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Comp Predictor Online Practice 2019 B
1. A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following
actions is the nurse's priority?
Answer: Assist with deep breathing and coughing
Rationale:
Deep breathing and coughing help prevent atelectasis and pneumonia, which are common
complications after abdominal surgery. This intervention helps maintain lung expansion and
prevent respiratory complications.
2. A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize
which of the following statements by the client as a constructive use of a defense mechanism?
Answer: "I told my doctor that I would like to start a support group for other women who are
sick in my community"
Rationale:
This statement indicates that the client is using sublimation, which is a constructive defense
mechanism. Sublimation involves channeling potentially maladaptive feelings or impulses into
socially acceptable behavior.
3. A nurse is caring for a client who has immunosuppression and a continuous IV infusion.
Which of the following actions should the nurse take?
Answer: Monitor the client's mouth every 8 hr- at least every 8 hr for manifestations of an
infection, such as sores or lesions.
Rationale:
Clients with immunosuppression are at increased risk for infections. Monitoring the client's
mouth for signs of infection, such as sores or lesions, allows for early detection and
intervention.
4. A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the
following areas should the nurse assess for manifestations of HD?

Answer: The nurse should assess the infant's abdomen for distention and visible peristalsis,
which are manifestations of HD.
Rationale:
HD is a condition where there is a lack of nerve cells in the muscles of the colon, leading to
difficulty passing stool. Abdominal distention and visible peristalsis (wave-like movements of
the intestines) are common manifestations of this condition.
5. A nurse at a mental health clinic is caring for four clients. The nurse should recognize the
following clients are using dissociation as a defense mechanism?
Answer: A client who was abused as a child describes the abuse as if it happened to someone
else
Rationale:
Dissociation is a defense mechanism where the individual separates themselves from their
thoughts, feelings, or memories. In this case, the client is describing the abuse as if it happened
to someone else, which is indicative of dissociation.
6. A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus.
The nurse should instruct the client to monitor for which of the following findings as a
manifestation of hypoglycemia?
Answer: Irritability
Rationale:

Irritability is a common manifestation of hypoglycemia. Other symptoms include sweating,
trembling, weakness, hunger, and confusion.
7. A nurse in an outpatient mental health clinic is caring for four clients. The nurse should
recognize that which of the following clients is effectively using sublimation as a defense
mechanism?
Answer: A client who channels their energy into a new hobby following the loss of their job
Rationale:
Sublimation involves channeling potentially maladaptive feelings or impulses into socially
acceptable behavior. In this case, the client is channeling their energy into a new hobby, which
is a constructive use of the defense mechanism.
8. A hospice nurse is consulting with a client and her family about receiving home services.
Which of the following statements should the nurse identify as an indication that the family
understands home hospice care?
Answer: "We can expect the hospice nurse to provide support for us after our mother's death"
Rationale:
This statement indicates that the family understands that hospice care includes bereavement
support for the family after the patient's death. Hospice care focuses on providing comfort and
support to both the patient and their family.
9. A nurse is caring for a client who has active tuberculosis. Which of the following actions
should the nurse take?
Answer: Assign the client to a private room with negative air pressure
Rationale:
Clients with active tuberculosis should be placed in a private room with negative air pressure to
prevent the spread of the disease to others. This helps contain the infectious particles within the
room.
10. A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled
for a 3-hour oral glucose tolerance test. Which of the following instructions should the nurse
include in the teaching?
Answer: "You will need to fast the night before the test"
Rationale:

Fasting is required for an oral glucose tolerance test to obtain accurate results. The client should
not eat or drink anything (except water) for at least 8 hours before the test.
11. A nurse on a pediatric unit has received change of shift report for four children. Which of
the following children should the nurse assess first?
Answer: A 10-year-old child who is awaiting surgery for an appendectomy and experienced
sudden relief from pain
Rationale:
Sudden relief from pain in a child awaiting surgery for appendectomy could indicate a rupture
of the appendix, which is a surgical emergency requiring immediate assessment and
intervention to prevent further complications.
12. A nurse in a community center is providing an education session to a group of clients about
ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse
include in the teaching?
Answer: Abdominal bloating
Rationale:
Abdominal bloating is a common symptom of ovarian cancer. Other symptoms include pelvic
or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms such as
urgency or frequency.
13. A nurse is caring for a client who is postoperative after receiving moderate (conscious)
sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the
following actions should the nurse take?
Answer: Check the client's oxygen saturation level
Rationale:
Sudden restlessness and lightheadedness in a postoperative client can indicate hypoxia.
Checking the client's oxygen saturation level can help determine if there is adequate
oxygenation.
14. A nurse is working in an emergency department is triaging four clients. Which of the
following clients should the nurse recommend for treatment first?
Answer: A middle adult client who has unstable vital signs
Rationale:

A client with unstable vital signs requires immediate attention to stabilize their condition. This
client should be prioritized for treatment to prevent further deterioration.
15. A nurse is providing teaching for a client who has a fracture of the right fibula with a short
leg cast in place and a new prescription for crutches. The client is nonweight bearing for 6
weeks. Which of the following instructions should the nurse include in the teaching?
Answer: Use a three-point gait
Rationale:
A three-point gait is appropriate for a nonweight bearing client using crutches. This gait
involves bearing weight on both crutches and the unaffected leg while advancing the affected
leg.
16. A nurse is preparing to initiate IV access for an older adult client. Which of the following
sites should the nurse select when initiating the IV for this client?
Answer: Radial vein of the inner arm
Rationale:
The radial vein of the inner arm is a suitable site for IV access in older adult clients. This site is
easily accessible and less prone to complications such as infiltration or phlebitis.
17. A nurse is planning to delegate client care tasks to an AP. Which of the following tasks
should the nurse plan to delegate to the AP?
Answer: Perform gastrostomy feedings through a client's established gastrostomy tube
Rationale:
Gastrostomy feedings through an established tube can be safely delegated to an AP who has
been trained to perform this task. It is within the scope of practice for an AP and does not
require nursing judgment.
18. A nurse is caring for a newborn immediately after delivery. Which of the following
interventions should the nurse implement to prevent heat loss by conduction?
Answer: Use a protective cover on the scale when weighing the infant
Rationale:
Using a protective cover on the scale when weighing the infant helps prevent heat loss by
conduction, as the infant is in direct contact with a warm surface. Conduction is the transfer of
heat between objects that are in direct contact with each other.

19. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the
following laboratory tests should the nurse review prior to adjusting the client's heparin?
Answer: aPTT
Rationale:
The activated partial thromboplastin time (aPTT) is monitored for clients receiving heparin to
assess the effectiveness of the medication in preventing clot formation. The nurse should review
the aPTT prior to adjusting the heparin infusion to ensure the client is within the therapeutic
range.
20. A nurse administers an incorrect dose of medication to a client. The nurse recognized the
error immediately and completes an incident report. Which of the following facts related to the
incident should the nurse document in the client's medical record?
Time the medication was given
Answer: Time the medication was given
Rationale:
Documenting the time the medication was given is important for accurate record-keeping and
can provide context for the error. This information helps ensure that the correct follow-up
actions are taken and that the incident is properly documented.
21. A nurse is providing education to the parent of a school-age child who has asthma. Which of
the following statements by the parent indicates an understanding of the teaching?
Answer: "I will ensure my child uses their inhaler before participating in physical activities at
school."
Rationale:
This statement demonstrates understanding because it shows the parent recognizes the
importance of pre-medicating with the child's inhaler before engaging in physical activities,
which can help prevent asthma exacerbations triggered by exercise.
22. A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain
after falling off a step stool at home. Which of the following prescriptions should the nurse
clarify with the provider?
Answer: The prescription for insulin dosage.
Rationale:

Severe ankle pain can indicate a potential fracture or injury that may require adjustments in the
client's insulin regimen due to changes in activity levels or stress response. It's essential to
clarify the insulin dosage with the provider to ensure it aligns with the client's current health
status.
23. A nurse is assessing a client who has a major depressive disorder and is taking amitriptyline.
Which of the following findings should the nurse identify as an adverse effect of the
medication?
Answer: Urinary retention.
Rationale:
Amitriptyline, a tricyclic antidepressant, can have anticholinergic effects leading to urinary
retention, which is an adverse effect the nurse should monitor for in clients taking this
medication.
24. A nurse is caring for a client who has signed an informed consent form to receive
electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now.
I'm afraid it's too risky." Which of the following responses should the nurse make?
Answer: "It's okay to feel unsure and scared. Let's talk more about your concerns, and I can
provide you with more information about ECT to help you make an informed decision."
Rationale:
This response acknowledges the client's feelings while offering support and the opportunity for
further discussion to address their concerns and provide additional information about ECT.
25. A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a
client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse
should administer?
Answer: 18 grams.
Rationale:
To calculate the dose, first convert the client's weight from pounds to kilograms (198 lb ÷ 2.2 =
90 kg), then multiply by the dosage (0.2 g/kg × 90 kg = 18 grams).
26. A nurse is preparing to administer an IM injection to a client who is obese. Which of the
following actions should the nurse plan to take?
Answer: Choose an appropriate needle length and site for injection, ensuring the needle is long
enough to reach the muscle.

Rationale:
Obese clients may have increased subcutaneous tissue depth, requiring a longer needle to
ensure the medication reaches the muscle for proper absorption.
27. A nurse is providing discharge teaching to a client who is to receive home oxygen therapy.
Which of the following instructions should the nurse include in the teaching?
Answer: Emphasize the importance of keeping oxygen away from heat sources and open
flames.
Rationale:
Oxygen supports combustion, so it's crucial to instruct the client to keep oxygen equipment
away from heat sources and open flames to prevent fire hazards.
28. A nurse is providing teaching to the guardians of a newborn about measures to prevent
sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an
understanding of the teaching?
Answer: "We will ensure that the baby sleeps on their back on a firm mattress."
Rationale:
Placing the baby on their back to sleep on a firm mattress is a key recommendation to reduce
the risk of SIDS, so this statement indicates understanding of the teaching.
29. A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a
boggy fundus. Which of the following medications should the nurse expect to administer?
Answer: Oxytocin (Pitocin).
Rationale:
Heavy lochia and a boggy fundus indicate uterine atony, a common cause of postpartum
hemorrhage. Oxytocin is a uterotonic medication used to stimulate uterine contractions and
control bleeding in this situation.
30. A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal
cancer. The client tells the nurse that they would like to go home to be with family and loved
ones. Which of the following actions should the nurse take?
Answer: Collaborate with the interdisciplinary team to arrange for home hospice care.
Rationale:

The nurse should honor the client's wishes to spend their remaining time at home by
coordinating with the interdisciplinary team to arrange for home hospice care, which provides
comfort and support for both the client and their family.
31. A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube.
Which of the following actions should the nurse take first?
Answer: Attempt to unclog the tube using warm water or gentle aspiration.
Rationale:
The nurse should first attempt to unclog the tube using non-aggressive methods such as warm
water or gentle aspiration before considering more invasive measures or contacting the
healthcare provider.
32. A nurse is creating a plan of care for a client who has left-sided weakness following a
stroke. Which of the following interventions should the nurse include in the plan?
Answer: Encourage the use of assistive devices such as a cane or walker on the unaffected side.
Rationale:
Encouraging the use of assistive devices on the unaffected side helps promote mobility and
independence while providing support and stability to prevent falls.
33. A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse
should plan to perform which of the following actions?
Answer: Position the client sitting upright and leaning over a bedside table.
Rationale:
Positioning the client sitting upright and leaning forward helps expand the intercostal spaces
and facilitates access to the pleural cavity for the thoracentesis procedure.
34. A charge nurse is providing an educational session about infection control for a group of
staff nurses. Which of the following statements by one of the staff nurses indicated an
understanding of isolation precautions?
Answer: "I will wash my hands before and after caring for each patient."
Rationale:
Hand hygiene is a fundamental component of infection control and is crucial in preventing the
spread of pathogens between patients and healthcare workers. This statement demonstrates an
understanding of the importance of hand hygiene in isolation precautions.

35. A nurse is providing dietary teaching to a client who has a new prescription for phenelzine.
Which of the following food recommendations should the nurse make?
• Broccoli
• Yogurt
• Cream cheese
Answer: Yogurt
Rationale:
Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with certain foods
containing high levels of tyramine, potentially leading to a hypertensive crisis. Yogurt is a lowtyramine food and is safe to consume while taking phenelzine.
NOTE: Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine.
Broccoli, yogurt, and cream cheese do not contain tyramine.
36. A nurse is assessing an older adult client who has pneumonia. Which of the following
findings should the nurse expect?
Answer: Confusion and altered mental status.
Rationale:
Older adults with pneumonia often present with atypical symptoms such as confusion and
altered mental status rather than typical respiratory symptoms. This is known as "geriatric
pneumonia" and is important for nurses to recognize in this population.
37. A nurse is providing teaching about home care to the parents of a child who has autism
spectrum disorder. Which of the following instructions should the nurse include?
Answer: Use a reward system to modify the child's behavior.
Rationale:
Using a reward system, such as positive reinforcement, can be an effective strategy for
modifying behavior in children with autism spectrum disorder. This approach focuses on
encouraging desired behaviors through rewards or praise.
38. A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The
drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion
to deliver how many gtt/min?
Answer: 50 gtt/min.
Rationale:

To calculate the infusion rate in gtt/min, divide the total volume to be infused (in mL) by the
time of infusion (in minutes) and multiply by the drop factor. In this case: (50 mL/hr × 15
gtt/mL) ÷ 60 min/hr = 50 gtt/min.
39. A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor
the client for which of the following complications related to vacuum-assisted birth?
Answer: Scalp lacerations.
Rationale:
Vacuum-assisted births carry a risk of scalp lacerations due to the application of suction to the
fetal scalp during the delivery process. The nurse should monitor the client for any signs of
scalp trauma or lacerations.
40. A nurse is assessing a client who has COPD. Which of the following findings should the
nurse expect?
Answer: Barrel chest.
Rationale:
Barrel chest, characterized by an increased anterior-posterior diameter of the chest, is a
common physical finding in clients with COPD due to chronic air trapping and hyperinflation
of the lungs.
41. A nurse is providing discharge teaching for the parents of a preschool age child who has a
new prescription for amoxicillin/clavulanate suspension. Which of the following instructions
should the nurse include in the teaching? SATA
Answer: • "Shake the medication bottle well before each dose is given
• "Store the medication in the refrigerator"
• "Report diarrhea to the provider immediately"
Rationale:
• "Shake the medication bottle well before each dose is given": This instruction is important
because it ensures that the medication is well-mixed, as some medications can settle at the
bottom of the bottle. Proper mixing helps to ensure that the child receives the correct dose of
medication.
• "Store the medication in the refrigerator": Amoxicillin/clavulanate suspension is typically
stored in the refrigerator to maintain its effectiveness. Storing it at room temperature may
reduce its potency or cause it to spoil.

• "Report diarrhea to the provider immediately": Diarrhea can be a side effect of
amoxicillin/clavulanate and may indicate a more serious infection or an adverse reaction to the
medication. It is important to report diarrhea promptly to the healthcare provider to determine
the appropriate course of action.
42. A nurse is preparing a client for a paracentesis. Which of the following actions should the
nurse take?
Answer: Position the client in a semi-Fowler's position.
Rationale:
Positioning the client in a semi-Fowler's position helps facilitate access to the abdomen and
allows for proper drainage of ascitic fluid during the paracentesis procedure.
43. A nurse is caring for a client who has active tuberculosis (TB). Which of the following
actions should the nurse plan to take to prevent the transmission of the disease?
Answer: Place the client in a negative pressure room.
Rationale:
Placing the client in a negative pressure room helps prevent the spread of airborne pathogens by
containing respiratory droplets within the room and preventing their dispersion to other areas.
44. A nurse is caring for a client who has a deep-vein thrombosis. Which of the following
actions should the nurse take?
Answer: Apply sequential compression devices.
Rationale:
Applying sequential compression devices helps prevent venous stasis and reduces the risk of
further clot formation in clients with deep-vein thrombosis by promoting venous return and
enhancing circulation.
45. A nurse is assessing a client who has a chest tube. Which of the following findings should
the nurse expect?
Answer: Continuous bubbling in the water seal chamber during expiration.
Rationale:
Continuous bubbling in the water seal chamber during expiration indicates an air leak in the
system, which should be promptly addressed to prevent pneumothorax and ensure proper lung
re-expansion.

46. A nurse on an inpatient mental health unit is monitoring a visit between a client who has a
history of aggressive behavior and the client's partner. Which of the following observations
should the nurse identify as an indication for potential violence?
Answer: Clenching fists and jaw, with a flushed face.
Rationale:
Clenching fists and jaw, along with a flushed face, are physical signs of increasing agitation and
arousal, which may precede aggressive behavior. The nurse should intervene promptly to
prevent escalation.
47. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to
an AP?
Answer: Assisting a client with toileting.
Rationale:
Assisting a client with toileting is a basic care task that can be safely delegated to an unlicensed
assistive personnel (AP) under the supervision of a nurse, as long as the client's condition is
stable and the task falls within the AP's scope of practice.
48. A nurse is caring for a client who has a prescription for chlorpromazine. Which of the
following findings should the nurse identify as an indication that the medication is effective?
Answer: Decreased hallucinations and delusions.
Rationale:
Chlorpromazine is an antipsychotic medication commonly used to treat hallucinations and
delusions in clients with psychotic disorders. A decrease in these symptoms indicates that the
medication is effectively managing the client's psychosis.
49. A nurse is performing an abdominal assessment on a client. Identify the sequence of actions
the nurse should take.
Answer: • Inspection
• Auscultation
• Percussion
• Palpation.
Rationale:
This sequence follows the standard order of abdominal assessment: Inspection allows the nurse
to observe abdominal contour and skin integrity, auscultation assesses bowel sounds, percussion

identifies areas of tenderness or organ enlargement, and palpation evaluates for masses or
abnormalities.
50. A nurse is updating the plan of care for a client who is 48 hours postoperative following a
laryngectomy and is unable to speak. Which of the following actions should the nurse plan to
take first?
Answer: Implement alternative communication methods.
Rationale:
Implementing alternative communication methods is the priority intervention to address the
client's inability to speak following laryngectomy, ensuring effective communication and
meeting the client's immediate needs.
51. A nurse is planning care for a client who has rheumatoid arthritis. Which of the following
interventions should the nurse include in the plan?
Answer: Increase the client's dietary iron intake
Rationale:
Clients who have rheumatoid arthritis require food high in protein, vitamins, and iron to
promote tissue repair.
52. A nurse is caring for a client who has acute blood loss following a trauma. The client
refuses a blood transfusion that might potentially save their life. Which of the following actions
should the nurse take first?
Answer: Explore the client's reasons for refusing the treatment
Rationale:
It is crucial to understand the client's reasons for refusing treatment to address any
misconceptions or fears they may have.
53. A nurse is caring for a group of clients. Which of the following clients should the nurse
attend to first?
Answer: An older adult client who is anxious and attempting to pull out an IV line
Rationale:
The client's behavior indicates distress and a potential risk of harm, so addressing this situation
takes priority.

54. A nurse is preparing to teach about dietary management to a client who has Crohn's disease
and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client
to decrease in their diet?
Answer: Fiber
Rationale:
Reducing fiber intake can help decrease the frequency of bowel movements and reduce the risk
of blockages or irritation in the intestines.
55. A nurse manager is preparing an educational session for nursing staff about how to provide
cost-effective care. Which of the following methods should the nurse include in the teaching?
Answer: Delegate non-nursing tasks to ancillary staff
Rationale:
Delegating non-nursing tasks allows nurses to focus on their core responsibilities, optimizing
their time and increasing efficiency in care delivery.
56. A nurse is assessing a newborn following a vaginal delivery. Which of the following
findings should the nurse report to the provider?
Answer: Nasal flaring
Rationale:
Nasal flaring in a newborn can indicate respiratory distress and may require further evaluation
and intervention.
57. A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse
should identify that which of the following physiological changes is the cause for the client's
visual loss?
Answer: Increased opacity of the lens
Rationale:
Cataracts cause a clouding of the lens, which obstructs the passage of light and leads to
decreased visual acuity.
58. A nurse must recommend clients for discharge in order to make room for several critically
injured clients from a local disaster. Which of the following clients should the nurse
recommend for discharge?
Answer: A client who has cellulitis and is receiving oral antibiotics every 8 hr
Rationale:

Cellulitis is a condition that can often be managed with oral antibiotics, and the client's stable
condition makes them a suitable candidate for discharge to create space for more critically
injured clients.
59. A nurse in an emergency department is caring for a client who is unconscious and requires
emergency medical procedures. The nurse is unable to locate members of the client's family to
obtain consent. Which of the following actions should the nurse take?
Answer: Proceed with provision of medical care
Rationale:
In emergency situations where consent cannot be obtained, providing necessary medical care to
stabilize the client's condition takes precedence over obtaining consent.
60. A nurse is creating a plan of care for a newly admitted child. Which of the following actions
should the nurse include in the plan?
Answer: Administer high-dose antibiotic therapy
Rationale:
If the child has a condition that requires high-dose antibiotic therapy, it is important to include
this in the plan of care to effectively treat the infection and promote recovery.
History and Physical
8-year-old male admitted with cystic fibrosis Reports shortness of breath Wheezing throughout
lung fields
Productive cough with thick sputum
Graphic Record
Heart rate 108/min Respiratory rate 26/min Temperature 37.2°C (98.9°F)
Blood pressure 100/62 mm Hg Oxygen saturation 92%
Diagnostic Results
Sputum culture: Burkholderia cepacian
61. A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of
the following statements should the nurse include in the teaching?
Answer: "Notify your provider if you experience increased thirst."
Rationale:
This statement is important because lithium can cause dehydration, which may lead to
increased thirst. Increased thirst can be an early sign of lithium toxicity, so it is crucial for the

client to report this symptom to their healthcare provider promptly. Monitoring and managing
side effects of lithium are essential for maintaining therapeutic levels and preventing
complications.
62. A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60,
and HCO3 of 25. The nurse should identify that the client has which of the following acid-base
imbalances?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
Answer: a. Respiratory acidosis
Rationale:
In respiratory acidosis, the pH is below 7.35, the PaCO2 is elevated (above 45 mmHg), and the
HCO3 may be normal or slightly elevated as a compensatory mechanism (in this case, HCO3 is
within normal range). The elevated PaCO2 indicates that the client is retaining carbon dioxide,
leading to an increase in carbonic acid and a decrease in pH, causing acidosis.
63. A nurse is providing teaching about advance directives to a middle adult client. Which of
the following client responses indicates an understanding of the teaching?
Answer: "I can designate my partner as my health care surrogate."
Rationale:
This response indicates an understanding of advance directives because designating a health
care surrogate allows the individual to appoint someone to make medical decisions on their
behalf if they become unable to do so. This shows that the client understands the purpose and
process of advance directives.
64. A charge nurse notices that one of the nurses on the shift frequently violates unit policies by
taking an extended amount of time for break. Which of the following statements should the
charge nurse make to address this conflict?
Answer: "I would like to talk to you about the unit policies regarding break time."
Rationale:
This statement is appropriate because it addresses the specific behavior (taking extended
breaks) and focuses on discussing the unit policies. It opens the door for a constructive

conversation about the issue and allows the nurse to understand the importance of adhering to
policies.
65. A nurse manager is preparing to teach a group of newly licensed nurses about effective time
management. Which of the following steps of the time management process should the nurse
manager include as the priority?
Answer: Making a list of activities to complete.
Rationale:
Making a list of activities is the first step in effective time management because it helps
prioritize tasks and organize workflow. Without a clear list, it can be challenging to know what
needs to be done first or how to allocate time efficiently. Therefore, this step is essential for
effective time management.
66. A nurse is teaching about adverse effects with a client who is starting to take captopril.
Which of the following findings should the nurse identify as an adverse effect of the medication
to report to the provider?
Answer: Cough
Rationale:
Cough is a common adverse effect of captopril, an ACE inhibitor. It occurs due to the
accumulation of bradykinin and other substances in the lungs, leading to irritation of the cough
receptors. While a cough can be a minor side effect, it can also indicate a more serious
condition called angioedema, which requires immediate medical attention. Therefore, any new
or persistent cough should be reported to the provider for further evaluation.
67. A home health nurse is caring for a group of older adult clients. The nurse should indicate a
referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following
clients?
Answer: A client whose caregiver requests adult day care services
Rationale:
PACE is a program designed to provide comprehensive, integrated care for older adults who
meet the criteria for nursing home level of care but wish to remain in the community. It offers a
range of services, including adult day care, medical care, and social services. A client whose
caregiver requests adult day care services may benefit from the comprehensive support and

services offered by PACE to help them remain in the community while receiving the care they
need.
68. A nurse is assessing a client for compartment syndrome. Which of the following findings
should the nurse expect? Edema- Compartment syndrome causes increased pain, pallor, and
paresthesias from increased edema in the compartment involved
Answer: Edema
Rationale:
Compartment syndrome is a serious condition that occurs when increased pressure within a
muscle compartment compromises circulation and function of the tissues within that space. The
nurse should expect to find edema, along with other classic signs and symptoms such as severe
pain that is out of proportion to the injury, pallor, and paresthesias. Edema occurs due to the
impaired circulation and increased capillary permeability in the affected compartment.
69. A nurse in an emergency department is caring for a child who has a fever and fluid-filled
vesicles on the trunk and extremities. Which of the following interventions should the nurse
identify as the priority?
Answer: Initiate transmission-based precautions
Rationale:
The child's presentation with fever and fluid-filled vesicles is suggestive of varicella
(chickenpox) infection, which is highly contagious. Therefore, the priority intervention is to
initiate transmission-based precautions to prevent the spread of the virus to others.
Transmission-based precautions for varicella include placing the child in a private room,
wearing gloves and a gown when providing care, and ensuring that anyone entering the room
wears a mask.
70. A nurse in an outpatient mental health facility is assessing a child who has autism spectrum
disorder. Which of the following manifestations should the nurse expect?
Answer: Strict adherence to routines
Rationale:
Children with autism spectrum disorder (ASD) often display strict adherence to routines and
rituals. They may become upset or anxious if their routines are disrupted or changed. This
characteristic is a common feature of ASD and is related to the need for predictability and

sameness in their environment. Understanding and accommodating these routines and
preferences can help support children with ASD in their daily lives.
71. A nurse is caring for a client who recently signed an informed consent form to donate a
kidney to her sibling who has end-stage kidney disease. The donator states to the nurse, "I don't
want my brother to die, but what if I need this kidney one day?" Which of the following
responses should the nurse make?
Answer: "You're afraid that your other kidney will fail at some point after the organ donation"
Rationale:
This response acknowledges the donor's fear and addresses the concern about the future need
for the donated kidney. It opens up a conversation about the donor's feelings and allows the
nurse to provide information and reassurance about the organ donation process.
72. A nurse is preparing to administer a blood transfusion to a client. Which of the following
procedures should the nurse follow to ensure proper client identification?
Answer: Verify the client and blood product information with another licensed nurse
Rationale:
Verifying the client and blood product information with another licensed nurse is an important
safety measure to ensure that the correct blood product is administered to the correct client.
This double-checking process helps prevent errors and ensures patient safety.
73. A nurse is preparing to transfer a client from the ICU to the medical floor. The client was
recently weaned from mechanical ventilation following a pneumonectomy. Which of the
following information should the nurse include in the change of shift report?
Answer: The time of the client's last dose of pain medication
Rationale:
The time of the client's last dose of pain medication is important information to include in the
change of shift report to ensure continuity of care. Pain management is crucial for this client,
especially following a pneumonectomy, and knowing the timing of the last dose helps the
receiving nurse plan for the next dose and assess the client's pain level.
74. A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and
received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse
report to the provider?
Answer: Sodium 148 mEq/L

Rationale:
A sodium level of 148 mEq/L is elevated and could indicate hypernatremia, which can be a
complication of hemodialysis. Hypernatremia can lead to neurological symptoms and requires
monitoring and possible treatment. Therefore, the nurse should report this elevated sodium
level to the provider for further evaluation and management.
75. A nurse is caring for a client who has fluid volume overload. Which of the following tasks
should the nurse delegate to an AP?
Answer: Measure the client's daily weight
Rationale:
Measuring the client's daily weight is a task that can be delegated to an assistive personnel (AP)
under the supervision of the nurse. Daily weight monitoring is important for clients with fluid
volume overload to assess for changes in fluid status. The nurse should provide clear
instructions to the AP on how to perform the measurement and communicate any significant
changes in the client's weight to the nurse for further evaluation.
76. A nurse is caring for an older adult client who is experiencing chronic anorexia and is
receiving enteral tube feedings. Which of the following laboratory values indicates that the
client needs additional nutrients added to the feeding?
Answer: Albumin 2.8 g/dL
Rationale:
The nurse should recognize that an albumin level of less than 3.5 indicates malnutrition and a
need for additional nutritional supplementation. The expected reference range for albumin is
3.5-5.0 g/dL. Monitoring albumin levels is important in clients receiving enteral tube feedings
to ensure adequate nutrition and prevent complications of malnutrition.
77. A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse
should initiate a request for a high-frequency chest compression vest in response to which of
the following parent statements?
Answer: "My child has only a small amount of mucus after percussion therapy"
Rationale:
Cystic fibrosis is a genetic disorder that causes thick, sticky mucus to build up in the lungs and
other organs. High-frequency chest compression vests are used to help loosen and clear this
mucus from the airways. A small amount of mucus after percussion therapy indicates that

additional interventions, such as the use of a high-frequency chest compression vest, may be
necessary to effectively clear the mucus and improve respiratory function in the child with
cystic fibrosis.
78. A nurse is assessing for the correct placement of a client's NG feeding tube prior to
administering a bolus feeding. Which of the following actions should the nurse take?
Answer: Aspirate the contents from the tube and verify the pH level
Rationale:
Aspirating the contents from the NG tube and verifying the pH level is a standard procedure to
ensure the correct placement of the tube in the stomach before administering a feeding. Gastric
aspirate should have a pH of less than 5, indicating that the tube is in the stomach. If the pH is
higher, it may indicate that the tube is in the respiratory tract or another location where the pH
is higher, and feeding should not be administered until proper placement is confirmed.
79. A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the
following aPTT values should the nurse expect?
Answer: 45 seconds
Rationale:
Hemophilia A is a genetic disorder that affects the blood's ability to clot properly. The activated
partial thromboplastin time (aPTT) is a laboratory test used to assess the blood's ability to clot.
In hemophilia A, the aPTT is prolonged due to a deficiency in clotting factor VIII. The expected
reference range for aPTT is typically 30 to 40 seconds, so a value of 45 seconds is elevated and
indicates a risk for spontaneous bleeding, which is a manifestation of hemophilia A.
80. A nurse is assessing a client whose partner recently died. The client states, "I don't know
what to do without my partner. Life is just not worth living." Which of the following responses
should the nurse make?
Answer: "You seem to be having a difficult time right now"
Rationale:
This response acknowledges the client's feelings of grief and loss without judgment. It opens up
a conversation and allows the nurse to explore the client's feelings further. It also provides an
opportunity for the nurse to assess the client's risk for self-harm or suicide and intervene
appropriately if necessary.

81. An RN is observing an LPN and an AP move a client up in bed. For which of the following
situations should the nurse intervene?
Answer: The LPN and the AP grasp the client under his arms to lift him up in bed
Rationale:
Grasping a client under the arms to lift them up in bed can cause injury to the client's shoulders
and arms. It can also be uncomfortable and may not provide adequate support. The nurse should
intervene and teach the correct method for moving the client, which typically involves using a
draw sheet or other assistive devices to avoid injury.
82. A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the
following findings should the nurse expect?
Answer: Hyponatremia
Rationale:
During the resuscitation phase of burn injury, there is a massive shift of fluids from the
intravascular space to the interstitial space due to increased capillary permeability. This shift
leads to edema formation and a dilutional effect on electrolytes, including sodium.
Hyponatremia is common in the resuscitation phase of burn injury due to sodium being drawn
to the edematous burn area and lost through plasma leakage.
83. A nurse on a mental health unit is conducting a mental status examination (MSE) on a
newly admitted client. Which of the following components of the MSE is the priority for the
nurse to assess?
Answer: Ideas of self-harm
Rationale:
Assessing ideas of self-harm is a priority in a mental status examination (MSE), especially in a
mental health setting where clients may be at risk for suicide. It is important to assess the
client's current suicidal ideation, intent, and plans to ensure their safety and to initiate
appropriate interventions if necessary.
84. A nurse manager is planning to use a democratic leadership style with the nurses on the unit.
Which of the following actions by the nurse manager demonstrates a democratic leadership
style?
Answer: Seeks input from the other nurses
Rationale:

A democratic leadership style involves seeking input from team members and involving them in
decision-making processes. By seeking input from the other nurses, the nurse manager
demonstrates a democratic leadership style that values collaboration and participation in
decision-making.
85. A home health nurse is developing a teaching plan for a client who has a new ileostomy.
Which of the following instructions should the nurse include?
Answer: Empty the appliance when it is one-third to one-half full
Rationale:
It is important to empty the ostomy appliance when it is one-third to one-half full to prevent
leakage and skin irritation. Emptying it before it becomes too full helps maintain the integrity
of the seal and prevents the appliance from becoming too heavy and pulling away from the
skin. Regular emptying also allows for better monitoring of output and helps prevent odor.
86. A nurse manager is preparing an educational session about advocacy to a group of nurses.
The nurse manager should include which of the following information in the teaching?
Answer: Advocacy is a leadership role that helps others to self-actualize
Rationale:
Advocacy in nursing is the act of supporting and promoting the well-being of clients. It
involves standing up for clients' rights, ensuring they have access to necessary healthcare
services, and helping them make informed decisions about their care. Advocacy is not just
about speaking up for clients but also empowering them to be active participants in their own
care and achieve their highest level of well-being, which aligns with the concept of selfactualization in leadership roles.
87. A nurse is caring for a client who has hyperthyroidism. Which of the following findings
should the nurse expect?
Answer: Tremors
Rationale:
Tremors are a common manifestation of hyperthyroidism, which is characterized by an
overactive thyroid gland that produces an excess of thyroid hormones. Other expected findings
in hyperthyroidism include tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia
(bulging eyes). Tremors result from the increased metabolic rate and sympathetic nervous
system stimulation caused by the excess thyroid hormones.

88. A nurse is assessing a client after administering epinephrine for an anaphylactic reaction.
Which of the following findings should the nurse identify as an adverse effect of this
medication?
Answer: Report of chest pain
Rationale:
Chest pain can be an adverse effect of epinephrine, especially at higher doses. Epinephrine can
cause vasoconstriction, which may increase cardiac workload and oxygen demand, leading to
chest pain. It is important for the nurse to assess the client for chest pain and other signs of
cardiovascular complications after administering epinephrine and to report any concerning
findings to the healthcare provider.
89. A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager
should tell the nurses that informed consent promotes which of the following ethical principles?
Answer: Autonomy
Rationale:
Informed consent is based on the ethical principle of autonomy, which recognizes the right of
individuals to make their own decisions about their healthcare. Informed consent ensures that
clients have the information they need to make decisions about their care and treatment,
including the risks, benefits, and alternatives. Respecting clients' autonomy is essential in
healthcare and is supported by obtaining informed consent.
90. A nurse manager is assessing a client who has bipolar disorder. Which of the following
alterations in speech is the client using?
Answer: Flight of ideas
Rationale:
Flight of ideas is a common alteration in speech seen in clients with bipolar disorder during the
manic phase. It is characterized by rapid, continuous speech with frequent topic changes that
are loosely connected or unrelated. Flight of ideas is a manifestation of the increased energy,
racing thoughts, and impulsivity that are typical of the manic phase of bipolar disorder.
91. A nurse is assessing a school-age child who has bacterial meningitis. Which of the
following findings should the nurse expect?
Answer: Nuchal rigidity
Rationale:

Nuchal rigidity, or stiffness in the neck, is a classic sign of meningitis, an inflammation of the
meninges (the membranes covering the brain and spinal cord). In bacterial meningitis, the
meninges become inflamed in response to a bacterial infection. Nuchal rigidity occurs due to
irritation of the meninges, making it difficult for the child to flex the neck forward. Other
common signs of bacterial meningitis include fever, headache, photophobia (sensitivity to
light), and altered mental status.
92. A nurse in a mental health clinic is assessing a client who has a history of seeking
counseling for relationship problems. The client shows the nurse multiple superficial selfinflicted lacerations on their forearms. The nurse should identify these behaviors as
characteristics of which of the following personality disorders?
Answer: Borderline
Rationale:
The client's behavior of seeking counseling for relationship problems and engaging in selfinflicted lacerations on the forearms is characteristic of borderline personality disorder (BPD).
Individuals with BPD often have unstable relationships, a distorted self-image, impulsivity, and
engage in self-harming behaviors such as cutting. These behaviors are often a way for
individuals with BPD to cope with intense emotional pain or to express their distress.
93. A nurse is caring for a client who has a fecal impaction. Which of the following actions
should the nurse take when digitally evacuating the stool?
Answer: Insert a lubricated gloved finger and advance along the rectal wall
Rationale:
Digital evacuation of a fecal impaction involves inserting a lubricated gloved finger into the
rectum and gently breaking up the stool mass. The nurse should advance the finger along the
rectal wall to help loosen and remove the stool. This procedure should be done carefully and
gently to avoid causing injury to the rectal mucosa. After the stool is evacuated, the nurse
should assess for any signs of rectal bleeding or injury.
94. A nurse is caring for a client who has cancer and is deciding between two treatment plans.
The client asks the nurse for assistance in making the decision. Which of the following
responses should the nurse make?
Answer: "Tell me more about your understanding of the options"
Rationale:

This response encourages the client to express their thoughts and feelings about the treatment
options, which can help the nurse understand the client's perspective and decision-making
process. It also allows the nurse to assess the client's level of understanding and provide
information or clarification as needed. This approach promotes shared decision-making and
helps the client feel empowered and involved in the decision-making process.
95. A nurse is assigning task roles for a group of clients in a community mental health clinic.
Which of the following tasks should the nurse assign to the member of the group functioning as
the orienteer?
Answer: Noting the progress of the group toward assigned goals
Rationale:
In group therapy, the orienteer is responsible for keeping the group focused on its goals and
noting the progress made toward those goals. The orienteer helps ensure that the group stays on
track and makes effective use of the therapy sessions. This role is important for maintaining the
group's cohesion and effectiveness.
96. A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin
via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning
laboratory values for the client are aPTT 98 seconds and INR 1.8. Which of the following
actions should the nurse take?
Answer: Withhold the heparin infusion
Rationale:
The client's aPTT of 98 seconds is above the therapeutic range (usually 60-80 seconds) for
heparin therapy, indicating a risk for bleeding. The nurse should withhold the heparin infusion
and notify the healthcare provider for further instructions. Monitoring the aPTT is essential to
ensure that the client is receiving an appropriate dose of heparin without an increased risk of
bleeding.
97. A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started
taking risperidone. Which of the following actions should the nurse take?
Answer: Implement fall precautions for the client
Rationale:
Risperidone can cause orthostatic hypotension and dizziness, which can increase the risk of
falls, especially in older adults. Implementing fall precautions, such as assisting the client with

ambulation and using a call light, can help prevent falls and ensure the client's safety while
taking risperidone.
98. A nurse is admitting a client to the psychiatric unit after attempting suicide. The client
states, "My family does not care whether I live or die." Which of the following responses
should the nurse make?
Answer: "How does this make you feel?"
Rationale:
This response is empathetic and encourages the client to express their feelings, which can help
the nurse understand the client's emotional state and provide appropriate support. It also opens
up a dialogue that allows the nurse to assess the client's risk for self-harm and develop a care
plan to address their emotional needs.
99. A nurse in an emergency department is assessing a school-age child who was brought in by
their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse.
Which of the following actions should the nurse take?
Answer: Contact Child Protective Services
Rationale:
Suspected cases of child abuse must be reported to the appropriate authorities, such as Child
Protective Services, to ensure the safety and well-being of the child. The nurse should follow
institutional policies and procedures for reporting suspected abuse and document findings
accurately.
100. A nurse is caring for a client who has a new prescription for clonidine. The nurse should
inform the client that which of the following findings is an adverse effect of this medication?
Answer: Dry mouth
Rationale:
Clonidine is an indirect-acting antiadrenergic agent used for hypertension, severe pain, and
attention deficit disorder. Dry mouth, or xerostomia, is a common adverse effect of clonidine.
The nurse should inform the client about this potential side effect and advise them to maintain
good oral hygiene and stay hydrated.
101. A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the
following interventions should the nurse plan to take?
Answer: Initiate continuous cardiac monitoring

Rationale:
Magnesium plays a crucial role in cardiac function, and abnormal levels can lead to serious
cardiac dysrhythmias. A magnesium level of 2.7 mEq/L is above the normal range (1.5-2.5
mEq/L), indicating hypermagnesemia, which can cause bradycardia, hypotension, and
potentially lethal cardiac arrest. Therefore, initiating continuous cardiac monitoring is essential
to promptly detect and manage any cardiac rhythm disturbances.
102. A rural community health nurse is developing a plan to improve health care delivery for
migrant farm workers. To identify health services data for this minority group, the nurse should
gather information from which of the following sources?
Answer: Agency for Healthcare Research and Quality
Rationale:
The Agency for Healthcare Research and Quality (AHRQ) is a federal agency that provides
data and research on healthcare delivery, including information specific to minority
populations. AHRQ's data can help the nurse identify the health services needs of migrant farm
workers and develop a plan to improve healthcare delivery for this group.
103. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to
severe pain in multiple joints. Which of the following actions should the nurse plan to take?
Answer: Allow for frequent rest periods throughout the day
Rationale:
Rheumatoid arthritis is a chronic autoimmune disorder characterized by joint inflammation and
pain. Providing frequent rest periods throughout the day can help reduce joint stress and
fatigue, which are common symptoms of rheumatoid arthritis. This intervention can improve
the client's comfort and overall quality of life.
104. A nurse manager in a long-term care facility is having difficulty with staffing for weekend
shifts and is planning to implement some changes to the scheduling procedure. Which of the
following actions should the nurse manager take first?
Answer: Form a committee of staff members to investigate current staffing issues
Rationale:
Before implementing any changes to the scheduling procedure, it is important for the nurse
manager to gather information about the current staffing issues. Forming a committee of staff
members can help identify the root causes of the staffing problems, such as inadequate staffing

levels, staff preferences, or scheduling conflicts. This information is essential for developing
effective solutions to address the staffing issues on weekend shifts.
105. A nurse is assessing a client following a colonoscopy. Which of the following findings
should indicate to the nurse that the client is hemorrhaging?
Answer: Rapid decrease in blood pressure
Rationale:
Hemorrhaging following a colonoscopy is a serious complication that requires immediate
intervention. A rapid decrease in blood pressure can indicate significant blood loss, which can
lead to hypovolemic shock if not promptly treated. Therefore, the nurse should closely monitor
the client's blood pressure and be prepared to intervene quickly if hemorrhaging is suspected.
106. A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin
via continuous IV infusion. Which of the following assessments is the nurse's priority?
Answer: Amount of vaginal bleeding
Rationale:
The fourth stage of labor is the period immediately after the delivery of the placenta, during
which the risk of postpartum hemorrhage is increased. Oxytocin, which is often administered
during this stage to help the uterus contract and prevent hemorrhage, can sometimes cause
uterine hyperstimulation, leading to excessive bleeding. Therefore, assessing the amount of
vaginal bleeding is a priority to promptly identify and manage any signs of hemorrhage.
107. A nurse is caring for a child who has hypotonic dehydration and is receiving an oral
rehydration solution. Which of the following laboratory results indicates that the treatment
regimen is effective?
Answer: Serum sodium 138 mEq/L
Rationale:
Hypotonic dehydration is characterized by a decrease in extracellular fluid volume with
relatively more loss of electrolytes than water, leading to hyponatremia (low serum sodium
levels). Receiving an oral rehydration solution helps restore electrolyte balance and increase
serum sodium levels. A serum sodium level of 138 mEq/L falls within the normal range (135145 mEq/L), indicating that the treatment regimen is effective in correcting the electrolyte
imbalance associated with hypotonic dehydration.

108. A nurse is assessing a newborn's heart rate. Which of the following actions should the
nurse take?
Answer: Auscultate the apical pulse for at least 1 minute
Rationale:
Auscultating the apical pulse for at least 1 minute allows the nurse to obtain an accurate heart
rate in newborns, as their heart rates can vary widely and may be irregular. A full minute of
auscultation helps ensure an accurate assessment of the newborn's heart rate.
109. A nurse is caring for a client who is taking valproic acid for seizure control. For which of
the following adverse effects should the nurse monitor and report?
Answer: Jaundice
Rationale:
Valproic acid is associated with hepatotoxicity, which can manifest as jaundice (yellowing of
the skin and eyes). Monitoring for signs of jaundice, such as yellowing of the skin or sclera, is
important to detect liver damage early and prevent further complications.
110. A nurse is providing information to a client immediately before his scheduled Romberg
test. Which of the following statements should the nurse make?
Answer: "I will be checking you once with your eyes open and once with them closed"
Rationale:
The Romberg test is a neurological assessment that evaluates balance and proprioception. The
nurse should inform the client that the test involves standing with eyes open and then closed to
assess the influence of vision on balance. Providing this information helps prepare the client for
the test and ensures that they understand what to expect during the procedure.
111. A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger
tea. Which of the following findings indicates the client's use of ginger tea is effective?
Answer: The client reports a decrease in episodes of nausea
Rationale:
Ginger has been used traditionally to alleviate nausea and vomiting, including those associated
with pregnancy (morning sickness). Research suggests that ginger may be effective in reducing
nausea and vomiting in pregnant women. Therefore, a decrease in episodes of nausea indicates
that the client's use of ginger tea is effective in managing their symptoms.

112. A nurse is assessing an infant who has hydrocephalus and is 6 hours postoperative
following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings
should the nurse report to the provider?
Answer: Irritability when being held
Rationale:
Irritability in an infant postoperatively can indicate pain or discomfort, which could be due to
various reasons, including shunt malfunction or infection. Given the recent surgery and the
presence of a VP shunt, irritability should be reported to the provider for further evaluation to
rule out any complications.
113. A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that
the client is experiencing fluid overload?
Answer: Dyspnea
Rationale:
Dyspnea (difficulty breathing) can be a sign of fluid overload, especially when fluid
accumulates in the lungs (pulmonary edema). IV fluids administered too rapidly or in excessive
amounts can lead to fluid overload, causing symptoms such as dyspnea, increased heart rate,
and edema. Monitoring for signs of fluid overload is crucial when administering IV fluids.
114. A nurse in an emergency department is caring for a client who is at 9 weeks of gestation
and reports nausea and vomiting for the past 2 days. Which of the following findings should the
nurse expect?
Answer: Urine specific gravity 1.052
Rationale:
Nausea and vomiting in early pregnancy can lead to dehydration, which can be reflected in the
urine specific gravity. A urine specific gravity of 1.052 is considered high and indicates
concentrated urine, suggesting dehydration. The nurse should expect this finding in a client
experiencing nausea and vomiting and should monitor the client's hydration status closely.
115. A nurse is developing a client education program about osteoporosis for older adult clients.
The nurse should include which of the following variables as a risk factor for osteoporosis?
Answer: Sedentary lifestyle
Rationale:

A sedentary lifestyle, characterized by lack of physical activity, is a risk factor for osteoporosis.
Weight-bearing and muscle-strengthening exercises are important for maintaining bone health
and reducing the risk of osteoporosis. Including information about the importance of physical
activity in preventing osteoporosis is essential in a client education program for older adults.
116. A nurse in the emergency department is assessing a preschooler who has a facial
laceration. The nurse should identify which of the following findings as a potential indication of
child sexual abuse?
Answer: The child exhibits discomfort while walking
Rationale:
Discomfort while walking could be a potential indication of child sexual abuse because it may
suggest injury or trauma to the genital area. It is important for the nurse to further assess the
child and gather additional information to determine the cause of the discomfort and whether
there are any signs of abuse.
117. A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for
6 months to treat juvenile idiopathic arthritis. Which of the following questions should the
nurse ask to assess for an adverse effect of this medication?
Answer: "Have you had any stomach pain or bloody stools?"
Rationale:
Ibuprofen is known to cause gastrointestinal adverse effects such as stomach pain and bleeding.
Asking about these symptoms can help the nurse assess for potential complications related to
the medication and take appropriate actions if needed.
118. A nurse is teaching a client who is at 20 weeks of gestation about common discomforts
associated with pregnancy. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: "I will wear a supportive bra overnight"
Rationale:
Wearing a supportive bra overnight can help alleviate breast discomfort and provide support as
the breasts undergo changes during pregnancy. This indicates that the client understands the
teaching about managing common discomforts associated with pregnancy.

119. A nurse at an urgent care clinic is assessing a client who reports impaired vision in one
eye. Which of the following reports by the client should indicate to the nurse that the client has
a detached retina?
Answer: Floating dark spots
Rationale:
Floating dark spots, also known as floaters, can be a symptom of a detached retina. The nurse
should recognize this report as a potential indication of a serious eye condition and should refer
the client for further evaluation and treatment by an eye care specialist.
120. A nurse is preparing a sterile field to perform a sterile dressing change. Which of the
following interventions should the nurse use to maintain surgical aseptic technique?
Answer: Maintain sterile objects within the line of vision
Rationale:
Maintaining sterile objects within the line of vision helps the nurse ensure that the sterile field
remains intact and free from contamination. This practice is important for preventing surgical
site infections and maintaining surgical aseptic technique during procedures.
121. A nurse is admitting a client who has pneumonia. The nurse should initiate which of the
following isolation precautions for the client?
Answer: Droplet
Rationale:
Pneumonia is typically spread through respiratory droplets. Therefore, the nurse should initiate
droplet precautions to prevent the spread of the infection. Droplet precautions include wearing a
mask when entering the room and placing the client in a private room or with another client
with the same infection.
122. A nurse is conducting a physical examination for an adolescent and is assessing the range
of motion of the legs. Which of the following images indicates the adolescent is abducting the
hip joint?
Answer: D- abducting the hip joint by moving the leg away from the midline of the body.

Rationale:
Abduction of the hip joint involves moving the leg away from the midline of the body. In the
image described, the leg is being moved away from the midline, indicating abduction of the hip
joint.
123. A nurse is providing discharge teaching about disease management for a client who has a
new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's
priority?
Answer: Ensure that the client understands the medication regimen
Rationale:
For a client newly diagnosed with type 1 diabetes mellitus, understanding the medication
regimen is a priority to ensure proper management of the condition and prevent complications.
It is essential for the nurse to provide clear and concise instructions and to verify the client's
understanding to promote successful disease management.
124. A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via
mechanical ventilation. The nurse should monitor the client for which of the following adverse
effects of PEEP?
Answer: Tension pneumothorax- The nurse should monitor the client's lung sounds hourly for
indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and
distended neck veins.
Rationale:
Positive end-expiratory pressure (PEEP) can increase the risk of developing a tension
pneumothorax, a potentially life-threatening condition. Monitoring for signs and symptoms of a

tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck
veins, is crucial to detect and treat this complication promptly.
125. During the change of shift report, a night shift nurse informs the day shift nurse that a
newly admitted client was disoriented and combative during the night. Which of the following
actions should the day shift nurse take?
Answer: Move the client to a room near the nurses' station
Rationale:
Moving the client to a room near the nurses' station allows for closer monitoring and quicker
response to any changes in the client's condition. It also provides a safer environment for both
the client and the healthcare team in case the client becomes combative again.
126. A nurse is providing teaching to a school-age child who has asthma about using an
albuterol metered-dose inhaler. Which of the following instructions should the nurse include?
Answer: Take medication 15 min before playing sports
Rationale:
Taking albuterol 15 minutes before playing sports can help prevent exercise-induced
bronchospasm in children with asthma. This timing allows the medication to open the airways
and improve breathing before physical activity begins.
127. A nurse is providing client teaching about the basal body temperature method of birth
control. Which of the following information should the nurse include in the teaching?
Answer: "Your body temperature might decrease slightly just before ovulation"
Rationale:
The basal body temperature method of birth control involves tracking changes in body
temperature to determine the fertile period of the menstrual cycle. Body temperature typically
decreases slightly just before ovulation and then rises after ovulation, indicating the end of the
fertile period. Understanding these temperature changes can help the client identify the most
fertile days and avoid unprotected intercourse during that time.
128. A nurse is preparing to administer insulin to a client via a pen device. Which of the
following actions should the nurse take?
Answer: Hold the insulin pen device perpendicular to the client's skin to inject the medicationthe nurse should hold the pen in place briefly for 6 to 10 seconds after injecting the insulin into
the subcutaneous skin to ensure that the insulin is received.

Rationale:
Holding the insulin pen device perpendicular to the client's skin ensures proper insertion of the
needle and delivery of the insulin into the subcutaneous tissue. Holding the pen in place for 6 to
10 seconds after injecting the insulin allows the medication to be absorbed effectively.
129. A nurse is caring for a client who is receiving continuous bladder irrigation following a
transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes
a decreased urinary output. Which of the following actions should the nurse take?
Answer: Irrigate the catheter with 0.9% sodium chloride irrigation
Rationale:
Bladder spasms and decreased urinary output following a transurethral resection of the prostate
may indicate clot retention in the bladder. Irrigating the catheter with 0.9% sodium chloride
irrigation can help dislodge and remove clots, improving urinary flow and reducing the risk of
complications such as urinary retention.
130. A nurse in a provider's office is caring for an 18-month-old toddler who has a blood lead
level of 3 mcg/dL. Which of the following actions should the nurse take?
Answer: Recommend rescreening in 1 year
Rationale:
A blood lead level of 3 mcg/dL is within the expected reference range for children. The nurse
should recommend rescreening in 1 year as part of routine lead screening recommendations.
Chelation therapy is not indicated for a blood lead level of 3 mcg/dL. Contacting the poison
control center is recommended for blood lead levels greater than 20 mcg/dL. Referral to social
services is considered for blood lead levels greater than 5 mcg/dL.
131. A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the
following actions by the newly licensed nurse requires intervention by the preceptor?
Answer: Starts a task then determines what supplies are needed
Rationale:
This action indicates a lack of proper preparation and organization, which could lead to
inefficiency and potentially compromise patient care. The nurse should assess the situation,
gather necessary supplies, and plan the task before starting it to ensure smooth execution.
132. A nurse is assessing a client who is taking propranolol. Which of the following findings
should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?

Answer: Wheezing
Rationale:
Wheezing is a potential sign of bronchospasm, which can be an adverse reaction to propranolol,
especially in patients with underlying respiratory conditions such as asthma. It is important for
the nurse to recognize this adverse reaction and take appropriate action, such as notifying the
healthcare provider.
133. A nurse is assessing a client who has pulmonary edema. Which of the following findings
should the nurse expect?
Answer: Pink, frothy sputum
Rationale:
Pink, frothy sputum is a classic symptom of pulmonary edema, indicating the presence of
blood-tinged fluid in the lungs. This finding is important for the nurse to recognize as it can
indicate a serious condition requiring prompt intervention.
134. A nurse is assessing a client who received 2 units of packed RBC's 48 hr ago. Which of the
following findings should indicate to the nurse that the therapy has been effective?
Answer: Hemoglobin 14.9 g/dL
Normal levels:
• females: 12 to 16 g/dL
• males: 14 to 18 g/dL
Rationale:
The hemoglobin level of 14.9 g/dL falls within the normal range for males, indicating that the
packed RBC transfusion has been effective in increasing the client's hemoglobin levels. This
suggests that the therapy has achieved its intended goal of improving the client's red blood cell
count and oxygen-carrying capacity.
135. A nurse has received change of shift report on four assigned clients. For which of the
following clients should the nurse intervene to prevent a potential food and medication
interaction?
Answer: A client who is receiving an MAOI and is requesting a cheeseburger for dinner
Rationale:

MAOIs (monoamine oxidase inhibitors) can interact with foods high in tyramine, such as
cheeseburgers, leading to a potentially dangerous increase in blood pressure. It is essential for
the nurse to intervene to prevent this interaction and ensure the client's safety.
136. A nurse is caring for a client who had a stroke 6 hr ago. Which of the following
interventions should the nurse implement to reduce the risk of increased ICP?
Answer: Place the client in a quiet environment
Rationale:
A quiet environment helps reduce stimuli that can increase intracranial pressure (ICP), which is
crucial in the acute phase of stroke care. Minimizing noise and activity can help prevent further
neurological damage and promote optimal recovery.
137. A nurse is planning care for a client who is receiving chemotherapy and has neutropenia.
Which of the following interventions should the nurse include in the plan?
Answer: Avoid including raw fruits in the client's diet
Rationale:
Raw fruits can harbor bacteria and fungi that may pose a risk of infection to
immunocompromised clients, such as those with neutropenia. It is important for the nurse to
include this intervention in the care plan to reduce the risk of infection and promote the client's
safety.
138. A school nurse is notified of an emergency in which several children were injured
following the collapse of playground equipment. Upon arrival at the playground, which of the
following actions should the nurse take first?
Answer: Survey the scene for potential hazards to staff and children
Rationale:
Surveying the scene for potential hazards is the first step in ensuring safety for both the injured
children and the responding healthcare providers. Identifying and addressing hazards can
prevent further injuries and allow for safe assessment and treatment of the injured children.
139. A nurse is caring for a school age child who is taking valproic acid. The nurse should
expect the provider to order which of the following diagnostic tests?
Answer: Serum liver enzyme levels
Rationale:

Valproic acid is known to potentially cause liver damage, so monitoring serum liver enzyme
levels is essential to assess liver function and detect any signs of hepatotoxicity early. Regular
monitoring can help ensure the safe use of valproic acid in children.
140. A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility.
The client's family tells the nurse they are concerned about the level of care the client will
receive. Which of the following actions should the nurse take?
Answer: Facilitate an interdisciplinary conference at the new facility for the family
Rationale:
Involving the client's family in an interdisciplinary conference at the new facility can help
address their concerns and ensure that they are informed about the care the client will receive.
This can help alleviate anxiety and build trust in the healthcare team, leading to better outcomes
for the client.
141. A charge nurse is speaking with the partner of a client. The partner states that the client is
not receiving adequate care. Which of the following actions should the charge nurse take first to
resolve the situation?
Answer: Ask the partner to list specific concerns
Rationale:
Asking the partner to list specific concerns helps identify the issues from their perspective and
allows the charge nurse to address them directly. This approach can help clarify
misunderstandings and facilitate a resolution to the perceived inadequate care.
142. A nurse is caring for a client who has a prescription for a continuous passive motion
(CPM) machine following a total knee arthroplasty. Which of the following actions should the
nurse take?
Answer: Turn off the CPM machine during mealtime
Rationale:
Turning off the CPM machine during mealtime prevents any potential interference with the
client's ability to eat comfortably. This ensures that the client can focus on their meal without
any distractions or discomfort from the CPM machine.
143. A nurse is providing discharge instructions about newborn care to a client who is
postpartum. Which of the following statements indicates to the nurse that the client understands
the teaching?

Answer: "I will cover my baby's body when I wash her hair"
Rationale:
This statement indicates an understanding of the need to protect the baby's body from getting
cold while washing the hair, which is an appropriate measure for newborn care. It shows that
the client has grasped the concept of maintaining the baby's comfort and warmth during
bathing.
144. A nurse has just received change of shift report on four clients. Which of the following
clients should the nurse assess first?
Answer: A client who is postoperative with abdominal distention and no bowel sounds
Rationale:
Abdominal distention and absent bowel sounds can indicate a paralytic ileus, which is a serious
complication that requires immediate assessment and intervention. The nurse should prioritize
assessing this client to ensure prompt management and prevent further complications.
145. A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use.
After the nurse opens the packet containing the new pouch, the client declines to accept it.
Which of the following actions should the nurse take?
Answer: Ask another nurse to witness the disposal of the new patch
Rationale:
Asking another nurse to witness the disposal of the new patch ensures proper documentation of
the disposal process and reduces the risk of any potential allegations of improper disposal or
diversion of the medication. It is a standard precautionary measure to protect both the client and
the nurse.
146. A nurse is teaching a client who has a new prescription for total parenteral nutrition
through a central line. Which of the following information should the nurse include in the
teaching?
Answer: "I will need to measure your weight daily"
Rationale:
Daily weight measurement is important to monitor the client's fluid status and nutritional status
while receiving total parenteral nutrition (TPN). It helps ensure that the TPN is providing
adequate nutrition and allows for adjustments to the prescription as needed to meet the client's
needs.

147. A nurse is performing an admission assessment on a client who had a recent positive
pregnancy test. The first day of her last menstrual period (LMP) was May 8. According
Nägele's rule, which of the following should the nurse document as the client's estimated date
of birth (EDB)?
Answer: February 15
Rationale:
Nägele's rule is used to estimate the client's due date by adding 7 days to the first day of the last
menstrual period (May 8) and then subtracting 3 months. Therefore, the estimated date of birth
(EDB) would be February 15.
148. A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of
the following findings should the nurse initiate a referral for occupational therapy?
Answer: Difficulty performing ADL's
Rationale:
Difficulty performing activities of daily living (ADLs) can significantly impact the client's
quality of life and independence. Occupational therapy can help the client regain or improve
their ability to perform ADLs and promote their overall functional status and independence.
149. A nurse is providing teaching to a client who is scheduled for electroconvulsive therapy
(ECT). The nurse should inform the client that which of the following findings is an adverse
effect of ECT?
Answer: Short-term memory loss
Rationale:
Short-term memory loss is a common adverse effect of electroconvulsive therapy (ECT). It is
important for the nurse to educate the client about this potential side effect and reassure them
that it is usually temporary and improves over time after the completion of ECT sessions.
150. An antepartum nurse is caring for four clients. For which of the following clients should
the nurse initiate seizure precautions?
Answer: A client who is at 33 weeks of gestation and has severe gestational hypertension
Rationale:
Severe gestational hypertension puts the client at risk for developing eclampsia, which is
characterized by seizures. Initiating seizure precautions, such as padding the side rails of the

bed and ensuring emergency medications and equipment are readily available, is essential to
protect the client and provide prompt intervention in case of a seizure.
Manifestations of Tardive Dyskinesia: repetitive, uncontrollable movements

Tongue thrusting

Lip smacking

Facial grimacing

Eye blinking

Involuntary pelvic rocking

Hip thrusting

Manifestations of Respiratory acidosis: HR changes r/t delayed electrical conduction

WIDE QRS interval

TALL ‘T’ waves

Prolonged PR interval

Bradycardia

HYPOactive deep tendon reflexes

Reduced muscle tone

THREADY pulse

Dry, pale, cyanotic skin

Redman syndrome s/s: flushing of the neck, face, upper body, arms, and back

TACHYcardia

HYPOtension

Urticaria

SLOW Vanco infusion rate: can lead to anaphylaxis

SHOCK
Early s/s

Normal BP

Anxious

Confused

Narrowe

d Pulse Pressure

Late s/s

Hypotension

Anuria

Decreased aldosterone and ADH production

Decreased LOC

Document Details

  • Subject: Nursing
  • Exam Authority: ATI
  • Semester/Year: 2019

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