2023 ATI PN Comprehensive Exam With Answers-179 Solved Questions

ATI PN COMPREHENSIVE PREDICTOR 2023 REAL EXAM 179
QUESTIONS AND ANSWERS
1. A nurse is caring for a group of clients, which of the following can be assigned to an
assistive personnel?
Answer: Collecting a stool specimen to test for occult blood
Rationale:
Collecting a stool specimen for occult blood testing is a task that can be delegated to assistive
personnel. It is a non-invasive procedure that does not require specialized nursing knowledge
or skills.
2. A nurse is working on a unit for clients with dementia. Which of the following client
situations requires the nurse to write an incident report?
Answer: A client is found lying on the floor next to a chair
Rationale:
Finding a client lying on the floor next to a chair is considered an adverse event and should
be documented in an incident report. Incident reports are used to record any unexpected or
adverse events that occur during the client's care.
3. A nurse is discharging a client who was admitted for newly diagnosed type 2 diabetes
mellitus. The client is independent and lives alone. Which of the following should be
included in the discharge plan?
Answer: Refer the client to a diabetic support group.
Rationale:
Referring the client to a diabetic support group can provide valuable education, resources,
and emotional support, which can be beneficial for managing diabetes independently. Support
groups can also help the client connect with others facing similar challenges, reducing
feelings of isolation and improving overall well-being.
4. A nurse is caring for a client who has type 2 diabetes mellitus and a blood glucose level of
60 mg/dL. For which of the following findings should the nurse monitor?
Answer: Fasting plasma glucose level
Rationale:
Monitoring the fasting plasma glucose level can help assess the effectiveness of diabetes
management and treatment. A low blood glucose level (hypoglycemia) such as 60 mg/dL
requires close monitoring to prevent complications and to adjust treatment as needed.

5. A female client who is in an abusive marriage has discussed with the nurse strategies to
prevent this abuse. Which of the following client statements indicate an understanding of an
appropriate strategy?
Answer: "I need to identify what triggers my husband's anger to prevent his abuse."
Rationale:
Understanding the triggers for abusive behavior can help the client anticipate and possibly
prevent instances of abuse. This demonstrates a proactive approach to managing the situation
and prioritizing safety.
6. A charge nurse in a long-term care facility is preparing to administer noon insulin to a
client. The nurse observes that the assistive personnel (AP) has not documented the client's
blood glucose level. Which of the following actions should the charge nurse take first?
Answer: Determine if the AP has completed the assignment.
Rationale:
Before taking any further action, the charge nurse should first ascertain whether the AP has
completed the assignment. This allows the charge nurse to gather information and assess the
situation before deciding on the next steps.
7. A client is scheduled for an outpatient colonoscopy. Which of the following actions is a
nursing responsibility in the informed consent process?
Answer: Verify that there is a signed and witnessed consent form in the client's chart.
Rationale:
It is the nurse's responsibility to ensure that the client has provided informed consent for the
procedure. This includes verifying that a signed and witnessed consent form is in the client's
chart before the procedure is performed.
8. A nurse smells alcohol on the breath of an assistive personnel (AP) during report. Which of
the following actions should the nurse take?
Answer: Report the situation to the nurse manager.
Rationale:
Suspected alcohol use by an AP should be reported to the nurse manager or supervisor
immediately for appropriate action. This ensures patient safety and adherence to workplace
policies.
9. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the
following clients is an appropriate assignment for the nurse to accept?
Answer: A client who had a cesarean delivery 24 hours ago.
Rationale:

A nurse from a medical-surgical unit can safely care for a postpartum client who had a
cesarean delivery 24 hours ago. The nurse should have the knowledge and skills necessary to
provide appropriate care for this client population.
10. A nurse in a provider's office is collecting data from a parent of an infant who is being
screened for cystic fibrosis. Which of the following supports a diagnosis of cystic fibrosis?
Answer: Frothy stools.
Rationale:
Frothy stools can be a symptom of cystic fibrosis, a genetic disorder that affects the lungs and
digestive system. Other common symptoms include salty-tasting skin, persistent coughing,
and poor growth despite a good appetite. Further diagnostic testing would be needed to
confirm a diagnosis of cystic fibrosis.
11. When caring for an assigned group of clients, the nurse should wear gloves when
Answer: Performing oral hygiene.
Rationale:
Wearing gloves during oral hygiene helps protect both the nurse and the client from potential
infections or pathogens present in the oral cavity.
12. A nurse is preparing a client for surgery. The client tells the nurse that he is concerned
about the safety of a large sum of money in his wallet. Which of the following actions is
appropriate for the nurse to take?
Answer: Contact security personnel to place the money in the facility safe.
Rationale:
It is important to address the client's concerns about the safety of his belongings. Contacting
security personnel to secure the client's money in the facility safe ensures its safety and
allows the client to focus on his surgery without worry.
13. A nurse is caring for a client who is receiving heparin. Which of the following is the
appropriate route of administration?
Answer: Subcutaneously.
Rationale:
Heparin is typically administered subcutaneously for prophylaxis against blood clot
formation. This route allows for slow and consistent absorption of the medication.
14. A nurse is reinforcing teaching about car seat safety to the parents of a newborn. The
nurse should instruct the parents to place the car seat in a
Answer: Rear-facing position in the back seat.
Rationale:

Placing the car seat in a rear-facing position in the back seat is recommended for newborns
and infants. This position provides optimal protection for the baby's head, neck, and spine in
the event of a crash.
15. A nurse is caring for a client and recognizes the client's rights to confidentiality have been
breached in which of the following situations?
Answer: A hospital risk manager includes information from a client's medical record in a
presentation about quality improvement measures without the client's consent.
Rationale:
Breaching a client's confidentiality by sharing information from their medical record without
consent is a violation of the client's privacy rights. Healthcare providers must obtain consent
before sharing any protected health information.
16. A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days ago. When
monitoring peripheral pulses, the nurse is unable to locate a pulse on the affected leg. Which
of the following actions should the nurse take?
Answer: Notify the charge nurse of the finding.
Rationale:
Inability to locate a peripheral pulse in a client who has had a femoral-popliteal bypass graft
may indicate a potential complication, such as graft occlusion or inadequate blood flow. It is
important to notify the charge nurse or healthcare provider promptly to assess the situation
and determine appropriate interventions.
17. A nurse is caring for a full-term newborn who was circumcised 6 hours ago. Which of the
following findings indicates that the newborn is experiencing pain?
Answer: Furrowed Brow
Rationale:
A furrowed brow is a sign of discomfort or pain in newborns. Other signs of pain in newborns
include crying, grimacing, and increased heart rate. It is important for the nurse to assess and
manage pain in newborns to promote comfort and well-being.
18. A nurse is reinforcing teaching with a client about organ donation. Which of the following
client statements indicates a need for further teaching?
Answer: "My doctor should decide if my organs will be donated."
Rationale:
Organ donation is a personal decision, and the client should be the one to make the decision
about organ donation. Healthcare providers can provide information and support to help the

client make an informed decision, but ultimately, the decision should be made by the client or
their designated decision-maker.
19. A client who is prescribed metoprolol (Lopressor) for hypertension tells the nurse, "I don't
want to take this medication because it makes me tired all the time." Which of the following
is the appropriate response?
Answer: "Let's talk with your doctor about other options."
Rationale:
It is important to address the client's concerns about medication side effects. The nurse should
collaborate with the healthcare provider to explore other medication options or adjust the
dosage to minimize side effects while effectively managing hypertension.
20. A nurse is preparing to administer an IM injection to a client. To reduce the risk of needle
stick injury, the nurse should?
Answer: Dispose of the used needle immediately in a puncture-proof sharps container.
Rationale:
Disposing of the used needle immediately in a puncture-proof sharps container reduces the
risk of needle stick injury to the nurse and others. Placing the needle directly into the
container without recapping or bending the needle minimizes the risk of accidental sticks.
21. A Nurse is contributing to the discharge plan for a client following surgery. Which of the
following findings indicate the need for an interdisciplinary care conference?
Answer: The client requires assistance to pay for dressing supplies.
Rationale:
The need for assistance to pay for dressing supplies suggests financial constraints that may
impact the client's ability to adhere to the postoperative care plan. An interdisciplinary care
conference involving financial counselors, social workers, and other team members can help
address these concerns and ensure continuity of care.
22. A client who is 24 hours postoperative suddenly develops chest pain, dyspnea, anxiety,
diaphoresis, and cough. Which of the following actions should the nurse take first?
Answer: Elevate the head of the client's bed.
Rationale:
Elevating the head of the client's bed helps improve ventilation and oxygenation by
expanding the chest cavity. This can be beneficial if the symptoms are due to respiratory
distress or cardiac issues, allowing the client to breathe more comfortably while the nurse
assesses further.

23. A nurse is caring for a 17-year-old client who is admitted for an emergency
appendectomy. Which of the following is an appropriate action by the nurse in obtaining
informed consent?
Answer: Obtain verbal consent from the client while waiting for the parents to arrive.
Rationale:
Verbal consent can be obtained from the client if they are capable of understanding the
procedure and its risks. However, the nurse should also make efforts to involve the parents or
legal guardians in the consent process, such as witnessing their signature or obtaining consent
from them if the client is unable to provide it.
24. A nurse has delegated care to an assistive personnel. At the end of the shift, the AP asks
the nurse to enter data for her because the AP has forgotten her password and needs to leave.
Which of the following actions should the nurse take?
Answer: Tell the AP to contact the IT department for charting assistance.
Rationale:
Sharing passwords violates security policies and compromises patient confidentiality. The
nurse should advise the AP to contact the IT department for assistance with accessing the
charting system, ensuring that proper protocols are followed.
25. A nurse is reinforcing discharge teaching to a client following a gastrectomy. To prevent
dumping syndrome, which of the following foods should the nurse instruct the client to
avoid?
Answer: Ice Cream
Rationale:
Ice cream is high in sugar and fat, which can exacerbate dumping syndrome in clients who
have undergone a gastrectomy. Dumping syndrome occurs when food moves too quickly
from the stomach to the small intestine, causing symptoms such as abdominal cramping,
diarrhea, and lightheadedness. Avoiding high-sugar and high-fat foods can help prevent these
symptoms.
26. A nurse is caring for a client admitted with shortness of breath who will be undergoing
arterial blood gas testing. Which of the following client statements indicates an understanding
of the purpose of drawing arterial blood gases?
Answer: "This will indicate how much acid is building up in my blood."
Rationale:
Arterial blood gas (ABG) testing measures the levels of oxygen and carbon dioxide in the
blood, as well as the acidity (pH). The statement by the client indicates an understanding that

ABG testing helps assess the acid-base balance in the blood, which can be affected by
respiratory and metabolic conditions.
27. A nurse manager is seeking ways to increase cost-effectiveness on the unit. In which of
the following client care situations should the nurse manager intervene?
Answer: Nurse discards a bottle of sterile saline after it has been open for 24 hours.
Rationale:
Sterile saline should be discarded after 24 hours of being open to prevent contamination and
reduce the risk of infection. However, if the bottle has not been used or has been used within
the recommended time frame, there is no need to discard it solely for cost-saving purposes.
28. A nurse is collecting data from a client who reports recent weight loss and a chronic
cough that is now producing blood-streaked sputum. For which of the following should the
nurse expect the client to have diagnostic testing?
Answer: Lung Cancer
Rationale:
The client's symptoms of recent weight loss, chronic cough, and blood-streaked sputum are
indicative of potential lung cancer, especially if they are long-term smokers or have other risk
factors. Diagnostic testing may include chest X-rays, CT scans, sputum cytology, and
possibly a biopsy to confirm the presence of cancer cells. Early detection is crucial for better
treatment outcomes in lung cancer cases.
29. A nurse is caring for an older adult client with a decreased level of consciousness. Which
of the following is an appropriate intervention related to the client's mouth care?
Answer: Uses a sponge toothette to cleanse the inside of the mouth.
Rationale:
Older adult clients with decreased consciousness may have difficulty maintaining oral
hygiene. Using a sponge toothette can help gently cleanse the inside of the mouth, removing
bacteria and debris to prevent infections such as pneumonia.
30. A nurse in a long-term care facility notes that the assistive personnel lack knowledge of
blood glucose monitoring. The nurse should bring this observation to the attention of which
of the following personnel?
Answer: Charge Nurse.
Rationale:
The charge nurse is responsible for overseeing the care provided by the nursing staff,
including the training and competency of assistive personnel. Bringing this observation to the

charge nurse's attention allows for appropriate action, such as additional training or
supervision, to ensure that all staff members are competent in blood glucose monitoring.
31. A nurse is reinforcing discharge teaching for a client admitted with an acute myocardial
infarction. Which of the following activities is appropriate for the client to participate in
during the first two weeks following discharge?
Answer: Walking.
Rationale:
Walking is a low-impact activity that can help improve cardiovascular health and overall
well-being. It is often recommended as part of cardiac rehabilitation following a myocardial
infarction, as it can help improve circulation and gradually increase physical activity levels.
32. A nurse is providing anticipatory guidance to the parent of a 6-year-old child. Which of
the following statements by the parent indicates an understanding of appropriate safety
precautions for the child?
Answer: "I will encourage my child to wear a bicycle helmet whenever bike riding."
Rationale:
Wearing a bicycle helmet is an important safety precaution to prevent head injuries while bike
riding. Encouraging the child to wear a helmet shows an understanding of the importance of
safety and injury prevention.
33. A nurse is collecting data from a client who presents to the clinic reporting vomiting.
Which of the following findings indicate that the client is experiencing a fluid volume
deficit?
Answer: Orthostatic hypotension.
Rationale:
Orthostatic hypotension, which is a drop in blood pressure when moving from a lying to a
standing position, can indicate fluid volume deficit. Other signs of fluid volume deficit
include increased heart rate, dry mucous membranes, and decreased skin turgor.
34. A nurse is reinforcing teaching for a client undergoing radiation therapy to the neck.
Which of the following should the nurse include?
Answer: Avoid exposing the neck to the cold.
Rationale:
Radiation therapy to the neck can increase the sensitivity of the skin in that area. Therefore, it
is important to avoid exposing the neck to extreme temperatures, including cold temperatures,
which can further irritate or damage the skin.

35. A nurse is caring for a client who is receiving warfarin (Coumadin) for deep vein
thrombosis. The nurse observes that the client's INR is 3.8. Which of the following actions
should the nurse take?
Answer: Withhold the ordered dose of the medication.
Rationale:
An INR of 3.8 is above the therapeutic range for warfarin therapy, which increases the risk of
bleeding. The nurse should withhold the medication and notify the healthcare provider for
further instructions, such as adjusting the dosage or frequency of administration.
36. A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home
visit. Which of the following findings in the infant's room indicates a need for further
teaching?
Answer: The infant is lying in the crib with a stuffed animal.
Rationale:
The presence of a stuffed animal in the crib poses a suffocation hazard for the infant. The
American Academy of Pediatrics recommends that infants sleep on their backs in a crib with
a firm mattress and no soft bedding, toys, or loose objects to reduce the risk of Sudden Infant
Death Syndrome (SIDS).
37. A nurse is caring for a client who has hepatitis B. When caring for the client, which of the
following actions places the nurse at highest risk for acquiring hepatitis B?
Answer: Performing oral hygiene.
Rationale:
Hepatitis B is transmitted through contact with infected blood or body fluids. Performing oral
hygiene, which involves contact with saliva, places the nurse at risk of exposure to the virus
if there are any open sores or bleeding gums in the client's mouth. Standard precautions,
including the use of gloves, should be followed to reduce the risk of transmission.
38. A nurse is reinforcing discharged teaching with the family of a client who has dependent
personality disorder. Which of the following instructions should the nurse include in the
teachings?
Answer: Assume responsibility for making the client's decisions.
Rationale:
Dependent personality disorder is characterized by a pervasive and excessive need to be taken
care of, which leads to submissive and clinging behavior and fears of separation. The nurse
should educate the family about the importance of encouraging the client to make decisions

and take responsibility for their actions, as this can help promote independence and selfconfidence.
39. A nurse is reinforcing teaching with school staff about streptococcal infection of the
pharynx. The nurse should instruct the staff that the period of contagion for children who
have this infection is which of the following?
Answer: From onset of symptoms until 24 hours of antibiotic therapy.
Rationale:
Streptococcal infections of the pharynx (strep throat) are contagious and are spread through
respiratory droplets. Children with strep throat should be considered contagious from the
onset of symptoms until they have been on antibiotics for at least 24 hours. It is important for
school staff to be aware of this to prevent the spread of infection among students and staff.
40. A nurse is caring for a client who is 2 days postoperative following a partial bowel
resection. The client reports that he "felt something pop" when he sneezed. The nurse
observes an evisceration. After calling for assistance, which of the following actions should
the nurse take first?
Answer: Cover the wound with sterile saline-soaked gauze.
Rationale:
Evisceration, the protrusion of abdominal organs through a wound opening, is a surgical
emergency that requires immediate intervention to prevent infection and further
complications. The nurse should cover the wound with sterile saline-soaked gauze to protect
the exposed organs and prevent them from drying out while waiting for the surgical team to
arrive.
41. A nurse is caring for a client who is in balanced skeletal traction for a leg fracture. Which
of the following should the nurse expect to be included in the care plan?
Answer: Increase countertraction every 24 hours. Inspect the ropes, knots, and pulleys every
8 hours.
Rationale:
Balanced skeletal traction is a method used to immobilize and align fractured bones. To
maintain proper alignment and prevent complications, such as skin breakdown and nerve
damage, the nurse should ensure that the countertraction is adjusted every 24 hours to
maintain the desired traction force. Additionally, the nurse should inspect the ropes, knots,
and pulleys every 8 hours to ensure they are intact and functioning properly to prevent
accidental dislodgement or loss of traction.

42. A nurse is using contact precautions while caring for a toddler. Which of the following
actions should the nurse take?
Answer: Use a designated stethoscope for the toddler.
Rationale:
Contact precautions are used to prevent the spread of infectious agents that are easily
transmitted by direct or indirect contact. Using a designated stethoscope for the toddler helps
prevent the potential spread of infection to other patients by avoiding contamination of
equipment.
43. A client's daughter calls the nurse requesting information about her mother's condition.
The client's chart does not specify that information can be released to the daughter. Which of
the following is an appropriate response by the nurse?
Answer: "You will need to contact your mother directly about her condition."
Rationale:
In order to protect patient privacy and adhere to HIPAA regulations, the nurse should not
disclose information about the client's condition to anyone unless the client has provided
consent or the information is necessary for the client's care. In this case, the nurse should
advise the daughter to contact her mother directly for information about her condition.
44. A nurse is reviewing the immunization records of a 9-year-old child during a routine
physical exam. Which of the following should indicate to the nurse that the child is not
current with the minimum required immunizations?
Answer: One MMR vaccine.
Rationale:
The minimum required immunizations for a 9-year-old child typically include vaccines for
measles, mumps, and rubella (MMR), among others. If the child has only received one dose
of the MMR vaccine, they are not considered fully immunized according to the recommended
schedule, which usually includes two doses of the MMR vaccine.
45. A nurse is reinforcing teaching with a new mother on facility security measures. Which of
the following statements by the mother indicates that the teaching was effective?
Answer: "I will have an identification band that matches the one my baby wears."
Rationale:
Matching identification bands for the mother and baby are a standard security measure in
healthcare facilities to prevent infant abduction. This statement indicates that the mother
understands the importance of this security measure and is likely to comply with it, which
suggests that the teaching was effective.

46. A nurse is reinforcing teaching with a client who is at 10 weeks gestation and has a
medical history of mild hypertension. The nurse should remind the client to call the clinic if
she:
Answer: Develops edema of the ankles.
Rationale:
Edema (swelling) of the ankles can be a sign of worsening hypertension in pregnancy, known
as preeclampsia. It is important for the client to notify the clinic if she develops edema, as it
may indicate a need for further evaluation and management to prevent complications.
47. A nurse is caring for a client who has been placed in restraints. Which of the following is
appropriate?
Answer: Monitor the client's skin integrity on a regular schedule.
Rationale:
When a client is placed in restraints, it is important to monitor their skin integrity regularly to
assess for signs of pressure ulcers or skin breakdown. Restraints can increase the risk of skin
damage, so frequent monitoring is essential to prevent complications.
48. A nurse working on a mental health unit is reviewing policies for client seclusion. For
which of the following is seclusion appropriate?
Answer: Aggressive behavior.
Rationale:
Seclusion may be appropriate for clients who are exhibiting aggressive behavior that poses a
risk to themselves or others. Seclusion is used as a last resort and should only be implemented
according to facility policy and state regulations.
49. A nurse in a long-term care facility has received a change-of-shift report on four clients.
Which of the following clients should the nurse attend to first?
Answer: A client who has COPD and dementia and was agitated during the night shift.
Rationale:
Agitation in a client with COPD and dementia could indicate a worsening of their condition
or an underlying issue that requires immediate attention. The nurse should attend to this client
first to assess their condition and provide appropriate care.
50. A nurse is applying a condom catheter to a male client who is incontinent. Which of the
following is an appropriate technique to use?
Answer: Leave space between the tip of the penis and the end of the condom catheter.
Rationale:

Leaving space between the tip of the penis and the end of the condom catheter allows for
proper drainage and prevents irritation or damage to the penile tissue. It is important to ensure
that the condom catheter is not applied too tightly or too close to the tip of the penis to avoid
complications.
51. A nurse is assisting a client to move up in bed. Which of the following actions should the
nurse take?
Answer: Ask the client to flex the hips and knees.
Rationale:
Asking the client to flex the hips and knees helps to reduce strain on the lower back and
makes it easier for the client to move up in bed. This position also provides better leverage
for the nurse to assist the client.
52. A nurse is supervising an assistive personnel (AP). During the morning meal, the nurse
observes the AP accidentally spill a cup of coffee on a client. Which of the following actions
should the nurse take?
Answer: Reinforce safe meal setup techniques.
Rationale:
Accidents can happen, but it is important to reinforce safe meal setup techniques to prevent
future spills and ensure client safety. The nurse should calmly address the situation and
provide education to the AP on how to prevent spills in the future.
53. A nurse is reinforcing teaching to a first-time mother about toddler safety. The nurse
should recognize the client's understanding of the teaching when the client states, "I will:
Answer: Install gates at the top and bottom of the stairs."
Rationale:
Installing gates at the top and bottom of stairs is an important safety measure to prevent
toddlers from falling down the stairs. This statement indicates that the client understands the
importance of this safety measure and is likely to implement it to protect her child.
54. A nurse is preparing a sterile field to perform a dressing change. Which of the following
actions should the nurse take?
Answer: Place sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field.
Rationale:
Placing sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field helps to
maintain the sterility of the field. Objects that come into contact with the edge of the field are
considered contaminated and should not be used during the procedure.

55. A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The
nurse recognizes the use of the defense mechanism of suppression when the client states:
Answer: "I guess I have to take some of the blame because of the way my friends and I
dress."
Rationale:
Suppression is a defense mechanism where a person consciously pushes unwanted thoughts
or feelings out of their mind. In this statement, the client is suppressing feelings of guilt by
blaming themselves for the abuse, rather than acknowledging the abuser's responsibility.
56. A client is prescribed 2g of ampicillin. The pharmacy dispenses this medication in 500 mg
tablets. Which of the following should the nurse give the client?
Answer: 4 tablets.
Rationale:
To determine the number of tablets to give, divide the total prescribed dose by the dose per
tablet: 2g (2000 mg) / 500 mg = 4 tablets.
57. A nurse is providing home care to a client and is reinforcing teaching regarding home
safety. Which of the following by the client indicates a need for further teaching?
Answer: "I will walk barefoot to prevent slipping."
Rationale:
Walking barefoot can increase the risk of slipping and falling, especially on slippery or
uneven surfaces. The client should wear non-slip footwear to prevent falls and injuries. This
statement indicates a need for further teaching on home safety.
58. A client with emphysema asks the nurse why he has difficulty exhaling. Which of the
following statements by the nurse is appropriate?
Answer: "Your windpipe is inflamed and constricted."
Rationale:
Emphysema is a type of chronic obstructive pulmonary disease (COPD) characterized by
damage to the air sacs in the lungs, leading to difficulty exhaling. This damage causes the air
sacs to lose their elasticity, making it difficult for the lungs to expel air. Inflammation and
constriction of the airways further contribute to difficulty exhaling.
59. A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute
alcohol withdrawal. Which of the following is an expected finding for the client?
Answer: Irritability.
Rationale:

Acute alcohol withdrawal is characterized by a range of symptoms, including irritability,
anxiety, tremors, sweating, and agitation. These symptoms can occur within hours to a few
days after the cessation of alcohol consumption and are due to the body's dependence on
alcohol and its reaction to its absence.
60. A nurse is caring for a client who is in active labor and is accompanied by her partner. The
client and her partner tell the nurse they were unable to attend childbirth preparation classes.
Which of the following responses by the nurse supports the partner's involvement during
labor?
Answer: "Breathing with your partner will help her to relax during contractions."
Rationale:
Involving the partner in breathing techniques can help the client relax and cope with
contractions during labor. It also provides a way for the partner to actively participate in the
birthing process and provide support to the client.
61. A nurse is planning tracheostomy care for a client in a long-term care facility. Which of
the following actions should the nurse plan to take first?
Answer: Remove the tracheostomy inner cannula.
Rationale:
Removing the tracheostomy inner cannula is often the first step in tracheostomy care. This
allows for cleaning and inspection of the inner cannula, which helps maintain a patent airway
and prevents complications such as infection.
62. A nurse in a provider's office is reinforcing teaching with the parents of a school-age child
who has an active case of pediculosis capitis. Which of the following should be included in
the teaching?
Answer: Wash the bed linens in hot water. Clean the child's toys with 1:10 bleach solution.
Rationale:
Pediculosis capitis, or head lice, is highly contagious and requires thorough cleaning of the
environment to prevent reinfestation. Washing bed linens in hot water and cleaning the child's
toys with a 1:10 bleach solution helps kill any lice or eggs that may be present.
63. A nurse caring for the mother of a newborn finds the client crying in her room. The client
tells the nurse, "I don't think I can handle caring for a baby." Which of the following nursing
interventions is appropriate?
Answer: Encourage the client to share her feelings.
Rationale:

Encouraging the client to share her feelings can help her feel supported and validated. It also
provides an opportunity for the nurse to assess the client's emotional state and provide
appropriate support and interventions.
64. A nurse is assisting with the care of a 36-year-old client who is at 16 weeks of gestation
and is scheduled for an amniocentesis. The nurse recognizes that the client understands the
amniocentesis is performed to identify:
Answer: Chromosomal abnormalities.
Rationale:
Amniocentesis is a prenatal test used to detect chromosomal abnormalities, genetic disorders,
and neural tube defects in the fetus. It involves collecting a small sample of amniotic fluid for
analysis.
65. A nurse is caring for a client who is requesting assistance with smoking cessation. For
which of the following medications should the nurse anticipate having to reinforce teaching?
Answer: Nicotinic Acid (niacin)
Rationale:
Nicotinic acid, also known as niacin, is not a medication typically used for smoking
cessation. Instead, medications such as nicotine replacement therapy (e.g., nicotine patches,
gum, lozenges) or prescription medications (e.g., bupropion, varenicline) are commonly used
to help individuals quit smoking. The nurse may need to reinforce teaching on the appropriate
smoking cessation medications and their use.
66. A nurse is caring for a client who is 12 hours postpartum. The nurse observes an increase
in vaginal bleeding. Which of the following actions should the nurse plan to take first?
Answer: Massage the fundus.
Rationale:
An increase in vaginal bleeding postpartum can indicate uterine atony, which is a common
cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contractions,
which can help control bleeding. It is important to address uterine atony promptly to prevent
complications.
67. A nurse is caring for a client with diabetes mellitus who has an order for daily morning
insulin before breakfast. The client refuses his blood glucose check at 0700. Which of the
following actions should the nurse take?
Answer: Reinforce client teaching.
Rationale:

Regular blood glucose monitoring is an important part of diabetes management, especially for
clients receiving insulin therapy. The nurse should reinforce the importance of blood glucose
monitoring to the client and explain the risks of not checking blood glucose levels regularly.
68. A nurse in a long-term care facility is reviewing a client's laboratory results. The client's
potassium level is 5.8 mEq/L. Which of the following findings should the nurse expect?
Answer: Abdominal cramps.
Rationale:
Hyperkalemia (elevated potassium levels) can cause abdominal cramps, along with other
symptoms such as muscle weakness, fatigue, and irregular heart rhythm. It is important for
the nurse to monitor the client closely for signs of hyperkalemia and report any abnormal
findings to the healthcare provider.
69. A nurse is collecting data during a well-child visit of a 12-month-old infant. Which of the
following statements made by the parent indicates a need for further evaluation?
Answer: "My child can't go from a lying to a sitting position."
Rationale:
By 12 months of age, most infants should be able to go from a lying to a sitting position
without difficulty. This milestone is important for assessing gross motor development. A
delay in achieving this milestone may indicate a developmental delay that requires further
evaluation.
70. A nurse is caring for a client who is receiving IV therapy. The nurse suspects fluid
infiltration. Which of the following findings should the nurse expect at the insertion site?
Answer: Edema.
Rationale:
Fluid infiltration occurs when IV fluids leak into the surrounding tissues instead of flowing
into the vein. Edema (swelling) at the insertion site is a common sign of fluid infiltration.
Other signs include coolness, pallor, and discomfort at the site. Prompt action is needed to
prevent further complications.
71. A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The
nurse should recognize that the client needs a referral for diabetic education when the client?
Answer: States that he will treat hypoglycemic reactions with 15 g of carbohydrates.
Rationale:
This statement indicates that the client understands how to manage hypoglycemia, a critical
aspect of diabetes care. Referral for diabetic education is essential to ensure that the client

receives comprehensive education on managing diabetes, including recognizing and treating
hypoglycemic reactions.
72. A nurse is reinforcing discharge instructions regarding umbilical cord care to the mother
of a newborn. Which of the following statements by the mother indicates the teaching was
effective?
Answer: I will wait until the cord falls off to give my baby a tub bath.
Rationale:
Waiting for the umbilical cord to fall off before giving the baby a tub bath is a correct
understanding of umbilical cord care. This approach helps prevent infection and promotes
healing of the umbilical stump.
73. A nurse in a long-term care facility is planning to perform hygiene care for a newly
admitted male client with Parkinson's disease who is ambulatory. Which of the following is
an appropriate statement by the nurse prior to starting routine care?
Answer: Do you usually take your bath in the morning or in the evening?
Rationale:
This question is appropriate because it respects the client's preferences and routines, which
can help promote cooperation and comfort during hygiene care. Parkinson's disease can cause
stiffness and difficulty with movement, so understanding the client's usual routine can
facilitate a more comfortable experience.
74. A client who is participating in an anger management session explains that his recent
behaviors are related to his job loss. Which of the following defense mechanisms is the client
using?
Answer: Rationalization.
Rationale:
Rationalization is a defense mechanism in which a person justifies or explains their behavior
by providing logical or socially acceptable reasons, even if these reasons are not the real
cause. In this case, the client is attributing his recent behaviors to his job loss, which may not
be the only or primary reason for his actions.
75. A nurse is reinforcing teaching with a new mother of a full-term newborn about
breastfeeding. The newborn is 5 days old. Which of the following statements by the mother
indicates an understanding of the teaching?
Answer: I should have my baby latch on to my nipple and areola during feeding.
Rationale:

This statement indicates an understanding of the correct technique for breastfeeding. Proper
latch is essential for effective milk transfer and to prevent nipple soreness or damage.
Including the areola in the latch helps the baby to suckle effectively and stimulates milk
production.
76. A nurse is reinforcing teaching to the parent of a child who has been prescribed ferrous
sulfate (Feosol) in liquid form. Which of the following statements made by the parent
indicates the teaching was effective?
Answer: "I will give the iron through a straw."
Rationale:
Giving iron through a straw can help prevent staining of the teeth, a common side effect of
iron supplements. This indicates that the parent understands the importance of administering
the medication in a way that minimizes this side effect.
77. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr.
The nurse should set the IV pump to deliver how many mL/hr?
Answer: 150 mL/hr
Rationale:
To calculate the infusion rate, divide the total volume by the total time in hours: 1000 mL ÷ 8
hr = 125 mL/hr. However, since the pump is typically set in increments of 10 or 25 mL/hr, the
nurse would round up to the nearest appropriate setting, which is 150 mL/hr.
78. A nurse is reinforcing teaching to a group of adolescent males. Which of the following
statements made by a student indicates a need for further teaching?
Answer: "I should perform a self-exam of my testes once a year."
Rationale:
Testicular self-examination should be performed monthly, not annually, to detect any changes
that may indicate testicular cancer. This statement indicates a misunderstanding of the
recommended frequency for this exam.
79. An infant is admitted to a pediatric unit following a motor-vehicle crash with a
subsequent head injury. For which of the following should the nurse monitor to identify
increased intracranial pressure?
Answer: Decreased motor response.
Rationale:
Decreased motor response can indicate increased intracranial pressure in infants. Other signs
include irritability, lethargy, altered level of consciousness, vomiting, and changes in vital

signs. Prompt recognition and management of increased intracranial pressure are crucial to
prevent further injury.
80. A nurse is caring for a client who is terminally ill and requires ongoing palliative care.
Which of the following interventions is consistent with the goals of this type of care?
Answer: Allowing the family overnight visitation.
Rationale:
Palliative care focuses on providing comfort and support for clients with serious illnesses,
with an emphasis on quality of life. Allowing family members to visit overnight can help
support the client's emotional well-being and enhance the quality of their remaining time. It
also aligns with the goal of maintaining the client's dignity and autonomy in decision-making.
81. A nurse in an inpatient psychiatric unit is caring for a client who was raised in an Asian
culture. Which of the following communication techniques demonstrates cultural sensitivity?
Answer: Holding eye contact for brief instances.
Rationale:
In many Asian cultures, prolonged eye contact can be perceived as disrespectful or
confrontational. By holding eye contact for brief instances, the nurse demonstrates respect for
the client's cultural norms while still maintaining a connection during the interaction.
82. A nurse is caring for a client who has an order for a 12-lead ECG. Which of the following
actions should the nurse take?
Answer: Instruct the client to take slow, deep breaths.
Rationale:
Taking slow, deep breaths can help the client relax and reduce respiratory movement artifact
on the ECG, which can interfere with the accuracy of the tracing. This instruction helps
ensure a high-quality ECG recording.
83. A newly admitted client tells the nurse that he does not have an advance directive. Which
of the following is the appropriate action for the nurse to take?
Answer: Provide the client with written information about advance directives.
Rationale:
Providing the client with written information about advance directives allows the client to
learn more about them and make an informed decision. It also demonstrates the nurse's
commitment to promoting the client's autonomy and right to make decisions about their own
healthcare.

84. A nurse is observing a client who is in the manic phase of bipolar disorder. The client
states, "Don't need to eat today. Where's the money? Time to write that speech." The nurse
should document this as which of the following?
Answer: Flight of ideas.
Rationale:
Flight of ideas is a common symptom of the manic phase of bipolar disorder characterized by
rapid, continuous, and disjointed thoughts. The client's statements reflect this symptom, as
they are jumping from one topic to another without logical connection.
85. A nurse is reinforcing dietary teaching to a client who has end-stage renal failure. Which
of the following instructions should the nurse include in the teaching?
Answer: a. Decrease calcium intake.
c. Decease sodium intake.
Rationale:
a. Decrease calcium intake.
In end-stage renal failure, the kidneys are unable to adequately excrete phosphorus, leading to
an imbalance between phosphorus and calcium levels. Decreasing calcium intake helps to
manage this imbalance and prevent complications such as renal osteodystrophy.
c. Decrease sodium intake.
Sodium retention is common in end-stage renal failure, leading to fluid retention and
increased blood pressure. Decreasing sodium intake helps to manage fluid balance and blood
pressure, reducing the risk of further kidney damage and cardiovascular complications.
86. A nurse is assisting with the admission of a client who attempted suicide. When the nurse
processes the client's belongings, which of the following items should the nurse remove from
the client's suitcase?
Answer: b. Perfume d. Emery Boards.
Rationale:
The nurse should remove items that could potentially be used for self-harm. Perfume and
emery boards could both be used in harmful ways, so it's important to remove them from the
client's access.
87. A nurse is collecting data from a client at an urgent care clinic. The client tells the nurse
that she hasn't been able to sleep since the death of her father 2 days ago. Which of the
following is the nurse's priority action?
Answer: Discuss coping skills that have worked for the client previously.
Rationale:

The nurse's priority is to assess the client's coping mechanisms and provide support. By
discussing coping skills that have worked in the past, the nurse can help the client manage her
current difficulty sleeping.
88. A nurse is planning care for a client who is 6 hours postoperative following a right knee
arthroplasty. Which of the following interventions should the nurse include in the client's care
plan?
Answer: Place a pillow under the client's surgical knee.
Rationale:
Placing a pillow under the client's surgical knee helps maintain proper alignment and reduces
pressure on the incision site, which can help prevent complications such as swelling and
discomfort.
89. A nurse in a pediatric clinic is reviewing the history of an 11-year-old child. Which of the
following immunizations should the nurse anticipate administering?
Answer: Rotavirus c. meningococcal conjugate
Rationale:
The rotavirus and meningococcal conjugate vaccines are recommended for children around
the age of 11. These vaccines help protect against serious illnesses caused by these bacteria
and viruses.
90. A nurse is caring for a client who was recently diagnosed with paranoid schizophrenia and
is taking risperidone (Risperdal). Which of the following statements by the family indicates a
need for further teaching?
Answer: Our son's symptoms will stop as soon as he begins his medications.
Rationale:
While risperidone can help manage the symptoms of paranoid schizophrenia, it is not a cure.
It may take some time for the medication to take effect, and symptoms may not stop
immediately. The family should be aware that ongoing treatment and monitoring are
necessary.
91. A nurse is caring for a newly postoperative client who has unilateral breath sounds and
asymmetrical chest expansion. The nurse should recognize these findings are indicative of
which of the following and should be reported to the provider?
Answer: Atelectasis.
Rationale:
Atelectasis is a condition in which there is a partial or complete collapse of the lung.
Unilateral breath sounds and asymmetrical chest expansion are classic signs of atelectasis. It

is important to report these findings to the provider because atelectasis can lead to further
complications if not addressed promptly.
92. A nurse is planning care for a client with delirium. Which of the following should the
nurse recognize as interfering with the client's recovery?
Answer: Providing the client with activities that vary daily.
Rationale:
Consistency is important in the care of clients with delirium to help minimize confusion and
disorientation. Providing activities that vary daily can increase confusion and interfere with
the client's recovery.
93. A nurse is caring for a client who has paranoid schizophrenia and believes that she is
being followed by FBI agents who are pretending to be psychiatric staff. Which of the
following responses should the nurse make?
Answer: The psychiatric staff are not FBI. They are here to help you.
Rationale:
It is important for the nurse to acknowledge the client's feelings and provide reassurance in a
calm and non-confrontational manner. This response validates the client's feelings while also
providing factual information to correct the client's delusions.
94. A nurse is monitoring a client who is in labor. Which of the following findings needs
further evaluation?
Answer: Uterine contractions lasting 100 to 120 seconds.
Rationale:
Uterine contractions lasting longer than 90 seconds can be concerning as they may indicate
uterine hyperstimulation, which can lead to fetal distress and other complications. Further
evaluation and intervention may be necessary to ensure the safety of both the mother and the
baby.
95. A nurse is taking the vital signs of an adult client who has just been transferred from the
PACU to the clinical unit. Which of the following findings should the nurse recognize as the
most significant?
Answer: Temperature 36 C (96.8 F)
Rationale:
A temperature of 36°C (96.8°F) is below the normal range for an adult and may indicate
hypothermia, which can be a serious complication, especially in a postoperative client.
Hypothermia can lead to increased risk of infection, impaired wound healing, and other

complications. The nurse should take immediate action to address the client's low
temperature.
96. A nurse observes a client who has Alzheimer's disease and is experiencing aphasia. Which
of the following behaviors should the nurse expect?
Answer: Difficulty understanding spoken words.
Rationale:
Aphasia is a common symptom of Alzheimer's disease and refers to difficulty understanding
or producing language. Difficulty understanding spoken words is a characteristic behavior of
aphasia in individuals with Alzheimer's disease.
97. A nurse in a long-term care facility is caring for an older adult client who has a history of
hypertension. Which of the following is indicative of transient ischemic attacks?
Answer: Pain radiating down the left arm c. sudden loss of vision in one eye.
Rationale:
Transient ischemic attacks (TIAs) are often referred to as "mini-strokes" and can present with
various symptoms, including sudden loss of vision in one eye (amaurosis fugax). This
symptom is indicative of a TIA and should be promptly assessed and reported.
98. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following
medications should the nurse anticipate administering?
Answer: Lorazepam (Ativan)
Rationale:
Lorazepam is a benzodiazepine medication commonly used to manage alcohol withdrawal
symptoms, including agitation, anxiety, and seizures. It helps to reduce the severity of
withdrawal symptoms and prevent complications associated with alcohol withdrawal.
99. A nurse is caring for a client who has borderline personality disorder. The client states, "I
look forward to seeing you in the morning because the night nurse treats me badly." Which of
the following behaviors is the client likely demonstrating?
Answer: Splitting
Rationale:
Splitting is a defense mechanism commonly seen in individuals with borderline personality
disorder. It involves viewing people and situations as all good or all bad, with no middle
ground. In this scenario, the client is demonstrating splitting by idealizing the nurse they look
forward to seeing and demonizing the night nurse.

100. A nurse is planning a health-promotion program for high school students. Which of the
following facts about cigarette smoking is likely to be most effective in changing the
adolescents' attitudes towards smoking?
Answer: Smoking causes unattractive stains on the teeth and hands.
Rationale:
Adolescents are often concerned about their appearance, so providing information about the
cosmetic effects of smoking, such as stains on the teeth and hands, can be an effective
strategy to change their attitudes towards smoking. Focusing on these tangible and visible
effects may resonate more with adolescents than abstract health risks.
101. A nurse is caring for a school-age child whose family adheres to a vegan diet in the
home. The nurse should recognize the child is at risk for deficiency of which of the
following?
Answer: Vitamin D
Rationale:
Vitamin D is primarily found in animal products, so individuals following a strict vegan diet
may be at risk for deficiency. Vitamin D is important for bone health and immune function, so
deficiency can lead to issues like rickets in children.
102. A nurse is caring for a client who has esophageal cancer. A gastrostomy tube is in place,
and the client is receiving continuous tube feedings. Which of the following actions should
the nurse take?
Answer: Keep the head of the bed elevated at least 30 degrees.
Rationale:
Keeping the head of the bed elevated helps prevent aspiration, especially in clients with
esophageal issues. It helps keep the stomach contents from refluxing up into the esophagus,
reducing the risk of aspiration pneumonia.
103. A nurse is reinforcing teaching with a group of expectant parents regarding the proper
use of a car seat. Which of the following statements by a parent indicates an understanding of
the teaching?
Answer: "I can place a rolled towel on each side of my newborn's head until he can hold his
head up."
Rationale:
Placing a rolled towel on each side of the newborn's head helps provide support and prevent
the head from flopping to the side, which can help maintain an open airway. This technique is
often recommended for newborns who cannot yet hold their heads up.

104. A nurse is preparing to apply a pulse oximeter to a client's finger. Which of the following
actions should the nurse take before applying the sensor?
Answer: Check the client's capillary refill.
Rationale:
Checking capillary refill helps assess peripheral perfusion. It is important to ensure adequate
perfusion to the finger before applying the pulse oximeter sensor to obtain an accurate
reading.
105. A nurse is caring for a client who is asking about the technique of effleurage and its use
in labor and delivery. Which of the following responses should the nurse make regarding this
technique?
Answer: "It is a light stroking of the skin during a uterine contraction."
Rationale:
Effleurage is a massage technique involving light stroking or circular movements on the skin.
It is often used during labor to provide comfort and relaxation during contractions. The
gentle, rhythmic motion can help distract from pain and promote relaxation.
106. A nurse is administering hydromorphone (Dilaudid) to a client who is experiencing
postoperative pain. Which of the following is an adverse effect of this medication?
Answer: Urinary Retention
Rationale:
Hydromorphone, like other opioid analgesics, can cause urinary retention as a side effect.
This is due to its effects on the smooth muscles of the bladder, which can lead to difficulty
urinating.
107. A nurse is administering medication. A client states, "I know that the Inderal helps my
blood pressure, but I don't like the way it makes me feel. I don't think I'll take it today."
Which of the following actions should the nurse take?
Answer: Ask the client to describe what he is experiencing.
Rationale:
It's important for the nurse to assess the client's specific concerns about the medication. By
asking the client to describe what he is experiencing, the nurse can better understand his
reasons for not wanting to take the medication and address any misconceptions or side effects
he may be experiencing.
108. A nurse is reinforcing teaching with a client regarding the use of guided imagery to
relieve back pain. Which of the following statements made by the nurse is appropriate?
Answer: "Think about a pleasant memory as you visualize your pain floating away."

Rationale:
Guided imagery involves using mental images to promote relaxation and reduce pain.
Encouraging the client to think about a pleasant memory can help distract from the pain and
promote relaxation, which may help alleviate back pain.
109. A nurse is caring for an older adult client who is postoperative following a total hip
replacement. The client is incontinent of stool and urine. To prevent skin breakdown, the
nurse should?
Answer: Apply moisture-absorbing undergarments.
Rationale:
Incontinence can increase the risk of skin breakdown due to prolonged exposure to moisture.
Applying moisture-absorbing undergarments can help keep the skin dry and reduce the risk of
skin breakdown.
110. A client comes to the clinic with reports of nasal congestion. Which of the following
medications should the nurse anticipate that the primary care provider will prescribe?
Answer: Pseudoephedrine (Sudafed)
Rationale:
Pseudoephedrine is a decongestant commonly used to relieve nasal congestion. It works by
constricting blood vessels in the nasal passages, which reduces swelling and congestion.
111. A nurse in a provider's office is reinforcing teaching to the parents of a school-age child
who has an ankle sprain. The nurse should include which of the following statements in the
teaching?
Answer: "Elevate the affected extremity to a level higher than the heart."
Rationale:
Elevating the affected extremity helps reduce swelling by allowing fluid to drain away from
the injury site. This can help decrease pain and promote healing. Aspirin is not recommended
for pain relief in children due to the risk of Reye's syndrome.
112. A nurse is caring for a client with a closed head injury. Which of the following findings
should indicate to the nurse a need for further data collection?
Answer: Inappropriate words when speaking.
Rationale:
Inappropriate words when speaking could indicate a neurological issue, such as aphasia or
dysphasia, which may be related to the head injury. Further data collection is needed to assess
the extent and nature of the speech issue.

113. A nurse is reinforcing teaching with the parents of a 1-year-old infant regarding
appropriate play activities for this age group. Which of the following activities should the
nurse include?
Answer: This is an appropriate toy for a 12-month-old infant. Beads that are too large to pass
through a toilet paper tube do not present a choking hazard. This toy would provide visual
and tactile stimulation for a 1-year-old infant.
Rationale:
Toys that provide visual and tactile stimulation are appropriate for a 1-year-old infant's
developmental stage. It's important to choose toys that are safe and age-appropriate to prevent
choking hazards.
114. A nurse is reinforcing teaching to the parents of an infant who has a Pavlik harness.
Which of the following statements should the nurse include in the teaching?
Answer: "The harness promotes hip joint development."
Rationale:
A Pavlik harness is used to treat developmental dysplasia of the hip (DDH) in infants by
holding the hip joint in a position that promotes proper development. The harness helps keep
the femoral head in the acetabulum, allowing for normal hip joint development.
115. A nurse is caring for a client in a mental health inpatient facility who reports auditory
and visual hallucinations. Which of the following should the nurse recognize as indicating the
client is most in need of intervention?
Answer: States he is being told to hit his roommate.
Rationale:
The statement indicating the client is being told to hit his roommate suggests that the auditory
hallucinations are commanding and potentially dangerous. This indicates a need for
immediate intervention to ensure the safety of the client and others.
116. A nurse is reinforcing teaching for a client who has just started taking amitriptyline
(Elavil). Which of the following should the nurse include as an adverse effect of this
medication?
Answer: Orthostatic hypotension.
Rationale:
Amitriptyline is a tricyclic antidepressant that can cause orthostatic hypotension as a side
effect. This is a drop in blood pressure that occurs when standing up from a sitting or lying
position, which can lead to dizziness or lightheadedness.

117. A nurse in a long-term care facility is caring for a client who uses a continuous positive
airway pressure (CPAP) machine at night for sleep apnea. The client reports daytime
sleepiness. Which of the following actions should the nurse take first?
Answer: Check for the proper fit of the mask on the CPAP machine.
Rationale:
Daytime sleepiness in a client using a CPAP machine for sleep apnea can be a sign of
improper mask fit or air leaks. Checking the mask fit is the first step in addressing this issue
to ensure effective treatment of sleep apnea.
118. A nurse is caring for a client in the provider's office who is experiencing an episode of
acute asthma. The nurse should administer which of the following medications?
Answer: Triamcinolone (Azmacort)
Rationale:
Triamcinolone is a corticosteroid inhaler used for the long-term control of asthma symptoms.
During an acute asthma episode, the priority is to administer a short-acting bronchodilator,
such as albuterol, to quickly relieve bronchospasm and improve airflow.
119. A nurse is assisting with the care of a client who is receiving IV therapy of 0.9% sodium
chloride. The client received 200mL more than prescribed in 1 hr because the infusion pump
was set incorrectly. Data collection reveals that the client is stable. This incident does not
meet the criteria for malpractice because?
Answer: The client was not harmed as a result of the incident.
Rationale:
Malpractice requires harm to the client as a result of negligence or failure to meet the
standard of care. Since the client is stable and not harmed by the extra fluid, this incident does
not meet the criteria for malpractice.
120. A nurse is reinforcing teaching with a client who is undergoing chemotherapy to treat
laryngeal cancer and has developed mucositis. Which of the following client statements
indicates an understanding of the teaching?
Answer: I will rinse my mouth with room-temperature saline solution.
Rationale:
Rinsing the mouth with room-temperature saline solution can help soothe and clean the
mucous membranes affected by mucositis, a common side effect of chemotherapy. This can
help reduce pain and prevent infection in the mouth.

121. A nurse is caring for a toddler who is admitted to the pediatric unit and is 2 hours
postoperative following a tonsillectomy. Which of the following findings is a sign of
hemorrhage?
Answer: Frequent swallowing
Rationale:
Frequent swallowing can be a sign of hemorrhage after a tonsillectomy, as blood may be
pooling in the back of the throat. Other signs of hemorrhage can include vomiting bright red
blood, restlessness, and signs of shock.
122. A nurse is caring for an adolescent client who has anorexia nervosa. Which of the
following findings should the nurse expect?
Answer: Absence of menses
Rationale:
Anorexia nervosa can lead to hormonal imbalances that result in the absence of menstrual
periods (amenorrhea). Additionally, individuals with anorexia nervosa may have low blood
pressure (hypotension) rather than elevated blood pressure.
123. A nurse has administered cephalexin (Keflex) to a client. Which of the following is the
earliest indicator of an anaphylactic reaction?
Answer: Wheezes
Rationale:
Wheezing can be an early sign of an anaphylactic reaction, which is a severe allergic reaction.
Other early signs can include itching, hives, and swelling. Hypotension is a later sign of
anaphylaxis and indicates a more severe reaction.
124. A nurse is admitting a client with active tuberculosis. Which of the following is an
appropriate nursing intervention?
Answer: Place the client in a room that is ventilated to the outside.
Rationale:
Clients with active tuberculosis should be placed in a negative pressure room with ventilation
to the outside to prevent the spread of the infectious agent. This helps reduce the risk of
transmission to others.
125. A nurse is providing change-of-shift report on four clients. Which of the following is
most important for the nurse to include in the report?
Answer: A client had a blood glucose of 140 mg/dL.
Rationale:

Reporting a blood glucose level of 140 mg/dL is important because it may indicate
hyperglycemia, which can require immediate intervention. Changes in blood glucose levels
can have significant effects on a client's condition and may require adjustments in treatment.
126. A nurse is caring for a client who has an order for NPH insulin (Humulin N) 10 units and
regular insulin (Humulin R) 15 units SQ. Which of the following actions should the nurse
perform first?
Answer: Inject 10 units of air into the NPH insulin vial.
Rationale:
When mixing two types of insulin, it is important to first inject air into the NPH insulin
(cloudy) vial to prevent the contamination of the regular insulin (clear) vial with the NPH
insulin. This prevents drawing the NPH insulin into the regular insulin vial, ensuring accurate
dosing and preventing contamination.
127. A nurse discovers a fire in the trash can of a client's room. Which of the following
actions should the nurse take first?
Answer: Escort the client to a secure area.
Rationale:
The priority in a fire situation is to ensure the safety of the client. The nurse should
immediately remove the client from the area of danger to a secure area, ensuring the client's
safety before addressing the fire.
128. A client has a large, deep ulcer on her right hip. The primary care provider has
prescribed a wound vacuum to be applied. Which of the following is an appropriate nursing
action?
Answer: Maintain hydrophilic material deep into the ulcer.
Rationale:
A wound vacuum (negative pressure wound therapy) is used to promote wound healing by
applying negative pressure to the wound bed, which helps remove excess fluid and promote
granulation tissue formation. Maintaining hydrophilic material deep into the ulcer ensures
proper wound bed preparation and promotes healing.
129. A nurse is reinforcing teaching to a client who has been taking digoxin 0.25 mg PO daily
for 6 months, which of the following indicates a need for further teaching?
Answer: d. I will call my provider if I experience a yellow tinge to my vision.
Rationale:
A yellow tinge to vision can indicate digoxin toxicity. However, it is a late sign of toxicity.
Early signs include nausea, vomiting, anorexia, and fatigue. Therefore, the client needs

further teaching to recognize the early signs of digoxin toxicity and to seek immediate
medical attention if these occur.
130. A nurse receives a verbal order for a client to receive a stat dose of meperidine
(Demerol) 100 mg PO. She administers the medication, charts the administration, and then
realizes she has administered Phenytoin (Dilantin) 100 mg PO. After obtaining the client's
vital signs, which of the following actions should the nurse take?
Answer: d. Notify the provider.
Rationale:
Administering the wrong medication is a serious error that should be promptly reported to the
provider. The nurse should also monitor the client for any adverse effects of the incorrect
medication and follow institutional policies for medication error reporting and
documentation.
131. A nurse is administering medication to a client. Which of the following actions is
appropriate for the nurse to take?
Answer: Verify with another nurse when calculating a new dose of medication.
Rationale:
Verifying calculations with another nurse is a safety measure to ensure accuracy and prevent
medication errors, especially when calculating new doses or performing complex
calculations.
132. A nurse is reinforcing discharge teaching to a client who is prescribed propylthiouracil.
For which of the following should the nurse instruct the client to monitor and report to the
provider immediately?
Answer: d. Sore throat.
Rationale:
Propylthiouracil is used to treat hyperthyroidism and can cause agranulocytosis, a serious
condition characterized by a low white blood cell count. Sore throat can be an early sign of
agranulocytosis, so the client should be instructed to report it immediately to the provider.
133. A nurse is reinforcing foot care to a client with diabetes mellitus. Which of the following
clients' statements indicates to the nurse a need for further teaching?
Answer: d. "I will soak my feet in warm water every night."
Rationale:
Soaking feet in warm water can lead to maceration and breakdown of the skin, which is
especially dangerous for clients with diabetes who are at risk for foot ulcers. The nurse

should teach the client to wash feet daily with mild soap and lukewarm water, pat them dry,
and moisturize with lotion, but avoid soaking.
134. A nurse is caring for a client who has heart failure and is taking furosemide (Lasix).
Which of the following statements made by the client indicates a need for the nurse to
intervene?
Answer: a. "I have to sleep sitting up."
Rationale:
The client's statement indicates that they may be experiencing orthopnea, which is a symptom
of worsening heart failure. The nurse should intervene by assessing the client's respiratory
status and notifying the provider if necessary.
135. A nurse is reinforcing teaching to a client who has a new prescription for transdermal
nitroglycerin (Nitro-Dur). Which of the following statements indicates the client understands
the teaching?
Answer: d. "I will leave the patch on for 12 to 14 hours each day."
Rationale:
Transdermal nitroglycerin patches are typically worn for 12 to 14 hours each day and then
removed for a 10- to 12-hour period to prevent tolerance. This statement indicates that the
client understands the correct application and removal schedule for the patch.
136. A nurse is caring for a client who is 2 days postoperative. The client has a prescription
for acetaminophen 300mg with codeine 30 mg (Tylenol #3), 1 tablet every 3 to 4 hr PRN for
pain. The nurse inadvertently gave the client 2 tablets. Which of the following is the proper
place to document this error?
Answer: a. Incident report
Rationale:
In medication errors, it is important to document the error in an incident report. This allows
for proper investigation, analysis, and implementation of corrective actions to prevent similar
errors in the future.
137. A nurse is caring for a client in a mental health unit who is pacing back and forth and
wringing his hands. Which of the following interventions should the nurse implement?
Answer: d. Take the client for a walk to the recreation room.
Rationale:
Taking the client for a walk to the recreation room can help distract the client and provide a
change of environment, which may help reduce anxiety and agitation.

138. A nurse is reinforcing teaching about levothyroxine (Synthroid) to a client who has
hypothyroidism. Which of the following should the nurse instruct the client to expect?
Answer: b. Increased energy c. weight loss.
Rationale:
Levothyroxine is a thyroid hormone replacement medication used to treat hypothyroidism.
One of the expected outcomes of treatment is an increase in energy levels and, sometimes,
weight loss as the body's metabolism improves.
139. A nurse is caring for a client who is in bed and experiencing a tonic-clonic seizure.
Which of the following actions should the nurse take?
Answer: Place the bed in the lowest position.
Rationale:
During a seizure, it is important to ensure the client's safety. Lowering the bed to the lowest
position can help prevent injury if the client falls out of bed during the seizure.
140. A nurse is preparing to irrigate a wound of a client who has methicillin-resistant
Staphylococcus aureus (MRSA). The nurse should use which of the following personal
protective equipment?
Answer: A face shield
Rationale:
When caring for a client with MRSA, it is important to use personal protective equipment
(PPE) to prevent the spread of infection. A face shield should be worn to protect the nurse's
face from exposure to infectious droplets during wound irrigation.
141. A nurse is collecting data for a client who has been receiving medroxyprogesterone
acetate (Depo-Provera) for the past 6 months. Which of the following statements made by the
client should be reported to the provider?
Answer: "I'm experiencing calf pain."
Rationale:
Calf pain can be a symptom of deep vein thrombosis (DVT), which is a potential
complication of medroxyprogesterone acetate therapy. It is important to report this symptom
to the provider for further evaluation and management.
142. A nurse is reinforcing teaching with a new mother regarding the use of breast milk.
Which of the following statements by the mother indicates an understanding of the teaching?
Answer: "I can store my breast milk in the freezer for up to 6 months."
Rationale:

Breast milk can be stored in the freezer for up to 6 months, which is important information
for the mother to know for proper storage and use of breast milk.
143. A nurse in a long-term care facility is caring for a client who has a spinal cord injury.
The client is demonstrating manifestations of autonomic dysreflexia. Which of the following
actions should the nurse take first?
Answer: Check the client for bladder distention.
Rationale:
Autonomic dysreflexia is a medical emergency that can occur in clients with spinal cord
injuries. The most common cause is bladder distention or urinary retention. Checking for and
addressing bladder distention is the first priority in managing autonomic dysreflexia.
144. A nurse is caring for a toddler who was admitted for pneumonia. Which of the following
findings has the highest priority?
Answer: Respiratory rate of 36/min
Rationale:
A respiratory rate of 36/min in a toddler with pneumonia is a sign of respiratory distress and
requires immediate attention. It is the highest priority finding because it indicates the child is
having difficulty breathing and may need interventions to improve oxygenation.
145. A nurse is reinforcing teaching for a client regarding various forms of contraception. The
nurse should recognize that the client understands the instructions if she says, "I will:
Answer: Use a spermicide with condoms to increase effectiveness."
Rationale:
Using a spermicide with condoms can increase the effectiveness of contraception by
providing an additional barrier to sperm. This indicates that the client understands the
importance of using contraception correctly to prevent pregnancy.
146. A nurse is preparing to administer K+ gluconate (Kaon) 60 mEq PO in three equally
divided doses. Available is K+ gluconate 20 mEq/15 mL. How many mL should the nurse
administer with each dose?
Answer: 15 mL
Rationale:
To administer 60 mEq of K+ gluconate in three equally divided doses, each dose should be 20
mEq. Since the available concentration is 20 mEq/15 mL, the nurse should administer 15 mL
with each dose (20 mEq ÷ 20 mEq/15 mL = 15 mL).
147. A nurse is reinforcing teaching to a client who has GERD and is prescribed ranitidine
(Zantac). Which of the following indicates an understanding of the teaching?

Answer: I have to remain upright for 1 hour after taking the medication.
Rationale:
Remaining upright for at least 1 hour after taking ranitidine helps prevent acid reflux by
allowing the medication to work effectively and reducing the risk of irritation to the
esophagus.
148. A nurse is reinforcing teaching with a client diagnosed with diabetes mellitus requiring
insulin injections. Which of the following statements made by the client indicates
understanding of the teaching?
Answer: I should remove bubbles from the syringe before injecting my insulin.
Rationale:
Removing air bubbles from the syringe before injecting insulin helps ensure the client
receives the correct dose of insulin. Air bubbles can displace insulin, leading to an inaccurate
dose.
149. A client newly diagnosed with bipolar disorder asks the nurse, "How long will I have to
take lithium?" Which of the following is an appropriate response by the nurse?
Answer: Medication is usually continued for 6 months after symptoms subside.
Rationale:
Lithium is typically continued for 6 months after symptoms subside to prevent relapse. The
duration of treatment may vary depending on the individual's response to medication and the
recurrence of symptoms.
150. A nurse in the birthing unit is assisting with the care of a client who is at 38 weeks
gestation and has bright red vaginal bleeding but denies pain.
Answer: Placenta previa.
Rationale:
Bright red vaginal bleeding in the absence of pain is a common symptom of placenta previa, a
condition where the placenta partially or completely covers the cervix. It is important to
monitor the client closely and notify the healthcare provider for further evaluation and
management.
151. A nurse is reinforcing teaching regarding the dietary intake needed to reduce the risk of
neural tube defects with a client who is planning to become pregnant.
Answer: Cooked spinach
Rationale:

Spinach is a good dietary source of folate, which is important for reducing the risk of neural
tube defects in newborns. Adequate folate intake is recommended for women planning to
become pregnant and during the early stages of pregnancy.
152. The parent of a 3-year-old child tells the nurse that he is concerned because his daughter
has begun playing with an imaginary friend. Which of the following is an appropriate
response by the nurse?
Answer: This is a common behavior for children of this age.
Rationale:
Imaginary friends are a normal part of many children's development, especially around the
age of 3. It can be a sign of creativity and imagination and is not typically a cause for
concern.
153. A nurse is reinforcing teaching regarding home care with a client who is scheduled for
discharge following a coronary artery bypass graft. Which of the following statements by the
client indicates understanding of the teaching?
Answer: I can begin my cardiac rehabilitation program within the week.
Rationale:
Cardiac rehabilitation is an important part of recovery after coronary artery bypass graft
surgery. Starting the program within the first week is often recommended to improve
outcomes and promote recovery.
154. A mother of two small children tells the nurse, "I just don't know what to do about my
cancer. I've seen three doctors, and each one recommended a different treatment options."
appropriate response.
Answer: Arranging a conference with your providers is something I could assist you with.
Rationale:
When faced with multiple treatment options, it can be helpful for the patient to have a
conference with all of their providers to discuss the options and make an informed decision.
The nurse can assist in arranging such a conference to provide support and facilitate
communication.
155. A nurse is reinforcing discharge instructions for an older adult client regarding
management of hypertension. Which of the following should the nurse instruct the client to
do when evaluating for the presence of orthostatic hypotension?
Answer: Take a blood pressure reading while sitting and another one 2 min later while
standing.
Rationale:

Orthostatic hypotension is a drop in blood pressure that occurs when standing up from a
sitting or lying position. Taking blood pressure readings in both positions can help diagnose
this condition.
156. A nurse is reinforcing teaching with a client who is scheduled to undergo a fiberoptic
bronchoscopy. Which of the following client statements indicates an understanding of the
procedure?
Answer: They will look into my lungs with a lighted tube to determine my problem.
Rationale:
A fiberoptic bronchoscopy involves inserting a flexible, lighted tube into the lungs to
visualize the airways and obtain samples for testing. This statement indicates that the client
understands the basic purpose and process of the procedure.
157. A nurse is caring for a client who is in labor and has requested an alternative birthing
plan. The client is experiencing back pain. Which of the following nursing actions is most
effective?
Answer: Provide sacral counter pressure using the fist or ball of the hand.
Rationale:
Sacral counter pressure can help relieve back pain during labor by providing firm pressure to
the sacrum, which can reduce the discomfort caused by contractions.
158. A nurse is caring for a postoperative client who has a midline abdominal incision and
notes dehiscence of the wound edges with protrusion of internal organs. Which of the
following actions should the nurse take?
Answer: Place pressure on the abdomen. Cover the wound with a sterile saline dressing.
Rationale:
Dehiscence of a surgical wound with protrusion of internal organs is a medical emergency
requiring immediate intervention. The nurse should apply pressure to the abdomen to reduce
the risk of evisceration (protrusion of organs) and cover the wound with a sterile dressing to
protect it from contamination.
159. A nurse is collecting data from a client who is pregnant and has hyperemesis
gravidarum. Which of the following findings should the nurse expect?
Answer: Decreased blood pressure.
Rationale:
Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can
lead to dehydration and electrolyte imbalances. Decreased blood pressure can be a result of
dehydration and fluid loss associated with this condition.

160. A nurse is caring for a postoperative client and obtains a pulse oximeter reading of 89%.
Which of the following interventions should the nurse take first?
Answer: Repeat the test on another finger.
Rationale:
A pulse oximeter reading of 89% indicates possible hypoxemia (low oxygen levels in the
blood), but it is important to verify the accuracy of the reading by repeating the test on
another finger before taking further action. Other interventions may be necessary based on
the client's overall condition and oxygenation status.
161. A nurse receives a report on four clients. The nurse should first collect data about the
client who has:
Answer: A decreased level of consciousness and vomiting.
Rationale:
A decreased level of consciousness and vomiting can indicate a serious condition such as
increased intracranial pressure or other neurological issues. Collecting data on this client first
is important to assess their neurological status and determine the appropriate interventions.
162. A clinic nurse is reviewing laboratory values for a client who is at 34 weeks of gestation.
Which of the following laboratory values should the nurse report to the provider?
Answer: Urine protein 3+
Rationale:
Proteinuria (urine protein 3+) in pregnancy can be a sign of preeclampsia, a serious
complication that requires close monitoring and management. The nurse should report this
finding to the provider for further evaluation and management.
163. A client who has inoperable cancer tells the nurse that she does not want to pursue the
recommended treatment. She asks if the provider can force her to have the treatment.
appropriate response.
Answer: You have the right to refuse the recommended treatment plan.
Rationale:
Clients have the right to refuse treatment, even if it is recommended by healthcare providers.
It is important for the nurse to respect the client's autonomy and provide support in making
informed decisions about their care.
164. A nurse is caring for a client receiving packed red blood cells (PRBCs). Which of the
following findings should the nurse recognize as indicative of excess fluid volume?
Answer: Crackles in the lung bases.
Rationale:

Crackles in the lung bases can indicate fluid accumulation in the lungs, which is a sign of
excess fluid volume. This finding should be recognized and reported to the healthcare
provider for further evaluation and management.
165. A nurse is caring for a client who was placed in a cast 12 hours ago due to a fractured
left tibia. Which of the following findings is the highest priority?
Answer: Numbness in the left foot.
Rationale:
Numbness in the left foot can indicate neurovascular compromise, such as decreased blood
flow or nerve damage, which is a serious complication that requires immediate attention. The
nurse should assess the client's circulation, sensation, and movement in the affected extremity
and report any changes to the healthcare provider promptly.
166. A nurse is collecting data from a female client who wishes to begin oral contraception.
Which of the following is a contraindication to the use of oral contraceptives?
Answer: Current use of nicotine.
Rationale:
Smoking, especially in women over 35 years old, increases the risk of serious cardiovascular
side effects when taking oral contraceptives. Therefore, current use of nicotine is a
contraindication to the use of oral contraceptives.
167. A nurse is monitoring a client who is receiving a unit of packed red blood cells (PRBCs).
The nurse recognizes an allergic reaction when the client reports
Answer: Urticaria.
Rationale:
Urticaria, or hives, is a common sign of an allergic reaction to a blood transfusion. Other
signs may include itching, flushing, or shortness of breath. The nurse should stop the
transfusion immediately and notify the healthcare provider.
168. A nurse finds a client's wife crying in the hallway. She states, "I just don't know how I
am going to go on after he is gone." Which of the following is an appropriate response by the
nurse?
Answer: Tell me more about how you are feeling.
Rationale:
This response encourages the wife to express her feelings and allows the nurse to provide
emotional support. It also demonstrates empathy and a willingness to listen.
169. A nurse is caring for a client whose previous blood pressure readings have been within
the expected reference range. The client's current blood pressure reading is suddenly elevated

above the expected range. Which of the following factors can contribute to a false high blood
pressure reading?
Answer: The blood pressure cuff is too small for the client's arm.
Rationale:
Using a blood pressure cuff that is too small for the client's arm can result in a false high
blood pressure reading. It can cause increased pressure on the artery, leading to an inaccurate
measurement. Ensuring the correct cuff size is essential for accurate blood pressure readings.
170. A nurse is caring for a client who is experiencing respiratory acidosis. The nurse should
expect which of the following serum pH levels?
Answer: pH 7.30
Rationale:
Respiratory acidosis is characterized by a decrease in pH (45 mmHg). A serum pH of 7.30 indicates acidosis.
171. A woman who is postmenopausal presents to a clinic for a well-woman examination.
She tells the nurse that she does not understand the need for a Pap test because she is no
longer experiencing menses. Which of the following responses by the nurse is appropriate?
Answer: A Pap test can help with early detection of cervical cancer.
Rationale:
Even though a woman is postmenopausal and no longer menstruating, she is still at risk for
cervical cancer. A Pap test is recommended for early detection of cervical cancer, regardless
of menopausal status.
172. A nurse in a provider's office is talking on the phone with a parent of a school-age child
who has varicella. The parent asks the nurse when the child can return to school. The nurse
tells the parent the child is no longer contagious when
Answer: All vesicles have crusted over.
Rationale:
Varicella (chickenpox) is considered contagious until all vesicles (blisters) have crusted over.
Once the lesions are crusted, the risk of transmission is significantly reduced.
173. A nurse is collecting data from a client who is in her third trimester of pregnancy during
a routine prenatal visit to the provider's office. The client reports she feels dizzy, has clammy
skin, and becomes pale while lying down. The nurse should tell the client that when she feels
this way, she should do which of the following?
Answer: Lie on her left side.
Rationale:

Feeling dizzy, clammy, and pale can be signs of supine hypotensive syndrome, which can
occur in pregnant women when lying on their back. Lying on the left side can help relieve
pressure on the inferior vena cava and improve blood flow to the heart and baby.
174. A nurse should monitor a client who is taking Lasix for which of the following adverse
effects?
Answer: Hypokalemia.
Rationale:
Lasix (furosemide) is a loop diuretic that can cause potassium loss, leading to hypokalemia.
Monitoring potassium levels is important to prevent complications such as cardiac
arrhythmias.
175. A nurse is implementing a bladder training program for a client after a cerebrovascular
accident. Which of the following interventions by the nurse is appropriate for the client?
Answer: Check for residual urine after voiding.
Rationale:
Checking for residual urine after voiding helps assess the effectiveness of bladder emptying.
In clients with neurological conditions such as a cerebrovascular accident, bladder training
aims to improve bladder control and reduce the risk of urinary retention.
176. A nurse is collecting data from a client who has right-sided heart failure. Which of the
following findings should the nurse expect?
Answer: Dependent edema.
Rationale:
Right-sided heart failure can lead to fluid retention, resulting in dependent edema, especially
in the lower extremities. This occurs due to impaired pumping of blood from the right side of
the heart to the lungs and can cause fluid buildup in the body.
177. A nurse is reinforcing teaching to an adult client who is prescribed Lipitor. The nurse
should advise the client that which of the following is an adverse effect of this medication
and should be reported to the provider?
Answer: Unexplained muscle pain.
Rationale:
Lipitor (atorvastatin) is a medication used to lower cholesterol levels. A rare but serious side
effect of statin medications like Lipitor is myopathy, which can cause unexplained muscle
pain, tenderness, or weakness. Clients should report these symptoms to their healthcare
provider promptly.

178. A nurse is planning client care for a shift. Which of the following should the nurse plan
to delegate to an assistive personnel?
Answer: Ambulating a client receiving patient-controlled analgesia.
Rationale:
Ambulating a client receiving patient-controlled analgesia can be safely delegated to assistive
personnel, as long as the client is stable and the ambulation does not interfere with the
administration of pain medication.
179. A nurse is assisting with the admission of an adolescent client who is suspected of
having bacterial meningitis. Which of the following findings should the nurse expect?
Answer: Nuchal rigidity
Rationale:
Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis, especially bacterial
meningitis. This finding occurs due to inflammation of the meninges, the protective
membranes covering the brain and spinal cord.