LPN MEDICAL SURGICAL ATI NCLEX | Essential Exam
Blueprint Q&A: Core Concepts with Explained Solutions
2025/2026
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.
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 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
Blueprint Q&A: Core Concepts with Explained Solutions
2025/2026
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.
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 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
