Ati rn adult med Surg 2023 NAXLEX
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1. A client who is deaf and Request an interpreter during the initial as-
communicates using sign lan- sessment.
guage is being admitted by a
nurse who does not know sign Requesting an interpreter during the initial
language. Which of the follow- assessment ensures effective communica-
ing actions should the nurse tion between the nurse and the client
take?
2. A nurse is caring for a Daytime oliguria
client who has left-sided heart
failure. Which of the follow-
ing manifestations should the
nurse expect?
3. A nurse enters a client's room Turn the client on their side
and observes the client hav-
ing a tonic-clonic seizure.
Which of the following actions
should the nurse take first?
4. A nurse is caring for a client Decreased anxiety
who has acute heart failure
and received morphine IV 30
min ago. Which of the follow-
ing findings should the nurse
identify as an indication that
the medication was effective?
5. A nurse is assessing a client Alopecia
who has anorexia. Which of
the following findings should
the nurse identify as a mani-
festation of malnutrition?
6. A nurse is caring for a client "The elastic bandage will prevent excessive
who is 2 days postoperative edema."
following a below-the-knee
amputation and asks about Maintaining an elastic bandage around the
the purpose of maintaining an residual limb helps to compress soft tis-
, Ati rn adult med Surg 2023 NAXLEX
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elastic bandage around the sues and minimize edema, promoting heal-
residual limb of the extremity. ing and aiding in the shaping of the residual
Which of the following is an limb for future prosthesis fitting.
appropriate response by the
nurse?
7. A nurse in the emergency de- Obtain an ECG
partment is managing the care
of a client who has an electri- Obtaining an ECG is the priority to assess
cal shock injury. Which of the for any cardiac dysrhythmias, which can
following actions should the be immediate and life-threatening conse-
nurse take first? quences of electrical shock injuries.
8. A nurse is caring for a client Initiate IV fluid replacement
who has a new onset of hyper-
glycemic hyperosmolar state
(HHS). Which of the following
interventions by the nurse is
the highest priority?
9. A nurse is reviewing the Peanuts
health history of a client who
is scheduled for exploratory
surgery. Which of the following
food allergies indicates a risk
for an allergic reaction to la-
tex?
10. A nurse is assessing a client You will need to follow up with your provider
who received a purified pro-
tein derivative (PPD) skin test
48 hr ago and notes erythema
with induration of 12 mm at the
injection site. Which of the fol-
lowing instructions should the
nurse provide to the client?
11. A nurse is planning to with- Dispose of the top of the ampule in a sharps
draw medication from an am- container.
pule to prepare for an injec-
, Ati rn adult med Surg 2023 NAXLEX
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tion. Which of the following ac- Disposing of the top of the ampule in
tions should the nurse plan to a sharps container is essential for safety
take? to prevent accidental injuries from broken
glass.
12. A nurse is caring for a Consider respite care services
client who has moderate
Alzheimer's disease. During
weekly home visits, the nurse
notices that the client's care-
giver is tired, irritable, and
impatient with the client.
Which of the following actions
should the nurse recommend
to the caregiver?
13. A nurse is assessing a client Neurovascular assessment
who is postoperative following
an open reduction and internal The neurovascular assessment, including
fixation (ORIF) of the femur. circulation, sensation, and movement, is
Which of the following assess- crucial for early detection of complications
ments should be the nurse's such as compartment syndrome or im-
priority? paired blood flow.
14. A nurse is caring for a client Encourage the client to perform circumduc-
who is 3 hr postoperative fol- tion of the feet
lowing a total knee arthroplas-
ty. Which of the following ac-
tions should the nurse take to
prevent venous thromboem-
bolism?
15. A nurse is admitting a client Stool for occult blood
who has arthritic pain and re-
ports taking ibuprofen several
times daily for 3 years. Which
of the following tests should
the nurse monitor?
16. Assist the client with ambulation.
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