2020 ATI PN Comprehensive Exit Version 1 to 4 With Answers-684 Solved Questions

ATI PN Comprehensive Exit Exam (8 Versions)(New)(Satisfaction
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ATI Comprehensive Exam
Version 1
A nurse in a paediatric unit is preparing to insert an IV catheter for 7-yearold. Which of the
following actions should the nurse take?
A. (Unable to read)
B. Tell the child they will feel discomfort during the catheter insertion.
C. Use a mummy restraint to hold the child during the catheter insertion.
D. Require the parents to leave the room during the procedure.
Answer: B. Tell the child they will feel discomfort during the catheter insertion.
A nurse is caring for a client who has arteriovenous fistula Which of the following findings
should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation.
Answer: B. Absence of a bruit.
A nurse is providing discharge teaching for a client who has an implantable cardioverter
defibrillator which of the following statements demonstrates understanding of the teaching?
A. “I will soak in the tub rather and showering”
B. “I will wear loose clothing around my ICD”
C. “I will stop using my microwave oven at home because of my ICD”
D. “I can hold my cell phone on the same side of my body as the ICD”
Answer: B. “I will wear loose clothing around my ICD”
A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence
about being pregnant. Which of the following responses should the nurse make?
A. “Describe your feelings to me about being pregnant”

B. “You should discuss your feelings about being pregnant with your provider”
C. “Have you discussed these feelings with your partner?”
D. “When did you start having these feelings?”
Answer: A. “Describe your feelings to me about being pregnant”
A nurse is planning care for a client who has a prescription for a bowel- training program
following a spinal cord injury. Which of the following actions should the nurse include in the
plan of care?
A. Encourage a maximum fluid intake of 1,500 ml per day.
B. Increase the amount of refined grains in the client’s diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
Answer: D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
A nurse is caring for a client who is in active labor and requests pain management. Which of
the following actions should the nurse take?
A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions.
D. Assist the client to a supine position.
Answer: B. Place the client in a warm shower.
A nurse in an emergency department is performing triage for multiple clients following a
disaster in the community. To which of the following types of injuries should the nurse assign
the highest priority?
A. Below-the knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm (4in) laceration to the forearm
Answer: A. Below-the knee amputation
A nurse manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse include?
A. Remove the client’s restraint every 4hr

B. Document the client’s condition every 15 min
C. Attach the restrain to the bed’s side rails
D. Request a PRN restrain prescription for clients who are aggressive
Answer: B. Document the client’s condition every 15 min
A nurse is teaching an in-service about nursing leadership. Which of the following
information should the nurse include about an effective leader?
A. Acts as an advocate for the nursing unit.
B. (Unable to read) for the unit
C. Priorities staff request over client needs.
D. Provides routine client care and documentation.
Answer: A. Acts as an advocate for the nursing unit.
A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports
that she has been following her (unable to read). care. The nurse should identify which of the
following findings indicates a need to revise the client’s plan of care.
A. Serum sodium 144 mEq/
B. (Unable to read)
C. Hba1c 10 %
D. Random serum glucose 190 mg/dl.
Answer: C. Hba1c 10 %
A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The
nurse should identify that which of the following sexually transmitted infections is a
nationally notifiable infectious disease that should be reported to the state health department?
A. Chlamydia
B. Human papillomavirus
C. Candidiasis
D. Herps simplex virus
Answer: A. Chlamydia
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a
group on a mental health unit. Which of the following group facilitation techniques should
the nurse include in the teaching?

A. Share personal opinions to help influence the group’s values
B. Measure the accomplishments of the group against a previous group
C. Yield in situations of conflicts to maintain group harmony
D. Use modelling to help the clients improve their interpersonal skills
Answer: D. Use modelling to help the clients improve their interpersonal skills
A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse
that (Unable to read). Passover holiday. Which of the following action should the nurse
include in the plan of care?
A. Provide chicken with cream sauce.
B. Avoid serving fish with fins and scales.
C. Provide unleavened bread.
D. Avoid serving foods containing lamb.
Answer: C. Provide unleavened bread.
A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the
effectiveness of the treatment
A. A chest x-ray reveals increased density in all fields.
B. The client reports feeling less anxious.
C. Diminished breath sounds are auscultated bilaterally
D. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg.
Answer: B. The client reports feeling less anxious.
A nurse in an emergency department is assessing a client who reports ingesting thirty
diazepam tablets (Unable to read). a respiratory rate of 10/min. After securing the client’s
airway and initiating an IV, which of the following actions should the nurse do next.
A. Monitor the client’s IV site for thrombophlebitis.
B. Administer flumazenil to the client.
C. Evaluate the client for further suicidal behavior.
D. Initiate seizure precautions for the client.
Answer: B. Administer flumazenil to the client.
A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago.
Which of the following findings should the nurse expect?

A. Hypotension
B. Memory loss
C. Slurred speech
D. Elevated temperature
Answer: D. Elevated temperature
A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the
following manifestations should the nurse expect?
A. Loose stools
B. Jitteriness
C. Hypertonia
D. Abdominal distention
Answer: B. Jitteriness
A nurse in a paediatric clinic is reviewing the laboratory test results of a school age child.
Which of the following findings should the nurse report to the provider?
A. Hgb 12.5 g/dl
B. Platelets 250,000/mm3
C. Hct 40%
D. WBC 14,000/mm3
Answer: D. WBC 14,000/mm3
A charge nurse is teaching a newly licensed nurse about clients designating a health care
proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of
the following information should the charge nurse include?
A. “The proxy should make health care decisions for the client regardless of the client’s
ability to do so.”
B. “The proxy can make financial decisions if the need arises.”
C. “The proxy can make treatment decisions if the client is under anaesthesia.”
D. “The proxy should manage legal issues for the client.”
Answer: C. “The proxy can make treatment decisions if the client is under anaesthesia.”
A nurse in the PACU is caring for a client who reports nausea. Which of the following actions
should the nurse take first?

A. Turn the client on their side.
B. Administer an analgesic
C. Administer antiemetic
D. Monitor the client’s vital signs.
Answer: A. Turn the client on their side.
A nurse is caring for a client who has a history of depression and is experiencing a situational
crisis. Which of the following actions should the nurse take first?
A. Confirm the client’s perception of the event
B. Notify the client’s support system
C. Help the client identify personal strengths
D. Teach the client relaxation techniques
Answer: A. Confirm the client’s perception of the event
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The
nurse obtained a verbal prescription for restraints. Which of the following should the actions
should the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client’s peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client’s condition every 15 minutes.
Answer: D. Document the client’s condition every 15 minutes.
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical
nurse (LPN) who has been sent from the (Unable to read). unit due to a staffing shortage.
Which of the following client should the nurse delegate to the LPN?
A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
B. A client who sustained a concussion and has unequal pupils.
C. A client who is postoperative following a bowel resection with an NG tube set to
continuous suction.
D. A client who fractured his femur yesterday and is experiencing shortness of breath.
Answer: C. A client who is postoperative following a bowel resection with an NG tube set to
continuous suction.

A nurse is working on a surgical unit is developing a care plan for a client who has
paraplegia. The client has an area of no blanchable erythema over his ischium. Which of the
following interventions should the nurse include in the care plan?
A. Place the client upright on a donut-shaped cushion
B. Teach the client to shift his weight every 15 min while sitting
C. Turn and reposition the client every 3 hr while in bed
D. Assess pressure points every 24 hr
Answer: A. Place the client upright on a donut-shaped cushion
A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following
pain-management (Unable to read). a safe option for the client?
A. Naloxone hydrochloride.
B. Spinal anaesthesia.
C. Pudendal block.
D. Butorphanol tartrate.
Answer: C. Pudendal block.
A nurse is assessing a client who has major depressive disorder. Which of the following
findings should the nurse identify as the (Unable to read) (Most important?)
A. The client changes the subject when future plans are mentioned.
B. The client talks about being in pain constantly.
C. The client sleeping over 12 hr. each day.
D. The client reports giving away personal items.
Answer: D. The client reports giving away personal items.
A nurse is providing teaching about immunizations to a client who is pregnant. The nurse
should inform the client that she can receive which of the following immunizations during
pregnancy? (Select all that apply)
A. Varicella vaccine.
B. Inactivated polio vaccine.
C. Tetanus diphtheria and acellular pertussis vaccine
D. Rubella vaccine.
E. Inactivated influenza vaccine.
Answer: C. Tetanus diphtheria and acellular pertussis vaccine

E. Inactivated influenza vaccine.
A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks
the nurse about becoming a living kidney donor for her father. Which of the following
condition in the child’s medical history should the nurse identify as a contraindication to the
procedure?
A. Amputation
B. Osteoarthritis
C. Hypertension
D. Primary glaucoma
Answer: C. Hypertension
A nurse is providing discharge teaching for a group of clients. The nurse should recommend a
referral to a dietitian
A. A client who has a prescription for warfarin and states “I will need to limit how much
spinach I eat”.
B. A client who has gout and states, “I can continue to eat anchovies on my pizza.”
C. A client who has a prescription for spironolactone and states “I will reduce my intake of
foods that contain potassium”.
D. A client who has (Unable to read). and states “I’ll plan to take my calcium carbonate with
a full glass of water”.
Answer: B. A client who has gout and states, “I can continue to eat anchovies on my pizza.”
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports
sleeping very little during the past week due to caring for his mother. Which of the following
responses should the nurse make?
A. “I can give you information about respite care if you are interested.”
B. “You should consider taking a sleeping pill before bed each night”
C. “It must be difficult taking care of someone who is terminally ill”
D. “You are doing a great job taking care of your mother”
Answer: A. “I can give you information about respite care if you are interested.”

A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an
increase in the child’s glucose. The nurse should identify this finding as an adverse effect of
which of the following medications
A. Methylprednisolone.
B. Ondansetron.
C. Guaifenesin.
D. Amoxicillin.
Answer: A. Methylprednisolone.
The nurse is providing teaching about folic acid to a client who is prima gravida. Which of
the following information should the nurse include in the teaching?
A. “You should take folic acid to decrease the risk of transmitting infections to your baby”
B. “You should consume a maximum of 300 micrograms of folic acid every day”.
C. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”.
D. “You can expect your urine to appear red-tingled while taking folic acid supplements”.
Answer: C. “You can increase your dietary intake of folic acid by eating cereals and citrus
fruits”.
A community health nurse is assessing an adolescent who is pregnant. Which of the
following assessments is the nurse’s priority?
A. Social relationship with peers.
B. Plans for attending school while pregnant.
C. (Unable to read). (Picked this one). Medicaid?
D. Understanding of infant care.
Answer: C. (Unable to read). (Picked this one). Medicaid?
A nurse manager is planning to teach staff about critical pathways. Which of the following
information should the nurse include?
A. Critical pathways have unlimited timeframe for completion
B. (Unable to read) decrease health care costs.
C. (Unable to read) critical pathway if variances (Unable to read)
D. (Unable to read). are used to create the critical pathway.
Answer: B. (Unable to read). decrease health care costs.

A nurse is reviewing the medical record of a client who has schizophrenia. Which of the
following should the nurse report to the provider?
Exhibit 1
Blood pressure: 102/56 mm Hg. Heart rate: 95/min
Respiratory rate: 18/min Temperature: 37.4C (99.3F)
Exhibit 2
Medication Administration Record
Clozapine 150 mg PO twice daily
Benztropine 0.5 mg PO twice daily as needed for tremors.
Exhibit 3
Nurse’s notes:
Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in
the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75%
of breakfast and reports slightly nauseous.
A. Dietary intake
B. Heart rate.
C. Sore throat.
D. Blood pressure.
Answer: C. Sore throat.
A charge nurse is educating a group of unit nurses about delegating client tasks to assistive
personnel
A. “The nurse is legally responsible for the actions of the AP”.
B. “An AP can perform tasks outside of his range if he has been trained”.
C. “An experienced AP can delegate to another AP”.
D. “An RN evaluates the client needs to determine tasks to delegate”
Answer: D. “An RN evaluates the client needs to determine tasks to delegate”
A nurse is assessing a client who is in active labor. Which of the following findings should
the nurse report to the provider?
A. Contractions lasting 80 seconds
B. FHR baseline 170/min
C. Early decelerations in the FHR
D. Temperature 37.4C (99.3)

Answer: B. FHR baseline 170/min
A nurse working in a rehabilitation facility is developing a discharge plan for a client who has
left-sided hemiplegia the following actions is the nurse’s priority?
A. Consult with a case manager about insurance coverage.
B. Counsel caregivers about respite care options.
C. Ensure that the client has a referral for physical therapy.
D. Refer the client to a local stroke support group.
Answer: C. Ensure that the client has a referral for physical therapy.
A nurse in a mental health unit is planning room assignments for four clients. Which of the
following client should be closest to the nurse’s station?
A. A client who has an anxiety disorder and is experiencing moderate anxiety.
B. A client who has somatic symptom disorder and reports chronic pain.
C. A client who has depressive disorder and reports feeling hopeless.
D. A client who has bipolar disorder and impaired social interactions.
Answer: C. A client who has depressive disorder and reports feeling hopeless.
A nurse is preparing to measure a temperature of an infant. Which of the following action
should the nurse take?
A. Place the tip of the thermometer under the centre of the infant’s axilla.
B. Pull the pinna of the infant’s ear forward before inserting the probe.
C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum.
D. Insert the thermometer in front of the infant’s tongue.
Answer: A. Place the tip of the thermometer under the centre of the infant’s axilla.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time in the day room
B. Withdraw the client’s TV privileges is the does not attend group therapy
C. Encourage the client to take frequent rest periods
D. Place the cline in seclusion when he exhibits signs of anxiety
Answer: C. Encourage the client to take frequent rest periods

A nurse is admitting medications to a group of clients. Which of the following occurrences
requires the completion of an incident report?
A. A client receives his antibiotics 2hr late
B. A client vomits within 20min of taking his morning medications
C. A client requests his statin to be administered at 2100
D. A client asks for pain medication 1hr early
Answer: A. A client receives his antibiotics 2hr late
A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns.
The client asks the nurse to warm up seaweed soup that the client’s partner brought for her.
Which of the following responses should the nurse make?
A. “Does the doctor know you are eating that?”
B. “Why are you eating seaweed soup?”
C. “Of course I will heat that up for you”
D. “The hospital good is more nutritious”
Answer: A. “Does the doctor know you are eating that?”
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.
Which of the following examples should the nurse include in the teaching?
A. Leaving a nasogastric tube clamped after administering oral medication
B. Documenting communication with a provider in the progress notes of the client’s medical
records
C. Administering potassium via IV bolus
D. Placing a yellow bracelet on a client who is at risk for falls
Answer: C. Administering potassium via IV bolus
A nurse is providing teaching to family members of a client who has dementia. Which of the
following instructions should the nurse include in the teaching?
A. Establish a toileting schedule for the client
B. Use clothing with buttons and sippers
C. Discourage physical activity during the day
D. Engage the client in activities that increase sensory stimulation
Answer: A. Establish a toileting schedule for the client

The nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client’s history is a contradiction to
the use of oral contraceptives?
A. Hyperthyroidism.
B. Thrombophlebitis.
C. Diverticulosis.
D. Hypocalcaemia.
Answer: B. Thrombophlebitis.
A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations.
The client states, “It’s hard not to listen to the voices.” Which of the following questions
should the nurse ask the client?
A. “Do you understand that the voices are not real?”
B. “Why do you think the voices are talking to you?”
C. “Have you tried going to a private place when this occurs?”
D. “What helps you ignore what you are hearing?”
Answer: D. “What helps you ignore what you are hearing?”
A charge nurse is teaching a group of newly licensed nurses about the correct use of
restraints. Which of the following should the nurse include in the teaching?
A. Placing a belt restraint on a school-age child who has seizures.
B. Securing wrist restraints to the bed rails for an adolescent.
C. Applying elbow immobilizers of an infant receiving cleft lip injury
D. Keeping the side rails of a toddler’s crib elevated.
Answer: C. Applying elbow immobilizers of an infant receiving cleft lip injury
A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the
following
A. Inject air into the NPH insulin vial.
B. (Unable to read)
C. Withdraw the prescribed dose of regular insulin
D. Withdraw the prescribed dose of NPH insulin
Answer: A. Inject air into the NPH insulin vial.

A Nurse is working with a client who has an anxiety disorder and is in the orientation phase
of the therapeutic relationship. Which of the following statements should the nurse make
during this phase?
A. “Let’s talk about how you can change your response to stress.”
B. “We should establish our roles in the initial session.”
C. “Let me show you simple relaxation exercises to manage stress.”
D. “We should discuss resources to implement in your daily life.”
Answer: B. “We should establish our roles in the initial session.”
A nurse in a paediatric clinic is teaching a newly hired nurse about the varicella rooster.
Which of the following information should the nurse include?
A. Children who have varicella are contagious until vesicles are crusted.
B. Children who have varicella should receive the herpes zoster vaccination.
C. Children who have varicella should be placed in droplet precaution.
D. Children who have varicella are contagious 4 days before the first vesicle eruption.
Answer: A. Children who have varicella are contagious until vesicles are crusted.
A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of
the following requires intervention by the staff nurse?
A. Waits 2 minutes between suctions.
B. Encourages the client to cough during suctioning.
C. Apply suctioning for 15 seconds.
D. Inserts the catheter without applying suction.
Answer: A. Waits 2 minutes between suctions.
A nurse is teaching at a community health fair about electrical fire prevention. Which of the
following information should the nurse include in the teaching?
A. Use three pronged grounded plugs.
B. Cover extension cords with a rug.
C. Check the tingling sensations around the cord to ensure the electricity is working.
D. Remove the plug from the socket by pulling the cord.
Answer: A. Use three pronged grounded plugs.

A nurse is providing care for a group of clients. Which of the following client’s should the
nurse identify as having the highest risk for developing a pressure injury?
A. A client who has a T-tube following an open cholecystectomy.
B. A client who had a knee 2 days ago following a sports injury.
C. A client who has dementia and is incontinent of urine and faces
D. A client who has a myocardial infarction and is receiving thrombolytic therapy.
Answer: A. A client who has a T-tube following an open cholecystectomy.
A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops.
Which of the following statements indicates an understanding of the teaching?
A. “I will place the eye drops in the centre of my eye”
B. “I will place pressure on the corner of my eye after using he eye drops”
C. “I should expect my tears to turn a red color after using the eye drops.”
D. “I should expect the eye drops to appear cloudy.”
Answer: B. “I will place pressure on the corner of my eye after using he eye drops”
A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report
to the provider. Which of the following findings should the nurse include in the teaching?
A. Bleeding gums
B. Faintness upon rising
C. Swelling of the face
D. Urinary frequency
Answer: C. Swelling of the face
A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the
following responses should the nurse make?
A. “I would recommend sharing your feelings with a psychologist”.
B. “I can give you information about making end of life decisions”.
C. “You should discuss your end life decisions with your family”
D. “Everyone feels this way at first. You will start feeling better soon”.
Answer: B. “I can give you information about making end of life decisions”.
A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via
continuous IV infusion. Which of the following actions should the nurse plan to take?

A. Keep client’s calcium gluconate at the client’s bedside
B. Monitor blood pressure every 2 hr.
C. (Limit or remove?) IV bag from exposure to light.
D. Attach tan inline filter to the IV tubing.
Answer: C. (Limit or remove?) IV bag from exposure to light.
A nurse is caring for a client who is experiencing mild anxiety. Which of the following
findings should the nurse expect?
A. Feelings of dread
B. Heightened perceptual field
C. Rapid speech
D. Purposeless activity
Answer: B. Heightened perceptual field
A nurse is reviewing the laboratory report of a client who has been having lithium carbonate
for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following
orders from the provider should the nurse expect?
A. Withhold the next dose.
B. Increase the dosage.
C. Discontinue the medication.
D. Administer the medication.
Answer: D. Administer the medication.
A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
A. Stay in bed at least 1hr if unable to fall asleep
B. Take 1 hr nap during the day
C. Perform exercise prior to bed
D. Eat a light snack before bedtime
Answer: D. Eat a light snack before bedtime
A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of
the following medications should the nurse administer?
A. Pregabalin

B. Lorazepam
C. Colchicine
D. Codeine.
Answer: A. Pregabalin
A nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to
read). following actions should the nurse take?
A. Assess the amount of drainage in the collection chamber.
B. Clamp the chest tube during ambulation.
C. Report continuous bubbling in the water seal chamber.
D. Strip the chest tube every 4 hr. to maintain patency.
Answer: C. Report continuous bubbling in the water seal chamber.
A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN.
The nurse should monitor for which of the following adverse effects?
A. Productive cough.
B. Urinary retention.
C. Rhinitis
D. Fever.
Answer: B. Urinary retention.
A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar
disorder. The partner states “I don’t know what to do. Everything has been happening so
quickly.” Which of the following by the nurse is therapeutic?
A. “Can you talk about what happens with your partner at home?”
B. “Why do you think your partner’s symptoms are progressing so quickly?”
C. “You should make sure your partner takes the prescribed medication.”
D. “You did the right thing by bringing your partner in for treatment.”
Answer: A. “Can you talk about what happens with your partner at home?”
A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis
of celiac disease. Which of the following statements by the guardian indicates an
understanding of the teaching?
A. “I will put my child on a gluten-free diet”.

B. “I will administer digestive enzymes with meals and snacks”.
C. “Provide my child with some high fibre foods.”
D. “I will give my child whole wheat toast and milk for breakfast”.
Answer: A. “I will put my child on a gluten-free diet”.
A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the
following actions should the nurse take?
A. Prime IV tubing with 0.9% sodium chloride.
B. Use a 24-gauge IV catheter
C. Obtain filter less IV tubing.
D. Place blood in the warmer for 1 hr.
Answer: A. Prime IV tubing with 0.9% sodium chloride.
A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of
continuous infusions should the nurse initiate?
A. 0.9% normal saline.
B. NPH insulin.
C. Glargine insulin.
D. 0.45% saline.
Answer: A. 0.9% normal saline.
A nurse is teaching who has chronic pain about avoiding constipation from opioid
medications. Which of the following should the nurse include in the teaching?
A. Drink 1.5L fluids each day.
B. Take mineral oil at bedtime.
C. Increase exercise activity
D. Decrease insoluble fibre.
Answer: C. Increase exercise activity
A nurse is teaching about preventative measures to a female client who has chronic urinary
tract infections. Which of the following interventions should the nurse include in the
teaching?
A. “Drink 2 litres of warm water per day”.
B. “Empty your bladder every 6 weeks.”.

C. “Soak in a warm bath everyday”.
D. “Take an oral estrogen tablet”.
Answer: A. “Drink 2 Liters of warm water per day”.
A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving monitoring
B. A client who has a hip fracture and a new onset of tachypnoea
C. A client who has epidural analgesia and weakness in the lower extremities
D. A client who has diabetes and a haemoglobin A1C of 6.8%
Answer: B. A client who has a hip fracture and a new onset of tachypnoea
A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel
syndrome. Which of the following recommendations should the nurse include?
A. Consume food high in bran fibre
B. Increase intake of milk products
C. Sweeten foods with fructose corn syrup
D. Increase foods high in gluten
Answer: A. Consume food high in bran fibre
A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy.
Which of the following actions should the nurse take?
A. The infant 30 ml (1 oz) glucose water every 2 hr.
B. Keep the infants head covered with a cap.
C. Ensure that the newborn wears a diaper.
D. Apply lotion to the newborn every 4 hr.
Answer: C. Ensure that the newborn wears a diaper.
A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the
following statements by a newly licensed nurse indicates an understanding of the teaching?
A. “(Unable to read). I feel to be in his best health care decision”
B. “I will intervene if there is conflict between a client and his provider”
C. “I should not advocate for a client unless he is able to ask me himself”
D. “I will inform a client that his family should help make his health care decisions.”

Answer: B. “I will intervene if there is conflict between a client and his provider”
A nurse is preparing to reposition a client who had a stroke. Which of the following actions
should the nurse take?
A. Raise the side rails on both sides of the client’s bed during repositioning.
B. Reposition the client without assistive devices.
C. Discuss the client’s preferences for determining a reposition schedule.
D. Evaluate the client’s ability to help with repositioning.
Answer: D. Evaluate the client’s ability to help with repositioning.
A nurse is caring for an infant who has coaction of the aorta. Which of the following should
the nurse identify as an expected finding?
A. Weak femoral pulses
B. Frequent nosebleeds
C. Upper extremity hypotension
D. Increased intracranial pressure
Answer: A. Weak femoral pulses
A nurse is auscultating for crackles on a client who has pneumonia. Which of the following
anterior chest wall locations should the nurse auscultate?
Answer: The nurse should auscultate for crackles over the anterior chest wall in the
following locations:
Just below the clavicles.
Along the midclavicular line at the second and third intercostal spaces.
Lateral to the sternum at the fourth and fifth intercostal spaces.
At the anterior axillary lines at the sixth intercostal space.
These areas are key for detecting lung sounds indicative of pneumonia. • The midclavicular
line at the fourth to sixth intercostal spaces: This area includes the lower lobes of the lungs,
which are commonly affected in pneumonia.
Therefore, the nurse should listen at the midclavicular line around the fourth to sixth
intercostal spaces on the anterior chest wall to effectively identify the presence of crackles.
A nurse is assisting with the development of an informed document for participation in a
research study. Which of the following information should the nurse include?

A. A statement that participants can leave the study at will.
B. An assignment of the participant to either the experimental or control group.
C. A list of the clients participating in the study.
D. A description of the framework the researchers will use to evaluate the data.
Answer: A. A statement that participants can leave the study at will.
A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the
following adverse effects should the nurse include?
A. Excessive sweating
B. Increased urinary frequency
C. Dry cough
D. Metallic taste in mouth
Answer: A. Excessive sweating
A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the
following should the nurse report to the provider?
A. The client’s pulse oximetry level is 96%.
B. (Unable to read)
C. The client develops hiccups.
D. The ECG shows pacing spikes after the QRS complex.
Answer: C. The client develops hiccups.
A nurse is preparing discharge information for a client who has type 2 diabetes mellitus.
Which of the following resources should the nurse provide to the client?
A. Personal blogs about managing the adverse effects of diabetes medications
B. Food label recommendations from the Institute of Medicine
C. Diabetes medication information from the Physicians’ Desk Reference
D. Food exchange lists for meal planning from the American Diabetes Association
Answer: D. Food exchange lists for meal planning from the American Diabetes Association
A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of
the following statements should the nurse include in the teaching?
A. “The PCA will deliver a double dose of medication when you push the button twice.”
B. “You can adjust the amount of pain medication you receive by pushing on the keypad.”

C. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.”
D. “You should push the button before physical activity to allow maximum pain control.”
Answer: D. “You should push the button before physical activity to allow maximum pain
control.”
A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin
for blood glucose management. The nurse should anticipate administering which of the
following types of insulin?
A. Glargine insulin.
B. Regular insulin.
C. NPH insulin.
D. Insulin as part.
Answer: A. Glargine insulin.
A nurse is caring for a toddler who has acute lymphocytic leukaemia. In which of the
following should the toddler participate?
A. Looking at alphabet flashcards.
B. Playing with a large plastic truck.
C. Use scissors cut out paper shapes.
D. Watching a cartoon in the dayroom.
Answer: B. Playing with a large plastic truck.
A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding
pump and is experiencing dumping syndrome. Which of the following actions should the
nurse take?
A. Administer a refrigerated feeding.
B. Increased the amount of water use to flush the tubing.
C. (Unable to read). rate of the client’s feedings.
D. Instruct the client to move onto their right side.
Answer: C. (Unable to read). rate of the client’s feedings.
A nurse in an emergency department is caring for a client who received a dose of penicillin
and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the
following actions is the nurse’s priority?

A. Monitor the client’s ECG
B. Take the client’s vital signs.
C. Administer oxygen
D. Insert an IV line.
Answer: C. Administer oxygen
A nurse is caring for a client who has Raynaud’s disease. Which of the following actions
should the nurse take?
A. Provide information about stress management.
B. Maintain a cool temperature in the client’s room.
C. Administer epinephrine for acute episodes.
D. Give glucocorticoid steroid twice per day.
Answer: A. Provide information about stress management.
A nurse is reviewing the medical history of a client who has angina. Which of the following
findings in the client’s medical history should identify as a risk factor for angina?
A. Hyperlipidaemia.
B. COPD
C. Seizure disorder
D. Hyponatremia.
Answer: A. Hyperlipidaemia.
A nurse is caring for a client who is 12 hr. postpartum and has a third degree perineal
laceration. The client reports not having a bowel movement for 4 days. Which of the
following medications should the nurse administer?
A. Bisacodyl 10 mg rectal suppository.
B. Magnesium hydroxide 30 ml PO.
C. Famotidine 20 mg PO.
D. Loperamide 4 mg PO.
Answer: B. Magnesium hydroxide 30 ml PO.
A nurse overhears two assistive personnel (AP) discussing care for a client while in the
elevator. Which of the following actions should the nurse take?
A. Contact the client’s family about the incident.

B. Notify the client’s provider about the incident.
C. File a complaint with the facility’s ethics committee.
D. Report the incident to the AP’s charge nurse.
Answer: D. Report the incident to the AP’s charge nurse.
A nurse is planning care for a client who is receiving haemodialysis. Which of the following
actions should the nurse include in the plan of care?
A. Withhold all medications until after dialysis
B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
C. Check the vascular access site for bleeding after dialysis.
D. Give an antibiotic 30 min before dialysis.
Answer: C. Check the vascular access site for bleeding after dialysis.
A nurse in the emergency department is caring for a client who reports intimate partner
violence. Which of the following interventions is the nurse’s priority?
A. Develop a safety plan with the client
B. (Unable. options for reporting the incident.
C. Refer the client to a community support group.
D. Determine if the client has any injuries.
Answer: D. Determine if the client has any injuries.
A nurse is caring for a client who is in active labor and note the FHR baseline has been
100/min for the past 15 min. The nurse should identify which of the following conditions as a
possible cause of fetal bradycardia?
A. Maternal fever
B. Fetal anaemia
C. Maternal hypoglycaemia
D. Chorioamnionitis
Answer: C. Maternal hypoglycaemia
A nurse is assessing a school-age child who has a urinary tract infection. Which of the
following findings should the nurse expect?
A. Periorbital edema.
B. Decreased frequency of urination.

C. Enuresis.
D. Diarrhoea.
Answer: C. Enuresis.
A charge nurse on a medical-surgical unit is assisting with the emergency response plan
following an external disaster in the community. In anticipation of multiple client admissions,
which of the following current clients should the nurse recommend for early discharge?
A. A client who has COPD and a respiratory rate of 44/min
B. A client who has cancer with a sealed implant for radiation therapy
C. A client who is receiving heparin for deep-vein thrombosis
D. A client who is 1 day postoperative following a vertebroplasty
Answer: D. A client who is 1 day postoperative following a vertebroplasty
A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous
infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The
client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr?
(Round the answer to the nearest whole number)
Answer: 6 mL/hr
A nurse is providing teaching to the parents of a newborn genetic screening. Which of the
following statement should the nurse include in the teaching?
A. “This test should be performed after your baby is 24 hours old.”
B. “A nurse will draw blood from your baby’s inner elbow.”
C. “Your baby will be given 2 ounces of water to drink prior to the test.”
D. “This test will be repeated when your baby is 2 months old.”
Answer: A. “This test should be performed after your baby is 24 hours old.”
A nurse is providing discharge teaching to a client who is postoperative following a colon
resection and has a new ascending colostomy. Which of the following statements by the client
indicates an understanding of the teaching?
A. “My stool will become fully formed within 3 weeks”
B. “My skin will need to be cleaned with alcohol before I apply a new pouch”
C. “I should avoid eating popcorn and fresh pineapple”
D. “I should expect bruising around the stoma”

Answer: C. “I should avoid eating popcorn and fresh pineapple”
A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and
hoarseness. Which of the following is the nurse’s priority?
A. Refer the client to a speech language pathologist.
B. Monitor the client’s prealbumin levels
C. Measure the client’s weight.
D. Place the client on NPO status.
Answer: D. Place the client on NPO status.
A nurse is providing teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
A. “Taking furosemide can cause your potassium levels to be high”
B. “Eat foods that are high in sodium”
C. “Rise slowly when getting out of bed”
D. “Taking furosemide can cause you to be overhydrated”
Answer: C. “Rise slowly when getting out of bed”
A nurse is planning a teaching session for a client who is postoperative following a colon
resection. Which of the following actions should the nurse take first?
A. Providing written material for the client to read
B. Plan a short instruction about coughing and deep breathing.
C. Determine the client’s current pain level.
D. Instruct the client about dietary restrictions.
Answer: C. Determine the client’s current pain level.
A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
A. Coffee with creamer.
B. Lettuce with sliced avocados.
C. Broiled skinless chicken breast with brown rice.
D. Warm toast with margarine.
Answer: C. Broiled skinless chicken breast with brown rice.

A nurse is caring for a client who asks for information regarding organ donation. Which of
the following should the nurse make?
A. “I cannot be a witness for your consent to donate.”
B. “Your name cannot be removed once you are listed on the organ donor list.”
C. “Your desire to be an organ donor must be documented in writing.”
D. “You must be at least 21 years of age to become an organ donor.”
Answer: C. “Your desire to be an organ donor must be documented in writing.”
A nurse is teaching a female client about personal hygiene. Which of the client actions
indicates an understanding go the teaching?
A. The client takes a hot bubble bath every day.
B. The client wipes back to front when toileting.
C. The client washes her perineum first when bathing.
D. The client brushes her teeth twice daily.
Answer: D. The client brushes her teeth twice daily.
A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should
the nurse plan to take?
A. Obtain the newborn’s body temperature using a tympanic thermometer.
B. (Unable to read) FACES pain scale.
C. Auscultate the newborn’s apical pulse for 60 seconds.
D. Measure the newborn’s head circumference over the eyebrows and below the occipital
prominence. (NOT)
Answer: C. Auscultate the newborn’s apical pulse for 60 seconds.
A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb. over the last 5
days. The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC
5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse
should report these finding to which of the following members of the interdisciplinary team?
A. Dietitian
B. Infection control nurse
C. Nephrologist
D. Cardiologist
Answer: C. Nephrologist

A nurse is caring for an infant who is in contact isolation and received a blood transfusion.
Which of the following actions is appropriate for the nurse to take to provide cost-effective
care?
A. Return unopened equipment to the supply centre
B. Leave the unused infusion pump in the room until discharge
C. Stock the room with a 2-day supply of disposable diapers
D. Being in formula as needed
Answer: A. Return unopened equipment to the supply centre
A nurse is reviewing the medical record of a client who is postoperative following a total hip
arthroplasty. For which of the following findings should the nurse contact the provider?
A. Hear rate 100/min
B. Temperature 37.8C (100F)
C. Albumin level 4.0 g/dL.
D. WBC count 14,000 mm3
Answer: D. WBC count 14,000 mm3
A nurse is preparing education material for a client. Which of the following techniques
should the nurse use in creating material?
A. Emphasize important information using bold lettering.
B. Use 7th grade reading level.
C. Avoid using cartoons in the teaching material.
D. Use words with three or four syllables.
Answer: A. Emphasize important information using bold lettering.
A nurse is creating for a client who has aids. The client states, “My mouth is sore when I eat.”
Which of the following instructions should the nurse provide?
A. “Add salt to season”
B. “Ice chips”
C. “Rinse your mouth with an alcohol-based mouthwash”
D. “Eat foods served at hot temperatures”
Answer: B. “Ice chips”

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The
nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions
Answer: D. Contractions
A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured
membrane. Which of the following actions should the nurse take?
A. Insert an indwelling urinary catheter.
B. Apply fetal heart rate monitor.
C. Initiate fundal massage.
D. Initiate an oxytocin IV infusion.
Answer: B. Apply fetal heart rate monitor.
A home health nurse is preparing to make an initial visit to a family following a referral from
a local provider. Identify the sequence of steps the nurse should take when conducting a home
visit. (Move the steps into the box on the right. Placing them in the order of performance)
A. Identify family needs interventions using the nursing process.
B. Record information about the home visit according to agency policy.
C. Contact the family to determine availability and readiness to make an appointment
D. Discuss plans for future visits with the family.
E. Clarify the reason for the referral with the provider’s office.
Answer: E. Clarify the reason for the referral with the provider’s office.
C. Contact the family to determine availability and readiness to make an appointment
A. Identify family needs interventions using the nursing process.
B. Record information about the home visit according to agency policy.
D. Discuss plans for future visits with the family.
A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and
a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my
baby needs an IV?” Which of the following responses should the nurse make?
A. “Your baby needs an IV because she is not producing any tears”

B. “Your baby needs an IV because her fontanels are budging”
C. “Your baby needs an IV because she is breathing slower than normal”
D. “Your baby needs an IV because her heart rate is decreasing”
Answer: A. “Your baby needs an IV because she is not producing any tears”
A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the
following places the client at risk for aspiration?
A. A residual of 65mL 1 hr postprandial
B. A History of gastroesophageal reflux disease
C. Sitting in a high-Fowler’s position during the feeding
D. Receiving a high osmolarity formula
Answer: B. A History of gastroesophageal reflux disease
A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving haemodialysis. Which of the following instructions should the nurse include in the
teaching?
A. Take magnesium hydroxide for indigestion
B. Drink at least 3L of fluid daily
C. Eat 1g/kg of protein per day
D. Consume foods high in potassium
Answer: C. Eat 1g/kg of protein per day
A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac
monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse
should interpret this finding as which of the following cardiac rhythms?
A. First degree AV block
B. Premature ventricular contraction.
C. Sinus bradycardia.
D. Atrial fibrillation.
Answer: A. First degree AV block
A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes
that the client coughs after each bite. After asking the AP to stop feeding the client, which of
the following actions should the nurse take next?

A. Provide the client with an instructional handout about swallowing exercises.
B. Ask a speech therapist to evaluate the client’s ability to swallow.
C. Discuss the manifestations of impaired swallowing with the AP.
D. Listens to the client’s lung sounds.
Answer: D. Listens to the client’s lung sounds.
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing
auditory hallucinations. Which of the following actions should the nurse include in the plan?
A. Ask the client directly what he is hearing
B. Encourage the client to lie down in a quiet room
C. Avoid eye contact with the client
D. Refer to the hallucinations as if they are real
Answer: A. Ask the client directly what he is hearing
The nurse is teaching a group of clients at a community health fair about genetic disease.
Which of the following statements by a client indicates an understanding of the teaching?
A. “If there is a genetic risk for future pregnancies, we can get treatment now to prevent the
disease”
B. “There is no need to have genetic counseling if I know that I have a family history of
mental illness.”
C. “My family has genetic risk for breast cancer, so I am considering a total mastectomy”
D. “Even if I have a genetic risk for a disease the chance, I will get the disease is probably
low due to current medical treatments.”
Answer: C. “My family has genetic risk for breast cancer, so I am considering a total
mastectomy”
A nurse is planning discharge teaching about cord care for the parents of a newborn. Which
of the following instructions should the nurse plan to include in the teaching?
A. “The cord stump will fall off in 5 days.”
B. “Contact the provider if the cord stump turns black.”
C. “Clean the base of the cord with hydrogen peroxide daily.”
D. “Keep the cord stump dry until it falls off.”
Answer: D. “Keep the cord stump dry until it falls off.”

A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the
following statements by the client indicates an understanding of the teaching?
A. “I have my eyes examines annually”
B. “I take a calcium vitamin supplement daily”
C. “I limit my intake of foods with potassium”
D. “I constantly take my medication between 8 and 9 each evening”
Answer: B. “I take a calcium vitamin supplement daily”
A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the
following actions by a newly licensed nurse indicates an understanding of the teaching?
A. Stands with feet together when lifting a client up in bed.
B. Raises the client’s head of bed before pulling the cline up.
C. Uses a mechanical lift to move client from bed to chair.
D. Places a gait belt around the client’s upper chest before assisting a client to stand.
Answer: C. Uses a mechanical lift to move client from bed to chair.
A client is requesting information from a nurse about a nitrazine test. Which of the following
statements should the nurse make?
A. “Your bladder should be full prior to me performing this test
B. “If this test is positive you will be required to have a non-stress test.
C. “This test will determine if there is leaking amniotic fluid”
D. “I will be taking a blood sample to test for changes in your hormones levels”
Answer: C. “This test will determine if there is leaking amniotic fluid”
A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which
of the following findings indicate the client is developing a complication of therapy?
A. Peripheral edema
B. Increased thirst.
C. Flattened neck veins.
D. Hypotension
Answer: A. Peripheral edema

A nurse is conducting a home visit for a family who has two young children. The nurse notes
several welts across the backs of the legs of one of the children. Which of the following
actions should the nurse take first?
A. Document clinical findings.
B. Contact child protective services.
C. Refer the parents to a self-help group.
D. Instruct the parents about methods of discipline.
Answer: B. Contact child protective services.
A nurse is planning care for a client who has thrombocytopenia. Which of the following
actions should the nurse include?
A. Encourage the client to floss daily.
B. Remove fresh flowers from the client’s room.
C. Provide the client what a stool softener.
D. Avoid serving the client raw vegetable.
Answer: C. Provide the client what a stool softener.
A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy.
Which of the following findings should the nurse to report?
A. Chest pain
B. Muscle spasms.
C. Cool, moist skin.
D. Incisional pain.
Answer: A. Chest pain
(Unable to read)
A. Use NPH insulin to treat ketoacidosis.
B. Administer NPH insulin 30 minutes before breakfast.
C. (Unable to read). I think this answer was 0.9% sodium chloride
D. Discard the NPH insulin vial if the medication is cloudy.
Answer: B. Administer NPH insulin 30 minutes before breakfast.

A nurse is caring for a client who has left-sided heart failure, and the provider is concerned
that the client might develop (Unable to read). Which of the following actions should the
nurse take?
A. Maintain the client’s oxygen saturation level at 89%.
B. Place the client’s lower extremities on two pillows.
C. Recommended that the client follow a 3g sodium diet.
D. Place the client in high fowler’s position.
Answer: D. Place the client in high fowler’s position.
A charge nurse is teaching a newly licensed nurse about the administration of total parenteral
nutrition. Which of the following should the charge nurse include?
A. “You will need to monitor the client’s electrolytes daily”
B. “You will need to change the IV dressing site once per week”
C. “You will need to warm the solution in the microwave before administration”
D. “You need to weigh the client twice per week”
Answer: A. “You will need to monitor the client’s electrolytes daily”
A nurse is teaching a prenatal class about infection at a community center. Which of the
following statements by a client indicates an understanding of the teaching?
A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
B. “I can clean my cat’s litter box during my pregnancy.”
C. “I should take antibiotics when I have a virus.”
D. “I should wash my hands for 10 seconds with hot after working in the garden.”
Answer: A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
A nurse is caring for a client who has end-stage liver cancer. Which of the following
statements should the nurse make to support the client’s right to autonomy?
A. “You should trust that your care team has your best interest at heart”
B. “I will not share any personal information without your permission
C. “The health care team will do their best to keep any promise we make to you”
D. “We encourage you to participate in all decisions about your treatment”
Answer: D. “We encourage you to participate in all decisions about your treatment”

A nurse is completing an incident report after a client fall. Which of the following
competencies of Quality and Safety Education for Nurse is the use demonstrating?
A. Quality improvement.
B. Patient (Unable to read)
C. Evidence based practice.
D. Informatics.
Answer: A. Quality improvement.
A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of
the following actions should the nurse take?
A. Confront the nurse about the suspected alcohol use.
B. Inform another nurse on the unit about the suspected alcohol use.
C. Ask the nurse to finish administering medications and then go home.
D. Notify the nursing manager about the suspected alcohol use.
Answer: D. Notify the nursing manager about the suspected alcohol use.
A charge nurse is teaching new staff members about factors that increase a client’s risk to
become violet. Which of the following risk factors should the nurse include as the best
predictor of future violence?
A. Previous violent behavior
B. A history of being in prison
C. Experiencing delusions
D. Male gender
Answer: A. Previous violent behavior
A charge nurse is teaching a newly licensed nurse about medication administration. Which of
the following information should the charge nurse include?
A. Inform clients about the action of each medication prior to administration.
B. (Unable to read). two times prior to administration.
C. Complete an incident report if a client vomits after taking a medication.
D. Avoid preparing medications for more than two clients at one time.
Answer: D. Avoid preparing medications for more than two clients at one time.

A charge nurse is evaluating the time management skills of a newly licensed nurse. For which
of the following actions by the newly licensed nurse should the charge nurse intervene?
A. Takes assigned breaks at regular intervals
B. Documents the clients care tasks at the end of the shift.
C. assisting with ADLs to perform time sensitive activities
D. Gather necessary supplies before beginning a dressing change.
Answer: B. Documents the clients care tasks at the end of the shift.
A nurse is caring for a client who has diaper dermatitis. Which of the following actions
should the nurse take?
A. Apply zinc oxide ointment to the irritated area.
B. (Unable to read)
C. Wipe stool from the skin using store bought baby wipes.
D. Apply talcum powder to the irritated area.
Answer: A. Apply zinc oxide ointment to the irritated area.
A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of
the following locations should the nurse expect to palpate the client’s fundus?
A. Above the umbilicus
B. At the level of the umbilicus
C. Below the umbilicus
Answer: C. Below the umbilicus
Typically, after an uncomplicated vaginal birth, the fundus should be palpable at the level of
the umbilicus immediately after delivery. Each day postpartum, the fundus generally
descends about 1 cm (or one fingerbreadth) below the umbilicus. By the third day
postpartum, the fundus is usually found about 2-3 cm below the umbilicus. Thus, the
expected location to palpate the fundus on the third postpartum day is below the umbilicus.
A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
A. “The client might act seductively.”
B. “The client is overly concentrated about minor details.”
C. “The client exhibits impulsive behaviours.”
D. “The client is exceptionally clingy to others.”

Answer: C. “The client exhibits impulsive behaviours.”
A nurse is caring for a client who has a prescription for warfarin. When reviewing the client’s
current medications, which of the following medications should the nurse identify as
contraindicated for use with warfarin? (Select all that apply)
A. Aspirin
B. Magnesium sulphate
C. Gingko biloba.
D. Cetirizine
E. Ibuprofen.
Answer: A. Aspirin
C. Gingko biloba.
E. Ibuprofen.
A nurse is completing an admission assessment for a client who has narcissistic personality
disorder. Which of the following findings should the nurse expect?
A. Ritual behavior
B. Suspicious of others
C. Exhibits separation anxiety
D. Preoccupied with aging
Answer: D. Preoccupied with aging
A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg (165.3 lb. and
is 1.8 m (5 ft 9 in) tall. The nurse should calculate the client’s BMI value as which of the
following?
A. 23
B. 42
C. 32
D. 8
Answer: A. 23
A nurses is assessing a preschooler who has recently experienced an unexpected death in the
family. Which of the following should the nurse recognize as an expected finding?
A. The child expresses curiosity about the death process.

B. The child refuses to talk about death.
C. The child believes the person will return.
D. The child focuses on his own mortality.
Answer: C. The child believes the person will return.
A nurse is assessing a client in the emergency department. Which of the following actions
should the nurse take first?
Exhibit 1
Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88%
Protein 320 mg/dl Glucose 35 mg/dl Cloudy in appearance
Exhibit 2
History and Physical
Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic.
Exhibit 3
Vital Signs
BP 166/96 mm Hg
Respiratory rate 24/min
Pulse rate 112/min
Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9
A. Place the client on a cooling blanket.
B. Administer an analgesic.
C. Obtain arterial blood gas levels.
D. Elevate the head of the client’s bed 30 degrees.
Answer: C. Obtain arterial blood gas levels.
A client is caring for a client following a paracentesis. Which of the following findings
should the nurse identify as an indication of a complication?
A. Decreased haematocrit.
B. Increased blood pressure.
C. Tachycardia.
D. Hypothermia.
Answer: C. Tachycardia.

A certified IV nurse is providing education about peripherally inserted catheters (PICC) to a
newly licensed nurse. Which of the following statements by the newly licensed nurse
indicated an understanding of the teaching?
A. “Use a vein in the middle of the lower arm to insert a PICC.”
B. “Flush a PICC using a 3-milliliter syringe.”
C. “Informed consent is required prior to PICC placement.”
D. “Position the client’s arm in adduction for PICC placement.”
Answer: C. “Informed consent is required prior to PICC placement.”
A nurse is reviewing admission prescriptions for a group of clients. Which of the following
prescriptions should the nurse identify as complete?
A. Furosemide 20 mg BID
B. Nitro-glycerine transdermal patch.
C. Aspirin 1 tablet daily.
D. Metoprolol 5mg IV now.
Answer: D. Metoprolol 5mg IV now.
A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the
following actions should the nurse take?
A. Hold hand flat to perform percussion on the child
B. Perform the procedure twice a day
C. Administer a bronchodilator after the procedure
D. Perform the procedure prior to meals
Answer: D. Perform the procedure prior to meals
A nurse is reviewing the medical records of four clients. The nurse should identify that which
of the following client findings requires follow up care?
A. A client who received a Mantoux test 48hr ago and has an induration
B. A client who is schedule for a colonoscopy and is taking sodium phosphate
C. A client who is taking warfarin and has an INR of 1.8
D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L
Answer: C. A client who is taking warfarin and has an INR of 1.8

A nurse is caring for a client who is postpartum and request information about contraception.
Which of the following instructions should the nurse include?
A. “The lactation amenorrhea method is effective for your first year postpartum”
B. “You can continue to use the diaphragm used before your pregnancy”
C. “Place transdermal birth control patch on your upper arm”
D. “I should avoid vaginal spermicides while breast feeding.”
Answer: C. “Place transdermal birth control patch on your upper arm”
A nurse is reviewing the facility’s safety protocols considering newborn abduction with the
parent of a newborn. Which of the following statements indicates an understanding of the
teaching?
A. “Staff will apply identification band after first bath”
B. “I will not publish public announcement about my baby’s birth”
C. “I can remove my baby’s identification band as long as she is in my room”
D. “I can leave my baby in my room while I walk in the hallway”
Answer: B. “I will not publish public announcement about my baby’s birth”
A nurse is developing a plan of care for a client who has preeclampsia and is to receive
magnesium sulphate via continuous IV infusion. Which of the following actions should the
nurse include in the plan?
A. Restrict the client’s total fluid intake to 250 mL/hr
B. Give the protamine if signs of magnesium sulphate toxicity occur
C. Monitor the FHR via Doppler every 30min
D. Measure the client’s urine output every hour
Answer: D. Measure the client’s urine output every hour
A nurse is receiving a telephone prescription from a provider for a client who requires
additional medication for pain control. Which of the following entries should the nurse make
in the medical record?
A. “Morphine 3 mg SQ every 4 hr. PRN for pain.”
B. “Morphine 3 mg Subcutaneous (Unable to read)
C. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.”
D. “Morphine 3 mg SC q 4 hr. PRN for pain.”
Answer: B. “Morphine 3 mg Subcutaneous (Unable to read)

A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The
client’s ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read). PaO2 90 mm Hg. Which
of the following conditions should the nurse expect?
A. Metabolic acidosis.
B. Metabolic alkalosis.
C. Respiratory acidosis.
D. Respiratory alkalosis.
Answer: A. Metabolic acidosis.
A nurse realizes that the wrong medication has been administered to a client. Which of the
following actions should the nurse take first?
A. Notify the provider.
B. Report the incident to the nurse manager.
C. Monitor vital signs.
D. Fill out an incident report.
Answer: C. Monitor vital signs.
Receives a telephone call from a parent reporting that their school-age child has a nosebleed
and that they cannot stop the bleeding. Which of the following instructions should the nurse
provide to the provider?
A. “Have your child lie down and turn their head to their side for 10 minutes”
B. “Use your thumb and forefinger to apply pressure to the (Unable to read). of your child’s
nose”
C. “Place a warm wet washcloth over your child’s forehead and the bridge of their nose”
D. “Tell your child to blow their nose gently and then sit down and tilt your head back”
Answer: B. “Use your thumb and forefinger to apply pressure to the (Unable to read. of your
child’s nose”
A nurse is preparing to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
A. Match the client’s blood type with the type and cross match specimens.
B. Confirm the provider’s prescription matches the number on the blood component.
C. Ask the client to state the blood type and the date of their last blood donation.

D. Ensure that the client’s identification band matches the number on the blood unit.
Answer: D. Ensure that the client’s identification band matches the number on the blood unit.
A nurse is transcribing new medication prescriptions for a group of client. For which of the
following prescriptions should the nurse contact the provider for clarifications?
A. Zolpidem 10mg PO one tablet at bedtime
B. Hydrochlorothiazide 12.5 mg PO BID
C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID
D. Lorazepam .5mg PO one tablet daily
Answer: D. Lorazepam .5mg PO one tablet daily
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit.
Which of the following is an appropriate action for the nurse to take?
A. Offer fluids every 2hr.
B. Document the client’s behavior prior to being placed in seclusion.
C. Discuss with the client his inappropriate behavior prior to seclusion.
D. Assess the client’s behavior once every hour.
Answer: A. Offer fluids every 2hr.
A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
A. “Dehydration is treated with calcium supplements”
B. “Dehydration can increase the risk of preterm labor”
C. “Dehydration associated gastroesophageal reflux
D. “Dehydration is caused by a decreased haemoglobin and haematocrit”
Answer: B. “Dehydration can increase the risk of preterm labor”
A nurse is using an IV pump for a newly admitted client. Which of the following actions
should the nurse take?
A. (Unable to read)
B. (Unable to read)
C. Grasp the IV pump cord when unplugging it from the electrical outlet.
D. (Unable to read) outlet has two prongs for the IV pump.
Answer: C. Grasp the IV pump cord when unplugging it from the electrical outlet.

A nurse is assessing a client who is postoperative following abdominal surgery and has an
indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the
following interventions should the nurse anticipate?
A. Clamp the (Unable to read)
B. Administer fluid bolus.
C. Obtain a urine specimen for culture and sensitivity
D. Initiate continuous bladder irrigation.
Answer: C. Obtain a urine specimen for culture and sensitivity
A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to
the administration of clozapine?
A. Heart rate 58/min
B. Fasting blood glucose 100 mg/dL
C. Hgb 14 g/dL
D. WBC count 2,900/mm3
Answer: D. WBC count 2,900/mm3
A nurse is receiving a change-of-shift report for an adult female client who is postoperative.
Which of the following client information should the nurse report?
A. (Unable to read)
B. (Unable to read)
C. Answer might be lower platelets.
D. (Unable to read)
Answer: C. Answer might be lower platelets.
A nurse is caring for a client who has depression and reports taking ST. John’s wort along
with citalopram. The nurse should monitor the client for which of the following conditions as
a result of an interaction between these substances?
A. Serotonin syndrome
B. Tardive dyskinesia
C. Pseudo parkinsonism.
D. Acute dystonia.

Answer: A. Serotonin syndrome
A client who sustained a major burn over 20% of the body. Which of the following
interventions should the nurse nutritional requirements?
A. (Unable to read). (Chose this one)
B. Keep a calorie count for food and beverages.
C. Schedule meals at 6 hr. intervals
D. Provide low-protein high carbohydrate diet
Answer: A. (Unable to read). (Chose this one)
A nurse in a provider’s office is preparing to administer the inactivated influenza vaccine.
The nurse should collect additional (Unable to read). for which of the following client prior to
administering the vaccine?
A. (Unable to read)
B. Client has (Unable to read). HIV/AIDS
C. Client has a sensitivity to eggs.
D. Client is experiencing seasonal allergies.
Answer: C. Client has a sensitivity to eggs.
A nurse is providing teaching about digoxin administration to the parents of a toddler which
as heart failure. Which of the following statements should the nurse include in the teaching?
A. “Limit your child’s potassium intake while she is taking this medication.”
B. “You can add the medication to a half-cup of your child’s favourite juice.”
C. “Repeat the does if your child vomits within 1 hour after taking the medication.”
D. “Have your child drink a small glass of water after swallowing the medication.”
Answer: D. “Have your child drink a small glass of water after swallowing the medication.”
A nurse is teaching about preventing sudden infant syndrome (SIDS) to parent of a 1-monthold infant. Which of the following indicates that the parent understands how to place the
infant in the crib at bed time?
A. Place the infant on their stomach to sleep.
B. Place the infant on their back to sleep.
C. Use a soft blanket to keep the infant warm.
D. Position the infant in a crib with pillows for support.

Answer: B
A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the
following actions should the nurse take?
A. Obtain the specimen immediately upon the client waking up.
B. Wait 1 day to collect the specimen if the client cannot provide sputum.
C. Ask the client to provide 15 to 20 ml of sputum in the container.
D. Wear sterile gloves to collect specimen from the client.
Answer: A. Obtain the specimen immediately upon the client waking up.
A nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For
which of the following laboratory results should the nurse withhold the medication and notify
the provider?
A. Digoxin 0.8 ng/ml
B. Sodium (Was out of range)
C. BUN 15
D. Potassium 3.1 mEq/L.
Answer: D. Potassium 3.1 mEq/L.
A nurse is caring for a client who wears glasses. Which of the following actions should the
nurse take?
A. Store the glasses in a labelled case.
B. Clean the glasses with hot water.
C. Clean the glasses with a paper towel.
D. Store the glasses on the bedside table.
Answer: A. Store the glasses in a labelled case.
A school nurse is teaching a parent about absent seizures. Which of the following information
should the nurse include?
A. “This type of seizure can be mistaken for daydreaming.”
B. “This type of seizure lasts 30 to 60 seconds.”
C. “The child usually has an aura prior to onset.”
D. “This type of seizure has a gradual onset.”
Answer: A. “This type of seizure can be mistaken for daydreaming.”

A nurse is planning care for a client who has cancer and is about to receive low dose
brachytherapy via a vaginal implant applicator. Which of the following interventions should
the nurse include in the plan of care?
A. Removal of vaginal packing
B. Insertion of an indwelling urinary catheter
C. Ambulation four times daily
D. Maintenance of NPO status until therapy is complete
Answer: B. Insertion of an indwelling urinary catheter
A nurse is caring for a client who has deep vein thrombosis and is receiving heparin therapy.
Which of the following tests should the nurse use to monitor and regulate the dosage of the
medications?
A. aPTT.
B. Pyro (Unsure if that’s the writing)
C. Platelet count.
D. INR.
Answer: A. aPTT.
A charge nurse is preparing to lead negotiations among nursing staff due to conflict about
overtime requirements. Which of the following strategies should the nurse use to promote
effective negotiation?
A. Identify solutions prior to negotiation
B. Focus on how the conflict occurred
C. Attempts to understand both sides of the issue
D. Personalize the conflict
Answer: C. Attempts to understand both sides of the issue
A nurse manager is developing a protocol for an urgent care clinic that often cares for clients
who do not speak the same language as clinical staff. Which of the following instructions
should the nurse include?
A. Use the client’s children to provide interpretation.
B. The nurse was going to do the interpretation
C. Offer client’s translation services for a nominal fee.

D. Evaluate the clients’ understanding at regular intervals.
Answer: B. The nurse was going to do the interpretation
A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which of
the following findings should the nurse identify as an indication of intercranial pressure?
A. Tachycardia.
B. Narrowed pulse pressure.
C. Hypotension.
D. Increasingly severe headache.
Answer: D. Increasingly severe headache.

SET 2
A nurse in an emergency department completes an assessment on an adolescent
client that has conduct disorder. The client threatened suicide to teacher at school.
Which of the following statements should the nurse include in the assessment?
A. Tell me about your siblings
B. Tell me what kind of music you like
C. Tell me how often do you drink alcohol
D. Tell me about your school schedule
Answer: C. Tell me how often do you drink alcohol
A nurse is observing bonding to the client her newborn. Which of following
actions by the client requires the nurse to intervene?
A. Holding the newborn in an en face position
B. Asking the father to change the newborn's diaper
C. Requesting the nurse take the newborn nursery so she can rest
D. Viewing the newborn’s actions to be uncooperative
Answer: D. Viewing the newborn’s actions to be uncooperative
A nurse is caring for client who is taking levothyroxin. Which of the following
findings should indicate that the medication is effective?
A. Weight loss

B. Decreased blood pressure
C. Absence of seizures
D. Decrease inflammation
Answer: A. Weight loss
A nurse is planning discharge teaching for cord care for the parent of a newborn.
Which instructions would you include in the teaching?
A. Contact provider if the cord still turns black (it’s going to turn black)
B. Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH
cleanser)
C. Keep the cord dry until it falls off (cord should be kept clean and dry to prevent
infection)
D. The cord stump will fall off in five days (cord falls off in 10-14 days)
Answer: C. Keep the cord dry until it falls off (cord should be kept clean and dry
to prevent infection)
A nurse is assessing a client in the PACU. Which of the following findings
indicates decreased cardiac output?
A. Shivering
B. Oliguria
C. Bradypnea
D. Constricted pupils
Answer: B. Oliguria
A nurse is assisting with mass casualty triage: explosion at a local factory. Which
of the following client should the nurse identify as the priority?
A. A client that has massive head trauma
B. A client has full thickness burns to face and trunk
C. A client with indications of hypovolemic shock
D. A client with open fracture of the lower extremity
Answer: C. A client with indications of hypovolemic shock
A nurse is a receiving report on four clients. Which of the following clients should
the nurse assess first?

A. A client who has illeal conduit and mucus in the pouch
B. Client pleasant arteriovenous additional vibration palpated
C. A client whose chronic kidney disease with cloudy daisy late outflow
D. A client was transurethral resection of the prostate with a red tinged urine in
the bag
Answer: C. A client whose chronic kidney disease with cloudy daisy late outflow
A nurse is caring for a client just received the first dose of lisinopril. The
following is an appropriate nursing intervention?
A. Place’s cardiac monitoring
B. Monitor the clients oxygen saturation level
C. Provide standby assist with the client from bed
D. Encourage foods high in potassium
Answer: A. Place’s cardiac monitoring
A nurse is caring for a client who is in labor and his seat is receiving electronic
fetal monitoring. The nurse is reviewing the monitor tracing and notes early
decelerations. Which the following should the nurse expect?
A. Feta hypoxia
B. Abrupto placentae
C. Post maturity
D. Head Compression
Answer: D. Head Compression
A nurse is caring for a client who has chronic kidney disease. The nurse should
identify which of the following laboratory values as in an indication for
hemodialysis?
A. Glomerular filtration rate of 14 mL/ minute
B. BUN 16 mg/DL
C. serum magnesium 1.8 mg mg/dl
D. Serum phosphorus 4.0 mg/dL
Answer: A. Glomerular filtration rate of 14 mL/ minute

A nurse is caring for an infant who has a prescription for continuous pulse
oximetry. The following is an appropriate action for the nurse to take?
A. Placed infant under radiant warmer
B. Move the probe site every 3 hours
C. Heat the skin one minute prior to placing the program
D. Placed a sensor on the index finger
Answer: A. Placed infant under radiant warmer
A nurse in a mental health facility receives a change of shift report on for clients.
Which of the following clients should the nurse plan to assess first?
A. Client placed in restraints to the aggressive behavior
B. A new limited client pleasures history of 4.5 kg weight loss in the past two
months
C. Client is receiving a PRN dose of health heard all two hours ago for increased
anxiety
D. Applied he’ll be receiving his first ECT treatment today
Answer: A. Client placed in restraints to the aggressive behavior
A nurse working at the clinic is teaching a group of clients who are pregnant on
the use of nonpharmacological pain management. Which of the following
statements by the nurse is an appropriate description of the use of hypnosis during
labor?
A. Hypnosis focuses on the biofeedback as a relaxation technique
B. Hypnosis promotes increased control of her pain perception during
contractions
C. Hypnosis uses therapeutic touch to reduce anxiety during labor
D. Hypnosis provides instruction to minimize pain
Answer: B. Hypnosis promotes increased control of her pain perception during
contractions
A nurse in a County Jail health clinic is leading group therapy session. A client
who was incarcerated for theft is addressing the group. Which of the following is
an example of reaction formation? (rxn formation is when you use opposite
feelings; ex: being super nice to someone you dislike)

A. I steal things because it’s the only way I can keep my mind off my bad
marriage
B. I can’t believe I was accused of something I didn’t do
C. I don’t want talk about my feelings right now. We will talk more next time
D. I think that people just you’re just lazy and should earn money honestly
Answer: D. I think that people just you’re just lazy and should earn money
honestly
A nurse is obtaining the medical history of a client who has a new prescription for
isosorbide mononitrate. Which of the following should the nurse identify as a
contraindication to medication?
A. Glaucoma
B. Hypertension
C. Polycythemia
D. Migraine headaches
Answer: D. Migraine headaches
The nurses is caring for a client recovering from an acute myocardial infarction.
Which following intervention should the nurse include in the point of care?
A. Draw a troponin level every four hours
B. Performance EKG every 12 hours
C. Plant oxygen tent fell over minutes via rebreather mask
D. Obtain a cardiac rehabilitation consult
Answer: D. Obtain a cardiac rehabilitation consult
A Nurses caring for client who has breast cancer and has been covering receiving
chemotherapy. Which of the following laboratory values should nurse report to
provider?
A. WBC 3,000/mm3
B. Hemoglobin 14 g/dl
C. Platelet 250,000/mm3
D. aPTT 30 seconds
Answer: A. WBC 3,000/mm3

Home health nurse is carefully planned for Alzheimer’s disease.To the following
action should the nurse include in the plan of care
A. Place a daily calendar in the kitchen
B. Replace button clothing with zippered items
C. Replace the carpet with hardwood floors
D. Create variation in daily routine
Answer: A. Place a daily calendar in the kitchen
Nurse is performing change of shift assessments on 4 clients. Which of the
following findings should the nurse report to provider first?
A. The client was cystic fibrosis and has a thick productive clock and reports
thirst
B. Client who has gastroenteritis and is lethargic and confused
C. The Client has diabetes mellitus has morning fasting Legal cost of 185 mg over
deal
D. The client was sick of signing it reports pain 15 minutes after receiving oral
analgesic
Answer: B. Client who has gastroenteritis and is lethargic and confused
A nurse is caring for a client was in the second trimester of pregnancy and asks
how to treat constipation. Which of the following statements by the nurse is
appropriate?
A. Decrease taking vitamins and supplements to every other day
B. Eat 15 g of fiber per day
C. Consume 48 ounces of water each day (need at least 64 oz)
D. Drink hot water with lemon juice each morning when you wake up
Answer: C. Consume 48 ounces of water each day (need at least 64 oz)
A nurse is caring for a client who is preparing his advance directives. Which is the
following statements by the client indicates an understanding of advanced
directives? select all that apply
A. I can’t change my instructions once a minute
B. My doctor will need to approve my advance directives
C. I need an attorney to witness my signature on the advance directives

D. I have the right to refuse treatment
E. My health care proxy can make medical decisions for me
Answer: D. I have the right to refuse treatment
A nurse is caring for a client who is at 32 weeks gestation and has a history of
cardiac disease. Which of the following positions should the nurse place the client
to best promote optimal cardiac output?
A. The chest
B. Standing
C. Supine
D. Left lateral
Answer: D. Left lateral
A nurse is caring for a group of clients. Which of the following clients should the
nurse assign to an AP?
A. Client who has chronic obstructive pulmonary disease and needs guidance on
incentive spirometry
B. Client who has awoken following a bronchoscopy and requests a drink
C. Client who had a myocardial infarction 3 days ago reports chest discomfort
D. Client who had a cerebrovascular accident two days ago and needs help
toileting
Answer: D. Client who had a cerebrovascular accident two days ago and needs
help toileting
Nurse providing discharge teaching to the client who has schizophrenia and is
starting therapy with clozapine. Which of the following is the highest priority for
the client tore port to the provider?
A. Constipation
B. blurred vision
C. Fever
D. Dry Mouth
Answer: C. Fever

A nurse observes an AP providing care to a child who is in skeletal traction.
Which of the following action requires intervention?
A. Providing a high protein snack
B. Assisting the child to reposition
C. Placing weights as a child’s bed
D. Massaging pressure points-causes skin breakdown
Answer: D. Massaging pressure points-causes skin breakdown
A nurse is planning to delegate to an AP the fasting blood glucose testing for a
client who has diabetes mellitus. Which of the following action should the nurse
take?
A. Determine if the AP is qualified to perform the test.
B. Help the AP performed the blood glucose test
C. Assign the AP to ask the client is taking his diabetic medication today
D. Have AP check the medical record for prior blood glucose test results
Answer: A. Determine if the AP is qualified to perform the test.
A nurse is assessing client brought to the hospital psychiatric emergency services
by a law enforcement officer. The client has disorganized, in coherent speech with
loose associations and religious content. You should recognize the signs and
symptoms as being consistent with which of the following?
A. Alzheimer’s disease
B. Schizophrenia
C. Substance intoxication
D. Depression
Answer: B. Schizophrenia
A nurse is caring for a child who has infectious mononucleosis.. Which of the
following findings are associated with this diagnosis? Select all that apply
A. splenomegaly
B. Koplik spots (this is associated with measles)
C. Malaise
D. Vertigo
E. Sore throat

Answer: A. splenomegaly
C. Malaise
E. Sore throat
Nurse is performing dressing change for client was a sacral wound using negative
pressure wound therapy. Which The following actions should the nurse take first?
A. Apply skin preparation to wound edges.
B. Normal saline
C. Don sterile gloves
D. Determine pain level
Answer: D. Determine pain level
A nurses caring for client recovery from the bowel surgery who has nasogastric
tube connected to low intermittent suction. Which the following assessment
findings should indicate to the nurse that the NG tube may not be functioning
properly?
A. Drainage fluid is greenish-yellow
B. aspirate pH of 3
C. Abdominal rigidity
D. air bubbles noted in the NG tube
Answer: C. Abdominal rigidity
A nurse is preparing to administer TPN with added fat supplements to a client
who has malnutrition. Which of the following action should the nurse take?
A. Piggyback 0.9 sodium chloride with TPN solution
B. Check for an allergy to eggs
C. Discuss the TPS solution for 12 hours
D. Monitor for hypoglycemia
Answer: B. Check for an allergy to eggs
A charge nurse is discussing the use of applying ice to a client’s injured knee with
a newly licensed nurse. Which of the following should the nurse identify as a
benefit? (A/C?)
A. Systemic analgesic effect

B. increase in your metabolism
C. Decreased capillary permeability
D. Vasodilation
Answer: C. Decreased capillary permeability
Nurse is developing discharge care plans for client has osteoporosis. To prevent
injury the nurse should instruct the client to
A. Perform weight bearing exercises
B. Avoid crossing the legs beyond the midline
C. Avoid sitting in one position for prolonged periods
D. Split affected area
Answer: A. Perform weight bearing exercises
A nurse on acute med-surgical unit is performing assessments on a group of
clients. Which is highest priority?
A. The client has surgical hypoparathyroidism and positive Trousseau’s sign
B. A client who was Clostridium difficile with acute diarrhea
C. A client who is acute kidney injury and urine with a low specific gravity
D. The client who has oral cancer and reports a sore on his gums
Answer: A. The client has surgical hypoparathyroidism and positive Trousseau’s
sign
Nurses caring for a client was congestive heart failure. Which of the following
prescriptions for the provider should the nurse anticipate?
A. Call the provider to clients respiratory rate is less 18/min
B. Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr
C. Give the client enalapril 2.5 mg PO twice daily
D. Call the provider if the clients pulse rate is less than 80/min
Answer: C. Give the client enalapril 2.5 mg PO twice daily
A nurse is caring for a client who has a prescription for sertraline to treat
depression. Which of the following statements by the client indicates an
understanding of the medication treatment plan?
A. I will be able starting this medication with feel better

B. I can expect to urinate frequently while on this medication
C. I understand I may experience difficulty sleeping on this medication
D. I should decrease my sodium intake while on this medication
Answer: C. I understand I may experience difficulty sleeping on this medication
A nurse has been caring for a female client who has bruises on her arms that she
explains are a result of physical abuse by her husband. The client states, “I don’t
know how much longer I can take this, but I’m afraid he’ll really hurt me if I
leave. “Which of the following is an appropriate nursing intervention?”
A. Offer to speak to the client’s husband regarding his abuse behavior.
B. Help the client to recognize the signs of escalation of abuse behavior
C. Assist the client to identify personal behaviors that trigger abusive behavior
D. Assist the client to Reports abusive behavior to the proper authority
Answer: B. Help the client to recognize the signs of escalation of abuse behavior
A client was having suicidal thoughts tells the nurse “It just does not seem worth
it anymore. Why not end my misery?” Which of the following responses for the
nurses appropriate?
A. Why do you think your life is not worth it anymore?
B. Do you have a plan to end your life?
C. I need to know what you mean my misery
D. You can trust me and tell me what you’re thinking
Answer: B. Do you have a plan to end your life?
A nurse is caring for a client who has schizophrenia. Which of the following
assessment findings should the nurse expect?
A. Decreased level consciousness
B. Unable to identify common objects
C. Poor problem solving ability
D. Preoccupation was somatic disturbances
Answer: C. Poor problem solving ability

A nurse is caring for a client who has deep vein thrombosis of the left lower
extremity. Which of the following action should nurse take? There are 3 tabs that
contain separate categories of data.
A. Position the client with the affected extremity lower than the heart
B. Administration of acetaminophen
C. Massage the affected extremity every 4 hrs.
D. Withhold heparin IV infusion
Answer: D. Withhold heparin IV infusion
Is caring for clients was a new prescription for enoxaparin for the prevention of
DVT. Which of the following is an appropriate action by the nurse?
A. Expel air bubble at the top of the prefilled syringe
B. Massage the injection site to evenly distribute the medication
C. Inject the medication the lateral abdominal wall
D. Administer an NSAID for injection site discomfort
Answer: C. Inject the medication the lateral abdominal wall
Nurses caring for four clients. Which of the following client data should the nurse
report to the provider?
A. A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10 when
coughing
B. Client was a total of 110 mL of serosanguineous fluid from the Jackson Pratt
drain within the first 24 hour following surgery
C. Client who is 4 hrs postoperative and has a heart rate of 98 per minute
D. The client was a prescription for chemotherapy and an absolute neutrophil
count of 75/mm3
Answer: D. The client was a prescription for chemotherapy and an absolute
neutrophil count of 75/mm3
Nurses caring for client was in end-stage osteoporosis and is reporting severe
pain. Clients respiratory rate is 14 per minute. Which of the following
medications should the nurse expect to be the highest priority to administer to the
client?
A. Promethazine

B. Hydromorphone
C. Ketorolac
D. Amitriptyline
Answer: B. Hydromorphone
A nurse is caring for a client who has DVT. Which of the following instructions
the nurse include in the plan of care?
A. Live with the clients fluid intake to 1500 mL per day
B. Massage place affected extremity to relieve pain
C. Apply cold packs of clients affected extremity
D. Elevate the client’s affected extremity when in bed
Answer: D. Elevate the client’s affected extremity when in bed
A nurse is caring for a client who is receiving oxytocin IV for augmentation of
labor. The client’s contractions are occurring every 45 seconds with a nine
seconds duration in the fetal heart rate is 170 to 180/minute. Which of the
following actions should nurse take?
A. Discontinue oxytocin infusion
B. Increased oxytocin infusion
C. Decreased oxytocin infusion
D. Maintain oxytocin infusion
Answer: A. Discontinue oxytocin infusion
A nurse is admitting a client who is in labor and at 38 weeks of gestation to the
maternal newborn unit. The client has a history of herpes simplex virus 2. Which
of the following questions is most appropriate for the nurse to ask the client?
A. Have your membranes ruptured?
B. How far apart are your contractions?
C. Do you have any active lesions?
D. Are you positive for beta strap?
Answer: C. Do you have any active lesions?
Nurse is providing teaching for child prescribed ferrous sulfate. Which of the
following instructions should the nurse include?

A. Take with meals
B. Take at bedtime
C. Take with a glass of milk
D. Take with a glass of orange juice
Answer: D. Take with a glass of orange juice
Four clients present to the emergency department. The nurse should plan to see
which of the following clients first?
A. A 6 year old client whose left shoulder is dislocated
B. A 26 year old client for sickle cell disease and a severe joint pain
C. A 76 year old client was confused, febrile and has foul smelling urine - uti
D. A 50- year old client who has slurred speech, is disoriented, and reports a
headache - stroke
Answer: D. A 50- year old client who has slurred speech, is disoriented, and
reports a headache - stroke
A nurse is completing a dietary assessment for client who is Jewish and observes
kosher dietary practices. Which of the following behaviors should the nurse
expect to find?
A. Leavened bread maybe eaten during Passover.
B. Shellfish is commonly consumed in the diet.
C. Meat and dairy products are eaten separately.
D. Fasting from meat occurs during Hanukkah.
Answer: C. Meat and dairy products are eaten separately.
A nurse is in an ER caring for client of multiple wounds due to a motor vehicle
crash. Which of the following interventions are appropriate?
Select all that apply
A. Apply direct pressure to bleeding wounds
B. Clean rest last rations and abrasions with hydrogen peroxide
C. Cover wounds with a sterile dressing
D. Administer 650 mg aspirin PO as needed for pain
E. Determine date of last tetanus toxoid vaccination.
Answer: A. Apply direct pressure to bleeding wounds

C. Cover wounds with a sterile dressing
E. Determine date of last tetanus toxoid vaccination.
The nurses reviewing clients admission laboratory results. Which of the findings
required further evaluation?
A. Sodium 138
B. Creatinine 1.8
C. Hemoglobin 15
D. Potassium 4.2
Answer: B. Creatinine 1.8
A nurse is providing teaching for a client has a new prescription for methadone.
Which of the phone following client statements indicates need for further
teaching?
A. I understand the methadone tends to slow my breathing
B. I understand the methadone may cause me to have difficulty sleeping
C. I will avoid alcohol while I’m taking this medication
D. I’ll change positions gradually especially from lying down to standing
Answer: B. I understand the methadone may cause me to have difficulty sleeping
Which of the following client is appropriate for the nurse to refer to speech
therapy for swallowing evaluation?
A. Premature infant with a poor suck reflex and failure to thrive
B. An older adults who has difficulty taking in fluids
C. Adolescent who anorexia who is cachectic
D. A middle aged adults was gastroesophageal reflux disease
Answer: A. Premature infant with a poor suck reflex and failure to thrive
A nurse is caring for a group of clients. Which of the following client should
nurse assess first?
A. A client whose benign prostatic hyperplasia and is unable to urinate
B. The client was heart failure and report shortness of breath while ambulating
C. A client who is open cholecystectomy and has green drainage from the T-tube
D. A client whose abdominal pain and is vomiting coffee ground emesis

Answer: B. The client was heart failure and report shortness of breath while
ambulating
A nurse is taking a medication history from client was type II diabetes mellitus is
scheduled for an arteriogram. Which of the following medications to the nurses
instruct the client to discontinue 48 hrs prior to the procedure?
A. Atorvastatin
B. Digoxin
C. Nifedipine
D. Metformin
Answer: D. Metformin
The nurses assessing client with posttraumatic stress disorder. Which of the
following findings to the nurse expect to find?
A. Dependence on family and friends
B. Loss of interest in usual activities
C. Ritualistic behavior
D. Passive aggressive behavior
Answer: B. Loss of interest in usual activities
A nurse working in a long-term care facility is caring for an older adult client has
dementia. The clients often agitated and frequently wanders the halls. Which of
the following intervention should the nurse include in the plan of care?
A. Give the client several choices when scheduling activities.
B. Confront the client regarding unacceptable behavior
C. Maintain Nutritional requirements by offering finger foods
D. Stimulate the client by leaving the television on throughout the day
Answer: C. Maintain Nutritional requirements by offering finger foods
A nurse on a mental health unit receives report on four clients. Which of the
following client should the nurse attend to first?
A. A client who has begun to demonstrate catatonic behavior
B. The client was compulsive behavior and is frequently drinking from the water
fountain

C. Client was having auditory hallucinations is becoming agitated
D. A client was making sexual comments to clients of the opposite sex
Answer: C. Client was having auditory hallucinations is becoming agitated
A nurse is caring for the full term newborn immediately following birth. Which of
the following actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment and the newborn’s eyes.
B. Place identification bracelets on the newborn.
C. Weigh the newborn.
D. Dry the newborn
Answer: D. Dry the newborn
A nurse receives report on a group of clients. Which of the following client should
the nurse attend to first?
A. A client who was admitted with asthma and has an SaO2 of 92% long
receiving oxygen at 1 L per minute via nasal cannula
B. A client was admitted with angina and reports left arm pain of 4 on a scale of 0
to 10
C. The client was type II diabetes mellitus in his blood with glucose level is at 80
mg/dL
D. A client who had a gastric endoscopy and whose nasogastric tube is draining
30 mL per hour of green fluid
Answer: A. A client who was admitted with asthma and has an SaO2 of 92% long
receiving oxygen at 1 L per minute via nasal cannula
A client at 38 weeks of gestation enters the emergency department. The nurse
should recognize that which of the following indicates that the client is in the
latent phase of labor?
A. The client reports the urge to push
B. The cervix is dilated 2 cm
C. Contractions are 2 to 3 minutes apart
D. The client reports nausea and vomiting
Answer: B. The cervix is dilated 2 cm

The charge nurse for medical surgical units discovers client care assignments that
should be reassigned. Which of the following delegated tasks should be
reassigned?
A. An AP is to calculate intake and output every two hours for client in acute renal
failure.
B. An AP is to collect vital signs every 30 minutes for client who had a
cholecystectomy
C. A licensed practical nurse is to check nasogastric tube placement for client list
had a bowel resection.
D. A licensed practical nurses to provide initial feeding for client who had a
cerebrovascular accident.
Answer: A. An AP is to calculate intake and output every two hours for client in
acute renal failure.
A nurse caring for the client who has a cast due to a compound fracture to the
right ankle. Which of the following findings requires immediate intervention?
A. pruiritus under the cast
B. Localized stabbing pain upon movement
C. paresthesia of the distal extremity
D. Edema present when leg is in the dependent position
Answer: C. paresthesia of the distal extremity
The nurses providing care for preschoolers with acute gastroenteritis. Basing
information below which of the following is an appropriate nursing action? Click
on the links of this below for additional client information
A. Offer the child a cup of chicken broth.
B. Encourage the child’s intake of gelatin.
C. Administer oral rehydration solutions.
D. Institute a banana, Rice, applesauce, and toast diet.
Answer: C. Administer oral rehydration solutions.
The nurses caring for a client whose taking allopurinol. The nurse should monitor
which of the following laboratory findings to determine the effectiveness of the
medication?

A. Serum chloride
B. Uric acid level
C. Serum albumin
D. Magnesium level
Answer: B. Uric acid level
A nurse is caring for a client on the cardiac care unit who is hemodynamically
unstable. Which of the following dysrhythmias should the nurse plan for
cardioversion?
A. Ventricular asystole
B. Third-degree AV block
C. Atrial fibrillation
D. Ventricular fibrillation
Answer: C. Atrial fibrillation
Nurse managers preparing an educational program on infection control measures.
Which of the following should the nurse include when discussing contact
precautions?
A. Scarlet fever
B. Herpes simplex
C. Varicella
D. Streptococcal pharyngitis
Answer: B. Herpes simplex
A nurse assesses an older adult client with the decrease caloric intake and weight
loss. Which of the following findings should the nurse report to the provider
immediately?
A. The clinic experiences coughing and wheezing after eating.
B. The client reports abdominal pain at a five on a scale of 0 to 10.
C. The client experience is a drop in oxygen saturation to 91% while eating.
D. The client reports a burning sensation in epigastric area.
Answer: A. The clinic experiences coughing and wheezing after eating.

A nurse and an assistive personnel are caring for a group of clients. Which of the
following tasks is appropriate for the nurse to delegate an AP?
A. Applying condom catheter for client for spinal cord injury
B. Administrative oral fluids to client was dysphasia
C. Documenting the report of pain from client who is postoperative
D. Reviewing active range of motion exercises with a client who is had a stroke
Answer: A. Applying condom catheter for client for spinal cord injury
A nurse from the state health department this is instructing a group nurses
regarding reportable infections. Which of the following infections should the
nurse report to the CDC?
A. Candida albicans
B. Herpes simplex virus 2
C. staphylococcus aureus
D. Lyme disease
Answer: D. Lyme disease
The nurse is assessing an adolescent client for sickle cell anemia. Which of the
following is a priority finding by the nurse?
A. A pain score 7 on a scale of 0 to 10
B. Shortness of breath
C. New onset of a new enuresis
D. Priapism
Answer: B. Shortness of breath
Nurses caring for a client whose 1 day postop following a Hypophysectomy for
the removal of the pituitary tumor. Which of the following findings requires
further assessment by nurse?
A. Glascow scale score a 15
B. Blood drainage on initial dressing measuring 3 cm
C. Report of dry mouth
D. Urinary output greater than fluid intake
Answer: D. Urinary output greater than fluid intake

A client with the left leg cast is using crutches for ambulation. The nurse
recognizes client needs further instruction of the client
A. Flexes elbows at 30 degrees when using the handgrips
B. Maintains 3 to 4 finger width between the crutch pad and axilla
C. Places the crutches 6 inches in front and side of each foot when standing.
D. Pushes up from a chair with crutches on the unaffected side.
Answer: B. Maintains 3 to 4 finger width between the crutch pad and axilla
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the
following actions should the nurse plan to take?
A. Use a designated stethoscope when caring for the toddler.
B. Wear an N95 respiratory mask while caring for the toddler.
C. Remove the disposable gown after leaving the toddler’s room
D. Place the toddler in a room with negative air pressure.
Answer: A. Use a designated stethoscope when caring for the toddler.
A nurse is admitting to a client to emergency department and initiates continuous
cardiac monitoring. Which of the following ECG with strips indicates sinus
tachycardia?
A. Heart rate of 60-100 bpm, regular rhythm, with normal P waves.
B. Heart rate of 100-150 bpm, regular rhythm, with normal P waves.
C. Heart rate of 40-60 bpm, irregular rhythm, with no identifiable P waves.
D. Heart rate of 150-180 bpm, irregular rhythm, with variable P waves.
Answer: B. Heart rate of 100-150 bpm, regular rhythm, with normal P waves.
A nurse is planning care for client to prevent complications of immobility. With
the following actions should the nurse including the plan of care?
A. Massage lower extremities daily to prevent DVT
B. Limit intake of Food high in calcium to prevent renal calculi.
C. Encourage client to lie supine prevent constipation.
D. Remove anti embolism stockings for 3 hours each day to decreased skin
breakdown.
Answer: D. Remove anti embolism stockings for 3 hours each day to decreased
skin breakdown.

A nurse discovers that the wrong dosage of medication was given to client. When
determining what action to take your should recognize that which of the following
ethical principles should be applied?
A. Utility
B. Paternalism
C. Veracity
D. Fidelity
Answer: C. Veracity
A nurse is review in the prescription for doxazosin with a client. Which of the
following should be included in the teaching?
A. Decrease caloric intake to reduce weight gain.
B. Increased dietary fiber to prevent constipation.
C. Rise slowly when sitting up from bed.
D. Take this medication each morning.
Answer: C. Rise slowly when sitting up from bed.
Addresses planning to provide teaching to young adult client who is insomnia.
Which of the following should the nurse include in the teaching?
A. Exercising an hour before bedtime
B. Take a short nap today
C. Keep bedroom cool at night
D. Consume a high carbohydrate snack at bedtime.
Answer: C. Keep bedroom cool at night
A nurse is caring for client who has a stool culture that is positive for Clostridium
difficile. Which of the following infection control precautions is appropriate?
A. Wear a face shield prior into entering the room.
B. Place the client private room.
C. Place the client in a negative pressure room.
D. Use alcohol based hand rub following client care.
Answer: C. Place the client in a negative pressure room.

A nurse is planning care for a child who has increased intracranial pressure with a
decreased level of consciousness. Which of the following intervention should the
nurse including the plan of care?
A. Perform active range of motion exercises.
B. Perform neurological checks every 4 hours.
C. Suction the airway frequently.
D. Maintain the head at a midline position.
Answer: D. Maintain the head at a midline position.
The nurse is assessing a client is receiving radiation therapy. Which of the
following findings should the nurse expect?
A. White blood cell count at 12,500 mm3
B. Excessive salivation
C. +3 pitting edema
D. Platelets 95,000 mm3
Answer: D. Platelets 95,000 mm3
A nurse is caring for a client who has preeclampsia and is experiencing
postpartum hemorrhage. The nurse should identify that which of the following
medications is contraindicated?
A. Methylergonovine.
B. Misoprostol
C. Dinoprostone
D. Oxytocin
Answer: A. Methylergonovine.
A nurse is caring for client was GERD. Which of the following assessment
findings the nurse expect to find?
A. Shortness of breath
B. Rebound tenderness
C. Atypical chest pain
D. Vomiting blood
Answer: C. Atypical chest pain

A nurse is caring for a newborn who is under phototherapy lights. Which of the
following is an appropriate nursing action?
A. Ensure eye shield is covering the eyes.
B. Apply lotion to expose skin.
C. Offer glucose water between feedings.
D. Discontinue breast-feeding during treatment.
Answer: A. Ensure eye shield is covering the eyes.
This is assessing clients as had a long arm cast. Which of the following findings
of the dress moderate and when assessing for acute compartment syndrome?
A. Shortness of breath
B. Petechiae
C. Change in mental status
D. Edema
Answer: D. Edema
I Just came from client is receiving IV moderate (Conscious) sedation with
midazolam. The client has a respiratory rate of 9/min and is not responding to
commands. Which of the following is an appropriate action by the nurse?
A. Placed the client in a prone proposition.
B. Implement Positive pressure ventilation.
C. Perform nasopharyngeal suctioning.
D. administer flumazenil
Answer: B. Implement Positive pressure ventilation.
A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing
a client. They are using the clients name and discussing details of his diagnosis.
Which of following actions should the nurse take first?
A. Report the AP’s behavior to the supervisor.
B. Completed instant report regarding the Aps conversation.
C. Provide the AP with written documentation regarding client confidentiality
D. Tell the AP to discontinue their conversation
Answer: D. Tell the AP to discontinue their conversation

A community health nurse is teaching a group of adults about the importance of
health screenings. The nurse should include African American males almost twice
as likely as Caucasian males to experience which of the following?
A. testicular Cancer
B. Obesity
C. Stroke
D. Melanoma
Answer: C. Stroke
A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the
following prescription is given by the provider should the nurse clarify?
A. Over the fact that extremities and two pillows.
B. Apply heat to affect extremity for 45 minutes on the 45 is off.
C. wrap the affected extremity with a compression dressing.
D. Assess the affected extremity for sensation movement impulse every four
hours
Answer: B. Apply heat to affect extremity for 45 minutes on the 45 is off.
A nurse is providing dietary teachings for client who has hepatic encephalopathy.
Which the following food selections indicates that client understands teaching?
A. A sandwich and milkshake
B. Rice with black beans
C. Cottage cheese and tuna lettuce
D. Three egg omelette with low-sodium ham
Answer: C. Cottage cheese and tuna lettuce
A nurse is planning care for client sealed radiation implant and is to remain in the
hospital for 1 week. Which of the following should the nurse include in the plan
of care?
A. Remove dirty linens from the room after double bagging.
B. Wear a dosimeter film badge while in the client’s room
C. Limit each of the clients is yours to one hour per day.
D. Ensure family members remain at least 3 feet from the client.
Answer: B. Wear a dosimeter film badge while in the client’s room

A nurses for Caring for four clients. Which of the following client should the
nurse care for first?
A. A client to receive a chemotherapy treatment or first national
B. A client who has an appendectomy to these don’t has diminished all sounds
C. A client is hypothyroidism and his stuporous
D. A client who is a burn requiring a sterile dressing change
Answer: C. A client is hypothyroidism and his stuporous
The nurses planning care for newly admitted adolescent who has bacterial
meningitis. Which the following instructions is appropriate for the nurse to
include in the plan of care?
A. Initiate droplet precautions for the client
B. Assisted client to supine position
C. Performing Glasgow coma scale every 24 hrs
D. Recommend prophylactic acyclovir there for the clients family.
Answer: A. Initiate droplet precautions for the client
Nurse is giving discharge instructions to client has new ileostomy. The nurse
should recognize that the teaching has been effective when the client states.
A. I want sure that my medications are enteric coated
B. My stoma will drain liquid fluid continuously
C. I will change my pump system every two weeks
D. My stoma size will stay the same even after healed
Answer: B. My stoma will drain liquid fluid continuously
A nurse in a provider’s office is interviewing a client who is requesting an oral
contraceptive. Which of the following findings in the client’s history is a
contraindication to use in combination oral contraceptives?
A. Thyroid disease
B. Allergy to penicillin
C. Impaired liver function
D. Abnormal blood glucose
Answer: C. Impaired liver function

The nurses providing teaching to a client who has mild persistent asthma has been
prescribed montelukast. Which of the following statements to the nursing put in
teaching?
A. This medication can be used to help you when have an acute asthma attack
B. This medication should be taken before exercise and physical activity
C. This medication can be taken for 10 days and then gradually discontinued
D. This medication helps decrease swelling and mucus production
Answer: D. This medication helps decrease swelling and mucus production
I nurse on the medical surgical unit is receiving reports on four clients. Which of
the following client should the nurse assess first?
A. A client who is receiving warfarin and has and INR of 3.3
B. A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN
52 mg/dL
C. A client who had a NG tube inserted 6 hr ago and has abdominal distention
D. A client who is 4 hr postoperative following a thyroidectomy and reports
fullness in the back of the throat
Answer: A. A client who is receiving warfarin and has and INR of 3.3
A nurse is assessing a client who has pericarditis. Which of the following findings
is priority
A. Paradoxical pulse
B. dependent edema
C. Pericardial friction rub
D. Substernal chest pain
Answer: A. Paradoxical pulse
A charge nurse is providing teaching to a new licensed nurse on how to cleanup
surfaces contaminated with blood. Which of the following agents said the nurse
include in the teaching?
A. Hydrogen peroxide
B. Chlorhexidine
C. Isopropyl alcohol

D. Chlorine bleach
Answer: D. Chlorine bleach
A nurse is preparing to feed a newly admitted patient with dysphagia. Which of
the following actions in response take?
A. instruct the client to lift her chin when swallowing
B. discourage the client from coughing during feedings
C. Sit at or below the clients eye level during feedings.
D. Talk with the client during her feeding.
Answer: A. instruct the client to lift her chin when swallowing
A nurses caring for a client who repeatedly refuses meals. The nurse overhears an
assistive personnel telling the client. “If you don't eat, I’ll put restraints on your
wrists and feed you.” The nurse should intervene and explain to the AP that this
statement constitutes which of the following torts?
A. Assault
B. Battery
C. Malpractice
D. Negligence
Answer: A. Assault
A charge nurse is evaluating the time management skills for new licensed nurse.
The charge nurse should intervene when a newly licensed nurse does which of the
following?
A. Re-Evaluate priorities halfway through the shift
B. Delegate changing sterile dressing for licensed practical nurse
C. Groups activities for the Same client
D. Works on several tasks simultaneously
Answer: B. Delegate changing sterile dressing for licensed practical nurse
A nurse is monitoring the client during an IV urography procedure. Which of the
following client reports is the priority finding?
A. Feeling flushed and warm
B. Abdominal fullness

C. Swollen lips
D. Metallic taste in mouth
Answer: C. Swollen lips
A nurse is planning to delegate client assignments to the assistive personnel.
which of the following task is appropriate for the nurse to delegate?
A. Just the flow rate of the clients oxygen tank
B. Collecting urine sample
C. Measuring the clients pain level
D. Monitoring blood glucose levels
Answer: B. Collecting urine sample
A nurse is assessing a client wasn’t following vital signs: Oral temperature of
37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory
rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse
pressure?
A. 92 mm Hg
B. 72 mm Hg
C. 40 mm Hg
D. 60 mm Hg
Answer: C. 40 mm Hg
A nurse if caring for a group of clients in a medical surgical unit. Which of the
following situations requires completion of an incident report?
A. A client who is absent gag reflex following a bronchoscopy
B. A client whose IV pump has malfunctioned
C. A client who requires insertion of NG tube due to a bowel obstruction
D. A client who is absent bell sounds following a gastrectomy
Answer: B. A client whose IV pump has malfunctioned
A nurse is caring for a client who has diabetes insipidus and is receiving
desmopressin. Which of the following should nurse monitor?
A. Fasting blood glucose
B. Carbohydrate intake

C. Haematocrit
D. Weight
Answer: C. Haematocrit
The nurses providing discharge instructions about engorgement for client has
decided not to breastfeed. Which of the following statements by the client
indicates a need for further instruction by the nurse?
A. I can wear support bra
B. I will play cold compression my breasts
C. I will manually express breastmilk
D. I can take a mild analgesic
Answer: C. I will manually express breastmilk
A nurses caring for client in preterm labor who is receiving magnesium sulfate by
continuous IV infusion. Which of the following client findings indicates
medication toxicity?
A. Blood glucose of 150 mg/dL
B. Urine output of 20 mL per hour
C. Systolic blood pressure at 140 mm Hg
D. BUN 20 mg/dL
Answer: B. Urine output of 20 mL per hour
The nurse is completing an assessment for newborn who is 2 hrs old. Which of
the following findings are indicative of cold stress?
A. Respiratory rate of 60 per minute
B. Jitteriness of the hands
C. Diaphoretic
D. Bounding peripheral pulses in all extremities
Answer: B. Jitteriness of the hands
A nurse is planning care for four clients. Which of the following clients is the
highest priority?
A. A client who is dry, black eschar on the heel
B. A client who is wearing an arm cast and reports numb fingers

C. The client was reddened skin area with blanching around the coccyx
D. The client who has frequent incontinence
Answer: B. A client who is wearing an arm cast and reports numb fingers
A nurse is caring for a male adolescent client who has heart failure. Based on the
client’s chart finds. Which of the following actions should the nurse plan to take?
A. Withholds spironolactone
B. Administer ferrous sulfate
C. Administer furosemide
D. Withhold digoxin (0.8-2.0)
Answer: C. Administer furosemide
The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the
following clinical manifestations are associated with this finding?
A. Confusion (hypoglycemia)
B. Thirst
C. Diaphoresis (hypoglycemia)
D. Shakiness (hypoglycemia)
Answer: B. Thirst
A nurse is assessing for allergies before administering Propofol to a client placed
on the mechanical ventilator. Which of the following allergies is a
contraindication to the medication?
A. Eggs
B. Milk
C. Shrimp
D. Peanuts
Answer: A. Eggs
A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the
client to interpret the following statement, “When the cat’s away, the mice will
play”. The client response was, “The mice come out when the cat is not around”.
The nurse should document this finding which of the following in the client’s
chart?

A. Echolalia
B. Associative looseness
C. Neologisms
D. Concrete thinking
Answer: D. Concrete thinking
A nurse caring for a client who is receiving total parental nutrition. Which of the
following assessment findings required immediate intervention by the nurse?
A. prealbumin level of 20 mg/dL
B. Weight increase of two kg/day
C. Temperature of 37.6°C
D. Blood glucose level of 120 mg/dL
Answer: B. Weight increase of two kg/day
A nurse in the telemetry unit is receiving the laboratory findings for adult male
client who’s been treated for myocardial function. The following is an expected
finding for the client?
A. Troponin 1 (TNI) 8 ng/ml
B. Brain natriuretic peptide (BNP) 10 ng/L
C. Alanine aminotransferase (ALT 45 unit/L
D. High density lipoprotein (HDL) 75 mg/dl
Answer: A. Troponin 1 (TNI) 8 ng/ml
A nurse is reviewing the results of an ABG performed on a client with chronic
emphysema. Which of the following results suggests the need for further
treatment?
A. paO2 level of 89 mm Hg
B. PaCO2 level of 55 mm Hg
C. HCO2 level of 25 mEq/L
D. pH level of 7.37
Answer: C. HCO2 level of 25 mEq/L
A nurse is teaching a client about nutritional intake. The nurse should include
which of the following in the teaching?

A. "Carbohydrates should be at least 45% of your caloric intake."
B. "Protein should be at least 55% of your calorie intake."
C. "Carbohydrates should be at least 30% of your caloric intake."
D. "Protein should be at least 60% of your caloric intake."
Answer: A. "Carbohydrates should be at least 45% of your caloric intake."
A nurse is caring for a client who has a prescription for vancomycin1 g IV every
12 hr. The client is scheduled to have the morning dose at 0
The nurse should schedule the trough level to be drawn at which of the following
times?
A. 2100
B. 0900
C. 1300
D. 1800
Answer: B. 0900
A nurse is planning an education session for a client who has type 1 diabetes
mellitus. Which of the following should the nurse plan to include when teaching
the client to monitor for hypoglycemia?
A. diaphoresis
B. polyuria
C. abdominal pain
D. thirst
Answer: A. diaphoresis
A nurse in an urgent-care clinic is collecting admission history from a client who
is 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize
that which of the following clinical findings are associated with this infection?
A. Frequency and dysuria
B. Profuse milky white discharge
C. Hematuria
D. Low grade fever
Answer: B. Profuse milky white discharge

A nurse is planning care for a client who has a new diagnosis of dysphagia. Which
of the following foods should be included when initiating feeding?
A. Beef broth
B. Oatmeal
C. Apple juice
D. Toast
Answer: B. Oatmeal
A nurse receives a change-of-shift report. Which of the following clients should
the nurse attend to first?
A. A client who reports tingling in the fingers following a thyroidectorny
B. A client who has dark, foul-smelling urine with a urine output of 320 mL in the
last 8 hr
C. A client who is in a long leg cast and reports cool feet bilaterally
D. A client who has a productive cough and an oral temperature of 36° C (96.80
F)
Answer: C. A client who is in a long leg cast and reports cool feet bilaterally
A nurse is caring for a client who has lactose intolerance and has eliminated dairy
products from his diet. The nurse should instruct the client to increase
consumption of which of the following foods?
A. spinach
B. peanut butter
C. ground beef
D. carrots
Answer: A. spinach
A client who is 8 hr postpartum asks the nurse if she will need to receive Rh
immune globulin. The client is gravida 2, para 2, and her blood type is AB
negative. The newborns blood type is B positive. Which of the following
statements is appropriate?
A. You only need to receive Rh immune globulin if you have a positive blood
type."
B. You should receive Rh immune globulin within 72 hours of delivery."

C. "Both you and your baby should receive Rh immune globulin at your -week
appointment."
D. "immune globulin is not necessary since this is your second pregnancy."
Answer: B. You should receive Rh immune globulin within 72 hours of delivery."
A nurse is caring for the mother of an adolescent who was killed in a motorvehicle crash after a school event. The mother states, I never should have let him
take the car. Its all my fault!" Which of the following responses by the nurse is
appropriate?
A. You had no way of knowing this would happen."
B. Most parents blame themselves when losing a child."
C. Tell me why you feel this is your fault."
D. You appear to be feeling overwhelmed"
Answer: C. Tell me why you feel this is your fault."
A nurse is educating a client about caloric intake and weight reduction. Which of
the following client statements indicates an understanding of the teaching?
A. “If I eat 500 fewer calories per day, I should lose 1 pound per week.”
B. “ If I eat 500 fewer calories per day, I should lose 1 pound per week."
C. "If I eat 450 fewer calories per day, I should lose 2 pounds per week."
D. "If I eat 250 fewer calories per day, I should lose 2 pounds per week."
E. "If I eat 300 fewer calories per day, I should lose 1 pound per week.”
Answer: A. “If I eat 500 fewer calories per day, I should lose 1 pound per week.”
A nurses is teaching post-operative care with the parents of a toddler following a
cleft palate repair. Which of the following should be included in the teaching?
A. Provide an orthodontic pacifier for comfort.
B. Offer fluids by using a straw.
C. Cleanse suture line with a cotton tip swab.
D. Remove elbow splints periodically to perform range of motion.
Answer: A. Provide an orthodontic pacifier for comfort.
A nurse is caring for four clients. Which of the following tasks can the nurse
delegate to an assistive personnel?

A. Perform chest compressions during cardiac resuscitation.
B. Perform a dressing change for a new amputee.
C. Assess effectiveness of antiemetic medication.
D. Provide discharge instructions
Answer: A. Perform chest compressions during cardiac resuscitation.
A nurse in an emergency department is serving on a committee that is reviewing
the facility protocol for disaster readiness. The nurse should recommend that the
protocol include which of the following as a clinical manifestation of smallpox?
A. Bloody diarrhoea
B. Ptosis of the eyelids
C. Descending paralysis
D. Rash in the mouth
Answer: D. Rash in the mouth
A nurse is preparing to perform closed intermittent bladder irrigation for a client
following a transurethral resection of the prostate (TURP). Which of the
following actions is appropriate by the nurse?
A. Aspirate the irrigation solution from the bladder.
B. Insert the tip of the irrigation syringe into the catheter opening.
C. Apply sterile gloves.1296 in med surgical book
D. open the flow clamp to the irrigating fluid infusion tubing.
Answer: B. Insert the tip of the irrigation syringe into the catheter opening.
A nurse is caring for a client who has been taking haloperidol for several years.
Which of the following assessment findings should the nurse recognize as a longterm side effect of this medication?
A. Lip smacking
B. Agranulocytosis
C. Clang association
D. Alopecia
Answer: A. Lip smacking

A nurse is planning care for a client who has Alzheimer’s disease and
demonstrates confusion and wandering behavior. Which of the following should
the nurse include in the plan of care?
A. Place the client in seclusion when she is confused.
B. Request a prescription for PRN restraints when the client is wandering.
C. Dim the lighting in the clients room.
D. Leave one side rail up on the clients bed.
Answer: B. Request a prescription for PRN restraints when the client is
wandering.
A nurse is reviewing the laboratory data of a client who has diabetes mellitus.
Which of the following laboratory tests is an indicator of long-term disease
management?
A. Post orandial blood glucose
B. Glycosylated haemoglobin - Ha1c
C. Glucose tolerance test
D. Fasting blood glucose
Answer: B. Glycosylated haemoglobin - Ha1c
A nurse on a paediatric care unit is delegating client care. Which of the following
tasks should the nurse delegate to an assistive personnel?
A. Initiate a dietary consult for a toddler.
B. Administer a glycerine suppository to a preschool-age child.
C. Evaluate gastric residual following intermittent feeding of an adolescent.
D. Transport a school-age child to x-ray.
Answer: D. Transport a school-age child to x-ray.
A nurse is caring for a client who has been taking propranolol. Which of the
following findings indicates a need to withhold the medication?
A. sodium 130 mEq/L
B. Blood pressure 156/90 mm Hg
C. Potassium 5.2 mEq/L
D. Pulse 54/min
Answer: D. Pulse 54/min

A nurse working in a mental health facility observes a client who has bipolar
disorder walk over to a table occupied by other clients and knock their game off
the table. Which of the following is an appropriate response by the nurse?
A. Apologize to the others for your behavior."
B. I am disappointed that you continue to act out when you are angry."
C. Come outside with me for a walk."
D. If you don’t calm down, you will have to go into seclusion."
Answer: C. Come outside with me for a walk."
A nurse is caring for a client who has human immunodeficiency virus (HIV) with
neutropenia. Which of the following precautions should the nurse take while
caring for this client
A. Wear an N95 respirator while caring for the client.
B. Use a dedicated stethoscope for the client.
C. Insert an indwelling urinary catheter to monitor urinary output.
D. Monitor the client’s vital signs every 8 hr.
Answer: B. Use a dedicated stethoscope for the client.
A nurse is checking laboratory results for a client. Which of the following
laboratory findings indicates hypervolemia?
A. serum sodium 138 mEq/L
B. Urine specific gravity 1.001
C. serum calcium 10 mg/dL
D. Urine pH 6
Answer: B. Urine specific gravity 1.001
A nurse is caring for a group of clients in a long-term care facility. Which of the
following situations should the nurse recognize as a safety hazard?
A. A client’s wrist restraints tied to the bed rails
B. A clients bedside table placed across the foot of the bed
C. A meal tray left at the bedside from breakfast
D. A call light extension cord pinned to the bedspread
Answer: A. A client’s wrist restraints tied to the bed rails

A nurse is caring for a client in a mental health facility. The clients daughter is
crying and tells the nurse that she feels guilty for leaving her father in the hospital.
Which of the following is an appropriate response?
A. I’d like to know more about what’s bothering you."
B. "Why are you feeling this way"
C. "You did the right thing by bringing him here."
D. "I’m sure your father doesn’t blame you."
Answer: C. "You did the right thing by bringing him here."
A nurse is planning care for a client following gastric bypass surgery. The nurse
should include which of the following dietary instructions when preparing the
client for discharge?
A. start each meal with a protein source.
B. Consume at least 25 g of fiber daily.
C. Check your blood glucose level before each meal.
D. Limit your meals to three times per day.
Answer: A. start each meal with a protein source.
A nurse is assessing a client who has a chest tube following a thoracotomy. Which
of the following findings requires intervention by the nurse?
A. Tidaling with spontaneous respirations
B. Drainage collection chamber is 1/3 full
C. 1 cm of water present in the water seal chamber
D. Suction chamber pressure of -20 cm H20
Answer: D. Suction chamber pressure of -20 cm H20
A provider has written a do not resuscitate order for a client who is comatose and
does not have advance directives. A member of the clients family says to the
nurse, “I wonder when the doctor will tell us what’s going on" Which of the
following actions should the nurse take first
A. Request that the provider provide more information to the family.
B. Refer the family to a support group for grief counseling.
C. Offer to answer questions that family members have.

D. Ask the family what the provider has discussed with them.
Answer: C. Offer to answer questions that family members have.
A nurse is performing a skin assessment on a client who has risk factors for
development of skin cancer. The nurse should understand that a suspicious lesion
is
A. Scaly and red
B. Asymmetric, with variegated coloring
C. Firm and rubbery
D. Brown with a wart-like texture
Answer: B. Asymmetric, with variegated coloring
A nurse is interviewing an older adult client about the physiological changes he
has been experiencing. Which of the following changes should the nurse
recognize is normally associated with the aging process?
A. Decreased sense of taste
B. Decreased blood pressure
C. Increased gastric secretions
D. Increased accommodation to near vision
Answer: B. Decreased blood pressure
A nurse in an intensive care unit is planning care for a client who has alcohol
withdrawal syndrome. Which of the following should the nurse include in the
plan of care?
A. Administer disulfiram.
B. Provide frequent orientation to time and place.
C. Engage the client in group therapy.
D. Perform gastric lavage.
Answer: B. Provide frequent orientation to time and place.
A nurse is assessing a client’s cardiovascular system. Identify where the nurse
should place the diaphragm of the stethoscope to best hear the closing of the
aortic heart valve. (Selectable areas or Hot Spots" can be found by moving your

cursor over the artwork until the cursor changes appearance, usually into a hand.
Click only on the Hot Spot that corresponds to your answer.)
A. Second intercostal space, right sternal border
B. Second intercostal space, left sternal border
C. Fifth intercostal space, midclavicular line
D. Fourth intercostal space, left sternal border
Answer: A. Second intercostal space, right sternal border
A nurse manager is planning an audit to measure the quality of care on the unit.
Which of the following is the most appropriate source for the nurse to consult?
A. Nursing manager colleagues
B. Evidence-based practice data
C. Hospital administrators
D. Protocols in other hospitals
Answer: B. Evidence-based practice data
A nurse is caring for a client who had gastric bypass surgery 1 week ago and has
signs of early dumping syndrome. Which of the following findings should the
nurse expect? (Select all that apply)
A. Facial flushing
B. Syncope
C. Diaphoresis
D. Vertigo
E. Bradycardia
Answer: A. Facial flushing
B. Syncope
C. Diaphoresis
D. Vertigo
A nurse is caring for a client who is experiencing mild anxiety. Which of the
following findings should the nurse expect?
A. feelings of dread
B. rapid speech
C. purposeless activity

D. heightened perceptual field
Answer: D. heightened perceptual field
A nurse is delegating tasks to an assistive personnel. Which of the following
instructions demonstrates appropriate communication of the task?
A. "Take a blood glucose fingerstick on the client in room 102 before breakfast
and then place the glucometer into the docking station."
B. "Obtain a blood pressure reading from the client in room 116 after lunch and
report a systolic level less than 90."
C. "Assist the client in room 110 to ambulate once around the unit and stop if she
gets short of breath."
D. "Turn the client in room 126 to prevent pressure areas on his hip bones."
Answer: A. "Take a blood glucose fingerstick on the client in room 102 before
breakfast and then place the glucometer into the docking station."
A nurse is caring for a client who has constricted pupils, delayed reflexes, and
decreased blood pressure. The nurse should recognize that these findings are
potential manifestations of which of the following?
A. Nicotine withdrawal
B. Heroin intoxication
C. Alcohol withdrawal
D. Amphetamine intoxication
Answer: B. Heroin intoxication
A nurse is assessing an older adult client who had a stroke. Which of the
following findings should the nurse recognize as an indication of dysphagia?
A. Abnormal movements of the mouth
B. Inability to stand without assistance
C. Paralysis of the right arm
D. Loss of appetite
Answer: A. Abnormal movements of the mouth

A nurse is providing preoperative teaching to a client who will use PCA morphine
sulfate following surgery. Which of the following information should the nurse
include?
A. The client should notify the nurse when administering a dose of the
medication.
B. The client can administer a dose of medication every 6 to 8 min.
C. The client should be cautious to avoid overmedication (OD).
D. Family members can administer a dose the client.
Answer: C. The client should be cautious to avoid overmedication (OD).
A nurse is assisting the provider with a paracentesis for a client who has ascites.
Following collection of the specimen, which of the following actions should the
nurse take next
A. Document the procedure.
B. Measure the drainage.
C. Record the color of the drainage.
D. Label the specimen.
Answer: D. Label the specimen.
A nurse is caring for a client in an inpatient facility who tells the nurse that she is
leaving because the facility policy prohibits smoking inside. Which of the
following actions should the nurse take?
A. Notify security to monitor the facility exits.
B. Place the client in seclusion.
C. Inform the client of the risks involved if she leaves.
D. Call the provider for a discharge prescription.
Answer: C. Inform the client of the risks involved if she leaves.
A nurse is preparing to administer a measles, mumps, rubella (MMR)
immunization to a child. Which of the following is a contraindication for
administration?
A. Recent blood transfusion
B. Allergy to penicillin
C. Minor acute illness

D. Low-grade fever
Answer: A. Recent blood transfusion
A nurse is preparing to administer 2.5 mL of medication intramuscularly to an
adult client. Which of the following is the safest site for the nurse to use?
A. Ventrogluteal
B. Dorsogluteal
C. Vastus lateralis
D. Rectus femoris
Answer: A. Ventrogluteal
A nurse is teaching a female client how to reduce the risk of urinary tract
infections (UTIs). Which of the following should the nurse include as a risk factor
for developing a UTI?
A. Wearing underwear with a cotton crotch
B. Wiping from front to back
C. Using perfumed toilet paper
D. Urinating immediately after intercourse
Answer: C. Using perfumed toilet paper
A nurse is providing discharge instructions for a client who has a new prescription
for furosemide. Which of the following client statements indicates a need for
further teaching?
A. "I will take my morning pills with food or milk."
B. "I will weigh myself every day."
C. "I will notify the nurse if I have muscle cramps."
D. "I will limit my intake of fish."
Answer: D. "I will limit my intake of fish."
A nurse is caring for a client who has a prescription for atorvastatin. Which of the
following client conditions is a contraindication to this medication?
A. hepatitis C
B. peptic ulcer disease
C. bronchitis

D. chrohn’s disease
Answer: A. hepatitis C
A nurse is planning care for an adolescent who has chronic renal failure. Which of
the following actions should the nurse include in the plan of care?
A. Encourage a diet high in calcium.
B. Provide a diet high in potassium.
C. Ensure increased fluid intake.
D. Restrict protein intake to the RDA.
Answer: D. Restrict protein intake to the RDA.
A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy
and located 2 cm above the umbilicus. Which of the following actions should the
nurse take first?
A. Take vital signs.
B. Assess lochia.
C. Massage the fundus.
D. Give oxytocin IV bolus.
Answer: C. Massage the fundus.
A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following interventions should the nurse perform
A. Give 100 mL of water with every feeding.
B. Obtain gastric residuals every 24 hr.
C. Position the head of bed at 30 degrees during feeding.
D. Mix the clients medications with the tube feedings.
Answer: C. Position the head of bed at 30 degrees during feeding.
A nurse is caring for a 7 month-old infant who is being treated for severe
dehydration. Which of the following assessment findings indicates treatment has
been effective?
A. Skin turgor displays tenting
B. Flat anterior fontanel
C. Cool, mottled skin

D. hyperpnea
Answer: B. Flat anterior fontanel
A nurse is providing teaching to a client who has esophageal cancer and is
scheduled to start radiation therapy. Which of the following should the nurse
include in the teaching?
A. Remove dye markings after each radiation treatment.
B. Apply a warm compress to the irradiated site.
C. Wear clothing over the area of radiation treatment.
D. Use a washcloth to bathe the treatment area.
Answer: C. Wear clothing over the area of radiation treatment.
A nurse in a provider's office is providing education to a client who is 16 weeks of
gestation and has a new prescription for ferrous sulfate. Which of the following
instructions should the nurse provide
A. Avoid strawberries, citrus fruit, and melon to ensure that your iron medication
is effective."
B. "Take your iron medication with fluids other than coffee or tea."
C. "It is important to take your iron medication on a full stomach."
D. "If you miss a dose one day, take two doses the next day."
Answer: B. "Take your iron medication with fluids other than coffee or tea."
A nurse receives a change-of-shift report on four clients. Based on the shift report
information, which of the following clients should the nurse plan to assess
A. A client who had a hip arthroplasty reports pain and erythema in his calf
B. A client who has anorexia and peripheral edema
C. A client who has Addison's disease with a blood glucose level of 75 mg/dL
D. A client who had a barium enema 2 days ago and reports constipation
Answer: A. A client who had a hip arthroplasty reports pain and erythema in his
calf
A nurse administers a dose of metoclopramide to a client prior to chemotherapy
treatment. Which of the following medications should the nurse administer?
A. Albuterol sulfate

B. Hydromorphone
C. Diphenhydramine
D. Amitriptyline
Answer: C. Diphenhydramine
A client who does not speak English arrives at the emergency department
accompanied by a child. Which of the following actions should the nurse take?
A. Ask the assistive personnel to assist the client in signing consent for treatment
B. Ask the child to interpret for the client.
C. Ascertain what language the client speaks and get an interpreter.
D. Try to find an adult relative to help the client communicate.
Answer: C. Ascertain what language the client speaks and get an interpreter.
A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate
after the client displays toxicity. Which of the following actions should the nurse
take?
A. Position the client supine.
B. Prepare an IV bolus of dextrose 5% in water
C. Administer calcium gluconate IV.
D. Administer methylergonovine IM.
Answer: C. Administer calcium gluconate IV.
A nurse is using Naegeles rule to calculate the expected delivery date for a newly
pregnant primigravida. The first day of the clients last period was October. What
is the expected delivery date? (Provide the date using four numerals, the first two
for the month and the second two for the day. For example, January 2 0102)
A. 0717 (July 17)
B. 0711 (July 11)
C. 0610 (June 10)
D. 0804 (August 4)
Answer: B. 0711 (July 11)

A nurse on a medical-surgical unit is receiving report on four clients. Which of the
following clients should the nurse assess first?
A. A client who is scheduled for chemotherapy and has a hemoglobin of 9
B. A client who is 24 hr postoperative following a transurethral resection of the
prostate (TURP) and has small blood clots in the urinary catheter
C. A client who is receiving a blood transfusion and reports low-back pain
D. A client who has a new colostomy with a reddish-pink stoma
Answer: C. A client who is receiving a blood transfusion and reports low-back
pain

SET 3
A nurse is planning care for a client who has a new diagnosis of HIV.
Answer: I can’t seem to gain any weight
Disaster triage following a natural disaster
Answer: A client who has agonal respirations
Client reports chest pain. Which of the following laboratory findings indicates
myocardial damage
Answer: Troponin I 1.8 ng/mL
Child who has pediculosis capitis
Answer: Store non-washable items in plastic bags for 14 days
Child who is unresponsive and has increased intracranial pressure
Answer: Pad the side rails of the bed
Client who is 8 hr postoperative following a right-modified radical mastectomy
Answer: Coughing, frothy, pink secretions
Newborn nursery is performing assessments on four neonates that are all less than
24 hr old

Answer: pinna below the outer canthus of the eye
Several client measurements were obtained with morning vital signs
Answer: A 4-year old who has closed head injury and heart rate of 60
Tetralogy of fallot
Answer: Pulse oximeter
Medical unit received change-of-shift report
Answer: 68 year old
Recovering from an acute myocardial infarction. left sided heart failure
Answer: Bilateral lung crackles
Nutritional assessment on a client who has a calcium deficiency
Answer: Osteogenesis
Involuntarily admitted to the psychiatric unit following a failed suicide attempt
experimental treatment
Answer: Witness consent before medication administration
Education to the mother of a toddler who has pertussis
Answer: Offer small amounts of fluid, frequently; monitor for airway obstruction
School nurse scabies
Answer: Red itchy papules on child’s groin area
Diabetes insipidus DI severe head injury
Answer: Urine output 250 ml
2 hr postoperative following an ileal conduit procedure bladder cancer
Answer: Dusky colored stoma
Mastitis of left breast does this mean that I must stop nursing my baby

Answer: No, you can continue to nurse from both your breasts
Orthopedic floor is completing the morning assessments on several clients
Answer: 24-year old male who has a casted femur fracture
Morning laboratory values to several clients
Answer: Client who is prescribed digoxin and furosemide
Education about electroconvulsive therapy ECT major depressive disorder
Answer: General anesthetic administered prior to ECT treatments
Charge nurse creating assignments for next shift for several nurses and one of the
nurses is pregnant
Answer: 60 year old who is recovering from shingles
Nurse is teaching a client who has left-leg weakness how to use a standard walker
Answer: Moves the left leg and walker ahead together
Diagnosis of antisocial personality disorder
Answer: Poor impulse control
Home health nurse is reviewing treatment goals with a client who has diabetes
mellitus evaluate laboratory tests to determine effective long-term management of
blood glucose levels
Answer: HbA1c
Haloperidol for the treatment of schizophrenia
Answer: Screen the client for tardive dyskinesia
Urinalysis done for a preschool age child
Answer: Pyelonephritis
Delegates the following tasks to the assistive personnel bathe four clients
distribute fresh water obtain morning vital signs

Answer: Set a clear time frame for the completion of each task
Hearing impairment incorporate which communication methods
Answer: Rephrase sentences the client does not understand
A nurse is discussing the z-track hydroxyzine hydrochloride with a newly licensed
nurse
Answer: This technique decrease risk of subcutaneous infiltration
A nurse is reviewing medical records for four clients. Which of the following
represents appropriate documentation
Answer: Lovenox 30mg SC every 12 hr
Performing postmortem care on an older adult client
Answer: Place absorbent pads under the buttocks area
Discussing a living will with a client
Answer: It communicates my wishes for end of life care
Benefit from a three-way indwelling catheter
Answer: Prone to development of blood clots in the urine
Dietary intervention for a client who is immobile due to pelvic and femur
fractures
Answer: Provide a high-protein diet
If something happens to me from which I cannot recover, I don't want to go on a
ventilator
Answer: You're concerned that something may go wrong? "I do not want to be
placed on a ventilator if I cannot recover."
Rising number of sexually transmitted infections in the community
Answer: Brainstorming session with nurses

Neutropenia
Answer: Remove fresh flowers from the clients room
Hyperthyroidism which of the following rooms is appropriate for the nurse to
assign this client
Answer: A room near the nurses station
Experiencing acute mania
Answer: Provide high-calorie nutritional supplements
Ileal conduit due to treatment for bladder cancer
Answer: Rinse the reusable pouch with hot water
Adolescent who has cystic fibrosis and has a prescription for pancrealipase
Answer: Take w meals
A nurse is planning to provide community education about viral hepatitis
Answer: Clients who have a history of viral hepatitis are unable to donate blood
Ap reports to the nurse that another Ap has spent the entire morning on the phone
and has not completed the morning assignment
Answer: Redirect the AP to discuss the issue with the other AP
A nurse is caring for a client who is receiving enteral nutrition
Answer: A poor skin turgor
Adolescent client who is in her third trimester of pregnancy
Answer: Postpartum depression
Client recovering from a closed head injury assumes a decerebrate posture in
response to stimuli
Answer: D lying flat, not curved backwards little bastard
Referral for a speech language pathologist

Answer: Client who has difficulty swallowing
Prescribed furosemide
Answer: Rales in lower lobes of lungs OR increasing oliguria
A nurse is admitting an infant who has bacterial meningitis
Answer: Minimize environmental stimuli
Laboratory data on a client who has dehydration
Answer: Elevated blood urea nitrogen
A nurse is caring for a client who has cirrhosis of the liver
Answer: Monitor for abdominal ascites
Difficulty falling asleep at night
Answer: Eat a bedtime snack containing carbohydrates
Perform wound irrigation for a client who has an open secondary wound when
creating a sterile field
Answer: Place the lid of a bottle of sterile solution within the sterile field
Laboratory values on a client who has taken an overdose of acetaminophen organ
damage
Answer: Alanine aminotransferase ALT
Nulliparous and in the first stage of labor the last internal assessment revealed
100% cervical effacement with 5 cm of dilatation. at the end of the last
contraction, the nurse observes a large gush of fluid coming out of the client's
perineal area.
Answer: Check the FHR
Health nurse is performing a vision screening on a 4-month-old infant. When
shining a light source into the infant's visual field.
Answer: IDK – Pupillary constriction – Fixate and follow a bright light or toy

Providing discharge teaching to a client who is postpartum and plans to
breastfeed. Which of the following should the nurse recommend the client
increase in her diet during lactation
Answer: Iron
Nurse volunteers to assist after witnessing a mass casualty incident involving a
train derailment. Which of the following clients should the nurse immediately and
completely immobilize
Answer: A client who reports substernal chest pain
A nurse is writing a plan of care for a client who is homebound and has stage 2
alzheimer's disease. Which of the following should the nurse include in the plan
of care?
Answer: Assist with money management
Nurse is caring for a client with fractured ribs, has developed thrombophlebitis,
and is being treated with a heparin drip. The client develops hematuria and has an
activated partial thromboplastin time aPTT of 100 seconds
Answer: Turn off the heparin drip
A nurse is teaching a client who has a new prescription for digoxin. Which of the
following should the nurse include in the teaching?
Answer: Notify your provider if you experience muscle weakness
A nurse is planning care for a newborn who has hyperbilirubinemia and is to
receive phototherapy
Answer: Place the newborn 45cm or 18 in from the light source
A nurse is providing teaching for a client who has a new prescription for lithium
carbonate
Answer: You should take this medication on an empty stomach

A nurse is caring for a client who is manic. Which of the following activities is
appropriate for the nurse to suggest?
Answer: Reading quietly in the room
A nurse is teaching a client who has low-literacy level about home management
of diabetes mellitus
Answer: Show the client an educational video
A client hospitalized for a bone marrow transplant is in protective isolation while
undergoing total body radiation and intense chemotherapy. The clients sibling
comes to visit but has obvious manifestations of an upper respiratory infection
Answer: Allow the sibling to visit after donning a sterile gown, mask, and gloves,
but prohibit physical contact.
A nurse working in an impatient mental health facility observes a client who is
agitated and threatening staff members in the day room
Answer: Accompany the client away from the common area
A client asks the nurse if it is safe for him to take a glucosamine supplement
Answer: Shellfish allergy
After evaluating the morning laboratory results on several clients, the provider
writes prescriptions for four clients assigned to the nurse's care
Answer: Infuse 10 mEQ/l potassium chloride IV over 1 hr to a client who has a
potassium of 3.2 meq/l
A nurse is caring for a client following insertion of a subclavian non-tunnleed
percutaneous central venous catheter CVC.
Answer: Review the chest x-ray report
A nurse is assessing a client who is 2 hr postoperative following insertion of a
chest tube connected to a chest drainage system as depicted in the diagram above
Answer: Fluctuation of the fluid level in chamber b (middle)

A nurse is assessing a client with schizophrenia
Answer: Auditory hallucinations
A nurse is admitting a client who has chronic gout
Answer: Allopurinol
A nurse in a mental health clinic is reviewing the history and physical for a 17year old client who has a new diagnosis of social phobia
Answer: The client reports minimal alteration in performance at a part-time job
A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr
Answer: Blood is backing up in the IV tubing
A nurse manager is presenting an in service for newly licensed nurses about
advance directives
Answer: Advanced directives must be notarized to be legally implemented
A nurse at the family planning clinic triages several clients over the phone
Answer: A client who uses diaphragm for contraception and has lost 30lb in the
past 6 months dieting
A nurse is teaching a family about home hospice care
Answer: Hospice care improves the quality of life through palliative care
Client who has a left femur fracture and is in skeletal traction. The client reports
pain due to muscle spasms in the affected leg
Answer: Realign the extremity in traction
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings
the nurse a list of client reports
Answer: Indigestion
A nurse is planning to change the dressings on a school-age child who has
sustained multiple burns

Answer: • Apply the dressings in a proximal to distal pattern
• Correct way is to wrap distal to proximal
Adolescent client who has no previous history of a seizure disorder and is
admitted after having a 3-min tonic-clonic seizure 2 weeks after sustaining a mild
concussion. EEG
Answer: Explain that the client may not have coffee prior to the EEG
A nurse is caring for a mother who was prescribed methadone during pregnancy
Answer: • Tachypnea
• Irritability
• tremors
A nurse is assessing a client who is postoperative following abdominal surgery. I
feel like my incision ripped open
Answer: Place the client in low-fowlers position
A nurse is caring for a postoperative client. Which of the following interventions
will reduce the risk of deep-vein thrombosis
Answer: Apply venous plexus foot pumps
Preparing to administer eye drops to a client
Answer: Use aseptic technique and drop the medication into the conjunctival sac
Client who is receiving a controlled epidural analgesia infusion
Answer: Covering the insertion site with a transparent dressing
Diagnosis of complete placenta previa is admitted to the labor and delivery suite
at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration
Answer: Prepare the client for a caesarean section
A nurse who typically works on the postpartum unit is assigned to float to the
maternal newborn unit. The nurse is very anxious about floating and
uncomfortable with the assignment the charge nurse has selected.

Answer: Ask the charge nurse to assign an experienced nurse to act as a resource
A community health nurse is planning to make home visits to several clients who
all live within a few miles radius of the office
Answer: An infant who has failure-to-thrive and was discharged from a facility
yesterday to a foster home on daily weights
Caring for a client who was involved in a motor-vehicle crash. The client reports
shortness of breath and chest pain and asks the nurse, "am I dying"?
Answer: Administer pain medication
A nurse notices smoke coming from a client’s room and discovers a fire in the
wastebasket. After moving the client to safety
Answer: Notify the facility operator
Providing postoperative teaching to a client who has a newly inserted pacemaker
Answer: I will use my cellphone on the ear opposite of my pacemaker
Reviewing data of four young children who are receiving treatment. Which of the
following should alert the charge nurse to the possibility of child abuse
Answer: A 3-month old infant who has a skull fracture from reportedly rolling off
the changing table
Preparing to obtain informed consent for a colonoscopy from a client who does
not speak English.
Answer: Provide a consent form in the client's spoken language
A nurse is providing teaching to the parent of a preschooler who was newly
diagnosed with a latex allergy
Answer: Bananas
Obsessive compulsive disorder OCD
Answer: Teach the client to meditate about obsessive thoughts

Client who has just given birth to a stillborn newborn
Answer: Acknowledging the reality of the newborns death
In-home assessment for an older adult client who is at risk for falls. Which of the
following assessment findings should the nurse identify as a potential hazard?
Answer: A computer chair with wheels
Recognizes that the teen pregnancy rate in the community has increased.
Answer: Arrange a meeting with teenage mothers who are high school students in
the community
Reviewing medications for a group of clients labor and delivery
Answer: Phenytoin for seizure disorder
Client following an open coletomy
Answer: Uncontrolled pain
Client who is 2 days postoperative following a lumbar laminectomy and is
reporting nausea
Answer: Administer an antiemetic
Client who reports the use of chondroitin and glucosamine
Answer: Improve joint functioning
Recovery room is assessing a client who has a new chest tube. The nurse finds
that the water seal is no longer tidaling
Answer: The tubing may be kinked
A nurse at a public health clinic is caring for a group of clients. Which of the
following should the nurse identify as a reportable diagnosis to the CDC
Answer: Hepatitis A
Discharge teaching about disease prevention to a client who has active
tuberculosis

Answer: Educating the client how to cover nose and mouth with tissues when
coughing
Gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin
for the augmentation of labor
Answer: Contractions occur every 90 seconds
Postpartum unit is caring for several clients
Answer: A client who is 4 days postpartum and has lochia serosa
Infection control nurse is reviewing care procedures for four clients
Answer: A client who has varicella zoster is placed in a negative pressure room
Creating an activity plan for a home-bound older adult client. in the planning, the
nurse considers the physiologic changes that may affect pulmonary function
related to the normal aging process
Answer: Decreased blood oxygenation
Immediate postoperative period following thoracic surgery, a nurse medicates a
client for pain on a schedule
Answer: Reduces the respiratory rate
Administer an injection to a client when the client states "I don't want that
injection. The last time I got that I was sore for a week
Answer: Battery
A nurse suspects another nurse is chemically impaired during their shift. Which of
the following is an appropriate action for the nurse to take?
Answer: Report to the nurse manager
Nurse is teaching a client who has a new diagnosis of gastroesophageal reflux
disease GERD
Answer: Sleep with the head of the bed elevated

A nurse supervisor receives notification of a disaster in the community and the
possibility for multiple admissions to the facility
Answer: A client who has an abdominal wound and is receiving negativepressure wound therapy
Preparing a client for surgery and has just administered the preoperative injection
Answer: Raise the side rails on the bed
Home health nurse is admitting a client who is prescribed peritoneal dialysis.
Answer: Clarify the clients actual and perceived health needs
A nurse is teaching a prenatal class about evidence of effective breastfeeding to a
group of parents
Answer: • Swallowing sounds are audible
• Stools are yellow and seedy after 7 days
• Maternal breasts become soft following feedings
Caring for a client who has a new prescription for chlorpromazine by IM injection
Answer: Check orthostatic pressure 1 hour after administration
Nurse educator is discussing modes of transmission with nursing students. Which
of the following should the nurse educator include as an example of vector-borne
transmission
Answer: West nile virus from a mosquito bite
Nurse manager is making staffing assignments for the medical-surgical unit.
Which of the following clients is appropriate to assign to a float nurse from the
postpartum unit.
Answer: A client who is 2 days postoperative following a colon resection
Inpatient psychiatric unit is setting short-term goals for an adolescent who was
admitted for treatment of anorexia nervosa
Answer: The client will develop a personalized meal plan

Nurse is caring for a client who will be receiving a transfusion of platelets
Answer: Decrease in bleeding from puncture sites
Nurse in an emergency department is assessing a client who has a nasal fracture.
Answer: Clear fluid drainage from the nares
Nurse Manager is presenting information to the nursing staff regarding the
appropriate use of client restraints.
Answer: Nurse should pad the bony prominences.
Provider’s prescription should include the type of restraint to use
Nurse in the emergency department is providing discharge teaching to a client
who has a sprained ankle. For the first 24 hr following surgery, the nurse should
instruct the client to do which of the following.
Answer: Intermittently place ice on the ankle
Admitting a client to the medical-surgical unit. Which of the following actions
should the nurse first take?
Answer: Observe the client's level of mobility
Nurse is admitting an unidentified female who was brought to the emergency
department.
Answer: 3 months
An emergency department nurse triages a group of school children injured in a
school bus crash
Answer: A child who reports diplopia and nausea and was unconscious at the
scene but is now awake
Nurse in a provider’s office is caring for a client who has Parkinson's disease and
has been taking levodopa for the past 5 weeks. The client reports a new onset of
muscle twitching
Answer: This is a manifestation of drug toxicity and may require a dosage
reduction.

After making morning rounds, the charge nurse on a surgical unit delegates the
following tasks to the assistive personnel AP
Answer: Set up a room for an expected postoperative admission
A nurse in a paediatric unit is caring for a group of clients. Which of the following
diseases should the nurse implement droplet precautions?
Answer: Pertussis
A client has just returned to the nursing unit following cardiac catheterization. In
the immediate post procedure period, which of the following is the priority
nursing action?
Answer: Immobilizing the affected extremity
Providing dietary teaching for a client who has a history of nephrolithiasis which
of the following is appropriate to include in the teaching?
Answer: Avoid foods that have high levels of oxalates
A home health nurse is conducting an initial home visit for a client who has
terminal breast cancer. The client has two minor children and a limited support
system.
Answer: Ask the client about her understanding of the diagnosis
Assessing a client who has systemic lupus erythematous SLE which of the
following is an expected finding?
Answer: Dry, raised facial rash
A nurse is planning care for a client who is prescribed a cane for ambulation.
Which of the following nursing actions should the nurse include in the plan of
care?
Answer: Remind the client to place the cane on the unaffected side
A nurse is caring for a group of clients. Which of the following tasks is
appropriate for the nurse to delegate to the assistive personnel AP

Answer: • Transfer a client from bed to chair with mechanical lift
• Provide postmortem care on a client who experienced cardiac arrest
Discussing care with a newly licensed nurse for a client who practices orthodox
Judaism
Answer: Roast beef and ice cream
Community health nurse is completing a newborn home visit and observes family
members smoking cigarettes in the house
Answer: Review the effects of second hand smoke with family members
A community health nurse is evaluating eligibility for home assistance for a client
who is quadriplegic
Answer: Determine the clients living situation
A nurse is preparing the auscultate a client's apical pulse at the point of maximal
impulse PMI
Answer: Fifth intercostal space at the left midclavicular line
A nurse is caring for a client who had a partial laryngectomy and is receiving
continuous enteral feedings at 65ml/hr through a gastrostomy tube
Answer: The client is lying in a supine position
A nurse is caring for a client who is receiving IV antibiotics and tests positive for
clostridium difficile C. difficile c diff
Answer: Place the client on contact precautions
An older adult client tells the nurse, "I thought immunizations were for kids." the
nurse informs the client that older adults should receive which of the following
immunizations
Answer: Herpes zoster vaccine
A nurse is preparing to administer potassium chloride intravenously to a client
who has hypokalemia. The client is receiving a current infusion of 0.9% sodium

chloride at 125ml/hr. Which of the following actions should the nurse plan to
take?
Answer: Dilute the solution prior to the infusion
A nurse in the emergency department is caring for a client following a motorvehicle crash.
Answer: Stabilize the cervical spine
Charge nurse on a paediatric unit is making assignments for a float nurse from the
medical unit.
Answer: A 10-year old who has pneumonia and is receiving respiratory
treatments.
A nurse is giving change-of-shift report about a client who is 36-hr postoperative
to another nurse
Answer: • Flushed IV w 0.9% sodium chloride or
• pain relieved by position change
Nurse plans to ambulate a client on the third day after cardiac surgery.
Answer: Pre-medicate the client with the prescribed analgesic
A nurse is reviewing the history and physical of a client who has right ventricular
heart failure
Answer: Confusion
Primagravida client in the emergency department at 12 weeks of gestation
hyperemesis gravidarum
Answer: 1000ml/hr
A nurse is electronically documenting assessment findings for a client.
Answer: The client reports a pain level of 6 on a scale from 0-10
Nurse is caring for a client who has end stage liver disease. The daughter of the
client asks about her father’s do-not-resuscitate request.

Answer: Tell me your feelings about your father’s prognosis
A home-health nurse is providing teaching about self administration of insulin to
a client who is newly diagnosed with diabetes mellitus
Answer: I can use the same area as long as I rotate injection sites
A nurse in the post anesthesia care unit is caring for four postoperative clients.
The nurse realizes that coughing poses a risk to which of the following clients
Answer: Thyroidectomy
A nurse is caring for a preschool-age child who has a short-leg, plaster cast
applied 1 hr ago.
Answer: Support the affected leg on a pillow.
A nurse is caring for a client who is receiving gentamicin. Which of the following
findings indicates the client is developing toxicity
Answer: Tinnitus
A nurse is caring for a client who has a newly implanted sealed internal radiation
device to treat cervical cancer.
Answer: Keep a 3-foot distance from the radiation implant
A nurse is caring for a client who has atypical depression and is taking
phenelzine.
Answer: Low-fat yogurt
A nurse is planning care for a client who is comatose and has stage II decubitus
ulcer on the coccyx
Answer: Provide the client with an alternating pressure mattress
A nurse is analyzing cardiac rhythms of four telemetry clients in the coronary care
unit
Answer: C looks normal but lots of artifact or fibs in between QRS's

A nurse in a mental health clinic is observing clients in the day room. The nurse
sits down to talk with an adolescent client who was admitted with clinical
depression. After a few minutes of conversation, the adolescent asks the nurse,
"Why did you choose to talk to me out of this room full of kids.
Answer: You're curious why I am interested in you and not the others?
A nurse is planning teaching for a client who is at 10 weeks of gestation and has a
history of urinary tract infections UTI
Answer: Empty the bladder before and after intercourse
A nurse is caring for a client who has heart failure and has started taking a loop
diuretic
Answer: Decreased reflexes
A nurse is caring for a client who is postoperative and at risk for development of
deep vein-thrombosis DVT
Answer: Prolonged bed rest
A nurse is caring for a client who has a new prescription for lithium carbonate.
Prior to administering the first dose, which of the following laboratory values
should the nurse evaluate?
Answer: Idk – Kidney fxn (BUN/Cr) or Na+ level or Thyroid level or CBC, or
Calcium
A nurse delegates tasks to a licensed practical nurse LPN and an assistive
personnel AP. when admitting a client who is experiencing acute liver failure and
who has ascites and an NG tube, which of the following tasks is most appropriate
to delegate to the LPN
Answer: Insert an indwelling catheter if the client has not voided in 3 hr.
A nurse is caring for a client who has just returned to the unit following a
bronchoscopy
Answer: Offers oral fluids to the client

A nurse is reviewing the employee health program for new employees. Which of
the following diagnostic assessments should the nurse recommend for all the new
employees to screen for the presence of tuberculosis?
Answer: Mantoux test
A nurse is interviewing a client who presents with multiple injuries that are
consistent with intimate partner abuse. After establishing trust and rapport, which
of the following should the nurse say?
Answer: Let's talk about what happened to you
A nurse is caring for an infant who is being treated for dehydration
Answer: Flat anterior fontanel
A nurse in the emergency department is caring for a client who has abdominal
pain. Which of the following actions by the nurse demonstrates veracity
Answer: The nurse explains the potential risks of treatment
A nurse is assessing a client 1 week after a successful bone marrow transplant.
The client reports peeling of skin on her hands and feet. The nurse should
recognize this desquamation as an indication of which of the following
complications
Answer: Graft-versus-host disease

SET 4
A nurse is planning care for a newborn who has hyper bilirubinaemia and is to
receive phototherapy. Which of the following interventions should the nurse
include?
Answer: Place the newborn 45 cm (18 in) from the light source
An assistive personnel tells the nurse that several client measurements were
obtained with morning vital signs. Which of the following clients should the nurse
plan to assess?

Answer: Head injury HR 60
A community health nurse recognizes that the teen pregnancy rate in the
community has increased. Which of the following program-planning strategies
should the nurse implement first?
Answer: Arrange a meeting with teenage mothers who are high school students in
the community
After making morning rounds, the charge nurse on a surgical unit delegates the
following task to the assistive personnel, which of the following task does the
nurse direct the AP to complete first?
Answer: Place an NPO sign on the door of a client scheduled surgery
A nurse is caring for a client who is receiving a localized epidural analgesia
infusion. Which of the following nursing actions is appropriate?
Answer: Covering insertion site with a transparent dressing
A nurse is performing disaster triage following a natural disaster. Which of the
following should the nurse identify as the highest priority to receive care?
Answer: A client who has agonal respirations
A nurse is planning to provide community education about viral hepatitis. Which
of the following should the nurse plan to include in the teaching?
Answer: Series of four hepatitis vaccines is recommended to prevent viral
hepatitis
A nurse in the emergency department caring for a client who has abdominal pain.
Which of the following actions by nurse demarcates veracity?
Answer: The nurse explains the potential risks of treatment
A nurse is about to administer an injection to a client who states, “I don’t want
that injection. The last time I got that I was sore for a week.” The nurse goes
ahead and administers the injection against the client’s wishes. The nurse
committed which of the following?

Answer: Battery
A home health nurse is assessing a client who is receiving from an acute
myocardial infarction (MI). Which of the following assessment findings should
the nurse report to the provider as a possible indication of left-sided heart failure?
Answer: Bilateral lung crackles
A nurse is caring for a group of clients. The nurse should request a referral for a
speech language pathologist for which of the following clients?
Answer: A client who has difficulty swallowing
A nurse is preparing to provide education about electroconvulsive therapy (ECT)
for a client who has major depressive disorder. Which of the following should the
nurse include in the teaching?
Answer: A general anesthetic is administered prior to ECT treatments
A nurse is caring for a mother who prescribed methadone during pregnancy. The
nurse should assess the newborn for which of the following manifestations of
neonatal abstinence syndrome
Answer: Tachypnea/irritability/tremors
A nurse is caring for a client following an open colectomy. Which of the
following findings places the client at risk for delayed wound healing?
Answer: Hyperemesis
A nurse who typically works on the postpartum unit is assigned to float to the
maternal newborn unit. The nurse is very anxious about floating and
uncomfortable with the assignment the charge nurse has selected. Which of the
following actions is appropriate for nurse to take?
Answer: Ask the charge nurse to assign an experienced nurse to act as a resource
A client hospitalized for a bone marrow transplant is in protective isolation while
undergoing total body radiation and intense chemotherapy. The client’s sibling

comes visit but has obvious manifestations of an upper respiratory infection.
Which of the following nursing actions is appropriate at this time?
Answer: Allow the sibling to wave at the client through the window or door
A nurse is caring for a client following insertion of a subclavian non tunneled
percutaneous central venous catheter (CVC). The provider writes a prescription to
initiate an IV infusion ringer’s lactate at 150 mL per hr.
prior to starting the infusion, which of the following actions should the nurse
take?
Answer: Review the chest x-ray report
A nurse is providing teaching to an adolescent client who has cystic fibrosis and
has a prescription for pancreas lipase. Which of the following should the nurse
include in the teaching?
Answer: Take with meals
A nurse is assessing laboratory values on a client who has taken an overdose of
acetaminophen. The nurse should expect which of the following laboratory values
indicative of organ damage from the overdose?
Answer: Alanine aminotransferase (ALT)
A nurse on an orthopedic floor is completing morning assessments on several
clients. Which of the following clients has the greatest risk for fat embolism
syndrome (FES)?
Answer: A 24-year-old male who has a casted femur fracture
A nurse is caring for a client who has end stage liver disease. The daughter of the
client asks about her father’s do-not-resuscitate request. Which of the following is
a therapeutic response by the nurse?
Answer: “Tell me your feelings about your father’s prognosis”
A nurse is providing teaching to the parent of preschooler who was newly
diagnosed with a latex allergy. The nurse should discuss that a cross reaction may
occur with which of the following foods?

Answer: Bananas
A nurse is planning to admit a client who has hyperthyroidism. Which of the
following rooms is appropriate for the nurse to assignment client to?
Answer: A room with a temperature of 20 degrees (68f)
A nurse has just returned to the nursing unit following cardiac catheterization. In
the immediate post procedure period, which of the following is the priority
nursing action?
Answer: Monitoring the insertion site for infection
A nurse is caring for an infant who is being treated for dehydration. Which of the
following findings indicate the treatment is effective?
Answer: Flat anterior fontanel
A nurse is reviewing medical for four clients. Which of the following represents
appropriate documentation?
Answer: Carafate 1 g PO 1 hr ac
A nurse in the clinic is providing information to a client who has mastitis of the
left breast. The client asks the nurse, “does this mean that I must stop nursing my
baby?” which of the following is an appropriate statement by the nurse?
Answer: “No, you can continue to nurse from both your breasts.”
A nurse in a mental health clinic is observing clients in the day room. The nurse
sits down to talk with an adolescent client who was admitted with clinical
depression. After a few minutes of conversation, the adolescent asks the nurse,
“why did you choose to talk to me out of this room full of kids?” which of the
following responses by the nurse is therapeutic?
Answer: “you’re curious why I am interested in you and not the other?”
A nurse working in an inpatient mental health facility observes a client who is
agitated and threatening staff members in the day room. Which of the following
actions should the nurse take first?

Answer: Accompany the client away from the common area
A client who is precepting a nursing student is brings the following client
observation to the nurse’s attention. Which of the following client should the
nurse assess first?
Answer: A client who is 3 days postoperative colectomy with a large, loose
melena stool
A nurse is planning teaching for a client who is at 10 weeks gestation and has a
history of urinary tract infections (UTIs). Which of the following information
should the nurse plan to include in the teaching about UTI prevention?
Answer: Empty the bladder before and after intercourse
A nurse in the emergency department is providing discharge teaching to a client
who has a sprained ankle. For the first 24 hr following injury, the nurse should
instruct the client to do which of the following?
Answer: Intermittently place ice on the ankle
After evaluating the morning laboratory results on several clients, the provider
writes prescriptions for four clients assigned to the nurse’s care. Which of the
following prescriptions is the nurse’s highest priority?
Answer: Administer vitamin K 10 mg IM to a client on warfarin with and INR of
6
A nurse is caring for a client who has ruptured ribs, has developed
thrombophlebitis, and is being treated with a heparin drip. The client develops
hematuria and has an activated partial thromboplastin time (aPTT) of 100
seconds. Which of the following should the nurse take first?
Answer: Turn off the heparin drip
A nurse is caring for a client who has a hearing impairment. When speaking to the
client, the nurse should incorporate which of the following communication
methods?
Answer: Exaggerate lip movements

A nurse is reviewing morning values of several clients. Which of the following
findings is the highest priority for the nurse to report to the provider?
Answer: A client who is prescribed digoxin and furosemide and has a potassium
level of 3.1 mEq/L
A nurse is caring for a client who has a new prescription for chlorpromazine by
IM injection. Which of the following is an appropriate action?
Answer: Check orthostatic blood pressure 1 hr after administration
A nurse is caring for a postoperative client. Which of the following interventions
will reduce the risk of deep-vein thrombosis?
Answer: Apply venous plexus foot pumps
A nurse is caring for a client who is manic. Which of the following activities is
appropriate for the nurse to suggest?
Answer: Taking a daily walk on the hospital grounds
A nurse is planning to perform wound irrigation for a client who has an open
secondary wound. When creating a sterile field, which of the following actions
should the nurse take?
Answer: Hold the bottle of sterile solution with the palm over the label while
pouring
A nurse is reviewing the history and physical on a client who has right ventricular
heart failure. Which of the following is an associated finding?
Answer: Elevated pulmonary artery pressure
A nurse is assessing a client who has schizophrenia. Which of the following
findings indicates a risk for self harm?
Answer: Auditory hallucinations

A nurse is providing postoperative teaching to a client who has a newly inserted
pacemaker. Which of the following statements by the client indicates that the
teaching has been effective?
Answer: “I’ll use my cell phone on the ear opposite of my pacemaker.”
A nurse is discussing care with a newly licensed nurse for a client who practices
Orthodox Judaism. Which of the following meal suggestions by the newly
licensed nurse indicates a need for further teaching?
Answer: Carrot sticks and cottage cheese
A nurse is preparing to auscultate a client’s apical pulse at the point of maximal
impulse (PMI). The nurse should place the diaphragm of the stethoscope at which
of the following locations?
Answer: Fifth intercostal space at the left midclavicular line
A charge nurse in the emergency department is reviewing the data of four young
children who are receiving treatment. Which of the following should alert the
charge nurse to the possibly of child abuse?
Answer: A 9-month-old infant who is dressed inappropriately for the current
weather conditions
A nurse is planning care for a client who is prescribed a cane for ambulation.
Which of the following nursing actions should the nurse include in the plan of
care?
Answer: Remind the client to place the cane on the unaffected side
A nurse is providing discharge teaching to a client who is postpartum and plans to
breastfeed. Which of the following should the nurse recommend the client
increase in her diet during lactation?
Answer: Calcium
A nurse in the post anesthesia care unit is caring for four postoperative clients.
The nurse realizes that coughing poses a risk to which of the following clients.
Answer: A client who had a thyroidectomy

A home health nurse is admitting a client who is prescribed peritoneal dialysis.
Which of the following actions should the nurse initiate first?
Answer: Demonstrate how to perform the procedure
A visiting nurse is writing a plan of care for a client who is homebound and has
stage 2 Alzheimer’s disease. Which of the following should the nurse include in
the plan of care?
Answer: Educate family about loss of family recognition
A nurse suspects another nurse is chemically impaired during the shift. Which of
the following is an appropriate action for the nurse to take?
Answer: Report to the nurse manager
A nurse is preparing to administer potassium chloride intravenously to a client
who has hypokalemia. The client is receiving a current infusion of 0.9% sodium
chloride at 125 mL/hr. Which of the following actions should the nurse plan to
take?
Answer: Dilute the solution prior to infusion
A nurse is caring for a client who had a partial laryngectomy and is receiving
continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the
following findings requires immediate intervention by the nurse?
Answer: The infusion pump for administering continuous feeding is turned off.
A nurse is admitting an unidentified female infant who was brought to the
emergency department. Based on the assessment findings, the nurse should
estimate the infant’s age to be which of the following?
Answer: 6 months
A nurse is preparing to administer eye drops to a client. Which of the following
nursing actions is appropriate?
Answer: Have the client tilt her head slightly so that the medication enters the
nasolacrimal duct

A nurse is caring for a client who reports the use of chondroitin and glucosamine.
The health benefit of this supplement combination is to do which of the
following?
Answer: Improve joint functioning
A nurse is performing a nutritional assessment on a client who has a calcium
deficiency. The nurse should identify that the client is at risk for which of the
following?
Answer: Tetany
A nurse is assessing a client who has systemic lupus erythematous (SLE). Which
of the following is an expected finding?
Answer: Dry, raised facial rash
A nurse is assessing a client who is 8 hr postoperative following a right-modified
radical mastectomy. Which of the following should the nurse recognized as the
priority finding?
Answer: Coughing frothy, pink secretions
A nurse in a provider’s office is caring or a client who has Parkinson’s disease and
has been taking levodopa for the past 5 weeks. The client reports a new onset of
muscle twitching. Which of the following statements by the nurse is appropriate?
Answer: “This is a manifestation of drug toxicity and may require a dosage
reduction.”
A nurse in the labor and delivery unit is receiving medications for a group of
clients. Which of the following medications places the fetus at risk for teratogenic
effects?
Answer: Phenytoin for seizure disorder
A nurse is providing discharge teaching about disease prevention to a client who
has active tuberculosis. Which of the following should the nurse include?

Answer: Educating the client how to cover nose and mouth with tissue when
coughing
A nurse is planning care for a client who has neutropenia. Which of the following
nursing interventions is appropriate to include in the care plan?
Answer: Remove fresh flowers from the client’s room.
A nurse is planning to change the dressing on a school age child who has
sustained multiple burns. Which of the following actions should the nurse plan to
take?
Answer: Apply the dressing in a proximal to distal pattern
An older adult client tells the nurse,” I thought immunizations were for kids.” The
nurse informs the client that older adults should receive which of the following
immunizations?
Answer: Herpes zoster vaccine
A nurse is caring for a client who was involuntarily admitted to the psychiatric
unit following a failed suicide attempt. The provider prescribes a medication that
is part of an experimental treatment. Which of the following actions should the
nurse take?
Answer: Exclude the client from the study due to involuntary admission
A nurse analyzing the laboratory data on a client who has dehydration. Which
finding should the nurse anticipate in a client who has fluid volume deficit?
Answer: Elevated blood urea nitrogen
A community health nurse is evaluating eligibility for home assistance for a client
who is quadriplegic. Which of the following actions should the nurse perform
first?
Answer: Determine the client’s living situation

A nurse is caring for a client who has heart failure and has started taking a loop
diuretic. Which of the following findings indicates the client is experiencing an
adverse effect of the medication?
Answer: Jugular vein distention
A nurse is assessing a client who is preparing for surgery. The client tells the
nurse, “If something happens to me from which I cannot recover don’t want to go
on a ventilator.” Which of the following is an appropriate response by the nurse?
Answer: “You’re concerned that something may go wrong?”
A nurse is interviewing a client who presents with multiple injuries that are
consistent with intimate partner abuse. After establishing trust and rapport, which
of the following should the nurse say?
Answer: “has you partner physically hurt you before?”
A nurse is caring for a client who reports pain. Which of the following laboratory
findings indicates myocardial damage?
Answer: Troponin I 1.8ng/mL
A nurse is caring for a client who is prescribed furosemide. The nurse understands
this medication is used to treat which of the following client conditions?
Answer: Rales in lower lobes of lungs
A nurse manager at a public health clinic is concerned about the rising number of
sexually transmitted infections in the community of which of the following is to
generate new ideas to address the public health concern?
Answer: A brainstorming session with nurses
A nurse on a medical-surgical unit is caring for a group of clients. Which of the
following clients would benefit from a three-way indwelling catheter?
Answer: A female client who is prone to development of blood clots in the urine

A nurse manager is presenting information to the nursing staff regarding the
appropriate use of the client restraints. Which of the following should the nurse
include?
Answer: The nurse should pad the bony prominences/ The nurse should remove
the restraints every 2hrs/ The provider’s prescription should include the type of
restraints to use
A nurse supervisor receives notification of a disaster in the community and the
possibility for multiple admissions to eh facility. Which of the following clients
should the nurse recommend for discharge?
Answer: A client who is 1-day postoperative laparoscopic cholecystectomy
whose temperature is 37.7 C
A nurse is admitting a client who has chronic gout. The nurse anticipates which of
the following provider prescriptions?
Answer: Allopurinol
A nurse is caring for a client who is 2 days postoperative following a lumber
laminectomy and is reporting nausea. Which of the following actions should the
nurse take first?
Answer: Administer an antiemetic
A nurse in the recovery room is a client who has a new tube. The nurse finds that
the water seal is no longer tidaling. The nurse should identify these finding as
resulting from which of the following?
Answer: Tubing may be kinked
A nurse is planning for a group of clients. Which of the following tasks is
appropriate for the nurse to delegate to the assistive personnel AP?
Answer: Measure I&O for a client who is receiving peritoneal dialysis Transfer
the client from bed to chair with mechanical lift provide postmortem care on a
client who experienced cardiac arrest

An assistive personnel (AP) at a long-term care facility reports to the nurse that
another AP has spent the entire morning on the phone and has not completed the
morning assignment. Which of the following is an appropriate action by the
nurse?
Answer: Ask the AP what work remains to be completed on the assignment
A community health nurse is completing a newborn home visit and observes
family members smoking cigarettes in the house. Which of the following is a
priority intervention?
Answer: Suggest smoking cessation strategies to family members
A nurse is teaching a prenatal class about evidence of effective breastfeeding to a
group of parents. Which of the following information should be included?
Answer: • Newborn swallowing sounds are audible while breastfeeding
• Newborns’ stools are yellow and seedy after 7 days of breastfeeding
• Maternal breasts become soft following feedings
A nurse is caring for a client who will be having a transfusion of platelets. The
nurse recognizes that the ___ outcome of ____ will be which of the following?
Answer: Decrease in bleeding from puncture sites
A nurse in a prenatal clinic is caring for an adolescent client is now in her third
trimester of pregnancy. The nurse identifies that the client is at an increased risk
for the which of the following?
Answer: Postpartum depression
A nurse is planning dietary intervention for a client who is immobile due to pelvic
and femur fractures. Which of the following should the nurse include in the plan?
Answer: Provide a high-protein diet
A home health nurse is providing teaching about self-administration of insulin to
a client who is newly diagnosed with DM. Which of the following statements by
the client a need for further teaching?
Answer: I will gently massage the injection site following administration

A school nurse is assessing a child who has scabies. Which of the following is an
expected finding?
Answer: Red, itchy papules on the child’s groin area
A nurse is caring for a client who is postoperative and at risk for development of
DVT. Which of the following should the nurse identify as increasing the risk of
developing venous stasis?
Answer: Prolonged bed rest
A nurse is caring for a client who is receiving enteral nutrition. Which of the
following findings indicates a need to decrease the rate of the enteral feeding?
Answer: Constipation
A nurse is assessing a client 1 week after a successful bone marrow transplant.
The client reports peeling of skin on her hands and feet. The nurse should
recognize ___ this desquamation as an indication of which of the following
complications?
Answer: Graft-versus-host disease
A nurse is providing education to the mother of a toddler who has pertussis. which
of the following statements by the parent indicates the teaching has been
effective?
Answer: If I get pregnant, I should check with my provider about receiving a
pertussis booster.
A nurse at the family planning clinic triages several clients over the phone. Which
of the following clients should the nurse instruct to come to the clinic?
Answer: A client who has started taking oral contraceptives and is experiencing
bright red vaginal breakthrough bleeding
A nurse in a pediatric unit is caring for a group of clients. For which of the
following diseases should the nurse implement droplet precautions?
Answer: pertussis

A nurse is planning the discharge of an infant who has tetralogy of Fallot. The
nurse anticipates the need for which of the following equipment?
Answer: Pulse oximeter
A nurse is admitting a client to the medical-surgical unit. Which of the following
actions should the nurse take first?
Answer: Observe the client’s level of mobility
A charge nurse on a paediatric unit is making assignments for a float nurse from
the medical unit. Which of the following clients is appropriate to assign to the
float nurse?
Answer: A 10-year-old client who has pneumonia and is receiving respiratory
treatments
A nurse in a residential mental health facility is planning care for a new client
who has OCD. Which of the following is appropriate for the nurse to include in
the plan of care?
Answer: Gradually decrease the time allowed for ritualistic behavior
A nurse delegates tasks to an LPN and AP. When admitting a client who is
experiencing acute liver failure and who has ascites and an NG tube, which of the
following tasks is most appropriate for the nurse to delegate to the LPN?
Answer: Measure the amount of gastric drainage every 2 hr.
A nurse is preparing to provide discharge teaching to a client who has an ileal
conduit due to treatment for bladder cancer. Which of the following instructions
should the nurse include in the teaching?
Answer: cleanse the skin around the stoma with a moisturizing soap
A nurse is caring for a client who has cirrhosis of the liver. Which of the
following actions by the nurse is appropriate?
Answer: Monitor for abdominal ascites

A nurse is providing teaching to the parent of a child who has pediculosis capitis.
Which of the following information should be included in the teaching?
Answer: Store non-washable items in plastic bags for 14 days
A nurse is teaching a client who has left-leg weakness how to use a standard
walker. Which of the following actions by the client indicates a need for further
teaching?
Answer: Places the walker 2 feet forward with each step
A nurse is caring for a client who has just returned to the unit following a
bronchoscopy. Which of the following actions by the assistive personnel AP
requires the nurse to intervene?
Answer: Offers oral fluids to the client
A nurse is caring for a client who is 2 hr postoperative following an ileal conduit
procedure for bladder cancer. For which of the following finding should the nurse
notify the provider?
Answer: A dusky-colored stoma
A nurse is providing teaching for the parents of a school-age boy who has
hemophilia. The parents tell the nurse that the child loves soccer. The child is
adamant about playing with his peers on the school team next year, and the
parents state that, “We are unable to say anything to convince him that ___ is
impossible.” Which of the following is an appropriate suggestion?
Answer: Encourage the child to be involved with the soccer team as the coach’s
assistant or team manger
A nurse is taking care of a client who has a diagnosis of HIV. Which of the
following client statement should the nurse address first?
Answer: I am lonely because I don't have anyone to talk to you.
A nurse is caring for a client who has I left femur fracture is a skeletal traction.
The client reports pain due to muscle spasms in the affected leg. Which of the
following action is appropriate by the nurse?

Answer: Increase the amount of traction
A nurse educator is discussing about modes of transmission with nursing students.
Which of the following should the nurse educator include as an example of
vector-borne transmission?
Answer: Transmission of West Nile Virus from a mosquito bite
A nurse is creating an activity plan for a home-bound older adult client. In the
planning the nurse considers the physiologic changes that may affect pulmonary
function related to the normal aging process. Which of the following age-related
physiologic changes should the nurse consider in the plan?
Answer: Decreased blood oxygenation
An emergency department nurse triages a group of school children injured in a
school bus crash. Which of the following children should the nurse have the
provider evaluate first?
Answer: A child who reports diplopia and nausea and was unconscious at the
scene but is now awake
A nurse plans to ambulate a client on the third day after cardiac surgery. Which of
the following interventions should the nurse take so that the client will best
tolerate ambulation?
Answer: Premedicate the client with the prescribed analgesic
A nurse is electronically documenting assessment findings for a client. Which of
the following is an example of subjective data?
Answer: The client reports a pain level of 6 on a scale from 0 to 10
A nurse notice smoke coming from a client’s room and discovers a fire in the
wastebasket. After moving the client to safety, which of the following is the
priority action?
Answer: Close the fire doors on the unit

A nurse is caring for a client who has a diagnosis of antisocial personality
disorder. The nurse should expect the client to demonstrate which of the
following?
Answer: Poor impulse control
A client who has a diagnosis of complete placenta previa is admitted to the labor
and delivery suite at 36 weeks gestation with contractions 5 min in frequency and
1 in in duration. Which of the following actions should the nurse take?
Answer: Prepare the client for a cesarean section
A nurse is planning care for a child who is unresponsive and increased ICP.
Which of the following actions should the nurse take?
Answer: Pad the side rails of the bed
A nurse is planning care for a client who takes haloperidol ___ the treatment of
schizophrenia. Which of the following should the nurse include in the plan of
care?
Answer: Screen the client for tardive dyskinesia
A nurse is caring for a client who was involved in a motor-vehicle crash. The
client reports shortness of breath and chest pain and asks the nurse, “Am I
dying?” Which of the following actions should the nurse take first?
Answer: Obtain a pulse oximetry reading
A nurse is caring for a client who is receiving gentamicin. Which of the following
findings indicates the client is developing toxicity?
Answer: Tinnitus
A nurse is caring for a client who has just given birth to a stillborn newborn.
Which of the following is the priority task for the nurses to facilitate the client’s
grief process?
Answer: Acknowledging the reality of the newborn’s death

A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux
disease. Which of the following instructions should the nurse include in the
teaching?
Answer: Sleep with the head of bed elevated
A nurse is caring for a client who has atypical depression and is taking
phenelzine. Which of the following is appropriate for the nurse to offer as an
evening snack?
Answer: Low fat yogurt
A nurse is admitting an infant who has bacterial meningitis. Which of the
following actions should the nurse take first?
Answer: Administer cefazolin
A client asks the nurse if it is safe for him to take a glucosamine supplement. The
nurse should assess for which of the following potential contraindications?
Answer: Shellfish allergy
A nurse is analyzing the cardiac rhythms of four telemetry clients in the coronary
care unit. Identify the rhythm strip that the nurse should recognize as indicative of
a client who should be receiving warfarin.
Answer: rhythm C
A nurse in a postpartum unit is caring for several clients. After receiving a change
of shifassess first?
Answer: A client who is 3 days postpartum and has not had a bowel movement
since prior to admission
A nurse is teaching a family about hospice care. Which of the following
appropriate for the nurse to include in the teaching?
Answer: Hospice care encourages the family to coordinate health care services
An infection control nurse is reviewing care procedures for four clients. Which of
the following requires the nurse to intervene?

Answer: A client who has pulmonary TB is placed in a positive pressure room.
A nurse is caring for a client who is at high risk for developing diabetes insipidus
following a severe head injury. Which assessment finding indicates to the nurse
that the client is developing DI?
Answer: Urine output of 250ml/hr
A nurse is providing teaching for the client who has a new prescription for lithium
carbonate. Which of the following should the nurse include the teaching?
Answer: Diarrhea is an indication of toxicity.
A nurse is caring for a client who is receiving a blood transfusion at 125ml/hr and
develops a hemolytic reaction. Which of the following actions should the nurse
perform?
Answer: Infuse 0.9% sodium chloride IV
A nurse is caring for an adolescent client who has no previous history of a seizure
disorder___ admitted after having a 3-minn tonic-clonic seizure 2 weeks after
sustaining a mild concussion. The client is scheduled to have an
electroencephalogram (EEG) in the morning. For breakfast, the client orders
coffee and a donut. Which of the following nursing actions is appropriate at this
time?
Answer: Explain that the client may not have coffee prior the EEG
At the beginning of the ____ shift, a team leader delegates the following tasks to
the assistive personnel (AP) have four clients, distribute fresh water and obtain
the morning vital signs. At noon, the nurse asks the AP to transport one client to
physical therapy. The AP reports two clients still need bed baths. Which of the
following is an appropriate strategy for the nurse to delegate more effectively in
the future?
Answer: Set a clear time from for the completion of each task

A nurse is planning care for a client who is comatose and has a stage II decubitus
ulcer on the coccyx. Which of the following interventions is appropriate to
include in the plan of care?
Answer: Provide the client with an alternating pressure mattress
A nurse is preparing a client for surgery and has just administered the
preoperative injection. Which of the following actions should the nurse take?
Answer: Raise the side rails on the bed
A nurse is performing postmortem care on an older adult client. Which of the
following action is appropriate to take?
Answer: Lower the head of the bed to a supine position
A nurse in the emergency department is caring for a client following a motorvehicle crash. Which of the following actions should the nurse take first?
Answer: Stabilize the cervical spine
A nurse is reviewing the employee health program for new employees. Which of
the following diagnostic assessments should the nurse recommend for all new
employees to screen for the presence of TB?
Answer: Mantoux test
A nurse volunteers to assist after witnessing a mass casualty incident involving a
train derailment. Which of the following clients should the nurse immediately and
completely immobilize?
Answer: A client who has a Glasgow Coma Score of 4
A nurse in a newborn nursery is performing assessments on four neonates that are
all less than 24 hr old. The nurse should plan to notify the provider of which of
the following findings?
Answer: Pinna below the outer canthus of the eye
A nurse is providing dietary teaching for a client who has a history of
nephrolithiasis. Which of the following is appropriate to include in the teaching?

Answer: Restrict dietary calcium intake
A nurse is caring for a client who reports difficulty falling asleep at night. Which
of the following suggestions should the nurse recommend?
Answer: Eat a bedtime snack containing carbohydrates
An immunity health nurse is planning to make home visits to several clients who
all live within a few miles’ radius of the office. Which of the following clients
should the nurse plan to visit first?
Answer: A legally blind client who has diabetes mellitus and whose insulin
syringes need to be prefilled for the coming week.
A nurse is teaching a client who has a new prescription for digoxin. Which of the
following should the nurse include in the teaching?
Answer: “Notify your provider if you experience muscle weakness.”
A nurse is caring for a client who is receiving IV antibiotics and tests positive for
C. difficle. Which of the following action by the nurse is appropriate?
Answer: Place the client on contact precautions
A charge nurse is creating assignments for the next shift for several nurses and
one of the nurses is pregnant. Which of the following clients should the charge
nurse assign to a nurse who is not pregnant?
Answer: An 80-year-old client who has alcoholic pancreatitis and is being treated
for impetigo
A nurse in an inpatient psychiatric unit is setting short-term goals for an
adolescent client who was admitted for treatment of anorexia nervosa. Which of
the following is an appropriate short-term goal the nurse should set?
Answer: The client will develop a personalized meal plan.
A nurse is caring for a preschool-age child who has a short leg, plaster cast
applied 1 hr ago. Which of the following is an appropriate interventions?
Answer: Support the affected leg on a pillow.

A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of
gestation and is receiving oxytocin for the augmentation of labor. The nurse
should decrease the infusion rate for which of the following findings?
Answer: Consistent contractions last 80 seconds.