ATI RN Fundamentals Proctored Exam
1. Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia?
Answer: Yes
2. A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which
of the following client's needs may the nurse assign to an assistive personnel (AP)?
A. Feeding a client who was admitted 24 hrs ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
Answer: C. Reapplying a condom catheter for a client who has urinary incontinence
Rationale: The application of a condom catheter is a non-invasive, routine procedure that the
nurse may delegate to the AP
3. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an
AP. Which of the following information should the nurse share with the AP? Select All.
A. The roommate is up independently.
B. The client ambulates with his slippers on over his ant embolic stockings
C. The client uses a front-wheeled walker when ambulating
D. The client had pain medication 30 min ago
E. The client is allergic to codeine
F. The client ate 50% of his breakfast this morning
Answer: B. The client ambulates with his slippers on over his ant embolic stockings
C. The client uses a front-wheeled walker when ambulating
4. An RN is making assignments for client care to a LPN at the beginning of the shift. Which of
the following assignments should the LPN question?
A. Assisting a client who is 24hr postop to use an incentive spirometer
B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump
Answer: D. Replacing the cartridge and tubing on a PCA pump
Rationale: The RN is responsible for the PCA pump
5. A nurse is preparing an in-service program about delegation. Which of the following elements
should she identify when presenting the 5 rights of delegation? Select all.
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances
Answer: B. Right supervision/evaluation
C. Right direction/communication
E. Right circumstances
Rationale: A and D are rights of medication administration
6. A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A
client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which
staff member should the nurse assign to this client?
A. Charge nurse
B. RN
C. LPN
D. AP
Answer: B. RN
Rationale: A client returning from surgery requires assessment and establishment of a plan of
care. RNs are responsible for this, especially if the client is potentially unstable.
7. A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells
him she will put a diaper on him if he does not use the urinal more carefully next time. Which of
the following torts is the AP committing?
A. Assault
B. Battery
C. False imprisonment
D. Invasion of privacy
Answer: A. Assault
Rationale: By threatening the client, the AP is committing as sault.
8. An adult client who is competent tells the nurse that he is thinking about leaving the hospital
against medical advice. The nurse believes that this is not in the client's best interest, so she
administers a PRN sedative med that the client has not requested along with his usual meds.
Which of the following tort has the nurse recommitted?
A. Assault
B. False imprisonment
C. Negligence
D. Breach of confidentiality
Answer: B. False imprisonment
Rationale: The nurse gave the med as a chemical restraint to keep the client from leaving the
facility against medical advice. The client did not consent.
9. A client who will undergo neurosurgery the following week tells the nurse in the surgeon's
office that he will prepare his advance directives before he goes to the hospital. Which of the
following statements by the client indicates to the nurse that he understands advance directives?
A. "I'd rather have my brother make decisions for me, but I know it has to be my wife."
B. "I know they won't go ahead with the surgery unless I prepare these forms."
C."I plan to write that I don't want them to keep me on a breathing machine."
D."I will get my regular doctor to approve my plan before I hand it in at the hospital."
Answer: C."I plan to write that I don't want them to keep me on a breathing machine."
Rationale: The client has the right to decide and specify which medical procedures he wants
when a life-threatening situation arrives
10. A client is about to undergo an elective surgical procedure. Which of the following actions
are appropriate for the nurse who is providing preop care regarding informed consent? Select all.
A. Make sure the surgeon obtained the client's consent
B. Witness the client's signature on the consent form
C. Explain the risks and benefits of the procedure
D. Describe the consequences of choosing not to have the surgery
E. Tell the client about alternatives to having the surgery
Answer: A. Make sure the surgeon obtained the client's consent
B. Witness the client's signature on the consent form
Rationale: The rest of the choices are the surgeon's responsibility, not the nurse
11. A nurse has noticed several occasions in the past week when another nurse on the unit
seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a
chair in the break room when she was not on break. Which of the following actions should the
nurse take?
A. Remind the nurse that safe client care is a priority on the unit
B. Ask others on the team whether they have observed the same behavior
C. Report observations to the nurse manager on the unit
D. Conclude that her coworker's fatigue is not her problem to solve
Answer: C. Report observations to the nurse manager on the unit
Rationale: Any nurse who notices behavior that could possibly jeopardize client care or indicate
a substance abuse problem has a duty to report the situation immediately to the nurse manager
12. A nurse is preparing info for a change-of-shift report. Which of the following info should the
nurse include in the report?
A. The client's input & output for the shift
B. The client's BP from the previous day
C. A bone scan that is scheduled for today
D. The med routine from the med administration record
Answer: C. A bone scan that is scheduled for today
Rationale: This is important because the nurse might have to modify the client's care to
accommodate them leaving the unit
13. A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower,
but I got myself back up & into my chair." How should the nurse document this in the client's
chart?
A. The client fell in the shower.
B. The client states he fell in the shower & was able to get himself back into his chair
C. The nurse should not document this info because she did not witness the fall
D. The client fell in the shower & is now resting comfortably
Answer: B. The client states he fell in the shower & was able to get himself back into his chair
Rationale: By writing what the client states, the info is subjective data
14. A nursing instructor is reviewing documentation with a group of nursing students. Which of
the following legal guidelines should they follow when documenting a client's record? Select all.
A. Cover errors with correction fluid, & write in the correct info
B. Put the date & time on all entries
C. Document objective data, leaving out opinions
D. Use as many abbreviations as possible
E. Wait until the end of the shift to document
Answer: B. Put the date & time on all entries
C. Document objective data, leaving out opinions
15. The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to
ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the
client is supine in bed. The nurse telephoned the physical therapist about the difficulties
containing the drainage from the fistula, so the therapist didn't ambulate the client today. The
client sat in a chair during lunch with an absorbent pad over the fistula. The client ate all the food
on her tray. The wound care nurse confirmed that she will see the client later today. The client
states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed
having a day to rest. Which of the following information should the nurse include in the changeof-shift report? Select all.
A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the client stands.
C. The client seemed to welcome having a "day off" from physical therapy
D. The wound care nurse will see the client later today
E. The client ate all the food on her lunch tray
Answer: A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the client stands.
D. The wound care nurse will see the client later today
16. A nurse is receiving a provider's prescription by telephone for morphine for a client who is
reporting moderate to severe pain. Which of the following nursing actions are appropriate?
Select all.
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain the prescriber's signature on the prescription within 24hrs
D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone
Answer: A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain the prescriber's signature on the prescription within 24hrs
17. A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He
states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which
of the following members of the health care team should the nurse refer him?
A. Registered dietitian
B. Occupational therapist
C. Physical therapist
D. Social worker
Answer: D. Social worker
Rationale: A social worker can make arrangements for a meal delivery service to provide
nutritious meals daily, or recommend a congregate meal site near the client's home
18. A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use
adaptive devices. The nurse caring for the client should initiate a referral with which of the
following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist
Answer: D. Occupational therapist
Rationale: An occupational therapist can assist clients who have physical challenges to use
adaptive devices & strategies to help with self-care activities
19. A client who is postop following a knee arthroplasty is concerned about the adverse effects of
the medication he is receiving for pain management. Which of the following members of the
interprofessional care team may assist the client in understanding the medication's effects? Select
all.
A. Provider
B. CNA
C. Pharmacist
D. RN
E. Respiratory therapist
Answer: A. Provider
C. Pharmacist
D. RN
20. A client who has had a cerebrovascular accident has persistent problems with dysphagia. The
nurse caring for the client should initiate a referral with which of the following members of the
interprofessional care team?
A. Social worker
B. CNA
C. Occupational therapist
D. Speech-language pathologist
Answer: D. Speech-language pathologist
Rationale: A speech-language pathologist can initiate specific therapy for clients who have
difficulty feeding due to swallowing difficulties
21. A nursing instructor is acquainting a group of nursing students with the roles of the various
members of the health care team they will encounter on a medical-surgical unit. When she gives
examples of the types of tasks CNAs may perform, which of the following client activities
should she include? Select all.
A. Bathing
B. Ambulating
C. Toileting
D. Determining pain level
E. Measuring vital signs
Answer: A. Bathing
B. Ambulating
C. Toileting
E. Measuring vital signs
Rationale: Determining pain level requires assessment, which is the job of the licensed
personnel.
22. A nurse in a provider's office is preparing to assess a young adult male client's
musculoskeletal system as part of a comprehensive physical examination. Which of the
following findings should the nurse expect? Select all.
A. A concave thoracic spine posteriorly
B. An exaggerated lumbar curvature
C. A concave lumbar spine posteriorly
D. An exaggerated thoracic curvature
E. Muscles slightly larger on his dominant side
Answer: C. A concave lumbar spine posteriorly
E. Muscles slightly larger on his dominant side
23. A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask
the client to close his eyes & identify which of the following items?
A. A word she whispers 30cm from his ear
B. A number she traces on the palm of his hand
C. The vibration of a tuning fork she places on his foot
D. A familiar object she places in his hand
Answer: D. A familiar object she places in his hand
Rationale: Stereognosis is tactile recognition
24. A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation
of her right shoulder. Which of the following activities is this problem likely to affect?
A. Mopping her floors
B. Brushing the back of her hair
C. Fastening her bra behind her back
D. Reaching into a cabinet above her sink
Answer: C. Fastening her bra behind her back
Rationale: Fastening a bra from behind requires internal rotation of the shoulder, so this activity
will illicit pain
25. A nurse is preforming a neurosensory examination for a client. Which of the following tests
should the nurse preform to test the client's balance? Select all.
A. Romberg test
B. Heel-to-toe walk
C. Snellen test
D. Spinal accessory function
E. Rosenbaum test
Answer: A. Romberg test
B. Heel-to-toe walk
Rationale: C and E test visual acuity , D tests cranial nerve XI is intact by asking the client to
shrug shoulders without complication.
26. A nurse is collecting data from an older adult client as part of a neurosensory examination.
Which of the following findings should the nurse expect as changes associated with aging?
Select all.
A. Slower light touch sensation
B. Some vision & hearing decline
C. Slower fine finger movement
D. Some short-term memory decline
E. Slower superficial pain sensation
Answer: B. Some vision & hearing decline
C. Slower fine finger movement
D. Some short-term memory decline
27. A nurse is providing discharge instructions to a client who has a prescription for the use of
oxygen in his home. Which of the following should the nurse teach the client about using oxygen
safely in his home? Select all.
A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use
B. Nail polish should not be used near a client who is receiving oxygen
C. A "No smoking" sign should be placed on the front door
D. Cotton bedding & clothing should be replaced with items made from wool
E. A fire extinguisher should be readily available in the home
Answer: B. Nail polish should not be used near a client who is receiving oxygen
C. A "No smoking" sign should be placed on the front door
E. A fire extinguisher should be readily available in the home
Rationale: Family members that smoke should do so outside, and wool creates static electricity
so it should be avoided.
28. A nurse educator is conducting a parenting class for new parents. Which of the following
statements made by a participant indicates a need for further clarification & instruction?
A. "I will begin swimming lessons as soon as my baby can close her mouth under water."
B. "Once my baby can sit up, he should be safe in the bathtub."
C. "I will test the temp of the water before placing my baby in the bath."
D. "Once my infant starts to push up, I will remove the mobile from over the bed."
Answer: B. "Once my baby can sit up, he should be safe in the bathtub."
Rationale: Although the baby can hold his head above the water by sitting up, this does not
make the baby safe in the tub. Parents should never leave a child unattended in a tub.
29. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client.
Which of the following information should the nurse include in her counseling?
A. Carbon monoxide has a distinct odor
B. Water heaters should be inspected every 5 years
C. The lungs are damaged from carbon monoxide inhalation
D. Carbon monoxide binds with hemoglobin in the body
Answer: D. Carbon monoxide binds with hemoglobin in the body
Rationale: Carbon monoxide is a very dangerous gas because it binds with hemoglobin &
ultimately reduces the oxygen supplied to the tissues in the body. Carbon monoxide is tasteless,
has no scent, and cannot be seen. The water heaters, gas-burning furnaces, and appliances should
be inspected annually The lungs are not damaged in the process of inhalation
30. A nurse educator is presenting a module on basic first aid for newly licensed home health
nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse
states the client who has heat stroke will have which of the following?
A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea
Answer: A. Hypotension
Rationale: Tachycardia, hot dry skin, and tachypnoea are other manifestations of heat stroke
31. A home health nurse is discussing the dangers of food poisoning with a client. Which of the
following info should the nurse include in her counseling? Select all.
A. Most food poisoning is caused by a virus
B. Immunocompromised individuals are at risk for complications from food poisoning
C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt,
cheese, or other dairy products
D. Healthy individuals usually recover from the illness in a few weeks
E. Handling raw & fresh food separately to avoid cross contamination may prevent food
poisoning
Answer: B. Immunocompromised individuals are at risk for complications from food poisoning
C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt,
cheese, or other dairy products
E. Handling raw & fresh food separately to avoid cross contamination may prevent food
poisoning
Rationale: Most food poisoning is caused by a bacteria such as E. coli. Healthy individuals
usually recover in a few days.
32. A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The
nurse is aware that health care professionals are required to report communicable & infectious
diseases. Which of the following illustrate the rationale for reporting? Select all.
A. Planning & evaluating control & prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
D. Identifying endemic disease
E. Monitoring for common-source outbreaks
Answer: A. Planning & evaluating control & prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
E. Monitoring for common-source outbreaks
Rationale: Not D because endemic disease is already prevalent within a population, so reporting
is not necessary
33. A nurse is contributing to the plan of care for a client who is being admitted to the facility
with a suspected diagnosis of pertussis. Which of the following should the nurse include in the
plan of care? Select all.
A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr
B. Wear a mask when providing care within 3 ft of the client
C. Place a surgical mask on the client if transportation to another dept is unavoidable
D. Use sterile gloves when handling soiled linens
E. Wear a gown when preforming care that may result in contamination from secretions
Answer: B. Wear a mask when providing care within 3 ft of the client
C. Place a surgical mask on the client if transportation to another dept is unavoidable
E. Wear a gown when preforming care that may result in contamination from secretions
Rationale: Private room with droplet precautions indicated for this client. The nurse should wear
a gown when contamination from body fluids might happen
34. A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles
with some crusting’s. Which of the following should the nurse suspect?
A. Allergic reaction
B. Ringworm
C. Systemic lupus erythematosus
D. Herpes zoster
Answer: D. Herpes zoster
Rationale: pink body rash = allergic reaction red circles with white centers = ringworm red
cheek rash bilaterally = lupus
35. A nurse is caring for a client who reports severe sore throat, pain when swallowing, &
swollen lymph nodes. The client is experiencing which of the following stages of infection?
A. Prodromal
B. Incubation
C. Convalescence
D. Illness
Answer: D. Illness
Rationale: specific s/s present is the illness stag
36. A nurse educator is reviewing with a newly hired nurse the difference in clinical
manifestations of a localized vs. a systemic infection. The nurse indicates understanding when
she states that which of the following are clinical manifestations of a systemic infection? Select
all.
A. Fever
B. Malaise
C. Edema
D. Pain or tenderness
E. Increase in pulse & respiratory rate
Answer: A. Fever
B. Malaise
E. Increase in pulse & respiratory rate
Rationale: Edema and pain and tenderness is localized
37. A nurse is teaching a young adult client about health promotion & illness prevention. Which
of the following statements by the client indicates an understanding of the teaching?
A. "I already had my immunizations as a child, so I'm protected in that area."
B. "It is important to schedule routine health care visits even if I'm feeling well."
C. "If I'm having any discomfort, I'll just got to an urgent care center."
D. "If I am felling stressed, I will remind myself that this is something I should expect."
Answer: B. "It is important to schedule routine health care visits even if I'm feeling well."
Rationale: routine health screenings are important at any age
38. A nursing instructor is explaining the various stages of the lifespan to a group of nursing
students. The nurse should offer which of the following behaviors by a young adult as an
example of appropriate psychosocial development?
A. Becoming actively involved in providing guidance to the next generation
B. Adjusting to major changes in roles and relationships due to losses
C. Devoting a great deal of time to establishing an occupation
D. Finding oneself "sandwiched" in between & being responsible for 2 generations
Answer: C. Devoting a great deal of time to establishing an occupation
Rationale: Exploring and establishing career options & establishing oneself is important
developmental task in a young adult
39. A nurse is counseling a young adult who describes having difficulty dealing with several
issues. Which of the following problems the client verbalized should the nurse identify as the
priority for further assessment & intervention?
A. "I have my own apartment now, but it's not easy living away from my parents."
B. "It's been so stressful for me to even think about having my own family."
C. "I don't even know who I am yet, & now I'm supposed to know what to do."
D. "My girlfriend is pregnant, & I don't think I have what it takes to be a good father."
Answer: C. "I don't even know who I am yet, & now I'm supposed to know what to do."
Rationale: Applying Erikson stages of development, knowing oneself is done in adolescence,
and this requires the most urgent help
40. A nurse is reviewing safety precautions with a group of young adults at a community health
fair. Which of the following recommendations should the nurse include specifically for this age
group? Select all.
A. Install bath rails & grab bars in bathrooms
B. Wear a helmet while skiing
C. Install a carbon monoxide detector
D. Secure firearms in a safe location
E. Remove throw rugs from the home
Answer: B. Wear a helmet while skiing
C. Install a carbon monoxide detector
D. Secure firearms in a safe location
Rationale: A is recommended for older adults and E as well for risk of falls
41. A nurse is reviewing the CDC's immunization recommendations with a young adult client.
Which of the following recommendations should the nurse include in this discussion? Select all.
A. Human papillomavirus
B. Measles, mumps, rubella
C. Varicella
D. Haemophilus influenzae type b
E. Polio
Answer: A. Human papillomavirus
B. Measles, mumps, rubella
C. Varicella
Rationale: D is not for after 18 months of age and polio is also given as a child and not usually
beyond 18yrs old
42. A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101
F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the
following are appropriate nursing interventions for this client? Select all.
A. Obtain culture specimens before initiating antimicrobials
B. Restrict the client's oral fluid intake
C. Encourage the client to limit activity & rest
D. Allow the client to shiver to dispel excess heat
E. Assist the client with oral hygiene frequently
Answer: A. Obtain culture specimens before initiating antimicrobials
C. Encourage the client to limit activity & rest
E. Assist the client with oral hygiene frequently
Rationale: The nurse should prevent shivering & encourage the client to increase fluids.
Why E-Oral hygiene helps prevent cracking of dry mucous membranes of the mouth & lips
43. A nurse is instructing an AP in caring for a client who has a low platelet count as a result of
chemo. Which of the following is the nurse's priority instruction for measuring vital signs for this
client?
A. "Don't measure the client's temp rectally."
B. "Count the client's radial pulse for 30 sec & multiply by 2."
C. "Don't let the client know you are counting her respirations."
D. "Let the client rest for 5 mins before you measure her BP."
Answer: A. "Don't measure the client's temp rectally."
Rationale: The greatest risk to a client with a low platelet count is injury that results in bleeding,
obtaining a temp this way increases the risk for bleeding.
44. A nurse is instructing a group of nursing students in measuring a client's RR. Which of the
following guidelines should the nurse include? Select all.
A. Place the client in semi-Fowler's position
B. Have the client rest an arm across the abdomen
C. Observe 1 full respiratory cycle before counting the rate
D. Count the rate for 1 min if it is regular
E. Count & report any signs the client demonstrates
Answer: A. Place the client in semi-Fowler's position
B. Have the client rest an arm across the abdomen
C. Observe 1 full respiratory cycle before counting the rate
Rationale: For D, this is if the rate is irregular after initial count, for E, sighs are expected &
don't need to be reported
45. A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94
mmHg. The client denies any history of HTN. Which of the following actions should the nurse
take next?
A. Request a prescription for an antihypertensive med
B. Ask the client if she is having pain
C. Request a prescription for an anti-anxiety med
D. Return in 30min to recheck the client's BP
Answer: B. Ask the client if she is having pain
Rationale: Perform a pain assessment would be the appropriate action to take next
46. A nurse is performing an admission assessment on a client. When measuring her vital signs,
the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse rate is 84/min.
What is the client's pulse deficit?
Answer: 16/min
Rationale: the pulse deficit is the difference between the apical & radial pulse rates. 84 – 68 =
16
47. A nurse is caring for a client who will perform fecal occult blood testing at home. Which of
the following info should the nurse include when explaining the procedure to the client?
A. Eating more protein is optimal prior to testing
B. One stool specimen is sufficient for testing
C. A red color change indicates a positive test
D. The specimen cannot be contaminated
Answer: D. The specimen cannot be contaminated
Rationale: The stool specimens cannot be contaminated with water or urine
48. A nurse is talking with a client who reports constipation. When the nurse discusses dietary
changes that can help prevent constipation, which of the following foods should the nurse
recommend?
A. Macaroni & cheese
B. Fresh fruit & whole wheat toast
C. Rice pudding & ripe bananas
D. Roast chicken & white rice
Answer: B. Fresh fruit & whole wheat toast
Rationale: A high-fiber diet promotes normal bowel elimination
49. A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the
client, the nurse should expect which of the following findings? Select all.
A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema
Answer: B. Hypotension
C. Fever
D. Poor skin turgor
Rationale: fever = caused by dehydration tachycardia not brady hypotension because of
decreased BP from dehydration fluid overload = peripheral edema
50. A nurse is preparing to administer a cleansing enema to an adult client in preparation for a
diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select
all.
A. Warm the enema prior to instillation
B. Position the client on the left side with the right leg flexed forward
C. Lubricate the rectal tube or nozzle
D. Slowly insert the rectal tube about 2 inches
E. Hang the enema container 24 inches above the client's anus
Answer: A. Warm the enema prior to instillation
B. Position the client on the left side with the right leg flexed forward
C. Lubricate the rectal tube or nozzle
Rationale: D is the appropriate length of insertion for a child, 3-4 for an adult. -24 inches is too
high & will cause it to run to fast & possible painful distention of the colon, 18 inches is the
recommended height
51. While a nurse is administering a cleansing enema, the client reports abdominal cramping.
Which of the following is the appropriate intervention?
A. Have the client hold his breath briefly
B. Discontinue the fluid instillation
C. Remind the client that cramping is common at this time
D. Lower the enema fluid container
Answer: D. Lower the enema fluid container
Rationale: This will slow the rate of instillation & relieve some discomfort
52. A nurse is caring for a client who has been sitting in a chair for 3 hrs. Which of the following
problems is the client at risk for developing?
A. Stasis of secretions
B. Muscle atrophy
C. Pressure ulcer
D. Fecal impaction
Answer: C. Pressure ulcer
Rationale: Unrelieved pressure over a bony prominence for too long increases the risk of a
pressure ulcer
A-sitting will help prevent stasis of secretions
B and D-these are from prolonged bed rest
53. A nurse is caring for a client who is on bed rest. Which of the following interventions should
the nurse implement to maintain the patency of the client's airway?
A. Encourage isometric exercises
B. Suction Q8 hr
C. Give low-dose heparin
D. Promote incentive spirometer use
Answer: D. Promote incentive spirometer use
Rationale: it helps keep airways open and prevent atelectasis
A-this strengthens skeletal muscles
B-this is not indicated
C-helps prevent thrombus formation
54. A nurse is caring for a client who is postop. Which of the following nursing interventions
reduce the risk of thrombus development? Select all.
A. Instruct the client not to use the Valsalva maneuver
B. Apply elastic stockings
C. Review lab values for total protein level
D. Place pillows under the client's knees & lower extremities
E. Assist the client to change position often
Answer: B. Apply elastic stockings
E. Assist the client to change position often
55. A nurse is instructing a postop client about the sequential compression device the provider
has prescribed. Which of the following statements should indicate to the nurse that the client
understands the teaching?
A. "This device will keep me from getting sores on my skin."
B. "This thing will keep the blood pumping through my leg."
C. "With this thing on, my leg muscles won't get weak."
D. "This device is going to keep my joints in good shape."
Answer: B. "This thing will keep the blood pumping through my leg."
Rationale: Sequential pressure devices promote venous return in the deep veins of the legs &
thus help prevent thrombus formation
56. To promote the safe use of a cane for a client who is recovering from a minor
musculoskeletal injury of the left lower extremity, which of the following instructions should the
nurse provide? Select all.
A. Hold the cane on the right side
B. Keep 2 points of support on the floor
C. Place the cane 15in in front of the feet before advancing
D. After advancing the cane, move the weaker leg forward
E. Advance the stronger leg so that it aligns evenly with the cane
Answer: A. Hold the cane on the right side
B. Keep 2 points of support on the floor
D. After advancing the cane, move the weaker leg forward
Rationale: C-the client should place the cane 6-10 inches in front before advancing not 15
E-the client should advance the stronger leg past the cane not aligned with it
57. A nurse is assessing the pain level of a client who has come to the ER reporting severe abd
pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is
assessing which of the following?
A. Presence of associated symptoms
B. Location of the pain
C. Pain quality
D. Aggravating & relieving factors
Answer: A. Presence of associated symptoms
Rationale: this is a common symptom people have when experiencing pain
58. A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can
best assess the intensity of the client's pain by:
A. asking what precipitates the pain
B. questioning the client about the location of the pain
C. offering the client a pain scale to measure his pain
D. using open-ended questions to identify the situation
Answer: C. offering the client a pain scale to measure his pain
Rationale: pain scale can measure the amount and intensity of the pain
59. A nurse is obtaining hx from a client who has pain. The nurse's guiding principle throughout
this process should be that:
A. some clients exaggerate their level of pain
B. pain must have an identifiable source to justify the use of opioids.
C. objective data are essential in assessing pain
D. pain is whatever the client says it is
Answer: D. pain is whatever the client says it is
Rationale: the client is the best source of information in their pain, it is a subjective experience
60. A nurse is caring for a client who is receiving morphine via a PCA infusion device after abd.
surgery. Which of the following statements indicates that the client knows how to use the device?
A. "I'll wait to use the device until it's absolutely necessary."
B. "I'll be careful about pushing the button so I don't get an overdose."
C. "I should tell the nurse if the pain doesn't stop after I use this device."
D. "I will ask my son to push the dose button when I am sleeping."
Answer: C. "I should tell the nurse if the pain doesn't stop after I use this device."
Rationale: The client should let the nurse know if not receiving adequate pain control, so they
can reevaluate the pain control plan
61. A nurse is monitoring a client who is receiving opioid analgesia for adv effects of the med.
Which of the following effects should the nurse anticipate? Select all.
A. Urinary incontinence
B. Diarrhea
C. Bradypnea
D. Orthostatic hypotension
E. Nausea
Answer: C. Bradypnea
D. Orthostatic hypotension
E. Nausea
Rationale: Urinary retention, not incontinence is an adv effect of these meds as well as
constipation, not diarrhea.
62. A nurse is assessing a client who takes haloperidol (Haldol) for the tx of schizophrenia.
Which of the following findings should the nurse document as extrapyramidal symptoms (EPS)?
Select all.
A. Orthostatic hypotension
B. Fine motor tremors
C. Acute dystonias
D. Decreased level of consciousness
E. Uncontrollable restlessness
Answer: B. Fine motor tremors
C. Acute dystonias
E. Uncontrollable restlessness
Rationale: A and D are adverse effects, but not EPS
63. A nurse is providing teaching about managing anti-cholinergic effects for a client who has a
new prescription for oxybutunin (Ditropan XL). Which of the following are appropriate to
include in the teaching? Select all.
A. Take frequent sips of water
B. Wear sunglasses when exposed to sunlight
C. Use a soft toothbrush when brushing teeth
D. Take the medication with an antacid
E. Urinate prior to taking the med
Answer: A. Take frequent sips of water
B. Wear sunglasses when exposed to sunlight
E. Urinate prior to taking the med
Rationale: side effects of this med include: dry mouth, photophobia, and urinary retention
64. A nurse is reviewing the reported meds of a client who was recently admitted. The meds
include cimetidine (Tagamet) & imipramine hydrochloride (Tofranil). Knowing that cimetidine
decreases the metabolism of imipramine hydrochloride, the nurse should identify that this
combination is likely to result in which of the following effects?
A. Decreased therapeutic effects of cimetidine
B. Increased risk of imipramine hydrochloride toxicity
C. Decreased risk of adv effects of cimetidine
D. Increased therapeutic effects of imipramine hydrochloride
Answer: B. Increased risk of imipramine hydrochloride toxicity
Rationale: A med that decreases the metabolism of a 2nd med increases the serum level of the
2nd med, increasing risk for toxicity
65. A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant.
The client currently takes a Category D pregnancy risk med for the control of seizures. Which of
the following statements by the nurse is appropriate?
A. "This med is prescribed if necessary but it is known to cause adverse effects to the fetus."
B. "This med has evidence indicating that it is safe to take during pregnancy & will not harm the
fetus."
C. "This med cannot be taken during pregnancy because the risk outweighs the potential
benefits."
D. "This med hasn't been studied in pregnant women but is believed to be safe for the fetus."
Answer: C. "This med cannot be taken during pregnancy because the risk outweighs the
potential benefits."
Rationale: Category D meds are known to cause harm to fetuses, however the use during
pregnancy may be warranted based on potential benefits.
66. A nurse in an outpatient surgical center is admitting a client for a laproscopic procedure. The
client has a prescription for preoperative diazepam (Valium). Prior to administering the med,
which of the following actions is the highest priority?
A. Teaching the client about the purpose of the med
B. Administering the med to the client at the prescribed time
C. Identifying the client's med allergies
D. Documenting the client's anxiety level
Answer: C. Identifying the client's med allergies
Rationale: The greatest risk to the client is an allergic reaction to the med
67. A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV
bolus. The amount available is 40 mg/mL. How many mL should the nurse administer? (round to
nearest tenth)
Answer: 0.3 mL
68. A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15min. The nurse
should set the infusion pump to deliver how many mL/hr? (round to nearest whole number)
Answer: 400 mL/hr
69. A nurse is preparing to administer 0.9% sodium chlo ride (0.9% NaCl) 250 mL IV to infuse
over 30min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the
manual IV infusion to deliver how many gtt/min? (round to nearest whole number)
Answer: 83 gtt/min
70. A nurse is caring for a client who is at high risk for aspiration. Which of the following is an
appropriate nursing intervention?
A. Give the client thin liquids.
B. Instruct the client to tuck her chin when swallowing.
C. Have the client use a straw.
D. Encourage the client to lie down & rest after meals.
Answer: B. Instruct the client to tuck her chin when swallowing.
Rationale: Tucking when swallowing allows food to pass down esophagus more easily.
71. A nurse is preparing a presentation about basic nutrients for a group of high school athletes.
She should explain that which of the following is the body's priority energy reserve?
A. Fat
B. Protein
C. Glycogen
D. Carbohydrates
Answer: D. Carbohydrates
Rationale: carbs provide glucose
72. A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see
which of the following foods on the client's meal tray?
A. Cooked barley
B. Pureed broccoli
C. Vanilla custard
D. Lentil soup
Answer: C. Vanilla custard
Rationale: low-residue diets are low in fiber and easy to digest: dairy products especially
73. A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate
her BMI & determine whether this client is obese based on her BMI.
Answer: BMI = 30
Rationale: above 30 equals obese so yes.
74. A nurse in a senior center is counseling a group of older adults about their nutritional needs &
consider actions. Which of the following info should the nurse include? Select all.
A. Older adults are more prone to dehydration than younger adults are
B. Older adults need the same amount of most vitamins & minerals as younger adults do
C. Many older men & women need calcium supplementation
D. Older adults need more calories than they did when they were younger
E. Older adults should consume a diet low in carbs
Answer: A. Older adults are more prone to dehydration than younger adults are
B. Older adults need the same amount of most vitamins & minerals as younger adults do
C. Many older men & women need calcium supplementation
Rationale: D-they need fewer calories not more
E-they need more carbs & fiber
75. A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The
client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication
administration record, which of the following medications should the nurse administer?
A. Meperidine (Demerol) 75 mg IM
B. Fentanyl 50 mcg/hr transdermal patch
C. Morphine 2 mg IV
D. Oxycodone 10 mg PO
Answer: C. Morphine 2 mg IV
Rationale: IV morphine is the best because the onset is rapid and absorption to the blood is
immediate, which is adequate for a client with a 10 pain severity
76. A nurse is teaching a client about taking multiple oral meds at home to include time-release
capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the
client indicates an understanding of the teaching?
A. "I can open the capsule with the beads in it & sprinkle them on my oatmeal."
B. "If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding."
C. "The pills with the coating on them can be crushed."
D. "I will eat 2 crackers with the pain pills."
Answer: D. "I will eat 2 crackers with the pain pills."
Rationale: this will prevent N&V from the narcotic
77. A nurse is teaching a client how to administer medication through a jejunostomy tube. Which
of the following instructions should the nurse include in the teaching?
A. "Flush the tube before & after each med."
B. "Administer your meds with your enteral feeding."
C. "Administer tablets through the tube slowly."
D. "Mix all the crushed meds prior to dissolving in water."
Answer: A. "Flush the tube before & after each med."
Rationale: The client should flush the tube with 15-30 mL of water to prevent clogging of the
tube
78. A nurse educator is teaching a module on pharmaco- kinetics to a group of newly licensed
nurses. Which of the following statements by a newly licensed nurse indicates an understanding
of the 1st-pass effect?
A. "Some meds block normal receptor activity regulated by endogenous compounds or receptor
activity caused by other meds."
B. "Some meds may have to be administered by a non-enteral route to avoid inactivation as they
travel through the liver."
C. "Some meds leave the body more slowly & there- fore have a greater risk of accumulation &
toxicity."
D. "Some meds have a wide safety margin, so there is no need for routine serum medication
level monitoring."
Answer: B. "Some meds may have to be administered by a non-enteral route to avoid
inactivation as they travel through the liver."
Rationale: first pass deals with the liver
79. A nurse is teaching an adult client how to administer ear drops. Which of the following
statements by the client indicates understanding of the proper technique?
A. "I will straighten my ear canal by pulling my ear
B. "I will gently apply pressure with my finger to the tragus of my ear after putting in the drops."
C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in."
D. "After the drops are in, I will place a cotton ball all the way into my ear canal."
Answer: B. "I will gently apply pressure with my finger to the tragus of my ear after putting in
the drops."
Rationale: The client should apply gentle pressure with the finger to the tragus of the ear after
administering the drops to help the drops go into the ear canal.
80. A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports
pain. Prior to administering, the nurse is called to another room to assist another client onto a
bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the
2nd nurse take?
A. Offer to assist the client needing the bedpan.
B. Administer the injection prepared by the other nurse
C. Prepare another syringe & administer the injection
D. Tell the client needing the bedpan she will have to wait for her nurse
Answer: A. Offer to assist the client needing the bedpan.
81. A nurse is preparing to administer a med to a client. The med was scheduled for
administration at 0900. Which of the following are acceptable administration times for this med?
Select all.
A. 0905
B. 0825
C. 1000
D. 0840
E. 0935
Answer: A. 0905
D. 0840
Rationale: 30min time frame for meds
82. A nurse is working with a newly hired nurse who is administering meds to clients. Which of
the following actions by the newly hired nurse indicates an understanding of med error
prevention?
A. Taking all meds out of the unit-dose wrappers before entering the client's room
B. Checking with the provider when a single dose requires administration of multiple tablets
C. Administering a med, then looking up the usual dosage range
D. Relying on another nurse to clarify a med prescription
Answer: B. Checking with the provider when a single dose requires administration of multiple
tablets
Rationale: this could indicate a possible error so it should be checked with the provider
83. A nurse educator is teaching a module on safe med administration to newly hired nurses.
Which of the following statements by the newly hired nurse indicate understanding of the nurse's
responsibility when implementing med therapy? Select all.
A. "I will observe for med side effects."
B. "I will monitor for therapeutic effects."
C. "I will prescribe the appropriate dose."
D. "I will change the dose if adverse effects occur."
E. "I will refuse to give a med if I believe it is unsafe."
Answer: A. "I will observe for med side effects."
B. "I will monitor for therapeutic effects."
E. "I will refuse to give a med if I believe it is unsafe."
84. A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want to
take that med. I do not want one more pill." Which of the following responses by the nurse is
appropriate in this situation?
A. "Your physician prescribed it for you, so you really should take it."
B. "Well, let's just get it over with quickly then."
C. "Okay, I'll just give you your other meds."
D. "Tell me your concerns with taking this med."
Answer: D. "Tell me your concerns with taking this med."
85. A nurse is assessing a client who has an acute resp. infection that puts her at risk for
hypoxemia. Which of the following findings are early indications that should alert the nurse that
the client is developing hypoxemia? Select all.
A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Pallor
Answer: A. Restlessness
B. Tachypnea
E. Pallor
Rationale: C and D are late manifestations of hypoxemia.
86. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed &
is already receiving oxygen therapy via nasal cannula. Which of the following interventions is
the nurse's priority?
A. Increase the oxygen flow
B. Assist the client to Fowler's position
C. Promote removal of pulmonary secretions
D. Obtain a specimen for arterial blood gases
Answer: B. Assist the client to Fowler's position
Rationale: Fowler's facilitates better breathing
87. A nurse is preparing to preform endotracheal suctioning for a client. Which of the following
are appropriate guidelines for the nurse to follow? Select all.
A. Apply suction while withdrawing the catheter
B. Perform suctioning on a routine basis, Q2-3 hours
C. Maintain medical asepsis during suctioning
D. Use a new catheter for each suctioning attempt
E. Limit suctioning to 2-3 attempts
Answer: A. Apply suction while withdrawing the catheter
D. Use a new catheter for each suctioning attempt
E. Limit suctioning to 2-3 attempts
Rationale: B-Suctioning is not without risk so it should be done as needed, not routinely.
C-endotracheal suctioning requires surgical asepsis
88. A nurse is caring for a client who has a tracheostomy. Which of the following actions should
the nurse take each time he provides tracheostomy care? Select all.
A. Apply the oxygen source loosely if the SPO2 decreases during the procedure
B. Use surgical asepsis to remove & clean the inner cannula
C. Clean the outer surfaces in a circular motion from the stoma site onward
D. Replace the tracheostomy ties with new ties
E. Cut a slit in gauze squares to place beneath the tube holder.
Answer: A. Apply the oxygen source loosely if the SPO2 decreases during the procedure
B. Use surgical asepsis to remove & clean the inner cannula
C. Clean the outer surfaces in a circular motion from the stoma site onward
Rationale: D-only replace ties if soiled or wet
E-use a commercially prepared gauze with slit not one nurse makes
89. A provider is discharging a client with a prescription from home oxygen therapy via nasal
cannula. Client & family teaching by the nurse should include which of the following? Select all.
A. Apply petroleum jelly around the inside of the nares
B. Remove the nasal cannula during mealtimes
C. Check the position of the cannula often
D. Report any nasal stuffiness, nausea, or fatigue
E. Post "no smoking" signs in a prominent location
Answer: C. Check the position of the cannula often
D. Report any nasal stuffiness, nausea, or fatigue
E. Post "no smoking" signs in a prominent location
90. A nurse is delivering an enteral feeding to a client who has an NG tube in place for
intermittent feedings. When the nurse pours water into the syringe after the formula drains from
the syringe, the client asks the nurse why the water is necessary. Which of the following is an
appropriate response by the nurse?
A. "Water helps clear the tube so it doesn't get clogged."
B. "Flushing helps make sure the tube stays in place."
C. "This will help you get enough fluids."
D. "Adding water makes the formula less concentrated."
Answer: A. "Water helps clear the tube so it doesn't get clogged."
Rationale: this action clears the excess formula preventing any clumps/clogging
91. A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place.
Which of the following is the nurse's highest assessment priority before performing this
procedure?
A. Check how long the feeding container has been opened
B. Verify the placement of the NG tube
C. Confirm that the client doesn't have diarrhea
D. Make sure the client is alert & oriented
Answer: B. Verify the placement of the NG tube
Rationale: the greatest risk is aspiration so verifying the placement of the tube is most important
92. A nurse is caring for a client who is receiving continuous enteral feedings. Which of the
following nursing interventions is the highest priority when the nurse suspects aspiration of the
feeding?
A. Auscultate breath sounds
B. Stop the feeding
C. Obtain a chest Xray
D. Initiate oxygen therapy
Answer: B. Stop the feeding
93. A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via
NG tube. Which of the following is an appropriate nursing action prior to administering the tube
feeding? Select all.
A. Auscultate bowel sounds.
B. Assist the client to an upright position.
C. Test the pH of gastric aspirate.
D. Warm the formula to body temp.
E. Discard any residual gastric contents.
Answer: A. Auscultate bowel sounds.
B. Assist the client to an upright position.
C. Test the pH of gastric aspirate.
Rationale: D-the formula should be room temp not body
E-unless the volume of the contents is more than 250 mL, the nurse should return the residual
content to the client's stomach
94. A nurse is preparing to insert an NG tube for a client who requires gastric decompression.
Which of the following actions should the nurse perform prior to beginning the procedure?
Select all.
A. Review a signal the client can use if feeling any distress
B. Lay a towel across the client's chest
C. Administer oral pain meds
D. Obtain a Dubroff tube for insertion
E. Have a petroleum-based lubricant available
Answer: A. Review a signal the client can use if feeling any distress
B. Lay a towel across the client's chest
95. An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The
client is tolerating a regular diet. He has ambulated successfully around the unit with assistance.
He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the
med. His incision is approximated & free of redness, with scant serous drainage on the dressing.
Which of the following risk factors for poor wound healing does this client have? Select all.
A. Extremes in age
B. Impaired circulation
C. Impaired/suppressed immune system
D. Malnutrition
E. Poor wound care
Answer: B. Impaired circulation
C. Impaired/suppressed immune system
96. A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon
suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to
initiate after collecting wound & blood specimens for culture & sensitivity. Which of the
following assessment findings should the nurse expect? Select all.
A. Increase in incisional pain
B. Fever & chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
E. Decrease in thirst
Answer: A. Increase in incisional pain
B. Fever & chills
C. Reddened wound edges
97. A nursing instructor is reviewing the wound healing process with a group of nursing students.
They should be able to identify which of the following alterations as a wound or injury that heals
by secondary intention? Select all.
A. Stage III pressure ulcer
B. Sutured surgical incision
C. Casted bone fracture
D. Laceration sealed with adhesive
E. Open burn area
Answer: A. Stage III pressure ulcer
E. Open burn area
Rationale: B and D are healed with primary intention
C is not a skin wound unless bone has pierced the skin
98. A client who had abd. surgery 24 hr ago reports a pulling sensation & pain in his surgical
incision. The nurse checks the client's surgical wound & finds the wound separated with viscera
protruding. Which of the following interventions is appropriate? Select all.
A. Cover the area with saline-soaked sterile dressings
B. Apply an abdominal binder snugly around the abd.
C. Use sterile gloves to apply gentle pressure to the exposed tissues
D. Position the client supine with his hips & knees bent
E. Offer the client a warm beverage, such as herbal tea
Answer: A. Cover the area with saline-soaked sterile dressings
D. Position the client supine with his hips & knees bent
99. A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which
of the following interventions should the nurse use to help maintain the integrity of the client's
skin? Select all.
A. Keep the head of the bed elevated 30 degrees
B. Massage the client's bony prominences often
C. Apply cornstarch liberally to the skin after bathing
D. Have the client sit on a gel cushion when in a chair
E. Reposition the client at least Q 3 hr while in bed
Answer: A. Keep the head of the bed elevated 30 degrees
D. Have the client sit on a gel cushion when in a chair
Rationale: not E because it should be at least every 2 hours
