ATI NCLEX-RN Comprehensive Practice Exam
A nurse is assessing a client who has hypokalemia. Which of the following findings should the nurse expect?
a) Hypertension
b) Hyperactive bowel sounds
c) Muscle weakness
d) Positive Chvostek’s sign
A nurse is preparing to administer packed red blood cells to a client. Which of the following actions should the nurse take first?
a) Obtain the client’s vital signs
b) Verify the blood product with another nurse
c) Ensure the IV site has a 20-gauge needle
d) Confirm the client’s blood type and Rh factor
A nurse is caring for a client with a history of a seizure disorder. Which precaution should the nurse implement?
a) Keep the client in high-Fowler’s position
b) Ensure suction equipment is at the bedside
c) Apply wrist restraints
d) Administer an anticonvulsant daily at bedtime
A client reports difficulty sleeping. Which nursing intervention should be implemented to promote sleep?
a) Encourage a daytime nap
b) Offer a glass of warm milk
c) Provide stimulating activities before bedtime
d) Administer sedatives every night
Which of the following is an early manifestation of hypoxia?
a) Cyanosis
b) Bradycardia
c) Restlessness
d) Hypotension
A nurse is reviewing laboratory results for a client who has heart failure. Which of the following laboratory values should the nurse expect?
a) Decreased B-type natriuretic peptide (BNP)
b) Increased serum albumin
c) Increased potassium
d) Increased BNP
A nurse is teaching a client with a new prescription for digoxin. Which adverse effect should the client report immediately?
a) Constipation
b) Vision changes
c) Weight gain
d) Fatigue
A nurse is assessing a client with acute cholecystitis. Where should the nurse expect to palpate tenderness?
a) Right lower quadrant
b) Left lower quadrant
c) Right upper quadrant
d) Left upper quadrant
A nurse is administering a Mantoux test. Which result indicates a positive test for tuberculosis in a healthy individual?
a) 2-mm induration
b) 5-mm induration
c) 10-mm induration
d) 15-mm induration
A client with diabetes is experiencing diaphoresis, tremors, and tachycardia. Which condition does the nurse suspect?
a) Hypoglycemia
b) Hyperglycemia
c) Diabetic ketoacidosis
d) Hyperosmolar hyperglycemic state
A nurse is caring for a client receiving TPN. Which assessment finding should be reported immediately?
a) Blood glucose of 140 mg/dL
b) Increased thirst
c) Crackles in the lungs
d) Weight gain of 1 kg in 24 hours
A nurse is providing discharge teaching for a client with a new diagnosis of asthma. Which statement indicates an understanding of the teaching?
a) “I will take my albuterol daily to prevent attacks.”
b) “I should avoid exercising outdoors in cold weather.”
c) “I will use my steroid inhaler for acute symptoms.”
d) “I should limit fluid intake to prevent mucus.”
A nurse is caring for a client with a new ileostomy. Which finding indicates a potential complication?
a) Liquid stool
b) Stoma is pale
c) Output of 800 mL/day
d) Stoma is moist
Which medication increases the risk of bleeding in a client taking warfarin?
a) Acetaminophen
b) Vitamin K
c) Aspirin
d) Calcium carbonate
A client with left-sided heart failure is admitted. Which finding should the nurse expect?
a) Peripheral edema
b) Jugular vein distention
c) Crackles in the lungs
d) Hepatomegaly
What is the priority intervention for a client experiencing a panic attack?
a) Provide immediate medication
b) Encourage deep, controlled breathing
c) Explain the cause of the attack
d) Leave the client alone to calm down
A client receiving chemotherapy has a WBC count of 2,000/mm³. What is the priority nursing action?
a) Monitor for signs of infection
b) Administer a blood transfusion
c) Place the client in isolation
d) Discontinue chemotherapy
A nurse is planning care for a client with Cushing’s syndrome. Which dietary recommendation should be included?
a) Low-protein
b) Low-calorie
c) Low-sodium
d) High-fat
Which assessment is most important for a client receiving magnesium sulfate?
a) Respiratory rate
b) Urine output
c) Blood pressure
d) Pain level
A nurse is assessing a client post-thyroidectomy. Which sign indicates hypocalcemia?
a) Bradycardia
b) Hyperreflexia
c) Positive Trousseau’s sign
d) Hypoactive bowel sounds
Answer: c) Positive Trousseau’s sign
A nurse is caring for a client with a chest tube. Which finding requires immediate intervention?
a) Continuous bubbling in the water seal chamber
b) Serosanguineous drainage
c) Fluctuation of the water level during respiration
d) Absence of breath sounds on the affected side
What should a nurse do first when a fire occurs in the hospital?
a) Activate the fire alarm
b) Contain the fire
c) Rescue clients in danger
d) Extinguish the fire
A nurse is caring for a client with SIADH. Which finding should be reported?
a) Serum sodium of 118 mEq/L
b) Blood glucose of 90 mg/dL
c) Serum potassium of 4.2 mEq/L
d) Urine specific gravity of 1.025
A nurse is caring for a client prescribed lithium. Which side effect indicates toxicity?
a) Constipation
b) Blurred vision
c) Increased thirst
d) Coarse tremors
A client with COPD is receiving oxygen therapy. Which flow rate is appropriate?
a) 2 L/min
b) 6 L/min
c) 8 L/min
d) 10 L/min
Set 2
1. A nurse is providing education about infant safe sleep practices. Which statement indicates the need for further teaching?
a) “I will place my baby on their back to sleep.”
b) “I will use a firm mattress with no loose bedding.”
c) “I will keep stuffed animals out of the crib.”
d) “I will place my baby on their side to prevent choking.”
2. A client with chronic obstructive pulmonary disease (COPD) reports increased dyspnea. Which action should the nurse take first?
a) Increase oxygen flow rate to 6 L/min.
b) Perform chest physiotherapy.
c) Elevate the head of the bed.
d) Administer a bronchodilator.
3. A nurse is monitoring a client receiving continuous bladder irrigation. Which finding requires immediate intervention?
a) Dark red drainage in the tubing
b) Output greater than input
c) Pale yellow drainage
d) Client reporting bladder spasms
4. Which intervention should the nurse prioritize for a client experiencing anaphylaxis?
a) Administer a corticosteroid.
b) Establish and maintain an airway.
c) Apply a cold compress to the affected area.
d) Obtain a blood culture.
5. A client with a serum potassium level of 6.8 mEq/L is admitted. Which prescription should the nurse question?
a) Administering sodium polystyrene sulfonate
b) Giving IV insulin and glucose
c) Administering spironolactone
d) Preparing the client for hemodialysis
6. A nurse is teaching a client with type 2 diabetes about foot care. Which statement indicates an understanding of the teaching?
a) “I will soak my feet daily to prevent dryness.”
b) “I will wear cotton socks to keep my feet dry.”
c) “I will use a heating pad to warm my feet in cold weather.”
d) “I will cut my toenails straight across.”
7. A nurse is assessing a client with diabetic ketoacidosis (DKA). Which finding is expected?
a) Bradycardia
b) Hypotension
c) Metabolic alkalosis
d) Decreased respiratory rate
8. A nurse is caring for a client with a central venous catheter. Which finding indicates a catheter-related bloodstream infection?
a) Blood pressure of 150/90 mmHg
b) Localized redness at the insertion site
c) Temperature of 102°F (38.9°C)
d) Bruising around the insertion site
9. A client with a history of asthma is prescribed montelukast. When should the nurse advise the client to take this medication?
a) During an asthma attack
b) At bedtime
c) Before exercising
d) With meals
10. A nurse is teaching a client with newly diagnosed hypertension about lifestyle changes. Which recommendation is appropriate?
a) Reduce sodium intake to less than 2,300 mg per day.
b) Engage in aerobic exercise 3 times per month.
c) Limit alcohol consumption to 3 drinks per day.
d) Use canned soups and frozen meals as convenient options.
11. A client receiving chemotherapy has a platelet count of 50,000/mm³. Which precaution should the nurse implement?
a) Encourage daily flossing.
b) Avoid intramuscular injections.
c) Administer acetaminophen for fever.
d) Insert an indwelling urinary catheter.
12. A nurse is caring for a client with meningitis. Which precaution is appropriate?
a) Airborne precautions
b) Droplet precautions
c) Contact precautions
d) Standard precautions
13. A nurse is assessing a postpartum client. Which finding requires immediate intervention?
a) Perineal pad saturated in 15 minutes
b) Uterus firm and midline
c) Moderate lochia rubra
d) Positive Homans’ sign
14. A nurse is providing dietary teaching to a client with a history of calcium oxalate kidney stones. Which food should the client avoid?
a) Milk
b) Spinach
c) Oranges
d) Chicken
15. A nurse is preparing to administer an influenza vaccine to a client. Which condition should cause the nurse to delay administration?
a) History of Guillain-Barré syndrome
b) Mild upper respiratory infection
c) Allergy to shellfish
d) Current pregnancy
16. A client is prescribed sertraline. Which statement indicates the need for further teaching?
a) “I will avoid alcohol while taking this medication.”
b) “I might feel more tired for the first few weeks.”
c) “I will stop the medication when I feel better.”
d) “I should notify my provider if I experience suicidal thoughts.”
17. A client receiving furosemide reports muscle cramps. Which laboratory value should the nurse check first?
a) Calcium
b) Sodium
c) Potassium
d) Magnesium
18. A nurse is caring for a client with cirrhosis. Which finding indicates hepatic encephalopathy?
a) Ascites
b) Asterixis
c) Jaundice
d) Hypoglycemia
19. A client is prescribed amiodarone for atrial fibrillation. Which adverse effect should the nurse monitor for?
a) Bradycardia
b) Hypertension
c) Hyperglycemia
d) Dry mouth
20. A nurse is preparing to administer insulin glargine to a client. Which action is appropriate?
a) Mix the insulin with regular insulin in the same syringe.
b) Administer the insulin intravenously.
c) Shake the vial gently before drawing up the dose.
d) Administer the insulin at bedtime.
21. A nurse is assessing a client who has a deep vein thrombosis (DVT). Which finding should the nurse report immediately?
a) Calf pain when walking
b) Localized redness over the affected area
c) Shortness of breath and chest pain
d) Swelling in the affected extremity
22. A client with a spinal cord injury is at risk for autonomic dysreflexia. Which finding indicates this condition?
a) Bradycardia and severe headache
b) Hypotension and dizziness
c) Hyperactive deep tendon reflexes
d) Involuntary muscle spasms
23. A nurse is preparing to administer medications to a client with enteral feeding through a gastrostomy tube. Which action is appropriate?
a) Mix all medications together before administering.
b) Administer medications in liquid form when possible.
c) Flush the tube with 10 mL of water between medications.
d) Crush all medications, including enteric-coated pills.
24. A client is being discharged following placement of a pacemaker. Which statement indicates the need for further teaching?
a) “I should avoid lifting my arm above my shoulder for 2 weeks.”
b) “I will use my cell phone on the opposite side of my pacemaker.”
c) “I should not go through metal detectors at airports.”
d) “I will notify my dentist about my pacemaker before procedures.”
25. A nurse is caring for a client with burns covering 40% of their body. Which finding indicates fluid resuscitation is effective?
a) Urine output of 50 mL/hr
b) Heart rate of 120 bpm
c) Blood pressure of 88/60 mmHg
d) Serum sodium level of 155 mEq/L
26. A nurse is educating a client who is prescribed a low-sodium diet. Which food should the client avoid?
a) Fresh apples
b) Grilled chicken
c) Canned soup
d) Steamed broccoli
27. A nurse is assessing a client following a thyroidectomy. Which finding should be reported immediately?
a) Difficulty speaking
b) Hoarseness
c) Positive Trousseau’s sign
d) Neck pain
28. A client with a traumatic brain injury is exhibiting decerebrate posturing. What does this indicate?
a) Brainstem injury
b) Spinal cord injury
c) Cerebellar damage
d) Frontal lobe injury
29. A client with Addison’s disease is receiving corticosteroid therapy. Which dietary recommendation should the nurse include?
a) Increase sodium intake.
b) Reduce protein intake.
c) Avoid potassium-rich foods.
d) Limit calcium-rich foods.
30. A nurse is assessing a client with schizophrenia who is experiencing auditory hallucinations. What is the priority nursing intervention?
a) Encourage the client to participate in group activities.
b) Ask the client to describe the hallucinations.
c) Reassure the client that the hallucinations are not real.
d) Administer prescribed antipsychotic medication.
31. A client is receiving vancomycin IV. Which assessment finding requires immediate intervention?
a) Flushing and redness of the neck
b) Increased urine output
c) Decreased appetite
d) Nausea and vomiting
32. A nurse is providing preoperative teaching for a client undergoing a colonoscopy. Which statement indicates understanding?
a) “I will take nothing by mouth 24 hours before the procedure.”
b) “I will have light sedation during the procedure.”
c) “I will need to take antibiotics before the procedure.”
d) “I will lie flat on my back during the procedure.”
33. A nurse is caring for a client receiving total parenteral nutrition (TPN). Which complication should the nurse monitor for?
a) Hypoglycemia
b) Hyperglycemia
c) Hyperkalemia
d) Hypocalcemia
34. A client with major depressive disorder is prescribed sertraline. What is the most important teaching point for the nurse to include?
a) “You will feel improvement within 1-2 days.”
b) “Avoid taking this medication with grapefruit juice.”
c) “You should expect vivid dreams and increased appetite.”
d) “Report worsening thoughts of self-harm immediately.”
35. A nurse is assessing a child with epiglottitis. Which finding is the priority?
a) Drooling
b) Fever
c) Hoarseness
d) Restlessness
36. A client with acute pancreatitis is admitted. Which intervention is a priority?
a) Administering IV fluids
b) Providing oral pancreatic enzymes
c) Initiating a clear liquid diet
d) Administering antidiarrheal medication
37. A nurse is providing care to a client in labor receiving oxytocin. Which finding requires immediate intervention?
a) Contractions lasting 90 seconds
b) Fetal heart rate of 150 bpm
c) Maternal blood pressure of 110/70 mmHg
d) Client reports mild back pain
38. A client is admitted with suspected tuberculosis (TB). What is the most important intervention?
a) Begin oxygen therapy immediately.
b) Start prophylactic antibiotics.
c) Initiate airborne precautions.
d) Collect a throat culture.
39. A nurse is preparing to administer insulin lispro to a client with type 1 diabetes. When should the insulin be given?
a) 30 minutes before a meal
b) Immediately after a meal
c) At bedtime
d) 15 minutes before a meal
Answer: d) 15 minutes before a meal
40. A client with heart failure has a prescription for furosemide. Which electrolyte imbalance is the nurse most concerned about?
a) Hypernatremia
b) Hypokalemia
c) Hypercalcemia
d) Hypomagnesemia
41. A client with cirrhosis is admitted with ascites. Which nursing intervention should the nurse prioritize?
a) Monitor abdominal girth daily.
b) Restrict protein intake.
c) Administer lactulose.
d) Place the client in a supine position.
42. A nurse is assessing a client with hypocalcemia. Which finding is consistent with this condition?
a) Positive Chvostek’s sign
b) Decreased deep tendon reflexes
c) Polyuria
d) Bradycardia
43. A client is being treated for a peptic ulcer caused by Helicobacter pylori. Which medications should the nurse expect to administer?
a) Proton pump inhibitor and antibiotics
b) Antacids and sucralfate
c) Corticosteroids and H2 receptor antagonists
d) NSAIDs and proton pump inhibitors
44. A nurse is caring for a client with hyperthyroidism. Which dietary recommendation is appropriate?
a) High-calorie, high-protein diet
b) Low-fiber diet
c) Low-protein diet
d) Low-calorie diet
45. A client with an exacerbation of heart failure has a BNP (B-type natriuretic peptide) level of 900 pg/mL. What does this indicate?
a) Normal heart function
b) Mild heart failure
c) Moderate heart failure
d) Severe heart failure
46. A nurse is providing teaching about lithium to a client with bipolar disorder. Which statement indicates understanding?
a) “I will avoid salt in my diet.”
b) “I need to drink 2-3 liters of water daily.”
c) “I can stop the medication once I feel better.”
d) “I should take the medication on an empty stomach.”
47. A nurse is preparing to administer blood to a client. Which action is most important before starting the transfusion?
a) Ensure the client has a 22-gauge IV catheter.
b) Verify the blood type with another nurse.
c) Prime the tubing with dextrose 5% in water.
d) Administer a diuretic prior to transfusion.
48. A client is admitted with acute glomerulonephritis. Which finding should the nurse expect?
a) Frothy urine
b) Peripheral edema
c) Increased urine output
d) Hypotension
49. A nurse is caring for a client with Guillain-Barré syndrome. Which assessment is the priority?
a) Skin integrity
b) Pain level
c) Respiratory function
d) Range of motion
50. A client is prescribed warfarin. Which statement indicates a need for further teaching?
a) “I will eat the same amount of green leafy vegetables every week.”
b) “I will use a soft toothbrush to avoid bleeding.”
c) “I can take aspirin if I have a headache.”
d) “I will have my INR checked regularly.”
51. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
a) Hyperreflexia
b) Respiratory rate of 10 breaths/min
c) Urine output of 30 mL/hr
d) Blood pressure of 150/90 mmHg
52. A nurse is educating a client about preventing osteoporosis. Which recommendation is appropriate?
a) Increase vitamin D intake.
b) Avoid weight-bearing exercises.
c) Limit calcium to 800 mg/day.
d) Consume a high-protein diet.
53. A nurse is assessing a client with Cushing’s syndrome. Which finding is expected?
a) Weight loss
b) Hypoglycemia
c) Purple striae on the abdomen
d) Hyperkalemia
54. A client with peripheral arterial disease (PAD) reports pain in their legs while walking that subsides with rest. How should the nurse document this finding?
a) Deep vein thrombosis
b) Intermittent claudication
c) Neuropathic pain
d) Raynaud’s phenomenon
55. A client receiving chemotherapy reports nausea and vomiting. Which action should the nurse take first?
a) Administer prescribed antiemetics.
b) Encourage the client to eat small, frequent meals.
c) Provide high-protein snacks.
d) Suggest complementary therapies such as ginger tea.
56. A nurse is preparing a teaching plan for a client with a new diagnosis of gout. Which food should the client avoid?
a) Low-fat yogurt
b) Grilled chicken
c) Sardines
d) Fresh fruit
57. A client is being treated for septic shock. Which assessment finding indicates improved perfusion?
a) Increased capillary refill time
b) Warm, flushed skin
c) Urine output of 40 mL/hr
d) Blood pressure of 80/40 mmHg
58. A nurse is teaching a client how to use a metered-dose inhaler. Which instruction is appropriate?
a) Exhale fully, then inhale medication quickly.
b) Hold the inhaler 3-4 inches from the mouth.
c) Shake the inhaler before each use.
d) Use the inhaler during a coughing episode.
59. A nurse is caring for a client with a chest tube. Which finding requires immediate intervention?
a) Continuous bubbling in the water seal chamber
b) Drainage of 50 mL/hr
c) Tidaling in the water seal chamber
d) Chest tube dressing intact and dry
60. A client with myasthenia gravis is prescribed pyridostigmine. What should the nurse include in the teaching?
a) “Take the medication on an empty stomach.”
b) “Avoid taking the medication before meals.”
c) “Report increased muscle weakness to your provider.”
d) “Skip a dose if symptoms improve.”
61. A nurse is caring for a client with bacterial meningitis. Which intervention is the priority?
a) Place the client in a supine position.
b) Initiate seizure precautions.
c) Administer antipyretics as prescribed.
d) Perform frequent neurological checks.
62. A client with diabetes is admitted for diabetic ketoacidosis (DKA). Which arterial blood gas (ABG) finding should the nurse expect?
a) pH 7.50, HCO3 30, PaCO2 40
b) pH 7.30, HCO3 18, PaCO2 25
c) pH 7.40, HCO3 24, PaCO2 40
d) pH 7.35, HCO3 28, PaCO2 50
63. A nurse is providing care for a client following a transurethral resection of the prostate (TURP). Which finding should the nurse report immediately?
a) Continuous bladder irrigation with pink-tinged output
b) Client reports the need to urinate constantly
c) Presence of large blood clots in the catheter drainage
d) Catheter output of 300 mL over 8 hours
64. A nurse is assessing a postpartum client who delivered 1 hour ago. Which finding requires immediate intervention?
a) Fundus firm and midline at the umbilicus
b) Saturation of one perineal pad in 15 minutes
c) Client reports mild uterine cramping
d) Small amount of lochia rubra noted on pad
65. A client is admitted with left-sided heart failure. Which clinical manifestation should the nurse expect?
a) Dependent edema
b) Jugular vein distention
c) Crackles in the lungs
d) Hepatomegaly
66. A nurse is providing dietary teaching for a client with chronic kidney disease (CKD). Which food should the client avoid?
a) Apples
b) Baked chicken
c) Bananas
d) Rice
67. A nurse is assessing a client with a fractured femur in traction. Which finding indicates a complication?
a) Pain relieved with repositioning
b) Weak pedal pulse on the affected leg
c) Client reports itching under the traction bandage
d) Capillary refill less than 2 seconds in toes
68. A client with COPD is receiving oxygen therapy. What is the nurse’s priority action?
a) Keep the oxygen flow rate between 1-3 L/min.
b) Encourage high-carbohydrate meals.
c) Administer bronchodilators only at bedtime.
d) Maintain oxygen saturation above 98%.
69. A nurse is preparing a sterile field for a dressing change. Which action breaks sterility?
a) Opening the sterile package away from the body
b) Touching the sterile gloves to adjust eyeglasses
c) Keeping hands above waist level
d) Pouring sterile solution onto the dressing tray
70. A client receiving chemotherapy has a platelet count of 20,000/mm³. What is the priority nursing action?
a) Administer oxygen as needed.
b) Avoid invasive procedures.
c) Provide high-protein meals.
d) Encourage fluid intake.
71. A nurse is caring for a client with an acute asthma exacerbation. Which medication should the nurse administer first?
a) Ipratropium bromide
b) Albuterol
c) Prednisone
d) Montelukast
72. A client with a history of substance abuse is admitted with suspected opioid overdose. Which finding supports this diagnosis?
a) Dilated pupils
b) Hyperventilation
c) Bradypnea
d) Increased pain sensitivity
73. A nurse is preparing to administer an intramuscular injection to an adult client. Which site is preferred?
a) Deltoid muscle
b) Ventrogluteal muscle
c) Rectus femoris muscle
d) Vastus lateralis muscle
74. A nurse is assessing a client with appendicitis. Which finding is most concerning?
a) Elevated white blood cell count
b) Rebound tenderness in the lower right quadrant
c) Sudden relief of pain
d) Nausea and vomiting
75. A client is receiving radiation therapy for cancer. Which side effect should the nurse monitor for?
a) Neutropenia
b) Alopecia
c) Hypoglycemia
d) Hypertension
76. A client is prescribed digoxin for heart failure. Which assessment finding indicates digoxin toxicity?
a) Heart rate of 68 beats per minute
b) Nausea and blurred vision
c) Blood pressure of 130/80 mmHg
d) Client reports increased energy
77. A client is admitted with a suspected stroke. Which intervention is the priority?
a) Obtain a CT scan of the head.
b) Administer anticoagulants.
c) Assess swallowing ability.
d) Monitor blood pressure closely.
78. A nurse is assessing a client following a motor vehicle accident. Which finding indicates a basilar skull fracture?
a) Battle’s sign
b) Dilated pupils
c) Elevated temperature
d) Hypertension
79. A client with a history of chronic kidney disease has a potassium level of 6.2 mEq/L. Which intervention should the nurse anticipate?
a) Administering potassium chloride
b) Starting a low-protein diet
c) Administering sodium polystyrene sulfonate
d) Providing IV fluids with added potassium
80. A nurse is caring for a client with hepatic encephalopathy. Which laboratory value is most important to monitor?
a) Serum bilirubin
b) Ammonia levels
c) Platelet count
d) Serum creatinine
81. A client with a gastric ulcer reports sudden, severe abdominal pain and a rigid abdomen. What is the nurse’s priority action?
a) Administer prescribed antacids.
b) Notify the healthcare provider immediately.
c) Encourage the client to lie in a supine position.
d) Provide a heating pad to relieve discomfort.
82. A client is being treated for a pneumothorax and has a chest tube in place. Which observation requires immediate intervention?
a) Intermittent bubbling in the water seal chamber
b) Chest tube drainage of 60 mL/hr
c) Absence of tidaling in the water seal chamber
d) Chest tube dressing clean and dry
83. A nurse is assessing a client who has been taking prednisone for 3 months. Which finding is a priority to report?
a) Moon-shaped face
b) Bruising on the arms
c) Blood glucose of 210 mg/dL
d) Purulent wound drainage
84. A client is receiving IV heparin for a pulmonary embolism. Which laboratory value indicates a therapeutic effect?
a) Platelets of 120,000/mm³
b) Hematocrit of 40%
c) aPTT of 70 seconds
d) INR of 2.5
85. A nurse is providing discharge teaching to a client with a new ileostomy. Which statement indicates a need for further teaching?
a) “I will avoid high-fiber foods initially.”
b) “I should drink at least 2 liters of water daily.”
c) “I will empty the pouch when it is half full.”
d) “I can take laxatives if I feel constipated.”
86. A nurse is teaching a client with newly diagnosed hypertension about lifestyle changes. Which recommendation is appropriate?
a) Limit sodium intake to 4,000 mg/day.
b) Engage in 30 minutes of aerobic exercise most days of the week.
c) Consume a diet high in saturated fats.
d) Limit alcohol intake to 3 drinks per day.
87. A client is receiving a blood transfusion and reports itching and hives. What is the nurse’s priority action?
a) Slow the infusion rate.
b) Administer prescribed antihistamines.
c) Stop the transfusion immediately.
d) Notify the healthcare provider.
88. A nurse is caring for a client with pancreatitis. Which laboratory value should the nurse monitor most closely?
a) Serum amylase
b) Serum calcium
c) Blood urea nitrogen (BUN)
d) Serum creatinine
89. A nurse is providing care for a client with increased intracranial pressure (ICP). Which intervention should be avoided?
a) Elevating the head of the bed to 30 degrees
b) Administering stool softeners
c) Performing frequent suctioning
d) Maintaining a quiet environment
90. A client has an indwelling urinary catheter. Which finding suggests a potential complication?
a) Urine output of 30 mL/hr
b) Cloudy urine with sediment
c) Catheter tubing secured to the thigh
d) Absence of urine leakage around the catheter
91. A nurse is preparing to administer vancomycin IV to a client with methicillin-resistant Staphylococcus aureus (MRSA). Which action is most important?
a) Administer the dose over 30 minutes.
b) Assess for a red man syndrome reaction.
c) Monitor the client’s urine output.
d) Evaluate the client for constipation.
92. A nurse is caring for a client with severe preeclampsia. Which medication should the nurse anticipate administering?
a) Oxytocin
b) Magnesium sulfate
c) Terbutaline
d) Betamethasone
93. A client with hypothyroidism is prescribed levothyroxine. Which statement by the client indicates an understanding of the medication?
a) “I will take the medication with my breakfast.”
b) “I may stop the medication once my symptoms improve.”
c) “I need to have my thyroid levels checked regularly.”
d) “I should avoid foods high in iodine while taking this medication.”
94. A nurse is educating a client on using crutches. Which instruction is correct?
a) “Place the crutches under your armpits for better support.”
b) “Keep your elbows fully extended while using the crutches.”
c) “Move the crutches forward with the injured leg.”
d) “Use the crutches for weight-bearing on both legs.”
95. A client is scheduled for a lumbar puncture. What is the nurse’s priority action post-procedure?
a) Place the client in a prone position.
b) Encourage fluid intake.
c) Administer prescribed analgesics.
d) Apply a warm compress to the puncture site.
96. A client is admitted with septic shock. Which order should the nurse implement first?
a) Administer broad-spectrum antibiotics.
b) Collect blood cultures.
c) Start intravenous fluids.
d) Monitor hourly urine output.
97. A nurse is assessing a client with rheumatoid arthritis. Which finding is most concerning?
a) Morning stiffness lasting 30 minutes
b) Ulnar deviation of fingers
c) Swelling in multiple joints
d) Warmth and erythema of joints
98. A client reports new onset chest pain. Which diagnostic test should the nurse prepare the client for first?
a) Troponin levels
b) 12-lead ECG
c) Chest X-ray
d) Echocardiogram
99. A nurse is caring for a client with a deep vein thrombosis (DVT). Which intervention is appropriate?
a) Apply sequential compression devices to the affected leg.
b) Encourage frequent ambulation.
c) Maintain the client on bed rest with the affected leg elevated.
d) Massage the affected leg to promote circulation.
100. A nurse is educating a client about the use of nitroglycerin for angina. Which statement indicates a need for further teaching?
a) “I should take the medication at the first sign of chest pain.”
b) “I can take up to three doses, five minutes apart.”
c) “I should store the medication in a dark, dry place.”
d) “I can drive myself to the hospital after taking nitroglycerin.”
101. A nurse is preparing to administer enoxaparin to a client. Where should the injection be given?
a) Deltoid muscle
b) Abdomen, at least 2 inches from the umbilicus
c) Vastus lateralis muscle
d) Gluteal muscle
102. A nurse is assessing a client with acute glomerulonephritis. Which clinical finding is expected?
a) Polyuria
b) Proteinuria
c) Hypercalcemia
d) Hypotension
103. A nurse is caring for a client with cirrhosis. Which diet should the nurse recommend?
a) High-protein, low-carbohydrate
b) Low-sodium, high-calorie
c) High-fat, low-sodium
d) Low-fat, high-protein
104. A client receiving chemotherapy reports mouth sores. Which intervention is most appropriate?
a) Provide a solution of hydrogen peroxide for rinsing.
b) Recommend a soft-bristled toothbrush.
c) Encourage the client to use a commercial mouthwash.
d) Advise the client to consume spicy foods to improve appetite.
105. A nurse is reviewing the medical record of a client receiving warfarin therapy. Which laboratory value indicates the need for adjustment?
a) Hemoglobin 14 g/dL
b) Platelets 200,000/mm³
c) INR 1.2
d) aPTT 40 seconds
106. A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about breathing exercises. Which instruction should the nurse include?
a) “Inhale deeply through your mouth and exhale quickly.”
b) “Perform pursed-lip breathing during activities that cause shortness of breath.”
c) “Breathe in and out through your nose only.”
d) “Hold your breath for 10 seconds before exhaling.”
107. A nurse is caring for a client with a traumatic brain injury. Which intervention is most effective in preventing increased intracranial pressure (ICP)?
a) Maintain the client in the Trendelenburg position.
b) Administer hypotonic IV fluids.
c) Keep the client’s head midline and elevate the head of the bed to 30 degrees.
d) Provide frequent oral suctioning.
108. A nurse is teaching a client about proper use of an incentive spirometer. Which instruction should the nurse provide?
a) “Exhale deeply into the spirometer.”
b) “Inhale slowly and maintain the ball at the designated level.”
c) “Use the spirometer every 4 to 6 hours while awake.”
d) “Repeat the process at least 3 times per session.”
109. A nurse is assessing a child with suspected epiglottitis. Which finding requires immediate intervention?
a) Fever of 102°F (38.9°C)
b) Drooling and difficulty swallowing
c) Barking cough and nasal flaring
d) Mild inspiratory stridor
110. A nurse is caring for a client in labor who is receiving oxytocin. Which assessment finding requires immediate action?
a) Contractions lasting 70 seconds
b) Fetal heart rate of 100 beats per minute
c) Maternal heart rate of 80 beats per minute
d) Client reports a pain level of 6 out of 10
111. A nurse is reviewing the medication list of a client with bipolar disorder. Which medication is most likely to require frequent monitoring of serum levels?
a) Risperidone
b) Lithium
c) Sertraline
d) Valproic acid
112. A nurse is educating a client with tuberculosis (TB) about isoniazid (INH) therapy. Which instruction should the nurse include?
a) “Take this medication with food.”
b) “Avoid alcohol during treatment.”
c) “Limit your intake of vitamin B6.”
d) “You may stop the medication after 2 months if you feel better.”
113. A client with type 1 diabetes reports nausea and vomiting. Which action is most important for the nurse to take?
a) Administer the client’s usual dose of insulin.
b) Monitor the client for signs of hypoglycemia.
c) Check the client’s blood glucose level.
d) Encourage the client to eat carbohydrates.
114. A nurse is caring for a client with suspected deep vein thrombosis (DVT). Which diagnostic test should the nurse anticipate?
a) Chest X-ray
b) Duplex ultrasonography
c) D-dimer test
d) Venogram
115. A nurse is assessing a client with acute cholecystitis. Which finding is expected?
a) Pain radiating to the right shoulder
b) Left lower quadrant tenderness
c) Dark, tarry stools
d) Increased appetite
116. A nurse is teaching a group of older adults about skin care. Which statement indicates understanding?
a) “I will use hot water to bathe to kill bacteria.”
b) “I should moisturize my skin daily.”
c) “I should exfoliate my skin frequently to remove dead cells.”
d) “I will limit my fluid intake to prevent edema.”
117. A client with newly diagnosed asthma asks about the use of a peak flow meter. Which instruction is correct?
a) “Use the peak flow meter immediately after taking your bronchodilator.”
b) “Perform the test three times and record the highest reading.”
c) “Measure your peak flow only when symptoms are present.”
d) “Blow into the meter for at least 10 seconds.”
118. A nurse is caring for a client following thyroidectomy. Which assessment finding requires immediate intervention?
a) Hoarseness of voice
b) Positive Trousseau’s sign
c) Blood pressure of 110/70 mmHg
d) Pain at the incision site
119. A client with severe burns is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor to evaluate the client’s response to therapy?
a) Serum calcium
b) Serum albumin
c) Serum sodium
d) Blood urea nitrogen (BUN)
120. A nurse is teaching a client about hypertension medications. Which statement by the client requires further teaching?
a) “I will avoid salt substitutes while taking potassium-sparing diuretics.”
b) “I will change positions slowly to avoid dizziness.”
c) “I can stop taking my medications if my blood pressure is normal.”
d) “I should avoid taking my medication with grapefruit juice.”
121. A nurse is caring for a client who has a chest tube in place. Which finding requires immediate action?
a) Gentle bubbling in the suction control chamber
b) 75 mL of drainage in the last hour
c) Continuous bubbling in the water seal chamber
d) Tidaling in the water seal chamber
122. A nurse is teaching a client about clopidogrel. Which statement by the client indicates a need for further teaching?
a) “I should report any unusual bleeding to my healthcare provider.”
b) “I can take this medication with food to prevent stomach upset.”
c) “I will avoid using aspirin while on this medication.”
d) “I should stop the medication immediately if I have bruising.”
123. A client with a history of heart failure presents with a potassium level of 6.5 mEq/L. Which medication should the nurse anticipate administering?
a) Spironolactone
b) Calcium gluconate
c) Furosemide
d) Sodium bicarbonate
124. A nurse is assessing a client who has Cushing’s syndrome. Which finding should the nurse expect?
a) Hypoglycemia
b) Weight loss
c) Truncal obesity
d) Increased skin turgor
125. A nurse is caring for a client with a gastrostomy tube who has developed diarrhea. What is the most appropriate action?
a) Increase the feeding rate.
b) Administer an antidiarrheal medication.
c) Dilute the feeding solution.
d) Provide the feeding at room temperature.
126. A nurse is monitoring a client who has received morphine for pain. Which finding is most concerning?
a) Respiratory rate of 8 breaths/min
b) Blood pressure of 90/60 mmHg
c) Pulse of 60 beats/min
d) Sedation score of 2 on a 0-4 scale
127. A nurse is caring for a client with septic shock. Which finding indicates the client is progressing to multiple organ dysfunction syndrome (MODS)?
a) Hypotension responsive to IV fluids
b) Decreased urine output
c) Warm, flushed skin
d) Increased capillary refill time
128. A nurse is caring for a client who is receiving a transfusion of packed red blood cells. Which action is a priority if the client reports chills and back pain?
a) Stop the transfusion immediately.
b) Administer acetaminophen.
c) Increase the infusion rate.
d) Reassess the client in 15 minutes.
129. A client with myasthenia gravis is prescribed pyridostigmine. Which outcome indicates the medication is effective?
a) Improved respiratory function
b) Decreased salivation
c) Increased muscle strength
d) Reduced muscle spasms
130. A nurse is teaching a client about the use of metered-dose inhalers (MDIs) for asthma. Which instruction should the nurse include?
a) “Inhale quickly and deeply to deliver the medication.”
b) “Hold your breath for 5-10 seconds after inhaling the medication.”
c) “Shake the inhaler before use only if it is a corticosteroid.”
d) “Use your rescue inhaler before the maintenance inhaler.”
131. A nurse is caring for a postpartum client who is Rh-negative and has just delivered an Rh-positive baby. When should Rho(D) immune globulin (RhoGAM) be administered?
a) Within 72 hours after delivery
b) Immediately after delivery
c) Before discharge from the hospital
d) At the first postpartum visit
132. A nurse is assessing a client who reports sudden vision loss in one eye. Which condition should the nurse suspect?
a) Retinal detachment
b) Glaucoma
c) Cataracts
d) Macular degeneration
133. A nurse is caring for a client with newly diagnosed Graves’ disease. Which finding should the nurse expect?
a) Bradycardia
b) Cold intolerance
c) Weight loss despite increased appetite
d) Dry, coarse hair
134. A nurse is caring for a client with a traumatic amputation of the right leg. Which intervention should the nurse implement to prevent phantom limb pain?
a) Keep the residual limb elevated at all times.
b) Massage the stump area.
c) Administer prescribed pain medications.
d) Apply heat packs to the stump.
135. A nurse is caring for a client with an acute asthma exacerbation. Which medication should the nurse administer first?
a) Fluticasone inhaler
b) Albuterol nebulizer
c) Montelukast tablet
d) Ipratropium inhaler
136. A client is undergoing chemotherapy and has a low neutrophil count. Which action is most important to reduce the risk of infection?
a) Restrict visitors who have colds or illnesses.
b) Provide fresh fruit and vegetables daily.
c) Encourage frequent use of mouthwash.
d) Ensure the client uses a humidifier in the room.
137. A nurse is teaching a client with Parkinson’s disease about carbidopa-levodopa. Which statement indicates understanding?
a) “This medication will cure my disease.”
b) “I may experience dizziness when standing up.”
c) “I should avoid foods high in protein.”
d) “This medication should be taken at bedtime.”
138. A nurse is caring for a client with end-stage renal disease (ESRD) who is receiving hemodialysis. Which dietary recommendation is appropriate?
a) High protein, low potassium
b) High potassium, low sodium
c) Low protein, high phosphorus
d) High phosphorus, low sodium
139. A nurse is teaching a client how to reduce the risk of osteoporosis. Which instruction should the nurse include?
a) “Engage in weight-bearing exercises like walking.”
b) “Increase your intake of caffeinated beverages.”
c) “Limit your vitamin D intake to avoid toxicity.”
d) “Avoid dairy products to prevent calcium overload.”
140. A nurse is assessing a client with sickle cell anemia. Which finding indicates a vaso-occlusive crisis?
a) Hemoglobin of 14 g/dL
b) Pain and swelling in joints
c) Increased urine output
d) Hyperactive bowel sounds
141. A nurse is teaching a client who is starting antihypertensive therapy. Which statement indicates the need for further teaching?
a) “I should monitor my blood pressure daily.”
b) “I can stop taking my medication if I feel fine.”
c) “I need to avoid drinking alcohol while on this medication.”
d) “I should inform my doctor if I experience dizziness.”
142. A nurse is caring for a client who has been diagnosed with type 2 diabetes. Which finding indicates the client needs further teaching?
a) The client states, “I will check my blood glucose before meals and at bedtime.”
b) The client eats three balanced meals per day.
c) The client says, “I will skip my medication if I plan to skip a meal.”
d) The client uses an insulin pen and rotates injection sites.
143. A nurse is assessing a client who is receiving diuretic therapy. Which finding should be reported to the healthcare provider?
a) Serum potassium level of 4.0 mEq/L
b) Weight gain of 1 kg (2.2 lbs) over the past 24 hours
c) Blood pressure of 120/80 mmHg
d) Urine output of 100 mL/hr
144. A nurse is caring for a client with chronic pain who is prescribed transdermal fentanyl patches. Which statement indicates a need for further teaching?
a) “I need to replace the patch every 72 hours.”
b) “I can cut the patch to make it last longer.”
c) “I should remove the old patch before applying a new one.”
d) “I should avoid exposing the patch to heat sources.”
145. A nurse is caring for a client with liver cirrhosis. Which finding should be reported to the healthcare provider immediately?
a) Slightly jaundiced skin
b) Ascites with 2+ pitting edema
c) Confusion and asterixis
d) Bilateral lower extremity edema
146. A nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which statement indicates a need for further teaching?
a) “I should eat smaller meals more frequently throughout the day.”
b) “I can drink a glass of milk before bed to soothe my stomach.”
c) “I need to avoid lying down for 2-3 hours after eating.”
d) “I should avoid wearing tight clothing around my abdomen.”
147. A nurse is reviewing the care plan for a client with an ileostomy. Which finding should be reported to the healthcare provider?
a) Stoma appears pink and moist
b) Output is a dark green color
c) Output is thick and pasty
d) Skin surrounding the stoma is red and inflamed
148. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is using oxygen therapy. Which action should the nurse take?
a) Limit oxygen flow to 6 liters per minute.
b) Assess the client’s oxygen saturation frequently.
c) Encourage the client to remove the oxygen when sleeping.
d) Ensure the oxygen delivery system is set at 100% concentration.
149. A nurse is caring for a client with a history of seizures. Which intervention should be implemented during a seizure?
a) Hold the client’s tongue to prevent biting it.
b) Place the client in a supine position with legs elevated.
c) Move objects away from the client to prevent injury.
d) Restrain the client’s arms and legs to prevent movement.
150. A nurse is assessing a client after a hip replacement. Which finding should be reported immediately?
a) The client is experiencing mild swelling of the leg.
b) The client reports pain at the surgical site.
c) The affected leg is shorter than the unaffected leg.
d) The client is able to ambulate with a walker.
151. A nurse is teaching a client with chronic kidney disease (CKD) about dietary changes. Which statement indicates understanding?
a) “I should limit my intake of foods high in sodium and potassium.”
b) “I can eat as much protein as I like to maintain muscle mass.”
c) “I need to consume foods high in phosphorus to maintain bone health.”
d) “I should monitor my fluid intake and output daily.”
152. A nurse is monitoring a client with a new diagnosis of diabetes mellitus. Which finding requires immediate attention?
a) Random blood glucose of 150 mg/dL
b) Client reports increased thirst and frequent urination
c) Blood glucose level of 400 mg/dL
d) Hemoglobin A1c of 7%
153. A nurse is providing discharge instructions to a client after a thyroidectomy. Which instruction should the nurse include?
a) “Avoid taking deep breaths to prevent swelling.”
b) “You may need to avoid sunlight for a few weeks.”
c) “Report any difficulty swallowing or breathing to your healthcare provider.”
d) “Resume normal activity and diet after 24 hours.”
154. A nurse is caring for a client with an abdominal aortic aneurysm (AAA). Which symptom indicates the aneurysm is at risk for rupture?
a) Mild abdominal pain
b) Pulsatile mass in the abdomen
c) Sudden severe back or abdominal pain
d) Nausea and vomiting
155. A nurse is teaching a client who is taking an angiotensin-converting enzyme (ACE) inhibitor. Which statement indicates understanding?
a) “I need to increase my intake of potassium-rich foods.”
b) “I should report a persistent cough to my healthcare provider.”
c) “I can take this medication with any food to prevent stomach upset.”
d) “I should stop the medication if I develop swelling in my hands.”
156. A nurse is assessing a client with an infection. Which finding is most concerning?
a) Elevated white blood cell count
b) Temperature of 100.4°F (38°C)
c) Heart rate of 110 beats per minute
d) Oxygen saturation of 90%
157. A nurse is caring for a client receiving tube feeding through a nasogastric (NG) tube. Which action should the nurse take to prevent aspiration?
a) Elevate the head of the bed to 15 degrees during feeding.
b) Keep the client in a supine position during the feeding.
c) Administer the feeding at room temperature.
d) Elevate the head of the bed to 30-45 degrees during feeding.
158. A nurse is caring for a client with heart failure who is receiving furosemide. Which finding should the nurse report immediately?
a) Decreased urinary output
b) Serum potassium level of 4.5 mEq/L
c) Blood pressure of 130/80 mmHg
d) Weight loss of 0.5 kg (1.1 lbs) in 24 hours
159. A nurse is caring for a client who has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching?
a) “Avoid eating foods high in fat for at least 2 weeks.”
b) “You can return to work after 1 day of rest.”
c) “Expect to experience moderate pain for several weeks.”
d) “You should take pain medication only if the pain is severe.”
160. A nurse is educating a client with Parkinson’s disease about medications. Which statement indicates the need for further teaching?
a) “I need to take my medication at the same time every day.”
b) “I should avoid foods that contain tyramine.”
c) “I should take my medication with a glass of orange juice.”
d) “I can stop taking my medication when I feel better.”
161. A nurse is caring for a client with chronic pancreatitis. Which finding should the nurse anticipate?
a) Elevated serum amylase and lipase
b) Increased weight gain
c) Hyperglycemia
d) Decreased liver enzymes
162. A nurse is caring for a client with a history of deep vein thrombosis (DVT) who is being treated with warfarin. Which lab value should the nurse monitor closely?
a) Potassium level
b) Prothrombin time (PT)
c) White blood cell count
d) Hemoglobin level
163. A nurse is assessing a newborn who was born at 37 weeks’ gestation. Which finding should be reported to the healthcare provider?
a) Soft, pliable fontanelle
b) Jaundice visible after 48 hours
c) Respiratory rate of 60 breaths/min
d) Grunting and nasal flaring
164. A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) how to use a peak flow meter. Which statement indicates the client understands the instructions?
a) “I will use the peak flow meter after each dose of my medication.”
b) “I should record the highest reading I get in the morning and evening.”
c) “I will take my peak flow reading when I am experiencing shortness of breath.”
d) “I will use the peak flow meter to measure how much air I can exhale.”
165. A nurse is caring for a client with a new diagnosis of heart failure. Which finding is most concerning?
a) Bilateral ankle edema
b) Crackles heard at lung bases
c) Increased appetite
d) Orthopnea
166. A nurse is preparing to administer a medication via IV push. Which action is essential before administering the medication?
a) Confirm the patient’s identity using at least two identifiers.
b) Dilute the medication with normal saline before administration.
c) Administer the medication over at least 30 minutes.
d) Place the IV push medication directly into the saline lock.
167. A nurse is providing discharge instructions to a client after a mastectomy. Which statement indicates that the client understands the teaching?
a) “I should avoid using my affected arm for any activities for the next 6 months.”
b) “I will wear a compression garment as directed to reduce swelling.”
c) “I can lift heavy objects with my affected arm after 1 week.”
d) “I need to keep my incision covered and dry for the first 2 weeks.”
168. A nurse is assessing a client receiving IV fluids for dehydration. Which finding indicates that the treatment is effective?
a) Increased skin turgor
b) Increased edema in the lower extremities
c) Urine output of 20 mL/hr
d) Weight loss of 1 kg over 24 hours
169. A nurse is teaching a client with diabetes about foot care. Which statement by the client indicates the need for further teaching?
a) “I will inspect my feet daily for any cuts or blisters.”
b) “I can soak my feet for 30 minutes in warm water to keep them clean.”
c) “I will wear shoes that fit properly to avoid foot injuries.”
d) “I should avoid using hot water on my feet to prevent burns.”
170. A nurse is caring for a client who is post-operative after a total knee replacement. Which activity should the nurse encourage the client to perform first?
a) Ambulate with assistance to the hallway.
b) Perform quadriceps-setting exercises.
c) Use the continuous passive motion (CPM) machine.
d) Sit in a chair for 30 minutes.
171. A nurse is teaching a client with bipolar disorder about medication adherence. Which statement indicates the client needs further teaching?
a) “I will take my medication even if I feel fine.”
b) “I should avoid caffeine and alcohol while on this medication.”
c) “I can stop taking my medication if I start feeling better.”
d) “I need to follow up with my healthcare provider regularly.”
172. A nurse is assessing a client with a suspected tension pneumothorax. Which finding requires immediate intervention?
a) Diminished breath sounds on the affected side
b) Subcutaneous emphysema at the neck
c) Shift of the trachea to the unaffected side
d) Increased respiratory rate of 22 breaths/min
173. A nurse is reviewing the laboratory results of a client who has been taking lithium for bipolar disorder. Which finding requires immediate action?
a) Serum lithium level of 0.6 mEq/L
b) Serum sodium level of 128 mEq/L
c) Serum creatinine level of 0.9 mg/dL
d) White blood cell count of 5,000/mm³
174. A nurse is assessing a client with a pressure ulcer that has a small, red base and a purulent drainage. Which stage of pressure ulcer is this?
a) Stage I
b) Stage II
c) Stage III
d) Stage IV
175. A nurse is providing education to a client who has a history of migraines and is prescribed sumatriptan. Which statement by the client indicates understanding?
a) “I should take this medication daily, even if I don’t have a headache.”
b) “I can take this medication with my migraine medication to make it more effective.”
c) “This medication can help stop my migraine once it starts.”
d) “I need to avoid drinking alcohol while taking this medication.”
176. A nurse is caring for a client who has a history of alcohol abuse and is in detox. Which finding requires immediate intervention?
a) Tremors and anxiety
b) Increased appetite and nausea
c) Seizures and confusion
d) Dehydration and headache
177. A nurse is preparing to discharge a client after a cardiac catheterization. Which instruction is appropriate?
a) “You should avoid drinking fluids for 24 hours.”
b) “You need to keep the site elevated for at least 4 hours.”
c) “Avoid heavy lifting and strenuous activity for 24-48 hours.”
d) “Take a hot bath to promote blood circulation.”
178. A nurse is caring for a client with Parkinson’s disease who is taking a dopamine agonist. Which finding indicates a potential complication?
a) Decreased muscle rigidity
b) Increase in hand tremors
c) Drowsiness and sudden sleep attacks
d) Improved posture and gait
179. A nurse is assessing a client with hypothyroidism. Which finding is expected?
a) Increased heart rate
b) Diarrhea
c) Weight gain
d) Insomnia
180. A nurse is caring for a client with a history of peptic ulcer disease. Which finding should be reported to the healthcare provider?
a) Slight abdominal discomfort after meals
b) Melena stool
c) Increased appetite
d) Mild indigestion that resolves with antacids