ATI PN ADULT MEDICAL SURGICAL 2023

1. A nurse is reinforcing teaching with a client about breast self-examinations.

Which of the following statements by the client indicates an understanding of the
teaching?
A. "I will perform breast exams the day my period begins."
B. "I will perform breast exams every other month."
C. "It is common for the skin on my breasts to dimple."
D. "It is common for one breast to be larger than the other."
The correct answer is choice D
Explanation
Choice A Reason:
"I will perform breast exams the day my period begins." This statement is incorrect because
performing breast exams just before or during your period might not be ideal. Breasts can be
more tender or swollen during this time, which could make it harder to detect any
abnormalities.
Choice B Reason:
"I will perform breast exams every other month." This statement is incorrect. Regular breast
self-exams are important, but doing them every other month might not be frequent enough.
It's generally recommended to perform breast self-exams once a month, ideally around the
same time each month, to detect any changes or abnormalities early.
Choice C Reason:
"It is common for the skin on my breasts to dimple." This statement is incorrect. Dimpling or
puckering of the skin on the breasts can sometimes be a sign of an underlying issue, such as
breast cancer. It's not considered a normal or common occurrence, so this statement doesn't
indicate an understanding of what to look for during a breast self-exam. If a person notices
skin changes like dimpling, it's recommended to seek medical advice.
Choice D Reason:
"It is common for one breast to be larger than the other." This statement reflects an
understanding that breast asymmetry, where one breast is slightly larger than the other, is a
common and normal occurrence.

2.A nurse is caring for a client who has a prescription for propranolol for the treatment
of atrial fibrillation. Which of the following actions should the nurse take?
A. Request a dosage increase if the apical heart rate is less than 60/min.
B. Withhold the medication if the systolic blood pressure is less than 90 mm Hg.
C. Administer the medication with an antacid.
D. Instruct the client to expect increased hair growth.
The correct answer is choice B
Explanation
Choice A Reason:
Requesting a dosage increase if the apical heart rate is less than 60/min is not necessary.
Propranolol is used to lower heart rate in conditions like atrial fibrillation, so a heart rate
below 60/min might be the desired effect of the medication.
Choice B Reason:
Withholding the medication if the systolic blood pressure is less than 90 mm Hg is
necessary. Propranolol is a beta-blocker that can lower blood pressure. If the systolic blood
pressure drops below 90 mm Hg, withholding the medication is necessary to prevent further
lowering of blood pressure, which could lead to adverse effects like dizziness, fainting, or
inadequate blood perfusion to vital organs.
Choice C Reason:
Administering the medication with an antacid might interfere with the absorption of
propranolol, so they shouldn't be taken together unless instructed by the healthcare provider.
Choice D Reason:
Expecting increased hair growth is not an anticipated effect of propranolol. Hair growth is not
a usual side effect associated with this medication.

3 . A nurse is assisting with the plan of care for an older adult client who has a new
prescription for transdermal clonidine. Which of the following information should the
nurse include in the plan of care?
A. Inform the client of the adverse effect of diarrhea.
B. Monitor the client for weight loss.
C. Advise the client about increased dry mouth.
D. Check the client for increased hypopigmentation under the patch.
The correct answer is choice C
Explanation
Choice A Reason:
 Informing the client of the adverse effect of diarrhea is less common with clonidine use,
especially in comparison to other side effects like dry mouth or skin irritation.
Choice B Reason:
Monitoring for weight loss isn't a primary concern specifically associated with transdermal
clonidine use.
Choice C Reason:
Advising the client about increased dry mouth is appropriate. Dry mouth is a common side
effect of clonidine, especially when it's administered transdermally (via a patch). Informing
the client about this potential side effect helps them anticipate and manage it. Other side
effects might include skin irritation or redness at the patch application site, but increased
hypopigmentation under the patch is not a recognized or typical side effect of transdermal
clonidine.
Choice D Reason:
Checking for increased hypopigmentation under the patch is not a recognized effect of
transdermal clonidine.

4. A nurse is reviewing the laboratory data of a client who is scheduled for a liver
biopsy. Which of the following values should the nurse report to the provider?
A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
B. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
C. Ammonia 55 mcg/dl. (10 to 80 mcg/dL)
D. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
The correct answer is choice D
Explanation
Choice A Reason:
Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL) is incorrect. Bilirubin levels within the normal range
typically indicate normal liver function. The value of 1.0 mg/dL falls within the expected
range, so it doesn't raise immediate concerns regarding the need for a liver biopsy.
Choice B Reason:
Aspartate aminotransferase 34 units/L (0 to 34 units/L) is incorrect. Aspartate
aminotransferase (AST) is an enzyme found in various tissues, including the liver, heart,
muscles, and red blood cells. While a value of 34 units/L is at the upper limit of the normal
range, it's still within the expected range and doesn't typically prompt immediate concern for
the need for a biopsy.
Choice C Reason:
Ammonia 55 mcg/dL (10 to 80 mcg/dL ) is incorrect. Ammonia levels can rise in cases of
liver dysfunction. The level of 55 mcg/dL falls within the reference range, indicating normal
or near-normal ammonia levels, which doesn't usually necessitate an urgent liver biopsy.
Choice D Reason:
Platelets 60,000/mm3 (150,000 to 400,000/mm3) is correct. Platelets are crucial for blood
clotting. A significantly low platelet count, such as 60,000/mm3, termed thrombocytopenia,
can indicate compromised clotting ability, which might pose a risk of bleeding during or after
a liver biopsy. In the context of a liver biopsy, a low platelet count warrants attention and
consideration before proceeding with the procedure to prevent excessive bleeding or
complications.

5 .A nurse is caring for a client who is postoperative following a right radical

mastectomy. Which of the following actions should the nurse take to prevent the
development of lymphedema?
A. Keep both arms below the level of the client's heart.
B. Limit range-of-motion exercises with the affected arm.
C. Use the client's left arm to obtain blood samples.
D. Obtain blood pressure readings using the client's right arm.
The correct answer is choice C
Explanation
Choice A Reason:
Keeping both arms below the level of the client's heart doesn't specifically address the
prevention of lymphedema and might not be necessary for this purpose.
Choice B Reason:
 Limiting range-of-motion exercises with the affected arm could potentially contribute to
stiffness and reduced function, but appropriate and gradual range-of-motion exercises are
generally recommended to prevent lymphedema.
Choice C Reason:
Using the client's left arm to obtain blood samples is correct. Lymphedema can occur due to
the disruption of lymphatic vessels during surgery, leading to the accumulation of lymph
fluid. To reduce the risk of lymphedema, medical procedures or blood draws should typically
avoid using the affected arm. In this case, after a right radical mastectomy, using the left arm
for blood samples can help protect the compromised lymphatic system in the right arm.
Choice D Reason:
Obtaining blood pressure readings using the client's right arm is not directly related to
preventing lymphedema. However, excessive pressure or trauma to the affected arm should
generally be avoided to reduce the risk of lymphedema.

6 .A nurse is collecting data from an older adult client. Which of the following findings
should indicate to the nurse that the client has a bladder infection?
A. Temperature 37.3° C (99.1° F)
B. Changed mental status
C. WBC count 9,000/mm3 (5000 to 10,000/mm3)
D. Diminished reflexes
The correct answer is choice B
Explanation
Choice A Reason:
Temperature 37.3°C (99.1°F) is incorrect . While a slightly elevated temperature can
sometimes accompany an infection, it's not specific to a bladder infection and might not be
present in all cases.
Choice B Reason:
Changed mental status is correct. Bladder infections or urinary tract infections (UTIs) in
older adults can often present with atypical symptoms, and changes in mental status or acute
confusion are common indicators in this population. UTIs can cause subtle but significant
alterations in mental function, particularly in the elderly, leading to confusion, agitation, or
cognitive impairment.
Choice C Reason:
WBC count 9,000/mm3 (5000 to 10,000/mm3) is incorrect .A WBC count within the normal
range doesn't necessarily rule out or confirm a bladder infection. In some cases, UTIs might
not significantly elevate the white blood cell count, especially in localized infections.
Choice D Reason:
Diminished reflexes is incorrect . Diminished reflexes are not typically associated with a
bladder infection. They might indicate other neurological or muscular issues but are not a
common sign of a UTI.

7 . A nurse is reinforcing teaching with a client who has diabetes mellitus about
reducing the risk for a stroke. Which of the following statements by the client indicates
an understanding of the teaching?
A. "Having a total cholesterol level below 200 mg/dl increases my risk for a stroke."
B. "My risk for a stroke increases if my HbA1c level is 6 percent or less."
C. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a
stroke."
D. "I can decrease my risk for a stroke by losing excess weight."
The correct answer is choice D
Explanation
Choice A Reason:
"Having a total cholesterol level below 200 mg/dl increases my risk for a stroke." This
statement is incorrect. Generally, having a total cholesterol level below 200 mg/dl is
considered beneficial for heart health and reducing the risk of stroke.
Choice B Reason:
"My risk for a stroke increases if my HbA1c level is 6 percent or less." This statement is
incorrect. An HbA1c level of 6 percent or less is an indicator of good blood sugar control,
which usually reduces the risk of stroke. A higher HbA1c level is associated with an
increased risk of complications in diabetes, including stroke.
Choice C Reason:
"My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke." -
Glucocorticoids are not typically prescribed to reduce the risk of stroke in individuals with
diabetes. These medications may have various uses but are not a standard preventive measure
for stroke in this context.
Choice D Reason:
"I can decrease my risk for a stroke by losing excess weight." This statement is appropriate.
Maintaining a healthy weight is a significant factor in reducing the risk of stroke, especially
for individuals with diabetes. Weight management contributes to better control of blood
pressure, cholesterol levels, and blood sugar, which collectively reduce the risk of stroke.

8.A nurse is contributing to the plan of care for a client who has developed an infectious
wound with foul-smelling drainage. Which of the following actions should the nurse
include in the plan of care?
A. Discard soiled wound care supplies in a trash receptacle outside the client's
room,
B. Administer antibiotic therapy before culturing the client's wound.
C. Place the client in a private room with a private bathroom.
D. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client's
room.
The correct answer is choice C
Explanation
Choice A Reason:
Discarding soiled wound care supplies in a trash receptacle outside the client's room is
generally a good practice for infection control. However, this action alone might not be
sufficient for managing an infectious wound. Proper disposal is essential, but placing the
client in isolation is more critical to prevent the spread of infection.
Choice B Reason:
Administering antibiotic therapy before culturing the wound might interfere with accurate
culture results. It's generally preferred to obtain wound cultures before starting antibiotic
therapy to identify the specific pathogens causing the infection and determine the most
effective treatment.
Choice C Reason:
Placing the client in a private room with a private bathroom is correct. Isolating the client in
a private room with a private bathroom helps minimize the spread of potential pathogens
present in the wound drainage. This measure helps contain the infection and prevents
exposure to others.
Choice D Reason:
Instructing visitors to perform hand hygiene for only 5 seconds after leaving the client's
room isn't thorough enough for proper infection control. Proper hand hygiene typically
involves washing hands with soap and water or using alcohol-based hand sanitizer for at least
20 seconds to effectively reduce the spread of infection.
9. A nurse is contributing to the plan of care for a client who has viral meningitis.
Which of the following interventions should the nurse recommend?
A. Measure the client's intake and output every 8 hr.
B. Dim the lighting in the client's room.
C. Monitor the client's temperature every 6 hr.
D. Initiate contact precautions for the client.
The correct answer is choice B
Explanation
Choice A Reason:
Measuring the client's intake and output every 8 hours is a general nursing intervention but
might not be specifically pertinent to managing viral meningitis.
Choice B Reason:
Dim the lighting in the client's room is correct. Meningitis often causes sensitivity to light
(photophobia) due to the inflammation of the meninges surrounding the brain and spinal cord.
Dimming the lighting in the client's room helps reduce discomfort and sensitivity to light,
which is a common symptom of meningitis.
Choice C Reason:
Monitoring the client's temperature every 6 hours is a routine nursing practice, but in viral
meningitis, more frequent temperature monitoring might be necessary, especially if the client
shows signs of fever or instability.
Choice D Reason:
Initiating contact precautions for viral meningitis is not typically necessary because it's
usually transmitted through respiratory secretions. Standard precautions for infection control,
including proper hand hygiene, are usually sufficient.

10 .A nurse is initiating the use of a continuous passive motion (CPM) device for a client
following a total knee arthroplasty. Which of the following actions should the nurse
take?
A. Set the degree of flexion and extension as tolerated by client.
B. Pad the CPM device with a thick pillow.
 C. Place the client in high-Fowler's position.
D. Align the client's joints with the joints on the frame.
The correct answer is choice D
Explanation
Choice A Reason:
Setting the degree of flexion and extension as tolerated by the client is generally appropriate
in a CPM device, but this should be done within the prescribed range recommended by the
healthcare provider. Simply allowing the client to adjust the degree of flexion and extension
without guidance might lead to overextension or inadequate movement, potentially causing
discomfort or hindering recovery.
Choice B Reason:
Padding the CPM device with a thick pillow isn't the recommended approach. CPM devices
typically come with appropriate padding to ensure comfort and proper positioning. Using a
thick pillow might alter the device's mechanics or cause uneven support, affecting the
intended movement of the knee.
Choice C Reason:
Placing the client in high-Fowler's position (sitting upright at a 90-degree angle) isn't a
standard or necessary position for using a CPM device after a knee arthroplasty. The client
can typically use the CPM device while lying in a comfortable and relaxed position,
following the healthcare provider's instructions regarding positioning during CPM therapy.
Choice D Reason:
Aligning the client's joints with the joints on the frame is essential for the correct function of
the CPM device. This alignment helps in providing the intended range of motion without
causing unnecessary stress or strain on the knee joint.

11. A nurse is preparing to administer warfarin to a client who has chronic atrial
fibrillation. Which of the following laboratory values should the nurse monitor prior to
administering the medication?
A. LDL
B. INR
C. BUN
 D. Hct
The correct answer is choice B
Explanation
Choice A Reason:
LDL (Low-Density Lipoprotein) is incorrect. This is a type of cholesterol and is not
specifically monitored in relation to warfarin therapy.
Choice B Reason:
INR (International Normalized Ratio) is correct. Warfarin is an anticoagulant medication,
and its dosage needs to be adjusted based on the INR levels. INR monitoring helps assess the
clotting tendency of the blood and ensures that the dosage of warfarin is within the
therapeutic range to prevent blood clots without causing excessive bleeding.
Choice C Reason:
BUN (Blood Urea Nitrogen) is incorrect. This value is primarily used to assess kidney
function and is not directly related to monitoring warfarin therapy.
Choice D Reason:
Hct (Hematocrit) is incorrect. This measures the percentage of red blood cells in the blood
and is not directly related to monitoring warfarin therapy for atrial fibrillation.

12 .A nurse is reinforcing discharge teaching with a client who has a new permanent
pacemaker. Which of the following statements by the client indicates an understanding
of the teaching?
A. "I'll make sure I stay away from microwave ovens."
B. "I should have an MRI, rather than a CAT scan, if necessary."
C. "Ill hold my cell phone against the ear on the opposite side of my body."
D. "I shouldn't travel by plane because of airport security."
The correct answer is choice C
Explanation
Choice A Reason:
"I'll make sure I stay away from microwave ovens." This statement is incorrect . While there
were concerns about interference in the past, modern pacemakers are generally not affected
by household appliances like microwave ovens.
Choice B Reason:
"I should have an MRI, rather than a CAT scan, if necessary." This statement is incorrect.
Both MRI and CAT scans have considerations when a person has a pacemaker. An MRI
might be contraindicated due to the magnetic field, while a CAT scan might be a safer
imaging choice.
Choice C Reason:
"I'll hold my cell phone against the ear on the opposite side of my body." This statement
reflects an understanding of the precaution to avoid holding a cell phone directly over the
implanted pacemaker. Keeping the phone on the opposite side helps minimize the potential
interference with the pacemaker's function.
Choice D Reason:
"I shouldn't travel by plane because of airport security." This statemen t is incorrect. Airport
security systems generally don't affect pacemakers, so traveling by plane is usually safe.
However, informing security personnel about the presence of a pacemaker is a good practice.

13 A nurse is contributing to the plan of care for a client who has AIDS and has
malnutrition. Which of the following actions should the nurse include in the plan of
care?
A. Encourage three large meals daily.
B. Administer an antiemetic after each meal.
C. Season foods with spices.
D. Provide a high-calorie diet.
The correct answer is choice D
Explanation
Choice A Reason:
Encouraging three large meals daily might not be feasible for someone experiencing
malnutrition and decreased appetite. Smaller, more frequent meals or snacks throughout the
day could be better tolerated and more beneficial.
Choice B Reason:
Administering an antiemetic after each meal assumes that the client will experience nausea
or vomiting regularly after eating. This might not be the case for all clients with AIDS and
may not be necessary if the primary issue is malnutrition without associated frequent
vomiting.
Choice C Reason:
Seasoning foods with spices might improve the taste of food and potentially stimulate
appetite, but it's not as direct or comprehensive a measure for addressing malnutrition as
providing a high-calorie diet.
Choice D Reason:
Provide a high-calorie diet is correct. Clients with AIDS often experience malnutrition due to
various factors such as decreased appetite, difficulty eating, or malabsorption. Offering a
high-calorie diet can help address the nutritional deficiencies and support the body's
increased energy needs.
14. A nurse is caring for a client who has a distal radius fracture with a short arm cast
applied. Which of the following actions should the nurse take?
A. Use a hair dryer to blow hot air into the cast to relieve itching.
B. Perform neurovascular checks of the affected extremity every 2 hr.
C. Position the fractured arm below the level of the client's heart.
D. Immobilize the client's fingers using a hand splint.
The correct answer is choice B
Explanation
Choice A Reason
Using a hair dryer to blow hot air into the cast is not recommended. It can cause burns, soften
the cast material, or create hot spots, potentially leading to skin damage or discomfort for the
client.
Choice B Reason:
Perform neurovascular checks of the affected extremity every 2 hours is correct. Performing
neurovascular checks regularly is crucial to assess the circulation, sensation, and movement
of the affected extremity. This monitoring helps identify any signs of compromised blood
flow or nerve function, which could indicate complications such as compartment syndrome.
Choice C Reason:
Positioning the fractured arm below the level of the client's heart is not advisable. Elevating
the injured limb above heart level can help reduce swelling and promote blood flow, aiding in
the healing process and preventing complications like swelling-related discomfort or
decreased circulation.
Choice D Reason:
Immobilizing the client's fingers using a hand splint might not be necessary with a short arm
cast. Typically, a short arm cast provides immobilization of the wrist and forearm while
allowing some movement and function of the fingers unless specifically directed by the
healthcare provider for individual circumstances.
15. A nurse is assisting in the plan of care for a client who has thrombocytopenia.
Which of the following actions should the nurse include in the plan?
A. Check the client for ecchymosis.
B. Initiate protective isolation for the client.
C. Administer ibuprofen for mild headache.
D. Instruct the client to shave with a disposable razor.
The correct answer is choice A
Explanation
Choice A Reason:
Checking the client for ecchymosis is appropriate. Thrombocytopenia increases the risk of
bleeding and bruising, so monitoring for ecchymosis (bruising) is essential to detect any signs
of bleeding. Ecchymosis can occur more easily in individuals with low platelet counts.
Choice B Reason:
Initiating protective isolation for the client is typically unnecessary solely due to
thrombocytopenia. Protective isolation is generally for clients with conditions that
compromise their immune system or make them more susceptible to infections.
Choice C Reason:
Administering ibuprofen for a mild headache might not be advisable in someone with
thrombocytopenia because ibuprofen can affect platelet function and potentially increase the
risk of bleeding.
Choice D Reason:
Instructing the client to shave with a disposable razor isn't recommended because using a
sharp blade can increase the risk of cuts and bleeding in someone with low platelet count.
Using an electric razor or avoiding shaving might be safer options to prevent injury and
bleeding.

16. A nurse is caring for a client who has a sulfa allergy. Which of the following
prescriptions should the nurse clarify with the provider?
A. Digoxin
B. Prednisone
C. Celecoxib
D. Atorvastatin
The correct answer is choice C
Explanation
Choice A Reason:
Digoxin is a cardiac medication used to treat heart conditions such as heart failure and certain
arrhythmias. There's no direct chemical relationship between digoxin and sulfa compounds.
Generally, digoxin does not contain sulfa components, so it's less likely to cause an allergic
reaction in individuals with sulfa allergies. This medication does not typically require
clarification for someone with a sulfa allergy.

Choice B Reason:
Prednisone is a corticosteroid used to treat a variety of conditions, including inflammation,
allergies, and autoimmune disorders. It does not contain sulfonamide groups in its structure.
As a corticosteroid, prednisone is distinct from sulfonamide drugs and is generally considered
safe for individuals with sulfa allergies. There is typically no need to clarify this medication
for a sulfa-allergic client.

Choice C Reason:
Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that belongs to the sulfonamide
class. While it is not the same as sulfonamide antibiotics, it contains a sulfonamide moiety in
its chemical structure. There's a possibility of cross-reactivity or allergic reactions in
individuals with sulfa allergies due to the structural similarity, making it essential to clarify
this prescription for someone with a sulfa allergy.

Choice D Reason:
Atorvastatin is a statin medication used to lower cholesterol levels. It does not contain a
sulfonamide group in its structure. Statins belong to a different drug class and do not typically
pose a risk of cross-reactivity in individuals with sulfa allergies. Therefore, atorvastatin is
generally considered safe and does not usually require clarification for a sulfa-allergic client.
17. An occupational health nurse is interpreting the results of a tuberculin skin test for
a group of clients who received the test 48 hr ago. Which of the following clients should
the nurse identify as having a positive test result?
A. A client whose injection site is scabbed
B. A client whose injection site is firm and measures 3 mm (0.1 in)
C. A client whose injection site has an elevated area measuring 15 mm (0.6 in)
D. A client whose injection site is ecchymotic
The correct answer is choice C
Explanation
Choice A Reason:
A client whose injection site is scabbed is incorrect. Scabbing at the injection site does not
provide information about the presence or absence of induration. It doesn't contribute to
interpreting the test result directly.
Choice B Reason:
A client whose injection site is firm and measures 3 mm (0.1 in) is incorrect. A measurement
of 3 mm of induration is generally considered a negative result for most individuals,
including those without any risk factors for tuberculosis (TB).
Choice C Reason:
A client whose injection site has an elevated area measuring 15 mm (0.6 is correct. An area
of induration measuring 15 mm or more is considered positive in individuals with no known
risk factors for TB.
Choice D Reason:
A client whose injection site is ecchymotic is incorrect. Ecchymosis (bruising) at the injection
site is not relevant to the interpretation of the tuberculin skin test. It does not contribute to
determining a positive or negative result.

18. A nurse is caring for a client who has cardiomyopathy and is experiencing sensory
overload. Which of the following actions should the nurse take?
A. Ensure the blinds in the client's room remain open.
B. Place the client in a room near the nurses' station.
C. Play quiet music in the client's room.
D. Break up nursing care into small, frequent sessions.
The correct answer is choice D
Explanation
Choice A Reason:
Ensure the blinds in the client's room remain open is not appropriate. Bright light can
contribute to sensory overload. It's better to create a subdued and calming environment, so
keeping the blinds closed or partially closed might help reduce excess stimuli.
Choice B Reason:
Place the client in a room near the nurses' station is not appropriate. Being near the nurses'
station could increase the noise and activity around the client, potentially worsening sensory
overload. It's advisable to place the client in a quieter area away from high-traffic zones to
minimize auditory and visual stimulation.
Choice C Reason:
Play quiet music in the client's room is incorrect. While soothing music might help some
individuals relax, for someone experiencing sensory overload, even low-volume music could
add to the stimuli. Silence or minimal ambient noise might be more beneficial.
Choice D Reason:
Break up nursing care into small, frequent sessions is correct. This action is beneficial for
managing sensory overload. Breaking up care into smaller sessions allows for adequate rest
periods between activities, reducing the overall sensory input at any given time.

19. A nurse is preparing to perform tracheostomy care for a client. In which order
should the nurse take the following steps? (Move the steps into the box on the right,
placing them in the order of performance. Use all the steps.)
A. Ensure a method to communicate during the procedure.
B. Wear clean gloves to remove the tracheostomy dressing.
C. Clean the inner cannula using a small brush.
D. Explain the procedure to the client.
E. Apply clean tracheostomy ties.
The correct step is D, B, C,E,A
Explanation
Step D: Explain the procedure to the client. It's crucial to inform the client about the
upcoming procedure to promote cooperation, reduce anxiety, and ensure they understand
what will happen during the care. This step also allows the client to ask questions and
participate in their care if possible.
Step B: Wear clean gloves to remove the tracheostomy dressing:** Wearing clean gloves is
essential to maintain aseptic technique and prevent contamination during the procedure.
Removing the dressing allows access to the tracheostomy site for cleaning and assessment.
Step C: Clean the inner cannula using a small brush: Cleaning the inner cannula helps prevent
blockages and ensures a patent airway for the client. Regular cleaning of the inner cannula
helps remove secretions and debris that could obstruct the airflow through the tracheostomy
tube.
Step E: Apply clean tracheostomy ties: Securing the tracheostomy tube in place with clean
ties is essential to prevent accidental dislodgement or movement of the tube. Properly
securing the tracheostomy ties helps maintain the tube's position and ensures the client's
safety.
Step A: Ensure a method to communicate during the procedure:** Communication is crucial
during tracheostomy care. Ensuring the client has a method to communicate (such as using a
communication board, gestures, or writing) allows them to express any discomfort or
concerns during the procedure when verbal communication might be limited due to the care
being performed. This step promotes client comfort and safety during the process.

20 .A nurse administered a dose of penicillin to a client 30 min ago. The client reports
she has hives and is itching. Which of the following statements by the nurse is the
highest priority?
A. “I’m going to take your heart rate."
B. "I need to give you diphenhydramine."
C. "Are you having difficulty breathing?"
D. "Do you have any allergies to medications?"
The correct answer is choice C
Explanation
Choice A Reason:
“I'm going to take your heart rate”. This statement is incorrect. Monitoring vital signs like
heart rate is essential in assessing a client's condition. However, in this scenario, the client's
report of hives, itching, and a potential allergic reaction is more indicative of an immediate
concern for anaphylaxis. While monitoring heart rate is relevant, assessing for signs of
anaphylaxis, especially difficulty breathing, takes precedence due to the urgency of potential
respiratory distress.
Choice B Reason:
"I need to give you diphenhydramine". This statement is incorrect, administering an
antihistamine like diphenhydramine can help alleviate allergic symptoms, including itching
and hives. However, confirming the severity of the reaction and ensuring there are no life-
threatening symptoms such as breathing difficulties is the immediate priority before
administering any medication.
Choice C Reason:
"Are you having difficulty breathing?" This statement is correct. This question directly
assesses the client's respiratory status, a crucial indicator of anaphylaxis. If the client is
experiencing difficulty breathing, it indicates a severe allergic reaction that requires
immediate intervention and emergency medical attention. Recognizing and addressing
potential respiratory distress is of utmost importance in managing an allergic reaction to
medication.
Choice D Reason:
"Do you have any allergies to medications? This statement is incorrect. Understanding the
client's medical history, including allergies, is crucial. However, in this acute situation where
the client is already experiencing symptoms of a potential allergic reaction shortly after
receiving penicillin, addressing the current symptoms and assessing for signs of anaphylaxis
is the most immediate concern.

21. A nurse is contributing to the plan of care for a client who has influenza. Which of
the following interventions should the nurse include in the plan?
A. Have the client wear a surgical mask during transport.
B. Wear an N95 mask while providing care to the client.
C. Administer an influenza immunization to the client.
D. Place the client in a negative airflow room.
The correct answer is choice A and B
Explanation
Choice A Reason:
Having the client wear a surgical mask during transport is recommendable. This intervention
aims to prevent the spread of respiratory droplets from the client, potentially reducing the risk
of infecting others. It's a preventive measure to contain the transmission of the virus.
Choice B Reason:
Wearing an N95 mask while providing care to the client is not recommended. N95 masks
offer a higher level of respiratory protection compared to surgical masks. They are designed
to filter out small particles and provide a closer facial fit, primarily protecting the wearer
from inhaling airborne particles, including viruses. Healthcare providers may use N95 masks
when working closely with infectious patients to reduce the risk of airborne transmission.
Choice C Reason:
Administering an influenza immunization to the client is not recommendable. Influenza
immunization is a preventive measure that can protect against specific strains of the influenza
virus. However, if the client already has influenza, administering the vaccine won't treat the
current infection. Nonetheless, it's essential for prevention in the future, especially for
individuals at risk of complications or for herd immunity.
Choice D Reason:
Placing the client in a negative airflow room is not recommendable. Negative airflow rooms
are designed to prevent airborne pathogens from spreading to other areas. However, these
rooms are typically utilized for airborne infections that require isolation due to their
transmission via small particles suspended in the air (such as tuberculosis or measles).
Influenza is primarily spread through droplets, and negative airflow rooms may not be
routinely used for influenza cases unless there are complications or the client has specific
medical conditions necessitating strict isolation.
22.A nurse is assisting with the care of a client who is receiving peritoneal dialysis.
Which of the following actions should the nurse take?
A. Chill the dialysate prior to infusion.
B. Monitor the client for diarrhea.
C. Weigh the client before and after the treatment.
D. Use clean gloves when handling dialysate bags.
The correct answer is choice C
Explanation
Choice A Reason:
Chill the dialysate prior to infusion .Generally, the dialysate used in peritoneal dialysis is
warmed to body temperature before infusion to enhance comfort and prevent abdominal
discomfort. Chilling the dialysate can cause discomfort and is not a standard practice in
peritoneal dialysis.
Choice B Reason:
Monitor the client for diarrhea. While gastrointestinal symptoms might occur in some
individuals undergoing peritoneal dialysis due to changes in fluid balance, diarrhea is not a
typical or expected outcome. However, monitoring for any unusual gastrointestinal symptoms
or changes in bowel habits is part of holistic client care.
Choice C Reason:
Weigh the client before and after the treatment. Weighing the client before and after
peritoneal dialysis is a critical step to assess the effectiveness of the treatment. The difference
in weight helps determine how much fluid was removed during the dialysis process,
providing valuable information about the treatment's efficacy and the client's fluid status.
Choice D Reason:
Use clean gloves when handling dialysate bags. Maintaining aseptic technique during
peritoneal dialysis is crucial to prevent infections. The use of clean gloves (not sterile gloves,
unless otherwise specified) when handling dialysate bags helps minimize the risk of
contamination, ensuring the safety of the procedure.
23.A nurse is assisting with the care of a client who has a seizure disorder. Which of the
following supplies should the nurse have at the client's bedside at all times?
A. Suction equipment
B. Padded tongue blades
C. Backboard
D. Wrist restraints
The correct answer is choice A
Explanation
Choice A Reason:
Suction equipment is recommended. This is a crucial supply to have at hand. During or after
a seizure, the client might have excessive secretions or vomit, which could potentially
obstruct their airway. Suction equipment helps clear the airway and maintain breathing,
making it an essential item to have bedside.
Choice B Reason:
Padded tongue blades is incorrect. The use of padded tongue blades during a seizure is not
recommended. Placing anything inside the mouth during a seizure could cause injury or pose
a risk of choking. Keeping the airway clear and ensuring the client's safety is more important
than attempting to manipulate the tongue.
Choice C Reason:
Backboard is incorrect.Backboards are typically used for spinal immobilization in cases of
suspected spinal injury, not specifically for seizure management. Unless there's a concurrent
injury or trauma, a backboard wouldn't be routinely necessary for a client having a seizure.
Choice D Reason:
Wrist restraints is incorrect. Restraints are generally not used for managing seizures. Using
restraints during a seizure could potentially cause harm, restrict movement, and increase the
risk of injury to the client. Restraints are not considered appropriate or safe for managing
seizures.
24. A nurse is reviewing a client's medical history to identify risk factors for
osteoporosis. The nurse should identify that which of the following findings is a risk
factor for developing osteoporosis?
A. Age 45 years
B. Regular aerobic exercise
C. Uses NSAIDS for pain relief
D. Smokes cigarettes
The correct answer is choice D
Explanation
Choice A Reason:
Age 45 years is incorrect.While age is a significant factor in osteoporosis risk, 45 years old
isn't inherently considered a high-risk age for developing osteoporosis. However, bone
density tends to decrease gradually with age, and after menopause in women, there's a more
significant decline due to hormonal changes.
Choice B Reason:
Regular aerobic exercise is incorrect. Regular exercise, particularly weight-bearing and
muscle-strengthening activities, is typically beneficial for bone health. It can help maintain or
improve bone density and strength, reducing the risk of osteoporosis. Therefore, regular
aerobic exercise is generally considered a protective factor against osteoporosis, rather than a
risk factor.
Choice C Reason:
Uses NSAIDs for pain relief is incorrect. While long-term use of certain medications, such as
glucocorticoids (steroids), can increase the risk of osteoporosis due to their impact on bone
density, the use of NSAIDs (nonsteroidal anti-inflammatory drugs) for pain relief isn't
directly linked to osteoporosis as a significant risk factor. However, chronic use of certain
medications might have implications for bone health and should be assessed on an individual
basis.
Choice D Reason:
Smoking is a known risk factor for osteoporosis. It can have detrimental effects on bone
health by interfering with the body's ability to absorb calcium, decreasing estrogen levels, and
impairing bone-forming cells. Consequently, smokers have a higher risk of developing
osteoporosis compared to non-smokers.

25. A nurse is reviewing a client's medical history to identify risk factors for
osteoporosis. The nurse should identify that which of the following findings is a risk
factor for developing steps
A. Age 45 years
B. Regular aerobic exercise
C. Uses NSAIDS for pain relief
D. Smokes cigarettes
The correct answer is choice D
Explanation
Choice A Reason:
Age 45 years is incorrect. While age is a significant factor in osteoporosis risk, 45 years old
isn't inherently considered a high-risk age for developing osteoporosis. However, bone
density tends to decrease gradually with age, and after menopause in women, there's a more
significant decline due to hormonal changes.
Choice B Reason:
Regular aerobic exercise is incorrect. Regular exercise, particularly weight-bearing and
muscle-strengthening activities, is typically beneficial for bone health. It can help maintain or
improve bone density and strength, reducing the risk of osteoporosis. Therefore, regular
aerobic exercise is generally considered a protective factor against osteoporosis, rather than a
risk factor.
Choice C Reason:
Uses NSAIDs for pain relief is incorrect. While long-term use of certain medications, such as
glucocorticoids (steroids), can increase the risk of osteoporosis due to their impact on bone
density, the use of NSAIDs (nonsteroidal anti-inflammatory drugs) for pain relief isn't
directly linked to osteoporosis as a significant risk factor. However, chronic use of certain
medications might have implications for bone health and should be assessed on an individual
basis.
Choice D Reason:
Smoking is a known risk factor for osteoporosis. It can have detrimental effects on bone
health by interfering with the body's ability to absorb calcium, decreasing estrogen levels, and
impairing bone-forming cells. Consequently, smokers have a higher risk of developing
osteoporosis compared to non-smokers.

26. A nurse is reinforcing teaching with a client who has a prescription for sublingual
nitroglycerin for unstable angina. Which of the following instructions should the nurse
include in the instructions?
A. Refill the prescription every 12 months.
B. Take a second tablet after 5 min for unrelieved chest pain.
C. Swallow the tablet whole with a glass of water.
D. Store the medication in the refrigerator.
The correct answer is choice B
Explanation
Choice A Reason:
Refill the prescription every 12 months. This statement focuses on the frequency of
prescription refills rather than guidance on the medication's use. While it's important to keep
prescriptions up to date, this instruction doesn't directly relate to the administration or use of
sublingual nitroglycerin for angina.
Choice B Reason:
Take a second tablet after 5 minutes for unrelieved chest pain. This advice is crucial because
if the chest pain persists after the first tablet, taking a second tablet after 5 minutes (and
seeking emergency medical assistance if pain persists after the second tablet) is part of the
recommended protocol for managing unstable angina with sublingual nitroglycerin.
Choice C Reason:
Swallow the tablet whole with a glass of water. Sublingual nitroglycerin is designed to
dissolve under the tongue, not to be swallowed. The medicine is absorbed through the blood
vessels in the mouth to provide rapid relief for angina symptoms. Instructing the patient to
swallow the tablet defeats the purpose of sublingual administration.
Choice D Reason:
Store the medication in the refrigerator. Nitroglycerin should generally be stored in a cool,
dry place and away from direct sunlight, but refrigeration is not necessary. Storing it in the
refrigerator might actually alter the medication's effectiveness or consistency, making it less
reliable for quick absorption when needed during an angina episode.

27 .A nurse is reinforcing teaching with a client who is taking enoxaparin. Which of the
following statements by the client indicates an understanding of the teaching?
A. "will use ibuprofen when I have a headache.”
B. “will use an electric razor for shaving”
C. “will avoid the use of stool softeners."
D. "I will massage the site after each injection.”
The correct answer is choice B
Explanation
Choice A Reason:
"Will use ibuprofen when I have a headache." This statement is inappropriate. Enoxaparin is
an anticoagulant, and using nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
can increase the risk of bleeding. So, using ibuprofen isn't recommended without consulting a
healthcare professional while on enoxaparin.
Choice B Reason:
“Will use an electric razor for shaving.” This statement is correct. Enoxaparin is an
anticoagulant, and using a sharp razor increases the risk of bleeding. Using an electric razor
reduces the chance of nicks or cuts that could lead to bleeding complications while on this
medication.
Choice C Reason:
“Will avoid the use of stool softeners." This statement is inappropriate. Enoxaparin doesn't
directly interact with stool softeners. However, it's crucial to consult a healthcare provider
before taking any new medications, including stool softeners, while on enoxaparin, as there
might be potential interactions or effects on clotting.
Choice D Reason:
"I will massage the site after each injection." This statement is inappropriate. Massaging the
site after an enoxaparin injection could potentially cause bruising or irritation. The usual
recommendation is to apply gentle pressure at the injection site for a short time after the
injection but not to massage it vigorously.

28.A nurse is caring for a client who has dysphagia following a stroke. The nurse should
recommend a referral to which of the following members of the interdisciplinary team?
A. Speech therapist
B. Respiratory therapist
C. Occupational therapist
D. Physical therapist
The correct answer is choice A
Explanation
Choice A Reason:
Speech therapists, also known as speech-language pathologists, specialize in evaluating and
treating swallowing difficulties (dysphagia) among other speech and language issues. They
are trained to assess and provide therapies to improve swallowing function, ensuring safe and
effective swallowing to prevent aspiration and related complications.
Choice B Reason:
Respiratory therapists primarily focus on the respiratory system and breathing issues. While
they play a crucial role in managing respiratory problems, their expertise generally centers
around respiratory treatments, ventilator management, and pulmonary function testing. They
might assist if dysphagia leads to aspiration and subsequent respiratory complications, but the
primary management of dysphagia itself falls within the scope of a speech therapist.
Choice C Reason:
Occupational therapists assist individuals in regaining independence in daily activities. While
they may help with certain aspects of dysphagia management, their primary focus isn't
specifically on evaluating and treating swallowing disorders. They might address related
issues, such as adapting eating utensils or positioning during meals to assist the client, but
they may not have the specialized training needed for direct dysphagia therapy.
Choice D Reason:
Physical therapists primarily focus on improving mobility, strength, and physical function.
While they might address certain issues related to oral motor function or posture during
eating that could affect swallowing, their expertise lies more in physical rehabilitation rather
than the specialized treatment of dysphagia.

29. A nurse is assisting with the care of a client who has a closed-chest tube drainage
system. Which of the following actions should the nurse take?
 A. Replace the unit when the drainage chamber is full.
B. Clamp the tube for 30 min every 8 hr.
C. Pin the tubing to the client's bed sheets.
D. Monitor for at least 150 mL of drainage every hour.
The correct answer is choice A
Explanation
Choice A Reason:
Replace the unit when the drainage chamber is full is correct. Regularly emptying the
drainage chamber when it becomes full is essential to ensure the drainage system functions
properly and continues to effectively remove fluids or air from the chest cavity.

Choice B Reason:
Clamp the tube for 30 min every 8 hr. is incorrect.
Clamping a chest tube without a specific medical order or indication can lead to
complications such as a buildup of pressure within the chest cavity or potential damage to the
lungs. It's generally not a routine action to clamp the tube without proper instruction.

Choice C Reason:
Pin the tubing to the client's bed sheets is incorrect. Pinning the tubing to the bed sheets can
cause tension on the chest tube, leading to accidental dislodgment or obstruction. The tubing
should be secured but not pinned to prevent inadvertent movement.

Choice D Reason:
Monitor for at least 150 mL of drainage every hour is incorrect. There isn't a standard or
prescribed amount of drainage that should occur hourly. The nurse should monitor the
drainage rate and characteristics but shouldn't expect a specific volume within a set
timeframe. Monitoring for excessive or decreased drainage and changes in characteristics is
crucial, but an hourly volume expectation isn't appropriate.

30. A nurse working the night shift is caring for an older adult client who has dementia
and is at risk for falls. Which of the following actions should the nurse take?
A. Leave the television on in the client's room
B. Raise all four side rails while the client is in bed.
C. Move the overbed table away from the bed.
D. Apply a motion sensor mat to the client's bed
The correct answer is choice D
Explanation
Choice A Reason:
Leave the television on in the client's room is incorrect. Leaving the television on doesn't
directly address the safety concern of falls. While it might provide some distraction or
comfort, it doesn't mitigate the risk of the client attempting to leave the bed unsafely.
Choice B Reason:
Raise all four side rails while the client is in bed is incorrect. Using all four side rails can be
considered a form of restraint and is generally not recommended due to the risk of
entrapment and potential psychological distress for the client. It can also increase the risk of
agitation and attempts to climb over the rails, potentially resulting in falls.
Choice C Reason:
Move the overbed table away from the bed is incorrect. Moving the overbed table might
reduce clutter around the bed area, but it doesn't directly address the risk of falls for a client
with dementia. It's more about optimizing the environment than specifically addressing the
safety concern related to the client's condition.
Choice D Reason:
Apply a motion sensor mat to the client's bed is correct. For an older adult with dementia at
risk for falls, a motion sensor mat can be an effective safety measure. It alerts the staff when
the client attempts to get out of bed, allowing for timely intervention to prevent falls. This
helps the nursing staff respond promptly, ensuring the client's safety.

31. A nurse is reviewing the results of a client's fecal occult blood screening test. Which
of the following findings from the client's history should the nurse identify as potentially
causing a false-positive result?
A. The client had a hemorrhoidectomy 1 year ago.
B. The client takes ibuprofen for headaches.
C. The client has a history of breast cancer.
D. The client consumed citrus juice 3 days before the test
The correct answer is choice B
Explanation
Choice A Reason:
The client had a hemorrhoidectomy 1 year ago is appropriate. While hemorrhoids involve
bleeding in the anal area, the blood from hemorrhoids is usually visibly present and not
considered "occult" or hidden. A history of hemorrhoidectomy is less likely to cause a false-
positive occult blood test result as the bleeding is typically visible.
Choice B Reason:
 The client takes ibuprofen for headaches is correct. Nonsteroidal anti-inflammatory drugs
(NSAIDs) like ibuprofen can irritate the gastrointestinal tract, leading to small amounts of
bleeding. This bleeding, although not typically visible, can be detected by occult blood tests,
resulting in a false-positive result
Choice C Reason:
The client has a history of breast cancer is incorrect. A history of breast cancer, in itself, is
not directly related to gastrointestinal bleeding that would lead to a false-positive result in an
occult blood test. Occult blood screening tests primarily detect bleeding from the
gastrointestinal tract.
Choice D Reason:
The client consumed citrus juice 3 days before the test is incorrect. Consumption of citrus
juice is not known to cause false-positive results in occult blood screening tests. These tests
are designed to detect blood specifically from the gastrointestinal tract and aren't affected by
citrus juice consumption.

32. A nurse is reinforcing teaching about the care of a client who has tinea corporis with
a newly licensed nurse. Which of the following should the nurse include in the teaching?
A. Place on airborne precautions.
B. Avoid direct contact.
C. Isolate for 24 hr. after lesions appear.
D. Administer a broad-spectrum antibiotic.
The correct answer is choice B
Explanation
Choice A Reason:
Place on airborne precautions. This is incorrect. Tinea corporis isn't transmitted through the
air. Airborne precautions are specific infection control measures for diseases transmitted
through airborne particles, like tuberculosis or measles, which are caused by specific bacteria
or viruses.
Choice B Reason:
Avoid direct contact is correct. Direct contact is a crucial precaution to prevent the spread of
tinea corporis. It's a contagious infection, often transmitted through skin-to-skin contact or by
sharing contaminated items such as clothing, towels, or bedding. Encouraging precautions
like not sharing personal items and avoiding direct skin contact helps prevent the spread of
the infection to others.
Choice C Reason:
Isolate for 24 hr. after lesions appear is incorrect. While it's essential to take precautions to
prevent spread, isolating for only 24 hours after lesions appear might not be sufficient. The
infection can remain contagious until it's effectively treated and lesions have resolved. More
extended isolation or precautions might be necessary until the infection is no longer
transmissible.
Choice D Reason:
Administer a broad-spectrum antibiotic is incorrect. Tinea corporis is a fungal infection, not a
bacterial one, so antibiotics would not be effective against it. Antifungal medications, such as
topical or oral antifungals, are the primary treatment for tinea corporis. Using an antibiotic
would not treat the fungal infection and might lead to inappropriate medication use.

33.A nurse is contributing to the plan of care for a client who is starting bowel training
for the management of fecal incontinence. Which of the following interventions should
the nurse recommend?
A. Assist the client to the restroom 30 min after meals.
B. Limit the client's physical activity until bowel continence is achieved.
C. Limit the client's fluid intake to 1500 mL/day.
D. Instruct the client to limit their intake of high-fiber foods
The correct answer is choice A
Explanation
Choice A Reason:
Assisting the client to the restroom 30 minutes after meals is correct recommendation. This
intervention aligns with the natural response of the gastrocolic reflex, which often leads to
increased colonic motility after eating. Timing the restroom visit to this period can take
advantage of the body's natural tendency to have a bowel movement after meals, potentially
aiding in achieving bowel continence.
Choice B Reason:
Limiting the client's physical activity until bowel continence is achieved is not appropriate.
Physical activity can actually stimulate bowel function and regularity. Moderate physical
activity, as appropriate for the client's condition, can promote regular bowel movements.
Restricting physical activity might hinder the overall success of bowel training.
Choice C Reason:
 Limiting the client's fluid intake to 1500 mL/day is not appropriate. Adequate hydration is
crucial for bowel health and regularity. Limiting fluid intake could lead to dehydration and
constipation, which can exacerbate fecal incontinence. It's important to encourage adequate
hydration unless there are specific medical reasons to restrict fluids.
Choice D Reason:
Instructing the client to limit their intake of high-fiber foods is incorrect. High-fiber foods are
beneficial for bowel regularity and can help manage fecal incontinence by promoting healthy
bowel movements. Limiting high-fiber foods could potentially lead to constipation or
exacerbate the issue of fecal incontinence.

34.A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client
who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the
client's blood with a solution of water and which of the following cleaning agents?
A. Isopropyl alcohol
B. Bleach
C. Hydrogen peroxide
D. Chlorhexidine
The correct answer is choice B
Explanation
Choice A Reason:
Isopropyl alcohol is the appropriate cleaning agent. While alcohol can be used as a
disinfectant for some purposes, it might not be as effective as bleach against bloodborne
pathogens like HIV. Bleach is generally recommended for disinfection in this context.
Choice B Reason:
Bleach is recommendable. Bleach is effective in disinfecting surfaces contaminated with
bloodborne pathogens, including HIV. It's recommended for cleaning and disinfecting areas
contaminated with blood as it can effectively kill many pathogens, including viruses like
HIV. The standard recommendation is to create a solution of bleach and water to clean
surfaces contaminated with blood.
Choice C Reason:
Hydrogen peroxide is not recommendable. Hydrogen peroxide has some disinfectant
properties, but bleach is more effective against bloodborne pathogens like HIV when used to
clean contaminated surfaces.
Choice D Reason:
Chlorhexidine is not appropriate. Chlorhexidine is an antiseptic commonly used for skin
disinfection before procedures. While it's effective for certain purposes, it's not typically
recommended for disinfecting surfaces contaminated with bloodborne pathogens like HIV.
Bleach is the preferred agent in such cases.
35. A nurse is providing first aid for a client who has a minor burn on one hand, which
of the following actions should the nurse take? (Select all that apply.)
A. Maintain skin integrity over the blisters.
B. Apply ice to the larger blisters.
C. Administer ibuprofen for pain.
D. Run cool water over the affected area.
E. Allow the affected area to remain open to air.
The correct answer is choice A,C,D
Explanation
Choice A Reason:
Maintaining skin integrity over the blisters is correct. Blisters form as a protective
mechanism for the skin underneath. Popping or breaking blisters increases the risk of
infection as it exposes the raw skin to bacteria and other contaminants.
Choice B Reason:
Applying ice to the larger blisters is incorrect.
Reason: Applying ice directly to a burn, especially to blisters, can further damage the skin
and exacerbate the injury. Ice can cause additional skin damage and can potentially increase
pain and delay healing.
Choice C Reason:
Administering ibuprofen for pain is correct. Ibuprofen is an effective over-the-counter pain
reliever that can help manage the discomfort caused by a minor burn. It also has anti-
inflammatory properties that can reduce swelling associated with burns.
Choice D Reason:
Running cool water over the affected area is correct. Running cool (not cold) water over the
burn helps to cool down the burned area, soothes the pain, and helps prevent further damage
to the skin. It's recommended to run water over the burn for around 10-15 minutes to
effectively cool the area.
Choice E Reason:
Allowing the affected area to remain open to air is incorrect. Keeping a minor burn
uncovered can increase the risk of infection as it exposes the burn to external contaminants.
Covering the burn with a sterile, non-stick dressing can protect it from further damage and
reduce the risk of infection.

36.A nurse is providing first aid for a client who has a minor burn on one hand. Which
of the following actions should the nurse take? (Select all that apply.)
A. Maintain skin integrity over the blisters
 B. Apply ice to the larger blisters.
C. Administer ibuprofen for pain.
D. Run cool water over the affected area.
E. Allow the affected area to remain open to air.
The correct answer is choice A,C,D
Explanation
Choice A Reason:
Maintaining skin integrity over the blisters is correct. Blisters form as a protective
mechanism for the skin underneath. Popping or breaking blisters increases the risk of
infection as it exposes the raw skin to bacteria and other contaminants.
Choice B Reason:
Applying ice to the larger blisters is incorrect.
Reason: Applying ice directly to a burn, especially to blisters, can further damage the skin
and exacerbate the injury. Ice can cause additional skin damage and can potentially increase
pain and delay healing.
Choice C Reason:
Administering ibuprofen for pain is correct. Ibuprofen is an effective over-the-counter pain
reliever that can help manage the discomfort caused by a minor burn. It also has anti-
inflammatory properties that can reduce swelling associated with burns.
Choice D Reason:
Running cool water over the affected area is correct. Running cool (not cold) water over the
burn helps to cool down the burned area, soothes the pain, and helps prevent further damage
to the skin. It's recommended to run water over the burn for around 10-15 minutes to
effectively cool the area.
Choice E Reason:
Allowing the affected area to remain open to air is incorrect. Keeping a minor burn
uncovered can increase the risk of infection as it exposes the burn to external contaminants.
Covering the burn with a sterile, non-stick dressing can protect it from further damage and
reduce the risk of infection.

37. A nurse is providing first aid for a client who has a minor burn on one hand. Which
of the following actions should the nurse take? (Select all that apply.)
A. Maintain skin integrity over the blisters
B. Apply ice to the larger blisters.
C. Administer (buprofen for pain.
D. Run cool water over the affected area.
E. Allow the affected area to remain open to air.
The correct answer is choice A,C,D
Explanation
Choice A Reason:
Maintaining skin integrity over the blisters is correct. Blisters form as a protective
mechanism for the skin underneath. Popping or breaking blisters increases the risk of
infection as it exposes the raw skin to bacteria and other contaminants.
Choice B Reason:
Applying ice to the larger blisters is incorrect.
Reason: Applying ice directly to a burn, especially to blisters, can further damage the skin
and exacerbate the injury. Ice can cause additional skin damage and can potentially increase
pain and delay healing.
Choice C Reason:
Administering ibuprofen for pain is correct. Ibuprofen is an effective over-the-counter pain
reliever that can help manage the discomfort caused by a minor burn. It also has anti-
inflammatory properties that can reduce swelling associated with burns.
Choice D Reason:
Running cool water over the affected area is correct. Running cool (not cold) water over the
burn helps to cool down the burned area, soothes the pain, and helps prevent further damage
to the skin. It's recommended to run water over the burn for around 10-15 minutes to
effectively cool the area.
Choice E Reason:
Allowing the affected area to remain open to air is incorrect. Keeping a minor burn
uncovered can increase the risk of infection as it exposes the burn to external contaminants.
Covering the burn with a sterile, non-stick dressing can protect it from further damage and
reduce the risk of infection.

38.A home health nurse is reinforcing teaching with an older adult client about safety
precautions to take in the home. Which of the following instructions should the nurse
include?
A. Place white tape on the edges of stairs.
B. Place area rugs on wooden floors.
C. Run wires and cords under carpeting.
D. Have the furnace inspected every 2 years.
The correct answer is choice D
Explanation
Choice A Reason:
 Placing white tape on the edges of stairs is not appropriate. While highlighting the edges of
stairs can help improve visibility, white tape might not provide sufficient contrast or
durability. Instead, using non-slip strips or adding handrails to stairs would be more effective
for preventing falls.
Choice B Reason:
Placing area rugs on wooden floors is not appropriate. Area rugs on wooden floors can pose
a tripping hazard, especially for older adults who might have mobility issues. They can easily
slip or trip on loose rugs. Securing rugs with non-slip backing or removing them entirely is a
better safety measure.
Choice C Reason:
Running wires and cords under carpeting is not appropriate. Running wires and cords under
carpeting can create tripping hazards and increase the risk of electrical issues, including
potential overheating and fire hazards. It's safer to secure cords along walls or use cord
covers to prevent tripping and reduce potential electrical hazards
Choice D Reason:
Having the furnace inspected every 2 years is appropriate. Regular maintenance and
inspection of heating systems, such as furnaces, are essential for ensuring their safe and
efficient operation. This action reduces the risk of malfunctions or potential hazards like
carbon monoxide leaks, which is particularly crucial for older adults who might be more
susceptible to the effects of such issues.

39.A nurse is preparing to administer subcutaneous enoxaparin. In which order should

the nurse perform the following steps? (Move the steps into the box on the right, placing
them in the order of performance. Use all the steps.)
A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
B. Check the medication administration record to verify the client's allergies.
C. Slowly inject the medication into the site without aspirating.
D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90°
angle.
E. Ensure an air bubble is present in the prefilled enoxaparin syringe.
The correct answer is choice B A D C E
Explanation
Check the medication administration record to verify the client's allergies (Step B): Before
administering any medication, it's crucial to confirm the client's allergies to prevent adverse
reactions. This ensures the safety of the client and helps avoid administering a medication to
which the client might have a known allergy.
Locate the injection site 5 cm (2 in) to the right or left of the umbilicus (Step A): Locating the
correct injection site ensures accuracy and consistency in administration. This positioning
provides a consistent area for injection and minimizes variability.
Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle (Step
D):Pinching the skin helps to create a skinfold, which makes the injection less painful and
ensures proper delivery into the subcutaneous tissue. Injecting at a 90° angle helps ensure that
the medication is delivered into the fatty layer just beneath the skin.
Slowly inject the medication into the site without aspirating (Step C): Enoxaparin is typically
administered without aspirating (drawing back on the plunger) to avoid potential damage to
the tissue or blood vessels. Injecting slowly ensures the medication is evenly distributed into
the subcutaneous tissue.
Ensure an air bubble is present in the prefilled enoxaparin syringe (Step E): Having an air
bubble in the prefilled syringe helps ensure that the full dose of medication is delivered. The
air bubble pushes the remaining medication out of the syringe, helping to ensure that the
entire dose is administered.

40. A nurse in a long-term care facility is providing care for a client who has
Alzheimer's disease and is agitated. Which of the following interventions should the
nurse implement?
A. Administer a prescribed oral dose of trazadone to the client.
B. Encourage the client to ambulate with a staff member.
C. Isolate the client in their room.
D. Apply bilateral wrist restraints to the client.
The correct answer is choice A
Explanation
Choice A Reason:
Administering a prescribed oral dose of trazodone to the client is correct. Trazodone is
sometimes used to manage agitation in patients with Alzheimer's disease, as it has calming
effects and can help reduce agitation and anxiety. However, the use of any medication should
be based on the client's individualized treatment plan and prescribed by a healthcare provider.
Choice B Reason:
Encouraging ambulation might not be suitable if the client is agitated, as it could potentially
escalate the situation or increase the risk of falls or injury. Safety should be a priority, and
ambulation might not be advisable during a state of agitation.
Choice C Reason:
Isolating the client in their room is incorrect. Isolating the client might increase feelings of
confusion, fear, or distress, potentially worsening the agitation. It's important to engage and
support the client rather than isolate them, which can be distressing for someone with
Alzheimer's disease.
Choice D Reason:
Applying bilateral wrist restraints to the client is incorrect. The use of restraints should only
be considered as a last resort when all other measures have failed and when there's an
immediate risk of harm to the client or others. Restraints can be physically and
psychologically harmful, leading to increased agitation, anxiety, and potential injury. They
should be used only under strict guidelines and with proper authorization when all other
interventions have been exhausted.

41.A nurse in a long-term care facility is providing care for a client who has Alzheimer's
disease and is agitated. Which of the following interventions should the nurse
implement?
A. Administer a prescribed oral dose of trazadone to the client.
B. Encourage the client to ambulate with a staff member.
C. Isolate the client in their room.
D. Apply bilateral wrist restraints to the client.
The correct answer is choice A
Explanation
Choice A Reason:
Administering a prescribed oral dose of trazodone to the client is correct. Trazodone is
sometimes used to manage agitation in patients with Alzheimer's disease, as it has calming
effects and can help reduce agitation and anxiety. However, the use of any medication should
be based on the client's individualized treatment plan and prescribed by a healthcare provider.
Choice B Reason:
Encouraging ambulation might not be suitable if the client is agitated, as it could potentially
escalate the situation or increase the risk of falls or injury. Safety should be a priority, and
ambulation might not be advisable during a state of agitation.
Choice C Reason:
Isolating the client in their room is incorrect. Isolating the client might increase feelings of
confusion, fear, or distress, potentially worsening the agitation. It's important to engage and
support the client rather than isolate them, which can be distressing for someone with
Alzheimer's disease.
Choice D Reason:
Applying bilateral wrist restraints to the client is incorrect. The use of restraints should only
be considered as a last resort when all other measures have failed and when there's an
immediate risk of harm to the client or others. Restraints can be physically and
psychologically harmful, leading to increased agitation, anxiety, and potential injury. They
should be used only under strict guidelines and with proper authorization when all other
interventions have been exhausted.

42. A nurse is evaluating a client's acceptance of having a new ileostomy. Which of the
following statements by the client indicates acceptance?
A. "I wish my sexual relationship with my partner was like it was before."
B. "I have my partner empty the bag for me, so I don't have to look at it”
C. “look forward to having normal bowel movements again."
D. "I will attend a support group to help me handle difficulties when they occur.”
The correct answer is choice D
Explanation
Choice A Reason:
"I wish my sexual relationship with my partner was like it was before." This statement
indicates a desire to return to the previous state, implying a sense of dissatisfaction or longing
for the way things were before the ileostomy surgery, rather than acceptance of the current
situation.
Choice B Reason:
"I have my partner empty the bag for me, so I don't have to look at it."While having a partner
assist with bag management might indicate some level of adaptation, the statement implies
avoidance or discomfort in dealing directly with the ileostomy. It may suggest a lack of full
acceptance or adjustment to the presence of the ileostomy.
Choice C Reason:
“I look forward to having normal bowel movements again." This statement expresses a
desire to return to the previous bodily function, indicating a longing for the way things were
before the surgery rather than complete acceptance of the ileostomy as a new way of
managing bowel movements.
Choice D Reason:
"I will attend a support group to help me handle difficulties when they occur." Attending a
support group demonstrates a proactive approach toward acceptance and adjustment to living
with an ileostomy. It shows the client's willingness to seek support, learn coping strategies,
and engage with others facing similar challenges.
43.A nurse is collecting data from a client who has peritonitis. Which of the following
findings should the nurse expect?
A. Polyuria
B. Peripheral edema
C. Decreased respirations
D. Absent bowel sounds
The correct answer is choice D
Explanation
Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased
urine production) is more commonly associated with conditions affecting the kidneys or
diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs
rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory
system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might
affect the depth of breathing or result in shallow breathing due to guarding against abdominal
pain. However, decreased respirations as a specific finding wouldn't commonly be expected
in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent
decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of
the abdominal cavity. This condition often leads to the loss or significant reduction of bowel
sounds due to the irritation and inflammation of the abdominal structures.
44.A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The
nurse should instruct the client that which of the following foods has the highest iron
content?
A. 3 oz chicken breast
B. 3 oz canned tuna
C. 3 oz pork roast
D. 3 oz ground beef
The correct answer is choice D
Explanation
Choice A Reason:
3 oz chicken breast is incorrect. Chicken breast contains iron, but its iron content is generally
lower compared to red meats like beef. It contains less heme iron, which is more readily
absorbed by the body, compared to the iron in red meats.
Choice B Reason:
3 oz canned tuna is incorrect. Tuna is a good source of protein but doesn't contain as much
iron as red meats. While it does have some iron content, it's generally lower compared to red
meats like ground beef.
Choice C Reason:
3 oz pork roast is incorrect. Pork contains iron, but its iron content might not be as high as
that found in red meats like ground beef. The specific cut and preparation method can also
affect the iron content, but generally, pork might not provide as much iron as beef.
Choice D Reason:
3 oz ground beef is correct. Red meat, like ground beef, generally contains higher amounts
of heme iron, which is more easily absorbed by the body compared to non-heme iron found
in plant-based sources. This makes ground beef a good source of iron for individuals with
iron-deficiency anemia.

45.A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384
mg/dl. (74 to 106 mg/dL). Which of the following findings should the nurse identify as
an indication of metabolic acidosis?
A. Positive Trousseau's sign
B. Dizziness upon standing
C. Tingling of the fingers
D. Increased respiratory rate
The correct answer is choice D
Explanation
Choice A Reason:
Positive Trousseau's sign is incorrect. Trousseau's sign is associated more with calcium
imbalances, particularly hypocalcemia, and is assessed by inflating a blood pressure cuff on
the arm to induce carpal spasm. It's not a specific indicator of metabolic acidosis related to
high glucose levels in diabetes mellitus.
Choice B Reason:
Dizziness upon standing is incorrect. Dizziness upon standing, also known as orthostatic
hypotension, is more commonly associated with blood pressure changes upon position
changes. While it can occur in various conditions, it's not a specific indicator of metabolic
acidosis in this context.
Choice C Reason:
Tingling of the fingers is incorrect. Tingling sensations, known as paresthesia, can occur due
to various reasons, including nerve damage related to chronic high blood sugar levels in
diabetes (diabetic neuropathy). However, it's not a direct and specific indicator of metabolic
acidosis caused by high glucose levels in diabetes mellitus.
Choice D Reason:
Increased respiratory rate is correct. Metabolic acidosis in a diabetic individual can trigger
compensatory mechanisms, such as increased respiratory rate (Kussmaul respirations), as the
body tries to eliminate excess acids through respiration to help regulate the acid-base balance.
This increased respiratory rate is an attempt to blow off carbon dioxide (a potential acidic
byproduct) and decrease the acidity in the blood.

46.A nurse is collecting admission history data from a client who is in a semi-private
room. Which of the following data is the priority for the nurse to address?
A. Experiences nocturia
B. History of generalized anxiety disorder
C. Recent exposure to tuberculosis
D. Reports periodic migraine headaches
The correct answer is choice C
Explanation
Choice A Reason:
Experiences nocturia is incorrect. Nocturia (waking up at night to urinate) is a common
symptom and, while it's important to address for the client's comfort and potential underlying
causes, it doesn't pose an immediate risk to the client's roommate or necessitate urgent
intervention in a shared room setting.

Choice B Reason:
History of generalized anxiety disorder is incorrect. A history of generalized anxiety disorder
is relevant to the client's mental health and overall care. However, in the context of a shared
room, it might not require immediate attention or interventions that directly impact the
roommate's health or safety.

Choice C Reason:
Recent exposure to tuberculosis is correct. Tuberculosis (TB) is an infectious disease that
spreads through the air when an infected person coughs or sneezes. In a shared room, a
history of recent exposure to TB is a significant concern as it poses a potential risk to both the
client and the roommate. Immediate measures to prevent transmission and ensure proper
isolation protocols are necessary to protect the health of both individuals in the shared space.

Choice D Reason:
Reports periodic migraine headaches is correct.
Periodic migraine headaches are a health concern for the client experiencing them, but they
typically do not pose an immediate risk or concern for the client's roommate. While
addressing pain management is important, it might not require immediate action in the shared
room environment.

47.A nurse is reinforcing discharge teaching for a client who had a cerebrovascular
accident (CVA) and requires assistance to perform their ADLs. Which of the following
statements should the nurse provide?
A. "You will not become fatigued when you use assistive devices."
B. "Plan to hire a home care aid to perform all of your ADLs."
C. "Install grab bars in your shower to assist with your balance."
D. "Place a towel in the shower to prevent slipping
The correct answer is choice C
Explanation
Choice A Reason:
"You will not become fatigued when you use assistive devices. “This statement might
provide an unrealistic expectation. While assistive devices can help, they might still require
physical effort and could potentially cause fatigue, especially during initial use or extended
periods.
Choice B Reason:
"Plan to hire a home care aid to perform all of your ADLs." This statement is not
appropriate.
While home care assistance can be beneficial, aiming to have someone perform all ADLs
might limit the client's independence and ability to regain skills. The goal is often to support
the client in performing ADLs independently whenever possible.
Choice C Reason:
"Install grab bars in your shower to assist with your balance." This statement is true.
Installing grab bars in the shower can significantly enhance safety and stability during
activities like showering, reducing the risk of falls for someone who might experience
balance or mobility challenges following a CVA.
Choice D Reason:
"Place a towel in the shower to prevent slipping." This statement is inappropriate. While
placing a towel might offer some traction, it might not provide sufficient stability or support,
especially for someone with balance issues post-CVA. Grab bars offer more reliable support
to prevent falls in the shower.

48.A nurse is reinforcing discharge teaching for a client who had a cerebrovascular
accident (CVA) and requires assistance to perform their ADLs. Which of the following
statements should the nurse provide?
A. "You will not become fatigued when you use assistive devices."
B. "Plan to hire a home care aid to perform all of your ADLs."
C. "Install grab bars in your shower to assist with your balance."
D. "Place a towel in the shower to prevent slipping."
The correct answer is choice C
Explanation
Choice A Reason:
"You will not become fatigued when you use assistive devices. “This statement might
provide an unrealistic expectation. While assistive devices can help, they might still require
physical effort and could potentially cause fatigue, especially during initial use or extended
periods.
Choice B Reason:
"Plan to hire a home care aid to perform all of your ADLs." This statement is not
appropriate.
While home care assistance can be beneficial, aiming to have someone perform all ADLs
might limit the client's independence and ability to regain skills. The goal is often to support
the client in performing ADLs independently whenever possible.
Choice C Reason:
"Install grab bars in your shower to assist with your balance." This statement is true.
Installing grab bars in the shower can significantly enhance safety and stability during
activities like showering, reducing the risk of falls for someone who might experience
balance or mobility challenges following a CVA.
Choice D Reason:
 "Place a towel in the shower to prevent slipping." This statement is inappropriate. While
placing a towel might offer some traction, it might not provide sufficient stability or support,
especially for someone with balance issues post-CVA. Grab bars offer more reliable support
to prevent falls in the shower.

49.A nurse is preparing to perform a blood glucose test. After performing hand hygiene
and donning gloves, in which order should the nurse perform the following actions to
obtain a capillary blood sample? (Move the steps into the box on the right, placing them
in the order of performance. Use all the steps.)
A. Allow the site to dry.
B. Pierce the puncture site quickly.
C. Squeeze the site gently to obtain a blood droplet.
D. Cleanse the site with an antiseptic swab.
E. Apply blood to the test strip.
The correct answer DBCAE
Explanation

D. Cleanse the site with an antiseptic swab:

Before obtaining the blood sample, it's crucial to clean the puncture site to minimize the risk
of infection and remove any potential contaminants from the skin.

B. Pierce the puncture site quickly:

After cleaning the site, promptly and accurately piercing the skin using a lancet allows for the
collection of a capillary blood sample.

C. Squeeze the site gently to obtain a blood droplet:

Applying gentle pressure to the puncture site helps in obtaining a sufficient amount of blood
needed for the test. This process encourages the blood to form a droplet for easy collection.

A. Allow the site to dry:

Allowing the puncture site to dry before applying the blood to the test strip ensures that the
area is not wet, which can affect the accuracy of the test results or interfere with the test
strip's performance.

E. Apply blood to the test strip:

Once the blood droplet has formed and the site is dry, applying the blood to the designated
area on the test strip allows for the accurate measurement of glucose levels in the blood
sample. This step initiates the testing process using the glucose monitoring device.

50. A nurse is preparing to perform a blood glucose test. After performing hand
hygiene and donning gloves, in which order should the nurse perform the following
actions to obtain a capillary blood sample? (Move the steps into the box on the right,
placing them in the order of performance. Use all the steps.)
A. Cleanse the site with an antiseptic swab.
B. Allow the site to dry.
C. Pierce the puncture site quickly.
D. Squeeze the site gently to obtain a blood droplet.
E. Apply blood to the test strip.
The correct answer is choice DBCAE
Explanation
D. Cleanse the site with an antiseptic swab:
Before obtaining the blood sample, it's crucial to clean the puncture site to minimize the risk
of infection and remove any potential contaminants from the skin.

B. Pierce the puncture site quickly:

After cleaning the site, promptly and accurately piercing the skin using a lancet allows for the
collection of a capillary blood sample.

C. Squeeze the site gently to obtain a blood droplet:

Applying gentle pressure to the puncture site helps in obtaining a sufficient amount of blood
needed for the test. This process encourages the blood to form a droplet for easy collection.

A. Allow the site to dry:

Allowing the puncture site to dry before applying the blood to the test strip ensures that the
area is not wet, which can affect the accuracy of the test results or interfere with the test
strip's performance.

E. Apply blood to the test strip:

Once the blood droplet has formed and the site is dry, applying the blood to the designated
area on the test strip allows for the accurate measurement of glucose levels in the blood
sample. This step initiates the testing process using the glucose monitoring device.
51. A nurse is preparing to perform a sterile dressing change for a client who has a
stage III pressure ulcer. Which of the following actions should the nurse plan to take?
A. Prepare the sterile dressing supplies 30 min before the dressing change.
B. Don sterile gloves before removing the dressing,
C. Disinfect the wound bed with alcohol before applying tape.
D. Offer the client pain medication before the procedure.
The correct answer is choice D
Explanation
Choice A Reason:
Preparing the sterile dressing supplies 30 min before the dressing change is correct. While
it's crucial to have all supplies ready before starting the procedure, preparing them 30 minutes
in advance might not align with the principles of maintaining sterility. It's generally best to
prepare sterile supplies just before the procedure to minimize the risk of contamination.
Choice B Reason:
Don sterile gloves before removing the dressing is incorrect. Sterile gloves should indeed be
worn during the dressing change, but they should be put on after removing the old dressing.
This ensures that the clean gloves don't touch potentially contaminated surfaces during the
removal of the old dressing.
Choice C Reason:
Disinfect the wound bed with alcohol before applying tape is incorrect. Using alcohol to
disinfect the wound bed is not recommended as it can cause tissue irritation and delay wound
healing. Sterile saline or another wound cleansing solution prescribed for wound care would
be more appropriate to clean the wound bed. Additionally, applying tape directly to the
wound is generally avoided to prevent further damage to the fragile tissues of a pressure
ulcer.
Choice D Reason:
Offering the client pain medication before the procedure is correct. Providing pain
medication before the procedure ensures the client's comfort and helps manage any
discomfort or pain associated with the dressing change, particularly when dealing with a
stage III pressure ulcer, which can be quite sensitive.

52.A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr. to an older

adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 mile
How many ml should the nurse administer? (Round the answer to the nearest whole number.
Use a leading zero if it applies. Do not use a trailing zero.)
The correct answer is 10mL
Explanation
Given:
Diphenhydramine syrup: 12.5 mg/5 MLX
Required dose: 25 mg
First, determine the ratio of the available dosage strength to the required dose:
12.5 mg (available dose) / 5 mL (volume) = 25 mg (required dose) / X mL
Cross-multiply to find X (the amount of syrup needed):
12.5 mg X mL = 25 mg 5 mL
Now, solve for X:
X = (25 mg 5 mL) / 12.5 mg
X = 125 / 12.5
X = 10
Therefore, the nurse should administer 10 mL of diphenhydramine syrup to provide a dose of
25 mg to the older adult client with rhinitis.

53. A nurse is caring for a client who has dysphagia following a stroke. When assisting
the client at mealtime, which of the following actions should the nurse plan to take?
A. Instruct the client to tilt their head back to facilitate swallowing
B. Encourage the client to use a straw.
C. Provide oral care before meals.
D. Schedule physical therapy directly before meals.
The correct answer is choice C
Explanation
Choice A Reason:
Instruct the client to tilt their head back to facilitate swallowing is not appropriate. Tilting the
head back can increase the risk of aspiration (food or liquid entering the airway) for
individuals with dysphagia. Instead, the client should maintain an upright position while
eating.
Choice B Reason:
Encouraging the client to use a straw is inappropriate. Using a straw might increase the risk
of aspiration because it can bypass the control mechanisms involved in safe swallowing,
especially for someone with swallowing difficulties.
Choice C Reason:
Providing oral care before meals is correct. Providing oral care before meals helps to ensure
that the client's mouth is clean, reducing the risk of infections and improving taste perception,
which can enhance the client's willingness and ability to eat.
Choice D Reason:
Schedule physical therapy directly before meals is incorrect. Scheduling physical therapy
directly before meals might tire the client and impact their ability to eat. Fatigue can
negatively affect swallowing ability, so it's generally better to allow some rest or recovery
time before meals.

54.A nurse is collecting data from a client who had a long arm cast applied 2 hr. ago.
Which of the following findings of the affected extremity should the nurse report to the
provider immediately?
A. The client's fingers are cool to the touch.
B. The client reports severe itching under the cast.
C. The client's capillary refill is 3 seconds.
D. The client reports increased pain at the area of the fracture.
The correct answer is choice A
Explanation
Choice A Reason:
The client's fingers are cool to the touch is correct. Coolness of the fingers within a short time
after a cast application can indicate compromised circulation or potential compartment
syndrome, which requires urgent attention to prevent tissue damage or loss of function. It
suggests impaired blood flow to the fingers, which is a serious concern requiring immediate
evaluation by the provider.
Choice B Reason:
The client reports severe itching under the cast is incorrect. While itching can be
uncomfortable, it might not pose an immediate threat. Itching can commonly occur as the
skin heals and can be managed through non-invasive means.
Choice C Reason:
The client's capillary refill is 3 seconds is incorrect. A capillary refill of 3 seconds is slightly
prolonged but doesn't typically indicates an immediate emergency. However, if this finding
worsens or if combined with other concerning symptoms, it might warrant further
assessment.
Choice D Reason:
The client reports increased pain at the area of the fracture is incorrect. Increased pain after a
cast application can be expected initially, especially within 2 hours of the procedure.
However, persistent or severe pain could indicate issues like poor alignment, swelling, or
other complications. While it's important to address pain, it might not require immediate
reporting unless accompanied by other concerning symptoms.

55.A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the
following statements by the client indicates an understanding of the teaching?
A. will use a skin sealant before I apply the bag."
B. will use moisturizing soap to clean around the stoma before applying the bag."
C. will cut the wafer opening one-fourth of an inch larger than the stoma
D. 1 will need to empty the bag every 4 to 6 hours."
The correct answer is choice A
Explanation
Choice A Reason:
"I will use a skin sealant before I apply the bag." This statement is appropriate. Using a skin
sealant before applying the ostomy bag helps protect the skin around the stoma, creating a
barrier against irritation and potential leaks from the stool. It demonstrates the client's
understanding of preventive measures to maintain skin integrity.
Choice B Reason:
"I will use moisturizing soap to clean around the stoma before applying the bag." This
statement is inappropriate. While keeping the area around the stoma clean is important, using
moisturizing soap might not be recommended as it can leave residue and interfere with the
adhesive properties of the bag. Typically, mild soap and water are recommended for
cleansing.
Choice C Reason:
"I will cut the wafer opening one-fourth of an inch larger than the stoma." This statement is
incorrect. Cutting the wafer opening one-fourth of an inch larger than the stoma might result
in an excessively large opening, potentially leading to leaks or irritation. The ideal size is
generally recommended to be as close to the stoma size as possible without causing pressure
on the stoma.
Choice D Reason:
"I will need to empty the bag every 4 to 6 hours." This statement is incorrect. While regular
emptying of the ostomy bag is necessary, the frequency can vary based on individual needs
and stoma output. Some individuals might need to empty it more frequently or less often,
depending on their stool output and comfort level.

56.A nurse enters a client's room and sees smoke coming from the bathroom. Which of
the following actions should the nurse take first?
A. Use a fire extinguisher at the source of the smoke.
B. Close the doors to the room and to the bathroom.
C. Activate the fire alarm system.
D. Assist the client to a nearby common area.
The correct answer is choice C
Explanation
Choice A Reason:
Using a fire extinguisher at the source of the smoke is not appropriate. While using a fire
extinguisher could potentially help contain a small fire, it's crucial to prioritize alerting others
about the fire first by activating the fire alarm. This action ensures that help is on the way and
that everyone is aware of the emergency.
Choice B Reason:
 Closing the doors to the room and to the bathroom is not appropriate. Closing doors can help
contain smoke and fire to some extent, but again, the priority in an emergency situation like
this is to activate the fire alarm to ensure a swift response and alert others.
In a situation where a nurse sees smoke coming from a client's room bathroom, the priority is
ensuring everyone's safety. The appropriate initial action would be:
Choice C Reason:
Activate the fire alarm system is appropriate. Activating the fire alarm alerts others in the
facility and initiates the emergency response protocol, helping to ensure that help is on the
way while potentially preventing the spread of fire. This step should be taken before
attempting to address the source of the smoke or assisting the client to safety, as it helps in
notifying others and initiating the necessary response from the fire department or other
emergency services.
Choice D Reason:
Assisting the client to a nearby common area is inappropriate. Ensuring the safety of the
client is vital, but in this scenario, activating the fire alarm takes precedence as it alerts
everyone in the facility about the potential danger, including the client, and prompts the
appropriate emergency response.

57.A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which
of the following findings indicates hyperglycemia?
A. Absence of Chvostek's sign
B. Presence of Kussmaul respirations
C. Presence of diaphoresis
D. Absence of urinary ketones
The correct answer is choice B
Explanation
Choice A Reason:
Absence of Chvostek's sign is a wrong indication. Chvostek's sign is a twitching of facial
muscles in response to tapping the facial nerve and is typically associated with low blood
calcium levels (hypocalcemia). It's not directly related to hyperglycemia or high blood sugar
levels. Hyperglycemia refers to high blood sugar levels, commonly associated with diabetes
mellitus.
Choice B Reason:
Presence of Kussmaul respirations is a right indication. Kussmaul respirations are deep,
rapid, and labored breathing patterns often seen in individuals with diabetic ketoacidosis
(DKA), a severe complication of diabetes characterized by significantly high blood sugar
levels and the presence of ketones in the blood and urine. This type of breathing pattern is the
body's attempt to compensate for the acidic state caused by high blood sugar and the buildup
of ketones.
Choice C Reason:
Presence of diaphoresis is a wrong indication. Diaphoresis refers to excessive sweating,
which can occur due to various reasons such as physical activity, heat, stress, or certain
medical conditions. While hyperglycemia can cause symptoms like increased thirst and
frequent urination, diaphoresis alone is not a specific indicator of high blood sugar levels.
Choice D Reason:
Absence of urinary ketones is a wrong indication. The presence of urinary ketones indicates
the body is breaking down fat for energy, which commonly occurs during periods of
insufficient insulin (such as in hyperglycemia or diabetic ketoacidosis). However, the absence
of urinary ketones doesn't necessarily rule out hyperglycemia. It's possible for hyperglycemia
to be present without ketones in the urine, especially in the early stages or when the body is
still managing blood sugar levels without significant ketone production.

58.A nurse is caring for a client who is receiving intermittent bolus enteral feedings
through a jejunostomy tube. Which of the following actions should the nurse take?
A. Elevate the head of the client's bed for 1 hr. after the feeding.
B. Administer the feeding solution at a cold temperature.
C. Rotate the jejunostomy tube once per day.
D. Flush the tube with 90 ml of sterile water before and after the feeding.
The correct answer is choice A
Explanation
Choice A Reason:
Elevate the head of the client's bed for 1 hr. after the feeding is appropriate. This action helps
minimize the risk of aspiration. Elevating the head of the bed (typically at least 30 to 45
degrees) can reduce the chance of reflux and aspiration of the feeding solution into the lungs.
This position should ideally be maintained for about 1 hour after the feeding to aid digestion
and reduce the risk of complications.
Choice B Reason:
Administering the feeding solution at a cold temperature is inappropriate. Feeding solutions
are generally administered at room temperature or slightly warmed to prevent discomfort and
minimize the risk of altering the client's core body temperature. Cold temperatures can cause
discomfort or cramping and might affect the absorption of the nutrients. Therefore,
administering the feeding solution at a cold temperature is not recommended.
Choice C Reason:
Rotating the jejunostomy tube once per day is inappropriate. Rotating the jejunostomy tube
is not typically part of routine care. Tube rotation can cause discomfort, irritation, and
potential injury to the gastrointestinal tract. Tubes should be secured properly to prevent
movement but not rotated unless specifically instructed by a healthcare provider for a
particular reason, such as checking for proper tube placement.
Choice D Reason:
Flushing the tube with 90 ml of sterile water before and after the feeding is inappropriate.
Flushing the tube with sterile water before and after the feeding helps ensure the patency of
the tube and prevents clogging. It's a standard procedure to clear the tube and maintain its
function.

59.A nurse is caring for a client who is receiving intermittent bolus enteral feedings
through a jejunostomy tube. Which of the following actions should the nurse take?
A. Elevate the head of the client's bed for 1 hr. after the feeding.
B. Administer the feeding solution at a cold temperature.
C. Rotate the jejunostomy tube once per day.
D. Flush the tube with 90 mL of sterile water before and after the feeding.
The correct answer is choice A
Explanation
Choice A Reason:
Elevate the head of the client's bed for 1 hr. after the feeding is appropriate. This action helps
minimize the risk of aspiration. Elevating the head of the bed (typically at least 30 to 45
degrees) can reduce the chance of reflux and aspiration of the feeding solution into the lungs.
This position should ideally be maintained for about 1 hour after the feeding to aid digestion
and reduce the risk of complications.
Choice B Reason:
Administering the feeding solution at a cold temperature is inappropriate. Feeding solutions
are generally administered at room temperature or slightly warmed to prevent discomfort and
minimize the risk of altering the client's core body temperature. Cold temperatures can cause
discomfort or cramping and might affect the absorption of the nutrients. Therefore,
administering the feeding solution at a cold temperature is not recommended.
Choice C Reason:
Rotating the jejunostomy tube once per day is inappropriate. Rotating the jejunostomy tube
is not typically part of routine care. Tube rotation can cause discomfort, irritation, and
potential injury to the gastrointestinal tract. Tubes should be secured properly to prevent
movement but not rotated unless specifically instructed by a healthcare provider for a
particular reason, such as checking for proper tube placement.
Choice D Reason:
Flushing the tube with 90 ml of sterile water before and after the feeding is inappropriate.
Flushing the tube with sterile water before and after the feeding helps ensure the patency of
the tube and prevents clogging. It's a standard procedure to clear the tube and maintain its
function
60. A nurse is assisting with the care of a postoperative client who has developed
malignant hyperthermia. Which of the following actions should the nurse take?
A. Administer meperidine IM.
B. Instill a warm enema solution.
C. Apply a cooling blanket.
D. Ventilate client with 50% oxygen.
The correct answer is choice C
Explanation
Choice A Reason:
Administer meperidine IM is incorrect. Reason why it's not the answer: Meperidine
(Demerol) is not recommended in cases of malignant hyperthermia. It can potentially
exacerbate the situation by further increasing muscle rigidity and potentially contributing to
the hypermetabolic state. Meperidine can trigger additional release of calcium from the
sarcoplasmic reticulum in muscles, worsening the symptoms.
Choice B Reason:
Instill a warm enema solution is incorrect. Reason why it's not the answer: Introducing warm
solutions can exacerbate the client's condition by further increasing body temperature.
Malignant hyperthermia is characterized by a dangerous increase in body temperature, and
adding heat through an enema would only make the situation worse.
Choice C Reason:
Applying a cooling blanket is recommendable. Reason why it's the answer: A cooling
blanket is a recommended intervention for managing malignant hyperthermia. Lowering the
body temperature is crucial in preventing further complications associated with the high
fever. Cooling blankets help dissipate heat from the body, aiding in rapidly reducing the
dangerously elevated temperature associated with malignant hyperthermia.
Choice D Reason:
Ventilate client with 50% oxygen is incorrect. Reason why it's not the answer: While
providing oxygen support might be necessary as part of managing the overall condition,
ventilating with 50% oxygen specifically may not directly address the core issue of rapidly
cooling the body during a malignant hyperthermia crisis. Ventilation may be required, but the
immediate concern is to cool the body to prevent complications arising from the elevated
body temperature.

61.A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client
asks the nurse why she needs to take four different antituberculotic medications. Which
of the following replies should the nurse make?
 A. "The organism that causes TB becomes resistant to antituberculotic medications
when you only take one medication."
B. Taking several antituberculotic medications will protect your liver from toxic
effects."
C. "People who have a severe form of TB need several antituberculotic medications,
but those who have less severe TB need just one medication."
D. "Adverse effects occur more often and are more severe when you take only one
antituberculotic medication."
The correct answer is choice A
Explanation
Choice A Reason:
"The organism that causes TB becomes resistant to antituberculotic medications when you
only take one medication." This statement is appropriate.
Tuberculosis bacteria tend to develop resistance to single medications when used alone.
Using multiple medications simultaneously helps prevent the bacteria from becoming
resistant to any single drug. This strategy, known as combination therapy, is crucial in
treating TB effectively and reducing the risk of drug resistance.
When TB bacteria are exposed to just one medication, they can mutate and become resistant
to that specific drug. However, using a combination of medications helps ensure that if one
medication fails to eliminate some bacteria due to resistance, the other drugs can still work
against the resistant strains.
Preventing drug resistance is essential for successful TB treatment and to avoid the need for
more complex and less effective medications if resistance develops.
Choice B Reason:
"Taking several antituberculotic medications will protect your liver from toxic effects." This
statement is incorrect. While it's true that some antituberculotic medications can have
hepatotoxic effects (adverse effects on the liver), the primary reason for using multiple
medications in TB treatment isn't solely to protect the liver. The main goal of using multiple
medications is to prevent the development of drug-resistant strains of TB bacteria. Protecting
the liver is an important consideration in medication selection and monitoring but isn't the
primary rationale for multiple medications.
Choice C Reason:
"People who have a severe form of TB need several antituberculotic medications, but those
who have less severe TB need just one medication." This statement is incorrect. The severity
of TB doesn't determine the number of medications required. The standard treatment
approach for TB involves multiple medications, regardless of the severity. This approach
aims to prevent the development of drug resistance, ensure effective treatment, and reduce
the risk of treatment failure. Using a combination of medications is a fundamental strategy to
combat TB effectively.
Choice D Reason:
 "Adverse effects occur more often and are more severe when you take only one
antituberculotic medication." This statement is incorrect. While it's true that adverse effects
can occur with antituberculotic medications, the primary reason for using multiple
medications isn't solely to reduce adverse effects. The main concern addressed by using
multiple drugs is preventing the development of drug-resistant TB strains. Using a
combination of medications reduces the likelihood of resistance developing and increases the
effectiveness of treatment, rather than solely minimizing adverse effects.

62. A nurse is reinforcing teaching about environmental modifications in the home with
a family member of a client who has Alzheimer's disease. Which of the following
information should the nurse include in the teaching?
A. Leave the television on.
B. Install locks at the top of doors.
C. Place throw rugs on the floor.
D. Schedule alternate caregivers.
The correct answer is choice B
Explanation
Choice A Reason:
Leaving the television on is incorrect. Constant background noise from the television might
be overwhelming and confusing for someone with Alzheimer's. It's generally better to have a
quiet and calming environment to reduce agitation and confusion.
Choice B Reason:
Installing locks at the top of doors is correct. This can be an essential safety measure to
prevent the person from wandering or accessing unsafe areas. Installing locks higher up on
doors can help prevent the individual from opening doors and wandering into potentially
dangerous situations.
Choice C Reason:
Placing throw rugs on the floor is incorrect. Throw rugs pose a tripping hazard, especially for
individuals with Alzheimer's who might have mobility issues or difficulties with depth
perception. Removing throw rugs or securing them firmly to the floor is essential to prevent
falls.
Choice D Reason:
Scheduling alternate caregivers is incorrect. While having alternate caregivers is important
for support, it doesn't directly relate to environmental modifications within the home.

63. A nurse is reinforcing teaching with a client who has gastroesophageal reflux
(GERD). Which of the following statements by the client indicates an understanding of
the teaching?
 A. “Twill increase vitamin C intake by drinking orange juice."
B. “will eat six small meals each day."
C. "I will lie down for 30 minutes after each meal."
D. “will sleep flat on my back at night."
The correct answer is choice B.
Explanation
Choice A Reason:
“Twill increase vitamin C intake by drinking orange juice." Reason why it might not indicate
an understanding: Citrus juices like orange juice can exacerbate GERD symptoms due to
their acidity. Increasing intake might worsen reflux symptoms for many individuals with
GERD.
Choice B Reason:
“Will eat six small meals each day." This statement indicates an understanding. Eating
smaller, more frequent meals instead of three large meals can help reduce pressure on the
lower esophageal sphincter (LES), minimizing the likelihood of stomach contents flowing
back into the esophagus, which commonly triggers GERD symptoms.
Choice C Reason:
"I will lie down for 30 minutes after each meal." Reason why it might not indicate an
understanding: Lying down after meals can worsen GERD symptoms. Remaining upright or
at least sitting upright for a few hours after meals helps prevent reflux by allowing gravity to
assist in keeping stomach contents from moving up into the esophagus.
Choice D Reason:
“Will sleep flat on my back at night." Reason why it might not indicate an understanding:
Sleeping flat on the back can aggravate GERD symptoms as it allows stomach acid to flow
more easily into the esophagus. Sleeping with the head elevated (using pillows or an
adjustable bed) is recommended to reduce nighttime reflux.

64. A nurse is collecting data from a client who has Cushing's syndrome. Which of the
following findings should the nurse expect?
A. Jaundice
B. Muscle rigidity
C. Weight loss
D. Easily bruised
The correct answer is choice D
Explanation
Choice A Reason:
 Jaundice, characterized by yellowing of the skin and eyes, is typically associated with liver
dysfunction or conditions affecting the breakdown of red blood cells, not directly linked to
Cushing's syndrome. While some liver abnormalities can be seen in Cushing's syndrome due
to metabolic changes, jaundice is not a typical manifestation of this condition.
Choice B Reason:
Muscle rigidity is more commonly associated with conditions like Parkinson's disease,
dystonia, or certain muscle disorders. In Cushing's syndrome, muscle weakness due to protein
breakdown and muscle wasting is a more expected finding rather than muscle rigidity.
Choice C Reason:
Weight loss is incorrect. Weight gain, particularly in the central part of the body (trunk) and
face (creating a "moon face"), is a more common characteristic of Cushing's syndrome. The
excess cortisol often leads to increased fat deposits, especially in these areas, rather than
weight loss.
Cushing's syndrome is characterized by an excess of cortisol in the body, either due to the
body producing too much cortisol or from long-term use of corticosteroid medications.
Considering this condition, the nurse should expect the following finding:
Choice D Reason:
Easily bruised is correct. Excess cortisol can lead to the thinning of the skin and weakening
of blood vessels, making individuals with Cushing's syndrome prone to easy bruising. Other
common findings associated with Cushing's syndrome include weight gain (especially in the
trunk and face), muscle weakness, high blood pressure, fatigue, and changes in skin such as
thinning and purple stretch marks.
65. A nurse is reinforcing teaching with a client who is scheduled to undergo a
bronchoscopy. Which of the following client statements indicates an understanding of
the teaching?
A. "I can have clear liquids up to 3 hours before the procedure."
B. "I can eat as soon as the procedure is completed."
C. "I will receive an injection of radioactive material prior to having the
procedure.”
D. "I might have blood-tinged sputum after the procedure."
The correct answer is choice A
Explanation
Choice A Reason:
"I can have clear liquids up to 3 hours before the procedure." This statement is accurate and
indicates an understanding. Generally, for a bronchoscopy, clear liquids are allowed up to a
certain timeframe before the procedure to ensure the stomach is empty, reducing the risk of
aspiration during the test.
Choice B Reason:
"I can eat as soon as the procedure is completed. “This statement is not accurate. After a
bronchoscopy, there's typically a recovery period during which eating might be restricted for
a certain duration. It's important to follow post-procedure instructions, which often include
specific guidelines about eating after the procedure.
Choice C Reason:
"I will receive an injection of radioactive material prior to having the procedure.” This
statement is not typical for a bronchoscopy. Radioactive material injections are not part of the
standard bronchoscopy procedure. This information might be confused with procedures
involving radioactive tracers for other types of imaging studies.
Choice D Reason:
"I might have blood-tinged sputum after the procedure." This statement is accurate and
indicates an understanding. Blood-tinged sputum can be expected after a bronchoscopy due
to irritation or minor injury to the airways during the procedure. It's a common and usually
harmless side effect.

66.A nurse is collecting data from a client who has a subdural hematoma following a
motor-vehicle crash. For which of the following findings should the nurse identify that
the client is experiencing an increase in intracranial pressure?
A. The client has a delayed response to verbal commands.
B. The client has ecchymosis around the eyes.
C. The client is unable to remember details of the motor-vehicle crash.
D. The client reports ringing in the ears.
The correct answer is choice A
Explanation
Choice A Reason:
The client has a delayed response to verbal commands. This finding can indicate increased
intracranial pressure. Changes in responsiveness, such as delayed responses to verbal
commands or other stimuli, can be indicative of neurological impairment due to elevated
pressure within the skull.
Choice B Reason:
The client has ecchymosis around the eyes. Ecchymosis around the eyes (raccoon eyes) can
occur with certain head injuries, but it's not a direct sign of increased intracranial pressure. It's
more commonly associated with basilar skull fractures rather than specifically reflecting
increased pressure within the skull.
Choice C Reason:
The client is unable to remember details of the motor-vehicle crash. Memory impairment or
amnesia regarding the event can occur due to head trauma, but it might not directly correlate
with an increase in intracranial pressure. It's more related to the effects of the injury on
memory function.
Choice D Reason:
The client reports ringing in the ears. Tinnitus or ringing in the ears might occur in some
cases of head trauma but is not a direct indicator of increased intracranial pressure. It might
result from the impact of the injury or other associated factors.

67.A nurse is caring for a client who has a peripheral IV infusion and notes that the
client's arm is edematous, cool, and tender at the catheter insertion site. Which of the
following complications of IV therapy should the nurse suspect?
A. Nerve damage
B. Infection
C. Infiltration
D. Phlebitis
The correct answer is choice D
Explanation
Choice A Reason:
Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered
sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms
described in the scenario are more indicative of localized inflammation rather than nerve-
related issues.
Choice B Reason:
 Infection is incorrect. Infection at the insertion site can manifest with redness, warmth,
tenderness, and possibly purulent drainage. While infection is a potential complication of IV
therapy, the symptoms described might indicate a different issue.
Choice C Reason:
Infiltration is incorrect. Infiltration occurs when the IV fluid leaks into the surrounding
tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid
accumulating in the tissue instead of going into the vein. These symptoms align with the
description provided.
Choice D Reason:
Phlebitis is correct. Phlebitis is the inflammation of a vein, typically presenting with
redness, warmth, and tenderness along the vein's path. The symptoms described in the
scenario—edematous, cool, and tender at the catheter insertion site—could be associated with
phlebitis.

68.A nurse is reinforcing teaching with a client who wants to lose 0.9 kg (2 lb.) of body
fat per week. The nurse knows that 0.45 kg (1 lb.) of body fat is equal to 3,500 calories.
The nurse should instruct the client to reduce his daily caloric intake by how many
calories? (Round the answer to the nearest whole number. Use a leading zero if it
applies. Do not use a trailing zero.)
The correct answer is 1,000 calories
Explanation
To lose 0.9 kg (2 lb.) of body fat per week, we can calculate the daily caloric deficit required.
1 lb. of body fat = 3,500 calories
So, for 2 lb. of body fat = 2 * 3,500 = 7,000 calories per week

To lose 0.9 kg (2 lb.) of body fat per week:

7,000 calories ÷ 7 days = 1,000 calories per day
Therefore, the client should reduce their daily caloric intake by approximately 1,000 calories
per day to achieve a weight loss of 0.9 kg (2 lb.) of body fat per week.

70. A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which
of the following statements by the client indicates an understanding of the teaching?
A. "I will apply heat to my affected ankle to decrease swelling."
B. "I can bear full weight on my affected ankle."
C. "I can dangle my affected ankle from the edge of the bed."
D. "I will wrap my affected ankle with an elastic bandage."
The correct answer is D
Explanation
Choice A Reason:
"I will apply heat to my affected ankle to decrease swelling." Heat application is generally
not recommended for acute injuries like ankle sprains. Heat can increase blood flow and
potentially worsen swelling. Cold therapy (like ice) is typically advised in the early stages to
reduce inflammation and swelling.
Choice B Reason:
"I can bear full weight on my affected ankle." For a grade 2 ankle sprain, bearing full weight
on the affected ankle might not be advisable initially. Grade 2 sprains involve partial tearing
of ligaments and usually require some period of rest or limited weight-bearing to allow
healing.
Choice C Reason:
"I can dangle my affected ankle from the edge of the bed. “Dangling the affected ankle from
the edge of the bed is a common recommendation to help with gentle movement and improve
blood flow without putting excessive stress on the injured ankle. This activity can aid in the
recovery process and is often recommended.
Choice D Reason:
"I will wrap my affected ankle with an elastic bandage. “Wrapping the affected ankle with an
elastic bandage is a supportive measure recommended for managing ankle sprains. It helps
provide compression, support, and stabilization to the injured area, assisting in reducing
swelling and providing comfort.

71. A nurse is reinforcing teaching with a client who will undergo a colonoscopy the
following week. Which of the following instructions should the nurse include?
A. Administer enemas 2 days before the procedure.
B. Do not eat or drink anything except water for 12 hr. before the procedure.
C. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
D. Expect the provider to schedule another procedure to remove any polyps.
The correct answer is C
Explanation
Choice A Reason:
Administering enemas 2 days before the procedure is incorrect. This approach isn't typically
recommended for routine colonoscopy preparation. The cleansing process before a
colonoscopy often involves specific bowel preparation solutions or laxatives provided by the
healthcare provider. Enemas might not thoroughly cleanse the entire colon.
Choice B Reason:
 Do not eat or drink anything except water for 12 hr. before the procedure. Fasting is
necessary before a colonoscopy to ensure the colon is clear for optimal visualization.
However, the duration of fasting is typically longer than 12 hours. Usually, instructions
involve not eating solid foods for about 24 hours before the procedure and clear liquids only
for a specified period.
Choice C Reason:
Restricting the diet to clear liquids for 1 to 3 days before the procedure is incorrect. This
instruction aligns more with the typical preparation for a colonoscopy. Usually, the healthcare
provider advises a switch to a clear liquid diet for a day or two before the procedure. This
step helps ensure the colon is as clear as possible for the examination.
Choice D Reason:
Expecting the provider to schedule another procedure to remove any polyps is incorrect.
While finding and removing polyps is part of the objective of a colonoscopy, scheduling
another procedure specifically for polyp removal isn't typically discussed beforehand. Polyp
removal is often performed during the colonoscopy procedure if any are found.

72. A nurse is reinforcing teaching for a client who was admitted with an exacerbation
of COPD. Which of the following should the nurse include in the client teaching?
A. "You should consume small, frequent meals each day."
B. "You should decrease your caloric intake by 200 calories per day."
C. "You should increase your oxygen to 5 liters per minute if you have shortness of
breath."
D. "You should discontinue your prednisone when your symptoms improve."
The correct answer is A
Explanation
Choice A Reason;
"You should consume small, frequent meals each day." This statement is advisable for
COPD management. Eating smaller, more frequent meals can help prevent bloating or feeling
overly full, which might interfere with breathing due to increased pressure on the diaphragm.
Choice B Reason:
"You should decrease your caloric intake by 200 calories per day." While maintaining a
healthy weight is important for COPD management, reducing caloric intake without specific
guidance or assessment might not be suitable. It's crucial to consult with a healthcare provider
or dietitian for individualized dietary recommendations.
Choice C Reason:
"You should increase your oxygen to 5 liters per minute if you have shortness of breath."
Adjusting oxygen flow should be done based on a healthcare provider's prescribed guidelines.
Self-adjustment of oxygen flow without medical advice can be risky and might not address
the underlying cause of shortness of breath during a COPD exacerbation.
Choice D Reason:
"You should discontinue your prednisone when your symptoms improve." Prednisone or
other corticosteroids are often prescribed during a COPD exacerbation to reduce
inflammation in the airways. However, discontinuing corticosteroids abruptly without a
healthcare provider's guidance can lead to a recurrence of symptoms or potential
complications. It's important to follow the prescribed regimen and complete the course as
directed.

73. A nurse is reinforcing teaching with a client who will undergo a colonoscopy the
following week. Which of the following instructions should the nurse include?
A. Administer enemas 2 days before the procedure
B. Do not eat or drink anything except water for 12 hr. before the procedure.
C. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
D. Expect the provider to schedule another procedure to remove any polyps
The correct answer is choice C
Explanation
Choice A Reason:
Administering enemas 2 days before the procedure. Enemas are not typically the primary
method of bowel preparation for a colonoscopy. Healthcare providers often recommend
specific bowel preparation solutions or laxatives that are more effective in thoroughly
cleansing the colon.
Choice B Reason:
Do not eat or drink anything except water for 12 hr. before the procedure. Fasting is
necessary before a colonoscopy to ensure the colon is clear for optimal visualization.
However, the duration of fasting is typically longer than 12 hours. Usually, instructions
involve not eating solid foods for about 24 hours before the procedure and clear liquids only
for a specified period.
Choice C Reason:
Restricting the diet to clear liquids for 1 to 3 days before the procedure. The transition to a
clear liquid diet for a day or two before the colonoscopy is a common preparation
recommendation. This step helps ensure the colon is as clear as possible for the examination.
Choice D Reason:
Expect the provider to schedule another procedure to remove any polyps. While identifying
and removing polyps is part of the objective of a colonoscopy, scheduling another procedure
specifically for polyp removal isn't usually discussed beforehand. Polyp removal is often
performed during the colonoscopy procedure if any are found.
74. A nurse is reinforcing teaching with the partner of a client who has contact
precautions in place for methicillin-resistant Staphylococcus aureus (MRSA). Which of
the following statements by the client's partner indicates an understanding of the
teaching?
A. "I can take my partner outside of the room as long as they wear a mask."
B. "I will wash my hands as soon as I leave the room."
C. "I will wear a gown when I help my partner take a bath."
D. "I can reuse unsoiled gloves when I re-enter the room."
The correct answer is B
Explanation
Choice A Reason:
"I can take my partner outside of the room as long as they wear a mask."MRSA contact
precautions typically involve limiting the spread of the bacteria. Taking the partner outside
the room while wearing a mask might not be sufficient for infection control, as MRSA can
spread through direct contact with surfaces. This statement might not indicate a full
understanding of MRSA precautions.
Choice B Reason:
"I will wash my hands as soon as I leave the room. “Hand hygiene is a crucial component of
infection control for MRSA. Washing hands with soap and water or using alcohol-based hand
sanitizer after leaving the room helps prevent the spread of MRSA to oneself or others.
Choice C Reason:
"I will wear a gown when I help my partner take a bath." Wearing a gown during tasks that
might involve contact with the patient's bodily fluids or surfaces that might be contaminated
is recommended for MRSA precautions. This statement aligns with infection control
practices.
Choice D Reason:
"I can reuse unsoiled gloves when I re-enter the room. “Reusing gloves, even if they appear
unsoiled, is generally not recommended as it can contribute to the spread of MRSA. Gloves
should be disposed of after each use and hands washed thoroughly.

75. A nurse is obtaining a sterile urine specimen from a client who has an indwelling
urinary catheter. Identify the sequence the nurse should follow. (Move the steps into the
box on the right, placing them in the selected order of performance. Use all the steps.)
A. Wipe the sample port with an alcohol wipe and let the alcohol dry.
B. Clamp the catheter tubing distal to the sampling port for 15 min.
C. Attach a sterile needleless syringe to the sample port and aspirate the specimen
 D. Document in the client's electronic medical record that the specimen was sent to
the laboratory.
E. Empty the urine into a sterile container labeled with the client identifiers
The correct answer is B A C E D
Explanation
Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing
distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine
specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.

Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling
port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample
during collection, ensuring a more sterile procedure.

Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a
sterile syringe prevents contamination and allows for the collection of a clean urine sample
directly from the catheter tubing, maintaining the sterility of the specimen.

Empty the urine into a sterile container labeled with the client identifiers. Transferring the
collected urine into a sterile container labeled with the client's identifiers ensures proper
identification and handling of the specimen for laboratory analysis.

Document in the client's electronic medical record that the specimen was sent to the
laboratory. Documenting in the client's medical record ensures that there is a clear record of
the specimen collection, its handling, and its dispatch to the laboratory for analysis,
maintaining proper documentation and continuity of care.

76. A nurse is obtaining a sterile urine specimen from a client who has an indwelling
urinary catheter. Identify the sequence the nurse should follow. (Move the steps into the
box on the right, placing them in the selected order of performance. Use all the steps.)
A. Empty the urine into a sterile container labeled with the client identifiers.
B. Document in the client's electronic medical record that the specimen was sent to
the laboratory.
C. Attach a sterile needleless syringe to the sample port and aspirate the specimen.
D. Wipe the sample port with an alcohol wipe and let the alcohol dry.
E. Clamp the catheter tubing distal to the sampling port for 15 min.
The correct answer is E D C A B
Explanation
Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing
distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine
specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.

Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling
port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample
during collection, ensuring a more sterile procedure.

Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a
sterile syringe prevents contamination and allows for the collection of a clean urine sample
directly from the catheter tubing, maintaining the sterility of the specimen.

Empty the urine into a sterile container labeled with the client identifiers. Transferring the
collected urine into a sterile container labeled with the client's identifiers ensures proper
identification and handling of the specimen for laboratory analysis.

Document in the client's electronic medical record that the specimen was sent to the
laboratory. Documenting in the client's medical record ensures that there is a clear record of
the specimen collection, its handling, and its dispatch to the laboratory for analysis,
maintaining proper documentation and continuity of care.

77. A nurse is caring for a client who is postoperative following the placement of a
colostomy. Which of the following findings indicates the colostomy is functioning
properly?
A. Passing of flatus
B. Stoma is pinkish-red
C. Tolerating a clear liquid diet
D. Absent bowel sounds
The correct answer is A
Explanation
Choice A Reason:
Passing of flatus is correct. Passing flatus (gas) is an encouraging sign that the digestive
system is functioning and that gas is moving through the colostomy. This is a positive
indicator of colostomy function.
Choice B Reason:
Stoma is pinkish-red. A pinkish-red stoma indicates good blood circulation to the area,
which is vital for the health of the stoma tissue. A healthy-colored stoma is a positive sign.
Choice C Reason:
Tolerating a clear liquid diet. Tolerating a clear liquid diet might be an indicator of
gastrointestinal function, but it might not specifically confirm the functionality of the
colostomy itself.
D. Absent bowel sounds
Absent bowel sounds might be present immediately postoperatively due to the effects of
anesthesia and abdominal surgery. However, bowel sounds aren't a direct indicator of
colostomy function.

78.
79.
80.
81.

82.
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84.
85.
86.
87.
89.
90.
91.
92.
93.
94.
95.
96.
97.
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100.
101.
102.
103.
104.
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106.
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108.
109.
110.
111.

112.
113.
114.
115.
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117.
118.
119. A nurse is caring for a client who is receiving intermittent bolus enteral feedings
through a jejunostomy tube. Which of the following actions should the nurse take?
A. Elevate the head of the client's bed for 1 hr after the feeding
B. Administer the feeding solution at a cold temperature.
C. Rotate the jejunostomy tube once per day.
D. Flush the tube with 50 mL of sterile water before and after the feeding
Correct answer is D
Explanation:
A. Elevate the head of the client's bed for 1 hr after the feeding:
This action is typically recommended for gastric (stomach) feeding, not for jejunostomy tube
feeding. For jejunostomy tube feeding, the head of the bed is not usually elevated.

B. Administer the feeding solution at a cold temperature:

Enteral feedings are generally administered at room temperature or at a temperature that is
comfortable for the patient. Cold temperatures can cause discomfort and may affect the
absorption of the feeding solution.

C. Rotate the jejunostomy tube once per day:

Rotation of the jejunostomy tube is not a standard practice. Jejunostomy tubes are typically
secured in place, and rotation is not necessary.

D. Flush the tube with 50 mL of sterile water before and after the feeding:
This is the correct action. Flushing the tube with sterile water before and after the feeding
helps ensure patency and prevents clogging. It also helps in delivering the enteral feeding
solution effectively.

120.
121.
122.
123.
124.
125.
126. A nurse is reinforcing teaching with a client who wants to lose 0.9kg (2lb) of body fat
per week. The nurse knows that 0.45 kg (1lb) of body fat is equal to 3500 calories. The nurse
should instruct the client to reduce his daily caloric intake by how many calories?
Correct answer is 1000 calories
Explanation:
To lose 0.9 kg (2 lb) of body fat per week, the client needs to create a weekly caloric deficit
of 7000 calories (3500 x 2).
This means that he needs to reduce his daily caloric intake by 1000 calories (7000 / 7).
The nurse should instruct the client to calculate his current daily caloric intake and then
subtract 1000 calories from that amount. The nurse should also advise the client to eat a
balanced diet and exercise regularly to achieve his weight loss goal.

127. A nurse is caring for a client who has a new prescription for simvastatin.
Exhibit 1
Exhibit 2
Exhibit 3
Which of the following client findings should the nurse identify as a contraindication to the
administration of simvastatin? Select all that apply.
Medical History
Admitting diagnosis: Hypertension
Past medical history: cardiovascular disease, prostate cancer
Prescription for diltiazem
Client report of muscle aches Creatinine kinase
BUN
Blood pressure
128. A nurse is caring for a client who has a new prescription for simvastatin
Which of the following client findings should the nurse identify as a contraindication to the
administration of simvastatin? Select all that apply.
Laboratory Results
Creatine kinase 200 units/L (55 to 172 units/L) Fasting blood glucose 100 mg/dl (70 to 110
mg/dL) Creatinine 1.0 g/dl (0.6 to 1.3 g/dL) BUN 15 mg/dL (10 to 20 mg/dL)
Prescription for dism
Clent report of muscle aches
Creatinine kinase
BUN
Blood pressure
129 .A nurse is caring for a client who has a new prescription for simvastatin
Blood pressure 140/90 mm Hg
Heart rate 74/min Respiratory rate 16/min
Spo, 97% on room air
which of the following client findings should the nurse identify as a contraindication to the
administration of simvastatin?
Select all that apply
Clent report of muscle aches
Creatine kinase
BUN
Blood pressure
130.A nurse is caring for a client who has a new prescription for simvastatin
Which of the following client findings should the nurse identify as a contraindication to the
administration of simvastatin?
Exhibit 3
Exhibit 4
Exhibit 5
Select all that apply.
Provider's Prescriptions
Tamsulosin 0.4 mg PO daily
Diltiazem 60 mg PO TID
Simvastatin 10 mg PO daily
Prescription for diltiazem
Client report of muscle aches
Creatinine kinase
BUN
Blood pressure
131. A nurse is assisting with the care of a client who is receiving penicilin via intermittent
IV bolus. Which of the following should the nurse recognize as a clinical manifestation of
anaphylaxis
Purbul
Pullor
11 .Exhibit 1
Exhibit 2
Dhibit 3
History and Physical
38-year-old Native American female Started menses at age 16 First pregnancy at age 25
A nurse in a provider's office is reviewing the medical record of a client. Based on the
information provided in the medical record, which of the following findings places the client
at risk for breast cancer? (Click on the "Exhibit" button for additional information about the
client. There are three tabs that contain separate categories of data.)
BRCA1 result
Biopsy result
Obstetric history
Race
132.Exhibit 1 Exhibit 2 Exhibit
Laboratory Results
Hemoglobin 15 g/dL (12 to 16 g/dL)
Hematocrit 42% (37% to 47%)
Cholesterol 180 mg/dL (less than 200 g/dL) Positive BRCA1 mutation
A nurse in a provider's office is reviewing the medical record of a client. Based on the
information provided in the medical record, which of the following findings places the client
at risk for breast cancer? (Click on the "Exhibit" button for additional information about the
client. There are three tabs that contain separate categories of data.)
BRCA1 result
Biopsy result
Obstetric history
Race
133.Exhibit 1
Exhibit 2
Exhibit 3
Graphic Record
Heart rate 112/min
Blood pressure 122/60 mm Hg Temperature 38.6° C (101.5° F) Respiratory rate 24/min
A nurse is reviewing the medical record of a client who has pneumonia. Which of the
following information is the priority for the nurse report to the provider? (Click on the
"Exhibit" button for additional information about the client. There are three tabs that contain
separate categories of data.)
Sputum results
Temperature
Creatinine level
WBC count
134.ExhibIt 1
Exhibit 2
Exhibit 3
Medication Administration Record
Ceftriaxone 2 gm IV R
Acetaminophen 325 mg PO every 4 hr PRN fever over 39° C (102.2°F)
Guaifenesin 200 mg PO every 4 hr PRN cough
A nurse is reviewing the medical record of a client who has pneumonia. Which of the
following information is the priority for the nurse report to the provider? (Click on the
"Exhibit" button for additional information about the client. There are three tabs that contain
separate categories of data.)
Sputum results
Temperature
Creatinine level
WBC count
135. Exhibit 1
Exhibit 2
Exhibit 3
Diagnostic Results A
Complete Blood Count:
Hemoglobin 15 g/dL (12 to 16 g/dL)
Hematocrit 45% (37% to 47%)
WBC count 15,000/mm3 (5000 to 10,000/mm)
Basic Metabolic Profile:
Creatinine 2.8 mg/dL (0.5 to 1.1 mg/dL)
BUN 19 mg/dL (10 to 20 mg/dL)
Sputum Culture and Sensitivity. Klebsiella pneumonia