2019 ATI RN Comprehensive Predictor Exam Form C With Answers-365 Solved Questions

ATI COMPREHENSIVE C
1. 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
2. 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
3. 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 diabetes mellitus and a haemoglobin A1C. of 6.8%
C. A client who has epidural analgesia and weakness in the lower extremities
D. A client who has a hip fracture and a new onset of tachypnoea
Answer: D. A client who has a hip fracture and a new onset of tachypnoea
4. 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
5. 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
6. 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
7. 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

8. 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.
9. 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
10. 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
11. 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
12. 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
13. 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
14. 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- 30 - 60 is normal
B. A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool
C. A 2 day old newborn who has a small amount of blood tinged vaginal discharge

D. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal
Answer: A. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal
22. A nurse on an acute unit has received change of shift report for 4 clients which of the
following clients should the nurse assess first? Pain pallor pulselessness paresthesia
A. A client who is 1 hr postoperative and has hypoactive bowel sounds
B. A client who has fractured left tibia and pallor in the affected extremity
C. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses
D. A client who has an elevated AST level following administration of azithromycin
Answer: B. A client who has fractured left tibia and pallor in the affected extremity
23. A nurse is providing discharge instructions to a client who has a new prescription for
haloperidol which of the following adverse effects should the nurse instruct the client to report to
the provider?
A. Weight gain
B. Dry mouth → anticholinergic effects
C. Sedation → s/s neuroleptic malignant syndrome??>> 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
24. 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.

25. 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
26. 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
27. 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
28. 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

29. 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
30. 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
31. 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)
32. 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
33. 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 problem however
B. Stop the oxytocin infusion
C. Perform a vaginal examination
D. Initiate an amnioinfusion
Answer: A. Continue the problem however
34. 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.
35. 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
36. 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. .
37. 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 ?
38. 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

39. 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
40. 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
41. 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

42. 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
43. 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
44. 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
45. 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%
46. 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.
47. 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
48. 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)

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?
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.
50. 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
51. 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: A. Transport the client to another area of the nursing unit (1)
B. Activate the facility’s fire alarm system (2)
C. Close all nearby windows and doors (3)
D. Use the unit’s fire extinguisher to attempt to put out the fire (4)

52. 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
53. 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
54. 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
55. 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
56. 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
57. 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”
58. 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. Offer the client saltine crackers between meals
B. Suggest rinsing his mouth with an alcohol-based mouthwash
C. Provide humidification of the room air
D. Instruct the client on the use of esophageal speech
Answer: C. Provide humidification of the room air

59. 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
60. 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
61. 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
62. 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
63. 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
64. 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.”
65. 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
66. 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
67. 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
68. 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
69. 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
70. 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.
71. 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

72. 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
Answer: Request a female translator interpreter through the facility
73. 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
74. 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
75. 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
76. 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
77. 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
78. 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

79. 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
80. 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
81. 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.
82. 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
83. 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
84. 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

85. 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
86. 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
87. 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
88. 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)
89. 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
90. 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.
91. 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%
92. 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
93. 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
94. 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.
Answer: 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
95. 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.”
96. 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.
97. 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
98. 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

99. 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
100. 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
101. 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
102. 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

103. 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”
104. 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
105. 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
106. 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
107. 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
108. 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
109. 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
110. 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
111. 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.
112. 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
113. 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
114. 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
115. 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
116. 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.

117. 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
118. 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
119. 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.
120. 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
121. 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
122. 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
123. 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

124. 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
125. 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.
126. 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).
127. 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
128. 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
129. 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.
130. 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)

131. 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
132. 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
133. 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
134. 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
135. 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
136. 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
137. 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

138. 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
139. 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
140. 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
141. 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.
142. 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)
143. 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”
144. 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

145. 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 ⅛ 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 ¼ or ½ full.
146. 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
147. 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 X 4.34 kg = 434 mg/day
434mg/125mgX1 = 3.472/day
3.472/2 = 1.736
148. 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”
149. 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
150. 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
151. 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

152. 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.
153. 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
154. 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.
155. 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.
156. 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.”
157. 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
158. 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.
159. 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
160. 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.
151. 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
152. 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.

153. 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
154. 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.
155. 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
157. 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
158. 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
159. 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 =
160. 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

161. 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.
162. 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.
163. 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

164. 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
165. 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
166. 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
167. 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
168. 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
169. 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
170. 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
171. 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
Rationale: MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as
migraine, epilepsy, asthma, kidney, or heart disease.
172. 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
173. 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.

174. 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
175. 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?”
176. 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
177. 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.”
178. 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.
179. 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
180. 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.”

ATI COMPREHENSIVE EXIT FINAL

1. A nurse in an emergency department completes an assessment on an adolescent client that has
conduct disorder. The client threatened suicide to teacher at school. Which of the following
statements should the nurse include in the assessment?
A. Tell me about your siblings
B. Tell me what kind of music you like
C. Tell me how often do you drink alcohol
D. Tell me about your school schedule
Answer: C. Tell me how often do you drink alcohol
2. A nurse is observing bonding to the client her newborn. Which of following actions by the
client requires the nurse to intervene?
A. Holding the newborn in an en face position
B. Asking the father to change the newborn's diaper
C. Requesting the nurse take the newborn nursery so she can rest
D. Viewing the newborn’s actions to be uncooperative
Answer: D. Viewing the newborn’s actions to be uncooperative
3. A nurse is caring for client who is taking levothyroxine. Which of the following findings
should indicate that the medication is effective?
A. Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism)
B. Decreased blood pressure
C. Absence of seizures
D. Decrease inflammation
Answer: A. Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism)
4. A nurse is planning discharge teaching for cord care for the parent of a newborn. Which
instructions would you include in the teaching?
A. Contact provider if the cord still turns black (it’s going to turn black)
B. Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser)
C. Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection)

D. The cord stump will fall off in five days (cord falls off in 10-14 days)
Answer: C. Keep the cord dry until it falls off (cord should be kept clean and dry to prevent
infection)
5. A nurse is assessing a client in the PACU. Which of the following findings indicates decreased
cardiac output?
A. Shivering
B. Oliguria
C. Bradypnea
D. Constricted pupils
Answer: B. Oliguria
6. A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the
following client should the nurse identify as the priority?
A. A client that has massive head trauma
B. A client has full thickness burns to face and trunk
C. A client with indications of hypovolemic shock
D. A client with open fracture of the lower extremity
Answer: C. A client with indications of hypovolemic shock
7. A nurse is a receiving report on four clients. Which of the following clients should the nurse
assess first?
A. A client who has illegal conduit and mucus in the pouch
B. Client pleasant arteriovenous additional vibration palpated
C. A client whose chronic kidney disease with cloudy diasylate outflow
D. A client was transurethral resection of the prostate with a red tinged urine in the bag
Answer: C. A client whose chronic kidney disease with cloudy diasylate outflow
8. A nurse is caring for a client just received the first dose of lisinopril. The following is an
appropriate nursing intervention?
A. Place’s cardiac monitoring

B. Monitor the clients oxygen saturation level
C. Provide standby assist with the client from bed
D. Encourage foods high in potassium
Answer: C. Provide standby assist with the client from bed
9. A nurse is caring for a client who is in labor and his seat is receiving electronic feta
monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the
following should the nurse expect?
A. Feta hypoxia
B. Abrupto placentae
C. Post maturity
D. Head Compression
Answer: D. Head Compression
10. A nurse is caring for a client who has chronic kidney disease. The nurse should identify
which of the following laboratory values as in an indication for haemodialysis?
A. glomerular filtration rate of 14 mL/ minute
B. BUN 16 mg/DL
C. serum magnesium 1.8 mg mg/dl
D. Serum phosphorus 4.0 mg/dL
Answer: A. glomerular filtration rate of 14 mL/ minute
11. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The
following is an appropriate action for the nurse to take?
A. Placed infant under radiant warmer
B. Move the probe site every 3 hours
C. Heat the skin one minute prior to placing the program
D. Placed a sensor on the index finger
Answer: C. Heat the skin one minute prior to placing the program

12. A nurse in a mental health facility receives a change of shift report on for clients. Which of
the following clients should the nurse plan to assess first?
A. Client placed in restraints to the aggressive behavior
B. A new limited client pleasures history of 4.5 kg weight loss in the past two months
C. Client is receiving a PRN dose of health heard all two hours ago for increased anxiety
D. Applied he’ll be receiving his first ECT treatment today
Answer: A. Client placed in restraints to the aggressive behavior
13. A nurse working at the clinic is teaching a group of clients who are pregnant on the use of
nonpharmacological pain management. Which of the following statements by the nurse is an
appropriate description of the use of hypnosis during labor?
A. Hypnosis focuses on the biofeedback as a relaxation technique
B. Hypnosis promotes increased control of her pain perception during contractions
C. Hypnosis uses therapeutic touch to reduce anxiety during labor
D. Hypnosis provides instruction to minimize pain
Answer: B. Hypnosis promotes increased control of her pain perception during contractions
14. A nurse in a County Jail health clinic is leading group therapy session. A client who was
incarcerated for theft is addressing the group. Which of the following is an example of reaction
formation? (rxn formation is when you use opposite feelings; ex: being super nice to someone
you dislike)
A. I steal things because it’s the only way I can keep my mind off my bad marriage
B. I can’t believe I was accused of something I didn’t do
C. I don’t want talk about my feelings right now. We will talk more next time
D. I think that people just you’re just lazy and should earn money honestly
Answer: D. I think that people just you’re just lazy and should earn money honestly
15. A nurse is obtaining the medical history of a client who has a new prescription for isosorbide
mononitrate. Which of the following should the nurse identify as a contraindication to
medication?
A. Glaucoma

B. Hypertension
C. Polycythaemia
D. Migraine headaches
Answer: A. Glaucoma
17. The nurses is caring for a client recovering from an acute myocardial infarction.
Which following intervention should the nurse include in the point of care?
A. Draw a troponin level every four hours
B. Performance EKG every 12 hours
C. Plant oxygen tent fell over minutes via rebreather mask
D. Obtain a cardiac rehabilitation consult
Answer: D. Obtain a cardiac rehabilitation consult
18. A Nurses caring for client who has breast cancer and has been covering receiving
chemotherapy. Which of the following laboratory values should nurse report to provider?
A. WBC 3,000/mm3
B. Haemoglobin 14 g/dl
C. Platelet 250,000/mm3
D. aPTT 30 seconds
Answer: A. WBC 3,000/mm3
19. Home health nurse is carefully planned for Alzheimer’s disease. To the following action
should the nurse include in the plan of care
A. Place a daily calendar in the kitchen
B. Replace button clothing with zippered items
C. Replace the carpet with hardwood floors
D. Create variation in daily routine
Answer: A. Place a daily calendar in the kitchen
20. Nurse is performing change of shift assessments on 4 clients. Which of the following
findings should the nurse report to provider first?

A. The client was cystic fibrosis and has a thick productive clock and reports thirst
B. Client who has gastroenteritis and is lethargic and confused
C. The Client has diabetes mellitus has morning fasting Legal cost of 185mg over deal
D. The client was sick of signing it reports pain 15 minutes after receiving oral analgesic
Answer: B. Client who has gastroenteritis and is lethargic and confused
21. A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat
constipation. Which of the following statements by the nurse is appropriate?
A. Decrease taking vitamins and supplements to every other day
B. Eat 15 g of fiber per day
C. Consume 48 ounces of water each day (need at least 64 oz)
D. Drink hot water with lemon juice each morning when you wake up
Answer: D. Drink hot water with lemon juice each morning when you wake up
23. A nurse is caring for a client who is preparing his advance directives. Which is the following
statements by the client indicates an understanding of advanced directives? select all that apply
A. I can’t change my instructions once a minute
B. My doctor will need to approve my advance directives
C. I need an attorney to witness my signature on the advance directives
D. I have the right to refuse treatment
E. My health care proxy can make medical decisions for me
Answer: D. I have the right to refuse treatment
E. My health care proxy can make medical decisions for me
24. A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac
disease. Which of the following positions should the nurse place the client to best promote
optimal cardiac output?
A. The chest
B. Standing
C. Supine
D. Left lateral

Answer: D. Left lateral
25. A nurse is caring for a group of clients. Which of the following clients should the nurse
assign to an AP?
A. Client who has chronic obstructive pulmonary disease and needs guidance on incentive
spirometry
B. Client who has awoken following a bronchoscopy and requests a drink
C. Client who had a myocardial infarction 3 days ago reports chest discomfort
D. Client who had a cerebrovascular accident two days ago and needs help toileting
Answer: D. Client who had a cerebrovascular accident two days ago and needs help toileting
26. Nurse providing discharge teaching to the client who has schizophrenia and is starting
therapy with clozapine. Which of the following is the highest priority for the client to report to
the provider?
A. Constipation
B. blurred vision
C. Fever
D. Dry Mouth
Answer: C. Fever
27. A nurse observes an AP providing care to a child who is in skeletal traction. Which of the
following action requires intervention?
A. Providing a high protein snack
B. Assisting the child to reposition
C. Placing weights as a child’s bed
D. Massaging pressure points-causes skin breakdown
Answer: C. Placing weights as a child’s bed
28. A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has
diabetes mellitus. Which of the following action should the nurse take?
A. Determine if the AP is qualified to perform the test.

B. Help the AP performed the blood glucose test
C. Assign the AP to ask the client is taking his diabetic medication today
D. Have AP check the medical record for prior blood glucose test results
Answer: A. Determine if the AP is qualified to perform the test.
29. A nurse is assessing client brought to the hospital psychiatric emergency services by a law
enforcement officer. The client has disorganized, incoherent speech with loose associations and
religious content. You should recognize the signs and symptoms as being consistent with which
of the following?
A. Alzheimer’s disease
B. Schizophrenia
C. Substance intoxication
D. Depression
Answer: B. Schizophrenia
30. A nurse is caring for a child who has infectious mononucleosis. Which of the following
findings are associated with this diagnosis? Select all that apply
A. splenomegaly
B. Koplik spots (this is associated with measles)
C. Malaise
D. Vertigo
E. Sore throat
Answer: A. splenomegaly
C. Malaise
E. Sore throat
31. Nurse is performing dressing change for client was a sacral wound using negative pressure
wound therapy. Which The following actions should the nurse take first?
A. Apply skin preparation to wound edges.
B. Normal saline
C. Don sterile gloves

D. Determine pain level
Answer: D. Determine pain level
32. A nurses caring for client recovery from the bowel surgery who has nasogastric tube
connected to low intermittent suction. Which the following assessment findings should indicate
to the nurse that the NG tube may not be functioning properly?
A. Drainage fluid is greenish-yellow
B. aspirate pH of 3
C. Abdominal rigidity
D. air bubbles noted in the NG tube
Answer: C. Abdominal rigidity
33. A nurse is preparing to administer TPN with added fat supplements to a client who has
malnutrition. Which of the following action should the nurse take?
A. Piggyback 0.9 sodium chloride with TPN solution
B. Check for an allergy to eggs
C. Discuss the TPS solution for 12 hours
D. Monitor for hypoglycaemia
Answer: B. Check for an allergy to eggs
34. A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly
licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?)
A. Systemic analgesic effect
B. increase in your metabolism
C. Decreased capillary permeability
D. Vasodilation
Answer: C. Decreased capillary permeability
35. Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the
nurse should instruct the client to
A. Perform weight bearing exercises

B. Avoid crossing the legs beyond the midline
C. Avoid sitting in one position for prolonged periods
D. Split affected area
Answer: A. Perform weight bearing exercises
36. A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is
highest priority?
A. The client has surgical hypoparathyroidism and positive Trousseau’s sign
B. A client who was Clostridium difficile with acute diarrhoea
C. A client who is acute kidney injury and urine with a low specific gravity
D. The client who has oral cancer and reports a sore on his gums
Answer: A. The client has surgical hypoparathyroidism and positive Trousseau’s sign
37. Nurses caring for a client was congestive heart failure. Which of the following prescriptions
for the provider should the nurse anticipate?
A. Call the provider to clients respiratory rate is less 18/min
B. Give the client 500 mL IV bolus of 0.9 sodium chloride over 1 hr
C. Give the client enalapril 2.5 mg PO twice daily
D. Call the provider if the clients pulse rate is less than 80/min
Answer: C. Give the client enalapril 2.5 mg PO twice daily
38. A nurse is caring for a client who has a prescription for sertraline to treat depression. Which
of the following statements by the client indicates an understanding of the medication treatment
plan?
A. I will be able starting this medication with feel better
B. I can expect to urinate frequently while on this medication
C. I understand I may experience difficulty sleeping on this medication
D. I should decrease my sodium intake while on this medication
Answer: C. I understand I may experience difficulty sleeping on this medication

39. A nurse has been caring for a female client who has bruises on her arms that she explains are
a result of physical abuse by her husband. The client states, “I don’t know how much longer I
can take this, but I’m afraid he’ll really hurt me if I leave. “Which of the following is an
appropriate nursing intervention?”
A. Offer to speak to the client’s husband regarding his abuse behavior.
B. Help the client to recognize the signs of escalation of abuse behavior
C. Assist the client to identify personal behaviours that trigger abusive behavior
D. Assist the client to Reports abusive behavior to the proper authority
Answer: B. Help the client to recognize the signs of escalation of abuse behavior
40. A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore.
Why not end my misery?” Which of the following responses for the nurses appropriate?
A. Why do you think your life is not worth it anymore?
B. Do you have a plan to end your life?
C. I need to know what you mean my misery
D. You can trust me and tell me what you’re thinking
Answer: B. Do you have a plan to end your life?
41. A nurse is caring for a client who has schizophrenia. Which of the following assessment
findings should the nurse expect?
A. Decreased level consciousness
B. Unable to identify common objects
C. Poor problem solving ability
D. Preoccupation was somatic disturbances
Answer: C. Poor problem solving ability
42. A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which
of the following action should nurse take? There are 3 tabs that contain separate categories of
data.
A. Position the client with the affected extremity lower than the heart
B. Administration of acetaminophen

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

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

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

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

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

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

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

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

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

76. A client with the left leg cast is using crutches for ambulation. The nurse recognizes client
needs further instruction of the client
A. Flexes elbows at 30 degrees when using the handgrips
B. Maintains 3 to 4 finger width between the crutch pad and axilla
C. Places the crutches 6 inches in front and side of each foot when standing.
D. Pushes up from a chair with crutches on the unaffected side.
Answer: B. Maintains 3 to 4 finger width between the crutch pad and axilla
77. A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following
actions should the nurse plan to take?
A. Use a designated stethoscope when caring for the toddler.
B. Wear an N95 respiratory mask while caring for the toddler.
C. Remove the disposable gown after leaving the toddler’s room
D. Place the toddler in a room with negative air pressure.
Answer: A. Use a designated stethoscope when caring for the toddler.
78. A nurse is admitting to a client to emergency department and initiates continuous cardiac
monitoring. Which of the following ECG with strips indicates sinus tachycardia?

Answer: b

79. A nurse is planning care for client to prevent complications of immobility. With the following
actions should the nurse including the plan of care?
A. Massage lower extremities daily to prevent DVT
B. Limit intake of Food high in calcium to prevent renal calculi.
C. Encourage client to lie supine prevent constipation.
D. Remove anti embolism stockings for 3 hours each day to decreased skin breakdown.
Answer: D. Remove anti embolism stockings for 3 hours each day to decreased skin breakdown.
80. A nurse discovers that the wrong dosage of medication was given to client. When
determining what action to take you should recognize that which of the following ethical
principles should be applied?
A. Utility
B. Paternalism
C. Veracity
D. Fidelity
Answer: C. Veracity
82. A nurse is review in the prescription for doxazosin with a client. Which of the following
should be included in the teaching?
A. Decrease caloric intake to reduce weight gain.
B. Increased dietary fiber to prevent constipation.
C. Rise slowly when sitting up from bed.
D. Take this medication each morning.
Answer: C. Rise slowly when sitting up from bed.
83. Addresses planning to provide teaching to young adult client who is insomnia. Which of the
following should the nurse include in the teaching?
A. Exercising an hour before bedtime
B. Take a short nap today
C. Keep bedroom cool at night
D. Consume a high carbohydrate snack at bedtime.

Answer: D. Consume a high carbohydrate snack at bedtime.
84. A nurse is caring for client who has a stool culture that is positive for Clostridium difficile.
Which of the following infection control precautions is appropriate?
A. Wear a face shield prior into entering the room.
B. Place the client private room.
C. Place the client in a negative pressure room.
D. Use alcohol based hand rub following client care.
Answer: B. Place the client private room.
85. A nurse is planning care for a child who has increased intracranial pressure with a decreased
level of consciousness. Which of the following intervention should the nurse including the plan
of care?
A. Perform active range of motion exercises.
B. Perform neurological checks every 4 hours.
C. Suction the airway frequently.
D. Maintain the head at a midline position.
Answer: D. Maintain the head at a midline position.
86. The nurse is assessing a client is receiving radiation therapy. Which of the following findings
should the nurse expect?
A. White blood cell count at 12,500 mm3
B. Excessive salivation
C. +3 pitting edema
D. Platelets 95,000 mm3
Answer: D. Platelets 95,000 mm3
87. A nurse is caring for a client who has preeclampsia and is experiencing postpartum
hemorrhage. The nurse should identify that which of the following medications is
contraindicated?
A. Methylergonovine.

B. Misoprostol
C. Dinoprostone
D. Oxytocin
Answer: A. Methylergonovine.
88. A nurse is caring for client was GERD. Which of the following assessment findings the nurse
expect to find?
A. Shortness of breath
B. Rebound tenderness
C. Atypical chest pain
D. Vomiting blood
Answer: C. Atypical chest pain
89. A nurse is caring for a newborn who is under phototherapy lights. Which of the following is
an appropriate nursing action?
A. Ensure eye shield is covering the eyes.
B. Apply lotion to expose skin.
C. Offer glucose water between feedings.
D. Discontinue breast-feeding during treatment.
Answer: A. Ensure eye shield is covering the eyes.
90. This is assessing clients as had a long arm cast. Which of the following findings of the dress
moderate and when assessing for acute compartment syndrome?
A. Shortness of breath
B. Petechiae
C. Change in mental status
D. Edema
Answer: D. Edema
91. I Just came from client is receiving IV moderate (Conscious) sedation with midazolam. The
client has a respiratory rate of 9/min and is not responding to commands.

Which of the following is an appropriate action by the nurse?
A. Placed the client in a prone proposition.
B. Implement Positive pressure ventilation.
C. Perform nasopharyngeal suctioning.
D. administer flumazenil
Answer: D. administer flumazenil
92. A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client.
They are using the clients name and discussing details of his diagnosis. Which of following
actions should the nurse take first?
A. Report the AP’s behavior to the supervisor.
B. Completed instant report regarding the Aps conversation.
C. Provide the AP with written documentation regarding client confidentiality
D. Tell the AP to discontinue their conversation
Answer: D. Tell the AP to discontinue their conversation
93. A community health nurse is teaching a group of adults about the importance of health
screenings. The nurse should include African American males almost twice as likely as
Caucasian males to experience which of the following?
A. testicular Cancer
B. Obesity
C. Stroke
D. Melanoma
Answer: C. Stroke
94. A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the following
prescription is given by the provider should the nurse clarify?
A. Over the fact that extremities and two pillows.
B. Apply heat to affect extremity for 45 minutes on the 45 is off.
C. wrap the affected extremity with a compression dressing.
D. Assess the affected extremity for sensation movement impulse every four hours

Answer: B. Apply heat to affect extremity for 45 minutes on the 45 is off.
95. A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which the
following food selections indicates that client understands teaching?
A. A sandwich and milkshake
B. Rice with black beans
C. Cottage cheese and tuna lettuce
D. Three egg omelette with low-sodium ham
Answer: B. Rice with black beans
96. A nurse is planning care for client sealed radiation implant and is to remain in the hospital for
1 week. Which of the following should the nurse include in the plan of care?
A. Remove dirty linens from the room after double bagging.
B. Wear a dosimeter film badge while in the client’s room
C. Limit each of the clients is yours to one hour per day.
D. Ensure family members remain at least 3 feet from the client.
Answer: B. Wear a dosimeter film badge while in the client’s room
97. A nurses for Caring for four clients. Which of the following client should the nurse care for
first?
A. A client to receive a chemotherapy treatment or first national
B. A client who has an appendectomy to these don’t has diminished all sounds
C. A client is hypothyroidism and his stuporous
D. A client who is a burn requiring a sterile dressing change
Answer: C. A client is hypothyroidism and his stuporous
98. The nurses planning care for newly admitted adolescent who has bacterial meningitis. Which
the following instructions is appropriate for the nurse to include in the plan of care?
A. Initiate droplet precautions for the client
B. Assisted client to supine position
C. Performing Glasgow coma scale every 24 hrs

D. Recommend prophylactic acyclovir there for the clients family.
Answer: A. Initiate droplet precautions for the client
99. Nurse is giving discharge instructions to client has new ileostomy. The nurse should
recognize that the teaching has been effective when the client states.
A. I want sure that my medications are enteric coated
B. My stoma will drain liquid fluid continuously
C. I will change my pump system every two weeks
D. My stoma size will stay the same even after healed
Answer: B. My stoma will drain liquid fluid continuously
100. A nurse in a provider’s office is interviewing a client who is requesting an oral
contraceptive. Which of the following findings in the client’s history is a contraindication to use
in combination oral contraceptives?
A. thyroid disease
B. Allergy to penicillin
C. impaired liver function
D. abnormal blood glucose
Answer: C. impaired liver function
101. The nurses providing teaching to a client who has mild persistent asthma has been
prescribed montelukast. Which of the following statements to the nursing put in teaching?
A. This medication can be used to help you when have an acute asthma attack
B. This medication should be taken before exercise and physical activity
C. This medication can be taken for 10 days and then gradually discontinued
D. This medication helps decrease swelling and mucus production
Answer: D. This medication helps decrease swelling and mucus production
102. I nurse on the medical surgical unit is receiving reports on four clients. Which of the
following client should the nurse assess first?
A. A client who is receiving warfarin and has and INR of 3.3

B. A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL
C. A client who had a NG tube inserted 6 hr ago and has abdominal distention
D. A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the back
of the throat
Answer: B. A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52
mg/dL
103. A nurse is assessing a client who has pericarditis. Which of the following findings is priority
A. Paradoxical pulse pg. 389 under complications
B. dependent edema
C. Pericardial friction rub
D. Substernal chest pain
Answer: A. Paradoxical pulse pg. 389 under complications
104. A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces
contaminated with blood. Which of the following agents said the nurse include in the teaching?
A. Hydrogen peroxide
B. Chlorhexidine
C. Isopropyl alcohol
D. Chlorine bleach
Answer: D. Chlorine bleach
105. A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the
following actions in response take?
A. instruct the client to lift her chin when swallowing
B. discourage the client from coughing during feedings
C. Sit at or below the clients eye level during feedings.
D. Talk with the client during her feeding.
Answer: C. Sit at or below the clients eye level during feedings.

106. A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive
personnel telling the client. “If you don't eat, I’ll put restraints on your wrists and feed you.” The
nurse should intervene and explain to the AP that this statement constitutes which of the
following torts?
A. Assault
B. Battery
C. Malpractice
D. Negligence
Answer: A. Assault
107. A charge nurse is evaluating the time management skills for new licensed nurse. The charge
nurse should intervene when a newly licensed nurse does which of the following?
A. Re-Evaluate priorities halfway through the shift
B. Delegate changing sterile dressing for licensed practical nurse
C. Groups activities for the Same client
D. Works on several tasks simultaneously
Answer: D. Works on several tasks simultaneously
108. A nurse is monitoring the client during an IV urography procedure. Which of the following
client reports is the priority finding?
A. Feeling flushed and warm
B. Abdominal fullness
C. Swollen lips
D. Metallic taste in mouth
Answer: C. Swollen lips
109. A nurse is planning to delegate client assignments to the assistive personnel. which of the
following task is appropriate for the nurse to delegate?
A. Just the flow rate of the clients oxygen tank
B. Collecting urine sample
C. Measuring the clients pain level

D. Monitoring blood glucose levels
Answer: B. Collecting urine sample
110. A nurse is assessing a client wasn’t following vital signs: Oral temperature of 37.2°C (99 F).
Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood
pressure of 132/40 mm Hg. What is the clients pulse pressure?
Answer: Systolic pressure subtracted by diastolic pressure (132 - 40) = 92
111. A nurse if caring for a group of clients in a medical surgical unit. Which of the following
situations requires completion of an incident report?
A. A client who is absent gag reflex following a bronchoscopy
B. A client whose IV pump has malfunctioned
C. A client who requires insertion of NG tube due to a bowel obstruction
D. A client who is absent bell sounds following a gastrectomy
Answer: B. A client whose IV pump has malfunctioned
112. A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin.
Which of the following should nurse monitor?
A. Fasting blood glucose
B. Carbohydrate intake
C. Hematocrit
D. Weight
Answer: D. Weight
113. The nurses providing discharge instructions about engorgement for client has decided not to
breastfeed. Which of the following statements by the client indicates a need for further
instruction by the nurse?
A. I can wear support bra
B. I will play cold compression my breasts
C. I will manually express breastmilk
D. I can take a mild analgesic

Answer: C. I will manually express breastmilk
114. A nurses caring for client in preterm labor who is receiving magnesium sulphate by
continuous IV infusion. Which of the following client findings indicates medication toxicity?
A. Blood glucose of 150 mg/dL
B. Urine output of 20 mL per hour
C. Systolic blood pressure at 140 mm Hg
D. BUN 20 mg/dL
Answer: B. Urine output of 20 mL per hour
115. The nurse is completing an assessment for newborn who is 2 hrs old. Which of the
following findings are indicative of cold stress?
A. Respiratory rate of 60 per minute
B. Jitteriness of the hands
C. Diaphoretic
D. Bounding peripheral pulses in all extremities
Answer: B. Jitteriness of the hands
116. A nurse is planning care for four clients. Which of the following clients is the highest
priority?
A. A client who is dry, black eschar on the heel
B. A client who is wearing an arm cast and reports numb fingers
C. The client was reddened skin area with blanching around the coccyx
D. The client who has frequent incontinence
Answer: B. A client who is wearing an arm cast and reports numb fingers
117. A nurse is caring for a male adolescent client who has heart failure. Based on the client’s
chart finds. Which of the following actions should the nurse plan to take?
A. Withholds spironolactone
B. Administer ferrous sulphate
C. Administer furosemide

D. Withhold digoxin (0.8-2.0)
Answer: D. Withhold digoxin (0.8-2.0)
118. The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following
clinical manifestations are associated with this finding?
A. Confusion (hypoglycaemia)
B. Thirst
C. Diaphoresis (hypoglycaemia)
D. Shakiness (hypoglycaemia)
Answer: B. Thirst
119. A nurse is assessing for allergies before administering Propofol to a client placed on the
mechanical ventilator. Which of the following allergies is a contraindication to the medication?
A. Eggs
B. Milk
C. Shrimp
D. Peanuts
Answer: A. Eggs
120. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to
interpret the following statement, “When the cat’s away, the mice will play”. The client response
was, “The mice come out when the cat is not around”. The nurse should document this finding
which of the following in the client’s chart?
A. Echolalia
B. Associative looseness
C. Neologisms
D. Concrete thinking
Answer: D. Concrete thinking
121. A nurse caring for a client who is receiving total parental nutrition. Which of the following
assessment findings required immediate intervention by the nurse?

A. prealbumin level of 20 mg/dL
B. Weight increase of two kg/day
C. Temperature of 37.6°C
D. Blood glucose level of 120 mg/dL
Answer: B. Weight increase of two kg/day
122. A nurse in the telemetry unit is receiving the laboratory findings for adult male client who’s
been treated for myocardial function. The following is an expected finding for the client?
A. Troponin 1 (TNI) 8 ng/ml
B. Brain natriuretic peptide (BNP) 10 ng/L
C. Alanine aminotransferase (ALT 45 unit/L
D. High density lipoprotein (HDL) 75 mg/dl
Answer: A. Troponin 1 (TNI) 8 ng/ml
123. A nurse is reviewing the results of an ABG performed on a client with chronic emphysema.
Which of the following results suggests the need for further treatment?
A. paO2 level of 89 mm Hg
B. PaCO2 level of 55 mm Hg
C. HCO2 level of 25 mEq/L
D. pH level of 7.37
Answer: B. PaCO2 level of 55 mm Hg
124. A nurse is teaching a client about nutritional intake. The nurse should include which of the
following in the teaching?
A. "Carbohydrates should be at least 45% of your caloric intake."
B. "Protein should be at least 55% of your calorie intake."
C. "Carbohydrates should be at least 30% of your caloric intake."
D. "Protein should be at least 60% of your caloric intake."
Answer: A. "Carbohydrates should be at least 45% of your caloric intake."

125. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The
client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level
to be drawn at which of the following times?
A. 2100
B. 0900
C. 1300
D. 1800
Answer: D. 1800
126. A nurse is planning an education session for a client who has type 1 diabetes mellitus.
Which of the following should the nurse plan to include when teaching the client to monitor for
hypoglycaemia?
A. diaphoresis
B. polyuria
C. abdominal pain
D. thirst
Answer: A. diaphoresis
127. A nurse in an urgent-care clinic is collecting admission history from a client who is16 weeks
of gestation and has bacterial vaginosis. The nurse should recognize that which of the following
clinical findings are associated with this infection?
A. Frequency and dysuria
B. Profuse milky white discharge
C. Haematuria
D. Low grade fever
Answer: B. Profuse milky white discharge
128. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the
following foods should be included when initiating feeding?
A. beef broth
B. oatmeal

C. apple juice
D. toast
Answer: B. oatmeal
129. A nurse receives a change-of-shift report. Which of the following clients should the nurse
attend to first?
A. A client who reports tingling in the fingers following a thyroidectorny
B. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr 19 of
28
C. A client who is in a long leg cast and reports cool feet bilaterally
D. A client who has a productive cough and an oral temperature of 36° C (96.80 F)
Answer: A. A client who reports tingling in the fingers following a thyroidectorny
130. A nurse is caring for a client who has lactose intolerance and has eliminated dairy products
from his diet. The nurse should instruct the client to increase consumption of which of the
following foods?
A. spinach
B. peanut butter
C. ground beef
D. carrots
Answer: A. spinach
131. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune
globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood
type is B positive. Which of the following statements is appropriate?
A. You only need to receive Rh immune globulin if you have a positive blood type."
B. You should receive Rh immune globulin within 72 hours of delivery."
C. "Both you and your baby should receive Rh immune globulin at your -week appointment."
D. "immune globulin is not necessary since this is your second pregnancy."
Answer: B. You should receive Rh immune globulin within 72 hours of delivery."

132. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash
after a school event. The mother states, I never should have let him take the car. It’s all my fault!"
Which of the following responses by the nurse is appropriate?
A. You had no way of knowing this would happen."
B. Most parents blame themselves when losing a child."
C. Tell me why you feel this is your fault."
D. You appear to be feeling overwhelmed"
Answer: D. You appear to be feeling overwhelmed"
133. A nurse is educating a client about caloric intake and weight reduction. Which of the
following client statements indicates an understanding of the teaching?
A. “If I eat 500 fewer calories per day, I should lose 1 pound per week.”
B. “ If I eat 500 fewer calories per day, I should lose 1 pound per week."
C. "If I eat 450 fewer calories per day, I should lose 2 pounds per week."
D. "If I eat 250 fewer calories per day, I should lose 2 pounds per week."
E. "If I eat 300 fewer calories per day, I should lose 1 pound per week.”
Answer: A. “If I eat 500 fewer calories per day, I should lose 1 pound per week.”
134. A nurses is teaching post-operative care with the parents of a toddler following a cleft palate
repair. Which of the following should be included in the teaching?
A. Provide an orthodontic pacifier for comfort.
B. Offer fluids by using a straw.
C. Cleanse suture line with a cotton tip swab.
D. Remove elbow splints periodically to perform range of motion.
Answer: D. Remove elbow splints periodically to perform range of motion.
135. A nurse is caring for four clients. Which of the following tasks can the nurse delegate toan
assistive personnel?
A. Perform chest compressions during cardiac resuscitation.
B. Perform a dressing change for a new amputee.
C. Assess effectiveness of antiemetic medication.

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

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

Answer: D. Pulse 54/min
143. A nurse working in a mental health facility observes a client who has bipolar disorder walk
over to a table occupied by other clients and knock their game off the table.
Which of the following is an appropriate response by the nurse?
A. Apologize to the others for your behavior."
B. I am disappointed that you continue to act out when you are angry."
C. Come outside with me for a walk."
D. If you don’t calm down, you will have to go into seclusion."
Answer: C. Come outside with me for a walk."
144. A nurse is caring for a client who has human immunodeficiency virus (HIV) with
neutropenia. Which of the following precautions should the nurse take while caring for this client
A. Wear an N95 respirator while caring for the client.
B. Use a dedicated stethoscope for the client.
C. Insert an indwelling urinary catheter to monitor urinary output.
D. Monitor the client’s vital signs every 8 hr.
Answer: B. Use a dedicated stethoscope for the client.
145. A nurse is checking laboratory results for a client. Which of the following laboratory
findings indicates hypervolemia?
A. serum sodium 138 mEq/L
B. Urine specific gravity 1.001
C. serum calcium 10 mg/dL
D. Urine pH 6
Answer: B. Urine specific gravity 1.001
146. A nurse is caring for a group of clients in a long-term care facility. Which of the following
situations should the nurse recognize as a safety hazard?
A. A client’s wrist restraints tied to the bed rails
B. A clients bedside table placed across the foot of the bed

C. A meal tray left at the bedside from breakfast
D. A call light extension cord pinned to the bedspread
Answer: A. A client’s wrist restraints tied to the bed rails
147. A nurse is caring for a client in a mental health facility. The clients daughter is crying and
tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is
an appropriate response?
A. I’d like to know more about what’s bothering you."
B. "Why are you feeling this way"
C. "You did the right thing by bringing him here."
D. "I’m sure your father doesn’t blame you."
Answer: A. I’d like to know more about what’s bothering you."
148. A nurse is planning care for a client following gastric bypass surgery. The nurse should
include which of the following dietary instructions when preparing the client for discharge?
A. start each meal with a protein source.
B. Consume at least 25 g of fiber daily.
C. Check your blood glucose level before each meal.
D. Limit your meals to three times per day.
Answer: A. start each meal with a protein source.
149. 149 A nurse is assessing a client who has a chest tube following a thoracotomy.
Which of the following findings requires intervention by the nurse?
A. Tidaling with spontaneous respirations
B. Drainage collection chamber is 1/3 full
C. 1 cm of water present in the water seal chamber
D. Suction chamber pressure of -20 cm H20
Answer: C. 1 cm of water present in the water seal chamber

150. A provider has written a do not resuscitate order for a client who is comatose and does not
have advance directives. A member of the clients family says to the nurse, “I wonder when the
doctor will tell us what’s going on" Which of the following actions should the nurse take first
A. Request that the provider provide more information to the family.
B. Refer the family to a support group for grief counseling.
C. Offer to answer questions that family members have.
D. Ask the family what the provider has discussed with them.
Answer: D. Ask the family what the provider has discussed with them.
151. A nurse is performing a skin assessment on a client who has risk factors for development of
skin cancer. The nurse should understand that a suspicious lesion is
A. scaly and red
B. asymmetric, with variegated colouring
C. firm and rubbery
D. brown with a wart-like texture
Answer: B. asymmetric, with variegated colouring
152. A nurse is interviewing an older adult client about the physiological changes he has been
experiencing. Which of the following changes should the nurse recognize is normally associated
with the aging process?
A. Decreased sense of taste
B. Decreased blood pressure
C. Increased gastric secretions
D. Increased accommodation to near vision
Answer: A. Decreased sense of taste
153. A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal
syndrome. Which of the following should the nurse include in the plan of care?
A. Administer disulfiram.
B. Provide frequent orientation to time and place.
C. Engage the client in group therapy.

D. Perform gastric lavage.
Answer: B. Provide frequent orientation to time and place.
154. A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place
the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable
areas or Hot Spots" can be found by moving your cursor over the artwork until the cursor
changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your
answer.)

Answer: A. Top left site
155. A nurse manager is planning an audit to measure the quality of care on the unit. Which of
the following is the most appropriate source for the nurse to consult?
A. Nursing manager colleagues
B. Evidence-based practice data
C. Hospital administrators
D. Protocols in other hospitals
Answer: B. Evidence-based practice data
156. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of
early dumping syndrome. Which of the following findings should the nurse expect? (Select all
that apply)
A. Facial flushing
B. Syncope

C. Diaphoresis
D. Vertigo
E. Bradycardia
Answer: A. Facial flushing
B. Syncope
C. Diaphoresis
157. A nurse is caring for a client who is experiencing mild anxiety. Which of the following
findings should the nurse expect?
A. feelings of dread
B. rapid speech
C. purposeless activity
D. heightened perceptual field
Answer: D. heightened perceptual field
158. A nurse is delegating tasks to an assistive personnel. Which of the following instructions
demonstrates appropriate communication of the task?
A. "Take a blood glucose fingerstick on the client in room 102 before breakfast and then place
the glucometer into the docking station."
B. "Obtain a blood pressure reading from the client in room 116 after lunch and report a systolic
level less than 90."
C. "Assist the client in room 110 to ambulate once around the unit and stop if she gets short of
breath."
D. "Turn the client in room 126 to prevent pressure areas on his hip bones."
Answer: B. "Obtain a blood pressure reading from the client in room 116 after lunch and report
a systolic level less than 90."
159. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased
blood pressure. The nurse should recognize that these findings are potential manifestations of
which of the following?
A. Nicotine withdrawal

B. Heroin intoxication
C. Alcohol withdrawal
D. Amphetamine intoxication
Answer: B. Heroin intoxication
160. A nurse is assessing an older adult client who had a stroke. Which of the following findings
should the nurse recognize as an indication of dysphagia?
A. Abnormal movements of the mouth
B. Inability to stand without assistance
C. Paralysis of the right arm
D. Loss of appetite
Answer: A. Abnormal movements of the mouth
161. A nurse is providing preoperative teaching to a client who will use PCA morphine sulphate
following surgery. Which of the following information should the nurse include?
A. The client should notify the nurse when administering a dose of the medication.
B. The client can administer a dose of medication every 6 to 8 min.
C. The client should be cautious to avoid overmedication (OD).
D. Family members can administer a dose the client.
Answer: B. The client can administer a dose of medication every 6 to 8 min.
162. A nurse is assisting the provider with a paracentesis for a client who has ascites. Following
collection of the specimen, which of the following actions should the nurse take next
A. Document the procedure.
B. Measure the drainage.
C. Record the colour of the drainage.
D. Label the specimen.
Answer: D. Label the specimen.

163. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving
because the facility policy prohibits smoking inside. Which of the following actions should the
nurse take?
A. Notify security to monitor the facility exits.
B. Place the client in seclusion.
C. Inform the client of the risks involved if she leaves.
D. Call the provider for a discharge prescription.
Answer: C. Inform the client of the risks involved if she leaves.
164. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a
child. Which of the following is a contraindication for administration?
A. Recent blood transfusion
B. Allergy to penicillin
C. Minor acute illness
D. Low-grade fever
Answer: A. Recent blood transfusion
165. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client.
Which of the following is the safest site for the nurse to use?
A. Ventrogluteal
B. Dorsogluteal
C. Vastus lateralis
D. Rectus femoris
Answer: A. Ventrogluteal
166. A nurse is teaching a female client how to reduce the risk of urinary tract infections(UTIs).
Which of the following should the nurse include as a risk factor for developing a UTI?
A. Wearing underwear with a cotton crotch
B. Wiping from front to back
C. Using perfumed toilet paper
D. Urinating immediately after intercourse

Answer: C. Using perfumed toilet paper
167. A nurse is providing discharge instructions for a client who has a new prescription for
furosemide. Which of the following client statements indicates a need for further teaching?
A. "I will take my morning pills with food or milk."
B. "I will weigh myself every day."
C. "I will notify the nurse if I have muscle cramps."
D. "I will limit my intake of fish."
Answer: D. "I will limit my intake of fish."
168. A nurse is caring for a client who has a prescription for atorvastatin. Which of the following
client conditions is a contraindication to this medication?
A. hepatits C
B. peptic ulcer disease
C. bronchitis
D. chrohn’s disease
Answer: A. hepatits C
169. A nurse is planning care for an adolescent who has chronic renal failure. Which of the
following actions should the nurse include in the plan of care?
A. Encourage a diet high in calcium.
B. Provide a diet high in potassium.
C. Ensure increased fluid intake.
D. Restrict protein intake to the RDA.
Answer: D. Restrict protein intake to the RDA.
170. A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and
located 2 cm above the umbilicus. Which of the following actions should the nurse take first?
A. Take vital signs.
B. Assess lochia.
C. Massage the fundus.

D. Give oxytocin IV bolus.
Answer: C. Massage the fundus.
171. A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following interventions should the nurse perform
A. Give 100 mL of water with every feeding.
B. Obtain gastric residuals every 24 hr.
C. Position the head of bed at 30 degrees during feeding.
D. Mix the clients medications with the tube feedings.
Answer: C. Position the head of bed at 30 degrees during feeding.
172. A nurse is caring for a 7 month-old infant who is being treated for severe dehydration.
Which of the following assessment findings indicates treatment has been effective?
A. Skin turgor displays tenting
B. Flat anterior fontanel
C. Cool, mottled skin
D. hyperpnea
Answer: B. Flat anterior fontanel
173. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start
radiation therapy. Which of the following should the nurse include in the teaching?
A. Remove dye markings after each radiation treatment.
B. Apply a warm compress to the irradiated site.
C. Wear clothing over the area of radiation treatment.
D. Use a washcloth to bathe the treatment area.
Answer: C. Wear clothing over the area of radiation treatment.
174. A nurse in a provider's office is providing education to a client who is 16 weeks of gestation
and has a new prescription for ferrous sulphate. Which of the following instructions should the
nurse provide
A. Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is effective."

B. "Take your iron medication with fluids other than coffee or tea."
C. "It is important to take your iron medication on a full stomach."
D. "If you miss a dose one day, take two doses the next day."
Answer: B. "Take your iron medication with fluids other than coffee or tea."
175. A nurse receives a change-of-shift report on four clients. Based on the shift report
information, which of the following clients should the nurse plan to assess
A. A client who had a hip arthroplasty reports pain and erythema in his calf
B. A client who has anorexia and peripheral edema
C. A client who has Addison's disease with a blood glucose level of 75 mg/dL
D. A client who had a barium enema 2 days ago and reports constipation
Answer: A. A client who had a hip arthroplasty reports pain and erythema in his calf
176. A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment.
Which of the following medications should the nurse administer?
A. Albuterol sulphate
B. Hydromorphone
C. Diphenhydramine
D. Amitriptyline
Answer: C. Diphenhydramine
177. A client who does not speak English arrives at the emergency department accompanied by a
child. Which of the following actions should the nurse take?
A. Ask the assistive personnel to assist the client in signing consent for treatment
B. Ask the child to interpret for the client.
C. Ascertain what language the client speaks and get an interpreter.
D. Try to find an adult relative to help the client communicate.
Answer: C. Ascertain what language the client speaks and get an interpreter.

178. 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 displays
toxicity. Which of the following actions should the nurse take?
A. Position the client supine.
B. Prepare an IV bolus of dextrose 5% in water
C. Administer calcium gluconate IV.
D. Administer methylergonovine IM.
Answer: C. Administer calcium gluconate IV.
179. A nurse is using Naegeles rule to calculate the expected delivery date for a newly pregnant
primigravida. The first day of the clients last period was October. What is the expected delivery
date? (Provide the date using four numerals, the first two for the month and the second two for
the day. For example, January 2 0102)
A. 0711 (July 7, 2011)
Formula: +1 year, -3 months, +7 days
Answer: A. 0711 (July 7, 2011)
180. A nurse on a medical-surgical unit is receiving report on four clients. Which of the
following clients should the nurse assess first?
A. A client who is scheduled for chemotherapy and has a haemoglobin of 9
B. A client who is 24 hr postoperative following a transurethral resection of the prostate (TURP)
and has small blood clots in the urinary catheter
C. A client who is receiving a blood transfusion and reports low-back pain
D. A client who has a new colostomy with a reddish-pink stoma
Answer: C. A client who is receiving a blood transfusion and reports low-back pain