2019 ATI Mental Health Proctored Exams With Answers-291 Solved Questions

ATI FUNDAMENTALS ATI 2019 PROCTORED EXAMS COMPLETE
GUIDE A+ PASS (REVISED VERSION)
1. A nurse is planning care for a group of clients. Which of the following tasks should the
nurse delegate to assistive personnel?
A. changing the dressing for a client who has stage 3 pressure injury
B. determining a client's response to a diuretic
C. comparing radial pulses for a client who is postoperative
D. providing post mortem care to a client
Answer: D
2. A Nurse is conducting a health assessment for a client who takes herbal supplements.
Which of the following statements by the client indicates an understanding of the use of the
supplements?
A. I take ginkgo biloba for a headache
B. I take echinacea to control my cholesterol
C. I take ginger when I get car sick
D. I use garlic for my menopausal symptoms
Answer: C
3. A nurse is caring for a client who has influenza and isolation precautions in place. Which
of the following actions should the nurse take to prevent the spread of infection?:
A. wear a mask when working within 3 ft of the client
B. administer metronidazole
C. don protective eyewear before entering the room
D. place the client in a negative airflow room
Answer: A
4. A Nurse obtains a prescription for wrist restraints for a client who is trying to pull out his
NG tube. Which of the following actions should the nurse take?
A. attach the restraints securely to the side rails of the client's bed.
B. apply the restraints to allow as little movement as possible
C. allow room for two fingers to fit between the clients skin and the restraints

D. remove the restraints every 4 hr.
Answer: C
5. A Nurse is admitting a client who has tuberculosis. Which of the following types of
transmission precautions should the nurse plan to initiate?
A. droplet
B. airborne
C. protective environment
D. contact
Answer: B
6. A Nurse in a well child clinic receives a telephone call from a parent who states that their
child accidentally swallowed paint thinner. The child is awake and alert. Which of the
following responses should the nurse take?:
A. Have your child drink one large glass of water
B. Hang up and call a poison control center hotline
C. Bring your child into the clinic later today
D. Induce vomiting in your child with syrup ipacac
Answer: A
7. A Nurse is documenting a child's medical record. Which of the following entries should the
nurse record?:
A. oral temperature slightly elevated at 0800
B. administered pain medication
C. incision without redness or drainage
D. drank adequate amounts of fluid with meals
Answer: B
8. A Nurse is providing oral care for a client who is unconscious. Which of the following
actions should the nurse take?:
A. Place the client in a side lying position
B. brush the clients teeth daily
C. apply mineral oil to the client's lips
D. rinse the client's mouth with an alcohol-based mouthwash

Answer: A
9. A nurse is collaborating with a risk management team about potential legal issues
involving client care. The nurse should identify which of the following situations is an
example of negligence?
A. A Nurse administers a medication without first identifying the client
B. assistive personnel discuss client care in the facility cafeteria with visitors present
C. A Nurse begins a blood transfusion without obtaining consent
D. assistive personnel prevent a client from leaving the facility
Answer: C
10. A Nurse is collecting a sputum specimen for culture from a client who has a respiratory
infection. Which of the following actions should the nurse take?:
A. wear sterile gloves when collecting the specimen
B. offer the client oral hygiene after the collection
C. collect the specimen in the evening
D. collect 1 ml of sputum.
Answer: B
11. A Nurse is assessing an older client. Which of the following findings should the nurse
expect?:
A. Decreased sense of balance
B. increased night time sleeping
C. heightened sense of pain
D. nighttime urinary incontinence
Answer: A
12. A nurse is completing discharge teaching about ostomy care with a client who has a new
stoma. Which of the following instructions should the nurse include in the teaching? (select
all that apply):
A. cut the opening of the pouch 1/8 of an inch larger than the stoma
B. place a piece of gauze over the stoma while changing the pouch
C. use povidone iodine to clean around the stoma
D. empty the ostomy pouch when it becomes one third full of contents

E. expect the stoma to turn a purple blue color as it heals
Answer: A, B, C, D
13. A Nurse is preparing to obtain informed consent from a client who speaks a different
language than the nurse. Which of the following actions should the nurse take?:
A. request the assistive personnel interpret the information for the client
B. use proper medical terms when giving information to the client
C. offer written information in the client's language
D. avoid using gestures when speaking to the client
Answer: C
14. A Nurse is teaching a client about home care equipment. Which of the following
information should the nurse include in the teaching? (Select all that apply):
A. avoid using wool blankets when receiving oxygen
B. keep the oxygen delivery system 0.6 m (2 feet) from any heat source
C. check the oxygen delivery rate at least once a day
D. align the middle of the ball in the flow meter with the line of the prescribed flow rate
Answer: A, C, D
15. A Nurse is planning care for a client who reports insomnia. Which of the following
actions should the nurse perform short before bedtime?:
A. provide a late supper
B. offer a wet washcloth for the client to wash her face
C. perform range of motion exercises
D. prepare hot cocoa or tea for the client
Answer: A
16. A Nurse on a medical-surgical unit is receiving a change of shift report for four clients.
Which of the following clients should the nurse see first?:
A. A. a client who has acute abdominal pain of 4 on a scale from 0 to 10
B. a client who has pneumonia and an oxygen saturation of 96%
C. a client who has a new onset of dyspnea 24 hours after a total hip arthroplasty
D. a client who has a urinary tract infection and low-grade fever
Answer: C

17. A Nurse is reviewing a client's intake and output and notes the following: 0.9% sodium
chloride 600mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100mL intermittent
IV bolus, 200mL emesis, 40mL voided urine, and 20mL urine from straight catheterization.
The nurse should record the client's net fluid intake as how many mL? (round the answer to
the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
A. 700mL, the rest are output
B. 600mL, the rest are output
C. 800mL, the rest are output
D. 400mL, the rest are output
Answer: A
18. A Nurse is discussing incident reports with a group of newly licensed nurses. The nurse
should include that which if the following requires the completion of incident report?:
A. a client's prescribed laboratory testing was not obtained
B. a client withdrew consent for a procedure
C. an oncoming nurse arrived to work late
D. A Nurse transfused a unit of packed RBCs in 2 hr.
Answer: A
19. A Nurse is caring for a client who has a new prescription for negative-pres- sure therapy
for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following
recourses should the nurse consult to learn more about the intervention?
A. the client's plan of care
B. the nurse practice act
C. the material safety data sheet
D. the policy and procedure manual
Answer: D
20. A Nurse is performing postural drainage with percussion and vibration for a client who
has cystic fibrosis. Which of the following actions should the nurse take?
A. cover the area of percussion with a towel
B. instruct the client to exhale quickly during vibrations
C. schedule postural drainage after meals

D. perform percussion over the lower back
Answer: D
21. A Nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child
who has difficulty swallowing pills. Available is diphenhy- dramine 12.5mg/5ml oral syrup.
Which of the following images indicates the correct number of mL the nurse should
administer? (round answer to the nearest whole number)
A. 8mL syringe
B. 10mL syringe
C. 12mL syringe
D. 5mL syringe
Answer: A
22. A Nurse is admitting a client who is malnourished. The client states, "my wedding ring is
loose and I'm worried I will lose it if it falls off." Which of the following is an appropriate
response by the nurse?
A. I will place it in your drawer so it won't get lost
B. I can pin it to your hospital gown so you won't lose it.
C. I will hold onto it until a family member can take it home
D. I can put it in a locked storage unit for you
Answer: D
23. A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In
which of the following clinical situations should the nurse apply restraints?
A. if the client is pacing in the hallway
B. as a part of a fall prevention program
C. at the request of the client's family
D. when the client poses a threat to self
Answer: D
24. To ensure client safety, A Nurse manager is planning to observe a newly licensed nurse
perform a straight catheterization on a client. In which of the following roles is the nurse
manager functioning?:
A. case manager

B. client educator
C. client care provider
D. client advocate
Answer: B
25. A charge nurse in a long term care facility is preparing an educational program about
delirium for newly hired nurses. Which of the following state- ments should the nurse plan to
include?:
A. delirium does not affect the client's perception of her environment
B. delirium does not affect a client's sleep cycle
C. delirium has an abrupt onset
D. delirium has a slow progression
Answer: C
26. A Nurse is speaking with a client who has recently received a diagnosis of a chronic
illness. The client states, the doctor must be wrong. I can't be that sick. The nurse should
inform the client that their reaction is an example of which of the following expected
responses to grief?
A. acceptance
B. denial
C. anger
D. depression
Answer: B
27. A Nurse on a medical surgical unit is providing care for four clients. The nurse should
identify which of the following situations as an ethical dilemma?
A. a surgeon who removed the wrong kidney during a surgical procedure refuses to take
responsibility for her actions
B. a client who has Crohn's disease reports that his prescription drug plan will not pay for his
medications
C. a client who has a new colostomy refuses to take instructions from the ostomy therapist
because she "doesn't like him"
D. the family of a client who has a terminal illness asks that the provider not tell the client the
diagnosis.

Answer: D
28. A Nurse is teaching a client about performing breast self examinations. Which of the
following statements by the client indicates an understanding of the teaching?
A. I should perform my self exam the week that my period starts
B. I should make different patterns on each breast when I do my self exam
C. I should use the palm of my hand to apply pressure to each breast
D. I should make circular motions with my fingertips under my arms
Answer: D
29. A Nurse is preparing to transfer a client who is partially weight bearing from the bed to
the chair. Which of the following actions should the nurse take?
A. keep his knees straight when moving the client
B. position the chair next to the bed as a 90 degree angle
C. stand with his feet together when lifting the client
D. have the client bear weight on her strong leg
Answer: D
30. A Nurse is caring for a client following a laparoscopic cholecystectomy. The client has a
prescription for ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify
the sequence of steps the nurse should follow to administer the medication.
A. perform hand hygiene
B. select the injection port of the IV tubing closest to the client
C. cleanse the injection port with an antiseptic swab
D. aspirate for blood return
E. inject the medication
Answer: A, B, C, D, E
31. A Nurse is teaching a client who has diabetes mellitus about mixing regular and NPH
insulin. Which of the following statements by the client indicates an understanding of the
teaching?:
A. I should wait 3 minutes after mixing the insulin to inject it
B. I should draw up the NPH insulin before regular insulin
C. I should inject air into the vial of regular insulin first

D. I should roll the vial of NPH insulin between my hands before drawing it up
Answer: D
32. A Nurse is assessing the body temperature of an adult client using a temporal artery
thermometer. Which of the following actions should the nurse take? (select all that apply)
A. slide the probe across the clients forehead
B. pull the clients pinna up and back
C. hold the clients hair aside while performing the procedure
D. document the clients temperature with AX next to the value
E. move the probe in a circular motion
Answer: A, C
33. A Nurse is preparing to insert a peripheral IV catheter into the clients arm. Which of the
following actions should the nurse take to help dilate the vein?:
A. stroke the skin near the vein in an upward position
B. dangle the client's arm over the edge of the bed
C. apply a cool compress to the vein for 10 mins
D. instruct the client to flex their arm with the hand open
Answer: B
34. A Nurse is preparing to suction a clients tracheostomy tube. Which of the following
should the nurse plan to take?:
A. apply intermittent suction during catheter insertion
B. suction the client's airway for 20 sections with each pass
C. hyperoxygenation the client manually for 30 to 60 sections before suctioning
D. decrease suction pressure to 150 mm Hg if the oxygen saturation level drop during
suctioning
Answer: D
35. A Nurse is assessing a client who received morphine for severe pain 30 mins ago. Which
of the following findings is the nurse's priority?
A. last bowel movement was 3 days ago
B. reports pain of 8 on a scale of 0 to 10
C. distended bladder

D. respiratory rate 7/min
Answer: D
36. A Nurse is caring for a client who has been reacted multiple time for STIs. Which of the
following responses should the nurse take?
A. you must have too many sexual partners
B. why do you keep letting this happen?
C. lets explore why this might be reoccurring
D. don't you have access to condoms?
Answer: C
37. A Nurse enters the room of a client who has a seizure disorder. The client is sitting in the
chair and begins to experience a seizure. Which of the following actions should the nurse
take?
A. move items in the room away from the client
B. turn the client onto their side
C. help the client lie on the floor
D. loosen the client's clothing
Answer: C
38. A Nurse is testing a client for conduction deafness by performing Weber's test. Which of
the following actions should the nurse take when performing this test?
A. move a vibrating tuning form in front of the client's ear canals one after the other
B. place the base of a vibrating tuning fork on the client's mastoid process
C. place the base of a vibrating tuning fork on the top of the client's head
D. count how many seconds a client can hear a tuning fork after it has been struck
Answer: C
39. A Nurse is obtaining he medication history of a client who asks about taking ginkgo
biloba. The nurse should identify which of the following medications can interact adversely
with this supplement?
A. warfarin
B. albuterol
C. levothyroxine

D. atorvastatin
Answer: A
40. A Nurse is obtaining informed consent from a client who is scheduled for surgery. The
client states, I don't want to go through with the procedure. Which of the following actions
should the nurse take?
A. discuss alternative treatments with the client
B. explain to the client the risks involved with not having the procedure
C. express approval of the client's decision to not have the procedure
D. document the client's decision in the medical record
Answer: D
41. A Nurse is providing teaching to a client about reducing the adverse ef- fects of
immobility. Which of the following statements by the client indicates an understanding of the
teaching?
A. I will have my partner help me change positions every 4 hours
B. I will remove my anti embolic stockings while I'm in bed
C. I will hold my breath while rising from a sitting position
D. I will perform ankle and knee exercises every hour
Answer: D
42. A Nurse is caring for a client who is postoperative and has a new prescription to advance
her diet to full liquids. Which of the following foods should the nurse offer the client as a part
of a full liquid diet?
A. oatmeal
B. applesauce
C. scrambled eggs
D. plain yogurt
Answer: D
43. Nurse is preparing a client who has terminal cancer for discharge. Which of the following
questions should the nurse ask when assessing the client's psychosocial history?
A. what medications are you currently taking?
B. are you experiencing any pain?

C. have any of your relatives been diagnosed with cancer?
D. what techniques do you use to cope with stress?
Answer: D
44. A Nurse is performing a skin assessment on an older adult client. Which of the following
findings should the nurse expect?
A. thickened outer layer of skin
B. increased skin elasticity
C. reduced sweat production
D. increased production of oils
Answer: C
45. A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer.
Which of the following responses should the nurse make?
A. I would get a second opinion if I were you
B. It might seem bad now, but things will get better
C. it must be difficult for you to receive this kind of news
D. I think you would benefit from speaking with our chaplain
Answer: C
46. A nurse is preparing to obtain a health history from a client. Which of the following
actions should the nurse take?:
A. use the clients first name when initially meeting the client
B. tell the client the purpose for collecting the information
C. explain to the client the necessity of full disclosure of information
D. avoid documenting direct quotes from the client as part of subjective data.
Answer: B
47. A Nurse is caring for a client who has brain cancer and is transferring to hospice care. The
client's son tells the nurse, I don't know what to tell my dad if he asks how he is going to die.
Which of the following is an appropriate response by the nurse?
A. Lets talk more about your dad's condition
B. The social worker will help you answer those questions
C. Try to help your dad enjoy this time as much as he can

D. I think that you should discuss this with the hospice nurse
Answer: A
48. A Nurse is preparing to administer several medications to a client. Which of the following
data should the nurse plan to use to confirm the client's identity?
A. the clients room number
B. the clients admitting diagnosis
C. the name of the clients next of kin
D. the clients telephone number
Answer: D
49. A Nurse is caring for a client who is prescribed a special diet. The client is concerned that
he does not have the resources to purchase the food he needs to adhere to the diet at home.
The nurse should notify which of the following members of the health care team.
A. social worker
B. occupational therapist
C. registered dietician
D. primary care provider
Answer: A
50. A Nurse is teaching a newly licensed nurse about the care of a client who has a methicillin
resistance staphylococcus aureus (MRSA) infection. Which of the following statements by
newly licensed nurse indicates an understanding of the teaching?
A. I will place the client in a private room
B. I will remove my gown before my gloves after providing client care
C. I will wear an N95 respiratory mask when caring for the client
D. I will tell the client's visitors to wear a mask when they are within 3 ft of the client
Answer: A
51. A Nurse is planning care for a client who reports having a latex allergy. Which of the
following interventions should the nurse include in the plan?
A. cover the blood pressure cuff with a stockinette
B. wear powdered gloves when providing care to the client
C. apply adhesive tape when securing an IV insertion site

D. use plastic syringes for medication administration
Answer: A
52. A Nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing
the clients signature, the client states, I trust my doctor but I don't understand what is meant
by resecting my intestines. Which of the following actions should the nurse take?:
A. describe the surgery to the client
B. notify the provider
C. complete an incident report
D. provide brochures about he procedure
Answer: B
53. A nurse is documenting client care. Which of the following abbreviations should the nurse
use?
A. SQ for subcutaneous
B. SS for sliding scale
C. BRP for bathroom privilege's
D. OJ for orange juice
Answer: C
54. A Nurse is preparing to bathe a client who has dementia. Which of the following actions
should the nurse take?
A. give detailed instructions for the client to follow
B. complete the bath even if the client is in distress
C. use distractions when bathing the client
D. allow the client to select the temperature of the bath water
Answer: C
55. A hospice nurse is caring for a client who has end stage cancer. Which of the following
interventions should the nurse include to promote the client's dignity?
A. provide guided imagery exercises to the client
B. refrain from discussing the clients prognosis
C. suggest that the client keep a journal
D. encourage the client to share their life story

Answer: B
56. A Nurse is caring for a client who has a closed wound drainage system. Which of the
following actions should the nurse take?:
A. wear sterile gloves when emptying the container
B. reset the container with the drainage port closed
C. connect the drain to high pressure suction
D. press straight down on the container to create a vacuum
Answer: D
57. A Nurse receives a telephone prescription from a provider for a client who is experiencing
pain. Which of the following responses should the nurse make?:
A. will you please spell the name of that medication for me?
B. let me clarify that you want the medication given qid, correct?
C. I will sign my name now and leave a space for you to sign your name
D. let me provide you with the client's medical record number for identification
Answer: A
58. During change of shift report, A Nurse discovers she overlooked a pre- scription for a
type and cross match of a client who is to have surgery the next day. Which of the following
actions should the nurse take first?
A. inform the provider of the delay in obtaining the type and cross match
B. obtain the client's type and cross match
C. prepare an incident report for risk management
D. document the incident in the client's medical record
Answer: A
59. A nurse is caring for a client who has pneumonia. The nurse should recognize which of
the following should be discarded in a biohazard bag?:
A. an emesis basin filled with blood from severe coughing
B. a bedpan containing diarrhea from a client who was receiving antibiotics
C. a disposable tissue containing expectorated sputum
D. a calibrated toilet insert filled with urine
Answer: A

60. A Nurse is caring for a client who is receiving enteral feeding via NG tube. Which of the
following should the nurse take prior to administering the formula?:
A. check for gastric residual volume
B. encourage the client to breathe deeply and cough
C. flush the tube with sterile 0.9% sodium chloride irrigation
D. encourage the client to take sips of water
Answer: A
61. A Nurse is caring for a client immediately following the insertion of an NG tube. Which
of the following findings should indicate to the nurse that the tube is placed incorrectly?
A. the client has a dry mouth
B. the client is coughing
C. the client has active bowel sounds
D. the client is hiccupping
Answer: B
62. A Nurse is inserting an NG tube for a client who requires gastric decom- pression. Which
of he following actions should the nurse take to verify proper placement of the tube?:
A. A. assess the client for a gag reflex
B. measure the pH of the gastric
C. place the end of the NG tube in the water to observe for bubbling
D. auscultate 2.5 cm above the umbilicus while injecting 15 ml of water
Answer: B
63. A Nurse is caring for a client who reports a pain level of 5 on a scale form 0-10. The
client informs the nurse that pan meds are not an option for managing pain. Which of the
following is an appropriate response by the nurse?:
A. A. would you like a back massage?
B. why do you think pain med is not going to help you?
C. you may take any herbal remedies you bring from home
D. I'm sure it will work if you just give it a chance
Answer: A

64. A Nurse is caring for a client who has an extracellular fluid volume deficit. Which of the
following findings should the nurse expect?
A. bradycardia
B. postural hypotension
C. distended neck veins
D. dependent edema
Answer: B
65. A nurse is caring for a client who is immunocompromised which of the following actions
should the nurse take?
A. use sterile gloves to provide perineal care
B. cleanse hands with an alcohol based hand rub before client contact
C. have the client apply a mask when children are visiting
D. place the client in a semi private room
Answer: B
66. A nurse is preparing to insert an IV catheter for a client following a right mastectomy.
Which of the following veins should the nurse select when initiating IV therapy?:
A. the radial vein on the left arm
B. the cephalic vein on the left distal forearm
C. the cephalic within on the back of the right hand
D. the basilic vein in the right antecubital fossa
Answer: B
67. A Nurse is caring for a client who has urinary incontinence. Which of the following
interventions should the nurse take to prevent skin breakdown?
A. apply powder to the client's perineal area
B. restrict clients fluid intake
C. request a prescription for an indwelling urinary catheter
D. apply a moisture barrier ointment after perineal hygiene
Answer: D

68. A Nurse is caring for a client who was recently diagnosed with a terminal illness. The
client tells the nurse, I am looking forward to seeing my grand- children grow up. The nurse
should identify the client is experiencing which of the following stages of grief?
A. acceptance
B. bargaining
C. anger
D. denial
Answer: D
69. A Nurse is teaching a client about the care and use of hearing aids. Which of the
following instructions should the nurse include in the teaching?
A. clean the hearing aid by soaking it in warm water
B. turn the hearing aid off and the volume down before insertion
C. replace the battery if the haring aid emits a whistling sound
D. leave the battery in place when the hearing aid is not in use
Answer: B
70. A Nurse is assessing a clients eyes for accommodation. Which of the following actions
should the nurse take?
A. observe the clients eyes for the six cardinal position of gaze
B. verify the client's ability to read letters on a Snellen eye chart
C. check the clients pupil reaction when focusing on distant and nearby objects
D. test the clients eyes for reaction to light response
Answer: C
71. A Nurse is teaching the assistive personnel about upper body mechanics to prevent injury.
Which of the following actions by the AP demonstrate an understanding of the teaching?
A. Hold the object close to the body
B. Bend at the waist to lift objects
C. Twist the body while lifting
D. Reach for the object with outstretched arms
Answer: A|

72. A nurse is assessing a client who is immobile and notices a red area of the client's coccyx.
Which of the following actions should the nurse take?
A. change the clients position every 4 hours
B. apply petroleum base ointment in the red area
C. assess the red area for blanching
D. use friction when cleansing the clients skin
Answer: C
73. A Nurse is planning care to prevent skin breakdown for a client who is immobile and has
urinary incontinence. Which of the following actions should the nurse include in the plan of
care?
A. Request a prescription for an indwelling urinary catheter
B. Use moisture-wicking bedding
C. Encourage frequent repositioning and skin assessments
D. Apply a thick layer of petroleum jelly to the skin
Answer: C. Encourage frequent repositioning and skin assessments
74. A nurse is teaching a client who had an enucleation about care of an artificial eye. Which
of the following information should be included in the teaching (select all that apply)
A. store the artificial eye in the label container filled with 0.9% sodium chloride irrigation
B. remove from the artificial eye by retracting the upper eyelid
C. apply pressure just below artificial eye to break down the suction
D. clear the artificial eye with hydrogen peroxide before storing
E. retract the upper and lower lids to reinsert the acritical eye
Answer: C, D, E
75. A nurse is caring for a client who is 2 days postoperative following bowel resection and
reports sudden severe abdominal pain. Which of the following actions should the nurse take
first?
A. determine areas of resonance across the abdomen using a systematic approach
B. expose the clients abdomen to look for changes in appearance
C. perform abdominal palpation by pressing gently with the finger pads
D. use the diaphragm of the stethoscope to listen for bowel sounds
Answer: B

76. nurse is providing care for a client who is to undergo a total laryngectomy Which of the
following interventions is the nurse's priority?
A. determine the client's reading ability
B. review the use of an artificial larynx
C. with the client schedule a support session
D. for the client explain the techniques of esophageal speech
Answer: D
77. A home care nurse is teaching a client about home safety. Which of the following
statements by the client indicates an understanding of the teaching? (Select all that apply)
A. I will use the bars when getting in and out of the bath tub
B. I need to check my medications for expiration dates
C. I need to have a fire escape plan with my family
D. I will apply tape over frayed areas of electrical cords
E. I need to set my hot water heater to 140 degrees Fahrenheit
Answer: A, B, C
78. A nurse in an emergency department is assessing a client who reports a right lower
quadrant pain, nausea, and vomiting for the past 48 hours? Which of the following actions
should the nurse take first?
A. offer pain medication
B. palpate the abdomen
C. auscultate bowel sounds
D. administer an antiemetic
Answer: C
79. A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which
of the following statements by the client partner indicates maladaptive coping?
A. "I don't know if I will be able to meet his physical needs."
B. "I'm trying to focus on the positive moments we have together."
C. "I’m looking into support groups for caregivers."
D. "I'm planning to take breaks when I need to."
Answer: A

80. A nurse is planning care for a client who has stage 1 pressure ulcer on the right heel. The
nurse should anticipate application of which of the following dressings?:
A. dry gauge
B. transparent
C. calcium alginate
D. hydrogel
Answer: B
81. A nurse is caring for a client who has brain cancer and is transferring to hospice care. The
client's son tells the nurse, I don't know what to tell my dad if he asks how he is going to die.
Which of the following is an appropriate response from the nurse?
A. "Let's discuss your concerns about your father and how you feel about this situation."
B. "It's best not to talk about death; it might upset him."
C. "You can just tell him everything will be okay."
D. "You should try to change the subject when he brings it up."
Answer: A
82. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to
care for corns and calluses toes. Which of the following statements by the client indicates
understanding of teaching?
A. I can apply lotion to soften the calluses as long as I don't put lotion between my toes
B. I can place an oval corn pad over toes that have corns as long as I remove the pad weekly
C. I should soak my feet in warm water daily to soften corns and calluses
D. I should use an over the counter liquid medication to remove corns
Answer: A
83. A nurse is caring for a client who has wrists restraints after an episode of violent behavior.
Which of the following actions should the nurse take?
A. tie the restraints to the side rail
B. secure restraints with a square knot
C. remove one restraint at a time
D. remove the restraints every 3 hours
Answer: C

84. A nurse is admitting a client who has a clostridium difficile infection. Which of the
following actions should the nurse take? (select all that apply)A. use an N95 respirator while providing client care
B. wear a gown and gloves when providing client care
C. assign the client to a private room with positive air flow
D. wash hands with soap and water after contact with the client ensure the client does not
receive fresh fruits
Answer: B, C, D
85. A nurse is planning care for a client who has latex allergy and is scheduled for surgery.
Which of the following actions is appropriate to include in the clients plan of care.
A. schedule the client as the first surgical procedure of the day
B. cleanse the stoppers with primidone iodine for withdrawing medication
C. remove the stop stocks from IV tubing
D. ensure the gloves in the surgical suite are powdered gloves
Answer: A
86. A nurse is providing discharge teaching to a client who does not speak the same language
as the nurse. Which of the following action should the nurse take?
A. Direct verbal discharge instruction to the interpreter
B. Speak slowly and clearly to the client in English
C. Use written instructions in the client’s language
D. Rely on family members to translate the information
Answer: A
87. A nurse is teaching a client how to self administer daily low dose heparin injections.
Which of the following factors is most likely to increase the client's motivation to learn?
A. the clients belief that his needs will be met through education
B. the nurse explaining the need for education to the client
C. the client seeking family approval by agreeing to a teaching plan
D. the nurse's empathy about the client having to self inject
Answer: A

88. A nurse is caring for a client who is receiving continuous enteral feedings through
gastrostomy tubes. Which of the following actions should the nurse take?
A. heat the formula to 105 degrees Fahrenheit
B. flush the tubing with 10ml of water every 2 hours
C. change the tubing every 72 hours
D. aspirate residual volume every 4 hours (every 4-8 hours is correct)
Answer: D
89. A nurse is caring for a client who has an incisional wound and a pre- scription for wound
care. Which of the following images indicates the proper method of cleaning a wound site?
A. Use a different sterile swab for each stroke
B. Wipe the wound from the center outward in a circular motion
C. Clean the wound in a straight line from top to bottom
D. Use the same swab to clean the wound multiple times
Answer: A
90. A nurse is teaching a client who requires maximum support about how to use a two
wheeled walker. Which of the following actions by the client indicates an understanding of
teaching?
A. the client picks up the walker with each step
B. the client stoops slightly forward when moving the walker
C. the client stands with her elbows slightly flexed while holding the walker
D. the client moves the walker ahead 10 inches with each step
Answer: C
91. A nurse is caring for a client who refuses to follow the providers prescription for bed rest.
The nurse over hears the assistive personnel tell the client that if she does not remain in bed,
he will place her in restraints. The nurse should identify that the AP is committing which of
the following torts?
A. libel
B. defemination of character
C. assault
D. battery
Answer: C

92. A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin.
Which of the following actions should the nurse take?
A. stabilize the vein by applying traction above the insertion site
B. engorge the vein by placing the arm in the dependent position
C. use friction at the insertion site to increase venous distention
D. leave the tourniquet on for 30 to 60 seconds after initial insertion
Answer: B
93. A nurse is planning care for a client who has a new prescription for parental nutrition in
20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in
the plan of care?
A. prepare the client for a central venous line
B. change the PN infusion bag every 48 hours
C. administer the PN and fat emulsion separately
D. obtain a random blood glucose daily
Answer: A
94. A nurse is caring for a client who is agitated and threating to harm others. The nurse
places the client in restraints but does not notify the provider or obtain a prescription for the
restraints. The situation respects which of the following torts?
A. false imprisonment
B. invasion of privacy
C. assault
D. negligence
Answer: A
95. A nurse is conducting a Weber’s test on a client. Which of the following is an
appropriation action for the nurse to take?
A. Place an activated tuning fork in the middle of the client's head
B. Strike the tuning fork and hold it against the client's ear
C. Ask the client to cover one ear during the test
D. Place the tuning fork on the client's mastoid process
Answer: A

96. A nurse on a medical unit is caring for a group of clients. For which of the following tasks
should the nurse wear a face shield.
A. Changing the brief of an older adult who has C. diff
B. Administering an intramuscular injection
C. Performing a sterile dressing change
D. Taking vital signs on a stable client
Answer: A
97. An adult client tells a nurse about recent lack of sleep due to changing to a night shift job.
Which of the following interventions should the nurse suggest?
A. use the television to mask external noise
B. listen to soft music before lying down
C. exercise just prior to bedtime
D. keep the sleeping environment warm
Answer: B
98. A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the
nurse that she wants to use traditional Chinese medicine for treatment instead of the
medication prescribed by her provider. Which of the following is an appropriate response by
the nurse?
A. "You should ask the provider if she recommends traditional Chinese medicine."
B. "Traditional Chinese medicine isn't effective for fibromyalgia."
C. "It’s important to follow your provider’s advice on medication."
D. "Let’s discuss your reasons for wanting to use traditional Chinese medicine."
Answer: D
99. A nurse is caring for a client who reports that she has insomnia. Which of the following
interventions is appropriate for the nurse to recommend?
A. eat a light carbohydrate snack before bedtime
B. exercise 1 hour before bedtime
C. drink a cup of hot cocoa before bedtime
D. take a 30 min nap daily
Answer: A

100. A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of
the following responses by a newly licensed nurse indicates understanding in the teaching?
A. each element has a range 1 to 5 points
B. the higher the score the higher the pressure ulcer risk
C. the clients age is part of the measurement
D. the scale measures 6 elements
Answer: D
101. A nurse is planning care for a client who is scheduled for an intravenous pyelogram.
Which of the following actions is appropriate for the nurse to include?
A. ensure the client is free of metal objects
B. administer 240 ml (8oz) oral contract before the procedure
C. monitor the client for pain in the suprapubic region
D. assist the client with a bowel cleansing
Answer: A
102. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on
clients who are confused. Which of the following instructions should the staff nurse include?
A. Use full-length side rails
B. Provide a calming environment with soft lighting
C. Encourage the client to stay in bed at all times
D. Use physical restraints when the client becomes agitated
Answer: B
103. A nurse is planning to obtain a blood sample from a client for capillary blood glucose
post test. Which of the following should the nurse take to obtain the sample?
A. the pad of the finger tip
B. the lateral aspect of the finger
C. the pinna of the ear
D. the side of the wrist
Answer: B

104. A nurse is planning to discharge a client who has diabetes and a new prescription for
insulin which of the following actions should the nurse plan to complete first?
A. provide the client with a contact number for a diabetes education specialist
B. make a copy of the medication record of the reconciliation for the client
C. determine whether the client can afford the insulin administration supplies
D. obtain printed information about self administration
Answer: C
105. A nurse is caring for a client who has influenza and isolation precautions in place. Which
of the following actions should the nurse take to prevent the spread of infection?
A. Wear a mask when working within 3 ft of the client
B. Perform hand hygiene only before entering the room
C. Avoid touching surfaces in the client's room
D. Wear gloves only when providing direct care
Answer: A
106. A nurse is delegating client's care to the assistive personnel. Which of the following
tasks should the nurse delegate to the AP?
A. ADL (bathing, grooming, toileting, ambulate)
B. specimen collection
C. I&O, vital signs if stable
D. obtain input and output for the patient that was stable
Answer: D
107. A nurse is teaching about home safety. Which of the instructions should the nurse
include?
A. use electrical tape to secure extension cords next to base boards on the floor
B. replace carpet floors with tiles
C. unplug electronics by grasping the cord
D. to use a fire extinguisher, aim high at the top of the flames
Answer: A
108. A nurse is caring for a client who has restrains to each extremity. Which of the following
assessments should the nurse perform first?

A. elimination needs
B. comfort level
C. Peripheral pulses
D. skin integrity
Answer: C
109. A nurse in a long-term care facility is assessing a client. Which of the following findings
should the nurse recognize as an indication of fecal impaction?
A. Seepage of liquid stool
B. Frequent bowel movements
C. Abdominal cramping
D. Presence of flatulence
Answer: A
110. A nurse is caring for a client who has a tracheostomy which of the following actions
should the nurse take?
A. cotton tip applicator to clean the inside of the cannula
B. soak the outer cannula in warm soapy tap water
C. cleanse the skin around the stoma with normal saline
D. secure the tracheostomy ties to allow one finger to fit snuggly underneath
Answer: D
111. A nurse is caring for a client who has a drainage evacuator. Which of the following is an
appropriate action by the nurse?
A. discontinue the drainage system when it becomes full
B. ensure the drainage suction is set on high pressure
C. measure drainage by emptying into a graduated cylinder
D. check the volume of the drainage every 24 hours
Answer: C
112. A nurse in an acute care facility is preparing to transfer a client to a long term facility.
Which of the following information should the nurse include in the hand off report?
A. Effectiveness of the last dose of pain medication
B. Personal opinions about the client's family

C. Details about the client's favorite TV shows
D. The nurse's own experiences with similar clients
Answer: A
113. A nurse is providing teaching to a client who is self administer an ophthalmic solution.
Which of the following statements by the client indicates understanding of the teaching?
A. I will keep my eyes closed for 5 mins after inserting drops
B. I will insert the drops in the center of the eye
C. I will press the inner corner of my eye after insert drops
D. I will raise my eye lid up while looking down and insert drops
Answer: C
114. A nurse in a long term care facility is planning care for 4 clients. Which of the following
clients is at greater risk of developing a pressure ulcer?
A. a client who is incontinent of urine 1 to 2 times a day
B. a client who is receiving enteral tube feeding
C. client who requires assistance to transfer from the bed to a chair
D. a client who is unresponsive to pain stimuli
Answer: D
115. A nurse is planning care for a group of clients. Which of the following tasks should the
nurse delegate to an assistive personnel?
A. Changing the dressing for a client who has a stage 3 pressure injury
B. Determining a client's response to a diuretic
C. Comparing radial pulses for a client who is postoperative
D. providing postmortem care to a client
Answer: D
116. A nurse is conducting a health assessment for a client who takes herbal supplements.
Which of the following statements by the client indicates an understanding of the use of the
supplements?
A. I take ginkgo biloba for a headache
B. I take echinacea to control my cholesterol
C. I use ginger when I get car sick

D. I use garlic for my menopausal symptoms
Answer: C
117. A nurse is caring for a client who has influenza and isolation precautions in place. Which
of the following actions should the nurse take to prevent the spread of infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room.
D. Place the client in a negative airflow room.
Answer: A
118. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his
NG tube. Which of the following actions should the nurse take?
A. Attach the restraints securely to the side rails of the client's bed.
B. Apply the restraints to allow as little movement as possible
C. Allow room for two fingers to fit between the clients skin and the restraints
D. remove the restraints every 4 hours:
Answer: C
119. A nurse is admitting a client who has tuberculosis. Which of the follow- ing types of
transmission precautions should the nurse plan to initiate?
A. Droplet
B. Airborne’s
C. protective environment
D. contact
Answer: B
120. A nurse in a well-child clinic receives a telephone call from a parent who states that their
child accidentally swallowed paint thinner. The child is awake and alert. Which of the
following responses should the nurse make?
A. Have your child drink one large glass of water.
B. Hang up and call a poison control center hotline.
C. Bring your child into the clinic later today.
D. Induce vomiting in your child with syrup of ipecac.

Answer: B
121. A nurse is documenting a client's medical record. Which of the following entries should
the nurse record.
A. Oral temperature slightly elevated at 0800
B. Administered pain medication
C. Incision without redness or drainage
D. Drank adequate amounts of fluid with meals.
Answer: C
122. A nurse is providing oral care for a client who is unconscious. Which of the following
actions should the nurse take?
A. Place the client in a side-lying position.
B. Brush the clients teeth daily
C. Apply mineral oil to the client's lips
D. Rinse the client's mouth with an alcohol-based mouthwash
Answer: A
123. A nurse is collaborating with a risk management team about potential legal issues
involving client care. The nurse should identify which of the following situations is an
example of negligence?
A. A nurse administers a medication without first identifying the client.
B. An assistive personnel discusses client care in the facility cafeteria with visitors present.
C. A nurse begins a blood transfusion without obtaining consent.
D. An assistive personnel prevents a client from leaving the facility.
Answer: A
124. A nurse is collecting a sputum specimen for culture from a client who has a respiratory
infection. Which of the following actions should the nurse take?
A. Wear sterile gloves when collecting the specimen.
B. Offer the client oral hygiene after the collection
C. Collect the specimen in the evening.
D. Collect 1 ml of sputum
Answer: B

125. A nurse is assessing an older client. Which of the following findings should the nurse
expect?
A. Decreased sense of balanced
B. Increased nighttime sleeping
C. Heightened sense of pain
D. Nighttime urinary incontinence
Answer: A
126. A nurse is completing discharge teaching about ostomy care with a client who has a new
stoma. Which of the following instructions should the nurse include in the teaching? (select
all that apply)
A. "Cut the opening of the pouch 1D8 of an inch larger than the stoma "
B. "Place a piece a gauze over the stoma while changing the pouch"
C. "Use povidone-iodine to clean around the stoma"
D. "Empty the ostomy pouch when it becomes one-third full of contents"
E. "Expect the stoma to turn a purple-blue color as its heals"
Answer: A, D
127. Cut the opening of the pouch 1D8 of an inch larger than the stoma
A. Cut the opening of the pouch 1/8 of an inch larger than the stoma
B. Place a piece of gauze over the stoma while changing the pouch
C. Use povidone-iodine to clean around the stoma
D. Empty the ostomy pouch when it becomes one-third full of contents
Answer: A
128. A nurse is preparing to obtain informed consent from a client who speaks a different
language than the nurse. Which of the following actions should the nurse take?
A. "Request that an assistive personnel interpret the information for the client"
B. "Use proper medical terms when giving information to the client"
C. "Offer written information in the client's language"
D. "Avoid using gestures when speaking to the client"
Answer: C

129. A nurse is teaching a client about home care equipment. Which of the following
information should the nurse include in the teaching? (select all that apply)
A. "Avoid using wool blankets when receiving oxygen"
B. check the O2 delivery rate at least once a day
C. align the middle of the ball in the flow meter with the line of the prescribed flow rate
D. "Keep the oxygen delivery system 0.6 m (2 feet) from any heat source"
E. "Lay the oxygen tank flat when storing"
Answer: A, C, D
130. A nurse is planning care for a client who reports insomnia. Which of the following
actions should the nurse perform shortly before bedtime?
A. Provide a late supper.
B. Offer a wet washcloth for the client to wash her face
C. Perform range-of-motion exercises
D. Prepare hot cocoa or tea for the client
Answer: B
131. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients.
Which of the following clients should the nurse see first?
A. A client who has acute abdominal pain of 4 on a scale from 0 to 10
B. A client who has pneumonia and an oxygen saturation of 96%
C. A client who has new onset of dyspnea 24hr after a total hip arthroplasty
D. A client who has a urinary tract infection and low-grade fever:
Answer: C
132. A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium
chloride 600mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100mL intermittent
IV bolus, 200mL emesis, 40mL voided urine, and 20mL urine from straight catheterization.
The nurse should record the client's net fluid intake as how many mL? (Round the answer to
the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
A. 600 mL
B. 440 mL
C. 700 mL
D. 260 mL

Answer: B
133. A nurse is discussing incident reports with a group of newly licensed nurses. The nurse
should include that which if the following requires the completion of an incident report?
A. A client's prescribed laboratory testing was not obtained
B. A client withdrew consent for a procedure
C. An oncoming nurse arrived to work late
D. A nurse transfused a unit of packed RBCs in 2 hr.
E. A client's prescribed laboratory testing was not obtained
Answer: A
134. A nurse is caring for a client who has a new prescription for negative-pressure therapy
for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following
resources should the nurse consult to learn more about the intervention.
A. The client's plan of care
B. The nurse practice act
C. The material safety data sheet
D. The policy and procedure manual
Answer: D
135. A nurse is performing postural drainage with percussion and vibration for a client who
has cystic fibrosis. Which of the following actions should the nurse take?
A. Cover the area of percussion with a towel.
B. Instruct the client to exhale quickly during vibration
C. Schedule postural drainage after meals
D. Perform percussion over the lower back
Answer: A
136. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child
who has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup.
Which of the following images indicates the correct number of mL the nurse should
administer? (round answer to the nearest whole number.)
A. 5 mL
B. 6 mL

C. 8 mL
D. 10 mL
Answer: C
137. A nurse is admitting a client who is malnourished. The client states, "My wedding ring is
loose and I'm worried I will lose it if it falls off." Which of the following is an appropriate
response by the nurse?
A. " I will place it in your drawer so it won't get lost."
B. I can pin it to your hospital gown so you won't lose it."
C. "I will hold onto it until a family member can take it home."
D. I can put it in a locked storage unit for you
Answer: C
138. A charge nurse is teaching a group of newly licensed nurses about the use of restraints.
In which of the following clinical situations should the nurse apply restraints?
A. If the client is pacing in the hallway
B. As a part of a fall prevention program
C. At the request of the client's family
D. When the client poses a threat to self
Answer: D
139. To ensure client safety, A Nurse manager is planning to observe a newly licensed nurse
perform a straight catheterization on a client. In which of the following roles is the nurse
manager functioning?
A. Case manager
B. Client educator
C. Client care provider
D. Client advocate
Answer: C
140. A charge nurse in a long-term care facility is preparing an educational program about
delirium for newly hired nurses. Which of the following statements should the nurse plan to
include?
A. "Delirium does not affect a client's perception of her environment."

B. "Delirium does not affect a client's sleep cycle."
C. "Delirium has an abrupt onset."
D. "Delirium has a slow progression."
Answer: B
141. A nurse is speaking with a client who has recently received a diagnosis of a chronic
illness. The client states, " The doctor must be wrong. I can't be that sick". The nurse should
inform the client that their reaction is an example of which of the following expected
responses to grief?
A. Acceptance
B. Denial
C. Anger
D. Depression
E. Denial
Answer: B
142. A Nurse on a medical-surgical unit is providing care for four clients. The nurse should
identify which of the following situations as an ethical dilemma?
A. A surgeon who removed the wrong kidney during a surgical procedure refuses to take
responsibility for her actions
B. A client who has Crohn's disease reports that his prescription drug plan will not pay for his
medications.
C. A client who has a new colostomy refuses to take instructions from the ostomy therapist
because she "doesn't like him."
D. the family of a client who has a terminal illness asks the provider not to
E. tell the client the diagnosis: the family of a client who has a terminal illness asks the
provider not to tell the client the diagnosis
Answer: E
143. A nurse is teaching a client about performing breast self-examinations. Which of the
following statements by the clients indicates an understanding of the teaching?
A. "I should perform my self-exam the week that my period starts"
B. "I should make different patterns on each breast when I do my self-exam."
C. "I should use the palm of my hand to apply pressure to each breast."

D. "I should make circular motions with my fingertips under my arms."
Answer: C
144. A nurse is preparing to transfer a client who is partially weight bearing from the bed to
the chair. Which of the following actions should the nurse take?
A. Keep his knees straight when moving the client
B. Position the chair next to the bed as a 90 degree angle
C. Stand with his feet together when lifting the client
D. Have the client bear weight on her stronger leg
Answer: D
145. A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a
prescription for ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify
the sequence of steps the nurse should follow to administer the medication. ( Move the steps
into the box on the right, placing them in the order of performance. Use all the steps.)
A. Cleanse the injection port with an antiseptic swab.
B. Aspirate for blood return.
C. Inject the medication.
D. perform hand hygiene
E. Select the injection port of the IV tubing closest to the client.
Answer: Correct Order: D, A, E, B, C
146. A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH
insulin. Which of the following statements but the client indicates an understanding of the
teaching
A. I should wait 3 minutes after mixing the insulin to inject it
B. I should draw up the NPH insulin before regular insulin
C. I should inject air into the vial of regular insulin first
D. I should roll the vial of NPH insulin between my hands before drawing it up
Answer: D
147. A nurse is assessing the body temperature of an adult client using a temporal artery
thermometer. Which of the following actions should the nurse take? (Select all that apply)
A. Slide the probe across the clients forehead

B. Pull the clients pinna up & back
C. Hold the client's hair aside while performing the procedure
D. Document the client's temperature with "AX" next to the value
E. Move the probe in a circular motion: Slide the probe across the clients forehead
Answer: A, C
148. A nurse is preparing to insert a peripheral IV catheter into the client's arm. Which of the
following actions should the nurse take to help dilate the vein?
A. Stroke the skin near the vein in an upward position
B. Dangle the client's arm over the edge of the bed
C. Apply a cool compress to the vein for 10 min
D. Instruct the client to flex their arm with the hand open
Answer: B
149. A nurse is preparing to suction a client's tracheostomy tube. Which of the following
actions should the nurse plan to take?
A. Apply intermittent suction during catheter insertion
B. Suction the client's airway for 20 seconds with each pass
C. Hyper oxygenate the client manually for 30 to 60 seconds before suctioning
D. decrease suction pressure to 150 mm Hg if the O2 sat levels drop during suctioning
Answer: C
150. A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which
of the following finding is the nurse's priority?
A. Last bowel movement was 3 days ago
B. Reports pain of 8 on a scale of 0 to 10
C. Distended bladder
D. Respiratory rate 7/min
Answer: D
151. A nurse is caring for a client who has been treated multiple times for STIs. Which of the
following responses should the nurse take?
A. "You must have too many sexual partners"
B. "Why do you keep letting this happen?"

C. "Let's explore why this might be reoccurring"
D. "Don't you have access to condoms?"
E. Let's explore why this might be reoccurring
Answer: C
152. A nurse enters the room of a client who has a seizure disorder. The client is sitting in a
chair and begins to experience a seizure. Which of the following actions should the nurse take
first?
A. Move items in the room away from the client
B. Turn the client onto their side
C. Help the client lie on the floor
D. Loosen the client's clothing
Answer: C
153. A nurse is testing a client for conduction deafness by performing Weber's test. Which of
the following actions should the nurse take when performing this test?
A. Move a vibrating tuning form in front of the client's ear canals one after the other
B. Place the base of a vibrating tuning fork on the client's mastoid process
C. Place the base of a vibrating tuning fork on the top of the client's head
D. Count how many seconds a client can hear a tuning fork after it has been struck
Answer: C
154. A nurse is obtaining the medication history of a client who asks about taking ginkgo
biloba. The nurse should identify which of the following medications can interact adversely
with this supplement?
A. Warfarin
B. Albuterol
C. Levothyroxine
D. Atorvastatin
E. Warfarin
Answer: A

155. A nurse is obtaining informed consent from a client who is scheduled for surgery. The
client states, "I don't want to go through with the procedure." Which of the following actions
should the nurse take?
A. Discuss alternative treatments with the client
B. Explain to the client the risks involved with not having the procedure
C. Express approval of the client's decision to not have the procedure
D. Document the client's decision in the medical record
Answer: C
156. A nurse is providing teaching to a client about reducing the adverse effects of
immobility. Which of the following statements by the client indicates an understanding of the
teaching?
A. " I will have my partner help me change position every 4 hours"
B. " I will remove my antiembolic stockings while I am in bed"
C. " I will hold my breath when rising from a sitting position"
D. " I will perform ankle and knee exercises every hour."
Answer: D
157. A nurse is caring for a client who is postoperative and has a new prescription to advance
her diet to full liquids. Which of the following foods should the nurse offer the client as a part
of a full liquid diet?
A. Oatmeal
B. Applesauce
C. Scrambled eggs
D. Plain Yogurt
Answer: D
158. A nurse is preparing a client who has terminal cancer for discharge. Which of the
following questions should the nurse ask when assessing the client's psychosocial history?
A. " What medications are you currently taking?"
B. " Are you experiencing any Pain?"
C. " Have any of your relatives been diagnosed with cancer?"
D. " What Techniques do you use to cope with stress?"
Answer: D

159. A nurse is performing a skin assessment on an older adult client. Which of the following
findings should the nurse expect?
A. Thickened outer layer of skin
B. Increased skin elasticity
C. Reduced sweat production
D. Increased Production of oils
Answer: C
160. A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer.
Which of the following responses should the nurse make?
A. " I would get a second opinion if I were you."
B. " it might seem bad now, but things will get better."
C. " it must be difficult for you to receive this kind of news."
D. "I think you would benefit from speaking with our chaplain."
Answer: C
161. A nurse is preparing to obtain a health history from a client. Which of the following
actions should the nurse take?
A. Use the client's first name when initially meeting the client.
B. Tell the client the purpose for collecting the information.
C. Explain to the client the necessity of full disclosure of information.
D. Avoid documenting direct quotes from the client as part of subjective data.
Answer: B
162. A nurse is caring for a client who has brain cancer and is transferring to hospice care.
The client's son tells the nurse, " I don't know what to tell my dad if he asks how he is going
to die." Which of the following is an appropriate response by the nurse?
A. " Let's talk more about your dad's condition."
B. "The social worker will help you answer those questions."
C. " Try to help your dad enjoy this time as much as he can."
D. " I think that you should discuss this with the hospice nurse."
Answer: A

163. A Nurse is preparing to administer several medications to a client. Which of the
following data should the nurse plan to use to confirm the client's identity?
A. The client's room number
B. The client's admitting diagnosis
C. The name of the client's next of kind.
D. The client's telephone number
Answer: A
164. A nurse is caring for a client who is prescribed a special diet. The client is concerned that
he does not have the resources to purchase the food he needs to adhere to the diet at home.
The nurse should notify which of the following members of the health care team.
A. Social worker
B. Occupational therapist
C. Registered Dietician
D. Primary care provider
Answer: A
165. A nurse is teaching a newly licensed nurse about the care of a client who has a
methicillin resistant Staphylococcus aureus (MRSA) infection. Which of the following
statements by newly licensed nurse indicates an understanding of the teaching?
A. " I will place the client in a Private room."
B. " I will remove my gown before my gloves after providing client care."
C. " I will wear an N95 respirator mask when caring for the client."
D. " I will tell the client's visitors to wear a mask when they are within 3 feet of the client."
Answer: A
166. A nurse is planning care for a client who reports having a latex allergy. Which of the
following interventions should the nurse include in the plan?
A. Cover the blood pressure cuff with a stockinette.
B. Wear powdered gloves when providing care to the client.
C. Apply adhesive tape when securing an IV insertion site.
D. Use plastic syringes for medication administration.
Answer: D

167. A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing
the client's signature, the client states, " I trust my doctor, but I don't understand what is
meant by resecting my intestines." Which of the following actions should the nurse take?
A. Describe the surgery to the client.
B. Notify the Provider.
C. Complete an incident report
D. Provide brochures about the procedure.
Answer: B
168. A nurse is documenting client care. Which of the following abbreviations should the
nurse use?
A. " SQ" for subcutaneous
B. "SS" for sliding scale
C. "BRP" for bathroom privileges
D. "OJ" for orange juice
Answer: C
169. A nurse is preparing to bathe a client who has dementia. Which of the following actions
should the nurse take?
A. Give detailed instructions for the client to follow.
B. Complete the bath even if the client is in distress.
C. Use distractions when bathing the client.
D. Allow the client to select the temperature of the bath water.
Answer: C
170. A hospice nurse is caring for a client who has end stage cancer. Which of the following
interventions should the nurse include to promote the client's dignity?
A. Provide guided imagery exercises to the client.
B. Refrain from discussing the client's prognosis
C. Suggest that the client keep a journal.
D. Encourage the client to share their life story.
Answer: D

171. A nurse is caring for a client who has a closed wound drainage system. Which of the
following actions should the nurse take?
A. Wear sterile gloves when emptying the container.
B. Reset the container with the drainage port closed
C. Connect the drain to high pressure suction.
D. Cleanse the drain plug with alcohol after emptying:
Answer: A
172. A nurse receives a telephone prescription from a provider for a client who is
experiencing pain. Which of the following responses should the nurse make?
A. " Will you please spell the name of that medication for me?"
B. "Let me clarify that you want the medication given qid, correct?"
C. " I will sign my name now and leave a space for you to sign your name."
D. "Let me provide you with the client's medical record number for identification."
Answer: B
173. During change of shift report, A Nurse discovers she overlooked a prescription for a type
and cross-match of a client who is to have surgery the next day. Which of the following
actions should the nurse take first?
A. Inform the provider of the delay in obtaining the type and cross-match.
B. Obtain the client's type and cross-match.
C. Prepare an incident report for risk management.
D. Document the incident in the client's medical record.
E. Inform the provider of the delay in obtaining the type and crossmatch
Answer: A
174. A nurse is caring for a client who is receiving enteral feedings via NG tube. Which
following actions should the nurse take prior to administering the formula?
A. Check for gastric residual volume
B. Encourage the client to breathe deeply and cough.
C. Flush the tube with sterile 0.9% sodium chloride irrigation.
D. Encourage the client to take sips of water.
Answer: A

175. A nurse is caring for a client immediately following the insertion of an NG tube. Which
of the following should indicate to the nurse that the tube is placed incorrectly?
A. The client has a dry mouth
B. The client is coughing
C. The client has active bowel sounds
D. The client is hiccupping
Answer: B
176. A nurse is inserting an NG tube for a client who requires gastric de- compression. Which
of the following actions should the nurse take to verify proper placement of the tube?
A. Assess the client for a gag reflex
B. Measure the pH of the gastric
C. Place the end of the NG tube in the water to observe for bubbling
D. Auscultate 2.5 cm above the umbilicus while injecting 15 ml of water
Answer: B
177. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The
client informs the nurse that pain meds are not an option for managing pain. Which of the
following is an appropriate response by the nurse?
A. Would you like to get you a back massage?
B. Why do you think pain med is not going to help you?
C. You may take any herbal remedies you bring from home
D. I'm sure it will work if you just give it a chance
Answer: A
178. A Nurse is caring for a client who has an extracellular fluid volume deficit. Which of the
following findings should the nurse expect?
A. Bradycardia
B. Postural hypotension
C. Distended neck vein
D. Dependent edema
E. Postural hypotension
Answer: B

179. A nurse is caring for a client who is immunocompromised which of the following
actions should the nurse take?
A. Use sterile gloves to provide perineal care
B. Cleanse hands with an alcohol based hand rub before client contact
C. Have the client apply a mask when children are visiting
D. Place the client in a semi-private room
Answer: A
180. Which of the following veins should the nurse select when initiating iv therapy?
A. The radial vein on the left arm
B. The cephalic vein in the left distal forearm
C. The cephalic within on the back of the right hand
D. The basilic vein in the right antecubital fossa
Answer: C
181. interventions should the nurse take to prevent skin breakdown?
A. Apply powder to the client perineal area
B. Restrict client's fluid intake
C. Request a prescriptions for an indwelling urinary catheter
D. Apply a moisture barrier ointment after perineal hygiene
Answer: D
182. client tells the nurse" I am looking forward to seeing my grandchildren grow up." the
nurse should identify the client is experiencing which of the following stages of grief?
A. Acceptance
B. Bargaining
C. Anger
D. Denial
Answer: A
183. A nurse is teaching a client about the care and use of hearing aids. Which of the
following instructions should the nurse include in the teaching?
A. clean the hearing aid by soaking it in warm water
B. Turn the hearing aid off and the volume down before insertion

C. Replace the battery if the hearing aid emits a whistling sound
D. Leave the battery in place when the hearing aid is not in use
Answer: C
184. A nurse is teaching a client about the care and use of hearing aids. Which of the
following should the nurse take?
A. Observe the client's eyes for the six cardinal position of gaze
B. Verify the client's ability to read letters on a snellen eye chart
C. Check the client's pupil reaction when focusing on distant and nearby objects
D. Test the client's eyes for reactions to light response
Answer: A
185. A nurse is teaching the assistive personnel about upper body mechanics to prevent
injury. Which of the following actions by the AP demonstrate an understanding of the
teaching?
A. Holding the object close to the body.
B. Twisting the body at the waist while lifting.
C. Keeping feet shoulder-width apart for stability.
D. Lifting with the arms instead of the legs.
Answer: A
186. A nurse is assessing a client who is immobile and notices a red area over the client's
coccyx. Which of the following actions should the nurse take?
A. Change the clients position every 4 hours
B. Apply petroleum base ointment in the red area
C. Assess the red area for blanching
D. Use friction when cleansing the client's skin
E. Assess the red area for blanching
Answer: C, E
187. A nurse is planning care to prevent skin breakdown for a client who is immobile and has
urinary incontinence. Which of the following actions should the nurse include in the plan of
care.
A. Request a prescription for an indwelling urinary catheter

B. Use moisture-wicking bedding
C. Encourage frequent repositioning and skin assessments
D. Apply a thick layer of petroleum jelly to the skin
Answer: C
188. A nurse is teaching a client who had an enucleation about care of an artificial eye. Which
of the following information should be included in the teaching? (select all that apply)
A. Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation
B. Remove from the artificial eye by retracting the upper eyelid
C. Apply pressure just below artificial eye to break the suction
D. Clear the artificial eye with hydrogen peroxide before storing
Answer: A, C
189. A nurse is caring for a client who is 2 days postoperative following bowel resection and
reports sudden severe abdominal pain. Which of the following actions should the nurse take
first?
A. Determine areas of resonance across the abdomen using a systematic approach
B. Expose the client's abdomen to look for changes in appearance
C. Perform abdominal palpation by pressing gently with the finger pads
D. Use the diaphragm of the stethoscope to listen for bowel sounds
Answer: B
190. A nurse is providing care for a client who is to undergo a total laryngectomy. Which of
the following interventions is the nurses priority?
A. Determine the client's reading ability
B. Review the use of an artificial larynx
C. With the client schedule a support session
D. For the client explain the techniques of esophageal speech
Answer: B
191. A home care nurse is teaching a client about home safety. Which of the following
statements by the client indicates an understanding of the teaching? (select all that apply)
A. I will use the bars when getting in and out of the bath tub
B. I need to check my medications for expiration dates

C. I need to have a fire escape plan with my family
D. I will apply tape over frayed areas of electrical cords
E. I need to set my hot water heater to 140 degrees Fahrenheit
F. I need to check my medications for expiration dates
G. I need to have a fire escape plan with my family
Answer: A, B, C
192. A Nurse in an emergency department is assessing a client who reports a right lower
quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions
should the nurse take first?
A. Offer pain medication
B. Palpate the abdomen
C. Auscultate bowel sounds
D. Administer an antiemetic
Answer: B
193. A nurse is caring for a client who recently received a diagnosis of terminal cancer.
Which of the following statement by the client partner indicates maladaptive coping?
A. "I don't know if I will be able to meet his physical needs."
B. "I am trying to focus on the time we have left together."
C. "I'm looking into support groups for caregivers."
D. "I’m trying to take it one day at a time."
Answer: A
194. A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel.
The nurse should anticipate application of which of the following dressings?
A. Dry gauge
B. Transparent
C. Calcium alginate
D. Hydrogel
Answer: B

195. A nurse is caring for a client who has brain cancer and is transferring to hospice care.
The client's son tells the nurse "I don't know what to tell my dad if he asks how he is going to
die". Which of the following is an appropriate response from the nurse?
A. "Let’s discuss your concerns about your father."
B. "It’s best not to talk about death; it might upset him."
C. "You can just tell him everything will be okay."
D. "You should try to change the subject when he brings it up."
Answer: A
196. A Nurse is teaching an older adult client who has type 2 diabetes mellitus about how to
care for corns and calluses toes. Which of the following statements by the client indicates
understanding of the teaching?
A. I can apply lotion to soften the calluses as long as I don't put lotion between my toes
B. I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly
C. I should soak my feet in warm water daily to soften corns and calluses
D. I should use an over the counter liquid medication to remove corns
Answer: A
197. A nurse is caring for a client who has wrists restraints after an episode of violent
behavior. Which of the following actions should the nurse take?
A. Tie the restraints to the side rail
B. Secure restraints with a square knot
C. Remove one restraint at a time
D. Remove the restraints every 3 hours
Answer: C
198. A nurse is admitting a client who has a clostridium difficile infection. Which of the
following actions should the nurse take? Select all that apply
A. Use an N95 respirator while providing client care
B. wear a gown and gloves when providing client care
C. assign the client to a private room with positive air flow
D. wash hands with soap and water after contact with the client
E. Ensure the client does not receive fresh fruits
Answer: B, D

199. A nurse is planning care for a client who has latex allergy and is scheduled for surgery.
Which of the following actions is appropriate to include in the clients plan of care?
A. Schedule the client as the first surgical procedure of the day
B. Cleanse the stoppers with primidone iodine for withdrawing medication
C. Remove the stop stocks from iv tubing
D. Ensure the gloves in the surgical suite are powdered gloves
E. Schedule the client as the first surgical procedure of the day
Answer: A
200. A nurse is providing discharge teaching to a client who does not speak the same
language as the nurse. Which of the following action should the nurse take?
A. Use a professional medical interpreter for the session.
B. Speak directly to the client while the interpreter translates.
C. Provide written materials in the client’s preferred language.
D. Confirm the interpreter understands the medical terminology used.
Answer: A
201. A nurse is teaching a client how to self-administer daily low dose heparin injections.
Which of the following factors is most likely to increase the clients motivation to learn?
A. The client's belief that his needs will be met through education
B. The nurse explaining the need for education to the client
C. The client seeking family approval by agreeing to a teaching plan
D. The nurse's empathy about the client having to self inject
E. The client's belief that his needs will be met through education
Answer: A
202. A nurse is caring for a client who is receiving continuous enteral feedings through
gastrostomy tubes. Which of the following actions should the nurse take?
A. Heat the formula to 105 degrees Fahrenheit
B. Flush the tubing with 10 ml of water every 2 hours
C. Change the tubing every 72 hours
D. Aspirate residual volume every 4 hours (Every 4-8 hours is correct)
Answer: D

203. A nurse is caring for a client who has an incisional wound and a prescription for wound
care. Which of the following answers indicates the proper method of cleaning a wound site?
A. Use a different sterile swab for each stroke
B. Wipe the wound from the center outward in a circular motion
C. Clean the wound in a straight line from top to bottom
D. Use the same swab to clean the wound multiple times
Answer: A
204. A nurse is teaching a client who requires maximum support about how to use a two
wheeled walker. Which of the following actions by the client indicates an understanding of
teaching?
A. The client picks up the walker with each step
B. The client stoops slightly forward when moving the walker
C. The client stands with her elbows slightly flexed while holding the walker
D. The client moves the walker ahead 10 inches with each step (Incorrect b/c 6 inches max)
Answer: C
205. A nurse is caring for a client who refuses to follow the providers pre- scription for bed
rest. The nurse over hears the assistive personnel tell the client that if she does not remain in
bed he will place her in restraints. The nurse should identify that the AP is committing which
of the following torts?
A. Libel
B. Defamation of character
C. Assault
D. Battery
Answer: C
206. A nurse is preparing to insert an IV catheter for an older adult client who has fragile
skin. Which of the following actions should the nurse take?
A. Stabilize the vein by applying traction above the insertion site
B. Engorge the vein by placing the arm in the dependent position
C. Use friction at the insertion site to increase venous distention
D. Leave the tourniquet on for 30 to 60 seconds after initial insertion

Answer: A
207. A nurse is planning care for a client who has a new prescription for parental nutrition in
20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in
the plan of care?
A. Prepare the client for a central venous line
B. Change the PN infusion bag every 48 hours
C. Administer the PN and fat emulsion separately
D. Obtain a random blood glucose daily
Answer: A
208. A nurse is caring for a client who is schedule for surgery while witnessing the client
signature. While the client is saying I trust my doctor, but I don't understand what he meant
when he said he'll reset my intestines. Which of the following actions should the nurse take?
A. Provide brochures about the procedure
B. Notify the provider
C. Complete an incident report
D. Describe the surgery to the client
E. Notify the provider
Answer: B
209. A nurse is caring for a client who is agitated and threatening to harm others. The nurse
places the client in restraints but does not notify the provider or obtain a prescription for the
restraints. The situation respects which of the following torts?
A. False imprisonment
B. Invasion of privacy
C. Assault
D. Negligence
Answer: A
210. A nurse is conducting a Webber test on a client. Which of the following is an appropriate
action for the nurse to take?
A. Place an activated tuning fork in the middle of the client's head
B. Strike the tuning fork and hold it against the client's ear

C. Ask the client to cover one ear during the test
D. Place the tuning fork on the client's mastoid process
Answer: A
211. A nurse on a medical unit is caring for a group of clients. For which of the following
tasks should the nurse wear a face shield.
A. Changing the brief of an older client who has Clostridium difficile
B. Administering an intramuscular injection
C. Performing a sterile dressing change
D. Taking vital signs on a stable client
Answer: A
212. An adult client tells A Nurse about recent lack of sleep due to changing to a night shift
job. Which of the following interventions should the nurse suggest?
A. Use the television to mask external noises
B. Listen to soft music before lying down
C. Exercise just prior to bedtime
D. Keep the sleeping environment warm
Answer: B
213. A nurse is caring for a client who reports that she has insomnia. Which of the following
interventions is appropriate for the nurse to recommend?
A. Eat a light carbohydrate snack before bedtime
B. Exercise 1 hour before bedtime
C. Drink a cup of hot cocoa before bedtime
D. Take a 30 min nap daily: a
Answer: A
214. A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells
the nurse that she wants to use traditional Chinese medicine for treatment instead of the
medication prescribed by her provider. Which of the following is an appropriate response by
the nurse?
A. "You should ask the provider if she recommends traditional Chinese medicine."
B. "Traditional Chinese medicine isn't effective for fibromyalgia."

C. "It's important to follow your provider’s advice on medication."
D. "Let’s discuss your reasons for wanting to use traditional Chinese medicine."
Answer: D
215. A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of
the following responses by a newly licensed nurse indicates understanding in the teaching?
A. Each element has a range 1 to 5 points
B. The higher the score the higher the pressure ulcer risk
C. The clients age is part of the measurement
D. The scale measures six elements
Answer: D
216. A nurse is planning care for client who is scheduled for an intravenous pyelogram.
Which of the following actions is appropriate for the nurse to include?
A. Ensure the client is free of metal objects
B. Administer 240 ml (8oz) oral contrast before the procedure
C. Monitor the client for pain in the suprapubic region
D. Assist the client with a bowel cleansing
Answer: A
217. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on
clients who are confused. Which of the following instructions should the staff nurse include
A. "Use a calm voice and maintain a comforting presence."
B. "I don't know if I will be able to meet his physical needs."
C. "Consider using physical restraints only when absolutely necessary."
D. "Encourage the client to stay in bed at all times."
Answer: A
218. A Nurse is planning to obtain a blood sample from a client for capillary blood glucose
post test. Which of the following should the nurse take to obtain the sample?
A. The pad of the finger tip
B. The lateral aspect of the finger
C. The pinna of the ear
D. The side of the wrist

Answer: B
219. A nurse is planning to discharge a client who has diabetes and a new prescription for
insulin which of the following actions should the nurse plan to complete first?
A. Provide the client with a contact number for a diabetes education specialist
B. Make a copy of the medication record of the reconciliation for the client
C. Determine whether the client can afford the insulin administration supplies
D. Obtain printed information about self-administration
Answer: C
220. A nurse is caring for a client who has influenza and isolation precautions in place. Which
of the following actions should the nurse take to prevent the spread of infection?
A. Wear a mask when working within 3 feet of the client
B. Perform hand hygiene only before entering the room
C. Avoid touching surfaces in the client's room
D. Wear gloves only when providing direct care
Answer: A
221. A nurse is delegating client's care to the assistive personnel. Which of the following
tasks should the nurse delegate to the AP?
A. Obtain input and output for the patient who was stable
B. Assess the client's condition for potential complications
C. Administer medications
D. Develop a care plan for the client
Answer: A
222. A nurse is teaching about home safety with. Which of the following instructions should
the nurse include?
A. Use electrical tape to secure extension cords next to base boards on the floor
B. Replace carpet floors with tiles
C. Unplug electronics by grasping the cord
D. To use a fire extinguisher, aim high at the top of the flames
Answer: A

223. A nurse is caring for a client who has restraints to each extremity. Which of the
following assessment should the nurse perform first?
A. Elimination needs
B. Comfort level
C. Peripheral pulses
D. Skin integrity
Answer: C
224. A nurse in a long-term care facility is assessing a client. Which of the following findings
should the nurse recognize as an indication a fecal impaction?
A. Seepage of liquid stool
B. Frequent bowel movements
C. Abdominal cramping
D. Presence of flatulence
Answer: A
225. A Nurse is caring for a client who has a tracheostomy which of the following actions
should the nurse take?
A. Cotton tip applicator to clean the inside of the cannula
B. Soak the outer cannula in warm soapy tap water
C. Cleanse the skin around the stoma with normal saline
D. Secure the tracheostomy ties to allow one finger to fit snuggly underneath
Answer: C
226. A nurse is caring for a client who has a drainage evacuator. Which of the following is an
appropriate action by the nurse?
A. Ensure the drainage evacuator is functioning properly and maintain the prescribed suction.
B. Empty the drainage evacuator only when it is full.
C. Change the dressing over the drainage site without wearing gloves.
D. Avoid documenting the amount of drainage in the client’s record.
Answer: A
227. A nurse is preparing to transfer a client who is partially weight bearing from the bed to a
chair. Which of the following action should the nurse

A. Have the client bear weight on her stronger leg
B. Use a mechanical lift for all transfers
C. Allow the client to initiate the transfer without assistance
D. Pivot on the weaker leg during the transfer
Answer: A
228. A nurse in an acute care facility is preparing to transfer a client to a long-term facility.
Which of the following information should be nurse include in the hand off report?
A. Effectiveness of the last dose of pain medication
B. Personal opinions about the client's family
C. The client's favorite activities
D. The nurse's experiences with similar clients
Answer: A
229. A nurse is providing teaching to a client who is self administer an ophthalmic solution.
Which of the following statements by the client indicates understanding of the teaching?
A. I will keep my eyes closed for 5 mins after inserting drops
B. I will insert the drops in the center of the eye
C. I will press the inner corner of my eye after insert drops
D. I will raise my eye lid up while looking down and insert drops
Answer: C
230. A nurse in a long-term care facility is planning care for 4 clients. Which of the following
client's is at greatest risk of developing a pressure ulcer?
A. A client who is incontinent of urine 1 to 2 times a day
B. A client who is receiving enteral tube feedings
C. Client who requires assistance to transfer from the bed to a chair
D. Client who is unresponsive to pain stimuli
Answer: D
231. A nurse is assessing a client's personal hygiene. Which of the following findings
indicates that the client might have difficulty with routinely bruising their teeth?
A. The clients mucosa is moist
B. The client gums feel spongy

C. The client has a missing tooth
D. The Client's tongue is a dull red color
Answer: B
232. A nurse is planning to discharge a client who has diabetes mellitus and a new
prescription for insulin. Which of the following actions should the nurse plan to complete
first?
A. Make a copy of the medication reconciliation form for the client
B. Provide the client with the contact number for a diabetes education specialist
C. Determine whether the client can afford the insulin administration sup plies
D. Obtain printed about insulin self administration
Answer: C
233. A community health nurse is teaching a group of clients about Kegel exercises to prevent
urinary incontinence. Which of the following instructions should the nurse include?
A. Contact your pelvic muscle when performing the exercises
B. Expect improvement after 2 weeks of performing the exercises
C. Hold your breath when performing the exercises
D. Tighten your buttocks when performing the exercises
Answer: A
234. A nurse is assessing the skin of a client who has worked outdoors for the past 20 years.
Which of the following findings is the nurse's priority?
A. Skin tags noted in the neck region
B. A change in appearance of a mole on the shoulder
C. A flat, nonpalpable, discovered area of skin on the trunk
D. Atrophic wart on the left index finger
Answer: B
235. A nurse is caring for a client who has a high fever. Which of the following actions
should the nurse take?
A. cover the client with heavy blankets after shivering subsides
B. place ice packs on the clients neck and behind the knees
C. apply a bath blanket between the client and a cooling blanket

D. give the client a sponge bath using alcohol water solution
E. apply a bath blanket between the client and a cooling blanket
Answer: C
236. A nurse is caring for an infant who is to undergo surgery. The nurse should identify
which of the following individuals should sign the consent form?
A. The infants 17 year old mother
B. The infants provider
C. The infants grandmother
D. The mother's 21 year old sibling
Answer: A
237. A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a
cast. Which of the following actions should the nurse use?
A. Encourage the client to try to defecate for 20 min while on the fracture pan.
B. Keep the bed flat while the client is on the fracture pan.
C. Hyperextend the clients back while the fracture pan is in place.
D. Place the shallow end of the fracture pan under the clients buttocks.
Answer: D
238. A nurse is reviewing the medical record of a client who asks about the use of a magnet
therapy for pain relief. The nurse should identify which of the follow- ing findings is a
contraindication for receiving this type of therapy?
A. The client is allergic to penicillin
B. The client has a prescription for metoprolol
C. The client has a history of alcohol use disorder
D. The client has an implanted defibrillator
Answer: D
239. A nurse is caring for a client who requires airborne precautions. The nurse is preparing
to leave the clients room following a dressing change. Which of the following pieces of
personal protective equipment should the nurse remove first?
A. Gloves
B. Eyewear

C. Gown
D. Mask
Answer: A
240. A nurse is teaching a newly licensed nurse about the care of a client who has methicillin
resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the
newly licensed nurse indicates an understand- ing of the teaching?
A. I will wear an N95 respirator mask when caring for the client
B. I will tell the clients visitors to wear a mask when they are within 3 feet of the client.
C. I will place the client in a private room
D. I will remove my gown before my gloves after providing client care.
Answer: C
241. A charge nurse in a long term care facility is preparing an educational program about
delirium for newly hired nurses. Which of the following statements should the nurse plan to
include?
A. Delirium has an abrupt onset.
B. Delirium is a chronic condition.
C. Delirium is always reversible.
D. Delirium only occurs in older adults.
Answer: A
242. A nurse is preparing to insert an IV catheter for an adult client. Which of the following
actions should the nurse take?
A. choose the most proximal site on the extremity selected
B. apply a cool compress for several minutes before insertion of the IV catheter
C. place the tourniquet below the proposed insertion site
D. place the extremity in a dependent position
Answer: D
243. A nurse is teaching a client who is about to undergo a bowel resection about advance
directives. Which of the following instructions should the nurse include in the teaching?
A. Your partner must be present when you sign the advance directives
B. You will receive written information about advance directives prior to signing

C. You are required to sign advance directives prior to surgery
D. Your provider must sign the advance directives before surgery
Answer: B
244. A nurse is caring for a client who has wrist restraints after an episode of violent
behavior. Which of the following actions should the nurse take?
A. Remove one restraint at a time
B. Leave the restraints on at all times without monitoring
C. Use the same type of restraint for all clients
D. Secure the restraints tightly to prevent movement
Answer: A
245. A nurse is preparing to administer several medications via NG tube to a client who is
receiving a continuous tube feeding. Which of the following actions should the nurse take?
A. Dilute each crushed medication with sterile water
B. Mix the medication together in a single syringe
C. Flush the NG tube with 5mL of sterile water prior to administration
D. Combine the medication with the formula in the feeding bag
Answer: A
246. A nurse is planning care for a client who has urinary incontinence. Which of the
following interventions should the nurse include in the client's plan of care?
A. Toilet the client every 4hr while the client is awake
B. Apply a moisture barrier in a thick layer to vulnerable skin areas
C. Cleanse the skin with antibacterial soap and hot water after each incontinence episode
D. Reduce the clients daily fluid intake
Answer: B
247. A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The
nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take
first?
A. Complete an incident report
B. Obtain the client's vital signs
C. Document the fluid infusion in the client's chart

D. Report the incident in to the unit manager
Answer: B
248. A home health nurse is teaching a client about home safety. Which of the following
statements by the client indicates an understanding of the teaching? (SATA)
A. I need to check my medications for expiration dates
B. I will use the grab bars when getting in and out of the bathtub
C. I need to have a fire escape plan with my family
D. I need to check my medications for expiration dates
Answer: A, B, C
249. A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing
the client's signature, the client states, I trust my doctor, but I don't understand what is meant
by resecting my intestine. Which of the following actions should the nurse take?
A. Notify the provider.
B. Explain the procedure in detail to the client.
C. Reassure the client that everything will be fine.
D. Ask the client to sign the consent form anyway.
Answer: A
250. A nurse is discussing the stages of general adaptation syndrome with a newly licensed
nurse. The nurse should identify that which of the following mani- gestations occurs during
the alarm reaction stage?
A. Dilated pupils
B. Physical exhaustion
C. Bradycardia
D. Depression
Answer: A
251. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when
plugging in the IV pump. Which of the following actions should the nurse take first?
A. Unplug the pump
B. obtain a replacement pump
C. Notify the biomedical department to fix the pump

D. Label the pump with a defective equipment sticker
Answer: A
252. A nurse is caring for a client who is receiving a warm, moist compress to relieve lower
back pain. Which of the following findings should indicate to the nurse that the compress has
been effective?
A. The client's skin on the lower back is intact without redness
B. The client's laughing at a television show
C. The client states that he is able to concentrate while eating
D. The clients’ vital signs are within the expected reference range
Answer: A
253. A nurse is preparing a sterile field to assist with suturing a clients laceration. Which of
the following actions should the nurse plan to take?
A. Pour the sterile solution with the bottle 20cm(8in) above the sterile bowl
B. Hold the bottle of sterile solution so that the label is facing the palm of the hand
C. Place the lid of the sterile solution bottle face down on the sterile drape
D. Apply sterile gloves before opening the bottle of sterile solution
Answer: C
254. A nurse is caring for a client who is scheduled to have his alanine amino transferase
(ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the
following is an appropriate response by the nurse?
A. This test will determine if your heart is performing properly
B. This test will indicate if you are at risk for developing blood clots
C. This test is used to check how your kidneys are working
D. This test will provide information about the function of your liver
Answer: D
255. A Nurse receives a new prescription over the telephone from a client's provider. Which
of the following actions should the nurse take first?
A. Ensure that the provider signs the prescription
B. Write down the complete prescription
C. Read back the prescription to the dr

D. Document the prescription as a telephone prescription in the medical record
Answer: C
256. A nurse is caring for a client who is on bed rest following abdominal surgery. Which of
the following findings indicates the need to increase the frequency of position changes?
A. Petechiae on the client's right anterior thigh
B. Flat rash on the client's ankle
C. non-palpable macule on the client's left shoulder
D. Non Blanching darkened area over the client's trochanter
Answer: D
257. A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which
of the following statements by the client indicates an understanding of the teaching?
A. After insert the hearing aid, i will turn it up as high as it will go
B. I should leave the battery in the hearing aid when i take it out to sleep
C. I will need to get a new hearing aide every year
D. I should gradually increase the time that i wear the hearing aid
Answer: D
258. A nurse is preparing to collect a specimen from a client. Which of the following actions
should the nurse take?
A. Collect the sputum specimen in the morning.
B. Instruct the client to rinse their mouth with water before collecting the specimen.
C. Use a sterile container for urine specimens only.
D. Collect the specimen after the client eats a meal.
Answer: A
259. A nurse is assessing a client who has diabetes mellitus prior to perform- ing a blood
glucose test. Which of the following findings should indicate to the nurse that the client has
hyperglycemia?
A. Thirst
B. Confusion
C. Cool skin
D. Shakiness

Answer: A
260. A nurse is assessing an older adult client. Which of the following find- ings should the
nurse expect?
A. Decreased sense of balance
B. Increased muscle mass
C. Improved reaction time
D. Enhanced sensory perception
Answer: A
261. A nurse is preparing to administer a controlled substance to a client for pain
management. Which of the following actions should the nurse take?
A. Report any discrepancy in the court total of the controlled substance after administration
B. Place the assisted portion of the controlled substance in the sharps container
C. Verify the count total of the controlled substance after removing the amount needed
D. Ask a second nurse to report her signature when wasting any unused portion of the
controlled substance
Answer: C
262. A nurse is caring for a client who has colon cancer and is scheduled for a colon resection
with a possible colostomy. Before the procedure, the client tells the nurse, i'm worried about
the bag. Which of the following is an appropriate response by the nurse?
A. You are worried about having to wear a colostomy bag?
B. Have you ever known someone who has a colostomy
C. Let's wait until after the surgery to discuss your concerns about your colostomy
D. The surgeon will only place the colostomy if it is necessary
Answer: A
263. A nurse is preparing to administer medication to a client. Which of the following should
the nurse use as a client identifier?
A. Age
B. Room number
C. Photograph
D. Bed number

Answer: C
264. A nurse is preparing to administer an injection to a client. Which of the following actions
should the nurse plan to take after administering the injection?
A. Discard the needle in a puncture proof container
B. Place the needle on the bedside table
C. Remove the needle from the syringe
D. Recap the needle before disposal
Answer: A
265. A nurse is planning care for a client who is concerned about her tobacco smoking habits
and is in the contemplation stage of health behavior change. Which of the following actions
should the nurse plan to take during this stage?
A. Assist the client in setting goals to make the change
B. Develop a plan for the client to integrate the change into her lifestyle
C. Present information about the benefits of quitting smoking
D. Recommend small changes for the client to make to change her behavior overtime
Answer: C
266. A nurse is providing teaching to a client who is at risk for thrombus formation. Which of
the following statements made by the client indicates an understanding of the teaching?
A. I will keep my legs crossed while sitting
B. I will perform exercises once every 4 hours while i am awake
C. I should massage my legs when they hurt
D. I should limit the time that i spend sitting in a chair
Answer: D
267. A nurse is documenting client care. Which of the following abbreviations should the
nurse use?
A. BRP for bathroom privileges
B. QD for every day
C. PC for after meals
D. PRN for as needed
Answer: A

268. A nurse who is documenting information in a clients electronic medical record is asked
to assist with an emergency. Which of the following actions should the nurse take?
A. Ask another nurse to monitor the computer
B. Turn the computer off
C. Move the computer to a secure place
D. Print out the current notes to finish later
Answer: A
269. A nurse is caring for a client who is receiving continuous enteral feeding via NG tube.
Which of the following is an unexpected finding?
A. Diarrhea one time in a 24 hour period
B. A weight gain of 0.91kg(2Ib) in 2 days
C. A gastric residual of 300mL at the end of the shift
D. A blood glucose level of 110 mg/dL
Answer: C
270. A nurse is planning care for a female client who has an indwelling urinary catheter.
Which of the following actions should the nurse include in the plan?
A. Tape the catheter to the lower abdomen
B. Attach the drainage bag to the side rails of the bed
C. Keep the drainage bag below the level of the bladder
D. Empty the drainage bag when it is three quarters full
Answer: C
271. A nurse is reviewing the medical record for a newly admitted client. Which of the
following laboratory values should the nurse report to the provider?
A. Sodium 140
B. Potassium 1.8
C. Magnesium 1.9
D. Calcium 6.5
Answer: B

272. A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220Ib.
How many mg should the nurse administer? (Round to the nearest whole number. Use a
leading zero if it applies. Do not use trailing zero).
A. 150 mg
B. 200 mg
C. 250 mg
D. 300 mg
Answer: B
273. A nurse is caring for a client who tells the nurse, since I retired, I have a lot of time on
my hands and nothing to do. I guess nobody needs me. Which of the following responses
should the nurse make?
A. If I were you, I would volunteer my time
B. Do you have family members you can visit
C. You need to realize that you have valuable skills to offer others
D. Tell me about some hobbies you enjoy
Answer: D
274. A nurse is caring for a client who has an NG tube and has repeatedly pulled it out. The
nurse should identify that which of the following findings indicates a need for restraints?
A. The client's family is unable to stay with the client
B. The client becomes confused at night
C. The client gets out of bed to use the bathroom frequently
D. The client is assigned a room near the nurses station
E. The client is assigned a room near the nurses station
Answer: B
275. A nurse is documenting a dressing change for a client who has a pressure injury. Which
of the following entries by the nurse demonstrate correct documentation?
A. No changes noted to the wound from previous nursing notes
B. Client pre-medicated with MSO4 sunq prior to dressing change
C. The wound seems clean and does not appear to be infected
D. New dressing applied as prescribed, no drainage on old dressing
E. Client pre-medicated with MSO4 sunq prior to dressing change

Answer: D
276. A Nurse is preparing to reposition a client who has a lower back injury. Which of the
following actions should the nurse take?
A. Place the clients arms at their sides
B. Flex the client's knees
C. Place the client at the side of the bed nearest the direction they will be turned
D. Roll the client as one unit in a smooth continuous motion.
Answer: D
277. A nurse is caring for a client who has TB. which of the following precautions should the
nurse plan to implement when working with the client?
A. Airborne precautions
B. Contact precautions
C. Droplet precautions
D. Standard precautions
Answer: A
278. A nurse is implementing seizure precautions for a client who has a seizure disorder.
Which of the following equipment should the nurse place at the client's bedside?
A. Oral suction equipment and oral airway
B. Restraints for safety
C. Extra pillows for comfort
D. An oxygen mask
Answer: A
279. A nurse is providing teaching to the family of a client who is at the end stage of life.
Which of the following client manifestations should the nurse instruct the family to expect?
A. Increased periods of wakefulness
B. Altered breathing patterns
C. Increased salivation
D. Warm and dry extremities
Answer: B

280. A nurse is preparing to obtain informed consent from a client who speaks a different
language than the nurse and is scheduled for surgery. Which of the following actions should
the nurse take?
A. Recommend an interpreter who is the same gender as the client.
B. Use a family member to interpret the information.
C. Provide written consent forms in the client's language.
D. Explain the procedure in simple terms without an interpreter.
Answer: A
281. A nurse is caring for a client who is receiving continuous enteral feedings through a
gastrostomy tube. Which of the following actions should the nurse take?
A. Aspirate residual volume every 4 hours
B. Flush the tube with water only after each feeding
C. Change the feeding bag every week
D. Keep the client in a supine position during feedings
Answer: A
282. A nurse is preparing to insert an IV catheter for a client following a right mastectomy.
Which of the following veins should the nurse select when initiating IV therapy?
A. The cephalic vein in the left distal forearm
B. The basilic vein in the right arm
C. The median cubital vein in the right arm
D. The radial vein in the right wrist
Answer: A
283. A nurse is caring for a client who is postoperative and has a new prescription to advance
her diet to full liquids. Which of the following foods should the nurse offer the client as a part
of a full liquid diet?
A. Plain yogurt
B. Broiled chicken
C. Steamed vegetables
D. Whole grain bread
Answer: A

284. A nurse is planning care for a client who has a latex allergy and is scheduled for surgery.
Which of the following actions is appropriate to include in the client's plan of care?
A. Schedule the client as the first procedure.
B. Use latex gloves during the procedure for safety.
C. Inform the surgical team about the latex allergy.
D. Provide the client with latex-containing postoperative supplies.
Answer: A
285. A nurse is caring for a male client who has a prescription for intermittent catheterization
with a crude catheter. Which of the following images show the type of catheter the nurse
should use?
A. A catheter with a straight end
B. A catheter with a curled end
C. A foley catheter with a balloon
D. A catheter with multiple ports
Answer: B
286. A nurse is caring for a client following a bilateral mastectomy. The client is often tearful
and avoids looking at her dressings. Which of the following actions should the nurse take
first?
A. Provide the client with a mirror to look at her mastectomy incisions
B. refer the client to a breast cancer support group
C. identify the impact of the mastectomy on the client's body image
D. encourage the client to assist with her dressing change
Answer: C
287. A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the
sequence in which the nurse should perform the following steps. (Place them in order of
performance. Use all steps)
A. Provide adequate lighting to inspect the abdomen
B. Listen to the abdomen arteries using the bell of a stethoscope
C. Percuss all four quadrants of the abdomen to measure sound quality
D. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm ( 1 to 3 in) into the
abdomen

E. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen
Answer: Correct Order: A, B, C, E, D
288. A Nurse working on a medical surgical unit is making client assignments for an
upcoming shift. Which of the following tasks should the nurse assign to an assistive
personnel?
A. Assisting with ambulation for a client who has a pulmonary infection
B. Administering medications to a client
C. Performing a sterile dressing change
D. Assessing a client's vital signs
Answer: A
289. A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe
for a client who has diabetes mellitus. Which of the following actions should the nurse take
first?
A. Inject air into the short-acting insulin vial.
B. Inject air into the intermediate insulin vial.
C. Draw up the short-acting insulin.
D. Draw up the intermediate insulin.
Answer: A
290. A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the
following interventions is the priority?
A. Develop a list of goals.
B. Provide information about palliative care options.
C. Assess the client’s physical and emotional needs.
D. Encourage the client to express their feelings and concerns.
Answer: C
291. A Nurse is caring for client who has pneumonia. The nurse should recognize which of
the following should be discarded in a biohazard bag?
A. An emesis basin filled with blood from severe coughing
B. A bedpan containing diarrhea from a client who was receiving antibiotics
C. A disposable tissue containing expectorated sputum

D. A calibrated toilet insert filled with urine.
E. An emesis basin filled with blood from severe coughing
Answer: C