2019 ATI Mental Health Proctored Exam With Answers-196 Solved Questions

ATI FUNDAMENTALS PROCTORED EXAM 2019
GRADED A+/ACTUAL EXAM QS &A/VERIFIED SOLUTIONS
1. A nurse is assessing a client’s personal hygiene. Which of the following findings indicates
that the client might have difficulty with routinely bruising their teeth?
a. The clients mucosa is moist
b. The client gums feel spongy
c. The client has a missing tooth
d. The Client’s tongue is a dull red color
Answer: b. The client gums feel spongy
2. A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for
insulin. Which of the following actions should the nurse plan to complete first?
a. Make a copy of the medication reconciliation form for the client
b. Provide the client with the contact number for a diabetes education specialist
c. Determine whether the client can afford the insulin administration supplies
d. Obtain printed about insulin self-administration
Answer: c. Determine whether the client can afford the insulin administration supplies
3. A community health nurse is teaching a group of clients about kegel exercises to prevent
urinary incontinence. Which of the following instructions should the nurse include?
a. Contact your pelvic muscle when performing the exercises
b. Expect improvement after 2 weeks of performing the exercises
c. Hold your breath when performing the exercises
d. Tighten your buttocks when performing the exercises
Answer: a. Contact your pelvic muscle when performing the exercises
4. A nurse is assessing the skin of a client who has worked outdoors for the past 20 years.
Which of the following findings is the nurse's priority?
a. Skin tags noted in the neck region
b. A change in appearance of a mole on the shoulder

c. A flat, nonpalpable, discovered area of skin on the trunk
d. Atrophic wart on the left index finger
Answer: b. A change in appearance of a mole on the shoulder
5. A nurse is caring for a client who has a high fever. Which of the following actions should the
nurse take?
a. cover the client with heavy blankets after shivering subsides
b. place ice packs on the clients neck and behind the knees
c. apply a bath blanket between the client and a cooling blanket
d. give the client a sponge bath using alcohol water solution
Answer: c. apply a bath blanket between the client and a cooling blanket
6. A nurse is caring for an infant who is to undergo surgery. The nurse should identify which of
the following individuals should sign the consent form?
a. The infants 17 year old mother
b. The infants provider
c. The infants grandmother
d. The mother’s 21 year old sibling
Answer: a. The infants 17 year old mother
7. A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast.
Which of the following actions should the nurse use?
a. Encourage the client to try to defecate for 20 min while on the fracture pan.
b. Keep the bed flat while the client is on the fracture pan.
c. Hyperextend the clients back while the fracture pan is in place.
d. Place the shallow end of the fracture pan under the clients buttocks.
Answer: d. Place the shallow end of the fracture pan under the clients buttocks.
8. A nurse is reviewing the medical record of a client who asks about the use of a magnet
therapy for pain relief. The nurse should identify which of the following findings is a
contraindication for receiving this type of therapy?

a. The client is allergic to penicillin
b. The client has a prescription for metoprolol
c. The client has a history of alcohol use disorder
d. The client has an implanted defibrillator
Answer: d. The client has an implanted defibrillator
9. A nurse is caring for a client who requires airborne precautions. The nurse is preparing to
leave the clients room following a dressing change. Which of the following pieces of personal
protective equipment should the nurse remove first?
a. Gloves
b. Eyewear
c. Gown
d. Mask
Answer: a. Gloves
10. A nurse is teaching a newly licensed nurse about the care of a client who has methicillin
resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the
newly licensed nurse indicates an understanding of the teaching?
a. I will wear an N95 respirator mask when caring for the client
b. I will tell the clients visitors to wear a mask when they are within 3 feet of the client.
c. I will place the client in a private room
d. I will remove my gown before my gloves after providing client care.
Answer: c. I will place the client in a private room
11. A charge nurse in a long term care facility is preparing an educational program about
delirium for newly hired nurses. Which of the following statements should the nurse plan to
include?
a. Delirium has an abrupt onset
b. Delirium is a chronic condition that progresses over time.
c. Delirium typically lasts for several months.
d. Delirium is always caused by a psychiatric disorder.

Answer: a. Delirium has an abrupt onset
12. A nurse is preparing to insert an IV catheter for an adult client. Which of the following
actions should the nurse take?
a. choose the most proximal site on the extremity selected
b. apply a cool compress for several minutes before insertion of the IV catheter
c. place the tourniquet below the proposed insertion site
d. place the extremity in a dependent position
Answer: d. place the extremity in a dependent position
13. A nurse is teaching a client who is about to undergo a bowel resection about advance
directives. Which of the following instructions should the nurse include in the teaching?
a. Your partner must be present when you sign the advance directives
b. You will receive written information about advance directives prior to signing
c. You are required to sign advance directives prior to surgery
d. Your provider must sign the advance directives before surgery
Answer: b. You will receive written information about advance directives prior to signing
14. A nurse is caring for a client who has wrist restraints after an episode of violent behavior.
Which of the following actions should the nurse take?
a. Remove one restraint at a time
b. Leave the client unattended while restrained.
c. Secure the restraints tightly to prevent movement.
d. Apply restraints to both wrists at the same time.
Answer: a. Remove one restraint at a time
15. A nurse is preparing to administer several medications via NG tube to a client who is
receiving a continuous tube feeding. Which of the following actions should the nurse take?
a. Dilute each crushed medication with sterile water
b. Mix the medication together in a single syringe
c. Flush the NG tube with 5 mL of sterile water prior to administration

d. Combine the medication with the formula in the feeding bag
Answer: c. Flush the NG tube with 5 mL of sterile water prior to administration
16. A nurse is planning care for a client who has urinary incontinence. Which of the following
interventions should the nurse include in the client's plan of care?
a. Toilet the client every 4 hr while the client is awake
b. Apply a moisture barrier in a thick layer to vulnerable skin areas
c. Cleanse the skin with antibacterial soap and hot water after each incontinence episode
d. Reduce the clients daily fluid intake
Answer: b. Apply a moisture barrier in a thick layer to vulnerable skin areas
17. A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse
administers a 500 mL IV bolus. Which of the following actions should the nurse take first?
a. Complete an incident report
b. Obtain the client’s vital signs
c. Document the fluid infusion in the client’s chart
d. Report the incident in to the unit manager
Answer: b. Obtain the client’s vital signs
18. A home health nurse is teaching a client about home safety. Which of the following
statements by the client indicates an understanding of the teaching? (SATA)
a. I need to check my medications for expiration dates
b. I will use the grab bars when getting in and out of the bathtub
c. I need to have a fire escape plan with my family
d. I can use any type of chair to reach items on high shelves.
e. I should keep my walking area clear of clutter.
Answer: a. I need to check my medications for expiration dates
b. I will use the grab bars when getting in and out of the bathtub
c. I need to have a fire escape plan with my family
e. I should keep my walking area clear of clutter.

19. A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the
client's signature, the client states, I trust my doctor, but I don't understand what is meant by
resecting my intestine. Which of the following actions should the nurse take?
a. Notify the provider.
b. Explain the procedure in detail to the client.
c. Encourage the client to sign the consent form anyway.
d. Ask the client to describe what they understand about the procedure.
Answer: a. Notify the provider.
20. A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse.
The nurse should identify that which of the following manifestations occurs during the alarm
reaction stage?
a. Dilated pupils
b. Physical exhaustion
c. Bradycardia
d. Depression
Answer: a. Dilated pupils
21. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when
plugging in the IV pump. Which of the following actions should the nurse take first?
a. Unplug the pump
b. obtain a replacement pump
c. Notify the biomedical department to fix the pump
d. Label the pump with a defective equipment sticker
Answer: a. Unplug the pump
22. A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back
pain. Which of the following findings should indicate to the nurse that the compress has been
effective?
a. The client’s skin on the lower back is intact without redness
b. The client’s laughing at a television show

c. The client states that he is able to concentrate while eating
d. The clients’ vital signs are within the expected reference range
Answer: c. The client states that he is able to concentrate while eating
23. A nurse is preparing a sterile field to assist with suturing a clients laceration. Which of the
following actions should the nurse plan to take?
a. Pour the sterile solution with the bottle 20 cm (8 in) above the sterile bowl
b. Hold the bottle of sterile solution so that the label is facing the palm of the hand
c. Place the lid of the sterile solution bottle face down on the sterile drape
D. Apply sterile gloves before opening the bottle of sterile solution
Answer: b. Hold the bottle of sterile solution so that the label is facing the palm of the hand
24. A nurse receives a new prescription over the telephone from a client’s provider.
Which of the following actions should the nurse take first?
a. Ensure that the provider signs the prescription
b. Write down the complete prescription
c. Read back the prescription to the provider
d. Document the prescription as a telephone prescription in the medical record
Answer: c. Read back the prescription to the provider
25. A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT)
level checked. The client asks the nurse to explain the laboratory test. Which of the following is
an appropriate response by the nurse?
a. This test will determine if your heart is performing properly
b. This test will indicate if you are at risk for developing blood clots
c. This test is used to check how your kidneys are working
d. This test will provide information about the function of your liver
Answer: d. This test will provide information about the function of your liver
26. A nurse is caring for a client who is on bed rest following abdominal surgery. Which of the
following findings indicates the need to increase the frequency of position changes?

a. Petechiae on the client’s right anterior thigh
b. Flat rash on the client’s ankle
c. nonpalpable macule on the client’s left shoulder
d. Non Blanching darkened area over the client’s trochanter
Answer: d. Non Blanching darkened area over the client’s trochanter
27. A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of
the following statements by the client indicates an understanding of the teaching?
a. After I insert the hearing aid, i will turn it up as high as it will go
b. I should leave the battery in the hearing aid when i take it out to sleep
c. I will need to get a new hearing aid every year
d. I should gradually increase the time that i wear the hearing aid
Answer: d. I should gradually increase the time that i wear the hearing aid
28. A nurse is preparing to collect a specimen from a client. Which of the following actions
should the nurse take?
a. Collect the sputum specimen in the morning.
b. Instruct the client to rinse their mouth with water before collecting the specimen.
c. Use a sterile container for the specimen.
d. Ask the client to take a deep breath and cough forcefully before collecting the specimen.
Answer: a. Collect the sputum specimen in the morning.
29. A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose
test. Which of the following findings should indicate to the nurse that the client has
hyperglycemia?
a. Thirst
b. Confusion
c. Cool skin
d. Shakiness
Answer: a. Thirst

30. A nurse is assessing an older adult client. Which of the following findings should the nurse
expect?
a. Decreased sense of balance.
b. Increased skin elasticity.
c. Enhanced visual acuity.
d. Increased muscle mass.
Answer: a. Decreased sense of balance.
31. A nurse preparing to administer a controlled substance to a client for pain management.
Which of the following actions should the nurse take?
a. Report any discrepancy in the court total of the controlled substance after administration
b. Place the assisted portion of the controlled substance in the sharps container
c. Verify the count total of the controlled substance after removing the amount needed
d. Ask a second nurse to report her signature when wasting any unused portion of the controlled
substance
Answer: a. Report any discrepancy in the court total of the controlled substance after
administration
32. A nurse is caring for a client who has colon cancer and is scheduled for a colon resection
with a possible colostomy. Before the procedure, the client tells the nurse, I’m worried about the
bag. Which of the following is an appropriate response by the nurse?
a. You are worried about having to wear a colostomy bag?
b. Have you ever known someone who has a colostomy
c. Let's wait until after the surgery to discuss your concerns about your colostomy
d. The surgeon will only place the colostomy if it is necessary
Answer: a. You are worried about having to wear a colostomy bag?
33. A nurse is preparing to administer medication to a client. Which of the following should the
nurse use as a client identifier?
a. Age
b. Room number

c. Photograph
d. Bed number
Answer: a. Age
34. A nurse is preparing to administer an injection to a client. Which of the following actions
should the nurse plan to take after administering the injection?
a. Discard the needle in a puncture proof container
b. Place the needle on the bedside table
c. Remove the needle from the syringe
d. Recap the needle before disposal
Answer: a. Discard the needle in a puncture proof container
35. A nurse is planning care for a client who is concerned about her tobacco smoking habits and
is in the contemplation stage of health behavior change. Which of the following actions should
the nurse plan to take during this stage?
a. Assist the client in setting goals to make the change
b. Develop a plan for the client to integrate the change into her lifestyle
c. Present information about the benefits of quitting smoking
d. Recommend small changes for the client to make to change her behavior over time
Answer: c. Present information about the benefits of quitting smoking
36. A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the
following statements made by the client indicates an understanding of the teaching?
a. I will keep my legs crossed while sitting
b. I will perform exercises once every 4 hours while i am awake
c. I should massage my legs when they hurt
d. I should limit the time that i spend sitting in a chair
Answer: d. I should limit the time that i spend sitting in a chair
37. A nurse is documenting client care. Which of the following abbreviations should the nurse
use?

a. BRP - Bathroom privileges
b. NPO - Nothing by mouth
c. PRN - As needed
d. QID - Four times a day
e. STAT - Immediately
Answer: a. BRP - Bathroom privileges
38. A nurse who is documenting information in a clients electronic medical record is asked to
assist with an emergency. Which of the following actions should the nurse take?
a. Ask another nurse to monitor the computer
b. Turn the computer off
c. Move the computer to a secure place
d. Print out the current notes to finish later
Answer: c. Move the computer to a secure place
39. A nurse is caring for a client who is receiving continuous enteral feeding via NG tube.
Which of the following is an unexpected finding?’
a. Diarrhea one time in a 24 hour period
b. A weight gain of 0.91 kg (2 Ib) in 2 days
c. A gastric residual of 300 mL at the end of the shift
d. A blood glucose level of 110 mg/dL
Answer: a. Diarrhea one time in a 24 hour period
40. A nurse is planning care for a female client who has an indwelling urinary catheter. Which
of the following actions should the nurse include in the plan?
a. Tape the catheter to the lower abdomen
b. Attach the drainage bag to the side rails of the bed
c. Keep the drainage bag below the level of the bladder
d. Empty the drainage bag when it is three quarters full
Answer: c. Keep the drainage bag below the level of the bladder

41. A nurse is reviewing the medical record for a newly admitted client. Which of the following
laboratory values should the nurse report to the provider?
a. Sodium 140
b. Potassium 1.8
c. Magnesium 1.9
d. Calcium 6.5
Answer: b. Potassium 1.8
42. A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220 Ib.
How many mg should the nurse administer? (Round to the nearest whole number. Use a leading
zero if it applies. Do not use trailing zero).
Answer: 200 mg
43. A nurse is caring for a client who tells the nurse, since I retired, I have a lot of time on my
hands and nothing to do. I guess nobody needs me. Which of the following responses should the
nurse make?
a. If i were you, i would volunteer my time
b. Do you have family members you can visit
c. You need to realize that you have valuable skills to offer others
d. Tell me about some hobbies you enjoy
Answer: d. Tell me about some hobbies you enjoy
44. A nurse is caring for a client who has an NG tube and has repeatedly pulled it out. The nurse
should identify that which of the following findings indicates a need for restraints?
a. The client’s family is unable to stay with the client
b. The client becomes confused at night
c. The client gets of bed to use the bathroom frequently
d. The client is assigned a room near the nurses station
Answer: d. The client is assigned a room near the nurses station

45. A nurse is documenting a dressing change for a client who has a pressure injury. Which of
the following entries by the nurse demonstrate correct documentation?
a. No changes noted to the wound from previous nursing notes
b. Client premedicated with MSO4 sunq prior to dressing change
c. The wound seems clean and does not appear to be infected
d. New dressing applied as prescribed, no drainage on old dressing
Answer: b. Client premedicated with MSO4 sunq prior to dressing change
46. A nurse is preparing to reposition a client who has a lower back injury. Which of the
following actions should the nurse take?
a. Place the clients arms at their sides
b. Flex the client's knees
c. Place the client at the side of the bed nearest the direction they will be turned
d. Roll the client as one unit in a smooth continuous motion
Answer: d. Roll the client as one unit in a smooth continuous motion
47. A nurse is caring for a client who has TB. which of the following precautions should the
nurse plan to implement when working with the client?
a. Airborne
b. Contact
c. Droplet
d. Standard
Answer: a. Airborne
48. A nurse is implementing seizure precautions for a client who has a seizure disorder. Which
of the following equipment should the nurse place at the client's bedside?
a. Oral suction equipment and oral airway
b. Padded side rails
c. Bite block or padded tongue blade
d. Emergency medication (if applicable)
Answer: a. Oral suction equipment and oral airway

49. A nurse is providing teaching to the family of a client who is at the end stage of life. Which
of the following client manifestations should the nurse instruct the family to expect?
a. Increased periods of wakefulness
b. Altered breathing patterns
c. Increased salivation
d. Warm and dry extremities
Answer: b. Altered breathing patterns
50. A nurse is preparing to obtain informed consent from a client who speaks a different
language than the nurse and is scheduled for surgery. Which of the following actions should the
nurse take?
a. Recommend an interpreter who is the same gender as the client
b. Use a professional interpreter
c. Provide written materials in the client’s language
d. Ensure that the interpreter is familiar with medical terminology
Answer: a. Recommend an interpreter who is the same gender as the client
51. A nurse is caring for a client who is receiving continuous enteral feedings through a
gastrostomy tube. Which of the following actions should the nurse take?
a. Aspirate residual volume every 4 hr
b. Flush the tube with water before and after feeding
c. Maintain the head of the bed elevated
d. Check for tube placement
Answer: a. Aspirate residual volume every 4 hr
52. A nurse is preparing to insert an IV catheter for a client following a right mastectomy.
Which of the following veins should the nurse select when initiating Iv therapy?
a. The cephalic vein in the left distal forearm
b. The basilic vein in the right arm
c. The median cubital vein in the right arm

d. The dorsal veins of the right hand
Answer: a. The cephalic vein in the left distal forearm
53. A nurse is caring for a client who is postoperative and has a new prescription to advance her
diet to full liquids. Which of the following foods should the nurse offer the client as a part of a
full liquid diet?
a. Plain yogurt
b. Scrambled eggs
c. Mashed potatoes
d. Broth
Answer: a. Plain yogurt
54. A nurse is planning care for a client who has a latex allergy and is scheduled for surgery.
Which of the following actions is appropriate to include in the client's plan of care?
a. Schedule the client as the first procedure
b. Type 2 diabetes mellitus patient with corns and calluses.
c. I can apply lotion to soften calluses as long as i don't put lotion between my toes
Answer: a. Schedule the client as the first procedure
55. A nurse is caring for a male client who has a prescription for intermittent catheterization
with a coude catheter. Which of the following images show the type of catheter the nurse should
use?
a. The picture with the curled end of the catheter
b. The picture with a straight, flexible end
c. The picture with multiple drainage holes
d. The picture with a balloon at the end
Answer: a. The picture with the curled end of the catheter
56. A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and
avoids looking at her dressings. Which of the following actions should the nurse take first?
a. Provide the client with a mirror to look at her mastectomy incisions

b. refer the client to a breast cancer support group
c. identify the impact of the mastectomy on the client's body image
d. encourage the client to assist with her dressing change
Answer: c. identify the impact of the mastectomy on the client's body image
57. A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the
sequence in which the nurse should perform the following steps. (Place them in order of
performance. Use all steps)
3. Percuss all four quadrants of the abdomen to measure sound quality
1. Provide adequate lighting to inspect the abdomen
4 Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen
2. Listen to the abdomen arteries using the bell of a stethoscope
5. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen
Answer: 1. Provide adequate lighting to inspect the abdomen
2. Listen to the abdomen arteries using the bell of a stethoscope
3. Percuss all four quadrants of the abdomen to measure sound quality
4 Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen
5. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen
58. A nurse working on a medical surgical unit is making client assignments for an upcoming
shift. Which of the following tasks should the nurse assign to an assistive personnel?
a. Assisting with ambulation for a client who has a pulmonary infection.
b. Administering medication to a client.
c. Assessing vital signs for a post-operative client.
d. Performing a wound dressing change for a client with a surgical incision.
Answer: a. Assisting with ambulation for a client who has a pulmonary infection.
59. A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe for a
client who has diabetes mellitus. Which of the following actions should the nurse take first?
a. Inject air into the short-acting insulin vial.
b. Inject air into the intermediate insulin vial.

c. Withdraw the short-acting insulin from its vial.
d. Withdraw the intermediate insulin from its vial.
Answer: a. Inject air into the short-acting insulin vial.
60. A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the
following interventions is the priority?
a. Develop a list of goals with the client.
b. Provide emotional support to the client and family.
c. Educate the client about the disease process.
d. Manage pain and symptoms effectively.
Answer: a. Develop a list of goals with the client.
61. A nurse is teaching a client about crutch use following an ankle sprain. Which of the
following actions by the client demonstrate an understanding of the teaching?
a. Holds the crutches with the elbows bent at a 30-degree angle.
b. Places the crutches too far forward when walking.
c. Puts weight on the crutches during the swing phase of gait.
d. Walks with crutches that are adjusted too high.
Answer: a. Holds the crutches with the elbows bent at a 30-degree angle.
62. A nurse is providing discharge instructions to a client about proper use of a cane for
maximum support. Which of the following statements by the client indicates an understanding
of the teaching?
a. I should hold my cane on my stronger side.
b. I should use the cane only when I feel unsteady.
c. I should advance the cane and my weaker leg together.
d. I should shorten the cane for better support.
Answer: a. I should hold my cane on my stronger side.
63. A nurse is caring for a client who requires droplet precautions. Which of the following
actions should the nurse take when wearing a surgical mask?

a. Tie both sets of ties above their ears.
b. Ensure the mask fits snugly over the nose and mouth.
c. Remove the mask by touching the front of it.
d. Reuse the mask if it is not soiled.
Answer: b. Ensure the mask fits snugly over the nose and mouth.
64. A nurse is preparing to insert an IV catheter for a client following a right mastectomy.
Which of the following veins should the nurse select when initiating IV therapy?
a. The cephalic vein in the left distal forearm.
b. The median cubital vein in the right arm.
c. The basilic vein in the right arm.
d. The dorsal venous network in the right hand.
Answer: a. The cephalic vein in the left distal forearm.
65. A nurse on a medical-surgical unit is receiving a change of shift report for four clients.
Which of the following clients should the nurse see first?
a. A client who has new onset of dyspnea 24 hrs after a total hip arthroplasty.
b. A client who is scheduled for discharge and needs education on medications.
c. A client with a fever of 101°F who had surgery 2 days ago.
d. A client who has a pain level of 6 on a scale of 0 to 10.
Answer: a. A client who has new onset of dyspnea 24 hrs after a total hip arthroplasty.
66. A nurse is obtaining informed consent from a client who is scheduled for surgery. The client
states, “I don’t want to go through with this procedure.” Which of the following actions should
the nurse take?
a. Document the client’s decision in the medical record.
b. Encourage the client to reconsider the decision.
c. Inform the surgeon of the client’s decision.
d. Ask the client to sign the consent form anyway.
Answer: a. Document the client’s decision in the medical record.

67. A nurse is assessing an older adult client. Which of the following findings should the nurse
expect?
a. Increased muscle strength.
b. Decreased sense of balance.
c. Enhanced visual acuity.
d. Heightened reflexes.
Answer: b. Decreased sense of balance.
68. A nurse is assessing a client who received morphine for severe pain 30 min ago. The
following finding is the nurse’s priority?
a. Blood pressure 90/60 mmHg.
b. Respiratory rate 7/min.
c. Heart rate 110/min.
d. Oxygen saturation 92%.
Answer: b. Respiratory rate 7/min.
69. A nurse is preparing to transfer a client who is partially weight-bearing from the bed to a
chair. Which of the following actions should the nurse take?
a. Have the client bear weight on her stronger side.
b. Ask the client to walk independently to the chair.
c. Use a lift to transfer the client without assistance.
d. Position the chair far from the bed to encourage movement.
Answer: a. Have the client bear weight on her stronger side.
70. A nurse is caring for a client who has brain cancer and is transferring to hospice care. The
client’s son tells the nurse, “I don’t know what to tell my dad if he asks how he is going to die.”
Which of the following is an appropriate response by the nurse?
a. "Let's talk more about your dad's condition."
b. "You should reassure him that everything will be okay."
c. "Just tell him not to worry about it."
d. "It's best if you don’t discuss it with him."

Answer: a. "Let's talk more about your dad's condition."
71. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG
tube. Which of the following actions should the nurse take?
a. Secure the restraints tightly around the client's wrists.
b. Allow room for two fingers to fit between the client's skin and the restraints.
c. Use soft cloth restraints only.
d. Remove the restraints every hour to assess circulation.
Answer: b. Allow room for two fingers to fit between the client's skin and the restraints.
72. A nurse is admitting a client who is at risk for falls to a medical surgical unit. Which of the
following actions should the nurse take?
a. Provide the patient with a night light.
b. Encourage the client to use the bathroom independently.
c. Keep the bed in a low position only.
d. Place a rug beside the bed for comfort.
Answer: a. Provide the patient with a night light.
73. A nurse manager overhears a nurse telling a client, “I will administer your medication by
injection if you don’t swallow your pills.” The nurse manager should identify that the nurse is
committing which of the following torts?
a. Battery.
b. Negligence.
c. Assault.
d. Defamation.
Answer: c. Assault.
74. A nurse is caring for a client who has pneumonia. The nurse should recognize that which of
the following should be discarded in a biohazard bag?
a. A used emesis basin filled with blood from severe coughing.
b. A disposable thermometer.

c. A soiled bed sheet.
d. A used nasal cannula.
Answer: a. A used emesis basin filled with blood from severe coughing.
75. A nurse is caring for a client who is receiving enteral feedings via NG tube. Which of the
following actions should the nurse take prior to administering the formula?
a. Check for gastric residual volume.
b. Aspirate the tube to check for placement.
c. Warm the formula to room temperature.
d. Administer a flushing solution before the feeding.
Answer: a. Check for gastric residual volume.
76. A nurse is planning care for a client who reports having a latex allergy. Which of the
following should the nurse include in the plan?
a. Schedule the client as the first surgical procedure of the day.
b. Cover the blood pressure cuff with a stockinette.
c. Use latex gloves only when necessary.
d. Inform all staff about the allergy.
Answer: d. Inform all staff about the allergy.
77. A nurse is teaching a client who has diabetes mellitus about mixing regular insulin and NPH
insulin. Which of the following statements by the client indicates an understanding of the
teaching?
a. "I should draw up the NPH insulin first."
b. "I should roll the vial of NPH insulin between my hands before drawing it up."
c. "I can mix the insulins in any order."
d. "I should shake the NPH insulin vigorously before use."
Answer: b. "I should roll the vial of NPH insulin between my hands before drawing it up."
78. A nurse is collecting a sputum specimen for culture from a client who has a respiratory
infection. Which of the following actions should the nurse take?

a. Offer the client oral hygiene after the collection.
b. Instruct the client to rinse their mouth before collecting the specimen.
c. Use a sterile container to collect the specimen.
d. Encourage the client to cough deeply to produce the specimen.
Answer: d. Encourage the client to cough deeply to produce the specimen.
79. A nurse receives a telephone prescription from a provider for a client who is experiencing
pain. Which of the following responses should the nurse make?
a. "Will you please repeat the dosage?"
b. "Can you clarify the frequency of this medication?"
c. "Will you please spell the name of the medication for me?"
d. "What is the route for this medication?"
Answer: c. "Will you please spell the name of the medication for me?"
80. A nurse administers an incorrect medication to a client and identifies the error. Which of the
following actions should the nurse take first?
a. Report the error to the client’s provider.
b. Document the error in the medical record.
c. Assess the client for adverse effects.
d. Notify the charge nurse about the error.
Answer: c. Assess the client for adverse effects.
81. A nurse is preparing to obtain a health history from a client. Which of the following actions
should the nurse take?
a. Explain the purpose of collecting the information.
b. Ask the client to fill out a questionnaire.
c. Begin with a physical examination.
d. Collect the data in a private area without introduction.
Answer: a. Explain the purpose of collecting the information.

82. A nurse is collecting data from a client who is postoperative and received an opioid
analgesic for pain. Which of the following findings should the nurse identify as an adverse
effect of this medication?
a. Nausea
b. Drowsiness
c. Urinary retention
d. Hypotension
Answer: c. Urinary retention.
83. A nurse is preparing to administer several medications to a client. Which of the following
data should the nurse plan to use to confirm the client’s identity?
a. The client's name and date of birth.
b. The client's room number.
c. The client's telephone number.
d. The client's medical record number.
Answer: a. The client's name and date of birth.
84. A nurse is admitting a client who is malnourished. The client states, "My wedding ring is
loose, and I’m worried I will lose it if it falls off." Which of the following is an appropriate
response by the nurse?
a. "You should remove it immediately."
b. "Lock it in a storage unit."
c. "You can wear it; just be careful."
d. "I can help you find a safe place to store it."
Answer: d. "I can help you find a safe place to store it."
85. A nurse is providing teaching about health promotion guidelines to a group of young adult
male clients. Which of the following guidelines should the nurse include?
a. "Have a testicular examination every 2 years."
b. "Schedule a prostate exam annually."
c. "Perform a self-testicular exam monthly."

d. "Get a colonoscopy every 5 years."
Answer: c. "Perform a self-testicular exam monthly."
86. A reading from a client who is sitting in a chair shows a blood pressure of 159/96 mm Hg.
Which of the following actions should the nurse take?
a. Recheck the client’s BP in her arm for comparison.
b. Ask the client about any recent activity.
c. Notify the healthcare provider immediately.
d. Document the reading as normal.
Answer: a. Recheck the client’s BP in her arm for comparison.
87. A nurse is documenting in a client’s medical record. Which of the following entries should
the nurse record?
a. "Oral temp slightly elevated at 0800."
b. "Client states he feels fine."
c. "Nurse observed the client looking well."
d. "Client is improving."
Answer: a. "Oral temp slightly elevated at 0800."
88. A nurse is conducting a health assessment for a client who takes herbal supplements. Which
of the following statements by the client indicates understanding of the supplements?
a. "I use ginger when I get car sick."
b. "I take St. John's Wort for my anxiety."
c. "I think all herbal supplements are safe."
d. "I use garlic for my cholesterol."
Answer: a. "I use ginger when I get car sick."
89. A nurse is assessing the body temperature of an adult client using a temporal artery
thermometer. Which of the following actions should the nurse take? (Select all that apply.)
a. Slide the probe across the client's forehead.
b. Hold the client's hair aside while performing the procedure.

c. Place the probe on the center of the forehead.
d. Wait 30 seconds after the client has been outside.
e. Press the button while sliding the probe.
Answer: a. Slide the probe across the client's forehead
e. Press the button while sliding the probe.
90. A nurse is providing oral care for a client who is unconscious. Which of the following
actions should the nurse take?
a. Place the client in a side-lying position.
b. Use a firm toothbrush to clean the teeth.
c. Offer the client water to rinse.
d. Keep the mouth closed while cleaning.
Answer: a. Place the client in a side-lying position.
91. A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the
following actions should the nurse take to help dilate the vein?
a. Dangle the client's arm over the edge of the bed.
b. Apply a tourniquet tightly above the insertion site.
c. Use a warm compress on the arm for 10 minutes.
d. Encourage the client to flex and extend their fingers.
Answer: a. Dangle the client's arm over the edge of the bed.
92. A nurse is collecting vital signs from a client. Which of the following actions should the
nurse take when measuring the client’s blood pressure?
a. Apply the cuff 2.5 cm (1 inch) above the client's antecubital space.
b. Place the cuff on the client's forearm.
c. Use a narrow cuff for accurate measurement.
d. Inflate the cuff to 200 mmHg.
Answer: a. Apply the cuff 2.5 cm (1 inch) above the client's antecubital space.

93. A nurse is obtaining the medication history of a client who asks about taking ginkgo. The
nurse should identify which of the following medications can interact with this supplement?
a. Acetaminophen
b. Warfarin
c. Lisinopril
d. Metformin
Answer: b. Warfarin.
94. A charge nurse in a long-term care facility is preparing an educational program about
delirium for newly hired nurses. Which of the following statements should the nurse plan to
include?
a. Delirium has a gradual onset.
b. Delirium is often reversible.
c. Delirium is the same as dementia.
d. Delirium occurs only in older adults.
Answer: b. Delirium is often reversible.
95. A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium
chloride 600 mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV
bolus, 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. The
nurse should record the client’s net fluid intake as how many mL?
a. 700 mL
b. 440 mL
c. 660 mL
d. 800 mL
Answer: a. 700 mL
96. A nurse is performing postural drainage with percussion and vibration for a client who has
cystic fibrosis. Which of the following actions should the nurse take?
a. Instruct the client to exhale quickly during vibration.
b. Percuss over the rib cage to avoid injury.

c. Position the client flat on their back.
d. Encourage the client to breathe deeply during percussion.
Answer: a. Instruct the client to exhale quickly during vibration.
97. A nurse is mixing short-acting insulin and intermediate-acting insulin in the same syringe
for a client who has diabetes mellitus. Which of the following actions should the nurse take
first?
a. Inject air into the intermediate-acting insulin vial.
b. Inject air into the short-acting insulin vial.
c. Withdraw the short-acting insulin first.
d. Withdraw the intermediate-acting insulin first.
Answer: a. Inject air into the intermediate-acting insulin vial.
98. A nurse is implementing seizure precautions for a client who has a seizure disorder. Which
of the following equipment should the nurse place at the client’s bedside? (Select all that apply.)
a. Oral airway
b. Oral suction equipment
c. Extra padding for the bedrails
d. Oxygen supply
e. Restraints
Answer: a. Oral airway
b. Oral suction equipment.
99. A nurse is caring for a client who has wrist restraints after an episode of violent behavior.
Which of the following actions should the nurse take?
a. Remove both restraints at the same time.
b. Remove one restraint at a time.
c. Check the restraints every 8 hours.
d. Document the use of restraints after applying them.
Answer: b. Remove one restraint at a time.

100. A nurse is teaching a client who is about to undergo bowel resection about advance
directives. Which of the following should the nurse include in the teaching?
a. "You will receive written information about advance directives prior to signing."
b. "Advance directives are not necessary for this procedure."
c. "You must complete the advance directive before the surgery."
d. "Advance directives can be changed at any time without notice."
Answer: a. "You will receive written information about advance directives prior to signing."
101. A nurse is collaborating with a risk management team about potential legal issues
involving client care. The nurse should identify that which of the following situations is an
example of negligence?
a. A nurse administers a medication without first identifying the client.
b. A nurse forgets to document a medication given.
c. A nurse discusses a client’s condition with a family member without permission.
d. A nurse fails to assess a client’s pain level after surgery.
Answer: a. A nurse administers a medication without first identifying the client.
102. A nurse is admitting a client who has TB. Which transmission-based precautions should
the nurse initiate?
a. Contact
b. Droplet
c. Airborne
d. Standard
Answer: c. Airborne.
103. A nurse is inserting an NG tube for a client who requires gastric decompression. Which of
the following actions should the nurse take to verify proper placement of the tube?
a. Auscultate for bowel sounds.
b. Measure the pH of the gastric aspirate.
c. Check the length of the tube outside the body.
d. X-ray verification only.

Answer: b. Measure the pH of the gastric aspirate.
104. A nurse is caring for a client who has a tracheostomy. Which of the following actions
should the nurse take?
a. Clean the skin around the stoma with normal saline.
b. Use hydrogen peroxide to clean the stoma area.
c. Change the tracheostomy ties every 2 days.
d. Leave the tracheostomy cuff inflated at all times.
Answer: a. Clean the skin around the stoma with normal saline.
105. A nurse is caring for a client who has left lower lobe atelectasis. In which of the following
positions should the nurse place the client for postural drainage?
a. Supine with legs elevated.
b. Prone with pillows under the lower extremities.
c. Side-lying on the right side.
d. Semi-Fowler's position.
Answer: c. Side-lying on the right side.
106. A nurse is performing a skin assessment on an older adult client. Which of the following
should the nurse expect?
a. Increased skin elasticity
b. Reduced sweat production
c. Thicker skin
d. Increased oil production
Answer: b. Reduced sweat production
107. A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the
following findings should the nurse expect?
a. Weight gain
b. Postural hypotension
c. Increased urine output

d. Elevated blood pressure
Answer: b. Postural hypotension
108. A home health nurse is caring for a client who has a chronic illness and recently moved in
with their adult child. Which of the following statements by the client indicates to the nurse that
the client has adapted to their new situational role?
a. "I feel like a burden to my child."
b. "I enjoy being able to help around the house."
c. "It’s nice having other people cook for me."
d. "I miss my independence."
Answer: c. "It’s nice having other people cook for me."
109. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who
has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which
of the following images indicates the correct number of mL the nurse should administer?
(Round the answer to the nearest whole number.)
a. 5 mL
b. 8 mL
c. 10 mL
d. 15 mL
Answer: b. 8 mL
110. A nurse is providing teaching to a client about the need to increase iron in their diet. Which
of the following food choices should the nurse include as the best source of iron?
a. 1 cup of spinach
b. 32 g (1/4 cup) lentils
c. 3 oz of chicken
d. 1/2 cup of tofu
Answer: b. 32 g (1/4 cup) lentils

111. A nurse is caring for a client who is prescribed a special diet. The client is concerned that
he does not have the resources he needs to adhere to the diet at home. The nurse should notify
which of the following members of the health care team?
a. Social worker
b. Dietitian
c. Case manager
d. Physician
Answer: a. Social worker
112. A nurse is caring for a client who was recently diagnosed with a terminal illness. The client
tells the nurse, “I am looking forward to seeing my grandchildren grow up.” The nurse should
identify that the client is experiencing which stage of grief?
a. Denial
b. Anger
c. Bargaining
d. Acceptance
Answer: d. Acceptance
113. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on
clients who are confused. Which of the following instructions should the staff nurse include?
a. Check on patients as they go to the bathroom.
b. Offer distractions such as music or television.
c. Increase the client's sedation levels.
d. Restrict visitors to reduce confusion.
Answer: b. Offer distractions such as music or television.
114. A nurse is assessing a client’s extraocular eye movements. Which of the following actions
should the nurse take?
a. Instruct the client to blink rapidly.
b. Instruct the client to follow a finger through the six cardinal positions of gaze.
c. Have the client read from a chart.

d. Shine a light in each eye.
Answer: b. Instruct the client to follow a finger through the six cardinal positions of gaze.
115. A nurse is teaching a client about performing breast self-examinations. Which of the
following statements by the client indicates an understanding of the teaching?
a. "I will perform circular motions with my fingertips under the arm."
b. "I will only check my breasts when I feel a lump."
c. "I should examine my breasts once a year."
d. "I can do the examination while lying flat on my back."
Answer: a. "I will perform circular motions with my fingertips under the arm."
116. A nurse manager is discussing an incident report with a group of newly licensed nurses.
Which of the following situations should the nurse manager identify as requiring an incident
report?
a. A visitor experienced an injury while in a client's room.
b. A client complains about the food quality.
c. A nurse forgets to document a medication.
d. A client expresses dissatisfaction with their care.
Answer: a. A visitor experienced an injury while in a client's room.
117. To ensure client safety, a nurse manager is planning to observe a newly licensed nurse
perform a straight catheterization. In which of the following roles is the nurse manager
functioning?
a. Educator
b. Client advocate
c. Supervisor
d. Mentor
Answer: c. Supervisor

118. During change of shift report, a nurse discovers she overlooked a prescription for a type
and crossmatch of a client who is to have surgery the next day. Which of the following actions
should the nurse take first?
a. Notify the surgeon about the oversight.
b. Obtain the client’s type and crossmatch.
c. Document the oversight in the client’s record.
d. Inform the nursing supervisor.
Answer: b. Obtain the client’s type and crossmatch.
119. A nurse is providing teaching to a client about reducing the adverse effects of immobility.
Which of the following statements by the client indicates an understanding of the teaching?
a. "I will perform ankle and knee exercises every hour."
b. "I will remain in bed as much as possible."
c. "I will only move when I feel comfortable."
d. "I will take long walks every day."
Answer: a. "I will perform ankle and knee exercises every hour."
120. A nurse is obtaining a health history while admitting a client. The client tells the nurse, “I
am under a lot of stress right now.” Which of the following manifestations should the nurse
expect?
a. Elevated heart rate
b. Increased appetite
c. Decreased blood pressure
d. Reduced anxiety
Answer: a. Elevated heart rate
121. A nurse on a medical-surgical unit is teaching newly licensed nurses about tasks to
delegate to assistive personnel (AP). Which of the following statements by the newly licensed
nurse indicates an understanding of the teaching?
a. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement
fluids."

b. "An AP can administer medications to clients."
c. "An AP should assist with feeding clients who require help."
d. "An AP may perform an assessment on a newly admitted client."
Answer: c. "An AP should assist with feeding clients who require help."
122. A nurse is caring for a group of clients. Which of the following clients should the nurse
assign to an assistive personnel?
a. A client who had a stroke 2 days ago and needs help toileting.
b. A client with unstable vital signs who needs monitoring.
c. A client receiving chemotherapy who has nausea.
d. A client who requires assistance with bathing and grooming.
Answer: d. A client who requires assistance with bathing and grooming.
123. A nurse is caring for a client who has a new prescription for negative pressure therapy for a
chronic wound. The nurse is unfamiliar with the procedure. Which of the following resources
should the nurse consult to learn more about the intervention?
a. The material safety data sheet
b. Hospital policies and procedures manual
c. A clinical practice guideline
d. The client’s medical record
Answer: c. A clinical practice guideline
124. A nurse is planning discharge for a client who had a stroke and has difficulty holding
utensils at mealtime. Which of the following referrals should the nurse anticipate?
a. Physical therapy
b. Speech therapy
c. Occupational therapy
d. Recreational therapy
Answer: c. Occupational therapy

125. A nurse is discussing incident reports with a group of newly licensed nurses. The nurse
should include that which of the following situations requires the completion of an incident
report?
a. A client's prescribed laboratory testing was not obtained.
b. A client asks for a medication refill.
c. A nurse provides care that deviates from the standard procedure.
d. A visitor expresses dissatisfaction with the hospital food.
Answer: a. A client's prescribed laboratory testing was not obtained.
126. A nurse is caring for a client who has terminal cancer. Which of the following actions
should the nurse take to promote the client’s autonomy?
a. Allow the client to choose treatment times.
b. Recommend the best treatment options.
c. Make decisions based on the client’s family input.
d. Limit the client's choices to avoid confusion.
Answer: a. Allow the client to choose treatment times.
127. A charge nurse is monitoring the documentation of medications by a newly licensed nurse.
The charge nurse should intervene if the newly licensed nurse uses which of the following
abbreviations?
a. QID
b. PO
c. Qd
d. BID
Answer: c. Qd
128. A nurse is testing a client for conduction deafness by performing the Weber’s test. Which
of the following actions should the nurse take when performing the test?
a. Place the base of the vibrating tuning fork on the top of the client’s head.
b. Hold the tuning fork in front of the client’s ears.
c. Place the fork on the mastoid bone behind the ear.

d. Strike the tuning fork against a hard surface.
Answer: a. Place the base of the vibrating tuning fork on the top of the client’s head.
129. A nurse is preparing to bathe a client who has dementia. Which of the following actions
should the nurse take?
a. Use distraction when bathing the client.
b. Rush through the process to reduce anxiety.
c. Explain each step in detail before starting.
d. Allow the client to bathe independently.
Answer: a. Use distraction when bathing the client.
130. A nurse is caring for a client who has urinary incontinence. Which of the following
interventions should the nurse take to prevent skin breakdown?
a. Request a prescription for an indwelling catheter.
b. Perform regular skin assessments and keep the skin clean and dry.
c. Apply moisture barrier cream after each episode.
d. Limit fluid intake to decrease urine output.
Answer: b. Perform regular skin assessments and keep the skin clean and dry.
131. A nurse is caring for a client who has a colostomy. Which of the following actions should
the nurse take?
a. Rub the peristomal skin dry after cleaning.
b. Use soap and water to cleanse the stoma.
c. Apply a new pouch immediately after cleaning.
d. Allow the peristomal area to air dry completely before applying a new pouch.
Answer: d. Allow the peristomal area to air dry completely before applying a new pouch.
132. A nurse is preparing a client who has terminal cancer for discharge. Which of the following
questions should the nurse ask when assessing the client’s psychosocial history?
a. "What techniques do you use to cope with stress?"
b. "How has your treatment been so far?"

c. "Do you have any family support?"
d. "What are your plans for the future?"
Answer: a. "What techniques do you use to cope with stress?"
133. A nurse is preparing change of shift report after the night using the ISBAR communication
tool. Which of the following data should the nurse include reporting background information?
a. Start first dose of penicillin at 1200.
b. The patient has a history of hypertension.
c. The patient was admitted with a broken leg.
d. The patient’s vital signs are stable.
Answer: c. The patient was admitted with a broken leg.
134. A nurse is changing a client’s colostomy pouch and notices peristomal skin irritation.
Which of the following actions should the nurse take?
a. Change the pouch once every 24 hr to prevent infection.
b. Apply a barrier cream to the irritated skin.
c. Use an alcohol-based cleanser on the peristomal area.
d. Leave the pouch off for an extended time to air out the skin.
Answer: b. Apply a barrier cream to the irritated skin.
135. A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a
cast. Which of the following actions should the nurse take?
a. Place the shallow end of the fracture pan under the client’s buttocks.
b. Elevate the foot of the bed to assist with positioning.
c. Ensure the pan is positioned at a 45-degree angle.
d. Have the client lift themselves onto the bedpan.
Answer: a. Place the shallow end of the fracture pan under the client’s buttocks.
136. A nurse is teaching a client about dietary recommendations to lower high blood pressure.
Which of the following statements by the client indicates an understanding of the teaching?
a. I should consume low fat dairy products.

b. I should avoid all dairy products.
c. I should eat more red meat.
d. I should increase my intake of processed foods.
Answer: a. I should consume low fat dairy products.
137. The nurse provides dietary instructions to a client who needs to limit intake of sodium. The
nurse instructs the client that which food items must be avoided because of their high sodium
content? (SATA)
a. Ham
b. Soy sauce
c. Fresh fruits
d. Whole grains
Answer: a. Ham
b. Soy sauce
138. A nurse is teaching a client about high fiber foods that can assist in lowering LDL. Which
of the following foods should be included in the teaching?
a. Beans
b. Whole grains
c. Broccoli
d. All of the above
Answer: d. All of the above
139. A nurse is creating a plan of care for a client who has left hemiplegia. Which of the
following interventions should the nurse include?
a. Apply an orthotic boot on the client’s left foot.
b. Encourage the client to use the right hand for all tasks.
c. Restrict mobility to prevent falls.
d. Provide assistive devices for the right hand.
Answer: a. Apply an orthotic boot on the client’s left foot.

140. A nurse is caring for a client who has a drainage evacuator. Which of the following is an
appropriate action by the nurse?
a. Measure drainage by emptying into a graduated cylinder.
b. Estimate the amount of drainage in the evacuator.
c. Change the evacuator every 48 hours.
d. Document drainage as soon as it is observed.
Answer: a. Measure drainage by emptying into a graduated cylinder.
141. A nurse is preparing to suction a client who has a tracheostomy. Which of the following
should the nurse do first?
a. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning.
b. Set up the suction equipment.
c. Administer a bronchodilator.
d. Explain the procedure to the client.
Answer: a. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning.
142. A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing
the client’s signature, the client states, “But I don’t understand what is meant by resecting my
intestines.” Which of the following actions should the nurse take?
a. Notify the provider.
b. Explain the procedure in detail.
c. Ask the client to proceed with signing.
d. Document the client's statement.
Answer: a. Notify the provider.
143. A nurse is obtaining informed consent from a client who is scheduled for surgery. The
client states, “I don’t want to go through with the procedure.” Which of the following actions
should the nurse take?
a. Document the client’s decision in the medical record.
b. Encourage the client to reconsider.
c. Inform the client about the benefits of the procedure.

d. Ask the client to sign the consent anyway.
Answer: a. Document the client’s decision in the medical record.
144. A nurse is documenting client care. Which of the following abbreviations should the nurse
use?
a. BRP for bathroom privileges
b. PO for orally
c. BID for twice a day
d. QD for daily
Answer: a. BRP for bathroom privileges.
145. A nurse is providing discharge teaching for an older adult who has heart failure and lives
alone. Which of the following should the nurse include in the teaching?
a. Use a night light in the bathroom.
b. Limit fluid intake to less than 1 liter daily.
c. Avoid all forms of exercise.
d. Keep the television on for background noise.
Answer: a. Use a night light in the bathroom.
146. A nurse is teaching assistive personnel about postmortem care of a client who practiced
Buddhism. Which of the following statements by the AP indicates understanding of the
teaching?
a. The family might stand at the head of the client’s bed to say prayers.
b. The body should be covered immediately after death.
c. The client’s personal items should be removed.
d. The family can only visit during designated hours.
Answer: a. The family might stand at the head of the client’s bed to say prayers.
147. A nurse is caring for a client who reports a pain level of 5 on a scale of 0 to 10. The client
informs the nurse that pain medications are not an option for managing pain. Which of the
following is an appropriate response by the nurse?

a. Why do you think pain medication is not going to help you?
b. Let’s discuss some alternative methods for pain management.
c. Pain medications are the best way to manage your pain.
d. You should really consider taking the medication.
Answer: b. Let’s discuss some alternative methods for pain management.
148. A nurse is completing discharge teaching about ostomy care with a client who has a new
stoma. Which of the following instructions should the nurse include in the teaching? (SATA)
a. "Cut the opening of the pouch 1/8 of an inch larger than the ostomy."
b. "Place a piece of gauze over the stoma while changing the pouch."
c. "Empty the pouch when it becomes ⅓ full of content."
d. "Clean the stoma with soap and water."
Answer: a. "Cut the opening of the pouch 1/8 of an inch larger than the ostomy."
c. "Empty the pouch when it becomes ⅓ full of content."
149. A nurse is caring for a client who is postoperative and has a new prescription to advance
her diet to full liquids. Which of the following foods should the nurse offer the client?
a. Plain yogurt
b. Grilled chicken
c. Steamed vegetables
d. Brown rice
Answer: a. Plain yogurt
150. A nurse is administering a buccal tablet to a client. Which of the following should the
nurse give the client?
a. Let the tablet dissolve against the inside of your cheek.
b. Chew the tablet thoroughly before swallowing.
c. Swallow the tablet with water.
d. Place the tablet under your tongue.
Answer: a. Let the tablet dissolve against the inside of your cheek.

151. The nurse is planning to obtain a blood sample from a client for a capillary blood glucose
test. Which of the following sites should the nurse plan to select to obtain the sample?
a. Earlobe
b. Heel
c. Pad of the fingertip
d. Side of the finger
Answer: c. Pad of the fingertip
152. A nurse enters a client's room and discovers a smoldering fire in the drapes. After moving
clients to a safe location, which of the following actions should the nurse take next?
a. Pull the fire alarm
b. Use a fire extinguisher
c. Close the door to the client’s room
d. Douse the fire with water
Answer: a. Pull the fire alarm
153. A nurse is planning to discharge a client who has diabetes mellitus and a new prescription
for insulin. Which of the following actions should the nurse plan to complete first?
a. Assess the client's visual acuity
b. Observe the client’s insulin injection technique
c. Obtain printed information about insulin self-administration
d. Determine the client’s understanding of glucose monitoring
Answer: c. Obtain printed information about insulin self-administration
154. A nurse is planning to prevent skin breakdown for a client who is immobile and has urinary
incontinence. Which of the following actions should the nurse include in the plan of care?
a. Apply a moisture barrier ointment
b. Request a prescription for an indwelling urinary catheter
c. Use a donut-shaped cushion
d. Reposition the client every 4 hours
Answer: a. Apply a moisture barrier ointment

155. A nurse in an acute care facility is preparing to transfer a client to a long-term care facility.
Which of the following information should the nurse include in the hand-off report?
a. Client’s preferred bath time
b. Client’s marital status
c. Effectiveness of the last dose of pain medication
d. Date of client’s last admission to the hospital
Answer: c. Effectiveness of the last dose of pain medication
156. A nurse is teaching a client how to perform a breast self-examination (BSE). Which of the
following instructions should the nurse include?
a. Use the palm of your hand to examine each breast
b. Squeeze the nipple to look for discharge
c. Perform the exam in the shower with soap
d. Examine your breasts every 6 months
Answer: b. Squeeze the nipple to look for discharge
157. A nurse is teaching a client how to self-administer daily low-dose heparin injections.
Which of the following factors is most likely to increase the client’s motivation to learn?
a. The client's belief that his needs will be met through education
b. The nurse’s use of simple language
c. The nurse’s positive reinforcement
d. The client’s family involvement
Answer: a. The client's belief that his needs will be met through education
158. A nurse is caring for a client who is receiving continuous enteral feedings through a
gastrostomy tube. Which of the following actions should the nurse take?
a. Flush the tube with 60 mL of water every 8 hours
b. Aspirate residual volume every 4 hours
c. Replace the tubing every 72 hours
d. Heat the formula to 40°C (104°F)

Answer: b. Aspirate residual volume every 4 hours
159. A nurse is caring for a client who has an incisional wound and a prescription for wound
care. Which of the following images indicates the proper method of cleaning a wound site?
a. Wiping outward
b. Wiping in a circular motion
c. Wiping from the outer edge to the center
d. Wiping in a back-and-forth motion
Answer: a. Wiping outward
160. A nurse is teaching a client who requires maximum support about how to use a twowheeled walker. Which of the following actions by the client indicates an understanding of the
teaching?
a. The client stands with her elbows slightly flexed while holding the walker
b. The client picks up the walker and moves it forward
c. The client uses a smooth, continuous motion while moving the walker
d. The client’s arms remain straight when using the walker
Answer: a. The client stands with her elbows slightly flexed while holding the walker
161. A nurse is caring for a client who refuses to follow the provider’s prescription for bed rest.
The nurse overhears an assistive personnel tell the client that if she does not remain in bed, he
will place her in restraints. The nurse should identify that the AP is committing which of the
following torts?
a. Negligence
b. Battery
c. Defamation
d. Assault
Answer: d. Assault
162. A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin.
Which of the following actions should the nurse take?

a. Use a tourniquet above the insertion site
b. Shave the area prior to insertion
c. Tap the vein vigorously to increase blood flow
d. Engorge the vein by placing the arm in a dependent position
Answer: d. Engorge the vein by placing the arm in a dependent position
163. A nurse is preparing to obtain informed consent from a client who speaks a different
language than the nurse. Which of the following actions should the nurse take?
a. Use written material in the client’s language
b. Avoid using gesture when speaking to the client
c. Explain the procedure using medical terminology
d. Ask a family member to translate
Answer: a. Use written material in the client’s language
164. A nurse is caring for a client who is grieving the loss of her partner. The client states, “I
don’t see the point of living anymore.” Which of the following actions should the nurse take?
a. Change the subject to distract the client
b. Ask the client if she plans to harm herself
c. Offer to contact the hospital chaplain
d. Tell the client to focus on positive memories
Answer: b. Ask the client if she plans to harm herself
165. A community health nurse is caring for a group of families. The nurse should identify
which of the following families is experiencing a maturational loss?
a. A family whose oldest child is moving away for college
b. A family whose dog recently died
c. A family experiencing divorce
d. A family whose home was destroyed in a fire
Answer: a. A family whose oldest child is moving away for college

166. A nurse is admitting a client who has C Diff infection. Which of the following actions
should the nurse take? (Select All That Apply.)
a. Wash hands with soap and water after contact with the client.
b. Wear a gown and gloves when providing client care.
c. Place the client in a semi-private room.
d. Use alcohol-based hand sanitizer after contact with the client.
e. Use a surgical mask when entering the client’s room.
Answer: a. Wash hands with soap and water after contact with the client.
b. Wear a gown and gloves when providing client care.
167. A nurse is preparing to obtain health history information from a client. Which of the
following actions should the nurse take?
a. Collect the information as quickly as possible.
b. Avoid asking sensitive questions.
c. Tell the client the purpose of collecting information.
d. Perform a physical assessment first.
Answer: c. Tell the client the purpose of collecting information.
168. A nurse is caring for a client who is crying and states, “I’m fine.” Which of the following
actions should the nurse take?
a. Tell the client to stop crying.
b. Offer to sit quietly next to the client.
c. Continue with the planned care.
d. Avoid discussing the client's feelings.
Answer: b. Offer to sit quietly next to the client.
169. A nurse is caring for a client following abdominal surgery. Which of the following findings
should the nurse report to the provider?
a. Blood pressure of 120/80 mm Hg
b. Urine output of 80 mL in 4 hr
c. Temperature of 37.5°C (99.5°F)

d. Heart rate of 90/min
Answer: b. Urine output of 80 mL in 4 hr
170. A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a
prescription for ondansetron 4 mg IV bolus every 6 hr PRN for nausea and vomiting. Identify
the sequence of steps the nurse should follow to administer the medication.
a. Perform hand hygiene
b. Select the injection port of the IV tubing closest to the client
c. Cleanse the injection port with an antiseptic swab
e. Inject the medication
d. Aspirate for a blood return
Answer: The correct sequence is as follows:
a. Perform hand hygiene
b. Select the injection port of the IV tubing closest to the client
c. Cleanse the injection port with an antiseptic swab
d. Aspirate for a blood return
e. Inject the medication
171. A nurse measures a client's blood pressure and finds a significant decrease in systolic
pressure and a significant increase in diastolic pressure from baseline measurement. The nurse
should identify that which of the following potential errors in technique has occurred?
a. Deflating the cuff too slowly
b. Using a cuff that is too wide
c. Wrapping the cuff too loosely
d. Positioning the arm above the level of the heart
Answer: c. Wrapping the cuff too loosely
172. A nurse on a medical-surgical unit is providing care for four clients. The nurse should
identify which of the following situations as an ethical dilemma?
a. A client who has a history of smoking requests medication for a persistent cough.
b. A client has a prescription for DNR, but the family wants the nurse to perform resuscitation.

c. A client who has a terminal illness asks for information about palliative care services.
d. The family of a client who has a terminal illness asks the provider not to tell the client the
diagnosis.
Answer: d. The family of a client who has a terminal illness asks the provider not to tell the
client the diagnosis.
173. A nurse enters the room of a client who has a seizure disorder. The client is sitting in a
chair and begins to experience a seizure. Which of the following actions should the nurse take
first?
a. Help the client lie on the floor.
b. Prepare to insert an oral airway.
c. Move furniture away from the client.
d. Check the client's airway patency.
Answer: a. Help the client lie on the floor.
174. A nurse is planning care for a client who is disoriented, has a history of wandering, and is
at risk for falling. Which of the following actions should the nurse plan to take?
a. Apply a motion sensor alarm to the client's bed.
b. Dim the lights in the client's room.
c. Place the client's bed in the lowest position.
d. Keep the door to the client's room closed.
Answer: a. Apply a motion sensor alarm to the client's bed.
175. A nurse is caring for a client who has a prescription for crutches. The nurse should initiate
a referral for which of the following members of the interprofessional team?
a. Social worker
b. Physical therapist
c. Occupational therapist
d. Speech therapist
Answer: b. Physical therapist

176. A nurse is teaching a client who reports experiencing chronic low-back pain. Which of the
following instructions should the nurse include in the teaching?
a. Sleep on the stomach to reduce pain.
b. Keep feet wide apart when lifting objects.
c. Maintain bed rest for at least 48 hr.
d. Wear high-heeled shoes when standing for long periods.
Answer: b. Keep feet wide apart when lifting objects.
177. A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which
of the following responses should the nurse make?
a. "Don’t worry, we can treat this disease."
b. "It must be very difficult for you to receive this kind of news."
c. "There is no need to cry; I am here to help you."
d. "I think you should get a second opinion."
Answer: b. "It must be very difficult for you to receive this kind of news."
178. A nurse is planning care for a client who reports insomnia. Which of the following actions
should the nurse perform shortly before bedtime?
a. Perform range of motion exercises.
b. Offer a cup of coffee.
c. Provide a large meal.
d. Play loud music.
Answer: a. Perform range of motion exercises.
179. A nurse is caring for a client who has influenza and isolation precautions in place. Which
of the following actions should the nurse take to prevent the spread of infection?
a. Place the client in a room with positive airflow.
b. Wear a gown when performing client care.
c. Wear a mask when working within 3 ft of the client.
d. Place a surgical mask on the client during transport.
Answer: c. Wear a mask when working within 3 ft of the client.

180. A nurse is teaching a newly licensed nurse about the care of a client who has methicillinresistant staphylococcus aureus (MRSA) infection. Which of the following statements by the
newly licensed nurse indicates an understanding of the teaching?
a. "I will place the client in a private room."
b. "I will wear an N95 respirator when caring for the client."
c. "I will remove PPE after leaving the client's room."
d. "I will wear a face shield when providing care."
Answer: a. "I will place the client in a private room."
181. A nurse is caring for a client who is immunocompromised. Which of the following actions
should the nurse take?
a. Avoid administering live vaccines to the client.
b. Use alcohol-based hand rub before entering the client's room.
c. Have the client apply a mask when children are visiting.
d. Use sterile gloves for all client care.
Answer: c. Have the client apply a mask when children are visiting.
182. A nurse is providing teaching to a client who is preoperative for a total hip arthroplasty.
Which of the following findings should the nurse identify as a barrier to learning?
a. Report pain as 8 on a scale of 0-10
b. Is watching television
c. Requests a family member to be present
d. Expresses interest in reading pamphlets
Answer: a. Report pain as 8 on a scale of 0-10
183. A nurse is discussing the use of complementary therapies with a client who has anxiety due
to partner violence. The nurse should identify the client's source of anxiety as a possible
contraindication for which of the following types of complementary therapy?
a. Meditation
b. Aromatherapy

c. Acupuncture
d. Guided imagery
Answer: a. Meditation
184. A nurse is teaching a client about home care of oxygen equipment. Which of the following
information should the nurse include in the teaching? (Select all that apply)
a. Align the middle of the ball in the flow meter with the line of prescribed flow rate
b. Check the oxygen delivery rate at least once per day
c. Use petroleum jelly to lubricate the client's lips and nostrils
d. Store oxygen tanks in an upright position
e. Avoid using wool blankets when receiving oxygen
Answer: a. Align the middle of the ball in the flow meter with the line of prescribed flow rate
b. Check the oxygen delivery rate at least once per day
e. Avoid using wool blankets when receiving oxygen
185. A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of
the following findings should the nurse identify as an indication of a possible anaphylactic
reaction to the medication?
a. Report of nausea
b. A sharp decrease in blood pressure
c. Presence of urticaria
d. Drowsiness
Answer: b. A sharp decrease in blood pressure
186. A nurse is providing oral care for a client who is unconscious. Which of the following
actions should the nurse take?
a. Place the client in a side-lying position
b. Use your finger to open the client's mouth
c. Keep both of the client's eyes open
d. Suction the back of the throat thoroughly
Answer: a. Place the client in a side-lying position

187. A nurse is performing postural drainage with percussion and vibration for a client who has
cystic fibrosis. Which of the following actions should the nurse take?
a. Perform the procedure in the client's room while the client is in the supine position
b. Administer bronchodilator therapy before performing the procedure
c. Place the client in a prone position
d. Instruct the client to exhale quickly during vibration
Answer: d. Instruct the client to exhale quickly during vibration
188. A community health nurse is teaching a group of clients about Kegel exercises to prevent
urinary incontinence. Which of the following instructions should the nurse include?
a. Perform the exercises 3 times a day for 1 week
b. Contract your pelvic muscles when performing the exercises
c. Relax your abdomen when performing the exercises
d. Stop performing the exercises when you feel discomfort
Answer: b. Contract your pelvic muscles when performing the exercises
189. A nurse is assessing clients for safety risks in a community clinic. Which of the following
clients is at risk for a safety hazard?
a. A school-aged child who rides a bicycle to school
b. An adolescent client who plays basketball
c. An older adult client who takes medication for depression
d. A middle-aged client who exercises daily
Answer: c. An older adult client who takes medication for depression
190. A nurse is providing discharge teaching about safety considerations to an older adult client
who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide.
Which of the following statements by the client indicates an understanding of the teaching?
a. "I will take my new medication in the evening."
b. "I will weigh myself once a month."
c. "I will avoid eating foods high in potassium."

d. "I will call my provider if I notice swelling in my feet."
Answer: d. "I will call my provider if I notice swelling in my feet."
191. A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which
of the following actions is appropriate for the nurse to include?
a. Administer a stimulant laxative 1 hour before the procedure
b. Monitor the client for pain in the suprapubic region
c. Provide an increased fluid intake before the procedure
d. Check the client for iodine or shellfish allergies
Answer: d. Check the client for iodine or shellfish allergies
192. A nurse is performing an admission assessment of a client. Which of the following actions
should the nurse take when reconciling the client's medications?
a. Assess the client for medication reactions
b. Determine the necessity of the medication
c. Compare the client's home medications with the provider's prescriptions
d. Consult with the pharmacy to identify medication interactions
Answer: c. Compare the client's home medications with the provider's prescriptions
193. During an admission history, a client tells a nurse that she is under a lot of stress. Which of
the following physiological responses should the nurse expect to increase as a result of stress?
a. Blood glucose
b. Urinary output
c. Saliva production
d. Peristalsis
Answer: a. Blood glucose
194. A nurse is caring for a client who has right-sided paralysis following a cerebrovascular
accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar
flexion contracture of the affected extremity?
a. Place the client's feet flat on the floor

b. Use a footboard
c. Use a hand roll
d. Apply an ankle-foot orthotic
Answer: d. Apply an ankle-foot orthotic
195. A nurse is caring for a client who is on bed rest following an abdominal surgery. Which of
the following findings indicates the need to increase the frequency of position changes?
a. Unilateral swelling in the lower extremity
b. Diminished bowel sounds
c. Non-blanching red area over the client's trochanter
d. Decreased urinary output
Answer: c. Non-blanching red area over the client's trochanter
196. A nurse on a medical-surgical unit is assigning tasks to assistive personnel (AP). Which of
the following tasks should the nurse delegate to the AP?
a. Insert an indwelling urinary catheter
b. Perform indwelling urinary catheter care
c. Initiate a plan of care for a new admission
d. Provide discharge teaching for a client
Answer: b. Perform indwelling urinary catheter care