ATI PN COMPREHENSIVE PREDICTOR 2020/2021 180
QUESTIONS WITH CORRECT ANSWERS HIGHLIGHTED LATEST
UPDATE
1. A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac
dysrhythmias. Which of the following actions should the nurse plan to take?
A. tell the client to expect a mild stinging sensation during the test
B. attach a blood pressure cuff to the clients upper arm
C. assist the client to the orthopneic position
D. instruct the client to remain as still as possible during the recording
Answer: D. instruct the client to remain as still as possible during the recording
2. A home health nurse is conducting a home inspection for a client who is at risk for falls.
Which of the following instructions should the nurse provide for the client?
A. place area rugs on slick floor surfaces
B. move the clients bed to the main floor of the house
C. keep lighting in the home dim
D. place the bedside table 2 feet away from the bed
Answer: B. move the clients bed to the main floor of the house
3. A nurse is reinforcing teaching about common discomforts during the first trimester with a
client who is at 10 weeks of gestation. Which of the following examples should the nurse
include?
A. burning during urination
B. leukorrhea
C. swelling of the face
D. diarrhea
Answer: B. leukorrhea
4. A nurse is monitoring a client nurse take when collecting data about the client's respirations
A. count the client's respirations for 15 seconds
B. observe the movements of the client's chest wall
C. place the client in a supine position
D. inform the client when beginning to observe his respirations
Answer: B. observe the movements of the client's chest wall
5. A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the
following actions should the nurse take first?
A. place the client on bedrest
B. elevate the head of the client's bed
C. prepare the client for a ventilation perfusion scan
D. obtain the clients ABG levels
Answer: B. elevate the head of the client's bed
6. A community health nurse is assisting in the development of a brochure about hypertension.
Which of the following actions should the nurse take?
A. explain medical terminology using basic, one-syllable words
B. present information from complex to simple
C. write the information at an 8th-grade reading level
D. use a 12 point font size
Answer: B. present information from complex to simple
7. A nurse is reinforcing teaching with the support person of a client who is in the first stage of
labor. Which of the following instructions should the nurse include regarding effleurage?
A. apply steady pressure with this tennis ball to her sacral area
B. help her to focus on an object in the room
C. gently stroke her abdomen during contractions
D. assist her to breathe in deeply at the beginning of each contraction
Answer: C. gently stroke her abdomen during contractions
8. A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication
prescriptions. Which of the following prescriptions should the newly licensed nurse identify is an
accurate transcription?
A. Heparin 5000 U subcutaneous every 8 hr
B. MgSO4 10 g PO daily
C. Doxazosin .5 mg PO at bedtime
D. Lorazepam 0.5 mg PO PRN at bedtime
Answer: D. Lorazepam 0.5 mg PO PRN at bedtime
9. A nurse is reviewing laboratory data from a client who has diabetes mellitus. Which of the
following laboratory tests is the most accurate indicator of long -term disease management?
A. Glycosylated hemoglobin.
B. Urine ketones.
C. Glucose tolerance test.
D. Fasting blood glucose
Answer: A. Glycosylated hemoglobin.
10. A nurse is reinforcing teaching with a client who has a new prescription for ciprofloxacin.
Which of the following information should the nurse include in the teaching?
A. Restrict your daily fluid intake while taking this medication
B. take an antacid if the medication causes gastrointestinal upset
C. this medication can increase your risk for sunburn
D. expect to experience diarrhea while taking this medication
Answer: C. this medication can increase your risk for sunburn
11. A charge nurse is discussing confidentiality requirements with a newly licensed nurse when
sharing a client's medical information. Which of the following individuals should the charge
nurse identify as appropriate with whom to share client information?
A. a nurse from another unit after a client commits suicide
B. a client's employer who is concerned about safety due to substance use
C. a social worker who is assigned to an involuntarily committed school-age client
D. a client’s partner after the client reports intimate partner abuse
Answer: C. a social worker who is assigned to an involuntarily committed school-age client
12. A nurse is caring for a client who follows a kosher diet. Which of the following menu items
should the nurse include on the tray?
A. clam chowder
B. shrimp salad
C. roasted salmon
D. pulled-pork sandwich
Answer: C. roasted salmon
13. A nurse is caring for a client who has been admitted to the mental health unit. While
reinforcing teaching about the clients prescribed medications, the nurse communicates truthfully
about the adverse effects of the medications. Which of the following ethical concepts is the nurse
exhibiting?
A. autonomy
B. beneficence
C. veracity
D. justice
Answer: C. veracity
14. A nurse on a mental health unit is reinforcing with a client who has anorexia nervosa. Which
of the following statements by the client indicates an understanding of the teaching?
A. the treatment goal is to be within 60 percent of my ideal body weight
B. the staff will weight me every night before I go to bed
C. the staff will watch me closely for 1 hour after each meal
D. I should gain half of a pound per week to meet my treatment goal
Answer: C. the staff will watch me closely for 1 hour after each meal
15. A nurse is reinforcing teaching about preventing dental caries with the parent of a 12monthold toddler. Which of the following instructions should the nurse provide?
A. clean the teeth with a small, soft-bristled toothbrush
B. use a 5-inch strip of toothpaste on the toothbrush
C. position the bristles of your child’s toothbrush against the teeth at a 90-degree angle
D. floss between your child’s teeth before brushing
Answer: A. clean the teeth with a small, soft-bristled toothbrush
16. A nurse is caring for a client who has major depressive disorder and is taking an
antidepressant. The nurse should identify which of the following findings as the priority to report
to the provider?
A. the client neglects personal hygiene
B. the client is withdrawn and uncommunicative
C. the client has a sudden increase in energy
D. the client reports a change in sleeping patterns
Answer: C. the client has a sudden increase in energy
17. A nurse in an acute care setting is preparing to administer medications to a client. Which of
the following information should the nurse obtain to identify the client?
A. clients telephone number
B. name of the client’s provider
C. clients full medical diagnosis
D. room number of the client
Answer: A. clients telephone number
18. A nurse overhears two assistive personnel discussing a client’s medical history in the hallway.
Which of the following actions should the nurse take first?
A. speak to the staff members in private about the client confidentiality
B. report the incident to the charge nurse
C. participate in an in-service about client confidentiality
D. tell the staff members to stop their discussion
Answer: D. tell the staff members to stop their discussion
19. A nurse is caring for a child who has terminal cancer. Which of the following responses by
the child’s school-age brother should the nurse expect?
A. alienates himself from his peers
B. believes his bad behavior is causing his brother’s death
C. regresses to an earlier developmental level
D. believes that his brother’s death will be reversible
Answer: B. believes his bad behavior is causing his brother’s death
20. A nurse is contributing to the plan of care for a client who has schizophrenia and is
experiencing auditory hallucinations. The client reports hearing voices. Which of the following
interventions should the nurse plan to take?
A. reinforce that, although the voices are real to the client, the nurse does not hear them
B. ensure that the client avoids other forms of auditory stimulations, such as music or television
C. provide extended periods of alone time for the client
D. discourage the client from discussing the hallucinations
Answer: A. reinforce that, although the voices are real to the client, the nurse does not hear them
21. A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking
methylphenidate. Which of the following statements by the parents indicates that the medication
is effective?
A. our child has lost some weight since his last appointment
B. our child has a better grasp of reality
C. our child has increased his daily caloric intake
D. our child is able to complete his homework on time
Answer: D. our child is able to complete his homework on time
22. A nurse is administering hydromorphone to a client who is experiencing postoperative pain.
Which of the following findings is an adverse effect of this medication?
A. dilated pupils
B. tachypnea
C. urinary retention
D. hypertension
Answer: C. urinary retention
23. A male nurse is assigned to care for an older adult female client. The client tells the nurse that
she wants a female nurse to care for her. Which of the following statements should the nurse
make?
A. you will need to speak with the nurse manager about this
B. I care for other female clients and they do not mind having a male nurse
C. I will ask to have you assigned to a female nurse
D. I will get a female assistive personnel to provide your bath
Answer: C. I will ask to have you assigned to a female nurse
24. A nurse is caring for a client who has a femur fracture with the leg in Buck’s traction. Which
of the following actions should the nurse take?
A. Apply 6.8 kg(15 lb) of weight for use in traction.
B. Remove the weights for the 20 min for the clients report of severe pain.
C. Compare bilateral pedal pulses
D. Position the knot of the rope at the top of the pulley
Answer: C. Compare bilateral pedal pulses
25. A nurse at a provider’s office is caring for a client who is in the third trimester of pregnancy.
Which of the following findings should the nurse report to the provider?
A. periodic numbness of the fingers
B. shortness of breath when climbing stairs
C. leukorrhea
D. blurred vision
Answer: D. blurred vision
26. A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has
mild hypertension. Which of the following statements by the client indicates an understanding of
the teaching?
A. I can have two glasses of wine with dinner
B. I will set my blood pressure goal at 130 over 84
C. I should decrease my salt intake to 2 grams per day
D. I should exercise for 15 minutes two times per week
Answer: C. I should decrease my salt intake to 2 grams per day
27. A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck.
Which of the following instructions should the nurse include in the teaching?
A. cleanse the neck by rubbing with a washcloth
B. limit fluid intake to 750 mL per day
C. avoid exposing the neck to the cold
D. eat three large meals each day
Answer: C. avoid exposing the neck to the cold
28. A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a
new prescription for timolol eye drops. Which of the following statements by the client indicates
an understanding of the teaching?
A. this medication will dilate my eyes
B. this medication will darken the color of my eyes
C. I should check my heart rate while taking this medication
D. I should take a zinc supplement while taking this medication
Answer: C. I should check my heart rate while taking this medication
29. A nurse is collecting data from a 9-year-old child during a well-child visit. Which of the
following findings should the nurse expect?
A. expresses conflict over independence and control
B. grasps concepts of cause-and-effect
C. demonstrates self-centered thinking
D. displays emotional detachment from parents
Answer: B. grasps concepts of cause-and-effect
30. A nurse is reinforcing teaching with a client who is about to start using an albuterol metereddose inhaler. Which of the following instructions should the nurse include in the teaching?
A. tilt your head forward while inhaling
B. exhale immediately after inhaling
C. take three quick breaths while depressing the canister
D. close your mouth around the mouthpiece
Answer: D. close your mouth around the mouthpiece
31. A charge nurse is monitoring a group of assistive personnel (AP) regarding the use of gloves
in contact isolation. For which of the following actions by an AP should the charge nurse
intervene?
A. removes gloves last after other personal protective equipment
B. washes hands after removing gloves
C. pulls gloves off inside-out when tasks are completed
D. changes gloves between tasks for the same client
Answer: A. removes gloves last after other personal protective equipment
32. A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following
techniques should the nurse use?
A. apply suction while inserting the catheter
B. apply intermittent suction for 30 seconds
C. wait 1 minute between suctioning attempts
D. insert the catheter 10 cm (4 in)
Answer: C. wait 1 minute between suctioning attempts
33. A nurse is caring for a client who recently gave birth to her first child. The newborn is crying
and the client states. “ I can't seem to do anything right. What should I do?” Which of the
following responses should the nurse make?
A. babies need to cry soon after they are born to develop their lungs
B. let me show you how to swaddle and cuddle him, then you try
C. if I turn him on his side, maybe he’ll go back to sleep
D. I’ll take him back to the nursery, so you can get some rest
Answer: B. let me show you how to swaddle and cuddle him, then you try
34. A nurse is caring for a group of clients. Which of the following clients should the nurse
recognize is experiencing fluid volume excess?
A. A client has a urinary tract infection with bladder distention two fingerbreadths below the
umbilicus.
B. A client who has heart failure and has had orthopnea for 2 days
C. A client who has COPD and an oxygen saturation of 92%
D. A client who is 1 day postoperative and has an Hgb level of 16 g/dl
Answer: B. A client who has heart failure and has had orthopnea for 2 days
35. A nurse in an acute care setting is assisting in collecting client information to include in a
referral for a physical therapist. Which of the following information should the nurse plan to
include?
A. family medical therapy
B. medications taken prior to admission
C. medical health insurance claims
D. physical assessment findings
Answer: D. physical assessment findings
36. A nurse is preparing to give a change-of-shift report on a client who is 2 days postoperative
following a total knee arthroscopy. Which of the following information about the client should
the nurse include in the report?
A. preferred bath time
B. time of last pain medication
C. steps required for dressing change
D. admission vital signs
Answer: A. preferred bath time
37. A nurse is reviewing the medical record of a client who has COPD. Which of the following
laboratory findings indicates a need to request a dietary referral for the client?
A. prealbumin 13 mg/dL
B. sodium 138 mEq/L
C. potassium 3.5 mEq/L
D. total calcium 10 mg/dL
Answer: A. prealbumin 13 mg/dL
38. A nurse is reviewing the home medications of a client who recently had transient ischemic
attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the
following over-the-counter medications interacts adversely with clopidogrel?
A. Ranitidine
B. Naproxen
C. Vitamin D3
D. Docusate sodium
Answer: B. Naproxen
39. A nurse is preparing to delegate client care to an assistive personnel (AP). Which of the
following information should the nurse verify prior to delegation?
A. the client’s age
B. the client’s length of facility stay
C. the AP’s years of experience
D. the AP’s job description
Answer: D. the AP’s job description
40. A nurse is reinforcing discharge teaching with a client who has a prescription for home
oxygen therapy. Which of the following statements by the client indicates an understanding of
the teaching?
A. I will increase the flow rate if I feel short of breath
B. I can use synthetic blankets on my bed
C. I will check my oxygen equipment at least once daily
D. I can use isopropyl alcohol to clean the nasal cannula when necessary
Answer: C. I will check my oxygen equipment at least once daily
41. A nurse on a mental health unit observes a client yelling at another client. Which of the
following actions should the nurse take first?
A. debrief staff members about the conflict
B. request security personnel restrain the client
C. place the client in seclusion
D. state expectations for the client’s behavior
Answer: D. state expectations for the client’s behavior
42. A nurse is assisting with the development of an education program for a group of older
adults. Which of the following actions should the nurse take first?
A. create handouts for participants
B. establish learning outcomes
C. determine the literacy level of participants
D. schedule a time to implement the program
Answer: B. establish learning outcomes
43. A nurse is preparing to apply a thigh-length sequential compression device for a client who is
postoperative. Which of the following actions should the nurse take?
A. position the client prone to apply the device
B. wrap the sleeve loosely around the clients lower leg
C. measure the circumference of the client’s upper leg
D. turn on the mechanical unit prior to applying the sleeve
Answer: C. measure the circumference of the client’s upper leg
44. A nurse is caring for a client who is on isolation precautions. Which of the following pieces
of personal protective equipment should the nurse remove first?
A. mask
B. gown
C. gloves
D. eyewear
Answer: C. gloves
45. A nurse is using a glucometer to measure a client’s capillary blood glucose level. Which of
the following actions should the nurse take?
A. select the central tip of a finger
B. keep the finger in a dependent position
C. test the first drop of blood that forms after the puncture
D. wear sterile gloves
Answer: B. keep the finger in a dependent position
46. A nurse is assisting with the care of a client who is 6 hr postoperative following a right knee
arthroplasty. Which of the following actions should the nurse take?
A. maintain the head of the client’s bed in high-fowler’s position it becomes saturated
B. check the client’s pedal pulses every hour
C. remove the client’s dressing when it becomes saturated
D. place an abductor wedge under the client’s right knee
Answer: B. check the client’s pedal pulses every hour
47. A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which
of the following interventions should the nurse recommend to include in the plan?
A. keep the client’s daily protein intake below 0.8 g/kg
B. measure the client’s abdominal girth daily
C. restrict the client’s sodium intake to 3 g per day
D. position the client supine with his legs elevated
Answer: B. measure the client’s abdominal girth daily
48. A nurse is preparing a vitamin K injection to give to a newborn. The newborn’s mother
questions the purpose of the medication. Which of the following responses should the nurse
make?
A. this medication will increase the immunity of your newborn
B. this medication will decrease the possibility of your newborn developing jaundice
C. this medication will decrease the risk of hemorrhage in your newborn
D. this medication will increase the absorption of nutrients in the intestine
Answer: C. this medication will decrease the risk of hemorrhage in your newborn
49. A nurse is reinforcing teaching with a client who has Rx for ferrous sulfate elixir.
Understanding teaching?
Answer: I will mix the medication with water
50. A nurse is caring for a female client who has indwelling catheter with a urinary drainage
system. Which of the following actions should the nurse take?
Answer: Coil the tubing on the bed above the collection bag
51. A nurse is caring for four clients. Which of the following situations requires a signed consent
form?
Answer: inserting a nasogastric tube
52. A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine.
Which of the following statements by the client indicates an understanding of the teaching?
A. I have to take this medication on an empty stomach
B. I have to remain upright for 1 hour after taking the medication
C. I should expect my tongue to turn black after I take this medication
D. I should take this medication in the morning and at bedtime
Answer: A. I have to take this medication on an empty stomach
53. A nurse is providing preoperative care to a client who reports he has no one at home to help
him after his outpatient surgery. Which of the following actions should the nurse take?
A. assist with a referral to a home health care agency
B. call the provider about admitting the client to the facility overnight
C. contact the next of kin to assist the client at home
D. give the client a list of home care assistants to contact
Answer: A. assist with a referral to a home health care agency
54. A nurse is assisting with the admission of a client who has varicella zoster. Which of the
following interventions should the nurse plan to implement?
A. administer aspirin if the client develops a fever
B. assign the client to a positive-airflow room
C. have visitors remain at least 0.91 m (3 feet) away from the client
D. initiate contact precautions for the client
Answer: D. initiate contact precautions for the client
55. A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.
The nurse notes that the client’s vagina and vulva are a purplish color. The nurse should
document this finding as which of the following?
A. chloasma
B. chadwick’s sign
C. ballottement
D. hegar’s sign
Answer: B. chadwick’s sign
56. A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which
of the following findings indicates fluid volume excess?
A. distended neck veins
B. decreased bowel sounds
C. urine output of 360 mL/12 hr
D. blood pressure of 100/74 mm Hg
Answer: A. distended neck veins
57. A nurse is reinforcing teaching with the guardian of a 2 month old infant about immunization.
Which of the following statements by a guardian indicates an understanding of the teaching?
A. I should not feed my baby anything for 2 hours prior to an immunization
B. My baby will receive the rotavirus immunization orally
C. I should expect my baby to have a high fever for 24 hours after immunization
D. my baby will receive three doses of the meningococcal immunization before kindergarten
Answer: B. My baby will receive the rotavirus immunization orally
58. A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should
expect which of the following instructions from the provider?
A. obtain an aPTT level
B. administer protamine sulfate
C. reduce the dosage of the medication
D. change the medication to heparin IV
Answer: C. reduce the dosage of the medication
59. A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse
should identify that which of the following actions by the AP demonstrates effective use of
supplies?
A. empties the sharps container when it is full
B. wears clean gloves when performing oral hygiene
C. wears an N95 mask when bathing a client who has C. difficile
D. disposes of contaminated sheets in a linen bag
Answer: B. wears clean gloves when performing oral hygiene
60. A nurse determines that clients who receive zolpidem postoperatively have an increased fall
rate compared to other postoperative clients. To which of the following members of the health
care team should the nurse report these findings?
A. the surgeon
B. the risk manager
C. the pharmacist
D. the case manager
Answer: B. the risk manager
61. A nurse is collecting data from the caregiver of a client who has Alzheimer’s disease. The
caregiver reports the client has difficulty sleeping at night and wanders throughout the house.
Which of the following interventions should the nurse recommend?
A. give the client a barbiturate medication at bedtime
B. allow the client to nap for at least 1 hr during the day
C. put a simple lock on the client’s bedroom door
D. encourage the client to take frequent walks during the day
Answer: D. encourage the client to take frequent walks during the day
62. A nurse is reinforcing teaching with a client who has stomatitis. Which of the following
instructions should the nurse include in the teaching?
A. consume soft, bland foods
B. use lemon glycerin swabs
C. eat foods high in Vitamin B12
D. rinse the mouth with an alcohol based mouthwash
Answer: A. consume soft, bland foods
63. A nurse should recognize that a client’s right to confidentiality has been breached in which of
the following situations?
A. a nurse tells the chaplain that her assigned client has a new diagnosis of cancer?
B. a newly licensed nurse discusses his client’s postoperative complications during shift report
C. a social worker reds a client’s chart as a follow-up to a requested consultation
D. a facility risk manager includes information from a client’s medical record in a written report
Answer: A. a nurse tells the chaplain that her assigned client has a new diagnosis of cancer?
64. A nurse is positioning a client in preparation for a lumbar puncture. In which of the following
positions should the nurse place the client?
A. lithotomy
B. lateral recumbent
C. semi-fowler’s
D. prone
Answer: B. lateral recumbent
65. A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After
attempting other measures to prevent the client from self-harm, the nurse places wrist restraints
on the client. Which of the following actions should the nurse take?
A. remove the restraints from the client’s wrists every 2 hr
B. check that one finger will fit between the client’s wrists and the restraints
C. fasten the restraints’ ties to the bed’s side rails
D. contact the provider within 48 hr to obtain a prescription for the restraints
Answer: B. check that one finger will fit between the client’s wrists and the restraints
66. A nurse is caring for a client who has dehydration due to diarrhea. Which of the following
findings should the nurse report to the provider?
A. serum creatinine 1.0 mg/dL
B. urine output 12 mL/hr
C. BUN 18 mg/dL
D. urine specific gravity 1.020
Answer: B. urine output 12 mL/hr
67. A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for
excessive vaginal bleeding. Which of the following findings should the nurse expect?
A. saturation of perineal pad in 15 min
B. client report of uterine cramping
C. boggy fundus 3 fingerbreadths above the umbilicus
D. client report of burning with urination
Answer: B. client report of uterine cramping
68. A nurse is reinforcing teaching about newborn care with a new guardian. Which of the
following statements by the guardian indicates an understanding of the teaching?
A. I will give my baby a bath every day
B. I will bathe my baby under a faucet of running water
C. I will wash my baby’s face with a warm, wet washcloth without soap
D. I will wash my baby’s head using a moist towelette
Answer: D. I will wash my baby’s head using a moist towelette
69. A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve
headache pain. Which of the following conditions in the client’s history should the nurse identify
as a contraindication?
A. diabetes mellitus
B. hepatitis C
C. hypotension
D. cystitis
Answer: B. hepatitis C
70. A nurse is assisting with the planning of an in-service about updates in wound care for
nursing staff. Which of the following sources should the nurse identify as providing the best
evidence-based information?
A. information from a wound care product vendor
B. an entry on a nursing blog addressing wound healing
C. a peer-reviewed journal article
D. first-hand experience with wound care products
Answer: D. first-hand experience with wound care products
71. A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of
dying. Which of the following findings requires intervention by the nurse?
A. a family member remains at the client’s bedside 24 hr each day
B. an assistive personnel is encouraging intake of oral fluids
C. supplemental oxygen is in use
D. Benzodiazepines are administered every 4 hr
Answer: B. an assistive personnel is encouraging intake of oral fluids
72. A nurse is reinforcing discharge teaching with the family of a client who has dependent
personality disorder. Which of the following instructions should the nurse include in the
teaching?
A. maintain a verbal no-harm contract with the client
B. assume responsibility for making the client’s decisions
C. encourage the client to be assertive
D. limit the client’s social interactions
Answer: C. encourage the client to be assertive
73. A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the
following statements should the nurse make?
A. it enhances quality of life by promoting comfort
B. it is for clients who are given 6 months or less to live
C. it is for clients who have a terminal illness
D. it includes restriction of nutritional support
Answer: A. it enhances quality of life by promoting comfort
74. A nurse at a long-term care facility is reviewing the plan of care for a client who has a
prescription for mitten restraints. Which of the following tasks should the nurse assign to an
assistive personnel?
A. determine the circulation status of the affected extremities every 2 hr
B. instruct the client’s family about the purpose of mitten restraints
C. evaluate the need for the client to remain in mitten restraints
D. assist the client with range-of-motion exercises of the hands
Answer: D. assist the client with range-of-motion exercises of the hands
75. A nurse is assisting with the plan of care for a client who is in the third trimester of
pregnancy and has ankle edema. Which of the following interventions should the nurse include
in the client’s plan of care?
A. administer diuretics
B. limit fluid intake
C. apply support stockings
D. place on bedrest
Answer: C. apply support stockings
76. A nurse is collecting data from a client whose partner died 1 year ago. Which of the
following findings indicates that the client is experiencing complicated grief?
A. the client keeps a framed picture of his partner on the wall
B. the client develops chest pain each time he talks about his partner
C. the client reports he has no interest in dating
D.-the client attends a grief support group twice each month
Answer: B. the client develops chest pain each time he talks about his partner
77. A nurse is reinforcing teaching with a client who is postoperative following a partial
gastrectomy. Which of the following instruction should the nurse include to prevent dumping
syndrome?
A. Ambulate for 15 min after each meal
B. include one serving of protein with each meal
C. consume high fiber foods at each meal
D. drink at least 240 mL (8oz) of liquid with each meal
Answer: B. include one serving of protein with each meal
78. A nurse is reinforcing teaching with a client who has a new prescription for transdermal
nitroglycerin patches. Which of the following statements any the client indicates an
understanding of the teaching?
A. I will replace the patch every 12 hours
B. I will apply the patch in the same place every day
C. I will remove the patch if I develop a headache
D. I will place the patch on a hairless area of skin
Answer: A. I will replace the patch every 12 hours
79. A charge nurse is reinforcing teaching with a newly licensed nurse about the nurse’s role in
obtaining informed consent. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
A. I will sign the consent form to indicate that the client has received written materials
explaining the procedure
B. I will provide the client with an explanation of the procedure before I sign the consent form
C. When I sign the consent form, I am stating that the client appears to be competent to give
consent
D. It is my responsibility to obtain informed consent from the client prior to the procedure
Answer: D. It is my responsibility to obtain informed consent from the client prior to the
procedure
80. A nurse is assisting with the admission of an adolescent client who is suspected to have
bacterial meningitis. Which of the following findings should the nurse expect?
A. hematuria
B. jaundice
C. nuchal rigidity
D. 2+ pedal edema
Answer: C. nuchal rigidity
81. A nurse is reinforcing teaching with a parent of a 4-month-old infant during a home visit.
Which of the following statements by the parent indicates an understanding of the teaching?
A. I will leave the plastic covering on the crib mattress
B. I will lay my baby’s head on a pillow while he is in the crib
C. I will leave my baby’s bib on while he is sleeping
D. I will use a cool-mist vaporizer in my baby’s room
Answer: D. I will use a cool-mist vaporizer in my baby’s room
82. A nurse is receiving a change-of-shift report on four clients. Which of the following clients
should the nurse plant to see first?
A. a client who had a laparoscopic appendectomy 8 hr ago and is waiting discharge
B. a client who had a renal biopsy 3 hr ago and has pink tinged urine
C. a client who has cirrhosis and severe pruritus
D. a client who has a femur fracture and reports numbness of the toes
Answer: D. a client who has a femur fracture and reports numbness of the toes
83. A nurse enters a client’s room and finds her sitting on the floor next to the shower. The client
states that she slipped on some water outside of the shower. Which of the following actions
should the nurse take first?
A. complete an incident report
B. document the fall in the client’s medical record
C. measure the client’s vital sign
D. notify the client’s provider
Answer: C. measure the client’s vital sign
84. A nurse is contributing to the plan of care for a client who is scheduled to receive
electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions
should the nurse recommend to include in the plan?
A. schedule follow-up ECT treatments 1 month apart
B. initiate NPO status 1 hr prior to ECT
C. instruct the client to notify the provider if discomfort is felt during ECT
D. provide frequent reorientation after ECT
Answer: D. provide frequent reorientation after ECT
85. A nurse is collecting data from a client who is in renal failure. The nurse should identify that
which of the following findings is a manifestation of hyperkalemia?
A. trousseau’s sign
B. dry mucous membranes
C. hyperactive reflexes
D. irregular heart rate
Answer: D. irregular heart rate
86. A nurse is collecting data from a 6-month-old infant during a well-child visit. Which of the
following findings should the nurse report to the provider (click “exhibit” button for additional
information about the client. There are three tabs that contain separate categories of data)
A. feeding habits
B. gross motor skills
C. temperature
D. weight
Answer: D. weight
87. A nurse is caring for a client who speaks a different language than the nurse. The client’s
partner tells the nurse that the client would like to go home against medical advice (AMA).
Which of the following actions should the nurse take?
A. discharge the client and notify the health care provider
B. request the services of an interpreter to determine the clients wishes
C. ask the partner to reiterate the consequences of leaving AMA to the client
D. have the client’s partner sign an AMA form
Answer: B. request the services of an interpreter to determine the clients wishes
88. A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has
hyperemesis gravidarum. Which of the following client statements indicates an understanding of
the nurse’s instructions?
A. I will eat a low-protein snack 30 minutes before going to bed each night
B. I will eat or drink something every 2 to 3 hours throughout the day
C. I will wait 1 hour after getting up in the morning to have breakfast
D. I will try to eat balanced meals instead of only foods that appeal to my taste
Answer: B. I will eat or drink something every 2 to 3 hours throughout the day
89. A nurse is assisting with monitoring a client who is receiving a unit of packed RBC’s. Which
of the following findings indicates the client is experiencing a transfusion reaction?
A. straw-colored urine
B. blood pressure 158/92 mm Hg
C. apical pulse rate 58/min
D. temperature 38.8 degree C(101.8 F)
Answer: D. temperature 38.8 degree C(101.8 F)
90. A nurse is reviewing information about advance directives with a newly admitted client.
Which of the following statements by the client indicates an understanding of the information?
A. advance directives include instructions for resolving financial matters after my death
B. advance directives include a living will
C. federal legislation dictates the legal guidelines for advance directives
D. my medical record should not include my advance directives
Answer: B. advance directives include a living will
91. A nurse is participating in an interprofessional client care conference for a client who has
experienced a stroke. The nurse should identify which of the following client care issues requires
reporting to the interprofessional team?
A. the client tells the nurse he prefers a snack before bedtime
B. the client is unable to grasp eating utensils
C. the client requires reinforcement of teaching about the purpose of his medications
D. the client requests to perform ADLs later in the day
Answer: B. the client is unable to grasp eating utensils
92. A nurse is assisting with the care of a client who has hearing loss and has questions regarding
their medication. Which of the following actions should the nurse take?
A. choose a room that is well lit
B. sit on the client’s right side
C. ask a few questions at a time
D. exaggerate lip movement while speaking
Answer: A. choose a room that is well lit
93. A nurse is a mental facility that is caring for a client who reports palpitations and a sense of
impending doom. Which of the following actions should the nurse take first?
A. explain to the client that anxiety causes physical manifestations
B. explore behaviors that have helped to reduce the client’s anxiety in the past
C. minimize environmental stimuli in the client’s surroundings
D. administer an anti-anxiety medication
Answer: C. minimize environmental stimuli in the client’s surroundings
94. A nurse is collecting data from a client who has acute cholecystitis. Which of the following
findings should the nurse expect?
A. pain in the right upper abdomen
B. discomfort with urination
C. pain radiating to the jaw
D. increased abdominal discomfort prior to meals
Answer: A. pain in the right upper abdomen
95. A nurse is assisting with the plan of care for a client who has burns to his lower extremities.
Which of the following actions should the nurse include in the plan?
Answer: cleanse the most contaminated wound first
96. A nurse is caring for a client who is postoperative following abdominal surgery and has a
wound evisceration. Which of the following actions should the nurse take?
A. place the client's knees in an extended position
B. hold gentle, direct pressure on the protruding organ
C. raise the head of the bed to a 45 degree angle
D. cover the wound with sterile, saline-soaked gauze
Answer: D. cover the wound with sterile, saline-soaked gauze
97. A nurse is collecting data from a client who is 1 day postoperative following a transurethral
resection of the prostate. Which of the following findings should the nurse report to the provider?
A. frequent urge to urinate
B. urine output of 300 mL over 8 hr
C. dark red urine
D. occasional small clots in the urine
Answer: C. dark red urine
98. A nurse is assisting with the care of a group of clients. Which of the following actions should
the nurse take to manage her time effectively? SATA
A. plan a time at the end of the shift to document nursing interventions
B. complete activities with one client before moving to another unit
C. delegate collection of vital signs to the assistive personnel on the team
D. make a priority to-do list a the beginning of the shift
E. keep track of how long it takes to complete certain tasks
Answer: B. complete activities with one client before moving to another unit
C. delegate collection of vital signs to the assistive personnel on the team
D. make a priority to-do list a the beginning of the shift
99. A nurse is caring for a client who is unable to perform ADLs and wears dentures. Which of
the following actions should the nurse take when providing denture care?
A. remove the lower dentures before the upper dentures
B. store the dentures in a dry denture cup on the bedside table after cleaning
C. place a towel in the sink when cleaning the dentures
D. use a circular motion to cleanse the biting surface of the dentures
Answer: C. place a towel in the sink when cleaning the dentures
100. A nurse is collecting data from a client who is at 12 weeks of gestation. The client states,
“we’ve been trying to get pregnant for several months, but now I’m not sure I’m ready.” Which
of the following responses should the nurse make?
A. many women experience feelings of ambivalence during pregnancy
B. I wouldn’t worry about it if I were you. You’ll be a good mother
C. you need to talk to a therapist about how you’re feeling
D. why do you feel that way if you’ve been trying to get pregnant
Answer: A. many women experience feelings of ambivalence during pregnancy
101. A charge nurse working in a long-term care facility overhears two assistive personnel (AP)
in the nurses’ station discussing a client who was just admitted. Which of the following actions
should the charge nurse take?
A. document the event in the client’s progress notes
B. tell the APs to stop the conversation
C. submit an incident report to the risk manager
D. inform the client of the APs actions
Answer: B. tell the APs to stop the conversation
102. A nurse is reinforcing teaching with a newly licensed nurse about the caring for a client who
has a history of dysphagia. Which of the following instructions should the nurse include in the
teaching?
A. use a needleless syringe to instill feedings
B. give the client a straw to use for drinking
C. provide thin liquid to help the client swallow
D. place oral suction equipment next to the client’s bedside
Answer: D. place oral suction equipment next to the client’s bedside
103. A nurse is preparing to complete a sterile dressing change for a client’s wound. Which of the
following actions should the nurse take first?
A. open the outermost flap of the sterile kit away from the nurse’s body
B. open the flap on the sterile kit nearest to the nurse and place the flap on the work surface
C. open the side flap of the sterile kit, allowing it to lie flat on the work surface
D. apply sterile gloves
Answer: A. open the outermost flap of the sterile kit away from the nurse’s body
104. A nurse is caring for a client who has paranoid schizophrenia and believes that they are
being followed by the FBI agents who are pretending to be psychiatric staff. Which of the
following responses should the nurse make?
A. what makes you think the staff is following you?
B. this must be very frightening for you, let’s talk more about it
C. the psychiatric staff is not FBI, they are here to help you
D. why do you feel the staff is the FBI
Answer: B. this must be very frightening for you, let’s talk more about it
105. A nurse is participating in a performance improvement program. Which of the following
actions should the nurse take to evaluate the effectiveness of the program?
A. identify data collection methods
B. review the facility’s policy and procedure manual
C. perform chart audits
D. define the problem
Answer: C. perform chart audits
106. A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular
insulin 15 units subcutaneously. After injecting 10 unit air into the NPH insulin vial, which of the
following actions should the nurse take next?
A. inject 15 units of air into the regular insulin vial
B. place the cap over the needle
C. verify the dosage with another nurse
D. withdraw 10 units of NPH insulin
Answer: A. inject 15 units of air into the regular insulin vial
107. A nurse is completing post mortem documentation for a client. Which of the following
information should the nurse include in the documentation?
A. location of the identification tag on the client’s body
B. cause of the clients death
C. last set of the client's vital signs
D. copy of the clients advance directives
Answer: B. cause of the clients death
108. A nurse is providing a change-of-shift report for a client. Which of the following
information should the nurse include in the report?
A. the client reports pain is reduced when he is positioned on his side
B. the clients mother died 4 years ago from breast cancer
C. the client received the prescribed antibiotic every 8 hours
D. the clients partner visited earlier today for 2 hours
Answer: A. the client reports pain is reduced when he is positioned on his side
109. A nurse is collecting data from a client who has left sided heart failure. For which of the
following findings should the nurse notify the provider?
A. fatigue when ambulating 152 m (500 ft)
B. productive cough with pink, frothy sputum
C. pale, clammy skin
D. weight loss of 1 kg (2.2 lb ) in the past 24 hr
Answer: B. productive cough with pink, frothy sputum
110. A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for
advanced breast cancer. The client states, “ I am thinking about stopping the treatments. “ Which
of the following responses should the nurse make?
A. I would feel the same way if I were you
B. tell me more about what you are thinking
C. You’ll be cancer free after you complete your treatment
D. why do you think that would be a good choice?
Answer: B. tell me more about what you are thinking
111. A nurse is reinforcing teaching with a client about monitoring her blood pressure at home
with a digital device. Which of the following statements by the client indicates an understanding
of the teaching?
A. I will make sure my hand is about 6 inches below my heart when i use the device
B. I will loosely wrap the blood pressure cuff around my upper arm
C. I will know my blood pressure is too high if I get a reading of 140 over 90 or higher
D. I will check my blood pressure at a different each day
Answer: C. I will know my blood pressure is too high if I get a reading of 140 over 90 or higher
112. A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of
the following findings should the nurse report to the provider?
A. BUN 15 mg/dL
B. fasting blood glucose 72 mg/dL
C. urine protein 3+
D. Hgb 13.2 g/Dl
Answer: C. urine protein 3+
113. A nurse in a provider’s office is caring for a group of clients who have communicable
diseases. Which of the following infections should the nurse report to the state health
department?
A. sarcoptes scabiei
B. impetigo contagiosa
C. human papillomavirus
D. neisseria gonorrhoeae
Answer: D. neisseria gonorrhoeae
114. A nurse is reinforcing teaching with a client about collecting a stool specimen to check for
occult blood. Which of the following statements by the client indicates an understanding of the
teaching?
A. I should collect a specimen once each week for 4 weeks
B. eating pasteurized dairy products will affect my test results
C. I should avoid eating red meat for 3 days before my test
D. having urine mixed in with the stool will not affect the results
Answer: C. I should avoid eating red meat for 3 days before my test
115. A nurse is reinforcing teaching about passive range-of-motion exercises with the family of a
client who has had a stroke. Which of the following instructions should the nurse include in the
teaching?
A. position the bed at mid-thigh level
B. repeat each exercise movement 10 times
C. move each joint just past the point of resistance
D. support the extremity above and below each joint during the exercise
Answer: D. support the extremity above and below each joint during the exercise
116. A nurse is reinforcing teaching with a client who has a new prescription for propranolol. The
nurse should include which of the following as a potential adverse effect of this medication?
A. increased urinary output
B. sudden weight loss
C. white patches on the tongue
D. decreased heart rate
Answer: D. decreased heart rate
117. A nurse enters the room of a school-age child and finds him on the floor experiencing a
tonic-clonic seizure. Which of the following actions should the nurse take?
A. turn the child onto his back
B. place a padded tongue blade in the child’s mouth
C. restrain the child’s upper extremities
D. place a pillow under the child’s head
Answer: D. place a pillow under the child’s head
118. A nurse is collecting data from a client who is 12 hr postoperative following intestinal
surgery. Which of the following findings should the nurse report to the charge nurse prior to
client ambulation?
A. oral temperature 37.6 degree C (99.7 F )
B. apical pulse rate 88/min
C. respiratory rate 20/min
D. oxygen saturation 90%
Answer: D. oxygen saturation 90%
119. A nurse is reinforcing teaching about ADL’s with a client who has multiple sclerosis. Which
of the following client statements should indicate to the nurse an understanding of the teaching?
A. I will decrease my fiber intake
B. I will take rest periods throughout the day
C. I will take tub baths rather than showers
D. I will eliminate vitamin D from my diet
Answer: B. I will take rest periods throughout the day
120. A nurse is caring for a client who has been given methylergonovine intramuscularly for a
postpartum hemorrhage. The nurse should monitor for which of the following adverse effect?
A. elevated blood pressure
B. diarrhea
C. uterine relaxation
D. hematuria
Answer: A. elevated blood pressure
121. A nurse is caring for a client who has anorexia nervosa and a behavioral management plan
in place. Which of the following findings should the nurse identify as an indication that the
behavioral plan is effective?
A. potassium 3.5 mEg/L
B. sodium 130 mEq/L
C. BMI 14.5
D. Hgb 10 g/dL
Answer: A. potassium 3.5 mEg/L
122. A nurse is assisting with the admission of a client who states, “The last time I was in this
hospital, the nurses took forever to answer my call light.” Which of the following is an
appropriate response by the nurse?
A. I am sure no one meant to ignore you
B. That must have been a difficult experience for you
C. Let’s discuss what brought you to the hospital this time
D. It will not happen this time because we have more staff
Answer: B. That must have been a difficult experience for you
123. A nurse is caring for a client who is 2 days postoperative. The client has a prescription for
acetaminophen 300 mg with a codeine 30 mg every 3 to 4 hr PRN pain. The nurse inadvertently
administers 2 tablets to the client. In which of the following locations should the nurse document
this error?
A. controlled substance inventory record
B. nursing care plan
C. incident report
D. provider’s progress notes
Answer: C. incident report
124. A nurse on a medical-surgical unit is preparing to assist with the admission of clients who
were injured in a tornado. Which of the following clients should the nurse recommend for
discharge to make room for the new admission?
A. a client who had a lobectomy and has a chest tube drainage system
B. a client who has cervical cancer and an internal radioactive implant
C. a client who had a radical mastectomy 36 hr ago and has a surgical drain
D. a client who had a cerebrovascular accident 8 hr ago and received thrombolytic therapy
Answer: C. a client who had a radical mastectomy 36 hr ago and has a surgical drain
125. A nurse in an acute mental health facility is caring for an adolescent who is exhibiting
destructive behavior. Which of the following actions should the nurse take after applying
physical restraints to the client?
A. ensure that the provider has signed a prescription for restrained within 48 hr
B. monitor the client’s range of motion every 60 min
C. offer the client a nutritious snack every 4 hr
D. plant to remove the restraints as soon as the client is calm
Answer: D. plant to remove the restraints as soon as the client is calm
126. A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which
of the following findings should the nurse expect?
A. blunted affect
B. hypersomnia
C. grandiose thinking
D. slurred speech
Answer: C. grandiose thinking
127. A community health nurse is assisting with the development of a pamphlet regarding
choking hazards for toddlers. Which of the following foods should the nurse include?
A. potatoes
B. oranges
C. grapes
D. corn
Answer: C. grapes
128. A nurse is caring for a 3-year old child immediately following a tonic-clonic seizure. Which
of the following actions should the nurse take?
A. place the child in a supine position
B. check the child for oral injuries
C. administer an oral antiepileptic medication
D. offer the child sips of clear fluids
Answer: B. check the child for oral injuries
129. A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse
should plan to initiate which of the following is the procedures when caring for this client?
A. droplet precautions
B. protective environment
C. contact precautions
D. airborne precautions
Answer: C. contact precautions
130. A nurse is reinforcing teaching with a client who is at 16 weeks of gestation and has a
prescription for ferrous sulfate to treat iron-deficiency anemia. Which of the following
recommendations should the nurse make to improve the absorption of the medication?
A. eliminate berries and citrus fruits from your diet
B. avoid drinking milk with the iron supplement
C. increase your dietary fiber intake
D. take the iron supplement with green tea
Answer: B. avoid drinking milk with the iron supplement
131. A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic
pain with contractions. Which of the following actions should the nurse take?
A. instruct the client to change positions frequently
B. apply fundal pressure during contractions
C. tell the client to push during contractions
D. encourage the client to soak in a hot bath
Answer: D. encourage the client to soak in a hot bath
132. A charge nurse is reinforcing teaching with a newly licensed nurse about infection control
measures. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
A. for a client who has C-Diff, I will cleanse my hands with an alcohol-based rub
B. soiled dressings should be placed in a biohazard trash receptacle
C. droplet precautions require that I wear a gown and gloves when providing client care
D. following a blood spill, I should use a bleach solution with a ratio of 1 to 20
Answer: B. soiled dressings should be placed in a biohazard trash receptacle
133. A nurse is reinforcing teaching with new parents about car seat safety. Which of the
following instructions should the nurse include?
A. place the shoulder harnesses at the level of the infant’s shoulders
B. position the care seat at a 90 degree angle
C. Keep the airbag on if the car seat is in the front seat
D. put a small cushion under the newborn’s head for support
Answer: A. place the shoulder harnesses at the level of the infant’s shoulders
134. A nurse is collecting data from a client who is 8 hr postoperative following an
appendectomy. Which of the following manifestations is the best indication that the client needs
a PRN analgesic?
A. the client demonstrates a decreased attention span
B. the client reports pain as 7 on a scale of 0 to 10
C. the client’s heart rate has increased to 110/min
D. the client grimaces when changing positions
Answer: B. the client reports pain as 7 on a scale of 0 to 10
135. A nurse is contributing to the plan of care for a client who is experiencing panic-level
anxiety and reports visual hallucinations. Which of the following actions should the nurse
recommend including in the plan of care?
A. use a low-pitched voice when speaking to the client
B. provide the client with a restricted-calorie meal
C. instruct the client to spend quiet time alone in their room
D. encourage the client to participate in a game in the day room
Answer: A. use a low-pitched voice when speaking to the client
136. A nurse is assisting in developing a list of internet sites for clients to obtain valid health
information. When evaluating internet resources, which of the following findings indicates the
information likely contains credible medical information?
A. the website was last updated 3 years ago
B. the author cites references to statement made
C. the author’s name is listed without credentials
D. the website URL is listed as .com
Answer: B. the author cites references to statement made
137. A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the
following findings should the nurse expect?
A. clammy skin
B. bounding pulse
C. elevated blood pressure
D. fruity breath odor
Answer: D. fruity breath odor
138. A nurse working in a clinic is reinforcing teaching with a client who has hepatitis A. Which
of the following client statements indicates an understanding of the teaching?
A. I know that this virus is transmitted by contact with my blood
B. I can continue to prepare meals for my family
C. I will wash my hands using an alcohol-based cleanser
D. I will use different hand towels than others in my home
Answer: D. I will use different hand towels than others in my home
139. A nurse is collecting data from a client who uses a continuous positive airway pressure
(CPAP) machine at night for sleep apnea. The nurse should identify which of the following
findings an as indication of proper CPAP use?
A. the therapeutic dose of albuterol is being inhaled
B. there is one finger width between the strap on the mask and the client’s face
C. the mask is secured over the client’s mouth and the client’s nose ins uncovered
D. the mask fits loosely so air can escape from underneath
Answer: B. there is one finger width between the strap on the mask and the client’s face
140. A nurse is caring for an older adult client who has acute delirium. Which of the following
actions should the nurse take first?
A. keep lights on in the client’s room
B. encourage visits from family members
C. administer an anxiolytic medication
D. determine the client’s level of consciousness
Answer: A. keep lights on in the client’s room
141. A nurse is reinforcing teaching with a new mother about facility security measures. Which
of the following statements by the mother indicates an understanding of the teaching?
Answer: I will have an identification band that matches the one my baby wears
142. A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube
in place. Besides obtaining an x-ray, which of the following methods should the nurse use to
verify the placement?
A. inject air and listen for bubbling
B. measure the gastric residual
C. test the pH of the gastric aspirate
D. add food coloring to the formula
Answer: C. test the pH of the gastric aspirate
143. A nurse is contributing to an in-service for newly licensed nurses about situations requiring
an incident report. Which of the following examples should the nurse include?
A. a nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to
a client
B. a nurse observes a client vomiting after receiving an oral pain medications
C. a nurse observes another nurse remove wrist restraints one at a time from a client who is
currently calm
D. a nurse discovers that a client’s family member has administered a PCA dose
Answer: A. a nurse discovers that an electronic IV pump delivered twice the prescribed amount
of fluid to a client
144. A nurse is reviewing the medical records of five clients. For which of the following events
should the nurse write an incident reports? (SATA)
A. A client who has an infection refused the evening meal
B. A client received an 0900 daily medication at 1000
C. A client received the first done of an antibiotic 1 hr before the collection of blood for culture
and sensitivity testing
D. An Approximate amount of urine was recorded after the urine leaked from the client’s catheter
bag
E. A client fell when ambulating to the bathroom alone
Answer: C. A client received the first done of an antibiotic 1 hr before the collection of blood for
culture and sensitivity testing
E. A client fell when ambulating to the bathroom alone
145. A nurse is reviewing the guidelines for documenting client care. Which of the following
actions should the nurse plan to take?
A. Document giving a dose of pain medication just prior to administration
B. Limit documentation to subjective information
C. Avoid quoting client comments when documenting
D. Document information telephoned in by a nurse who left the unit for the day
Answer: C. Avoid quoting client comments when documenting
146. A nurse in a provides office is reinforcing teaching about skin care with a client who has a
new diagnosis of systemic lupus erythematosus. Which of the following statements by the client
indicates an understanding of the teaching?
A. I will use an astringent on my face
B. I will limit my time in the tanning bed to 15 minutes
C. I will cleanse my skin using an antibacterial soap
D. I will dry my skin by patting it with a towel
Answer: C. I will cleanse my skin using an antibacterial soap
147. A nurse is caring for a client who has terminal cancer. Which of the following actions
should the nurse take to promote the client’s autonomy?
A. Be honest with the client about the prognosis
B. administer pain medication on a routine schedule
C. provide privacy during client care procedures
D. allow the client to choose treatment times
Answer: A. Be honest with the client about the prognosis
148. A nurse is monitoring a client who has received external radiation for throat cancer. Which
of the following findings should the nurse expect?
Answer: Loss of taste
149. A home health nurse is caring for an older adult client who lives with a family caregiver and
has urinary incontinence. The client states, “I guess I will be locked in my room again for
wetting the bed.” Which of the following actions should the nurse take?
A. review the medical record to see if the client has reported abuse in the past
B. report the suspected abuse to the nurse manager
C. restrict family members from visiting with the client
D. contact the clients caregiver to discuss the clients comment
Answer: D. contact the clients caregiver to discuss the clients comment
150. A nurse is collecting a health history from the guardian of a 4 year old child. Which of the
following statements by the guardian is the priority for the nurse to address?
A. I have noticed that my child is withdrawn since we switched day care providers
B. My child continually asks me the same questions
C. I have a difficult time getting my child to eat green vegetables
D. My child still wets the bed at least two times per week
Answer: B. My child continually asks me the same questions
151. A nurse is contacting an occupational therapist for a client who had a stroke with right-sided
weakness and has difficulty eating. Which of the following roles should the nurse expect the
occupational therapist to perform?
A. assists in finding an economic living arrangements for the client
B. promotes health by ensuring the client’s nutritional needs are met
C. provides and adjusts devices to assist the client with daily living activities
D. uses heat, massage and water to treat a client’s strength and movement
Answer: C. provides and adjusts devices to assist the client with daily living activities
152. A nurse is preparing to administer morphine 30 mg PO to a client who reports pain.
Available is morphine solution 20 mg/mL. How many mL should the nurse administer? (Round
the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero)
Answer: The nurse should administer 1.5 mL.
153. A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1
week. Which of the following client statements indicates an understanding of the teaching?
A. I will follow a full liquid diet the day before the procedure
B. This procedure will take place while I’m under general anesthesia
C. I can expect rectal bleeding for a week after the procedure
D. I’ll have my friend drive me home after the procedure
Answer: D. I’ll have my friend drive me home after the procedure
154. A nurse is caring for a client who has toxoplasmosis and asks about the cause of the
infection. Which of the following responses should the nurse make?
Answer: Handling cat feces
155. A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as
a form of contraception. Which of the following statements by the client indicates an
understanding of the teaching?
A. I should avoid using spermicide with the cervical cap
B. I should use the cap during my menstrual cycle to prevent pregnancy
C. I need to have my provider check the size of the cap every 6 months
Answer: C. I need to have my provider check the size of the cap every 6 months
156. A nurse is providing a client with IV fluids and finds that the IV pump screen is
malfunctioning. Which of the following actions should the nurse take?
A. replace the IV pump’s tubing
B. discontinue use and tag the IV pumps
C. plug the IV pumps cord into a different outlet
D. clear the settings and reset the IV pump
Answer: A. replace the IV pump’s tubing
157. A nurse is caring for a client who is 2 days postoperative following an above-the knee
amputation. Which of the following actions should the nurse take to promote progression toward
independence and mobility for the client?
A. encourage the client to use the over bed trapeze
B. keep a loose, absorbent dressing over the client’s surgical site
C. caution the client to avoid a prone position while in bed
D. maintain abduction of the client’s residual limb with a pillow
Answer: A. encourage the client to use the over bed trapeze
158. A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an
esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the
procedure?
A. administer an oral contrast solution
B. inform the client the procedure will take 60 min
C. ensure that the client’s bladder is full
D. ensure that the client gave informed consent
Answer: D. ensure that the client gave informed consent
159. A nurse is assisting with the care of a client who has schizophrenia and auditory
hallucinations. Which of the following responses should the nurse make?
Answer: “Let’s talk about what the voices are saying to you.”
160. A nurse is reinforcing teaching with a parent of a preschooler about immunization. Which of
the following statements by the parent indicates an understanding of the teaching?
A. I can make several office visits, so my child does not get so many immunization at once
B. I understand that immunizations will be withheld if my child has lactose intolerance
C. My child will need to start the human papillomavirus series when he enters kindergarten
D. It is recommended that my child receive his first flu immunization at the age of 6
Answer: D. It is recommended that my child receive his first flu immunization at the age of 6
161. A nurse is caring for a client who was admitted for observation following a head injury.
Which of the following findings by the nurse indicates the client is experiencing increased
intracranial pressure?
A. decreased blood pressure
B. irritability
C. pallor
D. pin-point pupils
Answer: C. pallor
162. A nurse is reinforcing teaching with a parent of a newborn about home safety precautions.
Which of the following statements by the parent indicates an understanding of the teaching?
A. I will attach the pacifier to my newborn’s clothing with a string at bedtime
B. I will place my newborn’s crib near a heat vent during cold weather
C. I will make sure that I can fit one finger between the mattress and the side of my newborn’s
crib
D. I will place my newborn face up on a pillow when sleeping
Answer: C. I will make sure that I can fit one finger between the mattress and the side of my
newborn’s crib
163. A nurse is caring for an older adult client who reports dry, itchy skin. Which of the
following actions should the nurse take?
A. add moisturizing oil to the client’s bath water
B. place a humidifier in the client’s room
C. apply powder to the client’s skin
D. encourage the client to bathe frequently
Answer: A. add moisturizing oil to the client’s bath water
164. A nurse is preparing to administer a nasal drop medication to a client. Identify the sequence
of actions the nurse should take. (Move the steps into the box on the right, placing them in the
order of performance. Use all the steps)
A. Instill the medications
B. have the client blow their nose gently
C. position the client's head as indicated for the affected sinus cavity
D. position the client on her back
Answer: B. have the client blow their nose gently
D. position the client on her back
C. position the client's head as indicated for the affected sinus cavity
A. Instill the medications
165. A nurse is reinforcing teaching with a client who has arthritis. Which of the following
instructions should the nurse include in the teaching.
A. Apply ice to the inflamed joint
B. Sleep on a soft mattress.
C. Encage in low impact aerobic exercises.
D. Use fingers to push off from the bed or chair.
Answer: A. Apply ice to the inflamed joint
166. A nurse is assisting with discharge planning for a group of clients. Which of the following
clients should the nurse recommend for a home care referral?
A. An adolescent client who has a tibia fracture and requires crutches.
B. A young adult client who has a substance use disorder.
C. An older adult client who has heart failure and lives alone.
D. A middle adult client who had a mastectomy and requires chemotherapy.
Answer: C. An older adult client who has heart failure and lives alone.