NCLEX ATI LPN/RN Medical Surgical Exam
2024 Updated 2025 with All Questions from
Actual Past Exam and Correct Answer
A client has a platelet count of 18,000 cells/mL. An appropriate nursing intervention is to do
which of the following?
Avoid intramuscular injections (IM).
Administer oxygen via nasal cannula.
Maintain a no visitors policy.
Provide meticulous oral hygiene every 3 to 4 hr. ------------ Correct Answer ------------ Avoid
intramuscular injections (IM).
The platelet count is dangerously low indicating thrombocytopenia (decreased platelet count).
Any invasive procedure, such as an IM injection, can precipitate hemorrhage that may be
difficult to stop. Bleeding precautions are necessary for this client.
The nurse is planning to initiate a socialization group for older residents of a long-term facility.
Which information would be most useful to the nurse when planning activities for the group?
A. The length of time each group member has resided at the nursing home.
B. A brief description of each resident's family life.
C. The age of each group member.
The usual activity patterns of each member of the group. ---------- Correct Answer -------------
A nurse is caring for a client who has pancreatitis and has been receiving TPN. Which of the
following laboratory tests should the nurse monitor for overall nutritional status?
a) Creatinine
b) Prealbumin
c) Lipsae
d) C-reactive protein ----------- Correct Answer -------------- b) Prealbumin
A nurse is teaching a client who has endometriosis about the adverse effects of leuprolide. Which
of the following manifestations should the nurse include in the teaching?
a) Pallor
b) Increased appetite
c) Bone loss
d) Hypoglycemia ----------- Correct Answer -------------- c) Bone loss
A nurse is providing teaching to a client who is receiving opioids for pain management. Which
of the following information should the nurse include in the teaching?
a) Monitor urinary output for retention
b) Avoid taking anitemetics with the medication
c) Restrict fluid intake if you are experiencing constipation
d) Itching indicates you are having an allergic reaction to the medication ----------- Correct
,Answer -------------- a) Monitor urinary output for retention
A nurse is providing discharge teaching to a client who has asthma and a new prescription for a
metered dose inhaler. Which of the following client statements indicates an understanding of the
teaching?
a) I should clean the cap of the inhaler once a week
b) I should shake the inhaler before I use it
c) I should wait 15 seconds between puffs
d) I should inhale the medication quickly ----------- Correct Answer -------------- b) I should shake
the inhaler before I use
A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the
nurse to ask the client?
"What dose of medication are you taking?"
"Are you eating foods rich in potassium?"
"Have you lost weight recently?"
"At what time do you take your medication?" ---------- Correct Answer ------------- "At what time
do you take your medication?"
Rationale
The nurse needs to first determine at what time of day the client takes the Lasix. Because of the
diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia
which may be the reason for the sleep difficulties.
A nurse asks a client who is diagnosed with asthma about the pathophysiology of the disorder.
Further reinforcement of teaching is indicated when the client states that the cause of airway
obstruction is due to which of the following?
Edema of the bronchial membranes
Collapse of the alveoli
Constriction of the bronchioles
Excessive production of mucus ------------ Correct Answer ------------ Collapse of the alveoli
Alveolar collapse does not contribute to an acute asthma attack. TEST-TAKING STRATEGY:
Whenever you are confronted with a negative-response question like this, the CORRECT answer
will be the INCORRECT choice.
A client with glaucoma is admitted for surgery the following day. The client is to continue
treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4 times a day. While instilling this
medication, an appropriate nursing action is which of the following?
Instruct the client to blink several times after instillation of the medication.
Ask the client to look straight ahead.
Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min.
Dab excess medication from the eye using a cotton ball 10 to 15 seconds after instillation. --------
---- Correct Answer ------------ Place the medication in the conjunctival sac applying pressure to
the puncta for 1 to 2 min.
,Eye drops are instilled into the conjunctival sac and pressure applied to the puncta for 1 to 2 min
to prevent loss of medication into the nasal lacrimal duct and into the systemic circulation.
A client has sprained an ankle while playing soccer. For the first 24 hr following the injury, the
nurse should instruct the client to do which of the following?
Perform gentle range of motion (ROM) exercises on the ankle joint to prevent contractures.
Keep moist heat on the ankle to prevent muscle spasm.
Keep the foot in a dependent position to aide circulation to the foot.
Keep ice on the ankle to prevent edema. ------------ Correct Answer ------------ Keep ice on the
ankle to prevent edema.
Ice or cold will constrict blood vessels to the injured area decreasing swelling. Nerve impulse
transmission will also be reduced, resulting in analgesia to the injured area and a reduction of
muscle spasms. Ice applications should not exceed 20 to 30 min per application.
A client diagnosed with viral encephalitis secondary to West Nile Virus is admitted to the
hospital for treatment. When assisting in the development of a nursing care plan, which
interventions are consistent with the client's diagnosis? (Select all that apply.)
Place the client on respiratory isolation.
Monitor vital signs every 4 hr.
Assess neurological status every 4 hr.
Assess for Brudzinski's sign.
Implement seizure precautions. ------------ Correct Answer ------------ Placing the client on
respiratory isolation is incorrect. West Nile Virus is an arbovirus. It can be transmitted to humans
only after a person is bitten by an infected organism such as the tick. The infection cannot be
transmitted person-to-person as with viral or bacterial infections.
Monitoring vital signs every 4 hr is correct. It is important to monitor vital signs to assess for
changes consistent with increased intracranial pressure.
Assessing neurological status every 4 hr is correct. Neurological status should be monitored at
least every 4 hr or more frequently as the client's status may indicate. The course of encephalitis
is unpredictable, so the client must be monitored closely for any signs of deteriorating
neurological functioning.
Assessing for Brudzinski's sign is correct. Brudzinski's sign is assessed by placing the client on
the back and forcibly bending the neck forward. If positive, a reflexive flexion of the knees
occurs, indicating meningeal irritation, which is one of the major clinical manifestations of viral
encephalitis.
Implementing seizure precautions is correct. Due to the inflammatory response of the brain to the
arbovirus the client is at risk for seizures. Precautions should be implemented to ensure client
safety if a seizure does occur.
While reviewing an admission assessment for a client with an exacerbation of asthma, the nurse
, learns the client has several food allergies. The most important nursing action in promoting this
client's safety is to do which of the following?
Place an allergy bracelet on the client's wrist.
Provide the dietitian with a list of the client's allergies.
Observe the client carefully for signs of anaphylaxis.
Have epinephrine available on the clinical unit. ------------ Correct Answer ------------ Provide the
dietitian with a list of the client's allergies.
Providing the dietitian with a list of the client's allergies will most likely prevent the client from
being served a tray with a hidden allergen. A hidden allergen may be an ingredient used in the
preparation of the meal. This is the highest risk to the client.
A client who had a traumatic amputation of the arm at the elbow is reporting pain in the hand of
the amputated limb. The client has dressing changes prescribed twice daily, hydrocodone
(Vicodin) and gabapentin (Neurontin) PRN, and cefuroxime sodium (Ceftin) 750 mg 3 times
daily IV. Which of the following actions by the nurse is appropriate?
Administer prescribed dose of gabapentin (Neurontin).
Administer prescribed dose of hydrocodone (Vicodin).
Contact the provider for a change in the antibiotic prescribed.
Increase the frequency of the dressing changes. ------------ Correct Answer ------------ Administer
prescribed dose of gabapentin (Neurontin).
This client is experiencing phantom limb pain. Even though amputated limbs are no longer
attached to the body, a client can feel pain in the amputated limb, especially after a traumatic
amputation. Opiates are not effective for this type of pain. Beta-blockers, antispasmodics and
anticonvulsants such as gabapentin, are more effective for treating this type of pain.
A nurse is caring for a client who underwent a transurethral resection of the prostate (TURP) for
benign prostatic hypertrophy (BPH). The client's bladder is continuously irrigated with saline via
a three-way catheter PRN. Which of the following findings should be reported immediately to
the provider?
An output less than the input coming from the catheter
Report of bladder spasms
Drainage that resembles ketchup coming from the catheter
A report of feeling a strong urge to urinate ------------ Correct Answer ------------ Drainage that
resembles ketchup coming from the catheter
Drainage that resembles ketchup coming from the catheter indicates arterial bleeding which
should be reported to the surgeon.
A nurse is caring for a client with arteriosclerosis. When reviewing the client's chart, which of
the following factors should the nurse realize is associated with the development of
arteriosclerosis?
Cholesterol level is 195 mg.
HDL serum levels are elevated.
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