RN VATI COMPREHENSIVE PREDICTOR 2023 FORM A B C AND D
REAL EXAM QUESTIONS AND CORRECT ANSWERS/ VATI RN
COMPREHENSIVE PREDICTOR 2023
A nurse on a mental health unit is admitting a client who has posttraumatic stress disorder.
Which of the following findings should the nurse expect?
a. Talks continuously about the event
b. Preoccupied with having a serious illness
c. Has difficulty concentrating on a task
d. Experiences frequent grandiose thoughts
Answer: c. Has difficulty concentrating on a task
A nurse is administering a scheduled medication to a client. The client reports that the
medication appears different than what they take home. Which of the following responses should
the nurse make?
a. "Did the doctor discuss with you that there was a change in this medication? "
b. "Do you know why this medication is being prescribed for you?"
c. "I will call the pharmacist now to check on this medication "
d. "I recommend that you take this medication as prescribed"
Answer: c. "I will call the pharmacist now to check on this medication "
A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should
Identify that which the following findings indicates altered tissue perfusion of the affected
extremity?
a. Purulent drainage at the site
b. Faint pedal pulse of left leg
c. Pain with movement of the left great toe
d. Warm skin temperature distal to pin site
Answer: b. Faint pedal pulse of left leg
A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the
following statements by the client indicates an understanding of the teaching?
a. "I will decrease my daily protein intake to 15 grams per day"
b. "I will use ibuprofen as needed to control abdominal pain"
c. "I will take sucralfate with meals three times per"
d. "I will avoid food and beverages that contain caffeine"
Answer: d. "I will avoid food and beverages that contain caffeine"
A nurse is caring for a client who is in the advanced stage of amyotrophic lateral sclerosis (ALS).
Which of the following referrals is the nurse's priority?
a. Occupational therapist
b. Social worker
c. Speech-language pathologist
d. Psychologist
Answer: c. Speech-language pathologist
A nurse administers digoxin 0.125 mg PO to an adult client. For which of the following findings
should the nurse notify the provider?
a. Constipation for 2 days
b. Potassium level 4.2 mEq/L
c. Digoxin level 1 ng/mL - normal levels 0.5- 2.0
d. Apical pulse 58/min
Answer: d. Apical pulse 58/min
A nurse is updating the plan of care for a client who has an exacerbation of psoriasis. Which of
the following interventions should the nurse include in the plan?
a. Discontinue ultraviolet light therapy if lesions become itchy
b. Cover lesions with an occlusive dressing after applying a corticosteroid.
c. Scrub external lesions with a pumice stone
d. Instruct the client to add rubbing alcohol to bath water
Answer: • Cover lesions with an occlusive dressing after applying a corticosteroid.
A nurse is verifying a record of informed consent for a client who scheduled for surgery. Which
of the following actions should the nurse take?
a. Provide Information on the informed consent form about the benefits of the surgery
b. Confirm the client's signature is authentic
c. Inform the client about the condition that requires treatment
d. Explain the procedure to the client before verifying informed consent.
Answer: b. Confirm the client's signature is authentic
A nurse is caring for a client who requests the creation of a living will. Which of the following
actions should the nurse take?
a. Schedule a meeting between the hospital ethics committee and client
b. Determine the client's preferences about postmortem care
c. Evaluate the client's understanding of life sustaining measures
d. Request a conference with the client's family
Answer: c. Evaluate the client's understanding of life sustaining measures
A nurse in an emergency department caring for a toddler who has burns following a house fire.
Which of the following actions should the nurse take first?
a. Administer antibiotics prophylactically to prevent sepsis.
b. Determine the location and depth of the burns.
c. Calculate fluid replacement based on vital signs and urinary output.
d. Check the mouth for soot and smoky breath.
Answer: d. Check the mouth for soot and smoky breath.
A nurse is caring for an older adult client who has prescriptions for multiple medications. Which
of the following factors should the nurse identify as an age-related change that increases the risk
for adverse effects from medications?
a. Prolonged medication half-life
b. Increased medication elimination
c. Decreased medication sensitivity
d. Rapid gastric emptying
Answer: a. Prolonged medication half-life
A nurse is caring for a client who is in a seclusion room following violent behavior. The client
continues to display aggressive behavior. Which of the following actions should the nurse take?
a. Express sympathy for the client's situation.
b. Confront the client about this behavior.
c. Speak assertively to the client.
d. Stand within 30 cm (1 fu of the client when speaking with them.
Answer: c. Speak assertively to the client.
A nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client's history is a contraindication to
the use of combination oral contraceptives?
a. Hypocalcemia
b. Diverticulosis
c. Hyperthyroidism
d. Thrombophlebitis
Answer: d. Thrombophlebitis
A nurse is creating a plan of care for a female client who has recurrent urinary tract infections.
Which of the following interventions should the nurse include in the plan?
a. Wear loose-fitting underwear.
b. Take a bubble bath after intercourse
c. Drink four 240 mL (8 oz) glasses of water each day
d. Void every to 6 hr during the day. NO
Answer: a. Wear loose-fitting underwear.
A nurse is consulting a pharmacological reference about medication compatibility prior to
administering warfarin to a client. Which of the following medications should the nurse identify
as being incompatible with warfarin?
a. Magnesium hydroxide
b. Naproxen NSAID’S
c. Lisinopril
d. Propranolol
Answer: b. Naproxen NSAID’S
A nurse in an emergency department is caring for a client following a motor-vehicle crash. The
client's Glasgow coma scale rating is 15. Which of the following findings should the nurse
expect?
a. The withdraws from pain.
b. The client is oriented times three.
c. The dent is unable to obey commands non.
d. The client opens eyes to sound.
Answer: b. The client is oriented times three.
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding.
The nurse speaks a different language than the client. The client's partner and 10- year-old child
are accompanying her. Which of the following actions should the nurse take to gather the client’s
admission data?
a. Request a female interpreter through the facility
b. Ask nursing student who speaks the same language as the client to translate
c. Allow the client’s partner to translate
d. Have the client’s child translate
Answer: a. Request a female interpreter through the facility
A nurse is planning care for a client who is recovering from an acute myocardial infarction that
occurred 3 days ago. Which of the following interventions should the nurse Include?
a. Perform an ECG every 12hr.
b. Place the client in a supine position while resting.
c. Draw a troponin level every 4hr.
d. Obtain a cardiac rehabilitation consultation.
Answer: d. Obtain a cardiac rehabilitation consultation.
A nurse in the infectious disease division of the local health department is caring for a client.
Which of the following infections should the nurse identify should be reported to the health
department?
a. Clostridium difficile
b. Human papilloma virus
c. Herpes simplex virus
d. Chlamydia trachomatis
Answer: d. Chlamydia trachomatis
A nurse is administering an intradermal injection for allergy testing to a client. Into which of the
following sites should the nurse inject the medication? (You will find hot spots to select in the
artwork below. Select only the hot spot that corresponds to your answer
A nurse is caring for a client who has compartment syndrome following the application of a cast
to the leg. Which of the following actions should the nurse take?
a. Apply ice to the extremity
b. Check the client’s pedal pulses.
c. Administer a dose of antiemetic medication
d. Position the client’s leg above the level of the heart
Answer: b. Check the client’s pedal pulses.
A nurse is caring for a client who speaks a language different from the nurse. Which of the
following actions should the nurse take?
a. Review the facility policy about the use of an interpreter.
b. Request a family member or friend to interpret information for the client.
c. Direct attention toward the interpreter when speaking to the client.
d. Request an interpreter of a different sex from the client.
Answer: a. Review the facility policy about the use of an interpreter.
A nurse is providing discharge instructions about newborn safety to a client who is 2 days
postpartum. Which of the following instructions should the nurse include?
a. Change smoke detector batteries every other year.
b. Use a car seat when traveling by airplane.
c. Place a plastic waterproof sheet over the crib bedding.
d. Lay the baby on his stomach to nap during the daytime.
Answer: b. Use a car seat when traveling by airplane.
A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a
staff member who exhibits unprofessional behavior. Identify the sequence of
steps the nurse manager should plan to take in response to the staff members conduct (Move the
steps into the box on the right placing them order of performance. Use all the steps)
Answer: 1. Verbal Warning
2. Written Warning
3. Suspension
4. Termination
A nurse is assessing a client who has a prescription for hydrocodone PRN. Which of the
following adverse effects should the nurse identity as priority for withholding this medication
and notifying the provider?
a. Hypotension
b. Nausea
c. Constipation - normal side effect
d. Urinary retention
Answer: a. Hypotension
A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which the
following instructions should the nurse give the client?
a. "Take your diuretic medication with your evening meal"
b. "Decrease your intake of cranberry juice"
c. "Plan to urinate every 3 hours while you are awake"
d. "Limit your fluid intake to 500 per day"
Answer: c. "Plan to urinate every 3 hours while you are awake"
A nurse is teaching participants at a community center about advance directives. Which of the
following information should the nurse include in the teaching?
a. A client must create a do not resuscitate order when completing advance directives.
b. A health care surrogate makes health care decision when the client is no longer able.
c. Advance directives cannot be changed once implemented.
d. Assigning a health care surrogate requires legal consultation.
Answer: b. A health care surrogate makes health care decision when the client is no longer able.
A nurse is caring for a client who has bipolar disorder. Which of the following behaviors should
the nurse identify indicating the client is experiencing mania?
a. The client speaks using word salad.
b. The client speaks using echopraxia.
c. The client is socially withdrawn.
d. The client is easily distracted by external stimuli.
Answer: d. The client is easily distracted by external stimuli.
A nurse is caring for a client who has colon cancer and is terminally ill. The client states, "I can't
believe I'm going to die." Which of the following statements should the nurse make?
a. "It might be comforting to pray for spiritual assistance."
b. "Your doctor will make sure you won't be in much pain "
c. "Tell me what is important to you right now."
d. "I felt the same way you're feeling when my mother died"
A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of
the following statements by the client indicates an understanding of the teaching?
a. "I will avoid picking up my baby too often to keep from spoiling him will"
b. "I will place a ticking clock nearby to soothe my baby throughout the day"
c. "I will hang a pastel-colored mobile 24 inches above my baby's crib. "
d. "I can use a firm pillow to prop up the bottle when feeding my baby. "
Answer: b. "I will place a ticking clock nearby to soothe my baby throughout the day"
A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should identify that
which of the following findings might indicate an allergic reaction to this medication?
a. Weight gain
b. Blurred vision
c. Difficulty swallowing
d. High blood pressure
Answer: c. Difficulty swallowing
A nurse is creating a plan of care for a newly admitted client who has obsessive- compulsive
disorder. Which of the following interventions should the nurse include?
a. Discourage the client from exploring irrational fears.
b. Provide negative reinforcement for ritualistic behaviors.
c. Allow the client enough time to perform rituals.
d. Give the client autonomy in scheduling activities.
Answer: c. Allow the client enough time to perform rituals.
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis.
Which of the following actions should the nurse include in the plan of care?
a. Give cromolyn nebulized solution every 8 hr.
b. Offer small amounts of clear liquids 6 hr following surgery.
c. Apply a warm compress to the operative site once daily.
d. Administer analgesics on a scheduled basis for the first 24 hr.
Answer: d. Administer analgesics on a scheduled basis for the first 24 hr.
A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol to deal
with stress. Which of the following actions should the nurse take to assist the client in
maintaining self-control of the behavior?
a. Give positive feedback to the client for using adaptive strategies.
b. Discuss strategies with the client to reduce alcohol consumption gradually.
c. Provide the client with periods of alone time for reflection in their behavior.
d. Have the client’s partner assume responsibility for monitoring the client’s alcohol intake.
Answer: a. Give positive feedback to the client for using adaptive strategies.
A nurse is providing dietary teaching to a client who has hyperlipidemia. The nurse should
include in the teaching that which of the following oils contains the lowest amount of saturated
fats?
a. Canola oil
b. Olive oil
c. Palm oil
d. Coconut
Answer: a. Canola oil
A nurse is teaching a childbirth education class and is discussing sexual intercourse during
pregnancy. Which of the following statements should the nurse make?
a. "Frequent intercourse increases the risk for miscarriage in early pregnancy"
b. "You should limit the frequency of intercourse after 34 weeks of pregnancy"
c. "Your sexual desire might increase during the first trimester of pregnancy"
d. "The female superior position can be used during the third trimester of pregnancy"
Answer: d. "The female superior position can be used during the third trimester of pregnancy"
A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the
following prescriptions should the nurse expect the provider to prescribe?
a. Atorvastatin
b. Enoxaparin
c. Interferon beta-1a
d. Amoxicillin
Answer: c. Interferon beta-1a
A nurse caring for a client who is labor and receiving oxytocin. Which of the following findings
indicates that the nurse should increase the rate of infusion?
a. Urine output of 20mL / hr
b. Montevideo units consistently 300 mmHg
c. Contractions every 5 min that last 30 seconds
d. FHR pattern with absent variability
Answer: c. Contractions every 5 min that last 30 seconds
A nurse is providing dietary teaching to a client who had an exacerbation of COPD. Which of the
following information should the nurse include in the teaching?
a. "While eating, you should drink liquids frequently. "
b. "During meals, you should eat foods with a high-calorie content first."
c. "You should eat hot foods to reduce your sense of fullness during a meal"
d. "Lunch should be your largest meal of the day"
Answer: b. "During meals, you should eat foods with a high-calorie content first."
A nurse is providing teaching about the administration of gastrostomy tube feeding to the parents
of a school age child. Which of the following Instructions should the nurse include?
a. Administer the feeding over 30 min
b. Place the child in a supine position after the feeding
c. Warm the formula in the microwave prior to administration
d. Change the feeding bag and tubing every 3 days
Answer: a. Administer the feeding over 30 min
A nurse in a community clinic is caring for a client who requests assistance with smoking
cessation. The nurse should expect a prescription for which of the following medications?
a. Chlordiazepoxide
b. Clonidine
c. Bupropion
d. Naltrexone
Answer: c. Bupropion
A newly licensed nurse is unsure if an assigned task is within their scope of practice. Which of
the following resources should the nurse consult?
a. Written prescription the provider
b. Verbal direction from the nurse manager
c. State Nurse Practice
d. Institutional policies and procedures
Answer: c. State Nurse Practice
A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of
following statements by the parent indicates an understanding of the teaching?
a. "I will position my baby at a 45- degree angle in the car seat."
b. "I will place my baby in a forward-facing car seat in my back seat"
c. "I can place my baby in the front seat with the airbag turned off"
d. "I can turn baby's car seat around when she weighs 15 pounds"
Answer: a. "I will position my baby at a 45- degree angle in the car seat."
A nurse is assessing a client who has heart failure and is prescribed a 2.000mL / 24 hr fluid
restriction. Which of the following findings should the nurse report to the provider?
a. Watery stools of 400 mL in 8 hr
b. Urinary output of 420 mL in 8 hr
c. Oral intake of 300 mL in 8 hr
d. Intravenous intake of 240 mL in 8 hr
Answer: b. Urinary output of 420 mL in 8 hr
420 × 3 = 1260 – 2,000 retaining 740 ml × day
A nurse is caring for a client who is postoperative immediately following a cardiac
catheterization with a right femoral approach Which the following actions should the nurse take?
a. Elevate the head of the client’s bed to 450
b. Instruct the client to flex the right every 30 min
c. Assess the client's peripheral pulses every 15 min
d. Change the client's dressing 4 hr following the procedure
Answer: c. Assess the client's peripheral pulses every 15 min
A nurse is reviewing the cardiac rhythm of a client who is on continuous ECG monitoring.
Which of the following findings should the nurse identify as an indication of ventricular
tachycardia?
a. QRS complexes wider than 0.15 seconds
b. P-wave present with every QRS complex
c. PR interval of 0.24 seconds
d. Sawtooth shaped P waves
Answer: a. QRS complexes wider than 0.15 seconds
A nurse is providing teaching to a client who has multiple sclerosis. Which of the following
statements should the nurse include in the teaching?
a. "Establish a voiding schedule by urinating once every 4 hours"
b. "Limit your daily intake of high-fiber foods"
c. "Avoid exercises that increase your body temperature"
d. "Wear an eye patch over one eye for an entire day before switching"
Answer: a. "Establish a voiding schedule by urinating once every 4 hours"
A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client.
Which of the following statements should the nurse include the teaching?
a. "You can adjust the amount of pain medication you receive by pushing on the keypad."
b. "The PCA will deliver a double dose of medication when you push the button twice."
c. "Continuous PCA infusion is designed to allow fluctuating plasma medication levels."
d. "You should push the button before physical activity to allow maximum pain control."
Answer: d. "You should push the button before physical activity to allow maximum pain
control."
A nurse realizes that the wrong medication has been administered to a client. Which of the
following actions should the nurse take first?
a. Fill out an incident report
b. Report the incident to the nurse manager
c. Measure the client's vital signs
d. Notify the provider
Answer: c. Measure the client's vital signs
A nurse is reviewing the facility's safety protocols concerning newborn abduction with the parent
of a newborn. Which of the following client statements indicates an understanding of the
teaching?
a. Staff will apply identification bands to my baby after her first bath.
b. "I will not publish a public announcement about my baby's birth."
c. I can remove my baby's Identification band as long as she is in my room.
d. "I can leave my baby in my room while I walk in the hallway
Answer: b. "I will not publish a public announcement about my baby's birth."
A nurse is assessing a client who immediately postoperative following a subtotal thyroidectomy.
The nurse observes tetany. Which of the following medications should the nurse expect to
administer?
a. Potassium chloride
b. Sodium phosphate
c. Sodium bicarbonate
d. Calcium gluconate
Answer: d. Calcium gluconate
A nurse is providing teaching to a client who is to begin external radiation therapy for cancer.
Which of the following Information should the nurse include?
a. You might experience altered taste sensations
b. Wash your skin thoroughly with a washcloth after each treatment
c. Wear a binder over the radiation.
d. Use rubbing alcohol to remove the ink markings.
Answer: a. You might experience altered taste sensations
A nurse is caring for a client who is 12 hr postoperative following aorta femoral bypass surgery.
Which of the following findings should the nurse expect in the affected extremity?
a. Cool extremities
b. Pedal pulse of 2+
c. Throbbing pain
d. Capillary of 4 seconds
Answer: b. Pedal pulse of 2+
A nurse is preparing to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
a. Ensure that the client’s identification band matches the number on the blood unit.
b. Confirm the provider's prescription matches number on the blood component.
c. Match the client’s blood type with the type and cross match specimen.
d. Ask the client to state his blood type and the date of the blood donation.
Answer: a. Ensure that the client’s identification band matches the number on the blood unit.
A nurse is teaching a community health fair about electrical fire prevention. Which of the
following information should the nurse include the teaching?
a. Cover extension cords with a rug.
b. Remove the plug from the socket by pulling the cord.
c. Check for a tingling sensation around the cord to ensure the electricity working.
d. Use three-pronged grounded plugs.
Answer: d. Use three-pronged grounded plugs.
A nurse is caring for a school-age child who has sickle cell anemia and is in vasoocclusive crisis.
Which of the following actions should the nurse take?
a. Promote active range of motion exercise.
b. Prepare for a transfusion of platelets.
c. Increase oral fluid intake
d. Apply cold compresses to the affected areas.
Answer: c. Increase oral fluid intake
A nurse is caring for a client who has a history of depression and is experiencing a situational
crisis. Which of the following actions should the nurse take first?
a. Teach the client relaxation techniques.
b. Notify the client’s support person.
c. Confirm the client’s perception of the event.
d. Help the client identify personal strengths.
Answer: c. Confirm the client’s perception of the event.
A nurse is caring for a client who has gestational hypertension and is experiencing toxic effects
due to magnesium sulfate therapy. The nurse should anticipate administering which of the
following medications?
a. Calcium gluconate
b. Magnesium citrate
c. Potassium chloride
d. Sodium bicarbonate
Answer: a. Calcium gluconate
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the
following conditions should the nurse recognize as a contraindication to the use of oxytocin?
a. Shoulder presentation
b. Postterm with oligohydramnios
c. Chorioamnionitis
d. Diabetes mellitus
Answer: a. Shoulder presentation
A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer.
Which of the following actions should the nurse take?
a. Limit the client's visitors to 30 min per day
b. Discard the client's linens in a double bag.
c. Cleanse equipment before removal from the client's room.
d. Discard the radioactive source in a biohazard bag.
Answer: a. Limit the client's visitors to 30 min per day
A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes
after beginning the transfusion, the client becomes febrile with chills. After stopping the
transfusion, which of the following actions should the nurse take?
a. Place the blood bag in a biohazard bag before discarding.
b. Document the reaction in the medical record.
c. Administer epinephrine subcutaneously.
d. Infuse 500 mL lactated Ringer's IV. only Normal saline is use with transfusions
Answer: b. Document the reaction in the medical record.
A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement.
Which of the following recommendations should the nurse include?
a. Apply warm compresses on the breasts before feedings.
b. Allow the infant to nurse on one breast per feeding,
c. Take aspirin to reduce pain and swelling.
d. Wear a tight-fitting underwire bra.
Answer: a. Apply warm compresses on the breasts before feedings.
A nurse is providing teaching to the parent of a child who has a recently inserted central venous
access device. Which of the following statements by the child's family member indicates an
understanding of the teaching?
a. "Will replace the dressing in 24 hours with an occlusive dressing."
b. "If my child develops an elevated temperature. I will contact you."
c. "I can expect my child to resume playing sports within 48 hours."
d. "I should encourage a daily shower to keep the insertion site clean."
Answer: b. "If my child develops an elevated temperature. I will contact you."
A nurse is caring for a client who tells the nurse that he feels he is being discharged from the
facility too soon. Which of the following state by the nurse demonstrates client advocacy?
a. "I know you will be able to recover faster at home."
b. "I will contact your insurance company to see if they will pay for you to be here longer."
c. "Your provider understands your illness and is acting according to your best interests."
d. "I will tell the provider about your concerns."
Answer: d. "I will tell the provider about your concerns."
A nurse is planning care for a child who has neutropenia due to leukemia. Which of the
following interventions should the nurse include in the plan of care?
a. Monitor the child for indications of active bleeding.
b. Prepare the child for a platelet transfusion.
c. Screen the child's visitors for active infections.
d. Initiate a low-protein diet for the child.
Answer: c. Screen the child's visitors for active infections.
A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy.
Which of the following findings is the priority for the nurse to report?
a. Chest pain
b. Cool, moist skin
c. Incisional pain
d. Muscle spasms
Answer: a. Chest pain
A nurse is providing teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
a. "Rise slowly when getting out of bed."
b. "Taking furosemide can cause you to be overhydrated."
c. "Eat foods that are high in sodium."
d. "Taking furosemide can cause your potassium levels to be high."
Answer: a. "Rise slowly when getting out of bed."
A nurse is teaching a client who had a left below-the-knee amputation 3 days ago. The nurse
should identify that which of the following statements by the client indicates an understanding of
the teaching?
a. "I will change the wrapping on my left leg once a day at home."
b. "I can elevate my left leg on a pillow while lying in bed."
c. "I should avoid moving the joints in my left leg."
d. "I might still experience the feeling of numbness and tingling in my left foot."
Answer: d. "I might still experience the feeling of numbness and tingling in my left foot."
A nurse is helping to prepare a client in the operating room prior to a surgical procedure. Which
of the following actions should the nurse take?
a. Minimize conversation with the client to reduce anxiety.
b. Provide padding to the pressure point areas when positioning the client.
c. Leave the client's arms and legs uncovered until after the induction of anesthesia.
d. Remove the client's eyeglasses upon arrival to the operating room.
Answer: b. Provide padding to the pressure point areas when positioning the client.
A nurse is preparing to measure the temperature of an infant. Which of the following actions
should the nurse take?
a. Place the tip of the thermometer under the center of the infant's axilla.
b. Pull the pinna of the infant's ear forward before inserting the probe.
c. Insert the oral thermometer in front of the infant's tongue
d. Insert the probe 3.8 cm (1.5 in) into the infant's rectum.
Answer: a. Place the tip of the thermometer under the center of the infant's axilla.
A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the
following client statements should the nurse report to the provider as an indication of major
depressive disorder?
a. "I am unable to feel any joy since my child died."
b. "I am angry that my child died."
c. "know that I will be reunited with my child someday."
d. "I feel guilty because my child died."
Answer: a. "I am unable to feel any joy since my child died."
A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar
disorder. The partner states. "I don't know what to do. Everything has been happening so
quickly." Which of the following responses by the nurse is therapeutic?
a. "You did the right thing by bringing your partner in for treatment."
b. "You should make sure your partner takes the prescribed medication."
c. "Can you talk about what was happening with your partner at home?"
d. "Why do you think your partner's symptoms are progressing so quickly"
Answer: c. "Can you talk about what was happening with your partner at home?"
A nurse in a clinic is assessing a 6-month-old Infant. Which of the following findings should the
nurse report to the provider?
a. Closed anterior fontanel
b. Pulse 140/min
c. Abdominal breathing
d. Respiratory rate 26/min
Answer: a. Closed anterior fontanel - posterior -closes around 2 months, anterior at 12-18
months
A nurse is caring for a client who is recovering from an amputation of her right arm below the
elbow. Which of the following information should the nurse report to the occupational therapist?
a. The client lives in a two-story home.
b. The client's parent is in a skilled nursing facility.
c. The client is allergic to penicillin
d. The client has two small children at home.
Answer: d. The client has two small children at home.
A nurse caring for a client who received a large amount of heparin IV in error. Which of the
following laboratory values should the nurse obtain?
a. Ferritin level
b. Albumin level
c. INR
d. aPTT
Answer: d. aPTT
A nurse is performing an initial assessment of a newborn. Which of the following actions should
the nurse take to prevent any heat loss through conduction?
a. Evaluate respirations by observing the newborn's uncovered chest for 1 min.
b. Cover the scale with a warmed blanket before weighing the baby.
c. Place the newborn's crib away from of an air vent to perform the assessment.
d. Perform the assessment immediately after birth before removing amniotic fluid.
Answer: b. Cover the scale with a warmed blanket before weighing the baby.
A client's partner tells a staff nurse that he overheard laboratory staff discussing the results of the
client's biopsy report while on the elevator Which of the following actions should the nurse take?
a. Review confidentiality policies with laboratory employees.
b. Report the information to the charge nurse.
c. Contact the laboratory manager regarding the situation
d. Notify the facility's legal department
Answer: b. Report the information to the charge nurse.
A nurse is teaching a client who has chronic low back pain about the use of alternative therapy to
manage pain. Which of the following statements by the client indicates an understanding of the
use of distraction?
a. "I should apply my heating blanket to my back to reduce tension."
b. "I will have electrodes inserted in my skin to treat the pain."
c. "I should jog every morning to improve my circulation."
d. "I will watch my favorite old movies when I want to reduce stress."
Answer: d. "I will watch my favorite old movies when I want to reduce stress."
A nurse is teaching a client who has systemic lupus erythematosus (SLE). Which of the
following statements by the client indicates an understanding of the teaching?
a. "I will not be able to go for my daily walk."
b. "I will cleanse my skin using a mild soap."
c. "I should apply powder to my skin after showering."
d. "I should check my skin once weekly for rashes." - need to be done daily
Answer: b. "I will cleanse my skin using a mild soap."
A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of the
following statements by a client indicates an understanding of the teaching?
a. "I will consume 48 ounces of carbonated beverages daily prior to the surgery."
b. "I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after
surgery."
c. "I will need to lose 25 percent of my excess body weight prior to surgery.
d. "I should wait 30 minutes after eating solid foods to drink beverages following surgery."
Answer: d. "I should wait 30 minutes after eating solid foods to drink beverages following
surgery."
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse
instruct the client to increase in her diet to prevent a neural tube defect?
a. Iron
b. Calcium
c. Folate
d. Zinc
Answer: c. Folate
A nurse is caring for a client who is near the end of life and is on complete bed rest.
The client states that he needs to have a bowel movement. and the nurse offers a bed pan. The
client states. "I've always used the bathroom." Which of the following responses should the nurse
make?
a. "I will have the physical therapist ambulate you to the bathroom."
b. "You have to use the bed pan for your own safety."
c. "Make sure to use nearby furniture to support yourself when walking to the bathroom"
d. "Tell me what concerns you have about using a bed pan."
Answer: d. "Tell me what concerns you have about using a bed pan."
A nurse is reviewing laboratory data from a client who has chronic kidney disease. Which
of the following findings should the nurse expect?
a. Increased calcium
b. Increased bicarbonate
c. Increased creatinine
d. Increased hemoglobin
Answer: c. Increased creatinine
A nurse is obtaining a urine specimen from a client who has had an indwelling urinary catheter
for three days. Which of the following actions should the nurse take after collecting the
specimen?
a. Place the specimen in a biohazard bag for transport.
b. Wipe the outside of the specimen container with an alcohol swab.
c. Obtain the specimen from the drainage collection bag.
d. Remove gloves after labeling the specimen
Answer: b. Wipe the outside of the specimen container with an alcohol swab.
A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the
following is an activity a nurse should engage in to assist in disaster preparedness?
a. Vaccinate susceptible children and adults against smallpox.
b. Assess types, levels, and scopes of disasters.
c. Make quarantine preparations for those exposed to anthrax,
d. Participate in community drills and mock events.
Answer: d. Participate in community drills and mock events.
A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse we use sterile gloves?
a. Performing tracheostomy care
b. Administering total parenteral nutrition through a central venous access device
c. Inserting an NG tube
d. Initiating IV access
Answer: a. Performing tracheostomy care
A charge nurse is recommending postpartum clients for discharge following a local disaster.
Which of the following clients should the nurse recommend for discharge first?
a. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration
b. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
c. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
d. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
Answer: a. A client who delivered precipitously 36 hr ago and has a second-degree perineal
laceration
A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the
following findings should the nurse report to the provider?
a. Platelets 150,000/mm3
b. Erythrocyte sedimentation rate 75 mm/hr
c. Aspartate aminotransferase 10 units/L
d. WBC count 8,000/mm3
Answer: b. Erythrocyte sedimentation rate 75 mm/hr
A nurse is discussing group treatment and therapy with a client. The nurse should include
which of the following as being a characteristic of a therapeutic group?
a. The group encourages clients to form dependent relationships.
b. The group encourages members to focus on a particular issue.
c. The group is organized in an autocratic structure.
d. The group must be led by a licensed psychiatrist.
Answer: d. The group must be led by a licensed psychiatrist.
A nurse is providing teaching about home safety to the adult child of an older adult client who is
postoperative following knee replacement surgery. Which of the following instructions should
the nurse include?
a. Place a throw rug over electrical cords.
b. Encourage the client to avoid wearing shoes at home,
c. Mark the edges of the doorway to the house with tape.
d. Ensure that area rugs have rubber backs.
Answer: d. Ensure that area rugs have rubber backs.
A nurse is assessing a client who is receiving packed RBCs. Which of the following findings
indicates fluid overload?
a. Dyspnea
b. Thready pulse
c. Low-back pain
d. Hypotension
Answer: a. Dyspnea
A nurse is admitting an older adult client who is transferring from another facility. The nurse
notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the
following actions should the nurse take to address suspicions of elder abuse?
a. Contact the family regarding the client's condition
b. Inform the transferring agency of the client's condition.
c. Notify risk management.
d. Privately interview the client about the injuries.
Answer: d. Privately interview the client about the injuries.
A nurse is providing discharge teaching to a client who has a new prescription for phenelzine.
The nurse should instruct the client that it is safe eat which of the following foods while taking
this medication?
a. Smoked salmon
b. Pepperoni pizza
c. Whole grain bread
d. Avocados
Answer: c. Whole grain bread
A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following
manifestations indicates acute chest syndrome and should be immediately reported to the
provider?
a. Substernal retractions
b. Sneezing
c. Hematuria
d. Temperature 37.9°C(100.2°F)
Answer: a. Substernal retractions
A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the
following actions should the nurse take?
a. Notify the nursing supervisor about the suspected alcohol use.
b. Inform another nurse on the unit about the suspected alcohol use.
c. Confront the nurse about the suspected alcohol use.
d. Ask the nurse to finish administering medications and then go home.
Answer: a. Notify the nursing supervisor about the suspected alcohol use.
A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse take?
a. Provide frequent stimulation for the newborn.
b. Encourage frequent eye contact with the newborn during feedings
c. Wrap the newborn loosely in a blanket.
d. Decrease the lighting levels in the nursery.
Answer: d. Decrease the lighting levels in the nursery.
A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.
Which of the following clients should the nurse instruct the AP to report to the nurse?
a. A client who has a prescription for compression stockings and did not receive them
b. A client who consumes all the food from their meal tray
c. A client who requests assistance to use the bedside commode
d. A client who requests to sit in the bedside chair while watching TV
Answer: a. A client who has a prescription for compression stockings and did not receive them
A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
a. "Dehydration can increase the risk for preterm labor."
b. "Dehydration is treated with calcium supplements."
c. "Dehydration is associated with gastroesophageal reflux."
d. "Dehydration is caused by a decreased hemoglobin and hematocrit. *the contrary increase
Answer: a. "Dehydration can increase the risk for preterm labor."
A nurse is preparing a change-of-shift report for an adult female client who is postoperative.
Which of the following client Information should the nurse include in the report?
a. RBC 4.4 million/mm3
b. Hgb 12.8 g/dL
c. Platelets 100,000/mm
d. Potassium 4.2 mEq/L
Answer: c. Platelets 100,000/mm - normal 150,000-400,000
A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding. Which
of the following actions should the nurse take?
a. Instruct the client to lie on his right side. No - Intubate, ET tube stabilizer, Lt lateral, largebore,
verify placement, aspirate gastric content , use warm NSS, charcol.
b. Use a cold irrigation solution.
c. Insert a large bore NG tube.
d. Instill 500 mL of solution through the NG tube.
Answer: c. Insert a large bore NG tube.
A nurse is caring for a client who is experiencing acute mania. Which of the following foods
should the nurse provide for this clients?
a. Oatmeal with butter
b. Peanut butter sandwich
c. Celery sticks
d. Chicken noodle soup
Answer: b. Peanut butter sandwich
A nurse is providing discharge teaching to a female client who has tuberculosis and a new
prescription for rifampin. Which of the following information should the nurse include?
a. "You should avoid sun exposure while taking this medication."
b. "You should avoid getting pregnant for 6 months after stopping this medication."
c. "Your urine will be orange while taking this medication."
d. "Weight gain is an expected adverse effect of this medication."
Answer: c. "Your urine will be orange while taking this medication."
A nurse is preparing to initiate IV therapy for an older adult client. Which of the following
actions should the nurse plan to take?
a. Apply a tourniquet firmly above the insertion site.
b. Use a 22-gauge catheter for insertion
c. Clean the site using vigorous friction.
d. Select a vein on the back of the hand.
Answer: b. Use a 22-gauge catheter for insertion
A nurse is assessing a newborn who has a blood glucose level of 30 mg/dL. Which of the
following manifestations should the nurse expect? Newborn BSL 40-50
a. Abdominal distention
b. Hypertonia
c. Loose Stools
d. Jitteriness
Answer: d. Jitteriness
A nurse is planning care for a client who is postoperative following a total hip arthroplasty.
Which of the following actions should the nurse plan to take when positioning the client?
a. Flex the client's hip up to 120° when sitting in a chair.
b. Maintain the client in a supine position for the first 24 hr after surgery.
c. Ensure that the client's hip remains in an abducted position.
d. Place the client's heels directly against the bed mattress.
Answer: c. Ensure that the client's hip remains in an abducted position.
A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of
the following recommendations should the nurse make?
a. Ensure that each client has a living will on file prior to treatment. - not always pt has living
will
b. Overestimate clients' acuity to prevent short staffing.
c. Place copies of incident reports in clients' medical records.
d. Obtain personal professional liability insurance coverage
Answer: d. Obtain personal professional liability insurance coverage
A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode.
Which of the following findings should the nurse expect?
a. Client expresses illusions of grandeur
b. Inability to carry out a simple task
c. Moves quickly from one idea to the next
d. Client reports auditory hallucinations
Answer: b. Inability to carry out a simple task
A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions
about the disease. To research the disease, the nurse should identify that which of the following
electronic databases has the most comprehensive collection of nursing journal articles?
a. MEDLINE
b. CINAHL
c. ProQuest
d. Health Source
Answer: b. CINAHL
A nurse in the emergency department is assessing a newly admitted client who is experiencing
drooling and hoarseness following a burn injury. Which of the following actions should the nurse
take first?
a. Obtain a blood specimen for ABG analysis.
b. Insert an 18-gauge IV catheter.
c. Apply 100% humidified oxygen
d. Obtain a baseline ECG.
Answer: c. Apply 100% humidified oxygen
A staff education nurse is evaluating a group of nurses during a new employee orientation on the
use of proper body mechanics when lifting. Which of the following images indicates the
appropriate use of ergonomic principles?
•
Answer: To evaluate the appropriate use of ergonomic principles for lifting, the image should
depict the following key aspects:
1. Feet Positioning: Feet should be shoulder-width apart for stability.
2. Body Alignment: The back should be straight, and the torso should be aligned with the legs.
3. Bending at the Knees: The knees should be bent, not the back, to lower the body to the object.
4. Lifting with Legs: The lift should come from the legs, not the back, by straightening the legs
while keeping the back straight.
5. Holding the Object Close: The object should be held close to the body to minimize strain on
the back.
In the correct image, you should see a person maintaining these principles to lift an object safely.
A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should
expect a prescription for which of the following laboratory tests?
a. Prealbumin
b. Creatinine clearance
c. Platelet count
d. Potassium level
Answer: c. Platelet count
A nurse is caring for a client following application of a cast. Which of the following actions
should the nurse take first?
a. Position the casted extremity on a pillow.
b. Teach the client to keep the cast clean and dry.
c. Palpate the pulse distal to the cast.
d. Place an ice pack over the cast.
Answer: c. Palpate the pulse distal to the cast.
A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months
ago. For which of the following clients should the nurse initiate a referral to assess for the
presence of posttraumatic stress disorder? (Select all that apply.)
a. A client who has frequent nightmares about the hurricane.
b. A client who describes having persistent feelings of anger about the hurricane.
c. A client who expresses a realization that life will not return to the way it was before the
hurricane.
d. A client who moved to an apartment located on higher ground than her previous home
e. A client who describes feeling disconnected from those around him following the hurricane.
Answer: e. A client who describes feeling disconnected from those around him following the
hurricane.
A nurse is caring for a client who has a pressure injury on the coccyx. Which of the following
findings should indicate to the nurse that the wound is a stage III pressure injury?
a. Subcutaneous fat is visible.
b. Slough and eschar are present.
c. Bone is exposed within the wound.
d. The skin is reddened and intact.
Answer: a. Subcutaneous fat is visible.
A nurse in an emergency department is assessing a client who has major depressive disorder.
Which of the following actions should the nurse take first? (Click on the exhibit tabs for
additional Information about the client. There are three tabs that contain separate categories of
data.)
Exhibit 1
Vital Signs: Temperature 37.3°C (99.1°F), Pulse 90/min, Respiratory rate 18/min, BP 140/90
mm/Hg
a. Administer ondansetron to the client for nausea.
b. Obtain a blood glucose level.
c. Obtain the client's weight.
d. Implement seizure precautions for the client.
Answer: d. Implement seizure precautions for the client.
A nurse is giving an Intramuscular injection to a newborn who was delivered at 38 weeks of
gestation. Which of the following pain scales should the nurse use to assess the newborn's pain?
a. Neonatal Infant Pain Scale (NIPS)
b. visual analog scale (VAS)
c. FACES pain rating scale
d. Premature Infant Pain Profile (PIPP)
Answer: a. Neonatal Infant Pain Scale (NIPS)
A nurse is teaching a client about using a 3-point gait for crutch-walking. Which of the following
actions by the client indicates understanding of the teaching?
a. Places weight on the axilla when advancing crutches
b. Applies full weight on the affected side when advancing crutches
c. Uses both crutches when advancing the affected leg
d. Advances the affected leg first prior to the nonaffected leg
Answer: c. Uses both crutches when advancing the affected leg
A charge nurse is assigning client care tasks for the upcoming shift. Which of the following tasks
should the charge nurse assign to an RN?
a. Inserting an endotracheal tube
b. Obtaining blood cultures from a central catheter
c. Inserting an epidural catheter
d. Performing a thoracentesis
Answer: b. Obtaining blood cultures from a central catheter
A nurse is preparing to administer eye drops to a school-age child, Identify the actions the nurse
should take. (Move the steps into the box on the right placing them in the order of performance.
Use all the steps.)
Answer: The correct order for administering eye drops to a school-age child:
1. Place the child in a sitting position.
2. Ask the child to look upward.
3. Pull the lower eyelid downward.
4. Instill the drops of medication.
5. Apply pressure to the lacrimal punctum.
A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which
of the following actions by the nurse indicates a break in surgical aseptic technique?
a. Putting on sterile gloves after preparing the sterile field
b. Applying a sterile gown after applying a sterile mask
c. Balancing the bottle on the sterile basin while pouring the liquid
d. Placing the supplies on the sterile field and leaving a 1-inch perimeter
Answer: c. Balancing the bottle on the sterile basin while pouring the liquid
A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the following
information should the nurse include about preventing the spread of the infection?
a. Wash soiled clothes in cold water
b. Buy disposable dishes for daily use.
c. Clean blood-contaminated surfaces with bleach
d. Use condoms with a petroleum-based lubricant.
Answer: c. Clean blood-contaminated surfaces with bleach
A nurse is caring for a client who is comatose and has advance directives that indicate the client
does not want life-sustaining measures. The client's family wants the client to have lifesustaining measures. Which of the following actions should the nurse take?
a. Arrange for an ethics committee meeting to address the family's concerns.
b. Complete an Incident report
c. Support the family's decision and initiate life-sustaining measures.
d. Encourage the family to contact an attorney.
Answer: a. Arrange for an ethics committee meeting to address the family's concerns.
A nurse is screening food brought in by a family member for a client who takes phenelzine. The
nurse should instruct the family member that which of the following foods can cause an
interaction with this medication?
a. Cottage cheese
b. Bologna sandwich
c. Orange gelatin
d. Iceberg lettuce salad
Answer: b. Bologna sandwich
A nurse is providing teaching to a client who has a new prescription for warfarin. The nurse
should include that which of the following medications can increase the effects of warfarin?
a. Oral contraceptives
b. Nafcillin - antibiotic –may decrease the effect of warfarin
c. Aspirin
d. Vitamin
Answer: c. Aspirin
A nurse is providing teaching to a client who is scheduled for radiation therapy to treat
esophageal cancer. Which of the following statements should the nurse make?
a. "Soften foods with gravy and sauces."
b. "Drink mostly clear liquids."
c. "Use commercial mouthwashes to rinse your mouth"
d. "Warm up foods before eating."
Answer: a. "Soften foods with gravy and sauces."
A nurse is caring for a 1-month-old Infant who has manifestations of severe dehydration and a
prescription for parenteral fluid therapy. The guardian asks, "What are the indications that my
baby needs an IV?" Which of the following responses should the nurse make?
a. "Your baby needs an IV because she is breathing slower than normal."
b. "Your baby needs an IV because she is not producing tears."
c. "Your baby needs an IV because her fontanels are bulging."
c. "Your baby needs an IV because her heart rate is decreased."
Answer: b. "Your baby needs an IV because she is not producing tears."
A nurse is providing discharge teaching to a group of clients. The nurse should recommend a
referral to a dietitian for which of the following clients?
a. A client who has osteoporosis and states, "I’ll plan to take my calcium carbonate with a full
glass of water."
b. A client who has gout and states. "I can continue to eat anchovies on my pizza."
c. A client who has a prescription for spironolactone and states. "I will reduce my intake of foods
that contain potassium."
d. A client who has a prescription for warfarin and states. "I will need to limit how much spinach
Teat."
Answer: b. A client who has gout and states. "I can continue to eat anchovies on my pizza."
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation pulmonary congestion?
a. Jugular vein distention
b. Bradypnea NO - breathing rate lower
c. Frothy, pink sputum
d. weight gain
Answer: c. Frothy, pink sputum
A nurse is admitting a client who does not speak the same language as the nurse and is scheduled
for outpatient surgery. Which of the following actions should the nurse take?
a. Explain the procedure to the client through an interpreter.
b. Provide a consent form that is written in the client's own language.
c. Request a family member to interpret the information.
d. Help the client look up the information about the procedure on the Internet.
Answer: b. Provide a consent form that is written in the client's own language.
A nurse is preparing to admit a client who is 35 weeks of gestation for evaluation of fetal wellbeing due to potential preterm labor. Which of the following pieces of equipment should the
nurse use to evaluate the fetal heart rate?
a. Ultrasound transducer
b. Toco transducer
c. Intrauterine pressure catheter
d. Spiral electrode
Answer: b. Toco transducer
A nurse is receiving a telephone prescription from a provider for a client who requires additional
medication for pain control. Which of the following entries should the nurse make in the medical
record?
a. "Morphine 3.0 mg sub q every 4 hr PRN for pain."
b. "Morphine 3 mg SQ every 4 hr PRN for pain."
c. "Morphine 3 mg subcutaneous every 4 hr PRN for pain."
d. "Morphine 3 mg SC 24 hr PRN for pain."
Answer: c. "Morphine 3 mg subcutaneous every 4 hr PRN for pain."
A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the
nurse plan to take?
a. Assess the newborn’s pain level using the FACES pain scale
b. Obtain the newborn's body temperature using a tympanic thermometer,
c. Auscultate the newborn's apical pulse for 60 seconds.
d. Measure the newborn's head circumference over the eyebrows and below the occipital
prominence
Answer: c. Auscultate the newborn's apical pulse for 60 seconds.
A community health nurse is reviewing laboratory reports for a group of clients. The nurse
should identity that which of the following disorders is on the CDC's Nationally Notifiable
Conditions list?
a. Pediculosis capitis
b. Bacterial vaginosis
c. Lyme disease
d. Respiratory syncytial virus
Answer: c. Lyme disease
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should
the nurse take?
a. Wipe stool from the skin using store-bought baby wipes.
b. Apply talcum powder to the irritated area.
c. Wipe urine from the skin using a cool cloth.
d. Apply zinc oxide ointment to the Irritated area.
Answer: d. Apply zinc oxide ointment to the Irritated area.
A nurse is reviewing the medical record of a client who has a prescription for intermittent heat
therapy for a foot Injury. Which of the following findings should the nurse identify as a
contraindication for heat therapy?
a. Peripheral neuropathy
b. Phlebitis
c. Osteoarthritis
d. Abdominal aortic aneurysm
Answer: a. Peripheral neuropathy
A nurse is providing discharge instructions to a client who has a new prescription for
spironolactone. Which of the following instructions should the nurse include in the teaching?
a. Take the medication in the morning.
b. Administer a potassium supplement daily.
c. Monitor weight once a week.
d. Use a salt substitute with meals
Answer: a. Take the medication in the morning.
A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the
following Information should the nurse include?
a. Choose high-fat cheese as a meat substitute.
b. Choose foods high in vitamin B12.
c. Limit Intake of foods high in vitamin C.
d. Limit Intake of nuts and legumes.
Answer: b. Choose foods high in vitamin B12.
A nurse is reviewing the laboratory results of a client and notes increased values for hemoglobin,
hematocrit, and urine osmolarity. The nurse should identify that these results are manifestations
of which of the following client conditions?
a. Anemia
b. Acute renal failure
c. Hepatic failure
d. Dehydration
Answer: d. Dehydration - fluid deficit
A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right
hemisphere stroke. Which of the following Interventions should the nurse include in the plan?
a. Provide total care in performing the client's ADLs.
b. Place food on the left side of the client's mouth when he is ready to eat.
c. Place the client's left arm on a pillow while he is sitting.
d. Maintain the client on bed rest.
Answer: c. Place the client's left arm on a pillow while he is sitting.
A nurse in a mental health facility receives change-of-shift report for four clients. Which of the
following clients should the nurse plan to assess first?
a. A client placed in restraints due to aggressive behavior.
b. A newly admitted client who has a history of 4.5 kg (10 lb) weight loss in the past 2 months.
c. A client who will be receiving her first ECT treatment today.
d. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety.
Answer: a. A client placed in restraints due to aggressive behavior.
A nurse is planning care for a group of clients and is working with one licensed practical nurse
(LPN) and one assistive personnel (AP). Which o following actions should the nurse take first to
manage her time effectively?
a. Delegate tasks to the AP.
b. Determine goals of the day.
c. Schedule daily activities.
d. Develop an hourly time frame for tasks.
Answer: b. Determine goals of the day.
A nurse is evaluating the response to the plan of care for a client who is grieving the death of a
partner. Which of the following findings should the nurse identify as indicating that the client is
experiencing maladaptive grieving?
a. The client has joined a support group.
b. The client openly expresses anger when discussing the partner's death.
c. The client reports feelings of guilt about the partner's death.
d. The client reports having good and bad days.
Answer: b. The client openly expresses anger when discussing the partner's death.
A nurse manager is planning to promote client advocacy among staff on a medical unit. Which of
the following actions should the nurse plan to take?
a. Instruct unit staff to share personal experiences to help clients make decisions.
b. Develop a system for staff members to report safety concerns in the client care environment
c. Encourage staff to implement the principle of paternalism when a client is having difficulty
making a choice.
d. Tell staff to explain procedures to clients before obtaining informed consent.
Answer: b. Develop a system for staff members to report safety concerns in the client care
environment
A nurse is caring for a client who has cancer of the throat and is receiving radiation therapy. The
nurse should monitor for which of the following findings as an adverse effect of the radiation?
a. Insomnia
b. Elevated platelet count
c. Altered taste sensation
d. Excessive salivation
Answer: c. Altered taste sensation
A nurse is teaching a group of newly licensed nurses about measures to take when caring for a
client who is on contact precautions. Which of the following should the nurse include in the
teaching?
a. Place the client in a room with negative air pressure.
b. Wear a mask when changing the linens in the client's room.
c. Remove the protective gown after leaving the client's room.
d. Wear gloves when providing care to the client.
Answer: d. Wear gloves when providing care to the client.
A nurse is caring for four clients on a medical-surgical unit. For which of the following clients
should the nurse complete a medication reconciliation?
a. A client who received twice the prescribed dose of a medication
b. A client who has a prescription for a gallbladder sonogram
c. A client who returns to the unit from the PACU following surgery
d. A client who transfers from a private room into a semi-private room
Answer: a. A client who received twice the prescribed dose of a medication
A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds.
Which of the following actions should the nurse take?
a. Place the arm above the level of the client's heart.
b. Deflate the cuff quickly.
c. Apply the largest cuff available.
d. Use the palpatory method to determine blood pressure.
Answer: d. Use the palpatory method to determine blood pressure.
A nurse is performing a safety assessment for a client who has Parkinson's disease. Which of the
following statements by the client indicates the need for a referral to physical therapy?
a. "have been experiencing more tremors in my left arm than before."
b. "I noticed that I am having a harder time holding on to my toothbrush."
c. "Sometimes, I feel like I am making a chewing motion when I'm not eating."
d. "Lately, I feel like my feet are freezing up, as if they are stuck to the ground."
Answer: d. "Lately, I feel like my feet are freezing up, as if they are stuck to the ground."
A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is
levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round
to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Answer: The nurse should administer 2 tablets per dose.
A community health nurse is developing a plan to Improve the community's environmental
health. Which of the following actions should the nurse take first?
a. Encourage community involvement in environmental improvement.
b. Request funding from community organizations.
c. Establish a timeframe for environmental improvements.
d. Collect information about the community's environment status.
Answer: d. Collect information about the community's environment status.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the
nurse that she lived in this facility years ago and took care of all the residents by herself. The
nurse should document this as which of the following findings?
a. Perseveration
b. Confabulation
c. Projection
d. Agnosia
Answer: b. Confabulation
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the
following actions should the nurse take? (Select all that apply).
a. Change the feeding container and tubing every 24 hr.
b. Ensure the formula is cold before administration.
c. Maintain the head of the client's bed at a 30° angle or higher.
d. Check gastric residuals every 4 hr.
e. Check placement of the feeding tube by X-ray once daily.
Answer:
a. Change the feeding container and tubing every 24 hr.
c. Maintain the head of the client's bed at a 30° angle or higher.
d. Check gastric residuals every 4 hr.
A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate
for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following
orders from the provider should the nurse expect?
a. Withhold the next dose
b. Increase the dosage
c. Administer the medication.
d. Discontinue the medication.
Answer: c. Administer the medication.
A nurse is caring for a client who has hypertension and a new prescription for chlorthalidone.
The nurse should monitor for which of the following adverse effects?
a. Hypoglycemia
b. Increased intraocular pressure
c. Hypokalemia
d. Euphoria
Answer: c. Hypokalemia
A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
a. Warm toast with margarine
b. Broiled, skinless chicken breast with brown rice
c. Lettuce with sliced avocados
d. Coffee with creamer
Answer: b. Broiled, skinless chicken breast with brown rice
A charge nurse is planning a staff education and competence session about operating newly
acquired cardiac monitoring equipment. Which of the following
actions should the nurse plan to take? (Select all that apply.)
a. Caution staff that the equipment is complicated to use.
b. Identify the current level of staff knowledge about the equipment.
c. Provide reinforcement of teaching until the skill is learned.
d. Require a return demonstration using the equipment.
e. Wait to offer feedback on staff use of the equipment until the end of the session.
Answer: b. Identify the current level of staff knowledge about the equipment.
c. Provide reinforcement of teaching until the skill is learned.
d. Require a return demonstration using the equipment.
A nurse is reviewing the formulary about NPH Insulin before administering the medication to a
client. Which of the following Information should the nurse expect?
a. Discard the NPH Insulin vial if the medication is cloudy.
b. Use NPH Insulin to treat ketoacidosis.
c. Administer NPH insulin 30 min before breakfast.
d. Give NPH Insulin by IV bolus.
Answer: c. Administer NPH insulin 30 min before breakfast.
A nurse is planning care for four clients who are at risk for fluid imbalances. The nurse
should identify that which of the following clients is at risk for fluid volume excess?
a. A client who has ulcerative colitis
b. A client who has diabetes insipidus
c. A client who has advanced stage liver cirrhosis
d. A client who has an exacerbation of peptic ulcer disease
Answer: c. A client who has advanced stage liver cirrhosis
A nurse is preparing to administer a blood transfusion to a client. Which of the following actions
should the nurse take?
a. Use an IV catheter that is at least 24-gauge.
b. Attach a single-line administration set.
c. Use tubing that does not have a filter in the drip chamber.
d. Prime the tubing with 0.9% sodium chloride.
Answer: d. Prime the tubing with 0.9% sodium chloride.
A nurse manager is reviewing documentation with a newly licensed nurse. Which of the
following notations by the newly licensed nurse indicates an understanding of the teaching?
a. "Administered 8 u regular insulin sq."
b. "Dressing changed qd."
c. "Given 2 mg MSO, IM for report of pain."
d. "OOB with assistance for breakfast."
Answer: d. "OOB with assistance for breakfast."
A nurse is caring for a client who has depression and reports taking St. John's wort along with
citalopram. The nurse should monitor the client for which of the following conditions as a result
of an interaction between these substances?
a. Pseudoparkinsonism
b. Acute dystonia
c. Tardive dyskinesia
d. Serotonin syndrome
Answer: d. Serotonin syndrome
A nurse in a mental health clinic receives a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should
the nurse make?
a. "We can provide a copy of your records, but the therapist's notes are not included."
b. "I don't think you will benefit from reviewing your therapist's notes right now."
c. "Why are you interested in seeing your therapist's notes?"
d. "Are you not happy with your treatment
Answer: a. "We can provide a copy of your records, but the therapist's notes are not included."
A nurse is completing an incident report after a client fall. Which of the following competencies
of Quality and Safety Education for Nurses is the nurse demonstrating?
a. Quality improvement
b. Informatics
c. Patient-centered care
d. Evidence-based practice
Answer: a. Quality improvement
A public health nurse is managing several projects for the community. Which of the following
interventions should the nurse identify as a primary prevention strategy?
a. Providing crisis intervention through a mobile counseling unit.
b. Referring clients who have obesity to community exercise programs.
c. Teaching parenting skills to expectant mothers and their partners.
d. Conducting mental health screenings at the local community center.
Answer: c. Teaching parenting skills to expectant mothers and their partners.
A nurse is caring for a client who has vision loss. Which of the following actions should the
nurse take? (Select all that apply.)
a. Touch the client gently to announce presence.
b. Approach the client from the side.
c. Ensure there is high-wattage lighting in the client's room.
Answer: a. Touch the client gently to announce presence.
c. Ensure there is high-wattage lighting in the client's room.
A nurse is reviewing the medical record of a client who has delayed healing of a leg ulcer. Which
of the following findings should the nurse identify as a contributing factor?
a. The client takes prednisone for arthritis
b. The client has an albumin level of 3.8 g/dL
c. The client has a total cholesterol level of 190 mg/dl.
d. The client is receiving IV dextrose 5% in water at 100 ml/hr.
Answer: a. The client takes prednisone for arthritis
A nurse is caring for an infant who has respiratory syncytial virus. Which of the following
interventions should the nurse take?
a. Initiate neutropenic precautions.
b. Request a prescription for guaifenesin.
c. Administer palivizumab intravenously.
d. Suction nares prior to feeding.
Answer: d. Suction nares prior to feeding.
A nurse is caring for a client who has heart failure. The nurse notes the client's 24-hr intake is
1.750 mL and output is 425 mL Which of the following actions should the nurse take first?
a. Reduce the client's sodium intake.
b. Compare the client's weight to the previous day
c. Encourage the client to change positions frequently
d. Administer furosemide to the client.
Answer: d. Administer furosemide to the client.
A nurse is caring for a client who wears glasses. Which of the following actions should the nurse
take?
a. Clean the glasses with hot water
b. Store the glasses in a labeled case
c. Store the glasses on the bedside table
d. Clean the glasses with a paper towel.
Answer: b. Store the glasses in a labeled case
d. Clean the glasses with a paper towel.
A nurse is preparing to obtain a client's signature on an informed consent form. Which of the
following actions should the nurse take first?
a. Witness the client signing the informed consent form.
b. Notify the provider if the client has questions about the procedure.
c. Inform the client of his right to change his mind.
d. Ask the client to explain his understanding of the procedure.
Answer: a. Witness the client signing the informed consent form.
A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following
activities should the nurse expect the child to participate?
a. Playing with a large plastic truck
b. Watching a cartoon in the activity room
c. Looking at alphabet flash cards
d. Using scissors to cut out paper shapes
Answer: a. Playing with a large plastic truck
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis
following a stroke. Which of the following actions by the nurse best promotes communication
among staff caring for the client?
a. Posting swallowing precautions at the head of the client's bed
b. Having interdisciplinary team meetings for the client on a regular basis
c. Recording the client's progress in the nurses' notes
d. Noting changes in the treatment plan in the client's medical record
Answer: a. Posting swallowing precautions at the head of the client's bed
A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The
high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is
unable to determine the cause of the alarm. Which of the following actions should the nurse
take?
a. Assess for disconnected tubing. - low pressure alarm
b. Decrease the ventilator flow rate.
c. Reevaluate the client for an Et cuff leak. - low pressure alarm
d. Deliver breaths manually with a resuscitation bag.
Answer: d. Deliver breaths manually with a resuscitation bag.
A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified
radical mastectomy. Which of the following statements by the client indicates an understanding
of the teaching?
a. "I will have my drains removed 1 hour prior to going home."
b. "I will complete my arm exercises four times a day. "
c. "I can shower within 48 hours of my surgery."
d. "I can begin to drive 24 hours after surgery."
Answer: b. "I will complete my arm exercises four times a day. "
A nurse in a provider's office is reviewing a female client's medical record during a
routine visit. The nurse should recommend increased dietary Intake of which of the following
vitamins? (click on the "Exhibit" button for additional information about the client. There are
three tabs that contain separate categories of data.)
Exhibit 1 History and Physical:
• Postmenopausal
• History of deep-vein thrombosis and iron deficiency anemia
• Works indoors
• Consumes 1 to 2 alcoholic beverages per week
Exhibit 2 Exhibit 3
• Vitamin B12
• Vitamin K
• Vitamin A
• Vitamin D
• A nurse is preparing to administer PRN pain medication to a client who the following
medications should the nurse plan to administer?
a. Metoclopramide
b. Ketorolac
c. Acetaminophen
d. Omeprazole
Answer: b. Ketorolac
A nurse is preparing to administer an IV medication to a client and accidently punctures the IV
bag, causing the medication to leak on the counter. Which of the following medications requires
the nurse to follow facility procedures in the safe handling of a biohazardous material spill?
a. Metronidazole
b. Phenytoin
c. Ampicillin sodium
d. Doxorubicin hydrochloride
Answer: d. Doxorubicin hydrochloride
