ATI RN COMPREHENSIVE PREDICTOR ONLINE
PRACTICE 2019 VERSIONS A & B {LATEST
UPDATE}/A+ GRADE
1. A nurse is planning care for a client who is receiving heparin to treat a L leg DVT. Nursing
intervention?
Answer: Elevate the leg.
Rationale:
Elevating the leg can help reduce swelling and improve circulation, which can be beneficial for
a client with a deep vein thrombosis (DVT) receiving heparin.
2. A nurse is teaching about child safety measures. What statement indicates understanding?
Answer: Avoid sun exposure 10am-2pm.
Rationale:
This statement indicates understanding of the need to avoid the sun's peak hours to reduce the
risk of sunburn and skin damage in children.
3. A home health nurse is teaching about infection prevention to a cancer patient on
chemotherapy. Which statement indicates understanding?
Answer: "I'll walk short distances throughout the day."
Rationale:
Walking short distances can help reduce pulmonary stasis, which can prevent respiratory
infections in a cancer patient on chemotherapy. Additionally, avoiding liquids at room
temperature for more than one hour can reduce the risk of infection. Cleaning the toothbrush at
least once a week in the dishwasher can also help prevent infections, as well as taking
temperature once a day.
4. A nurse is providing dietary teaching to the parents of a 6-month-old. What education should
the nurse give?
Answer: Introduce new foods over 5-7 days.
Rationale:
Introducing new foods gradually over 5-7 days can help identify any potential food allergies or
intolerances in the infant. An infant-sized portion is about 1 tablespoon per year of age.
5. A charge nurse is planning care for a client in mechanical restraints. What interventions
should be included?
Answer: Provide a staff member to stay with the client continuously.
Rationale:
Providing a staff member to stay with the client continuously is important to ensure the safety
and well-being of the client in restraints. Additionally, the client's physical needs should be
checked every 15-30 minutes and documented. The restraint order should be renewed every 4
hours for patients 18 years and older, and a staff member must be able to view the patient at all
times (either in the room or through video monitoring).
6. A community health nurse is assisting with the development of a disaster management plan.
What nursing responsibility should be included in the disaster response stage?
Answer: Perform a rapid needs assessment.
Rationale:
Performing a rapid needs assessment is crucial during the response phase of a disaster to
identify the immediate needs of the affected population and prioritize interventions accordingly.
7. A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the
following requires manager intervention?
Answer: Tells the hospital chaplain a client's diagnosis.
Rationale:
Disclosing a client's diagnosis without appropriate authorization violates patient confidentiality.
The nurse manager should intervene to address the breach of privacy and educate the newly
licensed nurse on the importance of patient confidentiality.
8. A nurse is caring for a client that is in labor at 39 weeks gestation. During the second stage of
labor, the nurse observes early decelerations on the monitor. What action should the nurse take?
Answer: Continue observing the fetal heart rate.
Rationale:
Early decelerations are typically benign and are caused by head compression during
contractions, which is an expected finding in the second stage of labor. The nurse should
continue to monitor the fetal heart rate closely and prepare for an emergency cesarean birth
only if late or variable decelerations occur despite interventions.
9. A nurse manager is planning to make changes to the current scheduling system on the unit.
To facilitate staff acceptance, what should the nurse manager do first?
Answer: Provide information about scheduling issues to staff.
Rationale:
To facilitate staff acceptance of changes to the scheduling system, the nurse manager should
first provide relevant information to the staff about the need for the changes. This helps build
understanding and acceptance among the staff by involving them in the decision-making
process.
10. A nurse is planning teaching about allowable foods for a client with uric acid-based urinary
calculi formation. What foods should the nurse recommend?
Answer: Oranges.
Rationale:
Oranges are recommended for clients with uric acid-based urinary calculi formation because
they are low in purines, which can help reduce the risk of uric acid stone formation.
11. A charge nurse is teaching a newly licensed nurse how to identify true labor. What should
the nurse include in the teaching?
Answer: The cervix transitions to an anterior position.
Rationale:
In true labor, the cervix transitions to an anterior position and begins to dilate in preparation for
birth. This is a key indicator that distinguishes true labor from false labor.
12. A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the
following findings should indicate to the nurse that the client can sign the informed consent?
Answer: The client can accurately describe the procedure.
Rationale:
Before signing an informed consent form, the client must understand the procedure and its
implications. The ability to accurately describe the procedure indicates that the client has the
necessary understanding to give informed consent.
13. A charge nurse assigns a new nurse to a client with a chest tube. The new nurse expresses
concern due to limited experience with monitoring drainage. What should the charge nurse do
to teach about chest tubes?
Answer: Ask the nurse about their knowledge of the procedure.
Rationale:
Assessing the new nurse's knowledge of chest tube management allows the charge nurse to
tailor the teaching to address any gaps or concerns. This approach promotes effective learning
and ensures the new nurse feels confident in caring for the client.
14. A nurse is teaching a client about a new prescription for estradiol. For which of the
following adverse effects should the nurse tell the client to monitor and contact the provider?
Answer: Headaches.
Rationale:
Headaches can be a sign of a thromboembolic stroke, which is a serious adverse effect
associated with estradiol therapy. Clients should be instructed to monitor for headaches and
contact their provider if they occur.
15. A nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a 22lb toddler who is
experiencing a grand mal seizure. Available is 5mg/mL. How many mLs should the nurse
administer?
Answer: 0.6 mL.
Rationale:
First, convert the weight from pounds to kilograms: 22 lb ÷ 2.2 = 10 kg. Then, calculate the
dose: 0.3 mg/kg × 10 kg = 3 mg. Next, determine the volume to administer using the available
concentration: 3 mg ÷ 5 mg/mL = 0.6 mL.
16. A nurse is caring for a 12-hour post-op patient on a PCA for pain control and requires a
blood pressure check in 10 minutes. Which of the following staff members should the nurse
assign to collect this information?
Answer: An AP who is assisting a client to return to bed.
Rationale:
The AP can perform the blood pressure check while assisting the client, ensuring that both tasks
are completed efficiently and safely.
17. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an
absolute neutrophil count of 400/mm3. What intervention should the nurse include in the plan?
Answer: Withhold the varicella vaccine.
Rationale:
With an absolute neutrophil count of 400/mm3, the child is at risk for infection and should not
receive live vaccines like varicella. This is a precaution to prevent potential complications.
18. A nurse is providing teaching about improving nutrition for a client who has MS. Which
instructions should the nurse include?
Answer: • "A speech pathologist will be performing a swallowing study for you."
• "You should rest before eating a meal."
• "Thicken your beverages before drinking."
Rationale:
These instructions are important for a client with MS to ensure safe and effective swallowing
and adequate nutrition.
19. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which
finding is the priority for the nurse to provide to the provider?
Answer: Temp 102.9°F.
Rationale:
A high temperature could indicate a serious adverse reaction to chlorpromazine, such as
neuroleptic malignant syndrome (NMS), which requires immediate medical attention. This
finding is a priority as it could indicate a life-threatening condition.
20. A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min
and a blood pressure of 90/44 mm Hg. What medication should the nurse anticipate
administering?
Answer: Flumazenil.
Rationale:
Flumazenil is a benzodiazepine receptor antagonist used to reverse the sedative effects of
benzodiazepines like lorazepam in cases of overdose or excessive sedation. This medication can
help reverse the respiratory depression and hypotension caused by lorazepam overdose.
21. A nurse is caring for an older adult client in the PACU following general anesthesia. What
finding should the nurse report to the provider?
Answer: Audible stridor.
Rationale:
Audible stridor, or a high-pitched sound heard in the client's airway, indicates edema, laryngeal
spasm, secretions, or some type of airway obstruction that could become life-threatening. This
finding requires immediate attention to maintain the client's airway.
22. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter on a male
client. Which technique should the nurse use to maintain aseptic technique?
Answer: Set the tray on the table at waist height.
Rationale:
Placing the tray at waist height helps maintain the sterility of the field by reducing the risk of
contamination from reaching over the field. This technique helps ensure that the catheter
insertion is performed using aseptic technique.
23. A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the
following actions should the nurse plan to take?
Answer: Clear objects from the client's walking area.
Rationale:
Cranial nerve II, or the optic nerve, is responsible for vision. Clearing objects from the client's
walking area helps prevent falls and injuries due to visual deficits, which can occur with cranial
nerve II deficits.
24. A nurse is providing discharge instructions to a client following a total hip arthroplasty.
Which instruction should the nurse include?
Answer: Install a raised toilet seat at home.
Rationale:
A raised toilet seat can help the client avoid excessive bending at the hip joint, reducing the risk
of dislocation after hip arthroplasty. This instruction promotes safe and effective recovery at
home.
25. A nurse is assessing a client who is receiving a blood transfusion. Which of the following
findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?
Answer: Low back pain.
Rationale:
Hemolytic transfusion reactions can cause low back pain due to the release of hemoglobin from
lysed red blood cells, which can lead to kidney damage. This finding is indicative of a serious
reaction that requires immediate intervention.
26. A nurse is caring for a child who is experiencing a tonic-clonic seizure. What action should
the nurse take?
Answer: Place the child in a side-lying position.
Rationale:
Placing the child in a side-lying position helps prevent aspiration and allows for drainage of
oral secretions during the seizure. This position helps maintain the child's airway and reduces
the risk of complications during the seizure.
27. A nurse is administering meds to a client who has a percutaneous gastrostomy tube for
enteral feedings. Which of the following actions should the nurse take to prevent the tube from
clogging?
Answer: Flush the patient's gastrostomy tube with 30 mL of water before administering the
medication.
Rationale:
Flushing the tube before and after medication administration helps maintain patency and
prevent clogging. This action ensures that the medication is delivered effectively and reduces
the risk of complications from a clogged tube.
28. A nurse is assessing a client who has macular degeneration. Which of the following findings
should the nurse expect?
Answer: Decreased central vision.
Rationale:
Macular degeneration affects the macula, leading to a loss of central vision while peripheral
vision remains intact. This finding is characteristic of macular degeneration and is important for
the nurse to assess and monitor in clients with this condition.
29. A nurse is assessing a client who has schizophrenia. The nurse should identify the following
alteration in speech as which of the following?
Answer: Clang association.
Rationale:
Clang association is a pattern of speech in which words are chosen based on their sound rather
than their meaning, often rhyming or having a similar sound. This alteration in speech is
characteristic of schizophrenia and is important for the nurse to recognize during the
assessment.
30. A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian
asks when the child can return to school. Which of the following responses should the nurse
make?
Answer: When crusts have formed on every lesion.
Rationale:
This is the appropriate time for a child with varicella to return to school, as it indicates that the
lesions are no longer infectious. The nurse should provide accurate information to the guardian
to prevent the spread of varicella to others.
31. A nurse is providing discharge instructions to a client who has a new prescription for
warfarin. Which client statement indicates the client understands the teaching?
Answer: "I should report a change in the color of my stools."
Rationale:
Warfarin is an anticoagulant that can increase the risk of bleeding. Changes in stool color, such
as black or tarry stools, can indicate gastrointestinal bleeding, which is a serious side effect of
warfarin therapy. It is essential for the client to report this symptom promptly to their healthcare
provider.
32. A nurse is assessing a child with CF. Which finding is a priority to report to the provider?
Answer: Hemoptysis 275mL in 24 hours.
Rationale:
Hemoptysis (coughing up blood) can be a sign of a serious complication in CF, such as a lung
infection or lung damage. The amount of blood, 275mL, is significant and requires immediate
medical attention to assess and manage the underlying cause.
33. When caring for a child, a nurse plans to use nonpharmacological interventions to enhance
pain medication effectiveness. Which of the following strategies incorporates visualization
techniques to help decrease the child's discomfort?
Answer: Blowing bubbles to "blow the hurt away."
Rationale:
Blowing bubbles is a distraction technique that can help children focus on something other than
their pain. The act of blowing can also be calming and may help the child relax, which can
enhance the effectiveness of pain medication.
34. An AP and a nurse are turning a patient on their right side. Which AP action requires the
nurse to intervene?
Answer: Places a pillow under the patient's right arm.
Rationale:
When turning a patient, it is important to support the limbs to prevent strain or injury. Placing a
pillow under the right arm while turning the patient onto the right side could cause discomfort
or strain to the arm. The nurse should intervene to ensure proper positioning and safety during
the procedure.
35. A nurse on a mental health unit has a patient refusing IM lorazepam. What is the nursing
action?
Answer: Document the refusal.
Rationale:
It is important to document any refusal of medication by a patient. This documentation helps to
ensure that all members of the healthcare team are aware of the patient's decisions and can
monitor for any potential issues or changes in the patient's condition.
36. A nurse is caring for four patients. What should the nurse delegate to the AP for meals?
A patient with Alzheimer's disease and is demonstrating aphasia.
Answer: Assist the patient with eating.
Rationale:
Patients with Alzheimer's disease and aphasia may have difficulty communicating and eating
independently. The AP can assist the patient with eating, ensuring that they receive adequate
nutrition and hydration during meals.
37. A mental health nurse is conducting the first of many meetings with a client whose partner
recently died. The nurse should perform which action to establish trust in the orientation phase
of the nurse-client relationship?
Answer: Establish the termination date.
Rationale:
Establishing a termination date is a part of the orientation phase of the nurse-client relationship.
It helps the client understand that the therapeutic relationship is time-limited, which can create a
sense of safety and trust.
38. A nurse is caring for a client at 28 weeks gestation. The client asks what's causing her
constipation. Which response should the nurse make?
Answer: "The enlarged uterus compresses the intestines and causes constipation."
Rationale:
During pregnancy, the growing uterus can compress the intestines, slowing down the movement
of food through the digestive tract. This can lead to constipation. Explaining this to the client
helps them understand the physiological changes occurring in their body.
39. A nurse manager reviews falls occur most often between 0530 and 0730. Which action
should the nurse take in root cause analysis?
Answer: Investigate environmental factors that might be contributing to client injury during
these hours.
Rationale:
Conducting a root cause analysis involves identifying the underlying causes of a problem or
issue. In this case, the nurse should investigate environmental factors that might contribute to
falls during the early morning hours, such as poor lighting, wet floors, or inadequate staffing
levels.
40. A nurse is caring for an immediately postoperative total vaginal hysterectomy. Which action
should the nurse take first?
Answer: Measure the patient's vital signs.
Rationale:
Assessing the patient's vital signs is the first priority in postoperative care to monitor for any
signs of complications, such as bleeding or shock. This assessment helps the nurse determine
the patient's overall condition and the need for further intervention.
41. A charge nurse is planning an educational session for staff nurses about working with
parents whose terminally ill children are candidates for organ donation. Which information
should the nurse plan to include?
Answer: The family can have the child in an open casket without fearing that the organ
donation might disfigure the child's body.
Rationale:
It's important for the charge nurse to include this information to alleviate concerns of the staff
nurses and the families of the terminally ill children. Knowing that organ donation does not
damage or violate the child's body in a way that would prevent an open casket funeral can
provide comfort to the families during an incredibly difficult time.
42. A nurse is teaching about TPN and IV lipid emulsions with a client who has an extensive
burn injury. Which of the following information should the nurse include?
Answer: "You will receive fingersticks for blood glucose testing."
Rationale:
Patients receiving TPN (total parenteral nutrition) and IV lipid emulsions are at risk for
hyperglycemia due to the high glucose content in these solutions. Monitoring blood glucose
levels with fingersticks is necessary to detect and manage hyperglycemia effectively.
43. A nurse is caring for a client with a closed femur fracture and has had a fiberglass leg
cylinder cast for 24 hours. Which of the following assessment findings should the nurse identify
as the priority?
Answer: The client's heel is red and tender.
Rationale:
A red and tender heel in a patient with a leg cast could indicate the development of pressure
ulcers, especially if the cast is not properly positioned or if the patient is not repositioned
regularly. Pressure ulcers can lead to serious complications and require immediate attention.
44. A home health nurse is providing teaching to a client that has Hepatitis A. Which of the
following instructions should the nurse include?
Answer: Use hydrogen peroxide to clean kitchen surfaces.
Rationale:
Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. Using
hydrogen peroxide to clean kitchen surfaces can help kill the virus and prevent its spread to
others in the household.
45. A nurse is preparing to perform an Intermittent Urinary Catheterization for a patient with
urinary retention. Which IMAGE shows the catheter the nurse should use?
Answer: Straight cath.
Rationale:
A straight catheter is typically used for intermittent urinary catheterization. It is inserted into the
bladder to drain urine and then removed, unlike an indwelling catheter which remains in place
for an extended period.
46. A community health nurse is preparing a health education program for a local rural
community. Which of the following actions should the nurse take first?
Answer: Identify health-related issues within the community.
Rationale:
Before developing a health education program, it is essential for the nurse to identify the
specific health needs and issues within the community. This assessment will help ensure that
the program is tailored to address the most pressing health concerns of the community
members.
47. A nurse is caring for a client who has generalized anxiety disorder and is going to start
alprazolam. Which action should the nurse take?
Answer: Initiate fall precautions.
Rationale:
Alprazolam, a benzodiazepine used to treat anxiety disorders, can cause drowsiness and
dizziness, increasing the risk of falls, especially in older adults. Therefore, initiating fall
precautions, such as ensuring the client's environment is free from hazards and providing
assistance with ambulation if needed, is important to prevent injuries.
48. A nurse in the delivery room is caring for a newborn immediately after birth. Which of the
following actions should the nurse take first?
Answer: Dry the newborn.
Rationale:
Drying the newborn immediately after birth helps prevent hypothermia and stimulates
breathing. It is a critical step in the initial care of a newborn and should be done before other
actions such as assessing the newborn's vital signs or clamping the umbilical cord.
49. A nurse in a mental health facility is planning care for a client who has anorexia nervosa.
Which intervention should the nurse include in the plan of care?
Answer: Supervise the client during and after eating.
Rationale:
Clients with anorexia nervosa may engage in behaviors such as self-induced vomiting or hiding
food to avoid eating. Supervising the client during and after meals can help ensure that they are
consuming an adequate amount of food and are not engaging in harmful behaviors related to
their eating disorder.
50. A nurse is talking with the partner of a client who attempted suicide. Which of the following
statements by the client's partner is priority?
Answer: "My husband doesn't know I’ve already moved out and filed for divorce."
Rationale:
This statement indicates a significant change in the client's support system and may have
implications for the client's mental health and well-being. It is important for the nurse to
address this issue and assess the client's emotional state and support network to ensure
appropriate care and intervention.
51. A nurse is assessing a client who has MS. Which manifestation should the nurse expect?
Answer: Nystagmus.
Rationale:
Multiple sclerosis (MS) is a neurological disorder that can affect the nerves responsible for eye
movement, leading to nystagmus, which is an involuntary and rhythmic movement of the eyes.
This is a common manifestation of MS due to the damage it causes to the nerves in the brain
and spinal cord.
52. A nurse is interviewing a client who is now without a home due to a natural disaster. After
ensuring the client's safety, what's the nurse's first action?
Answer: Determine the client's perception of the personal impact of the crisis.
Rationale:
Understanding the client's perception of the impact of the crisis is essential for providing
appropriate support and assistance. This information can help the nurse prioritize interventions
and address the client's immediate needs, such as shelter, food, and emotional support.
53. A nurse is administering enoxaparin. Where?
Answer: A- periumbilical area.
Rationale:
Enoxaparin is a low-molecular-weight heparin that is typically administered subcutaneously.
The periumbilical area is a common site for subcutaneous injections, as it has a good layer of
adipose tissue and is away from major blood vessels and nerves.
54. A nurse is assessing a client who has skeletal traction for a femur fracture. Which should the
nurse identify as the priority?
Answer: Upper chest petechiae.
Rationale:
Upper chest petechiae can be a sign of fat embolism syndrome (FES), a serious complication of
long bone fractures, including femur fractures. FES occurs when fat globules enter the
bloodstream and block small blood vessels, leading to tissue damage and organ dysfunction.
Prompt recognition and treatment of FES are essential to prevent serious complications.
55. A nurse is assessing a client with sickle cell anemia. What manifestation indicates a vasoocclusive crisis?
Answer: Hematuria.
Rationale:
Vaso-occlusive crisis is a common complication of sickle cell anemia characterized by the
blockage of blood vessels by sickle-shaped red blood cells. Hematuria, or blood in the urine,
can occur due to the blockage of blood vessels in the kidneys, leading to tissue damage and
bleeding.
56. A nurse is assessing a client who has been taking lithium carbonate for the past month to
treat bipolar disorder. Assessment finding priority?
Answer: Confusion.
Rationale:
Confusion can indicate lithium toxicity, which is a serious side effect of lithium carbonate
therapy. Monitoring for confusion is important because it can be an early sign of toxicity, and
prompt intervention is necessary to prevent further complications.
57. A nurse is providing teaching to the parent of a child who has a permanent trach. Steps of
trach care:
Answer: • Remove inner cannula
• Remove soiled dressing
• Clean with saline
• Change the trach collar
Rationale:
Tracheostomy care involves removing the inner cannula to clean it, removing any soiled
dressing around the tracheostomy site, cleaning the area with saline, and changing the trach
collar as needed. These steps help maintain the patency of the tracheostomy tube and prevent
infection.
58. A nurse in an ER is assessing a client that took MDMA. What should the nurse expect?
Answer: Diaphoresis.
Rationale:
MDMA, also known as ecstasy, is a stimulant drug that can cause increased sweating
(diaphoresis) as a side effect. Other common effects of MDMA include increased heart rate,
increased blood pressure, and euphoria.
59. A nurse is teaching a client who is to start taking misoprostol and is currently on long-term
NSAIDs for arthritis. The nurse should provide what information?
Answer: Complete a serum pregnancy test before taking the medication.
Rationale:
Misoprostol is contraindicated in pregnancy as it can cause miscarriage and birth defects.
Therefore, it is important for women of childbearing age who are taking misoprostol to
complete a serum pregnancy test before starting the medication to ensure they are not pregnant.
60. A nurse is caring for a client with a potassium level of 3. What manifestation should the
nurse monitor for?
Answer: Decreased Deep Tendon Reflexes.
Rationale:
Hypokalemia (low potassium level) can lead to decreased deep tendon reflexes due to impaired
nerve conduction. Monitoring deep tendon reflexes is important in clients with hypokalemia to
assess for neurological changes and prevent complications such as muscle weakness and
cardiac dysrhythmias.
61. A nurse in an ER is planning discharge for a client who has experienced intimate partner
violence. Which action should the nurse take first?
Answer: Develop a safety plan.
Rationale:
The priority for a client experiencing intimate partner violence is to ensure their safety.
Developing a safety plan with the client helps identify strategies to protect them from further
harm and provides resources for support and assistance.
62. A nurse is caring for a client at 37 weeks gestation and is experiencing abruptio placentae.
Which finding should the nurse expect?
Answer: Persistent uterine contractions.
Rationale:
Abruptio placentae is a serious complication of pregnancy characterized by the premature
separation of the placenta from the uterine wall. Persistent uterine contractions are a common
finding in abruptio placentae and can lead to significant maternal and fetal complications,
including hemorrhage and fetal distress.
63. A nurse is caring for a client in the manic phase of bipolar. Expected manifestations?
Answer: Grandiose delusions.
Rationale:
Clients in the manic phase of bipolar disorder typically exhibit behaviors that appear to be
euphoric. They may experience abrupt mood changes, expansiveness, unlimited energy, poor
impulse control, and grandiose delusions, such as believing they have special powers or
abilities.
64. "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked
out." The client demonstrates which defense mechanism?
Answer: Sublimation.
Rationale:
Sublimation is a defense mechanism in which socially unacceptable impulses or behaviors are
consciously transformed into socially acceptable actions or behavior. In this scenario, the client
is channeling their anger into a constructive activity (working out) rather than acting out
inappropriately.
65. Which of the foods has the highest amount of Vitamin A?
• 1 medium raw carrot contains 2,025 mcg/dL of vitamin A; therefore the best food to
recommend
• 1/2 cup cooked spinach contains 737 mcg/dL
• 1/2 cup cooked butternut squash contains 714 mcg/dL
• 1 cup sliced cantaloupe contains 516 mcg/dL
Answer: 1 medium raw carrot contains 2,025 mcg/dL of vitamin A; therefore, the best food to
recommend.
Rationale:
Carrots are an excellent source of vitamin A, with 1 medium raw carrot containing 2,025
mcg/dL. Vitamin A is important for maintaining healthy vision, skin, and immune function.
While other foods listed also contain vitamin A, the carrot provides the highest amount per
serving.
66. A nurse is teaching the parent of a school-age child about administering ear drops. Parent
response indicating understanding?
• “I should pull the top of the ear upward and back while instilling the medication”- child >3 yrs
• Pull the pinna downward and back in children 3 yrs.
Rationale:
Pulling the top of the ear upward and back helps straighten the ear canal in older children (>3
years) to facilitate the administration of ear drops. For children younger than 3 years, the ear
should be pulled downward and back to straighten the ear canal.
67. A nurse is caring for a client that requires PT after discharge. First nursing action?
Answer: Involve the client in selecting their PT provider.
Rationale:
Involving the client in selecting their physical therapy (PT) provider helps ensure that the
provider meets the client's needs and preferences. It promotes client-centered care and can
improve the client's engagement and compliance with the PT regimen.
68. A nurse is planning care for a client receiving HD from an AV fistula in the R arm. Which
intervention should the nurse include in the plan of care?
Answer: Auscultate the affected extremity for bruit.
Rationale:
Auscultating the AV fistula every 4 hours is essential to ensure that a bruit (swishing sound) is
present, which indicates patency of the fistula. A non-palpable or non-audible thrill or bruit
could indicate a clot or other issue that requires immediate attention.
69. A nurse is providing teaching for a client about newborn safety. Which statement should the
nurse include in the teaching?
Answer: Set your hot water heater temp at or below 120°F.
Rationale:
Setting the hot water heater temperature at or below 120°F helps prevent scald burns in infants
and children. Water that is too hot can cause serious burns in a short period of time, so it is
important to regulate the temperature of the hot water heater to a safe level.
70. A nurse is caring for a newborn with herpes simplex virus (HSV). Which isolation
precautions?
Answer: Contact.
Rationale:
Contact isolation precautions are necessary for newborns with herpes simplex virus (HSV)
infection to prevent the spread of the virus to other patients and healthcare workers. Contact
precautions involve wearing gloves and a gown when entering the room and ensuring that any
items touched by the newborn are cleaned and disinfected appropriately.
71. A home health nurse is planning care for an older adult client who has impaired vision.
Which intervention in the plan of care to prevent injury at home?
Answer: Mark the edges of stairs for contrast.
Rationale:
Marking the edges of stairs for contrast can help clients with impaired vision identify the steps
more easily and reduce the risk of falls and injuries. Using contrasting colors or materials can
make the edges more visible and help the client navigate the stairs safely.
72. A nurse is initiating discharge planning for a client who has had a stroke and is experiencing
right-sided weakness. Nurse's first action?
Answer: Request a referral for the patient to receive physical therapy.
Rationale:
Physical therapy (PT) is crucial for clients recovering from a stroke, especially those
experiencing weakness or paralysis on one side of the body. PT helps improve mobility,
strength, and coordination, which are essential for the client's recovery and independence.
73. A nurse is reviewing lab findings of a client experiencing chest pain. The nurse should
identify that an elevation in which lab indicates myocardial cell tissue injury?
Answer: Troponin T.
Rationale:
Troponin T is a marker for myocardial cell tissue injury. An elevation in troponin T levels
indicates damage to the heart muscle, such as in myocardial infarction (heart attack).
Monitoring troponin T levels helps diagnose and manage acute coronary syndromes and other
cardiac conditions.
74. 5,000U Sub-Q heparin, available 10,000U/mL. How much to administer?
Answer: 0.5 mL.
Rationale:
To calculate the dose of heparin, divide the total dose required (5,000 units) by the
concentration of the heparin available (10,000 units per mL). Therefore, 5,000 units divided by
10,000 units per mL equals 0.5 mL.
75. A nurse in an outpatient clinic is working with a client who has PTSD and asks for
recommended non-pharmacological therapy. What should the nurse recommend to help
alleviate distress?
Answer: Guided imagery.
Rationale:
Guided imagery is a relaxation technique that involves using mental images to promote
relaxation and reduce stress. It can be an effective non-pharmacological therapy for clients with
PTSD, as it helps them focus on positive images and feelings, leading to a sense of calm and
relief from distress.
76. A nurse manager is preparing a newly licensed nurse's performance appraisal. Which
method should the manager use to evaluate time management skills?
Answer: Maintain regular notes about the nurse's time management skills.
Rationale:
Maintaining regular notes allows the nurse manager to track the newly licensed nurse's time
management skills over time. This method provides a more comprehensive and accurate
assessment compared to relying on occasional observations or memory.
77. A nurse is caring for four clients at the beginning of a shift. After report, which client should
the nurse attend to first?
Answer: A patient who is confused and has been attempting to get out of bed.
Rationale:
The confused patient attempting to get out of bed is at risk for falls and injury. Ensuring the
patient's safety is the priority, so the nurse should attend to this patient first to prevent falls and
provide necessary assistance.
78. A night shift nurse is giving change-of-shift report to the day shift nurse on a client ready
for discharge. Priority information to oncoming nurse?
Answer: The client needs assistance when transferring from bed to wheelchair.
Rationale:
Providing information about the client's need for assistance with transfers is crucial for ensuring
the client's safety during the transition from the hospital to home. The day shift nurse needs to
be aware of this to provide appropriate assistance and prevent falls or injuries.
79. A nurse is assessing a client who has a stage II pressure injury. Expected wound
characteristics?
Answer: Partial thickness skin loss.
Rationale:
A stage II pressure injury involves partial thickness skin loss involving the epidermis and/or
dermis. The wound is shallow and presents as a blister, abrasion, or shallow crater. It does not
extend through the full thickness of the skin.
80. A nurse is providing discharge instructions to a client who has a new prescription for
amitriptyline to treat depression. Which client statement shows understanding of teaching?
Answer: "I should watch for dry mouth and constipation."
Rationale:
Monitoring for common side effects such as dry mouth and constipation is important when
taking amitriptyline, a tricyclic antidepressant. These side effects are related to the drug's
anticholinergic effects. The nurse's teaching should include strategies to alleviate these effects,
such as increasing dietary fiber, fluid intake, and using sugar-free gum.
81. A charge nurse is preparing to administer 0900 meds and is told by pharmacy the meds are
not available. First charge nurse action?
Answer: Inform the nurse manager
Rationale:
The charge nurse should inform the nurse manager immediately so that alternative medications
or solutions can be arranged. This ensures patient safety and continuity of care. Informing the
nurse manager is the first step in addressing the medication shortage.
82. A nurse is caring for a client that vomits on a reusable BP cuff. Nurses action?
Answer: Place the BP cuff in a labeled bag for decontamination
Rationale:
The nurse should place the BP cuff in a labeled bag for decontamination to prevent the spread
of infection. Proper handling and decontamination of equipment are essential to maintain a safe
and hygienic environment for both patients and healthcare providers.
83. A nurse is assessing a 2hr old newborn. Which of the following findings should be report to
the DR?
Answer: Axillary temp 36.2C (97.2F)
Rationale:
A temperature of 36.2°C (97.2°F) in a 2-hour-old newborn is below the normal range for a
newborn's temperature. Newborns are particularly vulnerable to temperature fluctuations, and
even a slight deviation from the normal range can indicate a potential issue. Therefore, it should
be reported to the doctor for further evaluation and intervention if necessary.
84. A nurse manager is on a planning committee to develop an emergency preparedness plan.
Which action takes place first when implementing an emergency preparedness plan?
Answer: Notify the incident commander
Rationale:
In an emergency preparedness plan, the first action to take is to notify the incident commander.
The incident commander is responsible for overall coordination and management of the
response to an emergency or disaster. By notifying the incident commander, the appropriate
chain of command is activated, and the response can be organized and coordinated effectively.
85. A nurse is preparing to administer 15U regular insulin along with 20U NPH. Which action
plan should the nurse take?
Answer: Inject 20 units of air into NPH insulin vial
Rationale:
When drawing up a mixed dose of regular insulin and NPH insulin, the nurse should first inject
air into the NPH insulin vial to equalize the pressure before withdrawing the NPH insulin. This
prevents creating a vacuum in the vial, which would make it difficult to withdraw the correct
dose of insulin. It's important to follow this step to ensure accurate dosing and prevent
medication errors.
86. A charge nurse overhears 2 staff nurses in the hallway discussing the nutritional status of a
client who has anorexia nervosa. Which action should the charge nurse take?
Answer: Tell the nurses to stop the discussion
Rationale:
Discussing a client's condition, especially one as sensitive as anorexia nervosa, in a public area
violates the client's right to privacy and confidentiality. The charge nurse should remind the
nurses of the importance of patient privacy and instruct them to discuss such matters in a
private and appropriate setting.
87. A nurse is assessing a client who is 2 hours post-op following a cardiac catheterization.
Which should report to DR?
Answer: Insertion site pain level of 6 on a scale of 0 to 10
Rationale:
Pain at the insertion site of a cardiac catheterization can indicate potential complications, such
as bleeding or infection. Pain management is an important aspect of post-operative care, and
any significant pain should be reported to the doctor for further evaluation and management.
88. A nurse is providing client education to a postpartum client who has decided to bottle-feed
their newborn. Instructions to prevent the discomfort of engorgement?
Answer: Place ice packs on the breasts for 15 minutes several times per day
Rationale:
Engorgement is caused by an accumulation of milk in the breasts. Applying ice packs can help
reduce swelling and discomfort by constricting blood vessels and decreasing blood flow to the
area. This can help relieve engorgement and provide comfort to the client.
89. A case manager is reviewing the medical records of several clients. For which of the
following clients should the nurse request an interprofessional care conference?
Answer: A client who has diabetes mellitus and has repeat admissions for diabetic ketoacidosis
(DKA)
Rationale:
Diabetic ketoacidosis (DKA) is a serious and potentially life-threatening complication of
diabetes mellitus. Clients who have repeat admissions for DKA may benefit from an
interprofessional care conference to ensure coordinated and comprehensive care. In an
interprofessional care conference, healthcare providers from different disciplines can
collaborate to develop a comprehensive care plan to address the client's complex needs and
reduce the risk of future admissions for DKA.
90. A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube.
Which of the following actions by the newly licensed nurse indicates understanding of the
procedure?
Answer: Keeps the head of the bed elevated to 45 degrees for 1 hour after feedings
Rationale:
Keeping the head of the bed elevated to 45 degrees for 1 hour after enteral feedings helps
prevent aspiration by promoting the flow of the feeding into the stomach and reducing the risk
of reflux. This position helps ensure that the feeding remains in the stomach and does not enter
the lungs, reducing the risk of aspiration pneumonia.
91. A nurse is assessing a client during the immediate postpartum period. Which finding
requires immediate intervention?
Answer: Boggy uterus
Rationale:
A boggy uterus, or a uterus that feels soft and mushy instead of firm and well-contracted, can
indicate uterine atony, which is a common cause of postpartum hemorrhage. Immediate
intervention, such as massage of the uterus or administration of oxytocic medications, is
necessary to prevent excessive bleeding and stabilize the client's condition.
92. A nurse is caring for a newborn whose parents ask why their baby is receiving vitamin K.
The nurse explains vitamin K prevents:
Answer: Bleeding
Rationale:
Newborns are born with low levels of vitamin K, which is essential for the blood to clot
properly. Administering vitamin K to newborns helps prevent a rare but serious bleeding
disorder called vitamin K deficiency bleeding (VKDB), which can occur in the first few days of
life. Vitamin K supplementation is a standard practice in newborn care to prevent this
potentially life-threatening condition.
93. A nurse is planning care for a client who has thrombocytopenia. Which of the following
instructions should the nurse include in the client's plan of care?
Answer: Avoid venipunctures when possible
Rationale:
Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an
increased risk of bleeding. To reduce the risk of bleeding, it is important to minimize invasive
procedures, such as venipunctures, whenever possible. This helps preserve the client's platelet
count and reduces the risk of bleeding complications.
94. A nurse is assessing a 2-month-old infant during a well-baby exam. Which of the following
actions should the nurse take to assess the infant's rooting reflex?
Answer: Stroke the cheek
Rationale:
The rooting reflex is a natural reflex in infants that helps them find the breast or bottle for
feeding. To assess the rooting reflex, the nurse should gently stroke the infant's cheek near the
corner of the mouth. The infant should turn their head toward the side that was stroked,
indicating the presence of the rooting reflex.
95. A nurse is teaching a client who has a new prescription for digoxin about manifestations of
toxicity. Which finding should the nurse include in the teaching?
Answer: Nausea
Rationale:
Nausea is a common early sign of digoxin toxicity. Other signs of digoxin toxicity can include
vomiting, diarrhea, confusion, and visual disturbances. It is important for the client to be aware
of these signs and to report them to their healthcare provider if they occur, as digoxin toxicity
can be serious and require medical intervention.
96. A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis.
Expected finding?
Answer: Protein
Rationale:
Acute glomerulonephritis is characterized by inflammation of the glomeruli in the kidneys,
which can lead to proteinuria (the presence of protein in the urine). The presence of protein in
the urine is a common finding in clients with acute glomerulonephritis due to the damage to the
glomeruli, which normally filter out excess protein from the blood.
97. A nurse working on a med-surg unit receives a telephone call requesting the status of a
client from an individual who identifies themselves as the client's parents. Nursing action?
Answer: Ask the caller for verification of their identity
Rationale:
It is important for the nurse to verify the identity of the caller before providing any information
about a client's status. This helps ensure the privacy and confidentiality of the client's health
information and prevents unauthorized access to sensitive information. Asking for verification
of identity is a standard practice to protect patient confidentiality.
98. A nurse is caring for a client who has end-stage Alzheimer's Disease. The adult child of the
client says 'I don't know why I bother to visit my mother anymore". Nurse response?
Answer: "It seems like you feel your visits are a waste of time."
Rationale:
The nurse's response reflects active listening and empathy, acknowledging the adult child's
feelings without judgment. This response opens the door for further discussion and allows the
adult child to express their feelings and concerns. It is important for the nurse to provide a
supportive and non-judgmental environment for family members dealing with the challenges of
caring for a loved one with Alzheimer's Disease.
99. A nurse is assessing a client who has antisocial personality disorder. Expected
manifestations?
Answer: Lack of remorse
Rationale:
Antisocial personality disorder is characterized by a pattern of disregard for and violation of the
rights of others. Individuals with this disorder often have a lack of remorse for their actions and
may rationalize harmful behaviors. Other manifestations can include deceitfulness, impulsivity,
irritability, aggressiveness, and irresponsibility.
100. A community health nurse is performing triage tagging following a mass casualty incident.
Black tag?
Answer: A patient with significant head trauma with agonal respirations
Rationale:
In the triage tagging system, a black tag is used to indicate a patient who is deceased or who has
injuries so severe that they are not expected to survive given the resources available. A patient
with significant head trauma and agonal respirations is in critical condition and would be
tagged black to prioritize care for those who have a higher likelihood of survival with medical
intervention.
101. A nurse is caring for a client who has dehydration secondary to nausea and vomiting. The
nurse should identify which of the following findings as fluid volume deficit?
Answer: orthostatic hypotension
Rationale:
Orthostatic hypotension, a drop in blood pressure when standing up, is a common finding in
fluid volume deficit. When there is dehydration, the body compensates by reducing blood
volume, leading to decreased blood pressure. Orthostatic hypotension is a result of this
decreased blood volume.
102. A nurse is providing discharge teaching to a new parent about car seat safety. Which
statement should the nurse include in the teaching?
Answer: "secure the retainer clip at the level of the baby's armpits"
Rationale:
Securing the retainer clip at the level of the baby's armpits ensures proper placement and
prevents the baby from sliding out of the car seat in case of sudden stops or accidents. Placing
the clip too high or too low can lead to improper restraint.
103. A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following
actions should the nurse take?
Answer: initiate oral rehydration therapy for the toddler
Rationale:
Oral rehydration therapy is the primary treatment for gastroenteritis in toddlers. It helps replace
lost fluids and electrolytes due to vomiting and diarrhea. ORT can prevent dehydration and the
need for more invasive treatments such as intravenous fluids.
104. A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should
assess the client for which condition prior to starting the procedure?
Answer: latex allergy
Rationale:
Assessing the client for latex allergy is crucial before inserting an indwelling urinary catheter,
as many catheters contain latex. A latex allergy can cause a severe reaction in some individuals,
so it's important to use latex-free products if the client is allergic.
105. A nurse is caring for an older adult client. Physiological change associated with aging?
Answer: decreased lung expansion
Rationale:
Aging is associated with decreased lung elasticity and a decrease in the number of functional
alveoli, leading to decreased lung expansion. This can result in decreased oxygen exchange and
an increased risk of respiratory issues such as pneumonia.
106. A charge nurse observes a staff nurse document a dressing change in a client's chart that
wasn't performed. First charge nurse action?
Answer: Gather more information about the staff nurse's actions
Rationale:
Before taking any further action, the charge nurse should gather more information to
understand the situation fully. This may involve speaking with the staff nurse to clarify what
happened, reviewing the client's chart for any additional documentation, and potentially
speaking with other staff members who were involved in the client's care.
107. A nurse is providing discharge teaching to a client following a cataract extraction. Client
statement understands teaching?
Answer: "bend at my knees when picking up objects from the floor"
Rationale:
Bending at the knees instead of the waist helps prevent increased intraocular pressure, which
can be harmful after a cataract extraction. This statement indicates that the client understands
the importance of this precaution in preventing complications.
108. A nurse is caring for a client with MRSA. Implement which precautions?
Answer: contact
Rationale:
Contact precautions are necessary for clients with MRSA to prevent the spread of infection.
This includes wearing gloves and a gown when providing care, and ensuring that any
equipment used for the client is properly cleaned and disinfected.
109. A nurse is caring for a client who is 4 hours postpartum with a boggy uterus and heavy
lochia. First nursing action?
Answer: massage the uterus to expel clots
Rationale:
A boggy uterus and heavy lochia indicate uterine atony, which can lead to postpartum
hemorrhage. The first nursing action should be to massage the uterus to help it contract and
expel any clots, which can help prevent further bleeding and stabilize the client.
110. A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg
(8 lbs) and is being breastfed. Effective breastfeeding?
Answer: The newborn has 6-8 wet diapers per day
Rationale:
Six to eight wet diapers per day is a sign of adequate fluid intake and effective breastfeeding in
a newborn. It indicates that the newborn is getting enough milk and is staying hydrated.
111. A nurse is caring for a client who has a closed-head injury and is receiving mechanical
ventilation. The nurse should expect to administer which medication to reduce intracranial
pressure?
Answer: mannitol
Rationale:
Mannitol is an osmotic diuretic commonly used to reduce intracranial pressure in clients with
closed-head injuries. It works by drawing excess fluid out of the brain tissue, reducing swelling
and pressure.
112. A nurse is teaching a newly admitted client who has heart failure about advance directives.
Nurse statement?
Answer: "you should complete advance directives in the case you can't express your own
wishes"
Rationale:
This statement is correct and encourages the client to consider completing advance directives to
ensure their wishes are known and followed if they are unable to express them due to their
health condition.
113. A nurse is teaching the parents of a preschooler about sleep promotion. Parents report child
reluctance in going to bed "I'm not tired." Statement shows parental understanding?
Answer: "we should read a story together before bed every night"
Rationale:
Reading a story before bed can be a calming and enjoyable bedtime routine that can help a child
relax and prepare for sleep. This statement indicates that the parents understand the importance
of establishing a bedtime routine to promote healthy sleep habits.
114. A nurse is planning care for a group of clients and is working with an LPN and an AP.
What tasks should the RN delegate to the LPN?
Answer: insert a NG tube
Rationale:
Inserting a nasogastric (NG) tube is within the scope of practice for an LPN and can be safely
delegated to them under the supervision of the RN. The RN should ensure that the LPN is
competent and properly trained to perform the task.
115. A nurse in an emergency department is admitting a client who has cardiac tamponade.
Which assessment finding should the nurse expect?
Answer: pulsus paradoxus
Rationale:
Pulsus paradoxus, a decrease in systolic blood pressure of more than 10 mm Hg during
inspiration, is a classic sign of cardiac tamponade. It occurs due to the increased pressure on the
heart caused by the pericardial effusion, leading to reduced cardiac output during inspiration.
116. A nurse is assessing a client who has delirium. Which manifestation should the nurse
expect?
Answer: rapid speech
Rationale:
Rapid speech is a common manifestation of delirium, which is characterized by a rapid onset of
confusion, disorientation, and changes in cognition. Clients with delirium may exhibit rapid and
incoherent speech patterns.
117. A nurse working in a long-term care facility is assessing an adult client. Which of the
following findings places the client at risk for developing a pressure injury?
Answer: recent weight loss
Rationale:
Recent weight loss can indicate poor nutritional status, which is a risk factor for developing
pressure injuries. Adequate nutrition is essential for maintaining skin integrity and preventing
pressure injuries.
118. A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the
bedside commode, which action should the nurse take first?
Answer: assess for functional limitations
Rationale:
Before transferring a client who had a stroke to the bedside commode, the nurse should assess
the client's functional limitations, including their ability to bear weight, balance, and
coordination. This assessment helps ensure a safe transfer and reduces the risk of falls.
119. A community health nurse is reviewing the medical records of four newly diagnosed
clients. The nurse should identify which of the following clients as having a nationally
notifiable infectious condition?
Answer: An adolescent with foodborne botulism
Rationale:
Foodborne botulism is a nationally notifiable infectious condition, meaning that healthcare
providers are required to report cases to public health authorities for surveillance and control
measures. This helps track the spread of the disease and prevent outbreaks.
120. A nurse performing trach care for a client post-op following a laryngectomy. Which of the
following actions should the nurse take when suctioning the client's airway?
Answer: apply suction for 10 seconds
Rationale:
When suctioning a client's airway, the nurse should apply suction for no more than 10 seconds
to prevent hypoxia and damage to the mucous membranes. Suctioning for longer periods can
lead to complications such as tissue trauma and hypoxia.
121. A nurse is caring for a client who has a sexually transmitted infection (STI) that must be
reported to the state health department. Which of the following actions should the nurse take?
Answer: Explain to the client why this information will be shared.
Rationale:
It is important for the nurse to explain to the client the reason for reporting the STI to the state
health department. This helps to maintain transparency and trust in the nurse-client relationship.
Additionally, it allows the client to understand the importance of public health reporting for
disease surveillance and control.
122. A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer.
When discussing the client's prognosis with the parents, the nurse should recognize which of
the following responses by the parents as an example of rationalization?
Answer: "Maybe this is better for our child because we don't want any suffering through
chemotherapy treatments."
Rationale:
Rationalization is a defense mechanism in which individuals justify or explain an unacceptable
behavior or feeling in a rational or logical manner, avoiding the true reasons. In this response,
the parents are rationalizing the situation by finding a positive aspect in their child's terminal
diagnosis, which helps them cope with the distressing reality.
123. A nurse is assessing a client who has obstructive sleep apnea. Which complication should
the nurse monitor?
Answer: Hypertension.
Rationale:
Obstructive sleep apnea (OSA) is associated with an increased risk of hypertension. The
repeated episodes of upper airway obstruction and hypoxemia during sleep can lead to
sympathetic activation, increased systemic vascular resistance, and elevated blood pressure,
increasing the risk of hypertension in individuals with OSA.
124. A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age
child who wears eyeglasses. Which of the following instructions should the nurse give to the
child?
Answer: "You should keep both eyes open during the test."
Rationale:
To obtain accurate visual acuity measurements, the child should keep both eyes open during the
test. Closing one eye can affect depth perception and may lead to inaccurate results.
125. A nurse is preparing to administer a long-acting insulin to a client who has diabetes
mellitus. Which of the following actions should the nurse plan to take first?
Answer: Check the dose with another nurse.
Rationale:
Before administering any medication, especially insulin which requires precise dosing, it is
important for the nurse to check the dose with another nurse to ensure accuracy and prevent
medication errors.
126. A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client
reports using acupressure bands on both wrists. Client statement indicates this therapy is giving
the desired effect?
Answer: "I haven't vomited as much recently."
Rationale:
Acupressure bands are commonly used to help alleviate nausea and vomiting, especially in
pregnancy. The client's report of decreased vomiting suggests that the acupressure bands are
providing the desired effect of reducing nausea and vomiting, which is common in the first
trimester of pregnancy.
127. A nurse is caring for a client who has hypertension and is taking captopril. Delegate task to
AP?
Answer: Obtain vital signs before giving medication.
Rationale:
It is appropriate to delegate the task of obtaining vital signs to an assistive personnel (AP)
before administering medication, as long as the AP is trained and competent to perform this
task. Vital signs are important to assess before giving antihypertensive medication like captopril
to ensure the client's blood pressure is within the desired range for administration.
128. A nurse is caring for a client receiving total parenteral nutrition (TPN) by IV at 60mL/hr.
The nurse discovers the infusion pump isn't working. Which action should the nurse take while
waiting for a new pump?
Answer: Infuse dextrose 10% in water using manual drip tubing at 60mL/hr.
Rationale:
Total parenteral nutrition (TPN) provides essential nutrients, including dextrose, to the client.
While waiting for a new infusion pump, the nurse can manually regulate the infusion rate using
manual drip tubing to ensure the client continues to receive the prescribed rate of TPN.
129. A nurse is performing gastric lavage for a client who has gastrointestinal (GI) bleeding and
a nasogastric (NG) tube in place. Nursing action?
Answer: Use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG
tube.
Rationale:
Gastric lavage is a procedure used to wash out the stomach, typically in cases of GI bleeding.
The nurse should use an appropriate solution such as 0.9% sodium chloride, sterile water, or tap
water for irrigation of the NG tube, as these solutions are safe and effective for this purpose.
130. A nurse is reviewing the medical record of a client who has schizophrenia and is to start
taking clozapine. Which finding is a contraindication for the client to receive clozapine?
Answer: White blood cell (WBC) count 2800/mm³.
Rationale:
Clozapine is an antipsychotic medication that requires regular monitoring of WBC counts due
to the risk of agranulocytosis, a potentially life-threatening side effect. A WBC count of
2800/mm³ is significantly below the normal range and is a contraindication for starting or
continuing clozapine due to the increased risk of agranulocytosis.
131. A nurse is performing an admission assessment on a preschooler who is in the acute phase
of Kawasaki disease. Which finding should the nurse expect?
Answer: Fever unresponsive to antipyretics.
Rationale:
Kawasaki disease is a condition that primarily affects children and involves inflammation of the
blood vessels. One of the hallmark signs of Kawasaki disease is a persistent fever that is
unresponsive to antipyretic medications, such as acetaminophen or ibuprofen. This fever is
often a key diagnostic indicator of the disease.
132. A nurse is caring for a group of clients. Which event requires an incident report?
Answer: Client's IV pump administers inadequate dose of medication.
Rationale:
Any event that compromises the safety or well-being of a patient should be documented in an
incident report. An IV pump administering an inadequate dose of medication is a critical
incident that could potentially harm the client and should be reported to ensure appropriate
follow-up and investigation.
133. A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is
becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently
using profanity and sexual references. Which of the following actions should the nurse take
first?
Answer: Move the client to a private place away from others.
Rationale:
The client's behavior suggests they may be experiencing a manic episode, which is common in
bipolar disorder. It is important to first ensure the client's privacy and safety by moving them to
a private area away from others. This can help prevent potential escalation of behavior and
protect the client's dignity.
134. A nurse is assessing a preschooler who has cystic fibrosis (CF) and has been receiving
oxygen therapy for the past 36 hours. Which finding shows oxygen toxicity?
Answer: Substernal pain.
Rationale:
Oxygen toxicity is a potential complication of prolonged oxygen therapy, especially at high
concentrations. Substernal pain is a symptom of oxygen toxicity and should be monitored for in
patients receiving oxygen therapy for an extended period. Other signs include dyspnea,
restlessness, and respiratory distress.
135. A charge nurse is watching a newly licensed nurse perform a physical assessment. Which
action should the charge nurse intervene?
Answer: The newly licensed nurse writes detailed notes while performing the head-to-toe
assessment.
Rationale:
While documentation is an essential part of the assessment process, the priority during a
physical assessment is to focus on the examination itself and interact with the patient. Writing
detailed notes during the assessment can distract from the thoroughness of the examination and
the nurse's ability to observe and interact with the patient.
136. A nurse is providing discharge teaching to a client who has colorectal cancer and a new
colostomy. "I'm worried about being discharged because I live alone. My insurance doesn't
cover ostomy supplies." Nursing action?
Answer: Refer to community-based social worker.
Rationale:
Referring the client to a community-based social worker can help address their concerns about
living alone and the lack of insurance coverage for ostomy supplies. Social workers can assist
in finding resources for financial assistance, support services, and community programs that
can help the client manage their ostomy care and adjust to life with a colostomy.
137. A nurse is administering cyclophosphamide to a school-age child with neuroblastoma.
Nursing action to administer medication?
Answer: Maintain hydration with liberal fluid intake.
Rationale:
Cyclophosphamide is a chemotherapy medication that can cause bladder irritation and increase
the risk of hemorrhagic cystitis. Maintaining hydration with liberal fluid intake can help prevent
bladder irritation and reduce the risk of cystitis associated with cyclophosphamide therapy.
138. A nurse is teaching home wound care to the family of a child who has a large wound.
Which intervention should the nurse recommend?
Answer: Double bag soiled dressings in plastic bags for disposal.
Rationale:
Proper disposal of soiled dressings is important to prevent the spread of infection. Double
bagging soiled dressings in plastic bags helps contain any potential pathogens and reduces the
risk of exposure during disposal.
139. A client who is 24 hours post-op following abdominal surgery refuses to ambulate. First
nursing action?
Answer: Ask the client to rate their pain level.
Rationale:
Pain is a common reason why patients may refuse to ambulate after surgery. Assessing the
client's pain level is the first step in addressing their refusal to ambulate. Once pain is managed,
the client may be more willing to participate in ambulation.
140. A nurse is providing colostomy care for a client using a two-piece pouch system. Which
action should the nurse take?
Answer: Place the skin barrier over the stoma and hold it for 30 seconds.
Rationale:
When applying a two-piece pouch system for a colostomy, it is important to ensure a proper
seal between the skin barrier and the stoma. Placing the skin barrier over the stoma and holding
it for 30 seconds helps ensure a secure seal, which is essential for preventing leakage and skin
irritation.
141. A nurse is preparing to administer 2 units of fresh frozen plasma (FFP) to a client. Which
action should the nurse plan to take?
Answer: Enter the plasma product number into the client's medical record.
Rationale:
It is important to document the administration of blood products, including FFP, by entering the
product number into the client's medical record. This helps ensure traceability and
accountability in the event of an adverse reaction or transfusion-related complication.
142. A nurse is assessing a client who is experiencing autonomic dysreflexia. Expected nursing
findings?
Answer: • Facial flushing: Flushing occurs from the point of the lesion upward.
• Nasal congestion.
• Headache.
Rationale:
Autonomic dysreflexia is a potentially life-threatening condition characterized by a sudden
onset of excessively high blood pressure. It is often triggered by a noxious stimulus below the
level of a spinal cord injury. Common signs and symptoms include facial flushing, nasal
congestion, and headache, among others.
143. A nurse is teaching a client who has opioid use disorder about methadone. Information to
include in teaching?
Answer: Sedation is a common adverse effect of this medication.
Rationale:
Methadone is a medication used to treat opioid use disorder. It is important for clients to be
aware that sedation is a common adverse effect of methadone, which can affect their ability to
perform activities that require alertness, such as driving or operating machinery.
144. A nurse is providing teaching to an adolescent following insertion of a tunneled central
venous catheter. Which of the following information should the nurse include in the teaching?
Answer: "You should keep the catheter clamped when not in use."
Rationale:
Keeping the catheter clamped when not in use helps prevent air from entering the catheter and
reduces the risk of infection. It is important for the adolescent and their family to understand
this aspect of catheter care to maintain its integrity and function.
145. A nurse is reviewing the arterial blood gas (ABG) results of a client with chronic
obstructive pulmonary disease (COPD). The results include pH 7.3, PaO2 56 mm Hg, PaCO2
54 mm Hg, HCO3 26 mEq/L, SaO2 87%. Correct interpretation?
Answer: Uncompensated respiratory acidosis.
Rationale:
In this ABG result, the pH is below the normal range (7.35-7.45), indicating acidosis. The
PaCO2 is elevated (normal range 35-45 mm Hg), indicating respiratory acidosis. The HCO3 is
within normal range, indicating that compensation has not occurred. Therefore, the
interpretation is uncompensated respiratory acidosis.
146. A nurse is assessing a client who has Raynaud's disease. Which finding should the nurse
expect?
Answer: Blanching of the fingers and toes.
Rationale:
Raynaud's disease is a condition characterized by vasospasm of the arteries, leading to reduced
blood flow to the fingers and toes. During an episode, the affected areas may become pale or
blanch due to the lack of blood flow.
147. A nurse is caring for a client who has a terminal illness and requests no life-saving
measures if a cardiac arrest occurs. Nurse should make what statement?
Answer: "I will provide you with information about medical treatment to include in your living
will."
Rationale:
This response acknowledges the client's request and offers support in documenting their wishes
regarding end-of-life care. Providing information about creating or updating a living will allows
the client to specify their preferences for medical treatment in advance.
148. A nurse is teaching the parents of a toddler about snacks. Which of the following foods
should the nurse recommend?
Answer: Diced steamed carrots.
Rationale:
Diced steamed carrots are a nutritious and age-appropriate snack for a toddler. They are easy to
chew and digest, and they provide vitamins and minerals that are important for growth and
development.
149. A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. What
should the nurse include in the plan of care?
Answer: Encourage the parents to bring toys from home.
Rationale:
Allowing the toddler to have familiar toys from home can help provide comfort and reduce
anxiety during the hospital stay. Familiar items can help create a sense of security in an
unfamiliar environment.
150. A nurse receives a request from a client to review the information in his medical record.
Which response should the nurse give?
Answer: "There's a protocol for reviewing your medical record, and I can initiate the process."
Rationale:
Patient confidentiality and privacy are critical aspects of healthcare. Informing the client that
there is a protocol for reviewing medical records helps ensure that the process is conducted
appropriately and in accordance with privacy regulations.
