Med Surg Practice B
Question 1
A nurse is assessing a client who has sickle cell anemia and is in sickle cell crisis. Which of the following findings is the nurse’s priority?
A. Enlarged spleen
B. Hematuria
C. Pain
D. Slurred speech
✅ Correct Answer: D. Slurred speech
Rationale: While pain is common in sickle cell crisis, slurred speech indicates cerebral hypoxia from sickling and possible stroke — this is the priority.
Question 2
A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?
A. Wear a mask
B. Wear a gown
C. Keep the client’s room well-lit
D. Maintain the head of the bed at a 45° elevation
✅ Correct Answer: A. Wear a mask
Rationale: Bacterial meningitis requires droplet precautions. A mask must be worn when within 3 ft of the client.
Question 3
A nurse is reinforcing teaching for a client who is receiving chemotherapy. Which client statement indicates understanding?
A. “I will take my temperature once a day.”
B. “I will eat fresh fruits and vegetables every day.”
C. “I will keep my toothbrush in the dishwasher once a month.”
D. “I will drink cold liquids that have been sitting out for 30 minutes.”
✅ Correct Answer: A. I will take my temperature once a day.
Rationale: Clients receiving chemotherapy are immunocompromised. Daily temperature monitoring helps detect infection early.
Question 4
A nurse is assessing a client who has hyperthyroidism. Which of the following findings should the nurse expect?
A. Weight gain
B. Bradycardia
C. Exophthalmos
D. Cold intolerance
✅ Correct Answer: C. Exophthalmos
Rationale: Exophthalmos (bulging eyes) is a classic finding of hyperthyroidism (Graves’ disease).
Question 5
A nurse is assessing a client who has a cast on their lower extremity and reports increasing pain despite analgesia. Which of the following findings indicates compartment syndrome?
A. Pallor of the toes
B. Bounding pedal pulses
C. Temperature of 98.6°F
D. Capillary refill less than 2 seconds
✅ Correct Answer: A. Pallor of the toes
Rationale: Compartment syndrome is characterized by the 6 P’s: Pain, Pallor, Paresthesia, Paralysis, Pulselessness, and Poikilothermia. Pallor is a warning sign.
Question 6
A nurse is caring for a client with cholecystitis. Which of the following foods should the client avoid?
A. Mashed potatoes
B. Turkey sandwich
C. Broiled salmon
D. Fried chicken
✅ Correct Answer: D. Fried chicken
Rationale: Clients with cholecystitis should avoid fatty, fried foods to prevent gallbladder stimulation and pain.
Question 7
A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?
A. Bradycardia
B. Pallor
C. Weight gain
D. Hypertension
✅ Correct Answer: B. Pallor
Rationale: A common manifestation of anemia is pallor due to decreased hemoglobin and oxygen delivery to tissues.
Question 8
A nurse is reinforcing teaching to a client with heart failure who is prescribed furosemide. Which statement by the client indicates understanding?
A. “I will eat foods high in potassium.”
B. “I will take this medication at bedtime.”
C. “I will weigh myself once a week.”
D. “I will increase my sodium intake.”
✅ Correct Answer: A. I will eat foods high in potassium.
Rationale: Furosemide is a loop diuretic that causes potassium loss. The client should increase potassium intake to prevent hypokalemia.
Question 9
A nurse is assessing a client with peripheral arterial disease (PAD). Which of the following findings should the nurse expect?
A. Warm, reddened skin
B. Diminished pedal pulses
C. Edema in lower extremities
D. Brown pigmentation of ankles
✅ Correct Answer: B. Diminished pedal pulses
Rationale: PAD results from decreased arterial blood flow, causing diminished or absent pulses, cool skin, and intermittent claudication.
Question 10
A nurse is teaching a client who has burns about ways to prevent infection. Which of the following client statements indicates understanding?
A. “I will wear nylon clothing to protect my skin.”
B. “I will apply lotion that contains alcohol.”
C. “I will take my prescribed antibiotics until finished.”
D. “I will limit protein intake in my diet.”
✅ Correct Answer: C. I will take my prescribed antibiotics until finished.
Rationale: Burn clients are at high risk for infection. Completing prescribed antibiotics helps prevent resistant infections.
Question 11
A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following instructions should the nurse include?
A. Soak your feet in warm water daily.
B. Wear cotton socks with shoes.
C. Trim toenails in a rounded shape.
D. Apply lotion between the toes.
✅ Correct Answer: B. Wear cotton socks with shoes.
Rationale: Diabetic clients should wear clean cotton socks to reduce risk of infection. No soaking (skin breakdown), nails straight across, and avoid lotion between toes (moisture → infection).
Question 12
A nurse is caring for a client who is postoperative following hip arthroplasty. Which of the following actions should the nurse take?
A. Place pillows under both knees.
B. Position the client’s hip at less than 90° flexion.
C. Turn the client onto the operative side every 2 hours.
D. Place a pillow under the client’s calf.
✅ Correct Answer: B. Position the client’s hip at less than 90° flexion.
Rationale: After hip replacement, avoid hip flexion > 90°, adduction, or internal rotation to prevent dislocation.
Question 13
A nurse is assessing a client who has pneumonia. Which of the following findings is the priority?
A. Fever
B. Productive cough
C. Shortness of breath
D. Fatigue
✅ Correct Answer: C. Shortness of breath
Rationale: Airway and oxygenation take priority (ABC framework). SOB indicates impaired gas exchange.
Question 14
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following interventions should the nurse implement first?
A. Administer IV insulin infusion.
B. Administer 0.9% sodium chloride IV bolus.
C. Administer potassium chloride.
D. Obtain a serum glucose level.
✅ Correct Answer: B. Administer 0.9% sodium chloride IV bolus.
Rationale: Priority in DKA is fluid replacement to restore perfusion before insulin.
Question 15
A nurse is teaching a client who has angina about nitroglycerin. Which of the following statements by the client indicates understanding?
A. “I will take a dose every 30 minutes until the pain is gone.”
B. “I will stop taking it if I feel dizzy.”
C. “I will call 911 if pain is not relieved after three doses.”
D. “I will take it with food to avoid stomach upset.”
✅ Correct Answer: C. “I will call 911 if pain is not relieved after three doses.”
Rationale: Sublingual nitro: take one every 5 min, up to 3 doses. If unresolved, call 911.
Question 16
A nurse is reviewing lab results for a client receiving warfarin. Which of the following INR results indicates the medication is therapeutic?
A. 1.0
B. 2.5
C. 4.5
D. 6.0
✅ Correct Answer: B. 2.5
Rationale: Therapeutic INR for anticoagulation = 2.0–3.0 (higher for mechanical valves).
Question 17
A nurse is teaching a client about continuous cardiac telemetry. Which statement indicates understanding?
A. “This measures how much blood my heart is pumping.”
B. “This identifies if I have a defective heart valve.”
C. “This identifies if the pacemaker cells are working properly.”
D. “This measures circulation to my heart muscle.”
✅ Correct Answer: C. “This identifies if the pacemaker cells are working properly.”
Rationale: Telemetry monitors cardiac rhythm, conduction, and dysrhythmias, not cardiac output or perfusion.
Question 18
A nurse is teaching a client who has partial-thickness burns of both arms. Which of the following interventions promotes healing?
A. Apply a topical antimicrobial ointment.
B. Leave blisters intact.
C. Apply an occlusive dressing with ice.
D. Cleanse the wounds daily with hydrogen peroxide.
✅ Correct Answer: A. Apply a topical antimicrobial ointment.
Rationale: Antimicrobials (silver sulfadiazine, bacitracin) prevent infection and promote healing. Blisters may need debridement.
Question 19
A nurse is teaching a client who has HIV infection about effective antiretroviral therapy (ART). Which of the following findings indicates effectiveness?
A. Decreased viral load
B. Increased WBC count
C. Decreased CD4 count
D. Increased serum creatinine
✅ Correct Answer: A. Decreased viral load
Rationale: Goal of ART is to suppress viral load to undetectable levels, preserving immune function.
Question 20
A nurse is assessing a client who is postoperative following nephrectomy. Which finding requires immediate intervention?
A. Abdominal pain
B. Urine output 25 mL/hr
C. Blood pressure 88/56 mm Hg
D. Report of fatigue
✅ Correct Answer: C. Blood pressure 88/56 mm Hg
Rationale: Hypotension indicates possible hemorrhage or shock → priority.
Question 21
A nurse is assessing a client who has diabetes insipidus. Which finding should the nurse expect?
A. Hypertension
B. Oliguria
C. Polyuria
D. Weight gain
✅ Correct Answer: C. Polyuria
Rationale: Diabetes insipidus = deficiency of ADH → excretion of large volumes of dilute urine → dehydration.
Question 22
A nurse is caring for a client with a chest tube connected to water seal drainage. Which finding requires intervention?
A. Constant bubbling in the water seal chamber
B. Fluctuations in the water seal chamber with respirations
C. Drainage of 50 mL in 8 hours
D. Occasional bubbling with coughing
✅ Correct Answer: A. Constant bubbling in the water seal chamber
Rationale: Continuous bubbling = air leak. Intermittent bubbling is expected.
Question 23
A nurse is teaching a client with a cast about compartment syndrome. Which finding should the client report immediately?
A. Itching under the cast
B. Swelling of the toes
C. Numbness of the fingers
D. Warmth of the extremity
✅ Correct Answer: C. Numbness of the fingers
Rationale: Numbness = neurovascular compromise, a late sign of compartment syndrome.
Question 24
A nurse is caring for a client who received morphine for severe pain. Which finding is the nurse’s priority?
A. Constipation
B. Urinary retention
C. Respiratory rate 10/min
D. Nausea
✅ Correct Answer: C. Respiratory rate 10/min
Rationale: Respiratory depression is the most serious adverse effect of opioids.
Question 25
A nurse is planning care for a client who has tuberculosis. Which intervention should the nurse include?
A. Wear an N95 respirator mask when entering the room.
B. Initiate droplet precautions.
C. Provide disposable utensils.
D. Place the client in a semiprivate room.
✅ Correct Answer: A. Wear an N95 respirator mask when entering the room.
Rationale: TB requires airborne precautions: N95 mask, negative pressure room, private room.
Question 26
A nurse is assessing a client who is postoperative following parathyroidectomy. Which finding is the priority?
A. Hoarseness
B. Muscle twitching
C. Dry skin
D. Constipation
✅ Correct Answer: B. Muscle twitching
Rationale: Muscle twitching indicates hypocalcemia (low PTH removal). Risk of laryngospasm → airway compromise.
Question 27
A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. Which complication should the nurse monitor for?
A. Respiratory acidosis
B. Oxygen toxicity
C. Hypercarbia
D. Nasal mucosal dryness
✅ Correct Answer: D. Nasal mucosal dryness
Rationale: Low-flow O₂ causes dryness; humidification may be needed.
Question 28
A nurse is assessing a client receiving total parenteral nutrition (TPN). Which finding requires intervention?
A. Blood glucose 220 mg/dL
B. BUN 18 mg/dL
C. Weight gain 0.5 kg in 1 week
D. Urine output 40 mL/hr
✅ Correct Answer: A. Blood glucose 220 mg/dL
Rationale: TPN can cause hyperglycemia → monitor and report elevated blood glucose.
Question 29
A nurse is teaching a client who has chronic constipation about dietary fiber. Which food should the nurse recommend?
A. White rice
B. Bananas
C. Kidney beans
D. Yogurt
✅ Correct Answer: C. Kidney beans
Rationale: High-fiber foods (beans, whole grains, vegetables) promote bowel regularity.
Question 30
A nurse is assessing a client with pneumonia. Which finding indicates the client is improving?
A. Respiratory rate 28/min
B. O₂ saturation 95% on room air
C. Productive cough with yellow sputum
D. Crackles in posterior bases
✅ Correct Answer: B. O₂ saturation 95% on room air
Rationale: Improved oxygenation indicates pneumonia resolution. Persistent crackles and sputum indicate ongoing infection.
Question 31
A nurse is reinforcing teaching with a client who has venous insufficiency. Which of the following statements indicates understanding of the teaching?
A. “I should avoid walking as much as possible.”
B. “I should sit and read for several hours each day.”
C. “I will wear clean graduated compression stockings every day.”
D. “I will keep my legs level with my body when I sleep at night.”
✅ Correct Answer: C. “I will wear clean graduated compression stockings every day.”
Rationale: Compression stockings reduce venous pooling and edema. Clients with venous insufficiency should also elevate legs and avoid prolonged sitting/standing.
Question 32
A nurse is teaching a client who has migraines and is taking feverfew. Which of the following medications can interact with feverfew?
A. Metoprolol
B. Bupropion
C. Atorvastatin
D. Naproxen
✅ Correct Answer: D. Naproxen
Rationale: Feverfew has antiplatelet effects and can increase bleeding risk with NSAIDs like naproxen.
Question 33
A nurse is caring for a client who has been receiving long-term mechanical ventilation via tracheostomy. Which of the following complications is associated with this treatment?
A. Elevated blood pressure
B. Dehydration
C. Stress ulcers
D. Hypernatremia
✅ Correct Answer: C. Stress ulcers
Rationale: Critically ill, ventilated clients are at risk for stress ulcers; prophylaxis with PPIs/H2 blockers is indicated.
Question 34
A nurse is reinforcing teaching with a client who has recurrent urinary tract infections (UTIs). Which of the following client statements indicates understanding of the teaching?
A. “I will avoid foods that are high in ascorbic acid.”
B. “I will add oatmeal to my bath water.”
C. “I will urinate every 6 hours.”
D. “I will take daily cranberry supplements.”
✅ Correct Answer: D. “I will take daily cranberry supplements.”
Rationale: Cranberry reduces bacterial adherence in the urinary tract. Clients should also void frequently and increase fluids.
Question 35
A nurse is caring for a client who received magnesium sulfate 1 g IV bolus. The nurse should monitor the client for which of the following adverse effects?
A. Hyperreflexia
B. Increased blood pressure
C. Respiratory paralysis
D. Tachycardia
✅ Correct Answer: C. Respiratory paralysis
Rationale: Magnesium toxicity depresses the CNS → hyporeflexia, hypotension, bradycardia, respiratory depression/paralysis.
Question 36
A nurse is reinforcing teaching with a client who has Alzheimer’s disease. Which of the following interventions should the nurse include? (Select all that apply.)
A. Position tabletop clocks with multi-colored backgrounds.
B. Explain how to complete a task while the client is doing it.
C. Place a calendar on the wall with days and weeks included.
D. Create complete outfits and allow the client to select one daily.
✅ Correct Answers: B and C
Rationale: Cueing with simple step-by-step instructions and orientation tools like calendars support independence. Too many choices or distractions increase confusion.
Question 37
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include?
A. Explain procedures as they occur.
B. Place personal items at the client’s bedside.
C. Orient the client once per shift.
D. Encourage the family to stay home until the client adjusts.
✅ Correct Answer: B. Place personal items at the client’s bedside.
Rationale: Familiar items provide comfort and orientation for dementia clients.
Question 38
A nurse is reinforcing teaching with a client who is postoperative following thyroidectomy with removal of parathyroid glands. The nurse should instruct the client that which of the following foods is highest in calcium?
A. 12 almonds
B. One small banana
C. 1 tbsp peanut butter
D. ½ cup tomato juice
✅ Correct Answer: A. 12 almonds
Rationale: Almonds are a good plant-based source of calcium, which is important after parathyroid removal due to risk of hypocalcemia.
Question 39
A nurse is reviewing admission history for a client scheduled for a CT scan with IV contrast. Which of the following findings requires further assessment?
A. History of asthma
B. Appendectomy 1 year ago
C. Allergy to penicillin
D. History of knee arthroplasty 6 months ago
✅ Correct Answer: A. History of asthma
Rationale: Asthma increases risk of allergic reaction to contrast dye.
Question 40
A nurse is teaching a client who is prescribed a TENS unit for bone cancer pain. Which effect should the nurse explain?
A. Produces feelings of heat
B. Provides cryotherapy
C. Realigns energy flow
D. Causes a tingling sensation that replaces pain
✅ Correct Answer: D. Causes a tingling sensation that replaces pain
Rationale: TENS produces tingling/buzzing sensations that block pain signals via gate control theory.
Question 41
A nurse is caring for a client with emphysema on mechanical ventilation. The high-pressure alarm is sounding and the client is restless. Which action should the nurse take first?
A. Obtain ABGs
B. Administer propofol
C. Instruct the client to relax
D. Disconnect and manually ventilate the client
✅ Correct Answer: D. Disconnect and manually ventilate the client
Rationale: High-pressure alarms = obstruction. If client is in distress, disconnect and bag to ensure oxygenation while troubleshooting.
Question 42
A nurse is planning referrals for clients. Which client should be referred to physical therapy?
A. Client receiving preoperative teaching for knee arthroplasty
B. Client who has difficulty obtaining a walker
C. Client with increased pain after hip arthroplasty
D. Client struggling emotionally with prosthesis
✅ Correct Answer: A. Client receiving preoperative teaching for knee arthroplasty
Rationale: PT teaches exercises and mobility strategies pre-op to improve recovery. Other cases require social work or counseling
Question 43
A nurse is caring for a client 8 hr postoperative following total hip arthroplasty who is unable to void on the bedpan. Which action should the nurse take first?
A. Document intake and output
B. Scan bladder with portable ultrasound
C. Pour warm water over perineum
D. Straight catheterize
✅ Correct Answer: B. Scan bladder with portable ultrasound
Rationale: Assess for urinary retention before invasive interventions.
Question 44
A nurse is preparing to administer phenytoin 600 mg PO daily. Available is phenytoin 125 mg/5 mL. How many mL should the nurse administer?
A. 18 mL
B. 20 mL
C. 24 mL
D. 30 mL
✅ Correct Answer: C. 24 mL
Rationale: 600 ÷ 125 × 5 = 24. Correct dose is 24 mL.
Question 45
A nurse is teaching a client with severe stage II Lyme disease. Which client statement shows understanding?
A. “I will need antibiotics for 1 year.”
B. “My partner needs antiviral medication.”
C. “My joints ache because of Lyme disease.”
D. “I bruise easily because of Lyme disease.”
✅ Correct Answer: C. “My joints ache because of Lyme disease.”
Rationale: Stage II Lyme disease often causes musculoskeletal pain. Treatment is 2–4 weeks of antibiotics, not antivirals.
Question 46
A nurse is teaching a client with AIDS. Which statement indicates understanding?
A. “I will clean my toothbrush in the dishwasher once a month.”
B. “I will eat more fresh fruit and vegetables.”
C. “I will avoid drinking cold liquids left out.”
D. “I will take my temperature once a day.”
✅ Correct Answer: D. “I will take my temperature once a day.”
Rationale: Daily temperature monitoring allows early infection detection in immunocompromised clients.
Question 47
A nurse is completing a pre-op assessment. Which food allergy suggests latex allergy?
A. Shellfish
B. Peanuts
C. Eggs
D. Avocados
✅ Correct Answer: D. Avocados
Rationale: Latex–fruit syndrome includes avocado, banana, kiwi, chestnut, tomato.
Question 48
A nurse is reinforcing teaching with a client receiving radiation therapy for throat cancer. Which statement shows correct understanding?
A. “I will wash the ink markings off after each treatment.”
B. “I will use my hands instead of a washcloth to clean the area.”
C. “I can be out in the sun 1 month after treatments.”
D. “I will use a heating pad if my neck is sore.”
✅ Correct Answer: B. “I will use my hands instead of a washcloth to clean the area.”
Rationale: Skin in radiation field must be handled gently. Markings should not be removed.
Question 49
A nurse is reviewing meds for a client scheduled for cataract surgery. Which medication is a contraindication?
A. Warfarin
B. Atorvastatin
C. Metoprolol
D. Insulin glargine
✅ Correct Answer: A. Warfarin
Rationale: Anticoagulants increase bleeding risk during surgery.
Question 50
A nurse is caring for a client after TURP who has clots in the catheter and decreased urine output. What should the nurse do?
A. Remove catheter
B. Clamp catheter
C. Irrigate the catheter
D. Notify provider
✅ Correct Answer: C. Irrigate the catheter
Rationale: Irrigation clears obstruction from clots and restores urine flow.
Question 51
A nurse is preparing a client for allergy skin testing. Which finding requires postponement?
A. Prednisone use
B. History of asthma
C. Recent URI
D. Family history of allergies
✅ Correct Answer: A. Prednisone use
Rationale: Corticosteroids suppress immune response and interfere with results.
Question 52
A nurse is reviewing labs for a client with chest pain 6 hr ago. Which finding indicates MI?
A. Cortisol 0.9 mcg/dL
B. Amylase 440 units/L
C. Calcium 7.5 mg/dL
D. Troponin I 8 ng/mL
✅ Correct Answer: D. Troponin I 8 ng/mL
Rationale: Troponin is the most specific marker for MI; elevated at 3–6 hr after onset.
Question 53
A nurse is assessing a client with acute cholecystitis. Which finding is the priority?
A. Anorexia
B. Abdominal pain radiating to right shoulder
C. Rebound tenderness
D. Tachycardia
✅ Correct Answer: C. Rebound tenderness
Rationale: Rebound tenderness suggests peritonitis from possible rupture, a life-threatening complication.
Question 54
A nurse is reinforcing teaching for a client with radiation implant for cervical cancer. Which intervention should the nurse plan?
A. Keep a lead-lined container in the room
B. Allow visitors for 1 hr per day
C. Place a dosimeter badge on the client
D. Remove soiled linens daily
✅ Correct Answer: A. Keep a lead-lined container in the room
Rationale: If implant dislodges, place in lead container with forceps.
Question 55
A nurse is updating the plan of care for a client receiving chemotherapy. Which finding is the priority?
A. Sore throat
B. Memory loss
C. Alopecia
D. Mucositis
✅ Correct Answer: A. Sore throat
Rationale: Sore throat may indicate infection, the greatest risk in immunosuppressed clients.
Question 56
A nurse is reinforcing teaching for a client about oral iron. Which statement indicates misunderstanding?
A. “I will take iron with a glass of milk.”
B. “I will avoid antacids with my iron.”
C. “I will include red meat in my diet.”
D. “I will increase fiber in my diet.”
✅ Correct Answer: A. “I will take iron with a glass of milk.”
Rationale: Calcium inhibits absorption of iron. Best absorbed with vitamin C on an empty stomach.
Question 57
A nurse is reinforcing teaching with a client before a total knee arthroplasty. Which statement indicates understanding? (Select all that apply.)
A. “Physical therapy will start after I go home.”
B. “I will do breathing exercises every 1–2 hours after surgery.”
C. “I will ask for pain meds before my knee hurts too much.”
D. “I will probably go home with a walker.”
E. “I cannot change my mind about the surgery now.”
✅ Correct Answers: B, C, D
Rationale: Clients should perform breathing exercises, request pain control before pain worsens, and expect a walker. PT starts in hospital.
Question 58
A nurse is caring for a client who is 2 weeks postop gastrectomy and reports dizziness, tachycardia, and abdominal cramping after meals. Which interventions should the nurse include? (Select all that apply.)
A. Eat several small meals daily
B. Avoid highly seasoned foods
C. Maintain a high-carbohydrate intake
D. Eat high-protein snacks
E. Avoid drinking fluids with meals
F. Eat five servings of fruit daily
✅ Correct Answers: A, B, D, E
Rationale: Dumping syndrome teaching: small frequent meals, avoid simple carbs, increase protein/fat, separate liquids from solids.
Question 59
A nurse is reinforcing teaching for a client who is receiving external beam radiation therapy. Which statement indicates understanding?
A. “I will use ice packs on my skin if it gets sore.”
B. “I will avoid direct sun exposure.”
C. “I will apply scented lotion to the area.”
D. “I will scrub the area gently with a washcloth.”
✅ Correct Answer: B. “I will avoid direct sun exposure.”
Rationale: Radiation-treated skin is sensitive; avoid sunlight, heat, and harsh products.
Question 60
A nurse is reinforcing teaching for a client scheduled for cataract surgery. Which instruction should the nurse include?
A. “You will need to avoid bending over after surgery.”
B. “You should avoid wearing sunglasses after surgery.”
C. “You will need to sleep flat after surgery.”
D. “You should rub your eye if it itches.”
✅ Correct Answer: A. “You will need to avoid bending over after surgery.”
Rationale: Bending increases intraocular pressure. Clients should also avoid rubbing and heavy lifting.
Question 61
A nurse is teaching a client with cirrhosis about dietary management. Which statement by the client indicates understanding?
A. “I will limit my protein intake.”
B. “I will increase my sodium intake.”
C. “I will drink plenty of water.”
D. “I will eat high-fat foods.”
✅ Correct Answer: A. “I will limit my protein intake.”
Rationale: Excess protein worsens ammonia buildup and hepatic encephalopathy in cirrhosis.
Question 62
A nurse is assessing a client who has left-sided heart failure. Which finding should the nurse expect?
A. Dependent edema
B. Jugular vein distention
C. Dyspnea on exertion
D. Hepatomegaly
✅ Correct Answer: C. Dyspnea on exertion
Rationale: Left-sided HF causes pulmonary congestion → SOB, crackles, orthopnea. Right-sided HF causes edema and JVD.
Question 63
A nurse is teaching a client who has a new prescription for verapamil. Which adverse effect should the nurse instruct the client to report?
A. Constipation
B. Increased appetite
C. Frequent urination
D. Tinnitus
✅ Correct Answer: A. Constipation
Rationale: Verapamil (calcium channel blocker) commonly causes constipation due to smooth muscle relaxation.
Question 64
A nurse is assessing a client who has peritonitis. Which finding is the priority?
A. Abdominal distention
B. Rigid, boardlike abdomen
C. Fever
D. Tachycardia
✅ Correct Answer: B. Rigid, boardlike abdomen
Rationale: Indicates severe peritoneal inflammation/perforation and requires immediate intervention.
Question 65
A nurse is teaching a client with asthma about the use of a metered-dose inhaler. Which statement by the client indicates understanding?
A. “I will shake the inhaler before each use.”
B. “I will exhale while pressing down on the inhaler.”
C. “I will inhale quickly while using the inhaler.”
D. “I will wait 5 seconds before using a second puff.”
✅ Correct Answer: A. “I will shake the inhaler before each use.”
Rationale: Proper technique includes shaking, slow inhalation, and waiting 1–2 min before second puff.
Question 66
A nurse is caring for a client who has hypovolemic shock. Which IV fluid should the nurse anticipate administering first?
A. 0.9% sodium chloride
B. Lactated Ringer’s
C. 0.45% sodium chloride
D. Dextrose 5% in water
✅ Correct Answer: A. 0.9% sodium chloride
Rationale: Isotonic fluids (NS, LR) are first-line for volume replacement in shock.
Question 67
A nurse is teaching a client who has a seizure disorder about phenytoin. Which statement indicates understanding?
A. “I should stop taking this medication if I feel better.”
B. “I will need to visit my dentist regularly.”
C. “I can drink alcohol occasionally while taking this.”
D. “I can skip a dose if I am sick.”
✅ Correct Answer: B. “I will need to visit my dentist regularly.”
Rationale: Phenytoin causes gingival hyperplasia → requires good oral care and regular dental visits.
Question 68
A nurse is assessing a client who has increased intracranial pressure (ICP). Which finding is the priority?
A. Headache
B. Projectile vomiting
C. Unequal pupils
D. Decerebrate posturing
✅ Correct Answer: D. Decerebrate posturing
Rationale: Indicates severe brain injury and brainstem dysfunction → priority emergency finding.
Question 69
A nurse is reviewing labs of a client with suspected pancreatitis. Which finding is expected?
A. Decreased amylase
B. Increased lipase
C. Increased hemoglobin
D. Decreased bilirubin
✅ Correct Answer: B. Increased lipase
Rationale: Elevated amylase and lipase are diagnostic for acute pancreatitis.
Question 70
A nurse is reinforcing teaching about furosemide. Which finding should the client report?
A. Muscle weakness
B. Tinnitus
C. Increased urination
D. Dizziness when standing
✅ Correct Answer: B. Tinnitus
Rationale: Loop diuretics may cause ototoxicity → report ringing in the ears.
Question 71
A nurse is planning care for a client following stroke. Which intervention is the priority?
A. Encourage fluid intake
B. Maintain NPO status until swallowing is evaluated
C. Provide passive ROM
D. Reposition every 2 hr
✅ Correct Answer: B. Maintain NPO status until swallowing is evaluated
Rationale: Prevents aspiration in clients with impaired gag reflex post-stroke.
Question 72
A nurse is caring for a client who has a chest tube following thoracotomy. Which finding indicates the system is functioning correctly?
A. Constant bubbling in the water seal
B. Fluctuation in the water seal chamber with respirations
C. Drainage of 200 mL in 8 hr
D. Absence of tidaling
✅ Correct Answer: B. Fluctuation in the water seal chamber with respirations
Rationale: Tidaling (fluctuation) = patent system. Constant bubbling = leak.
Question 73
A nurse is caring for a client with Addison’s disease. Which finding should the nurse expect?
A. Hypertension
B. Hypernatremia
C. Hyperpigmentation
D. Weight gain
✅ Correct Answer: C. Hyperpigmentation
Rationale: Addison’s disease = adrenal insufficiency → bronze skin, hypotension, hyponatremia, weight loss.
Question 74
A nurse is caring for a client with a tracheostomy. Which action should the nurse take?
A. Suction for 30 seconds
B. Use surgical asepsis when suctioning
C. Hyperventilate with 100% O₂ before suctioning
D. Suction every 2 hours routinely
✅ Correct Answer: C. Hyperventilate with 100% O₂ before suctioning
Rationale: Pre-oxygenate to prevent hypoxemia during suctioning. Limit suction to <10 sec.
Question 75
A nurse is assessing a client who has hypocalcemia. Which finding should the nurse expect?
A. Negative Chvostek’s sign
B. Hyperactive deep-tendon reflexes
C. Decreased bowel sounds
D. Bradycardia
✅ Correct Answer: B. Hyperactive deep-tendon reflexes
Rationale: Hypocalcemia increases neuromuscular excitability → tetany, twitching, hyperreflexia.
Question 76
A nurse is caring for a client who is postoperative following thyroidectomy. Which assessment is the priority?
A. Temperature
B. Respiratory effort
C. Pain level
D. Bowel sounds
✅ Correct Answer: B. Respiratory effort
Rationale: Post-thyroidectomy clients are at risk for airway obstruction due to edema/bleeding.
Question 77
A nurse is teaching a client who has AIDS. Which statement indicates understanding?
A. “I will clean my toothbrush in the dishwasher once a month.”
B. “I will eat more fresh fruit and vegetables.”
C. “I will avoid drinking cold liquids left out.”
D. “I will take my temperature once a day.”
✅ Correct Answer: D. “I will take my temperature once a day.”
Rationale: Daily temp monitoring helps detect infection early.
Question 78
A nurse is teaching a client who is prescribed oral iron. Which statement indicates a need for further teaching?
A. “I will take my iron with a glass of milk.”
B. “I will avoid taking antacids with my iron.”
C. “I will eat red meat for extra iron.”
D. “I will eat high-fiber foods to prevent constipation.”
✅ Correct Answer: A. “I will take my iron with a glass of milk.”
Rationale: Milk (calcium) inhibits absorption of iron. Take with vitamin C for best absorption.
Question 79
A nurse is obtaining a med history for a client scheduled for cataract surgery. Which med is contraindicated?
A. Warfarin
B. Atorvastatin
C. Metoprolol
D. Insulin
✅ Correct Answer: A. Warfarin
Rationale: Anticoagulants increase risk of bleeding during surgery.
Question 80
A nurse is caring for a client after TURP who has clots in catheter and decreased urine output. Which action should the nurse take?
A. Remove the catheter
B. Clamp the catheter
C. Irrigate the catheter
D. Notify the provider
✅ Correct Answer: C. Irrigate the catheter
Rationale: Irrigation restores patency by clearing clots.
Question 81
A nurse is preparing a client for allergy skin testing. Which finding requires postponement?
A. Prednisone use
B. History of asthma
C. Family history of allergies
D. Age over 50
✅ Correct Answer: A. Prednisone use
Rationale: Corticosteroids suppress immune response and interfere with test accuracy.
Question 82
A nurse is assessing a client 6 hr after chest pain. Which lab finding confirms MI?
A. Cortisol 0.9 mcg/dL
B. Amylase 440 units/L
C. Calcium 7.5 mg/dL
D. Troponin I 8 ng/mL
✅ Correct Answer: D. Troponin I 8 ng/mL
Rationale: Troponin is the most specific marker for MI.
Question 83
A nurse is assessing a client with acute cholecystitis. Which finding is priority?
A. Anorexia
B. RUQ pain radiating to right shoulder
C. Rebound tenderness
D. Tachycardia
✅ Correct Answer: C. Rebound tenderness
Rationale: Indicates peritonitis, a life-threatening complication.
Question 84
A nurse is reinforcing teaching for a client receiving sealed internal radiation therapy. Which action should the nurse take?
A. Keep a lead container in the room
B. Limit visitors to 1 hr/day
C. Place dosimeter badge on the client
D. Remove soiled linens daily
✅ Correct Answer: A. Keep a lead container in the room
Rationale: If implant dislodges, place in container with long-handled forceps.
Question 85
A nurse is updating care plan for a client on chemotherapy. Which finding is priority?
A. Sore throat
B. Memory loss
C. Alopecia
D. Mucositis
✅ Correct Answer: A. Sore throat
Rationale: Infection risk is priority in immunocompromised clients.
Question 86
A nurse is teaching a client before total knee arthroplasty. Which statements indicate understanding? (Select all that apply.)
A. “I will begin PT after I go home.”
B. “I will use my incentive spirometer every 1–2 hr.”
C. “I will ask for pain medication before my knee hurts too much.”
D. “I will probably go home with a walker.”
E. “I cannot change my mind now.”
✅ Correct Answers: B, C, D
Rationale: Clients should do breathing exercises, manage pain early, and use a walker after discharge. PT begins in hospital.
Question 87
A nurse is caring for a client 2 weeks post-gastrectomy with dizziness, tachycardia, and cramping after meals. Which teaching should the nurse reinforce? (Select all that apply.)
A. Eat several small meals daily
B. Avoid highly seasoned foods
C. Eat a high-carb diet
D. Consume high-protein snacks
E. Avoid fluids with meals
F. Eat 5 servings of fruit daily
✅ Correct Answers: A, B, D, E
Rationale: These reduce dumping syndrome. Avoid simple carbs and drinking with meals.
Question 88
A nurse is teaching a client scheduled for cataract surgery. Which instruction should the nurse include?
A. “Avoid bending at the waist.”
B. “Do not wear sunglasses.”
C. “Lie flat after surgery.”
D. “Rub your eye if it itches.”
✅ Correct Answer: A. “Avoid bending at the waist.”
Rationale: Bending increases intraocular pressure.
Question 89
A nurse is teaching a client with a sealed radiation implant. Which intervention is correct?
A. Keep lead container in room
B. Visitors 1 hr/day
C. Dosimeter badge on client
D. Remove linens daily
✅ Correct Answer: A. Keep lead container in room
Rationale: For safety in case of implant dislodgement.
Question 90
A nurse is updating care plan for a client receiving chemotherapy. Which finding is priority?
A. Sore throat
B. Memory loss
C. Alopecia
D. Mucositis
✅ Correct Answer: A. Sore throat
Rationale: Indicates possible infection, life-threatening in immunosuppressed clients.