2019 ATI RN Capstone, Proctored, Comprehensive Exam With Answers-234 Solved Questions

RN ATI Capstone Proctored Comprehensive
Assessment 2019 A Latest Update
Comprehensive Exam (South University)

RN ATI Capstone Proctored Comprehensive Assessment 2019 A
1. A nurse is teaching a client who has a new prescription for metformin extended-release
tablets. Which of the following statements by the client indicates an understanding of the
teaching?
A. I will avoid crushing this medication
B. I'll switch to a lactose-free formula
C. I will avoid taking this medication with food
Answer: A. I will avoid crushing this medication
2. A nurse is assessing a client who is receiving enteral feeding via an NG tube. The client has
developed hyperosmolar dehydration. Which of the following actions should the nurse take
when administering the client's findings?
A. Empty your ostomy pouch when it is half full
B. Switch to a lactose-free formula
C. Increase the rate of feeding
Answer: B. Switch to a lactose-free formula
3. A nurse is teaching the parents of a school-age child who has sickle cell anemia about
managing the disease at home. Which of the following instructions should the nurse include?
A. Apply cold compresses to painful areas
B. Ensure your child drinks plenty of fluids
C. Give your child iron supplements daily
Answer: B. Ensure your child drinks plenty of fluids
4. A nurse is teaching about the safe handling of formula to a client who is postpartum and
chooses to bottle-feed her newborn. Which of the following statements by the client indicates
an understanding of the teaching?
A. I should boil tap water for 2 minutes before I mix it with powdered formula

B. I should use sterile water when I mix it with powdered formula
C. I should boil the formula for 2 minutes before feeding it to my baby
Answer: A. I should boil tap water for 2 minutes before I mix it with powdered formula
5. A nurse is assessing a child who is post-operative following a tonsillectomy. Which of the
following findings should the nurse identify as the priority?
A. During this test, I will punch a button if the baby moves
B. Frequent swallowing
C. Complaints of throat pain
Answer: B. Frequent swallowing
6. A nurse is teaching a client who is pregnant about non-stress testing. Which of the
following statements by the client indicates an understanding of the teaching?
A. During this test, I will punch a button if the baby moves
B. During this test, I will punch a button if I feel stressed
C. During this test, I will punch a button if I experience contractions
Answer: A. During this test, I will punch a button if the baby moves
7. A nurse is monitoring a client who is receiving a transfusion of packed RBC's. The client
reports chills, headaches, low back pain, and a feeling of tightness in his chest. The nurse
should identify that the client has developed which of the following types of transfusion
reactions?
A. Pudendal nerve block
B. Acute hemolytic
C. Delayed hemolytic
Answer: B. Acute hemolytic
8. A nurse is caring for a client who is in the latent phase of labor and reports severe back
pain. The vaginal examination reveals that the cervix is dilated two centimeters, 25% effaced,
and -2 station. Which of the following interventions should the nurse implement?
A. You should wear a snug-fitting bra continuously for 72 hours
B. Request the provider prescribe a pudendal nerve block
C. Apply warm compresses to the lower abdomen
Answer: B. Request the provider prescribe a pudendal nerve block

9. A nurse is teaching about how to suppress lactation with a client who is postpartum and
bottle-feeding her newborn. Which of the following instructions should the nurse include in
the teaching?
A. You should wear a snug-fitting bra continuously for 72 hours
B. Room number
C. Frequency of diaper changes
Answer: A. You should wear a snug-fitting bra continuously for 72 hours
10. A nurse is preparing to administer medication to a client. What are the following
identifiers should the nurse use to identify the client?
A. Room number
B. MRN (Medical Record Number)
C. Date of birth
Answer: B. MRN (Medical Record Number)
11. A nurse is caring for a client who is taking antihypertensive medication and is moving
from a supine to a seated position. Which of the following findings should indicate to the
nurse that the client is experiencing orthostatic hypotension?
A. The client's systolic blood pressure decreases by 25 mmHg
B. The client's systolic blood pressure increases by 35 mmHg
C. The client's diastolic blood pressure decreases by 15 mmHg
Answer: A. The client's systolic blood pressure decreases by 25 mmHg
12. While a nurse is caring for a client who is receiving mechanical ventilation via an
endotracheal tube, the high-pressure alarm of the ventilator sounds. Which of the following
actions should the nurse take?
A. Look for a block in the tube's cuff
B. Look for a leak in the tube's cuff
C. Increase the ventilator rate
Answer: B. Look for a leak in the tube's cuff
13. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the
following actions should the nurse take first?

A. Monitor vital signs every hour throughout the transfusion
B. Position the sterile drape leaving the perineum exposed
C. Provide the client with pain medication
Answer: B. Position the sterile drape leaving the perineum exposed
14. A nurse is planning to administer packed RBC's to an older adult client who has a low
hemoglobin level. Which of the following actions should the nurse plan to take?
A. Monitor vital signs every hour throughout the transfusion
B. Monitor respiratory rate every hour throughout the transfusion
C. Administer pain medication before starting the transfusion
Answer: A. Monitor vital signs every hour throughout the transfusion
15. A new nurse in an acute mental health facility is teaching a client about potential adverse
effects of transcranial magnetic stimulation. The nurse tells the client that he might feel lightheaded but that it should not affect his memory. The nurse is demonstrating which of the
following ethical principles?
A. Beneficence
B. Non-maleficence
C. Justice
Answer: A. Beneficence
16. A nurse is teaching a class about providing care within the legal scope of practice to a
group of nurses. The nurse should include that which of the following procedures is outside
the legal scope of practice for an RN?
A. Irrigation of the external ear canal
B. Irrigation of the inferior ear canal
C. Irrigation of the middle ear canal
Answer: A. Irrigation of the external ear canal
17. A nurse in an acute care facility is caring for a client who has anorexia nervosa. During
the first week of care, which of the following actions should the nurse take?
A. Observe the client for 1 hour after meals
B. Observe the client for 6 hours after meals
C. Encourage the client to eat alone

Answer: A. Observe the client for 1 hour after meals
18. A nurse is planning care for a client who has sciatica and a prescription for a
transcutaneous electrical nerve stimulation (TENS) unit. Which of the following referrals
should the nurse anticipate for the client?
A. Primary Care Provider
B. Physical therapist
C. Occupational therapist
Answer: B. Physical therapist
19. A nurse is teaching a client who has generalized anxiety disorder about ways to help
manage stress. Which of the following instructions should the nurse give the client about
using Progressive relaxation?
A. Rest the muscle group, then release tension and move to the next one
B. Tighten the muscle group, then release tension and move to the next one
C. Flex the muscle group, then release tension and move to the next one
Answer: B. Tighten the muscle group, then release tension and move to the next one
20. A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe
abdominal pain with moderate vaginal bleeding and persistent uterine contraction. The
client's blood pressure is 88 over 50 mmHg, and her abdomen is rigid. The nurse should
identify these findings as indicating which of the following complications?
A. Placenta discharge
B. Placenta abruption
C. Placenta previa
Answer: B. Placenta abruption
21. A home health nurse is planning care for an older adult client who has a vision loss and
takes medication throughout the day. Which of the following actions should the nurse include
in the plan?
A. Use container lids of different shapes to indicate times of administration
B. Use container lids of different colors to indicate times of administration
C. Use container lids of different sizes to indicate times of administration
Answer: A. Use container lids of different shapes to indicate times of administration

22. A nurse at an acute care facility is teaching a client about fall risk prevention strategies for
use during their stay at the facility. Which of the following statements by the client indicates
an understanding of the teaching?
A. "I will wear call for help, so everyone knows I'm at risk for falling"
B. "I will wear a yellow wristband, so everyone knows I'm at risk for falling"
C. "I will wear a blue wristband, so everyone knows I'm at risk for falling"
Answer: B. "I will wear a yellow wristband, so everyone knows I'm at risk for falling"
23. A nurse is caring for a client who is taking disulfiram for alcohol-use disorder and reports
ingestion of alcohol. For which of the following adverse effects should the nurse monitor?
A. Headache
B. Hypertension
C. Hypoglycemia
Answer: A. Headache
24. A nurse at the health department is providing anticipatory guidance to a parent of a onemonth-old infant. The nurse should inform the parent that the infant should receive which of
the following immunizations at the age of two months?
A. C. Diff
B. Rotavirus
C. Meningococcal
Answer: B. Rotavirus
25. A Nurse is assisting in the selection of foods for a client who has dysphagia caused by a
stroke. Which of the following foods should the nurse recommend?
A. Fish
B. Scrambled eggs
C. Nuts and seeds
Answer: B. Scrambled eggs
26. A community health nurse is providing education to a group of older adults about
immunizations. Which of the following immunizations should the nurse recommend?
A. Tdap

B. HIV
Answer: A. Tdap
27. A nurse is caring for a client who is postoperative following a mitral balloon
valvuloplasty. Which of the following areas should the nurse auscultate to assess for mitral
areas of the heart? (you will find hot spots to select in the artwork below. Select only the hot
spot that corresponds to your answer.)
A. Aortic
B. Tricuspid
C. Mitral
Answer: C. Mitral
28. A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The
nurse should plan to administer which of the following medications?
A. Flumazenil
B. Furosemide
Answer: A. Flumazenil
29. A nurse is admitting a client to the medical-surgical unit. The patient self-determination
act requires the nurse to perform which of the following actions during the admission
process?
A. Document in the client's medical record if a client has advance directives
B. Document in the client's medical record if a client has PCP directives
Answer: A. Document in the client's medical record if a client has advance directives
30. A nurse is assessing a client who is postoperative following orthopedic surgery. Which of
the following findings should the nurse identify as an indication of paralytic Ileus?
A. Abdominal dissection
B. Abdominal distension
Answer: A. Abdominal distension
31. A nurse is performing an admission assessment of a school-age child with spina bifida.
The parents state that the child is allergic to latex. The nurse should assess further for crosssensitivity to which of the following foods?

A. Tomatoes
B. Bananas
C. Strawberries
Answer: B. Bananas
32. A nurse is planning care for a client at 32 weeks of gestation with severe preeclampsia.
Which of the following actions should the nurse plan to take?
A. Ensure that the bed is flat
B. Ensure that the side rails are down on the client's bed
C. Ensure that the side rails are up on the client's bed
Answer: C. Ensure that the side rails are up on the client's bed
33. A nurse is documenting admission data for a client in an acute care facility. Which of the
following actions should the nurse take?
A. Clarify medical issues with PCP
B. Note whether the client has a living will
C. Administer prescribed medications
Answer: B. Note whether the client has a living will
34. A client on an acute mental health unit says to a nurse, "Tie a bow. Row the boat. Now I
know. Whoa! I see you." The nurse should document that the client is exhibiting which of the
following speech alterations?
A. Stress association
B. Clang association
C. Loose association
Answer: B. Clang association
35. A nurse is caring for a client with Crohn's disease. The nurse calculates that the client's
BMI is 17.2. The nurse should document that the client's weight status is within which of the
following categories?
A. Normal weight
B. Overweight
C. Underweight
Answer: C. Underweight

36. A nurse is planning post-operative care for a client who is scheduled for a thoracotomy
with chest tube placement. Which of the following pieces of equipment should the nurse plan
to have at the client's bedside?
A. Tracheostomy tray
B. Bedside commode
Answer: A. Tracheostomy tray
37. A nurse is providing discharge teaching to a client who has GERD. Which of the
following information should the nurse include?
A. Avoid consuming foods containing potassium
B. Avoid consuming foods containing chocolate
Answer: B. Avoid consuming foods containing chocolate
38. A nurse is part of a task force planning to audit a facility's nursing unit concerning
adherence to hand hygiene protocols. Which of the following steps should the task force take
first?
A. Determine the accepted standards for hand hygiene
B. Determine the accepted standards for ambulation
Answer: A. Determine the accepted standards for hand hygiene
39. A nurse is planning educational materials for a client who has a new pacemaker. Which of
the following information should the nurse include?
A. Keep mobile phones 4 inches from the pacemaker generator
B. Keep mobile phones 6 inches from the pacemaker generator
Answer: A. Keep mobile phones 4 inches from the pacemaker generator
40. A nurse is providing discharge teaching to a client who is 1-day postoperative following a
right modified radical mastectomy. Which of the following instructions should the nurse
include in the teaching?
A. Avoid using the affected arm for eating
B. Explain how early ambulation is recommended
Answer: A. Avoid using the affected arm for eating

41. A nurse is planning care for a client prior to an amniocentesis. Which of the following
actions should the nurse include in the plan of care?
A. Monitor the fetal heart rate throughout the procedure
B. Monitor the patient's LOC throughout the procedure
C. Monitor the maternal blood pressure throughout the procedure
Answer: A. Monitor the fetal heart rate throughout the procedure
42. A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the
following findings indicates to the nurse that the toddler has a developmental delay?
A. Runs with a wide stance
B. Runs with a bi-lateral stance
C. Walks on tiptoes
Answer: A. Runs with a wide stance
43. A nurse is caring for a client following an involuntary admission to an acute mental health
facility. The client states, "I'm afraid they will give me drugs that put me to sleep." Which of
the following statements should the nurse make?
A. "What medications have you previously taken to help you sleep?"
B. "Why do you think your provider will prescribe you medications that will make you
sleep?"
C. "Don't worry, the medications we use here won't make you sleep."
Answer: B. "Why do you think your provider will prescribe you medications that will
make you sleep?"
44. A nurse in an emergency department is administering naloxone to a client who had a
heroin overdose. The nurse should identify which of the following assessment findings as an
indication that the medication is reversing the effects of the opioid overdose?
A. Increased respiratory rate
B. Decreased respiratory rate
C. Increased blood pressure
Answer: A. Increased respiratory rate
45. A nurse is caring for a client who is preoperative for cataract removal. Which of the
following statements by the client indicates an understanding of the procedure?

A. "I can expect my eyelids to be bruised after this procedure"
B. "I can expect my eyelids to be swollen after this procedure"
C. "I can expect my vision to improve immediately after this procedure"
Answer: A. "I can expect my eyelids to be bruised after this procedure"
46. A nurse is planning care for a client who is undergoing brachytherapy for a low dose
radiation implant for treatment of prostate cancer. Which of the following interventions
should the nurse include in the client's plan of care?
A. Encourage each of the client's visitors to stay 4-6 hours per day
B. Limit each of the client's visitors to two hours per day
Answer: B. Limit each of the client's visitors to two hours per day
47. A nurse is teaching a client about using transdermal scopolamine to treat motion sickness.
Which of the following instructions should the nurse include?
A. Apply the patch at the same location
B. Apply the patch prior to traveling
Answer: B. Apply the patch prior to traveling
48. A nurse is admitting a school-age child who has bacterial meningitis. Which of the
following types of isolation precautions should the nurse initiate?
A. Droplet
B. Contact
Answer: A. Droplet
49. A nurse is planning assignments for an upcoming shift. Which of the following tasks
should the nurse delegate to an assistive personnel? (Select all that apply.)
A. Record a client's intake after each meal
B. Transfer a client to physical therapy
C. Obtain the client's vital signs every 4 hours
D. Notify PCP client's morning weight
Answer: A. Record a client's intake after each meal; B. Transfer a client to physical
therapy; C. Obtain the client's vital signs every 4 hours

50. A nurse is interpreting a cardiac rhythm strip from a client who has recurrent episodes of
syncope. Which of the following images indicates the client has atrial fibrillation?
A. First Rhythm
B. Second Rhythm
Answer: A. First Rhythm (Second Rhythm is Atrial Flutter)
51. A community health nurse is planning an educational program on Lyme disease for the
general public. Which of the following statements should the nurse include in the program?
A. Remove embedded Ticks by squeezing the body with tweezers
B. Remove embedded Ticks by squeezing the body with light pressure
Answer: A. Remove embedded Ticks by squeezing the body with tweezers
52. A nurse is admitting a client to the medical-surgical unit. The patient self-determination
act requires the nurse inform which of the following actions during the admission process?
A. Document in the client's medical records if the client has advance directives
B. Document in the client's medical records if the client has a living will
Answer: A. Document in the client's medical records if the client has advance directives
53. A nurse is teaching a client how to care for his behind the ear hearing aid. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I'll disconnect the battery when I remove my hearing aids"
B. "I'll lower the sound level of my hearing aids at night"
Answer: A. "I'll disconnect the battery when I remove my hearing aids"
54. A nurse is caring for a client who is postpartum and expresses concern about how her
preschool-age son will react to having a baby sister. Which of the following strategies should
the nurse suggest?
A. Wait to introduce his new sister until he asks
B. Give your son a little gift from his new sister
Answer: B. Give your son a little gift from his new sister
55. A nurse is teaching a class about using niacin to reduce LDL cholesterol. The nurse
should include in the teaching that which of the following conditions is a contraindication for
receiving this medication?

A. Active liver disease
B. Acute kidney disease
Answer: A. Active liver disease
56. A school nurse is using the Weber test to check a child. Which of the following actions
should the nurse take?
A. Place a vibrating tuning fork on the tips of the child's toes
B. Place a vibrating tuning fork on the top of the child's head
Answer: B. Place a vibrating tuning fork on the top of the child's head
57. A nurse is reviewing the medical record of a client who has a prescription for misoprostol
for induction of labor. Which of the following findings is a contraindication for
administration of this medication?
A. Inverse fetal lie
B. Transverse fetal lie
Answer: B. Transverse fetal lie
58. A nurse is reviewing the results of laboratory screenings for a nine-month-old infant.
Which of the following results should the nurse report to the provider?
A. Iron 74 mcg/dL
B. Calcium 9 mg/dL
Answer: A. Iron 74 mcg/dL
59. A nurse is teaching a client who has a new prescription for sertraline to treat depression.
For which of the following findings should the nurse instruct the client to monitor and report
immediately as indicating serotonin syndrome?
A. Excessive sweating
B. Dry skin
Answer: A. Excessive sweating
60. A community health nurse is developing a plan of care for an older adult client who has
Type 2 diabetes mellitus and lives independently in a rural area. Which of the following
interventions should the nurse include?
A. Instruct the client about the use of Telehealth services

B. Instruct the client about the use of direct family services
Answer: A. Instruct the client about the use of Telehealth services
61. A nurse in a provider's office is monitoring the laboratory results of a client who has type
1 diabetes mellitus. Which of the following results indicates acceptable glycemic control for
the client?
A. HbA1c 6.8%
B. HbA1c 22%
Answer: A. HbA1c 6.8%
62. A nurse is providing dietary teaching to the guardian of a preschooler who has celiac
disease. Which of the following foods should the nurse recommend including in the
preschooler's diet?
A. A corn tortilla with black beans
B. Low-protein powder
Answer: A. A corn tortilla with black beans
63. A nurse is caring for a client who has a peritoneal catheter that requires a dressing change.
Identify the sequence of actions the nurse should take.
A. Mask self and the client
B. Remove the old dressing
C. Create a sterile field
D. Cleanse the site with povidone-iodine
E. Apply precut gauze pads to the site
Answer: Correct sequence:
B. Remove the old dressing
D. Cleanse the site with povidone-iodine
C. Create a sterile field
E. Apply precut gauze pads to the site
A. Mask self and the client
64. A case manager is performing a home visit for a client following a stroke. The client's
partner is providing care in the home. The client's partner states that she sometimes feels

exhausted. For which of the following referrals should the case manager recommend for the
caregiver?
A. Hospice care
B. Respite care
C. Despite care
Answer: B. Respite care
65. A nurse is reviewing the laboratory results of a client who is receiving Total Parenteral
Nutrition. Which of the following results should the nurse identify as an indication that the
client has developed a common complication of this nutritional therapy?
A. Capillary glucose 198 mg/dL
B. Capillary glucose 35 mg/dL
Answer: A. Capillary glucose 198 mg/dL
66. A nurse is teaching a newly licensed nurse about advance directives. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. Patient can resume control of health care after a temporary loss of competency
B. Patient needs to control health care before a temporary loss of competency
C. Patient can control health care only if they are currently competent
Answer: A. Patient can resume control of health care after a temporary loss of
competency
67. A nurse is assessing a client for an allergy before administering the Influenza vaccine. The
nurse should identify that an allergy to which of the following foods is a contraindication to
receiving this vaccine?
A. Eggs
B. Meat
C. Dairy
Answer: A. Eggs
68. A nurse is caring for a client who has deep vein thrombosis and a new prescription for an
anti-embolic stocking. Which of the following actions should the nurse take?
A. Measure the legs with a tape measure to determine stocking size
B. Measure the feet with a tape measure to determine stocking size

C. Use the client's shoe size to determine stocking size
Answer: A. Measure the legs with a tape measure to determine stocking size
69. A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids.
Which of the following actions should the nurse take?
A. Select a site proximal to previous venipuncture sites
B. Select a site distal to previous venipuncture sites
C. Select a site on the opposite arm from previous venipuncture sites
Answer: A. Select a site proximal to previous venipuncture sites
70. A charge nurse is evaluating a newly licensed nurse who is caring for a client who has
measles. Which of the following actions by the newly licensed nurse should the charge nurse
intervene?
A. The nurse wears an N95 respirator when performing client care
B. The nurse wears a gown when performing client care
C. The nurse wears gloves when performing client care
Answer: B. The nurse wears a gown when performing client care
71. A nurse is caring for a client who is 2 days postpartum. Which of the following findings
should the nurse report to the provider?
A. 1+ deep tendon reflexes
B. 4+ deep tendon reflexes
Answer: B. 4+ deep tendon reflexes
72. A nurse is observing an assistive personnel (AP) measure blood pressure from the right
arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in
the left arm of which of the following clients?
A. A client who had dialysis and is using an arteriovenous shunt in the left upper arm
B. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm
Answer: B. A client who had dialysis and is using an arteriovenous shunt in the left
lower forearm
73. A nurse is caring for a female client who requires bed rest and reports difficulty urinating
into a bedpan. Which of the following actions should the nurse take?

A. Turn on the faucet in the client's sink
B. Turn off the faucet in the client's sink
Answer: A. Turn on the faucet in the client's sink
74. A charge nurse observes smoke coming from a trash receptacle in the unit's waiting room.
Which of the following actions should the nurse take first?
A. Call code emergency
B. Evacuate clients from the area
Answer: B. Evacuate clients from the area
75. A nurse is caring for a client who has diabetic ketoacidosis. During the shift, the client
receives 0.45% sodium chloride IV at 500 mL over 3 hours, then at 200 mL/hour for 3 hours,
and then dextrose 5% in water at 75 mL/hour for 2 hours. What is the total volume the nurse
should document for the client's IV fluid intake? (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero.)
A. 1200 mL
B. 1250 mL
C. 1300 mL
Answer: B. 1250 mL
76. A nurse is teaching a client who is at 20 weeks of gestation about how to manage Harbor.
Which of the following instructions should the nurse include?
A. Eat a high-carb snack in the morning
B. Eat a high-fiber snack at bedtime
Answer: B. Eat a high-fiber snack at bedtime
77. A nurse is assessing a client who is taking Digoxin to treat chronic heart failure. Which of
the following findings should indicate to the nurse that the client is developing Digoxin
toxicity?
A. Blurred vision
B. Productive cough
Answer: A. Blurred vision

78. A charge nurse is observing an assistive Personnel perform delegated tasks. Which of the
following actions by the AP requires the charge nurse to intervene?
A. Washing hands with alcohol-based hand rub after bathing a client who has C. difficile
B. Washing hands with sterile hand rub after bathing a client who has
C. difficile
Answer: A. Washing hands with alcohol-based hand rub after bathing a client who has
C. difficile
79. A nurse is caring for four children in an emergency department. Which of the following
clients should the nurse assess first?
A. A child who has acute epiglottitis and is crying loudly
B. A child who has acute epiglottitis and is drooling
Answer: A. A child who has acute epiglottitis and is drooling
80. A nurse is reviewing the laboratory results of a client who is taking cyclosporine
following a kidney transplant. Which of the following findings should the nurse report?
A. Serum creatinine 1.6 mg/dL
B. Serum creatinine 1.01 mg/dL
Answer: A. Serum creatinine 1.6 mg/dL
81. A nurse is providing discharge instructions about newborn safety to a client who is 2 days
postpartum. Which of the following instructions should the nurse include?
A. Use a car seat when traveling by airplane.
B. No traveling by airplane.
Answer: A. Use a car seat when traveling by airplane.
82. A nurse is caring for a client who has major depressive disorder. The client tells the nurse,
"No one cares about me. I'm completely alone." Which of the following responses should the
nurse make?
A. "Can you give me an example of how others are making you feel this way?"
B. "Tell me why others are making you feel this way."
Answer: A. "Can you give me an example of how others are making you feel this way?"

83. A nurse on a medical-surgical unit is caring for a client who states that she plans to leave
the facility against medical advice. For which of the following actions by the nurse should the
charge nurse intervene?
A. Initiates a discussion with the client regarding her decision
B. Asks security to detain the client until the provider is notified
Answer: B. Asks security to detain the client until the provider is notified
84. A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The
nurse should tell the client she will undergo which of the following screening tests at 16
weeks of gestation?
A. Maternal serum alpha-fetoprotein
B. Maternal serum potassium
Answer: A. Maternal serum alpha-fetoprotein
85. A nurse is admitting a client who has schizophrenia and experiences occasional 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 these voices are talking to you?"
Answer: A. "Do you understand that the voices are not real?"
86. A nurse is planning care for a client who sustained a major burn over 20% of the body.
Which of the following interventions should the nurse include to support the client's
nutritional requirements?
A. Maintain protein intake at 1,500 per day
B. Maintain calorie intake at 1,500 per day
Answer: B. Maintain calorie intake at 1,500 per day
87. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict
about overtime requirements. Which of the following strategies should the charge nurse use
to promote effective negotiation?
A. Attempt to understand both sides of the issue
B. Separate clients
Answer: A. Attempt to understand both sides of the issue

88. A nurse is preparing to administer a NG tube feeding to a school-age child. Which of the
following actions should the nurse plan to take?
A. Measure the tubing from the nose to the distal port
B. Measure the tubing from the nose to the proximal port
Answer: A. Measure the tubing from the nose to the distal port
89. A nurse is developing a plan of care for a client who has preeclampsia and is to receive
magnesium sulfate via continuous IV infusion. Which of the following actions should the
nurse include in the plan?
A. Monitor the FHR via Doppler every 10 min
B. Monitor the FHR via Doppler every 30 min
Answer: B. Monitor the FHR via Doppler every 30 min
90. A nurse realizes that the wrong medication has been administered to a client. Which of the
following actions should the nurse take first?
A. Report to provider
B. Measure the client's vital signs
Answer: B. Measure the client's vital signs
91. 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. Anger
C. Drowsiness
Answer: A. Excessive sweating
92. A nurse is caring for a client who is postoperative and has a chest tube drainage system.
For which of the following findings should the nurse notify the provider?
A. Tidaling occurs when the client is breathing
B. Bi-tidaling occurs when the client is breathing
C. Tidaling occurs when the drainage chamber is level
Answer: A. Tidaling occurs when the client is breathing

93. A nurse is preparing to administer vancomycin IV to an adult. The client asks the nurse if
the medication can be given 2 hr earlier. Which of the following statements should the nurse
make?
A. "I can't start the medication any earlier."
B. "I can start the medication 15 min earlier."
C. "I can start the medication 30 min earlier."
Answer: C. "I can start the medication 30 min earlier."
94. A nurse in the emergency department is interviewing a client immediately following a
sexual assault. Which of the following actions should the nurse take first?
A. Determine a client's current stress level
B. Determine a client's current anxiety level
C. Determine a client's current pain level
Answer: B. Determine a client's current anxiety level
95. A nurse is caring for a client who has gestational hypertension and is experiencing toxic
effects due to magnesium sulfate therapy. The nurse should anticipate administering which of
the following medications?
A. Furosemide
B. Calcium gluconate
C. Hydralazine
Answer: B. Calcium gluconate
96. 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 their parent. Which of the following
conditions in the child's medical history should the nurse identify as a contraindication to the
procedure?
A. Hypertension
B. Oliguria
Answer: A. Hypertension
97. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after
receiving change-of-shift report. Identify the sequence of steps the nurse should follow when
delegating tasks to the APs. Put in order:

A. Review the skill level and qualifications of each AP
B. Monitor progress of tasks completion with each AP
C. Evaluate the APs' performance of each task
D. Communicate appropriate tasks to the APs with specific expectations
Answer: Correct Order: A. Review the skill level and qualifications of each AP, D.
Communicate appropriate tasks to the APs with specific expectations
B. Monitor progress of tasks completion with each AP
C. Evaluate the APs' performance of each task
98. A nurse is preparing to perform sterile wound irrigation and dressing change for a client.
Which of the following actions by the nurse indicates a break in surgical aseptic technique?
A. Balancing the bottle on the sterile basin while pouring the liquid
B. Balancing the bottle on the sterile basin while draining the liquid
Answer: A. Balancing the bottle on the sterile basin while pouring the liquid
99. 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. "We should establish our roles in the next session."
B. "We should establish our roles in the initial session."
Answer: B. "We should establish our roles in the initial session."
100. A nurse is caring for a client who is receiving intermittent enteral tube feeding. Which of
the following factors places the client at risk for aspiration?
A. A history of gastroesophageal reflux disease
B. A history of kidney disease
Answer: A. A history of gastroesophageal reflux disease
101. A nurse is caring for a client who is 4 hr postpartum. The client reports an urge to void
but is unable to void. Which of the following actions should the nurse take?
A. Encourage the client to attempt to void while using a Sitz bath
B. Encourage the client not to void while using a Sitz bath
Answer: Encourage the client to attempt to void while using a Sitz bath

102. A nurse is caring for a client who has preeclampsia and is experiencing a postpartum
hemorrhage. The nurse should expect the provider to prescribe which of the following
medications?
A. Oxytocin
B. Oxycodone
Answer: Oxytocin
103. A nurse is providing teaching to the parents of a newborn about newborn genetic
screening. Which of the following statements should the nurse include in the teaching?
A. "This test should be performed after your baby is 2 months old."
B. "This test should be performed after your baby is 24 hours old."
Answer: "This test should be performed after your baby is 24 hours old."
104. 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. Documenting communication with a provider in the progress notes of the client's medical
record
B. Documenting communication with previous nurses in the progress notes of the client's
medical record
Answer: Documenting communication with a provider in the progress notes of the
client's medical record
105. A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse assess first?
A. A client who has a hip fracture and a new onset of severe pain
B. A client who has a hip fracture and a new onset of tachypnea
Answer: A client who has a hip fracture and a new onset of tachypnea
106. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the
following actions should the nurse plan to take?
A. Secure the urinary catheter to the client's thigh
B. Secure the urinary catheter to the client's lower back
Answer: A. Secure the urinary catheter to the client's thigh

107. A nurse is planning care for a group of clients. Which of the following methods should
the nurse use to manage time effectively?
A. Gather supplies prior to completing a dressing change
B. Call nurses for help prior to completing a dressing change
Answer: A. Gather supplies prior to completing a dressing change
108. A nurse is preparing to assist the provider with a paracentesis for a client who has
ascites. Which of the following actions should the nurse plan to take?
A. Have the client wait to void until after the procedure
B. Have the client void prior to the procedure
Answer: B. Have the client void prior to the procedure
109. A nurse is teaching a prenatal class about infection prevention 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 visit my nephew who has chickenpox 2 weeks after the sores have crusted."
Answer: A. "I can visit my nephew who has chickenpox 5 days after the sores have
crusted."
110. A nurse is caring for a school-age child who has sickle cell anemia and is in
vasoocclusive crisis. Which of the following actions should the nurse take?
A. Increase oral fluid intake
B. Decrease oral fluid intake
Answer: A. Increase oral fluid intake
111. A nurse is assessing a client who is 2 hr postpartum for uterine atony. Which of the
following actions should the nurse take?
A. Palpate the client's fundus
B. Palpate the client's dorsalis
Answer: A. Palpate the client's fundus
112. A nurse manager is reviewing documentation with a newly licensed nurse. Which of the
following notations by the newly licensed nurse indicate an understanding of the teaching?
A. "OOB with assistance for breakfast."

B. "OOB with assistance for voiding."
Answer: A. "OOB with assistance for breakfast."
113. A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best
predictor of future violence?
A. Previous violent behavior
B. Previous hallucinations
Answer: A. Previous violent behavior
114. A nurse is teaching a wellness class about depression for a group of older adult clients.
Which of the following information should the nurse include in the teaching?
A. Depression can be misdiagnosed as an abnormal disorder in older adult clients
B. Depression can be misdiagnosed as a neurocognitive disorder in older adult clients
Answer: B. Depression can be misdiagnosed as a neurocognitive disorder in older adult
clients
115. A nurse is assessing a client who is receiving morphine IV for pain. Which of the
following findings should the nurse report to the provider first?
A. BP 143/92 mm Hg
B. BP 80/40 mm Hg
Answer: B. BP 80/40 mm Hg
116. A nurse is providing discharge teaching to a client who is postoperative following
surgery for carpal tunnel syndrome. Which of the following statements by the client indicates
an understanding of the teaching?
A. "I should not use my affected hand for 2 to 4 weeks."
B. "I should not use my affected hand for 4 to 6 weeks."
C. "I should not use my affected hand for 6 to 8 weeks."
Answer: B. "I should not use my affected hand for 4 to 6 weeks."
117. A nurse is using an IV pump for a newly admitted client. Which of the following actions
should the nurse take?
A. Check the cords of the IV pump for fraying

B. Check the cords of the IV pump for blocking
C. Check the IV tubing for kinks
Answer: A. Check the cords of the IV pump for fraying
118. A nurse is planning care for a client who has unilateral paralysis and dysphagia
following a right hemispheric stroke. Which of the following interventions should the nurse
include in the plan?
A. Place the client's right arm on a pillow while he is sitting
B. Place both arms on a pillow while he is sitting
C. Place the client's left arm on a pillow while he is sitting
Answer: C. Place the client's left arm on a pillow while he is sitting
119. A nurse on a pediatric unit is preparing to insert an IV catheter for a 7-year-old child who
is dehydrated. Which of the following actions should the nurse take?
A. Tell the child there will be discomfort during the catheter insertion
B. Tell the child there will be nausea during the catheter insertion
C. Tell the child there will be itching during the catheter insertion
Answer: A. Tell the child there will be discomfort during the catheter insertion
120. A nurse is caring for a client who has acute glomerulonephritis. The nurse should
identify that which of the following findings is the priority?
A. BUN 24 mg/dL
B. BUN 19 mg/dL
C. BUN 15 mg/dL
Answer: A. BUN 24 mg/dL
121. A nurse is assessing a client who is postoperative and has a history of pulmonary
embolism. Which of the following findings is the priority for the nurse to report to the
provider?
A. Hypotension
B. Shortness of breath (SOB)
Answer: A. Hypotension

122. A nurse is reviewing the medical record of a client. Which of the following findings
should the nurse report to the provider?
A. Temperature
B. Vision change
Answer: A. Temperature
123. A nurse in the infectious disease division of the local health department is caring for a
client. Which of the following infections should be reported to the health department?
A. Chlamydia trachomatis
B. Multiple myeloma
Answer: A. Chlamydia trachomatis
124. A nurse in a family practice clinic is screening an adolescent client for idiopathic
scoliosis. Which of the following assessments should the nurse perform as part of this
screening?
A. Measure the peripheral rotation
B. Measure the truncal rotation
Answer: B. Measure the truncal rotation
125. A nurse is assessing an older adult client who had a left-sided stroke. Which of the
following findings should the nurse expect?
A. Expressive aphasia
B. Depressive aphasia
Answer: A. Expressive aphasia
126. A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the
following instructions should the nurse plan to include?
A. Provide a diet high in protein and carbs
B. Provide a diet high in protein and calories
Answer: Provide a diet high in protein and calories
127. A nurse is reviewing the medical records of four clients. The nurse should identify which
of the following client findings requires follow-up care?
A. A client who received a Mantoux test 2 hr ago and has an induration

B. A client who received a Mantoux test 48 hr ago and has an induration
Answer: A client who received a Mantoux test 48 hr ago and has an induration
128. 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 foods high in bran iron
B. Consume foods high in bran fiber
Answer: Consume foods high in bran fiber
129. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the
following interventions to prevent skin breakdown should the nurse include in the plan of
care?
A. Ask the client to shift his weight every few hours while sitting in a chair
B. Ask the client to shift his weight every 20 min while sitting in a chair
Answer: Ask the client to shift his weight every 20 min while sitting in a chair
130. A nurse is caring for a client who has bipolar disorder and is experiencing acute
manifestations. The nurse obtained a verbal prescription for mechanical restraints. Which of
the following actions should the nurse take?
A. Assess the client's peripheral pulse rate every 2 hours
B. Assess the client's peripheral pulse rate every 30 min
Answer: Assess the client's peripheral pulse rate every 30 min
131. A nurse is teaching a guardian of an adolescent who has mild persistent asthma and a
new prescription for maintenance prednisone. Which of the following statements by the
guardian indicated an understanding of the teaching?
A. "This medication can decrease my son's risk for infection."
B. "This medication can increase my son's risk for infection."
Answer: B. "This medication can increase my son's risk for infection."
132. A charge nurse is teaching a group of newly licensed nurses about the correct use of
restraints. Which of the following examples should the charge nurse include in the teaching?
A. Keeping the side-rails of a toddler's crib elevated
B. Keeping the side-rails of a toddler's crib locked

Answer: A. Keeping the side-rails of a toddler's crib elevated
133. A nurse is reviewing assessment data from several clients. For which of the following
clients should the nurse recommend referral to a dietician?
A. A client who has a nonhealing leg ulcer
B. A client who has a progressive leg ulcer
Answer: A. A client who has a nonhealing leg ulcer
134. A nurse is assessing a client who is 1 day postoperative following the placement of an
ileostomy. Which of the following findings should the nurse report to the provider?
A. The stoma has a purplish hue
B. The stoma has a reddish hue
Answer: A. The stoma has a purplish hue
135. A nurse is caring for a client who is obese. The client is crying and states, "Everyone is
staring at me because of my weight." Which of the following responses should the nurse
make?
A. "Have you always felt uncomfortable being overweight?"
B. "Have you ever talked about being overweight?"
Answer: A. "Have you always felt uncomfortable being overweight?"
136. A nurse is preparing educational material for a client. Which of the following techniques
should the nurse use in creating the material?
A. Write information at a seventh-grade reading level
B. Write information at a fifth-grade reading level
Answer: A. Write information at a seventh-grade reading level
137. A nurse is caring for a client who has a new prescription for warfarin. When reviewing
the client's current medication, which of the following medications should the nurse identify
as contraindicated for use with warfarin? (Select All That Apply)
A. Ibuprofen
B. Gingko biloba
C. Aspirin
D. Heparin

Answer: A. Ibuprofen
C. Aspirin
138. A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
A. Eat 2g/kg of protein per day
B. Eat 1g/kg of protein per day
Answer: B. Eat 1g/kg of protein per day
139. A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the following actions should the nurse take?
A. Insert a small-bore NG tube
B. Insert a large-bore NG tube
Answer: B. Insert a large-bore NG tube
140. A nurse is reading a tuberculin skin test for a client who received a purified protein
derivative test 72 hr ago. Which of the following findings indicates a positive test?
A. An induration measuring 5 mm
B. An induration measuring 10 mm
Answer: A. An induration measuring 5 mm
141. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
The nurse should monitor which of the following complications?
A. Contractions
B. Decreased Contractions
C. Increased Fetal Movement
Answer: A. Contractions
142. A nurse is reviewing the medication administration record of a client. Which of the
following prescriptions should the nurse clarify?
A. Digoxin 0.250 PO daily
B. Digoxin 1.250 IV daily
C. Digoxin 0.250 IV daily

Answer: B. Digoxin 1.250 IV daily
143. A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has
ruptured membranes. Which of the following actions should the nurse take?
A. Apply a fetal glucose monitor
B. Apply a fetal heart rate monitor
C. Apply a uterine contraction monitor
Answer: B. Apply a fetal heart rate monitor
144. A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should
identify that which of the following findings might indicate an allergic reaction to this
medication?
A. Difficulty coughing
B. Difficulty swallowing
C. Difficulty breathing
Answer: B. Difficulty swallowing
145. 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. WBC count 20,000/mm3
B. WBC count 2,900/mm3
C. WBC count 8,000/mm3
Answer: B. WBC count 2,900/mm3
146. A nurse is providing teaching about crutch safety to a client. Which of the following
client actions indicates an understanding of the teaching?
A. The client places the crutches 30 cm (12 in) to the front and side of each foot while
standing
B. The client places the crutches 60 cm (12 in) to the front and side of each foot while
standing
Answer: A. The client places the crutches 30 cm (12 in) to the front and side of each foot
while standing

147. A nurse is teaching a newly licensed nurse about incident reports. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "They assist with unit quality improvement."
B. "They assist with unit discussion improvement."
Answer: A. "They assist with unit quality improvement."
148. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which
of the following instructions should the nurse include?
A. Restrict foods containing magnesium
B. Restrict foods containing phosphorus
Answer: B. Restrict foods containing phosphorus
149. A nurse is caring for a group of clients who have chronic pain. Which of the following
clients should the nurse identify as a candidate for occupational therapy?
A. A client who has painful hands due to degenerative joint disease
B. A client who has painful muscles due to degenerative joint disease
Answer: A. A client who has painful hands due to degenerative joint disease
150. A nurse is teaching a client who has chronic urinary tract infection. Which of the
following instructions should the nurse include?
A. Drink at least 1 L of fluid every day
B. Drink at least 4 L of fluid every day
Answer: A. Drink at least 1 L of fluid every day
151. A nurse is speaking with the partner of a client who is in the early stage of Alzheimer's
disease. The partner tells the nurse that she is able to manage the client's physical care, but
she doesn't want to leave him alone while she travels for work. Which of the following
referrals should the nurse make?
A. Respite care
B. Cardiate care
Answer: A. Respite care

152. A nurse is providing teaching about digoxin administration to the parents of a toddler
who has heart failure. Which of the following statements should the nurse include in the
teaching?
A. "Have your child drink a small glass of water before and after swallowing the
medication."
B. "Have your child drink a small glass of water after swallowing the medication."
Answer: B. "Have your child drink a small glass of water after swallowing the
medication."
153. A nurse is caring for a client who is recovering from an amputation of her right arm
below the elbow. Which of the following information should the nurse report to the
occupational therapist?
A. The client has no family support at home
B. The client has two small children at home
Answer: B. The client has two small children at home
154. A nurse is caring for a client following the application of a cast. Which of the following
actions should the nurse take first?
A. Palpate the pulse proximal to the cast
B. Palpate the pulse distal to the cast
Answer: A. Palpate the pulse distal to the cast
155. A nurse is preparing to assist with the lumbar puncture of an infant. The nurse should
plan to place the infant in which of the following positions?
A. Flexed supine lying
B. Flexed side lying
Answer: B. Flexed side lying
156. A newly licensed nurse is unsure if an assigned task is within their scope of practice.
Which of the following resources should the nurse consult?
A. Local Nurse Practice Act
B. State Nurse Practice Act
Answer: B. State Nurse Practice Act

157. A nurse is caring for a client who is experiencing a diazepam overdose. Which of the
following medications should the nurse administer?
A. Flumazenil
B. Digoxin
Answer: A. Flumazenil
158. A community health nurse is reviewing laboratory reports for a group of clients. The
nurse should identify that which of the following disorders is on the CDC's Nationally
Notifiable Conditions list?
A. Lyme disease
B. Ulcerative colitis
Answer: A. Lyme disease
159. A nurse manager is developing a protocol for staff discipline. Which of the following
actions should the nurse manager take when implementing this new protocol?
A. Inform clients about the purpose of the unit's new processes.
B. Inform staff about the purpose of the unit's new processes.
Answer: B. Inform staff about the purpose of the unit's new processes.
160. A nurse is providing discharge teaching to a client who has a new prescription for
phenelzine. The nurse should instruct the client that it is safe to eat which of the following
foods while taking this medication?
A. Whole grain bread
B. Fried meats
Answer: A. Whole grain bread
161. A nurse is administering a continuous enteral feeding to a client. Which of the following
actions should the nurse take?
A. Return aspirate residuals 300 mL or less.
B. Return aspirate residuals 600 mL or less.
Answer: A. Return aspirate residuals 300 mL or less.

162. A nurse in an urgent care clinic is caring for an infant who presents with vomiting,
diarrhea, and decreased oral intake. Which of the following manifestations should the nurse
expect?
A. Oliguria
B. Polyuria
Answer: A. Oliguria
163. A nurse is teaching a newly licensed nurse about postpartum hemorrhage. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "Postpartum hemorrhage can occur within the first 6 weeks after delivery."
B. "Postpartum hemorrhage can occur within the first week after delivery."
Answer: A. "Postpartum hemorrhage can occur within the first 6 weeks after delivery."
164. A Nurse Manager is updating protocols for the use of belt restraints. Which of the
following guidelines should the nurse manager include?
A. Document the client's condition every 15 min.
B. Document the client's condition every 2 hours.
Answer: A. Document the client's condition every 15 min.
165. A nurse is caring for a child who has cystic fibrosis and requires postural drainage.
Which of the following actions should the nurse take?
A. Perform the procedure prior to meals
B. Perform the procedure after meals
Answer: A. Perform the procedure prior to meals
166. A nurse on a medical-surgical unit is performing medication reconciliation for a newly
admitted client. Which of the following actions should the nurse take?
A. Compare the client's list of home medications to the admission prescriptions written for
the client.
B. Review the client's list of prescriptions written for the client.
Answer: A. Compare the client's list of home medications to the admission prescriptions
written for the client.

167. 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 exhibits impulsive behavior."
B. "The client exhibits erratic behavior."
Answer: A. "The client exhibits impulsive behavior."
168. A nurse is teaching a client who is pregnant and has a new prescription for an iron
supplement. Which of the following statements should the nurse include?
A. "You might experience diarrhea while taking this medication."
B. "You might become constipated while taking this medication."
Answer: B. "You might become constipated while taking this medication."
169. A nurse is caring for a client who has cancer of the throat and is receiving radiation
therapy. The nurse should monitor for which of the following findings as an adverse effect of
the radiation?
A. Altered taste sensation
B. Altered smell sensation
Answer: A. Altered taste sensation
170. A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies
a cooling blanket. Which of the following findings indicates the client is having an adverse
reaction to the cooling?
A. Sweating
B. Shivering
Answer: B. Shivering (Maybe restlessness)
171. A nurse is caring for an infant who has respiratory syncytial virus. Which of the
following interventions should the nurse take?
A. Suction nares prior to feeding
B. Suction nares after feeding
C. Suction nares during feeding
Answer: A. Suction nares prior to feeding

172. A nurse is caring for a client who is wearing anti-embolic stockings. Which of the
following interventions should the nurse include in the plan of care?
A. Fold the top of the stockings over neatly
B. Fold the top of the stockings over tightly
C. Leave the top of the stockings unfolded
Answer: A. Fold the top of the stockings over neatly
173. A nurse is reviewing the laboratory results of a client who is taking cyclosporine
following a kidney transplant. Which of the following findings should the nurse report?
A. Serum creatinine 1.6 mg/dL
B. Urine pH 6.2
C. BUN 18 mg/dL
Answer: A. Serum creatinine 1.6 mg/dL
174. A nurse is reviewing the laboratory report of a client who has been receiving lithium
carbonate for the past 12 months. The nurse notes a lithium carbonate level of 0.8 mEQ/L.
Which of the following orders from the provider should the nurse expect?
A. Discontinue the medication
B. Administer the medication
C. Adjust the dosage of the medication
Answer: B. Administer the medication
175. 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. Diabetes medication information from the Physicians' Desk Reference
B. Food exchange lists for meal planning from the American Diabetes Association
C. General nutrition guidelines from the Centers for Disease Control and Prevention
Answer: B. Food exchange lists for meal planning from the American Diabetes
Association
176. A nurse is teaching a group of clients at a community health fair about genetic risks for
disease. Which of the following statements by a client indicates an understanding of the
teaching?
A. "My family has a genetic risk for breast cancer, so I am considering a total mastectomy."

B. "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: A. "My family has a genetic risk for breast cancer, so I am considering a total
mastectomy."
177. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a
modified radical mastectomy. Which of the following statements by a client indicates an
understanding of the teaching?
A. "I will complete my arm exercises four times a day."
B. "I can shower within 48 hours of my surgery."
Answer: A. "I will complete my arm exercises four times a day."
178. A nurse is assessing a school-age child who has a urinary tract infection. Which of the
following findings should the nurse expect?
A. Enuresis
B. Periorbital edema
Answer: A. Enuresis
179. A nurse is caring for an infant who has coarctation of the aorta. Which of the following
should the nurse identify as an expected finding?
A. Weak femoral pulses
B. Frequent nosebleeds
Answer: A. Weak femoral pulses
180. 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. "Eat foods that are high in sodium"
B. "Rise slowly when getting out of bed"
Answer: B. "Rise slowly when getting out of bed"
181. A nurse is assisting with food selection for a client who follows kosher dietary traditions.
Which of the following food choices should the nurse include on the client's food tray?
A. Ham sandwich with milk
B. Scrambled eggs and toast with milk

Answer: Scrambled eggs and toast with milk
Clients who adhere to a kosher diet can eat dairy products combined with non-meat products
at the same meal.
182. A nurse is caring for a client who has chronic kidney failure and a serum potassium level
of 6.8 mEq/L. Which of the following actions should the nurse take first?
A. Give sodium sulfonate to the client
B. Prepare the client for hemodialysis
Answer: Prepare the client for hemodialysis
183. A nurse is transcribing new medication prescriptions for a group of clients. For which of
the following prescriptions should the nurse contact the provider for clarification?
A. Triamcinolone acetonide 100 mcg/inhalation two puffs TID
B. Lorazepam 0.5 mg PO one tablet daily
Answer: Lorazepam 0.5 mg PO one tablet daily
184. A nurse is reviewing the medication administration record of a client who has benign
prostatic hyperplasia (BPH). The client asks the nurse about taking saw palmetto. The nurse
should instruct the client that which of the following medications interacts adversely with
saw palmetto?
A. Clopidogrel
B. Penicillin
Answer: Clopidogrel
185. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunizations should the nurse recommend?
A. Varicella
B. Influenza
Answer: Influenza
186. 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 examined annually."
B. "I take a calcium vitamin supplement daily."

Answer: B. "I take a calcium vitamin supplement daily."
187. 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. Encourage the client to lie down in a quiet room.
B. Ask the client directly what he is hearing.
Answer: B. Ask the client directly what he is hearing.
188. A nurse is caring for a client who has schizophrenia and is experiencing delusions.
Which of the following actions should the nurse take?
A. Avoid assessing the client's delusions.
B. Direct long conversations about the delusions toward reality-based topics.
Answer: B. Direct long conversations about the delusions toward reality-based topics.
189. 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. Encourages the client to cough during suctioning.
B. Waits 2 minutes between suctions.
Answer: B. Waits 2 minutes between suctions.
190. A nurse is preparing to perform a heel stick on an infant. Which of the following actions
should the nurse plan to take to reduce the infant's pain during the procedure?
A. Provide the infant with a bottle of water during the procedure.
B. Promote skin-to-skin contact with the infant's guardian during the procedure.
Answer: B. Promote skin-to-skin contact with the infant's guardian during the
procedure.
191. A nurse is teaching participants at a community center about advance directives. Which
of the following information should the nurse include in the teaching?
A. A client must create a do-not-resuscitate order when completing advance directives.
B. Advance directives cannot be changed once implemented.
C. Advance directives are only applicable to elderly individuals.

Answer: A. A client must create a do-not-resuscitate order when completing advance
directives.
192. A nurse is assessing a newborn 2 hr following birth. Which of the following findings
should the nurse expect?
A. Heart Rate 190/min
B. Irregular respirations
C. Temperature of 36.8°C (98.2°F)
Answer: A. Heart Rate 190/min
193. 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. Encourage the client to take frequent rest periods
C. Encourage the client to engage in high-stimulation activities
Answer: B. Encourage the client to take frequent rest periods
194. A nurse is flushing a client's intermittent infusion device. The client states, "Why do you
have to do that if you are not giving me medicine?" Which of the following statements should
the nurse make?
A. "This prevents leakage of fluid and medication."
B. "This clears blood from the tubing and the catheter."
C. "This prevents air from entering the tubing."
Answer: B. "This clears blood from the tubing and the catheter."
195. A nurse is creating a plan of care for a newly admitted client who has obsessivecompulsive disorder. Which of the following interventions should the nurse include?
A. Discourage the client from exploring irrational fears
B. Allow the client enough time to perform rituals
C. Ignore the client's compulsive behaviors
Answer: B. Allow the client enough time to perform rituals

196. A director of nursing in a rehabilitation facility is planning to measure the quality of care
provided. Which of the following audits should the Director plan to use after clients are
discharged to gather information about the quality of care?
A. Concurrent audit
B. Outcome audit
Answer: B. Outcome Audit
197. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the
following clients should the nurse see first?
A. A client who has preeclampsia and reports a persistent headache
B. A client who has pregestational diabetes mellitus and an HbA1c of 6.2%
Answer: A. A client who has preeclampsia and reports a persistent headache
198. A nurse on a mental health unit is planning room assignments for four clients. Which of
the following clients should the nurse assign to a room near the nurses' station?
A. A client who has bipolar disorder and impaired social interactions
B. A client who has depressive disorder and reports feeling hopeless
Answer: B. A client who has depressive disorder and reports feeling hopeless
199. A nurse is caring for a client who is 12 hours postoperative following a transurethral
resection of the prostate. Which of the following findings should the nurse report to the
provider?
A. Urgency to void
B. Report of pain level of 5 on a scale of 0 to 10
Answer: A. Urgency to void
200. A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration
and a prescription for parenteral fluid therapy. The parent 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 breathing slower than normal."
B. "Your baby needs an IV because she is not producing tears."
Answer: B. "Your baby needs an IV because she is not producing tears."

201. A nurse is assessing a client who is pregnant and has a new diagnosis of hyperemesis
gravidarum. Which of the following findings should the nurse expect?
A. Urine output 20 mL/hr
B. Distended neck veins
Answer: Urine output 20 mL/hr
202. A nurse is caring for an infant who has respiratory syncytial virus. Which of the
following interventions should the nurse take?
A. Initiate neutropenic precautions
B. Administer palivizumab intravenously
Answer: Initiate neutropenic precautions
203. A nurse is teaching a client who is receiving radiation therapy about skin protection.
Which of the following client statements indicates an understanding of the teaching?
A. "I will make sure I have sterile water to wash the irradiated area of skin."
B. "I will apply my favorite unscented lotion to the irradiated area of skin twice each day."
Answer: "I will apply my favorite unscented lotion to the irradiated area of skin twice
each day."
204. 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. Place the client's lower extremities on two pillows.
B. Place the client in high Fowler's position.
Answer: B. Place the client in high Fowler's position.
205. 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 1 hour if unable to fall asleep
B. Eat a light snack before bedtime
Answer: B. Eat a light snack before bedtime
206. A nurse is teaching a client who has heart failure about engaging in an exercise program.
Which of the following statements by the client indicates an understanding of the teaching?

A. "I will slow my walking pace if I experience chest pain."
B. "I will work to achieve 60 minutes of exercise each day."
Answer: B. "I will work to achieve 60 minutes of exercise each day."
207. A nurse is caring for a client who experienced a traumatic brain injury 72 hours ago.
Which of the following findings should the nurse identify as an indication of intracranial
pressure?
A. Hypotension.
B. Increasingly severe headache.
Answer: B. Increasingly severe headache.
208. A nurse is performing an abdominal assessment as part of a client's comprehensive
physical examination. Which of the following is the final step the nurse should perform?
A. Palpation
B. Percussion
C. Auscultation
D) Inspection
Answer: A. Palpation
209. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving
phototherapy. Which of the following actions should the nurse take?
A. Keep the infant's head covered with a cap.
B. Ensure that the newborn wears a diaper.
Answer: B. Ensure that the newborn wears a diaper.
210. A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The
nurse should identify that which of the following findings indicates the client is responding
positively to the transfusion?
A. The client's lung sounds remain clear during the transfusion.
B. The client's hemoglobin level increases following the transfusion.
Answer: B. The client's hemoglobin level increases following the transfusion.
211. 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 antiemetic
Answer: A. Turn the client on their side.
212. A nurse is providing teaching to a client who is at 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
Answer: A. Bleeding gums
213. 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
Answer: B. A client who has cancer with a sealed implant for radiation therapy
214. A nurse is caring for a client who is in active labor and noted 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 hypoglycemia
B. Maternal fever
Answer: A. Maternal hypoglycemia
215. A nurse is caring for a client who has a major burn injury. Which of the following
actions is the nurse's priority to prevent wound infection?
A. Apply topical antibiotics to the client's wounds
B. Use sterile dressings for wound care
Answer: B. Use sterile dressings for wound care
216. 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. Notify the client's provider about the incident

B. Report the incident to the AP's charge nurse
C. Confront the APs about their behavior
Answer: B. Report the incident to the AP's charge nurse
217. A nurse is preparing to obtain a client's signature on an informed consent form. Which of
the following actions should the nurse take first?
A. Ask the client to explain his understanding of the procedure
B. Inform the client of his right to change his mind
C. Review the risks and benefits of the procedure with the client
Answer: A. Ask the client to explain his understanding of the procedure
218. A nurse is assessing a client who is in active labor. Which of the following findings
should the nurse report to the provider?
A. Temperature 37.4°C (99°F)
B. Contractions lasting 80 seconds
C. Fetal heart rate 150 beats per minute
Answer: B. Contractions lasting 80 seconds
219. A nurse in an emergency department is caring for a client who has a closed head injury.
Which of the following actions should the nurse take first?
A. Administer mannitol IV bolus to the client
B. Determine the client's Glasgow Coma Scale score
C. Initiate continuous monitoring of the client's vital signs
Answer: B. Determine the client's Glasgow Coma Scale score
220. 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.
A. Contact the family to determine availability and readiness to make an appointment
B. Clarify the reason for the referral with the provider's office
C. Record information about the home visit according to agency policy
D. Discuss plans for future visits with the family
E. Identify family needs and interventions using the nursing process
Answer: B. Clarify the reason for the referral with the provider's office

A. Contact the family to determine availability and readiness to make an appointment
E. Identify family needs and interventions using the nursing process
D. Discuss plans for future visits with the family
C. Record information about the home visit according to agency policy
221. A nurse is providing discharge teaching to a client who has type 1 diabetes mellitus
about preventing diabetic ketoacidosis when ill. Which of the following statements by the
client indicates an understanding of the teaching?
A. "I will not give myself insulin when I am sick."
B. "If I am sick, I will check my blood sugar twice a day."
Answer: B. "If I am sick, I will check my blood sugar twice a day."
222. A nurse is caring for a client who has respiratory depression from opioid administration.
After administering naloxone to the client, which of the following findings should the nurse
expect?
A. Hyperglycemia
B. Increased pain
Answer: B. Increased pain
223. A nurse is caring for a client who reports insomnia. Which of the following findings is a
priority for the nurse to report to the provider?
A. Takes 15-minute naps four to five times per day
B. Seems depressed and irritable
Answer: B. Seems depressed and irritable
224. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of
the following is an activity a nurse should engage in to assist in disaster preparedness?
A. Participate in community drills and mock events
B. Assess types, levels, and scopes of disasters
Answer: A. Participate in community drills and mock events
225. A nurse is planning care for a client who is receiving hemodialysis. Which of the
following actions should the nurse include in the plan of care?
A. Rehydrate with dextrose 5% in water for orthostatic hypotension

B. Check the vascular access site for bleeding after dialysis
Answer: B. Check the vascular access site for bleeding after dialysis
226. A nurse is caring for a client who has heart failure. For which of the following laboratory
values should the nurse withhold the client's morning dose of digoxin and contact the
provider?
A. Potassium 3.2 mEq/L
B. Calcium 9.2 mg/L
Answer: Potassium 3.2 mEq/L
227. A nurse working in a health department is conducting a health screening for a group of
farmworkers. Which of the following client statements indicates a possible health risk?
A. "My home has running water and electricity."
B. "I wear a hat and long sleeves while I am working."
C. "I am currently sharing my home with two roommates."
D. "I eat vegetables directly from the field where I work."
Answer: "I am currently sharing my home with two roommates."
228. A nurse is assessing a client who is currently taking furosemide. Which of the following
reports by the client indicates a manifestation of an adverse effect of this medication?
A. Weight gain
B. Increased urinary output
Answer: Weight gain
229. A nurse is reviewing laboratory findings for a client who is receiving total parenteral
nutrition. For which of the following findings should the nurse notify the provider?
A. Random glucose 120 mg/dL
B. Sodium 125 mEq/L
Answer: Sodium 125 mEq/L
230. A nurse is assessing a client's coccyx area for a pressure ulcer. The nurse notes that
superficial subcutaneous fat is visible and tunneling is present. Which of the following
pressure ulcer stages should the nurse document?
A. Stage IV

B. Unstageable
C. Stage III
D. Stage II
Answer: Stage III
231. A nurse in a mental health facility is caring for a client who is experiencing a panic level
of anxiety. Which of the following actions should the nurse take?
A. Use short sentences when communicating with the client
B. Encourage the client to talk about his feelings
Answer: A. Use short sentences when communicating with the client
232. A nurse in an intensive care unit is assessing a client who has heart failure and has been
receiving metoprolol for 3 days. Which of the following indicates the treatment has been
effective?
A. Increased heart rate
B. Decreased edema
Answer: B. Decreased edema
233. A school nurse is teaching a parent about absence seizures. Which of the following
information should the nurse include?
A. "This type of seizure lasts 30 to 60 seconds."
B. "This type of seizure can be mistaken for daydreaming."
Answer: B. "This type of seizure can be mistaken for daydreaming."
234. A nurse is reviewing home recommendations with a client who is postoperative
following knee surgery. Which of the following recommendations should the nurse make?
A. Place a handrail in the entryway of the house
B. Wear slippers with cloth soles
Answer: A. Place a handrail in the entryway of the house