ATI RN/VATI COMPREHENSIVE PREDICTOR 2019
FORM C 180 QUESTIONS AND CORRECT ANSWERS | A GRADE
(DOWNLOAD TO SCORE A)
Comprehensive Practice A
1. A client is postoperative following a lumbar discectomy and is having difficulty voiding. The
nurse should recognize that which of the following medications place the client at risk for
urinary retention?
A. Ketorolac
B. Hydromorphone (Dilaudid)
C. Bethanechol (Urecholine)
D. Tobramycin (Nebcin)
Answer: B. Hydromorphone (Dilaudid)
2. A practical nurse (PN) on medical-surgical unit is beginning her shift and is working with a
registered nurse (RN) and an assistive personnel (AP). The PN should expect to be assigned
which of the following tasks?
A. Teach a client who has a new diagnosis of diabetes mellitus how to self-administer insulin.
B. Create a plan of care for a newly admitted client.
C. Obtain a stool specimen from a client who has ulcerative colitis
D. Administer an NG tube feeding to a client who had a stroke
Answer: D. Administer an NG tube feeding to a client who had a stroke
3. A nurse on an acute mental health unit observes a client who begins to speak loudly in the
common room, saying that he can’t hear the TV. Which of the following is an appropriate
response by the nurse?
A. You will need to go to your room until you can calm down okay
B. The TV is loud enough for everyone to hear it
C. You are being inconsiderate. Please stop talking so loudly
D. Let’s go to another room to talk about what is upsetting you
Answer: D. Let’s go to another room to talk about what is upsetting you
4. A client tells a nurse that he would like to observe kosher dietary laws. The nurse should
recognize which of the following?
A. A vegetarian diet is the preferred diet
B. Dairy products are served separately from meat
C. Fasting during daylight is required during a month-long holiday
D. Fish with scales and fins should not be eaten
Answer: B. Dairy products are served separately from meat
5. A nursing unit receives new glucose monitoring equipment from staff development with the
promise that in-service education will be given soon. Which of the following instructions should
the nurse give to the assistive personnel (AP) who is preforming glucose monitoring on the unit?
A. Contact the staff development department for instruction
B. Continue using the current glucose monitors
C. Check for accuracy and proper functioning of the new monitor
D. Read the instruction manual before attempting to use the new monitor
Answer: B. Continue using the current glucose monitors
6. Which of the following should the nurse document as an indication of the IV infiltration in a
client’s forearm?
A. Redness along vein
B. Tissue sloughing at the site
C. Forearm that is warm to the touch
D. Pallor surrounding the infusion site
Answer: D. Pallor surrounding the infusion site
7. A client requests information about advanced directives. Which of the following is the
appropriate response by the nurse?
A. Advanced directives are written instructions regarding end of life care
B. Advanced directives provide education on palliative care issues
C. Advanced directives require the provider’s approval before changes can be implemented
D. Advanced directives help determine legal competency
Answer: A. Advanced directives are written instructions regarding end of life care
8. A nurse is caring for a client who is on telemetry. Which of the following ECG findings should
the nurse report to the charge nurse?
A. One P wave prior to each QRS complex
B. PR interval 0.24 seconds
C. QRS duration 0.06 seconds
D. Ventricular rate 75/min
Answer: B. PR interval 0.24 seconds
9. A nurse is checking the reflexes of a newborn. Which of the following techniques should the
nurse use to elicit the Babinski reflex?
A. Startle the infant by clapping hands
B. Stroke the sole of the infant’s foot upward and toward the great toe
C. Hold the infant upright and allow one foot to touch the table’s surface
D. Place an object in the palm of the infant’s hand
Answer: B. Stroke the sole of the infant’s foot upward and toward the great toe
10. A charge nurse in a long-term care facility notices an assistive personnel’s (AP) repeated
failure to provide oral care for clients. Which of the following actions should the nurse take?
A. Provide oral care for clients after the AP has completed other care
B. Develop an educational session about the importance of oral care for all Aps
C. Discuss the unacceptable behavior with the AP while reinforcing expectations
D. Suspend the AP for 3 days pending disciplinary action
Answer: C. Discuss the unacceptable behavior with the AP while reinforcing expectations
11. A nurse is caring for a client who has terminal cancer. Which of the following statements by
the client’s family should indicate the nurse that they are coping with their situation?
A. Dad I remember the time we all went to the lake fishing
B. Dad I truly believe that it’s not your time to leave us
C. I feel like I don’t know what to do anymore
D. I think we need to concentrate on whose house we plan to meet at for our holiday get-together
Answer: A. Dad I remember the time we all went to the lake fishing
12. A nurse is performing a dressing change for a client who had abdominal surgery 5 days ago.
The nurse notes organs protruding from the incision. Which of the following actions should the
nurse take?
A. Apply an abdominal binder
B. Have the client lie flat in bed.
C. Cover the exposed area with sterile, saline-soaked dressing
D. Place gentle pressure on the exposed organ with sterile gauze
Answer: A. Apply an abdominal binder
13. A nurse in a skilled nursing facility is caring for a client who is receiving warfarin
(Coumadin) therapy following a total hip replacement. An assistive personnel reports a positive
guaiac. Which of the following laboratory values should the nurse report to the provider?
A. Hematocrit 40%
B. International normalized ratio of 4.5
C. Hemoglobin 15 g/dL
D. Prothrombin time 18 seconds
Answer: B. International normalized ratio of 4.5
14. A nurse is reinforcing teaching with a client who has hypertension and is beginning
medication therapy with captopril (Capoten). Which of the following over-the-counter
medications should the nurse instruct the client to avoid?
A. Acetaminophen (Tylenol)
B. Diphenhydramine
C. Ibuprofen (Advil)
D. Guaifenesin (Robitussin)
Answer: C. Ibuprofen (Advil)
15. A nurse is reinforcing teaching for a client who is in her first trimester of pregnancy. Which
of the following physiological changes should the nurse instruct the client to expect during the
first trimester?
A. Leukorrhea
B. Shortness of breath
C. Pedal edema
D. Perineal pressure
Answer: A. Leukorrhea
16. A nurse is collecting data from a client who has a peptic ulcer disease. Which of the
following should the nurse identify as the priority finding?
A. Gnawing epigastric pain
B. Heartburn
C. Regurgitation
D. Hematemesis
Answer: D. Hematemesis
17. A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which
of the following behavioral indications should the nurse expect?
A. Dependence
B. Euphoria
C. Memory Loss
D. Hypervigilance
Answer: D. Hypervigilance
18. A nurse is collecting data from a client who has schizophrenia. Which of the following
statements by the client should the nurse identify as a delusion?
A. My doctor’s glasses have lasers that will burn holes in my brain if I look at him
B. The movie had an explosion. I once drove a green truck. Where is the ketchup
C. The voice keeps telling me to go kick the table over. Why won’t it stop
D. I can’t sit here because the purple monkey on the ceiling will jump on me
Answer: A. My doctor’s glasses have lasers that will burn holes in my brain if I look at him
19. A nurse is caring for a client who sustained a broken leg while assisting other from a
structural fire. The client states I am glad those people were saved but I sure wish I was not hurt.
Which of the following is an appropriate response by the nurse?
A. You are a real hero. I am sure that makes your injuries worthwhile
B. It is difficult to experience personal injuries for whatever reason
C. Things will get better before long
D. Let’s talk about this later when we have more time
Answer: B. It is difficult to experience personal injuries for whatever reason
20. A nurse is reinforcing teaching for a client who has a new prescription for lithium carbonate
(Lithobid). Which of the following instructions should the nurse include?
A. Eliminate all foods containing tyramine
B. Drink 2 to 3 liter of fluid each day
C. Take lithium carbonate on an empty stomach
D. Reduce your daily sodium intake to 1,000 mg
Answer: B. Drink 2 to 3 liter of fluid each day
21. A nurse in a provider’s office is reinforcing teaching with a client who is receiving peritoneal
dialysis via a newly inserted catheter. For which of the following should the nurse instruct the
client to contact the provider?
A. Bloody peritoneal fluid
B. Clear peritoneal fluid
C. Cloudy peritoneal fluid
D. Straw-colored peritoneal fluid
Answer: C. Cloudy peritoneal fluid
22. A child is brought to the clinic by his parents with injuries inconsistent with the reported
cause. A nurse suspects physical abuse. Which of the following actions should the nurse take?
A. Interview the child with the parents in the room
B. Ask the provider to talk to the child and parents
C. Make a note in the chart to check the child during the next visit
D. Report the suspected abuse to the appropriate agency
Answer: D. Report the suspected abuse to the appropriate agency
23. A nurse is reviewing discharge instructions with a client who has undergone a lumbar
laminectomy. Which of the following should the nurse include?
A. Use a soft mattress for sleeping
B. Practice bending from the waist several times daily
C. Sit in a straight backed chair
D. Wear shoes with a slightly raised heel to promote body alignment
Answer: C. Sit in a straight backed chair
24. A nurse is reinforcing teaching with a client about cancer prevention, the nurse should
instruct that frequent consumption of which of the following foods increases the risk of cancer?
A. Tuna
B. Lamb
C. Chicken
D. Turkey
Answer: B. Lamb
25. A nurse is reinforcing teaching to a client who is scheduled for a lumbar puncture. Which of
the following should the nurse include in the teaching?
A. Nausea is common adverse effect after this procedure
B. You should increase your fluid intake after this procedure
C. You will be instructed to remain in an upright position for the first 4 hours after the procedure
D. The provider will apply a pressure bandage to the puncture site
Answer: B. You should increase your fluid intake after this procedure
26. A newborn is scheduled to have a heel stick for blood glucose testing every 4hr. The
newborn’s blood glucose on admission was less than 40 mg/dL. Which of to the following
additional clinical manifestations should the nurse observe for in this newborn?
A. Jitteriness
B. Bradycardia
C. Inconsolability
D. Insomnia
Answer: A. Jitteriness
27. A nurse is contributing to the plan of care for a client who has a prescription for range of
motion exercise of the shoulder. To promote shoulder hyperextension, which of the following
exercises should the nurse recommend?
A. Move his arm behind his body with his elbow straight
B. Move his arm in a full circle
C. Raise his arm out to the side and reach it above his head with his palm facing away from his
head
D. Raise his arm from his side straight forward and then up above his head.
Answer: A. Move his arm behind his body with his elbow straight
28. A nurse is receiving change-of-shit report for four clients. Which of the following clients
should the nurse attend to first?
A. A client who requests to be moved to a room closer to the nurse’s station
B. A client who is postoperative and had received morphine twice during the last 8hrs
C. A client whose urinary output was 100 mL for the past 12hr
D. A client who insists on speaking with the provider prior to discharge
Answer: C. A client whose urinary output was 100 mL for the past 12hr
29. A nurse is reinforcing teaching regarding home safety to a client who has diabetes mellitus
and is being discharged after an admission for hepatitis B. Which of the following client
statements indicates an understanding of the teaching?
A. I will recap my used syringes and throw them away in a plastic bag
B. I will take Tylenol for aches and pains
C. I will use my own eating utensils and dishes at home
D. Houseguest will need to wear masks when they come to visit me
Answer: C. I will use my own eating utensils and dishes at home
30. A nurse in a long-term care facility is transcribing new prescriptions for four clients. Which
of the following prescription is accurately transcribed by the nurse?
A. Alprazolam (Xanax) 0.5 mg PO QHS for sleep
B. Regular insulin (Humulin R) 10 U SC at 0800
C. Docusate sodium (Colace) 250 mg PO QOD
D. Potassium chloride (Micro-K) 20mEq PO every morning
Answer: D. Potassium chloride (Micro-K) 20mEq PO every morning
31. A nurse is caring for a client who has altered mental status and has become increasing
belligerent. Which of the following medications prescriptions, if written for this client, should
the nurse question?
A. Haloperidol (Haldol)
B. Lorazepam (Ativan)
C. Zolpidem (Ambien)
D. Alprazolam (Xanax)
Answer: C. Zolpidem (Ambien)
32. A nurse is caring for a client who is experiencing acute kidney failure. The nurse should
monitor the client for which of the following acid-base imbalances?
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
Answer: B. Metabolic acidosis
33. A nurse in an urgent care clinic is collecting data from four clients. Which of the following
clients should the nurse recommend for treatment first?
A. A client who has a fever and abdominal pain in the upper aspect of the right lower quadrant
B. A client who has shortness of breath after taking a dose of amoxicillin (Amoxil)
C. A client who has hemoptysis and has taken medication for tuberculosis (TB) for 2 months
D. A client who has a purple stoma following an open colon resection with a colostomy 2 weeks
ago.
Answer: B. A client who has shortness of breath after taking a dose of amoxicillin (Amoxil)
34. A nurse on a medical unit is preforming an audit on his client assisgnment. For which of the
following should the client have a separate signed informed consent form.
A. Chest radiography
B. Echocardiogram
C. Indwelling urinary catheter
D. Lumbar puncture
Answer: D. Lumbar puncture
35. A nurse in an acute care hospital is planning to discharge an adult client who is
immunocompromised. Which of the following immunizations should the nurse plan to
administer before discharge.
A. Measles, mumps, and rubella (MMR) immunization
B. Pneumococcal polysaccharide (PPSV) immunization
C. Varicella immunization
D. Herpes zoster immunization
Answer: B. Pneumococcal polysaccharide (PPSV) immunization
36. A nurse is reinforcing teaching to a client regarding care of her newborn. The nurse
determines that the teaching is effective when the client points to which part of the newborn’s
head and states it will take 12 to 18 months for the soft stop to close.
Answer: (top of the head near face)
37. A parent of a 3yr old child tells the nurse that he cannot get his child to sit at the table to eat a
full meal. Which of the following responses by the nurse is appropriate?
A. Provide the child with foods of the same texture rather than a variety of unfamiliar foods
B. Engage the child in conversation during meals to encourage him to eat like the rest of the
family
C. Encourage active play prior to meals to increase the child’s appetite
D. Offer the child healthful snacks frequently, rather than expecting him to fully eat at mealtimes
Answer: D. Offer the child healthful snacks frequently, rather than expecting him to fully eat at
mealtimes
38. A nurse in a providers office is caring for four clients. Which of the following should the
nurse see first.
A. A client who is at 38 weeks gestation and reports urgency and frequency of urination
B. A client who is at 37 weeks gestation and reports edema of the ankles
C. A client who is at 36 weeks gestation and reports painless vaginal bleeding
D. A client who is at 34 weeks gestation and reports abundant amounts of odorless vaginal
mucus
Answer: C. A client who is at 36 weeks gestation and reports painless vaginal bleeding
39. A nurse and an assistive personnel (AP) are caring for four clients in a long-term-care facility.
For which of the following situations is it necessary to complete an incident report?
A. A client throws an object across the dining room
B. A client refuses his morning medications
C. A client who is prescribed full liquid diet receives a clear liquid diet
D. A client who is confused walks into another client’s room
Answer: A. A client throws an object across the dining room
40. A nurse working in the clinic receives a phone call from a mother whose child has just
ingested the contents of a bottle of acetaminophen (Tylenol). Which of the following is an
appropriate response by the nures?
A. Adminster syrup of ipecac to the child to induce vomiting
B. Take the child to the emergency department
C. Give the child a glass of milk to drink
D. Monitor the child’s level of consciousness
Answer: B. Take the child to the emergency department
41. A client is scheduled for colon cancer surgery in the morning. The night nurse learns that the
client has decided not to have the surgery, even though he has already signed the informed
consent form. Which of the following actions should the nurse take?
A. Inform the client that a signed consent form is legally in effect for 24hr
B. Report the situation to the surgeon who obtained the informed consent
C. Reinforce client teaching about the purpose of the procedure
D. Notify the client’s family about the refusal of treatment
Answer: B. Report the situation to the surgeon who obtained the informed consent
42. A nurse is caring for a newborn who is 1hr old. The mother received fentanyle (Sublimaze)
30 min before delivery. For which of the following should the nurse monitor for in the newborn?
A. Hyperbillrubinemia
B. Hypoglycemia
C. Respiratory depression
D. Increased heart rate
Answer: C. Respiratory depression
43. A nurse is reinforcing discharge teaching with the parent of a school-age child who had a
tonsillectomy. Which of the following statements by the parent indicates an understanding of the
instructions?
A. I will encourage my child to drink 4 ounces of orange juice twice a day
B. I will allow my child to chew gum to prevent throat
C. pain I will ensure my child uses a straw to drink fluids
D. I will give my child chocolate ice cream
Answer: B. I will allow my child to chew gum to prevent throat
44. A nurse is reviewing the laboratory results for an infant receiving gentamicin intermittent IV
bolus twice daily and notes the serum creatinine is 0.9 mg/dL. The nurse is aware that this result
can indicate an adverse effect on which of the following systems?
A. Hepatic
B. Renal
C. Gastrointestinal
D. Endocrine
Answer: B. Renal
45. A is reinforcing teaching with an adolescent client about a scheduled blood draw of HbA1c.
The nurse knows that the client understands the purpose for this test when the client states that
this test will measure his average blood glucose level over the past
A. 2 to 3 days
B. 6 weeks
C. 2 to 3 months
D. 6 months
Answer: C. 2 to 3 months
46. A nurse is caring for a client in Buck’s traction. Which of the following interventions should
the nurse perform while the client is in this traction?
A. Allow the weights to hang freely
B. Inspect the skin every 24hr
C. Remove the weights every 24hr
D. Let the client use the bedside commode
Answer: A. Allow the weights to hang freely
47. A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect
data, the nurse should obtain which of the following?
A. Motor response
B. Vital signs
C. Short-term memory
D. Gait
Answer: A. Motor response
48. A nurse is reinforcing teaching to a client who has a new prescription for atorvastatin
(Lipitor). For which of the following should the nurse tell the client to monitor and report to the
provider?
A. Anorexia
B. Muscle tenderness
C. Facial flushing
D. Insomnia
Answer: B. Muscle tenderness
49. A nurse working in a clinic is collecting data on a toddler. Which of the following findings
should the nurse identify as suggestive of physical neglect?
A. The toddler is inadequately dressed for the weather
B. The toddler has irriation to the external genitalla
C. The toddler has symmetrical burns to both legs
D. The toddler does not react when the nurse adminsters an injection
Answer: A. The toddler is inadequately dressed for the weather
50. A parent of a 2month old infant asks the nurse how she will know if her baby is growing
appropriately. Which of the following is an appropriate response by the nurse?
A. Your baby should weigh 2.5 time his height by 6 months
B. Your baby should gain 1 pound per month during the first 6 months
C. Your baby’s weight should be double his birth weight by 4 to 6 months
D. Your baby should grow half an inch per month during the first 6 months
Answer: C. Your baby’s weight should be double his birth weight by 4 to 6 months
51. A nurse is contributine to a teaching plan for a group of male adolescents regarding use of
anabolic steroids. Which of the following should the nurse include in the teaching as risk of
using anabolic steroids?
A. Decreased appetite
B. Reduced height potential
C. Increased dental caries
D. Impaired vision
Answer: B. Reduced height potential
52. A client who is 1 day postoperative is unable to ambulate. The nurse should recognize that
which of the following will promote venous return?
A. Encouraging the client to cough and deep breathe
B. Maintaining a sequential compression device
C. Elevating the head of the bed
D. Massaging the clients legs
Answer: B. Maintaining a sequential compression device
53. A nurse reinforces the use of a mask prior to a family entering the room of a client who has
tuberculosis (TB). Which of the following information should the nurse include?
A. Prior to entering the room, make sure the client puts on a mask
B. If you leave the client’s room for a break, you can reuse your mask upon returning
C. Wearing a mask will help protect you from the client’s illness
D. Masks are part of the hospital protocol, but family members do not have to wear them
Answer: C. Wearing a mask will help protect you from the client’s illness
54. A nurse is caring for a client recently diagnosed with adenocarcinoma of the lung. While
discussing teatment option with the client, the family asks the nurse about the use of herbal
medications for treatment. The nurse should respond by stating, Herbal medicines
A. Are untested for both safety and efficacy
B. Will protect against progression of your cancer
C. Are frequently cheaper than conventional medications
D. Must be prescribed by a provider
Answer: A. Are untested for both safety and efficacy
55. A client who is pregnant presents to the emergency department with a broken arm. The client
appears anxious and gives conflicting stories about how the injury occurred. The client’s spouse
is hovering over her and answering questions for her. What should the nurse do to handle this
situation?
A. Disregard the spouse’s remarks while continuing with data collection
B. Request that the spouse go to the waiting room
C. Bring a second nurse into the examination room
D. Ask the client’s spouse to refrain from answering for the client.
Answer: B. Request that the spouse go to the waiting room
56. A nurse is caring for a client who has a history of long-term alcohol use disorder. The client
has a prescription for disulfiram (Antabuse). The nurse should recognize that the use of this
medication is a form of which of the following types of therapy?
A. Operant conditioning
B. Systemtic desensitization
C. Aversion therapy
D. Cognitive therapy
Answer: C. Aversion therapy
57. A nurse is caring for a client who has impaired vision. Which of the following strategies
should the nurse include in the plan of care?
A. Keep the door to the client’s bathroom slightly ajar
B. Hold the client’s arm while standing even with the client’s shoulders while ambulating
C. During ambulation, the nurse should stand just ahead of the client and offer his arm for
guidance
D. Place frequently used items on the bedside table
Answer: C. During ambulation, the nurse should stand just ahead of the client and offer his arm
for guidance
58. A nurse has administerd lorazepam (Ativan) to a client who is scheduled for surgery within
the next hour. Which of the following actions should the nurse take?
A. Instruct the client to remain in bed
B. Ensure that the informed consent form has been signed
C. Assist the client to the bathroom to void
D. Reinforce teaching about deep breathing and coughing exericses
Answer: A. Instruct the client to remain in bed
59. A nurse is preparing to insert a nasogastric tube for a client. Identify the sequence the nurse
should follow after performing proper hand hygiene and preparing equipment at the bedside
A. Place the client in high-Fowler’s position
B. Determine which naris has the greatest airflow
C. Measure the distance to insert the tube
D. Lubricate 7.5 to 10 cm (3-4 in) of the end of the tube
D. Instruct the client to hyperextend her neck
Answer: A. Place the client in high-Fowler’s position
60. A nurse is reinforcing teaching about pancrelipase (Pancreaze) with the parent of a child who
has cystic fibrosis. Which of the following instructions should the nurse include in the teaching?
A. Place the medicine under the tongue
B. Take the medication after a meal
C. Sprinkle the contents of the capsule on food
D. Chew each capsule thoroughly
Answer: C. Sprinkle the contents of the capsule on food
61. A nurse brings her adolescent son to an urgent care center, stating that “he is high on
something and needs help.” The client is exhibiting agitation and paranola, and reports visual
hallucinations. The nurse should suspect intoxication with which of the following substances?
A. Methamphetamines
B. Opioids
C. Anbolic steroids
D. Alcohol
Answer: A. Methamphetamines
62. A nurse enters the room of a client who had a bone marrow transplant 3 days ago for
treatment of leukemia. Which of the following observations warrents intervention?
A. The client’s meal tray contains stewed tomatoes
B. A visitor brought the client a bouquest of flowers
C. The client is using an electric razor to shave
D. An assistive personnel is removing a bag of biohazardous materials
Answer: B. A visitor brought the client a bouquest of flowers
63. A nurse is collecting data from a client who is primigravida and at 25 weeks of gestation.
The client is tearful and tells the nurse, “I’m sorry, I’m just nervous and emotional today.” Which
of the following actions should the nurse take first?
A. Help the client identify a support person to talk to
B. Recoomend the client join a support group for first time mothers
C. Assist the client to schedule childbirth classes
D. Explore the client’s underlying concerns
Answer: D. Explore the client’s underlying concerns
64. A nurse is caring for a client who has expressive aphasia following a cerbrovascular accident.
Which of the following communication methods is appropriate for the nurse to use with this
client?
A. Ask open-ended questions
B. Speak slowly with a raised voice
C. Provide a picture board
D. Limit the use of gestures
Answer: C. Provide a picture board
65. A nurse is caring for a client who is postoperative following an open reduction with internal
fixation of the ankle. The client reports pain, and the nurse notes that the affected extremity is
cool, pale, and has a weak pulse. The nurse calls the surgical resident, who responds, “It has
always been like that.” Which of the following actions should the nurse take first?
A. Notify the nursing supervisor
B. Administer the prescribed pain medication
C. Recheck the client in 30 min
D. Reposition the client to improve anatomical alignment
Answer: Notify the nursing supervisor
66. A nurse is reinforcing teaching to a client about the adverse effects of propranolol
(Inderal). For which of the following effects should the nurse instruct the client to observe?
A. Bradycardia
B. Cough Paresthesias
C. Urinary retention
Answer: A. Bradycardia
67. A nurse is caring for a postpartum client who is breastfeeding. Which of the following is
appropirate for the nurse to reinforce about breastfeeding?
A. Look for slowed suck/swallow pattern as a sign that the newborn is finished eating
B. Ensure that the newborn has the entire areola in the mouth during feeding
C. Begin feeding the newborn on the same breast each time
D. Push the back of the newborn’s head toward the nipple
Answer: A. Look for slowed suck/swallow pattern as a sign that the newborn is finished eating
68. A nurse is reinforcing teaching for a client who has a new prescription for metronidazole
(Flagyl), The nurses should instruct the client to expect which of the following adverse effects
while taking this medication?
A. Reddish brown urine
B. Increased saliva production
C. Photophobia
D. Peripheral edema
Answer: A. Reddish brown urine
69. A nurse is admitting a client who is at risk for suicide. Which of the following is the nurse’s
highest priority?
A. Search the client’s personal belongings.
B. Place the client in a room close to the nurses’ station
C. Ask the client to sign a no-suicide contract
D. Review the client’s SAD PERSONS scale assessment
Answer: A. Search the client’s personal belongings.
70. A nures enters the room of an adolescent client and observes him on the floor experiencing a
tonic-clonic seizure. Which of the following actions should the nurse take when the seizure
subsides?
A. Insert a tongue blade in the client’s mouth
B. Assist the client to an upright position
C. Offer clear fluids through a straw
D. Keep the client in a side-lying position
Answer: D. Keep the client in a side-lying position
71. A nurse is reinforcing discharge teaching for a client who has a new prescription for digoxin
(Lanoxin). Which of the following should the nurse include in the instructions as an indication of
digoxin toxicity?
A. Visual changes
B. Skin irritation
C. Fever
D. Angina
Answer: A. Visual changes
72. A female client presents to an outpatient clinic. Which of the following findings place the
client at risk for coronary artery disease?
A. The client’s LDL level
B. The client’s daily alcohol consumption
C. The client’s weight for her height
D. The client’s blood pressure
Answer: A. The client’s LDL level
73. A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the
following should the nurse recognize as a positive response to the therapy?
A. Bulging fontanel
B. Capillary refill 6 seconds
C. Moist mucous membranes
D. Urine specific gravity 1.031
Answer: C. Moist mucous membranes
74. A nurse is reinforcing teaching for a client who has a new prescription for sub linguail
nitroglycerin (Nitrostat). Which of the following statements indicates client understanding?
A. I will take half a tablet before I exercise
B. I can take up to four tablets to relieve my pain
C. I will put the tablets in a medication container for easy acess
D. I may develop a headache after taking this medication
Answer: D. I may develop a headache after taking this medication
75. A nurse is caring for a client who has a new diagnosis of HIV. The client states, “I don’t want
anyone else to know that I have HIV.” Based on the recommendations of the Centers for Disease
Control and Prevention, which of the following is an appropriate response by the nurse?
A. Your HIV status will be protected by HIPPA regulations
B. Your HIV status needs to be reported to the state health department
C. We must report your HIV status to your employer
D. Your HIV status is protected under the Patient Care Partnership
Answer: B. Your HIV status needs to be reported to the state health department
76. A nurse is reinforcing discharge teaching with a client regarding self-administration of epid
insulin (Humulin R). Which of the following instructions should the nurse include?
A. Shake the insulin vial before administering
B. Administer insulin at room temperature
C. Administer insulin 15 min prior to each meal
D. Dissolve solid deposits by warming the insulin before administering
Answer: B. Administer insulin at room temperature
77. A nurse is reinforcing teaching to a client who has schizophrenia and his family regarding
treatment options. Which of the following statements by the nurse is appropriate?
A. Family therapy can assist clients and their families to learn effective coping skills
B. Cognitive remediation therapy is used to solve longstanding family problems resulting from
the disease
C. Use of medication is considered short-term therapy until symptoms are stabilized
D. Day treatment programs are the desired choice for achieving acute symptom stabilization
Answer: A. Family therapy can assist clients and their families to learn effective coping skills
78. A nurse notices an assistive personnel (AP) of the unit taking naps in the break room instead
of having a meal or a snack. She appears drowsy while performing routine tasks. Which of the
following actions should the nurse take?
A. Keep a record of the AP’s behavior over a period of time
B. Report the observations about the AP to the unit’s nurse manager
C. Ask other unit staff if they have observed the same behavior
D. Determine if the AP is having problems at home
Answer: B. Report the observations about the AP to the unit’s nurse manager
79. A nurse is assisting with the plan of care for a client following a transurethral resection of the
prostate (TURP) surgery. Which of the following is appropriate to include in the plan of care
A. Discontinue the urinary catheter 24hr after surgery
B. Adjust the bladder irrigation to keep the urine a bright yellow color
C. Use 50 mL sterile water to clear the urinary catheter of obstruction
D. Irrigate the bladder using sterile technique
Answer: D. Irrigate the bladder using sterile technique
80. A nurse is collecting a urine specimen from a client with diabetes insipidus. The nurse should
expect which of the following findings?
A. Proteinuria
B. Creatinine clearance of 100 mL/min/m
C. Urine specific gravity of 1.002
D. Hematuria
Answer: C. Urine specific gravity of 1.002
81. A nurse is reinforcing teaching with a newborn’s parents about umbilical cord care. Which of
the following statements by a parent indicates an understanding of the instructions?
A. I will give our baby sponge baths until the cord falls off
B. I will remove the cord clamp after 5 days
C. I will wrap the cord in petroleum jelly gauze
D. I will keep the cord protected by covering it with the diaper
Answer: A. I will give our baby sponge baths until the cord falls off
82. A nurse is preparing to administer a dose of furosemide (Lasix) 30 min past the scheduled
time. The nurse notes that there is a new potassium value alert on the client’s electronic record.
The nurse should
A. Review the laboratory value prior to preparing the medication
B. Administer the medication, and then review the client’s laboratory values
C. Hold the dose of medication until the provider makes rounds
D. Administer the medication, and notify the provider that new laboratory values are available
Answer: A. Review the laboratory value prior to preparing the medication
83. A nurse is assisting in the plan of care for a female client who is to undergo a 12-lead
electrocardiogram (ECG). Which of the following actions should the nurse include in the plan of
care?
A. Place the client in Sims’ position
B. Put chest electrodes on the client’s breast
C. Instruct the client to remain still while the ECG is performed
D. Cleanse the skin with providone-iodine prior to electrode placement
Answer: C. Instruct the client to remain still while the ECG is performed
84. A nurse is caring for an older adult client who is 48hr postoperative following abdominal
surgery. The provider writes a prescription to advance the client to a regular diet. After
evaluating the client, the nurse should notify the provider about which of the following findings?
A. The client has absent bowel sounds
B. The client is unable to sit for long periods of time
C. The clients incision is draining serous fluid
D. The client reports loss of appetite due to pain
Answer: A. The client has absent bowel sounds
85. A nurse is collecting data from an older client who has a hip fracture. Which of the following
findings should the nurse expect?
A. External rotation
B. Muscle flaccidity
C. Leg lengthening
D. Hyperreflexia
Answer: A. External rotation
86. A nurse is supevising an assistive personnel (AP) who is preparing to remove his personal
protective equipment (PPE) after providing direct care to a client who requires airborne and
contact precautions. The nurse identifies understanding of the procedure when the AP removes
which of the following items first?
A. Goggles
B. Gloves
C. Gown
D. Respirator
Answer: B. Gloves
87. A nurse is reinforcing newborn care to a client whose newborn underwent clamp
circumcision procedure. Which of the following statements made by the client indicates to the
nurse a need for further teaching?
A. I should apply petroieum jelly each time I change the diaper
B. I will apply gentle pressure if bleeding occurs
C. I will be sure to wipe off any yellow drainage
D. I should make sure my baby has at least six wet diapers in 24hrs
Answer: C. I will be sure to wipe off any yellow drainage
88. A client newly diagnosed with diabetes mellitus inquires about information concerning oral
antidiabetic agents. In addition to the provider, where should the nurse refer the client for
information? (select all)
A. Local pharmacist
B. Personal tesimonial web sites
C. Package inserts
D. Other clients in a diabetes support group
E. American Diabetes Association
Answer: A. Local pharmacist
C. Package inserts
E. American Diabetes Association
89. A nurse in an urgent care facility is reinforing teaching to a client about the safe use of
crutches. Which of the following statements indicates the client understands the teaching?
A. I will wear leather-soled shoes when walking with my crutches
B. I will ensure the pad of the crutch fits snugly in my armpit
C. I will hold both crutches on the side opposite my injured leg when sitting
D. I will switch to using only one crutch when I regain some strength
Answer: C. I will hold both crutches on the side opposite my injured leg when sitting
90. A nurse is reinforcing teaching on food selection for a client who has a moderate burn injury.
Which of the following foods should the nurse recommend as being high in vitamin C?
A. Tomatoes
B. Apricots
C. Avocados
D. Carrots
Answer: A. Tomatoes
91. A nurse is caring for an adolescent who has meningitis. To prevent the adolescent from
experiencing increase intracranial pressure, which of the following actions should the nurse take?
A. Keep the head of the bed flat
B. Withhold pain medication until the client is in severe pain
C. Suction the airway when necessary
D. Keep the client’s door open for visual observation
Answer: C. Suction the airway when necessary
92. A nurse is preparing to administer purified protein derivative (PPD) to a client who has
suspected tuberculosis, Which of the following actions should the nurse plan to take?
A. Inject 0.5 mL of medication
B. Insert the needle at a 10 degree angle
C. Ensure that the bevel of the needle is pointing down during administration
D. Aspirate the syringe prior to injecting the medication
Answer: B. Insert the needle at a 10 degree angle
93. A nurse is reinforcing discharge teaching with a client about adverse effects of prescribed
medications. The nurse should tell the client that if black, tarry stools are noted, the client should
stop taking which oft eh following medications and notify the provider?
A. Acetaminophen (Tylenol)
B. Aspirin (Ecotrin)
C. Guaifenesin (Robitussin)
D. Loratadine (Claritin)
Answer: B. Aspirin (Ecotrin)
94. A nurse in a clinic is reinforcing discharge teaching with a client who has a sprained ankle.
The nurse should instruct the client to rewrap the compression dressing if she experiences which
of the following manifestations?
A. Warm toes
B. Erythema of the ankle
C. Swollen toes
D. Increased ankle stiffness
Answer: C. Swollen toes
95. A nurse is observing an assistive personnel (AP) caring for a client. For which of the
following actions should the nurse intervene?
A. The AP documents morning care in the client’s electronic health care record at the bedside
B. The AP writes his own name on the client’s message board in the room
C. The AP instructs the client to void prior to obtaining a daily weight
D. The AP reports client information to the oncoming AP in the hallway
Answer: D. The AP reports client information to the oncoming AP in the hallway
96. A nurse in the rehabilitation unit is assisting in the development of a plan of care for a client
who had a knee arthroplasty. Which of the following should the nurse include first in the plan of
care?
A. Discuss with the client the need for family support
B. Assist the client to develop attainable goals
C. Evaluate the clients repsonse to therapy
D. Check the client’s mobility
Answer: D. Check the client’s mobility
97. A provider of prescribes levothyroxine (Synthroid) 0.3 mg PO daily for a client. Available is
levothyroxine 150 mcg/tablet. How many tablets does the patient get?
Answer: 2 tablets
98. A client is being discharge home after experiencing a cerbrovascular accident. Which of the
following documents should the nurse plan to include with the discharge instructions?
A. Physician progress notes
B. Physical therapy record
C. Medication adminstration record
D. List of symptoms to report
Answer: D. List of symptoms to report
99. Which of the following findings in a client who is postpartum should indicate to a nurse to
contact the provider?
A. Temperature of 37.8C (100.2F) after delivery
B. Redness and tenderness of the right calf
C. Breast discomfort on postpartum day 3
D. Increased lochia after breastfeeding
Answer: B. Redness and tenderness of the right calf
100. A nurse is assisting with admitting a client who has colorectal cancer. When collecting data
from the client, which of the following clinical manifestations should the nurse expect to find?
A. Abdominal cramps
B. Hematuria
C. Weight gain
D. Epigastfic pain
Answer: A. Abdominal cramps
101. A client who is crying tells a nurse that his provider informed him that he has a tumor and
will need a biopsy. Which of the following is an appropriate response by the nurse?
A. Try to relax as much as possible, because most tumors are benign
B. What have you done to help yourself get through stressful situations before
C. Perhaps you should wait to get your biopsy results before you become overly concerned
D. I will keep you in my thought and check on your results the next time I work
Answer: B. What have you done to help yourself get through stressful situations before
102. A nurse is reinforcing teaching about defense mechanisms with an adolescent who is angry
that her parents won’t let her go to a party. Which of the following statements by the client
should the nurse recognize as sublimation?
A. I guess I’ll just go to the mall with friends instead
B. People who go to parties are stupid They’ll probably all get into trouble
C. I’ll just quit cleaning my room and mowing the grass that’ll teach them
D. My parents are just afraid I will get into trouble
Answer: A. I guess I’ll just go to the mall with friends instead
103. A nurse is contributing to the plan of care for a client who is at risk of developing pressure
ulcers. Which of the following actions should the nurse recommend to include in the plan of
care?
A. Place the client in a 30degree lateral position
B. Limit time spent sitting in a chair to 4hr daily
C. Cleanse the client’s skin twice daily with soap and hot water
D. Massage reddened areas over bony prominences every 2hrs
Answer: A. Place the client in a 30degree lateral position
104. While making rounds, a nurse smells cigarette smoke in the unit. Upon entering the client’s
room, the nurse observes a pack of cigarettes on the bedside table. Which of the following
actions should the nurse take first?
A. Provide the client with smoking cessation information
B. Report the finding to the charge nurse
C. Remove the cigarettes from the clients room
D. Notify the provider of the clients behavior
Answer: C. Remove the cigarettes from the clients room
105. A nurse is caring for a client who reports a sudden onset of an itchy rash after being given
ciprofloxacin (Cipro) 1hr ago. Which of the following actions should the nurse take first?
A. Check the client for wheezing
B. Administer diphenhydramine
C. Prepare the client for insertion of an IV catheter
D. Obtain a set of vital signs
Answer: A. Check the client for wheezing
106. A nurse assigns an AP to collect a sputum specimen from a client who has tuberculosis. The
nurse should instruct the AP to collect the sputum specimen at which of the following times?
A. Immediately after the client brushes his teeth
B. After the client ambulates
C. When the client reports he is experiencing night sweats
D. As soon as the client wakes up
Answer: D. As soon as the client wakes up
107. A nurse is reinforcing discharge teaching with the family of a client who has dependent
personality disorder. Which of the following instructions should the nurse include in the
discharge teaching?
A. Demonstrate assertiveness
B. Refrain from engaging in power struggles
C. Permit expression of rituals
D. Avoid crowded environments
Answer: A. Demonstrate assertiveness
108. A nurse is caring for a client who is scheduled to receive hemodialysis through an
arteriovenous fistual in the left arm. Which of the following actions should the nurse take prior to
the procedure?
A. Ensure the client has fasted for 6hr
B. Obtain the client’s weight
C. Measure the client’s blood pressure about the fistula
D. Draw a blood sample from the fistula
Answer: B. Obtain the client’s weight
109. A nurse is reinforcing teaching with a client about how to replace her two-piece ostomy
pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the
following strategies should the nurse suggest?
A. Break the seal by tugging gently on the bottom of the pouch
B. Hold the skin taut while removing the barrier
C. Pull one corner of the barrier quickly over the stoma
D. Lift both sides of the skin barrier simultaneously
Answer: B. Hold the skin taut while removing the barrier
110. A nurse is caring for a client who has Alzheimer’s disease. Which of the following will help
the client maintain independence in eating?
A. Allow the client to choose foods from a menu
B. Place the tray of food directly in front of the client
C. Provide music or visula stimulation at mealtimes
D. Maintain a routine for mealtimes
Answer: D. Maintain a routine for mealtimes
111. A nurse is caring for a client who has a penrose drain. To ensure proper placement and
functioning of the drain, which of the following should the nurse observe?
A. The safety pin is present at the distal end of the drain
B. The suction bulb is fully compressed
C. Wall suction is set at low-intermittent suction
D. The evacuator unit gradulaly expands as it fills with drainage
Answer: A. The safety pin is present at the distal end of the drain
112. A nurse is preparing to administer digoxin (Lanoxin) to a client. Which of the following
should the nurse check prior to administration?
A. Platelet count
B. Liver enzymes
C. Serum potassium
D. Coagulation studies
Answer: C. Serum potassium
113. A nurse is assisting with the admission of an older adult client. Which of the following
actions should the nurse take first?
A. Orient the client to the room
B. Provide the client with non-skid footwear
C. Complete a fall risk assessment on the client
D. Reinforce safe ambulation techniques with the (AP) on the unit
Answer: C. Complete a fall risk assessment on the client
114. A client who is diagnosed with Parkinson’s disease verbalize frustration due to increase
difficulty with ambulation. Which of the following is an appropriate response for the nurse to
make?
A. Watch your feet when you walk to maintain balance to prevent falls
B. We should monitor your serum blood level of levodopa monthly
C. Perform active range of motion with your arms and legs three times a day
D. You should consider using a wheelchair instead of trying to walk
Answer: C. Perform active range of motion with your arms and legs three times a day
115. A nurse is caring for a client and notes the IV fluid rate has slowed. Which of the following
actions should the nurse take first?
A. Repostion the tip of the catheter
B. Check the tubing for kinks or obstructions
C. Position the IV tubing to avoid tension on the IV catheter
D. Tighten the IV tubin connections
Answer: B. Check the tubing for kinks or obstructions
116. A nurse administers a dose of digoxin (Lanoxin) that was prescribed to be given every other
day. She discovers 1hr later that the medication had been given yesterday. Which of the
following actions should the nurse take next?
A. Obtain a set of vital signs
B. Document the medication erro on an incident report
C. Report the error to the appropriate hospital personnel
D. Perform any treatments necessary
Answer: A. Obtain a set of vital signs
117. A nurse is reinforcing teaching with a client who has a prescription for isoniazid (Laniazid)
and rifampin (Rifadin) to treat tuberculosis. Which of the following should the nurse include in
the teaching?
A. You may need to take medicatons to treat tuberculosis for as long as two years
B. You can take isoniazid with an antacid if it upsets your stomach
C. You will need to have a tuberculin test in 3 months to determine the effectiveness of the
medications
D. You should notify the provider if your urine turns orange while taking the medication
Answer: A. You may need to take medicatons to treat tuberculosis for as long as two years
118. A nurse in an outpatient surgery center is reinforcing discharge teaching with a client
following a lithotripsy for uric acid stones. Which of the following should the nurse plan to
include in the teaching?
A. Limit fluid intake to 1 L per day
B. Report the appearance of blood in the urine
C. Strain the urine to collect stone fragments
D. Increase dietary protein intake
Answer: C. Strain the urine to collect stone fragments
119. A nurse is caring for a client who is expressing sorrow about the amputation of her leg 72hr
ago due to trauma. The nurse must leave the room but promises to return as soon as possible. The
nurse demonstrates which of the following ethical principles when he returns a promised?
A. Autonomy
B. Nonmaleficence
C. Justice
D. Fidelity
Answer: D. Fidelity
120. An upper airway x-ray indicates that a toddler has aspirated a bead. A nurse is reinforcing
teaching about the need for a bronchoscopy to the parents. Which of the following statements
given an accurate description?
A. A bronchoscope is a device that will help your child breathe
B. This is a scan that will help the doctor see if the bead has done any damage
C. This is a technique that will wash the bead out of the airway
D. A bronchoscope is a tube that allows the doctor to see and remove the bead
Answer: D. A bronchoscope is a tube that allows the doctor to see and remove the bead
121. A nurse is using the FLACC pain scale to determine the level of pain for an 11-month-old
infant who is postoperative. Which of the following factors should the nurse consider when using
this pain scale?
A. Quality of feeding
B. Level of activity
C. Respiratory effort
D. Skin color
Answer: B. Level of activity
122. A nurse is monitoring a client who is receiving lactated Ringer’s 500 mL IV over 4hr. The
drop factor of the manual IV tubing is 10 gtt/mL. The nurse should check that the manual IV
infusion is delivering how many gtt/min?
Answer: 21 gtt/min
123. A nurse is advising a group of AP about lifting clients in prepartion for transfer from the bed
to a chair. Which of the following instructions should the nurse include?
A. Stand with feet together
B. Use lower body strength
C. Turn at the waist
D. Raise the bed to a high position
Answer: B. Use lower body strength
124. A nurse is reinforcing teaching about conjunctivitis to the parent of a school-aged-child.
Which of the following should the nurse reinforce?
A. Maintain a warm compress on the affected eye at bedtime
B. Clean the eye from the outer to the inner canthus
C. Separate the child’s used washcloth from those of others
D. Instill ointment in the child’s affected eye each morning
Answer: C. Separate the child’s used washcloth from those of others
125. A nurse at a health fair for college students is reinforcing teaching about skin cancer
prevention. Which of the following instructions should the nurse include in her presentation?
A. Reapply sunscreen every 4hr during sun exposure
B. Sunscreen has a shelf life of 5 years
C. Limit sun exposure especially before noon
D. Use sunscreen with a sun protective factor of at least 15
Answer: D. Use sunscreen with a sun protective factor of at least 15
126. A home health nurse is caring for an older adult client in his home. Which of the following
should the nurse consider as an environmental risk factor?
A. Water heater set at 37.8C (100F)
B. Smooth shower stall floor
C. Carpeted floor
D. Table lamp next to the bed
Answer: B. Smooth shower stall floor
127. A nurse is reinforcing teaching about foot care with a client who has a new diagnosis of
diabetes mellitus. Which of the following should the nurse include in the teaching?
A. Trim toenails straight across
B. Apply lotion between toes daily to prevent dryness
C. Wear open-toed footwear
D. Use a heating pad on fee nightly to promote circulation
Answer: A. Trim toenails straight across
128. A nurse is reinforcing teaching with a client who is to undergo a coronary angiography at
0700. Which of the following instructions should the nurse include?
A. The client will receive general anestheia before the procedure
B. The client may feel a hot flush as the dye is injected
C. The client should report a metallic taste to the provider
D. The client will feel chest pain during the procedure
Answer: B. The client may feel a hot flush as the dye is injected
129. A nurse is caring for a client who has delirium. Which of the following should the nurse
expect?
A. Difficulty using correct words
B. Obsessive behaviors
C. Fluctuating levels of consciousness
D. Reports of hopelessness
Answer: C. Fluctuating levels of consciousness
130. A nurse is reinforcing teaching about coughing exercises to a client scheduled for surgery.
Which of the following information should the nurse include Ine the teaching?
A. Take one deep breath and then cough
B. Repeat coughing exercises twice consecutively
C. Perform coughing exercises every 3hr after surgery
D. Splint the incision with interlocked hands when coughing
Answer: D. Splint the incision with interlocked hands when coughing
131. A natural diseaster has occurred in a community. Clients who may have safely discharge
need to be identified to make room for incoming casualties. Which of the following clients
should the nurse recognize could be discharged in this situation?
A. A client who was admitted with diabetic ketoacidosis whose current blood glucose reading is
350 mg/dl
B. A client who was admitted this morning with the onset of fever severe headache and nuchal
rigidity
C. A client who has pneumonia who is currently receiving oral antibiotics
D. A client who had a small bowel resection with a loop ileostomy 24hr ago
Answer: C. A client who has pneumonia who is currently receiving oral antibiotics
132. A nurse is reinforcing teaching with a client who is schedule for modified radical
mastectomy with drainage tubes. Which of the following should the nurse include in the
teaching?
A. You should avoid exercise of the arm of the affected side
B. Keep your arms at your sides while lying in bed
C. Your drainage tube will be discontinued 24hr following surgery
D. You should avoid measuring your blood pressure on the affected side
Answer: D. You should avoid measuring your blood pressure on the affected side
133. A nurse is reinforcing teaching to a client who has cholecystitis. Which of the following
foods should the nurse instruct the client to avoid in her diet?
A. Orange juice
B. Eggs
C. Peanut butter
D. Wine
Answer: C. Peanut butter
134. A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural
effusion. In which of the following positions should the nurse place the client?
A. Supine with arms raised over the head
B. Prone with arms at sides
C. Upright with arms resting on the overbed table
D. Left lateral side position
Answer: C. Upright with arms resting on the overbed table
135. A client who has a chest tube drainage device asks the nurse for assistance in using the
bathroom. Which of the following actions should the nurse take?
A. Provide the client with a bedpan until the chest tube is removed
B. Keep the collection device below the level of the client’s chest
C. Strip the chest tube to create negative pressure
D. Clamp the collection device
Answer: B. Keep the collection device below the level of the client’s chest
136. A nurse has a prescription to perform a bladder scan for a client. Which of the following
actions should the nurse take?
A. Ask the client to sign a consent form
B. Use surgical aseptic technique
C. Check for allergies to iodine or shellfish
D. Tell the client she should not experience any discomfort
Answer: D. Tell the client she should not experience any discomfort
137. A nurse is assisting with the plan of care for a client who had a stroke and has dysphagia.
Which of the following interventions should the nurse include in the plan of care?
A. Offer a drink of ice water before meals
B. Maintain the client in an upright position for 10 mins after meals
C. Remind the client to swallow twice with each bite of food
D. Engage the client in conversation during the meal
Answer: C. Remind the client to swallow twice with each bite of food
138. A nurse is discussing the use of epidural analgesia with a newly licenesed nurse. Which of
the following statements by the newly licensed nurse indicated an understanding of this method
of pain control?
A. I should instruct the client to administer a dose of medication when he feels pain
B. I should monitor the client for hypertension when he is receiving the analgesia
C. I should instruct the client that the medication is administered directly to the nerve
D. I should report leaking at the insertion site to the anesthesiologist
Answer: D. I should report leaking at the insertion site to the anesthesiologist
139. A nurse at a mental health facility is assisting with the development of a an education
program for newly licensed nurses. The nurse should include that it is approprite to obtain a
prescription to place a client in seclusion in which of the following situations?
A. A client shouts degrading statesments at a family member
B. A client states she is going to leave the facillity in the middle of the night
C. A client refuses to take her medication and throws the pills toward the nurse’s desk
D. A client hits another client because she thought he was talking about her
Answer: D. A client hits another client because she thought he was talking about her
140. A nurse is collecting data about health risks from a young adult client. Which of the
following questions by the nurse is the priority?
A. How many fruits and vegetables do you include in your diet
B. How much alcohol do you consume on a regular basis
C. What types of physical activity do you engage in
D. Can you describe your peer relationships
Answer: B. How much alcohol do you consume on a regular basis
141. A client who is diagnosed with Parkinson’s disease verbalize frustration due to increase
difficulty with ambulation. Which of the following is an appropriate response for the nurse to
make?
A. Watch your feet when you walk to maintain balance to prevent falls
B. We should monitor your serum blood level of levodopa monthly
C. Perform active range of motion with your arms and legs three times a day
D. You should consider using a wheelchair instead of trying to walk
Answer: C. Perform active range of motion with your arms and legs three times a day
142. A nurse is caring for a client and notes the IV fluid rate has slowed. Which of the following
actions should the nurse take first?
A. Repostion the tip of the catheter
B. Check the tubing for kinks or obstructions
C. Position the IV tubing to avoid tension on the IV catheter
D. Tighten the IV tubin connections
Answer: B. Check the tubing for kinks or obstructions
143. A nurse is caring for a client who is NPO and has a NG tube attached to suction for gastric
decompression. Which of the following actions is appropriate if the nurse observes abdominal
distention?
A. Provide oral hygiene
B. Increase the suction pressure
C. Clamp the tube for 30 min
D. Irrigate the tube with normal saline
Answer: D. Irrigate the tube with normal saline
144. A nurse is caring for a client who is on telemetry. Which of the following ECG findings
should the nurse report to the charge nurse?
A. One P wave prior to each QRS complex
B. PR interval 0.24 seconds
C. QRS duration 0.06 seconds
D. Ventricular rate 75/min
Answer: B. PR interval 0.24 seconds
145. A nurse on an acute mental health unit observes a client who begins to speak loudly in the
common room, saying that he can’t hear the TV. Which of the following is an appropriate
response by the nurse?
A. You will need to go to your room until you can calm down okay
B. The TV is loud enough for everyone to hear it
C. You are being inconsiderate. Please stop talking so loudly
D. Let’s go to another room to talk about what is upsetting you
Answer: D. Let’s go to another room to talk about what is upsetting you
146. A nurse is caring for a client who is NPO and has a NG tube attached to suction for gastric
decompression. Which of the following actions is appropriate if the nurse observes abdominal
distention?
A. Provide oral hygiene
B. Increase the suction pressure
C. Clamp the tube for 30 min
D. Irrigate the tube with normal saline
Answer: D. Irrigate the tube with normal saline
147. A nurse is caring for a client who delivered a full-term newborn 16hr ago. The nures notes
excessive lochia discharge. Which of the following actions should the nurse take first?
A. Obtain a blood specimen for hematocrit
B. Perform fundal massage
C. Have the client empty her bladder
D. Administer carboprost tromethamine (Hemabate)
Answer: C. Have the client empty her bladder
148. A nurse is preparing to perform trachostomy care for a client. Which of the following
actions should the nurse take first?
A. Don sterile gloves
B. Open sterlie packages
C. Pour sterile solution in a bowl
D. Replace tracheostomy ties
Answer: B. Open sterlie packages
