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CACI Study Questions
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CACI Study QuestionsA female client with type 2 diabetes mellitus reports dysuria. Which assessment
finding is most important for the nurse to report to the healthcare provider? A)
Suprapubic pain and distention. B) Bounding pulse at 100 beats/minute. C)
Fingerstick glucose of 300 mg/dl. D) Small vesicular perineal lesions. -
CORRECT ANSWER-C) Fingerstick glucose of 300 mg/dl. Elevated fingerstick
glucose levels (C) spill glucose in the urine and provide a medium for bacterial
growth. (A, B, and D) should be reported, but the priority (C) is to notify the
healthcare provider for prescriptions to manage client to a euglycemic level.
A nurse is preparing to insert an IV catheter after applying an eutectic mixture of
lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should
the nurse take to maximize its therapeutic effect? A) Rub a liberal amount of
cream into the skin thoroughly. B) Cover the skin with a gauze dressing after
applying the cream. C) Leave the cream on the skin for 1 to 2 hours before the
procedure. D) Use the smallest amount of cream necessary to numb the skin
surface. - CORRECT ANSWER-C) Leave the cream on the skin for 1 to 2 hours
before the procedure. Topical anesthetic creams, such as EMLA, should be
applied to the puncture site at least 60 minutes to 2 hours before the insertion of
an IV catheter (C). (A, B, and D) do not ensure a therapeutic response.
The nurse is preparing an adult client for an upper gastrointestinal (UGI) series.
Which information should the nurse include in the teaching plan? A) The x-ray
procedure may last for several hours. B) A nasogastric tube (NGT) is inserted to
instill the barium. C) Enemas are given to empty the bowel after the procedure.
D) Nothing by mouth is allowed for 6 to 8 hours before the study. - CORRECT
ANSWER-D) Nothing by mouth is allowed for 6 to 8 hours before the study. The
client should be NPO for at least 6 hours before the UGI (D). (A) is not typical for
this procedure. A NGT is not needed to instill the barium (B) unless the client is
unable to swallow. A laxative, not enemas (C), is given after the procedure to
help expel the barium.
A client is admitted to the hospital with a traumatic brain injury after his head
violently struck a brick wall during a gang fight. Which finding is most important
for the nurse to assess further? A) A scalp laceration oozing blood. B)
,Serosanguineous nasal drainage. C) Headache rated 10 on a 0-10 scale. D)
Dizziness, nausea and transient confusion. - CORRECT ANSWER-B)
Serosanguineous nasal drainage. Any nasal discharge should be evaluated (B)
to determine the presence of cerebral spinal fluid which indicates a tear in the
dura making the client susceptible to meningitis. The scalp is highly vascular and
results in blood oozing from wounds (A). Pain is expected and can be treated
after further assessment of the presence of nasal discharge (C). Dizziness,
nausea, and transient confusion (D) are expected manifestations following a
traumatic brain injury and need ongoing monitoring, but (B) is most important.
Which finding should the nurse identify as an indication of carbon monoxide
poisoning in a client who experienced a burn injury during a house fire? A) Pulse
oximetry reading of 80%. B) Expiratory stridor and nasal flaring. C) Cherry red
color to the mucous membranes. D) Presence of carbonaceous particles in
sputum. - CORRECT ANSWER-C The saturation of hemoglobin molecules with
carbon monoxide and the subsequent vasodilation induce a cherry red color of
the mucous membranes (C) in a client who experienced a burn injury during a
house fire. Super heated air or smoke inhalation damage the lining of the airways
which causes swelling, decreased oxygenation (A), and an expiratory stridor (B).
Mouth breathing during the fire allows the inhalation of soot that is seen as
particles in the client's sputum (D).
The nurse is assessing a client with a chest tube that is attached to suction and a
closed drainage system. Which finding is most important for the nurse to further
assess? A) Upper chest subcutaneous emphysema. B) Tidaling (fluctuation) of
fluid in the water-seal chamber. C) Constant air bubbling in the suction-control
chamber. D) Pain rated 8 (0-10) at the insertion site. - CORRECT ANSWER-A
Subcutaneous emphysema (A) is a complication and indicates air is leaking
beneath the skin. Tidaling in the water-seal chamber and constant bubbling with
suction in the suction-control chamber (B and C) are expected findings that
indicate the closed drainage system is working. Pain at the insertion site is an
expected finding (D) and the prescribed analgesia should be given to assist the
client to breathe deeply and facilitate lung expansion.
In planning care for a client with an acute stroke resulting in right-sided
hemiplegia, which positioning should the nurse should use to maintain optimal
functioning? A) Mid-Fowler's with knees supported. B) Supine with trochanter
,rolls to the hips. C) Sim's position alternated with right lateral position q2 hours.
D) Left lateral, supine, brief periods on the right side, and prone - CORRECT
ANSWER-D After an acute stroke, a positioning and turning schedule that
minimizes lying on the affected side, which can impair circulation and cause pain,
and includes the prone position (D) to help prevent flexion contractures of the
hips, prepares the client for optimal functioning and ambulating. (A, B, and C) do
not maintain the client for optimal functioning.
A client's susceptibility to ulcerative colitis is most likely due to which aspect in
the client's history? A) Jewish European ancestry. B) H. pylori bowel infection. C)
Family history of irritable bowel syndrome. D) Age between 25 and 55 years. -
CORRECT ANSWER-A Ulcerative colitis is 4 to 5 times more common among
individuals of Jewish European or Ashkenazi ancestry (A). H. pylori is associated
with stomach inflammation and ulcer development (B). Irritable bowel syndrome
(C) does not progress to inflammatory bowel disease. UC has a peak between
the ages of 15 and 25 years, then a second peak between 55 and 65 years, not
(D).
An ER nurse is completing an assessment on a patient that is alert but struggles
to answer questions. When she attempts to talk, she slurs her speech and
appears very frightened. What additional clinical manifestation does the nurse
expect to find if patient's symptoms have been caused by a brain attack (stroke)?
A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon
reflexes. D. Decreased bowel sounds - CORRECT ANSWER-A) A carotid bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in clients with a
brain attack. A bruit is an abnormal sound heard on auscultation resulting from
interference with normal blood flow. Usually the blood pressure is hypertensive.
Initially flaccid paralysis occurs, resulting in hyporefkexic deep tendon reflexes.
Bowel sounds are not indicative of a brain attack.
Which clinical manifestation further supports an assessment of a left-sided brain
attack? A) Visual field deficit on the left side. B) Spatial-perceptual deficits. C)
Paresthesia of the left side. D) Global aphasia. - CORRECT ANSWER-D) Global
aphasia Rationale: Global aphasia refers to difficulty speaking, listening, and
understanding, as well as difficulty reading and writing. Symptoms vary from
person to person. Aphasia may occur secondary to any brain injury involving the
, left hemisphere. Visual field deficits, spatial-perceptual deficits, and paresthsia of
the left side usually occur with right-sided brain attack.
When preparing a patient for a noncontrast computed tomography (CT) scan
STAT, what nursing intervention should the nurse implement? A) Determine if the
client has any allergies to iodine B) Explain that the client will not be able to move
her head throughout the CT scan. C) Pre-medicate the client to decrease pain
prior to having the procedure. D) Provide an explanation of relaxation exercises
prior to the procedure. - CORRECT ANSWER-B) Explain that the client will not
be able to move her head throughout the CT scan. Rationale: Because head
motion will distort the images, Nancy will have to remain still throughout the
procedure. Allergies to iodine is important if contrast dye is being used for the CT
scan. Pre-medicating the client to decrease pain prior to the procedure is
unnecessary because CT scanning is a noninvasive and painless procedure.
Providing an explanation of relaxation exercises prior to the procedure is a
worthwhile intervention to decrease anxiety but is not of highest priority
A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT
for a patient. Which data warrants immediate intervention by the nurse
concerning this diagnostic test? A) Elevated blood pressure. B) Allergy to shell
fish. C) Right hip replacement. D) History of atrial fibrillation. - CORRECT
ANSWER-C) Right hip replacement. The magnetic field generated by the MRI is
so strong that metal-containing items are strongly attracted to the magnet.
Because the hip joint is made of metal, a lead shield must be used during the
procedure. Elevated blood pressure, an allergy to shell fish, and a history of atrial
fibrillation would not affect the MRI.
A client's daughter is sitting by her mother's bedside who was recently
transferred to the Intermediate Care Unit. She states "I don't understand what a
brain attack is. The healthcare provider told me my mother is in serious condition
and they are going to run several tests. I just don't know what is going on. What
happened to my mother?" What is the best response by the nurse? A) "I am
sorry, but according to the Health Insurance Portability and Accounting Act
(HIPAA), I cannot give you any information." B) "Your mother has had a stroke,
and the blood supply to the brain has been blocked." C) "How do you feel about
what the healthcare provider said?" D) "I will call the healthcare provider so
he/she can talk to you about your mother's serious condition." - CORRECT
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