ATI Comprehensive Predictor 2019 A Study Review Questions with Correct
Answers and Rationales Latest Update 2023.
A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so
angry I went to the gym and worked out." The nurse should recognize the client is demonstrating
which of the following defense mechanisms?
Answer: Sublimation
Rationale: The client is exhibiting behaviors consistent with sublimation, which is displayed
when a client substitutes socially unacceptable behavior for acceptable behavior.
A nurse is caring for a client who has generalized anxiety disorder and is to begin taking
alprazolam. Which of the following actions should the nurse take?
Answer: Initiate fall precautions for the client
Rationale: The nurse should initiate fall precautions for a client who has a new prescription for
alprazolam because common adverse effects associated with this medication are orthostatic
hypotension, dizziness, confusion, and lethargy.
A nurse on a med surgical unit is caring for a client prior to a surgical procedure. Which of the
following findings should indicate to the nurse that the client has the ability to sign the informed
consent?
Answer: The client is able to accurately describe the upcoming procedure
Rationale: The ability of the client to accurately describe the upcoming procedure indicates that
the provider adequately informed the client and that the client is able to sign the informed
consent
Assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the
following actions by the AP requires the nurse to intervene?
Answer: Places a pillow under the client's right arm.
Rationale: The AP should place a pillow under the client's left arm to prevent internal rotation of
the left shoulder.
A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the
following instructions should the nurse include?
Answer: Introduce new foods one at a time over 5 to 7 days.
A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following
precautions should the nurse implement?
Answer: Contact
Rationale: The nurse should implement contact precautions for a client who has an infection
spread by direct contact, such as MRSA.
A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia.
Which of the following actions should the nurse take first
Answer: Massage the uterus to expel clots
Rationale: Using the EBP approach to client care, the nurse should identify that the priority
action is massaging the client's uterus. Uterine massage will expel clots and increase uterine
firmness, resulting in decreased bleeding.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the
following statements should the nurse include in the teaching?
Answer: "Secure the retainer clip at the level of your baby's armpits"
A nurse is providing discharge teaching to a client who has colorectal cancer and a new
colostomy. The client states, "I'm worried about being discharged because I live alone, and my
insurance doesn't cover ostomy supplies. "Which of the following actions should the nurse take?
(SATA)
Answer:
• Refer the client to a community based social workers
• Initiate a consult with a home health care provider
• Give the client information about local support groups
Rationale:
• A social worker is necessary to help a client with self-care, as well as assist in locating agencies
who can help the client face challenges with self-care and paying for necessary ostomy supplies
• A home health nurse can assist the client in learning to care for the colostomy as well as
provide medication management and emotional support
• A client who has cancer and a new colostomy can get help with coping from a support group
and possibly receive assistance obtaining supplies from local agencies
A nurse manager is reviewing unit records and discovers that client falls occur most frequently
during the hours of 0530 and 0730. Which of the following actions should the nurse take when
conducting a root cause analysis?
Answer: Investigate environmental factors that might be contributing to client injury during
these hours.
Rationale: When conducting a root cause analysis, the nurse should look at the factors that could
possibly lead to the clients' falls. This can include environmental factors that might be causing
the problem.
A nurse is caring for a client who has terminal illness and requests lifesaving measures if a
cardiac arrest occurs. Which of the following statements should the nurse make?
Answer: "I will provide you with information about medical treatment to include in your living
will"
Rationale: The nurses' responsibility is to provide the client with information about specific
instructions for addressing medical treatment in a living will. The nurse should assist the client
while they are able to make decisions for themself by providing information about what end-oflife preferences to document.
A nurse is assessing a client who has delirium. Which of the following manifestations should the
nurse expect?
Answer: Rapid speech
Rationale: Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling
speech patterns
A night shift nurse is giving a change of shift report to the day shift nurse on a client who is
ready for discharge. Which of the following information is the priority for the nurse to
communicate to the oncoming nurse?
Answer: The client needs assistance when transferring from the bed to a wheelchair.
Rationale: The greatest risk to this client is injury due to a fall.
Therefore, the priority information for the nurse to communicate is that the client requires
assistance during transfers.
A nurse is assessing a client during the immediate postpartum period. Which of the following
findings requires immediate intervention by the nurse?
Answer: Boggy uterus
Rationale: When using urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse
should immediately intervene to stimulate uterine contractions and prevent blood loss. If the
uterus becomes relaxed during the postpartum period, the client will rapidly lose blood because
no permanent thrombi have formed at the placenta.
A nurse in an emergency department is preparing to discharge a client who has experienced
intimate partner violence. Which of the following actions should the nurse take first?
Answer: Develop a safety plan with the client
Rationale: The greatest risk to this client is injury from violence. Therefore, the first action the
nurse should take is to develop a safety plan with the client.
A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and
a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse
anticipate administering.
Answer: Flumazenil
Rationale: The nurse should anticipate administering flumazenil, a competitive benzodiazepine
receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should
continue to support the client's respirations with a bag valve mask.
A home health nurse is planning care for an older adult client who has impaired vision. Which of
the following interventions should the nurse include in the plant of care to prevent injury in the
home?
Answer: Mark the edges of the stairs for contrast
Rationale: Marking the edges of stairs with paint or colored tape for contrast can help older
adult clients who have impaired vision prevent injury by decreasing the risk of falls.
A nurse manager is planning to make changes to the current scheduling system on the unit. To
facilitate the staff's acceptance of this change, which of the following actions should the nurse
manager take first?
Answer: Provide information about scheduling issues to the staff.
Rationale: The first stage of the change process is the unfreezing stage, when the nurse should
inform the staff about the current staffing issues. This can increase their understanding of why
changes are necessary.
A nurse is teaching a group of guardians about child safety measures. Which of the following
statements by guardian indicates an understanding of the teaching?
Answer: "I should have my child avoid sun exposure between 10 am and 2 pm"
Rationale: To prevent sunburns, guardians should apply sunscreen, dress their child in protective
clothing, and avoid sun exposure between 1000 and 1400.
An RN is planning care for a group of clients and is working with a licensed practical nurse
(LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to
the LPN?
Answer: Insertion of a nasogastric tube
Rationale: The nurse should delegate the insertion of a nasogastric tube to the LPN because this
task is within the LPN's scope of practice.
A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse
report to the provider?
Answer: Axillary temperature 36.2 C (97.2 F)
Rationale: The expected reference range for the axillary temperature of newborn is between
36.5 C to 37.5 C (97.7 F to 99.5 F). An axillary temperature of 36.2 C (97.2 F) or below in a
newborn who is 2 hr old indicates cold stress and should be reported to the provider.
A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The
nurse should explain to the parent that the newborn should receive vitamin K to prevent which of
the following?
Answer: Bleeding
Rationale: The nurse should explain to the parent that newborns are deficient in vitamin K and
should receive it following birth because this deficiency can lead to bleeding.
A nurse is caring for a client who requires physical therapy following discharge. Which of the
following actions should the nurse take?
Answer: Involve the client in selection of a physical therapy provider/
Rationale: The nurse should involve the client in the referral process, including selection of the
physical therapist and the location.
A nurse in an emergency department is assessing a client who reports taking MDMA. Which of
the following should the nurse expect?
Answer: Diaphoresis
Rationale: Diaphoresis is an expected finding of MDMA use. Additionally, the client might
experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth
clenching, and mild hallucinogenic effects.
A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions
should the nurse take?
Answer: Place the BP cuff in a labeled bag to send it for decontamination.
Rationale: The nurse should place the BP cuff in a labeled bag before removing it from the
client's room and sending it to the proper facility location for decontamination.
A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking
clozapine. Which of the following findings should the nurse identify as a contraindication for the
client to receive clozapine?
Answer: WBC count 2,800/mm3
Rationale: Clozapine can cause agranulocytosis, which can be life threatening. Therefore, a
WBC count of less than 3,000/mm3 is a contraindication for the client to receive clozapine. The
nurse should withhold the medication and notify the provider of the client's WBC count.
A nurse is providing teaching to an adolescent following insertion of a tunnelled central venous
catheter without a pressure sensitive valve. Which of the following information should the nurse
include in the teaching?
Answer: "You should keep the catheter clamped when not in use"
Rationale: The adolescent should keep the catheter clamped to prevent blood backflow. Not all
tunnelled catheters have a pressure-sensitive valve that prevents blood reflux.
A nurse is conducting visual acuity testing when using the Snellen letter chart for a school age
child who has eyeglasses. Which of the following instructions should the nurse give to the child?
Answer: "You should keep both eyes open during the testing"
Rationale: The nurse should instruct the child to keep both eyes open during visual acuity
testing.
When caring for a child, a nurse plans to use non-pharmacological interventions to enhance the
effectiveness of pain medication. Which of the following strategies incorporates visualization
techniques to help decrease the child's discomfort?
Answer: Blowing bubbles with liquid soap to "blow the hurt away"
Rationale: Having the child blow bubbles is a visualization technique that can help to decrease
the child's discomfort. The child can visualize the pain as the bubble that they blow away from
themself and into the air.
A nurse is preparing to administer heparin 5,000 units SQ. Available is heparin injection 10,000
units/mL. How many mL should the nurse administer per dose?
Answer: 0.5 mL
Rationale: 5,000 units/ 10,000 units = 0.5 mL
A charge nurse is observing a newly licensed nurse performing a physical assessment on a client.
Which of the following actions by the nurse indicates that the charge nurse should intervene?
Answer: The newly licensed nurse writes detailed notes while performing the head-to-toe
assessment.
Rationale: The newly licensed nurse should record brief notes during the assessment to avoid
delays and write more detailed notes after completing the assessment.
A nurse is assessing a client who has schizophrenia. The nurse should identify the following
alteration in speech as which of the following?
(Audio)
Answer: Clang association
Rationale: Clang association is an alteration in speech in which the client uses words based on
their sound, rather than their meaning. Clients who have neurological disorders can also have this
alteration in speech.
A nurse is assessing a school age-child who has cystic fibrosis. Which of the following findings
is the priority for the nurse to report to the provider?
Answer: Hemoptysis 275 mL/24 hr
Rationale: Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for
hemorrhage. Therefore, this is the priority finding for the nurse to report.
Fever
A nurse is caring for a client who ha bipolar disorder. The nurse observes that the client is
becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently
using profanities and sexual references. Which of the following actions should the nurse take
first?
Answer: Move the client to a quiet place away from others.
Rationale: The client's behavior indicates the greatest risk is injury to others. Therefore, the first
action the nurse should take is to prevent harm to other clients by moving the client to a quiet
place away from others.
A nurse is providing colostomy care for a client using a two-piece pouching system. Which of
the following actions should the nurse take?
Answer: Place the skin barrier over the stoma and hold it for 30 seconds.
Rationale: The nurse should activate the adhesive in the skin barrier by holding it in place over
the stoma for 30 seconds.
A nurse is teaching the parent of a school-age about administering ear drops. Which of the
following response by the parent indicates an understanding of the teaching?
Answer: "I should pull the top of the ear upward and back while instilling the medication."
Rationale: The nurse should instruct the parent to pull the pinna upward and back in children
older than 3 years of age to straighten the ear canal and allow the medication to reach the entire
canal. For children younger than 3 years of age, the parent should gently pull the pinna
downward and back.
A nurse is assessing a client who is 2 hr postoperative following a cardiac catheterization. Which
of the following information should the nurse report to the provider?
Answer: Neurologic status
Rationale: This client is experiencing slurred speech and extremity weakness, which are
indications of a stroke, a potential complication of cardiac catheterization. The nurse should
report these findings to the provider.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by
continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working.
Which of the following actions should the nurse take while waiting for a new infusion pump?
Answer: Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr.
Rationale: The nurse should use an infusion pump when administering TPN solution to ensure
accurate dosage and should taper the infusion rate before discontinuing the solution to prevent
hypoglycemia. If the nurse is unable to continue the TPN infusion by infusion pump, the nurse
should use manual drip tubing to infuse dextrose 10% in water at the same rate as the TPN
solution.
A nurse is caring for a client who has an STI that must be reported to the state health department.
Which of the following actions should the nurse take?
Answer: Explain to the client why this information will be shared.
Rationale: It is the responsibility of the nurse to advocate for the client, provide confidential
information, and explain legal requirements. Reporting communicable disease occurrences helps
with identifying outbreaks and overall disease trends.
A nurse is caring for a group of clients. For which of the following events should the nurse
complete an incident report?
Answer: A client's IV pump delivers an inadequate dose of medication.
Rationale: The nurse should complete an incident report to record occurrences which resulted in
a medication error, such as a failure of the IV pump, as part of the quality improvement process.
Other situations requiring an incident report include significant complaints about care quality and
visitor or client injury.
A nurse is caring for a client who has hypertension and is taking captopril. Which of the
following tasks should the nurse delegate to an assistive personnel (AP)?
Answer: Obtain the client's blood pressure before the nurse administers medication.
Rationale: The nurse can delegate obtaining blood pressure before and after medication
administration because this task is within the range of function for an AP.
A nurse is assessing a client who is receiving a blood transfusion. Which of the following
findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?
Answer: Low back pain
Rationale: The nurse should expect low back pain in a client who is having a hemolytic
transfusion reaction.
A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions
should the nurse take?
Answer: Initiate oral rehydration therapy for the toddler.
Rationale: Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler
with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given
along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet
can be resumed.
A nurse is administering medications to a client who has percutaneous gastrostomy tube for
enteral feedings. Which of the following actions should the nurse take to prevent clogging of. the
tube?
Answer: Flush the client's gastrostomy tube with 30 mL of water before administering the
medication.
Rationale: The nurse should flush the gastrotomy tube with at least 30 mL of water before and
after medication administration to clear the tube of any residuals and to ensure patency.
A nurse is teaching home wound care to the family of a child who has a large wound. Which of
the following interventions should the nurse recommend?
Answer: Double-bag soiled dressings in plastic bags for disposal.
Rationale: The client should double-bag soiled dressings in plastic bags to prevent the spread of
micro-organisms to other household members.
A nurse is teaching the parents of a toddler about snacks. Which of the following foods should
the nurse recommend?
Answer: Diced steamed carrots
Rationale: Diced steamed carrots are a safe food choice for toddlers because they are soft and do
not present a choking hazard.
A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy
for the past 36 hr. Which of the following findings should the nurse identify is an indication that
the client has developed oxygen toxicity?
Answer: Substernal pain
Rationale: The nurse should identify substernal pain as a manifestation of oxygen toxicity due to
the increased work of breathing, such as in a preschooler who has cystic fibrosis.
A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube.
Which of the following actions by the newly licensed nurse indicates an understanding of the
procedure?
Answer: Keeps the head of the bed elevated to 45° for 1 hr after feedings
Rationale: The nurse should keep the client's head elevated to 30° to 45° for 1 to 2 hr after
feedings to decrease the risk for aspiration.
A nurse is assessing a client who has Raynaud's disease. Which of the following findings should
the nurse expect?
Answer: Blanching of the fingers and toes
Rationale: A client who has Raynaud's disease can have blanching of the fingers and toes in
response to exposure to cold or emotional stress. Pallor develops first, then cyanosis, followed by
redness or heat as the vessels reperfuse, before the skin returns to the client's baseline tone
A nurse is talking with the partner of a client who attempted suicide. Which of the following
statements by the client's partner should the nurse identify as the priority?
Answer: "My husband doesn't know that I've already moved out of the house and filed for a
divorce."
Rationale: A lack of social support and isolation indicates the client is at greatest risk for another
suicide attempt. Therefore, this is the priority concern that the nurse should report to the
provider.
A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks
when the child can return to school. Which of the following responses should the nurse make?
Answer: "When crusts have formed on every lesion."
Rationale: The child should return to school once all the lesions have crusted over. Varicella is
no longer contagious after crusts have formed on all lesions.
A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the
following should the nurse include in the toddler's plan of care?
Answer: Encourage the parents to bring toys from home.
Rationale: To help decrease the toddler's anxiety, the nurse should encourage the family to bring
familiar objects from home, such as toys, blankets, and feeding utensils.
A nurse is caring for an older adult client in the PACU following general anesthesia. Which of
the following findings should the nurse report to the provider?
Answer: Audible stridor
Rationale: Audible stridor, or a high-pitched sound heard in the client's airway indicates edema,
laryngeal spasm, secretions, or some type of airway obstruction that could become lifethreatening. The nurse should report this finding to the provider.
A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess
the client for which of the following conditions prior to starting the procedure?
Answer: Latex allergy
Rationale: The nurse should assess the client for a latex allergy prior to the insertion of an
indwelling urinary catheter due to the risk of an allergic reaction
A home health nurse is providing teaching about infection prevention to a client who has cancer
and is receiving chemotherapy. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: "I will walk for short distances throughout the day."
Rationale: The client should ambulate for short distances as tolerated throughout the day. This
will help to reduce pulmonary stasis and prevent the development of respiratory infections
A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client
says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the
following responses should the nurse make?
Answer: "It seems like you feel your visits are a waste of time."
Rationale: The nurse is using a clarifying technique that facilitates the nurse's understanding of
the adult child's feelings
A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse
expresses concern about having limited experience with monitoring chest tube drainage. Which
of the following actions should the charge nurse take first to provide teaching about chest tubes?
Answer: Ask the nurse about their knowledge of the procedure.
Rationale: The first action the charge nurse should take using the nursing process is to assess the
newly licensed nurse's knowledge about the procedure. By assessing the nurse's knowledge, the
charge nurse can identify the nurse's learning needs.
A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When
discussing the client's prognosis with the parents, the nurse should recognize which of the
following responses by the parents as an example of rationalization?
Answer: "Maybe this is better for our child because we don't want any suffering through
chemotherapy treatments."
Rationale: By justifying the adolescent's prognosis by searching for a more personally
acceptable explanation for the impending loss, the parent is using the defense mechanism of
rationalization.
A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain
what causes the nurse to explain what causes her to have constipation. Which of the following
responses should the nurse make?
Answer: "The enlarged uterus compresses the intestines and causes constipation."
Rationale: During the second and third trimesters, the size and weight of the growing uterus
cause both displacement and compression of the intestines. These changes cause a decrease in
motility, leading to constipation.
A nurse is teaching a client who has opioid use disorder about methadone. Which of the
following information should the nurse include in the teaching?
Answer: "Sedation is a common adverse effect of this medication."
Rationale: Sedation and drowsiness are common adverse effects of methadone. Sedation most
frequently occurs at the beginning of treatment or during dosage increases.
A community health nurse is reviewing the medical records of four newly diagnosed clients. The
nurse should identify which of the following clients as having a nationally notifiable infectious
condition?
Answer: An adolescent client who has foodborne botulism
Rationale: The nurse should report botulism to the CDC because this information is necessary
for the prevention and control of this disease. Clients who ingest the botulism toxin can develop
dysphasia, drooping eyelids, and vision changes, and in 12 to 36 hr can develop neurologic
symptoms such as symmetric, flaccid paralysis and cranial nerve impairment.
A nurse is assessing a client who is experiencing autonomic dysreflexia. which of the following
findings should the nurse expect? (SATA)
Answer: • Facial flushing is correct. The nurse should expect a client who has autonomic
dysreflexia to have facial flushing. Flushing occurs from the point of the lesion upward.
• Nasal congestion is correct. The nurse should expect a client who has autonomic dysreflexia to
have nasal congestion.
• Headache is correct. The nurse should expect a client who has autonomic dysreflexia to have a
severe headache.
A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and
requires a blood pressure check every 10 min. Which of the following staff members should the
nurse assign to collect this information?
Answer: An assistive personnel (AP) who is assisting a client to return to bed
Rationale: Performing a blood pressure check is within the range of function of an AP, and the
AP should be available to obtain a blood pressure within the specified time.
A charge nurse observes a staff nurse document a dressing change in a client's chart that was not
performed. Which of the following actions should the charge nurse take first?
Answer: Gather more information about the staff nurse's actions.
Rationale: The first action the nurse should take when using the nursing process is to assess the
reasons for the staff nurse's negligent actions.
Therefore, the charge nurse should gather additional information and discuss the issue with the
staff nurse before deciding on the next course of action.
A home health nurse is providing teaching to a client who has hepatitis A. Which of the
following instructions should the nurse include?
Answer: Use hydrogen peroxide to clean kitchen surfaces.
Rationale: The client should clean kitchen surfaces with hydrogen peroxide to kill the virus and
prevent transmission.
A nurse manager is on a planning committee to develop an emergency preparedness plan. The
nurse should recommend that which of the following actions takes place first when
implementing an emergency preparedness plan?
Answer: Notify the incident commander.
Rationale: The first action to take when implementing an emergency preparedness plan is to
notify the incident commander to initiate the command hierarchy and maintain order.
A nurse is performing an admission assessment of a preschooler who is in the acute phase of
Kawasaki disease. Which of the following findings should the nurse expect?
Answer: Fever unresponsive to antipyretics
Rationale: The nurse should expect a child who has acute Kawasaki disease to have a high fever
that is unresponsive to antibiotics or antipyretics.
A nurse is caring for an older adult client. Which of the following findings should the nurse
recognize as a physiological change associated with aging?
Answer: Decreased lung expansion
Rationale: Older adult clients are more likely to have decreased lung expansion due to decreased
mobility of the ribs.
A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis.
Which of the following instructions should the nurse include? (SATA)
Answer: • "A speech pathologist will be performing a swallowing study for you." is correct. The
nurse should instruct the client that a swallowing study will be performed to determine the
client's risk for aspiration due to difficulty swallowing, which is a manifestation of multiple
sclerosis.
• "You should rest before eating a meal." is correct. The nurse should encourage the client to rest
before each meal. Clients who have multiple sclerosis often report weakness and are easily
fatigued.
• "Thicken your beverages before drinking." is correct. The nurse should instruct the client that
liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is
a manifestation of multiple sclerosis.
A nurse is assessing a client who has obstructive sleep apnea. For which of the following
complications should the nurse monitor?
Answer: Hypertension
Rationale: The nurse should assess the client for hypertension, a complication of obstructive
sleep apnea from hypoxia. Other complications include heart failure and cardiac dysrhythmias.
A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the
following should the nurse include in the teaching?
Answer: The cervix transitions to an anterior position.
Rationale: In true labor, the cervix transitions to an anterior position and begins to dilate in
preparation for birth.
A nurse is planning care for a client who is receiving hemodialysis via an established
arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse
include in the client's plan of care?
Answer: Auscultate the affected extremity for a bruit.
Rationale: The nurse should auscultate the AV fistula every 4 hr to ensure a bruit is present,
which indicates patency.
A nurse is planning teaching about allowable foods for a client who has a history of uric acidbased urinary calculi formation. Which of the following foods should the nurse include in the
teaching?
Answer: Oranges
Rationale: A client who is prone to uric acid calculi formation can eat citrus fruits.
A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations
should the nurse expect?
Answer: Nystagmus
Rationale: Nystagmus is involuntary eye movements and muscle spasticity, which are
manifestations of multiple sclerosis.
A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus.
Which of the following actions should the nurse plan to take first?
Answer: Check the insulin dose with another licensed nurse.
Rationale: The greatest risk to the client is injury due to a medication error. Therefore, the
priority action is for the nurse to validate the correct dose of insulin with another licensed nurse
prior to administration. Insulin is a high-alert medication and incorrect dosages can be fatal for
the client
A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the
following manifestations should the nurse expect?
Answer: Grandiose delusions
Rationale: Clients who are in the manic phase of bipolar disorder typically exhibit behaviors
that appear to be euphoric. Clients can also have abrupt mood changes, expansiveness, unlimited
energy, poor impulse control, and grandiose delusions.
A case manager is reviewing the medical records of several clients. For which of the following
clients should the nurse request an interprofessional care conference?
Answer: A client who has diabetes mellitus and has had repeated hospitalizations for diabetic
ketoacidosis
Rationale: A client who is having repeated episodes of a life-threatening complication requires
an interprofessional care conference so team members can address the client's needs to provide
care and support.
A nurse working on a medical-surgical unit receives a telephone call requesting the status of a
client from an individual who identifies themself as the client's parent. Which of the following
actions should the nurse take?
Answer: Ask the caller for verification of their identity.
Rationale: According to HIPAA, if someone requests information about a client it is the nurse's
duty to protect that information. Therefore, the nurse should inform the caller that nurses cannot
release any client information over the phone without the permission of the client. The nurse
should ask for verification of the caller's identity to determine if they have been authorized by the
client to receive information.
A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio
placentae. Which of the following findings should the nurse expect?
Answer: Persistent uterine contractions
Rationale: The nurse should expect a client who has abruptio placentae to experience persistent
uterine contractions, board-like abdomen, and dark red vaginal bleeding.
A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of
the following instructions should the nurse include?
Answer: Install a raised toilet seat at home.
Rationale: The client should use a raised toilet seat at home to minimize hip flexion and prevent
hip dislocation.
A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to
administer the injection.
A. Periumbilical area (abdomen)
B. Deltoid muscle
C. Vastus lateralis (thigh)
D. Gluteal muscle
Answer: A.
The nurse should recognize that enoxaparin is administered subcutaneously, specifically in the
periumbilical area of the abdomen (at least 2 inches away from the umbilicus). This area is
preferred due to its subcutaneous fat, which allows for proper absorption of the medication. The
other options (deltoid muscle, vastus lateralis, gluteal muscle) are not appropriate for enoxaparin
administration.
A nurse in an outpatient mental health clinic is working with a client who has post-traumatic
stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to
provide relief of the manifestations. Which of the following complementary therapies should the
nurse teach the client to use to help alleviate the distress?
Answer: Guided imagery
Rationale: Helping clients imagine themselves as strong and capable and in settings that are
positive and therapeutic can assist clients who have PTSD by relieving anxiety and pain.
A nurse is caring for four clients. Which of the following clients should the nurse assign to an
assistive personnel (AP) to assist with meals?
Answer: A client who has Alzheimer's disease and is demonstrating aphasia
Rationale: Aphasia impairs the client's ability to communicate but does not interfere with
nutritional intake or place the client at an increased risk for aspiration while eating. Therefore,
assisting the client with meals is within the AP's range of function.
A community health nurse is assisting with the development of a disaster management plan. The
nurse should include which of the following nursing responsibilities in the disaster response
stage of the plan?
Answer: Performing a rapid needs assessment
Rationale: Disaster management includes prevention, preparedness, response, and recovery
stages. The nurse should perform a rapid needs assessment during the response phase of the
disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident,
the health needs of the community, and the priority actions needed during the response stage.
A community health nurse is preparing a health education program for a local rural community.
Which of the following actions should the nurse plan to take first?
Answer: Identify health-related issues within the community.
Rationale: The first action the nurse should take when using the nursing process is to assess the
clients living in the community to identify the prevalent health problems.
A charge nurse is planning an educational session for staff nurses about working with parents
whose terminally ill children are candidates for donating their organs. Which of the following
information should the nurse plan to include?
Answer: The family can have the child in an open casket without fearing that the organ donation
might disfigure the child's body.
Rationale: Removal of organs does not damage or violate the child's body in a way that would
prevent an open casket funeral.
A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the
following findings is the priority for the nurse to report the provider?
Answer: Temperature 39.4°C (102.9°F)
Rationale: The greatest risk to this client is injury from neuroleptic malignant syndrome, a
potentially life-threatening adverse effect of chlorpromazine that can cause the client to have a
high temperature, dysrhythmia, decreased level of consciousness, and a labile blood pressure.
Therefore, the priority finding for the nurse report to the provider is a fever.
A nurse is providing discharge teaching to a client following a cataract extraction. Which of the
following statements by the client indicates an understanding of the teaching?
Answer: "I will bend at my knees when picking an object up off the floor."
Rationale: The client should avoid bending at the waist, because this movement increases
intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an
object.
A nurse is assessing a client who has macular degeneration. Which of the following findings
should the nurse expect?
Answer: Decreased central vision
Rationale: The nurse should expect a client who has macular degeneration to have a decrease or
loss of central vision due to bleeding into the macula or yellow spots under the retina.
A nurse is planning care for a client who is receiving heparin to treat a deep-vein-thrombosis of
the left lower leg. Which of the following interventions should the nurse include in the plan of
care?
Answer: Elevate the affected leg.
Rationale: The nurse should elevate the client's affected extremity to reduce edema and decrease
the risk of chronic venous insufficiency.
A nurse is providing teaching to a client about newborn safety. Which of the following
statements should the nurse include in the teaching?
Answer: "Set your hot water heater temperature at or below 120 degrees Fahrenheit."
Rationale: The nurse should instruct the client to set the maximum hot water temperature to no
more than 49°C (120°F). The nurse should also instruct the client to test the temperature of the
bath water with her elbow prior to bathing the newborn.
A nurse manager is assisting the orientation of a newly licensed nurse. Which of the following
actions by the nurse requires the nurse manager to intervene?
Answer: Tells the hospital chaplain a client's diagnosis
Rationale: Discussing a client's diagnosis with the hospital chaplain is a breach of client
confidentiality and a violation of HIPAA.
A nurse is assessing a 2-month-old infant during a well-baby examination. Which of the
following actions should the nurse take to assess the infant's rooting reflex?
Answer: Stroke the infant's cheek.
Rationale: The nurse should stroke the infant's cheek to assess the rooting reflex, which should
cause the infant to turn towards that side and suck.
A nurse is providing client education to a postpartum client who has decided to bottle feed the
newborn. Which of the following instructions should the nurse include in the teaching to help
prevent the discomfort of engorgement?
Answer: Place ice packs on the breasts for 15 min several times per day.
Rationale: The client should place ice packs on the breasts to reduce swelling and relieve the
pain caused by engorgement.
A nurse receives a request from a client to review the information in his medical record. Which
of the following responses should the nurse give?
Answer: "There's a protocol for reviewing your medical record, and I can initiate the process."
Rationale: The client's record is the legal property of the facility, but the client has a right to
access the record, obtain a copy of the record, and request corrections to the document if there
are discrepancies. According to HIPAA, the nurse is responsible for following the facility's
policy when providing the client with access to the medical record.
A nurse is administering the cyclophosphamide orally to a school-age child who has a
neuroblastoma. Which of the following actions should the nurse take when administering this
medication?
Answer: Maintain hydration with liberal fluid intake.
Rationale: The nurse should offer fluids frequently to maintain hydration and prevent
hemorrhagic cystitis, which is an adverse effect of this medication.
A nurse in the delivery room is caring for a newborn immediately after birth. Which of the
following actions should the nurse take first?
Answer: Dry the newborn.
Rationale: The greatest risk to the newborn is cold stress. Therefore, the first action the nurse
should take is to dry the newborn.
A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of
the following findings should the nurse expect?
Answer: Protein
Rationale: A client who has glomerulonephritis has increased glomerular permeability, which
allows protein to filter into the urine. Therefore, the nurse should expect proteinuria on the
urinalysis report.
A nurse is initiating discharge planning for a client who had a stroke and is experiencing rightsided weakness. Which of the following actions should the nurse take first?
Answer: Request a referral for the client to receive physical therapy.
Rationale: The greatest risk to this client is injury from falls. Therefore, the first action the nurse
should take is to request a referral for physical therapy.
A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that
their child is demonstrating reluctance in going to bed at night and states, "I am not tired." Which
of the following statements by the parents indicate an understanding of the teaching?
Answer: "We should read a story together every night before bedtime."
Rationale: Preschoolers respond to rituals that prepare them for bed, such as hearing a story or
taking a bath.
A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports
using acupressure bands on both wrists. which of the followings statements by the client
indicates that this therapy is having the desired effect?
Answer: "I have not vomited as much recently."
Rationale: Using an acupressure band on the wrists is a type of complementary and alternative
therapy that applies pressure to a specific part of the body and can be used to alleviate nausea
and vomiting.
A nurse is planning care for a client who has thrombocytopenia. Which of the following
instructions should the nurse include in the client's plan of care?
Answer: Avoid venipunctures when possible.
Rationale: Clients who have thrombocytopenia have a decreased platelet count and are at risk
for bleeding. To reduce the risk for bleeding, the nurse should avoid venipunctures when
possible.
A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin.
Which of the following actions should the nurse plan to take?
Answer: Inject 20 units of air into the NPH insulin vial.
Rationale: The nurse should inject 20 units of air into the NPH insulin vial and withdraw the
needle without touching the insulin, then proceed to inject 15 units of air into the regular insulin
vial.
A nurse is caring for a client who is immediately postoperative following a total vaginal
hysterectomy. Which of the following actions should the nurse take first?
Answer: Measure the client's vital signs.
Rationale: The first action the nurse should take when using the nursing process is to assess the
client. The nurse should monitor the client's vital signs every 15 min until stable and then every 4
hr for the next 48 hr.
A nurse is providing discharge instructions to a client who has a new prescription for
amitriptyline to treat depression. The nurse should identify that which of the following client
statements indicates an understanding of the teaching?
Answer: "I should watch for common reactions like dry mouth and constipation."
Rationale: The nurse should reinforce that increasing dietary fiber, fluid intake, and chewing
sugar-free gum can alleviate the anticholinergic effects of dry mouth and constipation.
A nurse is teaching a client who has a new prescription for estradiol. For which of the following
adverse effects of this medication should the nurse instruct the client to monitor and report to the
provider.
Answer: Headaches
Rationale: The nurse should instruct the client to monitor for and report headaches. Headaches
can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse
cardiovascular events.
A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube.
Identify the sequence of steps the parent should follow to perform tracheostomy care.
Answer: When teaching the parent to provide tracheostomy care, the nurse should instruct the
parent to first remove the inner cannula. Next, the nurse should instruct the parent to remove the
soiled dressing and then clean the stoma with 0.9% sodium chloride irrigation. Finally, the nurse
should instruct the parent to change the tracheostomy collar.
A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following
isolation precautions should the nurse initiate?
Answer: Contact
Rationale: The nurse should initiate contact precautions because clients transmit HSV by direct
and indirect contact with others and the environment. The nurse should wear gloves when in
close contact with the newborn.
A nurse is assessing a client who has antisocial personality disorder. Which of the following
manifestations should the nurse expect?
Answer: Lack of remorse
Rationale: A client who has antisocial personality disorder is more likely to show a lack of
remorse.
A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the
bedside commode, which of the following actions should the nurse take first?
Answer: Assess the client for functional limitations.
Rationale: When using the nursing process, the first action the nurse should take is to assess the
client's functional limitations to determine how much the client can assist with the transfer.
A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb
and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL.
How many mL should the nurse administer?
Answer: 0.6 mL
A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of
labor, the nurse observes early decelerations on the monitor tracing. Which of the following
actions should the nurse take?
Answer: Continue observing the fetal heart rate.
Rationale: Early decelerations indicate the progression of labor and are an expected finding. The
nurse should continue to monitor the fetus by observing the fetal heart rate and tracing.
A nurse is interviewing a client who is now without a home due to a natural disaster. After
ensuring the client's safety, which of the following actions should the nurse take first?
Answer: Determine the client's perception of the personal impact of the crisis.
Rationale: The first action the nurse should take using the nursing process is to assess the client.
Therefore, the first action the nurse should take is to determine the client's feelings and
understanding of the natural disaster and its personal impact.
A charge nurse is planning care for a client who has mechanical restraints in place. Which of the
following interventions should the nurse include in the plan?
Answer: Provide a staff member to stay with the client continuously.
Rationale: A staff member must remain continuously with a client who is in restraints or view
the client via audiovisual equipment, if necessary, due to the risk of injury.
A nurse is performing tracheostomy care for a client who is postoperative following a
laryngectomy. Which of the following actions should the nurse take when suctioning the client's
airway?
Answer: Apply suction for 10 seconds.
Rationale: The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss.
A nurse is caring for a client who has a closed-head injury and is receiving mechanical
ventilation. The nurse should expect to administer which of the following medications to reduce
intracranial pressure?
Answer: Mannitol
Rationale: The client should receive mannitol, an osmotic diuretic, to reduce intracranial
pressure caused by cerebral edema.
A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a
client who has anorexia nervosa. Which of the following actions should the charge nurse take?
Answer: Tell the nurses to stop the discussion.
Rationale: The nurses are violating client confidentiality by having the discussion in a public
hallway. The charge nurse should tell the nurses to stop the discussion to prevent any further
breach of confidentiality.
A community health nurse is performing triage tagging following a mass casualty incident. On
which of the following clients should the nurse place a black tag?
Answer: A client who has significant head trauma and agonal respirations
Rationale: The nurse should place a black tag on a client who has significant head trauma and
agonal respirations because this client is not likely to recover or will require extensive resources
for care.
A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the
following actions should the nurse plan to take?
Answer: Clear objects from the client's walking area.
Rationale: The nurse should plan to clear objects from the client's walking area because CN II is
the optic nerve and a deficit can result in visual impairment which can lead to falls.
A nurse is teaching a client who is to start taking misoprostol and currently is on long-term
therapy with NSAIDs for arthritis. The nurse should provide the client with which of the
following information?
Answer: Complete a serum pregnancy test before taking the medication.
Rationale: Misoprostol can induce uterine contractions. Clients of childbearing age must rule
out pregnancy before taking misoprostol.
A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute
neutrophil count of 400/mm3. Which of the following interventions should the nurse include in
the plan?
Answer: Withhold administering the varicella vaccine to the child.
Rationale: A child who has severe immunodeficiency should not receive a live vaccine due to
the risk of developing the disease. Inactivated vaccines can be administered to children who are
immunosuppressed.
A nurse is assessing a client who has a stage II pressure injury. Which of the following wound
characteristics should the nurse expect?
Answer: Partial-thickness skin loss
Rationale: The nurse should expect to see partial-thickness skin loss or blister formation in a
client who has a stage II pressure injury.
A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of
the following assessment findings should the nurse expect?
Answer: Pulsus paradoxus
Rationale: The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10
mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade,
along with jugular vein distention, bradycardia, and hypotension.
A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse
should identify which of the following findings as an indication the client is experiencing fluid
volume deficit?
Answer: Orthostatic hypotension
Rationale: Clients who have a fluid volume deficit can experience orthostatic hypotension,
which is a result of the body's inability to maintain adequate blood pressure following position
changes.
A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the
following findings as a manifestation of vaso-occlusive crisis?
Answer: Hematuria
Rationale: The nurse should identify hematuria as a manifestation of vaso-occlusive sickle cell
crisis resulting from ischemia of the kidneys
A nurse is caring for a client who has a potassium level of 3 mEq/L. For which of the following
manifestations should the nurse monitor?
Answer: Decreased deep tendon reflexes
Rationale: A client who has hypokalemia can have muscle weakness and decreased deep tendon
reflexes.
A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift
report, which of the following clients should the nurse attend to first?
Answer: A client who is confused and has been attempting to get out of bed
Rationale: The nurse should recognize that a client who is confused and has been attempting to
get out of bed is at greatest risk for injury from a fall. Therefore, the nurse should attend to this
client first.
A client who is 24 hr postoperative following abdominal surgery refuses to ambulate. Which of
the following actions should the nurse take first?
Answer: Ask the client to rate their pain level.
Rationale: Using the nursing process, the first action the nurse should take is to assess the
client's level of pain. If indicated, the nurse should administer an analgesic, then wait 30 to 45
min to allow the analgesic to take effect before encouraging the client to ambulate. Management
of the client's pain is a priority for encouraging postoperative activity.
A nurse is teaching a client about foods high in vitamin A. Which of the following foods should
the nurse recommend as having the highest amount of vitamin A?
Answer: 1 medium raw carrot
Rationale: The nurse should identify that 1 medium raw carrot contains 2,025 mcg/dL of
vitamin A and is therefore the best food to recommend to the client.
A nurse working in a long-term care facility is assessing an adult client. Which of the following
findings places the client at risk for development of a pressure injury?
Answer: Recent weight loss
Rationale: Weight loss can increase the risk for pressure injury. Inadequate nutrition will cause
decreased nutrients for the skin and tissues and increases the chance for shearing against the
bony prominences.
A nurse is teaching a client who has a new prescription for digoxin about manifestations of
toxicity. Which of the following findings should the nurse include in the teaching?
Answer: Nausea
Rationale: The nurse should instruct the client to monitor for and report manifestations of
digoxin toxicity, such as nausea, anorexia, abdominal pain, bradycardia, and visual changes.
A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb)
and is being breastfed. Which of the following findings indicates effective breastfeeding?
Answer: The newborn has six to eight wet diapers per day.
Rationale: Measuring the number of wet diapers per day is an effective measurement of
adequate intake. Six to eight wet diapers each day after the fourth day of life indicates effective
breastfeeding.
A nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse
should identify that an elevation in which of the following laboratory values indicates cellular
injury of myocardial tissue?
Answer: Troponin T
Rationale: Troponin T is a myocardial muscle protein that is released into circulation after
cardiac injury. The nurse should expect increases in the client's troponin level within 2 to 3 hr
following a myocardial injury.
A nurse is teaching a newly admitted client who has heart failure about advance directives.
Which of the following statements should the nurse make?
Answer: "You should complete advance directives in the event you cannot express your own
wishes."
Rationale: The client should prepare advance directives to make their wishes known should they
be unable to communicate them in the future.
A nurse on a mental health unit is caring for a client who tells the nurse that she does not want to
receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take?
Answer: Document the client's refusal of the medication.
Rationale: The client has the right to refuse medication. The nurse should document the refusal
in the client's medical record.
A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the
following actions should the nurse plan to take?
Answer: Enter the plasma product number into the client's medical record.
Rationale: The nurse should complete documentation following blood product therapy, which
includes recording the type of product, amount administered, product number, infusion time, and
client response.
A nurse is providing discharge instructions to a client who has a new prescription of warfarin.
Which of the following client statements should the nurse identify as an indication that the client
understands the teaching?
Answer: "I should report a change in the color of my stools."
Rationale: The nurse should inform the client that red, black, or tarry stools can indicate
bleeding, an adverse effect of warfarin, and the client should report these findings to the
provider.
A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that
the medications are not available. Medications availability has been ongoing problem, and the
charge nurse has previously discussed this issue with the pharmacy staff. Which of the following
actions should the charge nurse take first?
Answer: Inform the nurse manager of the issue.
Rationale: The greatest risk to clients is injury from not receiving medications on time and
developing a medical complication. Therefore, the priority intervention the charge nurse should
take is to follow the chain of command and contact the nurse manager.
A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client
who has an extensive burn injury. Which of the following information should the nurse include?
Answer: "You will receive finger sticks for blood glucose testing."
Rationale: A client who is receiving TPN is at risk for hyperglycaemia due to the dextrose in the
TPN solution. Therefore, the client will require blood glucose monitoring
A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast
for 24 hr. Which of the following assessment findings should the nurse identify as the priority?
Answer: The client's heel is reddened and tender.
Rationale: The greatest risk to this client is injury from a pressure injury. Therefore, the priority
assessment finding the nurse should identify is a reddened and tender heel.
A mental health nurse is conducting the first of several meetings with a client whose partner
recently died. The nurse should perform which of the following actions to establish trust during
the orientation phase of the nurse-client relationship?
Answer: Establish the termination date of therapy.
Rationale: This task occurs in the orientation phase of a therapeutic relationship.
A nurse is performing gastric lavage for a client who has gastrointestinal bleeding an NG tube in
place. Which of the following actions should the nurse take?
Answer: Use 0.9% sodium chloride for irrigation of the NG tube.
Rationale: The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation
of the client's NG tube.
A nurse is assessing a client who has been taking lithium carbonate for the past month to treat
bipolar disorder. Which of the following assessment findings should the nurse identify as the
priority?
Answer: Confusion
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is confusion because it is an early manifestation of lithium
toxicity. The nurse should monitor the client for additional indications of lithium toxicity,
including coarse hand tremors, incoordination, ECG changes, and sedation.
A nurse is preparing to perform an intermittent urinary catheterization for a client who has
urinary retention. Which of the following images indicates the catheter the nurse should use?
Answer: A straight urinary catheter, which should be used to perform an intermittent
catheterization for a client who has urinary retention.
A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3,
PaO2 56 mm Hg, PaCO2 54 mm Hg, HCO 26 mEq/L, SaO2 87%. Which of the following is the
correct interpretation of these values?
Answer: Uncompensated respiratory acidosis
Rationale: A pH of 7.3 is below the expected reference range and indicates the client has
acidosis. The PaCO2 of 54 mm Hg is above the expected reference range, which, when combined
with the low pH, indicates that the acidosis has a respiratory origin. The HCO3- of 26 mEq/L is
within the expected reference range, indicating that the acidosis is not metabolic in origin and the
body has not yet corrected the imbalance through compensation.
A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the
following findings should the nurse identify as the priority?
Answer: Upper chest petechiae
Rationale: The greatest risk to this client is organ damage from fat embolism syndrome, a lifethreatening complication of fractures. In fat embolism syndrome, a fat embolus enters the blood
stream and can obstruct blood vessels of a major organ, such as the lung, kidney, or brain.
Manifestations include petechiae on the upper torso, dyspnea, hypoxia, headache, lethargy, and
confusion. Therefore, the nurse should identify this as the priority finding.
A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa.
Which of the following interventions should the nurse include in the client's plan of care?
Answer: Supervise the client during and after eating.
Rationale: The nurse should monitor the client during and for 1 hr after meals to prevent the
client from hiding food or purging.
A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male
client. Which of the following techniques should the nurse use to maintain surgical aseptic
technique?
Answer: Set the catheter tray on the overbed table at waist height.
Rationale: To maintain sterility, the nurse should place the catheter tray on a work surface at or
above waist level.
A nurse is caring for a child who is experiencing a tonic clonic seizure. Which of the following
actions should the nurse take?
Answer: Place the child in a side-lying position.
Rationale: The nurse should place the child in a side-lying position during a seizure to maintain
a patent airway, decrease the risk of aspiration, and facilitate drainage of oral secretions.
A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the
following methods should the nurse manager use to evaluate the nurse's time management skills?
Answer: Maintain regular notes about the nurse's time management skills.
Rationale: Maintaining notes over a period of time provides a comprehensive view of the
nurse's abilities so the manager can identify trends in the nurse's overall performance.
