CACI STUDY QUESTIONS WITH VERIFIED SOLUTIONS LATEST 2025-2026
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. - Answers 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. - Answers 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. - Answers 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. - Answers 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. - Answers 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.
- Answers 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 -
Answers 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. - Answers 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 - Answers 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. - Answers 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. - Answers 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. - Answers 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." - Answers 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? - Answers 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? -
Answers 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. - Answers 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.
A client is experiencing homonymous hemianopsia as the result of a brain attack. Which
nursing intervention would the nurse implement to address this condition? A) Turn Nancy every
two hours and perform active range of motion exercises. B) Place the objects Nancy needs for
activities of daily living on the left side of the table. C) Speak slowly and clearly to assist Nancy
in forming sounds to words. D) Request that the dietary department thicken all liquids on
Nancy's meal and snack trays. - Answers B) Place the objects Nancy needs for activities of daily
living on the left side of the table. Rationale: Homonymous hemianopsia is loss of the visual
field on the same side as the paralyzed side. This results in the client neglecting that side of the
body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack
so her right side is the weak side. Speaking slowly and clearly would address the client's verbal
deficits due to aphasia. Requesting all liquids to be thickened would address dysphagia. Turning
the client every 2 hours and performing active range of motion exercises would address the
client's risk for immobility due to paralysis.
A new nurse graduate is caring for a postoperative client with the following arterial blood gases
(ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation,
96%. Which of these actions by the new graduate is indicated? A) Encourage the client to use
the incentive spirometer and to cough. B) Administer oxygen by nasal cannula. C) Request a
prescription for sodium bicarbonate from the health care provider. D) Inform the charge nurse
that no changes in therapy are needed. - Answers A) Encourage the client to use the incentive
spirometer and to cough. Rationale: Respiratory acidosis is caused by CO2 retention and
impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2
elimination, including maintaining a patent airway and expanding the lungs through breathing
techniques. O2 is not indicated because Po2 and oxygen saturation are within the normal range.
Sodium bicarbonate is not indicated because the bicarbonate level is in the normal range;
promoting excretion of respiratory acids is the priority in respiratory acidosis. Post anesthesia,
the client will need interventions as described in A above or may progress to a state of
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. - Answers 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. - Answers 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. - Answers 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. - Answers 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. - Answers 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.
- Answers 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 -
Answers 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. - Answers 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 - Answers 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. - Answers 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. - Answers 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. - Answers 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." - Answers 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? - Answers 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? -
Answers 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. - Answers 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.
A client is experiencing homonymous hemianopsia as the result of a brain attack. Which
nursing intervention would the nurse implement to address this condition? A) Turn Nancy every
two hours and perform active range of motion exercises. B) Place the objects Nancy needs for
activities of daily living on the left side of the table. C) Speak slowly and clearly to assist Nancy
in forming sounds to words. D) Request that the dietary department thicken all liquids on
Nancy's meal and snack trays. - Answers B) Place the objects Nancy needs for activities of daily
living on the left side of the table. Rationale: Homonymous hemianopsia is loss of the visual
field on the same side as the paralyzed side. This results in the client neglecting that side of the
body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack
so her right side is the weak side. Speaking slowly and clearly would address the client's verbal
deficits due to aphasia. Requesting all liquids to be thickened would address dysphagia. Turning
the client every 2 hours and performing active range of motion exercises would address the
client's risk for immobility due to paralysis.
A new nurse graduate is caring for a postoperative client with the following arterial blood gases
(ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation,
96%. Which of these actions by the new graduate is indicated? A) Encourage the client to use
the incentive spirometer and to cough. B) Administer oxygen by nasal cannula. C) Request a
prescription for sodium bicarbonate from the health care provider. D) Inform the charge nurse
that no changes in therapy are needed. - Answers A) Encourage the client to use the incentive
spirometer and to cough. Rationale: Respiratory acidosis is caused by CO2 retention and
impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2
elimination, including maintaining a patent airway and expanding the lungs through breathing
techniques. O2 is not indicated because Po2 and oxygen saturation are within the normal range.
Sodium bicarbonate is not indicated because the bicarbonate level is in the normal range;
promoting excretion of respiratory acids is the priority in respiratory acidosis. Post anesthesia,
the client will need interventions as described in A above or may progress to a state of
