1.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour
ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the
next hour?
1. Urinary output of 20 mL/hour
2. Temperature of 37.6 °C (99.6 °F)
3. Blood pressure of 100/70 mm Hg
4. Serous drainage on the surgical dressing
Answer 1
Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An
output of less than 30 mL for 2 consecutive hours should be reported to the health care provider.
A temperature higher than 37.7 °C (100 °F) or lower than 36.1 °C (97 °F) and a falling systolic
blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The
client’s preoperative or baseline blood pressure is used to make informed postoperative
comparisons. Moderate or light serous drainage from the surgical site is considered normal.
Test-Taking Strategy: Note the strategic word, most. Focus on the subject, expected
postoperative assessment findings. To answer this question correctly, you must know the normal
ranges for temperature, blood pressure, urinary output, and wound drainage. Note that the
urinary output is the only observation that is not within the normal range.
2. A client is scheduled to have surgery. The nurse should place priority on determining whether
the surgeon wants which medications held in the preoperative period to assure client safety?
1. Warfarin
2. Furosemide
3. Famotidine
4. Multivitamin with minerals
Answer: 1
Rationale: The nurse is careful to question the surgeon about whether warfarin should be
administered in the preoperative period. This medication is often withheld for a period of time
preoperatively to minimize the risk of hemorrhage during surgery. The other medications may
also be withheld if specifically prescribed, but usually they are discontinued as part of an NPO
(nothing by mouth) after midnight prescription. Priority Nursing Tip: In the preoperative client,
the nurse should review the client’s medication list and question the primary health care provider
about medications that should be withheld. Test-Taking Strategy: Note the strategic word,
priority. Recalling that warfarin is an anticoagulant and that when a client is taking an
anticoagulant a risk for bleeding exists will direct you to the correct option.
3. The nurse providing care to a client with a leg fracture ensures that which intervention is first
implemented before the fracture is reduced in the casting room?
1. Obtaining an anesthesia consent
2. Administering an opioid analgesic
3. Notifying the operating room staff
4. Obtaining an informed consent for treatment
Answer: 4
Rationale: Before a fracture is reduced, an informed consent for treatment is needed. The nurse
should reinforce explanations according to the client’s needs and ability to understand.
Administration of anesthesia would only be done in the operating room for open reduction of
fractures. Closed reductions may be done in the emergency department without anesthesia. An
analgesic would be administered as prescribed because the procedure is painful, but the informed
consent form must be obtained before administering the medication. Priority Nursing Tip:
Minors (clients younger than 18 years) need a parent or legal guardian to sign an informed
consent form. Test-Taking Strategy: Focus on the strategic word, first. Note that the question
specifically states that the procedure is going to be done in the cast room. This will assist in
eliminating options 1 and 3. Recalling that an informed consent form must be obtained before
administering sedating medication will direct you to the correct option.
4. During the postoperative period, the client who underwent a pelvic exenteration (a radical
surgical treatment that removes all organs from a person's pelvic cavity) reports pain in the calf
area. What action should the nurse take?
1. Ask the client to walk and observe the gait.
2. Lightly massage the calf area to relieve the pain.
3. Check the calf area for temperature, color, and size.
4. Administer PRN morphine sulfate as prescribed for postoperative pain.
Answer: 3
Rationale: The nurse monitors the postoperative client for complications such as deep vein
thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep
vein thrombosis. Change in color, temperature, or size of the client’s calf could also indicate this
complication. Options 1 and 2 could result in an embolus if in fact the client had a deep vein
thrombosis. Administering pain medication for this client is not the appropriate nursing action
since further assessment needs to take place. Priority Nursing Tip: The primary signs of deep
vein thrombosis are calf or groin tenderness and pain and sudden onset of unilateral swelling of
the leg. Test-Taking Strategy: Focus on the information in the question and use the steps of the
nursing process. Assessment is the first step. Option 3 is the only option that addresses
assessment.
5. Which nursing assessment question should be asked to help determine the client’s risk for
developing malignant hyperthermia in the perioperative period?
1. “Have you ever had heat exhaustion or heat stroke?”
2. “What is the normal range for your body temperature?”
3. “Do you or any of your family members have frequent infections?”
4. “Do you or any of your family members have problems with general anesthesia?”
Answer: 4
Rationale: Malignant hyperthermia is a genetic disorder in which a combination of anesthetic
agents (the muscle relaxant succinylcholine and inhalation agents such as halothanes) triggers
uncontrolled skeletal muscle contractions that can quickly lead to a potentially fatal
hyperthermia. Questioning the client about the family history of general anesthesia problems
may reveal this as a risk for the client. Options 1, 2, and 3 are unrelated to this surgical
complication. Priority Nursing Tip: Early indicators of malignant hyperthermia include masseter
muscle contractions and tachycardia. An elevated temperature is a late sign. Test-Taking
Strategy: Focus on the subject, malignant hyperthermia. Think about the pathophysiology
associated with this disorder. Recalling that this disorder is genetic will direct you to the correct
option.
6. The nurse is ambulating a client for the first time after having abdominal surgery. What
clinical manifestations should indicate to the nurse that the client may be experiencing
orthostatic hypotension? Select all that apply.
1. Nausea
2. Dizziness
3. Bradycardia
4. Lightheadedness
5. Flushing of the face
6. Reports of seeing spots
Answer: 1, 2, 4, 6 Rationale: Orthostatic hypotension occurs when a normotensive person
develops symptoms of low blood pressure when rising to an upright position. Whenever the
nurse gets a client up and out of a bed or chair, there is a risk for orthostatic hypotension.
Symptoms of nausea, dizziness, lightheadedness, tachycardia, pallor, and reports of seeing spots
are characteristic of orthostatic hypotension. A drop of approximately 15 mm Hg in the systolic
blood pressure and 10 mm Hg in the diastolic blood pressure also occurs. Fainting can result
without intervention, which includes immediately assisting the client to a lying position. Priority
Nursing Tip: Baroreceptors (located in the walls of the aortic arch and carotid sinuses) are
specialized nerve endings affected by changes in the blood pressure. Increases in the arterial
pressure stimulate baroreceptors to decrease the pressure. Conversely, decreases in arterial
pressure reduce stimulation and the blood pressure increases. Test-Taking Strategy: Focus on the
subject, the manifestations of orthostatic hypotension. As you read each option, think about the
physiological changes that occur when the blood pressure drops. This will assist in answering the
question.
7. The nurse is encouraging the client to cough and deep breath after cardiac surgery. The nurse
ensures that which item is available to maximize the effectiveness of this procedure?
1. Nebulizer
2. Ambu bag
3. Suction equipment
4. Incisional splinting pillow
Answer: 4
Rationale: The use of an incisional splint such as a “cough pillow” can ease discomfort during
coughing and deep breathing. The client who is comfortable will do more effective deep
breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options 1, 2,
and 3 will not encourage the client to cough and deep breathe. Priority Nursing Tip: If a surgical
incision is located in the abdominal or thoracic area, instruct the client to place a folded towel or
pillow, or one hand with the other on top, over the incisional area to splint it during coughing and
deep breathing. Test-Taking Strategy: Focus on the subject, coughing and deep breathing after
cardiac surgery. Note the strategic word, effectiveness. The cough pillow is an item that will
maximize effectiveness. Eliminate options 2 and 3, which are items used by the nurse. A
nebulizer (option 1) is used to deliver medication.
8. A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day
postoperative. The nurse performs an abdominal assessment and notes the absence of bowel
sounds. What action should the nurse take?
1. Start the client on sips of water.
2. Remove the nasogastric (NG) tube.
3. Call the primary health care provider immediately.
4. Document the finding and continue to assess for bowel sounds.
Answer: 4
Rationale: Bowel sounds may be absent for 3 to 4 postoperative days because of bowel
manipulation during surgery. The nurse should document the finding and continue to monitor the
client. The NG tube should stay in place if present, and the client is kept NPO until after the
onset of bowel sounds. Additionally, the nurse does not remove the tube without a prescription to
do so. There is no need to call the primary health care provider immediately at this time. Priority
Nursing Tip: In the postoperative period, ask the client about the passage of flatus. This is the
best initial indicator of the return of intestinal activity.
Test-Taking Strategy: Focus on the subject, postoperative care. Note the words “1 day
postoperative.” Eliminate option 2 because there are no data in the question regarding the
presence of an NG tube. Additionally, an NG tube would not be removed, and the client would
not be fed (option 1) if bowel sounds were absent. Recalling that bowel sounds may not return
for 3 to 4 postoperative days will direct you to the correct option from the remaining options.
9. The nurse creates a discharge plan for a client who had an abdominal hysterectomy. Which
activity instructions should the nurse include in the plan? Select all that apply.
1. Avoid heavy lifting.
2. Sit as much as possible.
3. Take baths rather than showers.
4. Limit stair climbing to five times a day.
5. Gradually increase walking as exercise but stop before becoming fatigued.
6. Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks.
Answer: 1, 4, 5, 6
Rationale: After abdominal hysterectomy, the client should avoid lifting anything that is heavy
and limit stair climbing to five times a day. The client should walk indoors for the first week and
then gradually increase walking as exercise but stop before becoming fatigued. The client should
avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks. The client is also
told to avoid the sitting position for extended periods, to take showers rather than tub baths,
avoid crossing the legs at the knees, and avoid driving for at least 4 weeks or until the surgeon
has given permission to do so. Priority Nursing Tip: Monitor vaginal bleeding after
hysterectomy. More than one saturated pad per hour may indicate excessive bleeding. Test-
Taking Strategy: Focus on the subject, activity instructions after abdominal hysterectomy. Read
each option carefully, focusing on the type and location of the surgery and the importance of
protecting the surgical area. This will assist in eliminating options 2 and 3.
10. The nurse is teaching a client about coughing and deep-breathing techniques to prevent
postoperative complications. Which statement is most appropriate for the nurse to make to the
client at this time as it relates to these techniques?
1. “Use of an incentive spirometer will help prevent
pneumonia.”
2. “Close monitoring of your oxygen saturation will detect hypoxemia.”
3. “Administration of intravenous fluids will prevent or treat fluid imbalance.”
4. “Early ambulation and administration of blood thinners will prevent pulmonary embolism.”
Answer 1
Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli.
Atelectasis and other conditions may also be called collapsed lung. Atelectasis means that lung
sacs cannot inflate properly, which means your blood may not be able to deliver oxygen to
organs and tissues. Pneumonia is the inflammation of lung tissue that causes productive cough,
dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an
incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate
concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will
help to detect hypoxemia, monitoring is not directly related to coughing and deep breathing
techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and
surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related
to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the
pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to
clot formation. Early ambulation and administration of blood thinners helps to prevent this
complication; however, it is not related to coughing and deep-breathing techniques.
Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the subject, client
instructions related to coughing and deep-breathing techniques. Also, focus on the data in the
question and note the relationship between the words coughing and deep breathing in the
question and pneumonia in the correct option.
11. The nurse is creating a plan of care for a client scheduled for surgery. The nurse should
include which activity in the nursing care plan for the client on the day of surgery?
1. Avoid oral hygiene and rinsing with mouth wash.
2. Verify that the client has not eaten for the last 24 hours.
3. Have the client void immediately before going into surgery.
4. Report immediately any slight increase in blood pressure or pulse.
Answer: 3 Rationale:
The nurse would assist the client to void immediately before surgery so that the bladder will be
empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually
has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery
instead of 24 hours. A slight increase in blood pressure and pulse is common during the
preoperative period and is usually the result of anxiety.
Test-Taking Strategy: Focus on the subject, preoperative care measures. Think about the
measures that may be helpful and promote comfort. Oral hygiene should be administered since it
may make the client feel more comfortable. A client should be nothing by mouth (NPO) for 6 to
8 hours before surgery rather than 24 hours. A slight increase in blood pressure or pulse is
insignificant in this situation.
12. A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative
consent form because of sedation from opioid analgesics that have been administered. The nurse
should take which most appropriate action in the care of this client?
1. Obtain a court order for the surgery.
2. Have the charge nurse sign the informed consent immediately.
3. Send the client to surgery without the consent form being signed.
4. Obtain a telephone consent from a family member, following agency policy.
Answer 4.
Rationale: Every effort should be made to obtain permission from a responsible family member
to perform surgery if the client is unable to sign the consent form. A telephone consent must be
witnessed by 2 persons who hear the family member’s oral consent. The 2 witnesses then sign
the consent with the name of the family member, noting that an oral consent was obtained.
Consent is not informed if it is obtained from a client who is confused, unconscious, mentally
incompetent, or under the influence of sedatives. In an emergency, a client may be unable to
sign, and family members may not be available. In this situation, a health care provider is
permitted legally to perform surgery without consent, but the data in the question do not indicate
an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies
regarding informed consent should always be followed. Test-Taking Strategy: Note the strategic
words, most appropriate. Focus on the data in the question. Eliminate options 1 and 3 first.
Option 1 will delay necessary surgery and option 3 is inappropriate. Option 2 is not an acceptable
and legal role of a charge nurse. Select option 4 since it is the only legally acceptable option: to
obtain a telephone permission from a family member if it is witnessed by 2 persons.
13. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response
by the nurse is most likely to stimulate further discussion between the client and the nurse?
1. “If it’s any help, everyone is nervous before surgery.”
2. “I will be happy to explain the entire surgical procedure to you.”
3. “Can you share with me what you’ve been told about your surgery?”
4. “Let me tell you about the care you’ll receive after surgery and the amount of pain you can
anticipate.”
Answer: 3
Rationale: Explanations should begin with the information that the client knows. By providing
the client with individualized explanations of care and procedures, the nurse can assist the client
in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and
emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative
complications. Option 1 does not focus on the client’s anxiety. Explaining the entire surgical
procedure may increase the client’s anxiety. Option 4 avoids the client’s anxiety and is focused
on postoperative care. Test-Taking Strategy: Note that the client expresses anxiety. Use
knowledge of therapeutic communication techniques. Note that the question contains strategic
words, most likely, and also note the words stimulate further discussion. Also use the steps of the
nursing process. The correct option addresses assessment and is the only therapeutic response.
14. The nurse is conducting preoperative teaching with a client about the use of an incentive
spirometer. The nurse should include which piece of information in discussions with the client?
1. Inhale as rapidly as possible.
2. Keep a loose seal between the lips and the mouthpiece.
3. After maximum inspiration, hold the breath for 15 seconds and exhale.
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees.
Answer: 4
Rationale: For optimal lung expansion with the incentive spirometer, the client should assume
the semi-Fowler’s or high Fowler’s position. The mouthpiece should be covered completely and
tightly while the client inhales slowly, with a constant flow through the unit. The breath should
be held for 5 seconds before exhaling slowly. Test-Taking Strategy: Focus on the subject, correct
use of an incentive spirometer, and visualize the procedure. Note the words rapidly, loose, and 15
seconds in the incorrect options. Options 1, 2, and 3 are incorrect steps regarding incentive
spirometer use.
15. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week.
The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines
that the client needs additional teaching if the client makes which statement?
1. “Aspirin can cause bleeding after surgery.”
2. “Aspirin can cause my ability to clot blood to be abnormal.”
3. “I need to continue to take the aspirin until the day of surgery.”
4. “I need to check with my health care provider about the need to stop the aspirin before the
scheduled surgery.”
Answer: 3
Rationale: Antiplatelets alter normal clotting factors and increase the risk of bleeding after
surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued at
least 48 hours before surgery. However, the client should always check with his or her health
care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled.
Options 1, 2, and 4 are accurate client statements. Test-Taking Strategy: Note the strategic words,
needs additional teaching. These words indicate a negative event query and that you need to
select the incorrect client statement. Eliminate options1 and 2 first because they are comparable
or alike. From the remaining options, recalling that aspirin has properties that can alter platelet
aggregation will direct you to the correct option.
16. The nurse assesses a client’s surgical incision for signs of infection. Which finding by the
nurse would be interpreted as a normal finding at the surgical site?
1. Red, hard skin
2. Serous drainage (a thin, watery, and clear substance exiting the wound)
3. Purulent drainage (liquids draining from a wound are a milky texture. Purulent can be shades
of green, yellow, or gray, and tend to be rather thick in consistency but can also be thin).
4. Warm, tender skin
Answer: 2
Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate
signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin
around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also
may have a fever and chills. Purulent material may exit from drains or from separated wound
edges. Infection may be caused by poor aseptic technique or a contaminated wound before
surgical exploration; existing client conditions such as diabetes mellitus or immuno-compromise
may place the client at risk.
17. The nurse is monitoring the status of a postoperative client in the immediate postoperative
period. The nurse would become most concerned with which sign that could indicate an evolving
complication? 1. Increasing restlessness
2. A pulse of 86 beats/minute
3. Blood pressure of 110/70 mm Hg
4. Hypoactive bowel sounds in all 4 quadrants
Answer: 1
Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because
it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A
blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits.
Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate
postoperative period.
Test-Taking Strategy: Note the strategic word, most. Focus on the subject, a manifestation of an
evolving complication in the immediate postoperative period. Eliminate each of the in correct
options because they are comparable or alike and are normal expected findings, especially given
the timeframe noted in the question.
18. A client who has had abdominal surgery complains of feeling as though “something gave
way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of
bowel protruding through the incision. Which interventions should the nurse take? Select all that
apply.
1. Contact the surgeon.
2. Instruct the client to remain quiet.
3. Prepare the client for wound closure.
4. Document the findings and actions taken.
5. Place a sterile saline dressing and ice packs over the wound.
6. Place the client in a supine position without a pillow under the head.
Answer: 1, 2, 3, 4 Rationale: Wound dehiscence is the separation of the wound edges. Wound
evisceration is protrusion of the internal organs through an incision. If wound dehiscence or
evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to
contact the surgeon and obtain needed supplies to care for the client. The nurse places the client
in a low Fowler’s position, and the client is kept quiet and instructed not to cough. Protruding
organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive
effect. The treatment for evisceration is usually immediate wound closure under local or general
anesthesia. The nurse also documents the findings and actions taken. Test-Taking Strategy: Focus
on the subject, that the client is experiencing wound evisceration. Visualizing this occurrence
will assist you in determining that the client would not be placed supine and that ice packs would
not be placed on the incision.
19. A client who has undergone preadmission testing has had blood drawn for serum laboratory
studies, including a complete blood count, coagulation studies, and electrolytes and creatinine
levels. Which laboratory result should be reported to the surgeon’s office by the nurse, knowing
that it could cause surgery to be postponed?
1. Hemoglobin, 8.0 g/dL (80 mmol/L)
2. Sodium, 145 mEq/L (145 mmol/L)
3. Serum creatinine, 0.8 mg/dL (70.6 µmol/L)
4. Platelets, 210,000 cells/mm3
Answer: 1
Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis,
coagulation studies, and a serum creatinine test. The complete blood count includes the
hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a
client has a low hemoglobin level, the surgery likely could be postponed by the surgeon. Test-
Taking Strategy: Focus on the subject, an abnormal laboratory result that needs to be reported.
Use knowledge of the normal reference intervals to assist in answering correctly. The
hemoglobin value is the only abnormal laboratory finding.
20. The nurse receives a telephone call from the post-anesthesia care unit stating that a client is
being transferred to the surgical unit. The nurse plans to take which action first on arrival of the
client?
1. Assess the patency of the airway.
2. Check tubes or drains for patency.
3. Check the dressing to assess for bleeding.
4. Assess the vital signs to compare with preoperative measurements.
Answer: 1
Rationale: The first action of the nurse is to assess the patency of the airway and respiratory
function. If the airway is not patent, the nurse must take immediate measures for the survival of
the client. The nurse then takes vital signs followed by checking the dressing and the tubes or
drains. The other nursing actions should be performed after a patent airway as been established.
Test-Taking Strategy: Note the strategic word, first. Use the principles of prioritization to answer
this question. Use the ABCs—airway, breathing, and circulation. Ensuring airway patency is the
first action to be taken, directing you to the correct option
21. The nurse is reviewing a surgeon’s prescription sheet for a preoperative client that states that
the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to
clarify that which medication should be given to the client and not withheld?
1. Prednisone
2. Ferrous sulfate
3. Cyclobenzaprine
4. Conjugated estrogen
Answer: 1 Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause
adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe,
corticosteroids are essential to life. Before and during surgery, dosages may be increased
temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron
preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant.
Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal
women. These last 3 medications may be withheld before surgery without undue effects on the
client. Test-Taking Strategy: Focus on the subject, the medication that should be administered in
the preoperative period. Use knowledge about medications that may have special implications
for the surgical client. Prednisone is a corticosteroid. Recall that when stress is severe, such as
with surgery, corticosteroids are essential to life.
22. The nurse is caring for a client with acute pancreatitis and is monitoring the client for
paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence?
1. Inability to pass flatus
2. Loss of anal sphincter control
3. Severe, constant pain with rapid onset
4. Firm, nontender mass palpable at the lower right costal margin
Answer:1
Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most
common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of
paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with
paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option
4 is the description of the physical finding of liver enlargement. The liver may be enlarged in
cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver
is not a sign of paralytic ileus or intestinal obstruction. Test-Taking Strategy: Focus on the
subject, clinical manifestations of paralytic ileus. Noting the word paralytic will assist in
directing you to the correct option.
23. A client has been admitted with chest trauma after a motor vehicle crash and has undergone
subsequent intubation. The nurse checks the client when the high-pressure alarm on the
ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of
the lung. The nurse immediately assesses for other signs of which condition?
1. Right pneumothorax
2. Pulmonary embolism
3. Displaced endotracheal tube
4. Acute respiratory distress syndrome
Answer: 1
Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with
respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the
affected side. Pneumothorax can cause increased airway pressure because of resistance to lung
inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by
absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath
sounds, but the lack of breath sounds most likely would be on the left side because of the degree
of curvature of the right and left mainstem bronchi. Test-Taking Strategy: Note the strategic
word, immediately. Focus on the symptoms presented in the question and note the relationship
between right upper lobe and right pneumothorax in the correct option.
24. The nurse is assessing a client with multiple trauma who is at risk for developing acute
respiratory distress syndrome. The nurse should assess for which earliest sign of acute
respiratory distress syndrome?
1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate
Answer: 4
Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased
respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is
followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis.
Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
Test-Taking Strategy: Note the strategic word, earliest. Eliminate option 3 first because
intercostal retraction is a later sign of respiratory distress. Of the remaining options, recall that
adventitious breath sounds (options 1 and 2) would occur later than an increased respiratory rate.
25. The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of
developing this disorder?
1. A 25-year-old woman who runs
2. A 36-year-old man who has asthma
3. A70-year-old man who consumes excess alcohol
4. A sedentary 65-year-old woman who smokes cigarettes
Answer: 4
Rationale: Risk factors for osteoporosis include female gender, being postmenopausal, advanced
age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-
term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.
Test-Taking Strategy: Focus on the subject, risk factors for osteoporosis. The25-year-old woman
who runs (exercises using the long bones) has negligible risk. The 36-year-old man with asthma
is eliminated next because his only risk factor might be long-term corticosteroid use (if
prescribed) to treat the asthma. Of the remaining options, the 65-year-old woman has higher risk
(age, gender, postmenopausal, sedentary, smoking) than the 70-year-old man (age, alcohol
consumption).
26. The nurse has given instructions to a client returning home after knee arthroscopy. Which
statement by the client indicates that the instructions are understood?
1. “I can resume regular exercise tomorrow.”
2. “I can’t eat food for the remainder of the day.”
3. “I need to stay off the leg entirely for the rest of the day.”
4. “I need to report a fever or swelling to my health care provider.”
Answer: 4
Rationale: After arthroscopy, the client usually can walk carefully on the leg once sensation has
returned. The client is instructed to avoid strenuous exercise for at least a few days. The client
may resume the usual diet. Signs and symptoms of infection should be reported to the health care
provider. Test-Taking Strategy: Focus on the subject, teaching points following knee arthroscopy.
Recalling the general client teaching points related to surgical procedures and that a risk for
infection exists after a surgical procedure will direct you to the correct option.
27. The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg
appears fractured. Which intervention should the nurse take?
1. Try to reduce the fracture manually.
2. Assist the victim to get up and walk to the sidewalk.
3. Leave the victim for a few moments to call an ambulance.
4. Stay with the victim and encourage him or her to remain still.
Answer: 4
Rationale: With a suspected fracture, the victim is not moved unless it is dangerous to remain in
that spot. The nurse should remain with the victim and have someone else call for emergency
help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is
immobilized to prevent further injury. Test-Taking Strategy: Eliminate options 1 and 2 first
because they are comparable or alike in that either of these options could result in further injury
to the victim. Of the remaining options, the more prudent action would be for the nurse to remain
with the victim and have someone else call for emergency assistance. Review: Immediate care of
the victim with a fracture.
28. Which cast care instructions should the nurse provide to a client who just had a plaster cast
applied to the right forearm? Select all that apply.
1. Keep the cast clean and dry.
2. Allow the cast 24 to 72 hours to dry.
3. Keep the cast and extremity elevated.
4. Expect tingling and numbness in the extremity.
5. Use a hair dryer set on a warm to hot setting to dry the cast.
6. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.
Answer: 1, 2, 3
Rationale: A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast
and extremity should be elevated to reduce edema if prescribed. A wet cast is handled with the
palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all
sides of the wet cast will dry. A cool setting on the hairdryer can be used to dry a plaster cast
(heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast
needs to be kept clean and dry, and the client is instructed not to stick anything under the cast
because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for
circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or
diminished pulse. The health care provider is notified immediately if circulatory impairment
occurs.

29. The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse
would be most concerned with which finding?
1. Redness around the pin sites
2. Pain on palpation at the pin sites
3. Thick, yellow drainage from the pin sites
4. Clear, watery drainage from the pin sites
Answer: 3
Rationale: The nurse should monitor for signs of infection such as inflammation, purulent
drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site,
and serous drainage would be expected; the nurse should correlate assessment findings with
other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs.
Additionally, the nurse should compare any findings to baseline findings to determine if there
were any changes.
30. The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?
1. Dependent edema
2. Diminished distal pulse
3. Presence of a “hot spot” on the cast
4. Coolness and pallor of the extremity
Answer: 3
Rationale: Signs of infection under a casted area include odor or purulent drainage from the cast
or the presence of “hot spots,” which are areas of the cast that are warmer than others. The health
care provider should be notified if any of these occur. Signs of impaired circulation in the distal
limb include coolness and pallor of the skin, diminished distal pulse, and edema. Test-Taking
Strategy: Focus on the subject, signs of infection. Think about what you would expect to note
with infection—redness, swelling, heat, and purulent drainage. With this in mind, you can
eliminate options 2 and 4 easily. From the remaining options, remember that “dependent edema”
is not necessarily indicative of infection. Swelling would be continuous. The hot spot on the cast
could signify infection underneath that area. Review: Signs of infection in an extremity with a
cast
31. A client has sustained a closed fracture and has just had a cast applied to the affected arm.
The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and
administers an analgesic, with little relief. Which problem may be causing this pain?
1. Infection under the cast
2. The anxiety of the client
3. Impaired tissue perfusion
4. The recent occurrence of the fracture
Answer: 3 Rationale: Most pain associated with fractures can be minimized with rest, elevation,
application of cold, and administration of analgesics. Pain that is not relieved by these measures
should be reported to the health care provider because pain unrelieved by medications and other
measures may indicate neurovascular compromise. Because this is a new closed fracture and
cast, infection would not have had time to set in. Intense pain after casting is normally not
associated with anxiety or the recent occurrence of the injury. Treatment following the fracture
should assist in relieving the pain associated with the injury. Test-Taking Strategy: Focus on the
subject, intense pain, and focus on the data in the question. Use of the ABCs—airway–
breathing–circulation—will direct you to the correct option. Review: Care of the client with a
fracture and new cast
32. The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client
has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg?
1. Elevated for 3 hours, then flat for 1 hour
2. Flat for 3 hours, then elevated for 1 hour
3. Flat for 12 hours, then elevated for 12 hours
4. Elevated on pillows continuously for 24 to 48 hours
Answer: 4 Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to
minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Note the strategic word, best. Recalling that edema is a concern following
an injury and knowledge of the effects of gravity on edema will direct you to the correct option.
Review: Care of the client with a new cast
33. A client is being discharged to home after application of a plaster leg cast. Which statement
indicates that the client understands proper care of the cast?
1. “I need to avoid getting the cast wet.”
2. “I need to cover the casted leg with warm blankets.”
3. “I need to use my fingertips to lift and move my leg.”
4. “I need to use something like a padded coat hanger end to scratch under the cast if it itches.”
Answer: 1 Rationale: A plaster cast must remain dry to keep its strength. The cast should be
handled with the palms of the hands, not the fingertips, until fully dry; using the fingertips results
in indentations in the cast and skin pressure under the cast. Air should circulate freely around the
cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under
the cast because of the risk of altered skin integrity; the client may use a hair dryer on the cool
setting to relieve an itch.
34. A client being measured for crutches asks the nurse why the crutches cannot rest up
underneath the arm for extra support. The nurse responds knowing that which would most likely
result from this improper crutch measurement?
1. A fall and further injury
2. Injury to the brachial plexus nerves
3. Skin breakdown in the area of the axilla
4. Impaired range of motion while the client ambulates
Answer: 2
Rationale: Crutches are measured so that the tops are 2 to 3 finger widths from the axillae. This
ensures that the client’s axillae are not resting on the crutch or bearing the weight of the crutch,
which could result in injury to the nerves of the brachial plexus. Although the conditions in
options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly
on the crutches.
35. The nurse has given the client instructions about crutch safety. Which statement indicates that
the client understands the instructions? Select all that apply.
1. “I should not use someone else’s crutches.”
2. “I need to remove any scatter rugs at home.”
3. “I can use crutch tips even when they are wet.”
4. “I need to have spare crutches and tips available.”
5. “When I’m using the crutches, my arms need to be completely straight.”
Answer: 1, 2, 4
Rationale: The client should use only crutches measured for the client. When assessing for home
safety, the nurse ensures that the client knows to remove any scatter rugs and does not walk on
highly waxed floors. The tips should be inspected for wear, and spare crutches and tips should be
available if needed. Crutch tips should remain dry. If crutch tips get wet, the client should dry
them with a cloth or paper towel. When walking with crutches, both elbows need to be flexed not
more than 30 degrees when the palms are on the handle.
36. The nurse is caring for a client being treated for fat embolus after multiple fractures. Which
data would the nurse evaluate as the most favorable indication of resolution of the fat embolus?
1. Clear mentation
2. Minimal dyspnea
3. Oxygen saturation of 85%
4. Arterial oxygen level of 78 mm Hg (10.3 kPa)
Answer: 1
Rationale: An altered mental state is an early indication of fat emboli; therefore, clear mentation
is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal
sign. Arterial oxygen levels should be 80–100 mm Hg (10.6–13.33 kPa). Oxygen saturation
should be higher than 95%. Test-Taking Strategy: Note the strategic word, most. Knowing that
the arterial oxygen and oxygen saturation levels are below normal helps to eliminate options 3
and 4. Dyspnea, even at a minimal level, is not normal, so eliminate option 2.
37. The nurse has conducted teaching with a client in an arm cast about the signs and symptoms
of compartment syndrome. The nurse determines that the client understands the information if
the client states that he or she should report which early symptom of compartment syndrome?
1. Cold, bluish-colored fingers
2. Numbness and tingling in the fingers
3. Pain that increases when the arm is dependent
4. Pain that is out of proportion to the severity of the fracture
Answer: 2
Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and
tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases
with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that
is out of proportion to the severity of the fracture, along with other symptoms associated with the
pain, is not an early manifestation. Test-Taking Strategy: Note the strategic word, early. Knowing
that compartment syndrome is characterized by insufficient circulation and ischemia caused by
pressure will direct you to the correct option. Review: The early manifestations of compartment
syndrome
38. A client with diabetes mellitus has had a right below-knee amputation. Given the client’s
history of diabetes mellitus, which complication is the client at most risk for after surgery?
1. Hemorrhage
2. Edema of the residual limb
3. Slight redness of the incision
4. Separation of the wound edges
Answer: 4
Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound
healing because of the disease. Postoperative hemorrhage and edema of the residual limb are
complications in the immediate postoperative period that apply to any client with an amputation.
Slight redness of the incision is considered normal, as long as the incision is dry and intact.
39. The nurse is caring for a client who had an above knee amputation 2 days ago. The residual
limb was wrapped with an elastic compression bandage, which has come off. Which immediate
action should the nurse take?
1. Apply ice to the site.
2. Call the health care provider (HCP).
3. Rewrap the residual limb with an elastic compression bandage.
4. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow.
Answer: 3
Rationale: If the client with an amputation has a cast or elastic compression bandage that slips
off, the nurse must wrap the residual limb immediately with another elastic compression
bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in
rehabilitation. If the client had a cast that slipped off, the nurse would have to call the HCP so
that a new one could be applied. Elevation on 1 pillow is not going to impede the development of
edema greatly once compression is released. Ice would be of limited value in controlling edema
from this cause. If the HCP were called, the prescription likely would be to reapply the
compression dressing anyway. Test-Taking Strategy: Note the strategic word, immediate, and
focus on the data in the question. Recalling that excessive edema can form rapidly in the residual
limb will direct you to the correct option. Review: Care of the client after amputation
40. A client is complaining of low back pain that radiates down the left posterior thigh. The nurse
should ask the client if the pain is worsened or aggravated by which factor?
1. Bed rest
2. Ibuprofen
3. Bending or lifting
4. Application of heat
Answer: 3 Rationale: Low back pain that radiates into 1 leg (sciatica) is consistent with herniated
lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that
increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the
leg straight up while supine (straight leg-raising test). Bedrest, heat (or sometimes ice), and
nonsteroidal anti-inflammatory drugs (NSAIDs)usually relieve backpain.
41. The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The
nurse would be most concerned with which assessment finding?
1. Temperature of 101.6°F (38.7°C) orally
2. Complaints of discomfort during repositioning
3. Old bloody drainage outlined on the surgical dressing
4. Discomfort during coughing and deep breathing exercises
Answer: 1
Rationale: The nursing assessment conducted after spinal surgery is similar to that done after
other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular
status of the lower extremities, watches for signs and symptoms of infection, and inspects the
surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for
glucose). A mild temperature is expected after insertion of hardware, but a temperature of
101.6°F (38.7°C) should be reported. Test-Taking Strategy: Note the strategic word, most.
Determine if an abnormality exists. Thus, you are looking for the option that has the greatest
deviation from normal. Options 2 and 4 are expected after surgery and, although the nurse tries
to minimize discomfort, the client is likely to have some discomfort, even with proper analgesic
use. The word sold and outlined in option 3indicatethatthisisnotanewoccurrence. This leaves the
temperature of 101.6°F (38.7°C), which is excessive and should be reported.
42. A client with a hip fracture asks the nurse about Buck’s (extension) traction that is being
applied before surgery and what is involved. The nurse should provide which information to the
client?
1. Allows bony healing to begin before surgery and involves pins and screws
2. Provides rigid immobilization of the fracture site and involves pulleys and wheels
3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws
4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves
pulleys and wheels
Answer: 4
Rationale: Buck’s (extension) traction is a type of skin traction often applied after hip fracture
before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to
immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid
immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel
severance. This type of traction involves pulleys and wheels, not pins, and screws. Test-Taking
Strategy: Focus on the subject, use of traction following a hip fracture. Read each option
carefully and note that each option has more than one part. All parts of the option need to be
correct in order for the answer to be correct. Noting the words provides comfort and fracture
immobilization will direct you to the correct option.
43. A client who has sustained a neck injury is unresponsive and pulseless. What should the
emergency department nurse do to open the client’s airway?
1. Insert oropharyngeal airway.
2. Tilt the head and lift the chin.
3. Place in the recovery position.
4. Stabilize the skull and push up the jaw.
Answer: 4
Rationale: The health care team uses the jaw-thrust maneuver to open the airway until a
radiograph confirms that the client’s cervical spine is stable to avoid potential aggravation of a
cervical spine injury. Options 1 and 2 require manipulation of the spine to open the airway, and
option 3 can be ineffective for opening the airway. Priority Nursing Tip: If a neck injury is
suspected in a victim who sustained an injury, the jaw-thrust maneuver (rather than the head-tilt
chin-lift) is used to open the airway to prevent further spine damage. Test-Taking Strategy: Focus
on the ABCs—airway, breathing, and circulation. Recalling the principles related to airway
management will assist in eliminating options 1 and 2. From the remaining options, visualize
each and eliminate option 3 because this action can be ineffective if the client is unable to
maintain the airway. Review: open airway in a client with a neck injury.
44. A client with significant flail chest has arterial blood gases (ABGs) that reveal a Pao2 of 68
and a Paco2 of 51. Two hours ago, the Pao2 was 82 and the Paco2 was 44. Based on these
changes, which item should the nurse assure easy access to in order to help ensure client safety?
1. Intubation tray
2. Injectable lidocaine
3. Chest tube insertion set
4. Portable chest x-ray machine
Answer: 1
Rationale: Flail chest occurs from a blunt trauma to the chest. The loose segment from the chest
wall becomes paradoxical to the expansion and contraction of the rest of the chest wall. The
client with flail chest has painful, rapid, shallow respirations while experiencing severe dyspnea.
The laboratory results indicate worsening respiratory acidosis. The effort of breathing and the
paradoxical chest movement have the net effect of producing hypoxia and hypercapnia. The
client develops respiratory failure and requires intubation and mechanical ventilation, usually
with positive end-expiratory pressure (PEEP); therefore, an intubation tray is necessary. None of
the other options have a direct purpose with the client’s current respiratory status. Priority
Nursing Tip: The client with a flail chest experiences paradoxical respirations (inward movement
of a segment of the thorax during inspiration with outward movement during expiration). Test-
Taking Strategy: Focus on the subject, flail chest. Review the changes in the ABG values. Recall
that a falling arterial oxygen level and a rising carbon dioxide level indicate respiratory failure.
The usual treatment for respiratory failure is intubation, which will lead you to the correct
option.
45. A client with a central venous catheter who is receiving total parenteral nutrition (TPN)
suddenly experiences signs/symptoms associated with an air embolism. The nurse should
implement which interventions to minimize the client’s risk for injury? Select all that apply.
1. Monitors vital signs
2. Clamps the catheter
3. Checks the line for air
4. Notifies the primary health care provider
5. Boluses the client with 500 mL normal saline
6. Places the client in Trendelenburg position on the left side
Answer: 2, 4, 6
Rationale: If the client experiences air embolus, the client is placed in the lateral Trendelenburg
position on the left side to trap the air in the right atrium. The nurse should also clamp the
catheter and notify the primary health care provider. Although vital signs are monitored
continuously, doing without a related action does not directly assist the client. A fluid bolus
would cause the air embolus to travel. Priority Nursing Tip: Air embolism can be caused by an
inadequately primed intravenous (IV) line or a loose connection. Air embolism may occur during
tubing change or during removal of the IV. Test-Taking Strategy: Focus on the subject, suspected
air embolism. Recall that air embolism is a life-threatening condition requiring immediate
nursing intervention that includes notifying the primary health care provider.
46. A client arrives at the emergency department with upper gastrointestinal (GI) bleeding that
began 3 hours ago. What is the priority action?
1. Obtaining vital signs
2. Inserting a nasogastric (NG) tube
3. Asking the client about the precipitating events
4. Completing an abdominal physical assessment
Answer: 1
Rationale: The priority action for the client with GI bleeding is to obtain vital signs to determine
whether the client is in shock from blood loss and obtain a baseline by which to monitor the
progress of treatment. The client may not be able to provide subjective data until the immediate
physical needs are met. A complete abdominal physical assessment must be performed but is not
the priority. Insertion of an NG tube may be prescribed but is not the priority action. Priority
Nursing Tip: For the client experiencing active gastrointestinal bleeding, assess for signs of
dehydration and hypovolemic shock. Test-Taking Strategy: Note the strategic word, priority.
Recall that the client with a GI bleed is at risk for shock. Also, the correct option addresses the
ABCs —airway, breathing, and circulation.
47. A visiting home care nurse finds a client unconscious in the bedroom. The client has a history
of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse should immediately
conduct which assessment?
1. Pulse
2. Respirations
3. Blood pressure
4. Urinary output
Answer: 2
Rationale: In an emergency situation, the nurse should determine breathlessness first and then
assess for a pulse. Blood pressure would be assessed after these assessments are performed.
Urinary output is also important but is not the priority at this time. Priority Nursing Tip:
Selective serotonin reuptake inhibitors (SSRIs) can interact with numerous medications.
Therefore, it is important to check the client’s prescribed medications to determine the potential
for an adverse interaction. Test-Taking Strategy: Note the strategic word, immediately. Use the
ABCs— airway, breathing, and circulation—as the guide for answering this question.
Respirations specifically relate to airway and breathing.
48. The nurse admits a client who is bleeding freely from a scalp laceration that resulted from a
fall. The nurse should take which action first in the care of this wound?
1. Prepare for suturing the area.
2. Determine when the client last had a tetanus vaccine.
3. Cleanse the wound by flushing with sterile normal saline.
4. Apply direct pressure to the laceration to stop the bleeding.
Answer: 4
Rationale: The initial nursing action is to stop the bleeding, and direct pressure is applied. The
nurse will then cleanse the wound thoroughly with sterile normal saline. This action removes dirt
or foreign matter in the wound and allows visualization of the size of the wound. If suturing is
necessary, the surrounding hair may be shaved. The date of the client’s last tetanus shot is
determined, and prophylaxis is given if needed. Priority Nursing Tip: The nurse must ask the
client who sustains a laceration about the date of the last tetanus immunization because the client
may need a tetanus injection. Test-Taking Strategy: Note the strategic word, first, which implies
that more than one or all of the options may be partially or totally correct. Focus on ABCs —
airway, breathing, circulation. This will direct you to the correct option.
49. A client admitted to the nursing unit with a closed head injury 6 hours ago has begun to
vomit, and reports being dizzy and having a headache. Based on these data, which is the most
important nursing action?
1. Administering a prescribed antiemetic
2. Notifying the primary health care provider of the client’s condition
3. Having the client rate the headache pain on a scale of 1 to 10
4. Reminding the client to use the call bell when needing help to the bathroom
Answer: 2
Rationale: The client with a closed head injury is at risk of developing increased intracranial
pressure (ICP). Increased ICP is evidenced by signs and symptoms such as headache, dizziness,
confusion, weakness, and vomiting. Because of the implications of the client’s manifestations,
the most important nursing action is to notify the primary health care provider. Although the
other nursing actions are not inappropriate, none of them address the critical issue of the
potential of the client developing ICP. Priority Nursing Tip: The head of the bed of the client
with increased intracranial pressure should be elevated 30 to 40 degrees. Test-Taking Strategy:
Note the strategic words, most important. This directs you to prioritize the possible nursing
actions. Considering the client’s diagnosis, a closed head injury, and the signs and symptoms, the
nurse should suspect increased ICP. The primary health care provider needs to be notified.
50. A client is brought into the emergency department after sustaining a possible closed head
injury. Which assessment will the nurse perform first?
1. Level of consciousness
2. Pulse and blood pressure
3. Respiratory rate and depth
4. Ability to move extremities
Answer: 3
Rationale: The first action of the nurse is to ensure that the client has an adequate airway and
respiratory status. In rapid sequence, the client’s circulatory status is evaluated (option 2),
followed by evaluation of the status of the cardiovascular and neurological systems. Priority
Nursing Tip: Complications of a head injury include cerebral bleeding, hematomas, uncontrolled
increased intracranial pressure, infections, and seizures. Test-Taking Strategy: Note the strategic
word, first. Use the ABCs—airway, breathing, and circulation. The correct option will most often
be the one that deals with the client’s airway. Respiratory rate and depth support this action.
51. A postoperative client has been vomiting and has absent bowel sounds, and paralytic ileus
has been diagnosed. The primary health care provider prescribes the insertion of a nasogastric
tube. The nurse explains the purpose of the tube and the insertion procedure to the client. The
client says to the nurse, “I’m not sure I can take any more of this treatment.” Which therapeutic
response should the nurse make to the client?
1. “Let’s just put the tube down, so that you can get well.”
2. “If you don’t have this tube put down, you will just continue to vomit.”
3. “You are feeling tired and frustrated with your recovery from surgery?”
4. “It is your right to refuse any treatment. I’ll notify the primary health care provider.”
Answer: 3
Rationale: In option 3, the nurse uses empathy. Empathy, comprehending, and sharing a client’s
frame of reference are important components of the nurse–client relationship. This assists clients
with expressing and exploring feelings, which can lead to problem-solving. The other options are
examples of barriers to effective communication, including option 1, which is stereotyping;
option 2, which is defensiveness; and option 4, which is showing disapproval. Priority Nursing
Tip: In the postoperative period, vomiting, abdominal distention, and the absence of bowel
sounds may be signs of paralytic ileus. Test-Taking Strategy: Use therapeutic communication
techniques. Option 3 is an open-ended question and a communication tool; it also focuses on the
client’s feelings.
52. The nurse assesses a client after abdominal surgery who has a nasogastric (NG) tube in place
that is connected to suction. Which observation by the nurse indicates most reliably that the tube
is functioning properly?
1. The suction gauge reads low intermittent suction.
2. The client indicates that pain is a 3 on a scale of 1 to 10.
3. The distal end of the NG tube is pinned to the client’s gown.
4. The client denies nausea and has 250 mL of fluid in the suction collection container.
Answer: 4
Rationale: An NG tube connected to suction is used postoperatively to decompress and rest the
bowel. The gastrointestinal tract lacks peristaltic activity as a result of manipulation during
surgery. The client should not experience symptoms of ileus (nausea and vomiting) if the tube is
functioning properly. Although the nurse makes pertinent observations of the tube to ensure that
it is secure and properly connected to suction, the client is assessed for the effect. A pain
indicator of 3 is an expected finding in a postoperative client. Priority Nursing Tip: To determine
the true or actual amount of NG drainage during a nursing shift, subtract the amount of irrigating
solution used during the shift from the amount of drainage in the collection device. Test-Taking
Strategy: Note the strategic word, most. Focus on the subject that the NG tube is functioning
properly. Recalling the purpose of an NG tube in a postoperative client will direct you to the
correct option.
53. Four days after abdominal surgery a client has not passed flatus and there are no bowel
sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the
ileus?
1. Decreased blood supply
2. Impaired neural functioning
3. Perforation of the bowel wall
4. Obstruction of the bowel lumen
Answer: 2
Paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia,
infection, or surgery. 1 Interference in blood supply will result in necrosis of the bowel. 3
Perforation of the bowel will result in pain and peritonitis. 4 Obstruction of the bowel will
initially cause increased peristalsis and bowel sounds.
54. A client experiences abdominal distention following surgery. Which nursing actions are
appropriate? Select all that apply.
1. Encouraging ambulation
2. Giving sips of ginger ale
3. Auscultating bowel sounds
4. Providing a straw for drinking 5. Offering the prescribed opioid analgesic
Answer: 1, 3.
1 Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. 2
Carbonated beverages such as ginger ale increase flatulence and should be avoided. 3 Monitoring
bowel sounds is important because it provides information about peristalsis. 4 Using a straw
should be avoided because it causes swallowing of air, which increases flatulence. 5 Opioids will
slow peristalsis, contributing to increased distention.
55. During assessment of a patient who has sustained a recent thoracic spinal injury, the nurse
auscultates the adolescent’s abdomen. The nurse explains to the parents that this is necessary
because clients with spinal cord injury often develop which of the following?
1. Abdominal cramping.
2. Hyperactive bowel sounds.
3. Paralytic ileus.
4. Profuse diarrhea
Answer: 3.
A thoracic spinal cord injury involves the muscles of the lower extremities, bladder, and rectum.
Paralytic ileus often occurs as a result of decreased gastrointestinal muscle innervation. The
nurse evaluates this by auscultating the abdomen. Because the client has a thoracic spinal cord
injury, the client may not feel abdominal cramping. Additionally, auscultation would provide no
evidence of cramping. Hyperactive bowel sounds would be evidenced with increased peristalsis;
peristalsis would probably be diminished with this injury. Profuse diarrhea, resulting from
increased peristalsis, would not be an expected finding. Diarrhea would be more commonly
associated with a gastrointestinal infection
56. A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an
incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the
client complains of abdominal distention. The nurse checks the progress notes in the medical
record, as shown below.
Nurses Progress Notes
Date Time Progress Notes 07/07/07 10:00 pm The client is receiving D5W, 1,000 mL q 8 h. The
NG tube is attached to low suction and draining well. The client has been NPO except ice chips.
The client has had 10 mg morphine for pain at 6 a.m. E. Levine, RN
What is most likely contributing to the client’s abdominal distention?
1. Nasogastric (NG) tube.
2. Ice chips.
3. I.V. fluid intake.
4. Morphine.
Answer: 4.
The client is experiencing paralytic ileus. One of the adverse effects of morphine used to manage
pain is decreased GI motility. Bowel manipulation and immobility also contribute to a
postoperative ileus. Insertion of an NG tube generally prevents a postoperative ileus. The ice
chips and I.V. fluids will not affect the ileus.
57. Which of the following interventions would be the most appropriate for preventing the
development of a paralytic ileus in a client who has undergone renal surgery?
1. Encourage the client to ambulate every 2 to 4 hours.
2. Offer 3 to 4 oz of a carbonated beverage periodically.
3. Encourage use of a stool softener.
4. Continue I.V. fluid therapy.
Answer: 1. Ambulation stimulates peristalsis. A client with paralytic ileus is kept on nothing-by-
mouth status until peristalsis returns. Carbonated beverages will increase gas and distention but
will not stimulate peristalsis. A stool softener will not stimulate peristalsis. I.V. fluid infusion is a
routine postoperative order that does not have any effect on preventing paralytic ileus.

58. After instructing a 40-year-old woman about osteoporosis after menopause, the nurse
determines that the client needs further instruction when the client states which of the following?
1. “One cup of yogurt is the equivalent of one glass of milk.”
2. “Women who do not eat dairy products should consider calcium supplements.”
3. “African American women are at the greatest risk for osteoporosis.”
4. “Estrogen therapy at menopause can reduce the risk of osteoporosis.”
Answer: 3.
Small-boned, fair-skinned women of northern European descent are at the greatest risk for
osteoporosis, not African American women. One cup of yogurt or 1.5 oz of hard cheese is the
equivalent of one glass of milk. Women who do not eat dairy products, such as women who are
lactose intolerant, should consider using calcium supplements. Inadequate lifetime intake of
calcium is a major risk factor for osteoporosis. Estrogen therapy, or some of the newer
medications that are not estrogen based, can greatly reduce the incidence of osteoporosis.
59. A client with osteoporosis needs education about diet and ways to increase bone density.
Which of the following should be included in the teaching plan? Select all that apply.
1. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and
cereals.
2. Choose good calcium sources, such as figs, broccoli, and almonds.
3. Use alcohol in moderation because a moderate intake has no known negative effects.
4. Try swimming as a good exercise to maintain bone mass.
5. Avoid the use of high-fat foods, such as avocados, salad dressings, and fried foods.
Answer: 1, 2.
A diet with adequate amounts of vitamin D aids in the regulation, absorption, and subsequent
utilization of calcium and phosphorus, which are necessary for the normal calcification of bone.
Figs, broccoli, and almonds are very good sources of calcium. Moderate intake of alcohol has no
known negative effects on bone density, but excessive alcohol intake does reduce bone density.
Swimming, biking, and other non–weight-bearing exercises do not maintain bone mass. Walking
and running which are weight-bearing exercises, do maintain bone mass. The client should eat a
balanced diet but does not need to avoid the use of high-fat foods.

60. The nurse instructs the client with osteoporosis that food products high in calcium include:
1. Rice.
2. Broccoli.
3. Apples.
4. Meat
Answer: 2.
Food sources high in calcium include steamed broccoli, dairy products, and fortified cereals.
Rice, apples, and meat are not calcium-rich sources. Menopausal women need 1,500 mg of
calcium daily.

61. When planning a presentation on the topic of osteoporosis to a group of middle-aged women,
which of the following should the nurse plan to include in the presentation?
1. An early symptom of osteoporosis is the dowager’s hump.
2. African American and Latina women are at greater risk.
3. Loss of height is an early symptom of the disease.
4. Conventional radiographs are usually used to confirm the disease.
Answer: 3.
Loss of height and back pain are early indications of the disease that are caused by collapse of
the vertebrae. Later signs include the dowager’s hump and loss of the waistline. The dowager’s
hump is a later sign of osteoporosis that occurs when the vertebrae can no longer support the
upper body in an upright position. Fair-skinned, small boned, white, and Asian women are at
greater risk for osteoporosis. Conventional radiographs are little help because more than 30% of
the bone mass must be lost before the disease is detected. High-density bone scans can detect the
disease earlier.
62. Which of the following nursing measures is most useful in preventing the development of
osteoporosis in a client who is immobilized?
1. Beginning weight-bearing activities as soon as possible.
2. Increasing the client’s calcium intake in the diet.
3. Performing passive range-of-motion (ROM) exercises four times a day.
4. Teaching the client to perform isometric exercises.
Answer: 1.
In order to prevent disuse osteoporosis, it is important to implement weight-bearing activities as
soon as medically allowed. Increasing the client’s calcium intake will not prevent the
development of osteoporosis without the inclusion of weight-bearing activity. Passive ROM
exercises and isometric exercises do not provide the bone stress necessary to reduce the risk of
osteoporosis.
63. The nurse is obtaining a health history for a client with osteoporosis. The nurse should
specifically ask the client about which of the following? Select all that apply.
1. Amount of alcohol consumed daily.
2. Use of antacids.
3. Dietary intake of fiber.
4. Use of Vitamin K supplements
5. Intake of fruit juices
Answer: 1, 2, 3, 4.
The nurse should ask the client about alcohol use because heavy alcohol use causes fluid
excretion resulting in heavy losses of calcium in urine. If the client uses antacids containing
aluminum or magnesium, a net loss of calcium can occur. If the client has a high-fiber diet, the
fiber can bind up some of the dietary calcium. People with hip fractures have been found to have
low vitamin K intakes; vitamin K plays an important role in production of at least one bone
protein. Fruit juices do not affect calcium absorption.
64. A nurse who witnesses an accident involving an adolescent riding a motorcycle, hitting a tree,
and being thrown 30 feet into a field stops to help. The adolescent reports that he is now unable
to move his legs. While waiting for the emergency medical service to arrive, what should the
nurse do?
1. Flex the adolescent’s knees to relieve stress on his back.
2. Leave the adolescent as he is, staying close by.
3. Remove the adolescent’s helmet as soon as possible.
4. Assess the adolescent for abdominal trauma.
Answer: 2.
The adolescent’s signs and symptoms suggest a spinal cord injury. A client with suspected spinal
cord injury should not be moved until the spine has been immobilized. Removing the helmet
could further aggravate a spinal cord injury. The nurse could assess for abdominal trauma, but
only if it can be done without moving the adolescent.
65. After a thoracotomy (surgical incision into the chest wall), the nurse instructs the client to
perform deep-breathing exercises. Which of the following is an expected outcome of these
exercises?
1. Deep breathing elevates the diaphragm, which enlarges the thorax and increases the lung
surface available for gas exchange.
2. Deep breathing increases blood fl ow to the lungs to allow them to recover from the trauma of
surgery.
3. Deep breathing controls the rate of air fl ow to the remaining lobe so that it will not become
hyperinflated.
4. Deep breathing expands the alveoli and increases the lung surface available for Ventilation
Answer: 4.
Deep breathing helps prevent micro atelectasis and pneumonitis and also helps force air and fluid
out of the pleural space into the chest tubes. More than half of the ventilatory process is
accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of
respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating
surface. Deep breathing increases blood fl ow to the lungs; however, the primary reason for deep
breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates
to fill the space created by the resected lobe. This is an expected phenomenon.
66. A nurse should interpret which of the following as an early sign of a tension pneumothorax in
a client with chest trauma?
1. Diminished bilateral breath sounds.
2. Muffled heart sounds.
3. Respiratory distress.
4. Tracheal deviation
Answer: 3.
Respiratory distress or arrest is a universal finding of a tension pneumothorax. Unilateral,
diminished, or absent breath sounds is a common finding. Tracheal deviation is an inconsistent
and late finding. Muffled heart sounds are suggestive of pericardial tamponade.
67. A client who is recovering from chest trauma is to be discharged home with a chest tube
drainage system intact. The nurse should instruct the client to call the physician for which of the
following?
1. Respiratory rate greater than 16 breaths/ minute.
2. Continuous bubbling in the water-seal chamber.
3. Fluid in the chest tube.
4. Fluctuation of fluid in the water-seal chamber.
Answer: 2. Continuous bubbling in the water-seal chamber indicates a leak in the system, and the
client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory
rate of more than 16 breaths/minute may not be unusual and does not necessarily mean that the
client should notify the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid
in the water seal chamber.
68. Which of the following findings would suggest pneumothorax in a trauma victim?
1. Pronounced crackles.
2. Inspiratory wheezing.
3. Dullness on percussion.
4. Absent breath sounds.
Answer: 4.
Pneumothorax means that the lung has collapsed and is not functioning. The nurse will hear no
sounds of air movement on auscultation. Movement of air through mucus produces crackles.
Wheezing occurs when airways become obstructed. Dullness on percussion indicates increased
density of lung tissue, usually caused by accumulation of fluid.
69. A 21-year-old male client is transported by ambulance to the emergency department after a
serious automobile accident. He complains of severe pain in his right chest where he struck the
steering wheel. Which is the primary client goal at this time?
1. Reduce the client’s anxiety.
2. Maintain adequate oxygenation.
3. Decrease chest pain.
4. Maintain adequate circulating volume.
Answer: 2.
Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is
the priority for the client. Decreasing the client’s anxiety is related to maintaining effective
respirations and oxygenation. Although pain is distressing to the client and can increase anxiety
and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation.
Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.
70. An 87-year-old woman is brought to the emergency department for treatment of a fractured
arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client’s chest
and legs and asks the client how the bruises were sustained. The client, although reluctant, tells
the nurse in confidence that her son frequently hits her if supper is not prepared on time when he
arrives home from work. Which is the most appropriate nursing response?
1. “Oh, really? I will discuss this situation with your son.”
2. “Let’s talk about the ways you can manage your time to prevent this from happening.”
3. “Do you have any friends who can help you out until you resolve these important issues with
your son?”
4. “As a nurse, I am legally bound to report abuse. I will stay with you while you give the report
and help find a safe place for you to stay.”
Answer: 4
Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and
other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed
with nonmedical personnel or the client’s family or friends without the client’s permission.
Clients should be assured that information is kept confidential unless it places the nurse under a
legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do
not ensure a safe environment for the client.
71. The nurse employed in an emergency department is assigned to triage clients coming to the
emergency department for treatment on the evening shift. The nurse should assign priority to
which client?
1. A client complaining of muscle aches, a headache, and history of seizures
2. A client who twisted her ankle when rollerblading and is requesting medication for pain
3. A client with a minor laceration on the index finger sustained while cutting an eggplant
4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
Answer: 4
Rationale: In an emergency department, triage involves brief client assessment to classify clients
according to their need for care and includes establishing priorities of care. The type of illness or
injury, the severity of the problem, and the resources available govern the process. Clients with
trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute
neurological deficits, or who have sustained chemical splashes to the eyes, are classified as
emergent and are the number-1priority.Clients with conditions such as a simple fracture, asthma
without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent
needs and are classified as a number-2 priority. Clients with conditions such as a minor
laceration, sprain, or cold symptoms are classified as non-urgent and are a number-3 priority.
72. A client involved in a motor vehicle crash presents to the emergency department with severe
internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that
which intravenous (IV) solution will most likely be prescribed for this client?
1. 5% dextrose in lactated Ringer’s solution
2. 0.33% sodium chloride (1/3 normal saline)
3. 0.45% sodium chloride (1/2 normal saline)
4. 0.225% sodium chloride (1/4 normal saline)
Answer: 1
Rationale: For this client, the goal of therapy is to expand intravascular volume as quickly as
possible. In this situation, the client will likely experience a decrease in intravascular volume
from blood loss, resulting in decreased blood pressure. Therefore, a solution that increases
intravascular volume, replaces immediate blood loss volume, and increases blood pressure is
needed. The 5% dextrose in lactated Ringer’s (hypertonic) solution would increase intravascular
volume and immediately replace lost fluid volume until a transfusion could be administered,
resulting in an increase in the client’s blood pressure. The solutions in the remaining options
would not be given to this client because they are hypotonic solutions and, instead of increasing
intravascular space, the solutions would move into the cells via osmosis.