HESI Medical Surgical Review Questions With Answers (244 Solved Questions)
Improve your problem-solving speed with HESI Medical Surgical Review Questions With Answers, a collection of past exams.
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A client who has undergone abdominal surgery calls the nurse and reports that she just felt
“something give way” in the abdominal incision. The nurse checks the incision and notes the
presence of wound dehiscence. The nurse immediately:
Contacts the physician
Documents the findings
Places the client in a supine position with the legs flat
Covers the abdominal wound with a sterile dressing moistened with sterile saline solution
Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When
dehiscence occurs,the nurse immediately places the client in a low Fowler’s position or supine
with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion
of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened
with sterile saline. The physician is notified, and the nurse documents the occurrence and the
nursing actions that were implemented in response.
Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.”
Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is
the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing
actions to be taken immediately in the event of wound dehiscence if you had difficulty with this
question.
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is
restless and her pulse rate is increased. As the nurse continues the assessment, the client
begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:
Notify the surgeon
Continue the assessment
Check the client’s blood pressure
Obtain a flashlight, gauze, and a curved hemostat
Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the
client vomits a large amount of bright-red blood or the pulse rate increases and the patient is
restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror,
gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The
nurse should also gather additional assessment data, but the surgeon must be contacted
immediately.
Test-Taking Strategy: Focus on the data in the question. Noting the words “bright-red blood” will
assist in directing you to the correct option. Remember that the presence of bright-red blood
indicates active bleeding. Review the nursing actions to be taken immediately when bleeding
occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question.
“something give way” in the abdominal incision. The nurse checks the incision and notes the
presence of wound dehiscence. The nurse immediately:
Contacts the physician
Documents the findings
Places the client in a supine position with the legs flat
Covers the abdominal wound with a sterile dressing moistened with sterile saline solution
Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When
dehiscence occurs,the nurse immediately places the client in a low Fowler’s position or supine
with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion
of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened
with sterile saline. The physician is notified, and the nurse documents the occurrence and the
nursing actions that were implemented in response.
Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.”
Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is
the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing
actions to be taken immediately in the event of wound dehiscence if you had difficulty with this
question.
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is
restless and her pulse rate is increased. As the nurse continues the assessment, the client
begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:
Notify the surgeon
Continue the assessment
Check the client’s blood pressure
Obtain a flashlight, gauze, and a curved hemostat
Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the
client vomits a large amount of bright-red blood or the pulse rate increases and the patient is
restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror,
gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The
nurse should also gather additional assessment data, but the surgeon must be contacted
immediately.
Test-Taking Strategy: Focus on the data in the question. Noting the words “bright-red blood” will
assist in directing you to the correct option. Remember that the presence of bright-red blood
indicates active bleeding. Review the nursing actions to be taken immediately when bleeding
occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question.
A client who has undergone abdominal surgery calls the nurse and reports that she just felt
“something give way” in the abdominal incision. The nurse checks the incision and notes the
presence of wound dehiscence. The nurse immediately:
Contacts the physician
Documents the findings
Places the client in a supine position with the legs flat
Covers the abdominal wound with a sterile dressing moistened with sterile saline solution
Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When
dehiscence occurs,the nurse immediately places the client in a low Fowler’s position or supine
with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion
of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened
with sterile saline. The physician is notified, and the nurse documents the occurrence and the
nursing actions that were implemented in response.
Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.”
Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is
the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing
actions to be taken immediately in the event of wound dehiscence if you had difficulty with this
question.
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is
restless and her pulse rate is increased. As the nurse continues the assessment, the client
begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:
Notify the surgeon
Continue the assessment
Check the client’s blood pressure
Obtain a flashlight, gauze, and a curved hemostat
Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the
client vomits a large amount of bright-red blood or the pulse rate increases and the patient is
restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror,
gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The
nurse should also gather additional assessment data, but the surgeon must be contacted
immediately.
Test-Taking Strategy: Focus on the data in the question. Noting the words “bright-red blood” will
assist in directing you to the correct option. Remember that the presence of bright-red blood
indicates active bleeding. Review the nursing actions to be taken immediately when bleeding
occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question.
“something give way” in the abdominal incision. The nurse checks the incision and notes the
presence of wound dehiscence. The nurse immediately:
Contacts the physician
Documents the findings
Places the client in a supine position with the legs flat
Covers the abdominal wound with a sterile dressing moistened with sterile saline solution
Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When
dehiscence occurs,the nurse immediately places the client in a low Fowler’s position or supine
with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion
of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened
with sterile saline. The physician is notified, and the nurse documents the occurrence and the
nursing actions that were implemented in response.
Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.”
Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is
the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing
actions to be taken immediately in the event of wound dehiscence if you had difficulty with this
question.
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is
restless and her pulse rate is increased. As the nurse continues the assessment, the client
begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:
Notify the surgeon
Continue the assessment
Check the client’s blood pressure
Obtain a flashlight, gauze, and a curved hemostat
Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the
client vomits a large amount of bright-red blood or the pulse rate increases and the patient is
restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror,
gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The
nurse should also gather additional assessment data, but the surgeon must be contacted
immediately.
Test-Taking Strategy: Focus on the data in the question. Noting the words “bright-red blood” will
assist in directing you to the correct option. Remember that the presence of bright-red blood
indicates active bleeding. Review the nursing actions to be taken immediately when bleeding
occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question.
A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and
tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets
about:
Preparing the client for a perfusion scan
Attaching the client to a cardiac monitor
Administering oxygen by way of nasal cannula Correct
Ensuring that the intravenous (IV) line is patent
Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately
administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the
physician is notified. IV infusion lines are needed to administer medications or fluids. A
perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for
the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for
arterial blood gas determinations drawn. The immediate priority, however, is the administration
of oxygen.
Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Apply the
ABCs (airway, breathing, and circulation) to find the correct option. Review the nursing actions
to be taken immediately in the event of pulmonary embolism if you had difficulty with this
question.
A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes
constant bubbling in the water seal chamber. What actions should the nurse take? (Select all
that apply).
Clamping the chest tube
Changing the drainage system
Assessing the system for an external air leak
Reducing the degree of suction being applied
Documenting assessment findings, actions taken, and client response
Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system
may indicate the presence of an air leak. The nurse would assess the chest tube system for the
presence of an external air leak if constant bubbling were noted in this chamber. If an external
air leak is not present and the air leak is a new occurrence, the physician is notified immediately,
because an air leak may be present in the pleural space. Leakage and trapping of air in the
pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect.
Additionally, a chest tube is not clamped unless this has been specifically prescribed in the
agency’s policies and procedures. Changing the drainage system will not alleviate the problem.
Reducing the degree of suction being applied will not affect the bubbling in the water seal
chamber and could be harmful. The nurse would document the assessment findings and
interventions taken in the client’s medical record.
Test-Taking Strategy: Use the process of elimination and your knowledge regarding the priority
actions in the care of a closed chest tube drainage system. Focus on the data in the question,
tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets
about:
Preparing the client for a perfusion scan
Attaching the client to a cardiac monitor
Administering oxygen by way of nasal cannula Correct
Ensuring that the intravenous (IV) line is patent
Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediately
administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the
physician is notified. IV infusion lines are needed to administer medications or fluids. A
perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for
the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for
arterial blood gas determinations drawn. The immediate priority, however, is the administration
of oxygen.
Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Apply the
ABCs (airway, breathing, and circulation) to find the correct option. Review the nursing actions
to be taken immediately in the event of pulmonary embolism if you had difficulty with this
question.
A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes
constant bubbling in the water seal chamber. What actions should the nurse take? (Select all
that apply).
Clamping the chest tube
Changing the drainage system
Assessing the system for an external air leak
Reducing the degree of suction being applied
Documenting assessment findings, actions taken, and client response
Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system
may indicate the presence of an air leak. The nurse would assess the chest tube system for the
presence of an external air leak if constant bubbling were noted in this chamber. If an external
air leak is not present and the air leak is a new occurrence, the physician is notified immediately,
because an air leak may be present in the pleural space. Leakage and trapping of air in the
pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect.
Additionally, a chest tube is not clamped unless this has been specifically prescribed in the
agency’s policies and procedures. Changing the drainage system will not alleviate the problem.
Reducing the degree of suction being applied will not affect the bubbling in the water seal
chamber and could be harmful. The nurse would document the assessment findings and
interventions taken in the client’s medical record.
Test-Taking Strategy: Use the process of elimination and your knowledge regarding the priority
actions in the care of a closed chest tube drainage system. Focus on the data in the question,
noting that there is bubbling in the water seal chamber. Recalling that this may indicate an air
leak will direct you to the correct options. Review the nursing actions to be taken immediately in
the event that complications of a closed chest tube drainage system occur if you had difficulty
with this question.
A nurse is helping a client with a closed chest tube drainage system get out of bed and into a
chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the
insertion site. The immediate priority on the part of the nurse is:
Contacting the physician
Reinserting the chest tube
Transferring the client back to bed
Covering the insertion site with a sterile occlusive dressing
Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the
site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the
client back into bed, and contacts the physician. The nurse does not reinsert the chest tube. The
physician will reinsert the chest tube as necessary.
Test-Taking Strategy: Use the process of elimination, noting the strategic word “immediate.”
Eliminate the option that involves reinsertion of the chest tube first, because a nurse is not
trained to insert a chest tube. To select from the remaining options, focus on the subject,
dislodgment of a chest tube from its insertion site, and recall the complications associated with
this occurrence; this will direct you to the correct option. Review the nursing actions to be taken
immediately in the event of complications associated with a closed chest tube drainage system
if you had difficulty with this question.
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody
secretions. The nurse would first:
Continue suctioning to remove the blood
Check the degree of suction being applied
Encourage the client to cough out the bloody secretions
Remove the suction catheter from the client’s nose and begin vigorous suctioning through the
mouth
Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs,
the nurse should first assess the client and then determine the degree of suction being applied.
The degree of suction pressure may need to be decreased. The nurse must also remember to
apply intermittent suction and perform catheter rotation during suctioning. Continuing the
suctioning or performing vigorous suctioning through the mouth will result in increased trauma
and therefore increased bleeding. Suctioning is normally performed on clients who are unable to
expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody
secretions.
leak will direct you to the correct options. Review the nursing actions to be taken immediately in
the event that complications of a closed chest tube drainage system occur if you had difficulty
with this question.
A nurse is helping a client with a closed chest tube drainage system get out of bed and into a
chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the
insertion site. The immediate priority on the part of the nurse is:
Contacting the physician
Reinserting the chest tube
Transferring the client back to bed
Covering the insertion site with a sterile occlusive dressing
Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the
site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the
client back into bed, and contacts the physician. The nurse does not reinsert the chest tube. The
physician will reinsert the chest tube as necessary.
Test-Taking Strategy: Use the process of elimination, noting the strategic word “immediate.”
Eliminate the option that involves reinsertion of the chest tube first, because a nurse is not
trained to insert a chest tube. To select from the remaining options, focus on the subject,
dislodgment of a chest tube from its insertion site, and recall the complications associated with
this occurrence; this will direct you to the correct option. Review the nursing actions to be taken
immediately in the event of complications associated with a closed chest tube drainage system
if you had difficulty with this question.
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody
secretions. The nurse would first:
Continue suctioning to remove the blood
Check the degree of suction being applied
Encourage the client to cough out the bloody secretions
Remove the suction catheter from the client’s nose and begin vigorous suctioning through the
mouth
Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs,
the nurse should first assess the client and then determine the degree of suction being applied.
The degree of suction pressure may need to be decreased. The nurse must also remember to
apply intermittent suction and perform catheter rotation during suctioning. Continuing the
suctioning or performing vigorous suctioning through the mouth will result in increased trauma
and therefore increased bleeding. Suctioning is normally performed on clients who are unable to
expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody
secretions.
Test-Taking Strategy: Use the process of elimination. Eliminate the options of continuing the
suctioning to remove the blood and removing the suction catheter from the nose to begin
vigorous suctioning through the mouth, because they are comparable or alike. Next eliminate
the option that involves encouraging the client to cough out the bloody secretions, because it is
unlikely that the client will be able to do so. Review the nursing actions to be taken immediately
in the event of a complication during suctioning if you had difficulty with this question.
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client
begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter
from the client’s trachea but is unable to do so. The nurse would first:
Call a code
Contact the physician
Administer a bronchodilator
Disconnect the suction source from the catheter
Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the
client’s symptoms presented in the question, indicates the presence of bronchospasm and
bronchoconstriction. The nurse immediately disconnects the suction source from the catheter
but leave the catheter in the trachea. The nurse then connects the oxygen source to the
catheter. The physician is notified and will most likely prescribe an inhaled bronchodilator. The
nurse also prepares for emergency resuscitation if the bronchospasm is not relieved.
Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Eliminate
the option of administering a bronchodilator, because this action requires a physician’s
prescription. To select from the remaining options, visualize the situation presented in the
question. Noting that the nurse is unable to remove the suction catheter from the client’s trachea
will direct you to the correct option. Review the nursing actions to be taken immediately in the
event of a complication during suctioning if you had difficulty with this question.
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy
24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour.
The nurse first:
Contacts the physician
Checks for kinks in the drainage system
Checks the client’s blood pressure and heart rate
Connects a new drainage system to the client’s chest tube
Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest
drainage system. The nurse also observes the client for signs of respiratory distress or
mediastinal shift; and if such signs are noted, the physician is notified. Checking the heart rate
and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new
drainage system to the client’s chest tube is done once the fluid drainage chamber is full. A
specific procedure is followed when a new drainage system is connected to a client’s chest
tube.
suctioning to remove the blood and removing the suction catheter from the nose to begin
vigorous suctioning through the mouth, because they are comparable or alike. Next eliminate
the option that involves encouraging the client to cough out the bloody secretions, because it is
unlikely that the client will be able to do so. Review the nursing actions to be taken immediately
in the event of a complication during suctioning if you had difficulty with this question.
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client
begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter
from the client’s trachea but is unable to do so. The nurse would first:
Call a code
Contact the physician
Administer a bronchodilator
Disconnect the suction source from the catheter
Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the
client’s symptoms presented in the question, indicates the presence of bronchospasm and
bronchoconstriction. The nurse immediately disconnects the suction source from the catheter
but leave the catheter in the trachea. The nurse then connects the oxygen source to the
catheter. The physician is notified and will most likely prescribe an inhaled bronchodilator. The
nurse also prepares for emergency resuscitation if the bronchospasm is not relieved.
Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Eliminate
the option of administering a bronchodilator, because this action requires a physician’s
prescription. To select from the remaining options, visualize the situation presented in the
question. Noting that the nurse is unable to remove the suction catheter from the client’s trachea
will direct you to the correct option. Review the nursing actions to be taken immediately in the
event of a complication during suctioning if you had difficulty with this question.
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy
24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour.
The nurse first:
Contacts the physician
Checks for kinks in the drainage system
Checks the client’s blood pressure and heart rate
Connects a new drainage system to the client’s chest tube
Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest
drainage system. The nurse also observes the client for signs of respiratory distress or
mediastinal shift; and if such signs are noted, the physician is notified. Checking the heart rate
and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new
drainage system to the client’s chest tube is done once the fluid drainage chamber is full. A
specific procedure is followed when a new drainage system is connected to a client’s chest
tube.
Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Focusing
on the subject, a lack of chest tube drainage, will direct you to the correct option. Review
unexpected outcomes and related interventions in the care of a chest tube drainage system if
you had difficulty with this question.
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s
urine output for the past hour was 25 mL. On the basis of this finding, the nurse first:
Calls the physician
Increases the rate of the IV infusion
Checks the client’s overall intake and output record
Administers a 250-mL bolus of normal saline solution (0.9%)
Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign of
hypovolemia is decreasing urine output. However, the nurse needs additional data to make an
accurate interpretation. Neither an increase in the rate of the IV infusion nor administration of a
250-mL bolus of normal saline (0.9%) would be implemented without a prescription from the
physician. The physician is called once the nurse has gathered all necessary assessment data,
including the overall fluid status and vital signs.
Test-Taking Strategy: Note the strategic word “first.” Try to visualize the situation and use the
steps of the nursing process to answer the question. The correct option addresses the process
of assessment. Eliminate increasing the rate of the IV infusion and administering a 250-mL
bolus of normal saline (0.9%), because each requires a physician’s prescription. In this situation,
the nurse needs to gather additional information before contacting the physician. Review
unexpected outcomes after surgery and priority nursing interventions in the event of such
outcomes if you had difficulty with this question.
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of
the bed, and the client complains of dizziness. Which of the following actions should the nurse
take first?
Checking the client’s blood pressure
Checking the oxygen saturation level
Having the client take some deep breaths
Lowering the head of the bed slowly until the dizziness is relieved
Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned
upright for the first time after surgery. If this occurs, the nurse lowers the head of the bed slowly
until the dizziness is relieved. The nurse then checks the client’s pulse and blood pressure.
Because the problem is circulatory, not respiratory, checking the oxygen saturation level and
having the client take some deep breaths are not the first actions to be taken.
Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Note the
relationship between the subject of the question (the client becomes dizzy) and the correct
on the subject, a lack of chest tube drainage, will direct you to the correct option. Review
unexpected outcomes and related interventions in the care of a chest tube drainage system if
you had difficulty with this question.
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s
urine output for the past hour was 25 mL. On the basis of this finding, the nurse first:
Calls the physician
Increases the rate of the IV infusion
Checks the client’s overall intake and output record
Administers a 250-mL bolus of normal saline solution (0.9%)
Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign of
hypovolemia is decreasing urine output. However, the nurse needs additional data to make an
accurate interpretation. Neither an increase in the rate of the IV infusion nor administration of a
250-mL bolus of normal saline (0.9%) would be implemented without a prescription from the
physician. The physician is called once the nurse has gathered all necessary assessment data,
including the overall fluid status and vital signs.
Test-Taking Strategy: Note the strategic word “first.” Try to visualize the situation and use the
steps of the nursing process to answer the question. The correct option addresses the process
of assessment. Eliminate increasing the rate of the IV infusion and administering a 250-mL
bolus of normal saline (0.9%), because each requires a physician’s prescription. In this situation,
the nurse needs to gather additional information before contacting the physician. Review
unexpected outcomes after surgery and priority nursing interventions in the event of such
outcomes if you had difficulty with this question.
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of
the bed, and the client complains of dizziness. Which of the following actions should the nurse
take first?
Checking the client’s blood pressure
Checking the oxygen saturation level
Having the client take some deep breaths
Lowering the head of the bed slowly until the dizziness is relieved
Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned
upright for the first time after surgery. If this occurs, the nurse lowers the head of the bed slowly
until the dizziness is relieved. The nurse then checks the client’s pulse and blood pressure.
Because the problem is circulatory, not respiratory, checking the oxygen saturation level and
having the client take some deep breaths are not the first actions to be taken.
Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Note the
relationship between the subject of the question (the client becomes dizzy) and the correct
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answer. Review unexpected outcomes after surgery and the priority nursing interventions in the
event of such outcomes if you had difficulty with this question.
A nurse is preparing for intershift report when a nurse’s aide pulls an emergency call light in a
client’s room. Upon answering the light, the nurse finds a client who returned from surgery
earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60
mm Hg. Which action should the nurse take first?
Calling the physician
Checking the hourly urine output
Checking the IV site for infiltration
Placing the client in a modified Trendelenburg position
Rationale: The client is exhibiting signs of shock and requires emergency intervention. The first
action is to place the client in a modified Trendelenburg position to increase blood return from
the legs, which in turn increases venous return and subsequently the blood pressure. The nurse
calls the physician, verifies the client’s blood volume status by assessing urine output, and
ensures that the IV infusion is proceeding without complications.
Test-Taking Strategy: Note the strategic word “first.” Use your knowledge of the ABCs (airway,
breathing, circulation). The correct option addresses the client’s circulatory status. Review the
nursing interventions to be taken immediately in the event of postoperative shock if you had
difficulty with this question.
A nurse is assessing the chest tube drainage system of a postoperative client who has
undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody
drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after
the initial assessment, the nurse notes that the bubbling in the water seal chamber is now
constant, and the client appears dyspneic. On the basis of these findings, the nurse should first
assess:
The client’s vital signs
The amount of drainage
The client’s lung sounds
The chest tube connections
Rationale: The client’s dyspnea is most likely related to an air leak caused by a loose
connection. Other causes might be a tear or incision in the pulmonary pleura, which requires
physician intervention. Although the interventions identified in the other options should also be
taken in this situation, they should be performed only after the nurse has tried to locate and
correct the air leak. It only takes a moment to check the connections, and if a leak is found and
corrected, the client’s symptoms should resolve.
Test-Taking Strategy: Note the strategic word “first” and focus on the data in the question.
Recalling that a constant bubbling in the water seal chamber could indicate a leak in the system
event of such outcomes if you had difficulty with this question.
A nurse is preparing for intershift report when a nurse’s aide pulls an emergency call light in a
client’s room. Upon answering the light, the nurse finds a client who returned from surgery
earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60
mm Hg. Which action should the nurse take first?
Calling the physician
Checking the hourly urine output
Checking the IV site for infiltration
Placing the client in a modified Trendelenburg position
Rationale: The client is exhibiting signs of shock and requires emergency intervention. The first
action is to place the client in a modified Trendelenburg position to increase blood return from
the legs, which in turn increases venous return and subsequently the blood pressure. The nurse
calls the physician, verifies the client’s blood volume status by assessing urine output, and
ensures that the IV infusion is proceeding without complications.
Test-Taking Strategy: Note the strategic word “first.” Use your knowledge of the ABCs (airway,
breathing, circulation). The correct option addresses the client’s circulatory status. Review the
nursing interventions to be taken immediately in the event of postoperative shock if you had
difficulty with this question.
A nurse is assessing the chest tube drainage system of a postoperative client who has
undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody
drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after
the initial assessment, the nurse notes that the bubbling in the water seal chamber is now
constant, and the client appears dyspneic. On the basis of these findings, the nurse should first
assess:
The client’s vital signs
The amount of drainage
The client’s lung sounds
The chest tube connections
Rationale: The client’s dyspnea is most likely related to an air leak caused by a loose
connection. Other causes might be a tear or incision in the pulmonary pleura, which requires
physician intervention. Although the interventions identified in the other options should also be
taken in this situation, they should be performed only after the nurse has tried to locate and
correct the air leak. It only takes a moment to check the connections, and if a leak is found and
corrected, the client’s symptoms should resolve.
Test-Taking Strategy: Note the strategic word “first” and focus on the data in the question.
Recalling that a constant bubbling in the water seal chamber could indicate a leak in the system
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will direct you to the correct option. Review care of the client with a closed chest tube drainage
system if you had difficulty with this question.
A client recovering from surgery has a large abdominal wound. Which of the following foods,
high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound
healing?
Steak
Veal
Cheese
Oranges
Rationale: Citrus fruits and juices are especially high in vitamin C. Other sources are potatoes,
tomatoes, and other fruits and vegetables. Meats and dairy products are not especially high in
vitamin C. Meats are high in protein. Dairy products are high in calcium.
Test-Taking Strategy: Note the strategic word "high" in the question. Eliminate steak and veal
first because they are comparable or alike in that they are meats. To select from the remaining
options, recall that cheese is high in calcium, not vitamin C; this will direct you to the correct
option. If you are unfamiliar with foods high in vitamin C, review this content.
A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The
physician has prescribed a clear liquid diet for the client. Which of the following items does the
nurse ensure is available in the client’s room before allowing the client to drink?
Straw
Napkin
Suction equipment
Oxygen saturation monitor
Rationale: Aspiration is a concern when fluids are offered to a client who has just undergone
surgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia. The
nurse checks the gag and swallow reflexes before offering fluids to the client, but suction
equipment still must be available. An oxygen saturation monitor is unnecessary when fluids are
being administered, nor is a napkin or straw necessary; in fact, the straw could contribute to the
formation of flatus, resulting in gastrointestinal discomfort.
Test-Taking Strategy: The subject of the question is protecting the client’s gag and swallow
reflexes. Use your knowledge of the ABCs (airway, breathing, and circulation) to answer this
question. The correct option helps maintain airway clearance. If you had difficulty with this
question, review care of the client who has recently undergone surgery.
A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran).
Which of the following occurrences would prompt the nurse to administer this medication to the
client?
Paralytic ileus
system if you had difficulty with this question.
A client recovering from surgery has a large abdominal wound. Which of the following foods,
high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound
healing?
Steak
Veal
Cheese
Oranges
Rationale: Citrus fruits and juices are especially high in vitamin C. Other sources are potatoes,
tomatoes, and other fruits and vegetables. Meats and dairy products are not especially high in
vitamin C. Meats are high in protein. Dairy products are high in calcium.
Test-Taking Strategy: Note the strategic word "high" in the question. Eliminate steak and veal
first because they are comparable or alike in that they are meats. To select from the remaining
options, recall that cheese is high in calcium, not vitamin C; this will direct you to the correct
option. If you are unfamiliar with foods high in vitamin C, review this content.
A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The
physician has prescribed a clear liquid diet for the client. Which of the following items does the
nurse ensure is available in the client’s room before allowing the client to drink?
Straw
Napkin
Suction equipment
Oxygen saturation monitor
Rationale: Aspiration is a concern when fluids are offered to a client who has just undergone
surgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia. The
nurse checks the gag and swallow reflexes before offering fluids to the client, but suction
equipment still must be available. An oxygen saturation monitor is unnecessary when fluids are
being administered, nor is a napkin or straw necessary; in fact, the straw could contribute to the
formation of flatus, resulting in gastrointestinal discomfort.
Test-Taking Strategy: The subject of the question is protecting the client’s gag and swallow
reflexes. Use your knowledge of the ABCs (airway, breathing, and circulation) to answer this
question. The correct option helps maintain airway clearance. If you had difficulty with this
question, review care of the client who has recently undergone surgery.
A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran).
Which of the following occurrences would prompt the nurse to administer this medication to the
client?
Paralytic ileus
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Incisional pain
Urine retention
Nausea and vomiting
Rationale: Ondansetron is an antiemetic that is used in the treatment of postoperative nausea
and vomiting, as well as nausea and vomiting associated with chemotherapy. This medication is
not used to treat any of the problems identified in the other options.
Test-Taking Strategy: To answer this question accurately, it is necessary to know the
classification of this medication. Focusing on the clinical setting identified in the question should
narrow your choices to nausea and vomiting and incisional pain. To correctly select from these
two options, it is necessary to know that ondansetron is an antiemetic. Review the action of this
medication if you had difficulty with this question.
A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which
side effect of this medication does the nurse monitor the client?
Pupil constriction
Increased urine output
Complaints of dry mouth
Complaints of feeling sweaty
Rationale: Scopolamine, an anticholinergic medication, often causes the side effects of dry
mouth, urine retention, decreased sweating, and pupil dilation. The other options are incorrect.
Test-Taking Strategy: Note the words “in preparation for surgery” and use the process of
elimination. Recalling that this medication dries body secretions will direct you to the correct
option. Review the expected side effects of this medication if this question was difficult for you.
A nurse is preparing a client for transfer to the operating room. Which of the following actions
should the take in the care of this client at this time?
Ensuring that the client has voided
Administering all daily medications
Practicing postoperative breathing exercises
Verifying that the client has not eaten for the last 24 hours
Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place.
The nurse does not administer all daily medications just before sending a client to the operating
room. Rather, the physician writes a specific prescription outlining which medications may be
given with a sip of water. The client is usually prescribed to have nothing by mouth for 8 hours
before surgery, not 24 hours. The time of transfer to the operating room is not the time to
practice breathing exercises. This should have been done earlier.
Test-Taking Strategy: Note the words “at this time.” Eliminate the option that involves
administering all daily medications because of the close-ended word “all.” Eliminate the option
that involves verifying that the client has not eaten for the last 24 hours because of the words
Urine retention
Nausea and vomiting
Rationale: Ondansetron is an antiemetic that is used in the treatment of postoperative nausea
and vomiting, as well as nausea and vomiting associated with chemotherapy. This medication is
not used to treat any of the problems identified in the other options.
Test-Taking Strategy: To answer this question accurately, it is necessary to know the
classification of this medication. Focusing on the clinical setting identified in the question should
narrow your choices to nausea and vomiting and incisional pain. To correctly select from these
two options, it is necessary to know that ondansetron is an antiemetic. Review the action of this
medication if you had difficulty with this question.
A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which
side effect of this medication does the nurse monitor the client?
Pupil constriction
Increased urine output
Complaints of dry mouth
Complaints of feeling sweaty
Rationale: Scopolamine, an anticholinergic medication, often causes the side effects of dry
mouth, urine retention, decreased sweating, and pupil dilation. The other options are incorrect.
Test-Taking Strategy: Note the words “in preparation for surgery” and use the process of
elimination. Recalling that this medication dries body secretions will direct you to the correct
option. Review the expected side effects of this medication if this question was difficult for you.
A nurse is preparing a client for transfer to the operating room. Which of the following actions
should the take in the care of this client at this time?
Ensuring that the client has voided
Administering all daily medications
Practicing postoperative breathing exercises
Verifying that the client has not eaten for the last 24 hours
Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place.
The nurse does not administer all daily medications just before sending a client to the operating
room. Rather, the physician writes a specific prescription outlining which medications may be
given with a sip of water. The client is usually prescribed to have nothing by mouth for 8 hours
before surgery, not 24 hours. The time of transfer to the operating room is not the time to
practice breathing exercises. This should have been done earlier.
Test-Taking Strategy: Note the words “at this time.” Eliminate the option that involves
administering all daily medications because of the close-ended word “all.” Eliminate the option
that involves verifying that the client has not eaten for the last 24 hours because of the words
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“last 24 hours.” To select from the remaining options, focus on the words “at this time”; this will
direct you to the correct option. Remember that the client is likely to be anxious at this time,
meaning that it would be inappropriate to practice breathing exercises. Review preoperative
client care measures if you had difficulty with this question.
A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports
that a client is being transferred to the surgical unit. What should the nurse plan to do first on
arrival of the client?
Assess the patency of the airway
Check tubes and drains for patency
Check the dressing for bleeding
Assess the vital signs to compare them with preoperative measurements
Rationale: The first action of the nurse is to assess the patency of the airway. The nurse then
performs an assessment of cardiovascular function, the condition of the surgical site, the
patency of tubes and drains for patency, and the function of the central nervous system. If the
airway is not patent, immediate measures must be taken to help ensure the survival of the
client.
Test-Taking Strategy: Use your knowledge of the ABCs (airway, breathing, and circulation).
Airway patency is the priority. The incorrect options are all nursing actions that should be
performed after a patent airway has been established. Review priority nursing assessments in
the client who has undergone surgery if you had difficulty with this question.
A client without a history of respiratory disease has a pulse oximeter in place after surgery. The
nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:
85%
89%
95%
100%
Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen
saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the
expected reading is at least 95%. Therefore the other options are incorrect. Readings of 85%
and 89% are lower than what is desired in the postoperative period. A level of 100% is most
desirable, but the level should remain at least 95%
Test-Taking Strategy: Familiarity with the pulse oximeter and normal readings is needed to
answer this question. Noting the strategic word “above” in the question will help you answer
correctly. If you had difficulty with this question, review the purpose and expected results of
pulse oximetry.
direct you to the correct option. Remember that the client is likely to be anxious at this time,
meaning that it would be inappropriate to practice breathing exercises. Review preoperative
client care measures if you had difficulty with this question.
A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports
that a client is being transferred to the surgical unit. What should the nurse plan to do first on
arrival of the client?
Assess the patency of the airway
Check tubes and drains for patency
Check the dressing for bleeding
Assess the vital signs to compare them with preoperative measurements
Rationale: The first action of the nurse is to assess the patency of the airway. The nurse then
performs an assessment of cardiovascular function, the condition of the surgical site, the
patency of tubes and drains for patency, and the function of the central nervous system. If the
airway is not patent, immediate measures must be taken to help ensure the survival of the
client.
Test-Taking Strategy: Use your knowledge of the ABCs (airway, breathing, and circulation).
Airway patency is the priority. The incorrect options are all nursing actions that should be
performed after a patent airway has been established. Review priority nursing assessments in
the client who has undergone surgery if you had difficulty with this question.
A client without a history of respiratory disease has a pulse oximeter in place after surgery. The
nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:
85%
89%
95%
100%
Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen
saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the
expected reading is at least 95%. Therefore the other options are incorrect. Readings of 85%
and 89% are lower than what is desired in the postoperative period. A level of 100% is most
desirable, but the level should remain at least 95%
Test-Taking Strategy: Familiarity with the pulse oximeter and normal readings is needed to
answer this question. Noting the strategic word “above” in the question will help you answer
correctly. If you had difficulty with this question, review the purpose and expected results of
pulse oximetry.
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A client who underwent preadmission testing 1 week before surgery had blood drawn for
several serum laboratory studies. Which abnormal laboratory results should the nurse report to
the surgeon’s office? Select all that apply.
Hematocrit 30%
Sodium 141 mEq/L
Hemoglobin 8.9 g/dL
Platelets 210,000 cells/mm3
Serum creatinine 0.8 mg/dL
Rationale: Routine screening tests include complete blood cell count, serum electrolyte
analysis, coagulation studies, and serum creatinine tests. The complete blood cell count
includes the hemoglobin and hematocrit analysis. All of these values are within their normal
ranges except the hemoglobin and hematocrit. If a client has low hemoglobin and hematocrit
levels, the surgery may be postponed by the surgeon. The normal hemoglobin level ranges from
12 to 16.5 g/dL, and the hematocrit ranges from 35% to 52%.
Test-Taking Strategy: Note the strategic word “abnormal” in the question and focus on the
subject, laboratory results that could necessitate the postponement of surgery. Recalling the
normal values for the laboratory studies identified in the options will direct you to the correct
ones. Review these normal laboratory values if you had difficulty answering this question.
A client has been scheduled for magnetic resonance imaging (MRI). For which of the following
conditions, a contraindication to MRI, does the nurse check the client’s medical history?
Pancreatitis
Pacemaker insertion
Type 1 diabetes mellitus
Chronic airway limitation
Rationale: The candidate for MRI must be free of metal devices or implants. A careful history is
conducted to determine whether any such metal objects, such as orthopedic hardware,
pacemakers, artificial heart valves, aneurysm clips, and intrauterine devices, are inside the
client. These may heat up in the magnetic field generated by the MRI device, become
dislodged, or malfunction during the procedure. The other medical problems listed do not pose a
risk or contraindication for this procedure.
Test-Taking Strategy: Use the process of elimination. Note that each of the incorrect options is a
medical disorder. The correct option is the name of a procedure in which a device is implanted
into the client. Remember that it is crucial to ensure that there are no metal objects in the vicinity
of the MRI machine. Review contraindications to MRI if you had difficulty with this question.
A client has just undergone lumbar puncture. Into which position does the nurse assist the client
after the procedure?
Flat
Semi-Fowler
several serum laboratory studies. Which abnormal laboratory results should the nurse report to
the surgeon’s office? Select all that apply.
Hematocrit 30%
Sodium 141 mEq/L
Hemoglobin 8.9 g/dL
Platelets 210,000 cells/mm3
Serum creatinine 0.8 mg/dL
Rationale: Routine screening tests include complete blood cell count, serum electrolyte
analysis, coagulation studies, and serum creatinine tests. The complete blood cell count
includes the hemoglobin and hematocrit analysis. All of these values are within their normal
ranges except the hemoglobin and hematocrit. If a client has low hemoglobin and hematocrit
levels, the surgery may be postponed by the surgeon. The normal hemoglobin level ranges from
12 to 16.5 g/dL, and the hematocrit ranges from 35% to 52%.
Test-Taking Strategy: Note the strategic word “abnormal” in the question and focus on the
subject, laboratory results that could necessitate the postponement of surgery. Recalling the
normal values for the laboratory studies identified in the options will direct you to the correct
ones. Review these normal laboratory values if you had difficulty answering this question.
A client has been scheduled for magnetic resonance imaging (MRI). For which of the following
conditions, a contraindication to MRI, does the nurse check the client’s medical history?
Pancreatitis
Pacemaker insertion
Type 1 diabetes mellitus
Chronic airway limitation
Rationale: The candidate for MRI must be free of metal devices or implants. A careful history is
conducted to determine whether any such metal objects, such as orthopedic hardware,
pacemakers, artificial heart valves, aneurysm clips, and intrauterine devices, are inside the
client. These may heat up in the magnetic field generated by the MRI device, become
dislodged, or malfunction during the procedure. The other medical problems listed do not pose a
risk or contraindication for this procedure.
Test-Taking Strategy: Use the process of elimination. Note that each of the incorrect options is a
medical disorder. The correct option is the name of a procedure in which a device is implanted
into the client. Remember that it is crucial to ensure that there are no metal objects in the vicinity
of the MRI machine. Review contraindications to MRI if you had difficulty with this question.
A client has just undergone lumbar puncture. Into which position does the nurse assist the client
after the procedure?
Flat
Semi-Fowler
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Side-lying, with the head of the bed elevated
Sitting up in a recliner with the feet elevated
Rationale: After lumbar puncture, the client must remain flat for as long as 12 hours to help
prevent post-procedure spinal headache and leakage of cerebrospinal fluid. Therefore the other
options are incorrect.
Test-Taking Strategy: Use the process of elimination. Note that the incorrect options are
comparable or alike in that they all involve elevation of the client’s head. Review care of the
client after lumbar puncture if you had difficulty with this question.
A client has just returned to the nursing unit after computerized tomography (CT) with contrast
medium. Which of the following actions should the nurse plan to take as part of routine
after-care for this client?
Administering a laxative
Encouraging fluid intake
Maintaining the client on strict bed rest
Holding all medications for at least 2 hours
Rationale: After CT scanning, the client may resume all usual activities. The client should be
encouraged to consume extra fluids to replace those lost during diuresis of the contrast dye.
Medications do not have to be withheld. There is no reason to administer a laxative; also, a
physician’s prescription is needed for this intervention.
Test-Taking Strategy: Use the process of elimination and note the strategic words “contrast
medium” in the question. Recalling the importance of flushing the dye from the system after this
procedure will direct you to the correct option. Review care after a CT scan if you had difficulty
with this question.
A client reports for a scheduled electroencephalogram (EEG). Which statement by the client
indicates a need for additional preparation for the test?
“I didn’t shampoo my hair.”
“I ate breakfast this morning.”
“I didn’t take my anticonvulsant today.”
“It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.”
Rationale: Preprocedure care for EEG involves client teaching about the procedure, ensuring
that the client’s hair has been freshly shampooed, and providing a light meal and fluids to
prevent hypoglycemia, which could alter brain waves. Medications such as antidepressants,
tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure as
prescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld.
Test-Taking Strategy: Use your knowledge of the EEG procedure to answer the question and
note the strategic words “needs additional preparation.” Recalling the purpose of an EEG and
Sitting up in a recliner with the feet elevated
Rationale: After lumbar puncture, the client must remain flat for as long as 12 hours to help
prevent post-procedure spinal headache and leakage of cerebrospinal fluid. Therefore the other
options are incorrect.
Test-Taking Strategy: Use the process of elimination. Note that the incorrect options are
comparable or alike in that they all involve elevation of the client’s head. Review care of the
client after lumbar puncture if you had difficulty with this question.
A client has just returned to the nursing unit after computerized tomography (CT) with contrast
medium. Which of the following actions should the nurse plan to take as part of routine
after-care for this client?
Administering a laxative
Encouraging fluid intake
Maintaining the client on strict bed rest
Holding all medications for at least 2 hours
Rationale: After CT scanning, the client may resume all usual activities. The client should be
encouraged to consume extra fluids to replace those lost during diuresis of the contrast dye.
Medications do not have to be withheld. There is no reason to administer a laxative; also, a
physician’s prescription is needed for this intervention.
Test-Taking Strategy: Use the process of elimination and note the strategic words “contrast
medium” in the question. Recalling the importance of flushing the dye from the system after this
procedure will direct you to the correct option. Review care after a CT scan if you had difficulty
with this question.
A client reports for a scheduled electroencephalogram (EEG). Which statement by the client
indicates a need for additional preparation for the test?
“I didn’t shampoo my hair.”
“I ate breakfast this morning.”
“I didn’t take my anticonvulsant today.”
“It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.”
Rationale: Preprocedure care for EEG involves client teaching about the procedure, ensuring
that the client’s hair has been freshly shampooed, and providing a light meal and fluids to
prevent hypoglycemia, which could alter brain waves. Medications such as antidepressants,
tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure as
prescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld.
Test-Taking Strategy: Use your knowledge of the EEG procedure to answer the question and
note the strategic words “needs additional preparation.” Recalling the purpose of an EEG and
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the anatomical location of this test will direct you to the correct option. Review preparation for an
EEG if you had difficulty with this question.
Blood is drawn from a client with suspected uric acid calculi for a serum uric acid determination.
Which value does the nurse recognize as a normal uric acid level?
1.7 mg/dL
5.8 mg/dL
8.9 mg/dL
12.8 mg/dL
Rationale: The normal range for uric acid is 4.5 to 8 mg/dL for males and 2.5 to 6.2 mg/dL for
females. Therefore the other options are incorrect.
Test-Taking Strategy: To answer this question correctly, you must be familiar with the normal
range of values for serum uric acid. Review this reference range if you had difficulty with this
question.
A nurse is providing post-procedure instructions to a client returning home after arthroscopy of
the shoulder. The nurse should tell the client:
To resume full activity the next day
Not to eat or drink anything until the next morning
To keep the shoulder completely immobilized for the rest of the day
To report to the physician the development of fever or redness and heat at the site
Rationale: After arthroscopy, signs and symptoms of infection such as fever or redness and heat
at the site should be reported to the physician. The client may resume the usual diet
immediately. The arm does not have to be completely immobilized once sensation has returned,
but the client is usually encouraged to refrain from strenuous activity for at least a few days.
Test-Taking Strategy: Use the process of elimination. Eliminate keeping the shoulder completely
immobilized for the rest of the day and resuming full activity the next day, because they
represent extremes of activity variations. To select from the remaining options, remember that
the client is always taught to report signs and symptoms of infection to the physician. Review
client instructions after arthroscopy if you had difficulty with this question.
A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and
the test result is positive. The nurse should tell the client that:
HIV infection has been confirmed
The client probably has an opportunistic infection
The test will need to be confirmed with the use of a Western blot
A positive test is a normal result and does not mean that the client is infected with HIV
Rationale: The normal value for an ELISA test is negative. A positive ELISA test must be
confirmed with the use of the Western Blot. The other options are incorrect.
EEG if you had difficulty with this question.
Blood is drawn from a client with suspected uric acid calculi for a serum uric acid determination.
Which value does the nurse recognize as a normal uric acid level?
1.7 mg/dL
5.8 mg/dL
8.9 mg/dL
12.8 mg/dL
Rationale: The normal range for uric acid is 4.5 to 8 mg/dL for males and 2.5 to 6.2 mg/dL for
females. Therefore the other options are incorrect.
Test-Taking Strategy: To answer this question correctly, you must be familiar with the normal
range of values for serum uric acid. Review this reference range if you had difficulty with this
question.
A nurse is providing post-procedure instructions to a client returning home after arthroscopy of
the shoulder. The nurse should tell the client:
To resume full activity the next day
Not to eat or drink anything until the next morning
To keep the shoulder completely immobilized for the rest of the day
To report to the physician the development of fever or redness and heat at the site
Rationale: After arthroscopy, signs and symptoms of infection such as fever or redness and heat
at the site should be reported to the physician. The client may resume the usual diet
immediately. The arm does not have to be completely immobilized once sensation has returned,
but the client is usually encouraged to refrain from strenuous activity for at least a few days.
Test-Taking Strategy: Use the process of elimination. Eliminate keeping the shoulder completely
immobilized for the rest of the day and resuming full activity the next day, because they
represent extremes of activity variations. To select from the remaining options, remember that
the client is always taught to report signs and symptoms of infection to the physician. Review
client instructions after arthroscopy if you had difficulty with this question.
A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and
the test result is positive. The nurse should tell the client that:
HIV infection has been confirmed
The client probably has an opportunistic infection
The test will need to be confirmed with the use of a Western blot
A positive test is a normal result and does not mean that the client is infected with HIV
Rationale: The normal value for an ELISA test is negative. A positive ELISA test must be
confirmed with the use of the Western Blot. The other options are incorrect.
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Test-Taking Strategy: Read each option carefully and note that the test result is positive.
Recalling that an ELISA test is an HIV antibody-screening test and that a positive result must be
confirmed with the use of the Western blot will direct you to the correct option. Review
interpretations of the results of an ELISA test if you had difficulty with this question.
A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the
test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:
Improvement in the client
The need for antiretroviral therapy
The need to discontinue antiretroviral therapy
An effective response to the treatment for HIV
Rationale: The normal CD4+ count is between 500 and 1600 cells/mcL. Antiretroviral therapy is
recommended when the CD4+ count is less than 500 cells/mcL or below 25%, or when the
client shows symptoms of HIV. The other options are incorrect.
Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate the
incorrect options because they are comparable or alike in that they indicate a positive response
to treatment. If you had difficulty with this question, review the CD4+ count and the interpretation
of its results.
A client has just undergone a renal biopsy. Which intervention should the nurse include
intervention in the post-procedure plan of care?
Restricting fluid intake for the first 24 hours
Periodically testing the urine for occult blood
Avoiding the administration of opioid analgesics
Having the client ambulate in the room and hall for short distances
Rationale: After renal biopsy, bed rest is maintained and the client’s vital signs and puncture site
are assessed frequently. Urine is tested periodically for occult blood to detect bleeding as a
complication.Fluids are encouraged to reduce the risk of clot formation at the biopsy site. Opioid
analgesics are often needed to manage the renal colic pain that some clients feel after this
procedure.
Test-Taking Strategy: Use the process of elimination. Recalling that pain and bleeding are
potential concerns after this procedure will direct you to the correct option. Review care of the
client after renal biopsy if you had difficulty with this question.
A nurse has a prescription to collect a 24-hour urine specimen from a client. Which of the
following measures should the nurse take during this procedure?
Keeping the specimen at room temperature
Saving the first urine specimen collected at the start time
Discarding the last voided specimen at the end of the collection time
Asking the client to void, discarding the specimen, and noting the start time
Recalling that an ELISA test is an HIV antibody-screening test and that a positive result must be
confirmed with the use of the Western blot will direct you to the correct option. Review
interpretations of the results of an ELISA test if you had difficulty with this question.
A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the
test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:
Improvement in the client
The need for antiretroviral therapy
The need to discontinue antiretroviral therapy
An effective response to the treatment for HIV
Rationale: The normal CD4+ count is between 500 and 1600 cells/mcL. Antiretroviral therapy is
recommended when the CD4+ count is less than 500 cells/mcL or below 25%, or when the
client shows symptoms of HIV. The other options are incorrect.
Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate the
incorrect options because they are comparable or alike in that they indicate a positive response
to treatment. If you had difficulty with this question, review the CD4+ count and the interpretation
of its results.
A client has just undergone a renal biopsy. Which intervention should the nurse include
intervention in the post-procedure plan of care?
Restricting fluid intake for the first 24 hours
Periodically testing the urine for occult blood
Avoiding the administration of opioid analgesics
Having the client ambulate in the room and hall for short distances
Rationale: After renal biopsy, bed rest is maintained and the client’s vital signs and puncture site
are assessed frequently. Urine is tested periodically for occult blood to detect bleeding as a
complication.Fluids are encouraged to reduce the risk of clot formation at the biopsy site. Opioid
analgesics are often needed to manage the renal colic pain that some clients feel after this
procedure.
Test-Taking Strategy: Use the process of elimination. Recalling that pain and bleeding are
potential concerns after this procedure will direct you to the correct option. Review care of the
client after renal biopsy if you had difficulty with this question.
A nurse has a prescription to collect a 24-hour urine specimen from a client. Which of the
following measures should the nurse take during this procedure?
Keeping the specimen at room temperature
Saving the first urine specimen collected at the start time
Discarding the last voided specimen at the end of the collection time
Asking the client to void, discarding the specimen, and noting the start time
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Rationale: Because the 24-hour urine collection is a timed quantitative determination, the test
must be started with an empty bladder. Therefore the first urine is discarded. Fifteen minutes
before the end of the collection time, the client should be asked to void, and this specimen is
added to the collection. The collection should be refrigerated or placed on ice to help prevent
changes in urine composition.
Test-Taking Strategy: Use the process of elimination. Recalling that the 24-hour urine collection
is a timed quantitative determination will assist you in identifying the correct option. Review the
procedure for collecting a 24-hour urine specimen if you had difficulty with this question.
A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is
most important?
Administering a sedative
Encouraging fluid intake
Administering an oral preparation of radiopaque dye
Questioning the client about allergies to iodine or shellfish
Rationale: Some IVP dyes are iodine based; if the dye to be used in this procedure is one of
them and the client has an allergy to iodine or shellfish, he may experience an allergic reaction,
manifested as itching, hives, rash, a tight feeling in the throat, shortness of breath, or
bronchospasm. For this reason, assessing the client for allergies is the priority. The dye is
injected intravenously. The client may or may not receive premedication. Nothing-by-mouth
status is generally imposed after midnight on the day before the test.
Test-Taking Strategy: Knowledge regarding preprocedure care for this diagnostic test is
necessary to answer this question. Noting the word “intravenous” in the name of the test
indicates that a dye will be injected. This will help direct you to the correct option. Review the
priority assessments in preprocedure care for this diagnostic test if you had difficulty with this
question.
A client who has undergone renal biopsy complains of pain, radiating to the front of the
abdomen, at the biopsy site. For which of the following findings should the nurse assess the
client?
Bleeding
Renal colic
Infection at the site
Increased temperature
Rationale: Bleeding should be suspected if pain originates at the biopsy site and begins to
radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing
hematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs of
infection would not appear immediately after a biopsy. There is no information in the question to
indicate the presence of renal colic.
must be started with an empty bladder. Therefore the first urine is discarded. Fifteen minutes
before the end of the collection time, the client should be asked to void, and this specimen is
added to the collection. The collection should be refrigerated or placed on ice to help prevent
changes in urine composition.
Test-Taking Strategy: Use the process of elimination. Recalling that the 24-hour urine collection
is a timed quantitative determination will assist you in identifying the correct option. Review the
procedure for collecting a 24-hour urine specimen if you had difficulty with this question.
A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is
most important?
Administering a sedative
Encouraging fluid intake
Administering an oral preparation of radiopaque dye
Questioning the client about allergies to iodine or shellfish
Rationale: Some IVP dyes are iodine based; if the dye to be used in this procedure is one of
them and the client has an allergy to iodine or shellfish, he may experience an allergic reaction,
manifested as itching, hives, rash, a tight feeling in the throat, shortness of breath, or
bronchospasm. For this reason, assessing the client for allergies is the priority. The dye is
injected intravenously. The client may or may not receive premedication. Nothing-by-mouth
status is generally imposed after midnight on the day before the test.
Test-Taking Strategy: Knowledge regarding preprocedure care for this diagnostic test is
necessary to answer this question. Noting the word “intravenous” in the name of the test
indicates that a dye will be injected. This will help direct you to the correct option. Review the
priority assessments in preprocedure care for this diagnostic test if you had difficulty with this
question.
A client who has undergone renal biopsy complains of pain, radiating to the front of the
abdomen, at the biopsy site. For which of the following findings should the nurse assess the
client?
Bleeding
Renal colic
Infection at the site
Increased temperature
Rationale: Bleeding should be suspected if pain originates at the biopsy site and begins to
radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing
hematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs of
infection would not appear immediately after a biopsy. There is no information in the question to
indicate the presence of renal colic.
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Test-Taking Strategy: Use the process of elimination. Eliminate the options of increased
temperature and infection at the site first because they are comparable or alike. To choose
between the remaining options, recall that the information in the question is not indicative of
renal colic. Review the complications associated with renal biopsy if you had difficulty with this
question.
A client has undergone renal angiography by way of the right femoral artery. The nurse
determines that the client is experiencing a complication of the procedure on noting:
Urine output of 40 mL/hr
Blood pressure of 118/76 mm Hg
Respiratory rate of 18 breaths/min
Pallor and coolness of the right leg
Rationale: Complications of renal angiography include allergic reaction to the dye, dye-induced
renal damage, and a number of vascular complications, including hemorrhage, thrombosis, and
embolism. The nurse detects these complications by monitoring the client for signs and
symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the
insertion site, and signs of diminished circulation to the affected leg. The incorrect options are
normal findings.
Test-Taking Strategy: Use the process of elimination and note the words “a complication of the
procedure,” which should tell you that the correct option is an abnormal assessment finding.
Eliminate the incorrect options, because they are normal findings. Pallor and coolness indicate
thrombosis or hematoma and should be further assessed and reported. Review the signs of
complications after renal angiography if you had difficulty with this question.
A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as
abnormal?
pH of 6.0
An absence of protein
The presence of ketones
Specific gravity of 1.018
Rationale: The normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from
1.016 to 1.022. The urine is typically screened for protein, glucose, ketones, bilirubin, casts,
crystals, red blood cells, and white blood cells, none of which should be present.
Test-Taking Strategy: Use the process of elimination and note the strategic word “abnormal” in
the query of the question. The words “the presence of” should direct you to the correct option.
Review normal urinalysis findings if you had difficulty with this question.
A nurse provides information to a client who is scheduled for cardiac catheterization to rule out
coronary occlusion. The nurse should tell the client that:
The procedure is performed in the operating room
temperature and infection at the site first because they are comparable or alike. To choose
between the remaining options, recall that the information in the question is not indicative of
renal colic. Review the complications associated with renal biopsy if you had difficulty with this
question.
A client has undergone renal angiography by way of the right femoral artery. The nurse
determines that the client is experiencing a complication of the procedure on noting:
Urine output of 40 mL/hr
Blood pressure of 118/76 mm Hg
Respiratory rate of 18 breaths/min
Pallor and coolness of the right leg
Rationale: Complications of renal angiography include allergic reaction to the dye, dye-induced
renal damage, and a number of vascular complications, including hemorrhage, thrombosis, and
embolism. The nurse detects these complications by monitoring the client for signs and
symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the
insertion site, and signs of diminished circulation to the affected leg. The incorrect options are
normal findings.
Test-Taking Strategy: Use the process of elimination and note the words “a complication of the
procedure,” which should tell you that the correct option is an abnormal assessment finding.
Eliminate the incorrect options, because they are normal findings. Pallor and coolness indicate
thrombosis or hematoma and should be further assessed and reported. Review the signs of
complications after renal angiography if you had difficulty with this question.
A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as
abnormal?
pH of 6.0
An absence of protein
The presence of ketones
Specific gravity of 1.018
Rationale: The normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from
1.016 to 1.022. The urine is typically screened for protein, glucose, ketones, bilirubin, casts,
crystals, red blood cells, and white blood cells, none of which should be present.
Test-Taking Strategy: Use the process of elimination and note the strategic word “abnormal” in
the query of the question. The words “the presence of” should direct you to the correct option.
Review normal urinalysis findings if you had difficulty with this question.
A nurse provides information to a client who is scheduled for cardiac catheterization to rule out
coronary occlusion. The nurse should tell the client that:
The procedure is performed in the operating room
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Health Education Systems, Inc.