ATI COMPREHENSIVE PREDICTOR EXAM 2023-2024 FORM

A,B,C /COMP ATI PREDICTOR EXAM NEWEST VERSION 2023

COMPLETE EACH VERSION 80 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED
A.
A nurse working in a rehabilitation unit is administering medications to
two clients who have the same name. Which of the following identifiers
should the nurse use to verify the identities of each client?
A.The room numbers of the clients
B.The diagnoses of the clients
C.The names of the clients' nearest relatives
D.The telephone numbers of the clients
The Correct Answer is D

A nurse is assessing a client in the PACU. Which of the following findings

indicates decreased cardiac output?
a) Shivering
b) Oliguria
c) Bradypnea
d) Constricted pupils - ANSWER-b) Oliguria

A nurse is assisting with mass casualty triage: explosion at a local factory.

Which of the following client should the nurse identify as the priority?
a) A client that has massive head trauma
b) A client has full thickness burns to face and trunk
c) A client with indications of hypovolemic shock
d) A client with open fracture of the lower extremity - ANSWER-c) A client
with indications of hypovolemic shock

A nurse is a receiving report on four clients. Which of the following clients

should the nurse assess first?
a) A client who has illeal conduit and mucus in the pouch
b) Client pleasant arteriovenous additional vibration palpated
c) A client whose chronic kidney disease with cloudy diasylate outflow
d) A client was transurethral resection of the prostate with a red tinged
urine in the bag - ANSWER-c) A client whose chronic kidney disease with
cloudy diasylate outflow

A nurse is caring for a client just received the first dose of lisinopril. The
following is an appropriate nursing intervention?
a) Place's cardiac monitoring
b) Monitor the clients oxygen saturation level
c) Provide standby assist with the client from bed
d) Encourage foods high in potassium - ANSWER-c) Provide standby assist
with the client from bed

A nurse is caring for a client who is in labor and his seat is receiving
electronic fetal monitoring. The nurse is reviewing the monitor tracing and
notes early decelerations. Which the following should the nurse expect?
a) Feta hypoxia
b) Abrupto placentae
c) Post maturity
d) Head Compression - ANSWER-d) Head Compression

A nurse is caring for a client who has chronic kidney disease. The nurse
should identify which of the following laboratory values as in an indication
for hemodialysis?
a) glomerular filtration rate of 14 mL/ minute
b) BUN 16 mg/DL
c) serum magnesium 1.8 mg mg/dl
d) Serum phosphorus 4.0 mg/dL - ANSWER-a) glomerular filtration rate of
14 mL/ minute

A nurse is caring for an infant who has a prescription for continuous pulse
oximetry. The following is an appropriate action for the nurse to take?
a) Placed infant under radiant warmer
b) Move the probe site every 3 hours
c) Heat the skin one minute prior to placing the program
d) Placed a sensor on the index finger - ANSWER-c) Heat the skin one
minute prior to placing the program

A nurse in a mental health facility receives a change of shift report on for

clients. Which of the following clients should the nurse plan to assess first?
a) Client placed in restraints to the aggressive behavior
b) A new limited client pleasures history of 4.5 kg weight loss in the past
two months
c) Client is receiving a PRN dose of health heard all two hours ago for
increased anxiety
d) Applied he'll be receiving his first ECT treatment today - ANSWER-a)
Client placed in restraints to the aggressive behavior

A nurse working at the clinic is teaching a group of clients who are

pregnant on the use of non-pharmacological pain management. Which of
the following statements by the nurse is an appropriate description of the
use of hypnosis during labor?
a) Hypnosis focuses on the biofeedback as a relaxation technique
b) Hypnosis promotes increased control of her pain perception during
contractions
c) Hypnosis uses therapeutic touch to reduce anxiety during labor
d) Hypnosis provides instruction to minimize pain - ANSWER-b) Hypnosis
promotes increased control of her pain perception during contractions

A nurse in a County Jail health clinic is leading group therapy session. A

client who was incarcerated for theft is addressing the group. Which of the
following is an example of reaction formation?
a) I steal things because it's the only way I can keep my mind off my bad
marriage
b) I can't believe I was accused of something I didn't do
c) I don't want talk about my feelings right now. We will talk more next
time
d) I think that people just you're just lazy and should earn money honestly
- ANSWER-d) I think that people just you're just lazy and should earn
money honestly

A nurse is obtaining the medical history of a client who has a new

prescription for isosorbide monotitrate. Which of the following should the
nurse identify as a contraindication to medication?
a) Glaucoma
b) Hypertension
c) Polycythemia
d) Migraine headaches - ANSWER-a) Glaucoma

The nurses is caring for a client recovering from an acute myocardial

infarction. Which following
intervention should the nurse include in the point of care?
a) Draw a troponin level every four hours
b) Performance EKG every 12 hours
c) Plant oxygen tent fell over minutes via rebreather mask
d) Obtain a cardiac rehabilitation consult - ANSWER-d) Obtain a cardiac
rehabilitation consult

A Nurses caring for client who has breast cancer and has been covering
receiving chemotherapy. Which of
the following laboratory values should nurse report to provider?
a) WBC 3,000/mm3
b) Hemoglobin 14 g/dl
c) Platelet 250,000/mm3
d) aPTT 30 seconds - ANSWER-a) WBC 3,000/mm3

Home health nurse is carefully planned for Alzheimer's disease. To the

following action should the nurse
include in the plan of care
a) Place a daily calendar in the kitchen
b) Replace button clothing with zippered items
c) Replace the carpet with hardwood floors
d) Create variation in daily routine - ANSWER-a) Place a daily calendar in
the kitchen

Nurse is performing change of shift assessments on 4 clients. Which of the

following findings should the
nurse report to provider first?
a) The client was cystic fibrosis and has a thick productive clock and reports
thirst
b) Client who has gastroenteritis and is lethargic and confused
c) The Client has diabetes mellitus has morning fasting Legal cost of 185 mg
over deal
d) The client was sick of signing it reports pain 15 minutes after receiving
oral analgesic - ANSWER-b) Client who has gastroenteritis and is lethargic
and confused
A nurse is caring for a client was in the second trimester of pregnancy and
asks how to treat constipation.
Which of the following statements by the nurse is appropriate?
a) Decrease taking vitamins and supplements to every other day
b) Eat 15 g of fiber per day
c) Consume 48 ounces of water each day
d) Drink hot water with lemon juice each morning when you wake up -
ANSWER-d) Drink hot water with lemon juice each morning when you
wake up

A nurse is caring for a client who is preparing his advance directives. Which
is the following statements by
the client indicates an understanding of advanced directives? select all that
apply
a) I can't change my instructions once a minute
b) My doctor will need to approve my advance directives
c) I need an attorney to witness my signature on the advance directives
d) I have the right to refuse treatment
e) My health care proxy can make medical decisions for me - ANSWER-d) I
have the right to refuse treatment
e) My health care proxy can make medical decisions for me

A nurse is caring for a client who is at 32 weeks gestation and has a history
of cardiac disease. Which of
the following positions should the nurse place the client to best promote
optimal cardiac output?
a) The chest
b) Standing
c) Supine
d) Left lateral - ANSWER-d) Left lateral

A nurse is caring for a group of clients. Which of the following clients

should the nurse assign to an AP?
a) Client who has chronic obstructive pulmonary disease and needs
guidance on incentive spirometry
b) Client who has awoken following a bronchoscopy and requests a drink
c) Client who had a myocardial infarction 3 days ago reports chest
discomfort
d) Client who had a cerebrovascular accident two days ago and needs help
toileting - ANSWER-d) Client who had a cerebrovascular accident two days
ago and needs help toileting

Nurse providing discharge teaching to the client who has schizophrenia and
is starting therapy with
clozapine. Which of the following is the highest priority for the client to
report to the provider?
a) Constipation
b) blurred vision
c) Fever
d) Dry Mouth - ANSWER-c) Fever

A nurse observes an AP providing care to a child who is in skeletal traction.

Which of the following action
requires intervention?
a) Providing a high protein snack
b) Assisting the child to reposition
c) Placing weights as a child's bed
d) Massaging pressure points-causes skin breakdown - ANSWER-c) Placing
weights as a child's bed

A nurse is planning to delegate to an AP the fasting blood glucose testing

for a client who has diabetes
mellitus. Which of the following action should the nurse take?
a) Determine if the AP is qualified to perform the test.
b) Help the AP performed the blood glucose test
c) Assign the AP to ask the client is taking his diabetic medication today
d) Have AP check the medical record for prior blood glucose test results -
ANSWER-a) Determine if the AP is qualified to perform the test.

A nurse is assessing client brought to the hospital psychiatric emergency

services by a law enforcement
officer. The client has disorganized, incoherent speech with loose
associations and religious content.
You should recognize the signs and symptoms as being consistent with
which of the following?
a) Alzheimer's disease
b) Schizophrenia
c) Substance intoxication
d) Depression - ANSWER-b) Schizophrenia

A nurse is caring for a child who has infectious mononucleosis.. Which of

the following findings are
associated with this diagnosis? Select all that apply
a) splenomegaly
b) Koplik spots
c) Malaise
d) Vertigo
e) Sore throat - ANSWER-a) splenomegaly
c) Malaise
e) Sore throat

Nurse is performing dressing change for client was a sacral wound using
negative pressure wound
therapy. Which The following actions should the nurse take first?
a) Apply skin preparation to wound edges.
b) Normal saline
c) Don sterile gloves
d) Determine pain level - ANSWER-d) Determine pain level

A nurses caring for client recovery from the bowel surgery who has
nasogastric tube connected to
low intermittent suction. Which the following assessment findings should
indicate to the nurse that the NG
tube may not be functioning properly?
a) Drainage fluid is greenish-yellow
b) aspirate pH of 3
c) Abdominal rigidity
d) air bubbles noted in the NG tube - ANSWER-c) Abdominal rigidity

A nurse is preparing to administer TPN with added fat supplements to a

client who has malnutrition.
Which of the following action should the nurse take?
a) Piggyback 0.9 sodium chloride with TPN solution
b) Check for an allergy to eggs
c) Discuss the TPS solution for 12 hours
d) Monitor for hypoglycemia - ANSWER-b) Check for an allergy to eggs

A charge nurse is discussing the use of applying ice to a client's injured

knee with a newly licensed nurse.
Which of the following should the nurse identify as a benefit? (A/C?)
a) Systemic analgesic effect
b) increase in your metabolism
c) Decreased capillary permeability
d) Vasodilation - ANSWER-c) Decreased capillary permeability

Nurse is developing discharge care plans for client has osteoporosis. To

prevent injury the nurse should
instruct the client to
a) Perform weight bearing exercises
b) Avoid crossing the legs beyond the midline
c) Avoid sitting in one position for prolonged periods
d) Split affected area - ANSWER-a) Perform weight bearing exercises

A nurse on acute med-surgical unit is performing assessments on a group

of clients. Which is highest
priority?
a) The client has surgical hypoparathyroidism and positive Trousseau's sign
b) A client who was Clostridium difficile with acute diarrhea
c) A client who is acute kidney injury and urine with a low specific gravity
d) The client who has oral cancer and reports a sore on his gums -
ANSWER-a) The client has surgical hypoparathyroidism and positive
Trousseau's sign

Nurses caring for a client was congestive heart failure. Which of the
following prescriptions for the
provider should the nurse anticipate?
a) Call the provider to clients respiratory rate is less 18/min
b) Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr
c) Give the client enalapril 2.5 mg PO twice daily
d) Call the provider if the clients pulse rate is less than 80/min - ANSWER-c)
Give the client enalapril 2.5 mg PO twice daily

A nurse is caring for a client who has a prescription for sertraline to treat
depression. Which of the
following statements by the client indicates an understanding of the
medication treatment plan?
a) I will be able starting this medication with feel better
b) I can expect to urinate frequently while on this medication
c) I understand I may experience difficulty sleeping on this medication
d) I should decrease my sodium intake while on this medication - ANSWER-
c) I understand I may experience difficulty sleeping on this medication

A nurse has been caring for a female client who has bruises on her arms
that she explains are a result of
physical abuse by her husband. The client states, "I don't know how much
longer I can take this, but I'm
afraid he'll really hurt me if I leave. "Which of the following is an
appropriate nursing intervention?"
a) Offer to speak to the client's husband regarding his abuse behavior.
b) Help the client to recognize the signs of escalation of abuse behavior
c) Assist the client to identify personal behaviors that trigger abusive
behavior
d) Assist the client to Reports abusive behavior to the proper authority -
ANSWER-b) Help the client to recognize the signs of escalation of abuse
behavior

A client was having suicidal thoughts tells the nurse "It just does not seem
worth it anymore. Why not end
my misery?" Which of the following responses for the nurses appropriate?
a) Why do you think your life is not worth it anymore?
b) Do you have a plan to end your life?
c) I need to know what you mean my misery
d) You can trust me and tell me what you're thinking - ANSWER-b) Do you
have a plan to end your life?

A nurse is caring for a client who has schizophrenia. Which of the following
assessment findings should
the nurse expect?
a) Decreased level consciousness
b) Unable to identify common objects
c) Poor problem solving ability
d) Preoccupation was somatic disturbances - ANSWER-c) Poor problem
solving ability
A nurse is caring for a client who has deep vein thrombosis of the left
lower extremity. Which of the
following action should nurse take? There are 3 tabs that contain separate
categories of data.
a) Position the client with the affected extremity lower than the heart
b) Administration of acetaminophen
c) Massage the affected extremity every 4 hrs.
d) Withhold heparin IV infusion - ANSWER-d) Withhold heparin IV infusion

Is caring for clients was a new prescription for enoxaparin for the
prevention of DVT. Which of the
following is an appropriate action by the nurse?
a) Expel air bubble at the top of the prefilled syringe
b) Massage the injection site to evenly distribute the medication
c) Inject the medication the lateral abdominal wall
d) Administer an NSAID for injection site discomfort - ANSWER-c) Inject the
medication the lateral abdominal wall

Nurses caring for four clients. Which of the following client data should the
nurse report to the provider?
a) A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10
when coughing
b) Client was a total of 110 mL of serosanguineous fluid from the Jackson
Pratt drain within the first 24
hour following surgery
c) Client who is 4 hrs postoperative and has a heart rate of 98 per minute
d) The client was a prescription for chemotherapy and an absolute
neutrophil count of 75/mm3 - ANSWER-d) The client was a prescription for
chemotherapy and an absolute neutrophil count of 75/mm3

Nurses caring for client was in end-stage osteoporosis and is reporting

severe pain. Clients respiratory
rate is 14 per minute. Which of the following medications should the nurse
expect to be the highest
priority to administer to the client?
a) Promethazine
b) Hydromorphone
c) Ketorolac
d) Amitriptyline - ANSWER-b) Hydromorphone

A nurse is caring for a client who has DVT. Which of the following
instructions the nurse include in the
plan of care?
a) Live with the clients fluid intake to 1500 mL per day
b) Massage place affected extremity to relieve pain
c) Apply cold packs of clients affected extremity
d) Elevate the client's affected extremity when in bed - ANSWER-d) Elevate
the client's affected extremity when in bed

A nurse is caring for a client who is receiving oxytocin IV for augmentation

of labor. The client's
contractions are occurring every 45 seconds with a nine seconds duration
in the fetal heart rate is 170 to
180/minute. Which of the following actions should nurse take?
a) Discontinue oxytocin infusion
b) Increased oxytocin infusion
c) Decreased oxytocin infusion
d) Maintain oxytocin infusion - ANSWER-a) Discontinue oxytocin infusion

A nurse is admitting a client who is in labor and at 38 wks of gestation to

the maternal newborn
unit. The client has a history of herpes simplex virus 2. Which of the
following questions is most
appropriate for the nurse to ask the client?
a) Have your membranes ruptured?
b) How far apart are your contractions?
c) Do you have any active lesions?
d) Are you positive for beta strap? - ANSWER-c) Do you have any active
lesions?

Nurse is providing teaching for child prescribed ferrous sulfate. Which of

the following instructions should
the nurse include?
a) Take with meals
b) Take at bedtime
c) Take with a glass of milk
d) Take with a glass of orange juice - ANSWER-d) Take with a glass of
orange juice

Four clients present to the emergency department. The nurse should plan
to see which of the following
clients first?
a) A 6 year old client whose left shoulder is dislocated
b) A 26 year old client for sickle cell disease and a severe joint pain
c) A 76 year old client was confused, febrile and has foul smelling urine
d) A 50- year old client who has slurred speech, is disoriented, and reports
a headache - ANSWER-d) A 50- year old client who has slurred speech, is
disoriented, and reports a headache

A nurse is completing a dietary assessment for client who is Jewish and

observes kosher dietary practices.
Which of the following behaviors should the nurse expect to find?
a) Leavened bread maybe eaten during Passover.
b) Shellfish is commonly consumed in the diet.
c) Meat and dairy products are eaten separately.
d) Fasting from meat occurs during Hanukkah. - ANSWER-c) Meat and dairy
products are eaten separately.

A nurse is in an ER caring for client of multiple wounds due to a motor

vehicle crash. Which of the
following interventions are appropriate? Select all that apply
a) Apply direct pressure to bleeding wounds
b) Clean rest last rations and abrasions with hydrogen peroxide
c) Cover wounds with a sterile dressing
d) Administer 650 mg aspirin PO as needed for pain
e) Determine date of last tetanus toxoid vaccination. - ANSWER-a) Apply
direct pressure to bleeding wounds
c) Cover wounds with a sterile dressing
e) Determine date of last tetanus toxoid vaccination.

The nurses reviewing clients admission laboratory results. Which of the

findings required further
evaluation?
a) Sodium 138
b) Creatinine 1.8
c) Hemoglobin 15
d) Potassium 4.2 - ANSWER-b) Creatinine 1.8

A nurse is providing teaching for a client has a new prescription for

methadone. Which of the phone
following client statements indicates need for further teaching?
a) I understand the methadone tends to slow my breathing
b) I understand the methadone may cause me to have difficulty sleeping
c) I will avoid alcohol while I'm taking this medication
d) I'll change positions gradually especially from lying down to standing -
ANSWER-b) I understand the methadone may cause me to have difficulty
sleeping

Which of the following client is appropriate for the nurse to refer to speech
therapy for swallowing
evaluation?
a) Premature infant with a poor suck reflex and failure to thrive
b) An older adults who has difficulty taking in fluids
c) Adolescent who anorexia who is cachectic
d) A middle aged adults was gastroesophageal reflux disease - ANSWER-b)
An older adults who has difficulty taking in fluids

A nurse is caring for a group of clients. Which of the following client should
nurse assess first?
a) A client whose benign prostatic hyperplasia and is unable to urinate
b) The client was heart failure and report shortness of breath while
ambulating
c) A client who is open cholecystectomy and has green drainage from the T-
tube
d) A client whose abdominal pain and is vomiting coffee ground emesis -
ANSWER-d) A client whose abdominal pain and is vomiting coffee ground
emesis

VERSION B
A nurse is taking a medication history from client was type II diabetes
mellitus is scheduled for an
arteriogram. Which of the following medications to the nurses instruct the
client to discontinue 48 hrs
prior to the procedure?
a) Atorvastatin
b) Digoxin
c) Nifedipine
d) Metformin - ANSWER-d) Metformin

The nurses assessing client with posttraumatic stress disorder. Which of

the following findings to the
nurse expect to find?
a) Dependence on family and friends
b) Loss of interest in usual activities
c) Ritualistic behavior
d) Passive aggressive behavior - ANSWER-b) Loss of interest in usual
activities

A nurse working in a long-term care facility is caring for an older adult

client has dementia. The clients
often agitated and frequently wanders the halls. Which of the following
intervention should the nurse
include in the plan of care?
a) Give the client several choices when scheduling activities.
b) Confront the client regarding unacceptable behavior
c) Maintain Nutritional requirements by offering finger foods
d) Stimulate the client by leaving the television on throughout the day -
ANSWER-c) Maintain Nutritional requirements by offering finger foods

A nurse on a mental health unit receives report on four clients. Which of

the following client should the
nurse attend to first?
a) A client who has begun to demonstrate catatonic behavior
b) The client was compulsive behavior and is frequently drinking from the
water fountain
c) Client was having auditory hallucinations is becoming agitated
d) A client was making sexual comments to clients of the opposite sex -
ANSWER-c) Client was having auditory hallucinations is becoming agitated

A nurse is caring for the full term newborn immediately following birth.
Which of the following actions
should the nurse take first?
a) Instill erythromycin ophthalmic ointment and the newborn's eyes.
b) Place identification bracelets on the newborn.
c) Weigh the newborn.
d) Dry the newborn - ANSWER-d) Dry the newborn

A nurse receives report on a group of clients. Which of the following client

should the nurse attend to first?
a) A client who was admitted with asthma and has an SaO2 of 92% long
receiving oxygen at 1 L per
minute via nasal cannula
b) A client was admitted with angina and reports left arm pain of 4 on a
scale of 0 to 10
c) The client was type II diabetes mellitus in his blood with glucose level is
at 80 mg/dL
d) A client who had a gastric endoscopy and whose nasogastric tube is
draining 30 mL per hour of green
fluid - ANSWER-b) A client was admitted with angina and reports left arm
pain of 4 on a scale of 0 to 10

A client at 38 weeks of gestation enters the emergency department. The

nurse should recognize that which
of the following indicates that the client is in the latent phase of labor?
a) The client reports the urge to push
b) The cervix is dilated 2 cm
c) Contractions are 2 to 3 minutes apart
d) The client reports nausea and vomiting - ANSWER-b) The cervix is
dilated 2 cm

The charge nurse for medical surgical units discovers client care
assignments that should be reassigned.
Which of the following delegated tasks should be reassigned?
a) An AP is to calculate intake and output every two hours for client in
acute renal failure.
b) An AP is to collect vital signs every 30 minutes for client who had a
cholecystectomy
c) A licensed practical nurse is to check nasogastric tube placement for
client list had a bowel resection.
d) A licensed practical nurses to provide initial feeding for client who had a
cerebrovascular accident. - ANSWER-d) A licensed practical nurses to
provide initial feeding for client who had a cerebrovascular accident.

A nurse caring for the client who has a cast due to a compound fracture to
the right ankle. Which of the
following findings requires immediate intervention?
a) pruiritus under the cast
b) Localized stabbing pain upon movement
c) paresthesia of the distal extremity
d) Edema present when leg is in the dependent position - ANSWER-c)
paresthesia of the distal extremity

The nurses providing care for preschoolers with acute gastroenteritis.

Basing information below which of
the following is an appropriate nursing action? Click on the links of this
below for additional client
information
a) Offer the child a cup of chicken broth.
b) Encourage the child's intake of gelatin.
c) Administer oral rehydration solutions.
d) Institute a banana, Rice, applesauce, and toast diet. - ANSWER-c)
Administer oral rehydration solutions.

The nurses caring for a client whose taking allopurinol. The nurse should
monitor which of the following
laboratory findings to determine the effectiveness of the medication?
a) Serum chloride
b) Uric acid level
c) Serum albumin
d) Magnesium level - ANSWER-b) Uric acid level

A nurse is caring for a client on the cardiac care unit who is

hemodynamically unstable. Which of the
following dysrhythmias should the nurse plan for cardioversion?
a) Ventricular asystole
b) Third-degree AV block
c) Atrial fibrillation
d) Ventricular fibrillation - ANSWER-c) Atrial fibrillation

Nurse managers preparing an educational program on infection control

measures. Which of the following
should the nurse include when discussing contact precautions?
a) Scarlet fever
b) Herpes simplex
c) Varicella
d) Streptococcal pharyngitis - ANSWER-b) Herpes simplex

A nurse assesses an older adult client with the decrease caloric intake and
weight loss. Which of the
following findings should the nurse report to the provider immediately?
a) The clinic experiences coughing and wheezing after eating.
b) The client reports abdominal pain at a five on a scale of 0 to 10.
c) The client experience is a drop in oxygen saturation to 91% while eating.
d) The client reports a burning sensation in epigastric area. - ANSWER-a)
The clinic experiences coughing and wheezing after eating.

A nurse and an assistive personnel are caring for a group of clients. Which
of the following tasks is
appropriate for the nurse to delegate an AP?
a) Applying condom catheter for client for spinal cord injury
b) Administrative oral fluids to client was dysphasia
c) Documenting the report of pain from client who is postoperative
d) Reviewing active range of motion exercises with a client who is had a
stroke - ANSWER-b) Administrative oral fluids to client was dysphasia

A nurse from the state health department this is instructing a group nurses
regarding reportable infections.
Which of the following infections should the nurse report to the CDC?
a) Candida albicans
b) Herpes simplex virus 2
c) staphylococcus aureus
d) Lyme disease - ANSWER-d) Lyme disease

The nurse is assessing an adolescent client for sickle cell anemia. Which of
the following is a priority
finding by the nurse?
a) A pain score 7 on a scale of 0 to 10
b) Shortness of breath
c) New onset of a new enuresis
d) Priapism - ANSWER-b) Shortness of breath

Nurses caring for a client whose 1 day postop following a Hypophysectomy

for the removal of the
pituitary tumor. Which of the following findings requires further
assessment by nurse?
a) Glascow scale score a 15
b) Blood drainage on initial dressing measuring 3 cm
c) Report of dry mouth
d) Urinary output greater than fluid intake - ANSWER-d) Urinary output
greater than fluid intake

A client with the left leg cast is using crutches for ambulation. The nurse
recognizes client needs further
instruction of the client
a) Flexes elbows at 30 degrees when using the handgrips
b) Maintains 3 to 4 finger width between the crutch pad and axilla
c) Places the crutches 6 inches in front and side of each foot when
standing.
d) Pushes up from a chair with crutches on the unaffected side. - ANSWER-
b) Maintains 3 to 4 finger width between the crutch pad and axilla

A nurse is caring for a toddler who has respiratory syncytial virus. Which of
the following actions
should the nurse plan to take?
a) Use a designated stethoscope when caring for the toddler.
b) Wear an N95 respiratory mask while caring for the toddler.
c) Remove the disposable gown after leaving the toddler's room
d) Place the toddler in a room with negative air pressure. - ANSWER-a) Use
a designated stethoscope when caring for the toddler.

A nurse is planning care for client to prevent complications of immobility.

With the following
actions should the nurse including the plan of care?
a) Massage lower extremities daily to prevent DVT
b) Limit intake of Food high in calcium to prevent renal calculi.
c) Encourage client to lie supine prevent constipation.
d) Remove anti embolism stockings for 3 hours each day to decreased skin
breakdown. - ANSWER-d) Remove anti embolism stockings for 3 hours
each day to decreased skin breakdown.
A nurse discovers that the wrong dosage of medication was given to client.
When determining
what action to take your should recognize that which of the following
ethical principles should be applied?
a) Utility
b) Paternalism
c) Veracity
d) Fidelity - ANSWER-c) Veracity

A nurse is review in the prescription for doxazosin with a client. Which of

the following should be
included in the teaching?
a) Decrease caloric intake to reduce weight gain.
b) Increased dietary fiber to prevent constipation.
c) Rise slowly when sitting up from bed.
d) Take this medication each morning. - ANSWER-c) Rise slowly when
sitting up from bed.

Addresses planning to provide teaching to young adult client who is

insomnia. Which of the
following should the nurse include in the teaching?
a) Exercising an hour before bedtime
b) Take a short nap today
c) Keep bedroom cool at night
d) Consume a high carbohydrate snack at bedtime. - ANSWER-d) Consume
a high carbohydrate snack at bedtime.

A nurse is caring for client who has a stool culture that is positive for
Clostridium difficile. Which
of the following infection control precautions is appropriate?
a) Wear a face shield prior into entering the room.
b) Place the client private room.
c) Place the client in a negative pressure room.
d) Use alcohol based hand rub following client care. - ANSWER-b) Place the
client private room.

A nurse is planning care for a child who has increased intracranial pressure
with a decreased
level of consciousness. Which of the following intervention should the
nurse including the plan of care?
a) Perform active range of motion exercises.
b) Perform neurological checks every 4 hours.
c) Suction the airway frequently.
d) Maintain the head at a midline position. - ANSWER-d) Maintain the
head at a midline position.

The nurse is assessing a client is receiving radiation therapy. Which of the

following findings
should the nurse expect?
a) White blood cell count at 12,500 mm3
b) Excessive salivation
c) +3 pitting edema
d) Platelets 95,000 mm3 - ANSWER-d) Platelets 95,000 mm3

A nurse is caring for a client who has preeclampsia and is experiencing

postpartum hemorrhage.
The nurse should identify that which of the following medications is
contraindicated?
a) Methylergonovine.
b) Misoprostol
c) Dinoprostone
d) Oxytocin - ANSWER-a) Methylergonovine.

A nurse is caring for client was GERD. Which of the following assessment
findings the nurse expect
to find?
a) Shortness of breath
b) Rebound tenderness
c) Atypical chest pain
d) Vomiting blood - ANSWER-c) Atypical chest pain

A nurse is caring for a newborn who is under phototherapy lights. Which of

the following is an
appropriate nursing action?
a) Ensure eye shield is covering the eyes.
b) Apply lotion to expose skin.
c) Offer glucose water between feedings.
d) Discontinue breast-feeding during treatment. - ANSWER-a) Ensure eye
shield is covering the eyes.

This is assessing clients as had a long arm cast. Which of the following
findings of the dress
moderate and when assessing for acute compartment syndrome?
a) Shortness of breath
b) Petechiae
c) Change in mental status
d) Edema - ANSWER-d) Edema

I Just came from client is receiving IV moderate (Conscious) sedation with

midazolam. The client
has a respiratory rate of 9/min and is not responding to commands. Which
of the following is an appropriate
action by the nurse?
a) Placed the client in a prone proposition.
b) Implement Positive pressure ventilation.
c) Perform nasopharyngeal suctioning.
d) administer flumazenil - ANSWER-d) administer flumazenil
A nurses in a hospital cafeteria overhears two assistive personnel (AP)
discussing a client. They are
using the clients name and discussing details of his diagnosis. Which of
following actions should the nurse
take first?
a) Report the AP's behavior to the supervisor.
b) Completed instant report regarding the Aps conversation.
c) Provide the AP with written documentation regarding client
confidentiality
d) Tell the AP to discontinue their conversation - ANSWER-d) Tell the AP to
discontinue their conversation

A community health nurse is teaching a group of adults about the

importance of health screenings.
The nurse should include African American males almost twice as likely as
caucasian males to
experience which of the following?
a) testicular Cancer
b) Obesity
c) Stroke
d) Melanoma - ANSWER-c) Stroke

A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which
of the following
prescription is given by the provider should the nurse clarify?
a) Over the fact that extremities and two pillows.
b) Apply heat to affect extremity for 45 minutes on the 45 is off.
c) wrap the affected extremity with a compression dressing.
d) Assess the affected extremity for sensation movement impulse every
four hours - ANSWER-b) Apply heat to affect extremity for 45 minutes on
the 45 is off.

A nurse is providing dietary teachings for client who has hepatic

encephalopathy. Which the
following food selections indicates that client understands teaching?
a) A sandwich and milkshake
b) Rice with black beans
c) Cottage cheese and tuna lettuce
d) Three egg omelette with low-sodium ham - ANSWER-b) Rice with black
beans

A nurse is planning care for client sealed radiation implant and is to remain
in the hospital for 1
week. Which of the following should the nurse include in the plan of care?
a) Remove dirty linens from the room after double bagging.
b) Wear a dosimeter film badge while in the client's room
c) Limit each of the clients is yours to one hour per day.
d) Ensure family members remain at least 3 feet from the client. -
ANSWER-b) Wear a dosimeter film badge while in the client's room
A nurses for Caring for four clients. Which of the following client should the
nurse care for first?
a) A client to receive a chemotherapy treatment or first national
b) A client who has an appendectomy to these don't has diminished all
sounds
c) A client is hypothyroidism and his stuporous
d) A client who is a burn requiring a sterile dressing change - ANSWER-c) A
client is hypothyroidism and his stuporous

The nurses planning care for newly admitted adolescent who has bacterial
meningitis. Which the
following instructions is appropriate for the nurse to include in the plan of
care?
a) Initiate droplet precautions for the client
b) Assisted client to supine position
c) Performing Glasgow coma scale every 24 hrs
d) Recommend prophylactic acyclovir there for the clients family -
ANSWER-a) Initiate droplet precautions for the client

Nurse is giving discharge instructions to client has new ileostomy. The

nurse should recognize that
the teaching has been effective when the client states.
a) I want sure that my medications are enteric coated
b) My stoma will drain liquid fluid continuously
c) I will change my pump system every two weeks
d) My stoma size will stay the same even after healed - ANSWER-b) My
stoma will drain liquid fluid continuously

A nurse in a provider's office is interviewing a client who is requesting an

oral contraceptive. Which
of the following findings in the client's history is a contraindication to use
in combination oral
contraceptives?
a) thyroid disease
b) Allergy to penicillin
c) impaired liver function
d) abnormal blood glucose - ANSWER-c) impaired liver function

The nurses providing teaching to a client who has mild persistent asthma
has been prescribed
montelukast. Which of the following statements to the nursing put in
teaching?
a) This medication can be used to help you when have an acute asthma
attack
b) This medication should be taken before exercise and physical activity
c) This medication can be taken for 10 days and then gradually
discontinued
d) This medication helps decrease swelling and mucus production -
ANSWER-d) This medication helps decrease swelling and mucus production
A nurse on the medical surgical unit is receiving reports on four clients.
Which of the following
client should the nurse assess first?
a) A client who is receiving warfarin and has and INR of 3.3
b) A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a
BUN 52 mg/dL
c) A client who had a NG tube inserted 6 hr ago and has abdominal
distention
18 of 28
d) A client who is 4 hr postoperative following a thyroidectomy and reports
fullness in the back of the
throat - ANSWER-b) A client who has an acute kidney injury, a creatinine of
4 mg/dL, and a BUN 52 mg/dL

A nurse is assessing a client who has pericarditis. Which of the following

findings is priority
a) Paradoxical pulse
b) dependent edema
c) Pericardial friction rub
d) Substernal chest pain - ANSWER-a) Paradoxical pulse

A charge nurse is providing teaching to a new licensed nurse on how to

cleanup surfaces
contaminated with blood. Which of the following agents said the nurse
include in the teaching?
a) Hydrogen peroxide
b) Chlorhexidine
c) Isopropyl alcohol
d) Chlorine bleach - ANSWER-d) Chlorine bleach

A nurse is preparing to feed a newly admitted patient with dysphagia.

Which of the following
actions in response take?
a) instruct the client to lift her chin when swallowing
b) discourage the client from coughing during feedings
c) Sit at or below the clients eye level during feedings.
d) Talk with the client during her feeding - ANSWER-c) Sit at or below the
clients eye level during feedings.

A nurses caring for a client who repeatedly refuses meals. The nurse
overhears an assistive
personnel telling the client. "If you don't eat, I'll put restraints on your
wrists and feed you." The nurse
should intervene and explain to the AP that this statement constitutes
which of the following torts?
a) Assault
b) Battery
c) Malpractice
d) Negligence - ANSWER-a) Assault

A charge nurse is evaluating the time management skills for new licensed
nurse. The charge nurse
should intervene when a newly licensed nurse does which of the
following?
a) Re-Evaluate priorities halfway through the shift
b) Delegate changing sterile dressing for licensed practical nurse
c) Groups activities for the Same client
d) Works on several tasks simultaneously - ANSWER-d) Works on several
tasks simultaneously

A nurse is monitoring the client during an IV urography procedure. Which

of the following client
reports is the priority finding?
a) Feeling flushed and warm
b) Abdominal fullness
c) Swollen lips
d) Metallic taste in mouth - ANSWER-c) Swollen lips

VERSION C
A nurse is planning to delegate client assignments to the assistive
personnel. which of the following
task is appropriate for the nurse to delegate?
a) Just the flow rate of the clients oxygen tank
b) Collecting urine sample
c) Measuring the clients pain level
d) Monitoring blood glucose levels - ANSWER-b) Collecting urine sample

A nurse is assessing a client wasn't following vital signs: Oral temperature

of 37.2°C (99 F). Apical
pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min,
and blood pressure of 132/40 mm
Hg. What is the clients pulse pressure? - ANSWER-a) Systolic presssure
subtracted by diastolic pressure (132 - 40) = 92

A nurse if caring for a group of clients in a medical surgical unit. Which of

the following situations
requires completion of an incident report?
a) A client who is absent gag reflex following a bronchoscopy
b) A client whose IV pump has malfunctioned
c) A client who requires insertion of NG tube due to a bowel obstruction
d) A client who is absent bell sounds following a gastrectomy - ANSWER-b)
A client whose IV pump has malfunctioned

A nurse is caring for a client who has diabetes insipidus and is receiving
desmopressin. Which of
the following should nurse monitor?
a) Fasting blood glucose
b) Carbohydrate intake
c) Hematocrit
d) Weight - ANSWER-d) Weight

The nurses providing discharge instructions about engorgement for client

has decided not to
breastfeed. Which of the following statements by the client indicates a
need for further instruction by the
nurse?
a) I can wear support bra
b) I will play cold compression my breasts
c) I will manually express breastmilk
d) I can take a mild analgesic - ANSWER-c) I will manually express
breastmilk

A nurses caring for client in preterm labor who is receiving magnesium

sulfate by continuous IV
infusion. Which of the following client findings indicates medication
toxicity?
a) Blood glucose of 150 mg/dL
b) Urine output of 20 mL per hour
c) Systolic blood pressure at 140 mm Hg
d) BUN 20 mg/dL - ANSWER-b) Urine output of 20 mL per hour

The nurse is completing an assessment for newborn who is 2 hrs old.

Which of the following
findings are indicative of cold stress?
a) Respiratory rate of 60 per minute
b) Jitteriness of the hands
c) Diaphoretic
d) Bounding peripheral pulses in all extremities - ANSWER-b) Jitteriness of
the hands

nurse is planning care for four clients. Which of the following clients is the
highest priority?
a. A client who is dry, black eschar on the heel
b. A client who is wearing an arm cast and reports numb fingers
c. The client was reddened skin area with blanching around the coccyx
d. The client who has frequent incontinence - ANSWER-b. A client who is
wearing an arm cast and reports numb fingers

A nurse is caring for a male adolescent client who has heart failure. Based
on the client's chart
finds. Which of the following actions should the nurse plan to take?
a. Withholds spiranolactone
b. Administer ferrous sulfate
c. Administer furosemide
d. Withhold digoxin (0.8-2.0) - ANSWER-d. Withhold digoxin (0.8-2.0)

The nurses assessing a client plus blood glucose level of 250 mg/dl. Which
of the following clinical
manifestations are associated with this finding?
a. Confusion
b. Thirst
c. Diaphoresis
d. Shakiness - ANSWER-b. Thirst

A nurse is assessing for allergies before administering Propofol to a client

placed on the mechanical
ventilator. Which of the following allergies is a contraindication to the
medication?
a. Eggs
b. Milk
c. Shrimp
d. Peanuts - ANSWER-a. Eggs

A nurse is assessing a client diagnosed with schizophrenia. The nurse asks

the client to interpret the
following statement, "When the cat's away, the mice will play". The client
response was, "The mice
come out when the cat is not around". The nurse should document this
finding which of the following in
the client's chart?
a. Echolalia
b. Associative looseness
c. Neologisms
d. Concrete thinking - ANSWER-d. Concrete thinking

A nurse caring for a client who is receiving total parental nutrition. Which
of the following
assessment findings required immediate intervention by the nurse?
a. prealbumin level of 20 mg/dL
b. Weight increase of two kg/day
c. Temperature of 37.6°C
d. Blood glucose level of 120 mg/dL - ANSWER-b. Weight increase of two
kg/day

A nurse in the telemetry unit is receiving the laboratory findings for adult
male client who's been
treated for myocardial function. The following is an expected finding for
the client?
a. Troponin 1 (TNI) 8 ng/ml
b. Brain natriuretic peptide (BNP) 10 ng/L
c. Alanine aminotransferase (ALT 45 unit/L
d. High density lipoprotein (HDL) 75 mg/dl - ANSWER-a. Troponin 1 (TNI) 8
ng/ml

A nurse is reviewing the results of an ABG performed on a client with

chronic emphysema. Which
of the following results suggests the need for further treatment?
a. paO2 level of 89 mm Hg
b. PaCO2 level of 55 mm Hg
c. HCO2 level of 25 mEq/L
d. pH level of 7.37 - ANSWER-b. PaCO2 level of 55 mm Hg

A nurse is teaching a client about nutritional intake. The nurse should

include which of the
following in the teaching?
a. "Carbohydrates should be at least 45% of your caloric intake."
b. "Protein should be at least 55% of your calorie intake."
c. "Carbohydrates should be at least 30% of your caloric intake."
d. "Protein should be at least 60% of your caloric intake." - ANSWER-a.
"Carbohydrates should be at least 45% of your caloric intake."

A nurse is caring for a client who has a prescription for vancomycin 1 g IV

every 12 hr. The client
is scheduled to have the morning dose at 0700. The nurse should schedule
the trough level to be drawn
at which of the following times?
a. 2100
b. 0900
c. 1300
d. 1800 - ANSWER-d. 1800

A nurse is planning an education session for a client who has type 1

diabetes mellitus. Which of the
following should the nurse plan to include when teaching the client to
monitor for hypoglycemia?
a. diaphoresis
b. polyuria
c. abdominal pain
d. thirst - ANSWER-a. diaphoresis

A nurse in an urgent-care clinic is collecting admission history from a client

who is 16 weeks of
gestation and has bacterial vaginosis. The nurse should recognize that
which of the following clinical
findings are associated with this infection?
a. Frequency and dysuria
b. Profuse milky white discharge
c. Hematuria
d. Low grade fever - ANSWER-b. Profuse milky white discharge

A nurse is planning care for a client who has a new diagnosis of dysphagia.
Which of the following
foods should be included when initiating feeding?
a. beef broth
b. oatmeal
c. apple juice
d. toast - ANSWER-b. oatmeal
A nurse receives a change-of-shift report. Which of the following clients
should the nurse attend to
first?
a. A client who reports tingling in the fingers following a thyroidectorny
b. A client who has dark, foul-smelling urine with a urine output of 320 mL
in the last 8 hr
c. A client who is in a long leg cast and reports cool feet bilaterally
d. A client who has a productive cough and an oral temperature of 36° C
(96.80 F) - ANSWER-a. A client who reports tingling in the fingers following
a thyroidectorny

A nurse is caring for a client who has lactose intolerance and has
eliminated dairy products from
his diet. The nurse should instruct the client to increase consumption of
which of the following foods?
a. spinach
b. peanut butter
c. ground beef
d. carrots - ANSWER-a. spinach

A client who is 8 hr postpartum asks the nurse if she will need to receive
Rh immune globulin. The
client is gravida 2, para 2, and her blood type is AB negative. The newborns
blood type is B positive.
Which of the following statements is appropriate?
a. You only need to receive Rh immune globulin if you have a positive
blood type."
b. You should receive Rh immune globulin within 72 hours of delivery."
c. "Both you and your baby should receive Rh immune globulin at your -
week appointment."
d. "immune globulin is not necessary since this is your second pregnancy."
- ANSWER-b. You should receive Rh immune globulin within 72 hours of
delivery."

A nurse is caring for the mother of an adolescent who was killed in a

motor-vehicle crash after a
school event. The mother states, I never should have let him take the car.
Its all my fault!" Which of the
following responses by the nurse is appropriate?
a. You had no way of knowing this would happen."
b. Most parents blame themselves when losing a child."
c. Tell me why you feel this is your fault."
d. You appear to be feeling overwhelmed" - ANSWER-d. You appear to be
feeling overwhelmed"

A nurse is educating a client about caloric intake and weight reduction.

Which of the following
client statements indicates an understanding of the teaching?
a. "If I eat 500 fewer calories per day, I should lose 1 pound per week."
b. " If I eat 500 fewer calories per day, I should lose 1 pound per week."
c. "If I eat 450 fewer calories per day, I should lose 2 pounds per week."
d. "If I eat 250 fewer calories per day, I should lose 2 pounds per week."
e. "If I eat 300 fewer calories per day, I should lose 1 pound per week." -
ANSWER-a. "If I eat 500 fewer calories per day, I should lose 1 pound per
week."

A nurses is teaching post-operative care with the parents of a toddler

following a cleft palate
repair. Which of the following should be included in the teaching?
a. Provide an orthodontic pacifier for comfort.
b. Offer fluids by using a straw.
c. Cleanse suture line with a cotton tip swab.
d. Remove elbow splints periodically to perform range of motion. -
ANSWER-d. Remove elbow splints periodically to perform range of motion.
A nurse in an emergency department completes an assessment on an
adolescent client that has conduct disorder. The client threatened suicide
to teacher at school. Which of the following statements should the
nurse include in the assessment?
a) Tell me about your siblings
b) Tell me what kind of music you like
c) Tell me how often do you drink alcohol
d) Tell me about your school schedule - ANSWER-c) Tell me how often do
you drink alcohol
A nurse is observing bonding to the client her newborn. Which of following
actions by the client requires the nurse to intervene?
a) Holding the newborn in face position
b) Asking the father to change the newborn's diaper
c) Requesting the nurse take the newborn nursery so she can rest
d) Viewing the newborn's actions to be uncooperative - ANSWER-d)
Viewing the newborn's actions to be uncooperative

A nurse is caring for client who is taking levothyroxin. Which of the

following findings should indicate that the medication is effective?
a) Weight loss
b) Decreased blood pressure
c) Absence of seizures
d) Decrease inflammation - ANSWER-a) Weight loss

A nurse is planning discharge teaching for cord care for the parent of a
newborn. Which instructions would you include in the teaching?
a) Contact provider if the cord still turns black
b) Clean the base of the cord with hydrogen peroxide daily
c) Keep the cord dry until it falls off
d) The cord stump will fall off in five days - ANSWER-c) Keep the cord dry
until it falls off

A nurse is caring for four clients. Which of the following tasks can the nurse
delegate to an assistive
personnel?
a. Perform chest compressions during cardiac resuscitation.
b. Perform a dressing change for a new amputee.
c. Assess effectiveness of antiemetic medication.
d. Provide discharge instructions - ANSWER-a. Perform chest compressions
during cardiac resuscitation.

A nurse in an emergency department is serving on a committee that is

reviewing the facility
protocol for disaster readiness. The nurse should recommend that the
protocol include which of the
following as a clinical manifestation of smallpox?
a. Bloody diarrhea
b. Ptosis of the eyelids
c. Descending paralysis
d. Rash in the mouth - ANSWER-d. Rash in the mouth

A nurse is preparing to perform closed intermittent bladder irrigation for a

client following a
transurethral resection of the prostate (TURP). Which of the following
actions is appropriate by the
nurse?
a. Aspirate the irrigation solution from the bladder.
b. Insert the tip of the irrigation syringe into the catheter opening.
c. Apply sterile gloves
d. open the flow clamp to the irrigating fluid infusion tubing. - ANSWER-c.
Apply sterile gloves

A nurse is caring for a client who has been taking haloperidol for several
years. Which of the
following assessment findings should the nurse recognize as a long-term
side effect of this medication?
a. Lipsmacking
b. Agranulocytosis
c. Clang association
d. Alopecia - ANSWER-a. Lipsmacking

A nurse is planning care for a client who has Alzheimers disease and
demonstrates confusion and
wandering behavior. Which of the following should the nurse include in the
plan of care?
a. Place the client in seclusion when she is confused.
b. Request a prescription for PRN restraints when the client is wandering.
c. Dim the lighting in the clients room.
d. Leave one side rail up on the clients bed - ANSWER-d. Leave one side rail
up on the clients bed

A nurse is reviewing the laboratory data of a client who has diabetes

mellitus. Which of the
following laboratory tests is an indicator of long-term disease
management?
a. Postorandial blood glucose
b. Glycosylated hemoglobin
c. Glucose tolerance test
d. Fasting blood glucose - ANSWER-b. Glycosylated hemoglobin

A nurse on a pediatric care unit is delegating client care. Which of the

following tasks should the
nurse delegate to an assistive personnel?
a. Initiate a dietary consult for a toddler.
b. Administer a glycerin suppository to a preschool-age child.
c. Evaluate gastric residual following intermittent feeding of an adolescent.
d. Transport a school-age child to x-ray. - ANSWER-d. Transport a school-
age child to x-ray.

A nurse is caring for a client who has been taking propranolol. Which of the
following findings
indicates a need to withhold the medication?
a. sodium 130 mEq/L
b. Blood pressure 156/90 mm Hg
c. Potassium 5.2 mEq/L
d. Pulse 54/min - ANSWER-d. Pulse 54/min
A nurse working in a mental health facility observes a client who has
bipolar disorder walk over to
a table occupied by other clients and knock their game off the table. Which
of the following is an
appropriate response by the nurse?
a. Apologize to the others for your behavior."
b. I am disappointed that you continue to act out when you are angry."
c. Come outside with me for a walk."
d. If you dont calm down, you will have to go into seclusion." - ANSWER-c.
Come outside with me for a walk."

A nurse is caring for a client who has human immunodeficiency virus (HIV)
with neutropenia.
Which of the following precautions should the nurse take while caring for
this client
a. Wear an N95 respirator while caring for the client.
b. Use a dedicated stethoscope for the client.
c. Insert an indwelling urinary catheter to monitor urinary output.
d. Monitor the client's vital signs every 8 hr. - ANSWER-b. Use a dedicated
stethoscope for the client.

A nurse is checking laboratory results for a client. Which of the following

laboratory findings
indicates hypervolemia?
a. serum sodium 138 mEq/L
b. Urine specific gravity 1.001
c. serum calcium 10 mg/dL
d. Urine pH 6 - ANSWER-b. Urine specific gravity 1.001

A nurse is caring for a group of clients in a long-term care facility. Which of

the following
situations should the nurse recognize as a safety hazard?
a. A client's wrist restraints tied to the bed rails
b. A clients bedside table placed across the foot of the bed
c. A meal tray left at the bedside from breakfast
d. A call light extension cord pinned to the bedspread - ANSWER-a. A
client's wrist restraints tied to the bed rails

A nurse is caring for a client in a mental health facility. The clients daughter
is crying and tells the
nurse that she feels guilty for leaving her father in the hospital. Which of
the following is an
appropriate response?
a. I'd like to know more about what's bothering you."
b. "Why are you feeling this way"
c. "You did the right thing by bringing him here."
d. "I'm sure your father doesn't blame you." - ANSWER-a. I'd like to know
more about what's bothering you."
A nurse is planning care for a client following gastric bypass surgery. The
nurse should include
which of the following dietary instructions when preparing the client for
discharge?
a. start each meal with a protein source.
b. Consume at least 25 g of fiber daily.
c. Check your blood glucose level before each meal.
d. Limit your meals to three times per day. - ANSWER-a. start each meal
with a protein source.

149 A nurse is assessing a client who has a chest tube following a

thoracotomy. Which of the
following findings requires intervention by the nurse?
a. Tidaling with spontaneous respirations
b. Drainage collection chamber is 1/3 full
c. 1 cm of water present in the water seal chamber
d. Suction chamber pressure of -20 cm H20 - ANSWER-c. 1 cm of water
present in the water seal chamber

A provider has written a do not resuscitate order for a client who is

comatose and does not have
advance directives. A member of the clients family says to the nurse, "I
wonder when the doctor will
tell us what's going on" Which of the following actions should the nurse
take first
a. Request that the provider provide more information to the family.
b. Refer the family to a support group for grief counseling.
c. Offer to answer questions that family members have.
d. Ask the family what the provider has discussed with them - ANSWER-d.
Ask the family what the provider has discussed with them

A nurse is performing a skin assessment on a client who has risk factors for
development of skin
cancer. The nurse should understand that a suspicious lesion is
a. scaly and red
b. asymmetric, with variegated coloring
c. firm and rubbery
d. brown with a wart-like texture - ANSWER-b. asymmetric, with
variegated coloring

A nurse is interviewing an older adult client about the physiological

changes he has been
experiencing. Which of the following changes should the nurse recognize is
normally associated with
the aging process?
a. Decreased sense of taste
b. Decreased blood pressure
c. Increased gastric secretions
d. Increased accommodation to near vision - ANSWER-a. Decreased sense
of taste
A nurse in an intensive care unit is planning care for a client who has
alcohol withdrawal
syndrome. Which of the following should the nurse include in the plan of
care?
a. Administer disulfiram.
b. Provide frequent orientation to time and place.
c. Engage the client in group therapy.
d. Perform gastric lavage. - ANSWER-b. Provide frequent orientation to
time and place.

A nurse manager is planning an audit to measure the quality of care on the

unit. Which of the
following is the most appropriate source for the nurse to consult?
a. Nursing manager colleagues
b. Evidence-based practice data
c. Hospital administrators
d. Protocols in other hospitals - ANSWER-b. Evidence-based practice data

A nurse is caring for a client who had gastric bypass surgery 1 week ago
and has signs of early
dumping syndrome. Which of the following findings should the nurse
expect? (Select all that apply)
a. Facial flushing
b. Syncope
c. Diaphoresis
d. Vertigo
e. Bradycardia - ANSWER-b. Syncope
d. Vertigo

A nurse is caring for a client who is experiencing mild anxiety. Which of the
following findings
should the nurse expect?
a. feelings of dread
b. rapid speech
c. purposeless activity
d. heightened perceptual field - ANSWER-d. heightened perceptual field

A nurse is delegating tasks to an assistive personnel. Which of the

following instructions
demonstrates appropriate communication of the task?
a. "Take a blood glucose fingerstick on the client in room 102 before
breakfast and then place the glucometer into the docking station."
b. "Obtain a blood pressure reading from the client in room 116 after lunch
and report a systolic level less than 90."
c. "Assist the client in room 110 to ambulate once around the unit and stop
if she gets short of breath."
d. "Turn the client in room 126 to prevent pressure areas on his hip bones."
- ANSWER-b. "Obtain a blood pressure reading from the client in room 116
after lunch and report a systolic level less than 90."
A nurse is caring for a client who has constricted pupils, delayed reflexes,
and decreased blood
pressure. The nurse should recognize that these findings are potential
manifestations of which of the
following?
a. Nicotine withdrawal
b. Heroin intoxication
c. Alcohol withdrawal
27 of 28
d. Amphetamine intoxication - ANSWER-b. Heroin intoxication

A nurse is assessing an older adult client who had a stroke. Which of the
following findings should
the nurse recognize as an indication of dysphagia?
a. Abnormal movements of the mouth
b. Inability to stand without assistance
c. Paralysis of the right arm
d. Loss of appetite - ANSWER-a. Abnormal movements of the mouth

A nurse is assisting the provider with a paracentesis for a client who has
ascites. Following
collection of the specimen, which of the following actions should the nurse
take next
a. Document the procedure.
b. Measure the drainage.
c. Record the color of the drainage.
d. Label the specimen. - ANSWER-d. Label the specimen.

A nurse is providing preoperative teaching to a client who will use PCA

morphine sulfate following surgery. Which of the following information
should the nurse include?
a. The client should notify the nurse when administering a dose of the
medication.
b. The client can administer a dose of medication every 6 to 8 min.
c. The client should be cautious to avoid overmedication (OD).
d. Family members can administer a dose the client. - ANSWER-b. The
client can administer a dose of medication every 6 to 8 min.

A nurse is caring for a client in an inpatient facility who tells the nurse that
she is leaving because
the facility policy prohibits smoking inside. Which of the following actions
should the nurse take?
a. Notify security to monitor the facility exits.
b. Place the client in seclusion.
c. Inform the client of the risks involved if she leaves.
d. Call the provider for a discharge prescription. - ANSWER-c. Inform the
client of the risks involved if she leaves.
A nurse is preparing to administer a measles, mumps, rubella (MMR)
immunization to a child.
Which of the following is a contraindication for administration?
a. Recent blood transfusion
b. Allergy to penicillin
c. Minor acute illness
d. Low-grade fever - ANSWER-a. Recent blood transfusion

A nurse is preparing to administer 2.5 mL of medication intramuscularly to

an adult client. Which
of the following is the safest site for the nurse to use?
a. Ventrogluteal
b. Dorsogluteal
c. Vastus lateralis
d. Rectus femoris - ANSWER-a. Ventrogluteal

A nurse is teaching a female client how to reduce the risk of urinary tract
infections (UTIs). Which
of the following should the nurse include as a risk factor for developing a
UTI?
a. Wearing underwear with a cotton crotch
b. Wiping from front to back
c. Using perfumed toilet paper
d. Urinating immediately after intercourse - ANSWER-c. Using perfumed
toilet paper
A nurse is providing discharge instructions for a client who has a new
prescription for furosemide.
Which of the following client statements indicates a need for further
teaching?
a. "I will take my morning pills with food or milk."
b. "I will weigh myself every day."
c. "I will notify the nurse if I have muscle cramps."
d. "I will limit my intake of fish." - ANSWER-d. "I will limit my intake of
fish."

A nurse is caring for a client who has a prescription for atorvastatin. Which
of the following client
conditions is a contraindication to this medication?
a. hepatits C
b. peptic ulcer disease
c. bronchitis
d. chrohn's disease - ANSWER-a. hepatits C

A nurse is planning care for an adolescent who has chronic renal failure.
Which of the following
actions should the nurse include in the plan of care?
a. Encourage a diet high in calcium.
b. Provide a diet high in potassium.
c. Ensure increased fluid intake.
d. Restrict protein intake to the RDA. - ANSWER-d. Restrict protein intake
to the RDA.

A nurse is assessing a client 1 hr following birth and notes that her uterus is
boggy and located 2
cm above the umbilicus. Which of the following actions should the nurse
take first?
a. Take vital signs.
b. Assess lochia.
c. Massage the fundus.
d. Give oxytocin IV bolus. - ANSWER-c. Massage the fundus.

A nurse is caring for a client who is receiving intermittent enteral tube

feedings. Which of the
following interventions should the nurse perform
a. Give 100 mL of water with every feeding.
b. Obtain gastric residuals every 24 hr.
c. Position the head of bed at 30 degrees during feeding.
d. Mix the clients medications with the tube feedings - ANSWER-c. Position
the head of bed at 30 degrees during feeding.

A nurse is caring for a 7 month-old infant who is being treated for severe
dehydration. Which of
the following assessment findings indicates treatment has been effective?
a. Skin turgor displays tenting
b. Flat anterior fontanel
c. Cool, mottled skin
d. hyperpnea - ANSWER-b. Flat anterior fontanel

A nurse is providing teaching to a client who has esophageal cancer and is

scheduled to start radiation therapy. Which of the following should the
nurse include in the teaching?
a. Remove dye markings after each radiation treatment.
b. Apply a warm compress to the irradiated site.
c. Wear clothing over the area of radiation treatment.
d. Use a washcloth to bathe the treatment area. - ANSWER-c. Wear
clothing over the area of radiation treatment.

A nurse in a provider's office is providing education to a client who is 16

weeks of gestation and
has a new prescription for ferrous sulfate. Which of the following
instructions should the nurse provide
a. Avoid strawberries, citrus fruit, and melon to ensure that your iron
medication is effective."
b. "Take your iron medication with fluids other than coffee or tea."
c. "It is important to take your iron medication on a full stomach."
d. "If you miss a dose one day, take two doses the next day." - ANSWER-b.
"Take your iron medication with fluids other than coffee or tea."
175 A nurse receives a change-of-shift report on four clients. Based on the
shift report information,
which of the following clients should the nurse plan to assess
a. A client who had a hip arthroplasty reports pain and erythema in his calf
b. A client who has anorexia and peripheral edema
c. A client who has Addison's disease with a blood glucose level of 75
mg/dL
d. A client who had a barium enema 2 days ago and reports constipation -
ANSWER-a. A client who had a hip arthroplasty reports pain and erythema
in his calf

A nurse administers a dose of metoclopramide to a client prior to

chemotherapy treatment. Which
of the following medications should the nurse administer?
a. Albuterol sulfate
b. Hydromorphone
c. Diphenhydramine
d. Amitriptyline - ANSWER-c. Diphenhydramine

A client who does not speak English arrives at the emergency department
accompanied by a child.
Which of the following actions should the nurse take?
a. Ask the assistive personnel to assist the client in signing consent for
treatment
b. Ask the child to interpret for the client.
c. Ascertain what language the client speaks and get an interpreter.
d. Try to find an adult relative to help the client communicate. - ANSWER-c.
Ascertain what language the client speaks and get an interpreter.

A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate
intravenously. The nurse discontinues the magnesium sulfate after the
client displays toxicity. Which of
the following actions should the nurse take?
a. Position the client supine.
b. Prepare an IV bolus of dextrose 5% in water
c. Administer calcium gluconate IV.
d. Administer methylergonovine IM. - ANSWER-c. Administer calcium
gluconate IV.

A nurse is using Naegeles rule to calculate the expected delivery date for a
newly pregnant
primigravida. The first day of the clients last period was October. What is
the expected delivery date? - ANSWER-a. 0711 (July 7, 2011)

A nurse on a medical-surgical unit is receiving report on four clients. Which

of the following
clients should the nurse assess first?
a. A client who is scheduled for chemotherapy and has a hemoglobin of 9
b. A client who is 24 hr postoperative following a transurethral resection of
the prostate (TURP) and has small blood clots in the urinary catheter
c. A client who is receiving a blood transfusion and reports low-back pain
d. A client who has a new colostomy with a reddish-pink stoma - ANSWER-
c. A client who is receiving a blood transfusion and reports low-back pain