LPN MEDICAL SURGICAL ATI NCLEX
Questions and Answers QuestionBank
A nurse is caring for a client with a history of congestive heart failure at risk for development of
fluid volume excess. The nurse should monitor for which of the following that is a manifestation
of left sided heart failure?
Swelling of the fingers and hands
Jugular neck vein distension
3+ ankle edema
Dyspnea with a cough that is worse at night - <CORRECT ANSWER >>Dyspnea with a cough that
is worse at night
Dyspnea with a cough that is worse at night is an indication of left-sided heart failure. Left-sided
heart failure causes blood to back up in the heart and lungs with decreased distribution of
blood throughout the body.
Which client problem should receive highest priority when a client is admitted with an acute
exacerbation of rheumatoid arthritis?
Difficulty with hygiene and grooming
Impaired physical mobility
Body-image disturbance
Anxiety - <CORRECT ANSWER >>Impaired physical mobility
When setting priorities for nursing care, physiological needs should be addressed first according
to Maslow's Hierarchy of Needs. Reducing the client's pain will help with other needs, such as
hygiene and grooming.
,A nurse is caring for a client with hypoparathyroidism. Because of the potential electrolyte
disturbance associated with this diagnosis, the nurse should observe the client for evidence of
which of the following?
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss - <CORRECT ANSWER >>Involuntary muscle spasms
A decrease in parathormone secretion leads to hypocalcemia (decreased serum calcium levels),
which may cause tetany. Involuntary muscle spasms are a common symptom associated with
hypothyroidism.
A client with glaucoma is admitted for surgery the following day. The client is to continue
treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4 times a day. While instilling this
medication, an appropriate nursing action is which of the following?
Instruct the client to blink several times after instillation of the medication.
Ask the client to look straight ahead.
Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min.
Dab excess medication from the eye using a cotton ball 10 to 15 seconds after instillation. -
<CORRECT ANSWER >>Place the medication in the conjunctival sac applying pressure to the
puncta for 1 to 2 min.
Eye drops are instilled into the conjunctival sac and pressure applied to the puncta for 1 to 2
min to prevent loss of medication into the nasal lacrimal duct and into the systemic circulation.
A client has sprained an ankle while playing soccer. For the first 24 hr following the injury, the
nurse should instruct the client to do which of the following?
Perform gentle range of motion (ROM) exercises on the ankle joint to prevent contractures.
, Keep moist heat on the ankle to prevent muscle spasm.
Keep the foot in a dependent position to aide circulation to the foot.
Keep ice on the ankle to prevent edema. - <CORRECT ANSWER >>Keep ice on the ankle to
prevent edema.
Ice or cold will constrict blood vessels to the injured area decreasing swelling. Nerve impulse
transmission will also be reduced, resulting in analgesia to the injured area and a reduction of
muscle spasms. Ice applications should not exceed 20 to 30 min per application.
A nurse is assisting with the discharge of a client newly diagnosed with diabetes. When
reviewing information about proper foot care, which of the following would be appropriate to
include?
Soak feet every night in warm water.
Wear clean cotton socks daily.
Walk barefoot at home when possible.
Get fitted for shoes in the morning. - <CORRECT ANSWER >>Wear clean cotton socks daily.
Cotton socks should be worn by clients who are diabetic. They are soft and will wick excess
moisture away from the foot.
Following a transient ischemic attack (TIA), a client is alert, slightly confused, and has a blood
pressure of 204/102 mm Hg. The client is also incontinent of urine. When contributing to the
client's plan of care, which nursing action would be appropriate?
Offer the client a bedpan every 2 hr.
Place an adult diaper on the client and check every 2 hr.
Request a prescription for an indwelling urinary catheter from the client's provider.
Ambulate the client to the bathroom every 4 hr. - <CORRECT ANSWER >>Offer the client a
bedpan every 2 hr.
The effects of a TIA are usually temporary, and the nurse should try to help the client regain
bladder control. This option helps the client regain bladder control, uses an appropriate time
interval (2 hr) for bladder training, and keeps the client safe by maintaining bed rest.
Questions and Answers QuestionBank
A nurse is caring for a client with a history of congestive heart failure at risk for development of
fluid volume excess. The nurse should monitor for which of the following that is a manifestation
of left sided heart failure?
Swelling of the fingers and hands
Jugular neck vein distension
3+ ankle edema
Dyspnea with a cough that is worse at night - <CORRECT ANSWER >>Dyspnea with a cough that
is worse at night
Dyspnea with a cough that is worse at night is an indication of left-sided heart failure. Left-sided
heart failure causes blood to back up in the heart and lungs with decreased distribution of
blood throughout the body.
Which client problem should receive highest priority when a client is admitted with an acute
exacerbation of rheumatoid arthritis?
Difficulty with hygiene and grooming
Impaired physical mobility
Body-image disturbance
Anxiety - <CORRECT ANSWER >>Impaired physical mobility
When setting priorities for nursing care, physiological needs should be addressed first according
to Maslow's Hierarchy of Needs. Reducing the client's pain will help with other needs, such as
hygiene and grooming.
,A nurse is caring for a client with hypoparathyroidism. Because of the potential electrolyte
disturbance associated with this diagnosis, the nurse should observe the client for evidence of
which of the following?
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss - <CORRECT ANSWER >>Involuntary muscle spasms
A decrease in parathormone secretion leads to hypocalcemia (decreased serum calcium levels),
which may cause tetany. Involuntary muscle spasms are a common symptom associated with
hypothyroidism.
A client with glaucoma is admitted for surgery the following day. The client is to continue
treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4 times a day. While instilling this
medication, an appropriate nursing action is which of the following?
Instruct the client to blink several times after instillation of the medication.
Ask the client to look straight ahead.
Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min.
Dab excess medication from the eye using a cotton ball 10 to 15 seconds after instillation. -
<CORRECT ANSWER >>Place the medication in the conjunctival sac applying pressure to the
puncta for 1 to 2 min.
Eye drops are instilled into the conjunctival sac and pressure applied to the puncta for 1 to 2
min to prevent loss of medication into the nasal lacrimal duct and into the systemic circulation.
A client has sprained an ankle while playing soccer. For the first 24 hr following the injury, the
nurse should instruct the client to do which of the following?
Perform gentle range of motion (ROM) exercises on the ankle joint to prevent contractures.
, Keep moist heat on the ankle to prevent muscle spasm.
Keep the foot in a dependent position to aide circulation to the foot.
Keep ice on the ankle to prevent edema. - <CORRECT ANSWER >>Keep ice on the ankle to
prevent edema.
Ice or cold will constrict blood vessels to the injured area decreasing swelling. Nerve impulse
transmission will also be reduced, resulting in analgesia to the injured area and a reduction of
muscle spasms. Ice applications should not exceed 20 to 30 min per application.
A nurse is assisting with the discharge of a client newly diagnosed with diabetes. When
reviewing information about proper foot care, which of the following would be appropriate to
include?
Soak feet every night in warm water.
Wear clean cotton socks daily.
Walk barefoot at home when possible.
Get fitted for shoes in the morning. - <CORRECT ANSWER >>Wear clean cotton socks daily.
Cotton socks should be worn by clients who are diabetic. They are soft and will wick excess
moisture away from the foot.
Following a transient ischemic attack (TIA), a client is alert, slightly confused, and has a blood
pressure of 204/102 mm Hg. The client is also incontinent of urine. When contributing to the
client's plan of care, which nursing action would be appropriate?
Offer the client a bedpan every 2 hr.
Place an adult diaper on the client and check every 2 hr.
Request a prescription for an indwelling urinary catheter from the client's provider.
Ambulate the client to the bathroom every 4 hr. - <CORRECT ANSWER >>Offer the client a
bedpan every 2 hr.
The effects of a TIA are usually temporary, and the nurse should try to help the client regain
bladder control. This option helps the client regain bladder control, uses an appropriate time
interval (2 hr) for bladder training, and keeps the client safe by maintaining bed rest.
