2019 ATI RN Comprehensive Predictor Exam Form C With Answers-188 Solved Questions

ATI RN Comprehensive Predictor 2019 Form C
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 the
nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client’s peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client’s condition every 15 minutes
Answer: D. Document the client’s condition every 15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative following perforated
appendicitis. Which of the following actions should the nurse include in the plan of care?
A. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
B. Give cromolyn nebulizer solution every 6 hr (for asthma)
C. Apply a warm compress to the operative site every 4 hr
D. Administer analgesics on a scheduled basis for the first 24 hr
Answer: D. Administer analgesics on a scheduled basis for the first 24 hr
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following
actions should the nurse take?
A. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote
absorption; avoid oily or broken skin)
B. Wear gloves to apply the patch to the client’s skin
C. Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
D. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed
together)
Answer: B. Wear gloves to apply the patch to the client’s skin
A nurse has just received change-of-shift report for four clients. Which of the following clients
should the nurse assess first?

A. A client who was just given a glass of orange juice for a low blood glucose level
B. A client who is schedule for a procedure in 1 hr (can wait)
C. A client who has 100 mL fluid remaining in his IV bag (can wait)
D. A client who received a pain medication 30 min ago for postoperative pain
Answer: A. A client who was just given a glass of orange juice for a low blood glucose level
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 history of gastroesophageal reflux disease
B. Receiving a high osmolarity formula
C. Sitting in a high-Fowler’s position during the feeding
D. A residual of 65 mL 1hr postprandial
Answer: A. A history of gastroesophageal reflux disease
A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse
should expect the client to have an increase in which of the following laboratory values?
A. Serum glucose level- increased
B. Serum calcium level-decreased
C. Lymphocyte count- decreased immune system.
D. Serum potassium level- decreased
Answer: A. Serum glucose level- increased
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulphate
intravenously. The nurse discontinues the magnesium sulphate after the client displaces toxicity.
Which of the following actions should the nurse take?
A. Position the client supine
B. Prepare an IV bolus of dextrose 5% in water
C. Administer methylergonovine IM
D. Administer calcium gluconate IV
Answer: D. Administer calcium gluconate IV

Calcium gluconate is given for magnesium sulphate toxicity. Always have an injectable form of
calcium gluconate available when administering magnesium sulphate by IV.
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. Experiencing delusions
B. Male gender
C. Previous violent behavior
D. A history of being in prison
Answer: C. Previous violent behavior
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent
angry reactions with cognitive disorders). Individual Assessment for Violence
A nurse is preparing to perform a sterile dressing change. Which of the following actions should
the nurse take when setting up the sterile field?
A. Place the cap from the solution sterile side up on clean surface
B. Open the outermost flap of the sterile kit toward the body → flap AWAY from the body's first
C. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1inch) border around any sterile drape or wrap that is considered contaminated.
D. Set up the sterile field 5 cm (2 in) below waist level → it says BELOW waist level; should be
ABOVE waist level
Answer: A. Place the cap from the solution sterile side up on clean surface
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. Eat a light snack before bedtime
B. Stay in bed at least 1 hr if unable to fall asleep
C. Take a 1 hr nap during the day
D. Perform exercises prior to bedtime

Answer: A. Eat a light snack before bedtime
A home health nurse is preparing for an initial visit with an older adult client who lives alone.
Which of the following actions should the nurse take first?
A. Educate the client about current medical diagnosis
B. Refer the client to a meal delivery program
C. Identify environmental hazards in the home
D. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first.
Answer: C. Identify environmental hazards in the home
A nurse is assessing the remote memory of an older adult client who has mild dementia. Which
of the following questions should the nurse ask the client?
A. “Can you tell me who visited you today?”
B. “What high school did you graduate from
C. “Can you list your current medications?”
D. “What did you have for breakfast yesterday?”
Answer: B. “What high school did you graduate from
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the
following goals should the nurse include in the teaching
A. HbA1c level greater than 8%- 6.5 - 8 is the target reference. >
B. Blood glucose level greater than 200 mg/dL at bedtime
C. Blood glucose level less than 60 mg/dL before breakfast- > life threatening
D. Shuffling gait → A/E EPS: is an indication of parkinsonism and should be reported to t
Answer: D. Shuffling gait → A/E EPS: is an indication of parkinsonism and should be reported
to t
A nurse is planning discharge teaching about cord care for the parents of a newborn which of the
following instructions should the nurse plan to include in the teaching?
A. Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths
B. The cord stump will fall off in 5 days- about 10 - 14 days
C. Contact the provider if the cord stump turns black
D. Keep the cord stump dry until it falls off
Answer: D. Keep the cord stump dry until it falls off
Cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn
black and dry.
A nurse is teaching dietary guidelines to a client who has celiac disease which of the following
food choices is appropriate for the client?
A. White flour tortillas
B. Potato pancakes
C. Wheat crackers
D. Canned barley soup
Answer: B. Potato pancakes

A nurse is working in acute care mental health facility is assessing a client who has
schizophrenia. Which of the following findings should the nurse expect?
A. All or nothing thinking
B. Euphoric mood
C. Disorganized speech
D. Hypochondriasis (anxiety disorder)
Answer: C. Disorganized speech
A nurse is caring for a client who is immobile which of the following interventions is appropriate
to prevent contracture?
A. Align a trochanter wedge between the clients legs
B. Place a towel roll under the clients neck
C. Apply an orthotic to the clients foot
D. Position a pillow under the client's knees
Answer: C. Apply an orthotic to the clients foot
A public health nurse working in a rural area is developing a program to improve health for the
local population. Which of the following actions should the nurse plan to take?
A. Provide anticipatory guidance classes to parents through public schools
B. Have a nurse from the outside the community provide health lectures at the county hospital
C. Encourage rural residents to focus health spending on tertiary health interventions
D. Launch a media campaign to increase awareness about industrial pollution
Answer: A. Provide anticipatory guidance classes to parents through public schools
A nurse in the emergency department is performing triage for multiple clients following a
disaster in the community. To which of the following types of injuries should the nurse assign the
highest priority?
A. Below the knee amputation → ESI Level 1
B. 10cm (4 in) laceration → ESI Level 4
C. Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocation then
level 1.

D. 95% full thickness body burn →
Answer: A. Below the knee amputation → ESI Level 1
A nurse is preparing a change of shift report for an adult female client who is postoperative.
Which of the following client information should the nurse include in the report? CONFIRMED
A. Hgb 12.8 g/dl - 12- 16
B. Potassium 4.2 meq/l 3.5 - 5.0 meq
C. RBC 4.4 million/mm3
D. Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding
Answer: D. Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding
A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected
finding?
A. Iron 90 mcg/dl
B. Prealbumin 10 mcg/dl (normal: 16-40)
C. Serum creatinine 0.8 mg/dl
D. Calcium 9.5 mg/dl
Answer: B. Prealbumin 10 mcg/dl (normal: 16-40)
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse
(LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which
of the following client assignments should the nurse delegate to the LPN?
A. A client who is postoperative following a bowel resection with an NGT set to continuous
suction
B. A client who has fractured a femur yesterday and is expecting SOB
C. A client who sustained a concussion and has unequal pupils
D. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs
Answer: A. A client who is postoperative following a bowel resection with an NGT set to
continuous suction

A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor
induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the
following nursing actions should the nurse take ?
A. Continue the monitor the fetal heart rate- - Not a problem- absent or late are a problem
however CONFIRMED
B. Stop the oxytocin infusion
C. Perform a vaginal examination
D. Initiate an amnioinfusion
Answer: A. Continue the monitor the fetal heart rate- - Not a problem- absent or late are a
problem however CONFIRMED
A nurse is conducting an initial assessment of a client and noticed a discrepancy between the
clients current IV infusion and the information received during the shift report. Which of the
following actions should the nurse take?
A. Complete an incident report and place it in the client's medical record.
B. Compare the current infusion with the prescription in the client's medication record.
C. Contact the charge nurse to see if the prescription was changed.
D. Submit a written warning for the nurse involved in the incident.
Answer: B. Compare the current infusion with the prescription in the client's medication record.
A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to the
administration of clozapine ?
A. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normal range
B. Fasting blood glucose 100 mg/dl
C. Hgb 14 g/Dl
D. Heart rate 58/min
Answer: A. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normal range

A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis c. The
client asks the nurse if she will be able to breastfeed. Which of the following responses by the
nurse is appropriate?
A. You may breastfeed unless your nipples are cracked or bleeding. .
B. You must use a breast pump to provide breast milk.
C. You must use nipple shield when breastfeeding.
D. You may breastfeed after your baby develops his antibiotics.
Answer: A. You may breastfeed unless your nipples are cracked or bleeding. .
A nurse is caring for a client who has returned to the medical-surgical unit following a
transurethral resection of the prostate. Which of the following should the nurse identify as
priority nursing assessment after reviewing the clients information? Exhibit.
A. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ?
B. Skin turgor
C. Deep-tendon reflexes
D. Bowel sounds
Answer: A. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the
brain ?
C. Deep-tendon reflexes
A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse
to take ?
A. Submerge the adolescent feet in ice water
B. Cover the adolescent with a thermal blanket → if hypothermia.
C. Administer oral acetaminophen
D. Initiate seizure precautions
Answer: D. Initiate seizure precautions
A nurse manager is updating protocols for belt restraints. Which of the following guidelines
should the nurse include.
A. Document the client's conditions every 15 minutes

B. Attach the restraints to the beds side rails
C. Request a PRN restraints prescription for clients who are aggressive
D. Remove the client restraints every 4 hours
Answer: A. Document the client's conditions every 15 minutes
A nurse in emergency department is caring for a client who has full thickness burn of the thorax
and upper torso. After securing the client's airway, which of the following is the nurse's priority
intervention?
A. Providing pain management
B. Offering emotional support
C. Preventing infection
D. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd spacing
Answer: D. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd
spacing
A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s
daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.”
which of the following responses by the nurse is appropriate? (SATA)
A. Hospice will take good care of your mom, so I wouldn’t worry about that.
B. Let's talk about your mom’s cancer and how things will progress from here.
C. Tell me how you are feeling about your mom dying.
D. Tell her not to worry. She still has plenty of time left.
E. You sound like you have questions about your mom dying. Let’s talk about it.
Answer: B. Let's talk about your mom’s cancer and how things will progress from here.
C. Tell me how you are feeling about your mom dying.
E. You sound like you have questions about your mom dying. Let’s talk about it.
Therapeutic communication
A nurse is reviewing the medical records of four clients. The nurse should identify that which of
the following client findings follow up care?
A. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal)

B. A client who is scheduled for colonoscopy and taking sodium phosphate
C. A client who received a Mantoux test 48 hours ago and has induration
D. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin)
Answer: C. A client who received a Mantoux test 48 hours ago and has induration
A community health nurse receives a referral for a family home visit. Which of the following
tasks should the nurse perform first?
A. Clarify the source of the referral
B. Implement the nursing process
C. Schedule a time for the home visit
D. Contact the family by phone
Answer: A. Clarify the source of the referral
A nurse is caring for a client who will undergo a procedure. The client states he does not want
the provider to discuss the results with his partner. Which of the following is an appropriate
response for the nurse to make?
A. You have the right to decide who receives information
B. Your partner can be a great source of support for you at this time
C. Is there a reason you don’t want your partner to know about your procedure?
D. The provider will be tactful when talking to your partner
Answer: A. You have the right to decide who receives information
A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb.
from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following
total percentage?
A. 7.5%
B. 15%
C. 8.1%
D. 13.3%
Answer: A. 7.5%

A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which
of the following interventions should the nurse implement?
A. Perform fundal massage (massage if fundus is boggy)
B. Pour water from a squeeze bottle over the client’s perineal area.
C. Insert an indwelling urinary catheter.
D. Apply cold therapy to the client’s perineal area.(warm)
Answer: B. Pour water from a squeeze bottle over the client’s perineal area.
A nurse is providing discharge teaching to a client who has cancer and a prescription for a
fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse
include in the teaching?
A. Avoid hot tub while wearing the patch
B. Apply patch to your forearm
C. Avoid high-fiber foods while taking this medication
D. Remove the patch for 8 hours every day to reduce the risk for tolerance.
Answer: A. Avoid hot tub while wearing the patch
A nurse 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?
A. Teach the client to shift his weight every 15 min while sitting (cannot do this because he is
paraplegic)
B. Place the client upright on a donut-shaped cushion
C. Assess pressure points every 24 hr.- must assess
D. Turn and reposition the client every 3 hrs. while in bed. - must be q 2 hours in bed, 1 hour in
chair.
Answer: A. Teach the client to shift his weight every 15 min while sitting (cannot do this
because he is paraplegic)

A nurse is working with a client who has an anxiety disorder and is in the orientation phase of
the therapeutic relationship. Which of the following statements should the nurse make during this
phase?
A. We should discuss resources to implement in your daily life
B. Let me show you simple relaxation exercises to manage stress.
C. Let’s talk about how you can change your response to stress
D. We should establish our roles in the initial session.
Answer: D. We should establish our roles in the initial session.
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. Avocados
B. Whole grain bread
C. Pepperoni pizza
D. Smoked salmon
Answer: B. Whole grain bread
A nurse enters a client’s room and sees a small fire in the client’s bathroom. Identify the
sequence of steps the nurse should take. (Move the steps into the box on the right, placing them
in the selected order of performance. Use all steps)
A. Transport the client to another area of the nursing unit
B. Activate the facility’s fire alarm system
C. Close all nearby windows and doors
D. Use the unit’s fire extinguisher to attempt to put out the fire.
Answer: Correct Order is A. Transport the client to another area of the nursing unit
B. Activate the facility’s fire alarm system
C. Close all nearby windows and doors
D. Use the unit’s fire extinguisher to attempt to put out the fire

A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings
should the nurse expect?
A. Heightened perceptual field
B. Rapid speech -severe
C. Feelings of dread
D. Purposeless activity
Answer: A. Heightened perceptual field
A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not
feeling well. Which of the following findings should indicate to the nurse that the client is
hypoglycaemic? (Select all that apply.)
A. Tremors
B. Polydipsia = hyperglycaemia
C. Acetone Breath Odor = DKA
D. Diaphoresis
E. Inability to concentrate
Answer: A. Tremors
D. Diaphoresis
E. Inability to concentrate
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. Upper extremity hypotension
B. Increased intracranial pressure
C. Frequent nosebleeds
D. Weak femoral pulses
Answer: D. Weak femoral pulses
A community health nurse is planning primary prevention activities to reduce the occurrence of
abuse. Which of the following strategies should the nurse include in the plan?

A. Instruct healthcare professionals to identify abusive situations (screening = secondary
prevention)
B. Locate financial support to open a shelter for abuse survivors (3rd)
C. Teach parenting skills to families at risk for abuse
D. Connect abuse survivors with legal counsel (3rd)
Answer: C. Teach parenting skills to families at risk for abuse
A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following
tasks is appropriate for the nurse to delegate to the AP?
A. Documenting the report of pain for a client who is postoperative
B. Administering oral fluids to a client who has dysphagia
C. Applying a condom catheter for a client who has a spinal cord injury
D. Reviewing active range-of-motion exercise with a client who had a stroke
Answer: C. Applying a condom catheter for a client who has a spinal cord injury
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 take sucralfate with meals three times per day”
B. “I will avoid food and beverages that contain caffeine”
C. “I will decrease my daily protein intake to 15 grams per day”
D. “I will use ibuprofen as needed to control abdominal pain”
Answer: B. “I will avoid food and beverages that contain caffeine”
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible.
Which of the following is an appropriate action by the nurse?
A. Encourage the client to increase fluid intake
B. Advise the client to suck on sugar-free candies
C. Provide humidification of the room air
D. Instruct the client to avoid using alcohol-based mouthwashes
Answer: C. Provide humidification of the room air

A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an
assistive personnel?
A. Assess effectiveness of antiemetic medication
B. Perform chest compressions during cardiac resuscitation
C. Perform a dressing change for a new amputee
D. Apply a transdermal nicotine patch
Answer: B. Perform chest compressions during cardiac resuscitation
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets
the flu. The nurse should recognize which of the following findings as a potential
contraindication for using lavender?
A. The client takes vitamin C daily
B. The client has a history of alcohol use disorder
C. The client has a history of asthma
D. The client takes furosemide twice daily
Answer: C. The client has a history of asthma
A nurse is caring for a client who has major depressive disorder and a new prescription for
amitriptyline. The nurse should monitor for which of the following adverse effects?
A. Increased salivation- dry it will cause - anticholinergic effects
B. Weight loss
C. Urinary retention
D. Hypertension- orthostatic hypotension it will cause instead
Answer: C. Urinary retention
A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the
following disorders is a contraindication for oral contraceptive use?
A. Asthma
B. Hypertension
C. Fibromyalgia
D. Fibrocystic breast condition

Answer: B. Hypertension
A nurse is preparing to witness a client’s signature on a consent form for a colon resection. The
nurse should recognize that which of the following information should be provided to the client
by the provider before signing the form? (SATA)
A. Explain the procedure
B. Expected outcome of the procedure
C. Potential complications
D. Possible alternative treatments
E. Cost of the procedure
Answer: A. Explain the procedure
B. Expected outcome of the procedure
C. Potential complications
D. Possible alternative treatments
A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI)
scan. Which of the following statements is appropriate to include in the teaching?
A. “You should not have this procedure if you are allergic to iodine.”
B. “You should not have this procedure if you have a tattoo.”
C. “The nurse will ask you to wear protective eyewear during this procedure.”
D. “The nurse will ask you to remove any transdermal patches prior to the procedure.”
Answer: A. “You should not have this procedure if you are allergic to iodine.”
A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit.
The nurse should recommend increasing dietary intake of which of the following vitamins?
(Exhibit) --only tab shown is Tab 3:
H&P: postmenopausal, hx DVT and iron deficiency anaemia, works indoors, consumes 12
alcoholic beverages per week
A. Vitamin D
B. Vitamin K
C. Vitamin A

D. Vitamin B12
Answer: D. Vitamin B12
A nurse is caring for a child who has sickle cell anaemia and experiencing vasoconstrictive crisis.
Which of the following actions should the nurse include in the plan of care?
A. Initiate IV fluid replacement
B. Start a 24-hr urine collection- not the priority
C. Give aspirin to reduce pain- acetaminophen or ibuprofen. As a might lead to reye's disease
D. Encourage ambulation- we want to promote rest to decrease 02 consumption
Answer: A. Initiate IV fluid replacement
A nurse is teaching a parent about safety securing her 3-month-old infant in a car seat. Which of
the following images indicates that the parent understands the teaching?

Answer: B
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. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion
assess prior to infusion then be with them for first 15 - 30 minutes.
B. Set the IV infusion pump to administer the blood over 6 hr

C. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
D. Administer the blood via a 21-gauge IV needle
Answer: C. Flush the blood administration tubing with 0.9% sodium chloride prior to the
transfusion
A nurse is caring for a client who is dissatisfied with the care from the provider and decides to
leave the facility against medical advice. After notifying the provider, which of the following
actions is appropriate for the nurse to take?
A. Summon a security guard
B. Explain the risks of leaving
C. Complete an incident report
D. Notify a social worker
Answer: B. Explain the risks of leaving
A nurse is making an initial postpartum home visit. Which of the following client statements
should the nurse identify as a manifestation of increased risk for child abuse?
A. “I try to respond to the baby quickly .”
B. “I think the baby should be sleeping through the night by now.
C. “I have several friends who come by to help out with the baby.”
D. “I want to meet other parents to see if they are going through the same thing.”
Answer: B. “I think the baby should be sleeping through the night by now.
A nurse is caring for an infant who has gastroenteritis. Which of the following assessments
should the nurse report to the provider?
A. Temperature 38 C(100.4 F) and pulse rate 124/min p
B. Decreased appetite and irritability
C. Pale and 24-hour fluid deficit of 30 mL
D. Sunken fontanels and dry mucous membranes
Answer: D. Sunken fontanels and dry mucous membranes

A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding,
The nurse does not speak the same language as the client . The client partner and a 10 year old
child are accompanying her. Which of the following actions should the nurse take to gather the
clients information?
A. Ask a student nurse who speaks the same language to translate
B. Have the child translate
C. Allow the clients partner to translate
D. Request a female translator interpreter through the facility
Answer: D. Request a female translator interpreter through the facility
A nurse is caring for a client who has pernicious anemia, Which of the following laboratory
values should the nurse evaluate effectiveness of the treatment ?
A. Folate level
B. INR level
C. Vitamin B12 level
D. Creatinine level
Answer: C. Vitamin B12 level
A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the
nurse assign to the AP?
A. Suction a new tracheostomy
B. Remove an NG tube
C. Perform post mortem care
D. Change the dressing on an implanted central venous access device
Answer: C. Perform post mortem care
A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the
following findings should indicate to the nurse that the client’s ability to eliminate urine from the
bladder is restored?
A. Two voids of 150 mL each over the past 2 hours = 2 × 30 = 60 mls
B. Fundus 2 fingerbreadths above the umbilicus(needs to be below or at the umbilicus)

C. Uterine atony(fundus not firm which means possible hemorrhage)
D. Fundus firm and to the right of the abdominal midline(fundus not midline, bladder may cause
shifting if patient not voiding properly)
Answer: A. Two voids of 150 mL each over the past 2 hours = 2 × 30 = 60 mls
A nurse is caring for a client who has acute glomerulonephritis .Which of the following should
the nurse expect ?
A. Polyuria- oliguria
B. Hypotension- hypertension
C. Hematuria - urinalysis will show red blood cells and protein, also reddish brown col coloured
urine
D. Weight loss - weight gain
Answer: C. Hematuria - urinalysis will show red blood cells and protein, also reddish brown col
coloured urine
A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the
following effects should the nurse include? SSRI for social anxiety ,PTSD,
A. Excessive sweating
B. Increased urinary frequency
C. Dry cough
D. Metallic taste in mouth
Answer: A. Excessive sweating
A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the
following statements should the nurse include in the teaching?
A. your baby will be given 2 ounces of water to drink prior to the test
B. this test will be repeated when your baby is 2 months old
C. a nurse will draw blood from your baby’s inner elbow
D. this test should be performed after you baby is 24 hours old
Answer: D. this test should be performed after you baby is 24 hours old

a nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the
following actions should the nurse take?
A. perform the procedure prior to meals : AVOID Before or AFTER meals
B. perform the procedure twice a day
C. administer a bronchodilator after the procedure
D. hold hand flat to perform percussions on the child
Answer: B. perform the procedure twice a day
A nurse is preparing an Inservice for a group of nurses about malpractice issues in nursing.
Which of the following examples should the nurse include in the teaching?
A. placing a yellow bracelet on a client who is at risk for falls → correct approach; yellow
bracelet indicates fall risk
B. administering potassium via IV bolus
C. documenting communication with a provider in the progress notes of the client’s medical
record
D. leaving a nasogastric tube clamped after administering oral medication →
Answer: B. administering potassium via IV bolus
A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the
nurse should palpate to check the client’s maxillary sinus for tenderness.

Answer: Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the
sides of the nose to the corner of the mouth.
A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions
should the nurse instruct the client to take prior to initiating postural drainage?
A. Take pancrelipase
B. Complete oral hygiene
C. Eat a meal
D. Use an albuterol inhaler
Answer: D. Use an albuterol inhaler
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 minutes → circulation
B. Maintain strict bedrest for first 12 hr- only for prescribed time, older adults usually are up to
4hours.
C. Keep the client NPO for 24 hr- doesn’t say anything about restrictions AFTER the procedure ,
and npo b4 the procedure is up to 8 hours.
D. Place the client in Fowler’s position- supine they must be
Answer: A. Monitor the dorsalis pedis pulse every 15 minutes → circulation
A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of
the following actions should the nurse take?
A. Offer high-calorie, high protein snacks to the client
B. Recommend the family provide the client privacy during meals
C. Weigh the client once each day
D. Encourage the client to eat foods selected by the dietitian
Answer: A. Offer high-calorie, high protein snacks to the client

A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The
nurse is demonstrating which of the following ethical principles when respecting the client's
decision to wear his own clothing ?
A. Non maleficence
B. Veracity
C. Autonomy
D. Justice
Answer: C. Autonomy
Autonomy: The ability of the client to make personal decisions, even when those decisions might
not be in the client’s own best interest
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. Check the mouth for smooth and smoky breath - airway obstruction via foreign body
B. Calculate the fluid replacement based on vital signs and urinary output
C. Determine the location and depth of burns
D. Administer antibiotics to prevent sepsis.
Answer: A. Check the mouth for smooth and smoky breath - airway obstruction via foreign
body
A nurse is assessing a client who had heart failure is taking furosemide. Which of the following
findings should the nurse monitor?
A. Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow
B. Hyperkalemia
C. Hypercalcemia
D. hypoglycaemia
Answer: A. Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium
will follow
A nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to
decrease calorie intake by 500 Cal/day for 25 weeks produce a weight loss of 1 pound per week.

What is the expected goal weight for the client in pounds at the end of the 25 weeks? (round the
answer to the nearest whole number. Use leading zero if it applies. No trailing Zero) _____ 140?
(not sure. _______ pounds
Answer: 1 lb per week × 25 week = 25 lbs
75 × 2.2 = 165 lbs
165 lbs-25 lbs =140 lbs or 63.6 kg (64 kg)
A nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which
of the following statements by the parent indicates an understanding of the teaching?
A. I will change my baby’s diaper at least every 4 hours
B. I will apply an ice pack to my baby’s penis twice daily to decrease swelling
C. I will wash the penis with soap and warm water until the circumcision has healed
D. I will apply topical lidocaine following each diaper change Teach the parents to keep the area
clean.
Answer: A. I will change my baby’s diaper at least every 4 hours
A home health nurse is caring for an adult client who reports, “I keep coughing when I try to
swallow my food, but not at other times.” Which of the following actions should the nurse take?
A. encourage the client to increase fluid intake
B. initiate a consultation with a speech → language pathologist; swallow eval
C. instruct the client that this is due to increased salivary flow that occurs with aging
D. recommend an antitussive 30 minutes prior to each meal
Answer: B. initiate a consultation with a speech → language pathologist; swallow eval
Refer to speech language therapist for dysarthria and dysphagia.
A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his
blood glucose is being adequately controlled. The nurse should identify that which of the
following laboratory values is the best indicator of adequate blood glucose control?
A. Postprandial blood glucose 190 mg/dl
B. Fasting blood glucose 60 mg/dl
C. HbA1c 6.5%

D. Hct 42%
Answer: C. HbA1c 6.5%
A nurse is planning to administer Atenolol to a client. Which of the following should the nurse
assess prior to administering the medication?
A. BUN
B. Blood pressure
C. Respiratory rate
D. aPTT
Answer: B. Blood pressure
A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of
the following pain management strategies by the newly licensed nurse requires intervention?
A. Encouraging the client to use jet therapy on her lower back for 1 hr
B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen
C. Using effleurage on a client’s lower abdomen
D. Instructing a client’s partner how to apply counterpressure to the client’s sacral spine for 30
min
Answer: B. Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s
abdomen
A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving
change-of-shift report. Identify the sequence of steps the nurse should follow when delegating
tasks to the APs.
A. Review the skill level of and qualifications of each AP 1
B. Communicate appropriate tasks to the APs with specific expectations 2
C. Monitor progress of task completion with each AP 3
D. Evaluate the APs’ performance of each task 4
Answer: A. Review the skill level of and qualifications of each AP 1

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 should take antibiotics when I have a virus.”
B. “I should wash my hands for 10 seconds with hot water after working in the garden.”
C. “I can clean my cat’s litter box during my pregnancy.”
D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
Answer: D. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
A nurse I caring for a school-age child who is 2 hr postoperative following a cardiac
catheterization. The nurse observes blood on the child’s dressing. Which of the following actions
should the nurse take?
A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
B. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.
C. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.
Answer: C. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
A nurse is reviewing the medical record of a client who has a prescription for intermittent heat
therapy for a foot injury. Which if the following findings should the nurse identify as a
contraindication for heat therapy?
A. Phlebitis
B. Abdominal aortic aneurysm
C. Osteoarthritis
D. Peripheral neuropathy
Answer: D. Peripheral neuropathy
A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of
the following findings is expected during the procedure?
A. Sensation of skin warmth
B. Headache
C. Increased salivation

D. Numbness and tingling of the extremities
Answer: A. Sensation of skin warmth
A nurse is transcribing new medication prescriptions for a group of clients. For which of the
following prescriptions should the nurse contact the provider for clarification?
A. Lorazepam .5 mg PO one tablet daily
B. Hydrochlorothiazide 12.5 mg PO BID
C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID
D. Zolpidem 10 mg PO one tablet at bedtime
Answer: A. Lorazepam .5 mg PO one tablet daily
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. Swelling of the face
B. Urinary frequency
C. Faintness upon rising
D. Bleeding gums
Answer: A. Swelling of the face
A nurse is providing care for a client who has esophageal cancer and has received radiation
therapy. Which of the following finding should the nurse identify as the priority?
A. Excoriation of the skin on the neck and chest
B. Dysphagia
C. Client reports a pain level of 6 on scale from 0-10
D. Xerostomia
Answer: B. Dysphagia
A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following
action should the nurse take?
A. Monitor the client’s urinary output
B. Check the client VS

C. Evaluate the client's pain level
D. Palpate the client’s fundus
Answer: D. Palpate the client’s fundus
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. “The child usually has an aura prior to onset”
C. This type of seizure last 30-60 sec”
D. “This type of seizure has a gradual onset”
Answer: A. “This type of seizure can be mistaken for daydreaming”
A nurse in a surgical suite is planning care for a client who requires surgery and has a latex
sensitivity. Which of the following is appropriate for this client?
A. Disinfect and powder any latex products before use
B. Tape stockinet over monitoring device and cords
C. Schedule the client as the last surgery of the day
D. Remove poopsocks from the IV
Answer: B. Tape stockinet over monitoring device and cords
A nurse is reviewing the medical record of a client. The nurse should identify that the client is at
risk for which of the following complication.
A. Dumping syndrome
B. Ketoacidosis
C. Hepatotoxicity
D. Thyroid storm
Answer: A. Dumping syndrome
A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of
the following action should nurse take? (SATA)
A. Place the client in a semi-private room

B. Wear a lead apron when providing care
C. Limit visitors to 30 mins
D. Instruct visitors who are pregnant to remain 3 ft from the client
E. Close the door to the client's room
Answer: B. Wear a lead apron when providing care
C. Limit visitors to 30 mins
A CN (charge nurse. is providing teaching for group of newly licensed nurse about grieving
process. Which of the following information should the CN include in the teaching?
A. Client can expect to have feeling of hopelessness
B. Client might feel guilt over some aspect of their loss
C. Client will experience anhedonia
D. Client will experience low self-esteem
Answer: B. Client might feel guilt over some aspect of their loss
A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn
arrives. Which of the following statements by the nurse is appropriate?
A. Offer your son a gift when the baby receives one
B. Move your son to a toddler bed when the baby arrives
C. Tell your son to kiss the baby
D. Teach your son to change the baby diapers - not the answer
Answer: A. Offer your son a gift when the baby receives one
D. Teach your son to change the baby diapers - not the answer
A nurse is obtaining a nutritional health hx on a client who reports problems with constipation.
Which of the following should the nurse identify as a cause of constipation?
A. Following high-fiber diet
B. Currently taking probiotics
C. New prescription for an iron supplement
D. Intolerance to lactose
Answer: C. New prescription for an iron supplement

A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following
findings should the nurse except?
A. Increase PaO2
B. Hypoglycaemia
C. Board-like abdomen
D. Bounding pulse
Answer: D. Bounding pulse
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. Measure the client’s urine output every hour. - monitor for toxicity.
B. Restrict the client’s total fluid intake to 250ml/hr.
C. Monitor the FHR via Doppler every 30 min
D. Give the client protamine if sign of magnesium sulphate toxicity occur. .
Answer: A. Measure the client’s urine output every hour. - monitor for toxicity.
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. Hypertension
B. Primary glaucoma
C. Osteoarthritis
D. Amputation
Answer: A. Hypertension
A nurse is caring for a client who has COPD and is 5kg (11lb). below her ideal body weight. The
client experiences shortness of breath when eating. Which of the following actions should the
nurse take?
A. Administer a bronchodilator following meals.

B. Request non gas forming foods from the dietary department
C. Limit the client’s food consumption between meals.
D. Arrange for a low protein diet. HIGH PROTEIN.
Answer: B. Request non gas forming foods from the dietary department
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 infectious disease that should be
reported to the state health department?
A. Candidiasis
B. Herpes simplex virus
C. Human papillomavirus
D. Chlamydia
Answer: D. Chlamydia
A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin.
The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a
creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to
take?
A. Place a cardiac monitor on the client
B. Stop the IV infusion of insulin
C. Administer oral potassium to the client- potassium is already high
D. Initiate a 24 hr urine collection
Answer: A. Place a cardiac monitor on the client
A nurse is providing discharge teaching to a client who is postoperative following the surgical
repair of a detached retina. Which of the following statements by the client indicates an
understanding of the teaching?
A. I can go jogging after 2 weeks. -Avoid vigorous activities.
B. I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds.
C. I can resume activities, such as sewing.
D. I should bend at the waist when putting on my shoes. -Avoid bending at the waist level.

Answer: C. I can resume activities, such as sewing.
A nurse is planning to administer vancomycin IV to a client. Which of the following actions
should the nurse take to reduce the risk of an adverse reaction to the vancomycin?
A. Give the dose over 60 min
B. Administer the medication undiluted
C. Obtain trough level 30 min after the medication infusion
D. Inject 1% lidocaine prior to each dose
Answer: A. Give the dose over 60 min
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 -not for pts with CKD or dialysis.
B. Eat 1g/kg of protein per day
C. Drink at least 3L of fluid daily -too much fluid
D. Consume foods high in potassium -low potassium diet
Answer: B. Eat 1g/kg of protein per day
A nurse is delegating tasks to an assistive personnel group of clients. Which of the following
statements should the nurse make?
A. Take the client in room 106 to radiology
B. Take the vital signs of the clients on the side of the unit
C. Tell me the standing weight of the client in room 102 before breakfast
D. The client in room 109 has spilled his water pitcher
Answer: C. Tell me the standing weight of the client in room 102 before breakfast
Right direction/communication. Leadership.
A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of
low dose dopamine. Which of the following findings is the highest priority?
A. Erythema 5 cm (2in) above the IV site

B. Blood pressure 92/68 mm Hg
C. Urine output 35mL/hr
D. Pedal pulse of +1 bilaterally
Answer: A. Erythema 5 cm (2in) above the IV site
A nurse is providing teaching about the use of crutches using a three-point gait to a client who
has tibia fracture. Which of the following actions by the client indicates an understanding of the
teaching?
A. Positioning both hands on the grips with his elbows slightly flexed
B. Supporting his body weight while leaning on the axillary crutch pads (Support body weight
using both Crutches when shifting weight)
C. Stepping with his affected leg first when going up stairs (Unaffected First)
D. Moving both crutches with the stronger leg forward
Answer: A. Positioning both hands on the grips with his elbows slightly flexed
A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following
developmental tasks should the toddler be able to perform?
A. Hop on one foot
B. Kick a ball forward
C. Climb Stairs with alternate feet
D. Ride a tricycle
Answer: B. Kick a ball forward
A case manager is meeting with a client who asks about using alternative therapies to manage her
rheumatoid arthritis. Which of the following statements should the nurse make?
A. I’m sure you can find alternative remedies through an online support group
B. If there are therapies available to you, your provider will tell you about them
C. Feel free to try whatever therapies that fit within your personal belief system
D. We can review some information to help you select a safe alternative practitioner.
Answer: D. We can review some information to help you select a safe alternative practitioner.
● Facilitating continuous

● Improving efficiency of care and utilization of resources
A nurse is assessing a client following an ischemic stroke. Which of the following findings is the
priority for the nurse to report to the provider?
A. The client reports a metallic taste in his mouth
B. A client reports a decreased appetite
C. The client coughs after swallowing
D. The client has poor fitting dentures
Answer: C. The client coughs after swallowing
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis.
Which of the following actions should the nurse take to evaluate effectiveness of the procedure?
A. Compare the client's current weight with preprocedural weight.
B. Check the client's serum albumin levels
C. Examine for leakage at this site of the procedure
D. Confirm that the client is able to urinate
Answer: A. Compare the client's current weight with preprocedural weight.
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse include in the plan?
A. Swaddle the newborn with this leg extended.
B. Maintain eye contact with the newborn during feedings.
C. Minimize noise in the newborn environment
D. Administer naloxone to the newborn
Answer: C. Minimize noise in the newborn environment
● Reduce environmental stimuli (decrease lights, lower noise level).
A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the
following is an activity a nurse should engage in to assist in disaster preparedness?
A. Participate in community drills and mock events.

B. Vaccinate susceptible children and adults against smallpox
C. Assess types, levels and scopes of disasters.
D. Make quarantine preparations for those exposed to anthrax
Answer: A. Participate in community drills and mock events.
Assess First
A nurse is completing an admission assess for a client who has narcissistic personality disorder.
Which of the findings should the nurse expect?
A. Ritualistic behavior (OCD)
B. Exhibits separation anxiety (Dependent)
C. Preoccupied with aging
D. Suspicious of others. (Paranoid)
Answer: C. Preoccupied with aging
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. Withdraw the client's TV privileges if he does not attend group therapy
B. Place the client in seclusion when exhibits signs of anxiety
C. Encourage the client to take frequent rest periods.
D. Encourage the client to spend time in the day room
Answer: C. Encourage the client to take frequent rest periods.
A nurse is obtaining a client’s medical history before initiating 1000 ml of 0.9% NaCl with 20
mEq/L KCl IV to correct hypokalaemia. Which of the following findings is a contraindication to
the client receiving this IV solution?
A. Severe renal impairment. (Stage IV Kidney Disease)
B. Chronic alcohol use disorder
C. Multiple sclerosis
D. Advanced cardiac disease.
Answer: A. Severe renal impairment. (Stage IV Kidney Disease)

A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a
soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space.
Which of the following is an appropriate documentation of the findings?
A. Fourth heart sound at the aortic area
B. Murmur at the mitral area
C. Third heart sound at the tricuspid area
D. Pericardial friction rub at the pulmonic area
Answer: B. Murmur at the mitral area
A nurse is teaching a client who has a newly documented latex allergy. Which of the following
statements by the clients indicates an understanding of the teaching?
A. I will remove dairy products from my diet
B. I will remove peanuts from my diet
C. I will remove bananas from my diet
D. I will remove gluten from my diet
Answer: C. I will remove bananas from my diet
● People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit, plum,
strawberry, tomato
A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes
mellitus. The nurse should report which of the following conditions is a contraindication for the
use of metformin?
A. Seizure disorder
B. Polycystic ovary syndrome
C. Renal insufficiency
D. Gluten intolerance
Answer: C. Renal insufficiency
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. Contractions

B. Vomiting
C. Hypertension
D. Epigastric pain -google
Answer: A. Contractions
D. Epigastric pain -google
A nurse on a surgical paediatric care unit receives report prior to providing care for a group of
clients. Which of the following clients should the nurse assess first?
A. A 15 year old who is 6 hr postop following a herniorrhaphy and reports pain at the IV site
B. 3 month old who is 1 day postop following cleft lip repair and has a pulse of 120
C. 12 year old who is 2 days postop following an appendectomy and is refusing to ambulate
D. 8 year old client who is 12 hr postop following a tonsillectomy and is experiencing frequent
swallowing – bleeding
Answer: D. 8 year old client who is 12 hr postop following a tonsillectomy and is experiencing
frequent swallowing - bleeding
A nurse is teaching a client how to perform Kegel exercises. Which of the following client
statements indicates understanding of the teaching?
A. I will alternately contract and relax my gluteal muscles
B. I will perform the exercises once each day before bed
C. I will try to hold my urine for a little after I first feel the urge to urinate
D. I will determine which muscles to contract by stopping and starting my stream of urine
Answer: D. I will determine which muscles to contract by stopping and starting my stream of
urine
A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which
of the following statements indicates that the client understands the teaching?
A. I need to have an enema before the test
B. I should urinate before the test
C. I will lie on my left side during the test
D. I will drink an oral glucose solution during the test

Answer: B. I should urinate before the test
A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago.
Which of the following findings should the nurse expect?
A. Memory loss
B. Slurred speech
C. Elevated temperature
D. hypotension
Answer: C. Elevated temperature
• Dizziness, tremor, blurred vision, seizures, fever, tachycardia, hypertension
A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the
following clinical manifestations is an expected finding for this client?
A. Report of occipital headache
B. Scratchy, high pitched sound upon chest auscultation
C. ECG demonstrates a depressed ST segment
D. White, diffuse peritonsillar pustules
Answer: B. Scratchy, high pitched sound upon chest auscultation
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. Consume food high in bran fiber
C. Sweeten foods with fructose corn syrup
D. Increase intake of milk product
Answer: B. Consume food high in bran fiber
• Limit gas forming foods, caffeine, alcohol. Encourage high fiber and fluids
A nurse is admitting an older adult client who is transferring from another facility. The nurse
notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the
following actions should the nurse take to address the suspicions of elder abuse?

A. Inform the transferring agency of the client’s condition.
B. Privately interview the client about her condition.
C. Notify risk management
D. Contact the family regarding the client’s condition.
Answer: B. Privately interview the client about her condition.
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. Maintain NPO status for client(ABC)
B. Change client's position every 2 hours
C. Perform range-of-motion exercises to client’s extremities.
D. Place the clients right hand in supination position.
Answer: A. Maintain NPO status for client(ABC)
A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks
of gestation about managing diabetes during pregnancy. Which of the following statements by
the client indicates an understanding of the teaching?
A. “I will decrease my protein intake during the third trimester”(increase protein for basic
growth)
B. “I will need to increase my insulin doses later in my pregnancy”
C. “I will increase my carbs at breakfast and limit them the rest of the day”
D. “I will decrease my calorie consumption during the first trimester”(increase calorie)
Answer: B. “I will need to increase my insulin doses later in my pregnancy”
A home health nurse is preparing to assess a client who reports tingling around the mouth and
laxative use at least once daily. Which of the following assessments should the nurse perform
first?
A. Test the client for Trousseau’s sign
B. Assess the client’s skin turgor
C. Check the client’s motor strength
D. Measure the client’s pupil size

Answer: A. Test the client for Trousseau’s sign
A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the
following statements by the client requires further teaching?
A. “I should clean my stoma with warm water”(can use low ph. soap and water)
B. “ My stoma should be bright pink or red”(pink, red and moist)
C. “I should change the stoma pouch every day”
D. “I should cut my pouch opening (1/8) inch larger than my stoma”(allow expansion)
Answer: C. “I should change the stoma pouch every day”
ATI ostomy care video pouches good for up to 2-7 days, empty at (1/4) or (1/2) full.
A nurse is assessing a client who is receiving magnesium sulphate by continuous IV infusion.
Which of the following findings should the nurse recognize as a result of magnesium sulphate
toxicity?
A. Hyporeflexia
B. Tachypnoea(bradypnea, less than 12/min)
C. Pruritus(sign of allergic reaction)
D. Polyuria (oliguria, less than 30 ml/hr)
Answer: A. Hyporeflexia
A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a
newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many millilitres
should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero
if it applies. Do not use a trailing zero)
Answer: 1.7 mL per dose
100mg × 4.34 kg = 434 mg/day
434mg/125mgX1 = 3.472/day
3.472/2 = 1.736
A nurse is caring for a client who asks for information regarding organ donation. Which of the
following responses should the nurse make?

A. “Your desire to be an organ donor must be documented in writing”
B. “I cannot be a witness for your consent to donate”
C. “You must be at least 21 years of age to become an organ donor”
D. “Your name cannot be removed once you are listed on the organ donor list
Answer: A. “Your desire to be an organ donor must be documented in writing”
A nurse is admitting a client who has acute heart failure. Which of the following prescriptions
from the provider should the nurse anticipate?
A. Administer enalapril 2.5 mg PO twice daily
B. Ambulate the client every 4 hr while awake(bedrest)
C. Provide the client with 4 g sodium diet
D. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr
Answer: A. Administer enalapril 2.5 mg PO twice daily
A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling
urinary catheter. Which of the following actions should the nurse take during collection?
A. Drain the specimen from the drainage bag(not sterile use the port for culture and UA)
B. Clamp the catheter distal to the injection port
C. Collect 2 mL of urine for each specimen
D. Obtain the urinalysis specimen before the culture specimen
Answer: B. Clamp the catheter distal to the injection port
A nurse is caring for a client who reports diarrhoea for 3 days. The nurse should monitor the
client for which of the following manifestations?
A. Orthostatic Hypertension
B. Dependent Edema
C. Decreased Haematocrit
D. Neck Vein Distension
Answer: A. Orthostatic Hypertension

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 is overly concerned about minor details.
B. The client exhibits impulsive behavior.
C. The client is exceptionally clingy to others.
D. The client may act seductively.- histrionic
Answer: B. The client exhibits impulsive behavior.
A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings
should the nurse report to the provider?
A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require
action unless there are symptoms of magnesium toxicity.)
B. Protruding Haemorrhoids
C. Urinary Frequency (expected)
D. Supine Hypotension
Answer: B. Protruding Haemorrhoids
A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing
to discontinue the chest tube before the medication has taken affect. Which of the following
actions should the nurse prepare to take first?
A. Inform the provider of the time of the last dose of pain medication.
B. Document the sequence of events as they occur.
C. Provide non-pharmacological pain management interventions.
D. Instruct the client about the steps of the procedure.
Answer: A. Inform the provider of the time of the last dose of pain medication.
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which
of the following statements should the nurse include in the hand-off report?
A. The client was intubated without complications.
B. The estimated blood loss was 250 millilitres.
C. There was a total of 10 sponges used during the procedures.

D. The client is a member of the board of directors.
Answer: B. The estimated blood loss was 250 millilitres.
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. “You can add the medication to a half-cup of your child’s favourite juice.”
B. “Repeat the dose if your child vomits within 1 hour after taking the medication.”
C. “Limit your child’s potassium intake while she is taking this medication.”
D. “Have your child drink a small glass of water after swallowing the medication.”
Answer: D. “Have your child drink a small glass of water after swallowing the medication.”
A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should
recognize that an elevated PAWP indicates which of the following complications?
A. Left ventricular failure
B. Cardiogenic shock
C. Hypovolemia
D. Hypotension
Answer: A. Left ventricular failure
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 treatment.
C. A client who is 1 day postoperative following a vertebroplasty
D. A client who is receiving heparin for deep vein thrombosis.
Answer: C. A client who is 1 day postoperative following a vertebroplasty
D. A client who is receiving heparin for deep vein thrombosis.
A nurse is caring for four clients who are scheduled for surgery the same day. Which of the
following laboratory values indicates the need for intervention before surgery?

A. Fasting blood glucose 108 mg/dl (WNL)
B. WBC 9,800/mm (WNL)
C. Creatinine 0.9 mg/dl (WNL)
D. Potassium 5.2 mEq/L
Answer: D. Potassium 5.2 mEq/L
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? Paul for 158 would u pick D ?
A. Engage the client in activities that increase sensory stimulation.
B. Discourage physical activity during the day.
C. Establish a toileting schedule for the client.
D. Use clothing with buttons and zippers.
Answer: C. Establish a toileting schedule for the client.
A nurse is caring for a client who reports diarrhoea for 3 days. The nurse should monitor the
client for which of the following manifestations
A. Orthostatic hypotension
B. Dependant Edema- fluid volume excess
C. Decreased Hematocrit - fluid volume excess d/t super diltion
D. Neck vein distention - fluid volume excess
Answer: A. Orthostatic hypotension
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 is overly concerned about minor details
B. The client exhibits impulsive behavior - spending money giving away money or possessions.
C. The client is exceptionally clingy to others
D. The client might act seductively
Answer: B. The client exhibits impulsive behavior - spending money giving away money or
possessions.

A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings
should the nurse report to the provider ?
A. 3+ deep tendon reflexes -preeclampsia
B. Protruding haemorrhoids
C. Urinary frequency ch 4 p. 21 maternal
D. Supine hypotension - teach them side lying position
Answer: A. 3+ deep tendon reflexes -preeclampsia
A nurse is administering an analgesic to a client who has a chest tube . The provider is preparing
to discontinue the chest tube before the medication has taken effect. Which of the following
actions should the nurse take first ?
A. Inform the provider of the time of the last does of pain medication
B. Document the sequence of events as they occur
C. Provide non pharmacological pain management interventions
D. Instruct the client about the steps of the procedure
Answer: A. Inform the provider of the time of the last does of pain medication b.
A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which
of the following statements should the nurse include in the hand off report ?
A. The client was intubated without complication
B. The estimated blood loss was 250 millilitres
C. There was a total of 10 sponges used during the procedure - what kind
D. The client is a member of the board of directors
Answer: B. The estimated blood loss was 250 millilitres
A nurse is assessing a clients PAWP. The nurse should recognize that an elevated PAWP indicates
which of the following complication?
A. Left ventricular failure
B. Cardiogenic shock
C. Hypovolemia
D. Hypotension

Answer: A. Left ventricular failure
A charge nurse on a medical surgical unit is assisting with the emergency responses plan
following an external disaster in the community. In anticipation of multiple client admissions,
which of the following current client should the nurse recommend for early discharge ?
A. A client who has COPD and a respiratory rate of 44/ min - RR is too high out of range
B. A client who has cancer with a sealed implant for radiation therapy - an implant is inside
them, and its active
C. A client who is 1 day postoperative following a vertebroplasty
D. A client who is receiving heparin for deep vein thrombosis - as said in class Heparin for
Hospital and that other Coumadin for home
Answer: C. A client who is 1 day postoperative following a vertebroplasty
A nurse is caring for four client who are scheduled for surgery the same day. Which of the
following laboratory values indicates the need for intervention before surgery ?
A. Fasting blood glucose 108 mg/ dl
B. WBC 9,800 mm3 > 4,800 is normal
C. Creatinine 0.9 mg/dl , < 1.0 is normal
D. Potassium 5.2 meq / L 3.5 - 5.0 =
Answer: D. Potassium 5.2 meq / L 3.5 - 5.0 =
A nurse is providing teaching to family members of a client who has dementia. Which of the
following instructions should the nurse include in the teaching ?
A. Engage the client in activities that increase sensory stimulation.
B. Discourage physical activity during the day
C. Establish a toileting schedule for the client
D. Use clothing with buttons and zippers
Answer: C. Establish a toileting schedule for the client

A charge nurse is preparing to lead negotiations among nursing staff due to conflict about
overtime requirements. Which of the following strategies should the charge nurse use to promote
effective negotiation?
A. Identify Solutions prior to negotiation
B. personalize the conflict
C. Attempt to understand both sides of the issue
D. Focus on how the conflict occurred
Answer: C. Attempt to understand both sides of the issue
Assess the situation first prior to trying to solve it.
A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the
peripheral IV site. Which of the following actions should the nurse plan to take?
A. Insert a new IV catheter distal to the discontinued IV site
B. apply pressure dressing at the IV site
C. Please a warm moist compress on the site
D. Express drainage from the IV site and send it to be cultured
Answer: C. Please a warm moist compress on the site
Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is
commonly treated by discontinuing the IV line and applying a moist, warm compress over the
area.
A nurse is preparing to administer three medications to a client who is receiving continuous
enteral tube feeding through an NG tube. Which of the following actions is appropriate for the
nurse to take?
A. ADD medication directly to enteral feeding - not without crushing them first
B. Dissolve the medications together- some medications can mix others can’t
C. Use a syringe to allow the medications to Flow by gravity
D. Flush the NG tube with 5 ml water- 10ml
Answer: C. Use a syringe to allow the medications to Flow by gravity

The nurse is caring for a client who has histrionic personality disorder. Which of the following
findings should the nurse expect?
A. Repeated acts of unlawful Behavior
B. Suspicious demeanor
C. Seductive Behavior
D. Lack of remorse
Answer: C. Seductive Behavior
A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management
during labor. Which of the following statements by the client indicates an understanding of the
teaching?
A. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught
earlier to control other pain, not pain of labor
B. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess
with the readings of the pt and baby
C. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no.
D. I can use my ultrasound picture as a focal point during contractions
Answer: D. I can use my ultrasound picture as a focal point during contractions
A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse
report to the provider?
A. Heart rate 98 per minute - wnr
B. ST segment elevations Remember this could possibly lead to infarctions
C. 2 PVCs per minute
D. Widened P wave
Answer: B. ST segment elevations Remember this could possibly lead to infarctions
A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn
to a client. Which of the following actions by the newly licensed nurse indicates a need for the
nurse to intervene?
A. Plans for a check of the clients fingerstick glucose every 6 hours

B. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok
C. Uses the tpn IV tubing to administer the clients next dose of antibiotic
D. Increases the tpn infusion rate each hour until the prescribed rate is achieved
Answer: C. Uses the tpn IV tubing to administer the clients next dose of antibiotic
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a
group on a mental health unit. which of the following group facilitation techniques should the
nurse include in the teaching?
A. Yield in situations of conflict to maintain group Harmony - If conflict arises it is your
responsibility to contain it
B. Share personal opinions to help influence the group's values -your focus is having group share
their personal thoughts and feelings to facilitate discussion
C. Use modelling to help the clients improve their interpersonal skills
D. Measure the accomplishments of the group against a previous group - no comparison
Answer: C. Use modelling to help the clients improve their interpersonal skills
A nurse is assessing a client's respirations which of the following actions should the nurse take?
A. Assess respirations before counting radial pulsations -either or is fine
B. Multiply the number of respirations in 15 seconds by 4 - short way to do it, not necessarily the
right way
C. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear
D. Count respirations for 1 minute if the rhythm is irregular
Answer: D. Count respirations for 1 minute if the rhythm is irregular
A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the
clients biopsy report while on the elevator. Which of the following actions should the nurse take?
A. Report the information to the charge nurse
B. review confidentiality policies with laboratory employees- would be the job of the Facility
manager or someone who audits or teaches HIPAA stuff
C. contact the laboratory manager regarding the situation - you are not high enough up the chain
to do that

D. Notify the facilities legal department - no need to go that far
Answer: A. Report the information to the charge nurse
A nurse is assessing a client who requests an oral contraceptive. Which of the following findings
in the client’s medical history should the nurse identify as a contraindication for the use of a
combination oral contraceptive?
A. Concurrent use of levothyroxine
B. Allergy to penicillin
C. Recurrent urinary tract infections
D. Migraines with aura
Answer: D. Migraines with aura
MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as migraine,
epilepsy, asthma, kidney, or heart disease.
A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following
clients should the nurse see first?
A. A client who is at 36 weeks of gestation and has a biophysical profile score of 8
B. A client who has pregestational diabetes mellitus and an HbA1c of 6.2%
C. A client who is at 28 weeks of gestation and reports leukorrhea
D. A client who has preeclampsia and reports a persistent headache
Answer: D. A client who has preeclampsia and reports a persistent headache
A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the
following actions should the nurse include in the plan of care?
A. Instruct the client to empty her bladder prior to the procedure.
B. Position the client over an overbed table prior to the procedure.
C. Administer 1 L dextrose 5% in water IV bolus prior to the procedure.
D. Initiate NPO status 4 hr prior to the procedure.
Answer: A. Instruct the client to empty her bladder prior to the procedure.

A nurse is caring for a client who is in active labor and notes the FHR baselines has been
100/min for the past 15 min. The nurse should the identify which of the following conditions as a
possible cause of fetal bradycardia?
A. Maternal hypoglycaemia
B. Chorioamnionitis
C. Fetal anaemia
D. Maternal fever
Answer: A. Maternal hypoglycaemia
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. “You should make sure your partner takes the prescribed medication.”
B. “Why do you think your partner’s symptoms are progressing so quickly?”
C. “You did the right thing by bringing your partner in for treatment.”
D. “Can you talk about what was happening with your partner at home?”
Answer: D. “Can you talk about what was happening with your partner at home?”
A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory
tests should the nurse monitor?
A. Arterial blood gas
B. Serum potassium
C. Liver function test
D. Serum creatinine
Answer: C. Liver function test
A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client.
Which of the following statements should the nurse include in the teaching?
A. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.”
B. “The PCA will deliver a double dose of medication when you push the button twice.”
C. “You should push the button before physical activity to allow maximum pain control.”

D. “You can adjust the amount of pain medication you receive by pushing on the keypad.”
Answer: C. “You should push the button before physical activity to allow maximum pain
control.”
A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an
appropriate action for the nurse to take?
A. Discard the first 10 mL of urine.
B. Apply EMLA cream prior to the procedure.
C. Obtain a 12 French catheter.
D. Don sterile gloves prior to the procedure.
Answer: D. Don sterile gloves prior to the procedure.
A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the
following levels should the nurse report to the provider?
A. Potassium 3.2 mEq/L 3.5 - 5.0 is normal
B. BUN 16 mg/dL (Normal 10-20)
C. PT 12.2 seconds (Normal 11-14)
D. Fasting blood glucose 103 mg/dL
Answer: A. Potassium 3.2 mEq/L 3.5 - 5.0 is normal
A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.”
Which of the following responses is the priority for the nurse to state?
A. “How long have you been hearing the voices?”
B. “What are the voices telling you?”
C. “Have you taken your medication today?”
Answer: B. “What are the voices telling you?”
“I realize the voices are real to you, but I don’t hear anything.”