ATI Cardiovascular Predictor Exam
A nurse is caring for a client who has heart failure and reports difficulty with limiting sodium
in their diet. Which of the following recommendations should the nurse provide?
A. Replace bottled salad dressing with homemade vinegar and oil dressing.
B. Increase intake of processed foods for convenience.
C. Use table salt liberally to enhance flavor.
D. Choose high-sodium snacks for variety.
Answer: A. Replace bottled salad dressing with homemade vinegar and oil dressing.
A nurse is contributing to the plan of care for a newborn who is experiencing heroin
withdrawal. The nurse should anticipate a prescription for which of the following
medications?
A. Methadone
B. Meperidine
C. Hydromorphone
D. entanyl
Answer: A. Methadone
A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of
a car seat. Which of the following statements by a parent indicates an understanding of the
teaching?
A. "I can place a rolled towel on each side of my newborn's head until he can hold his head
up."
B. "It's safe for my newborn to ride in a front-facing car seat as soon as we leave the
hospital."
C. "I should position the car seat so that it is tilted back at a 45-degree angle."
D. "Once my baby reaches 20 pounds, we can switch to a booster seat."
Answer: C. "I should position the car seat so that it is tilted back at a 45-degree angle."
A nurse is contributing to the discharge plans for four clients. The nurse should identify that
which of the following clients requires an interdisciplinary care conference?
A. A client who has hemiparesis and lives alone.
B. A client who is being discharged after a routine appendectomy and has a supportive family.
C. A client with controlled hypertension who is ready for discharge.
D. A client who has a minor fracture and is self-sufficient at home.
Answer: A. A client who has hemiparesis and lives alone.
A nurse is reinforcing discharge teaching with a client who has type 1 diabetes mellitus.
Which of the following client statements indicates an understanding of the teaching?
A. "I will dispose of insulin needles in a puncture-proof container."
B. "I will store opened insulin vials in my refrigerator."
C. "I will shake the insulin vial before drawing it into the syringe."
D. "I will expect my regular insulin to appear cloudy."
Answer: A. "I will dispose of insulin needles in a puncture-proof container."
A nurse is planning to reinforce teaching with a preschooler who is about to undergo an
incision and drainage for cellulitis on the left arm. Which of the following techniques should
the nurse use?
A. Take the child on a tour of the surgery and recovery areas.
B. Use medical jargon to explain the procedure in detail.
C. Show the child pictures of the instruments that will be used.
D. Explain the procedure using simple language and engage in play therapy.
Answer: D. Explain the procedure using simple language and engage in play therapy.
A nurse in a pediatric clinic is reviewing the urine laboratory results for an adolescent. For
which of the following results should the nurse notify the provider?
A. Positive ketones
B. Trace amounts of protein
C. Specific gravity of 1.020
D. Negative glucose
Answer: A. Positive ketones
A nurse is visiting with the family of a client who has just died. Which of the following
actions should the nurse take to promote comfort for the family?
A. Allow the family as much time as they want with the client.
B. Encourage the family to leave the room quickly to avoid distress.
C. Immediately discuss funeral arrangements to keep them focused.
D. Suggest they not express their emotions openly to maintain composure.
Answer: A. Allow the family as much time as they want with the client.
A nurse on a maternal newborn unit is assisting with the preparation of an in-service
presentation about infection control. Which of the following information should the nurse
recommend to include?
A. Visitors who have an upper respiratory infection should wear a mask.
B. Hand hygiene is only necessary after contact with the newborn.
C. It is safe to allow pets to visit the newborn in the hospital.
D. Visitors can freely hold the newborn without restrictions.
Answer: A. Visitors who have an upper respiratory infection should wear a mask.
A nurse is collecting data from a client who is postoperative and received hydromorphone 4
mg PO 15 min ago. The client tells the nurse, "My pain level is still 8 on a 0 to 10 scale."
Which of the following actions should the nurse take first?
A. Reevaluate the client's response to the medication in 30 minutes.
B. Assess the client's vital signs and pain level again immediately.
C. Administer an additional dose of hydromorphone right away.
D. Notify the healthcare provider of the client's pain level.
Answer: B. Assess the client's vital signs and pain level again immediately.
A nurse in a provider's office is reinforcing teaching with the parents of a school-age child
who has an active case of Pediculosis humanus capitis. Which of the following should the
nurse include in the teaching?
A. Wash the bed linens in hot water.
B. Use an oil-based product to suffocate the lice.
C. Keep the child home from school for at least two weeks.
D. Apply the treatment only once, as it is sufficient.
Answer: A. Wash the bed linens in hot water.
A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following
clients is an appropriate assignment for the nurse to accept?
A. A client who had a cesarean delivery 24 hours ago.
B. A client who had a vaginal delivery and is 6 hours postpartum with heavy bleeding.
C. A client who is experiencing severe postpartum depression.
D. A client who had a cesarean delivery 4 days ago and is ready for discharge.
Answer: A. A client who had a cesarean delivery 24 hours ago.
A nurse is assisting with the care of a client who is in active labor. Which of the following
data is the priority for the nurse to collect following an amniotomy?
A. Maternal blood pressure
B. Fetal heart rate
C. Contraction pattern
D. Maternal temperature
Answer: B. Fetal heart rate
A nurse is assisting in the preparation of an in-service for a group of unit nurses about ethical
principles. Which of the following nursing actions should the nurse include as an example of
fidelity?
A. A nurse keeps a promise made to a client.
B. A nurse advocates for a client’s wishes during a care conference.
C. A nurse maintains patient confidentiality at all times.
D. A nurse provides education about treatment options to a client.
Answer: A. A nurse keeps a promise made to a client.
A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate
repair. Which of the following actions should the nurse include?
A. Maintain elbow restraints on the infant.
B. Allow the infant to use a sippy cup for feeding.
C. Encourage the infant to play with small toys to promote recovery.
D. Position the infant flat on their back during sleep.
Answer: A. Maintain elbow restraints on the infant.
A nurse administered an IM injection to a client. Which of the following actions should the
nurse take to reduce the risk of a needlestick injury?
A. Dispose of the used needle immediately in a sharps container.
B. Recap the needle before disposal.
C. Place the needle on the counter until the procedure is completed.
D. Use a safety-engineered needle device only when necessary.
Answer: A. Dispose of the used needle immediately in a sharps container.
A nurse is collecting data from a client who has hepatitis A. Which of the following findings
should the nurse expect
A. Abdominal pain
B. High blood pressure
C. Increased heart rate
D. Severe headache
Answer: A. Abdominal pain
A nurse is reinforcing teaching with a client about caring for a new olostomy. Which of the
following statements should the nurse make?
A. "You should empty the colostomy bag when it is three-fourths full."
B. "You can change the colostomy bag every week, regardless of how it looks."
C. "You can eat any foods you like without any concerns."
D. "It is important to clean the skin around the stoma with soap and water."
Answer: A. "You should empty the colostomy bag when it is three-fourths full."
A charge nurse is explaining the role of a licensed practical nurse to an assistive personnel
(AP). Which of the following responsibilities should the charge nurse include?
A. Assessing a client's health status.
B. Administering medications without supervision.
C. Performing sterile procedures independently.
D. Assisting with activities of daily living.
Answer: D. Assisting with activities of daily living.
A nurse is assisting with the admission of a client who has mononucleosis. Which of the
following isolation precautions should the nurse initiate?
A. Contact precautions
B. Airborne precautions
C. Droplet precautions
D. Standard precautions
Answer: C. Droplet precautions
A nurse is reinforcing teaching with a client who was diagnosed with diabetes mellitus and
requires insulin injections. Which of the following client statements indicates an
understanding of the teaching?
A. "I should dispose of my used syringes in the household trash."
B. "I will store my current bottle of insulin in the refrigerator."
C. "I will hold the needle at a 15° angle to my skin."
D. "I should use an injection site that is 1 inch from the previous site."
Answer: D. "I should use an injection site that is 1 inch from the previous site."
A nurse is reinforcing teaching about home safety with the parent of an 8-month-old infant.
Which of the following statements by the parent indicates an understanding of the teaching?
A. "I will keep the door to the bathroom closed."
B. "I will place the baby's crib near the window for fresh air."
C. "I will allow the baby to explore the kitchen while I cook."
D. "I will keep small toys and objects on the floor for the baby to play with."
Answer: A. "I will keep the door to the bathroom closed."
A nurse is collecting data from a newly admitted client. Which of the following questions
should the nurse ask to assess the client's abstract thinking ability?
A. "Who is the current President of the United States?"
B. "What does the phrase 'butterflies in my stomach' mean?"
C. "Can you count backward from 20 to 1?"
D. "Can you draw a clock that shows the hands at 4:30?"
Answer: B. "What does the phrase 'butterflies in my stomach' mean?"
A nurse is collecting health history data from a client who has hemorrhoids. Which of the
following findings should the nurse expect?
A. Chronic constipation
B. Excessive flatulence
C. Frequent stools
D. Fecal incontinence
Answer: A. Chronic constipation
A nurse is reviewing client care assignments prior to the beginning of a shift. Which of the
following client assignments should the nurse identify as being outside the scope of practice
for an LPN?
A. A client who has a new onset of chest pain
B. A client who has a tracheostomy
C. A client who is receiving enteral feedings
D. A client who has urinary retention
Answer: A. A client who has a new onset of chest pain
A nurse is checking the home environment of a client for safety hazards. Which of the
following items require intervention by the nurse?
A. The television set is turned to a loud volume.
B. There are rugs on the floor in the hallway.
C. The kitchen knives are stored in a drawer with a childproof latch.
D. The smoke detectors are installed in each room.
Answer: B. There are rugs on the floor in the hallway.
A nurse is reinforcing teaching about home care with the parents of a child who has a seizure
disorder. Which of the following instructions should the nurse include?
A. Call EMS if a seizure lasts 5 minutes or more.
B. Allow the child to sleep after every seizure without monitoring.
C. Place a soft object in the child's mouth during a seizure to prevent biting.
D. Encourage the child to participate in all physical activities without limitations.
Answer: A. Call EMS if a seizure lasts 5 minutes or more.
A nurse is caring for a client who is asking about the technique of effleurage and its use in
labor and delivery. Which of the following responses should the nurse make regarding this
technique?
A. "It is a light stroking of the skin during a uterine contraction."
B. "It involves applying deep pressure to the lower back during contractions."
C. "It is a technique used for medication administration during labor."
D. "It is a method to encourage the baby's position for delivery."
Answer: A. "It is a light stroking of the skin during a uterine contraction."
A newly licensed nurse is having difficulty finishing client care tasks during their shift.
Which of the following techniques should the nurse plan to use to assist with time
management?
A. Try to complete a task before moving on to the next.
B. Prioritize tasks based on client needs and urgency.
C. Focus on one client at a time, regardless of urgency.
D. Avoid delegating tasks to other team members.
Answer: B. Prioritize tasks based on client needs and urgency.
A nurse is contributing to the plan of care for a client who has bulimia nervosa. Which of the
following interventions should the nurse recommend?
A. Observe the client for 1 hour after meals.
B. Allow the client to eat unrestricted portions of food.
C. Encourage the client to engage in excessive exercise after eating.
D. Provide privacy during mealtimes to prevent observation.
Answer: A. Observe the client for 1 hour after meals.
A nurse is collecting data from a child who has acute glomerulonephritis. Which of the
following findings should the nurse expect?
A. Periorbital edema
B. Weight loss
C. Hyperactivity
D. Decreased urine output
Answer: A. Periorbital edema
A nurse is providing preoperative teaching for an adolescent who is scheduled for a cardiac
catheterization. Which of the following instructions should the nurse include?
A. "You can resume a regular diet 3 days after your procedure."
B. "You can take a shower 1 day after your procedure."
C. "You can begin exercising 2 days after your procedure."
D. "You can return to school 1 week after your procedure."
Answer: B. "You can take a shower 1 day after your procedure."
A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a
client who has type 1 diabetes mellitus. Which of the following actions should the nurse take
first?
A. Withdraw 5 units of regular insulin from the vial.
B. Draw up the NPH insulin before the regular insulin.
C. Verify the insulin doses with another nurse.
D. Clean the tops of the insulin vials with an alcohol swab.
Answer: A. Withdraw 5 units of regular insulin from the vial.
A nurse working at a crisis hotline call center receives a call from a client who states, "I
cannot take it. My life is over." Which of the following is the priority response by the nurse?
A. "Are you thinking of harming yourself?"
B. "Can you tell me what is making you feel this way?"
C. "It's important to stay positive and think of good things."
D. "You need to talk to someone who can help you."
Answer: A. "Are you thinking of harming yourself?"
A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen
via nasal cannula. Which of the following actions should the nurse take?
A. Check the client's heart rate on the oximeter.
B. Compare the result with the baseline reading.
C. Decrease the amount of oxygen administered.
D. Perform another reading while the client ambulates.
Answer: B. Compare the result with the baseline reading.
A nurse is caring for a newborn following a circumcision. Which of the following
manifestations indicates the newborn is experiencing pain?
A. Lip smacking
B. Diaphoresis
C. Hypoglycemia
D. Transient strabismus
Answer: A. Lip smacking
A nurse is reinforcing teaching with the parents of a preschool-age child who has a new
diagnosis of celiac disease. Which of the following foods should the nurse recommend?
A. Corn tortillas with black beans
B. Wheat pasta with marinara sauce
C. Barley cereal
D. Rye bread with butter
Answer: A. Corn tortillas with black beans
A nurse is preparing to in still anotic suspension into an adult client's ear. Which of the
following methods should the nurse plan to use?
A. Pull the auricle upward and backward.
B. Pull the auricle downward and backward.
C. Pull the auricle straight out to the side.
D. Pull the auricle downward and forward.
Answer: A. Pull the auricle upward and backward.
A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the
following should the nurse identify as an indication that the newborn is breastfeeding
effectively?
A. Makes audible swallowing sounds.
B. Feeds for at least 30 minutes at each session.
C. Shows signs of fatigue after each feeding.
D. Has frequent, loose stools.
Answer: A. Makes audible swallowing sounds.
A nurse is assisting with the admission of an older adult client. Which of the following
subjective findings suggests that the client may have cataracts?
A. Cloudy vision.
B. Sudden onset of flashes of light.
C. Difficulty seeing at night.
D. Blurred vision that improves with eye drops.
Answer: A. Cloudy vision.
A nurse is collecting data from the guardian of a toddler during a well-child visit. The
guardian expresses concern to the nurse because his child has a poor appetite, but drinks a
quart of milk each day. The nurse should identify that this practice places the toddler at risk
for which of the following conditions?
A. Lactose intolerance.
B. Iron deficiency anemia.
C. Vitamin D deficiency.
D. Obesity.
Answer: B. Iron deficiency anemia.
A nurse in a mental health unit asks a client who has schizophrenia, "How are you?" Which
of the following responses should the nurse identify as the speech alteration of echolalia?
A. "How are you?"
B. "I'm fine, thank you."
C. "I’m fine, how are you?"
D. "It's a nice day today, isn't it?"
Answer: A. "How are you?"
A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin.
For which of the following findings should the nurse instruct the adolescent to monitor and
report to the provider?
A. Depression.
B. Diarrhea.
C. Skin rash.
D. Nausea.
Answer: C. Skin rash.
A nurse is reinforcing teaching with a client who has a new prescription for digoxin to treat
heart failure. Which of the following should the nurse include as an expected effect of this
medication?
A. Increased heart rate.
B. Decreased heart contractility.
C. Improved heart contractility.
D. Decreased blood pressure.
Answer: C. Improved heart contractility.
A nurse is reinforcing teaching with a school-age child who has hemophilia about
participating in school sports. Which of the following sports should the nurse recommend for
the child? (Select all that apply.)
A. Soccer
B. Basketball
C. Gymnastics
D. Golf
E. Swimming
Answer: D. Golf
E. Swimming
A nurse is caring for a client who attempted suicide. Which of the following actions should
the nurse take?
A. Serve meals with plastic utensils.
B. Allow the client to have a private room.
C. Provide the client with sharp objects for self-soothing.
D. Encourage the client to discuss their feelings in private.
Answer: A. Serve meals with plastic utensils.
A nurse is preparing a client's insulin regimen. Which of the following insulins can be mixed?
(Select all that apply.)
A. Insulin aspart (rapid-acting)
B. Regular insulin (short-acting)
C. Insulin lispro (rapid-acting)
Answer: Regular insulin and Insulin lispro.
A nurse in a long-term care facility has received change-of-shift report about four clients.
Which of the following clients should the nurse attend to first?
A. A client who has COPD and dementia and was agitated during the night shift.
B. A client with a new diagnosis of diabetes who needs to learn about blood sugar
monitoring.
C. A client who is scheduled for a routine dressing change.
D. A client who has a history of falls and is requesting assistance to the bathroom.
Answer: A. A client who has COPD and dementia and was agitated during the night shift.
A nurse is caring for a client who has a new colostomy. The client tells the nurse, "I don't
want anyone to see me with this bag." Which of the following responses should the nurse
make
A. "Why don't you want people to see the colostomy bag?"
B. "Many people feel that way initially; it's okay to have these feelings."
C. "You’ll get used to it over time."
D. "Let’s talk about how to care for it."
Answer: B. "Many people feel that way initially; it's okay to have these feelings."
A nurse is reinforcing teaching with a client who has a permanent pacemaker in place. Which
of the following statements by the client indicates an understanding of the teaching?
A. "I will remove my microwave oven from my home."
B. "I can use my cell phone as long as I keep it in my pocket."
C. "I need to avoid heavy lifting for a few weeks."
D. "I can travel by airplane without any concerns."
Answer: C. "I need to avoid heavy lifting for a few weeks."
A nurse is caring for a client who is receiving prazosin. The client's blood pressure is 100/60
mm Hg. Which of the following actions should the nurse take?
A. Instruct the client to stand up slowly.
B. Administer a dose of fluid to increase blood pressure.
C. Hold the next dose of prazosin and notify the provider.
D. Encourage the client to increase physical activity.
Answer: A. Instruct the client to stand up slowly.
A nurse is collecting data from a client who is taking heparin to prevent deep-vein thrombosis
and has bloody stools. Which of the following laboratory values should the nurse report to the
provider?
A. Platelets 200,000/mm3
B. RBC count 5.4 million/mm3
C. Hgb 14 g/dL
D. INR 5.2
Answer: D. INR 5.2
A nurse is collecting data from a client who has a long-leg cast on his left leg and reports
severe pain. Which of the following findings should the nurse identify as an indication that
the client might have compartment syndrome? (Select all that apply.)
A. Pallor in the exposed portion of the left foot
B. Inability to move the left foot
C. Increased warmth of the exposed portion of the left foot Ecchymosis in the exposed
portion of the left foot
D. Paresthesia in the left foot
Answer: A. Pallor in the exposed portion of the left foot
B. Inability to move the left foot
D. Paresthesia in the left foot
A nurse is providing change-of-shift report for a client who has heart failure. Which of the
following information should the nurse include in the report?
A. The client's most recent blood pressure reading was 110/60 mm Hg.
B. The client's morning laboratory results included a potassium level of 4.9 mg/dL.
C. The client has +2 pitting edema in the lower extremities.
D. The client's partner assisted them with their meal tray.
Answer: C. The client has +2 pitting edema in the lower extremities.
A nurse is reinforcing teaching with a newly licensed nurse about the HIPAA Privacy Rule.
Which of the following statements by the newly licensed nurse indicates an understanding of
the teaching?
A. "A client has the right to view their medical record."
B. "Healthcare providers can share patient information with anyone if they have good
intentions."
C. "Patients cannot request corrections to their medical records."
D. "A client's information can be disclosed to family members without their consent."
Answer: A. "A client has the right to view their medical record."
A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of
the following statements indicates an understanding of the instructions?
A. "I will feed my baby six to eight times a day."
B. "I will give my baby water in between feedings."
C. "I can use whole milk starting at three months."
D. "I will let my baby finish the entire bottle at every feeding."
Answer: A. "I will feed my baby six to eight times a day."
A nurse is caring for a female client who has a new diagnosis of breast cancer. The client is
concerned about potential changes to her body image depending on her choice of treatment.
Which of the following actions should the nurse take?
A. Reassure the client that she will adjust to changes to her body.
B. Contact an occupational therapist to talk with the client.
C. Initiate a client referral to Reach to Recovery.
D. Explain that surgery can restore the breast to its original appearance.
Answer: C. Initiate a client referral to Reach to Recovery.
A nurse is caring for a client who has COPD. The nurse should identify that which of the
following findings is the priority to report?
A. Hgb 20 g/dL
B. Oxygen saturation 92%
C. Productive cough with green sputum
D. Chest x-ray shows hyperinflation of lungs
Answer: C. Productive cough with green sputum
A nurse is reinforcing discharge teaching with a client who had an above-the-knee amputation
and has a prosthesis. Which of the following instructions should the nurse include?
A. Keep initial pressure dressing in place for 1 week after surgery.
B. Leave the prosthesis in place when going to bed.
C. Avoid extension of the hips when lying down.
D. Clean the prosthesis using a damp, soapy cloth.
Answer: D. Clean the prosthesis using a damp, soapy cloth.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal
tube. Which of the following actions should the nurse take?
A. Monitor the client's vital signs every 8 hr.
B. Reposition the endotracheal tube every 12 hr.
C. Place the client in a supine position.
D. Perform oral care every 2 hr.
Answer: D. Perform oral care every 2 hr.
A charge nurse in a long-term care unit is planning care for a group of clients. Which of the
following care tasks should the nurse plan to delegate to an assistive personnel?
A. Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract
infection.
B. Administering a medication through a feeding tube.
C. Assessing a wound for signs of infection.
D. Performing a blood glucose check for a client with diabetes.
Answer: A. Measuring urine output every 2 hr for a client recently diagnosed with a urinary
tract infection.
A nurse is preparing to remove a peripheral IV for a preschooler. In which order should the
nurse complete the following steps? (Move the steps into the box on the right, placing them
in the order of performance. Use all the steps.)
A. Turn off the IV infusion pump and clamp the IV tubing.
B. Allow the preschooler to assist with removing the transparent dressing over the IV.
C. Remove the IV catheter while keeping the catheter hub parallel to the insertion site.
D. Inspect the IV catheter tip.
E. Apply firm pressure at the IV site.
Answer: Correct Order
A. Turn off the IV infusion pump and clamp the IV tubing.
B. Allow the preschooler to assist with removing the transparent dressing over the IV.
E. Apply firm pressure at the IV site.
C. Remove the IV catheter while keeping the catheter hub parallel to the insertion site.
D. Inspect the IV catheter tip.
A nurse is assisting with developing a discharge plan for a client who has a new diagnosis of
diabetes mellitus. The client is independent and lives alone. Which of the following
interventions should the nurse plan to include?
A. Provide the client with 1 week's supply of insulin syringes.
B. Arrange for a home health nurse to visit the client daily.
C. Notify the family of the client's health status.
D. Refer the client to a diabetic support group.
Answer: D. Refer the client to a diabetic support group.
A nurse is reinforcing teaching with a client who is at 35 weeks of gestation and has a
prescription for a lecithin/sphingomyelin ratio. Which of the following statements should the
nurse make?
A. "This test will determine fetal lung maturity."
B. "This test will check for fetal genetic abnormalities."
C. "This test measures the level of fetal hemoglobin."
D. "This test will assess for maternal diabetes."
Answer: A. "This test will determine fetal lung maturity."
A nurse is caring for a client who has schizophrenia. The client tells the nurse, "Government
agents are out to get me." Which of the following responses should the nurse make?
A. "It must be frightening to believe that someone is after you."
B. "That's not true; you’re just imagining things."
C. "Why do you think the government agents are after you?"
D. "You shouldn’t worry about that; let’s talk about something else."
Answer: A. "It must be frightening to believe that someone is after you."
A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The
nurse should identify that which of the following actions by the AP indicates an
understanding of the procedure?
A. Elevates the client's legs before applying the stockings
B. Instructs the client to dorsiflex their feet while applying the stockings
C. Massages the client's legs before applying the stockings
D. Folds the top of the stockings over after applying them
Answer: A. Elevates the client's legs before applying the stockings
A nurse is caring for a client who is in mechanical restraints after becoming violent with a
staff member. Which of the following actions should the nurse take?
A. Request that the provider write an as-needed prescription for restraints.
B. Document the client's behavior and the use of restraints in the medical record.
C. Remove the restraints after 30 minutes to assess the client's behavior.
D. Ensure that the client is in a private room and isolated from others.
Answer: B. Document the client's behavior and the use of restraints in the medical record.
A nurse is caring for a client who had a transurethral resection of the prostate and now is
receiving continuous bladder irrigation. Which of the following actions should the nurse
take? (Select all that apply.)
A. Document urine color.
B. Monitor the client for reports of bladder spasms.
C. Check the drainage tubing for obstructions.
D. Maintain the client in a left side-lying position.
E. Use clean technique for intermittent irrigation.
Answer: A. Document urine color.
B. Monitor the client for reports of bladder spasms.
C. Check the drainage tubing for obstructions.
A nurse is reinforcing teaching with the parent of an infant who is receiving furosemide. The
nurse should reinforce with the parent that which of the following laboratory tests will be
monitored while the infant is receiving this medication?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
Answer: B. Potassium
A nurse is caring for a client who is using a non-rebreather mask for oxygen delivery. The
nurse should identify which of the following as an indication that the equipment is
functioning properly?
A. Air is heard escaping from around the mask.
B. The flow control meter dial is at the correct setting.
C. The attached reservoir bag is inflated.
D. The exhalation ports are covered during inspiration and expiration.
Answer: C. The attached reservoir bag is inflated.
A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease
and is experiencing a vaso-occlusive crisis. Which of the following should the nurse
recommend to include in the plan of care?
A. Perform passive range-of-motion exercises.
B. Encourage the child to ambulate as tolerated.
C. Apply cold compresses to painful areas.
D. Administer prescribed analgesics as needed.
Answer: D. Administer prescribed analgesics as needed.
A nurse is admitting a client who is scheduled for an elective surgery. Which of the following
actions should the nurse take to verify the status of the client's advance directives?
A. Ask the client whether they have advance directives.
B. Review the client's medical history for previous advance directives.
C. Contact the client's family to discuss advance directives.
D. Assume that the client does not have advance directives unless stated otherwise.
Answer: A. Ask the client whether they have advance directives.
A nurse is preparing to administer cefaclor to a preschooler who weighs 20 kg. The child is to
receive cefaclor 30 mg/kg/day to divide equally every 8 hr. Available is cefaclor suspension
125 mg/5 mL. How many mL should the nurse administer for one dose?
A. 4 mL
B. 6 mL
C. 8 mL
D. 10 mL
Answer: C. 8 mL
A nurse is reinforcing teaching about complete and incomplete proteins with a client who has
a prescription for a high-protein diet. The nurse should identify which of the following foods
as sources of complete proteins? (Select all that apply.)
A. Salmon
B. Hard-boiled eggs
C. Cottage cheese
D. Whole wheat bread
E. Steamed spinach
Answer: D. Whole wheat bread
A nurse in an urgent care clinic is collecting data from a client who reports having diarrhea
for the past 3 days. Which of the following findings indicates hypokalemia?
A. Pitting edema
B. Diplopia
C. Muscle weakness
D. Hyperactive bowel sounds
Answer: C. Muscle weakness
A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the
following is a subjective indication that the client needs PRN pain medication?
A. The client's heart rate is 110/min.
B. The client is guarding their abdominal incision.
C. The client exhibits facial grimacing.
D. The client reports pain.
Answer: D. The client reports pain.
A nurse is collecting data from a client who has a gastrostomy tube and is experiencing
diarrhea. Which of the following factors should the nurse identify as a potential cause of the
diarrhea?
A. The formula infusion rate of the feeding was too slow.
B. The formula was given immediately following removal from the refrigerator.
C. The feeding tube was partially obstructed during the infusion.
D. The client is experiencing delayed gastric emptying.
Answer: B. The formula was given immediately following removal from the refrigerator.
A nurse is caring for an adolescent who has an allergy to penicillin. Which of the following
prescriptions should the nurse clarify with the provider?
A. Doxycycline
B. Vibramycin
C. Cefazolin
D. Gentamicin
Answer: C. Cefazolin
A nurse is collecting data from a client who is 1 day postoperative following a total hip
arthroplasty and has deep-vein thrombosis. Which of the following findings should the nurse
expect in the affected extremity?
A. Dull, aching pain
B. Warmth and redness in the limb
C. Coolness and pallor of the limb
D. Swelling and edema in the limb
Answer: A. Dull, aching pain
A nurse is caring for an infant who is drinking a cow's milk formula and has bloody stools.
Which of the following recommendations should the nurse make to the infant's guardian?
A. Switch to a soy-based formula.
B. Switch to a goat's milk formula.
C. Switch to an unpasteurized milk formula.
D. Switch to a condensed milk formula.
Answer: A. Switch to a soy-based formula.
A nurse is reinforcing discharge teaching with an older adult client who has osteoarthritis.
Which of the following statements by the 52A6658V49client indicates an understanding of
the teaching?
A. "I will limit purine intake in my diet."
B. "I will perform high-impact exercises to strengthen my joints."
C. "I will maintain a healthy weight to reduce stress on my joints."
D. "I will stop taking my pain medications as soon as I feel better."
Answer: C. "I will maintain a healthy weight to reduce stress on my joints."
A nurse is preparing to administer required immunizations to a toddler during a well-child
visit. The parent asks the nurse how many baby aspirins he should administer if the toddler
develops a fever. Which of the following responses should the nurse make?
A. "You should follow the label directions based on your child's weight."
B. "You can give a full adult dose if the child has a fever."
C. "It's safe to give baby aspirin to children for any fever."
D. "You should avoid giving aspirin to your child; try acetaminophen or ibuprofen instead."
Answer: D. "You should avoid giving aspirin to your child; try acetaminophen or ibuprofen
instead."
A nurse is assisting with the admission of an older adult client who has impaired mobility and
is at risk for falls. Which of the following actions should the nurse plan to perform first?
A. Assess the client's mobility and fall risk.
B. Check the client's ability to use the call light.
C. Review the client's medication list for fall risk factors.
D. Ensure the environment is free of hazards.
Answer: B. Check the client's ability to use the call light.
A nurse is reinforcing teaching about a safety plan for a client who reports partner violence.
Which of the following instructions should the nurse include?
A. "Call a shelter in another county."
B. "Leave your partner immediately."
C. "Keep a packed bag by your front door."
D. "Rehearse your escape route."
Answer: D. "Rehearse your escape route."
A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which
of the following client statements indicates understanding of the teaching?
A. "I will apply petroleum jelly to the penis with each diaper change."
B. "I will clean the area with alcohol after each diaper change."
C. "I will remove the yellow crust that forms on the penis."
D. "I will give my baby a bath in the tub every day."
Answer: A. "I will apply petroleum jelly to the penis with each diaper change."
A nurse is collecting data from a client who has asthma. Which of the following prescribed
medications should the nurse administer first for severe wheezing?
A. Bronchodilators
B. Beta blocker
C. Inhaled steroids
D. Anti‑inflammatory agent
Answer: A. Bronchodilators
A nurse is reinforcing teaching with the parent of a newborn about security procedures.
Which of the following instructions should the nurse include?
A. "You should verify the identity of anyone who wants to remove your baby from the room."
B. "It's fine to allow anyone to hold your baby if they ask nicely."
C. "You don't need to worry about who can take your baby; the hospital staff knows
everyone."
D. "You should leave your baby's identification band on the bed when you're not with them."
Answer: A. "You should verify the identity of anyone who wants to remove your baby from
the room."
A nurse is reinforcing discharge teaching about limiting sodium intake with a client who has
a new diagnosis of cardiomyopathy. Which of the following client responses indicates an
understanding of the teaching?
A. "I can have mustard on my sandwiches."
B. "I can season foods with celery salt."
C. "I can have a frozen juice bar for dessert."
D."I can drink vegetable juice with my meals."
Answer: C. "I can have a frozen juice bar for dessert."
A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying.
Which of the following actions should the nurse take to reduce the risk of aspiration?
A. Administer using a needleless syringe in the buccal cavity.
B. Give the medication while the infant is lying flat.
C. Pour the medication into the infant’s mouth quickly.
D. Use a straw to help the infant drink the medication.
Answer: A. Administer using a needleless syringe in the buccal cavity.
A charge nurse is supervising a newly licensed nurse who is caring for a client who is
experiencing auditory hallucinations and is refusing medication. The newly licensed nurse
suggests placing the medication in the client's food to the charge nurse. Which of the
following actions should the charge nurse take?
A. Remind the newly licensed nurse that the client has a right to refuse medication.
B. Support the suggestion and instruct the nurse to proceed.
C. Report the newly licensed nurse to the nursing supervisor.
D. Discuss the importance of medication compliance with the client.
Answer: A. Remind the newly licensed nurse that the client has a right to refuse medication.
After receiving change-of-shift report, which of the following clients should the nurse collect
data from first?
A. A client who has heart failure and reports severe dyspnea.
B. A client who is 1 day postoperative and has mild incisional pain.
C. A client with a chronic respiratory condition who needs routine medication.
D. A client who is awaiting discharge and has no current complaints.
Answer: A. A client who has heart failure and reports severe dyspnea.
A nurse is reinforcing teaching about safety with the parent of a newborn. Which of the
following instructions should the nurse include?
A. "Take the newborn to the nursery before showering."
B. "Keep the baby in a crib near your bed while you sleep."
C. "Place the baby in a car seat while you are at home."
D. "Use a soft blanket to swaddle the baby during sleep."
Answer: B. "Keep the baby in a crib near your bed while you sleep."
A nurse is reinforcing teaching about epidural PCA with a client who is in active labor.
Which of the following statements should the nurse include?
A. "The machine is programmed to prevent you from administering more than a safe dose."
B. "During medication administration, you will not be able to move your legs freely."
C. "This method of pain control will shorten the second stage of labor."
D. "This type of anesthesia commonly causes a postpartum headache."
Answer: A. "The machine is programmed to prevent you from administering more than a
safe dose."
A nurse working on a mental health unit is meeting with a client who has been on the unit for
2 days. The nurse greets the client and asks, "What has been happening with you today?"
Which of the following therapeutic techniques is the nurse using?
A. Focusing
B. Reflecting
C. Clarifying
D. Exploring
Answer: A. Focusing
A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy.
Which of the following instructions should the nurse include?
A. "Change the perineal pad with each void."
B. "You can use tampons instead of pads for bleeding."
C. "Avoid using ice packs on the perineal area."
D. "You can resume sexual intercourse as soon as you feel ready."
Answer: A. "Change the perineal pad with each void."
A nurse is caring for an older adult client who states, "I can't pay for my care because my kid
took all my money." Which of the following actions should the nurse take?
A. Report the possible abuse to adult protective services.
B. Encourage the client to confront their child about the money.
C. Assist the client in applying for financial assistance programs.
D. Suggest that the client move in with a relative for support.
Answer: A. Report the possible abuse to adult protective services.
A nurse is caring for a client who is scheduled for open heart surgery. The client states, "I am
confident I will be able to go home a few hours after the surgery." The nurse should identify
that the client is experiencing which of the following stages of grief?
A. Denial
B. Anger
C. Bargaining
D. Acceptance
Answer: A. Denial
A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which
of the following positions should the nurse recommend for instillation of the drops?
A. Orthopneic
B. Supine
C. Sitting upright
D. Lying flat
Answer: C. Sitting upright
A nurse is reinforcing teaching with a client about smoking cessation. Which of the following
client statements indicates an understanding of the teaching?
A. "I should join a support group to help me be successful."
B. "I can smoke occasionally as long as I don't do it often."
C. "Using nicotine gum is enough to help me quit."
D. "I can stop smoking without any help or support."
Answer: A. "I should join a support group to help me be successful."
A nurse is reviewing the medication record of a client who has a new prescription for
fluoxetine. Which of the following medications should the nurse expect the provider to
discontinue 2 weeks before starting fluoxetine treatment?
A. Levothyroxine
B. Acetaminophen
C. Simvastatin
D. Phenelzine
Answer: D. Phenelzine
A nurse is caring for a client who has viral pneumonia. Which of the following actions should
the nurse take?
A. Administer azithromycin.
B. Encourage the client to increase fluid intake.
C. Administer a corticosteroid.
D. Initiate oxygen therapy.
Answer: B. Encourage the client to increase fluid intake.
A nurse is contributing to the plan of care for a client who has Parkinson's disease. Which of
the following interventions should the nurse plan to include?
A. Restrict the client's fluid intake.
B. Keep suction equipment at the client's bedside.
C. Instruct the client to look down when ambulating.
D. Position the client supine after eating.
Answer: B. Keep suction equipment at the client's bedside.
A nurse is reinforcing teaching with the guardian of a preschooler who has a new diagnosis of
enterobiasis. Which of the following information should the nurse include in the teaching?
A. "One dose of medication is all that will be necessary."
B. "Everyone who lives in the home will need medication."
C. "Allow the child to take tub baths instead of showers."
D. "Wash all clothes and bed linens in cold water."
Answer: B. "Everyone who lives in the home will need medication."
A nurse is reinforcing teaching about confidentiality with a client. Which of the following
statements should the nurse include in the teaching?
A. "Your nurse will provide information about the risks and benefits of surgical procedures."
B. "Only health care staff providing care will see your medical record."
C. "The provider must grant you access to your personal health information."
D. "You have to authorize our providers to prescribe treatments for your condition."
Answer: B. "Only health care staff providing care will see your medical record."
A nurse is caring for a client who is participating in a therapy session for anger management.
The client states that their recent behavior is due to the loss of their job. The nurse should
identify that the client is using which of the following defense mechanisms?
A. Rationalization
B. Projection
C. Displacement
D. Denial
Answer: A. Rationalization
A nurse is caring for a client who has a cast on their left lower leg. Which of the following
actions should the nurse take?
A. Massage areas around the edge of the client's cast with lotion.
B. Avoid elevating the extremity when the client is resting in bed.
C. Give the client a dull object to scratch the skin under the cast.
D. Tell the client to expect numbness in their toes.
Answer: A. Massage areas around the edge of the client's cast with lotion.
A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of
the following foods should the nurse include?
A. Graham crackers
B. Whole grapes
C. Popcorn
D. Nuts
Answer: A. Graham crackers
A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of
the following actions should the nurse take?
A. Frequently remind the client of the expectations for her behavior.
B. Allow the client to set her own limits on behavior.
C. Redirect the client to a quiet area when she becomes too loud.
D. Encourage the client to engage in competitive activities with peers.
Answer: C. Redirect the client to a quiet area when she becomes too loud.
A nurse is preparing to admit a client who has bacterial meningitis. Which of the following
items should the nurse place in the client's room?
A. Oral irrigating device
B. Seizure pads
C. Sterile gloves
D. Tongue blade
Answer: B. Seizure pads
A nurse is caring for a client who was recently admitted to an inpatient mental health unit.
The client tells the nurse that he is not coming out of his room anymore because other clients
on the unit make fun of him. Which of the following responses by the nurse is appropriate?
A. "You feel upset by the responses of others."
B. "Why do you think they are making fun of you?"
C. "You should try to ignore them and focus on yourself."
D. "It's important to be social; you can't stay in your room."
Answer: A. "You feel upset by the responses of others."
A nurse is reinforcing dietary teaching with an adolescent who is at 10 weeks of gestation.
Which of the following statements should the nurse make?
A. "You need to limit your sodium intake to less than 2 grams per day."
B. "You should consume more than 40 milligrams of fiber each day."
C. "You need to drink 5 to 6 glasses of fluids each day."
D. "You should consume 1,300 milligrams of calcium each day."
Answer: D. "You should consume 1,300 milligrams of calcium each day."
A client who has inoperable cancer tells the nurse that she does not want to pursue the
recommended treatment. She asks if the provider can force her to have the treatment. Which
of the following is an appropriate response by the nurse?
A. "You have the right to refuse the recommended treatment plan."
B. "Your provider can explain why the treatment is necessary."
C. "It's important to consider the benefits of the treatment."
D. "You might change your mind after discussing it with your family."
Answer: A. "You have the right to refuse the recommended treatment plan."
A nurse is expressing concern about his assignment with the charge nurse. The nurse states
that he has more work to do than anyone else. Which of the following statements by the
charge nurse demonstrates the conflict resolution strategy of competing?
A. "We will take a look at the assignments together and attempt to modify the workload you
are concerned about."
B. "I understand you're feeling overwhelmed, but everyone has a full workload."
C. "I need you to manage your time better and prioritize your tasks."
D. "Let’s discuss how to redistribute some of the tasks among the team."
Answer: C. "I need you to manage your time better and prioritize your tasks."
A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of
the following actions should the nurse take to elicit this reflex?
A. Clap hands after laying the newborn on a flat surface.
B. Hold the newborn in a sitting position and suddenly lower them.
C. Gently lift the newborn by the arms and then let them fall back slightly.
D. Startle the newborn with a loud noise while they are sleeping.
Answer: A. Clap hands after laying the newborn on a flat surface.
A nurse is reviewing the medical record for a client who is at 38 weeks of gestation, tested
positive for group B streptococcus ß-hemolytic, and is allergic to penicillin. The nurse should
identify that which of the following medications is contraindicated for this client?
A. Ampicillin
B. Erythromycin
C. Cefazolin
D. Clindamycin
Answer: A. Ampicillin
A nurse is caring for a client who is receiving total parenteral nutrition. Which of the
following laboratory results indicates a possible complication of this therapy?
A. Serum calcium 12.5 mg/dL
B. Serum glucose 150 mg/dL
C. Serum albumin 3.0 g/dL
D. Serum electrolytes within normal limits
Answer: A. Serum calcium 12.5 mg/dL
A nurse is assisting with triaging clients in a mass casualty situation. The nurse should
recommend that which of the following clients receive care first?
A. A client who has diminished breath sounds and paradoxical chest movement
B. A client with a deep laceration to the thigh and moderate bleeding
C. A client with a broken arm and stable vital signs
D. A client who is confused but has stable vital signs
Answer: A. A client who has diminished breath sounds and paradoxical chest movement
A nurse in an acute mental health facility observes a client having a panic attack. Which of
the following interventions should the nurse implement first?
A. Instruct the client to use abdominal breathing.
B. Encourage the client to talk about their feelings.
C. Provide the client with a calming environment.
D. Administer prescribed anti-anxiety medication.
Answer: A. Instruct the client to use abdominal breathing.
A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the
following actions should the nurse take?
A. Collect 2 mL of sputum in an emesis basin.
B. Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection. C.
Swab the oropharynx with a sterile swab.
D. Refrigerate the specimen until the time of transport to the laboratory.
Answer: D. Refrigerate the specimen until the time of transport to the laboratory.
A nurse is contributing to the plan of care for a client who has bipolar disorder and is
experiencing mania. Which of the following actions should the nurse include in the plan of
care?
A. Decrease the level of environmental stimuli.
B. Encourage the client to engage in group activities.
C. Allow the client to make decisions about their care.
D. Increase the frequency of visits from family and friends.
Answer: A. Decrease the level of environmental stimuli.
A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric
decompression. Which of the following supplies should the nurse obtain prior to the
procedure?
A. Oil-based lubricant
B. Enteric feeding pump
C. Sterile gloves
D. pH strips
Answer: A. Oil-based lubricant
A nurse is assisting in the development of an in-service for staff members about physical
abuse of children. Which of the following children are at an increased risk for physical
abuse?
A. Children who were born after 38 weeks of gestation
B. Children with disabilities or special needs
C. Children who excel academically
D. Children with a supportive family environment
Answer: B. Children with disabilities or special needs
A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a
cleft palate repair. Which of the following pain rating tools should the nurse use?
A. FLACC scale
B. Numeric rating scale
C. Wong-Baker FACES scale
D. Oucher scale
Answer: A. FLACC scale
A nurse is caring for a child who has terminal cancer. Which of the following responses by
the child's siblings should the nurse expect?
A. The school-age sister is concerned about the impact of her sibling's death on herself.
B. The teenage brother expresses anger toward the parents for not doing enough.
C. The younger sibling shows indifference to the situation.
D. The siblings all express understanding and acceptance of the situation.
Answer: A. The school-age sister is concerned about the impact of her sibling's death on
herself.
A nurse is reinforcing teaching with an older adult client about physical changes that occur
with aging. Which of the following should the nurse include as an expected age-related
change?
A. Increased joint stiffness due to loss of elasticity in joint cartilage.
B. Increased muscle mass and strength.
C. Decreased risk of chronic diseases.
D. Enhanced sensory perception.
Answer: A. Increased joint stiffness due to loss of elasticity in joint cartilage.
A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of
the following actions should the nurse recommend for the plan of care?
A. Give directions using simple phrases.
B. Encourage the client to make complex decisions independently.
C. Use abstract language when communicating.
D. Increase sensory stimulation in the environment.
Answer: A. Give directions using simple phrases.
A nurse is assisting with the care of an adolescent who is scheduled for surgery. Which of the
following actions should the nurse plan to take?
A. Provide a tour of the perioperative area prior to surgery.
B. Explain that anesthesia is a special type of sleep.
C. Wait until after surgery to explain the importance of coughing and deep breathing.
D. Keep medical equipment out of the client's sight.
Answer: A. Provide a tour of the perioperative area prior to surgery.
A nurse is caring for an older adult client who is postoperative following a total hip
arthroplasty. The nurse is preparing to change the client's surgical dressing. Which of the
following actions should the nurse take to demonstrate sensitivity to age-related changes?
A. Use paper tape for securing the new dressing.
B. Apply the dressing tightly to prevent fluid accumulation.
C. Use adhesive tape that may irritate the skin.
D. Delay changing the dressing to minimize discomfort.
Answer: A. Use paper tape for securing the new dressing.
A nurse is reinforcing teaching with a client who is about to undergo an upper gastrointestinal
series with fluoroscopy. Which of the following information should the nurse provide?
A. "You will receive an injection of contrast dye during the test."
B. "You will need to fast for 12 hours prior to the test."
C. "You will drink a barium solution to help visualize the upper GI tract."
D. "This test will take approximately 30 minutes to complete."
Answer: C. "You will drink a barium solution to help visualize the upper GI tract."
A nurse is reinforcing teaching with a postpartum client about bathing her newborn. Which of
the following statements should the nurse include?
A. "Wash your newborn's head under a stream of running water."
B. "Use soap for the entire body during the first bath."
C. "Submerge your newborn in water during the bath."
D. "Support your newborn's head and neck during bathing."
Answer: D. "Support your newborn's head and neck during bathing."
A nurse receives report on four clients. The nurse should first collect data about the client
who has which of the following?
A. A client with a decreased level of consciousness and vomiting.
B. A client with stable vital signs and scheduled for discharge.
C. A client with a mild headache and no other symptoms.
D. A client with a recent diagnosis of hypertension but no acute symptoms.
Answer: A. A client with a decreased level of consciousness and vomiting.
A nurse on a mental health unit is discussing client rights with a group of coworkers. Which
of the following statements should the nurse include?
A. "A client must withdraw consent for treatment in writing if he is competent to do so."
B. "Clients can be forcibly treated even if they refuse."
C. "Clients have the right to access their medical records at any time."
D. "A client can be restrained without consent if staff believes it's necessary."
Answer: A. "A client must withdraw consent for treatment in writing if he is competent to do
so."
A nurse in a prenatal clinic is reinforcing teaching with a client about a nonstress test. Which
of the following statements should the nurse include?
A. "You will be asked to press a button when you feel your baby move."
B. "This test will monitor your blood pressure during labor."
C. "You will need to be fasting before the test."
D. "The test will assess the baby's heartbeat while you are in labor."
Answer: A. "You will be asked to press a button when you feel your baby move."
A nurse is preparing to administer medication to a child through an enteral tube. Which of the
following actions should the nurse take after administering the medication?
A. Flush the tubing.
B. Clamp the tubing.
C. Check patency of the tubing.
D. Aspirate the tubing.
Answer: A. Flush the tubing.
A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis
(MG) and a prescription for neostigmine. Which of the following information should the
nurse include about the action of the medication?
A. "It reduces inflammation in the muscles."
B. "It improves muscle strength."
C. "It increases blood flow to the muscles."
D. "It prevents muscle spasms."
Answer: B. "It improves muscle strength."
A nurse in a clinic is reinforcing teaching with a client who has a new prescription for a
combination contraceptive transdermal patch. Which of the following should the nurse
include in the teaching?
A. "Apply the patch to the lower abdomen."
B. "You should replace the patch every day."
C. "The patch can be applied to the breast area."
D. "You can use lotion on the skin before applying the patch."
Answer: A. "Apply the patch to the lower abdomen."
A nurse is reviewing the laboratory results of a client who has DKA. The client's ABG results
are pH 7.30, PaCO2 34 mm Hg, and HCO3- 21 mEq/L. The nurse should identify that these
values indicate which of the following acid-base imbalances?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
Answer: C. Metabolic acidosis
A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain
medication. After the nurse administers the medication, which of the following tasks should
the nurse assign to the AP?
A. Document the client's respiratory rate in 1 hr.
B. Assess the client's pain level after the medication is administered.
C. Teach the client about the side effects of the pain medication.
D. Monitor the client for any adverse reactions immediately after the medication is given.
Answer: A. Document the client's respiratory rate in 1 hr.
A nurse is collecting data from a client who is 24 hr postoperative following a total knee
arthroplasty. Which of the following findings on the operative leg should the nurse identify as
a manifestation of a deep-vein thrombosis?
A. Increase in calf size
B. Capillary refill of 2 seconds
C. Palpable cord-like vein
D. Extremity feels cool to the touch
Answer: A. Increase in calf size
A nurse is reviewing the medical record of a client who has sustained a full-thickness burn
and is in the emergent phase of the burn. Which of the following findings should the nurse
expect?
A. Hyperkalemia
B. Hypercalcemia
C. Hyponatremia
D. Hypoglycemia
Answer: A. Hyperkalemia
A nurse is caring for several clients who are receiving well-child check-ups. The nurse should
identify that the initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for
which of the following clients?
A. A 6-month-old infant
B. A 12-month-old toddler
C. A 4-year-old child
D. A 10-year-old child
Answer: A. A 6-month-old infant
A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic
relationship should the nurse help the client develop problem-solving skills?
A. Orientation phase
B. Working phase
C. Termination phase
D. Pre-interaction phase
Answer: B. Working phase
A nurse is reinforcing discharge teaching with the guardian of a client who is neutropenic.
Which of the following instructions should the nurse include?
A. "You can take your child to stores on weekends."
B. "You should inspect your child's mouth weekly for ulcers."
C. "You should notify your provider if your child has a fever."
D. "You can give your child fresh fruit for snacks."
Answer: C. "You should notify your provider if your child has a fever."
A nurse is collecting data on a client who has swelling of the lower leg. The nurse should
identify that which of the following findings is a manifestation of compartment syndrome?
A. Affected extremity warm to touch
B. Moderate pain on the ankle of the affected extremity
C. Blanch time of 2 seconds in the toenail beds of the affected extremity
D. Palpation of a +1 dorsal pedal pulse of the affected extremity
Answer: C. Blanch time of 2 seconds in the toenail beds of the affected extremity
A nurse is collecting data from a client who received IV morphine for postoperative pain. The
nurse should identify that which of the following findings indicates a therapeutic response to
the medication?
A. The client's blood pressure has been reduced.
B. The client reports a pain level of 2 on a scale of 0 to 10.
C. The client's heart rate has increased.
D. The client is drowsy but easily arousable.
Answer: B. The client reports a pain level of 2 on a scale of 0 to 10.
A nurse is reinforcing discharge teaching with a client who is postoperative following laser
surgery for open-angle glaucoma. Which of the following statements by the client indicates
an understanding of the instructions?
A. "I will resume my normal activities immediately."
B. "I will avoid bending over to lift heavy objects."
C. "I can stop taking my eye drops once my vision improves."
D. "I will take a stool softener to prevent constipation."
Answer: D. "I will take a stool softener to prevent constipation."
A nurse is preparing to administer medication to a newborn. Which of the following
information should the nurse use to identify the newborn?
A. Name and medical record number
B. Birth date and mother's name
C. Age and diagnosis
D. Footprints and identification number
Answer: A. Name and medical record number
A nurse is caring for a client who is near death. Which of the following actions should the
nurse take?
A. Administer scheduled pain medications.
B. Encourage family members to say goodbye.
C. Discuss advanced directives with the client.
D. Provide a quiet environment.
Answer: A. Administer scheduled pain medications.
A nurse is establishing a baseline postoperative assessment for a client who is recovering
from a right femoropopliteal bypass graft. Which of the following findings in the assessment
of the client's right leg should be of the most concern to the nurse?
A. The client's pedal pulse in the right foot is not palpable.
B. The client's leg is slightly edematous.
C. The client's skin is warm to touch.
D. The client reports mild pain at the incision site.
Answer: A. The client's pedal pulse in the right foot is not palpable.
A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse
should recognize that the client needs a referral for diabetic education when the client does
which of the following?
A. States that he will treat hypoglycemic reactions with 15 g of carbohydrates.
B. Expresses concerns about insulin injections.
C. Asks about dietary modifications.
D. Says he does not need to monitor his blood glucose levels.
Answer: D. Says he does not need to monitor his blood glucose levels.
A nurse is caring for a client who has been placed on contact isolation precautions. Which of
the following interventions should the nurse implement?
A. Inform visitors to remain at least 3 feet away from the client.
B. Apply sterile gloves when entering the client's room.
C. Leave all equipment that is used routinely in the client's room.
D. Place the client in a negative-pressure airflow room.
Answer: C. Leave all equipment that is used routinely in the client's room.
A nurse is collecting data from a client whose Hgb is 8.8 mg/dL. C. Which of the following
statements should the nurse expect?
A. "I have a lot of energy and feel great."
B. "I feel tired all the time."
C. "I haven't noticed any changes in my health."
D. "I sleep better than ever."
Answer: B. "I feel tired all the time."
A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should
identify which of the following findings as an indication of pain?
A. Lip-smacking
B. Stiff posture
C. Weak cry
D. Tongue-darting
Answer: B. Stiff posture
A nurse is assisting with an admission interview for a client who has schizophrenia. He tells
the nurse that he is receiving special audible messages from the Central Intelligence Agency
that no one else is able to hear. The nurse should identify that the client is having which of the
following alterations in perception?
A. Illusion
B. Hallucination
C. Delusion
D. Derealization
Answer: B. Hallucination
A nurse is reinforcing teaching with a client who is about to undergo a thoracentesis. Which
of the following statements by the client indicates an understanding of the information?
A. "I will need to lie flat on the table during the procedure."
B. "I will have a chest x-ray following the procedure."
C. "I can eat a light meal before the procedure."
D. "I should expect to feel a lot of pain during the procedure."
Answer: B. "I will have a chest x-ray following the procedure."
A nurse is setting up a sterile field prior to performing a dressing change. Which of the
following actions should the nurse take?
A. Pour liquid by holding the bottle with the label facing the sterile field.
B. Prepare the sterile field 5 cm (2 in) below the level of the waist.
C. Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field.
D. Open the outermost flap of the wrapper toward the body.
Answer: C. Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field.
A nurse is collecting data from a client who has substance use disorder and reports recently
taking opioids. Which of the following findings should the nurse identify as a manifestation
of opioid intoxication?
A. Increased heart rate
B. Pinpoint pupils
C. Dilated pupils
D. Hyperactivity
Answer: B. Pinpoint pupils.
A nurse is caring for a client who has major depressive disorder and is refusing their
medication. The client's family suggests placing the client's medication in their food. Which
of the following actions should the nurse take?
A. Inform the family that the client has the right to not take the medication.
B. Encourage the family to discuss the medication with the client.
C. Suggest the family members administer the medication when the client is not watching.
D. Explain that the medication must be taken for the client's health.
Answer: A. Inform the family that the client has the right to not take the medication.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of
the following actions by the nurse demonstrates cost-effective care?
A. Flexes the client's affected hip to 120°
B. Adducts the client's affected leg
C. Checks the neurovascular status of the client's lower extremities every 6 hr
D. Applies a sequential compression device to the client's lower extremities
Answer: D. Applies a sequential compression device to the client's lower extremities
A nurse is reviewing the medical record of a client who is requesting an oral contraceptive.
Which of the following findings should the nurse identify as a contraindication to the use of
oral contraceptives?
A. History of renal calculi
B. History of smoking
C. History of migraine headaches
D. History of hypertension
Answer: C. History of migraine headaches.
A nurse is reinforcing teaching with a client who has rheumatoid arthritis and is using a
straight-legged cane for ambulation. Which of the following instructions should the nurse
include?
A. "Maintain your elbow flexed at a 90-degree angle."
B. "Keep the cane on the stronger side of the body."
C. "Place the cane forward 5 to 10 cm (2 to 4 in)."
D. "Move the stronger leg forward first."
Answer: B. "Keep the cane on the stronger side of the body."
A nurse is collecting data from a client who has preeclampsia and is receiving magnesium
sulfate via a continuous IV infusion. Which of the following findings should the nurse report
to the provider?
A. Urine output 20 mL/hr
B. Provider Prescriptions
C. Carvedilol 6.25 mg PO BID
D. Docusate 50 mg PO daily
E. Warfarin 5 mg PO daily
Answer: A. Urine output 20 mL/hr
A nurse in a provider's office is collecting data from a client who was discharged from the
facility 7 days ago following treatment for a deep-vein thrombosis. Which of the following
findings is the nurse's priority?
A. The client takes ibuprofen daily to treat musculoskeletal pain.
B. The client reports mild swelling in the affected leg.
C. The client has a new prescription for anticoagulation therapy.
D. The client mentions having occasional leg cramps.
Answer: A. The client takes ibuprofen daily to treat musculoskeletal pain.
A nurse is caring for a client who has a new prescription for furosemide and asks the nurse
about the purpose of the medication. The nurse states, "This medication is a diuretic that
removes excess fluid from your body." Which of the following ethical concepts is the nurse
exhibiting?
A. Autonomy
B. Justice
C. Veracity
D. Beneficence
Answer: C. Veracity.
A nurse is planning to administer an ophthalmic medication to a client. Which of the
following actions will minimize systemic absorption of the medication?
A. Wait 5 min after instillation before instilling the drops in the other eye.
B. Apply gentle pressure to the inner canthus after instillation.
C. Administer the drops with the client's head tilted backward.
D. Warm the medication in the hands before administration.
Answer: B. Apply gentle pressure to the inner canthus after instillation.
A nurse is assisting with planning care for a group of clients. Which of the following tasks
should the nurse delegate to an assistive personnel?
A. Administering a large-volume enema to a client
B. Monitoring vital signs of a post-operative client
C. Performing a wound dressing change
D. Assisting a client with mobility
Answer: D. Assisting a client with mobility
A nurse is caring for a school-age child whose family adheres to a vegan diet in the home.
The nurse should recognize the child is at risk for deficiency of which of the following?
A. Vitamin B12
B. Iron
C. Calcium
D. Vitamin D
Answer: A. Vitamin B12
A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint
pain, swelling, and stiffness. Which of the following client statements indicates
understanding of the teaching?
A. "I will rest my joints completely when they are inflamed."
B. "I will use heat therapy only when I feel pain."
C. "I will exercise my joints as much as I can when they are inflamed."
D. "I will alternate between hot and cold treatments to manage symptoms."
Answer: D. "I will alternate between hot and cold treatments to manage symptoms."
A nurse is assisting with planning care for a newly admitted client who has anorexia nervosa.
Which of the following interventions should the nurse recommend to include in the plan of
care?
A. Encourage the client to gain 2.3 kg (5 lb) per week.
B. Monitor the client for 15 min after meals.
C. Weigh the client each morning after voiding.
D. Reinforce teaching about healthy eating during meals.
Answer: C. Weigh the client each morning after voiding.
A nurse is assisting in the care of a client who is experiencing a postpartum hemorrhage.
Which of the following medications should the nurse plan to administer?
A. Oxytocin
B. Methylergonovine
C. Carboprost
D. Misoprostol
Answer: A. Oxytocin
A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation. For
which of the following results should the nurse notify the provider?
A. Hemoglobin 12 g/dL
B. Platelet count 90,000/mm³
C. Glucose 80 mg/dL
D. White blood cell count 11,000/mm³
Answer: B. Platelet count 90,000/mm³
A nurse is caring for a client who is receiving IV fluids. The nurse realizes that the incorrect
IV solution is infusing. Which of the following actions should the nurse take?
A. Remove the IV catheter.
B. Slow the infusion rate.
C. Change the IV solution to the correct one.
D. Notify the healthcare provider.
Answer: D. Notify the healthcare provider.
A nurse is receiving change-of-shift report on a group of clients. Which of the following
clients should the nurse see first?
A. A client who is exhibiting flight of ideas
B. A client with stable vital signs who is 1 day postoperative
C. A client experiencing mild anxiety before a procedure
D. A client who is requesting discharge instructions
Answer: A. A client who is exhibiting flight of ideas
A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following
actions should the nurse take?
A. Apply a heat pack 5 to 10 min prior to the procedure.
B. Use a 23-gauge needle for the heel stick.
C. Clean the site with alcohol and allow it to dry.
D. Position the newborn in a supine position with legs extended.
Answer: A. Apply a heat pack 5 to 10 min prior to the procedure.
A nurse is providing postmortem care for a client prior to the family viewing the body. Which
of the following actions should the nurse take?
A. Apply surgical tape to the client's eyes.
B. Remove all medical equipment from the room.
C. Leave the client's mouth open for viewing.
D. Place a pillow under the client's
Answer: A. Apply surgical tape to the client's eyes.
A nurse is collecting data for a client following electroconvulsive therapy. Which of the
following adverse effects should the nurse expect?
A. Confusion
B. Drowsiness
C. Nausea
D. Headache
Answer: A. Confusion
A nurse is preparing a client who has a small bowel obstruction for insertion of a nasogastric
tube. Which of the following equipment should the nurse gather prior to the procedure?
A. Suction device
B. Infusion pump
C. Disposable feeding bag
D. Sterile gloves
Answer: A. Suction device
A nurse is admitting a client who has active tuberculosis. Which of the following nursing
interventions is appropriate?
A. Place the client in a room that is ventilated to the outside.
B. Use standard precautions only while caring for the client.
C. Place the client in a semi-private room with another client who has the same diagnosis.
D. Ensure the client wears a surgical mask at all times.
Answer: A. Place the client in a room that is ventilated to the outside.
