2019 ATI RN Comprehensive Predictor Exam With Answers-690 Solved Questions

ATI RN Comprehensive Predictor Retake 2019
1. A nurse is caring for a child with sickle cell anaemia and is having a Vaso-occlusive crisis.
Which intervention should the nurse implement first?
Answer: Increase oral fluid
2. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy.
Which of the following actions should the nurse take?
Answer: Ensure that the newborn wears a diaper.
3. A nurse is preparing a client for a paracentesis. What action should the nurse take?
Answer: Instruct the client to void prior to the procedure.
4. A nurse is providing dietary teaching to a client who has end-stage of kidney disease and a
potassium level of 6. Which of the following is the best food the nurse to recommend?
Answer: Hard boiled eggs.
5. A director of nursing in a rehab facility is planning for measure of quality care provided.
Which of the following should the nurse director plan to use after the client is discharged to
gather information about quality of care?
Answer: Outcome audit
6. A nurse is caring for a client who repeatedly refuses meals, a nurse overhears an AP telling the
client “If you don’t eat, I’ll put restraint on you” … The nurse should intervene.
Answer: Assault
7. A nurse is caring for a client who reports insomnia. Which of the following is a priority for the
nurse to report to the provider?
Answer: Wake up to urinate during the night.

8. 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?
Answer: Massage reddened area over bony prominences
9. Charge nurse is teaching a group of newly licensed nurses about the correct use of restraints.
Which of the following should the nurse include in the teaching?
Answer: Applying elbow immobilizers of an infant receiving cleft lip injury
10. A nurse preparing to initiate IV fluid via infusion pump to a client. Which of the following
action should the nurse take?
Answer: Check the expiration date?
11. A nurse is proving discharge instruction about newborn to client who is 2 days postpartum.
Which of the following should be include?
Answer: Use car seat when travelling by airplane
12. A nurse as identified task to delegate to a group of an AP.
Answer: Evaluate to perform each task
Communicate appropriate task to AP
13. Adverse effect of furosemide?
Answer: Hearing loss
14. New diagnose of type 2 diabetes. Client readiness to learn:
Answer: I like to wait when my partner is here so we can both learn together.
15. Diazepam overdose medication for reversal?
Answer: Flumazenil
16. The nurse is planning a community health program about Parkinson’s disease. Which of the
following intervention the nurse indicates as a tertiarily prevention strategy?

Answer: Ambulation for client with Parkinson’s disease
17. A nurse is teaching a newly license nurse about incident report. Which of the following
statement indicate understanding?
Answer: They assist with quality improvement.
18. Peak expiratory flow meter teaching:
Answer: Blow air as hard and quickly as possible.
19. A nurse is caring for an infant who has RSV.
Answer: Suction prior to feeding.
20. A nurse is preparing to teach the parent of a child who has cystic fibrosis. Which of the
following teaching should the nurse plan to include?
Answer: Provide a diet high in protein and calories.
21. Taking Cyclosporine following a kidney transplant. Which Lab to report?
Answer: Creatinine of 1.6
22. Auditory Hallucination teaching?
Answer: Encourage the client listen to music.
23. A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding.
Which of the following action should the nurse take?
Answer: Insert a large-bore NG tube.
24. A nurse is planning care for a group of clients, which of the following measure should the
nurse to manage time effectively?
Answer: Gather supplies prior to completing a dressing change.

25. A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the
following statements by a newly licensed nurse indicates an understanding of the teaching?
Answer: “I will intervene if there is conflict between a client and his provider”
26. A nurse is assessing a client who is pregnant and has new diagnosis of hyperemesis
gravidarum. Which of the following finding should the nurse expect?
Answer: Urine output of 20 mL/Hr.
27. Apply physical restraint:
Answer: to maintain the patency of an IV line
28. A nurse is assessing a client who has anorexia nervosa. Which of the following finding
indicates effectiveness of the treatment plan?
Answer: The client has clinical manifestation of dehydration
29. A nurse is assessing and older adult for social isolation. The nurse should identify that which
of the following statement by the client indicates a risk for social isolation?
Answer: My hearing aids have lost so I don’t attend Bingo like I used to.
30. A nurse is teaching a client who is pregnant and has a new prescription for Iron supplement.
Which of the following statement should the nurse include?
Answer: You might become constipated while taking this medication.
31. Abdominal Assessment orders:
Answer: Inspection; Auscultation; Percussion; Palpation.
32. First indication of Peritonitis?
Answer: Abdominal pain
33. A nurse in an emergency department is caring for a 3-year-old child who has suspected
epiglottitis. Which of the following action should the nurse take?

Answer: Prepare client for intubation
34. A nurse is caring for a client who is 4 hours postpartum, client report urges to void but unable
to void. Which of the following action should the nurse take?
Answer: Massage the fundus
35. Screening an adolescent for idiopathic scoliosis, which of the following assessment should
the nurse perform part of the screening?
Answer: Measure the trunk location
36. Postpartum haemorrhage teaching?
Answer: Inversion of the uterus.
37. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about
overtime requirements. Which of the following strategies should the nurse use to promote
effective negotiation?
Answer: Attempts to understand both sides of the situation.
38. Kosher diet tradition food choice?
Answer: Scramble eggs and toast with milk.
39. A nurse is caring for client who is 11 weeks’ gestation, which of the following immunization
should the nurse recommends?
Answer: Inactivated Influenza vaccine
Tetanus diphtheria and acellular pertussis vaccine.
40. A home health nurse is preparing to make an initial visit to a family home from a local
provider. Identify the sequence of the step the nurse should take when conducting a home visit.
A. Identify family needs interventions using the nursing process.
B. Record information about the home visit according to agency policy.
C. Contact the family to determine availability and readiness to make an appointment

D. Discuss plans for future visits with the family.
E. Clarify the reason for the referral with the provider’s office.
Answer: E. Clarify the reason for the referral with the provider’s office.
C. Contact the family to determine availability and readiness to make an appointment
A. Identify family needs interventions using the nursing process.
B. Record information about the home visit according to agency policy.
D. Discuss plans for future visits with the family.
41. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulphate. The
nurse should identify that which of the following finding as sign of magnesium toxicity.
Answer: Hyperventilation
42. Newborn that has been circumcised. Which of the following instruction should the nurse
include in the teaching?
Answer: Apply petroleum jelly at each diaper changes
43. Discharge teaching for client with type 1 diabetes about preventing diabetic-ketoacidosis:
Answer: I should check my blood sugar twice a day
44. The nurse is caring for a client who is obese, the client is crying “everyone is staring at me
because my weight”, which of the following is the proper response should the nurse make?
Answer: Do you feel uncomfortable around others?
45. A nurse is teaching about preventative measures to a female client who has chronic urinary
tract infections. Which of the following interventions should the nurse include in the teaching?
Answer: Void every 4 hours.
46. A nurse is teaching a client who has heart failure about engaging in exercise program. Which
of the following statement by the client indicates an understanding of teaching?
Answer: Make sure you can still talk while exercising

47. Leave against medical advice:
Answer: Ask the client to sign a form.
48. A nurse is assessing a client who has opioid use disorder. Which of the following should the
nurse expect for opioid withdrawal?
Answer: Tachycardia
49. Client with COPD?
Answer: Give the client autonomy and scheduling activity
50. Anti-embolic stocking:
Answer: Make sure the client stockings are biding.
51. Pressure ulcer where Coccyx fat is visible is:
Answer: Stage 3
52. Oxycodone?
Answer: Avoid grapefruit juice
53. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the
following notations by the newly licensed nurse indicates an understanding of the teaching?
Answer: “Administered 8 u regular insulin sq.”
54. Dressing change in a child?
Answer: Explain in simple term how the procedure is going to affect the child.
55. Phenelzine what can you eat?
Answer: Whole grain bread
56. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured
membrane. Which of the following actions should the nurse take?

Answer: Apply fatal heart rate monitor
57. Teaching about security computerized?
Answer: Information technology will install a firewall to protect client information.
58. Client advocacy
Answer: a client gets a second opinion for diagnosis.
59. 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?
Answer: Food exchange lists for meal planning from the American Diabetes Association
60. A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via
continuous IV infusion. Which of the following actions should the nurse plan to take?
Answer: (Limit or remove?) IV bag from exposure to light.
61. The nurse is teaching a group of clients at a community health fair about genetic disease.
Which of the following statements by a client indicates an understanding of the teaching?
Answer: “My family has genetic risk for breast cancer, so I am considering a total mastectomy”
62. National notifiable disease:
Answer: Lyme disease.
63. Intracranial pressure following a brain injury?
Answer: Increased intracranial pressure (ICP) following a brain injury can lead to brain
herniation, decreased blood flow, and brain damage if not managed promptly.
64. Positive Skin TB test for a client:
Answer: 10

65. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and
a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my
baby needs an IV?” Which of the following responses should the nurse make?
Answer: “Your baby needs an IV because she is not producing any tears”
66. Postpartum haemorrhage medication:
Answer: Methylergonovine
67. 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?
Answer: Place the client’s left arm on a pillow while he is sitting.
68. Child has been sexually abused by family member.
Answer: Use leading statement to obtain information from the child.
69. A nurse realizes that the wrong medication has been administered to a client. Which of the
following actions should the nurse take first?
Answer: Monitor vital signs.
70. Client partner recently died; the nurse stays with the client:
Answer: Beneficent
RN Comprehensive Predictor 2019 Form A
1. A nurse in a paediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the
following actions should the nurse take?
Answer: Tell the child they will feel discomfort during the catheter insertion.
2. A nurse is caring for a client who has arteriovenous fistula Which of the following findings
should the nurse report?

Answer: Absence of a bruit.
3. A nurse is providing discharge teaching for a client who has an implantable cardioverter
defibrillator which of the following statements demonstrates understanding of the teaching?
Answer: “I will wear loose clothing around my ICD”
4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence
about being pregnant. Which of the following responses should the nurse make?
Answer: “Describe your feelings to me about being pregnant”
5. A nurse is planning care for a client who has a prescription for a bowel- training program
following a spinal cord injury. Which of the following actions should the nurse include in the
plan of care?
Answer: Administer a rectal suppository 30 minutes prior to scheduled defecation times.
6. A nurse is caring for a client who is in active labor and requests pain management. Which of
the following actions should the nurse take?
Answer: Place the client in a warm shower.
7. A nurse in an emergency department is performing triage for multiple clients following a
disaster in the community. To which of the following types of injuries should the nurse assign the
highest priority?
Answer: Below-the knee amputation
8. A nurse manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse include?
Answer: Document the client’s condition every 15 min
9. A nurse is teaching an in-service about nursing leadership. Which of the following information
should the nurse include about an effective leader?
Answer: Acts as an advocate for the nursing unit.

10. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports
that she has been following her (unable to read) care. The nurse should identify which of the
following findings indicates a need to revise the client’s plan of care.
Answer: Hba1c 10 %
11. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The
nurse should identify that which of the following sexually transmitted infections is a nationally
notifiable infectious disease that should be reported to the state health department?
Answer: Chlamydia
12. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading
a group on a mental health unit. Which of the following group facilitation techniques should the
nurse include in the teaching?
Answer: Use modelling to help the clients improve their interpersonal skills
13. A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse
that (Unable to read) Passover holiday. Which of the following action should the nurse include in
the plan of care?
Answer: Provide unleavened bread.
14. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the
effectiveness of the treatment
Answer: The client reports feeling less anxious.
15. A nurse in an emergency department is assessing a client who reports ingesting thirty
diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airway
and initiating an IV, which of the following actions should the nurse do next.
Answer: Administer flumazenil to the client.

16. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago.
Which of the following findings should the nurse expect?
Answer: Elevated temperature
17. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the
following manifestations should the nurse expect?
Answer: Jitteriness
18. A nurse in a paediatric clinic is reviewing the laboratory test results of a school age child.
Which of the following findings should the nurse report to the provider?
Answer: WBC 14,000/mm3
19. A charge nurse is teaching a newly licensed nurse about clients designating a health care
proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the
following information should the charge nurse include?
Answer: “The proxy can make treatment decisions if the client is under anaesthesia.”
20. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions
should the nurse take first?
Answer: Turn the client on their side.
21. A nurse is caring for a client who has a history of depression and is experiencing a situational
crisis. Which of the following actions should the nurse take first?
Answer: Confirm the client’s perception of the event
22. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The
nurse obtained a verbal prescription for restraints. Which of the following should the actions
should the nurse take?
Answer: Document the client’s condition every 15 minutes.

23. A nurse is working on a surgical unit is developing a care plan for a client who has
paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the
following interventions should the nurse include in the care plan?
Answer: Place the client upright on a donut-shaped cushion
24. A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following
pain-management (Unable to read) a safe option for the client? following is an appropriate
nursing intervention?
Answer: Place the bedside table on the right side of the bed.
25. A nurse is assessing a client who has major depressive disorder. Which of the following
findings should the nurse identify as the (Unable to read) (Most important?)
Answer: The client reports giving away personal items.
26. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse
should inform the client that she can receive which of the following immunizations during
pregnancy? (Select all that apply)
Answer: Tetanus diphtheria and acellular pertussis vaccine
Inactivated influenza vaccine.
27. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks
the nurse about becoming a living kidney donor for her father. Which of the following condition
in the child’s medical history should the nurse identify as a contraindication to the procedure?
Answer: Hypertension
28. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports
sleeping very little during the past week due to caring for his mother. Which of the following
responses should the nurse make?
Answer: “I can give you information about respite care if you are interested.”

29. A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an
increase in the child’s glucose. The nurse should identify this finding as an adverse effect of
which of the following medications
Answer: A. Methylprednisolone.
30. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of
the following information should the nurse include in the teaching?
Answer: “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”.
31. A community health nurse is assessing an adolescent who is pregnant. Which of the
following assessments is the nurse’s priority?
A. Social relationship with peers.
B. Plans for attending school while pregnant.
C. (Unable to read) (Picked this one) Medicaid
D. Understanding of infant care.
Answer: (Unable to read) (Picked this one) Medicaid
32. A nurse manager is planning to teach staff about critical pathways. Which of the following
information should the nurse include?
Answer: decrease health care costs.
33. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the
following should the nurse report to the provider?
Exhibit 1
Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C
(99.3F)
Exhibit 2
Medication Administration Record
Clozapine 150 mg PO twice daily
Benztropine 0.5 mg PO twice daily as needed for tremors.
Exhibit 3 Nurse’s notes:

Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the
past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of
breakfast and reports slightly nauseous.
Answer: Sore throat.
34. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive
personnel
Answer: “An RN evaluates the client needs to determine tasks to delegate”
35. A nurse is assessing a client who is in active labor. Which of the following findings should
the nurse report to the provider?
Answer: FHR baseline 170/min
36. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has
left-sided hemiplegia the following actions is the nurse’s priority?
Answer: Ensure that the client has a referral for physical therapy.
37. A nurse in a mental health unit is planning room assignments for four clients. Which of the
following client should be closest to the nurse’s station?
Answer: A client who has depressive disorder and reports feeling hopeless.
38. A nurse is preparing to measure a temperature of an infant. Which of the following action
should the nurse take?
Answer: Place the tip of the thermometer under the centre of the infant’s axilla.
39. 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?
Answer: Encourage the client to take frequent rest periods
40. A nurse is admitting medications to a group of clients. Which of the following occurrences
requires the completion of an incident report?

Answer: A client receives his antibiotics 2hr late
41. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns.
The client asks the nurse to warm up seaweed soup that the client’s partner brought for her.
Which of the following responses should the nurse make?
Answer: “Does the doctor know you are eating that?”
42. 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?
Answer: Administering potassium via IV bolus
43. A nurse is providing teaching to family members of a client who has dementia. Which of the
following instructions should the nurse include in the teaching?
Answer: Establish a toileting schedule for the client
44. The nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client’s history is a contradiction to the
use of oral contraceptives?
Answer: Thrombophlebitis.
45. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations.
The client states, “It’s hard not to listen to the voices.” Which of the following questions should
the nurse ask the client?
Answer: “What helps you ignore what you are hearing?”
46. A charge nurse is teaching a group of newly licensed nurses about the correct use of
restraints. Which of the following should the nurse include in the teaching?
Answer: Applying elbow immobilizers of an infant receiving cleft lip injury
47. A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The
results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the

Answer: Respiratory alkalosis
48. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the
following
Answer: Inject air into the NPH insulin vial.
49. 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?
Answer: “We should establish our roles in the initial session.”
50. A nurse in a paediatric clinic is teaching a newly hired nurse about the varicella rooster.
Which of the following information should the nurse include?
Answer: Children who have varicella are contagious until vesicles are crusted.
51. A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of
the following requires intervention by the staff nurse?
Answer: Waits 2 minutes between suctions.
52. A nurse is teaching at a community health fair about electrical fire prevention. Which of the
following information should the nurse include in the teaching?
Answer: Use three pronged grounded plugs.
53. A nurse is providing care for a group of clients. Which of the following client’s should the
nurse identify as having the highest risk for developing a pressure injury?
Answer: A client who has a T-tube following an open cholecystectomy.
54. A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops.
Which of the following statements indicates an understanding of the teaching?
Answer: “I will place pressure on the corner of my eye after using he eye drops”

55. A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report
to the provider. Which of the following findings should the nurse include in the teaching?
Answer: Swelling of the face
56. A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the
following responses should the nurse make?
Answer: “I can give you information about making end of life decisions”.
57. A nurse is caring for a client who is experiencing mild anxiety. Which of the following
findings should the nurse expect?
Answer: Heightened perceptual field
58. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate
for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following
orders from the provider should the nurse expect?
Answer: Administer the medication.
59. 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?
Answer: Eat a light snack before bedtime
60. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of
the following medications should the nurse administer?
Answer: Pregabalin
61. A nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to
read) following actions should the nurse take?
Answer: Report continuous bubbling in the water seal chamber.
62. A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN.
The nurse should monitor for which of the following adverse effects?

Answer: Urinary retention.
63. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar
disorder. The partner states “I don’t know what to do. Everything has been happening so
quickly.” Which of the following by the nurse is therapeutic?
Answer: “Can you talk about what happens with your partner at home?”
64. A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis
of celiac disease. Which of the following statements by the guardian indicates an understanding
of the teaching?
Answer: “I will put my child on a gluten-free diet”.
65. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the
following actions should the nurse take?
Answer: Prime IV tubing with 0.9% sodium chloride.
66. A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of
continuous infusions should the nurse initiate?
Answer: 0.9% normal saline.
67. A nurse is teaching who has chronic pain about avoiding constipation from opioid
medications. Which of the following should the nurse include in the teaching?
Answer: Increase exercise activity
68. A nurse is teaching about preventative measures to a female client who has chronic urinary
tract infections. Which of the following interventions should the nurse include in the teaching?
Answer: “Drink 2 litters of warm water per day”.
69. A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
Answer: A client who has a hip fracture and a new onset of tachypnea

70. 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?
Answer: Consume food high in bran fiber
71. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy.
Which of the following actions should the nurse take?
Answer: 2. Ensure that the newborn wears a diaper.
72. A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the
following statements by a newly licensed nurse indicates an understanding of the teaching?
Answer: “I will intervene if there is conflict between a client and his provider”
73. A nurse is preparing to reposition a client who had a stroke. Which of the following actions
should the nurse take?
Answer: Evaluate the client’s ability to help with repositioning.
74. A nurse is orientation a newly licensed nurse who is caring for a client who is receiving
mechanical ventilation and is receiving mechanical ventilation and is on pressure support
ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates
and understanding of PSV?
Answer: “It allows preset pressure delivered during spontaneous ventilation.”
75. A nurse is caring for an infant who has coaction of the aorta. Which of the following should
the nurse identify as an expected finding?
Answer: Weak femoral pulses
76. A nurse is auscultating for crackles on a client who has pneumonia. Which of the following
anterior chest wall locations should the nurse auscultate?

Answer: C
77. A nurse is assisting with the development of an informed document for participation in a
research study. Which of the following information should the nurse include?
Answer: A statement that participants can leave the study at will.
78. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the
following adverse effects should the nurse include?
Answer: Excessive sweating
79. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the
following should the nurse report to the provider?
Answer: The client develops hiccups.

80. 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?
Answer: Food exchange lists for meal planning from the American Diabetes Association
81. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of
the following statements should the nurse include in the teaching?
Answer: “You should push the button before physical activity to allow maximum pain control.”
82. A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin
for blood glucose management. The nurse should anticipate administering which of the following
types of insulin?
Answer: Glargine insulin.
83. A nurse is caring for a toddler who has acute lymphocytic leukaemia. In which of the
following should the toddler participate?
Answer: Playing with a large plastic truck.
84. A nurse is caring for a client who is receiving intermittent feedings via a feeding via a
feeding pump and is experiencing dumping syndrome. Which of the following actions should the
nurse take?
Answer: (Unable to read) rate of the client’s feedings.
85. A nurse in an emergency department is caring for a client who received a dose of penicillin
and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following
actions is the nurse’s priority?
Answer: Administer oxygen
86. A nurse is caring for a client who has Raynaud’s disease. Which of the following actions
should the nurse take?
Answer: Provide information about stress management.

87. A nurse is reviewing the medical history of a client who has angina. Which of the following
findings in the client’s medical history should identify as a risk factor for angina?
Answer: Hyperlipidemia.
88. A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal
laceration. The client reports not having a bowel movement for 4 days. Which of the following
medications should the nurse administer?
Answer: Magnesium hydroxide 30 ml PO.
89. 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?
Answer: Report the incident to the AP’s charge nurse.
90. A nurse is planning care for a client who is receiving haemodialysis. Which of the following
actions should the nurse include in the plan of care?
Answer: Check the vascular access site for bleeding after dialysis.
91. A nurse in the emergency department is caring for a client who reports intimate partner
violence. Which of the following interventions is the nurse’s priority?
Answer: Determine if the client has any injuries.
92. A nurse is caring for a client who is in active labor and note the FHR baseline has been
100/min for the past 15 min. The nurse should identify which of the following conditions as a
possible cause of fetal bradycardia?
Answer: Maternal hypoglycaemia
93. A nurse is assessing a school-age child who has a urinary tract infection. Which of the
following findings should the nurse expect?
Answer: Enuresis.

94. 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?
Answer: A client who is 1 day postoperative following a vertebroplasty
95. A nurse is providing teaching to the parents of a newborn genetic screening. Which of the
following statement should the nurse include in the teaching?
Answer: “This test should be performed after your baby is 24 hours old.”
96. A nurse is providing discharge teaching to a client who is postoperative following a colon
resection and has a new ascending colostomy. Which of the following statements by the client
indicates an understanding of the teaching?
Answer: “I should avoid eating popcorn and fresh pineapple”
97. A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and
hoarseness. Which of the following is the nurse’s priority?
Answer: Place the client on NPO status.
98. 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?
Answer: “Rise slowly when getting out of bed”
99. A nurse is planning a teaching session for a client who is postoperative following a colon
resection. Which of the following actions should the nurse take first?
Answer: Determine the client’s current pain level.
100. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
Answer: Broiled skinless chicken breast with brown rice.

101. A nurse is caring for a client who asks for information regarding organ donation. Which of
the following should the nurse make?
Answer: “Your desire to be an organ donor must be documented in writing.”
102. A nurse is teaching a female client about personal hygiene. Which of the client actions
indicates an understanding go the teaching?
Answer: D. The client brushes her teeth twice daily.
103. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should
the nurse plan to take?
Answer: Auscultate the newborn’s apical pulse for 60 seconds.
104. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last
5 days. The client’s laboratory values this morning are the following: WBC 10,000/mm 3, RBC
5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse
should report these finding to which of the following members of the interdisciplinary team?
Answer: Nephrologist
105. A nurse is caring for an infant who is in contact isolation and received a blood transfusion.
Which of the following actions is appropriate for the nurse to take to provide cost-effective care?
Answer: Return unopened equipment to the supply centre
106. A nurse is reviewing the medical record of a client who is postoperative following a total
hip arthroplasty. For which of the following findings should the nurse contact the provider?
Answer: WBC count 14,000 mm3
107. A nurse is preparing education material for a client. Which of the following techniques
should the nurse use in creating material?
Answer: Emphasize important information using bold lettering.

108. A nurse is creating for a client who has aids. The client states, “My mouth is sore when I
eat.” Which of the following instructions should the nurse provide?
Answer: “Ice chips”
109. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
The nurse should monitor the client for which of the following complications?
Answer: Contractions
110. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has
ruptured membrane. Which of the following actions should the nurse take?
Answer: Apply fetal heart rate monitor.
111. A home health nurse is preparing to make an initial visit to a family following a referral
from a local provider. Identify the sequence of steps the nurse should take when conducting a
home visit. (Move the steps into the box on the right. Placing them in the order of performance)
A. Identify family needs interventions using the nursing process.
B. Record information about the home visit according to agency policy.
C. Contact the family to determine availability and readiness to make an appointment
D. Discuss plans for future visits with the family.
E. Clarify the reason for the referral with the provider’s office.
Answer: E. Clarify the reason for the referral with the provider’s office.
C. Contact the family to determine availability and readiness to make an appointment
A. Identify family needs interventions using the nursing process.
B. Record information about the home visit according to agency policy.
D. Discuss plans for future visits with the family.
112. A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the
following places the client at risk for aspiration?
Answer: A History of gastroesophageal reflux disease

113. A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving haemodialysis. Which of the following instructions should the nurse include in the
teaching?
Answer: Eat 1g/kg of protein per day
114. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac
monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse
should interpret this finding as which of the following cardiac rhythms?
Answer: First degree AV block
115. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse
observes that the client coughs after each bite. After asking the AP to stop feeding the client,
which of the following actions should the nurse take next?
Answer: Listens to the client’s lung sounds.
116. 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?
Answer: Ask the client directly what he is hearing
117. The nurse is teaching a group of clients at a community health fair about genetic disease.
Which of the following statements by a client indicates an understanding of the teaching?
Answer: “My family has genetic risk for breast cancer, so I am considering a total mastectomy”
118. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which
of the following instructions should the nurse plan to include in the teaching?
Answer: “Keep the cord stump dry until it falls off.”
119. 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?
Answer: “I take a calcium vitamin supplement daily”

120. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the
following actions by a newly licensed nurse indicates an understanding of the teaching?
Answer: Uses a mechanical lift to move client from bed to chair.
121. A client is requesting information from a nurse about a nitrazine test. Which of the
following statements should the nurse make?
Answer: “This test will determine if there is leaking amniotic fluid”
122. A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which
of the following findings indicate the client is developing a complication of therapy?
Answer: Peripheral edema
123. A nurse is conducting a home visit for a family who has two young children. The nurse
notes several welts across the backs of the legs of one of the children. Which of the following
actions should the nurse take first?
Answer: Contact child protective services.
124. A nurse is planning care for a client who has thrombocytopenia. Which of the following
actions should the nurse include?
Answer: Provide the client what a stool softener.
125. A nurse is assessing a client who is 30 min postoperative following an arterial
thrombectomy. Which of the following findings should the nurse to report?
Answer: Chest pain
126. 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?
Answer: Place the client in high fowler’s position.

127. A charge nurse is teaching a newly licensed nurse about the administration of total
parenteral nutrition. Which of the following should the charge nurse include?
Answer: “You will need to monitor the client’s electrolytes daily”
128. A nurse is teaching a prenatal class about infection at a community center. Which of the
following statements by a client indicates an understanding of the teaching?
Answer: “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
129. A nurse is caring for a client who has end-stage liver cancer. Which of the following
statements should the nurse make to support the client’s right to autonomy?
Answer: “We encourage you to participate in all decisions about your treatment”
130. A nurse is completing an incident report after a client fall. Which of the following
competencies of Quality and Safety Education for Nurse is the use demonstrating?
Answer: Quality improvement.
131. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of
the following actions should the nurse take?
Answer: Notify the nursing manager about the suspected alcohol use.
132. A charge nurse is teaching new staff members about factors that increase a client’s risk to
become violet. Which of the following risk factors should the nurse include as the best predictor
of future violence?
Answer: Previous violent behavior
133. A charge nurse is teaching a newly licensed nurse about medication administration. Which
of the following information should the charge nurse include?
Answer: Avoid preparing medications for more than two clients at one time.
134. A charge nurse is evaluating the time management skills of a newly licensed nurse. For
which of the following actions by the newly licensed nurse should the charge nurse intervene?

Answer: Documents the clients care tasks at the end of the shift.
135. A nurse is caring for a client who has diaper dermatitis. Which of the following actions
should the nurse take?
Answer: Apply zinc oxide ointment to the irritated area.
136. A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
Answer: “The client exhibits impulsive behaviours.”
137. A nurse is caring for a client who has a prescription for warfarin. When reviewing the
client’s current medications, which of the following medications should the nurse identify as
contraindicated for use with warfarin? (Select all that apply)
Answer: 1. Aspirin
2. Gingko biloba.
3. Ibuprofen.
138. A nurse is completing an admission assessment for a client who has narcissistic personality
disorder. Which of the following findings should the nurse expect?
Answer: Preoccupied with aging
139. A nurses is assessing a preschooler who has recently experienced an unexpected death in the
family. Which of the following should the nurse recognize as an expected finding?
Answer: The child believes the person will return.
140. A nurse is assessing a client in the emergency department. Which of the following actions
should the nurse take first?
Exhibit 1
Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl
Glucose 35 mg/dl Cloudy in appearance
Exhibit 2

History and Physical
Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic.
Exhibit 3
Vital Signs
BP 166/96 mm Hg
Respiratory rate 24/min
Pulse rate 112/min
Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9
Answer: Obtain arterial blood gas levels.
141. A client is caring for a client following a paracentesis. Which of the following findings
should the nurse identify as an indication of a complication?
Answer: Tachycardia.
142. A certified IV nurse is providing education about peripherally inserted catheters (PICC) to a
newly licensed nurse. Which of the following statements by the newly licensed nurse indicated
an understanding of the teaching?
Answer: “Informed consent is required prior to PICC placement.”
143. A nurse is reviewing admission prescriptions for a group of clients. Which of the following
prescriptions should the nurse identify as complete?
Answer: Metoprolol 5mg IV now.
144. A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of
the following actions should the nurse take?
Answer: Perform the procedure prior to meals
145. A nurse is reviewing the medical records of four clients. The nurse should identify that
which of the following client findings requires follow up care?
Answer: A client who is taking warfarin and has an INR of 1.8

146. A nurse is caring for a client who is postpartum and request information about
contraception. Which of the following instructions should the nurse include?
Answer: “Place transdermal birth control patch on your upper arm”
147. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the
parent of a newborn. Which of the following statements indicates an understanding of the
teaching?
Answer: “I will not publish public announcement about my baby’s birth”
148. A nurse is developing a plan of care for a client who has preeclampsia and is to receive
magnesium sulphate via continuous IV infusion. Which of the following actions should the nurse
include in the plan?
Answer: Measure the client’s urine output every hour
149. A nurse is receiving a telephone prescription from a provider for a client who requires
additional medication for pain control. Which of the following entries should the nurse make in
the medical record?
Answer: “Morphine 3 mg Subcutaneous
150. A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min.
The client’s ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which
of the following conditions should the nurse expect?
Answer: Metabolic acidosis.
151. A nurse realizes that the wrong medication has been administered to a client. Which of the
following actions should the nurse take first?
Answer: Monitor vital signs.
152. Receives a telephone call from a parent reporting that their school-age child has a nosebleed
and that they cannot stop the bleeding. Which of the following instructions should the nurse
provide to the provider?

Answer: “Use your thumb and forefinger to apply pressure to the (Unable to read) of your
child’s
153. A nurse is preparing to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
Answer: Ensure that the client’s identification band matches the number on the blood unit.
154. A nurse is transcribing new medication prescriptions for a group of client. For which of the
following prescriptions should the nurse contact the provider for clarifications?
Answer: Lorazepam .5mg PO one tablet daily
155. A nurse is caring for a client who requires seclusion to prevent harm to others on the unit.
Which of the following is an appropriate action for the nurse to take?
A. Offer fluids every 2hr.
B. Document the client’s behavior prior to being placed in seclusion.
C. Discuss with the client his inappropriate behavior prior to seclusion.
D. Assess the client’s behavior once every hour.
Answer: A. Offer fluids every 2hr.
156. A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
Answer: “Dehydration can increase the risk of preterm labor”
157. A nurse is assessing a client who is postoperative following abdominal surgery and has an
indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the following
interventions should the nurse anticipate?
Answer: Obtain a urine specimen for culture and sensitivity
158. 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?

Answer: WBC count 2,900/mm3
159. A nurse is caring for a client who has depression and reports taking ST. John’s wort along
with citalopram. The nurse should monitor the client for which of the following conditions as a
result of an interaction between these substances?
Answer: Serotonin syndrome
160. A nurse in a provider’s office is preparing to administer the inactivated influenza vaccine.
The nurse should collect additional (Unable to read) for which of the following client prior to
administering the vaccine?
Answer: Client has a sensitivity to eggs.
161. A nurse is providing teaching about digoxin administration to the parents of a toddler which
as heart failure. Which of the following statements should the nurse include in the teaching?
Answer: “Have your child drink a small glass of water after swallowing the medication.”
162. A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the
following actions should the nurse take?
Answer: Obtain the specimen immediately upon the client waking up.
163. A nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For
which of the following laboratory results should the nurse withhold the medication and notify the
provider?
Answer: Potassium 3.1 mEq/L.
164. A nurse is caring for a client who wears glasses. Which of the following actions should the
nurse take?
Answer: Store the glasses in a labelled case.
165. A school nurse is teaching a parent about absent seizures. Which of the following
information should the nurse include?

Answer: “This type of seizure can be mistaken for daydreaming.”
166. A nurse is planning care for a client who has cancer and is about to receive low dose
brachytherapy via a vaginal implant applicator. Which of the following interventions should the
nurse include in the plan of care?
Answer: Insertion of an indwelling urinary catheter
167. A nurse is caring for a client who has deep vein thrombosis and is receiving heparin therapy.
Which of the following tests should the nurse use to monitor and regulate the dosage of the
medications?
Answer: aPTT.
168. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about
overtime requirements. Which of the following strategies should the nurse use to promote
effective negotiation?
Answer: Attempts to understand both sides of the issue
169.which of the following findings should the nurse identify as an indication of intercranial
pressure?
Answer: Increasingly severe headache.
RN Comprehensive Predictor 2019 Form B
1. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school
age child. Which of the following instructions should the nurse take?
Answer: Administer the feeding over 30 min.
2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following
findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L.
Answer: Digoxin level 1 ng/ml.

3. A nurse is caring for a client who is comatose and has advance directives that indicate the
client does not want life-sustaining measures. The client’s family want the client to have life
sustaining measures. Which of the following action should the nurse take?
Answer: Arrange for an ethics committee meeting to address the family’s concerns.
4. A nurse is caring for a client who wears glasses. Which of the following actions should the
nurse take?
Answer: Store the glasses in a labelled case.
5. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a
client who is on contact precautions. Which of the following should the nurse include in the
teaching?
Answer: Wear gloves when providing care to the client.
6. A nurse is planning on care for a client who is recovering from an acute myocardial infarction
that occurred 3 days ago. Which of the following instructions should the nurse include?
Answer: Obtain a cardiac rehabilitation consultation.
7. The nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client’s history is a contradiction to the
use of oral contraceptives?
Answer: Thrombophlebitis.
8. A nurse is caring for a client who request the creation of a living will. Which of the following
actions should the nurse take?
Answer: Evaluate the client’s understanding of life-sustaining measures.
9. A nurse is caring for an adolescent who has sickle-cell anaemia. Which of the following
manifestations indicates acute chest syndrome and should be immediately reported to the
provider?
Answer: Substernal retractions.

10. A nurse is providing care for a client who is in the advance stage of amyotrophic lateral
sclerosis. (ALS). Which of the following referrals is the nurse’s priority?
Answer: Speech-language pathologist.
11. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of
the following findings should the nurse report to the provider? A. WBC count 8,000/mm 3.
Answer: Erythrocyte sedimentation rate 75 mm/hr
12. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse
should expect a prescription for which of the following laboratory tests?
Answer: Platelet count.
13. A nurse is caring for a client following application of a cast. Which of the following actions
should the nurse take first?
Answer: Palpate the pulse distal to the cast.
14. A nurse is caring for a client who has vision loss. Which of the following actions should the
nurse take? (Select all that apply)
Answer: A. Keep objects in the client’s room in the same place.
B. Ensure there is high-wattage lighting in the client’s room.
D. Allow extra time for the client to perform tasks.
15. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has
questions about the disease. To research the nurse should identify that which of the following
electronic database has the most comprehensive collection of nursing (Unable to read) articles?
Answer: CINAHL.
16. A nurse in an emergency department is assessing newly admitted client who is experiencing
drooling and hoarseness following a burn injury. Which of the following should actions should
the nurse take first? A. Obtain a baseline ECG.

Answer: Administer 100% humidified oxygen.
17. 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?
Answer: Place the client’s left arm on a pillow while he is sitting.
18. A nurse is caring for a client who is in a seclusion room following violent behavior. The
client continues to display aggressive behavior. Which of the following actions should the nurse
take?
Answer: Confront the client about this behavior.
19. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer.
Which of the following actions should the nurse take?
Answer: Limit the client’s visitors to 30 min per day.
20. A nurse is assessing a client who has left-sided heart failure. Which of the following should
the nurse identify as a manifestation of pulmonary congestion?
Answer: Bradypnea
21. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the
following conditions should the nurse recognize as a contraindication to the use of oxytocin.
Answer: Post term with oligohydramnios
22. A nurse is assessing a client who has left-sided heart failure. Which of the following should
the nurse identify as a manifestation of pulmonary congestion?
Answer: Bradypnea
23. 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?
Answer: “Rise slowly when getting out of bed”

24. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive
disorder. Which of the following interventions should the nurse take?
Answer: Allow the client enough time to perform rituals.
25. A nurse is caring for a client who has depression and reports taking ST. John’s wort along
with citalopram. The nurse should monitor the client for which of the following conditions as a
result of an interaction between these substances?
Answer: Serotonin syndrome
26. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings
indicate fluid overload?
Answer: Dyspnea.
27. A nurse is discussing group treatment and therapy with a client. The nurse should include
which of the following as being a characteristic of a therapeutic group?
Answer: The group is organized in an autocratic structure.
The group encourages members to focus on a particular issue.
28. A public health nurse is managing several projects for the community. Which of the
following interventions should the nurse identify as a primary prevention strategy?
Answer: Teaching parenting skills to expectant mothers and their partners.
29. A nurse is preparing to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
Answer: Match the client’s blood type with the type and cross match specimens.
30. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the
following statements by the client indicates the need for a referral to physical therapy?
Answer: “Lately, I feel like my feet are freezing up, as they are stuck to the ground”

31. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of
the following findings should the nurse expect?
Answer: Increased creatine.
32. A nurse is administering a scheduled medication to a client. The client reports that the
medication appears different than what they take at home. Which of the following responses
should the nurse take?
Answer: “I will call the pharmacist now to check on this medication”
33. A nurse is teaching at a community health fair about electrical fire prevention. Which of the
following information should the nurse include in the teaching?
Answer: Use three pronged grounded plugs.
34. A charge nurse is recommending postpartum client discharge following a local disaster.
Which of the following should the nurse recommend for discharge?
Answer: A client who delivered precipitously 36 hr. ago and has a second-degree perineal
laceration.
35. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which
to report?
Answer: Chlamydia
36. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a
referral to a dietitian
Answer: A client who has gout and states, “I can continue to eat anchovies on my pizza.”
37. A nurse is preparing to measure a temperature of an infant. Which of the following action
should the nurse take?
Answer: Place the tip of the thermometer under the centre of the infant’s axilla.

38. A nurse in a paediatric clinic is teaching a newly hired nurse about the varicella rooster.
Which of the following information should the nurse include?
Answer: Children who have varicella are contagious until vesicles are crusted.
39. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate
for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following
orders from the provider should the nurse expect?
Answer: Administer the medication.
40. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of
the following medications should the nurse administer?
Answer: Pregabalin
41. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the
following actions should the nurse take?
Answer: Prime IV tubing with 0.9% sodium chloride.
42. A nurse is caring for a toddler who has acute lymphocytic leukaemia. In which of the
following should the toddler participate?
Answer: Playing with a large plastic truck.
43. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
Answer: Broiled skinless chicken breast with brown rice.
44. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should
the nurse plan to take?
Answer: Auscultate the newborn’s apical pulse for 60 seconds.
45. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured
membrane. Which of the following actions should the nurse take?

Answer: B. Apply fetal heart rate monitor.
46. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy.
Which of the following findings should the nurse to report?
Answer: A. Chest pain
47. A nurse is completing an incident report after a client fall. Which of the following
competencies of Quality and Safety Education for Nurse is the use demonstrating?
Answer: Quality improvement.
48. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of
the following actions should the nurse take?
Answer: Notify the nursing manager about the suspected alcohol use.
49. A nurse is caring for a client who has diaper dermatitis. Which of the following actions
should the nurse take?
Answer: Apply zinc oxide ointment to the irritated area.
50. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the
parent of a newborn. Which of the following statements indicates an understanding of the
teaching?
Answer: “I will not publish public announcement about my baby’s birth”
51. A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
Answer: “Dehydration can increase the risk of preterm labor”
52. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients
who do not speak the same language as clinical staff. Which of the following instructions should
the nurse include?
Answer: the nurse was going to do the interpretation

53. A nurse is preparing an in-service for a group of nurses about malpractice Issues in nursing.
Which of the following examples should the nurse include in the teaching?
A. Leaving a nasogastric tube clamped after administering oral medication
B. Documenting communication with a provider in the progress notes of the client's medical
record
C. Administering potassium via IV bolus
D. Placing a yellow bracelet on a client who is at risk for falls
Answer: C. Administering potassium via IV bolus
54. 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. Avocados
C. Smoked salmon
D. Pepperoni pizza
Answer: A. Whole grain bread
55. A nurse manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse include?
A. Attach the restraint to the bed's side rails.
B. Request a PRN restraint prescription for clients who are aggressive.
C. Document the client's condition every 15 min.
D. Remove the client's restraint every 4 hr.
Answer: C. Document the client's condition every 15 min.
56. A charge nurse on a medical-surgical unit is assisting with the emergency response plan
following an external disaster in the community. In anticipation of multiple client admissions,
which of the following current clients should the nurse recommend for early discharge?
A. A client who has COPD and a respiratory rate of 44/min

B. A client who has cancer with a sealed implant for radiation therapy
C. A client who is receiving heparin for deep-vein thrombosis
D. A client who is 1 day postoperative following a vertebroplasty
Answer: D. A client who is 1 day postoperative following a vertebroplasty
57. 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
C. Swelling of the face
D. Urinary frequency
Answer: C. Swelling of the face
58. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing
auditory hallucinations. Which of the following actions should the nurse include in the plan?
A. Ask the client directly what he is hearing.
B. Encourage the client to lie down in a quiet room.
C. Avoid eye contact with the client.
D. Refer to the hallucinations as if they are real.
Answer: A. Ask the client directly what he is hearing.
59. A nurse is preparing to perform a 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. Applying a sterile gown after applying a sterile mask
B. Balancing the bottle on the sterile basin while pouring the liquid
C. Placing the supplies on the sterile field and leaving a 1-inch perimeter
D. Putting on sterile gloves after preparing the sterile field
Answer: B. Balancing the bottle on the sterile basin while pouring the liquid
60. A nurse is teaching a prenatal class about infection prevention at a community centre. Which
of the following statements by a client indicates an understanding of the teaching?

A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted."
B. "I can clean my cat's litter box during my pregnancy."
C. "I should take antibiotics when I have a virus."
D. "I should wash my hands for 10 seconds with hot water after working in the garden."
Answer: A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted."
61. A nurse is planning care for a group of clients and is working with one licensed practical
nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse
take first to manage her time effectively?
A. Develop an hourly time frame for tasks.
B. Schedule daily activities.
C. Determine goals of the day.
D. Delegate tasks to the AP.
Answer: C. Determine goals of the day.
62. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will decrease my daily protein intake to 15 grams per day."
B. "I will use ibuprofen as needed to control abdominal pain."
C. "I will take sucralfate with meals three times per day."
D. "I will avoid food and beverages that contain caffeine."
Answer: D. "I will avoid food and beverages that contain caffeine."
63. A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which
of the following recommendations should the nurse make?
A. Place copies of incident reports in clients' medical records.
B. Overestimate clients’ acuity to prevent short staffing.
C. Ensure that each client has a living will on file prior to treatment.
D. Obtain personal professional liability Insurance coverage.
Answer: C. Ensure that each client has a living will on file prior to treatment.

64. A nurse is providing preoperative teaching about patient-controlled analgesia (RCA) to a
client. Which of the following statements should the nurse include in the teaching?
A. "The PCA will deliver a double dose of medication when you push the button twice.'*
B. "You can adjust the amount of pain medication you receive by pushing on the keypad."
C. "Continuous PCA infusion Is designed to allow fluctuating plasma medication levels."
D. "You should push the button before physical activity to allow maximum pain control."
Answer: D. "You should push the button before physical activity to allow maximum pain
control."
65. A charge nurse is teaching a newly licensed nurse about clients designating a health care
proxy in situations that require a durable power of attorney for health care (DPAHC). Which of
the following information should the charge nurse include?
A. "The proxy should make health care decisions for the client regardless of the client's ability to
do so."
B. "The proxy can make financial decisions if the need arises."
C. "The proxy can make treatment decisions if the client is under anaesthesia."
D. "The proxy should manage legal issues for the client."
Answer: C. "The proxy can make treatment decisions if the client is under anaesthesia."
66. A nurse is caring for a client who has a history of depression and is experiencing a situational
crisis. Which of the following actions should the nurse take first?
A. Confirm the client's perception of the event.
B. Notify the client's support person.
C. Help the client identify personal strengths.
D. Teach the client relaxation techniques.
Answer: A. Confirm the client's perception of the event.
67. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks
the nurse about becoming a living kidney donor for her father. Which of the following conditions
in the child's medical history should the nurse identify as a contraindication to the procedure?
A. Amputation

B. Osteoarthritis
C. Hypertension
D. Primary glaucoma
Answer: C. Hypertension
68. A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time in the day room.
B. Withdraw the client's TV privileges if he does not attend group therapy.
C. Encourage the client to take frequent rest periods.
D. Place the client in seclusion when he exhibits signs of anxiety.
Answer: C. Encourage the client to take frequent rest periods.
69. A nurse is working with a client who has an anxiety disorder and is in in the orientation phase
of the therapeutic relationship. Which of the following statements should the nurse make during
this phase?
A. "Let's talk about how you can change your response to stress."
B. "We should establish our roles in the initial session."
C. "Let me show you simple relaxation exercises to manage stress."
D. "We should discuss resources to implement in your daily life."
Answer: B. "We should establish our roles in the initial session."
70. 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 hr If unable to fall asleep.
B. Take a 1 hr nap during the day.
C. Perform exercises prior to bedtime.
D. Eat a light snack before bedtime.
Answer: D. Eat a light snack before bedtime.

71. A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar
disorder. The partner states, "I don’t know what to do. Everything has been happening so
quickly." Which of the following responses by the nurse is therapeutic?
A. "Can you talk about what was happening with your partner at home?"
B. "Why do you think your partner's symptoms are progressing so quickly?"
C. "You should make sure your partner takes the prescribed medication."
D. "You did the right thing by bringing your partner in for treatment."
Answer: A. "Can you talk about what was happening with your partner at home?"
72. A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving cardiac monitoring
B. A client who has a hip fracture and a new onset of tachypnoea
C. A client who has epidural analgesia and weakness in the lower extremities
D. A client who has diabetes mellitus and a haemoglobin A1C of 6.8%
Answer: B. A client who has a hip fracture and a new onset of tachypnea
73. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel
syndrome. Which of the following recommendations should the nurse include?
A. Consume food high in bran fibre.
B. Increase intake of milk products.
C. Sweeten foods with fructose com syrup.
D. Increase intake of foods high in gluten.
Answer: A. Consume food high in bran fibre.
74. 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
C. Upper extremity hypotension
D. Increased intracranial pressure

Answer: A. Weak femoral pulses
75. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the
following adverse effects should the nurse include?
A. Excessive sweating
B. Increased urinary frequency
C. Dry cough
D. Metallic taste in mouth
Answer: A. Excessive sweating
76. A nurse is caring for a client who is in active labor and notes the FHR baseline has been
100/min for the past 15 min. The nurse should identify which of the following conditions as a
possible cause of fetal bradycardia?
A. Maternal fever
B. Fetal anaemia
C. Maternal hypoglycaemia
D. Chorioamnionitis
Answer: C. Maternal hypoglycaemia
77. 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 24 hours old."
B. "A nurse will draw blood from your baby's inner elbow."
C. "Your baby will be given 2 ounces of water to drink prior to the test."
D. "This test will be repeated when your baby is 2 months old."
Answer: A. "This test should be performed after your baby is 24 hours old."
78. A nurse is caring for a client who asks for information regarding organ donation. Which of
the following responses should the nurse make?
A. "I cannot be a witness for your consent to donate."
B. "Your name cannot be removed once you are listed on the organ donor list."

C. "Your desire to be an organ donor must be documented in writing."
D. "You must be at least 21 years of age to become an organ donor."
Answer: C. "Your desire to be an organ donor must be documented in writing."
79. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The
nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions
Answer: D. Contractions
80. A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving haemodialysis. Which of the following instructions should the nurse include in the
teaching?
A. Take magnesium hydroxide for indigestion.
B. Drink at least 3 L of fluid daily.
C. Eat 1 g/kg of protein per day.
D. Consume foods high in potassium.
Answer: C. Eat 1 g/kg of protein per day.
81. 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. A history of being in prison
C. Experiencing delusions
D. Male gender
Answer: A. Previous violent behavior

82. A nurse is teaching a client who is trying to conceive. Which of the following should the
nurse instruct the client to increase in her diet to prevent a neural tube defect?
A. Folate
B. Zinc
C. Iron
D. Calcium
Answer: A. Folate
83. A nurse is caring for a client who is experiencing acute mania. Which of the following foods
should the nurse provide for this client?
A. Peanut butter sandwich
B. Oatmeal with butter
C. Chicken noodle soup
D. Celery sticks
Answer: A. Peanut butter sandwich
84. A nurse is preparing to administer an IV medication to a client and accidently punctures the
IV bag causing the medication to leak on the counter. Which of the following medications
requires the nurse to follow facility procedures in the safe handling of a biohazardous material
spill?
A. Doxorubicin hydrochloride
B. Ampicillin sodium
C. Metronidazole
D. Phenytoin
Answer: A. Doxorubicin hydrochloride
85. A nurse in a provider's office is reviewing a female client's medical record during a routine
visit. The nurse should recommend increased dietary intake of which of the following vitamins?
(Click on the "Exhibit" button for additional information about the client. There are three tabs
that contain separate categories of data.)
A. Vitamin D

B. Vitamin K
C. Vitamin B12
D. Vitamin A
Answer: C. Vitamin B12
86. A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
A. "The client might act seductively."
B. "The client is overly concerned about minor details."
C. "The client exhibits impulsive behavior."
D. "The client is exceptionally clingy to others."
Answer: C. "The client exhibits impulsive behavior."
87. A nurse is completing an admission assessment for a client who has narcissistic personality
disorder. Which of the following findings should the nurse expect?
A. Ritualistic behavior
B. Suspicious of others
C. Exhibits separation anxiety
D. Preoccupied with aging
Answer: D. Preoccupied with aging
88. 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. Hold hand flat to perform percussions on the child.
B. Perform the procedure twice a day.
C. Administer a bronchodilator after the procedure.
D. Perform the procedure prior to meals.
Answer: D. Perform the procedure prior to meals.

89. A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to the
administration of clozapine?
A. Heart rate 58/min
B. Fasting blood glucose 100 mg/dL
C. Hgb 14 g/dL
D. WBC count 2,900/mm3
Answer: D. WBC count 2,900/mm3
90. 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. "Limit your child's potassium intake while she is taking this medication."
B. "You can add the medication to a half-cup of your child's favourite juice."
C. "Repeat the dose if your child vomits within 1 hour after taking the medication."
D. "Have your child drink a small glass of water after swallowing the medication.”
Answer: D. "Have your child drink a small glass of water after swallowing the medication.”
91. A school nurse is teaching a parent about absence seizures. Which of the following
information should the nurse include?
A. This type of seizure can be mistaken for daydreaming.
B. "This type of seizure lasts 30 to 60 seconds."
C. "The child usually has an aura prior to onset."
D. "This type of seizure has a gradual onset."
Answer: A. This type of seizure can be mistaken for daydreaming.
92. A nurse is reviewing assessment data from several clients. For which of the following clients
should the nurse recommend referral to a dietitian?
A. An older adult client who has a BMI of 24
B. A client who has a nonhealing leg ulcer
C. An older adult client who has presbyopia
D. A client who has an albumin level of 3.7 g/dL

Answer: B. A client who has a nonhealing leg ulcer
93. A nurse Is caring for a client who is receiving intermittent enteral tube feedings. Which of the
following places the client at risk for aspiration?
A. Sitting in a high-Fowler's position during the feeding
B. A history of gastroesophageal reflux disease
C. Receiving a high osmolarity formula
D. A residual of 65 mL 1 hr postprandial
Answer: B. A history of gastroesophageal reflux disease
94. A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse use sterile gloves?
A. Inserting an NG tube
B. Administering total parenteral nutrition through a central venous access device
C. Initiating IV access
D. Performing tracheostomy care
Answer: D. Performing tracheostomy care
95. 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 24 hours old.”
B. "A nurse will draw blood from your baby's inner elbow."
C. "Your baby will be given 2 ounces of water to drink prior to the test."
D. "This test will be repeated when your baby is 2 months old."
Answer: A. "This test should be performed after your baby is 24 hours old.”
96. A nurse In a mental health clinic receives a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should
the nurse make?
A. "We can provide a copy of your records, but the therapist's notes are not included."
B. "I don't think you will benefit from reviewing your therapist's notes right now."

C. "Why are you interested in seeing your therapist's notes?"
D. "Are you not happy with your treatment?"
Answer: A. "We can provide a copy of your records, but the therapist's notes are not included."
97. A nurse is developing a plan of care for a client who has preeclampsia and is to receive
magnesium sulphate via continuous IV infusion. Which of the following actions should the nurse
include in the plan?
A. Monitor the FHR via Doppler every 30 min.
B. Restrict the client's total fluid intake to 250 mL/hr.
C. Give the client protamine if signs of magnesium sulphate toxicity occur.
D. Measure the client's urine output every hour.
Answer: D. Measure the client's urine output every hour.
98. A nurse is assessing a client who is in active labor, Which of the following findings should
the nurse report to the provider?
A. Contractions lasting 80 seconds
B. FHR baseline 170/min
C. Early decelerations in the FHR
D. Temperature 37.4° C (99.3° F)
Answer: B. FHR baseline 170/min
99. A nurse is caring for a client who is in labor and has received an epidural. Which of the
following actions should the nurse take?
A. Decrease the maintenance infusion rate of IV fluid.
B. Have protamine sulphate available at the bedside.
C. Reposition the client side-to-side each hour.
D. Monitor the client for hypertension.
Answer: C. Reposition the client side-to-side each hour.
100. A nurse is building a therapeutic relationship with a newly admitted client. Which of the
following actions should the nurse plan to take during the orientation phase of the relationship?

A. Determine previous coping skills used by the client.
B. Establish the responsibilities of the nurse and client.
C. Facilitate the client's problem-solving skills.
D. Assist the client in expressing alternative behaviours.
Answer: B. Establish the responsibilities of the nurse and client.
101. 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. Increase intake of foods high in gluten.
B. Increase intake of milk products.
C. Sweeten foods with fructose corn syrup.
D. Consume food high in bran fibre.
Answer: D. Consume food high in bran fibre.
102. A nurse is reviewing the medical records of four clients. The nurse should identify that
which of the following client findings requires follow up care?
A. A client who received a Mantoux test 48 hr ago and has an induration
B. A client who is scheduled for a colonoscopy and is taking sodium phosphate
C. A client who is taking warfarin and has an INR of 1.8
D. A client who is taking bumetanide and has a potassium level of 3.6 me/L
Answer: C. A client who is taking warfarin and has an INR of 1.8
103. A nurse is caring for a client who is 2 hr postoperative following a cardiac catheterization.
Which of the following is the priority assessment finding?
A. Report of burning sensation at the insertion site
B. Absence of pedal pulse in the affected extremity
C. Urinary output 25 mL/hr
D. Oxygen saturation 91%
Answer: B. Absence of pedal pulse in the affected extremity

104. 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. Hold hand flat to perform percussions on the child.
B. Perform the procedure twice a day.
C. Perform the procedure prior to meals.
D. Administer a bronchodilator after the procedure.
Answer: C. Perform the procedure prior to meals.
105. A nurse in a mental health facility receives change-of-shift report for four clients. Which of
the following clients should the nurse plan to assess first?
A. A client placed in restraints due to aggressive behavior
B. A client who will be receiving her first ECT treatment today
C. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety
D. A newly admitted client who has a history of 4.5 kg (10 lb) weight loss in the past 2 months
Answer: A. A client placed in restraints due to aggressive behavior
106. A nurse is providing discharge teaching about car seat safety to a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
A. "I can turn my baby's car seat around when she weighs 15 pounds."
B. "I can place my baby in the front seat with the airbag turned off."
C. "I will place my baby in a forward-facing car seat in my back seat.”
D. "I will position my baby at a 45-degree angle in the car seat.”
Answer: D. "I will position my baby at a 45-degree angle in the car seat.”
107. A nurse in a clinic is assessing a 6-month-old infant. Which of the following findings should
the nurse report to the provider?
A. Pulse 140/min
B. Closed anterior fontanel
C. Respiratory rate 26/min
D. Abdominal breathing
Answer: B. Closed anterior fontanel

108. 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. Place the client in seclusion when he exhibits signs of anxiety.
C. Withdraw the client's TV privileges if he does not attend group therapy.
D. Encourage the client to take frequent rest periods.
Answer: D. Encourage the client to take frequent rest periods.
109. 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. Metallic taste in mouth
B. Dry cough
C. Increased urinary frequency
D. Excessive sweating
Answer: D. Excessive sweating
110. 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 might act seductively."
C. "The client is exceptionally clingy to others."
D. "The client is overly concerned about minor details."
Answer: A. "The client exhibits impulsive behavior."
111. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of
the following places the client at risk for aspiration?
A. A residual of 65 mL 1 hr postprandial
B. Sitting in a high-Fowler's position during the feeding
C. A history of gastroesophageal reflux disease
D. Receiving a high osmolarity formula

Answer: C. A history of gastroesophageal reflux disease
112. A nurse is caring for a client following a cardiac catheterization through the left groin.
Which of the following actions should the nurse take?
A. Monitor the dorsalis pedis pulse every 15 min.
B. Keep the client NPO for 24 hr.
C. Place the client in Fowler's position.
D. Maintain strict bedrest for the first 12 hr.
Answer: A. Monitor the dorsalis pedis pulse every 15 min.
113. A nurse is reviewing the medical record of a client who has a prescription for intermittent
heat therapy for a foot injury. Which of the following findings should the nurse identify as a
contraindication for heat therapy?
A. Peripheral neuropathy
B. Osteoarthritis
C. Abdominal aortic aneurysm
D. Phlebitis
Answer: A. Peripheral neuropathy
114. A nurse in an emergency department is caring for a toddler who has burns following a house
fire. Which of the following actions should the nurse take first?
A. Calculate fluid replacement based on vital signs and urinary output.
B. Determine the location and depth of the burns.
C. Check the mouth for soot and smoky breath.
D. Administer antibiotics prophylactically to prevent sepsis.
Answer: C. Check the mouth for soot and smoky breath.
115. A nurse is caring for a client following a stroke. The client has right-sided weakness and
facial drooping. Which of the following nursing actions is the priority?
A. Perform range-of-motion exercises to the client's extremities.
B. Place the client's right hand in a supination position.

C. Change the client's position every 2 hr.
D. Maintain NPO status for the client.
Answer: D. Maintain NPO status for the client.
116. A nurse is caring for an adult client who has chronic anaemia and is scheduled to receive a
transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
A. Administer the blood via a 21-gauge IV needle.
B. Set the IV infusion pump to administer the blood over 6 hr.
C. Check the client's vital signs from the previous shift prior to the initiation of the transfusion.
D. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion.
Answer: D. Flush the blood administration tubing with 0.9% sodium chloride prior to the
transfusion.
117. Intradermal Injection areas
Answer: Upper back.
118. A nurse is caring for a client who has left homonymous hemianopsia. Which of the
following is an appropriate nursing intervention? ide of her body.
Answer: Place the bedside table on the right side of the bed.
119. A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure,
which of the following actions should the nurse take?
Answer: Position the client in an upright position, leaning over the bedside table.
120. A nurse is assessing a client following bronchoscopy. Which of the following findings
should the nurse report to the provider?
Answer: Bronchospasms
121. A nurse is caring for a client following a thoracentesis. Which of the following
manifestations should the nurse recognize as risks for complications? (Select all that apply.)
Answer: Dyspnoea

122. A nurse is caring for a client who has a chest tube and drainage system in place. The nurse
observes that the chest tube was accidentally removed. Which of the following actions should the
nurse take first?
Answer: Apply sterile gauze to the insertion site.
123. A nurse is assisting a provider with the removal of a chest tube. Which of the following
should the nurse instruct the client to do?
Answer: Perform the Valsalva maneuver.
124. A nurse is planning care for a client following the insertion of a chest tube and drainage
system. Which of the following should be included in the plan of care? (Select all that apply.)
Answer: Obtain a chest x-ray.
125. A nurse is orientation a newly licensed nurse who is caring for a client who is receiving
mechanical ventilation and is receiving mechanical ventilation and is on pressure support
ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates
and understanding of PSV?
Answer: “It allows preset pressure delivered during spontaneous ventilation.”
126. A nurse is caring for a client who is experiencing respiratory distress. Which of the
following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.)
Answer: Pale skin
Elevation blood pressure.
127. A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which
of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to
Answer: Venturi mask

128. A nurse in a clinic is caring for a client whose partner states the client woke up this
morning, did not recognize him, and did not know where she was. The client reports chills and
chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority?
Answer: Obtain baseline vital signs and oxygen saturation.
129. A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques
should the nurse use to identify manifestations of this disorder?
Answer: Palpation of the orbital areas
130. A nurse is teaching a group of clients about influenza. Which of the following client
statements indicates an understanding of the teaching?
Answer: “I should wash my hands after blowing my nose to prevent spreading the virus.”
131. A nurse is caring for a client 2 hours after admission. The client has an SaO 2 of 91%,
exhibits audible wheezes, and is using accessory muscles when breathing. Which of the
following classes of medication should the nurse expect to administer?
Answer: Beta2 agonist
132. A nurse is providing discharge teaching to a client who has a new prescription for
prednisone for asthma. Which of the following client statements indicates an understanding in
teaching?
Answer: “I will take my medication with meals.”
133. A nurse is assessing a client who has a history of asthma. Which of the following factors
should the nurse identify as a risk for asthma?
Answer: Environmental allergies
134. A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator.
Which of the following client statements indicates an understanding of the teaching?
Answer: “I take this medication to prevent asthma attacks.”

135. A nurse is providing discharge teaching to a client who has COPD and a new prescription
for albuterol. Which of the following statements by the client indicates and understanding of the
teaching?
Answer: “I can have an increase in my heart rate while taking this medication.”
136. A nurse is preparing to administer a dose of a new prescription of prednisone to a client who
has COPD. The nurse should monitor for which of the following adverse effects of this
medication? (Select all that apply.)
Answer: Hypokalemia
Fluid retention
Black, tarry stools
137. A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that
he will never be able to leave his house now that he is on continuous oxygen. Which of the
following is an appropriate response by the nurse?
Answer: “There are portable oxygen delivery systems that you can take with you.”
138. A nurse is instructing a client on the use of an incentive spirometer. Which of the following
statements by the client indicates an understanding of the teaching?
Answer: “I will take in a deep breath and hold it before exhaling.”
139. A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the
following should the nurse include in the plan of care?
Answer: Take a deep breath in through your nose.
140. A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed
on a multi-medication regimen. Which of the following instructions should the nurse give the
client related to ethambutol?
Answer: “Watch for any changes in vision.”

141. A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has
tuberculosis. The nurse should instruct the client to report which of the following findings as an
adverse effect of the medication?
Answer: “You might notice tingling of your hands.”
142. A nurse is providing information about tuberculosis to a group of clients at a local
community center. Which of the following manifestations should the nurse include in the
teaching? (Select all that apply.)
Answer: Persistent cough
143. A nurse is caring for a group of clients. Which of the following clients are at risk for
pulmonary embolism? (Select all that apply.)
Answer: A client who has a fractured femur
A client who has chronic atrial fibrillation
144. A nurse is assessing a client who has a pulmonary embolism. Which of the following
information should the nurse expect to find? (Select all that apply.)
Answer: Pleural friction rub
145. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The
client states she is anxious and is unable to get enough air. Vital signs are HR 117/min,
respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of
the following nursing actions is the priority?
Answer: Administer oxygen therapy.
146. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the
following statements by the client should indicate and immediate concern for the nurse?
Answer: “I take antacids several times a day.”
147. A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following
factors should the nurse recognize as a contraindication to the therapy?

Answer: Hip arthroplasty 2 weeks ago
148. A nurse is assessing a client following a gunshot wound to the chest. For which of the
following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.)
Answer: Pleuritic pain
149. A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the
following actions should the nurse perform first?
Answer: Obtain a large-bore IV needle for decompression.
150. A nurse is reviewing discharge instructions for a client who experienced a pneumothorax.
Which for the following statement should the nurse use when teaching the client?
Answer: “Notify your provider if you experience a productive cough.”
151. A nurse in the emergency department is assessing a client who has a suspected flail chest.
Which of the following findings should the nurse expect? (Select all that apply.)
A. Bradycardia
B. Paradoxic chest movement
C. Administer oxygen via high-flow mask.
Answer: C. Administer oxygen via high-flow mask.
152. A nurse is orientation a newly licensed nurse on the purpose of administering vecuronium to
a client who has acute respiratory distress syndrome (ARDS). Which of the following statements
by the newly licensed nurse indicates understanding of the teaching?
Answer: “This medication is given to facilitate ventilation.”
153. A nurse is reviewing the health records of five clients. Which of the following clients are at
risk for developing acute respiratory distress syndrome? (Select all that apply.)
Answer: A client who has a haemoglobin of 15.1 mg/dL

154. A nurse is planning care for a client who has severe respiratory distress system (SARS).
Which of the following actions should be included in the plan of care for this client? (Select all
that apply.)
Answer: Provide supplemental oxygen.
155. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress
syndrome. Which of the following medications should the nurse anticipate administering with
this medication? (Select all that apply.)
Answer: Fentanyl
Midazolam
156. A nurse is orienting a newly licensed nurse on the care of a client who is to have a line
placed for hemodynamic monitoring. Which of the following statements by the newly licensed
nurse indicates effectiveness of the teaching?
Answer: “A chest x-ray is needed to verify placement after the procedure.”
157. A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use.
After opening the packet with the new pouch, the patient refuses to accept it. Which action
should the nurse take?
Answer: Ask another nurse to witness the disposal of the new patch.
158. A nurse is caring for a client with a PE. The client is receiving heparin IV at 1,200 units/hr
and warfarin 5 mg PO daily. The morning lab values are aPTT 98 seconds and INR 1.8. Which
action should the nurse take?
Answer: Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by
a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the
expected reference range, indicating that the dosage should be reduced, or the infusion withheld
until the aPTT returns to the therapeutic range.

159. A nurse at an urgent care clinic is assessing a patient with impaired vision in 1 eye. Which
report from the patient should indicate to the nurse that the client has a detached retina?
Answer: Floating dark spots
160. A nurse is assessing an infant with hydrocephalus and is 6 hours post-op following
placement of a VP shunt. Which finding should the nurse report to the provider?
Answer: Irritability when being held
161. A nurse is assessing a newborn's HR. Which action should the nurse take?
Answer: Auscultate the apical pulse and count beats for at least 1 min.
162. A nurse is caring for a client with a fecal impaction. Which action should the nurse take
when digitally evacuating the stool?
Answer: Insert a lubricated gloved finger and advance along the rectal wall.
163. A nurse is providing dietary teaching to a patient taking phenelzine. Which food
recommendations should the nurse make? (Select all)
Answer: A. Broccoli
B. Yogurt
C. Cream cheese
164. A nurse administers an incorrect dose of a med to a client. The nurse recognizes the error
immediately and completes an incident report. Which fact related to the incident should the nurse
document in the client's medical record?
Answer: Time the medication was given
165. A nurse on a paediatric unit received report on 4 children. Which child should the nurse
assess first?
Answer: A 10-year-old child who is awaiting surgery for an appendectomy and experienced
sudden relief from pain

Using the urgent vs. non-urgent approach to client care, the nurse should determine that the client
to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this
can be an indication of peritonitis from a ruptured appendix.
166. A community health nurse is providing teaching about home safety with a group of elderly
clients. Which statement should the nurse make?
Answer: "Have grab bars installed around your bathtub and toilet."
167. A nurse in the ED is assessing a school-age child who was brought in by her parents and has
scald burns to both hands and wrists. The nurse suspects physical abuse. Which action should the
nurse take?
Answer: Contact child protective services.
168. A nurse is caring for a patient with acute blood loss following a trauma. The patient refuses
a blood transfusion that could save his life. Which action should the nurse take first?
Answer: Explore the client's reasons for refusing the treatment.
169. A nurse is teaching a client at 20 weeks gestation about common prenatal discomfort. Which
statement by the client indicates an understanding of the teaching?
Answer: "I will wear a supportive bra overnight."
170. A nurse is providing discharge education to a patient who is to receive home oxygen
therapy. Which instruction should the nurse include in the teaching?
Answer: Wear clothing made with cotton fabrics while oxygen is in use.
The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the
mucous membranes because products containing oils are flammable when near oxygen.
171. A nurse manager is preparing an education session about advocacy to a group of nurses. The
nurse manager should include what information in the teaching?
Answer: Advocacy is a leadership role that helps others to self-actualize.

172. A nurse is caring for a patient receiving continuous bladder irrigation following a
transurethral resection of the prostate. The patient reports bladder spasms and the nurse observes
a decreased urinary output. Which action should the nurse take?
Answer: Irrigate the catheter with 0.9% sodium chloride irrigation.
Decreased urine output and bladder spasms indicate internal obstructions of the catheter.
Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify
the provider if the obstruction does not clear.
173. A nurse is caring for a child with sickle cell anaemia and is having a Vaso-occlusive crisis.
Which intervention should the nurse implement first?
Answer: Infuse IV fluids.
The priority action the nurse should take when using the airway, breathing, circulation approach
to client care is to infuse IV fluids to promote hydration and circulation. Increased fluid reduces
the tissue and organ ischemia caused by the clumping of the RBCs.
174. A nurse is providing patient education about the basal body temperature method of birth
control. What information should the nurse include in the teaching?
Answer: "Your body temperature might decrease slightly just prior to ovulation."
175. The nurse should teach the client that a drop in body temperature of approximately 0.25° C
(0.5°)
Answer: commonly occurs immediately prior to ovulation.
176. A nurse in the ED is caring for a client who is unconscious and requires emergency medical
procedures. The nurse is unable to locate members of the client's family to obtain consent. Which
action should the nurse take?
Answer: Proceed with provision of medical care.
177. A nurse is caring for a client who has fluid volume overload. Which task should the nurse
delegate to the AP?
Answer: Measure the client's daily weight.

178. A nurse is assessing a patient with hypocalcaemia. Which site should the nurse tap to elicit a
positive Chvostek's sign?
Answer: cheek
179. A nurse is reviewing the urinalysis report of a client with acute glomerulonephritis. Which
finding should the nurse expect in the client's urine?
Answer: Protein
Increased glomerular permeability allows protein to filter into the urine. Therefore, this is an
expected finding in a client who has glomerulonephritis.
180. A nurse is creating a plan for care of a newly admitted child. Which action should the nurse
include in the plan? (Click exhibit)
Answer: Administer high dose antibiotic therapy.
The nurse should include administering high-dose antibiotic therapy in the child's plan of care.
Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses
of antibiotics to help fight aggressive infections such as Burkholder cepacia.
181. A nurse is caring for a client with cancer and is deciding between 2 treatment options. The
client asks the nurse for assistance with the decision. Which response should the nurse make?
Answer: "Tell me more about your understanding of the options."
182. A nurse is caring for a patient receiving hemodialysis with an AV fistula in the right arm.
Which intervention should the nurse include in the patient's plan of care?
Answer: Auscultate the affected extremity for a bruit.
183. A nurse in the oncology unit is administering doxorubicin to a client with breast cancer.
Which action should the nurse take?
Answer: Inspect the client's mucosa for petechiae every 8 hr.

The nurse should inspect the client's mucosa for petechiae every 8 hr because this medication
causes thrombocytopenia and increases the risk of bleeding. The nurse should also assess the
client for hematuria, guaiac, and bruising.
184. A hospice nurse is consulting with a patient and her family about receiving home services.
Which statement should the nurse identify as an indication that the family understands home
hospice care?
Answer: "We can expect the hospice nurse to provide support for us after our mother's death."
185. A nurse is caring for a patient with major depressive disorder and has signed an informed
consent to receive ECT. The patient states "I'm not sure about this now. I'm afraid it's too risky."
What response should the nurse make?
Answer: "You have the right to refuse to have the ECT, even after you have agreed to it."
186. A nurse is providing discharge instructions about newborn care to a client 2 days
postpartum. Which statements indicate understanding of the teaching? (Select all)
Answer: "I will cover my baby's body when I wash her hair."
"I will use the bulb syringe first in her mouth and then in her nose."
187. A nurse is assigning task roles for a group of patients in a community mental health clinic.
Which task should the nurse assign to the mother of the group functioning as the orienteer?
Answer: Noting the progress of the group toward assigned goals
188. A nurse must recommend clients for discharge to make room for several critically injured
clients from a local disaster. Which client should the nurse recommend for discharge?
Answer: A client who has cellulitis and is receiving oral antibiotics every 8 hr
189. A nurse is developing a client education program about osteoporosis for older adult clients.
What variable is a risk factor for osteoporosis?
Answer: Sedentary lifestyle

190. A charge nurse is providing an educational session about infection control for a group of
staff nurses. Which statement by a staff nurse indicates understanding of isolation precautions?
Answer: "A client who requires airborne precautions should be placed in a negative-pressure
airflow room."
191. A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. What action
should the nurse plan to perform?
Answer: Instruct the client to avoid deep breathing during the procedure.
It is important for the nurse to remind the client to avoid deep breathing during a thoracentesis to
avoid puncturing the pleura.
192. A nurse is caring for a school-age child taking valproic acid. The nurse should expect the
provider to order which diagnostic test?
Answer: Serum liver enzyme levels
Valproic acid can cause hepatic toxicity. Therefore, the nurse should expect the provider to
prescribe laboratory tests to assess the child's liver function.
193. A nurse on an inpatient mental health unit is monitoring a visit between a client who has a
history of aggressive behavior and the client's partner. Which observation should the nurse
identify as an indicator for potential violence?
Answer: The client is pacing around the chair in which his partner is sitting.
Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should
assess the situation further and attempt to de-escalate the client by speaking to him in a low, calm
voice using short sentences.
194. A home health nurse is evaluating a school-age child with cystic fibrosis. The nurse should
indicate a request for a high-frequency chest compression vest in response to which parent
statement?
Answer: "My child has only a small amount of mucus after percussion therapy."

195. A nurse is creating a plan of care for a patient with left-sided weakness following a stroke.
Which intervention should the nurse include in the plan?
Answer: Support the client's left arm on a pillow while sitting.
196. A nurse on an impatient unit is caring for a client with schizophrenia and recently started
taking risperidone. Which action should the nurse take?
Answer: Implement fall precautions for the client.
Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. Therefore,
the nurse should initiate fall precautions for the client.
197. A nurse in the ED is caring for a child with a fever and fluid-filled vesicles on the trunk and
extremities. Which intervention should the nurse identify as priority?
Answer: Initiate transmission-based precautions.
These findings indicate this child most likely has varicella, which is an infectious disease.
Therefore, the first action the nurse should take is to initiate transmission-based precautions.
198. A nurse is assessing a client for compartment syndrome. Which finding should the nurse
expect?
Answer: Edema
199. A nurse has received report on 4 patients. Which should the nurse assess first?
Answer: A client who is postoperative with abdominal distention and no bowel sounds
200. A nurse is assessing a client after administering epinephrine for an anaphylactic reaction.
Which finding should the nurse identify as an adverse effect of this medication?
Answer: Report of chest pain
The nurse should recognize that a report of chest pain by the client can indicate an adverse effect
of the medication. Epinephrine increases cardiac workload and oxygen demand, which can result
in angina.

201. A nurse is providing teaching to a patient 24 weeks gestation and is scheduled for a 3 hour
oral glucose tolerance test. Which instruction should the nurse include in the teaching?
Answer: "You will need to fast the night before the test."
202. A nurse is assessing an older adult client with pneumonia. Which finding should the nurse
expect?
Answer: Acute confusion
An older adult client who has pneumonia will also typically have acute confusion, fatigue,
lethargy, and anorexia.
203. A nurse is providing teaching for a client about his right to confidentiality. Which statement
should the nurse make?
Answer: "You can provide a list of family members who can receive information about your
diagnosis."
204. A nurse in the ED is caring for a patient with nausea and vomiting for 2 days. Which finding
should the nurse expect?
Answer: Urine specific gravity 1.052
The nurse should recognize this urine specific gravity is significantly elevated, indicating
dehydration from vomiting.
205. A nurse is caring for a post-op patient after receiving moderate (conscious) sedation. The
patient suddenly becomes restless and reports feeling lightheaded. Which action should the nurse
take?
Answer: Check the client's oxygen saturation level.
206. A nurse is assessing a client at 11 weeks gestation and reports drinking ginger tea. Which
finding indicates the client's use of ginger tea is effective?
Answer: The client reports a decrease in episodes of nausea.

207. A nurse is providing teaching to a patient with a new diagnosis of type 1 DM. The nurse
should instruct the client to monitor which finding as a manifestation of hypoglycaemia?
Answer: Irritability
208. A nurse is caring for a client who has a DVT. Which action should the nurse take?
Answer: Instruct the client to elevate the affected extremity when sitting.
209. A nurse is providing information to a client immediately before his scheduled Romberg test.
Which statement should the nurse make?
Answer: "I will be checking you once with your eyes open and once with them closed."
210. A nurse is providing teaching to the parents of a child who has autism spectrum disorder.
Which instruction should the nurse include?
Answer: Use a reward system to modify the child's behavior.
211. A nurse is providing teaching to a client who is to undergo ECT. The nurse should inform
the client that which finding is an adverse effect of ECT?
Answer: Short-term memory loss
212. A nurse is caring for a client who has TB. Which action should the nurse plan to take to
prevent the transmission of the disease?
Answer: Have the client wear a surgical mask while being transported outside the room.
213. A nurse on a mental health unit is conducting a mental status examination (MSE) on a
newly admitted client. Which component of the MSE is priority for the nurse to assess?
Answer: Ideas of self-harm
214. A nurse is caring for a client who is taking chlorpromazine. Which finding should the nurse
identify as an indication that the med is effective?
Answer: Decreased hallucinations

215. A nurse is assessing a client whose partner recently died. The client states "I don't know
what to do without my partner. Life is just not worth living." Which of the following responses
should the nurse make?
Answer: "You seem to be having a difficult time right now."
216. A nurse is developing a discharge plan for a school-age child with thrombocytopenia. The
nurse should instruct the child to avoid what?
Answer: Blowing the nose
The nurse should instruct the child who has thrombocytopenia to avoid blowing the nose because
it increases the risk for bleeding or haemorrhaging.
217. A nurse is reviewing the lab report of a client who has end-stage kidney disease and
received haemodialysis 24 hours ago. Which of the following lab values should the nurse report
to the provider?
Answer: Sodium 148 mEq/L
218. A nurse is caring for a client with a magnesium level of 2.5. Which intervention should the
nurse plan to take?
Answer: Initiate continuous cardiac monitoring.
The nurse should initiate continuous cardiac monitoring because a client who has
hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest.
219. A nurse in an outpatient mental health clinic is caring for 4 patients. The nurse should
recognize which client is effectively using sublimation as a defense mechanism?
Answer: A client who channels her energy into a new hobby following the loss of her job
220. A nurse is caring for a group of clients. Which client should the nurse see first?
Answer: An older adult client who is anxious and attempting to pull out his IV line

221. A nurse is preparing to teach about dietary management to a patient with Crohn's disease
and an enter enteric fistula. Which nutrient should the nurse instruct the client to decrease in his
diet?
Answer: Fiber
The nurse should instruct the client who has Crohn's disease and an enter enteric fistula to
consume a low-fibre diet to reduce residue and decrease exacerbations.
222. A nurse is caring for a client in the resuscitation phase of burn injury. Which findings should
the nurse expect?
Answer: Hyponatremia
The nurse should expect the client to have a decrease in sodium levels because sodium is drawn
to the edematous burn area and lost through plasma leakage.
223. A nurse is teaching self-administration of insulin to a patient with a new prescription for a
shortacting and intermediate-acting insulin. Which action by the client indicates an
understanding of the teaching?
Answer: Pinches the skin prior to injecting the insulin
224. A nurse is providing teaching to a client 26 weeks gestation and is to have an oral glucose
tolerance test. Which action should the nurse instruct the client to take before the test?
Answer: Avoid caffeine.
225. A nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect?
Answer: Tremors
226. A nurse is caring for a newborn who has herpes simplex virus (HSV). Which isolation
precaution should the nurse initiate?
Answer: Contact
227. An antepartum nurse is caring for 4 patients. Which patient should the nurse initiate seizure
precautions?

Answer: A client who is at 33 weeks of gestation and has severe gestational hypertension
The nurse should initiate seizure precautions for a client who has severe gestational hypertension
because an extremely elevated blood pressure in an antepartum client can trigger seizure activity.
The nurse should provide the client with a quiet, darkened environment; place suction equipment
and oxygen at the bedside; and place the call button within the client's reach.
228. A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6
months to treat juvenile idiopathic arthritis. Which question should the nurse ask to assess for an
adverse effect of this med?
Answer: "Have you had any stomach pain or bloody stools?"
229. A nurse is caring for an older adult client experiencing chronic anorexia and is receiving
enteral tube feedings. Which lab values indicates the client needs additional nutrients added to
the feeding?
Answer: Albumin 2.8 g/dL
230. A nurse is providing teaching to a school-age child with asthma about using albuterol
mertereddose inhaler. Which instructions should the nurse include?
Answer: Take the medication 15 min before playing sports.
231. A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse
should identify which physiological change is the cause for the client's visual loss?
Answer: Increased opacity of the lens
232. A nurse at a mental health clinic is caring for 4 clients. Which client is using dissociation as
a defense mechanism?
Answer: A client who was abused as a child describes the abuse as if it happened to someone
else.
The nurse should recognize that this client is using dissociation because he is separating painful
events from his conscious mind and is describing the events as if they happened to another
person.

233. A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg
(8 lb) and is being breastfed. Which finding indicates effective breastfeeding?
Answer: The newborn has six to eight wet diapers per day.
234. A nurse is preparing to administer a blood transfusion to a client. Which procedure should
the nurse follow to ensure proper client identification?
Answer: Verify the client and blood product information with another licensed nurse.
235. A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager
should tell the nurses that informed consent promotes which ethical principle?
Answer: Autonomy
236. A nurse is providing teaching about lithium to a client with bipolar disorder. Which
statement should the nurse include in the teaching?
Answer: "Notify your provider if you experience increased thirst."
The nurse should recognize that an increase in thirst is a manifestation of lithium toxicity. The
nurse should instruct the client to report increased thirst, vomiting, diarrhoea, or tremors to the
provider.
237. During report, a night shift nurse informs the day shift nurse that a newly admitted client
was disoriented and combative during the night. What action should the day shift nurse take?
Answer: Move the client to a room near the nurses' station.
238. A nurse in a provider's office is caring for a 19-month old toddler who has a blood lead level
of 3. Which action should the nurse take?
Answer: Recommend rescreening in 1 year.
The nurse should schedule chelation therapy for a blood lead level greater than 45 mcg/dL.
239. A nurse is assessing a client with bipolar disorder. Which alterations in speech is the client
using? (Listen to the clip)

Answer: Flight of ideas
Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden,
frequent topic changes.
240. A nurse working in the ED is triaging 4 patients. Which patient should the nurse recommend
for treatment first?
Answer: A middle adult client who has unstable vital signs
241. A nurse is performing an admission assessment on a patient with a recent positive
pregnancy test. The first day of her last menstrual period was May 8. According to Nagele's rile,
which of the following dates should the nurse document as the patient's estimated date of birth?
Answer: February 15
Using Naegle’s rule, the nurse should add 7 days to the first day of the client's LMP (8 + 7 = 15)
and then subtract 3 months. Therefore, the nurse should document the client's EDB as February
15th.
242. A nurse is assessing a patient who received 2 units of packed RBCs 48 hours ago. Which
finding should indicate the therapy is effective?
Answer: Haemoglobin 14.9 g/dL
243. A nurse is caring for a patient who recently signed an informed consent form to donate a
kidney to her sibling who has end-stage kidney disease. The donor states "I don't want my
brother to die, but what if I need this kidney one day?" Which response should the nurse make?
Answer: "You're afraid that your other kidney will fail at some point after the organ donation."
244. A nurse is preparing to administer an IM injection to a client who is obese. Which action
should the nurse plan to take?
Answer: Use the ventrogluteal site.
245. A nurse is providing education to the parent of a school-age child with asthma. Which
statement by the parent indicates an understanding of the teaching?

Answer: "I will make sure my child receives a yearly influenza vaccination."
Children who have asthma should be immunized and protected from infections. Therefore, the
nurse should educate the parent to ensure the child receives a yearly influenza vaccine.
246. A nurse is admitting a client with pneumonia. The nurse should initiate which isolation
precaution?
Answer: Droplet
247. A nurse is assessing a client with COPD. Which finding should the nurse expect?
Answer: pH 7.31
Respiratory acidosis is an expected finding for a client who has COPD. A pH level of 7.35 or less
indicates respiratory acidosis.
248. A nurse is providing teaching for a client who has a fracture of the right fibula with a shortleg cast in place. The client is non-weight bearing for 6 weeks. Which instruction should the
nurse include in the teaching?
Answer: Use a three-point gait.
A three-point gait allows the client to be mobile without bearing weight on the affected
extremity.
249. A nurse is caring for a child with hypotonic dehydration and is receiving an oral rehydration
solution. Which lab result indicates the treatment regimen is effective?
Answer: Serum sodium 136 mEq/L
A child who has hypotonic dehydration has a serum sodium level below 130 mEq/L. A serum
sodium level of 136 mEq/L, which is within the expected reference range, indicates that this
child is responding well to the oral rehydration solution.
250. A nurse is assessing a client with pulmonary edema. Which finding should the nurse expect?
Answer: Pink, frothy sputum

251. A nurse has received report on 4 patients. Which patient should the nurse intervene to
prevent a potential food and medication interaction?
Answer: A client who is receiving an MAOI and is requesting a cheeseburger for dinner
252. A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a
boggy fundus. Which med should the nurse expect to administer?
Answer: Oxytocin
A client should receive oxytocin, a hormone that stimulates uterine contractions, to prevent
bleeding.
253. A nurse on a med-surg unit is caring for a patient with a new diagnosis of terminal cancer.
The patient wants to go home to be with family and loved ones. What action should the nurse
take?
Answer: Make a referral for social services.
254. A nurse is caring for a patient taking valproic acid for seizure control. Which adverse effect
should the nurse monitor and report?
Answer: Jaundice
The nurse should monitor the client for jaundice and report any indication to the provider. Clients
who take valproic acid are at risk for liver damage, which can lead to jaundice.
255. A nurse manager is planning to use a democratic leadership style with the nurses on the unit.
Which action by the nurse manager demonstrates a democratic leadership style?
Answer: Seeks input from the other nurses
256. A nurse in a mental health clinic is assessing a client who has a history of seeking
counseling for relationship problems. The client shows the nurse multiple superficial selfinflicted lacerations on the forearms. These behaviours are characteristics of which personality
disorder?
Answer: Borderline

The nurse should recognize that clients who have borderline personality disorder are unstable
emotionally, have troubled interpersonal relationships, and often engage in harmful behaviours
such as cutting, substance use, and suicidal thoughts.
257. A nurse preceptor is evaluating the performance of a newly licensed nurse. Which action by
the newly licensed nurse requires intervention by the preceptor?
Answer: Starts a task then determines what supplies are needed
258. A nurse is providing teaching about advance directives to a middle adult client. Which client
response indicates an understanding of the teaching?
Answer: "I can designate my partner as my health care surrogate."
259. A nurse educator is teaching a group of newly licensed nurses about the need to complete an
incident report. Which example should the nurse include as a reportable incident and an
indication for completing a report?
Answer: A nurse administered a medication via the wrong route.
260. A nurse is caring for a newborn immediately after delivery. Which intervention should the
nurse implement to prevent hearing loss by conduction?
Answer: Use a protective cover on the scale when weighing the infant.
261. A nurse is caring for a client in the 4th stage of labor and is receiving oxytocin via
continuous IV infusion. Which assessment is the nurse's priority?
Answer: Amount of vaginal bleeding
262. A nurse is preparing to transfer a patient from ICU to medical floor. The patient was weaned
from mechanical ventilation following a pneumonectomy. Which information should the nurse
include in report?
Answer: The time of the client's last dose of pain medication

263. A charge nurse notices that one of the nurses on her shift frequently violates unit policies by
taking an extended amount of time for her break. Which statement should the charge nurse make
to address this conflict?
Answer: "I would like to talk to you about the unit policies regarding break time."
264. A nurse is providing discharge teaching about disease management for a client who has a
new diagnosis of type 1 DM. Which activity is the nurse's priority?
Answer: Ensure that the client understands the medication regimen.
265. A nurse is caring for a patient with GI bleeding and an NG tube in place. While performing
gastric lavage, which action should the nurse take?
Answer: Ask the client to lie on the left side.
The nurse should ask the client to lie on the left side because this position limits the flow of the
instilled solution out of the stomach and prevents aspiration.
266. A nurse is planning to delegate client care tasks to an AP. Which task should the nurse plan
to delegate to the AP?
Answer: Perform gastrostomy feedings through a client's established gastrostomy tube.
267. A nurse is providing teaching to a client who has a peripheral arterial disease. Which client
action indicates understanding of the teaching?
Answer: Applies lubricating lotion to her feet
268. A nurse is providing discharge teaching for the parents of a preschool;-age child taking
amoxicillin/clavulanate suspension. Which instructions should the nurse include in the teaching?
(Select all)
Answer: "Shake the medication bottle well before each dose is given."
"Store the medication in the refrigerator."
"Report diarrhoea to the provider immediately."

269. A nurse is caring for a patient with COPD and becomes extremely SOB. Which intervention
by the nurse requires completion of an incident report?
Answer: Increasing oxygen via nasal cannula to 6 L/min
270. A nurse is assessing for correct placement of a client's NG feeding tube prior to
administering a bolus feeding. Which action should the nurse take?
Answer: Aspirate contents from the tube and verify the pH level.
271. A nurse is preparing to transfer a client who had a stroke to a rehab facility. The client's
family tells the nurse they are concerned about the level of care the client will receive. What
action should the nurse take?
Answer: Facilitate an interdisciplinary conference at the new facility for the family.
272. A nurse is caring for a client receiving continuous heparin infusion. What lab test should the
nurse review prior to adjusting the client's heparin?
Answer: aPTT
Prior to adjusting the client's continuous heparin infusion, the nurse should review the client's
activated partial thromboplastin time (aPTT). The expected reference range for the aPTT is 40
seconds. Clients who are receiving continuous heparin therapy should have an aPTT of 60 to 80
seconds, which is 1.5 to 2 times of the expected aPTT level. The nurse should increase or
decrease the heparin infusion according to this value.
273. A nurse is providing care for a client with a colostomy. Which action should the nurse take?
Answer: Place the skin barrier over the stoma and hold it for 30 seconds.
274. A nurse is preparing to mix haloperidol lactate 5 mg/mL and diphenhydramine 25 mg/1.5
mL to administer IM for a client who is agitated. Which action should the nurse take?
Answer: Inject air into both vials prior to withdrawing the medications.
The nurse should avoid administering more than 1 mL of medication into the deltoid site. Both
haloperidol and diphenhydramine should be administered deep into a large muscle mass. The

nurse should plan to use a 2-in needle for an IM injection of the combination of the 2
medications.
275. A nurse is talking with a patient who has stage 4 breast cancer. The nurse should recognize
which statement by the client as a constructive use of a defense mechanism?
Answer: "I told my doctor that I would like to start a support group for other women who are
sick in my community."
This statement indicates that the client is using the constructive defense mechanism sublimation
by devising a socially acceptable alternative to facing a reality that she does not wish to accept.
276. A nurse is preparing a sterile field to perform a sterile dressing change. Which intervention
should the nurse use to maintain surgical aseptic technique?
Answer: Maintain sterile objects within the line of vision.
Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep
sterile objects in direct sight to maintain surgical asepsis.
277. A nurse manager is preparing to teach a group of newly licensed nurses about effective time
management. Which step of the time management process should the nurse manager include as
priority?
Answer: Making a list of activities to complete
278. A nurse is reviewing the ABG values of a client. pH 7.20, PaCo2 60, and HCO 3 25. What
acid base imbalance does the client have?
Answer: Respiratory acidosis
279. A client is receiving IV fluids at 150 mL/hr. Which finding indicates the client is
experiencing fluid overload?
Answer: Dyspnea
280. A nurse is caring for a patient who is 2 days postpartum. Which behavior indicated the client
is bonding with her newborn?

Answer: The client tells visitors how much the newborn looks like her sister.
Comparing physical and behavioral attributes to those of family members demonstrates
acceptance and bonding behaviours.
281. A nurse in the ED is assessing a preschooler who has a facial laceration. Which finding is a
potential indication of sexual abuse?
Answer: The child exhibits discomfort while sitting.
282. A nurse enters a client's room and sees smoke coming from a small fire in the trash can.
What should the nurse do first?
Answer: Remove the client from the room.
283. A rural community health nurse is developing a plan to improve health care delivery for
migrant farmworkers. To identify health services data for this minority group, the nurse gathers
information from which source?
Answer: Agency for Healthcare Research and Quality
The nurse should gather data from the Agency for Healthcare Research and Quality (AHRQ)
regarding health care services for migrant farmworkers. The AHRQ strives to improve the
quality of health care services for all populations, including low-income groups and minorities.
This data should help the nurse to develop an evidence-based plan to improve health care
services for specific populations.
284. A nurse is assessing a newborn following a vaginal delivery. Which finding should the nurse
report to the provider?
Answer: Nasal flaring
285. A nurse manager in a long-term care facility is having difficulty with staffing weekend
shifts and is planning to implement changes to the scheduling procedure. Which action should
the nurse manager take first?
Answer: Form a committee of staff members to investigate current staffing issues.

286. A nurse is assessing a client who has depressive disorder and is taking amitriptyline. Which
finding is an adverse effect of this medication?
Answer: Blurred vision
287. A school nurse is notified of an emergency in which several children were injured following
the collapse of playground equipment. Upon arrival at the playground, which action should the
nurse take first?
Answer: Survey the scene for potential hazards to staff and children
288. A nurse manager is preparing an educational session for nursing staff about how to provide
cost-effective care. Which method should the nurse include in the teaching?
Answer: Delegate non-nursing tasks to ancillary staff.
289. A nurse is creating a plan of care for a child with acute lymphoid leukaemia and an absolute
neutrophil count of 400. Which intervention should the nurse do?
Answer: Administer granulocyte colony-stimulating factor to the child.
290. A nurse is providing teaching to a client who speaks a different language than the nurse
about an upcoming diagnostic procedure. What action should the nurse take?
Answer: Use pictures to illustrate the procedure to the client.
291. A nurse is caring for a client with a prescription for continuous passive motion (CPM)
machine following a TKA. Which action should the nurse take?
Answer: Turn off the CPM machine during mealtime.
292. A nurse is caring for a client receiving PEEP via mechanical ventilation. What is an adverse
effect of PEEP?
Answer: Tension pneumothorax
293. A nurse is performing an abdominal assessment. Identify the sequence of actions the nurse
should take.

Answer:
Inspection
Auscultation
Percussion
Palpation
294. A nurse is caring for a patient taking clonidine. Which finding is an adverse effect of this
medication?
Answer: Dry mouth
295. A nurse is reviewing the lab results of a toddler with haemophilia A. Which aPTT value
should the nurse expect?
Answer: 45 seconds
This value is above the expected reference range, indicating a risk for spontaneous bleeding,
which is a manifestation of haemophilia A.
296. A nurse is updating the plan of care for a patient 48 hours post-op following a laryngectomy
and is unable to speak. What action should the nurse take first?
Answer: Determine the client's reading skills.
297. A nurse is caring for a patient who asks about taking ginseng to improve her appetite.
Ginseng can decrease the effectiveness of which med?
Answer: Timolol
298. A nurse is preparing a client for a paracentesis. What action should the nurse take?
Answer: Instruct the client to void.
299. An RN is observing an LPN and an AP move a client up in bed. Which situation should the
nurse intervene?
Answer: The LPN and the AP grasp the client under his arms to lift him up in bed.

300. A nurse on a med-surg unit is assessing a client who had a stroke. Which finding indicates a
need for a referral for occupational therapy?
Answer: Difficulty performing ADLs
301. A nurse is assessing a client taking propranolol. Which finding should indicate to the nurse
the client is experiencing an adverse reaction to propranolol?
Answer: Coughing at night
302. A nurse is conducting a visual acuity test using the Snellen letter chart for a school-age child
with eyeglasses. Which instructions should the nurse give to the child?
Answer: "You should keep both eyes open during the testing."
303. A nurse is caring for a multiparous client following a vacuum-assisted birth. The nurse
should assess the client for which complication related to this birth method?
Answer: Cervical laceration
1. A nurse is performing tracheostomy care for a client who is postop following a laryngectomy.
Which of the following actions take when suctioning the client’s airway?
Answer: Apply suction for 10 seconds
2. A nurse is preparing to administer a long acting insulin to a client who has DM. Which of the
following actions should the nurse take first?
Answer: Check the correct dose with another licensed nurse
3. A nurse is caring for an older adult client in the PACU following gen anaesthesia. Which of the
following should the nurse report to the provider?
Answer: Audible stridor
4. A nurse is planning an educational session for staff nurses about working with parents whose
terminally ill children are candidates for donating their organs. Which of the following
information should the nurse plan to include?

Answer: The family can have the child in an open casket without fearing that the organ donation
might disfigure the child’s body.
5. A nurse manager is planning to make changes to the current scheduling system on the unit. To
facilitate the staff’s acceptance of this change, which of the following actions should the nurse
manager take first?
Answer: Provide information about scheduling issues to the staff
6. A nurse is assessing a client who is receiving a blood transfusion. Which of the following
findings should indicate to the nurse that the client is having a haemolytic transfusion reaction?
Answer: Low back pain
7. A nurse is assessing a client who has macular degeneration. Which of the following findings
should the nurse expect?
Answer: Decreased central vision
8. A nurse who is working in a long-term care facility is assessing an adult client. Which of the
following findings places the client at risk for development of a pressure injury?
Answer: Recent weight loss
9. A nurse is teaching about TPN and IV lipid emulsion with a client who has an extensive burn
injury. Which of the following information should the nurse include?
Answer: “you will receive finger sticks for blood glucose testing.”
10. A nurse is caring for a client who has dehydration secondary to nausea and vomiting. The
nurse should identify which of the following findings as an indication of fluid volume deficit?
Answer: Orthostatic hypotension
11. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second
stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the
following actions should the nurse take?

Answer: Continue observing the fetal heart rate
12. A nurse is caring for a client who requires physical therapy following discharge. Which of the
following actions should the nurse take?
Answer: Involve the client in the selection of a physical therapy provider
13. A nurse is assessing a client who has sickle cell anaemia. The nurse should identify which of
the following findings as a manifestation of vaso-occlusive crisis?
Answer: Hematuria
14. A nurse is teaching a group of guardians about child safety measures. Which of the following
statements by a guardian indicates an understanding of the teaching?
Answer: I should have my child avoid sun exposure between 10am and 2pm
15. A nurse is caring for four clients at the beginning of a shift. After receiving change of shift
report, which of the following clients should the nurse attend to first?
Answer: A client who is confused and has been attempting to get out of bed.
16. A nurse is assessing a client who has been taking lithium carbonate for the past month to treat
bipolar disorder. Which of the following assessment findings should the nurse identify as the
priority?
Answer: Confusion
17. A nurse manager is on a planning committee to develop an emergency preparedness plan.
The nurse should recommend that which of the following actions takes place first when
implementing an emergency preparedness plan?
Answer: Notify the incident commander
18. A nurse is planning care for a client who is receiving haemodialysis via an established AV
fistula in the right arm. Which of the following interventions should the nurse include in the
client’s plan of care?

Answer: Auscultate the affected extremity for a bruit
19. A nurse receives a request from a client to review the information in his medical record.
Which of the following responses should the nurse give?
Answer: There is a protocol for reviewing your medical record, and I can initiate the process
20. A nurse is assessing a client who has OSA. For which of the following complications should
the nurse monitor?
Answer: Hypertension
21. A nurse in an ED is assessing a client who reports taking MDMA. Which of the following
should the nurse expect?
Answer: Diaphoresis
22. A nurse is caring for a client who has a terminal illness and requests no lifesaving measure if
a cardiac arrest occurs. Which of the following statements should the nurse make?
Answer: I will provide you with information about medical treatment to include in your living
will
23. A nurse is administering cyclophosphamide orally to a school-aged child who has
neuroblastoma. Which of the following actions should nurse take when administering this
medication?
Answer: Maintain hydration with liberal fluid intake
24. A nurse is reviewing the UA report of a client who has glomerulonephritis. Which of the
following findings should the nurse expect?
Answer: Protein
25. A nurse is providing colostomy care for a client using a two-piece pouching system. Which
of the following actions should the nurse take?
Answer: Place the skin barrier over the stoma and hold it for 30 seconds

26. A nurse is administering meds to a client who has a percutaneous gastrostomy tube for
enteral feedings. Which of the following actions should the nurse take to prevent clogging of the
tube?
Answer: Flush the client’s gastrostomy tube with 30 mL of water before administering the
medication
27. A night shift nurse is giving change of shift report to the day shift nurse who is ready for
discharge. Which of the following information is the priority for the nurse to communicate to the
oncoming nurse?
Answer: The client needs assistance when transferring from the bed to a wheelchair
28. A nurse is planning teaching about allowable foods for a client who has a history of uric acidbased urinary calculi formation. Which of the following food should the nurse include in the
teaching?
Answer: Oranges
29. An RN is planning care for a group of clients and is working with an LPN and AP. Which of
the following tasks should the RN delegate to the LPN?
Answer: Insertion of nasogastric tube
30. A nurse is caring for a newborn who has HSV. Which of the n=following isolation
precautions should the nurse initiate?
Answer: Contact
31. A nurse is performing gastric lavage for a client who has GI bleeding and an NG tube in
place. Which of the following actions should the nurse take?
Answer: Use NS for irrigation of the NG tube
32. A nurse is providing discharge instructions to a client following total hip arthroplasty. Which
of the following instructions should the nurse include?

Answer: Install a raised toilet seat at home
33. A nurse is reviewing lab findings of a client who is experiencing chest pain. The nurse should
identify that an elevation in which of the following lab values indication cellular injury of
myocardial tissue?
Answer: Troponin
34. A nurse is talking with the partner of a client who attempted suicide. Which of the following
statements by the client’s partner should the nurse identify as the priority?
Answer: My husband doesn’t know that I’ve already moved out and filed for divorce
35. A nurse is interviewing a client who is now without a home due to a natural disaster. After
ensuring the client’s safety, which of the following actions should the nurse take first?
Answer: Determine the client’s perception of the personal impact of the crisis
36. An AP and a nurse are turning a client onto the right side. Which of the following actions by
the AP requires the nurse to intervene?
Answer: places a pillow under the client’s right arm
37. A community health nurse is performing triage tagging following a mass casualty incident.
On which of the following clients should the nurse place a black tag?
Answer: A client who has significant head trauma and agonal respirations
38. A nurse is caring for a client who has MRSA in an Abd wound. Which of the following
precautions should the nurse implement?
Answer: Contact
39. A nurse is teaching a client about foods high in vitamin A. which of the following foods
should the nurse recommend as having the highest amount of vitamin A?
Answer: 1 medium raw carrot

40. A nurse is caring for a client who has a recent stroke. Prior to transferring the client to the
bedside commode, which of the following actions should the nurse take first?
Answer: Assess the client for functional limitations
41. A nurse is conducting visual acuity testing using the Snellen letter chart for a school aged
child who has eyeglasses. Which of the following instruction s should the nurse give to the
child?
Answer: You should keep both eyes open during the testing
42. A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio
placentae. Which of the following findings should the nurse expect?
Answer: Persistent uterine contraction
43. A nurse is assessing a client who Raynaud’s disease. Which of the following findings should
the nurse expect?
Answer: Blanching of the fingers and toes
44. A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH
insulin. Which of the following actions should the nurse plan to take?
Answer: Inject 20 units of air into the NPH insulin vial
45. A nurse is creating a plan of care for a child who has acute lymphoid leukaemia and an
absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse
include in the plan?
Answer: Withhold administering the varicella vaccine to the child
46. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male
client. Which of the of the following techniques should the nurse use to maintain surgical aseptic
technique?
Answer: Set the catheter tray on the overhead table at waist height

47. A home health nurse is assessing a 2 week old newborn who has a birth weight of 3.64 kg
and is being breastfed. Which of the following findings indicates effective breastfeeding?
Answer: The newborn has 6-8 wet diapers per day
48. A community health nurse is reviewing the medical records of four newly diagnosed clients.
The nurse should identify which clients as having a nationally notifiable infectious condition?
Answer: An adolescent client who has foodborne botulism
49. A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is
becoming increasingly restless. The client is pacing and speaking rapidly, frequently using
profanities and sexual references. Which of the following actions should the nurse take first?
Answer: Move the client to a quiet place away from others
50. A nurse in an outpatient mental health clinic is working with a client who has posttraumatic
stress disorder and asks the nurse to recommend a nonpharm therapy to use to provide relief of
the manifestations. Which of the following complementary therapies should the nurse teach the
client to use to help alleviate the distress?
Answer: Guided imagery
51. A case manager is reviewing the medical records of several clients. For which of the
following clients should the nurse requests an inter-professional care conference
Answer: A client who has DM and has had repeated hospitalizations for diabetic ketoacidosis
52. A nurse is caring for a client who states, “My boss accused me of stealing yesterday. I was so
angry I went to the gym and worked out.” The nurse should recognize the client is demonstrating
which of the following defense mechanisms?
Answer: Sublimation
53. A nurse is caring for an older adult client. Which of the following findings should the nurse
recognize as a physiological change associated with aging?
Answer: Decreased lung expansion

54. A client who is 24 hr postop following abdominal surgery refuses to ambulate. Which of the
following actions should the nurse take first?
Answer: Ask the client to rate their pain
55. A nurse is providing discharge instructions to a client who has a new prescription for
warfarin. Which of the following client statements should the nurse identify as indication that the
client understands the teaching?
Answer: I should report change in the colour in my stools
56. A nurse is providing discharge teaching to a new parent about care seat safety. Which of the
following statements should the nurse include in the teaching?
Answer: Secure the retainer clip at the level of your baby’s armpits
57. A nurse is caring for a client who has an STI that must be reported to the state health
department. Which of the following actions should the nurse take?
Answer: Explain to the client to a social worker for counseling
58. A nurse is teaching a client who has a new prescription for digoxin about manifestations for
toxicity. Which of the following should the nurse include in the teaching?
Answer: Nausea
59. A nurse is providing dietary teaching to the parents of a 6-month =-old infant. Which of the
following instructions should the nurse include?
Answer: Introduce new foods one at a time over 5 to 7 days.
60. A nurse is assessing a client during the immediate postpartum period. Which of the following
findings requires immediate intervention by the nurse?
Answer: Boggy uterus

61. A nurse is caring for a client who has end-stage Alzheimer’s disease. The adult child of the
client says to the nurse, “I don’t know why I bother to visit my mother anymore.” Which of the
following responses should the nurse take?
Answer: It seems like you feel your visits are a waste of time.”
62. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis
of the left lower leg. Which of the following should the nurse include in the plan of care?
Answer: Elevate the affected leg
63. A nurse is an acute mental health facility as planning care for a client who has anorexia
nervosa. Which of the following interventions should the nurse include in the client’s plan of
care?
Answer: Supervise the client during and after eating
64. A nurse is providing discharge instructions to a client who has a new prescription for
amitriptyline to treat depression. The nurse should identify that which of the following client
statements indicates an understanding of the teaching?
Answer: I should watch for common reactions like dry mouth and constipation
65. A nurse manager is assisting with the orientation for a newly licensed nurse. Which of the
following actions by the nurse requires the nurse manager to intervene?
Answer: Tells the hospital chaplain a client’s diagnosis
66. A nurse is caring for a client who is in the first trimester of pregnancy. The client reports
using acupressure bands on both wrists. Which of the following statements by the clients
indicates that this therapy is having the desired effect?
Answer: I have not vomited as much recently
67. A nurse manager is reviewing unit records and discovers that client falls occur most
frequently during the hours of 0530 and 0730. Which of the following actions should the nurse
take when conducting a root cause analysis

Answer: Investigate environmental factors that might be contributing to client injury during
these hours
68. A nurse is caring for a client who is immediately post op following a total vaginal
hysterectomy. Which of the following actions should the nurse take first?
Answer: Measure the client’s vital signs
69. A nurse is assessing a client who is 2 hr postop following a cardiac cath. Which of the
following information should the nurse report to the provider?
Answer: Neurologic status
70. A nurse is caring for a client who is 12 hr post op, is receiving PCA for pain control, and
requires a blood pressure check in 10 min. which of the following staff members should the
nurse assign to collect this information?
Answer: An AP who is assisting a client to return to bed.
71. A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the
following actions should the nurse plan to take?
Answer: Clear objects from the client’s walking area.
72. A nurse is teaching the parent of a school-age child about administering ear drops. Which of
the following responses by the parent indicates an understanding of the teaching?
Answer: I should pull the top of the ear upward and back while instilling the medication
73. A nurse is assessing a preschooler who has CF and has been receiving O2 therapy for the
nurse the past 36 hr. Which of the following findings should the nurse identify is an indication
that the client has developed oxygen toxicity?
Answer: Substernal pain

74. A nurse working on a med surge unit receives a phone call requesting the status of a client
from an individual who identifies themselves as the client’s parent. Which of the following
actions should the nurse take?
Answer: Ask the caller for verification of their identity
75. A nurse is assessing a client who has a skeletal traction for a femur fracture. Which of the
following findings should the nurse identify as the priority?
Answer: Upper chest petechiae
76. A charge nurse overhears two staff nurses in the hallway discussing the nutrional status of a
client who has anorexia nervosa. Which of the following actions should the charge nurse take?
Answer: Tell the nurses to stop the discussion
77. A nurse is assessing a client who has antisocial personality disorder. Which of the following
manifestations should the nurse expect?
Answer: Lack of remorse
78. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The
nurse expresses concern about having limited experience with monitoring chest tube drainage.
Which of the following actions should the nurse take first to provide teaching about chest tubes?
Answer: Ask the nurse about their knowledge of the procedure
79. A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder
for 24 hours. Which of the following assessment findings should the nurse identify as the
priority?
Answer: The clients heal is redden and tender.
80. A nurse is caring for a client who has a potassium level of 3mEq/L. for which of the
following manifestations should the nurse monitor?
Answer: Decreased deep tendon reflexes

81. A nurse is caring for a client who is 4 hour postpartum and has a boggy uterus with heavy
lochia. Which of the following actions should the nurse take first?
Answer: Massage the uterus to expel clots
82. A charge nurse observes a staff nurse document a dressing change in client’s chart that was
not performed. Which of the following actions should the charge nurse take first?
Answer: Gather more information about the nurse’s actions
83. A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When
discussing the client’s prognosis with the parents, the nurse should recognize which of the
following responses by the parents as an example of rationalization?
Answer: Maybe this is better for our child because we don’t want any suffering through
chemotherapy treatments
84. A nurse is assessing a client who has schizophrenia and is chlorpromazine. Which of the
following findings is the priority for the nurse to report to the provider
Answer: Temperature 39.4
85. A home health nurse is providing teaching to a client who has hep A. which of the following
instructions should the nurse include?
Answer: Use hydrogen peroxide to clean kitchen surfaces
86. A nurse manager is preparing a newly licensed nurse’s performance appraisal. Which of the
following methods should the nurse manager use to evaluate the nurse’s time management skills?
Answer: Maintain regular notes about the nurse’s time management skills
87. A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should
use to administer the injection
Answer: Periumbilical area

88. A nurse is assessing a client who has multiple sclerosis. Which of the following should the
nurse expect?
Answer: Nystagmus
89. A nurse is reviewing the ABG results of client who has COPD. The results include a ph of
7.3, Pa O2 56mmHg, CO2 54, HCO3 26, O2 87
Answer: Uncompensated respiratory acidosis
90. A nurse is caring for a newborn whose parent asks why the baby is receiving vit k. the nurse
should explain to the parent that the newborn should receive vit k to prevent which of the
following?
Answer: Bleeding
91. A nurse should is caring for a toddler who has infectious gastroenteritis. Which of the
following actions should the nurse take?
Answer: Initiate oral rehydration therapy for the toddler
92. A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the
following should the nurse expect?
Answer: Facial flushing, nasal congestion, headache
93. A nurse in a clinic receives a call form a guardian whose child has varicella. The guardian
asks when the child can return to school. Which of the following should the nurse make?
Answer: When crusts have formed on every lesion
94. A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to
explain what causes her to have constipation. Which of the following responses should the nurse
make?
Answer: The enlarged uterus compresses the intestines and causes constipation

95. A nurse is initiating dc planning for a client who has a stroke and is experiencing right sided
weakness. Which of the following actions should the nurse take first?
Answer: Request a referral for the client to receive physical therapy
96. A nurse is providing teaching to an adolescent following insertion of a tunnelled central
venous catheter. Which of the following information should the nurse include in the teaching?
Answer: You should keep the catheter clamped when not in use
97. A nurse is assessing a client who has schizophrenia. The nurse should identify the following
alteration in speech as which of the following?
Answer: Clang association
98. A nurse is taking caring of a child who is experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
Answer: Place the child in a side lying position
99. A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the
actions should the nurse plan to take?
Answer: Enter the plasma product number into the client’s medical record
100. A home health nurse is planning care for an older adult client who has impaired vision.
Which of the following interventions should the nurse include in the plan of care to prevent
injury at home?
Answer: Mark the edges of stairs for contrast
101. A nurse is providing teaching about improving nutrition for a client who has multiple
sclerosis. Which of the following instructions should the nurse include?
Answer: A speech pathologist, should rest before eating meal, thicken beverages before drinking
102. A nurse in the delivery room is caring for a newborn immediately after birth. Which of the
following actions should the nurse take?

Answer: Dry the newborn
103. A home health nurse is proving teaching about infection prevention to a client who has
cancer and is receiving chemotherapy. Which of the following statements by the client indicates
an understanding of the teaching?
Answer: I will walk short distances throughout the day
104. A nurse is teaching a newly admitted client who has heart failure about advance directives.
Which of the following statements should the nurse make?
Answer: You should complete advanced directives in the event you cannot express your own
wishes
105. A nurse is teaching a client who has a new prescription for estradiol. For which of the
following adverse effects of this medication should the nurse instruct the client to monitor and
report to the provider?
Answer: Headaches
106. A nurse in an emergency department is preparing to dc a client who has experienced
intimate partner violence. Which of the following actions should the nurse take first?
Answer: Develop a safety plan with the client
107. A nurse is caring for a client who is the manic phase of bipolar disorder. Which of the
following manifestations should the nurse expect?
Answer: Grandiose delusions
108. A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube.
Which of the following actions by the newly licensed nurse indicates an understanding of the
procedure?
Answer: Keeps the HOB elevated to 45 degrees for 1 hr after feedings

109. A nurse is proving client education to a post-partum client who has decided to bottle feed
the newborn. Which of the following instructions should the nurse include in the teaching to help
prevent the discomfort of engorgement?
Answer: Place ice packs on the breasts for 15 min several times a day
110. A nurse is preparing to perform an intermittent urinary cath for a client who has urinary
retention. Which of the following images indicates the catheter the nurse should use?
Answer: Straight cath
111. A nurse is teaching a client who has opioid use disorder about methadone. Which of the
following information should the nurse include in the teaching?
Answer: Sedation is a common adverse effect of this medication
112. A charge nurse is planning care for a client who has mechanical restraints in place. Which of
the following interventions should the nurse include in the plan?
Answer: Provide a staff member to stay with the client continuously
113. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should be
reported to the provider?
Answer: Axillary temp 36.2
114. A nurse is teaching a client who is to start taking misoprostol and currently is on long-term
therapy with NSAIDs for arthritis. The nurse should provide the client with which of the
following instructions?
Answer: Complete a serum pregnancy test before taking the medication
115. A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following
actions should the nurse take?
Answer: Place the BP cuff in a labelled bag to send it for decontamination

116. A nurse is teaching home wound care to the family of a child who has a large wound. Which
of the following interventions should the nurse recommend?
Answer: Double bag soiled dressings in plastic bags for disposal
117. A charge nurse is preparing to administer 0900 medications and is told by the pharmacy
staff that the medications are not available. Medication availability has been an ongoing problem,
and the charge nurse previously discussed this issue with the pharmacy staff. Which of the
following actions should the charge nurse take first?
Answer: Inform the nurse manager of the issue.
118. A nurse is providing discharge teaching to a client with who has colorectal cancer and a new
colostomy. The client states, “I’m worried about being discharged because I live alone, and my
insurance does not cover ostomy supplies.”
Answer: Refer client to community based social worker, initiate a consult with a home health
care provider, give the client information about local support group
119. A nurse is caring for a client who has hypertension and is taking captopril. Which of the
following tasks should the nurse delegate to an assistive personal?
Answer: Obtain the client’s blood pressure before the nurse administers medication
120. A nurse is caring for a group of clients. For which of the following events should the nurse
complete an incident report?
Answer: A client’s IV pump delivers an inadequate dose of medication
121. A nurse is teaching the parents of a toddler about snacks. Which of the following foods
should the nurse recommend?
Answer: Diced steamed carrots
122. A mental health nurse is conducting the first of several meetings with a client whose partner
recently died. The nurse should perform which of the following actions to establish trust during
the orientation phase of the nurse-client relationship?

Answer: Establish the termination date of therapy
123. A nurse is providing teaching to a client about newborn safety. Which of the following
statements should the nurse include in the teaching?
Answer: Set your hot water heater temp at or below 120 degrees F
124. A nurse is assessing a client who has a stage II pressure injury. Which of the following
wound characteristics should the nurse expect?
Answer: Partial-thickness skin loss
125. A nurse on a mental health unit is caring who tells the nurse that she does not want to
receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take?
Answer: Document the client’s refusal of the medication
126. A nurse is caring for a toddler who is admitted to the paediatric unit for surgery. Which of
the following should the nurse include in the toddler’s plan of care?
Answer: Encourage the parents to bring toys from home
127. A nurse is caring for a client who has generalized anxiety disorder and is to begin taking
alprazolam. Which of the following actions should the nurse take?
Answer: Initiate fall precautions
128. A client is receiving lorazepam IV for panic attacks and develops a resp rate of 6/min and a
BP of 90/44 mmHg. Which of the following medications should the nurse anticipate
administering?
Answer: Flumazenil
129. A nurse is assessing a 2-month old during a well-baby exam. Which of the following action
should the nurse take to assess the infant’s rooting reflex?
Answer: Stroke the infant’s cheek

130. A charge nurse is observing a newly licensed nurse performing a physical assessment on a
client. Which of the following actions by the nurse indicates that the charge nurse should
intervene?
Answer: The newly licensed nurse writes detailed notes while performing the head-to-toe
assessment
131. A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the
following should the nurse include in the teaching?
Answer: The cervix transitions to an anterior position
132. A nurse is performing an admission assessment of a preschooler who is in the acute phase of
Kawasaki disease. Which of the following findings should the nurse expect?
Answer: Fever unresponsive to antipyretics
133. A nurse is caring for client who is receiving TPN solution by continuous IV infusion at
60mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following
actions should the nurse take while waiting for a new infusion pump?
Answer: Provide dextrose 10% in water solution using manual drip tubing at 60ml/hr
134. A nurse is teaching the parents of a preschooler about sleep promotion. The parents report
that their child is demonstrating reluctance in going to bed at night and states, “I’m not tired.”
Which of the following statement by the parents indicates an understanding of the teaching?
Answer: We should read a story together every night before bedtime
135. A nurse is caring for four clients. Which of the following should the nurse assign to an AP to
assist with meals?
Answer: A client who has Alzheimer’s disease and is demonstrating aphasia.
136. A nurse is providing teaching to a parent of a child who has a permanent trach tube. Identify
the sequence of steps to the parent should follow to perform trach care.
Answer: Remove inner cannula, remove soiled dressing, clean stoma, change trach collar

137. A nurse is caring for a client who has a closed head injury and is receiving mechanical
ventilation. The nurse should expect to administer which of the following medications to reduce
intracranial pressure?
Answer: Mannitol
138. A nurse on a med-surge unit is caring for a client prior to surgical procedure. Which of the
following findings should indicate to the nurse that the client has the ability to sign the informed
consent?
Answer: The client is able to accurately describe the upcoming procedure
139. When caring for a child, a nurse plans to use nonpharm interventions to enhance the
effectiveness of pain medications. Which of the following strategies incorporates visualization
techniques to help decrease the child’s discomfort?
Answer: Blowing bubbles with liquid soap to “blow the hurt away”
140. A community health nurse is assisting with the development of a disaster management plan.
The nurse should include which of the following nursing responsibilities in the disaster response
stage of the plan?
Answer: Performing a rapid needs assessment
141. A nurse is planning care for a client who has thrombocytopenia. Which of the following
instructions should the nurse include in the client’s plan of care
Answer: Avoid venipunctures when possible
142. A nurse is reviewing the medical record of a client who has schizophrenia and is to start
taking clozapine. Which of the following findings should the nurse identify as a contraindication
for the client to receive clozapine?
Answer: WBC count 2,800/mm3

143. A nurse in an emergency department is admitting a client who has cardiac tamponade.
Which of the following assessment findings should the nurse expect?
Answer: Pulsus paradoxus
144. A community health nurse is preparing a health education program for a local rural
community. Which of the following actions should the nurse plan to take first?
Answer: Identify health-related issues within the community
145. A nurse is providing discharge teaching to a client following a cataract extraction. Which of
the following statements by the client indicates an understanding of the teaching?
Answer: I will bend at my knees when picking an object off the floor
146. A nurse is preparing to insert an indwelling urinary cath for a client. The nurse should assess
the client for which of the following conditions prior to starting the procedure?
Answer: Latex allergy
147. A nurse is assessing a school aged child who has CF. which of the following findings is the
priority for the nurse to report to the provider?
Answer: Haemoptysis 275mL/hr
148. A nurse is assessing a client who has delirium. Which of the following manifestations
should the nurse expect?
Answer: Rapid speech