A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). WOTF interventions by the nurse is the highest priority?

Measure the client’s urinary output

Teach the client about manifestations of HHS

A nurse is caring for a client who has a flail chest. WOTF actions should the nurse take?

Administer antibiotic medication

Administer acetaminophen orally

A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. WOTF interventions should the nurse include in the plan of care?

Maintain the client on NPO status

Place the client in a supine position

Administer antihypertensive medications

Monitor the client for hypercalcemia

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Administer oxygen to the client

Check the client’s vital signs

A nurse is caring for a client who has acute heart 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?

Increased respiratory rate to 26/min

A nurse is taking an admission history from a client who reports Raynaud’s disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud’s?

Using a nicotine transdermal patch

Taking amlodipine for hypertension

Eating a strict vegetarian diet

A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client’s airway, WOTF interventions should the nurse take first?

Start an IV with a large-bore needle

Administer analgesic medication

A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. WOTF statements by the client indicates an understanding of the teaching?

I will notify my provider if I experience muscle weakness.

I will take this medication with fiber to prevent constipation.

I will increase my dose if my vision becomes blurred.

I will take my digoxin if my pulse is less than 50 bpm.

A nurse is caring for an older adult client who reports vaginal dryness and itching. WOTF responses should the nurse make?

“Your symptoms are likely due to decreasing estrogen levels.”

“These discomforts should decrease with time.”

“Women your age experience thickening of the vaginal tissue.”

“You should avoid intercourse to prevent injury to your vagina.”

A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

The client has a history of urinary incontinence

The client asks for help before ambulating

The client lives with their caregiver

A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate?

Gentle bubbling in the water seal chamber

Drainage and warmth at tube insertion site

Crackling sensation felt around tube insertion site

Drainage output less than 70 mL/hr.

A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take?

Log roll the client onto the operative side

Keep client’s affected heel on the bed

Perform internal and external rotation exercises of the hip

A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

Moderate serosanguineous drainage

A nurse is assessing a female client who has pneumonia. The nurse should identify WOTF findings increases the client’s risk of skin breakdown?

Receiving bronchodilator medication

Hemoglobin 17 g/dL (12 to 16 g/dL)

A nurse is admitting a client who has neutropenia. WOTF precautions should the nurse take?

Monitor vital signs at least every 4 hr

Insert an indwelling urinary catheter

Change the client’s linens three times a day

Place the client in a room with negative airflow

A nurse is caring for a female client who has a stroke. WOTF findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?

Albumin 3.1 g/dL (3.5 to 5 g/dL)

WBC 12,000/mm3 (5,000 to 10,000/mm3)

25-Hydroxyvitamin D 92 ng/mL (25 to 80 ng/mL)

A nurse is reviewing providers’ prescriptions for four clients. WOTF prescriptions should the nurse verify with the provider?

Apply a vest restraint daily at bedtime to prevent nighttime wandering

Apply mitten restraints to prevent the client from disconnecting their tube feeding.

Apply an abduction pillow between the client’s knees while they are in bed to prevent hip dislocation

Apply soft heel protectors bilaterally while client is in bed.

A charge nurse is observing a newly licensed nurse care for a client who has MRSA. WOTF observations of the newly licensed nurse indicates an understanding of infection control precautions?

Wears clean gloves when caring for the client

Remains 3 feet away from the client

Wears an N95 mask when providing wound care

Disposes of isolation gown outside of the client’s room

A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. WOTF statements by the client indicates an understanding of the teaching?

I will have my liver function tested while I am taking this medication.

This medication may cause my blood pressure to increase.

I should take an antacid with each dose of this medication.

I plan to take this medication for 1 week.

A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. WOTF statements by the caregiver indicates an understanding of the teaching?

I will support their feet with a rolled pillow when they are lying on their back.

I will ensure my neck is flexed backwards when they’re lying on their stomach

I will rest their heels on the mattress when they are sitting up in bed.

I will use a thick pillow under their head to support the neck.

A nurse is planning care for a client who has bacterial meningitis. WOTF interventions should the nurse implement?

Ensure lights are dimmed in the client’s room

Ensure the client’s bed is positioned to greater than 45 degrees

A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

Evaluate the client for a cuff leak

Empty water from the client’s ventilator tubing

Increase the client’s ventilator flow rate

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate?

Monitor serum blood glucose during infusion

Verify the solution with another RN prior to infusion

Obtain the client’s daily weight

Increase the rate of infusion if administration is delayed

Infuse 0.9% sodium chloride is the solution is not available

A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

Make sure the client’s room has positive-pressure airflow

Monitor the client’s temperature once every 6 hours

Wear an N95 respirator when providing direct client care

Make sure dietary plates and utensils are disposable

A nurse is providing discharge teaching to a client who reports they cannot afford their prescribed medication. Which of the following statements should the nurse make?

I can arrange for a social worker to talk with you before you leave.

Contact your pharmacy to inquire about a different medication

You should ask your provider to prescribe a cheaper medication

I can contact the occupational therapist to schedule a home visit.

A nurse is preparing to administer fresh frozen plasma to a client. Which of the following is correct?

Administer the plasma immediately after thawing.

Administer the transfusion through a 25-gauge saline lock

Hold the transfusion if the client is actively bleeding

A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Place pillows between the client’s knees when in a side-lying position

Use moisturizing lotion while massaging the client’s bony prominences

Instruct the client to sit on a rubber ring when seated in a chair

Raise the head of the client’s bed to a 90 degree angle

A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

A client who has pancreatitis reports pain in the left shoulder

A client who has peritonitis reports generalized abdominal pain

A client who is postoperative reports incisional pain

A client who has angina reports substernal chest pain

A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, “I am afraid to have this procedure.” WOTF responses should the nurse make?

Let’s discuss your concerns about this procedure

Are you afraid of needles that will be used during the procedure?

Tell me why you are scared to have this procedure

After this procedure, you will feel much better

A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. WOTF interventions should the nurse include in the plan of care?

Pad the upper two side rails of the client’s bed

Teach assistive personnel how to apply restraints

Keep a padded tongue blade at the client’s bedside.

NAXLEX CMS REVIEW ATI RN ADULT MEDICAL SURGICAL 2023 part 1

Authored by Ramen Noodles

Health Sciences

Professional Development

Used 2+ times

NAXLEX CMS REVIEW ATI RN ADULT MEDICAL SURGICAL 2023 part 1

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MULTIPLE CHOICE QUESTION

30 mins • 1 pt

A nurse is planning to meet with the interprofessional team about the care of a client who has a new diagnosis of ulcerative colitis. Which of the following recommendations should the nurse plan to make during the meeting?

The client should be referred to pain management

The client should be referred to hospice services

The client should be referred to a wound, ostomy, and continence nurse.

The client should be referred to a dietitian.

MULTIPLE CHOICE QUESTION

30 mins • 1 pt

A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect is the client has impaired function of the vestibulocochlear nerve (cranial nerve VII)?

Inability to smell

Loss of peripheral vision

Disequilibrium with movement

Deviation of the tongue from midline

MULTIPLE CHOICE QUESTION

30 mins • 1 pt

A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?

Diphenhydramine

Ondansetron

Sertraline

Methylprednisolone

MULTIPLE CHOICE QUESTION

30 mins • 1 pt

A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?

Chlorpromazine

Dobutamine

Mannitol

Propranolol

MULTIPLE CHOICE QUESTION

30 mins • 1 pt

A nurse is caring for a client who has left-sided heart failure. WOTF manifestations should the nurse expect?

Pedal edema

Neck vein distention

Daytime oliguria

Enlarged liver

MULTIPLE CHOICE QUESTION

30 mins • 1 pt

A nurse enters a client’s room and observes the client having a tonic-clonic seizure. WOTF actions should the nurse take first?

Turn the client on their side

Perform a neurologic check

Obtain the client’s vital signs

Notify the rapid response team

MULTIPLE CHOICE QUESTION

30 mins • 1 pt

A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?

Joint inflammation

Tophi

Esophagitis

“Bull’s Eye” Lesion

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NAXLEX CMS REVIEW ATI RN ADULT MEDICAL SURGICAL 2023 part 1

A nurse is planning to meet with the interprofessional team about the care of a client who has a new diagnosis of ulcerative colitis. Which of the following recommendations should the nurse plan to make during the meeting?

A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect is the client has impaired function of the vestibulocochlear nerve (cranial nerve VII)?

A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?

A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?

A nurse is caring for a client who has left-sided heart failure. WOTF manifestations should the nurse expect?

A nurse enters a client’s room and observes the client having a tonic-clonic seizure. WOTF actions should the nurse take first?

A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?

A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). WOTF interventions by the nurse is the highest priority?

A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?

A nurse is reviewing the health history of a client who is scheduled for exploratory surgery. WOTF food allergies indicates a risk of an allergic reaction to latex?

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