CACI Study Questions
A female client with type 2 diabetes mellitus reports C) Fingerstick glucose of 300 mg/dl. Elevated fingerstick glucose levels (C) spill
dysuria. Which assessment finding is most important for glucose in the urine and provide a medium for bacterial growth. (A, B, and
D) the nurse to report to the healthcare provider? A) should be reported, but the priority (C) is to notify the healthcare provider
for Suprapubic pain and distention. B) Bounding pulse at 100 prescriptions to manage client to a euglycemic level.
beats/minute. C) Fingerstick glucose of 300 mg/dl.
D) Small vesicular perineal lesions.
A nurse is preparing to insert an IV catheter after applying C) Leave the cream on the skin for 1 to 2 hours before the procedure. Topical
an eutectic mixture of lidocaine and prilocaine (EMLA), a anesthetic creams, such as EMLA, should be applied to the puncture site
at least topical anesthetic cream. What action should the nurse 60 minutes to 2 hours before the insertion of an IV catheter (C).
(A, B, and D) do take to maximize its therapeutic effect? A) Rub a liberal not ensure a therapeutic response.
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.
The nurse is preparing an adult client for an upper D) Nothing by mouth is allowed for 6 to 8 hours before the study. The client
should gastrointestinal (UGI) series. Which information should the be NPO for at least 6 hours before the UGI (D). (A) is not typical for
this procedure. nurse include in the teaching plan? A) The x-ray A NGT is not needed to instill the barium (B) unless the client is
unable to swallow. procedure may last for several hours. B) A nasogastric A laxative, not enemas (C), is given after the procedure
to help expel the barium. 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.
,A client is admitted to the hospital with a traumatic brain B) Serosanguineous nasal drainage. Any nasal discharge should be
evaluated (B) injury after his head violently struck a brick wall during ato determine the presence of cerebral spinal fluid which indicates
a tear in the dura gang fight. Which finding is most important for the nurse making the client susceptible to meningitis. The scalp is
highly vascular and results to assess further? A) A scalp laceration oozing blood. B) in blood oozing from wounds (A). Pain is
expected and can be treated after further Serosanguineous nasal drainage. C) Headache rated 10 assessment of the presence of nasal
discharge (C). Dizziness, nausea, and transient on a 0-10 scale. D) Dizziness, nausea and transient confusion (D) are expected
manifestations following a traumatic brain injury and confusion. need ongoing monitoring, but (B) is most important.
Which finding should the nurse identify as an indication of C The saturation of hemoglobin molecules with carbon monoxide and
the carbon monoxide poisoning in a client who experienced subsequent vasodilation induce a cherry red color of the mucous
membranes (C) a burn injury during a house fire? A) Pulse oximetry in a client who experienced a burn injury during a house fire.
Super heated air or reading of 80%. B) Expiratory stridor and nasal flaring. C) smoke inhalation damage the lining of the airways
which causes swelling,
Cherry red color to the mucous membranes. D) Presence decreased oxygenation (A), and an expiratory stridor (B). Mouth breathing
during of carbonaceous particles in sputum. 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 A Subcutaneous emphysema (A) is a complication and indicates air is leaking
attached to suction and a closed drainage system. Which beneath the skin. Tidaling in the water-seal chamber and constant
bubbling with finding is most important for the nurse to further assess? suction in the suction-control chamber (B and C)
are expected findings that
A) Upper chest subcutaneous emphysema. B) Tidaling indicate the closed drainage system is working. Pain at the insertion site is an
(fluctuation) of fluid in the water-seal chamber. C) expected finding (D) and the prescribed analgesia should be given to assist
the Constant air bubbling in the suction-control chamber. D) client to breathe deeply and facilitate lung expansion.
Pain rated 8 (0-10) at the insertion site.
In planning care for a client with an acute stroke resulting D After an acute stroke, a positioning and turning schedule that minimizes
lying on in right-sided hemiplegia, which positioning should the the affected side, which can impair circulation and cause pain,
and includes the nurse should use to maintain optimal functioning? A) Mid- prone position (D) to help prevent flexion
contractures of the hips, prepares the Fowler's with knees supported. B) Supine with trochanter client for optimal functioning and
ambulating. (A, B, and C) do not maintain the rolls to the hips. C) Sim's position alternated with right client for optimal functioning.
lateral position q2 hours. D) Left lateral, supine, brief
periods on the right side, and prone
A client's susceptibility to ulcerative colitis is most likely A Ulcerative colitis is 4 to 5 times more common among individuals of
Jewish due to which aspect in the client's history? A) Jewish European or Ashkenazi ancestry (A). H. pylori is associated with stomach
European ancestry. B) H. pylori bowel infection. C) Family inflammation and ulcer development (B). Irritable bowel syndrome (C)
does not history of irritable bowel syndrome. D) Age between 25 progress to inflammatory bowel disease. UC has a peak
between the ages of 15 and 55 years. and 25 years, then a second peak between 55 and 65 years, not (D).
An ER nurse is completing an assessment on a patient A) A carotid bruit. Rationale: the carotid artery (artery to the brain) is narrowed
in that is alert but struggles to answer questions. When she clients with a brain attack. A bruit is an abnormal sound heard on
auscultation attempts to talk, she slurs her speech and appears very resulting from interference with normal blood flow. Usually the
blood pressure is frightened. What additional clinical manifestation does the hypertensive. Initially flaccid paralysis occurs,
resulting in hyporefkexic deep nurse expect to find if patient's symptoms have been tendon reflexes. Bowel sounds are not
indicative of a brain attack.
caused by a brain attack (stroke)? A. A carotid bruit B.
A hypotensive blood pressure C. hyperreflexic deep
tendon reflexes. D. Decreased bowel sounds
Which clinical manifestation further supports an D) Global aphasia Rationale: Global aphasia refers to difficulty speaking,
listening, assessment of a left-sided brain attack? A) Visual field and understanding, as well as difficulty reading and writing.
Symptoms vary from deficit on the left side. B) Spatial-perceptual deficits. C) person to person. Aphasia may occur secondary to any
brain injury involving the Paresthesia of the left side. D) Global aphasia. 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 B) Explain that the client will not be able to move her head throughout the
computed tomography (CT) scan STAT, what nursing CT scan. Rationale: Because head motion will distort the images, Nancy will have
intervention should the nurse implement? A) to remain still throughout the procedure. Allergies to iodine is important if
Determine if the client has any allergies to iodine B) contrast dye is being used for the CT scan. Pre-medicating the client to decrease
Explain that the client will not be able to move her pain prior to the procedure is unnecessary because CT scanning is a
head throughout the CT scan. C) Pre-medicate the noninvasive and painless procedure. Providing an explanation of relaxation
client to decrease pain prior to having the procedure. exercises prior to the procedure is a worthwhile intervention to decrease
D) Provide an explanation of relaxation exercises anxiety but is not of highest priority
prior to the procedure.
A neurologist prescribes a magnetic resonance C) Right hip replacement. The magnetic field generated by the MRI is so
imaging (MRI) of the head STAT for a patient. Which strong that metal-containing items are strongly attracted to the magnet. Because
data warrants immediate intervention by the nurse the hip joint is made of metal, a lead shield must be used during the procedure.
concerning this diagnostic test? A) Elevated blood Elevated blood pressure, an allergy to shell fish, and a history of atrial fibrillation
pressure. B) Allergy to shell fish. C) Right hip would not affect the MRI.
replacement. D) History of atrial fibrillation.
A client's daughter is sitting by her mother's bedside who B) "Your mother has had a stroke, and the blood supply to the brain has
was recently transferred to the Intermediate Care Unit. been blocked." Rationale: The nurse can discuss what a diagnosis means. Nancy
She states "I don't understand what a brain attack is. The is unable to make decisions, so the next of kin, her daughter, Gail, needs
healthcare provider told me my mother is in serious sufficient information to make informed decisions. The nurse has the knowledge,
condition and they are going to run several tests. I just and the responsibility, to explain Nancy's condition to Gail. The nurse should give
don't know what is going on. What happened to my facts first, and then address her feelings after the information is provided
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."
What is the normal range for cardiac output? 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. Thrombolytic therapy is contraindicated in clients with symptom onset longer
Their symptoms began 24 hours before being admitted. than 3 hours prior to admission. This client had symptoms for 24 hours before
Why would this client not be a candidate for thrombolytic being brought to the medical center
therapy?
Which condition is considered a non-modifiable risk D) Advanced age. Rationale: People over age 55 are a high-risk group for a brain
factor for a brain attack? A) High cholesterol levels. attack because the incidence of stroke more than doubles in each successive
B) Obesity. C) History of atrial fibrillation. D) Advanced decade of life. Non-modifiable means the client cannot do anything to change the
age. risk factor. All the other options are modifiable risk factors.
A client is experiencing homonymous hemianopsia as B) Place the objects Nancy needs for activities of daily living on the left side of the
the result of a brain attack. Which nursing intervention table. Rationale: Homonymous hemianopsia is loss of the visual field on the same
would the nurse implement to address this condition? side as the paralyzed side. This results in the client neglecting that side of the
A) Turn Nancy every two hours and perform active body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere
range of motion exercises. B) Place the objects brain attack so her right side is the weak side. Speaking slowly and clearly
Nancy needs for activities of daily living on the left would address the client's verbal deficits due to aphasia. Requesting all liquids
side of the table. C) Speak slowly and clearly to to be thickened would address dysphagia. Turning the client every 2 hours and
assist Nancy in forming sounds to words. D) Request performing active range of motion exercises would address the client's risk for
that the dietary department thicken all liquids on immobility due to paralysis.
Nancy's meal and snack trays.
A female client with type 2 diabetes mellitus reports C) Fingerstick glucose of 300 mg/dl. Elevated fingerstick glucose levels (C) spill
dysuria. Which assessment finding is most important for glucose in the urine and provide a medium for bacterial growth. (A, B, and
D) the nurse to report to the healthcare provider? A) should be reported, but the priority (C) is to notify the healthcare provider
for Suprapubic pain and distention. B) Bounding pulse at 100 prescriptions to manage client to a euglycemic level.
beats/minute. C) Fingerstick glucose of 300 mg/dl.
D) Small vesicular perineal lesions.
A nurse is preparing to insert an IV catheter after applying C) Leave the cream on the skin for 1 to 2 hours before the procedure. Topical
an eutectic mixture of lidocaine and prilocaine (EMLA), a anesthetic creams, such as EMLA, should be applied to the puncture site
at least topical anesthetic cream. What action should the nurse 60 minutes to 2 hours before the insertion of an IV catheter (C).
(A, B, and D) do take to maximize its therapeutic effect? A) Rub a liberal not ensure a therapeutic response.
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.
The nurse is preparing an adult client for an upper D) Nothing by mouth is allowed for 6 to 8 hours before the study. The client
should gastrointestinal (UGI) series. Which information should the be NPO for at least 6 hours before the UGI (D). (A) is not typical for
this procedure. nurse include in the teaching plan? A) The x-ray A NGT is not needed to instill the barium (B) unless the client is
unable to swallow. procedure may last for several hours. B) A nasogastric A laxative, not enemas (C), is given after the procedure
to help expel the barium. 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.
,A client is admitted to the hospital with a traumatic brain B) Serosanguineous nasal drainage. Any nasal discharge should be
evaluated (B) injury after his head violently struck a brick wall during ato determine the presence of cerebral spinal fluid which indicates
a tear in the dura gang fight. Which finding is most important for the nurse making the client susceptible to meningitis. The scalp is
highly vascular and results to assess further? A) A scalp laceration oozing blood. B) in blood oozing from wounds (A). Pain is
expected and can be treated after further Serosanguineous nasal drainage. C) Headache rated 10 assessment of the presence of nasal
discharge (C). Dizziness, nausea, and transient on a 0-10 scale. D) Dizziness, nausea and transient confusion (D) are expected
manifestations following a traumatic brain injury and confusion. need ongoing monitoring, but (B) is most important.
Which finding should the nurse identify as an indication of C The saturation of hemoglobin molecules with carbon monoxide and
the carbon monoxide poisoning in a client who experienced subsequent vasodilation induce a cherry red color of the mucous
membranes (C) a burn injury during a house fire? A) Pulse oximetry in a client who experienced a burn injury during a house fire.
Super heated air or reading of 80%. B) Expiratory stridor and nasal flaring. C) smoke inhalation damage the lining of the airways
which causes swelling,
Cherry red color to the mucous membranes. D) Presence decreased oxygenation (A), and an expiratory stridor (B). Mouth breathing
during of carbonaceous particles in sputum. 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 A Subcutaneous emphysema (A) is a complication and indicates air is leaking
attached to suction and a closed drainage system. Which beneath the skin. Tidaling in the water-seal chamber and constant
bubbling with finding is most important for the nurse to further assess? suction in the suction-control chamber (B and C)
are expected findings that
A) Upper chest subcutaneous emphysema. B) Tidaling indicate the closed drainage system is working. Pain at the insertion site is an
(fluctuation) of fluid in the water-seal chamber. C) expected finding (D) and the prescribed analgesia should be given to assist
the Constant air bubbling in the suction-control chamber. D) client to breathe deeply and facilitate lung expansion.
Pain rated 8 (0-10) at the insertion site.
In planning care for a client with an acute stroke resulting D After an acute stroke, a positioning and turning schedule that minimizes
lying on in right-sided hemiplegia, which positioning should the the affected side, which can impair circulation and cause pain,
and includes the nurse should use to maintain optimal functioning? A) Mid- prone position (D) to help prevent flexion
contractures of the hips, prepares the Fowler's with knees supported. B) Supine with trochanter client for optimal functioning and
ambulating. (A, B, and C) do not maintain the rolls to the hips. C) Sim's position alternated with right client for optimal functioning.
lateral position q2 hours. D) Left lateral, supine, brief
periods on the right side, and prone
A client's susceptibility to ulcerative colitis is most likely A Ulcerative colitis is 4 to 5 times more common among individuals of
Jewish due to which aspect in the client's history? A) Jewish European or Ashkenazi ancestry (A). H. pylori is associated with stomach
European ancestry. B) H. pylori bowel infection. C) Family inflammation and ulcer development (B). Irritable bowel syndrome (C)
does not history of irritable bowel syndrome. D) Age between 25 progress to inflammatory bowel disease. UC has a peak
between the ages of 15 and 55 years. and 25 years, then a second peak between 55 and 65 years, not (D).
An ER nurse is completing an assessment on a patient A) A carotid bruit. Rationale: the carotid artery (artery to the brain) is narrowed
in that is alert but struggles to answer questions. When she clients with a brain attack. A bruit is an abnormal sound heard on
auscultation attempts to talk, she slurs her speech and appears very resulting from interference with normal blood flow. Usually the
blood pressure is frightened. What additional clinical manifestation does the hypertensive. Initially flaccid paralysis occurs,
resulting in hyporefkexic deep nurse expect to find if patient's symptoms have been tendon reflexes. Bowel sounds are not
indicative of a brain attack.
caused by a brain attack (stroke)? A. A carotid bruit B.
A hypotensive blood pressure C. hyperreflexic deep
tendon reflexes. D. Decreased bowel sounds
Which clinical manifestation further supports an D) Global aphasia Rationale: Global aphasia refers to difficulty speaking,
listening, assessment of a left-sided brain attack? A) Visual field and understanding, as well as difficulty reading and writing.
Symptoms vary from deficit on the left side. B) Spatial-perceptual deficits. C) person to person. Aphasia may occur secondary to any
brain injury involving the Paresthesia of the left side. D) Global aphasia. 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 B) Explain that the client will not be able to move her head throughout the
computed tomography (CT) scan STAT, what nursing CT scan. Rationale: Because head motion will distort the images, Nancy will have
intervention should the nurse implement? A) to remain still throughout the procedure. Allergies to iodine is important if
Determine if the client has any allergies to iodine B) contrast dye is being used for the CT scan. Pre-medicating the client to decrease
Explain that the client will not be able to move her pain prior to the procedure is unnecessary because CT scanning is a
head throughout the CT scan. C) Pre-medicate the noninvasive and painless procedure. Providing an explanation of relaxation
client to decrease pain prior to having the procedure. exercises prior to the procedure is a worthwhile intervention to decrease
D) Provide an explanation of relaxation exercises anxiety but is not of highest priority
prior to the procedure.
A neurologist prescribes a magnetic resonance C) Right hip replacement. The magnetic field generated by the MRI is so
imaging (MRI) of the head STAT for a patient. Which strong that metal-containing items are strongly attracted to the magnet. Because
data warrants immediate intervention by the nurse the hip joint is made of metal, a lead shield must be used during the procedure.
concerning this diagnostic test? A) Elevated blood Elevated blood pressure, an allergy to shell fish, and a history of atrial fibrillation
pressure. B) Allergy to shell fish. C) Right hip would not affect the MRI.
replacement. D) History of atrial fibrillation.
A client's daughter is sitting by her mother's bedside who B) "Your mother has had a stroke, and the blood supply to the brain has
was recently transferred to the Intermediate Care Unit. been blocked." Rationale: The nurse can discuss what a diagnosis means. Nancy
She states "I don't understand what a brain attack is. The is unable to make decisions, so the next of kin, her daughter, Gail, needs
healthcare provider told me my mother is in serious sufficient information to make informed decisions. The nurse has the knowledge,
condition and they are going to run several tests. I just and the responsibility, to explain Nancy's condition to Gail. The nurse should give
don't know what is going on. What happened to my facts first, and then address her feelings after the information is provided
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."
What is the normal range for cardiac output? 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. Thrombolytic therapy is contraindicated in clients with symptom onset longer
Their symptoms began 24 hours before being admitted. than 3 hours prior to admission. This client had symptoms for 24 hours before
Why would this client not be a candidate for thrombolytic being brought to the medical center
therapy?
Which condition is considered a non-modifiable risk D) Advanced age. Rationale: People over age 55 are a high-risk group for a brain
factor for a brain attack? A) High cholesterol levels. attack because the incidence of stroke more than doubles in each successive
B) Obesity. C) History of atrial fibrillation. D) Advanced decade of life. Non-modifiable means the client cannot do anything to change the
age. risk factor. All the other options are modifiable risk factors.
A client is experiencing homonymous hemianopsia as B) Place the objects Nancy needs for activities of daily living on the left side of the
the result of a brain attack. Which nursing intervention table. Rationale: Homonymous hemianopsia is loss of the visual field on the same
would the nurse implement to address this condition? side as the paralyzed side. This results in the client neglecting that side of the
A) Turn Nancy every two hours and perform active body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere
range of motion exercises. B) Place the objects brain attack so her right side is the weak side. Speaking slowly and clearly
Nancy needs for activities of daily living on the left would address the client's verbal deficits due to aphasia. Requesting all liquids
side of the table. C) Speak slowly and clearly to to be thickened would address dysphagia. Turning the client every 2 hours and
assist Nancy in forming sounds to words. D) Request performing active range of motion exercises would address the client's risk for
that the dietary department thicken all liquids on immobility due to paralysis.
Nancy's meal and snack trays.
