NSG 4060 Comprehensive ATI Practice B
1. A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the
following findings should indicate to the nurse that the therapy has been effective?
Answer: Hemoglobin 14.9 g/dL
Rationale: The nurse should identify that packed RBCs are administered to clients who have a
decreased level of hemoglobin or hematocrit. This hemoglobin level is within the expected
reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females, indicating the therapy
has been effective.
2. A nurse working in a n 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: Using the stable vs unstable approach to client care, the nurse should recommend
priority treatment for the client who has unstable vital signs because this client requires
immediate treatment to reduce the risk of further injury or possible death.
3. A nurse is caring for a client who has fluid volume overload. Which of the following tasks
should the nurse delegate to the CNA?
Answer: Measure the client’s daily weight
Rationale: It is within the CNAs range of function to measure a client’s daily weight, so the
nurse should delegate this task to them.
4. A nurse is preparing to administer mannitol 0.2g/kg IV bolus over 5 min as a test dose to a
client who has severe oliguria. The client weighs 198lb. What is the amount in grams the nurse
should administer?
Answer: 18 g
5. A nurse is conduction 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: In the correct image, the adolescent is abduction the hip joint by moving the leg away
from the midline of the body.
6. 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 manifestation of hyperthyroidism, along with tachycardia, diaphoresis,
weight loss, insomnia, and exophthalmia.
7. A nurse is assessing a school-aged child who has bacterial meningitis. Which of the following
findings should the nurse expect?
Answer: Nuchal rigidity
Rationale: This is a manifestation of bacterial meningitis.
8. A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse
take?
Answer: Auscultate the apical pulse at least 1 min.
Rationale: The nurse should auscultate the apical pulse to obtain an accurate assessment of heart
rate and rhythm. Auscultation of a newborn’s heart sounds can be difficult because of the rapid
rate and the transmission of respiratory sounds.
9. 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: Instruct the client to avoid coughing during the procedure.
Rationale: It is important for the nurse to remind the client to avoid coughing and to lie still
during a thoracentesis to avoid puncturing the pleura.
10.
A nurse in the ED 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: The nurse should identify this finding as a potential indication of child sexual abuse.
11.
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: The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea
and inflammation.
12.
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.
This promotes client comfort and dietary intake.
13.
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 the client?
Answer: Radial vein of the inner arm.
Rationale: This site will have adequate subcutaneous tissue.
14.
A nurse is developing a client education program a bout osteoporosis for older adult
clients. The nurse should include which of the following variables as a risk factor for
osteoporosis?
Answer: Sedentary lifestyle.
Rationale: This is a risk factor for osteoporosis. The nurse should encourage older adult clients
to engage in weight-bearing exercises because they will promote bone health by increasing
calcium and phosphorus levels.
15.
A nurse in an ED 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: When using the urgent vs nonurgent approach to client care, the nurse should
determine that the priority action is to initiate transmission-based precautions for the child. The
child most likely has varicella. Therefore, the nurse should isolate the child to prevent the spread
of the infection.
16.
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: Change the position of the client.
Rationale: When providing client care, the nurse should use the least restrictive intervention
first. Therefore, the nurse should reposition the client to remove any kinks in the tube, which can
lead to clogging. If this method is unsuccessful, the nurse should attempt to flush or aspirate the
client’s tube to remove the clog.
17.
A home health care 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: The ileostomy pouch should be emptied when it is one-third to one-half full to
prevent stool leakage and skin irritation.
18.
A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and
received hemodialysis 24 yr ago. Which of the following lab values should the nurse report to
the provider?
Answer: Sodium 148 mEq/L
Rationale: The nurse should report this sodium level because it is above the expected reference
range of 136 to 145 mEq/L, indicating hypernatremia. Clients who have kidney disease often
retain sodium and require sodium-restricted diets.
19.
A nurse is caring for four clients. Which of the following tasks should the nurse delegate to
a CNA?
Answer: Arrange the lunch tray for a client who has a hip fracture.
Rationale: Assisting a client with meals is within the range of function of the CNA.
20.
A nurse is preparing a client for a paracentesis. Which of the following actions should the
nurse take?
Answer: Instruct the client to void.
Rationale: The nurse should instruct the client to void prior to the procedure because an empty
bladder decreases the risk of a bladder puncture and minimizes the client’s discomfort during the
procedure.
21.
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. This
client’s food selection contains tyramine. Clients prescribed an MAOI must restrict the intake of
foods that contain tyramine due to adverse effects, such as hypertension.
22.
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: The nurse should encourage the client to balance rest with exercise to maintain
muscle strength, joint function, and range of motion.
23.
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 action should the nurse take?
Answer: Irrigate the catheter with 0.9% sodium chloride irrigation.
Rationale: Decreased urine output and bladder spasms indicate internal obstruction of the
catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation
and notify the provider if the obstruction does not clear.
24. A nurse is assessing a client who has COPD. Which of the following findings should the
nurse expect?
Answer: pH 7.31
Rationale: Respiratory acidosis is an expected finding for a client who has COPD. The expected
reference range of pH is 7.35-7.45. A pH level of less than 7.35 indicates acidosis. For a client
who has COPD, a decrease in pH will be accompanied by an increase in the level of carbon
dioxide over the expected reference range of 35 to 45 mm Hg, indicating respiratory acidosis.
25.
A nurse in a community center is providing an educational 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: The nurse should include the presence of abdominal bloating as an early
manifestation of ovarian cancer. Other manifestations include an increase in abdominal girth,
pelvic or abdominal pain, early satiety, and urinary frequency or urgency.
26.
A nurse is caring for a client who has active TB. Which of the following actions should the
nurse plan to take to prevent the transmission of the disease?
Answer: Have the client wear a surgical mask while being transported outside the room. This
will prevent the transmission of the disease.
27.
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. This client is
at greater risk of injury.
28.
An RN is observing an LPN and a CNA move a client up in bed. For which of the
following situations should the nurse intervene?
Answer: The LPN and the CNA grasp the client under his arms to lift him up in bed. They
should not grasp the client under the arms when lifting, as this can result in shoulder dislocation
or other injuries to the client. The RN should intervene and instruct the nurses to use a draw
sheet or friction-reducing device to lift the client.
29.
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 medication.
This ensures the insulin enters the sub Q tissue.
30.
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.
Rationale: Check for manifestations of infection, such as sores or lesions.
31.
A nurse is providing teaching about advance directives to a middle-aged 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 statement indicates that the client recognizes that designating a health care
surrogate is part of advance directives.
32.
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
Rationale: This is a hormone that stimulates uterine contractions, to decrease vaginal bleeding.
33.
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: This includes members of the team when making decisions and encourages staff
members to participate in the decision-making process.
34.
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. This is the task of the
orienteer.
35.
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? See Exhibit button Administer high-dose antibiotic
therapy.
Answer: Children who have cystic fibrosis metabolize antibiotics more rapidly and require
higher doses of antibiotics to help fight aggressive infections such as Burkholderia cepacia.
36.
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: Heat loss by conduction is a loss of heat between the newborn’s skin and the cooler
surface beneath it.
37.
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: The priority action the nurse should take when using the airway, breathing,
circulation approach to client care is to assist the client with deep breathing and coughing, which
reduces the risk of postop pneumonia.
38.
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: client who channels their energy into a new hobby following the loss of their job.
Channeling negative feelings over the loss of their job into a new hobby is using the defense
mechanism of sublimation.
39.
A nurse is assessing f or 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 contents from the tube and verify the pH level.
The nurse should verify that the pH level of the client’s gastric aspirate is less than 5 to
determine proper placement.
40.
An antepartum nurse i s caring for four clients. For which of the following clients should
the nurse initiate seizure precautions?
Answer: A client who is at 33 weeks gestation and has severe gestational hypertension. The
nurse should initiate seizure precautions for a client who has severe gestational because
extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse
should provide the client with a quiet, darkened environment, place suction equipment and
oxygen at the bedside, and position the call light within the client’s reach.
41.
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: Wear clothing made with cotton fabrics while oxygen is in use.
Woolen and synthetic fabrics can generate static electricity, which increases the risk of a fire.
42.
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 non-weight bearing for 6
weeks. Which of the following instructions should the nurse include in the teaching?
Answer: Use the three-point gait.
Rationale: This allows the client to be mobile without bearing weight on the affected extremity.
43.
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 nurse should recognize than an effective handoff report provides a baseline of
the client’s status for comparison and should include any recent changes or priority situations
affecting the client’s condition. The time of the client’s last dose of pain meds is important to
include so the receiving nurse can anticipate what time to give the next dose.
44.
A nurse is assessing a n infant who has hydrocephalus and is 6 hr postop 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: This is a manifestation of increased intracranial pressure, which is an indication that
the VP shunt is malfunctioning. This finding should be reported to the provider immediately.
45.
A nurse is caring for a client who has a prescription for chlorpromazine. Which of the
following finding should the nurse identify as an indication that the medication is effective?
Answer: Decreased hallucinations.
Rationale: This is an antipsychotic medication administered to decrease hallucinations and other
manifestations of schizophrenia.
46.
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: Increased thirst is a manifestation of lithium toxicity. The nurse should instruct the
client to report increased thirst, vomiting, diarrhea, or tremors to the provider.
47.
A nurse 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. This is the correct
way of doing this.
48.
A nurse is planning to delegate client care tasks to a CNA. Which of the following tasks
should the nurse plan to delegate to the CNA?
Answer: Perform gastrostomy feedings through a client’s established gastrostomy tube. This
task is within their range of function.
49.
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: It is an effective method of providing high-quality, cost-effective care because this
will allow additional time for nurses to focus on skilled tasks.
50.
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 should the nurse
identify as an indication of potential violence?
Answer: The client is pacing around the chair in which their partner is sitting.
Rationale: Hyperactivity and pacing indicate that this client is at risk for violent behavior. The
nurse should assess the situation further and attempt to de-escalate the situation by speaking to
the client in a low, calm voice using short sentences.
51.
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: “You have the right to change your mind about this procedure at any time.”
Rationale: The client can refuse to consent at any time for a procedure. The nurse is
demonstrating advocacy by respecting the client’s wishes regarding care.
52.
A rural community health nurse is developing a plan to improve health care delivery for
migrant farmworkers. To identify health services data for this minority group, the nurse should
gather information from which of the following sources?
Answer: Agency for Healthcare Research and Quality
Rationale: The goal of the Agency for Healthcare Research and Quality (AHRQ) is to improve
the quality of health care services for all populations, including low-income groups and
minorities. This data should help the nurse to develop an evidence-based plan to improve health
care services for specific populations.
53.
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: This indicates respiratory distress. Signs are nasal flaring, retractions, and grunting.
54.
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: The first action the nurse should take u sing the nursing process is to assess the
situation by asking the partner to list specific concerns.
55.
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 will be performed once with eyes open and once with eyes closed.
This is performed to assess balance and motor function.
56.
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 even while sleeping can promote comfort by providing
support to enlarged breasts during pregnancy.
57.
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: Monitor the client for jaundice and report any indications to the provider. Clients
who take valproic acid are at risk for liver damage, which can lead to jaundice.
58.
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”
“I will use the bulb syringe first in her mouth and then in her nose”
Newborns are highly susceptible to heat loss. The client should wrap the newborn in a towel
when washing the hair to minimize heat loss.
The client should suction the newborn’s mouth first to remove secretions that the newborn could
aspirate when suctioning the nares.
59.
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: The greatest risk to this client is injury from ideas of self-harm. The priority
assessment the nurse should make is to determine whether the client has had suicidal or
homicidal ideas.
60.
A nurse is preparing to administer lactated Ringer’s 1500 mL to infuse at 50 mL/hr. The
drop factor of the manual I V tubing is 15 gtt/min. The nurse should set the manual IV infusion
to deliver how many gtt/min?
Answer: 13 gtt/min
61.
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: The nurse should instruct the client to monitor for irritability, which can indicate
decreased blood glucose levels.
62.
A nurse is providing teaching to a client who is scheduled for ECT. The nurse should
inform the client that which of the following is an adverse effect of ECT?
Answer: Short-term memory loss
Rationale: This is a common adverse effect of ECT.
63.
A charge nurse notices that one of the nurses on the shift frequently violates unit policies
by taking an extended amount of time for a 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: The charge nurse is dealing with the conflict i n a cooperative, positive manner by
using this statement to open the conversation in a nonthreatening way. The focus is on the length
of the break time and is not a personal affront.
64.
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: The nurse should recognize this urine specific gravity is significantly elevated above
the expected reference range of 1.005 to 1.030. An increased urine specific gravity indicates
dehydration from vomiting.
65.
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 g/dL indicates
malnutrition and a need for additional nutritional supplementation. The expected reference range
for albumin is 3.5 to 5 g/dL.
66.
A nurse is conducting group therapy with clients who have breast cancer. The nurse should
recognize which of the following statements by a client as an example of altruism?
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 demonstrating altruism by reaching out and
helping others.
67.
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?
Answer: Broccoli, yogurt, cream cheese
Rationale: Clients taking an MAOI should not eat foods that contain tyramine. Fermented meat
such as pepperoni and bologna are high in tyramine.
68.
A nurse is assessing a client for compartment syndrome. Which of the following findings
should the nurse expect?
Answer: Edema
Rationale: Compartment syndrome causes increased pain, pallor, and paresthesias from
increased edema in the compartment involved.
69.
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: The priority action the nurse should take when using the safety vs risk reduction
approach to client care is to ensure the client understands the medication regimen. The greatest
risk to the client is the potential to develop hypoglycemia or hyperglycemia, which can be lifethreatening if treated incorrectly.
70.
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: These are a manifestation of a detached retina due to bulges, folds, or holes in the
affected retina.
71.
A nurse on a med-surg 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 ADLs
Rationale: A referral for occupational therapy to teach the client the skills necessary to become
independent in performing ADLs such as bathing, dressing, and eating.
72.
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: This is an indication of hemorrhage.
73.
A nurse is caring for a client who recently signed an informed consent form to donate a
kidney to her sibling who had end-stage kidney disease. The donor 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: The nurse is restating the client’s statement, which lets the client know that the nurse
is listening and paying attention to what the client is communicating.
74.
A nurse is assessing a client who has pulmonary edema. Which of the following findings
should the nurse expect?
Answer: Pink, frothy sputum
Rationale: A client who has manifestations of pulmonary edema can have pink, frothy sputum
due to fluid leaking across the pulmonary capillaries and into the lung tissue.
75.
A nurse administers an incorrect dose of medication to a client. The nurse recognizes 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?
Answer: Time the medication was given
Rationale: The nurse should document the time, the name of the med, the dose, and the route in
which the med was given on the client’s MAR immediately after it was administered. The nurse
should also document the time that the incorrect med was administered to the client in the
incident report, as this is a fact directly related to the occurrence.
76.
A nurse is caring for a client who is post-op 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: Restlessness and light headedness are indications of hypoxia. The nurse should check
the client’s oxygen saturation level.
77.
A nurse in an ED is assessing a school-aged 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: The nurse has a legal responsibility to report suspected physical abuse to Child
Protective Services.
78.
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.
79.
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 encourages the client to evaluate their feelings.
80.
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?
Answer: Shake the medication bottle well before each dose is given.
Store the medication in the refrigerator
Report diarrhea to the provider immediately
81.
A nurse on a med surg 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: Make a referral for social services
Rationale: As a client advocate, the nurse should support the client’s decisions and obtain a
referral for social services to ensure that the client’s needs a t home are met. Social services can
set up home care or hospice care services for the client if needed.
82.
A nurse is assessing a client who has a chest tube. Which of the following findings should
the nurse expect?
Answer: Occlusive dressing on the insertion site.
Rationale: This prevents air from leaking and is an expected finding.
83.
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: This will address the family’s concerns about providing optimal care for the client.
84.
A nurse is assessing a client who has major depressive disorder and is taking amitriptyline.
Which of the following should the nurse identify as an adverse effect of the medication?
Answer: Blurred vision
Rationale: This is an adverse effect of amitriptyline and the provider should be notified.
85.
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 indicates an
understanding of isolation precautions?
Answer: “A client who requires airborne precautions should be placed in a negative-pressure
airflow room.”
Rationale: Airborne precautions require a negative-pressure airflow room that has at least 6-12
air exchanges each hour using a HEPA filtration system.
86.
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: The nurse should compare the blood product label against the medical record and the
client’s identification number with another nurse to ensure the correct blood product is
administered to the correct client.
87.
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 nurse should identify that clients who have borderline personality disorder tend
to be emotionally unstable, have troubled interpersonal relationships, and often engage in
harmful behaviors such as cutting, substance use, and suicidal ideation.
88.
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: Apply a cold pack to the client’s ankle for 30 min/hr
Rationale: The nurse should clarify a prescription for a cold pack to the client’s ankle because
type 1 diabetes mellitus is a contradiction for receiving cold therapy. A client who has type 1
diabetes mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory
perception due to neuropathy. Ice can further impair circulation.
89.
A nurse is teaching about adverse effects with a client who is s tarting to take captopril.
Which of the following findings should the nurse identify a s an adverse effect of the medication
to report to the provider?
Answer: Cough
Rationale: This is due to the buildup of bradykinin in the lungs. The client should report this to
the provider.
90.
A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60
mm Hg. and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the
following acid-base imbalances?
Answer: Respiratory acidosis
Rationale: A client who has respiratory acidosis will have decreased pH below the expected
reference range of 7.35-7.45, an increased PaCO2 above the expected reference range of 35-45
mm Hg, and an HCO3 within the expected reference range of 22-26 mEq/L.
91.
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 med?
Answer: “Have you had any stomach pain or bloody stools?”
Rationale: These are an indication of gastrointestinal bleeding, an adverse effect of ibuprofen.
92.
A nurse in a pediatric unit has received a 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 f or an appendectomy and experienced
sudden relief from pain.
Rationale: Using the urgent vs nonurgent approach to client care, the nurse should determine
that the client to assess first is the child awaiting an appendectomy who suddenly experiences
pain relief as this can be an indication of peritonitis from a ruptured appendix. The nurse should
notify the provider immediately.
93.
A nurse on an inpatient u nit 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 lead to falls.
The nurse should initiate fall precautions for the client.
94.
A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse
should identify which of the following physiological changes is the cause of the client’s visual
loss?
Answer: Increased opacity of the lens
Rationale: A cataract is a cloudy or opaque area in the lens of the eye that inhibits light
penetration.
95.
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: Cervical laceration
Rationale: Complications are perineal, vaginal, or cervical lacerations.
96.
A nurse is updating the plan of care for a client who is 48 hr. post-op following a
laryngectomy and is unable to speak. Which of the following actions should the nurse plan to
take first?
Answer: Determine the client’s reading skills
Rationale: Using the nursing process to assess the client, determine the client’s level of reading
skills and cognition. The nurse can best provide the client with a variety of customized
techniques to practice and use after verbal skills are lost.
97.
A nurse is caring for a school-aged child who has dehydration and is receiving an oral
rehydration solution. Which of the following lab results indicates that the treatment regimen is
effective?
Answer: Serum sodium 138 mEq/L
Rationale: Sodium level of 138 mEq/L, is within the expected reference range of 136-145
mEq/L and is an indication that the child is responding to the oral rehydration solution.
98.
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: Using the nursing process, assess the situation. By surveying the scene, the nurse can
identify potential hazards to staff and children. These findings allow the nurse and staff to enter
the scene and safely provide care to injured children and help decrease the risk of further injury.
99.
A nurse in an ED is caring for a client who is unconscious and requires emergency medical
procedures. The nurse is unable to locate members of the client’s family to obtain consent.
Which of the following actions should the nurse take?
Answer: Proceed with provision for medical care.
Rationale: When a client is unable to give informed consent in an emergency, health care
personnel can proceed with necessary life-saving care because the law considers this implied
consent.
100. A nurse is caring for a school-aged 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 can cause hepatic toxicity. The nurse should expect the provider to
prescribe lab tests to assess the child’s liver function prior to and periodically during therapy.
101. 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: According to evidence-based practice, planning is the most important step in
managing time effectively. The nurse manager should include making a list of activities to
complete as the priority. Other planning activities include setting goals, establishing priorities,
and scheduling activities.
102. A nurse is caring for a client who has a pulmonary embolism. The client is receiving
heparin via continuous IV infusion at 1200 units/hr and warfarin 5 mg PO daily. The morning
lab 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 expected value for aPTT is 40 seconds. A therapeutic level of heparin increases
the aPTT by a factor of 1.5-2, making the aPTT 60-80 seconds. An aPTT level of 98 is above the
expected reference range, indicating that the dosage should be reduced, or the infusion withheld
until the aPTT returns to the therapeutic range.
103. 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 the medication 15 mins before playing sports.
Rationale: Take 5-20 min prior to exercise to promote bronchodilation. The meds effects begin
immediately, peak in 30-60 min, and can last for up to 5 hr.
104. A home health nurse is evaluating a school aged 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: The nurse should recommend a high-frequency chest compression vest for a child
who has inadequate results from other airway clearance therapy techniques. Older children often
require other techniques in addition to percussion and postural drainage to achieve adequate
mucus expectoration.
105. A nurse is planning care for a patient 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. This reduces the risk of bacterial
infections.
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 first action the nurse should take u sing the nursing process is assessing the
amount of vaginal bleeding. A client who is in the fourth stage of labor is at risk for hemorrhage,
so assessing the amount of vaginal bleeding is the nurse’s priority.
107. 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: The nurse should expect a decrease i n sodium levels because sodium is drawn to the
edematous burn areas and lost through plasma leakage.
108. 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: The nurse should instruct the client that daily w eight measurement is a necessary
part of administering nutrition through a central line to avoid fluid overload and monitor for
adequate weight gain.
109. A nurse is assessing a client who has bipolar disorder. Which of the following alterations in
speech is the client u sing?
Answer: Flight of ideas.
Rationale: Flight of ideas is an alteration in speech in which the speaker talks continuously with
sudden, frequent topic changes.
110. A home health nurse is caring for a group of older adult clients. The nurse should initiate 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 daycare services.
Rationale: The nurse should initiate a referral for PACE for this client because PACE provides
adult day care services along with in-home assessments and supportive services.
111. A nurse at a mental health clinic is caring for four clients. The nurse should recognize that
which of the following clients i s 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: The nurse should identify that this client i s using the defense mechanism of
dissociation because they are separating painful events from the conscious mind and describing
the events as if they happened to another person.
112. A nurse is caring for a client who has active pulmonary tuberculosis. Which of the
following actions should the nurse take?
Answer: Assign the client to a private room with negative air pressure.
Rationale: To control the spread of active TB, the nurse should assign the client to a private
room with negative air pressure.
113. A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled
for a 3 hr 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: The nurse should instruct the client that they will need to fast the night before the test
to prevent inaccurate test results.
114. 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? “I will
make sure my child receives a yearly influenza immunization.”
Answer: Children who have asthma should be immunized and protected from infections. The
nurse should educate the parent to ensure the child receives a yearly influenza immunization.
115. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the
following lab tests should the nurse review prior to adjusting the client’s heparin?
Answer: aPTT
Rationale: Prior to adjusting the client’s continuous heparin infusion, the nurse should review
the client’s activated partial thromboplastin (aPTT). T he expected reference range for the aPTT
is 40 secs. Clients who are receiving continuous heparin therapy should have an aPTT of 60-80
secs, which is 1.5-2 times the expected aPTT level. The nurse should increase or decrease the
heparin infusion according to this value.
116. 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: The nurse should recognize that wheezing can indicate the client is experiencing an
adverse reaction to the med.
117. A client is receiving IV fluids at 150 m L/hr. Which of the following findings indicates that
the client is experiencing fluid overload?
Answer: Dyspnea
Rationale: The nurse should recognize that dyspnea indicates the client could be experiencing
fluid overload. Fluid overload can lead to the backup of fluid in the pulmonary system resulting
in shortness of breath.
118. 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 statement makes an observation, which is a therapeutic response by the nurse. It
encourages the client to express their thoughts and feelings.
119. 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
discharge?
Answer: A client who has cellulitis and is receiving oral antibiotics every 8 hr. This client can
safely continue this treatment at home.
120. 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 to
Nagele’s rule, which of the following dates should the nurse document as the client’s estimated
date of birth (EDB)?
Answer: February 15.
Rationale: Add 7 days to the first day of the client’s LMP and then subtract 3 months.
121. 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? Use a rewards
system to modify the child’s behavior.
Answer: Children who have autism spectrum disorder respond well to a reward system, which
can provide structure and expectations for behavior.
122. A nurse in a provider’s office is caring for an 18-month-old toddler who has a blood level
of 3 mcg/dL. Which of the following actions should the nurse take?
Answer: Recommend rescreening in 1 year.
Rationale: This level is within the expected reference range.
123. 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 is therapeutic because it is offering a general lead that facilitates communication
between the nurse and the client and will help the nurse to explore the client’s feelings about the
treatment options.
124. 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 med?
Answer: Dry mouth.
Rationale: Clonidine is an indirect-acting antiadrenergic agent used for HTN, severe pain, and
ADD. The nurse should inform the client that dry mouth, or xerostomia, is a common adverse
effect of this med.
125. 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: Support the client’s left arm on a pillow while sitting.
Rationale: This prevents the extremity from hanging freely because this can cause shoulder
subluxation.
126. 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: This is assessment. The nurse should gather more data regarding the client’s decision
to refuse the blood transfusion.
127. 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: Inspect to assess skin integrity and symmetry. Auscultate. Percuss for tympany,
dullness, absence or flatness of resonance. Palpate for tenderness, pain, or the presence of a
mass.
128. 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: “I will not allow anyone to smoke near my baby.”
Rationale: Research indicates a strong correlation between exposure to cigarette smoke and the
occurrence of SIDS.
129. 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 with the line of vision.
Rationale: Objects out of the line of vision are not considered sterile. Keep sterile items at least
1 inch (2.5cm) away from the border of a sterile drape. Hold gloved hands away from the body
and above waist level to prevent contamination.
130. 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: This client is at risk for cardiac dysrhythmias and cardiac arrest.
131. 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: The client can also use ginger ale and ginger snaps to alleviate nausea associated
with pregnancy.
132. A nurse is caring for a client who has a deep vein thrombosis. Which of the following
actions should the nurse take?
Answer: Instruct the client to elevate the affected extremity when sitting. Reduce edema and
facilitate venous return.
133. A nurse is preparing to replace a client’s transdermal fentanyl patch after 72 hours of use.
After the nurse opens the packet containing the new patch, 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: Place the med in a secure receptacle, according to agency policy, when disposing of
any unused portion of a controlled substance.
134. A nurse is assessing a n older adult client who has pneumonia. Which of the following
findings should the nurse expect?
Answer: Acute confusion.
Rationale: Will have acute confusion, fatigue, lethargy, and anorexia.
135. A nurse is providing client teaching about the basal body temp method of birth control.
Which of the following information should the nurse include in the teaching?
Answer: “Your body temp might decrease slightly just prior to ovulation.”
Rationale: A decrease of 1° F commonly occurs immediately prior to ovulation.
136. A nurse manager in a long term 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: Assess the staffing issue. The first stage of change is the “unfreezing stage,” in which
information is gathered about the problem. The first action the nurse manager should take is to
form a committee to investigate the problem.
137. 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: Use the ventrogluteal site.
Rationale: It has a thick area of muscle and contains no large nerves or blood vessels.
138. 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.”
Hospice care includes bereavement services after a family member’s death.
139. 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
Rationale: The nurse should identify that tension pneumothorax is a possible adverse effect of
PEEP. 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.
140. A nurse manager is reviewing the client’s rights with the nurses on the unit. The nurse
manager should tell the nurses that informed consent promotes which of the following ethical
principles? Autonomy
Answer: Autonomy refers to a client’s ability to make their own decisions about treatment.
Informed consent promotes autonomy by providing clients with complete information about
treatment.
141. 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 determine what supplies are needed.
Rationale: The preceptor should intervene and instruct the newly licensed nurse to gather
supplies before performing client tasks to practice effective time management.
142. A nurse manager is preparing an educational session about advocacy for 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: The nurse manager should teach that advocacy is a leadership role that can help
others to grow personally and professionally through self-actualization.
143. 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: The nurse should initiate droplet precautions for this client by placing the client in a
private room and wearing a surgical mask when caring for the client. Pneumonia is transmitted
by droplet particles.
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. Using
the acute vs chronic approach to client care, the nurse should first assess the client who is
postoperative with abdominal distention and no bowel sounds because these manifestations are
an indication of paralytic ileus.
145. During a 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: The day shift nurse should move the client to a room near the nurses’ station to
enhance the staff’s ability to keep the client under frequent observation.
146. A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of
the aPTT values should the nurse expect?
Answer: 45 seconds
Rationale: This value is above the expected reference range of 30-40 seconds and indicates a
risk for spontaneous bleeding, which is a manifestation of hemophilia A.
147. 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 foods high in protein, vitamins, and
iron to promote tissue repair. The nurse should encourage the client to increase their intake of
dietary iron.
148. A nurse is an outpatient mental health facility i s assessing a child who has autism
spectrum disorder. Which of the following manifestations should the nurse expect?
Answer: Strict adherence to routines
Rationale: The nurse should identify that a child who has autism spectrum disorder can exhibit
strict adherence to routines or rituals, a fixation to specific objects, and resistance to change.
149. 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 intracranial pressure
(ICP)?
Answer: Place the client in a quiet environment.
Rationale: The nurse should keep the client’s environment quiet to minimize the risk of
increasing ICP.
