IMMUNO/HEMA
Injection of factor X
374. The nurse analyzes the laboratory
results of a child with hemophilia. The nurse
understands that which result will most likely
be abnormal in this child?
1. Platelet count
2. Hematocrit level
3. Hemoglobin level
4. Partial thromboplastin time
375. The nurse is providing home care
instructions to the parents of a 10-year-old
child with hemophilia. Which sport activity
should the nurse suggest for this child?
1. Soccer
2. Basketball
3. Swimming
4. Field hockey
376. The nursing student is presenting a
clinical conference and discusses the cause
of β-thalassemia. The nursing student
informs the group that a child at greatest
risk of developing this disorder is which
one?
1. A child of Mexican descent
2. A child of Mediterranean descent
3. A child whose intake of iron is extremely
poor
4. A breast-fed child of a mother with
chronic anemia
377. A child with β-thalassemia is receiving
long-term blood transfusion therapy for the
treatment of the disorder. Chelation therapy
is prescribed as a result of too much iron
from the transfusions. Which medication
should the nurse anticipate to be
prescribed?
1. Fragmin
2. Meropenem (Merrem)
3. Metoprolol (Toprol-XL)
4. Deferoxamine (Desferal)
378. The clinic nurse instructs parents of a
child with sickle cell anemia about the
precipitating factors related to sickle cell
crisis. Which, if identified by the
parents as a precipitating factor, indicates
the need for further instructions?
1. Stress
2. Trauma
3. Infection
4. Fluid overload
379. A 10-year-old child with hemophilia A
has slipped on the ice and bumped his
knee. The nurse should prepare to
administer which prescription?
1.
2. Intravenous infusion of iron
3. Intravenous infusion of factor VIII
4. Intramuscular injection of iron using the
Z-track method
380. The nurse is instructing the parents of
a child with iron deficiency anemia
regarding the administration of a liquid oral
iron supplement. Which instruction should
the nurse tell the parents?
1. Administer the iron at mealtimes.
2. Administer the iron through a straw.
3. Mix the iron with cereal to administer.
4. Add the iron to formula for easy
administration.
381. Laboratory studies are performed for a
child suspected to have iron deficiency
anemia. The nurse reviews the laboratory
results, knowing that which result indicates
this type of anemia?
1. Elevated hemoglobin level
2. Decreased reticulocyte count
3. Elevated red blood cell count
4. Red blood cells that are microcytic
and hypochromic
858. The nurse prepares to give a bath and
change the bed linens of a client with
cutaneous Kaposi’s sarcoma lesions. The
lesions are open and draining a scant
amount of serous fluid. Which would the
nurse incorporate into the plan during
the bathing of this client?
1. Wearing gloves
2. Wearing a gown and gloves
3. Wearing a gown, gloves, and a mask
4. Wear a gown and gloves to change the
bed linens and gloves only for the bath
859. The nurse provides home care
instructions to a client with systemic lupus
erythematosus and tells the client about
methods to manage fatigue. Which
statement by the client indicates a need for
further instructions?
1. “I should take hot baths because they
are relaxing.”
2. “I should sit whenever possible to
conserve my energy.”
3. “I should avoid long periods of rest
because it causes joint stiffness.”
4. “I should do some exercises, such as
walking, when I am not fatigued.”
861. A client with pemphigus is being seen
in the clinic regularly. The nurse plans care
based on which description of this
condition?
1. The presence of tiny red vesicles
2. An autoimmune disease that causes
blistering in the epidermis
3. The presence of skin vesicles found
along the nerve caused by a virus
4. The presence of red, raised papules and
large plaques covered by silvery scales
862. The nurse is assisting in planning care
for a client with a diagnosis of
immunodeficiency and should incorporate
which action as a priority in the plan?
1. Protecting the client from infection
2. Providing emotional support to decrease
fear
3. Encouraging discussion about lifestyle
changes
4. Identifying factors that decreased the
immune function
863. A client calls the nurse in the
emergency department and states that he
was just stung by a bumble bee while
gardening. The client is afraid of a severe
reaction because the client’s neighbor
experienced such a reaction just 1 week
ago. Which nursing action should the nurse
take?
1. Advise the client to soak the site in
hydrogen peroxide.
2. Ask the client if he ever sustained a
bee sting in the past.
3. Tell the client to call an ambulance for
transport to the emergency department.
4. Tell the client not to worry about the sting
unless difficulty with breathing occurs.
864. The community health nurse is
conducting a research study and is
identifying clients in the community at risk
for latex allergy. Which client population is
at most risk for developing this type of
allergy?
1. Hairdressers
2. The homeless
3. Children in day care centers
4. Individuals living in a group home
866. The camp nurse prepares to instruct a
group of children about Lyme disease.
Which information should the nurse include
in the instructions?
1. Lyme disease is caused by a tick
carried by deer.
2. Lyme disease is caused by contamination
from cat feces.
3. Lyme disease can be caused by the
inhalation of spores from bird droppings.
4. Lyme disease can be contagious through
skin contact with an infected individual.
867. A client is diagnosed with scleroderma.
Which intervention should the nurse
anticipate to be prescribed?
1. Maintain bed rest as much as possible.
2. Administer corticosteroids as
prescribed for inflammation.
3. Advise the client to remain supine for 1 to
2 hours after meals.
4. Keep the room temperature warm during
the day and cool at night.
869. The nurse is preparing a group of Cub
Scouts for an overnight camping trip and
instructs the scouts about the methods to
prevent Lyme disease. Which statement by
one of the Cub Scouts indicates a need for
further instructions?
1. “I need to bring a hat to wear during the
trip.”
2. “I should wear long-sleeved tops and long
pants.”
3. “I should not use insect repellents
because it will attract the ticks.”
4. “I need to wear closed shoes and socks
that can be pulled up over my pants.”
870. The client with acquired
immunodeficiency syndrome is diagnosed
with cutaneous Kaposi’s sarcoma. Based on
this diagnosis, the nurse understands that
this has been confirmed by which finding?
1. Swelling in the genital area
2. Swelling in the lower extremities
3. Positive punch biopsy of the
cutaneous lesions
4. Appearance of reddish-blue lesions noted
on the skin
872. The home care nurse is performing an
assessment on a client who has been
diagnosed with an allergy to latex. In
determining the client’s risk factors, the
nurse should question the client about an
allergy to which food item?
1. Eggs
2. Milk
3. Yogurt
4. Bananas
873. The client with acquired
immunodeficiency syndrome and
Pneumocystis jiroveci infection has been
receiving pentamidine (Pentam 300). The
client develops a temperature of 101° F. The
nurse continues to assess the client,
knowing that this sign most likely indicates
which condition?
1. That the dose of the medication is too low
2. That the client is experiencing toxic
effects of the medication
3. That the client has developed inadequacy
of thermoregulation
4. That the client has developed another
infection caused by leukopenic effects of
the medication
877. The nurse is reviewing the results of
serum laboratory studies drawn on a client
with acquired immunodeficiency syndrome
who is receiving didanosine (Videx).
The nurse interprets that the client may
have the medication discontinued by the
health care provider if which elevated result
is noted?
1. Serum protein level
2. Blood glucose level
3. Serum amylase level
4. Serum creatinine level
878. The nurse is caring for a postrenal
transplantation client taking cyclosporine
(Sandimmune). The nurse notes an
increase in one of the client’s vital signs and
the client is complaining of a headache.
What vital sign is most likely increased?
1. Pulse
2. Respirations
3. Blood pressure
4. Pulse oximetry
879. Amikacin (Amikin) is prescribed for a
client with a bacterial infection. The nurse
instructs the client to contact the health care
provider (HCP) immediately
if which occurs?
1. Nausea
2. Lethargy
3. Hearing loss
4. Muscle aches
880. The nurse is assigned to care for a
client with cytomegalovirus retinitis and
acquired immunodeficiency syndrome who
is receiving foscarnet, an antiviral
medication. The nurse should monitor the
results of which laboratory study while
the client is taking this medication?
1. CD4 cell count
2. Lymphocyte count
3. Serum albumin level
4. Serum creatinine level
881. A client who is human
immunodeficiency virus seropositive has
been taking stavudine (d4T, Zerit). The
nurse should monitor which most closely
while the client is taking this medication?
1. Gait
2. Appetite
3. Level of consciousness
4. Gastrointestinal function
530. The nurse is reviewing the laboratory
results of a client diagnosed with multiple
myeloma. Which would the nurse expect to
note specifically in this disorder?
1. Increased calcium level
2. Increased white blood cells
3. Decreased blood urea nitrogen level
4. Decreased number of plasma cells in the
bone marrow
531. The nurse is developing a plan of care
for the client with multiple myeloma and
includes which priority intervention in the
plan?
1. Encouraging fluids
2. Providing frequent oral care
3. Coughing and deep breathing
4. Monitoring the red blood cell count
533. While giving care to a client with an
internal cervical radiation implant, the nurse
finds the implant in the bed. The nurse
should take which initial action?
1. Call the health care provider (HCP).
2. Reinsert the implant into the vagina.
3. Pick up the implant with gloved hands
and flush it down the toilet.
4. Pick up the implant with long-handled
forceps and place it in a lead container.
534. The nurse should plan to implement
which intervention in the care of a client
experiencing neutropenia as a result of
chemotherapy?
1. Restrict all visitors.
2. Restrict fluid intake.
3. Teach the client and family about the
need for hand hygiene.
4. Insert an indwelling urinary catheter to
prevent skin breakdown.
535. The home health care nurse is caring
for a client with cancer who is complaining
of acute pain. The most appropriate
determination of the client’s pain should
include which assessment?
1. The client’s pain rating
2. Nonverbal cues from the client
3. The nurse’s impression of the client’s
pain
4. Pain relief after appropriate nursing
intervention
536. The nurse is caring for a client who is
postoperative following a pelvic
exenteration and the health care provider
changes the client’s diet from NPO status to
clear liquids. The nurse should check which
priority item before administering the diet?
1. Bowel sounds
2. Ability to ambulate
3. Incision appearance
4. Urine specific gravity
537. A client is admitted to the hospital with
a suspected diagnosis of Hodgkin’s
disease. Which assessment finding would
the nurse expect to note specifically in
the client?
1. Fatigue
2. Weakness
3. Weight gain
4. Enlarged lymph nodes
538. During the admission assessment of a
client with advanced ovarian cancer, the
nurse recognizes which symptom as typical
of the disease?
1. Diarrhea
2. Hypermenorrhea
3. Abnormal bleeding
4. Abdominal distention
540. A client who has been receiving
radiation therapy for bladder cancer tells the
nurse that it feels as if she is voiding
through the vagina. The nurse interprets
that the client may be experiencing which
condition?
1. Rupture of the bladder
2. The development of a vesicovaginal
fistula
3. Extreme stress caused by the diagnosis
of cancer
4. Altered perineal sensation as a side
effect of radiation therapy
541. The nurse is instructing a client to
perform a testicular self-examination (TSE).
The nurse should provide the client with
which information about the procedure?
1. To examine the testicles while lying down
2. That the best time for the examination
is after a shower
3. To gently feel the testicle with one finger
to feel for a growth
4. That testicular self-examinations should
be done at least every 6 months
542. A client is diagnosed with multiple
myeloma and the client asks the nurse
about the diagnosis. The nurse bases the
response on which description of this
disorder?
1. Altered red blood cell production
2. Altered production of lymph nodes
3. Malignant exacerbation in the number of
leukocytes
4. Malignant proliferation of plasma cells
within the bone
543. A gastrectomy is performed on a client
with gastric cancer. In the immediate
postoperative period, the nurse notes
bloody drainage from the nasogastric tube.
The nurse should take which most
appropriate action?
1. Measure abdominal girth.
2. Irrigate the nasogastric tube.
3. Continue to monitor the drainage.
4. Notify the health care provider (HCP).
544. The nurse is teaching a client about
the risk factors associated with colorectal
cancer. The nurse determines that further
teaching is necessary related to colorectal
cancer if the client identifies which item as
an associated risk factor?
1. Age younger than 50 years
2. History of colorectal polyps
3. Family history of colorectal cancer
4. Chronic inflammatory bowel disease
545. The nurse is assessing the perineal
wound in a client who has returned from the
operating room following an abdominal
perineal resection and notes
serosanguineous drainage from the wound.
Which nursing intervention is most
appropriate?
1. Clamp the Penrose drain.
2. Change the dressing as prescribed.
3. Notify the health care provider (HCP).
4. Remove and replace the perineal
packing.
546. The nurse is assessing the colostomy
of a client who has had an abdominal
perineal resection for a bowel tumor. Which
assessment finding indicates that the
colostomy is beginning to function?
1. The passage of flatus
2. Absent bowel sounds
3. The client’s ability to tolerate food
4. Bloody drainage from the colostomy
547. The nurse is reviewing the history of a
client with bladder cancer. The nurse
expects to note documentation of which
most common symptom of this type of
cancer?
1. Dysuria
2. Hematuria
3. Urgency on urination
4. Frequency of urination
548. The nurse is assessing a client who
has a new ureterostomy. Which statement
by the client indicates the need for more
education about urinary stoma care?
1. “I change my pouch every week.”
2. “I change the appliance in the morning.”
3. “I empty the urinary collection bag
when it is two-thirds full.”
4. “When I’m in the shower I direct the flow
of water away from my stoma.”
550. The nurse is monitoring a client for
signs and symptoms related to superior
vena cava syndrome. Which is an early sign
of this oncological emergency?
1. Cyanosis
2. Arm edema
3. Periorbital edema
4. Mental status changes
551. The nurse manager is teaching the
nursing staff about signs and symptoms
related to hypercalcemia in a client with
metastatic prostate cancer and tells the staff
that which is a late sign of this oncological
emergency?
1. Headache
2. Dysphagia
3. Constipation
4. Electrocardiographic changes
552. As part of chemotherapy education,
the nurse teaches a female client about the
risk for bleeding and self-care during the
period of greatest bone marrow
suppression (the nadir). The nurse
understands that further teaching is needed
if the client makes which statement?
1. “I should avoid blowing my nose.”
2. “I may need a platelet transfusion if my
platelet count is too low.”
3. “I’m going to take aspirin for my
headache as soon as I get home.”
4. “I will count the number of pads and
tampons I use when menstruating.”
553. The community health nurse is
instructing a group of young female clients
about breast self-examination. The nurse
should instruct the clients to perform the
examination at which time?
1. At the onset of menstruation
2. Every month during ovulation
3. Weekly at the same time of day
4. 1 week after menstruation begins
555. The nurse is caring for a client
following a mastectomy. Which nursing
intervention would assist in preventing
lymphedema of the affected arm?
1. Placing cool compresses on the affected
arm
2. Elevating the affected arm on a pillow
above heart level
3. Avoiding arm exercises in the immediate
postoperative period
4. Maintaining an intravenous site below the
antecubital area on the affected side
MUSCULOSKELETAL
465. A child has a right femur fracture
caused by a motor vehicle crash and is
placed in skin traction temporarily until
surgery can be performed. During
assessment, the nurse notes that the
dorsalis pedis pulse is absent on the right
foot. Which action should the nurse take?
1. Administer an analgesic.
2. Release the skin traction.
3. Apply ice to the extremity.
4. Notify the health care provider (HCP).
466. A child is placed in skeletal traction for
treatment of a fractured femur. The nurse
develops a plan of care and includes which
intervention?
1. Ensure that all ropes are outside the
pulleys.
2. Ensure that the weights are resting lightly
on the floor.
3. Restrict diversional and play activities
until the child is out of traction.
4. Check the health care provider’s
(HCP’s) prescriptions for the amount of
weight to be applied.
467. A 4-year-old child sustains a fall at
home and after an x-ray examination, the
child is determined to have a fractured arm
and a plaster cast is applied. The nurse
provides instructions to the parents
regarding care for the child’s cast. Which
statement by the parents indicates a need
for further instruction?
1. “The cast may feel warm as the cast
dries.”
2. “I can use lotion or powder around the
cast edges to relieve itching.”
3. “A small amount of white shoe polish can
touch up a soiled white cast.”
4. “If the cast becomes wet, a blow drier set
on the cool setting may be used to
dry the cast.”
468. The parents of a child with juvenile
idiopathic arthritis call the clinic nurse
because the child is experiencing a painful
exacerbation of the disease. The parents
ask the nurse if the child can perform
range-of-motion exercises at this time. The
nurse should make which response?
1. “Avoid all exercise during painful
periods.”
2. “Range-of-motion exercises must be
performed every day.”
3. “Have the child perform simple
isometric exercises during this time.”
4. “Administer additional pain medication
before performing range-of-motion
Exercises.”
469. A child who has undergone spinal
fusion for scoliosis complains of abdominal
discomfort and begins to have episodes of
vomiting. On further assessment, the nurse
notes abdominal distention. On the basis of
these findings, the nurse should take which
action?
1. Administer an antiemetic.
2. Increase the intravenous fluids.
3. Place the child in a Sims’s position.
4. Notify the health care provider (HCP).
470. The nurse is providing instructions to
the parents of a child with scoliosis
regarding the use of a brace. Which
statement by the parents indicates a need
for further instruction?
1. “I will encourage my child to perform
prescribed exercises.”
2. “I will have my child wear soft fabric
clothing under the brace.”
3. “I should apply lotion under the brace
to prevent skin breakdown.”
4. “I should avoid the use of powder
because it will cake under the brace.”
471. The nurse is assisting a health care
provider (HCP) examining an infant with
developmental dysplasia of the hip perform
an Ortolani maneuver. The nurse
understands that this maneuver is
performed for which purpose?
1. To assess for hip instability
2. To assess for movement of the hips
3. To push the femoral head out of the
acetabulum
4. To ensure that hyperextension and full
range of motion exist
472. A 1-month-old infant is seen in a clinic
and is diagnosed with developmental
dysplasia of the hip. On assessment, the
nurse understands that which finding should
be noted in this condition?
1. Limited range of motion in the affected
hip
2. An apparent lengthened femur on the
affected side
3. Asymmetrical adduction of the affected
hip when the infant is placed supine
with the knees and hips flexed
4. Symmetry of the gluteal skinfolds when
the infant is placed prone and the legs
are extended against the examining table
473. Parents bring their 2-week-old infant to
a clinic for treatment after a diagnosis of
clubfoot made at birth. Which statement by
the parents indicates a need for
further teaching regarding this disorder?
1. “Treatment needs to be started as soon
as possible.”
2. “I realize my infant will require follow-up
care until fully grown.”
3. “I need to bring my infant back to the
clinic in 1 month for a new cast.”
4. “I need to come to the clinic every week
with my infant for the casting.”
830. 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 jogs
2. A 36-year-old man who has asthma
3. A 70-year-old man who consumes
excess alcohol
4. A sedentary 65-year-old woman who
smokes cigarettes
831. 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 site
inflammation to my health care
provider.”
832. The nurse is one of several persons
who witnessed a vehicle hit a pedestrian at
fairly low speed on a small street. The victim
is dazed and tries to get up. The
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 the
person to remain still.
834. The nurse is evaluating the pin sites of
a client in skeletal traction. The nurse
would be least concerned with which
finding?
1. Inflammation
2. Serous drainage
3. Pain at a pin site
4. Purulent drainage
835. 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
836. 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
837. The nurse is admitting a client with
multiple trauma 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. Flat for 12 hours, then elevated for 12
hours.
2. Elevated for 3 hours and then flat for 1
hour.
3. Flat for 3 hours and then elevated for 1
hour.
4. Elevated on pillows continuously for
24 to 48 hours.
838. 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.”
839. 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
841. 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
842. 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
843. A client with diabetes mellitus has had
a right below-knee amputation. Given the
client’s history of diabetes mellitus, which
should the nurse specifically observe in the
postoperative period?
1. Hemorrhage
2. Edema of the residual limb
3. Slight redness of the incision
4. Separation of the wound edges
844. 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. Apply a dry sterile dressing and elevate it
on one pillow.
4. Rewrap the residual limb with an
elastic compression bandage.
845. 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. Bending or lifting
3. Application of heat
4. Ibuprofen (Motrin IB)
846. 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 orally
2. Complaints of discomfort during
repositioning
3. Old bloody drainage outlined on the
surgical dressing
4. Discomfort during coughing and
deep-breathing exercises
847. The nurse is caring for a client with a
diagnosis of gout. Which laboratory value
would the nurse expect to note in the client?
1. Calcium level of 9.0 mg/dL
2. Uric acid level of 8.6 mg/dL
3. Potassium level of 4.1 mEq/L
4. Phosphorus level of 3.1 mg/dL
848. A client with a hip fracture asks the
nurse why Buck’s (extension) traction is
being applied before surgery. The nurse
provides a response based on which
purpose of Buck’s (extension) traction?
1. Allows bony healing to begin before
surgery
2. Provides rigid immobilization of the
fracture site
3. Lengthens the fractured leg to prevent
severing of blood vessels
4. Provides comfort by reducing muscle
spasms and provides fracture
immobilization
849. A client has been on treatment for
rheumatoid arthritis for 3 weeks. During the
administration of etanercept, which is most
important for the nurse to assess?
1. The injection site for itching and edema
2. The white blood cell counts and
platelet counts
3. Whether the client is experiencing fatigue
and joint pain
4. Whether the client is experiencing a
metallic taste in the mouth, and a loss of
Appetite
850. Allopurinol (Zyloprim) is prescribed for
a client and the nurse provides
medication instructions to the client. Which
instruction should the nurse provide?
1. Drink 3000 mL of fluid a day.
2. Take the medication on an empty
stomach.
3. The effect of the medication will occur
immediately.
4. Any swelling of the lips is a normal
expected response.
851. Colchicine (Colcrys) is prescribed for a
client with a diagnosis of gout. The nurse
reviews the client’s record, knowing that this
medication would be used
with caution in which disorder?
1. Myxedema
2. Kidney disease
3. Hypothyroidism
4. Diabetes mellitus
852. Alendronate (Fosamax) is prescribed
for a client with osteoporosis and the nurse
is providing instructions on administration of
the medication. Which instruction should the
nurse provide?
1. Take the medication at bedtime.
2. Take the medication in the morning with
breakfast.
3. Lie down for 30 minutes after taking the
medication.
4. Take the medication with a full glass of
water after rising in the morning.
853. The nurse is preparing discharge
instructions for a client receiving baclofen.
Which instruction should be included in the
teaching plan?
1. Restrict fluid intake.
2. Avoid the use of alcohol.
3. Stop the medication if diarrhea occurs.
4. Notify the health care provider (HCP) if
fatigue occurs.
854. The nurse is analyzing the laboratory
studies on a client receiving dantrolene
sodium (Dantrium). Which laboratory test
would identify an adverse effect
associated with the administration of this
medication?
1. Platelet count
2. Creatinine level
3. Liver function tests
4. Blood urea nitrogen level
855. Cyclobenzaprine hydrochloride
(Flexeril) is prescribed for a client for muscle
spasms and the nurse is reviewing the
client’s record. Which disorder, if noted in
the record, would indicate a need to contact
the health care provider about the
administration of this medication?
1. Glaucoma
2. Emphysema
3. Hypothyroidism
4. Diabetes mellitus
857. The nurse is administering an
intravenous dose of methocarbamol
(Robaxin) to a client with multiple sclerosis.
For which side/adverse effects should the
nurse monitor?
1. Tachycardia
2. Rapid pulse
3. Bradycardia
4. Hypertension
PERIOP
166. 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
167. A postoperative client asks the nurse
why it is so important to deep-breathe and
cough after surgery. When formulating a
response, the nurse incorporates the
understanding that retained pulmonary
secretions in a postoperative client can lead
to which condition?
1. Pneumonia
2. Hypoxemia
3. Fluid imbalance
4. Pulmonary embolism
168. The nurse is developing 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
mouthwash.
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.
169. A client with a perforated 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.
170. 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.”
171. 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.
172. 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
(aspirin). 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.”
178. The nurse is reviewing a health care
provider’s (HCP’s) prescription sheet for a
preoperative client that states that the client
must be NPO after midnight. The nurse
would telephone the HCP to clarify that
which medication should be given to the
client and not withheld?
1. Prednisone
2. Ferrous sulfate
3. Cyclobenzaprine (Flexeril)
4. Conjugated estrogen (Premarin)

173. 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
3. Purulent drainage
4. Warm, tender skin

174. The nurse is monitoring the status of a

postoperative client. 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 four
quadrants

176. 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. Sodium, 141 mEq/L
2. Hemoglobin, 8.0 g/dL
3. Platelets, 210,000/mm3
4. Serum creatinine, 0.8 mg/dL

177. The nurse receives a telephone call

from the postanesthesia 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.
DAVIS
HEMA
1. A homeless client, visiting a health clinic,
is noted to have a smooth and reddened
tongue and ulcers at the corners of the
mouth. The client was tentatively diagnosed
with a hematological disorder, and
laboratory tests were prescribed. Based on
this information, a nurse should expect the
client’s laboratory results to reveal:
1. low hemoglobin.
2. elevated red blood cells (RBCs).
3. prolonged prothrombin time (PT).
4. low white blood cells (WBCs).
2. A nurse teaches a 55-year-old strict
vegetarian that, to decrease the risk of
developing megaloblastic anemia, the client
should:
1. undergo a Schilling test.
2. increase intake of foods high in iron.
3. supplement the diet with vitamin B12.
4. have a monthly hemoglobin level drawn
3. A nurse should assess a client with
hemolytic anemia for weakness, fatigue,
malaise, skin and mucous membrane pallor,
and:
1. jaundice.
2. a smooth red tongue.
3. a craving for ice.
4. a poor intake of fresh vegetables.
4. A client is neutropenic following treatment
for acute lymphocytic leukemia and is now
experiencing hypotension, tachycardia, and
an elevated temperature. Because an
infection is suspected, a nurse notifies a
physician. Which physician order should be
the nurse’s priority?
1. Portable chest x-ray
2. Urine and blood cultures
3. Vancomycin (Vancocin®) 1 gm
intravenously (IV)
every 12 hours
4. Filgrastim (Neupogen®) 10 mg/kg
subcutaneously daily
5. A nurse obtains the following assessment
data for a client diagnosed with acute
myeloid leukemia. For which finding should
a nurse plan interventions first?
1. Pain from mucositis
2. Weakness and fatigue
3. T 99°, P100, R 20, and BP 132/64 mmHg
4. Ecchymosis and petechiae noted on
arms
6. A client who is receiving doxorubicin
(Adriamycin®) for the first time to treat
multiple myeloma develops flushing, facial
swelling, headache, chills, and back pain.
Which statement made by the nurse is
best?
1. “These symptoms are uncomfortable
for you, and I can give more medication
for symptom control; these usually
resolve in 1 day and are limited to the
first dose.”
2. “These symptoms are concerning. You
may want to consider terminating treatment
because these are signs of unacceptable
toxicity.”
3. “Next time you can receive premedication
with ondansetron (Zofran®), an antiemetic
to prevent these symptoms.”
4. “Side effects will occur with
chemotherapy. Focus on the goal of curing
your cancer, and then the side effects will
be more tolerable.”
7. Following a shift report on an oncology
unit, a nurse determines that which client
should be assessed first?
1. A client with breast cancer who has an
order for ondansetron (Zofran®) 8 mg
intravenously (IV) 30 minutes prior to
chemotherapy
2. A client just admitted with a
temperature of 101°F (38.3°C),
diaphoresis, and an absolute neutrophil
count of 98/mm3
3. A client with breast cancer who is
scheduled for external beam radiation in 15
minutes
4. A client with stomatitis associated with
tonsilar cancer who receives gastrostomy
tube feedings
8. A female client is to receive
chemotherapy and radiation for Hodgkin’s
lymphoma with cervical and axillary node
involvement. A nurse evaluates that the
client is coping positively when the client
states:
1. “I selected a wig that matches my hair
color, but I will miss my own hair.”
2. “I am so glad that the chemotherapy and
radiation treatments won’t cause me to lose
my hair.”
3. “The chemotherapy-drug combination will
prevent mucositis and immunosuppression.”
4. “I have faith that my doctor will be able to
cure me and I won’t have any long-term
effects.”
9. A physician documents that a client,
diagnosed with stage III non-Hodgkin’s
lymphoma (NHL), is experiencing “B
symptoms.” A nurse interprets this to mean
that the client has:
1. bleeding associated with low platelets
counts.
2. a B lymphocyte malignancy and has
progressed to an untreatable stage.
3. symptoms from exposure to a viral
infection, such as Epstein-Barr virus.
4. recurrent fever, drenching night
sweats, and an unintentional weight loss
of 10% or more.
10. A nurse teaches a coworker that the
treatment for hemophilia will likely include
periodic selfadministration of:
1. platelets.
2. whole blood.
3. factor concentrates.
4. fresh frozen plasma.
11. A client diagnosed with von Willebrand’s
disease calls a clinic after experiencing
hemarthrosis. Which treatment should a
nurse recommend?
1. “Treat the pain with two 325-mg aspirin
(Ecotrin®) tablets every 4 hours.”
2. “Apply cold packs 2 hours on and 2
hours off of the affected site for 24 to 48
hours.”
3. “Come to the clinic immediately so you
can receive an infusion of fresh frozen
plasma.”
4. “If you are wearing a splint, remove it
immediately to avoid compartment
syndrome.”
12. A client has a wound suction device for
blood salvage following a left total knee
replacement so that the blood can be
reinfused into the client within the
first 6 hours postoperatively. Which
intervention should a nurse plan to
implement to care for this wound suction
device?
1. Discard the first 500 mL in the suction
container and wait until the container is full
again before beginning a reinfusion.
2. As soon as the prescribed amount is
noted in the container, obtain the blood
and prepare it for reinfusion into the
client intravenously.
3. Separate the blood from the drainage,
and reinfuse the blood back through the
drainage system into the wound.
4. Remove the blood from the drainage
system and send it to the blood bank to be
prepared for an infusion.
13. The family of a client who is scheduled
for emergency surgery following an accident
asks if they can donate blood for the client.
The client’s blood type is B negative. A
nurse informs the family that packed
red blood cells (PRBCs) could likely be
used from family members whose blood
type is:
1. type A positive.
2. type B positive.
3. type B negative.
4. type O positive.
5. type O negative.
6. type AB positive.
14. A client who has received 50 mL of a
unit of whole blood complains of low back
pain. In response to this client’s symptom, a
nurse should first:
1. reposition the client.
2. assess the pain further.
3. administer an analgesic.
4. stop the blood transfusion.
15. A young adult with a diagnosis of
hemophilia A is receiving a monthly
scheduled dose of factor VIII cryoprecipitate
(Bioclate®). While a nurse is administering
the Bioclate®, the client begins to cry.
Which nursing response would be most
appropriate?
1. “Why are you crying? You seem afraid
when I am administering the Bioclate®.”
2. “Is it painful when I administer the
Bioclate® intravenous push? If it is, I can
administer it by infusion.”
3. “I know this is uncomfortable for you, but
this will only take about 3 minutes to
administer.”
4. “If you want to talk to me about what
you are feeling, I am here to listen.”
16. A client with leukemia asks a nurse to
explain how donor cells are obtained for
peripheral blood stem cell transplantation
(PBSCT). Which statement by the nurse is
correct?
1. “A large amount of bone marrow tissue is
harvested from a donor’s hip bone under
general anesthesia in the operating room.”
2. “Stem cells are collected from the
donor’s blood, which goes through a
machine, removes the stem cells, and
then returns the blood back to the
donor.”
3. “Stem cells are collected from a donor
through a process called apheresis, which
removes the stem cells from the blood. This
typically takes 10 to 15 minutes.”
4. “Stem cells are obtained similar to other
blood donations, where the blood is
collected and then administered to you
immediately following collection.”
17. A female nurse tells a coworker that she
is confused because a physician stated that
graft-versus-host disease (GVHD)
symptoms were desirable for a particular
client after a bone marrow transplant. In
which type of malignancy is GVHD
sometimes desirable?
1. Gastrointestinal
2. Reproductive
3. Neurological
4. Hematological
18. A client diagnosed with acute myeloid
leukemia receives a bone marrow
transplant. Which medication to prevent
graft-versus-host disease (GVHD) should a
nurse anticipate receiving an order to
administer?
1. A cephalosporin antibiotic, such as
ceftazidime
(Fortaz®)
2. An immunosuppressant, such as
cyclosporine
(Neoral®)
3. A chemotherapeutic agent, such as
cisplatin
(Platinol A-Q®)
4. Peginterferon alfa-2a (Pegasys®) for
prevention and treatment of hepatitis
19. A nurse is evaluating a client’s
understanding of teaching about changes to
expect following a bone marrow transplant
(BMT). Which statement by the client
indicates the client misunderstood the
expected changes?
1. “You can have weight gain from the side
effects of your steroid immunosuppressant
medications.”
2. “Sterility can occur from the destruction of
your own stem cells with chemotherapy and
radiation.”
3. “Cataracts may develop after total body
irradiation.”
4. “Changes to the mouth include a
white, patchy tongue.”
20. Which nursing diagnosis should have
the highest priority for a client experiencing
superior vena cava syndrome secondary to
lung cancer?
1. Ineffective breathing pattern
2. Ineffective tissue perfusion
3. Risk for infection
4. Impaired skin integrity
21. A nurse explains “watchful waiting”
(ongoing visits to a physician for
observation of signs and symptoms without
treatment) to a client with prostate cancer.
Under which circumstance should the nurse
recommend “watchful waiting”?
1. When bone cancer is diagnosed along
with prostate cancer
2. When the client is older than age 70
with a life expectancy of less than 10
years with low-grade disease
3. When a client has extension of the tumor
outside of the prostate
4. When a client has an elevated prostate
specific antigen, has no symptoms, and is
under the age of 60
22. Which actions should a nurse initiate for
a client who had a left modified radical
mastectomy (a total mastectomy with
axillary node dissection and removal of the
lining over the pectoralis major muscle)?
1. Elevate the left arm above the head.
2. Insert all intravenous (IV) access sites
on the right side.
3. Have the client view the incision site as
soon as possible.
4. Initiate strengthening exercises of the left
arm within 24 hours of surgery.
23. A client diagnosed with Hodgkin’s
lymphoma develops radiation pneumonitis 3
months after radiation treatment. For which
symptoms of radiation pneumonitis should a
nurse observe the client?
1. Tachypnea, hypotension, and fever
2. Cough, fever, and dyspnea
3. Bradypnea, cough, and decreased urine
output
4. Cough, tachycardia, and altered mental
status
24. A nurse cares for a client receiving
combination chemotherapy of oxaliplatin
(Eloxatin®), fluorouracil (5-FU), and
leucovorin (Wellcovorin®). For which
common side effects of this chemotherapy
should the nurse assess the client?
1. Neurotoxicities and diarrhea
2. Cardiomyopathy and dysphagia
3. Renal insufficiency and gastritis
4. Photophobia and stomatitis
25. A nurse assesses that a client, who is
receiving radiation for cervical cancer,
continues to have diarrhea. Which nursing
advice is most appropriate for this client?
1. Take sitz baths twice daily and eat a
low-residue diet.
2. Drink fluids low in potassium and take
frequent tub baths.
3. Increase your intake of milk products and
take frequent showers.
4. Drink fluids high in sodium and apply
hydrocolloid dressings to reddened areas.
26. When assessing a client who is
recovering from a radical hysterectomy with
vulvectomy, a nurse notes lymphedema of
the lower extremities. Which intervention
should be implemented by the nurse?
1. Elevate the head of the bed to a
45-degree angle.
2. Increase the client’s intake of fluids high
in sodium.
3. Encourage the client to exercise the
lower extremities.
4. Apply lower-extremity splints
27. A client phones a nurse after having
three basal cell carcinoma (BCC) lesions
excised the day before and is concerned
that the wounds are draining a small
amount of serosanguineous fluid and that
the small
dressing is leaking. Which action should the
nurse recommend?
1. Apply ice to the area.
2. Contact the physician.
3. Take medication for pain.
4. Change the dressings.
28. A client presents with a meningioma and
symptoms of increased intracranial
pressure. Which manifestations should a
nurse least expect to find on assessment
of this client?
1. Headache
2. Vomiting
3. Pyrexia
4. Papilledema
29. When caring for a client with epigastric
pain and suspected gastric cancer, which
diagnostic test should a nurse address with
the client because it is the specific test used
to diagnose the cancer?
1. Arthroscopy
2. Bronchoscopy
3. Colonoscopy
4. Esophagogastroduodenoscopy
30. Which nursing diagnosis should a nurse
plan to document for the client with gastric
cancer experiencing hematemesis?
1. Impaired oral mucous membrane
2. Decreased cardiac output
3. Impaired gas exchange
4. Fluid volume deficit
31. A client diagnosed with esophageal
cancer is having work-related problems.
Which organization should a nurse advise
the client to contact for assistance with
these issues?
1. National Cancer Institute
2. Leukemia Society of America
3. Corporate Angel Network
4. Patient Advocate Foundation
32. Which vaccine should a nurse
recommend for prevention of liver cancer?
1. Varicella vaccine
2. Hepatitis A vaccine
3. Meningococcal vaccine
4. Hepatitis B vaccine
33. A nurse is caring for a client diagnosed
with hepatocellular carcinoma who is
exhibiting a paraneoplastic syndrome. For
which signs should the nurse assess?
1. Erythrocytosis and hypercalcemia
2. Hyperkalemia and hyperalbuminemia
3. Hypernatremia and hypomagnesemia
4. Hypocalcemia and hyperleukocytosis
34. In the assessment of a client for
endometrial cancer, a nurse would most
likely find which symptoms at diagnosis of
the disease?
1. Abnormal vaginal bleeding and pain in
the pelvic region
2. Weight loss and profuse sweating
3. Anorexia and enlarged supraclavicular
lymph node
4. Unexplained fevers and splenomegaly
35. A nurse counsels a family member of a
cancer client about the caregiving role.
Which self-care activity would help the
family member cope with the caregiver role?
1. Being open to technologies and ideas
that promote a loved one’s dependence
2. Trusting that you are doing the right thing
and staying focused on your loved one
3. Grieving over losing personal time for self
or care of other family members
4. Self-education about a loved one’s
condition and how to communicate
effectively with health-care providers

36. For a client experiencing severe cancer
pain (pain intensity of 7 to 10 on a scale of 0
to 10, where 0 equals no pain and 10
equals the worst possible pain), which
medication should a nurse plan to
administer?
1. Meperidine (Demerol®)
2. Propoxyphene (Darvon®)
3. Pentazocine (Talwin®)
4. Oxycodone (Oxycontin®)
37. A nurse is caring for a client who is
experiencing pain related to cancer
treatment. The client tells the nurse,
“Methadone (Dolophine®) has always
worked well for me in the past.” Which
effects of methadone should the nurse
consider before obtaining an order for the
medication?
1. Long half-life and high potency
2. Central nervous system toxicity and
potential to cause confusion
3. Frequent allergic reactions and
therapeutic doses causing liver failure
4. Coagulation toxicity and short half-life
38. A client with cancer pain may require
treatment with coanalgesics or adjuvant
medications to control pain. Which adjuvant
medication gives the best response when
given with opioids?
1. Promethazine (Phenergan®)
2. Gabapentin (Neurontin®)
3. Diphenhydramine (Benadryl®)
4. Droperidol (Inapsine®)
MUSCULO
39. Which treatments should a nurse plan
for a client being seen in the clinic for a
second-degree ankle sprain?
1. Rest, elevate the extremity, apply ice,
and apply a compression bandage.
2. Perform range of motion to determine the
extent of injury, apply heat, check circulation
and sensation, and examine the ankle.
3. Reduce pain with moist heat, then apply
ice to reduce swelling; check circulation,
motion, and sensation; and elevate the
ankle.
4. Refer the client immediately to an
orthopedic surgeon, administer analgesics,
control swelling with ice, and encourage rest
and elevation.
40. A client is suspected of having a fat
embolism following a pelvic fracture from a
motor vehicle accident. A nurse should
assess for which sign that is specific to a fat
emboli?
1. Dyspnea
2. Chest pain
3. Delirium
4. Petechiae
41. Which order written by a physician
should be a priority for a nurse caring for a
client who sustained an unstable pelvic
fracture in a motor vehicle accident?
1. Urinalysis
2. Blood alcohol level
3. Computed tomography (CT) scan of the
pelvis
4. Two units of cross-matched whole
blood
42. A licensed practical nurse is reporting
observations and cares to a registered
nurse (RN). Based on the report, which
client should the RN assess immediately?
1. The client, 2 hours following a total knee
replacement, who has 100 mL bloody
drainage in the suction container of an
autotransfusion drainage system
2. The client with a crush injury to the
arm who was given another analgesic
and a skeletal muscle relaxant for
throbbing, unrelenting pain
3. The client in a new body cast who was
turned every 2 hours and supported with
waterproof pillows
4. The client with an external fixator on the
left leg, having serous drainage from the pin
sites
43. A clinic nurse has completed teaching
for a client with a rotator cuff tear who is
being treated conservatively. Which client
statement indicates that further teaching is
needed?
1. “I received a corticosteroid injection in my
shoulder to reduce the inflammation.”
2. “I will be doing progressive stretching and
strengthening exercises now that the pain is
controlled.”
3. “I should continue taking ibuprofen
(Advil®) with food for pain control.”
4. “I will need an open acromioplasty
surgery to repair the torn cuff after the
swelling is reduced.”
44. A 28-year-old client and his spouse
were involved in a motorcycle accident in
which his spouse was killed. The client,
being treated in the progressive care unit for
multiple rib fractures and a broken leg, asks
the nurse in which room his wife is located.
Which response is most appropriate?
1. “Your wife is not in the hospital.”
2. “I’m sorry, but your wife did not
survive the accident.”
3. “I need to get your family so that you can
talk to them about your wife.”
4. “The doctor will be talking to you about
your wife and where she is located.”
45. An elderly client with Alzheimer’s
dementia is being admitted from a
postanesthesia unit following a hip
hemiarthroplasty to treat a hip fracture.
Which intervention should a nurse initially
plan for the client’s pain control?
1. Apply a fentanyl (Duragesic®)
transdermal patch.
2. Initiate morphine sulfate per
patient-controlled analgesia (PCA) with a
basal rate.
3. Administer intravenous morphine sulfate
based on the client’s report of pain.
4. Administer scheduled doses of
morphine sulfate intravenously around
the clock.
47. A diabetic client is admitted with a
tentative diagnosis of osteomyelitis
secondary to a wound on the ankle. The
client’s ankle is painful, red, swollen, and
warm, and the wound is persistently
draining. The client’s temperature is 102.2°F
(39°C). Based on the client’s status, which
written physician’s order should a nurse
plan to defer until later?
1. Obtain wound culture.
2. Administer ceftriaxone (Rocephin®) 1 g
IV (intravenously) q12 hours.
3. Apply splint to immobilize ankle.
4. Begin teaching on self-administration
of home IV antibiotics.
48. A nurse is assessing an elderly client in
Buck’s traction to temporally immobilize a
fracture of the proximal femur prior to
surgery. Which finding requires the nurse to
intervene immediately?
1. Reddened area on the sacrum
2. Voiding concentrated urine, 50 mL/hr
3. Capillary refill 3 seconds, dorsiflexion and
sensation intact, pedal pulses palpable
4. Lower leg secure in traction boot and
ropes and pulleys and 5 lb weight hanging
freely
49. A nurse is providing instructions to a
client who has a plaster cast to attain
adequate molding following a fracture to the
right wrist. Which statement, if made by the
nurse, is incorrect?
1. “Keep your cast uncovered while drying
so that moisture can evaporate.”
2. “Your cast will have a musty odor and dull
gray appearance until it dries. But once fully
dry, your cast should be odorless and shiny
white.”
3. “Your cast will feel sticky and very
warm during the drying process, but it
will dry very quickly in about 30
minutes.”
4. “Support the cast by elevating it on
pillows and avoid any sharp or hard
surfaces, especially while your cast is
drying, because it can cause denting and
pressure areas.”
50. A male client has been in a body cast
for the past 2 days to treat numerous
broken vertebrae from a fall. The client is
reporting dyspnea, vomiting, epigastric pain,
and abdominal distention. Which action
demonstrates the best clinical judgment by
a nurse?
1. Immediately notifies the client’s
physician of these findings
2. Initiates oxygen at 2 liters per nasal
cannula to relieve the dyspnea
3. Places ice packs around the cast to
reduce the abdominal distention
4. Administers ondansetron (Zofran®), the
prescribed antiemetic on the client’s MAR
51. An experienced nurse observes a new
nurse caring for a client in skeletal traction
to stabilize a fracture of the proximal femur
prior to surgery. Which observation by the
experienced nurse indicates the new nurse
needs additional orientation?
1. Positions the client so the feet stay clear
of the bottom of the bed
2. Checks ropes so that they are positioned
in the wheel groves of the pulleys
3. Removes weights from the ropes until
the weights hang freely off the bed frame
4. Performs pin site care with chlorhexidine
solution twice daily
52. A client diagnosed with osteoarthritis,
tells a clinic nurse about the inability to
ambulate and staying on bedrest because
of hip stiffness. In addition to teaching the
client measures to reduce joint stiffness,
which referral for the client should the nurse
plan to discuss with the health-care
provider?
1. Psychiatrist
2. Social worker
3. Physical therapist
4. Arthritis Foundation
53. Which nursing action should be
implemented on the second postoperative
day for a client who received a right total hip
replacement (THR) with a cemented
prosthesis?
1. Assisting the client to the bathroom,
which has an elevated toilet seat, using a
walker and partial weight bearing of the
right leg
2. Removing the Hodgkin’s splint, which
maintained leg alignment during the night,
and positioning pillows to adduct the client’s
right leg
3. Reinfusing the returns from a Stryker®
wound autotransfusion drainage system,
which has collected 400 mL in the past 24
hours
4. Assisting the client to get out of bed on
the left side so the client can stand to use
the urinal
54. One month after discharge, a client who
had a left total hip replacement calls a clinic
reporting acute constant pain in the left
groin and hip area and feeling like the left
leg is shorter than the right. A nurse advises
the client to come to the clinic immediately
suspecting:
1. wound infection.
2. deep vein thrombosis (DVT).
3. dislocation of the prosthesis.
4. aseptic loosening of the prosthesis.
55. To prevent circulatory complications
after a right total knee replacement, a nurse
should ensure that the client is:
1. flexing both feet and exercising
uninvolved joints every hour while
awake.
2. using the continuous passive motion
device (CPM) every 2 hours for 30 minutes.
3. assisted up to a chair as soon as the
effects of anesthesia have worn off.
4. using the trapeze to lift the buttocks off
the bed and then rotating each leg
intermittently.
56. Which priority nursing diagnosis should
a nurse document in the plan of care for a
client following a C5–C6 anterior cervical
discectomy?
1. Potential ineffective breathing pattern
2. Potential impaired tissue perfusion
3. Risk for infection
4. Impaired skin integrity
57. A nurse receives an order to administer
cyclobenzaprine (Flexeril®) 30 mg orally
three times daily to a client hospitalized with
acute cervical neck pain. The pharmacy has
supplied 10-mg tablets. Which action by the
nurse is best?
1. Administer three 10-mg tablets with food.
2. Call the physician to question the
order.
3. Observe the client for drowsiness after
administration.
4. Administer morphine sulfate
intravenously for immediate pain control.
58. A nurse assesses a client 6 hours
postoperatively following a lumbar spinal
fusion. The client is experiencing a
headache rated at 8 out of 10 but denies
nausea. The neurovascular status of the
lower extremities is intact, and the vital
signs are within the normal range. The client
log rolls with assistance. The lungs have
fine crackles in the left base. The back
dressing has a dime-sized bloody spot
surrounded by a moderate amount of clear
yellowish drainage. Which nursing action
demonstrates the nurse’s best clinical
judgment?
1. Administering morphine sulfate
intravenously
2. Encouraging coughing and deep
breathing
3. Reinforcing the incisional dressing
4. Notifying the client’s physician
59. Which action should a nurse plan in the
care of the client who had a surgical repair
of a right Dupuytren’s contracture?
1. Elevating the right lower extremity above
the level of the heart
2. Assisting the client with bathing,
dressing, grooming, and toileting
3. Instructing the client on obtaining proper
fitting shoes
4. Frequent rewrapping of the elastic
bandage on the right extremity to decrease
edema
60. To which client should a nurse plan to
provide teaching about genetic resources?
1. Client who had an ankle fracture
secondary to a boating accident
2. Client who had a ganglion removed from
the dorsum of the wrist
3. Client who had a surgical repair of a
fracture due to osteoporosis
4. Client who had a total knee replacement
due to degenerative joint disease
61. When analyzing the serum laboratory
report for a client diagnosed with lung
cancer that has metastasized to the pelvic
bone, which finding should a nurse
anticipate?
1. Elevated calcium
2. Decreased hemoglobin
3. Elevated creatinine (Scr)
4. Elevated creatine kinase (CK)
62. A nurse reads the chart of a 25-year-old
male and notes that he has been diagnosed
with an osteosarcoma of the distal femur.
Which statement indicates the nurse’s
correct interpretation of the client’s
diagnosis?
1. The tumor originated elsewhere in the
client’s body and metastasized to the bone.
2. Osteosarcoma is the most common
and most often fatal primary malignant
bone tumor.
3. The only treatment for osteosarcoma is a
leg amputation well above the tumor growth.
4. Osteosarcoma is a nonmalignant growth
that can be excised and the bone replaced
with a bone graft.
63. A client, with a lower leg amputation, is
experiencing edema, so a nursing assistant
(NA) elevates the client’s residual left limb
on pillows. What is the most appropriate
action by the nurse when observing that the
client’s leg has been elevated?
1. Thank the NA for being so observant and
intervening appropriately.
2. Remove the pillows, raise the foot of
the bed, and inform the NA that the limb
should not be elevated on pillows
because it could cause a flexion
contracture.
3. Inform the NA that this was the correct
action at this time in the client’s recovery,
but once the client’s incision heals the leg
should not be elevated.
4. Report the incident to the surgeon and
tell the NA to complete a variance report
because the client’s leg should not have
been elevated.
PERIOP
64. A nurse plans care for a client and notes
that all of the following must be completed
for a client being prepared for surgery.
Which intervention should the nurse
complete first?
1. Complete the preoperative checklist.
2. Assess the client’s preoperative vital
signs.
3. Remove the client’s rings, gold chain, and
wristwatch.
4. Administer 10 mEq KCL IV for a serum
potassium level of 3.0 mEq/L.
65. Which client statement made during a
presurgical admission assessment needs
the most immediate follow-up?
1. “I haven’t eaten foods or had any fluids
for the past 12 hours.”
2. “I donated my own blood in case I need a
transfusion; the last donation was 4 days
ago.”
3. “I took my usual dose of warfarin
(Coumadin®) and other cardiac meds
this morning with a sip of water.”
4. “I brought a copy of my Health Care
Directives so others will know my wishes
should my heart stop during surgery.”
66. A nurse is to witness the signature of a
surgical consent for multiple clients
scheduled for surgery the following day. In
evaluating the health history of each client,
the nurse should plan to obtain a signature
from the next of kin for:
1. a 75-year-old client who is blind.
2. a 60-year-old client who does not
understand English.
3. a 50-year-old client who is forgetful, but
fully oriented.
4. a 16-year-old educated client who fully
understands the surgery
67. A nurse receives the written laboratory
results of a positive pregnancy test for a
client scheduled for an emergency
appendectomy. The nurse should first:
1. call the lab to verify the results of the test.
2. inform the client of the positive results.
3. report the results immediately to the
surgeon.
4. notify the client’s primary physician of the
results.
68. During a presurgical admission
assessment, a client states, “I’ve told my
surgeon that I am a Jehovah’s Witness and
I won’t accept a blood transfusion.” Which
statement by the nurse would be most
appropriate?
1. “Tell me about your fear of receiving a
blood transfusion.”
2. “Your request to not receive a
transfusion would be honored. Your
consent is needed to administer blood or
blood products.”
3. “You don’t need to worry about getting a
blood transfusion. We have newer
equipment that causes less blood loss
during surgery.”
4. “Are you sure you wouldn’t want a blood
transfusion if one is needed during surgery?
You can always change your mind after
surgery
69. A nurse is analyzing serum laboratory
results for a 73-year-old female client
scheduled for surgery in 2 hours. The nurse
concludes that which result would warrant
the most immediate notification of the
physician?
1. Hemoglobin 10 g/dL
2. Creatinine 1.0 mg/dL
3. Potassium 4.5 mEq/dL
4. Prothrombin time 22 seconds
70. A physician writes an order to hold all
medications the morning of surgery for a
client with a history of type 1 diabetes
mellitus and hypertension. A nurse should
call the physician to clarify the hold order for
what medication?
1. Acetylsalicylic acid (aspirin)
2. Ducosate sodium (Colace®)
3. Regular and NPH insulin (Humulin®)
4. Clonidine (Catapres®)
71. Which client statement indicates that a
client who is scheduled for a 3-hour surgery
under general anesthesia needs further
teaching?
1. “A breathing tube will be placed when I
am in the operating room.”
2. “I should shave the skin in the
surgical area the evening prior to
surgery.”
3. “I should splint my incision with a pillow
when coughing and deep breathing after
surgery.”
4. “I might need a urinary catheter inserted
before surgery so my urine output can be
monitored.”
72. Which nursing action would be best
when a preoperative client verbalizes fear of
postoperative pain?
1. Providing diversional activities when
client reports fear of pain
2. Encouraging the client to verbalize
concerns regarding the fear of pain
3. Informing the client of experiences and
the likelihood of pain pre- and
postoperatively
4. Explaining the medications ordered
for pain control, availability, and
treatment goals
73. Which statement by a nurse is most
effective when collecting data about a
preoperative client’s recreational drug use?
1. “Describe the drugs you use and the
frequency that you use these drugs.”
2. “Do you use any over-the-counter
medications or illegal substances?”
3. “Tell me about all medications and
substances you take because complications
can occur if you are taking something we do
not know about.”
4. “Because herbs, medications, and
recreational drugs such as marijuana
and cocaine affect the type and amount
of anesthesia you need, list any of these
you take and how often you use them.”
74. A nurse evaluates that a preoperative
client can properly use a volume incentive
spirometer when which client action is
noted?
1. Sits upright, inserts the mouthpiece, and
blows until the lungs are emptied of air
2. Sits upright, exhales, seals lips around
the mouthpiece, inhales, and holds
breath for 5 seconds
3. Sits at the edge of the bed, coughs,
inserts the mouthpiece, and blows slowly for
10 seconds
4. Sits at the edge of the bed, breathes
deeply five times, inserts the mouthpiece,
and inhales quickly
75. A client in an operating room holding
area, who is to receive general anesthesia,
reports having a dry mouth because food
and fluids have been withheld for 8 hours.
Which action by a nurse is most
appropriate?
1. Teach the client that the primary
reason food and fluids have been
withheld is to prevent vomiting and
potential complications
2. Clarify that food and fluids should have
been withheld only for 4 hours and offer a
small sip of water
3. Explain to the client that a full stomach
puts pressure on the diaphragm and
prevents full lung expansion during surgery
4. Tell the client that the general anesthetic
will soon make the client sleepy and
unaware of the mouth dryness
76. A nurse is caring for a client who
received conscious sedation during a
surgical procedure. Which assessment of
this client is most important for a nurse to
make postoperatively?
1. Lung sounds
2. Amount of urine output
3. Ability to swallow liquids
4. Rate and depth of breathing
77. Upon arrival to an operating room
holding area, a client who is scheduled for
abdominal surgery is noted to have
replaced a tongue ring that was removed
when the operative checklist was
completed. Which is the most appropriate
initial action by a nurse?
1. Document the findings on the client’s
medical record
2. Request that the client once again
remove the tongue ring
3. Complete a variance report, noting that
the client has replaced the tongue ring
4. Notify the surgeon and the
anesthesiologist of the replacement of the
tongue ring
78. A nurse is orienting a new nurse to a
postanesthesia care unit (PACU). Which
statement by the new nurse indicates
further orientation is needed?
1. “Lactated Ringer’s (LR) and 5% dextrose
with LR are typical IV solutions administered
in the PACU.”
2. “If a client has an opioid overdose, I
should expect to administer naloxone
hydrochloride (Narcan®).”
3. “I should monitor vital signs and perform
a pain assessment every 15 minutes or
more often if necessary.”
4. “Once a client responds verbally after
a spinal anesthetic, the client can be
transferred to the nursing unit.”
79. Which information is most important for
a postanesthesia care unit nurse to include
in a report on a postoperative client to a
surgical unit nurse?
1. Location of the relatives
2. Review of the surgical consent
3. Placement of client belongings
4. Last dose and type of pain medication
80. A nurse evaluates that a client has
achieved an expected outcome for the
second postoperative day following
abdominal surgery under general
anesthesia. Which finding supports the
nurse’s conclusion?
1. Passing flatus
2. Urine output 680 mL in 24 hours
3. Crackles in bilateral lung bases
4. Rates incisional pain at 4 out of 10 on a 0
to 10 rating scale 60 minutes after analgesic
given
81. A nurse is planning the discharge of a
client following recovery from an exploratory
laparotomy. The client has a history of
chronic back pain and limited ability to
ambulate. The nurse plans for further
discharge teaching when the client states:
1. “I can leave my elastic antiembolic
(TEDS®) stockings off once I get home.”
2. “I should be eating a diet high in protein,
calories, and vitamin C now and when I get
home.”
3. “An alternative method to control pain
and reduce swelling is applying ice to my
incision.”
4. “I use my incentive spirometer every 2
hours so I can reach my volume goal before
discharge.”
82. A nurse is reviewing a plan of care for a
postoperative client with a history of sickle
cell disease. Which nursing diagnosis,
documented on the client’s care plan,
should the nurse address first?
1. Anxiety
2. Impaired skin integrity
3. Deficient fluid volume
4. Ineffective airway clearance
83. A nurse is caring for a postoperative
client who reports an inability to void. Which
initial action by the nurse is most
appropriate?
1. Turning on running water
2. Inserting a urinary catheter
3. Palpating the client’s bladder
4. Reviewing the client’s chart for the time of
the last voiding
84. A postoperative client who received a
spinal anesthetic is experiencing a
headache, photophobia, and double vision.
A nurse’s initial intervention should be to:
1. immediately notify the surgeon.
2. position the client flat in bed.
3. limit the client’s fluid intake.
4. administer steroid medications.
85. A physician documents in a client’s
postoperative progress notes that the client
is experiencing a respiratory infection with a
shift to the left in the white blood cell (WBC)
differential count. Which finding by a nurse
reviewing the client’s laboratory report
would support the physician’s
documentation?
1. Decreased WBC count
2. Increased band cells
3. Decreased hemoglobin
4. Increased C-reactive protein
86. In reviewing a physician’s orders for a
postoperative client who underwent
gynecological surgery, which order should a
nurse determine is specifically written with
the intent to prevent postoperative
thrombophlebitis and pulmonary embolism?
1. Have the client dangle the legs the
evening of surgery
2. Administer enoxaparin (Lovenox®) 40
mg subcutaneously daily
3. Administer hydromorphone (Dilaudid®) 1
to 4 mg IV every 3 to 4 hours as needed
(prn)
4. Encourage coughing and deep breathing
(C&DB) every hour while awake
87. A nurse assesses that a client on the
second postoperative day following
abdominal surgery has diminished breath
sounds in both lung bases, is taking shallow
breaths, is able to achieve only 500 mL on
an incentive spirometer, and has been
smoking one pack of cigarettes per day
prior to surgery. The nurse’s best
interpretation of these findings is that the
client is experiencing:
1. atelectasis.
2. pneumonia.
3. a normal postoperative course.
4. chronic obstructive pulmonary disease
(COPD).
88. A nurse notes redness, swelling, and
warmth of and around the incision when
assessing a client’s leg incision 48 hours
after femoral popliteal bypass surgery. The
nurse’s best analysis should be that the
incision is:
1. healing normally for the second
postoperative day.
2. showing signs of rejection of the suture
materials.
3. inflamed and could indicate the
presence of an infection.
4. infected and showing signs of wound
dehiscence.
89. Which outcome should indicate to a
nurse that a postsurgical client’s coughing
and deep breathing (C&DB) is most
effective?
1. Respirations are 16 per minute and
unlabored.
2. Lung sounds are audible and clear on
auscultation.
3. Coughs include small amount of clear
secretions.
4. Cough effort is strong and productive.
90. A client is to receive a second dose of
oxycodone/ acetaminophen (Percocet®) for
postoperative incisional pain. When a nurse
brings the medication to the client, the client
says, “Why bring this medication again? It
makes me feel sick.” Which statement is the
most appropriate initial nurse response?
1. “I can call the doctor to see what else can
be ordered for your pain.”
2. “Describe what you feel when you say
that the medication makes you feel sick.”
3. “The doctor has ordered an antacid. I can
give you this along with the medication.”
4. “Many people say the same thing. The
aspirin in the medication is hard on your
stomach.”
91. A nurse evaluates that the drainage
from a client’s nasogastric (NG) tube,
inserted for gastric decompression during
emergency surgery, would be normal if it:
1. returns brown-liquid in color.
2. returns greenish-yellow in color.
3. has an alkalotic hydrogen level (pH).
4. measures less than 25 mL in volume.
92. A nurse notifies a physician after
assessing a client 5 days after an
exploratory laparotomy and noting a
distended abdomen, abdominal pain,
absence of flatus, and absent bowel
sounds. Which typical complication of
abdominal surgery should the nurse
conclude may be occurring?
1. Paralytic ileus
2. Silent peritonitis
3. Fluid volume excess
4. Malabsorption syndrome
93. Which statement should a nurse include
when teaching a client prior to discharge
following abdominal surgery?
1. “Return to work in about 4 weeks
because working increases your physical
activity gradually.”
2. “The ordered iron and vitamins tablets
will promote wound healing and red
blood cell growth.”
3. “Daily walking carrying 10-pound weights
will help to strengthen your incision.”
4. “Home-care nursing service is usually
paid by insurance if you need help around
the house.”
HEMA CHILD
94. Which nursing diagnosis should be the
priority for a child hospitalized in sickle cell
crisis?
1. Risk for deficient fluid volume related to
inadequate fluid intake
2. Chronic pain related to chronic physical
disability and clustering of sickled cells
3. Risk for infection related to ineffectively
functioning spleen
4. Ineffective tissue perfusion related to
pulmonary infiltrates of abnormal blood
cells
95. The parents of an 8-year-old African
American child diagnosed with sickle cell
anemia are being taught pain control
measures for their child. Which measure is
most important to teach the parents to
prevent the onset of vaso-occlusive pain?
1. Apply ice packs to all joints as soon as
the child awakens.
2. Encourage drinking large amounts of
fluids daily.
3. Administer acetaminophen (Tylenol®)
650 mg orally daily.
4. Increase outdoor exercise and exposure
to the fresh air and sunshine.
96. After 7 days of iron therapy, a child
diagnosed with iron-deficiency anemia has
serum laboratory tests completed. Which
finding indicates that the medication is
beginning to correct the anemia?
1. Increased reticulocyte count
2. Increased granulocytes
3. Increased indirect bilirubin
4. Increased erythropoietin levels
97. A child diagnosed with aplastic anemia
has had human leukocyte antigen (HLA)
typing, evaluation of organ function, and
laboratory studies completed as an
outpatient. Which action should a nurse
plan to implement first when the child is
admitted to a transplant center for a
hematopoietic stem cell transplant?
1. Checking the patency of the central line
catheter
2. Placing the child in protective isolation
3. Ensuring that all food entering the child’s
room has been irradiated
4. Preparing the child to receive high
doses of chemotherapy
98. A child diagnosed with hemophilia is
brought to a clinic due to pain and restricted
movement of the left knee after tripping
going upstairs. A nurse assesses that the
knee is hot, swollen, and tender to touch.
The nurse should initially conclude that the
child is likely experiencing:
1. a Baker’s cyst.
2. hemarthrosis.
3. a patella fracture.
4. disseminated intravascular coagulation
(DIC).
99. Which finding should a nurse expect
when reviewing the laboratory results of an
infant newly diagnosed with hemophilia A?
1. Prolonged prothrombin time (PT)
2. Decreased hemoglobin level
3. Decreased hematocrit level
4. Prolonged activated partial
thromboplastin time (aPTT)
100. A new nurse is telling an experienced
nurse about treatments that a physician
discussed with the parents of a child who
has thalassemia major. Which statement by
the new nurse should the experienced
nurse question?
1. “Plasmapheresis will help remove the
toxins that are destroying the red blood
cells.”
2. “Blood transfusions will need to be
administered about every 2 to 4 weeks.”
3. “A splenectomy may become necessary
to reduce the child’s abdominal discomfort.”
4. “Bone marrow stem cell transplant can
possibly cure this child’s thalassemia
major.”
101. A child has iron overload from
receiving multiple blood transfusions for
treating thalassemia major. A nurse should
anticipate the physician will likely:
1. order intravenous (IV) fluids to dilute
the excess iron and increase urinary
excretion.
2. change the type of blood product being
transfused.
3. reduce the frequency of blood
transfusions.
4. begin chelation therapy.
102. During a routine physical examination,
a parent states to a nurse, “When I am
taking pictures of my baby using the camera
flash, I see a red coloration to my baby’s left
eye but the right eye has a white reflection.
Is this normal?” Which response by the
nurse is correct?
1. “Yes, the white reflection is normal;
sometimes the light from the camera flash
only catches one eye directly.”
2. “Interesting. Your baby’s eyes may be
changing color. Many babies are born with
what appears to be blue eyes but later they
change to brown.”
3. “It is good that you brought this to our
attention because it is not the usual
response. After further examining your
baby’s eyes, we can discuss what the
white reflection may suggest.”
4. “You seem concerned that your baby’s
eyes have different responses to the flash of
the camera. Tell me more about your
concern.”
103. A hospitalized child diagnosed with
leukemia is being discharged after an initial
treatment with chemotherapy. A nurse is
teaching the parents about the allopurinol
(Zyloprim®), which the child will continue to
take at home. The nurse explains that the
purpose of this medication is to:
1. help promote the child’s sleep.
2. treat the joint pain and swelling caused
by the child’s gout.
3. prevent the child from developing gouty
arthritis.
4. protect the child’s kidneys by reducing
the formation of uric acid.
104. Four parents call a clinic to have their
children seen for unusual lumps or swelling.
A nurse is trying to work the children into a
physician’s overbooked schedule. Which
child should the nurse schedule to be seen
first?
1. A child with Down’s syndrome
2. A child who lives close to power lines
3. A child who has had chronic ear
infections
4. A child whose sibling was treated for an
osteosarcoma
105. Following diagnostic testing for an
enlarged cervical lymph node, a health-care
provider informs a 20-year-old female client
of a diagnosis of Hodgkin’s disease and
explains the disease process and
recommended treatment. Which statement,
overhead by a nurse when the client
telephoned her parents, indicates that the
client understands the diagnosis and
treatment?
1. “I am so relieved; I was worried that I had
cancer and there wasn’t anything that could
be done to treat it.”
2. “I have a good chance of being cured
with radiation therapy, chemotherapy, or
a combination of both.”
3. “I will need to have a laparotomy to stage
the disease before I can start irradiation and
chemotherapy.”
4. “I am so upset; I wanted to go to college,
marry, and raise a family. Now, I won’t be
able to do any of this.”
106. A nurse suspects that a 10-year-old
client diagnosed with non-Hodgkin’s
lymphoma (NHL) has superior vena cava
syndrome when assessing that the client
has:
1. thrombocytopenia and leukocytosis.
2. hyperuricemia, hypocalcemia, and
hyperphosphatemia.
3. tingling and paresthesias of the lower
extremities and pain on light touch.
4. cyanosis of the upper chest, neck,
face, upper extremity edema, and
distended neck veins.
107. An experienced nurse and a new nurse
are providing preoperative care for a
5-year-old child diagnosed with Wilms’
tumor. The experienced nurse should
intervene when observing the new nurse:
1. inform the child that water is not allowed
because the procedure will be performed
soon.
2. palpate the child’s abdomen during
assessment.
3. provide the child with a doll for play that
has removable kidneys.
4. state to the child, “You’ll get some
medicine that you breathe or get through
your arm to make you sleep.”
108. While an experienced nurse is
orienting a new nurse to a pediatric
oncology unit, the new nurse asks why
there seems to be so many adolescents
with osteosarcoma and not other age
groups. The experienced nurse explains
that osteosarcoma has a peak incidence
during adolescence because of the:
1. increase in hormonal production.
2. epiphyseal growth plates have closed.
3. rapid growth spurt experienced during
adolescence.
4. increase in sports-related injuries that
occurs during this time.
109. A 5-year-old child, hospitalized
following surgical intervention for
osteosarcoma, is uninterested in eating.
Which nursing action would best support the
child’s nutrition?
1. Providing only foods that the child likes
best
2. Asking the child’s parents to visit at
mealtime
3. Turning on the television so the child is
distracted while eating
4. Offering juice, popsicles, or ice cream
every 2 hours
110. A nurse is planning care for a child
following removal of brain tumor. The child
is confused, disoriented, and restless.
Which nursing diagnosis should receive the
highest priority?
1. Sensory perceptual alterations related to
neurological surgery
2. Self-care deficit related to confusion and
restlessness
3. Impaired verbal communication related to
confusion
4. Risk for injury related to disorientation
and restlessness
111. A 6-year-old child is being seen in a
clinic after discharge from a hospital for
removal of a brain tumor. Which finding,
reported by a parent, best suggests the
child has likely developed a complication?
1. Reports occasional headaches
2. Voiding large amount of dilute urine
3. Able to walk with use of crutches
4. Ventricular–peritoneal shunt tubing
palpable under the skin
112. Prior to administering L-asparaginase
to a 12-year-old child with acute lymphocytic
leukemia, a nurse reviews the child’s
laboratory report. Which lab value should
prompt the nurse to notify a physician
before administering the chemotherapeutic
agent?
1. Hemoglobin (Hgb) 11.8 mg/dL
2. Blood glucose 252 mg/dL
3. Total bilirubin 1.2 mg/dL
4. Absolute neutrophil count (ANC) 1,078
113. Prednisone is ordered three times a
day for a child receiving chemotherapy.
Which is the best schedule for a nurse to
suggest to a parent?
1. 6 a.m., 2 p.m., and 10 p.m.
2. 8 a.m., 1 p.m., and 6 p.m.
3. 10 a.m., 6 p.m., and 2 a.m.
4. 11 a.m., 4 p.m., and 9 p.m.
114. A 5-year-old girl with alopecia
secondary to chemotherapy refuses to wear
a wig. The child’s mother consults a nurse
because she thinks her daughter should
wear a wig. She states feeling
uncomfortable when people stare at her
daughter. Which response is most
appropriate?
1. “Have you tried having your child wear a
colorful hat instead?”
2. “Does your child feel uncomfortable when
others are looking at her?”
3. “You seem concerned about people
looking at your daughter. Tell me more
about what you are feeling.”
4. “Your daughter only needs to wear a
head covering when she is exposed to
sunlight, wind, or the cold.”
115. A nurse is preparing a child for
abdominal irradiation. Which medications
should the nurse plan to administer to
prevent nausea and vomiting?
1. Ondansetron (Zofran®) and
dexamethasone (Decadron®)
2. Promethazine (Phenergan®) and
cyclophosphamide (Cytoxan®)
3. Metoclopramide (Reglan®) and
methotrexate (Amethopterin®)
4. Marijuana and L-asparaginase (Elspar®)
MUSCULO CHILD
116. A child with myelodysplasia has a TEV
(talipes equinovarus) repair that requires a
cast application. In the postoperative period,
a nurse notes serosanguineous drainage on
the cast. What should the nurse do when
making this observation?
1. Cut a window where the drainage is
seeping through the cast
2. Petal the cast to minimize skin irritation
and decrease leakage
3. Measure the area of drainage and
document this finding
4. Notify the surgeon
117. A nurse is reinforcing teaching to the
parents of a child with myelomeningocele,
which was diagnosed at birth and surgically
corrected, about safety considerations. The
nurse’s instructions should include:
1. making sure that braces lie smoothly
against the child’s skin.
2. teaching the child to shift position at least
every 3 hours.
3. placing a blanket between the child and
the wheelchair.
4. checking all of the child’s skin daily
for redness or irritation.
118. A nurse is developing teaching
materials for new mothers. The nurse
should include information about which
common practice that can increase the
risk for developmental dysplasia of the hip
(DDH)?
1. Carrying a child in a backpack
2. Carrying a child in a frontpack
3. Swaddling
4. Extended time in a car seat
119. Which screening test is a neonatal
nurse likely to use to detect developmental
dysplasia of the hip (DDH)?
1. Barlow’s maneuver
2. Pavlik’s maneuver
3. Gower’s maneuver
4. Allis’s maneuver
120. A nurse is educating a family whose
child is newly diagnosed with scoliosis. The
nurse explains that the goal of therapy is to:
1. limit or stop progression of the
curvature.
2. prepare the child for surgery.
3. minimize the psychosocial complications
of prolonged immobilization.
4. develop a pain management protocol that
will minimize complications of medications.
121. A nurse is asked to provide education
for a 15-year-old who requires surgical
treatment for scoliosis. Which should be an
appropriate explanation for the adolescent?
“The goal of surgery is to:
1. allow you to be taller.”
2. prevent pain.”
3. prevent problems with breathing.”
4. allow clothes to fit you better.”
122. A nurse is completing a thorough
assessment of the spine. The nurse is
concerned about a curve in a young child
and records the exaggerated lumbar curve
as:
1. scoliosis.
2. lordosis.
3. kyphosis.
4. kyphoscoliosis.
123. A school-aged child has an Ilizarov
external fixator applied to a lower extremity
for bone lengthening. Which action should a
nurse include when caring for the child?
1. Loosening the bolts and lengthen the
rods on the fixator every other day
2. Cleansing the pin sites with sterile
saline twice daily
3. Discouraging the child from bearing any
weight on the involved extremity
4. Removing sections of the fixator
apparatus when the child is positioned in
bed
124. A nurse at the high school works with
the trainers to develop early identification of
injuries. The nurse teaches the trainers that
adolescent soccer players are at increased
risk for:
1. varus knee deformities.
2. valgus knee deformities.
3. varus ankle deformities.
4. valgus ankle deformities.
125. A 7-year-old has had hip pain for
several months. Because it was mild pain,
the parent did not pay a great deal of
attention. The child was ultimately given a
diagnosis of Legg-Calvé-Perthes disease. In
preparing the child and family for treatment,
the nurse should instruct the parents that:
1. most of the child’s treatment will be done
while
the child is hospitalized.
2. activities that promote hip adduction are
encouraged.
3. treatment is likely to continue for about
6 months.
4. the desired outcome is a pain-free
joint with full
range of motion.
126. The parents of a child with Duchenne
muscular dystrophy have just learned that
children with the disease have a limited life
expectancy. They ask what this means for
how they will raise their son. Which
explanation by the nurse is best?
1. “Because he will be cognitively impaired,
there is no reason to deal with the
prognosis.”
2. “Throughout his disease, we will focus
on maximizing his abilities and keeping
him comfortable.”
3. “There is not enough known about this
disease to know what will happen to your
son.”
4. “Nothing is likely to happen for a long
time; we’ll deal with it when the time
comes.”
127. A child is admitted to an emergency
department with a dislocated kneecap that
occurred while skiing. Which most
immediate treatment by a healthcare
provider (HCP) should a nurse anticipate?
1. Realignment of the kneecap by sliding
it back into position in the front of the
knee
2. Open surgical intervention to repair the
kneecap
3. Arthroscopy to surgically repair the torn
cartilage
4. Application of a cast to the affected leg
until the kneecap heals
128. A nurse has been asked to continue
teaching with a group of parents of children
with neurological and musculoskeletal
conditions. For which condition should a
nurse tell the parents that there is no
genetic basis to the condition?
1. Osteomyelitis
2. Muscular dystrophy
3. Spina bifida
4. Tourette’s Syndrome
129. A nurse explains to a child’s parents
that the role of methotrexate (Rheumatrex®)
in treating children with juvenile arthritis is
to:
1. decrease the inflammatory response.
2. improve functional ability.
3. control the febrile response.
4. minimize the effects of uveitis
130. A 10-year-old is scheduled to receive
methotrexate (Rheumatrex®) to treat
juvenile arthritis. Which laboratory findings
should lead the nurse to decide to withhold
the dose and contact the health-care
provider?
1. Urine pH 7.4
2. Hemoglobin 13 g/dL
3. Serum creatinine 2.2 mg/dL
4. Alanine aminotransferase (ALT) less than
40 international units/L (U/L)
rehabilitation unit. A nurse is teaching the
client about the need to be diligent in skin
protection. The nurse explains that the
primary reason for the client’s increased risk
for alterations in skin integrity is:
1. the inability to perceive extremes in
temperature leading to burns.
2. the circulatory changes that cause
vasoconstriction and decreased blood
supply.
3. the inability to feel skin irritation such
as wrinkled clothing.
4. the increased likelihood of bowel and
bladder dysfunction and skin irritation.
134.A pediatric client with a spinal cord
injury undergoes range of motion exercises
several times each day. In teaching the
parent how to do range of motion at home,
the nurse observes the client increasing the
angle between the extremity and the
midline. The nurse concludes that the client
is safely performing:
1. abduction.
2. adduction.
3. flexion.
4. extension.

131. During a physical examination of a

1-month-old infant, a nurse notes that the
infant has blue sclerae. The nurse suspects
that the infant may have:
1. juvenile arthritis.
2. Tay-Sachs disease.
3. muscular dystrophy (MD).
4. osteogenesis imperfecta.

132. A teen is brought to an emergency

department with a likely spinal cord injury.
To minimize the damage from the spinal
cord injury, which classification of
medications should a nurse expect a
health-care provider to prescribe?
1. An antibiotic
2. An analgesic
3. A steroid medication
4. An antihypertensive medication

133. An adolescent client diagnosed with a

T12 spinal cord injury (SCI) is admitted to a
PERIOP
1. A client tells the nurse on admission that
she is uneasy about having to leave her
children with a relative while being in the
hospital for surgery. The most appropriate
action by the nurse is to do which of the
following?
1. Reassure the client that her children will
be fine and she should stop worrying.
2. Contact the relative to determine his/her
capacity to be an adequate care
provider.
3. Encourage the client to call the children
to make sure they are doing well.
4. Gather more information about the
client's feelings about the childcare
arrangements.
3. When the nurse asks the client who is to
have abdominal surgery today if the
client understands the procedure, the client
replies, “No, not really; I talked about
several different things with my surgeon,
and I am just not sure.” The nurse should:
1. Teach the client all the details of the
planned procedure.
2. Utilize a second witness when the client
signs for consent.
3. Notify the surgeon of the client's
expressed lack of understanding.
4. Administer the prescribed preoperative
narcotics and/or sedatives.
4. During preadmission testing for same-day
surgery, a client states that she has added
two cloves of garlic each day to her diet to
help control her blood pressure. The nurse
should further inquire about which of the
following?
1. The type of surgery the client is having.
2. What her blood pressure has been
running.
3. The amount of garlic she is eating.
4. Her preference for the type of anesthesia.
5. What action should this nurse (see figure)
take to avoid spreading nosocomial
infections?
1. Remove the face mask.
2. Remove the hair covering.
3. Wash her hands before tying the strings
on the mask.
4. Tie the dangling strings of the mask
around her neck.
7. The nurse is reviewing the chart of a
55-year-old male client who is scheduled
for a lumbar laminectomy. The nurse should
report which of the following to the surgeon?
1. Pimple on the lower back.
2. Abnormal electrocardiogram (ECG).
3. Hearing aid.
4. Allergy to iodine.
8. Prior to going to surgery, the client tells
the nurse that she cannot hear without her
hearing aid and asks to wear it to surgery
and recovery. What is the nurse's best
response?
1. Explain to the client that it is policy not to
take personal items to surgery because
they may be lost or broken.
2. Tell the client that a nurse will bring the
hearing aid to the postanesthesia care
unit so that she can have it as soon as she
wakes up.
3. Explain to the client that she will have a
premedication that will make her sleepy
before she goes to surgery and she won't
need to hear.
4. Call the surgery unit to explain the
client's concern and ask if she can wear
her hearing aid to surgery.
9. The adult daughters of an elderly male
client inform the nurse that they fully
expect their father to be combative after
surgery. Preoperatively, they request that
the nurse put all four side rails up and use
restraints to keep him safe. The nurse
should tell the daughters:
1. “Certainly; we will want to be sure to keep
your father safe too.”
2. “We will call the physician to get a
prescription right away.”
3. “We will first try to keep him safe
without restraint.”
4. “Restraint use is prohibited at our hospital
at all times.”
10. The client is to take nothing by mouth
after 4:00 AM. The nurse recognizes that
the client has deficient knowledge when he
states that he:
1. Ate a gelatin dessert at 3:30 AM.
2. Brushed his teeth at 4:00 AM but did not
swallow.
3. Held a cold washcloth against his lips.
4. Smoked a cigarette at 6:00 AM.
11. The client tells the nurse that he is
allergic to shellfish. The nurse should ask
the client if he is also allergic to:
1. All other seafood.
2. Iodine skin preparations.
3. Caffeine.
4. Alcohol-based skin preparations.
12. The surgeon prescribes cefazolin
(Ancef) 1 g to be given IV at 7:30 AM when
the client's surgery is scheduled at 8:00 AM.
What is the primary reason to start the
antibiotic exactly at 7:30 AM?
1. Legally the medication has to be given at
the prescribed time.
2. The antibiotic is most effective in
preventing infection if it is given 30 to 60
minutes before the operative incision is
made.
3. The postoperative dose of Ancef needs to
be started exactly 8 hours after the
preoperative dose of Ancef.
4. The peak and titer levels are needed for
antibiotic therapy.
13. Which of the following is the best way
for the nurse to begin the preoperative
interview?
1. Walk in the client's room and ask, “Are
you Mrs. Smith?”
2. Walk in the client's room, sit down, and
take the client's blood pressure.
3. Walk in the client's room, sit down,
maintain eye contact, and make an
introduction.
4. Walk in the client's room and ask the
client's name.
14. A client who is to receive general
anesthesia has a serum potassium level of
5.8 mEq/L (5.8 mmol/L). What should be the
nurse's first response?
1. Call the surgeon.
2. Send the client to surgery.
3. Make a note on the front of the chart.
4. Notify the anesthesiologist.
15. Prior to being transported to the surgery
suite, the nurse asks the client whether he
has any allergies. The client responds,
“Doesn't anyone communicate with anyone?
I have been asked that question over and
over!” What is the nurse's best response?
1. “I'm sorry! I just have to ask that question
for the record.”
2. “It's an important question and we just
have to check.”
3. “You will hear it again and again as you
go through surgery.”
4. “This question is asked for verification
and safety with each new phase of
treatment.”
17. On the day of surgery, a client with
diabetes who takes insulin on a sliding
scale is to have nothing by mouth and all
medications withheld. The client's 6 AM
glucose level is 300 mg/dL (16.7 mmol/L).
The nurse should:
1. Withhold all medications.
2. Administer the insulin dose dictated by
the sliding scale.
3. Call the physician for specific
prescriptions based on the glucose level.
4. Notify the surgery department.
18. The nurse is preparing a preoperative
teaching plan for a client who is
undergoing a bilateral breast reduction.
Which aspect of the plan is the priority?
1. Reduction of risk potential.
2. Physiologic adaptation.
3. Psychosocial integrity.
4. Health promotion and maintenance.
19. A client is scheduled to have an elective
mandibular osteotomy to correct a
mandibular fracture sustained in an accident
6 months earlier. Which statement by the
client indicates to the nurse the client is
having difficulty coping?
1. “I will be glad to have my jaw fixed
because my wife thinks I do not look like
myself.”
2. “I am somewhat afraid to have the
surgery but feel OK about it.”
3. “My wife will help me, but I don't think I
will need that much help.”
4. “I am ready to get this over with.”
20. The nurse is assessing a client's
nutritional status before surgery. Which of
the following observations would indicate
poor nutrition in a 5-foot 7-inch female
(170.2 cm) client who is 21 years of age?
1. Poor posture.
2. Brittle nails.
3. Dull expression.
4. Weight of 128 lb (58.1 kg).
21. A 92-year-old who is independent and
lives alone has an inguinal hernia repair.
Which teaching method is the best
approach to use for the postoperative and
discharge teaching plans?
1. Explaining all the instructions to the
client.
2. Demonstrating the instructions for the
client.
3. Explaining all the instructions to a family
member.
4. Writing the instructions down for the
client.
22. A client is admitted for an arthroscopy of
the right shoulder through same-day
surgery. Which nurse is responsible for
starting the client's discharge planning?
1. Preadmission nurse.
2. Preoperative nurse.
3. Intraoperative nurse.
4. Postoperative nurse.
23. The nurse is preparing to administer a
preoperative medication. Which of the
following actions should the nurse take first?
1. Have the family present.
2. Ensure that the preoperative shave is
completed.
3. Have the client empty the bladder.
4. Make sure the client is covered with a
warm blanket.
24. Before surgery, a client states that she
is afraid of surgery because her cousin
died in surgery when having her tonsils
removed. What is the nurse's best
response?
1. Reassure the client that technology has
changed over the last 10 years.
2. Encourage the client to further express
her concerns.
3. Explain to the client that it is normal to be
afraid.
4. Ask the client if anyone else in her
family has had trouble when they had
surgery.
25. Which of the following clients has a
greater risk for latex allergies?
1. A woman who is admitted for her
seventh surgery.
2. A man who works as a sales clerk.
3. A man with well-controlled type 2
diabetes.
4. A woman who is having laser surgery.
26. The nurse is preparing to start an
intravenous infusion and has raised the
head of the client's bed. After the nurse
applies gloves to insert an IV catheter, the
client begins to rub her eyes and wipe away
nasal drainage. Which of the following
should the nurse do first?
1. Distract the client's attention.
2. Assess the client for pain.
3. Remove the IV catheter and assess the
client's vital signs.
4. Lower the head of the client's bed.
27. When evaluating a client's preoperative
cognitive-perceptual pattern, which of the
following questions should the nurse ask the
client?
1. “Do you have difficulty swallowing?”
2. “Do you need special equipment to
walk?”
3. “Do you smoke?”
4. “Do you wear glasses?”
28. When attempting to check the pupils of
a client scheduled to receive general
anesthesia, the nurse notices that the client
has trouble tilting the head back. Which of
the following is the primary concern related
to this finding?
1. The client has limited movement of his
neck.
2. The client is at risk for postoperative neck
pain.
3. The client is at risk for difficult
intubation.
4. The ability to assess the client's pupils is
limited.
29. A client is to have a below-the-knee
amputation. Prior to the surgery, the
circulating nurse in the operating room
should:
1. Insert a Foley catheter.
2. Start an intravenous infusion.
3. Initiate a time-out.
4. Verify that the surgeon possesses the
degree of expertise needed.
31. The nurse receives the preoperative
blood work report for a client who is
scheduled to undergo surgery. Which of the
following laboratory findings should be
reported to the surgeon?
1. Red blood cells, 4.5 million/mm3
(4.5 × 1012/L).
2. Creatinine, 2.6 mg/dL (198 μmol/L).
3. Hemoglobin, 12.2 g/dL (122 g/L).
4. Blood urea nitrogen, 15 mg/dL (5.3
mmol/L).
32. A client will receive IV midazolam
hydrochloride (Versed) during surgery.
Which of the following should the nurse
determine as a therapeutic effect?
1. Amnesia.
2. Nausea.
3. Mild agitation.
4. Blurred vision.
33. When administering IV midazolam
hydrochloride (Versed) the nurse should:
1. Assess the blood pressure.
2. Monitor the pulse oximeter.
3. Encourage slow, deep breaths.
4. Explain relaxation techniques.
34. When the nurse administers IV
midazolam hydrochloride (Versed), the
client demonstrates signs of an overdose.
The nurse should next collaborate with the
surgical team to:
1. Ventilate with an oxygenated
bag-valve mask (Ambu bag).
2. Shock the client with ECG paddles.
3. Administer 0.5 mL 1:1,000 epinephrine.
4. Titrate flumazenil (Romazicon).
35. Metoclopramide is prescribed as a
premedication for a client about to undergo
a gastroduodenoscopy. Which of the
following is the expected therapeutic effect?
1. Increased gastric pH.
2. Increased gastric emptying.
3. Reduced anxiety.
4. Inhibited respiratory secretions.
36. What therapeutic outcome does the
nurse expect for a client who has received a
premedication of glycopyrrolate?
1. Increased heart rate.
2. Increased respiratory rate.
3. Decreased secretions.
4. Decreased amnesia.
38. After the nurse has administered
droperidol, care is taken to move the client
slowly based on the knowledge of
droperidol's effect on the:
1. Central nervous system.
2. Respiratory system.
3. Cardiovascular system.
4. Psychoneurologic system.
39. A client is to receive enoxaparin
(Lovenox) 6 hours before the scheduled
time of laparoscopic vaginal assisted
hysterectomy. Which of the following effects
does the nurse recognize as an intended
therapeutic action of the enoxaparin?
1. Increase in red blood cell production.
2. Reduction of postoperative thrombi.
3. Decrease in postoperative bleeding.
4. Promotion of tissue healing.
40. During the preoperative interview, the
nurse obtains information about the
client's medication history. Which of the
following is not necessary to record about
the client?
1. Current use of medications, herbs, and
vitamins.
2. Over-the-counter medication use in the
last 6 weeks.
3. Steroid use in the last year.
4. All drugs taken in the last 18 months.
41. When the nurse is conducting a
preoperative interview with a client who is
having a vaginal hysterectomy, the client
states that she forgot to tell her doctor that
she had a total hip replacement 3 years
ago. The nurse communicates this
information to the perioperative nurse
because:
1. The prosthesis may cause a problem with
the electrosurgical unit used to control
bleeding.
2. The client should not have her hip
externally rotated when she is positioned
for the procedure.
3. The perioperative nurse can inform the
rest of the team about the total hip
replacement.
4. There is not enough time to notify the
surgeon and note this finding on the history
and physical information before the
procedure.
42. The nurse learns that a client who is
scheduled for a tonsillectomy has been
taking 40 mg of oral prednisone daily for the
last week for poison ivy on the leg. What is
the nurse's best action?
1. Document the prednisone with current
medications.
2. Notify the surgeon of the poison ivy.
3. Notify the anesthesiologist of the
prednisone administration.
4. Send the client to surgery.
43. A client who is scheduled for an open
cholecystectomy has a 20-pack-year
history of smoking. For which postoperative
complication is the client most at risk?
1. Deep vein thrombosis.
2. Atelectasis and pneumonia.
3. Delayed wound healing.
4. Prolonged immobility.
44. The family cannot go with the client past
the doors that separate the public from the
restricted area of the operating room suite.
These measures are designed to:
1. Protect the privacy of clients.
2. Prevent electrical sparks that could ignite
the anesthetic gases.
3. Separate the family from the surgical
team while they are working on the client.
4. Provide for an aseptic environment to
prevent infection.
45. Which of the following clients is most at
risk for potential hazards from the
surgical experience?
1. An 80-year-old client.
2. A 50-year-old client.
3. A 30-year-old client.
4. A 5-year-old client.
46. Which pediatric surgery client should not
play with a balloon?
1. A child having the 15th laser surgery
for a hemangioma.
2. A child having a tonsillectomy.
3. A child having an inguinal hernia repair.
4. A child having an orchiopexy.
47. In which of the following clients is an
autotransfusion possible?
1. The client who has cancer.
2. The client who is in danger of cardiac
arrest.
3. The client with a contaminated wound.
4. The client with a ruptured bowel.
48. The nurse teaches a client who had
cystoscopy about the urge to void when the
procedure is over. What other teaching
should be included?
1. Ignore the urge to void.
2. Increase intake of fluids.
3. Ask for the bedpan.
4. Ring for assistance to go to the
bathroom.
49. Which of the following nursing
interventions is most important in preventing
postoperative complications?
1. Progressive diet planning.
2. Pain management.
3. Bowel and elimination monitoring.
4. Early ambulation
50. A client who had a gastrectomy has
been in the postanesthesia recovery room
for 30 minutes when the vital signs suddenly
change. The nurse checks the recovery
room record (see chart). In addition to
notifying the physician, what other action
should the nurse take immediately?
1. Administer dantrolene.
2. Elevate the head of the bed 30 degrees.
3. Administer a bolus of IV fluids.
4. Insert an indwelling urinary catheter.
51. The nurse should do which of the
following to decrease a female client's
anxiety about being placed in the lithotomy
position for surgery?
1. Explain in detail what will occur in the
operating room.
2. Determine what the client is
concerned about.
3. Pad the stirrups for comfort.
4. Reassure the client that an all-female
surgical team will be present.
54. A client has been in the position shown
in the figure for surgery. The nurse
should document that the client has been in
which of the following positions?
1. Reverse Trendelenburg.
2. Low Fowler's.
3. High lithotomy.
4. Prone.
55. A client arrives from surgery to the
postanesthesia care unit. Which of the
following respiratory assessments should
the nurse complete first?
1. Oxygen saturation.
2. Respiratory rate.
3. Breath sounds.
4. Airway flow.
56. The nurse assesses vital signs on a
client who has had epidural anesthesia. For
which of the following should the nurse
assess next?
1. Bladder distention.
2. Headache.
3. Postoperative pain.
4. Ability to move the legs.
57. When assessing a client who has had
spinal anesthesia, which of the following
would the nurse expect to find?
1. The client feels pain before moving the
legs.
2. The blood pressure is significantly
increased.
3. Sensation returns to the toes first,
then progresses to the perineal area.
4. The client has a headache while in the
lying position.
58. The nurse in the postanesthesia care
unit notes that one of the client's pupils is
larger than the other. The nurse should:
1. Rate the client on the Glasgow Coma
Scale.
2. Administer oxygen.
3. Check the client's baseline data.
4. Call the surgeon.
59. A client is admitted to the
postanesthesia care unit following a left hip
replacement. The initial nursing assessment
is: T 96.6°F (35.9°C), Pulse 90, RR 14, and
BP 128/80. The client only responds with
moaning when spoken to. The nurse should
first:
1. Observe the surgical dressing.
2. Position the client on the right side.
3. Remove the oral airway remaining from
surgery.
4. Administer sedation reversal agent such
as flumazenil.
60. The surgical floor receives a client from
the postanesthesia care unit.
Assessment reveals that the client has a
patent airway and stable vital signs. The
nurse should next:
1. Check the dressing for signs of
bleeding.
2. Empty any peri-incisional drains.
3. Assess the client's pain level.
4. Assess the client's bladder.
61. When preparing a teaching plan for an
adult client about general anesthesia
induction, which explanation would be most
appropriate?
1. “Your premedication will put you to sleep.”
2. “You will breathe in an inhalant
anesthetic mixed with oxygen through a
facial mask and receive intravenous
medication to make you sleepy.”
3. “You will receive intravenous medication
to make you sleepy.”
4. “You will breathe in medication through a
facial mask to make you sleepy.”
62. A client with impaired cardiac
functioning is at risk during anesthesia
induction with thiopental sodium (Sodium
Pentothal) because this drug causes:
1. Bradycardia.
2. Complete muscle relaxation.
3. Hypotension.
4. Tachypnea.
63. The nurse anticipates that a client who
has received propofol (Diprivan) as the
induction and maintenance agent for
general anesthesia will most likely
experience:
1. Minimal nausea and vomiting.
2. Hypotension.
3. Slow induction of anesthesia.
4. Small tremors of the skeletal muscles.
64. What is the main reason desflurane
(Suprane) and sevoflurane (Ultane), volatile
liquid anesthesia agents, are used for
surgical clients who go home the day of
surgery?
1. These agents are better tolerated.
2. These agents are predictable in their
cardiovascular effects.
3. These agents are nonirritating to the
respiratory tract.
4. These agents are rapidly eliminated.
65. A 250-lb (113.4-kg) male client
recovering from general anesthesia has the
following assessment findings: pulse, 150
bpm; blood pressure, 90/50 mm Hg;
respiratory rate, 28 breaths/min; tympanic
temperature, 99.8°F (37.7°C); and rigid
muscles. The nurse determines that the
client is:
1. Recovering as expected from the
anesthesia and continues monitoring him.
2. Exhibiting the effects of excessive blood
loss experienced in the operating room
and increases the rate of his IV infusion.
3. In the early stages of malignant
hyperthermia and obtains emergency
medications and notifies the
anesthesiologist.
4. In pain and offers him pain medication.
66. The nurse is assessing a client
recovering from anesthesia. Which of the
following is an early indicator of hypoxemia?
1. Somnolence.
2. Restlessness.
3. Chills.
4. Urgency.
68. An 80-year-old client had spinal
anesthesia for a transurethral resection of
the prostate and received 4,000 mL of room
temperature isotonic bladder irrigation. He
now has continuous irrigation through a
three-way indwelling urinary catheter. Which
postoperative nursing intervention is most
important to include in his plan of care?
1. Empty the catheter drainage bag.
2. Cover the client with warm blankets.
3. Hang new bags of irrigation.
4. Turn the client.
69. Which of the following clients is
expected to retain anesthetic agents
longest?
1. A client who is 6 feet 2 inch tall (188 cm)
and weighs 250 lb (113.4 kg).
2. A client who is 5 feet 4 inch (162.6 cm)
tall and weighs 110 lb (49.9 kg).
3. A client who is 5 feet 1 inch (155 cm)
tall and weighs 200 lb (90.7 kg).
4. A client who is 5 feet 7 (170.2 cm) inch
tall and weighs 145 lb (65.8 kg).
70. An awake postoperative client received
an intravenous regional nerve block (Bier
block) in the arm that is now casted and
elevated on a pillow. What action should the
nurse encourage the client to avoid until
sensation returns?
1. Holding the operated arm close to the
face.
2. Holding the operated arm with the
unoperated arm.
3. Using the unoperated arm.
4. Using pain medication.
71. The physician prescribed IV naloxone
(Narcan) to reverse the respiratory
depression from morphine administration.
After administration of the naloxone the
nurse should:
1. Check respirations in 5 minutes because
naloxone is immediately effective in
relieving respiratory depression.
2. Check respirations in 30 minutes
because the effects of morphine will have
worn off by then.
3. Monitor respirations frequently for 4 to
6 hours because the client may need
repeated doses of naloxone.
4. Monitor respirations each time the client
receives morphine sulfate 10 mg IM.
72. The nurse should monitor the surgical
client closely for which clinical manifestation
with the administration of naloxone
(Narcan)?
1. Dizziness.
2. Biliary colic.
3. Bleeding.
4. Urine retention.
73. The nurse anticipates that the client who
has received epidural anesthesia is at
decreased risk for a spinal headache
because:
1. A 17G needle is used.
2. A subarachnoid injection is made.
3. A noncutting needle is used.
4. A faster onset occurs.
74. Which of the following systems is not
blocked by spinal anesthesia?
1. The sympathetic nervous system.
2. The sensory system.
3. The parasympathetic nervous system.
4. The motor system.
76. A client in the postanesthesia care unit
is being actively rewarmed with an
external warming device. How often should
the nurse monitor the client's body
temperature?
1. Every 5 minutes.
2. Every 10 minutes.
3. Every 15 minutes.
4. Every 20 minutes.
78. On the first day after surgery, a client
has been breathing room air. The vital
signs are normal, and the O2 saturation is
89%. The nurse should first:
1. Lower the head of the bed.
2. Notify the physician.
3. Assist the client to take several deep
breaths and cough.
4. Administer oxygen by nasal cannula as
prescribed at 2 L/min.
79. A client has been unable to void since
having abdominal surgery 7 hours ago.
The nurse should first:
1. Encourage the client to increase oral fluid
intake.
2. Insert an intermittent urinary catheter.
3. Notify the health care provider.
4. Assist the client up to the toilet to
attempt to void.
80. Following abdominal surgery, a client
refuses to deep breathe and cough every
2 hours as prescribed. The nurse should do
which of the following first?
1. Ask the client's wife to insist that the
client take the deep breaths every 2 hours.
2. Respect the client's wishes and turn the
client from side-to-side more frequently.
3. Suggest that the client increase the daily
fluid intake to at least 2,500 mL.
4. Explain the risks of not expanding the
lungs and why the exercise is important.
81. Eight hours after surgery, a client has a
distended bladder and is unable to void.
Which of the following interventions is
contraindicated?
1. Facilitate voiding by normal position.
2. Pour running water over perineum.
3. Insert an indwelling urinary catheter.
4. Insert a straight catheter every 4 hours.
82. A client who had open heart surgery is
being transported to the intensive care
unit (ICU) for postoperative recovery from
anesthesia. The nurse in the ICU is
assessing the client's level of
consciousness. When asked, the client can
give his name but is not sure about where
he is or the time of day. What should the
nurse do?
1. Notify the surgeon.
2. Rub the client's sternum to arouse the
client.
3. Encourage the client's wife to orient the
client.
4. Tell the client where he is and the time
of day.
83. Following surgery, a client is receiving
1,000 mL normal saline (IV) with 40
mEq (40 mmol/L) KCl, which has been
prescribed to be infused at 125 mL/h. The
client states, “My IV hurts.” What should the
nurse do first?
1. Contact the client's physician for a
different IV prescription.
2. Slow down the infusion to a keep-open
rate (20 to 50 mL/h).
3. Assess the IV site for signs of
phlebitis, extravasation, or IV-related
infection.
4. Check the hanging parenteral fluid and
administration set for documentation as to
when they were last changed.
84. A nurse is assessing a client when she
returns from same-day surgery for a
dilatation and curettage. The nurse checks
preoperative vital signs at 8:30 AM to
compare them with the current vital signs at
10:30 PM (see chart). What should the
nurse do first?
1. Call the physician for pain medication.
2. Cover the client with warmed blankets.
3. Administer oxygen at 4 L/min.
4. Increase the IV fluid rate.
86. The nurse is caring for a client receiving
a continuous infusion of narcotics for relief
of postoperative pain. On assessment, the
client's vital signs are as follows: HR 84, RR
8, BP 104/56, and oxygen saturation of 88%
on room air. Which of the following is the
nurse's first action?
1. Administer Narcan as prescribed.
2. Stop the continuous infusion of narcotics.
3. Assist the client to sit and stimulate
coughing/deep breathing.
4. Call the rapid response team.
87. A client had a colectomy 8½ hours ago
and has received 1,500 mL of dextrose 5%
in water with normal saline solution. The
client has just used a patient-controlled
analgesia pump to administer morphine for
pain, has been repositioned for comfort, and
has stable pulse rate, respirations, and
blood pressure. What should the nurse do
next?
1. Check that the family is comfortable.
2. Assess vital signs following the use of
morphine.
3. Dim the lights in the room.
4. Increase nasal oxygen from 2 to 3 L.
88. A client who had an esophageal hernia
repair 4 hours ago has a pulse rate of 90
bpm, respiration rate of 16/min, blood
pressure of 130/80 mm Hg, pulse oximeter
of 91, and a temperature of 100.4°F (38°C).
What should the nurse do first?
1. Obtain a culture of the incision.
2. Notify the surgeon to obtain an antibiotic
prescription.
3. Offer pain medication.
4. Assist the client to a sitting position to
take deep breaths.
89. After completing client teaching on the
use of patient-controlled analgesia
(PCA), the nurse determines that the client
understands the use of the PCA when the
client states:
1. “It is OK for my family to press the button
for me if I'm too tired to do it myself.”
2. “I should wait until the pain is really bad
before I push the button to get more pain
medicine.”
3. “The machine will only give me the
prescribed amount of pain medication
even if I push the button too soon.”
4. “I have to be careful about pushing the
button too many times or I will overdose
myself.”
90. A client had a total abdominal
hysterectomy and bilateral oophorectomy
for ovarian carcinoma yesterday. She
received 2 mg of morphine sulfate IV by
patientcontrolled analgesia (PCA) 10
minutes ago. The nurse was assisting her
from the bed to a chair when the client felt
dizzy and fell into the chair. The nurse
should:
1. Discontinue the PCA pump.
2. Administer oxygen.
3. Take the client's blood pressure.
4. Assist the client back to bed.
91. Immediately following pelvic surgery, a
client has an indwelling urinary catheter.
Which of the following would be helpful to
prevent catheter-related urinary tract
infection?
1. Provide catheter and perineal care twice
daily.
2. Monitor the color, clarity, and amount of
urine output.
3. Advocate for limited use of and
duration of indwelling urinary catheters.
4. Palpate for lower abdominal distension
once per shift.
93. The postoperative nursing assessment
of a client's ability to swallow fluids before
providing oral fluids is based on the type of
anesthesia given. Which of the following
clients would not have delayed fluid
restrictions?
1. The client who has undergone a
bronchoscopy under local anesthesia.
2. The client who has undergone a
transurethral resection of a bladder tumor
under general anesthesia.
3. The client who has undergone a repair
of carpal tunnel syndrome under local
anesthesia.
4. The client who has undergone an inguinal
herniorrhaphy with spinal and
intravenous conscious sedation.
94. The client has just returned to bed
following the first ambulation since
abdominal surgery. The client's heart rate
and blood pressure are slightly elevated;
oxygen saturation is 91% on room air, but
the client reports being “a little short of
breath,” but does not have dizziness or
pain. The nurse should first:
1. Obtain a 12-lead EKG.
2. Administer pain medication.
3. Allow the client to rest for a few
minutes, then reassess.
4. Request new activity prescriptions from
the health care provider.
95. Eight hours following bowel surgery, the
nurse observes that the client's urine
output has decreased from 50 to 20 mL/h.
The nurse should assess the client further
for which of the following?
1. Bowel obstruction.
2. Adverse effect of opioid analgesics.
3. Hemorrhage.
4. Hypertension.
96. A client who had a left thoracoscopy
sustained an injury secondary to the
surgery position. The nurse should assess
the client for:
1. Footdrop.
2. Knee swelling and pain.
3. Tingling in the arm.
4. Absence of the Achilles reflex.
97. Which of the following types of surgery
is most likely to cause the client to
experience postoperative nausea and
vomiting?
1. Total hip replacement.
2. Mitral valve repair.
3. Abdominal hysterectomy.
4. Mastectomy of the left breast.
99. The nurse is planning to teach incisional
care to a client before discharge.
Which of the following instructions should
be included?
1. “Do not touch your incision before your
next appointment.”
2. “Clean your incision three times a day
with hydrogen peroxide and water.”
3. “Do not be concerned about uneven
lumps under the suture lines.”
4. “If the staples don't come out by
themselves before your next appointment,
the surgeon will remove them.”
100. The nurse is removing the client's
staples from an abdominal incision when
the client sneezes and the incision splits
open, exposing the intestines. Which of the
following actions should the nurse take
next?
1. Press the emergency alarm to call the
resuscitation team.
2. Cover the abdominal organs with
sterile dressings moistened with sterile
normal saline.
3. Have all visitors and family leave the
room.
4. Call the surgeon to come to the client's
room immediately.
102. The nurse is making rounds and
observes the client receiving oxygen (see
figure). The nurse should do which of the
following?
1. Position the mask lower on the client's
nose.
2. Verify that the reservoir bag remains
deflated.
3. Confirm that the flow rate is set to
deliver oxygen at 6 to 10 L/min.
4. Loosen the elastic band on the client's
face.
103. Which of the following should be
included in the plan of care for a client with
a surgical wound that requires a wet-to-dry
dressing?
1. Place a dry dressing in the wound.
2. Use Burow's solution to wet the dressing.
3. Pack the wet dressing tightly into the
wound.
4. Cover the wet packing with a dry
sterile dressing.
104. Two days following abdominal surgery,
a client is refusing to take a narcotic pain
medication, even though the pain rating is
an 8 on a 0–10 scale. The client tells the
nurse, “I don't want to get dependent on that
stuff.” Which of the following is the most
appropriate response from the nurse?
1. “You will recover more quickly and
more effectively if you take pain
medication now.”
2. “Newer pain medications do not cause
dependence or addiction.”
3. “It is your right to not take pain
medication.”
4. “You do not need to worry about
becoming addicted so soon.”
105. The nurse empties a Jackson-Pratt
drainage bulb. Which of the following
nursing actions ensures correct functioning
of the drain?
1. Irrigating it with normal saline.
2. Connecting it to low intermittent suction.
3. Compressing it and then plugging it to
establish suction.
4. Connecting it to a drainage bag and
clamping it off.
106. Which of the following interventions
should the nurse implement for pulmonary
emboli prophylaxis?
1. Have the client perform leg exercises
every hour while awake.
2. Encourage the client to cough and deep
breathe.
3. Massage the client's calves.
4. Have the client wear antiembolism
stockings when out of bed.
107. The nurse assesses a client who has
just received morphine sulfate. The client's
blood pressure is 90/50 mm Hg; pulse rate,
58 bpm; respiration rate, 4 breaths/min. The
nurse should check the client's chart for a
prescription to administer:
1. Flumazenil (Romazicon).
2. Naloxone hydrochloride (Narcan).
3. Doxacurium (Nuromax).
4. Remifentanil (Ultiva).
108. The nurse observes the client with an
intermittent compression device in place
after abdominal surgery. The nurse should:
1. Elevate the client's legs.
2. Apply stockings to be worn under the
device.
3. Instruct the client not to move while the
device is inflated.
4. Make sure the client is comfortable.
109. A client is being discharged from
same-day surgery. Which of the following
statements indicates that the client has
deficient knowledge?
1. “My husband is taking the day off from
work to drive me home.”
2. “I can drive myself home after
surgery.”
3. “I am taking a taxi home, and my
daughter will meet me at home.”
4. “My son will be here at noon to take me
home.”
110. The nurse is teaching a client who has
had a laparoscopic cholecystectomy
about postoperative pain management.
Which of the following statements indicates
that the client has deficient knowledge?
1. “My pain is related to the gas used to
distend my abdominal cavity.”
2. “My diet should include eating bland
foods until the gas clears up.”
3. “My pain is related to the large
incision and manipulation.”
4. “My pain should be relieved by walking to
eliminate the gas.”
111. The initial postoperative assessment is
completed on a client who had an
arthroscopy of the knee. Assessment of
which of the following parameters is not
necessary every 15 minutes during the first
postoperative hour?
1. Vital signs including pulse oximeter.
2. Pain rating of the operative site.
3. Urine output.
4. Neurovascular check distal to the
operative site.
112. After surgery, a client was treated for
postoperative nausea and vomiting and now
is experiencing hypotension and
tachycardia. The nurse should review the
medication record to determine if the client
has received which of the following
medications?
1. Ondansetron hydrochloride.
2. Droperidol.
3. Prochlorperazine.
4. Promethazine.
113. When an epidural catheter is used for
postoperative pain management, the
nurse should:
1. Assess but not disturb the epidural
dressing.
2. Change the epidural dressing daily.
3. Change the epidural dressing daily only if
it is wet.
4. Use strict aseptic technique when
handling the epidural catheter.
114. The nurse understands that the client
who has epidural pain management
postoperatively can ambulate because:
1. The analgesia is periodically
administered through the epidural catheter.
2. A low concentration of analgesia is
used with the catheter.
3. The analgesia from the epidural catheter
bathes the spinal fluid.
4. The epidural medication affects the
sympathetic and motor function.
115. The nurse is caring for a client who is
using a portable wound suction unit (see
figure). Six hours following surgery, the
drainage unit is full. The nurse should do
which of the following?
1. Remove the drain from the incision.
2. Notify the surgeon.
3. Empty drainage.
4. Record the amount in the unit as output
on the client's chart.
116. Two days after surgery, a client
continues to take hydrocodone 7.5 mg and
acetaminophen 500 mg (Lortab 7.5/500).
What should the nurse ask the client before
administering the pain medication?
1. “Where is your pain located?”
2. “Have you emptied your bladder?”
3. “How long has it been since your last
dose?”
4. “Is your pain better than before you had
surgery?”
117. A client wakes up in the
postanesthesia care unit and sees a drain
with bright red fluid in it exiting from the total
hip incision, and asks the nurse, “Is this the
way it is supposed to be?” Which of the
following represents the nurse's best
response?
1. “The drainage is blood and fluid that
must be drained out for healing.”
2. “Don't worry about it. I will explain it when
you are more awake.”
3. “This blood is being kept sterile and will
be given back to you.”
4. “I will give you something to make you
sleep so you will not worry.”
118. A client has a Jackson-Pratt drainage
tube in place the first day after surgical
repair of a ruptured diverticulum. The client
asks the nurse the purpose of the drain.
What is the nurse's best response?
1. “The drainage tube is used to prevent
infection in the peritoneal cavity.”
2. “The drainage tube is used to prevent
bleeding into the peritoneal cavity.”
3. “The drainage tube is used to prevent
pressure on the bladder.”
4. “The drainage tube is used to prevent
pressure on the gallbladder.”
119. A client who had a cholecystectomy
has a biliary drainage tube in place.
Which of the following colors of the drainage
is expected?
1. Pinkish red.
2. Dark yellow-orange.
3. Clear.
4. Green.
120. A client is to be discharged from
same-day surgery 7 hours after his inguinal
hernia repair. Which of the following
indicates this client is ready to be
discharged?
1. The client voids 500 mL of urine.
2. The client tolerates eating a hamburger.
3. The client is pain free.
4. The client walks in the hallway
unassisted.
121. A client is eligible for patient-controlled
analgesia (PCA) when:
1. A family member is able to assist with
self-dosing.
2. There is a court-appointed advocate to
assist with self-dosing.
3. The client has the ability to self-dose.
4. There is a nurse to assist with
self-dosing.
122. How often should the client's
temperature be assessed during the first 24
hours after surgery?
1. Every 2 hours.
2. Every 4 hours.
3. Every 6 hours.
4. Every 8 hours.
123. A nurse is assessing a client's blood
pressure 8 hours after surgery. The client's
blood pressure before surgery was 120/80
mm Hg, and on admission to the
postsurgical nursing unit, it was 110/80 mm
Hg. The client's blood pressure is now
90/70 mm Hg. What should the nurse do
first?
1. Notify the health care provider.
2. Elevate the head of the bed.
3. Administer pain medication.
4. Check the intake and output record.
124. A client has been positioned in the
lithotomy position under general anesthesia
for a pelvic procedure. In which anatomic
area may the client expect to experience
postoperative discomfort?
1. Shoulders.
2. Thighs.
3. Legs.
4. Feet.
125. Which of the following does not aid in
meeting the goal of clear breath sounds?
1. Offering pain relief before having the
client cough.
2. Providing a minimum of 1,000 mL of
fluid per day.
3. Using an incentive spirometer.
4. Assisting with early ambulation.
126. The nurse is teaching the client about
deep-breathing techniques. Which of the
following client statements indicates the
need for additional education?
1. “I will use my incentive spirometer every
hour while I'm awake.”
2. “I should place my hands lightly over my
lower ribs and upper abdomen.”
3. “I should get into a comfortable
position before doing my breathing
exercises.”
4. “I should take four deep breaths and then
cough deeply from the lungs.”
127. A client has had a nasogastric tube
connected to low intermittent suction. The
client is at risk for which of the following
complications?
1. Confusion.
2. Muscle cramping.
3. Edema.
4. Tremors.
128. On admission to same-day surgery, the
nurse reviews the chart to verify the
client's identification documentation. Which
of the following is most important?
1. Admitting record.
2. Addressograph labels.
3. Identification bracelet.
4. Location of family.
129. Which of the following items of
documentation is not required for the nurse
to have on the chart before the client is
transported to the operating suite?
1. Operative consent.
2. History and physical information.
3. Laboratory test results.
4. Anesthesia note.
130. A 15-year-old client needs life-saving
emergency surgery, but the relatives
live an hour away from the hospital and
cannot sign the consent form. What is the
nurse's best response?
1. Send the client to surgery without the
consent.
2. Call the family for a consent over the
telephone and have another nurse listen
as a witness.
3. No action is necessary in this case
because consent is not needed.
4. Have the family sign the consent form as
soon as they arrive.
131. A client is being prepared to have a
craniotomy for a brain tumor. As a client
advocate, the nurse is evaluating the client's
understanding of the informed consent
before witnessing the client's signature on
the operative consent form. Which of the
following indicates that the nurse needs to
contact the surgeon for further
communication with the client?
1. “We talked about the effect of my
diabetes on healing.”
2. “The surgeon explained how the
craniotomy was done.”
3. “There are no major risks from this
surgery.”
4. “I will die if the tumor is not removed from
my brain.”
132. The nurse is helping to prepare a client
for nonemergency surgery. The nurse
should:
1. Obtain informed consent from the client.
2. Explain the surgical procedure in detail.
3. Verify that the client understands the
consent form.
4. Inform the client about the risks of the
surgery to be performed.
133. When a client cannot read or write but
is of sound mind, the nurse should read the
consent to the client in the presence of two
witnesses and:
1. Have the client's next-of-kin sign the
consent.
2. Have the client put an “X” on the
signature line.
3. Have a court appoint a guardian for the
client.
4. Have a hospital quality management
coordinator sign for the client.
134. The nurse applies which ethical
principle when telling the truth to a client
about the prognosis?
1. Nonmaleficence.
2. Fidelity.
3. Beneficence.
4. Veracity
136. The nurse is planning care for a client
with severe postoperative pain. There is a
prescription for morphine written as “10 mg
MSO4” on the chart. Which of the following
should the nurse do first?
1. Obtain an intravenous infusion system.
2. Prepare the medication for
administration.
3. Contact the Pharmacy Department.
4. Contact the physician who prescribed
the medication.
137. The client has returned to the surgery
unit from the postanesthesia care unit
(PACU). The client's respirations are rapid
and shallow, the pulse is 120, and the blood
pressure is 88/52. The client's level of
consciousness is deteriorating. The nurse
should do which of the following first?
1. Call the PACU.
2. Call the primary care physician.
3. Call the respiratory therapist.
4. Call the Rapid Response Team (RRT).
138. When completing the Preoperative
Checklist on the nursing unit, the nurse
discovers an allergy that the client has not
reported. What should the nurse do first?
1. Administer the prescribed preanesthetic
medication.
2. Note this new allergy prominently at the
front of the chart.
3. Contact the scrub nurse in the operating
room.
4. Inform the nurse anesthetist.
140. A very elderly, drowsy client with fragile
skin is being transferred from the
surgery cart to the bed. How should the
nurse plan to direct the transfer to prevent
skin shearing?
1. With two people at each side using a
drawsheet.
2. With two people, one at each side using a
drawsheet, and one person at the head.
3. With two people using a roller and a
drawsheet.
4. With two people, one at each side
using a drawsheet, one person at the
head, andone person at the feet.
141. The client's identification armband was
cut and removed to start an IV line as
a part of the preoperative preparation. The
transport team has arrived to transport the
client to the operating room. The nurse
notices that the client's identification band is
not on either wrist. What is the nurse's best
response?
1. Send the removed armband with the
chart and the client to the operating room.
2. Place a new identification armband on
the client's wrist before transport.
3. Tape the cut armband back onto the
client's wrist.
4. Send the client without an armband
because the client is alert and can respond
to questions about his or her identity.
On the second day after surgery, the nurse
assesses an elderly client and finds the
following: BP 148/92, HR 98, RR 32
O2 saturation of 88 on 4 L/min of oxygen
administered by nasal cannula. Breath
sounds are coarse and wet bilaterally with a
loose, productive cough. Client voided 100
mL very dark, concentrated urine during the
last 4 hours, Bilateral pitting pedal edema.
Using the SBAR method to notify the health
care provider of current assessment
findings, which of the following is the most
appropriate recommendation to make?
1. Administer an antihypertensive
medication.
2. Encourage additional fluid intake.
3. Administer a diuretic medication.
4. Increase oxygen liter flow rate.
143. Which of the following physician
prescriptions is written correctly on the
chart?
1. Fentanyl 50 mcg given IV every 2
hours as needed for pain greater than
6/10.
2. Give 4 U regular insulin IV now.
3. .5 mg MS given IM for c/o pain.
4. 60.0 mg Toradol given IM for c/o pain
145. While making rounds, the nurse
observes that a client's primary bag of
intravenous (IV) solution is light yellow. The
label on the IV bag says the solution is
D5W. What should the nurse do first?
1. Continue to monitor the bag of IV
solution.
2. Ask another nurse to look at the solution.
3. Notify the physician.
4. Hang a new bag of D5W and complete
an incident report.
PERIOP
2. A client is to have elective surgery. The
nurse should plan with the client to schedule
the surgery:
n 1. If the client wishes to have the
procedure done.
n 2. At the client’s convenience.
n 3. Within the next 2 weeks.
n 4. Within the next 2 days.
3. A client is to have NPO for at least 2 hr
before same-day surgery. A nurse learns
the client had half a glass of orange juice 3
hr prior to admission. The nurse should:
n 1. Report the incident to the nursing
supervisor.
n 2. Inform the surgery department.
n 3. Notify the anesthesiologist.
n 4. Reschedule the surgery.
4. A client is anxious prior to surgery. The
nurse should:
n 1. Administer an antianxiety agent.
n 2. Describe the entire intraoperative
experience.
n 3. Reassure the client about the capability
of the surgeon.
n 4. Encourage verbalization of feelings.
5. A client is receiving atropine sulfate
(Atropair) prior to surgery. Which of the
following is the intended outcome of this
drug?
n 1. Constricts pupils.
n 2. Stimulates the central nervous system.
n 3. Decreases cardiac output.
n 4. Suppresses oral secretions.
6. The intended outcome of a client
receiving cimetidine (Tagamet) prior to
surgery is to:
n 1. Decrease the volume of gastric
secretions.
n 2. Decrease the pH of gastric secretions.
n 3. Reduce the amount of anesthetic
needed.
n 4. Dispel the memory of unpleasant
factors associated with surgery.
7. A client arrives in the operating room
wearing two post earrings on each eyebrow.
The nurse should do which of the following?
n 1. Ask client to remove the earrings
and place them in a labeled container.
n 2. Call a nurse on the medical-surgical
clinical unit and request that he or she come
to remove the earrings and give them to the
client’s family.
n 3. Remind anesthetist to remove the
earrings when the client is anesthetized.
n 4. Secure the earrings with paper tape.
8. The nurse notices that a cart brought by
an operating room transporter to transport a
client has a nonfunctioning clasp on the
safety belt. The nurse should do which of
the following?
n 1. Call the Safety/Security Department to
report the problem.
n 2. Use a draw sheet to secure the client
during transport.
n 3. Contact the Clinical Engineering
Department to repair the clasp.
n 4. Request that the transporter bring a
different cart with a functional clasp.
9. A scrub nurse puts on the hair covering
after putting on sterile gloves. The charge
nurse should base a response to this nurse
on which of the following?
n 1. If a sterile item comes in contact
with an unsterile item, it is contaminated.
n 2. Contaminated items should be removed
immediately from the sterile field.
n 3. A wide margin of safety must be
maintained between the sterile and unsterile
field.
n 4. Bacteria harbor on the client’s and the
team members’ hair, skin, and respiratory
tracts and must be confined by appropriate
attire.
10. A scrub nurse in the operating room
should do which of the following?
n 1. Scrub for a minimum of 3 min.
n 2. Scrub without mechanical friction.
n 3. Scrub from the hands to the elbows.
n 4. Hold the hands higher than the
elbows.
11. In the operating room the surgeon is
checking the x-ray of a client who is to have
lobe of the left lung removed. The nurse
notes that the name on the x-ray is not the
same name as that of the client. The nurse
should:
n 1. Call the x-ray technician to take another
x-ray.
n 2. Call the surgeon aside to ask to have
the xray checked.
n 3. Look for the correct x-ray.
n 4. Call a time out.
12. A client is receiving a large volume of
PRBCs during surgery. The nurse should
observe the client for hypocalcemia
because?
n 1. Extra calcium is needed during stressful
events.
n 2. Anesthesia causes hypocalcemia.
n 3. Hypoperfusion to the parathyroid
glands affects calcium levels.
n 4. The preservative in PRBCs binds
with calcium.
13. A client who had a partial gastrectomy
24 hr ago has a nasogastric tube in place.
The expected outcome of using a
nasogastric tube following a partial
gastrectomy is to:
n 1. Assess the pH of gastric secretions.
n 2. Remove stomach contents.
n 3. Delay peristalsis until initial healing
takes place.
n 4. Assess characteristics of drainage at
anastomosis
15. The nurse assesses that a client is
restless in the immediate postoperative
period. The nurse should first:
n 1. Administer a sedative.
n 2. Offer ice chips.
n 3. Administer oxygen.
n 4. Apply wrist restraints.
16. A nurse auscultates a client’s breath
sounds on the fourth postoperative day and
hears loud, low-pitched, rumbling sounds on
expiration. The nurse should first:
n 1. Administer oxygen.
n 2. Encourage the client to cough.
n 3. Request an order for incentive
spirometry.
n 4. Reposition the client to high-Fowler
position.
17. During the extended postoperative
period following an abdominal
hysterectomy, a client has a urine output of
20 ml/hour. The nurse should:
n 1. Consider this to be normal.
n 2. Evaluate the client’s fluid intake.
n 3. Prepare to return the client to the
operating room.
n 4. Consult the urologist.
18. On the first day after abdominal surgery,
the nurse auscultates a client’s abdomen for
bowel sounds; there are none. The nurse
should first:
n 1. Encourage a client to use the client
controlled analgesia pump more often.
n 2. Ask another nurse to validate the
absence of bowel sounds.
n 3. Encourage the client to take more ice
chips.
n 4. Document assessment findings in
the client’s medical record.
19. Prior to nonemergency surgery, the
client needs to give consent for the
procedure. Which of the following measures
is the responsibility of the nurse?
n 1. Obtain informed consent.
n 2. Explain the surgical procedure.
n 3. Verify the client understands the
consent form.
n 4. Inform the client about surgical risks
1. The physician orders an MRI of the brain
for an adult male client. Which of the
following findings in the client’s history
should the nurse report to the physician?
(A) Allergy to contrast dye
(B) Implanted cardiac pacemaker
(C) Chronic obstructive pulmonary disease
(COPD)
(D) Hernia repair
2. The nurse is developing a care plan for a
client with hepatitis C. The nurse knows that
the primary route of transmission of this
hepatitis virus is which of the following?
(A) Contaminated food
(B) Feces
(C) Blood
(D) Sputum
3. The nurse is preparing to discharge a
client with rheumatic heart disease who is
recovering from endocarditis. Which of the
following statements from the client
indicates that the client understands the
teaching?
(A) “I’m so glad I don’t need any more
antibiotics now that I’m feeling better.”
(B)“I can restart my exercise program in a
day or two.”
(C) “I will watch for signs of relapse the first
few days after discharge.”
(D) “I will inform my dentist should I ever
need any dental work.”
4. The nurse is preparing to test a client
who has allergies from an unknown cause.
Which of the following tests should the
nurse perform?
(A) Tzanck test
(B) Patch test
(C) Rinne test
(D) Stress test
5. The nurse is preparing a client with
acquired immunodeficiency syndrome
(AIDS) for discharge to home. Which of the
following instructions should the nurse
include?
(A) “Avoid sharing articles such as
razors and toothbrushes.”
(B) “Do not share eating utensils with family
members.”
(C) “Limit the time you spend in public
places.”
(D) “Avoid eating food from serving dishes
shared with others.”
6. The nurse is preparing to administer a
tuberculin (Mantoux) skin test to a client
suspected of having tuberculosis (TB). The
nurse knows that the test will reveal which
of the following?
(A) How long the client has been infected
with TB
(B) Active TB infection
(C) Latent TB infection
(D) Whether the client has been infected
with TB bacteria
7. An older adult has been admitted with
diagnosis of stroke and a history of
dementia. Which of the following nursing
diagnoses has the highest priority for this
client?
(A) Bathing/hygiene self-care deficit
(B) Risk for injury
(C) Impaired physical mobility
(D) Disturbed thought processes
8. The nurse has just administered insulin to
a diabetic client. In which of the following
ways should the nurse dispose of the
needle?
(A) Re-cap the needle and discard it in the
nearest puncture resistant container.
(B) Re-cap the needle and discard it in the
nearest biohazard container.
(C) Discard the needle in a
puncture-resistant container.
(D) Break the needle and discard it in the
nearest puncture resistant container.
10. Two nurses are preparing to lift a client
up in bed. Which of the following should the
nurses do to help avoid injuring their backs?
(A) Bend from the waist.
(B) Lift with the back, not with the legs.
(C) Lower the head of the bed to about 30
degrees, if the client can tolerate it.
(D) Make certain the bed is in a
reasonably high position.
11. In the emergency room, the nurse
assesses a 4-year-old child suspected of
having measles. Which of the following
kinds of precautions should the nurse
initiate?
(A) Contact precautions
(B) Droplet precautions
(C) Airborne precautions
(D) Reverse isolation
12. A female client comes to the Emergency
Department reporting vaginal discharge,
irritation of the vagina, and the need to
urinate often. The nurse suspects a sexually
transmitted disease (STD), and the
physician orders diagnostic testing of the
vaginal discharge. Which of the following
STDs does the nurse know must be
reported to the Department of Public
Health?
(A) Genital herpes
(B) Human papillomavirus infection
(C) Gonorrhea
(D) Trichomoniasis
14. The nurse is preparing to administer a
unit of PRBCs to an anemic client. After
obtaining the blood from the blood bank, the
nurse must begin administering it within
which of the following time periods?
(A) 15 minutes
(B) 30 minutes
(C) 45 minutes
(D) 60 minutes
15. The nurse is assessing an elderly client
for risk of falls. Which of the following
should the nurse collect?
(A) The facility’s restraint policy
(B) Gait, balance, and visual impairment
information
(C) Psychosocial history
(D) The facility’s environmental safety plan
16. The nurse is administering nightly
medications, which include an anticoagulant
and a stool softener. Which of the following
should the nurse do FIRST before
administering the medications?
(A) Scan the medication label and the
client’s wristband.
(B) Ask the client his or her name to
properly identify this client as the one for
whom the medications were ordered.
(C) Match the client’s date of birth and
name on the client’s wristband with the
same information on the medication
order.
(D) Match the client’s name and room
number with the medication order.
17. The physician verbally orders a
medication for a client during an emergency
code. Which of the following should the
nurse do?
(A) Repeat the order back to the
physician for confirmation and
administer it.
(B) Retrieve the medication and administer
it.
(C) Write the order down, retrieve the
medication, and administer it.
(D) Read the order to another nurse, have
that nurse retrieve the medication, and stay
with the client.
19. Which of the following actions by the
nurse is the MOST effective means of
preventing infection?
(A) Washing hands after client contact
(B) Washing hands after removing gloves
(C) Hand hygiene between clients
(D) Hand hygiene before entry to a
client’s room and upon exit of a client’s
room
20. The client is an obese male with
decubitus ulcers. Treatment of the ulcers
requires frequent turning and repositioning.
The nursing unit has a special lift that allows
for turning of clients and placement onto a
bedpan without any lifting on the part of the
staff. The client urgently requests the
bedpan. Because the lift apparatus takes a
few minutes to set up, which of the following
should the nurse do?
(A) Quickly assist the client onto the bedpan
without the lift because he needs to use it
urgently.
(B) Encourage the client to try to be
patient, and set up the apparatus.
(C) Get the assistance of an aide to help lift
the client.
(D) Encourage the client to wear an
incontinence brief.
21. The client has experienced multiple
episodes of hyperglycemia not manageable
by subcutaneous insulin injections. The
client has an active order for infusion of an
insulin drip for glycemic management to be
discontinued at bedtime, after which the
client is NPO. The client’s most recent blood
sugar level, taken at 3 P.M., was 60. Which
of the following actions by the nurse is the
MOST appropriate?
(A) The nurse should follow the order and
allow the insulin to infuse until bedtime.
(B) The nurse should recheck the client’s
blood sugar.
(C) The nurse should bring this blood
sugar level to the physician’s attention
and discuss stopping the infusion.
(D) The nurse should seek advice from
other nurses.
22. The adult children of a hospice home
care client inquire about whether it is safe to
hug their mother, because she has had a
methicillin-resistant Staphylococcus aureus
(MRSA) infection in the past. Which of the
following statements by the children would
indicate a need for further teaching by the
nurse?
(A) “We should wash our hands frequently.”
(B) “We should use hand sanitizer.”
(C) “Those of us with poor immune systems
should be extra careful.”
(D) “We should wear gowns and gloves
at all times when having contact with our
mother.”
23. The nurse witnesses another nurse,
wearing a gown and gloves, enter a client
room labeled “Airborne Precautions.” Which
of the following actions by the witnessing
nurse is MOST appropriate? (A) Notify the
nurse manager to discuss policies with the
other nurse.
(B) Ask a physician to give a presentation
on which precautions require which types of
personal protective equipment (PPE).
(C) Remind the other nurse that she
needs a mask in addition to a gown and
gloves for airborne-type precautions.
(D) Ask the other nurse to look up the policy
about precautions.
24. The nurse discovers a client on the floor
in the client’s hospital room. After examining
the client and assisting him safely back to
bed, which of the following should the nurse
do FIRST?
(A) File an incident report.
(B) Put the bed alarm back on.
(C) Institute a client observer to sit with the
client and prevent further falls.
(D) Notify the nurse manager.
25. The hospitalized client is receiving an
infusion and the pump has malfunctioned.
Which of the following actions by the nurse
is MOST appropriate once the infusion has
been stopped and restarted with a
functioning pump?
(A) Place a “Broken” sticker on the
malfunctioning pump according to
hospital policy, and place the pump in
the designated malfunctioning
equipment area.
(B) Place the malfunctioning pump in the
utility room.
(C) Remove the malfunctioning pump from
the client’s room and place with other
pumps.
(D) Place the malfunctioning pump to the
side in the client’s room.
26. The nurse completes a peripherally
inserted central catheter (PICC) line
dressing change for a home care client.
When removing the PPE, the nurse should
do which of the following?
(A) Remove the mask and then the gloves.
(B) Remove the gloves and then the mask.
(C) Remove only the gloves; there is no
need to wear a mask.
(D) Remove only the mask; there is no need
to wear gloves.
27. The client is found on the floor by the
nursing assistive personnel (NAP). Once
the client is safe, which of the following
should the nurse do next?
(A) Document the event in the client’s
medical record and file an incident report.
(B) File an incident report only.
(C) Document the event in the client’s
medical record and have the NAP file an
incident report.
(D) Document the event in the client’s
medical record only.
28. The nurse is making a home visit to an
elderly client during the winter. The nurse
notices upon arrival that the client has the
oven turned on with the oven door open,
and is using it as a form of heat. Which of
the following actions by the nurse is MOST
appropriate?
(A) Take care of the client’s medical needs
and do not get involved in the client’s
private matters.
(B) Shut the oven off and continue with the
home visit.
(C) Report the event to the local Fire
Department.
(D) Have a meeting with the client and
family and warn them of the fire and
safety risks of using the oven for heat.
29. The medical center encounters a bomb
threat. The emergency response team
informs the staff that the threat is legitimate
and that clients should start being
evacuated. Which of the following clients
should the nurse begin evacuating FIRST to
the safe designated area?
(A) Ambulatory clients
(B) Bedridden clients
(C) ICU clients
(D) Infant clients
30. The nurse discovers that the last dose
of intravenous antibiotic administered to a
client was the wrong dose. Which of the
following should the nurse do?
(A) Document the event in the client’s
medical record only.
(B) File an incident report, and document
the event in the client’s medical record.
(C) Document in the client’s medical record
that an incident report was filed.
(D) File an incident report, but don’t
document the event in the client’s medical
record, because information about the
incident is protected.
PERIOP
Which test is the best resource for
determining the preoperative status of a
client's liver function?
A. Serum electrolytes
B. Blood urea nitrogen (BUN), creatinine
C. Alanine amino transferase (ALT),
aspirate amino transferase (AST),
bilirubin
D Serum albumin
A client who is having a mastectomy
expresses sadness about losing her breast.
Based on this information, the nurse would
identify that the client is at risk for which
nursing diagnosis?
A. Body Image Disturbance
B. Anticipatory Grieving
C. Fear
D. Ineffective Coping
Which statement by the client indicates that
the preoperative teaching regarding
gallbladder surgery has been effective?
A. "I cannot eat or drink anything after
midnight."
B. "I'm not going to cough after surgery
because it might open my incision."
C. "I might have a stroke if I stop taking my
anticoagulant."
D. "The nurse showed me how to
contract and
relax my calf muscles."
The nurse assesses a postoperative client
who has a rapid, weak pulse; urine output
less than 30 mL/hr; and decreased blood
pressure. The client's skin is cool and
clammy. What complication should the
nurse suspect?
A. Thrombophlebitis
B. Hypovolemic shock
C. Pneumonia
D. Wound dehiscence
The client is most likely to require the
greatest amount of analgesia for pain during
which period?
A. Immediately after surgery
B. 4 hours after surgery
C. 12 to 36 hours after surgery
D. 48 to 60 hours after surgery
A semiconscious client in the
postanesthesia care unit (PACU) is
experiencing dyspnea (difficulty breathing).
Which action should the nurse perform first?
A. Place a pillow under the client's head.
B. Remove the oropharyngeal airway.
C. Administer oxygen by mask.
D. Reposition the client to keep the
tongue forward.
Five minutes after receiving a preoperative
sedative medication by IV injection, a
patient asks to get up to go to the bathroom
to urinate. What is the most appropriate
action for the nurse to take?
A. Offer the patient to use the
urinal/bedpan after explaining the need
to maintain safety.
B. Assist the patient to the bathroom and
stay next to the door to assist patient back
to bed when done.
c. Allow the patient to go to the bathroom
since the onset of the medication will be
more than 5 minutes.
d. Ask the patient to hold the urine for a
short period since a urinary catheter will be
placed in the operating room.
What is the primary reason for accurately
recording the patient's current medications
during a preoperative assessment?
A. Some medications may alter the patient's
perceptions about surgery.
B. Many anesthetics alter renal and hepatic
function, causing toxicity of other drugs.
C. Some medications may interact with
anesthetics, altering the potency and
effect of the drugs.
D. Routine medications are withheld the day
of surgery, requiring dosage and schedule
adjustments after surgery
While performing preoperative teaching, the
patient asks when she needs to stop
drinking water before the surgery. Based on
the most recent practice guidelines
established by the American Society of
Anesthesiologists, the nurse tells the patient
that
A. she must be NPO after breakfast.
B. she needs to be NPO after midnight.
C. she can drink clear liquids up to 2
hours before surgery.
D. she can drink clear liquids up until she is
moved to the OR.
The nurse is admitting a patient to the
same-day surgery unit. The patient tells the
nurse that he was so nervous he had to
take kava last evening to help him sleep.
Which nursing action would be most
appropriate?
A. Tell the patient that using kava to help
sleep is often helpful.
B. Inform the anesthesiologist of the
patient's recent use of kava.
C. Tell the patient that the kava should
continue to help him relax before surgery.
D. Inform the patient about the dangers of
taking herbal medicines without consulting
his health care provider.
Which preoperative patient has the greatest
risk of bleeding as a result of his or her
medication?
A. A woman who takes metoprolol
(Lopressor) for the treatment of
hypertension
B. A man whose type 1 diabetes is
controlled with insulin injections four times
daily
C. A man who is taking clopidogrel
(Plavix) after the placement of a coronary
artery stent
D, A man who recently started taking
finasteride (Proscar) for the treatment of
benign prostatic hyperplasia
The patient is having a mole removed that
has changed appearance. What does the
nurse teach the patient about the rationale
for this surgical procedure?
A. It is to prevent malignancy.
B. It is to alleviate symptoms.
C. It is to cure the malignancy.
D. It is to provide cosmetic improvement.
This will be the patient's first surgical
experience and the patient states, "I am
nervous about this." The vital signs show
BP 158/88, HR 96, RR 24. In the
assessment, the nurse finds that the lungs
are clear, bowel tones are evident,
peripheral pulses are strong, and the patient
is fidgeting nervously. The patient took
alprazolam (Xanax) at bedtime last night
and takes acetaminophen (Tylenol) for
tension headaches. Related to this
assessment information, what should the
nurse do before the patient goes to
surgery?
A. Review the surgery with the patient.
B. Notify the anesthesia care provider
(ACP).
C. Administer another dose of alprazolam
(Xanax).
D. Tell the patient that everything will be
okay with the surgery.
When reviewing the preoperative forms, the
nurse notices that the informed consent
form is not present or signed. What is the
best action for the nurse to take?
A. Have the patient sign the consent form.
B. Have the family sign the form for the
patient.
C. Call the surgeon to obtain consent for
surgery.
D. Teach the patient about the surgery and
get verbal permission
As the nurse is preparing a patient for
outpatient surgery, the patient wants to give
his hearing aid to his wife so it will not be
lost during surgery. Which action by the
nurse should be taken in this situation?
A. Give the hearing aid to the wife as he
wishes.
B. Tape the hearing aid to his ear to prevent
loss.
C. Encourage the patient to wear it for
the surgery.
D. Tell the surgery nurse that he has his
hearing aid out.
An alert male patient needs a tracheostomy
because he has been intubated for 7 days
with an endotracheal tube and cannot be
weaned from the ventilator. The patient
does not want the tracheostomy, but his
family insists that the surgery be performed.
What is the best action for the nurse to
take?
A. Advocate for the patient's rights.
B. Try to change the patient's mind.
C. Call surgery to cancel the procedure.
D. Tell the family they cannot interfere.
A. Advocate for the patient's rights.
The nurse is doing a preoperative
assessment on a male patient who has type
2 diabetes mellitus, weighs 146 kg, and is 5
feet 8 inches tall. Which patient assessment
is a priority related to anesthesia?
A. Has hemoglobin A1C of 8.5%
B. Has several seasonal allergies
C. Has body mass index of 48.8 kg/m2
D. Has history of postoperative vomiting
The nurse would be alerted to the
occurrence of malignant hyperthermia when
the patient demonstrates what
manifestation?
A. Hypocapnia
B. Muscle rigidity
C. Decreased body temperature
D. Confusion upon arousal from anesthesia
What event in the surgical suite represents
a violation of aseptic technique?
A. A glove contacts the leg of the table
that supports the sterile field.
B. The cuff of the scrub nurse's sterile gown
contacts the sterile field.
C. The sterile field was established at 0650,
and the current time is 0900.
D. Bacteria are present in the nares and
upper respiratory passages of the nurse
A 71-year-old male patient who is currently
undergoing coronary artery bypass graft
(CABG) surgery has just experienced
intraoperative vomiting. The nurse should
consequently anticipate the use of which
drug?
A. Midazolam (Versed)
B. Fentanyl (Sublimaze)
C. Meperidine (Demerol)
D. Ondansetron (Zofran)
A surgical patient's premedication regimen
includes midazolam (Versed). What are the
most likely desired effects of this
medication?
A. Monitored anesthesia care and
amnesia
B. Potentiates volatile agents to speed
induction
C. Analgesia and prevention of
intraoperative vomiting
D. Relaxation of skeletal muscles and
facilitation of endotracheal intubation
The new nursing student is confused about
where the patient's family (who are wearing
street clothes) can be with the patient in the
surgical suite. Which explanation should the
perioperative nurse give to the student
nurse?
A. The family is not allowed to talk to the
nurse at the nursing station.
B. The family can be with the patient in
the preoperative holding area.
C. The family cannot be with the patient
until the postanesthesia care unit.
D. The family is only allowed in the
conference room for preoperative teaching.
Which National Patient Safety Goal (NPSG)
requirement is enacted immediately before
surgery with a surgical time-out?
A. Prevention of infection
B. Improved staff communication
C. Identify patients at risk for suicide.
D. Patient, surgical procedure, and site
are checked.
A patient having an open reduction internal
fixation (ORIF) of a left lower leg fracture
will receive regional anesthesia during the
procedure. As the patient is prepared in the
operating room, what should the nurse
implement to maintain patient safety during
surgery that is directly related to the type of
anesthesia being used?
A. Apply grounding pad to unaffected leg.
B. Assess peripheral pulses and skin color.
C. Verify the last oral intake before surgery.
D. Ensure a smooth surface under the
patient

A 78-year-old patient is having surgery.
What risk areas will the nurse need to be
especially aware of for this patient during
surgery?
A. Sterility
B. Paralysis
C. Urine output
D. Skin integrity
The patient is going to have a colonoscopy.
Which type of anesthesia should the nurse
expect to be used?
A. Local anesthesia
B. Moderate sedation
C. General anesthesia
D. Monitored anesthesia care (MAC)
In which surgical area will the patient's skin
be prepped for surgery, and what clothing
will the person doing the prepping be
wearing?
A. Surgical suite wearing a lab coat
B. Preoperative holding area wearing street
clothes
C. Postanesthesia care unit (PACU)
wearing scrubs
D. Operating room wearing surgical
attire and masks
Unless contraindicated by the surgical
procedure, which position is preferred for
the unconscious patient immediately
postoperative?
A. Supine
B. Lateral
C. Semi-Fowler's
D. High-Fowler's
The nurse is working on a surgical floor and
is preparing to receive a postoperative
patient from the postanesthesia care unit
(PACU). What should the nurse's initial
action be upon the patient's arrival?
A. Assess the patient's pain.
B. Assess the patient's vital signs.
C. Check the rate of the IV infusion.
D. Check the physician's postoperative
orders.
When assessing a patient's surgical
dressing on the first postoperative day, the
nurse notes new, bright-red drainage about
5 cm in diameter. In response to this finding,
what should the nurse do first?
A. Recheck in 1 hour for increased
drainage.
B. Notify the surgeon of a potential
hemorrhage.
C. Assess the patient's blood pressure
and heart rate.
D. Remove the dressing and assess the
surgical incision.
In planning postoperative interventions to
promote repositioning, ambulation,
coughing, and deep breathing, which action
should the nurse recognize will best enable
the patient to achieve the desired
outcomes?
A. Administering adequate analgesics to
promote relief or control of pain
B. Asking the patient to demonstrate the
postoperative exercises every 1 hour
C. Giving the patient positive feedback
when the activities are performed correctly
D. Warning the patient about possible
complications if the activities are not
performed
Bronchial obstruction by retained secretions
has contributed to a postoperative patient's
recent pulse oximetry reading of 87%.
Which health problem is the patient
probably experiencing?
A. Atelectasis
B. Bronchospasm
C. Hypoventilation
D. Pulmonary embolism
In caring for the postoperative patient on the
clinical unit after transfer from the PACU,
which care can be delegated to the
unlicensed assistive personnel (UAP)?
A. Monitor the patient's pain.
B. Do the admission vital signs.
C. Assist the patient to take deep breaths
and cough.
D. Change the dressing when there is
excess drainage
The patient had abdominal surgery. The
estimated blood loss was 400 mL. The
patient received 300 mL of 0.9% saline
during surgery. Postoperatively, the patient
is hypotensive. What should the nurse
anticipate for this patient?
A. Blood administration
B. Restoring circulating volume
C. An ECG to check circulatory status
D. Return to surgery to check for internal
bleeding
The patient donated a kidney, and early
ambulation is included in her plan of care.
But the patient refuses to get up and walk.
What rationale should the nurse explain to
the patient for early ambulation?
A. "Early walking keeps your legs limber
and strong."
B. "Early ambulation will help you be ready
to go home."
C. "Early ambulation will help you get rid of
your syncope and pain."
D. "Early walking is the best way to
prevent postoperative complications."
An older patient who had surgery is
displaying manifestations of delirium. What
should the nurse do first to provide the best
care for this new patient?
A. Check his chart for intraoperative
complications.
B. Check which medications were used for
anesthesia.
C. Check the effectiveness of the
analgesics he has received.
D. Check his preoperative assessment
for previous delirium or dementia.
A patient is having elective cosmetic
surgery performed on her face. The surgeon
will keep her at the surgery center for 24
hours after surgery. What is the nurse's
postoperative priority for this patient?
A. Manage patient pain.
B. Control the bleeding.
C. Maintain fluid balance.
D. Manage oxygenation status.
A nurse is providing preoperative teaching
to a client who is scheduled for a
gastrectomy in 1 week. The client is anxious
about the surgery. Which of the following is
an appropriate action for the nurse to take?
a. sympathize with client's feelings
b. reassure the client that the surgery will go
fine
c. change the subject
d. provide concise, factual information
A nurse is providing preoperative teaching
for a client. Which of the following
prescribed medications should the nurse
instruct the client to discontinue 48 hr prior
to the surgery?
a. furosemide
b. digoxin
c. prednisone
d. warfarin
A nurse is reviewing the medical record of a
client who is to undergo general anesthesia.
What should the nurse report to the
provider?
a. potassium level 2.8 mEq/L
b. Sodium level 140 mEq/L
c. INR 1.5
d. BUN 12 mg/dL
A nurse is caring for a client who is
postoperative and has a jackson-pratt drain
in place. Which of the following
interventions should the nurse use to
ensure proper functioning of the drain?
a. secure the drain to the client's bed sheet
b. clamp drain when client is ambulating
c. empty and compress the drain
reservoir as needed
d. keep the drain higher than surgical site
A nurse is providing teaching for a client
who is scheduled to undergo moderate
(conscious) sedation for a bronchoscopy.
The nurse should verify that the client
understands the procedure when the client
states which of the following?
a. "I will need to complete a bowel prep the
day b4 procedure"
b. "i will drink plenty of fluids the morning of
the procedure"
c. "I can eat as soon as the procedure is
over"
d. "I can expect to feel sleepy for several
hours after the procedure"
A nurse is taking a preoperative medication
history on a client who is scheduled for
surgery. Which of the following medications
should the nurse recognize as placing the
client at risk for complications due to
interaction with anesthetic agents?
a. captopril
b. atorvastatin
c. Ranitidine
d. Ciprofloxacin
A nurse is caring for a client who is
postoperative following abdominal surgery.
Which of the following nursing interventions
should the nurse perform to prevent
respiratory complications?
a. Instruct client to exhale into the inception
spirometer every 1 to 2 hrs
b. minimize the amount of pain medication
to prevent sedation
c. advice the client to splint the surgical
incision when coughing and deep
breathing
d. reposition the client every 8 hr for the 1st
48 hrs.
A nurse is providing preoperative teaching
for a client who is scheduled to have a
mastectomy. Which of the following
statements by the client indicates a need for
further teaching?
a. " I should wait 3 to 4 weeks after surgery
to do water aerobics"
b. ill wait until a week after surgery to
start hand strengthening exercises"
c. "I should avoid having blood drawn from
the arm on the side I had my mastectomy"
d. "Ill be able to shower after the doctor
removes the drain"
A nurse is providing teaching for a client
who is in the immediate postoperative
period and has a PCA pump. Which of the
following statements should the nurse
include in the teaching?
a. "You will receive a dose of medication
every time you push the bottom"
b. "Do not allow your family to push the
PCA button if you are sleeping"
c. "You cannot receive too much medication
by pushing the button"
d. "Do not push the PCA button until your
pain reaches a severe level"
A nurse is assessing a client in the PACU to
determine if he is ready for discharge.
Which of the following assessment findings
indicates the client is ready for discharge?
a. clients preoperative BP was 140/90
mmHg and her postoperative BP is 100/65
mm Hg
b. client rates her pain a 4/10
c. client is able to move all four
extremities on command
d. client requires tactile stimulation to
awaken
A nurse is receiving afternoon report on four
clients who have returned from the PACU
this morning. The nurse should assess
which of the following clients first?
a. client who is postoperative following a
thoracotomy; has a chest tub with 150
mL bright red blood in the collection
chamber from the past hour
b. client who is postoperative following a
small bowel resection and has a temporary
colostomy; absent bowel sounds in all four
quadrants
c. client who is postoperative following a
tonsillectomy has had one episode of
coffee-ground emesis
d. client who is postoperative following a
TKA and has a PCA pump and reporting a
knee pain of 7/10
A client is transferred from the surgical suite
to the PACU following oral surgery. While
monitoring VS, nurse finds that the tongue
has become swollen and is obstructing the
airway. Which of the following should the
nurse take first?
a. contact the anesthesiologist
b. assist with endotracheal intubation
c. increase the client's flow of oxygen
d. use the head-tilt, chin-lift method to
open the airway
A client had an open transverse colectomy
5 days ago. The nurse enters the client's
room and recognizes that the wound has
been eviscerated. After covering the wound
with a sterile, saline-soaked dressing, which
of the following actions should the nurse
take?
a. Go to nurses; station to seek assistance
b. reinsert the organs into abdominal cavity
c. place client in reverse trendelenburg
position
d. obtain vital signs to assess for shock
A nurse is caring for a client who is 2 days
post-operative following a cholecystectomy.
The client has been vomiting for the past 24
hrs and reports pain of 8/10. The nurse
notes a hard, distended abdomen, and
absent bowel sounds. After conferring with
the provider, which of the following actions
should the nurse take first?
a. draw the client's blood for electrolytes
b. insert a NG tube
c. Administer pain medication
d. Initiate I and O's
A nurse is caring for a client receiving
moderate (concious) sedation with
midazolam and fentanyl. The client's
respirations decrease from 16/min to 6/min,
and the oxygen saturation decreases from
92% to 85%. Which of the following actions
should the nurse take first?
a. gather suction equipment
b. obtain equipment necessary for CPR
c. Administer reversal agents
d. start an additional IV line
A nurse is assessing a client who is 2 hr
postoperative following an appendectomy.
Which of the following findings should the
nurse report to the provider?
a. Urine output 20 mL/hr
b. Temperature 36.5C (97.7F)
c. A 2X2 cm area of bloody drainage on the
dressing
d. Jackson-Pratt drainage 30 ml/hr
A nurse is caring for a patient who is
postoperative. To prevent formation of
thrombi in the postoperative period, the
nurse should do which of the following?
a. change client's position every 4 hrs
b. have client perform dorsal and plantar
flexion of feet every hr
c. place the client in bed with a pillow under
the knees
d. assess pedal and posterior tibial pulses
every 2 hr.
A nurse is caring for a client who has an NG
tube set to continuous low suction following
a gastrectomy. Which of the following
findings should the nurse report to the
provider?
a. gastric distention
b. absent bowel sounds
c. Incisional pain of 9/10
d. small amount of bloody drainage in the
NG tube
A nurse is caring for a client during surgery.
To prevent neuromuscular complications
during the surgical procedure, the nurse
should take which of the following actions?
a. administer an IV bolus of normal saline
b. massage the client's lower extremities
during the procedure
c. support the client's bony prominences
with foam padding
d. extend the client;s joints and maintain
position with padded straps
A nurse is caring for a client who has a
surgical wound with a Penrose drain in
place. Which of the following interventions
should the nurse plan to perform?
a. cut a slit in a 4 inch gauze pad to place
around drain
b. use sterile technique while performing
dressing changes
c. establish a clamping schedule prior to
removal
d. apply negative pressure when emptying
drain
A nurse is assessing a client's recovery
from spinal anesthesia. Which of the
following sensations should the nurse
expect to return to the client first?
a. pain
b. cold
c. touch
d. warmth
A nurse is completing a preoperative
assessment for a client who is a Jehovah's
witness. Which of the following should the
nurse recognize as a situation that could
pose special care needs for this client?
a. having preoperative blood drawn
b. giving information about sexual history
c. providing informed consent to receive
blood products
d. receiving care from a nurse of the
opposite gender
A surgical nurse enters the surgical suite to
ensure surgical asepsis is maintained.
Which of the following observations requires
an intervention?
a. scrub technologist is wearing a watch
under his scrubs
b. the circulating nurse opens dressing
packages before applying sterile gloves
c. surgeon has her hands folded 5 cm (2in)
above the waist
d. holding area nurse is performing client
education
A nurse is monitoring a client receiving
succinylcholine during a surgical procedure.
Which of the following actions should the
nurse take if the client develops malignant
hyperthermia?
a. administer dantrolene
b. institute seizure precautions
c. monitor blood glucose
d. Give IV atropine
A nurse is completing an initial PACU
assessment of a client who is postoperative
following a TKA and recieved spinal
anesthesia. Which of the following findings
indicates the need to notify the provider?
a. client states having numbness to the
lower extremities bilaterally
b. spinal anesthesia is at T10 level
c. client rouses to tactile stimuli
d. The client reports chest pain
A nurse is preparing a client for surgery. Tje
client appears apprehensive and asks
multiple questions about the risks of the
procedure. Which of the following actions
should the nurse take before witnessing the
client's signing of the informed consent
form?
a. explain risks and benefits of the surgery
to client
b. ask the surgeon to speak to the client
for clarification
c. reassure the client that the procedure is
necessary for recovery
d. document the client's lack of preoperative
teaching
A nurse who is working in the surgical suite
should check that the rooms are maintained
at a cool temperature with low humidity to
decrease which of the following?
a. risk for malignant hyperthermia
b. amount of anesthetic agents clients need
c. risk for infection
d. amount of oxygen clients need
A nurse is providing discharge instructions
for a client who is postoperative following
abdominal surgery. Which of the following
client statements indicates a need for
further teaching?
a. "I will call my doctor if I have an increase
in temperature or wound drainage"
b. "I will eat foots high in protein and vitamin
C during recovery"
c. "I will complete the entire course of
antibiotics"
d. "I will remain on bed rest until my
follow-up appointment with my doctor"
A nurse is caring for a client who is
postoperative following a total hip
arthroplasty. Which of the following
assessment date indicates the client is at an
increased risk for infection?
a. use of herbal remedies
b. long term use of corticosteroids
c. excessive exposure to sunlight
d. diet high in cholesterol
A nurse is assessing a client who is 2 days
postoperative following a total
prostatectomy. The nurse notes the client;s
right calf is red, edematous, and warm to
touch. Which of the following actions should
the nurse take?
a. Apply ice pack to the client's right calf
b. elevate the client's right extremity
c. administer testosterone to the client
d. gently massage the client's right calf
PERIOP
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
A postoperative client asks the nurse why
it is so important to deep-breathe and
cough after surgery. When formulating a
response, the nurse incorporates the
understanding that retained pulmonary
secretions in a postoperative client can
lead to which condition?
1. Pneumonia
2. Hypoxemia
3. Fluid imbalance
4. Pulmonary embolism
The nurse is developing 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
mouthwash.
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.
A client with a perforated 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.
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."
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.
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
(aspirin). 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."
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
3. Purulent drainage
4. Warm, tender skin
The nurse is monitoring the status of a
postoperative client. 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 four
quadrants
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. Sodium, 141 mEq/L
2. Hemoglobin, 8.0 g/dL
3. Platelets, 210,000 cells/mm3
4. Serum creatinine, 0.8 mg/dL
The nurse receives a telephone call from
the postanesthesia 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.
The nurse is reviewing a health care
provider's (HCP's) prescription sheet for a
preoperative client that states that the client
must be NPO after midnight. The nurse
would telephone the HCP to clarify that
which medication should be given to the
client and not withheld?
1. Prednisone
2. Ferrous sulfate
3. Cyclobenzaprine (Flexeril)
4. Conjugated estrogen (Premarin)
The nurse is caring for a client who is
postoperative following a pelvic exenteration
and the health care provider changes the
client's diet from NPO status to clear liquids.
The nurse should check which priority item
before administering the diet?
1. Bowel sounds
2. Ability to ambulate
3. Incision appearance
4. Urine specific gravity
A gastrectomy is performed on a client with
gastric cancer. In the immediate
postoperative period, the nurse notes
bloody drainage from the nasogastric tube.
The nurse should take which most
appropriate action?
1. Measure abdominal girth.
2. Irrigate the nasogastric tube.
3. Continue to monitor the drainage.
4. Notify the health care provider (HCP).
The nurse is assessing the colostomy of a
client who has had an abdominal perineal
resection for a bowel tumor. Which
assessment finding indicates that the
colostomy is beginning to function?
1. The passage of flatus
2. Absent bowel sounds
3. The client's ability to tolerate food
4. Bloody drainage from the colostomy
The nurse in a surgical unit receives a
postoperative client from the postanesthesia
care unit. After the initial assessment of the
client, the nurse should plan to continue
with postoperative assessment activities
how often?
1. Every hour for 2 hours, and then every 4
hours as needed
2. Every 30 minutes for the first hour, every
hour for 2 hours, and then every 4 hours as
needed
3. Every 15 minutes for the first hour,
every 30 minutes for 2 hours, every hour
for 4 hours, and then every 4 hours as
needed
4. Every 5 minutes for the first half-hour,
every 15 minutes for 2 hours, every 30
minutes for 4 hours, and then every hour as
needed
The nurse is developing a plan of care for a
preoperative client who has a latex allergy.
Which intervention should be included in the
plan?
1. Avoid using medications from glass
ampules.
2. Use medications that are from ampules
with rubber stoppers.
3. Avoid using intravenous (IV) tubing that is
made of polyvinyl chloride.
4. Apply a cloth barrier to the client's arm
under a blood pressure cuff when taking
the blood pressure.
A client is admitted to the ambulatory
surgery center for elective surgery. The
nurse asks the client whether any food,
fluid, or medication was taken today. Which
medication, if taken by the client, should
indicate to the nurse the need to contact the
health care provider (HCP)?
1. A β-blocker
2. An antibiotic
3. An anticoagulant
4. A calcium-channel blocker
The home care nurse visits a client to
perform a dressing change on a leg ulcer.
The client has diabetes mellitus and a
history of cardiac disease and is taking one
aspirin daily in addition to other medications
as prescribed. The client tells the nurse that
dental surgery is scheduled and asks the
nurse whether the aspirin should be
discontinued. The nurse should most
appropriately make which statement to the
client?
1. "The pharmacist should be called."
2. "There is no risk to having such a minor
surgery while taking aspirin."
3. "Aspirin has no effect on the surgical
procedure and may minimize discomfort."
4. "Dental surgery can safely be done
usually 10 days after stopping the
aspirin, depending on the health care
provider's (HCP) preference."
A nurse is providing preoperative teaching
to a client scheduled for a cholecystectomy.
Which intervention would be of highest
priority in the preoperative teaching plan?
1. Teaching leg exercises
2. Teaching coughing and deep
breathing exercises
3. Providing instructions regarding fluid
restrictions
4. Assessing the client's understanding of
the surgical procedure
A client who has undergone radical neck
dissection is experiencing problems with
verbal communication related to
postoperative hoarseness. The nurse
should formulate which outcome as the
most appropriate goal for this client
problem?
1. Uses nonverbal communication only
2. Describes that hoarseness will be
permanent
3. Initiates communication only when
necessary
4. Incorporates nonverbal forms of
communication as needed
A preoperative client has received a dose of
scopolamine as prescribed by the
anesthesiologist. The nurse should assess
the client for which anticipated side effect of
this medication?
1. Diaphoresis
2. Pupillary constriction
3. Increased urinary output
4. Dry oral mucous membranes
A client arrives at the surgical unit after
nasal surgery. The client has nasal packing
in place. The nurse reviews the health care
provider's prescriptions and understands
that it is essential that the client be placed in
which position to reduce swelling?
1. Sims
2. Prone
3. Supine
4. Semi-Fowler's position
The nurse is providing discharge
instructions to the client who has had a
pneumonectomy and prepares a list of
postoperative instructions for the client.
Which intervention should the nurse include
in the list?
1. Contact the HCP if any feelings of
weakness and fatigue occur.
2. Avoid breathing exercises to allow the
diaphragm to strengthen.
3. Avoid lifting any objects greater than 30
pounds for at least 3 weeks.
4. Report any signs of respiratory
infection to the health care provider
(HCP).
A postoperative client with a large
abdominal wound requiring frequent
dressing changes is starting to develop skin
irritation in the area where the dressing tape
is applied to the skin. The nurse determines
that the client would benefit most from
which measure?
1. Obtaining a wound culture
2. The use of Montgomery straps
3. The use of hypoallergenic tape
4. Cleansing the irritated area with
povidone-iodine
A client is recovering well 24 hours after
cranial surgery but is fatigued. The
neurosurgeon advances the client from
NPO status to clear liquids. The nurse
knows that which information is least
reliable in determining the client's readiness
to take in fluids?
1. Appetite
2. Absence of nausea
3. Presence of bowel sounds
4. Presence of a swallow reflex
The nurse is caring for a 25-year-old client
who will undergo bilateral orchidectomy for
testicular cancer. Which statement by the
nurse would be helpful in exploring the
client's concerns about loss of reproductive
ability?
1. "You must be sad that you won't be able
to have children after surgery."
2. "Has the health care provider told you
that you will not be able to have children?"
3. "Can you share with me any concerns
about how this surgery will affect you in
the future?"
4. "Do you feel that the health care provider
has told you all you need to know about the
upcoming surgery?"
The nurse has a prescription to remove the
nasogastric (NG) tube from a client on the
first postoperative day after cardiac surgery.
The nurse should question the prescription
if which finding was noted on assessment of
the client?
1. The client is drowsy.
2. Bowel sounds are absent.
3. The abdomen is slightly distended.
4. NG tube drainage is Hematest negative.
A client arrives at the surgical unit after
undergoing rhinoplasty and has a nose
splint and gauze drip (moustache dressing)
in place. The nurse reviews the health care
provider's prescriptions and anticipates that
which client position will be prescribed?
1. Sims
2. Prone
3. Supine
4. Semi-Fowler's
The nurse has instructed a preoperative
client using an incentive spirometer to
sustain the inhaled breath for 3 seconds.
When the client asks about the rationale for
this action, the nurse explains that this
action achieves which function?
1. Dilates the major bronchi
2. Increases surfactant production
3. Maintains inflation of the alveoli
4. Enhances ciliary action in the
tracheobronchial tree
A client has a risk for infection following
radical vulvectomy. Therefore, the nurse
should avoid which action when giving
perineal care to this client?
1. Cleansing with warm tap water
2. Intermittently exposing the wound to air
3. Providing prescribed sitz baths after the
sutures are removed
4. Providing perineal care after each voiding
and bowel movement (BM)
In preparation for ambulation, the nurse is
planning to assist a postoperative client to
progress from a lying position to a sitting
position. Which nursing action is most
appropriate to maintain the safety of the
client?
1. Assess the client for signs of
dizziness and hypotension.
2. Allow the client to rise from the bed to a
standing position unassisted.
3. Elevate the head of the bed quickly to
assist the client to a sitting position.
4. Assist the client to move quickly from the
lying position to the sitting position.

A client has returned to the nursing unit
after an abdominal hysterectomy. The client
is lying supine. To thoroughly assess the
client for postoperative bleeding what is the
primary nursing action?
1. Check the heart rate.
2. Check the blood pressure.
3. Roll the client to one side and check
her perineal pad.
4. Ask the client about sensation of
moistness on her perineal pad.
A client has received atropine sulfate
intravenously during a surgical procedure.
The nurse should monitor the client for
which side effect of the medication in the
immediate postoperative period?
1. Diarrhea
2. Bradycardia
3. Urinary retention
4. Excessive salivation
The nurse is providing home care
instructions to the parents of an infant who
had a surgical repair of an inguinal hernia.
What instruction should the nurse include to
prevent infection at the surgical site?
1. Report a fever immediately.
2. Restrict the infant's physical activity.
3. Change the diapers as soon as they
become damp.
4. Soak the infant in a tub bath twice a day
for the next 5 days.
The nurse is assessing a client who had
abdominal surgery earlier in the day. Which
preexisting medical condition would place
the client at most risk for postoperative
complications?
1. Pacemaker
2. Osteoporosis
3. Alcohol abuse
4. Peptic ulcer disease
An 85-year-old client is hospitalized for a
fractured right hip. During the postoperative
period, the client's appetite is poor and the
client refuses to get out of bed. Which
nursing statement would be most
appropriate to make to the client?
1. "We need to give you iodine so to help in
hemoglobin synthesis."
2. "It is important for you to get out of
bed so that calcium will go back into the
bone."
3. "We need to increase your calcium intake
because you are spending too much time in
bed."
4. "You need to remember to turn yourself in
bed every 2 hours to keep from getting so
stiff."
The nurse is obtaining a pulse oximetry
reading from a postoperative client who
appears short of breath. The client has dark
fingernail polish on top of artificial nails.
What is the most appropriate action?
1. Take the pulse oximetry reading from any
finger.
2. Remove one of the artificial nails and
then obtain the reading from the finger.
3. Obtain a pulse oximetry reading from
another appropriate area, such as an
earlobe.
4. Obtain fingernail polish remover, remove
the polish, and then obtain the pulse
oximetry reading from a finger.
A client returns to the nursing unit following
a pyelolithotomy for removal of a kidney
stone. A Penrose drain is in place. Which
action should the nurse include in the
client's postoperative plan of care?
1. Positioning the client on the affected side
2. Irrigating the Penrose drain using sterile
procedure
3. Changing dressings frequently around
the Penrose drain
4. Weighing dressings and adding the
amount to the output
Which assessment finding indicates that a
client who had a mastectomy is
experiencing a complication related to the
surgery?
1. Pain at the incisional site
2. Arm edema on the operative side
3. Sanguineous drainage in the
Jackson-Pratt drain
4. Complaints of decreased sensation near
the operative site
An operating room nurse is positioning a
client on the operating room table to prevent
the client's extremities from dangling over
the sides of the table. A nursing student
who is observing for the day asks the nurse
why this is so important. The nurse
responds that this is done primarily to
prevent which condition?
1. An increase in pulse rate
2. A drop in blood pressure
3. Nerve and muscle damage
4. Muscle fatigue in the extremities
The nurse is preparing a preoperative client
for transfer to the operating room. The
nurse should take which action in the care
of this client at this time?
1. Ensure that the client has voided.
2. Administer all the daily medications.
3. Verify that the client has not eaten for the
last 24 hours.
4. Have the client practice postoperative
breathing exercises.
When performing a surgical dressing
change on a client's abdominal dressing,
the nurse notes an increased amount of
drainage and separation of the incision line.
The underlying tissue is visible to the nurse.
The nurse should take which action in the
initial care of this wound?
1. Leave the incision open to the air to dry
the area.
2. Irrigate the wound and apply a sterile dry
dressing.
3. Apply a sterile dressing soaked with
normal saline.
4. Apply a sterile dressing soaked in
povidone-iodine (Betadine).
The nurse is developing a list of home care
instructions for a client being discharged
after a laparoscopic cholecystectomy.
Which instruction would be least appropriate
to include in the postoperative discharge
plan of care?
1. Wound care
2. Follow-up care
3. Activity restrictions
4. Deep-breathing exercises
A man has had an invasive abdominal
surgery to relieve an obstruction in his
common bile duct. The man's surgery is
completed and he has been transferred to
the postanesthesia care unit (PACU). The
PACU nurse observes that the man
suddenly appears red in the face and
appears to be coughing despite the
presence of an endotracheal tube and
ventilator support. What action should the
PACU nurse take first?
1. Suction the client through the
endotracheal tube.
2. Instruct the client in the use of an
incentive spirometer.
3. Turn the client from a 30-degree lateral
position to a supine position.
4. Instruct the client to use a communication
board to tell the nurse what is wrong.
When a client is transferred from the
post-anesthesia care unit (PACU) and
arrives on the surgical unit, which should be
the first action taken by the nurse?
1. Assess the client's pain.
2. Obtain the client's vital signs.
3. Administer oxygen to the client.
4. Check the rate of the intravenous
infusion.
A nurse provides instructions to a
preoperative client about the use of an
incentive spirometer. The nurse determines
that the client needs further instruction if the
client indicates that he or she will take which
action?
1. Sit upright when using the device.
2. Inhale slowly, maintaining a constant flow.
3. Place the lips completely over the
mouthpiece.
4. After maximal inspiration, hold the
breath for 10 seconds and then exhale.
A client has a prescription for continuous
monitoring of oxygen saturation by pulse
oximetry for a preoperative client. The nurse
should perform whichbest action to ensure
accurate readings on the oximeter?
1. Apply the sensor to a finger that is cool to
the touch.
2. Apply the sensor to a finger with very
dark nail polish.
3. Ask the client to limit motion in the
hand attached to the pulse oximeter.
4. Place the sensor distal to an intravenous
(IV) site with a continuous IV infusion.
The preoperative client expresses anxiety to
the nurse about the upcoming surgery.
Which statement by the nurse is most likely
to stimulate further discussion between the
client and the nurse?
1. "If it's any help, everyone is very nervous
before surgery."
2. "I will be happy to explain the entire
surgical procedure to you."
3. "Let me tell you about the amount of pain
you can anticipate."
4. "Can you share with me what you've
been told about your surgery?"
A nurse is preparing the client for transfer to
the operating room. The nurse should take
which action first?
1. Ensure that the client has voided.
2. Administer all the daily medications.
3. Verify the client has not eaten for the last
24 hours.
4. Teach and practice postoperative
breathing exercises.
The nurse is caring for a client who recently
returned from the operating room. On data
collection, the nurse notes that the client's
vital signs are blood pressure (BP), 118/70
mm Hg; pulse, 91 beats/minute; and
respirations, 16 breaths/minute.
Preoperative vital signs were BP, 132/88
mm Hg; pulse, 74 beats/minute; and
respirations, 20 breaths/minute. Which
action should the nurse plan to take first?
1. Call the surgeon immediately.
2. Shake the client gently to arouse.
3. Cover the client with a warm blanket.
4. Recheck the vital signs in 15 minutes.

The nurse has just reassessed the condition

of the postoperative client who was
admitted 1 hour ago to the surgical unit.
Which parameter should the nurse carefully
monitor during the next hour?
1. Urinary output of 20 mL/hr
2. Temperature of 37.6° C (99.6° F)
3. Blood pressure of 116/78 mm Hg
4. Serous drainage on the surgical dressing

The nurse is caring for a client who was

admitted to the surgical unit postoperatively
with a wound drain (Jackson-Pratt) in place.
What is the primary purpose of a
Jackson-Pratt drain?
1. It decreases the risk of evisceration and
dehiscence.
2. It provides an accurate measurement of
wound drainage.
3. It reduces the risk of infection and helps
the wound heal faster.
4. It assists in the evacuation of fluid and
blood from the surgical wound.

A nurse is reviewing the health care

provider's prescription sheet for a
preoperative client, which states that the
client must be NPO after midnight. Which
medication should the nurse clarify to be
given and not withheld?
1. Atenolol (Tenormin)
2. Atorvastatin (Lipitor)
3. Cyclobenzaprine (Flexeril)
4. Conjugated estrogen (Premarin)