CACI Study Exam UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS
A 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 ANSWER B) "Your mother has
had a stroke, and the blood supply to the brain has been blocked." Rationale: The nurse can
discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her
daughter, Gail, needs sufficient information to make informed decisions. The nurse has the
knowledge, and the responsibility, to explain Nancy's condition to Gail. The nurse should
give facts first, and then address her feelings after the information is provided
What is the normal range for cardiac output? - CORRECT ANSWER The normal range
for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min.
A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours
before being admitted. Why would this client not be a candidate for thrombolytic therapy? -
CORRECT ANSWER Thrombolytic therapy is contraindicated in clients with
symptom onset longer than 3 hours prior to admission. This client had symptoms for 24 hours
before being brought to the medical center
Which condition is considered a non-modifiable risk factor for a brain attack? A) High
cholesterol levels. B) Obesity. C) History of atrial fibrillation. D) Advanced age. - CORRECT
ANSWER D) Advanced age. Rationale: People over age 55 are a high-risk group for a
brain attack because the incidence of stroke more than doubles in each successive decade of
life. Non-modifiable means the client cannot do anything to change the risk factor. All the
other options are modifiable risk factors.
QUESTIONS AND CORRECT ANSWERS
A 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 ANSWER B) "Your mother has
had a stroke, and the blood supply to the brain has been blocked." Rationale: The nurse can
discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her
daughter, Gail, needs sufficient information to make informed decisions. The nurse has the
knowledge, and the responsibility, to explain Nancy's condition to Gail. The nurse should
give facts first, and then address her feelings after the information is provided
What is the normal range for cardiac output? - CORRECT ANSWER The normal range
for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min.
A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours
before being admitted. Why would this client not be a candidate for thrombolytic therapy? -
CORRECT ANSWER Thrombolytic therapy is contraindicated in clients with
symptom onset longer than 3 hours prior to admission. This client had symptoms for 24 hours
before being brought to the medical center
Which condition is considered a non-modifiable risk factor for a brain attack? A) High
cholesterol levels. B) Obesity. C) History of atrial fibrillation. D) Advanced age. - CORRECT
ANSWER D) Advanced age. Rationale: People over age 55 are a high-risk group for a
brain attack because the incidence of stroke more than doubles in each successive decade of
life. Non-modifiable means the client cannot do anything to change the risk factor. All the
other options are modifiable risk factors.
