CACI KEY EXAM 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 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. - CORRECT 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. - CORRECT 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. - CORRECT 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. - CORRECT 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.
- CORRECT 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 -
CORRECT 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. - CORRECT 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 - CORRECT 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. - CORRECT 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. - CORRECT 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. - CORRECT 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." - CORRECT 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? - CORRECT ANSWERS The normal range for
cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min.
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 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. - CORRECT 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. - CORRECT 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. - CORRECT 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. - CORRECT 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.
- CORRECT 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 -
CORRECT 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. - CORRECT 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 - CORRECT 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. - CORRECT 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. - CORRECT 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. - CORRECT 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." - CORRECT 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? - CORRECT ANSWERS The normal range for
cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min.
