periumbilical discoloration (D) and indicates the presence of a splenic rupture, a lifethreatening complication of blunt abdominal injury
...

The PET (positron emission tomography) scan is commonly used with oncology clients
to provide for which diagnostic information?
A) A description of inflammation, infection, and tumors
...

C) Imaging of tumors without exposure to radiation
...
- CORRECT ANSWER Correct
Answer(s): D

* PET scans provide information regarding certain diseases of the heart (determination
of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors
and their aggressiveness
...
(A, B, and C) are not the purpose of PET
...
Which effect is characteristic of (NSAIDs) used for treating
rheumatoid arthritis?
A) Production of replacement cartilage is stimulated
...

C) Inflammation is reduced by inhibiting prostaglandin synthesis
...
- CORRECT
ANSWER Correct Answer(s): C
* Nonsteroidal anti-inflammatory drugs (NSAIDs), used for treating rheumatoid arthritis,
inhibit the synthesis of prostaglandins and relieve associated pain (C), but they do not
generate new cartilage (A)
...
Joint destruction is not preventable with this disease process (B)
...

B) Hemophilia
...

D) Oxalic acid toxicity
...
The most common cause is lack of intrinsic factor, a glucoprotein produced by
the parietal cells of the gastric lining
...

A client with a history of hypertension, myocardial infarction, and heart failure is
admitted to the surgical intensive care unit after coronary artery bypass surgery graft
(CABG)
...
5 mEq/L
...

B) Decrease the IV solution flow rate
...

D) Administer potassium replacement as prescribed
...
Documentation of
the normal finding (C) is indicated at this time
...

A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL
...
In 15 minutes the client's
capillary glucose is 74 mg/dL
...

B) Administer insulin per sliding scale
...

D) Collect a glycosylated hemoglobin specimen
...
Blood glucose
has just been checked and a serum level is not indicated at this time (A)
...
A glycosylated hemoglobin (hemoglobin A1C) level is not
indicated at this time (D)
...
What action should the nurse implement?
A) Notify the healthcare provider
...

C) Place the client in the supine position
...
- CORRECT ANSWER
Correct Answer(s): A
* Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a
client with a myocardial infarction indicate impending cardiogenic shock related to heart
failure, a common complication of MI
...

Increasing the IV rate (B) increases the cardiac workload and contributes to cardiac
decompensation
...
Although an emergency echocardiography (D) should be performed, the
healthcare provider should be notified for differentiating diagnosis
...

B) Pedal edema, brown pigmentation
...


D) Peripheral neuropathy, cold extremities
...
(B) are signs related to venous
insufficiency
...
Although (D) may be related to
complications of diabetes mellitus resulting in poor circulation, arterial insufficiency
causes impaired perfusion resulting in hypoxic pain or intermittent claudication
...
Which finding should the nurse assess further?
A) Thinning hair and dry scalp
...

C) Increase in muscle tone but decreased muscle strength
...
- CORRECT ANSWER Correct Answer(s): D
* An increase in the abdominal girth (D) may be indicative of the onset of metabolic
syndrome, which places the client at risk for cardiac disease and requires further
assessment
...

The nurse directs an unlicensed assistive personnel (IAP) to obtain the vital signs for a
client who returns to the unit after having a mastectomy for cancer
...

B) Apply the blood pressure cuff to the arm on the unoperative side
...

D) Collect a fingerstick blood specimen from the arm on the operative side
...
The arm on the operative side of the mastectomy should be
elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage,
not (C)
...

The severity of diabetic retinopathy is directly related to which condition?
A) Poor blood glucose control
...

C) Susceptibility to infection
...
- CORRECT ANSWER Correct Answer(s): A

* Poor glucose control (A) worsens diabetic retinopathy, where as tight glucose control
can lessen its severity
...

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing
final examination week at college
...

B) Achieve a sense of control
...

D) Increased focus of attention
...
Because the client is experiencing
anxiety, achieving a sense of control is a key need (B) before (A, C and D) are
addressed
...

B) A 63-year-old complaining of foot and ankle pain
...

D) A 55-year-old newly admitted client complaining of jaw pain and indigestion
...
While
severe back pain (A) may indicate a dissecting abdominal aortic aneurysm, a 27-yearold client is less likely to be experiencing cardiac syndrome
...
The client with
pancreatitis (C) requires pain management but this is not as high a priority as (D)
...
Which
nursing action should be included in the plan of care?
A) Perform active range of motion three times daily
...

C) Teach measures to avoid the Valsalva maneuver
...
- CORRECT ANSWER Correct
Answer(s): C
* The Valsalva maneuver, straining with bowel movements while holding one's breath,
increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral
blood vessels (C)
...
Battle's sign (B), bruising noted behind the ear, is a manifestation that may be

seen with a basilar skull fracture, not hemorrhagic stroke
...

The nurse is assessing a client admitted from the emergency room with gastrointestinal
bleeding related to peptic ulcer disease (PUD)
...
)
A) Vagal stimulation
...

C) Decreased duodenal inhibition
...

E) An increased number of parietal cells
...
Vagal stimulation (A) and
decreased duodenal inhibition (C) also increase the secretion of caustic fluids
...

Which condition is associated with an oversecretion of renin?
A) Hypertension
...

C) Diabetes insipidus
...
- CORRECT ANSWER Correct Answer(s): A
* Renin is an enzyme synthesized and secreted by the juxtaglomerular cells of the
kidney in response to renal artery blood volume and pressure changes
...
(B, C, and D) are not
directly related to renin oversecretion
...

Which findings should the nurse document that indicate the client is developing
syndrome of inappropriate antidiuretic hormone (SIADH)?
A) Hypernatremia and periorbial edema
...

C) Weight gain with low serum sodium
...
- CORRECT ANSWER Correct Answer(s): C
* SIADH most frequently occurs when cancer cells manufacture and release ADH,
which is manifested by water retention causing weight gain and hyponatremia (C)
...


The nurse is assessing a postmenopausal woman who is complaining of urinary
urgency and frequency and stress incontinence
...
These complaints are most likely due to which condition?
A) Cystocele
...

C) Pyelonephritis
...
- CORRECT ANSWER Correct Answer(s): A
* This constellation of signs in a postmenopausal woman are characteristic of a
cystocele (A)
...

The nurse is caring for a client who returns to the unit following a colonoscopy
...

B) Tympanic abdomen and hyperactive bowel sounds
...

D) Complaint of feeling weak with watery diarrheal stools
...
Clients typically experience a large amount of flatus (A)
and may have mucus from bowel irritation from the procedure
...

Weakness and watery stools are a result from the preparation and are common
symptoms experienced after a colonoscopy (D)
...
Which nurse should the nurse manager assign to provide the discharge
instructions for the client?
A) A graduate registered nurse (RN) with three weeks of experience
...

C) A floating registered nurse (RN) with five years of nursing experience
...
CORRECT ANSWER Correct Answer(s): B
* The RN case manager (B) is the best qualified nurse to assess and provide discharge
educational needs, obtain resources for the client, enhance coordination of care, and
prevent fragmentation of care
...
The float nurse (C) lacks case
management expertise to advocate adequately for the client, coordinate care, and
provide community resources
...


A client's susceptibility to ulcerative colitis is most likely due to which aspect in the
client's history?
A) Jewish European ancestry
...
pylori bowel infection
...

D) Age between 25 and 55 years
...
H
...
Irritable bowel syndrome (C) does not progress to inflammatory bowel
disease
...

A college student who is diagnosed with a vaginal infection and vulva irritation describes
the vaginal discharge as having a cottage-cheese appearance
...

B) Instill the first dose of nystatin (Mycostatin) vaginally per applicator
...

D) Obtain a blood specimen for sexually transmitted diseases (STDs)
...
(A, C, and D)
may implemented after (B)
...
What action should the
nurse implement first?
A) Notify the client's healthcare provider
...

C) Prepare a warm enema solution for rectal instillation
...
- CORRECT
ANSWER Correct Answer(s): A
* Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells
clogging the microcirculation in the penis, causing a reduction of blood flow and
oxygenation to the penis, so the healthcare provider should be notified immediately (A)
...
Treatment may consist of
noninvasive measures such as applying ice to the penis, instilling a warm solution
enema to increase outflow in the corpora cavernosa (C) and giving pain medications,

but (A) has priority
...

The healthcare provider prescribes high-protein, high-fat, low-carbohydrate diet with
limited fluids during meals for a client recovering from gastric surgery
...
Which rationale should be included in
the nurse's explanation to this client?
A) It is quickly digested
...

C) It does not dilate the stomach
...
- CORRECT ANSWER Correct Answer(s): D
* This type of diet is slowly digested and is slow to leave the stomach (D)
...
(A, B, and C) are incorrect rationales
...
To evaluate if the client can tolerate cuff deflation to promote
speaking and swallowing, what action should the nurse implement?
A) Ask the client to try to speak
...

C) Auscultate for pulmonary crackles after the client drinks a small amount of clear
water
...
- CORRECT ANSWER Correct Answer(s): D
* To evaluate the risk for aspiration after the cuff is deflated, the client should be
instructed to swallow a small amount of colored water, then observed for coughing up
colored sputum (D), or the tracheostomy should be suctioned for the presence of
colored water
...
Large
volumes of oral intake are more likely to cause respiratory distress (B) or crackles (C),
and should not be used to evaluate the client's risk for aspiration
...
What information should the
nurse include in the explanation to the family?
A) A central monitoring system reduces the risk of complications undetected by
observation
...

C) Pulmonary artery catheters allow for early detection of lung problems
...
- CORRECT
ANSWER Correct Answer(s): B

* Pulmonary artery catheters are used to measure central pressures and fluid balance
(B)
...
PA lines do not detect pulmonary problems (C)
...

An older female client is admitted with atrophic vaginitis and perineal cutaneous
candidiasis
...

B) Impaired comfort
...

D) Ineffective health maintenance
...
Perineal cutaneous candidiasis contributes to other
manifestations of vaginal infections, such as vaginal irritation, burning, pruritus,
increased leukorrhea, bleeding, and dyspareunia, and support the primary nursing
diagnosis, Impaired comfort (B)
...

A male client with a prostatic stent is preparing for discharge
...

B) The client should not undergo magnetic resonance imaging
...

D) The client should not be catheterized through the stent for at least three months
...
Long term antibiotic use for
one year (A) is not a part of illness management
...
Frequent assessment of prostate health is part of
client teaching for health promotion (C), but is not increased because of the stent
placement
...

B) A 55-year-old woman with abnormal bleeding and pain for 3 years
...

D) A 29-year-old woman whose uterus ruptured after giving birth to her first child
...
The client with a
family and positive life events (A), the menopausal client with physical distress (B), the
post-menopausal client with support of peers with similar positive outcomes (C) are less
likely to be psychologically distressed
...
What is the most important nursing action to implement?
A) Limit the client's intake of oral fluids and food
...

C) Encourage the client to ambulate as tolerated
...
- CORRECT ANSWER Correct
Answer(s): B
* Pain management is the priority for a client during sickle cell crisis
...
(A, C, and D) are not
indicated at this time
...

B) Nausea with profuse vomiting
...

D) Fluid and electrolyte imbalances
...
(B, C, and D) are findings associated with small bowel obstruction
...
Which intervention should the nurse perform after the procedure?
A) Progress activity as soon as possible
...

C) Place the client in the left lateral position
...
- CORRECT ANSWER
Correct Answer(s): B
* Assessment for signs of bleeding (B) should be implemented because internal
bleeding is the greatest risk following a liver biopsy
...
Because of the increased risk
for bleeding, a gradual return to normal activities over 1-2 days is desired (A)
...

The home health nurse is assessing a client with terminal lung cancer who is receiving
hospice care
...

B) Clarify family members' feelings about the meaning of client behaviors and
symptoms
...

D) Teach the family to recognize restlessness and grimacing as signs of client
discomfort
...
Administering
medication and monitoring for therapeutic and adverse effects (A) is within the scope of
practice for the PN
...

A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is
angry at her ex-boyfriend and says she is not going to tell him that he is infected
...

B) Because there is no cure for this disease, telling him is of no benefit to him or to you
...

D) You should tell him, so he can feel as guilty and miserable as you do now, knowing
that you have this disease
...
Although HPV is not a
reportable disease in many states, all contacts should be informed of the infection,
treatment, transmission, and precautions to minimize infecting others (C)
...
(D) is
not therapeutic
...
Which observation
should alert the nurse to call the Rapid Response Team (RRT)?
A) Fresh bleeding noted on abdominal surgical wound dressing
...

C) Temperature of 103
...

D) Weakness, diaphoresis, complaints of feeling faint
...
- CORRECT
ANSWER Correct Answer(s): B

* The RRT should be called to intervene for a client with an acute life-threatening
change, such as (B)
...
(B) indicates an infection and (D) may indicate post operative diuresis
with corresponding hypotension
...

A client with Ménière's disease is incapacitated by vertigo and is lying in bed grasping
the side rails and staring at the television
...

B) Change the client's position every two hours
...

D) Turn off the television and darken the room
...
Turning off the television and darkening the room (D)
minimize fluorescent lights, flickering television lights, and distracting sound
...

B) Steatosis hepatitis
...

D) Clavicular fracture
...
Superior vena cava syndrome is likely to occur with metastatic
cancer (C) from a primary tumor in the upper lobe of the right lung that compresses the
superior vena cava
...

A client with osteoarthritis receives a prescription for Naproxen (Naprosyn)
...

B) Muscle fasciculations
...

D) Gastrointestinal disturbance
...
It is recommended that this drug be
taken with food to avoid gastrointestinal upset
...

What information should the nurse include in a teaching plan about the onset of
menopause? (Select all that apply)
...

B) Oophorectomy with hysterectomy
...

D) Cardiac disease
...

F) Chemotherapy exposure
...
Factors
influencing the onset of menopause include smoking (A), genetic influences (E), early
menarche (C), surgical removal (B), and exposure to chemotherapy agents and
radiation (F)
...

The nurse is caring for a client with a small bowel obstruction
...
What action should the nurse implement?
A) Administer antiemetics every 2 to 3 hours
...

C) Encourage ice chips sparingly
...
- CORRECT ANSWER Correct Answer(s): D
* When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral
fluids with sodium chloride, bicarbonate, and potassium should be administered (D)
...
(B) may or may not be a position of comfort for the client
...

Shingles select all that apply questions is - CORRECT ANSWER pain, skin, functional
mobility
The nurse is providing pre-operative education for a Jewish client scheduled to receive
a xenograft graft to promote burn healing
...
the xenograft is taken from nonhuman sources
...
grafting increases the risk for bacterial infection
c
...
as the burn heals, the graft permantly attaches - CORRECT ANSWER a
...


A client brought to the ER who had a heart attack and received CPR
...
The nurse notes that he is cold, diaphoretic and cyanotic
...
What
is the infection? - CORRECT ANSWER Gastrocenteritis both viral and bacterial
...
Abdominal pain, cramping
and borboygmi (hyperactive bowel sounds) may occur from gas released from
undigested food, irritation of the bowel mucosa, and distention of the intestines
...
- CORRECT ANSWER fair skin construction worker
Dosage question for heparin, a patient weighs 175lbs, order reads 80 units/kg
...
There is 10000 units/mL
...
6 mL
Dosage questions: the order reads 135mg
...
How
many mL should the nurse administer? - CORRECT ANSWER 0
...
What should a nurse do? - CORRECT ANSWER
Discharge teaching for patients with a foley bag
...
What should the nurse
do? - CORRECT ANSWER Automatic BP to monitor hypotension
A client experiences an ABO incompatibility reaction after multiple blood transfusions
...
low back pain and hypotension
b
...
delayed painful rash with urticaria
d
...
- CORRECT ANSWER a
...
What should the nurse advise? - CORRECT ANSWER Apply warm blankets to
the feet
...
Which information is most useful in determining the possible
cause of the symptoms?
a
...
recently received an influenza immunization
c
...
a grandson and his new dog recently visited - CORRECT ANSWER d
...
How does the nurse the
treatment is effective? - CORRECT ANSWER Decrease episodes of ventricular
tachycardia

A patient who had intercourse 4 days ago comes to the clinic with burning
pain/sensation when urinating - CORRECT ANSWER Obtain discharge in a swab for
culture
open angle glaucoma - CORRECT ANSWER decrease in peripheral vision
obstruction of the common bile duct - CORRECT ANSWER yellow sclera
a patient is having a seizure is assisted to the floor
...
- CORRECT ANSWER Palpate bladder
about the pubic syphysis
patient is unable to wear his shoes - CORRECT ANSWER ask about weight
Sodium level is 117
...
With excessive water retention
the sodium levels appear decreased (dilution)
...
focus on positive aspects of living and avoid situations that induce emotional upset
...
schedule frequent follow-up visits for monitoring disease progression
c
...

d
...
CORRECT ANSWER c
...

The client's vital signs are: HR 110m RR 28, BP 160/88
...
Which activity should be limited
until after the first postoperative visit with his healthcare provider? - CORRECT
ANSWER Driving a car
...
Which additional finding warrants the most immediate action by the nurse? CORRECT ANSWER Further decline in level of consciousness

After a CT scan with intravenous medium, a client returns to the room complaining of
shortness of breath and itching
...

How should the nurse respond?
a
...

b
...

c
...

d
...
- CORRECT
ANSWER b
...

A female college student comes to the school's health clinic complaining of urinary
frequency and burning with right lower back pain
...

When preparing a teaching plan for a client newly diagnosed with DM, the nurse should
describe which situation as requiring the most immediate action by the client or family? CORRECT ANSWER Hypoglycemic shock
Clint is about to go to physical therapy but before that is having a wound debridement
(whirlpool therapy)? What should the nurse do? - CORRECT ANSWER Give
analgesic
The nurse is assessing a group of older adults
...
Smokes cigars
b
...
Has intestinal polyps
d
...
Has intestinal polyps
* Intestinal polyps are precancerous lesions and are a major risk for colon cancer
patient complaining of pain in the back/sacrum ar - CORRECT ANSWER check vital
signs first
patient complaining of leg pain - CORRECT ANSWER check peripheral pulses
...
Which
observations by the nurse require immediate intervention to reduce the likelihood of
harm to this client? (Select all that apply)
...
A peripheral IV is saline-locked
b
...


c
...
A prescribed diet that is low in sodium
e
...
A bedside commode is located near the bed
...
The client is
lying supine in bed
...
Oxygen is flowing at 5 liters/minute via mask
e
...

What is the best initial nursing action?
a
...
admin a topical analgesic per prn protocol
c
...
encourage frequent mouth care - CORRECT ANSWER b
...

and flexion to pain (decorticate posturing)
...
13
b
...
5
d
...
5
A client who was alert and oriented during admission 4 hours ago cannot be awakened
...
what intervention should the nurse implement first?
a
...
auscultate for carotid bruits
c
...
obtain blood glucose finger stick - CORRECT ANSWER d
...
Obtaining a blood glucose
finger stick will assess the client's current blood sugar level
...
She is anxious and is complaining of dry mouth
...
administer a prescribed sedative
b
...
apply a high-flow venturi mask
d
...
assist her to an upright
position
* the client needs to be placed in a position that enhances adequate ventilation, such
as, upright leaning forward if possible
...
Nuchal rigidity
b
...
jugular vein distenstion
d
...
carotid bruit
* A bruit is a swooshing sound auscultated at the site of turbulent blood flow
...
stimulates production of the red blood cells and prevents anemia
...
helps the body produce white blood cells to fight infection
c
...

d
...
prevents increased levels of uric acid that could harm the kidneys
...

The package was in impervious wrapper
...
discard the package and its contents
b
...
open the contents to the sterile field if the package integrity is intact
...
document on the OR record that a sterile package was dropped on the floor
...
open the contents to the sterile field if the package integrity is
intact
...
bring a crash cart to the exam room
b
...

c
...
determine the defibrillator reading - CORRECT ANSWER d
...
Which intervention should the nurse implement first?
a
...
palpate the right flank for tenderness
c
...
measure her temperature and pulse rate - CORRECT ANSWER d
...

* first, the nurse should determine if the student is exhibiting systemic symptoms of
infection by measuring her temperature and pulse rate
...

A client who suffered an electrical injury with the entrance site on the left hand and the
exit site on the
...
Which intervention is most important for the nurse to
include in this client's plan of care?
a
...
continuous cardiac monitoring
c
...
perform passive range of motion - CORRECT ANSWER b
...
Which finding reflects the expected
therapeutic response?
a
...

b
...

c
...
healing with a return to normal skin appearance - CORRECT ANSWER a
...

Which position is best for this client?
a
...
30 degree semi-fowler's to drop the diaphram
...
left side-lying to reduce stres on the suture line
d
...
- CORRECT ANSWER b
...

A female with acute hymphocytic leukemia finished a chemotherapy course two weeks
ago and her
...
Which instruction is most
important for the nurse to teach with result of lab data?

a
...
assess temperature if feeling hot, and report any fever
...
do not take any medications that contain aspirin
d
...
take precautions to avoid all known sources of infection
...
the picture
...
provide instruction on correctly inserting the airway
b
...
prepare to assist with the Heimilch maneuver
d
...
offer to call the
rapid response team
The nurse assesses the dressing of a client who has just returned from post-anesthesia
and finds that the dressing has moderate amount of bright red bloody drainage
...
reinforce the dressing and document that a moderate amount of sanguineous
drainage was on the dressing
...
replace dressing with a new sterile dressing, and monitor the wound hourly until
bleeding is stopped
...
document that the dressing was saturated with serous drainage, and do not change
the dressing
...
call surgery and request that the surgeon see the wound prior to leaving the hospital
...
reinforce the dressing and document that a moderate
amount of sanguineous drainage was on the dressing
...
invite friends over regularly to share in meal times
b
...
coach the client to make intentional efforts to swallow
d
...
coach the client to make intentional efforts to swallow
A client with pheocromocytoma reports the onset of a severe headache
...
Which assessment data should the nurse
obtain next?
a
...
body temperature
c
...
oxygen saturation - CORRECT ANSWER a
...
The client has taken an oral
antibiotic and cleansed the wound today with povidone-iodine (Betadine) solution
...
determine if the client has a history of diabetes
b
...
obtain samples for complete blood count and cultures
d
...
assess
airway patency and oxygen saturation
Which nursing problem has the highest priority when planning care for a client with
osteomalacia?
a
...
risk of infection
c
...
sleep pattern disturbance - CORRECT ANSWER c
...
Administer eye ointment before applying eye drops
b
...
Use a metal eye shield on operative eye during the day
d
...

Light housekeeping is permitted, but avoid heavy lifting
action is most important for the nurse to implement to reduce the risk for deep vein
thrombosis in a postoperative client?
a
...
Assist the client in turning from side to side q2h
...
Encourage frequent cough and deep breathing exercises
d
...

Advise the client to perform leg exercises regularly
During spring break, a young adult presents at the urgent care clinic and reports a stiff
neck, fever for the past 6 hours, and a headache
...
initiate isolation precautions
b
...
admin an antipyretic
d
...
initiate isolation precautions

1
...
While obtaining consent, the client
complains of thirst and admits drinking a small amount of orange juice two hours ago
...
Increase intravenous flow rate
b
...
Delay procedure for 6 hours
d
...
Delay procedure for 6 hours
An adult female client is diagnosed with restless leg syndrome and is referred to the
sleep clinic
...
Which laboratory values should the nurse monitor?
a
...
Serum electrolytes
c
...
Neutrophils and eosinophils - CORRECT ANSWER c
...
Which
statement made by the mother warrants further assessment by the nurse?
a
...
"
b
...
"
c
...
"
d
...
" CORRECT ANSWER b
...
"
The nurse is caring for a client who is 3 hrs post-op and who received hydromorphone
IV 30 minutes ago for severe pain
...
The client's respiratory rate it now 14
breaths/minute and pulse rate is 94 beats/minute
...
pupillary response to light
b
...
orientation to person and place
d
...
level of consciousness
* Hypotension is a common side effect of opiate analgesics, especially in association
with cumulative effects of other perioperative drugs
...
(A, C, and D) are additional neurologic
assessments, but level of consciousness should be assessed first
...

When preparing to insert a nasogastric (NG) tube, which intervention should the nurse
implement?
a
...
elevate the head of the bed 60 to 90 degrees
c
...
measure from corner of mouth to angle of jaw - CORRECT ANSWER b
...
Thyroxine (T4) 4 mcg/dl
b
...
Serum potassium 3
...
Triiodothyronine (T3) level 0
...
serum sodium 122
mEq/L
A potential donor of corneal tissue for the eye bank has just died
...
What action should the nurse take next?
a
...
instill the eyedrops before placing small ice packs over the closed eyes
c
...
withhold the eyedrops and apply sterile dressing over both closed eyes - CORRECT
ANSWER a
...
(C and D) do not include the measures necessary to protect and
preserve the corneas
...
To
promote venous return, which action should the nurse encourage the client to take?
a
...

b
...
sit at the side of the bed for 15 minutes before standing
d
...
- CORRECT
ANSWER b
...
(A) is important to prevent clot formation, but it does not promote venous

return
...
(D) reduces risk for injury,
especially for diabetics, but is not helpful in promoting venous return

---