Galen NUR 265 (NUR265) Exam 4 – ATI-Style Review Guide | Complete Questions & Answers | Latest Fall 2026.

Complete Galen College of Nursing NUR 265 (NUR265) Exam 4 ATI-Style Review Guide featuring organized questions and answers for focused exam preparation. Designed to reinforce key Advanced Concepts of Medical-Surgical Nursing material and support efficient ATI-style practice for Exam 4. Latest updated for Fall 2026. 1. A charge nurse is discussing disaster response with nursing staff. Which of the following statements indicates an understanding of the Hospital Incident Command System (HICS)? A. HICS replaces standard hospital administrative roles with external military coordinators. B. HICS is a national agency that takes direct control of hospital clinical assignments. C. HICS is only utilized for natural disasters and is inactive during chemical or infectious outbreaks. D. HICS identifies facility responsibilities and channels of reporting within the facility to provide a uniform response plan. 2. A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following is a realistic goal for this client's care? A. The client will increase physical activity to perform 30 minutes of aerobic exercise daily. B. The client will maintain a CD4 count above 1000 cells/mm3 through daily antiretroviral therapy. C. The client will receive medication to minimize episodes of breakthrough pain. D. The client will undergo aggressive chemotherapy to reverse Kaposi's sarcoma lesions. 3. A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy (BPH). The client states, "I don't know what I will do if they find I have cancer." Which of the following therapeutic responses should the nurse make? A. "Don't worry, BPH is always benign, so there is absolutely no chance of cancer." B. "I'm sure everything will be fine; the surgeon is highly experienced in these procedures." C. "Let's focus on your surgery today rather than worrying about what might happen next week." D. "I'm hearing that you are concerned that it might turn out that you have cancer." 4. A middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for developing which of the following conditions? A. Endometrial cancer B. Laryngeal cancer C. Breast cancer D. Skin cancer 5. A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing an acute myocardial infarction? A. Administer a dose of morphine sulfate B. Obtain a sputum culture C. Check the client's capillary refill time D. Perform a 12-lead ECG 6. A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first? A. Place the client in a rigid cervical collar. B. Assess the client for peripheral bleeding. C. Complete a detailed neurological check. D. Open the client's airway using the jaw-thrust maneuver. 7. A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse? A. Performing a concise client triage assessment B. Preventing cross-contamination of incoming clients C. Transferring a stable client to the discharge location D. Maintaining a client tracking system 8. A nurse is caring for a client who is dying of metastatic breast cancer and has a PRN prescription for an opioid. The nurse is concerned that administering the pain medication might hasten death. Which of the following ethical principles supports administering the medication? A. Utilitarianism B. Veracity C. Nonmaleficence D. Fidelity 9. A nurse in the emergency department is caring for a client who was sexually assaulted. Which of the following resources provides the most effective support immediately following the incident? A. A close friend B. A social worker C. A psychologist D. A facility chaplain 10. A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions? A. Gingival hyperplasia B. Kaposi's sarcoma C. Candidiasis D. Actinic keratosis 11. A nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take? A. Position the head of the bed at 10 degrees. B. Encourage a restricted fluid intake of 1500 mL/day. C. Instruct the client to cough and deep breathe every 8 hours. D. Obtain a sputum culture. 12. A nurse is teaching a client about how to use her new hearing aids. Which of the following statements by the client indicates that she needs further instruction? A. "I will expect the hearing aids to whistle when I cup my hand over them." B. "I will change the batteries once a week." C. "I will not use hairspray if I am wearing the hearing aids." D. "I will clean the hearing aids with alcohol wipes." 13. A nurse is teaching a client's family about lightning strike prevention. Which of the following instructions should the nurse include? A. Seek safety inside an isolated metal or wooden shed. B. If caught in an open field, seek shelter under a tall tree. C. Avoid using a corded landline telephone during a storm. D. Lie completely flat on the ground to reduce your profile. 14. A community health nurse is providing a community education program about disaster preparedness. Which of the following items should the nurse recommend including in a family's disaster readiness "go bag"? A. A box of fresh fruits and flowers B. An electric space heater C. A full course of oral antibiotics D. Copies of insurance cards 15. A nurse is teaching a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching? A. "Eating a high-fiber diet will reduce my risk of developing skin cancer." B. "I should apply broad-spectrum sunscreen before going outdoors." C. "I should avoid sun exposure during peak hours from 10 AM to 4 PM." D. "I will perform a self-skin examination monthly to check my moles." 16. A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the family. The client's spouse is confused and states she does not know what to do. Which of the following responses by the nurse is appropriate? A. "Organ donation is required by federal law for patients with severe head trauma." B. "What do you think your spouse would have wanted?" C. "You should make the decision that makes you feel most comfortable right now." D. "I think you should proceed with the organ donation; it helps save lives." 17. A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide? A. Use this inhaler immediately to relieve an acute asthma attack. B. Limit your fluid intake to prevent mucosal swelling. C. Avoid brushing your teeth for at least 1 hour after inhalation. D. Rinse the mouth with water after each administration. 18. A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client's earliest clinical manifestation was: A. Dysphagia B. Unexplained weight loss C. Hoarseness D. Dyspnea 19. A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following findings should the nurse identify as an indication of acute organ rejection? A. Hypothermal response B. Hypotension C. Polyuria D. Oliguria 20. A nurse in an emergency department is assessing a client who was bitten on the leg by a poisonous snake. The client has placed elastic bandages snugly above and below the bite marks. Which of the following actions should the nurse take? A. Obtain a prescription for the appropriate anti-venom. B. Keep the bandages tightly in place to prevent venom spread. C. Apply a cold ice pack directly to the bite site. D. Elevate the affected leg above the level of the heart. 21. A nurse is caring for a middle adult client who has just received a diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is the client most likely to report? A. Postmenopausal bleeding B. Extreme abdominal pain with intercourse C. Green, malodorous vaginal discharge D. Unilateral swelling of the vulva 22. A nurse is caring for a client who is to start taking cyclosporine following a kidney transplant. The nurse should instruct the client to avoid which of the following dietary items due to a risk of adverse interaction? A. Grapefruit juice B. Smoked salmon C. Orange juice D. Pepperoni 23. A nurse is planning care for a client who has terminal cancer and is prescribed morphine. Which of the following interventions should the nurse include in the plan of care? A. Restrict fluid intake to prevent fluid overload from medication. B. Avoid using non-pharmacological pain relief methods. C. Withhold the medication if the client's heart rate drops below 100/min. D. Instruct the client to actively cough to prevent a buildup of secretions. 24. A nurse is providing an educational program about dietary interventions to reduce the risk for prostate cancer. Which of the following information should the nurse include in the teaching? A. Increase intake of red meats and processed poultry. B. Limit fluid intake to less than 1.5 liters per day. C. Increase intake of fatty fish rich in omega-3 fatty acids. D. Restrict the intake of dietary fiber. 25. A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take? A. Discharge all clients who have been in the unit for more than 48 hours. B. Focus on providing care that prevents life-threatening emergencies. C. Proactively stock additional unit supplies from the central warehouse. D. Suspend all documentation of patient vital signs. 26. The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? A. Check the pupillary response to light. B. Check the client's response to questions about orientation. C. Evaluate chest expansion. D. Assess the capillary refill time. 27. A nurse is teaching a class at a community center regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include in the program? A. Women should start having clinical breast examinations yearly at age 45. B. Clients should have their first colonoscopy screening at age 40. C. Women should start yearly mammography screenings at age 30. D. Clients should have a yearly test to check for fecal occult blood. 28. A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include? A. Widespread purplish-brown lesions on the trunk B. Chronic wasting syndrome with severe weight loss C. Flu-like symptoms and night sweats D. Bilateral lung infiltrates and severe dyspnea 29. A nurse is instructing a group of clients about nutrition and eating foods high in iron. Which of the following substances should the nurse include as an aid in the absorption of iron? A. Black tea B. Oxalates C. Vitamin C D. Calcium supplements 30. A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? A. Auscultate the client's lungs for wheezing. B. Prepare to administer intramuscular epinephrine. C. Initiate a large-bore intravenous access line. D. Place the client in a modified Trendelenburg position. 31. A nurse in an emergency department is caring for a client who has a deep laceration on her forearm and is bleeding heavily. Which of the following interventions should the nurse perform first? A. Elevate the extremity above the level of the heart. B. Apply direct pressure to the wound. C. Cleanse the wound thoroughly with sterile saline. D. Apply a tight tourniquet just above the wound. 32. A nurse is caring for a client brought to the emergency department immediately following a venomous snake bite to his forearm. Which of the following interventions should the nurse take? A. Place the affected extremity in a dependent position. B. Pack the bite site with ice to restrict blood flow. C. Elevate the forearm above the level of the heart. D. Apply a tight arterial tourniquet proximal to the bite. 33. A nurse is assessing a client with a chest knife wound who is suspected of developing cardiac tamponade. Which of the following clinical findings supports this suspicion? A. Muffled heart sounds B. Flattened neck veins C. Widened pulse pressure D. Hyperresonance on chest percussion 34. A nurse is analyzing the laboratory and clinical findings of a client with HIV over a six-month period. Which of the following findings is diagnostic of progression to HIV Stage III (AIDS)? A. Flu-like symptoms and swollen lymph nodes. B. A dry skin rash with persistent itching. C. A CD4-T-cell count of 90 cells/mm3. D. A weight loss of 15 lbs over 3 months. 35. A nurse is reviewing the results of a radioallergosorbent test (RAST) for a client with seasonal allergies. An elevation in which of the following immunoglobulins indicates a positive result? A. Immunoglobulin G (IgG) B. Immunoglobulin M (IgM) C. Immunoglobulin E (IgE) D. Immunoglobulin A (IgA) 36. A nurse in a provider's office is assessing an AIDS client who has multiple, widespread, raised, purplish-brown skin lesions. The nurse should recognize these findings as indicative of which condition? A. Actinic keratosis B. Toxic epidermal necrolysis C. Basal cell carcinoma D. Kaposi's sarcoma 37. A nurse enters a client's room and finds him unresponsive. After immediately calling the rapid response team, which of the following actions should the nurse take first? A. Deliver two rescue breaths using a bag-valve-mask. B. Check for a carotid pulse for 5 to 10 seconds. C. Initiate high-quality chest compressions. D. Apply automated external defibrillator (AED) pads. 38. A nurse is assessing a client who is 6 weeks postoperative following a renal transplant. The client reports worsening fatigue and a decrease in urination. Which of the following laboratory findings supports a suspicion of acute transplant rejection? A. Creatinine level of 2.0 mg/dL B. Potassium level of 4.1 mEq/L C. BUN level of 12 mg/dL D. Sodium level of 138 mEq/L 39. A nurse is caring for a client who is postoperative and experiences a wound evisceration. Which of the following is the priority emergency nursing intervention? A. Carefully attempt to push the protruding organs back into the abdominal cavity. B. Cover the protruding organs with a sterile dressing saturated with warm sterile saline. C. Apply a tight abdominal binder over the wound site to secure the organs. D. Place the client in a high-Fowler's position to relieve abdominal tension. 40. A client is experiencing an acute asthma emergency triggered by a bee sting. Which of the following medications should the nurse prepare to administer first? A. Intravenous aminophylline B. Inhaled fluticasone C. Oral montelukast D. Epinephrine 41. A nurse is assessing a client and notes paresthesia of the fingers and lips, tetany, and muscle twitching. Which of the following electrolyte imbalances should the nurse suspect? A. Hypokalemia B. Hypercalcemia C. Hypocalcemia D. Hyponatremia 42. A nurse is collecting data from a client with suspected peripheral vascular disease (PVD). Which of the following findings is an expected clinical sign of PVD? A. Warm, flushed skin of the lower extremities. B. Bounding pedal pulses bilaterally (+4). C. A bruit heard over the femoral and aortic arteries. D. Increased hair growth on the shins and toes. 43. A nurse is reinforcing discharge teaching with a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include? A. Cross your legs at the knees to promote centralized blood flow. B. Apply cold ice packs to the legs if they feel warm or painful. C. Elevate your legs above the level of your heart when resting. D. Incorporate walking 8 times a day into your daily routine. 44. A nurse is teaching a client with peripheral arterial disease (PAD) about proper skin care. Which of the following instructions should the nurse include? A. Apply highly perfumed lotions between the toes. B. Wash the lower extremities with warm water and a mild soap. C. Vigorously scrub dry skin with a stiff bath brush. D. Soak your feet in hot water daily for 30 minutes. 45. A nurse is assessing a client for suspected meningitis. Which of the following expected findings should the nurse anticipate? A. Hypothermia, bradycardia, and a bounding pulse. B. Nuchal rigidity, photophobia, and a red macular rash. C. Flushed skin, fruity breath, and rapid deep breathing. D. Urge to void, lower back pain, and polyuria. 46. A nurse is planning care for a client who has meningitis. Which of the following positioning restrictions should the nurse implement to prevent a dangerous rise in intracranial pressure? A. Place the client in a prone position for 2 hours every shift. B. Avoid raising the legs above the level of the heart, crossing the legs, or extreme hip flexion. C. Position the client in a high-Fowler's position with the neck fully hyperextended. D. Keep the head of the bed completely flat at 0 degrees. 47. A nurse is assessing a client with a head injury. Which of the following clinical findings is indicative of increased intracranial pressure (ICP) or hypoglycemia? A. Oliguria, lower abdominal pain, and JVD. B. Flushed skin, bounding pulse, and deep rapid respirations. C. Bradycardia, hypotension, and generalized muscle flaccidity. D. Clammy pale skin, irritability, weakness, and tremors. 48. A nurse is reinforcing discharge teaching with a client who has a urinary tract infection (UTI). Which of the following instructions should the nurse include? A. Restrict your daily fluid intake to less than 1 liter. B. Take hot bubble baths daily to soothe the perineal area. C. Attempt to empty your bladder completely every 3 to 4 hours. D. Wear synthetic or nylon underwear to keep moisture out. 49. A nurse is teaching a female client with a history of recurrent urinary tract infections (UTIs) about proper hygiene. Which of the following actions should the nurse instruct the client to perform? A. Cleanse the vaginal area with over-the-counter douching solutions. B. Wipe the perineal area from front to back after voiding. C. Wipe from back to front to ensure urethral cleanliness. D. Wash the perineal area with harsh scented soaps daily. 50. A nurse is preparing to collect a catheterized urine specimen for residual urine testing. Which of the following actions should the nurse take to safely withdraw the specimen? A. Disconnect the catheter tubing from the drainage bag to drain urine. B. Aspirate urine directly from the main drainage bag using a needle. C. Cleanse the urinary meatus with sterile saline after the procedure. D. Cleanse the side port of the catheter with alcohol before withdrawing. 51. A nurse is reinforcing discharge teaching for a client who had a lower limb amputation. Which of the following instructions should the nurse include to prevent hip flexion contractures? A. Perform active hip flexion exercises every hour. B. Sit in a soft armchair for at least 8 hours each day. C. Elevate the residual limb on a pillow continuously for the first week. D. Lie in a prone position for 20 to 30 minutes, 6 times a day. 52. A nurse is planning care for a client who is receiving mechanical ventilation. How often should the nurse assess and document the ventilator's cuff pressure? A. Every 2 hours B. Only when the ventilator high-pressure alarm sounds C. Once every 24 hours D. Every 8 hours 53. A client is prescribed methylprednisolone (Medrol) for systemic lupus erythematosus (SLE). Which of the following infection control instructions should the nurse reinforce? A. Limit close contact with individuals who have a suspected infection. B. Receive live-attenuated vaccines monthly to boost immunity. C. Increase your intake of fresh fruits and raw vegetables daily. D. Stop taking the medication immediately if a mild sore throat develops. 54. A nurse is evaluating a client for systemic lupus erythematosus (SLE) medication safety. The client is taking high-dose oral steroids. Which of the following environments should the nurse instruct the client to avoid? A. Large groups of people and crowded public areas B. Walking outdoors in a shaded park C. Individual outpatient physical therapy sessions D. Air-conditioned rooms or closed spaces 55. A nurse is assessing a client for suspected right-sided heart failure. Which of the following clinical findings should the nurse expect? A. Bradycardia, hypotension, and a localized macular rash. B. Jugular vein distention, ascending dependent edema, weight gain, and hepatomegaly. C. Flushed skin, rapid breathing, and a dry nonproductive cough. D. Dyspnea, crackles, frothy sputum, oliguria, and apnea. 56. A nurse is assessing a client with left-sided heart failure. Which of the following clinical findings should the nurse expect? A. Apnea, dyspnea, crackles, oliguria, frothy sputum, and a displaced apical pulse. B. Flushed skin, dry mucous membranes, and a fruity breath odor. C. Jugular vein distention, ascites, and lower extremity edema. D. Paresthesia of the fingers, muscle twitching, and tetany. 57. A client is postoperative following surgery for benign prostatic hypertrophy (BPH) and has a continuous bladder irrigation system with a three-way catheter in place. Which of the following instructions should the nurse reinforce? A. You will likely feel a continuous urge to void while the catheter is in place. B. You should attempt to urinate around the catheter to clear clots. C. Urine output will be measured and calculated once every 24 hours. D. You must maintain strict bed rest and avoid sitting in a chair. 58. A nurse is caring for a client with a three-way indwelling urinary catheter following BPH surgery. How often should the nurse calculate and document the client's actual urine output? A. Every 8 hours B. At the end of each 12-hour shift C. Only when the irrigation bag runs out D. Every 2 hours 59. A nurse is reinforcing discharge instructions with a client who underwent a transurethral resection of the prostate (TURP) for BPH. Which of the following instructions should the nurse include? A. Limit your fluid intake to prevent bladder distention. B. Expect your urine output to be less than 50 mL every 4 hours. C. Perform pelvic tilt exercises immediately after discharge. D. Avoid heavy lifting and sexual intercourse for 2 to 6 weeks. 60. A nurse is preparing to feed a client who is recovering from a cerebrovascular accident (CVA) and has mild dysphagia. Which of the following positioning techniques should the nurse use? A. Have the client sit upright and lean their head backward when swallowing. B. Have the client sit upright and swallow with the head and neck flexed slightly forward. C. Position the client side-lying with the head of the bed flat. D. Position the client in a semi-Fowler's position with the neck hyperextended. 61. A nurse is assisting with a meal for a client who has hemiparesis following a CVA. Where should the nurse place the food in the client's mouth? A. In the front of the mouth on the affected side. B. Directly on the tip of the tongue. C. Underneath the tongue on the weak side. D. In the back of the mouth on the unaffected side. 62. A nurse is reinforcing feeding instructions for a post-CVA client. Which of the following types of food should the nurse recommend to help stimulate saliva production and make swallowing easier? A. Bland, lukewarm purées B. Thick, sticky peanut butter C. Sour or tart foods D. Dry, crumbly breads 63. A nurse is assessing a client for hyperglycemia. Which of the following clinical findings should the nurse expect? A. Clammy pale skin, irritability, weakness, and tremors. B. Nuchal rigidity, photophobia, headache, and a macular rash. C. Flushed skin, fruity breath, rapid breathing, and extreme thirst. D. Bradycardia, hypotension, oliguria, and sunken eyes. 64. A nurse is working in a hospital when a fire breaks out in a neighboring ward. According to standard disaster planning and fire safety, what is the nurse's first priority action? A. Remove and rescue patients from immediate danger first. B. Pull the fire alarm pull-station to alert the fire department. C. Close all patient room doors to contain the smoke. D. Attempt to extinguish the fire using the nearest extinguisher. 65. A facility incident commander has initiated disaster discharge protocols to free up beds for incoming casualties. Which of the following clients must the nurse recommend to remain hospitalized? A. A client who is waiting for outpatient physical therapy placement. B. A client who has an active fever. C. A client who is 2 days postoperative with stable vital signs. D. A client who is scheduled for elective BPH surgery tomorrow. 66. A nurse is planning care for an older adult client in an adult day care setting who has a cognitive disorder. Which of the following is the priority nursing assessment? A. Calculate the client's body mass index (BMI). B. Perform a detailed cranial nerve assessment. C. Check and document the client's mental status. D. Evaluate the client's peripheral circulation. 67. A nurse is caring for a client who is postoperative following a CVA. Which of the following multidisciplinary referrals is the priority to address the client's swallowing difficulties? A. Physical Therapist B. Occupational Therapist C. Speech Therapist D. Social Worker 68. A nurse is admitting a client and needs to secure the client's valuables. Which of the following is the correct legal and institutional action for the nurse to take? A. Instruct the client to hide their valuables under the mattress. B. Keep the client's cash in the bedside drawer for easy access. C. Lock the valuables in the staff medication cart until discharge. D. Hand the money and valuables directly to facility security for safekeeping. 69. A nurse is reviewing the regulations for infectious diseases. Which of the following pathogens is classified as a nationally notifiable infectious disease? A. Escherichia coli (E. coli) B. Candida albicans C. Staphylococcus aureus D. Streptococcus pneumoniae 70. A nurse is discussing organ donation with a client's family. The nurse should explain that the decision to become an organ donor must legally be made by: A. The primary care physician. B. The patient themselves (unless incapacitated without prior designation). C. The facility's ethics committee. D. The transplant coordinator. 71. A nurse is planning a discharge referral for a client who suffered a spinal cord injury. Which of the following professionals should the nurse include to help the client regain daily living skills? A. Respiratory Therapist and Social Worker. B. Speech Therapist and Dietician. C. Chaplain and Psychologist. D. Occupational Therapy Assistant (OTA) and Physical Therapist (PT). 72. A client is preparing an advance directive and asks the nurse about the function of a living will. Which of the following explanations should the nurse provide? A. A living will designates a specific legal proxy to make all financial decisions. B. A living will is legally binding only if signed by the primary care physician. C. A living will expresses the patient's personal wishes regarding medical treatments in the event of incapacitation. D. A living will guarantees that a client will receive experimental medical treatments. 73. A nurse is reinforcing teaching with a client about the appropriate use of a vaginal diaphragm for contraception. Which of the following instructions should the nurse include? A. The diaphragm does not require professional fitting and can be bought over-the-counter. B. The diaphragm should be replaced every 10 years. C. Keep the diaphragm in place for at least 6 hours after intercourse. D. Use a male condom and a female condom simultaneously for extra protection. 74. A nurse is teaching a male adolescent client about testicular self-examination (TSE). Which of the following instructions should the nurse provide? A. Perform the exam weekly before getting out of bed in the morning. B. Perform the examination monthly after a warm shower. C. Vigorously squeeze each testicle to check for deep-seated nodules. D. Examine the testicles once a year during your physical exam. 75. A nurse is reviewing contraindications for childhood immunizations. Which of the following is a recognized contraindication for certain childhood vaccines? A. A sibling who is currently receiving chemotherapy. B. A severe allergy to gelatin or active pregnancy. C. A mild localized reaction to a previous dose. D. A history of a mild common cold without a fever. 76. A nurse is teaching a female client about breast self-examination (BSE). When is the most appropriate time for the client to perform this monthly exam? A. During the peak of ovulation. B. At the exact same calendar date each month, regardless of menstruation. C. On the first day of the menstrual cycle. D. One week after the menstrual cycle ends. 77. A nurse is caring for a client who is experiencing severe body image changes following an amputation. Which of the following is the priority nursing action? A. Keep the residual limb completely covered and avoid discussing the surgery. B. Refer the client immediately for long-term inpatient psychiatric care. C. Instruct the client to avoid looking at the limb until prosthetic fitting. D. Monitor for clinical signs of anger, withdrawal, and sadness, and assist with residual limb preparation. 78. A nurse is caring for a newborn undergoing phototherapy for hyperbilirubinemia. Which of the following clinical findings indicates an expected side effect of this treatment? A. Oliguria, brick-dust urine, and localized sclera bruising. B. Hypothermia, bradycardia, and generalized muscle tetany. C. Severe nuchal rigidity and high-pitched crying. D. Maculopapular rash, dehydration, and green liquid stools. 79. A nurse is planning care for an infant undergoing phototherapy. Which of the following nursing interventions is essential for client safety? A. Mask the infant's eyes, keep them undressed, and remove them from the light every 4 hours. B. Apply thick zinc-oxide ointment to the infant's skin. C. Dress the infant in a thick cotton onesie with a hat. D. Keep the infant under continuous light without any breaks. 80. A nurse is reinforcing teaching with a postpartum mother about breastfeeding adequacy. Which of the following indicates that the newborn is receiving sufficient breast milk? A. The infant sleeps continuously for 8 hours without waking to feed. B. The infant wet-diapers 6 to 8 times a day and has loose, pale-yellow stools. C. The infant's skin exhibits mild facial and scleral jaundice. D. The infant wets 2 diapers a day and has dark-green sticky stools. 81. A nurse is teaching a postpartum client about correct breastfeeding latch and positioning. Which of the following instructions should the nurse include? A. Feed the infant for exactly 5 minutes on each breast. B. Ensure the infant's mouth covers a significant portion of the areola. C. Avoid feeding the infant more than 3 times a day. D. The infant should latch strictly onto the tip of the nipple. 82. A nurse is teaching a mother about storing expressed breast milk. What is the maximum safe duration for freezing expressed breast milk in a standard home freezer? A. 3 to 6 months B. 12 to 18 months C. 1 to 2 weeks D. 5 years 83. A nurse is planning isolation precautions for a client who has active pulmonary tuberculosis. Which of the following measures must the nurse implement? A. Place the client in a negative air pressure room and require a surgical mask on the client during transport. B. Keep the client in a positive-pressure room with protective isolation. C. Maintain standard precautions and keep the client's room door open. D. Wear a sterile gown and gloves for all routine care interactions. 84. A nurse is caring for an immunocompromised client with cancer. Which of the following environmental modifications should the nurse implement? A. Encourage multiple large family gatherings inside the room. B. Instruct the client to avoid using soft-bristle toothbrushes. C. Avoid placing fresh flowers or fresh fruit in the client's room. D. Keep the room temperature cold between 60 and 65 degrees. 85. A nurse is preparing to perform hand hygiene. According to the medical and surgical asepsis guidelines, which of the following is correct? A. Use highly scented hand towels to dry from wrist to fingers. B. Wash hands for a maximum of 3 seconds under hot running water. C. Maintain elbows up and hands pointing down when washing hands. D. Hold hands above the level of the elbows during hand hygiene. 86. A child has varicella (chickenpox). At what point should the nurse inform the parents that the child is no longer contagious and can return to school? A. Exactly 24 hours after starting oral antiviral medications. B. When the macular rash turns into fluid-filled vesicles. C. Once all of the skin lesions have completely crusted over. D. When the fever resolves and the child's appetite returns. 87. A nurse is caring for a client with a contagious respiratory illness. How long after starting appropriate antibiotic therapy can the client safely return to work or school? A. Immediately upon starting the first dose of antibiotics B. 24 hours after the initiation of antibiotics C. 7 days after completing the entire course of antibiotics D. When a follow-up chest x-ray is completely clear 88. A nurse is monitoring a client who is receiving oxygen therapy via nasal cannula. Which of the following actions is required to maintain safety and hygiene? A. Change the nasal cannula tubing every 2 hours. B. Instruct the client to avoid using any water-soluble lip lubricants. C. Keep the oxygen humidifier filled with tap water. D. Change the humidification water every 24 hours and clean the client's nose regularly. 89. A client is admitted with a suspected electrolyte imbalance and reports a severe headache, blurred vision, and epigastric pain. The nurse should recognize these findings as indicative of: A. A benign response to high-dose intravenous magnesium infusion. B. Mild hypocalcemia that can be managed with oral calcium supplements. C. Preeclampsia or severe clinical distress needing immediate reporting. D. An expected, minor side effect of oral sodium restriction. 90. A nurse is planning discharge care for a client. When should the nurse initiate the discharge planning process? A. Only after the physician writes the formal discharge order. B. At the time of the client's admission to the facility. C. When the client or family explicitly requests home care. D. Exactly 24 hours before the scheduled discharge time. 91. A charge nurse has delegated a task to an assistive personnel (AP). Which of the following actions is required during the supervision phase of delegation? A. Instruct the AP to delegate the task to another AP if they get busy. B. Supervise after delegation, determine task performance and completion, and reevaluate. C. Document the findings in the client's medical record on behalf of the AP. D. Allow the AP to perform the task without any follow-up to show trust. 92. A nurse is planning discharge teaching for a client with diabetes mellitus. Which of the following instructions should the nurse reinforce? A. Avoid checking your blood glucose on days when you feel healthy. B. Soak your feet in hot water daily to improve peripheral circulation. C. If your blood glucose is low, wait 1 hour before checking it again. D. Check your blood glucose before meals and at bedtime, and monitor for foot injuries. 93. A nurse is assessing a client with suspected anorexia nervosa. Which of the following clinical findings should the nurse expect? A. Nuchal rigidity, photophobia, and a red macular rash. B. Hypermenorrhea, high self-esteem, and indifference toward caloric intake. C. Amenorrhea, extreme fear of being fat, and preoccupation with food and eating rituals. D. Excessive weight gain, high blood pressure, and polyphagia. 94. A nurse is planning discharge teaching for a client with a personality disorder. Which of the following interventions should the nurse encourage? A. Participation in group, family, and psychotherapy sessions. B. Using daily PRN sedative medications as the primary coping mechanism. C. Avoiding any communication regarding emotional stressors. D. Extended periods of isolation to avoid interpersonal conflicts. 95. A client is experiencing a panic attack. Which of the following clinical findings should the nurse expect to assess? A. Palpitations, shortness of breath, chest pain, nausea, chills, and agoraphobia. B. Nuchal rigidity, macular rash, photophobia, and high fever. C. Flushed dry skin, fruity breath, thirst, and polyuria. D. Bradycardia, bradypnea, extreme sleepiness, and generalized numbness. 96. A nurse is assessing a client in an emotional crisis. The nurse should recognize that a crisis is an emotional response that cannot be managed with normal coping and often lasts: A. 6 to 12 months B. 4 to 6 weeks C. 1 to 2 days D. 5 years 97. A nurse is caring for a client who is on suicide precautions. Which of the following is a priority nursing action? A. Allow the client to use standard metal utensils during meals to promote normalcy. B. Keep the room dark and quiet to promote rest and relaxation. C. Place the client in a private room with the door closed and checked every hour. D. Keep the client in sight and physically close at all times, and check their hands regularly. 98. A nurse is planning care to promote venous return in a client on bed rest. Which of the following actions should the nurse include in the plan of care? A. Place pillows directly under the client's knees to maintain flexion. B. Keep the client's legs crossed at the ankles when lying supine. C. Massage the client's calves vigorously once per shift. D. Assess the legs every 8 hours and apply moisturizing lotion. 99. A nurse is reviewing a client's laboratory results. Which of the following values represents the expected reference range for serum sodium? A. 98 to 106 mEq/L B. 125 to 132 mEq/L C. 136 to 145 mEq/L D. 146 to 155 mEq/L 100. A nurse is reviewing a client's laboratory results. Which of the following values represents the expected reference range for serum potassium? A. 5.1 to 6.2 mEq/L B. 1.3 to 2.1 mEq/L C. 9.0 to 10.5 mEq/L D. 3.5 to 5.0 mEq/L