LPN MEDICAL SURGICAL ATI
NCLEX EXAM 2025 QUESTIONS
AND ANSWERS |100% SOLVED
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 - ....ANSWER ...-Dyspnea with
a cough that is worse at night
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,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 - ....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
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,Cold intolerance
Weight loss - ....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. - ....ANSWER ...-Place the medication in the conjunctival sac
applying pressure to the puncta for 1 to 2 min.
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 3
, 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. - ....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?
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 4
NCLEX EXAM 2025 QUESTIONS
AND ANSWERS |100% SOLVED
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 - ....ANSWER ...-Dyspnea with
a cough that is worse at night
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 1
,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 - ....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
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 2
,Cold intolerance
Weight loss - ....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. - ....ANSWER ...-Place the medication in the conjunctival sac
applying pressure to the puncta for 1 to 2 min.
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 3
, 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. - ....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?
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 4
