Ati rn med Surg 2023 NAXL
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1. A client who is deaf and communicates using sign Request an inter-
language is being admitted by a nurse who does not preter during the
know sign language. Which of the following actions initial assessment.
should the nurse take?
2. A nurse is caring for a client who has left-sided heart Daytime oliguria
failure. Which of the following manifestations should
the nurse expect?
3. A nurse enters a client's room and observes the client Turn the client on
having a tonic-clonic seizure. Which of the following their side
actions should the nurse take first?
4. A nurse is caring for a client who has acute heart Decreased anxiety
failure and received morphine IV 30 min ago. Which
of the following findings should the nurse identify as
an indication that the medication was effective?
5. A nurse is assessing a client who has anorexia. Which Alopecia
of the following findings should the nurse identify as
a manifestation of malnutrition?
6. A nurse is caring for a client who is 2 days postopera- "The elastic ban-
tive following a below-the-knee amputation and asks dage will prevent
about the purpose of maintaining an elastic bandage excessive ede-
around the residual limb of the extremity. Which of the ma."
following is an appropriate response by the nurse?
7. A nurse in the emergency department is managing Obtain an ECG
the care of a client who has an electrical shock injury.
Which of the following actions should the nurse take
first?
8. A nurse is caring for a client who has a new onset Initiate IV fluid re-
of hyperglycemic hyperosmolar state (HHS). Which of placement
the following interventions by the nurse is the highest
priority?
9. A nurse is reviewing the health history of a client who Strawberries
is scheduled for exploratory surgery. Which of the
, Ati rn med Surg 2023 NAXL
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following food allergies indicates a risk for an allergic
reaction to latex?
10. A nurse is assessing a client who received a purified "You will need to
protein derivative (PPD) skin test 48 hr ago and notes return in 48 hours
erythema with induration of 12 mm at the injection for re-evaluation."
site. Which of the following instructions should the
nurse provide to the client?
11. A nurse is planning to withdraw medication from an Place a paper
ampule to prepare for an injection. Which of the fol- towel around the
lowing actions should the nurse plan to take? ampule's neck to
break off the top
with both hands
12. A nurse is caring for a client who has moderate Consider respite
Alzheimer's disease. During weekly home visits, the care services
nurse notices that the client's caregiver is tired, ir-
ritable, and impatient with the client. Which of the
following actions should the nurse recommend to the
caregiver?
13. A nurse is assessing a client who is postoperative fol- Pain assessment
lowing an open reduction and internal fixation (ORIF)
of the femur. Which of the following assessments
should be the nurse's priority?
14. A nurse is caring for a client who is 3 hr postopera- Encourage the
tive following a total knee arthroplasty. Which of the client to perform
following actions should the nurse take to prevent circumduction of
venous thromboembolism? the feet
15. A nurse is admitting a client who has arthritic pain Stool for occult
and reports taking ibuprofen several times daily for 3 blood
years. Which of the following tests should the nurse
monitor?
16. A nurse is caring for a client who is 16 hr postopera- Assist the client
tive and is experiencing abdominal gas pains. Which with ambulation.
of the following actions should the nurse take?
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