2022-2023 ATI Comprehensive Exit Exam With Answers-179 Solved Questions

ATI COMPREHENSIVE EXIT EXAM RETAKE LATEST 2022/2023
1. A nurse is caring for a client who is at 33 weeks gestation following an amniocentesis. The
nurse should monitor the client for which of the following complications?
A. contractions
B. Hypertension
C. Epigastric pain
D. vomiting
Answer: A. Contraction
Rationale:
Amniocentesis
• Can't be done before 16 weeks, not enough amniotic fluid.
• maternal risks: haemorrhage, feta maternal haemorrhage, infection, contractions/labor, abruptio
placentae, damage to intestines or bladder, amniotic fluid embolism
• fatal risks: death, haemorrhage, infection, direct injury from the needle, miscarriage, and
preterm, leakage of amniotic fluid
2. A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
A. Stay in bed at least 1 hr if unable to fall asleep.
B. Take a 1 hr nap during the day
C. Perform exercises prior to bedtime
D. Eat a light snack before bedtime
Answer: D. Eat a light snack before bedtime
Rationale:
Consume a light snack of carbohydrates at bedtime
3. A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor
displays ventricular tachycardia. Which of the following actions should the nurse first take
determining the client does not have a palpable pulse?
A. Assess heart sounds

B. Defibrillate
C. Establish IV access
D. Administer Epinephrine
Answer: B. Defibrillate
Rationale:
The nurse needs to assess the client to determine stability before proceeding with further
interventions. If the client has a pulse and is relatively stable, elective cardioversion or
antidysrhythmic medications may be prescribed. The drug of choice for stable ventricular
tachycardia with a pulse is amiodarone. If the client is pulseless or nonresponsive, the client is
unstable and defibrillation is used
4. A nurse is admitting a client who is one week postpartum and reports excessive vaginal
bleeding. The nurse does not speak the same language as the client the client’s partner and 10year-old child are accompanying her. Which of the following actions should the nurse take to
gather the client’s admission data?
A. Have the client’s child translate
B. Allow the client’s partner to translate
C. Request a female interpreter through the facility
D. Ask a nursing student who speaks the same language as the client to translate.
Answer: C. Request a female interpreter through the facility
Rationale:
We been told not to use family members if not facility interpreters
5. A nurse is caring for a client who is febrile(fever). To reduce the client’s fever, the nurse
applies cooling. Which of the following indicates the client is having an adverse reaction to the
cooling
A. Flushing
B. Tachycardia
C. Restlessness
D. Shivering
Answer: D. shivering

Rationale:
Hypothermia is the adverse reaction of cooling system for a febrile patient s/s of hypothermia:
shivering, slurred speech, weak pulse drowsiness, confusion, loss of memory
6. A nurse is caring for a client who has deep-vein thrombosis of the left lower extremity. Which
of the following actions should the nurse take?
Answer: ensure that the lower extremity is elevated.
Rationale:
DVT causes edema; therefore, the UAP should elevate the extremity to promote venous return.
Dependent positioning is appropriate for a client with arterial insufficiency. Placing a pillow
under the knee would position the foot in a low position, and pressure behind the knee may
obstruct venous flow. Massaging the extremity could dislodge the thrombus
7. A nurse is reviewing assessment data from several clients. For which of the following clients
should the nurse recommend referral to a dietitian?
A. An older adult client who has BMI of 24
B. A client who has a nonhealing leg ulcer
C. An older adult client who had presbyopia
D. A client who has an albumin level of 3.7 g/dl
Answer: B. A client who has a nonhealing leg ulcer
Rationale:
type of patients that can be referred to dietitian are the ones that present: Physical S&S
Malnutrition Hair is dull, brittle, dry, or falls out easily
Swollen glands of neck and cheeks
Dry, rough, or spotty skin
Poor or delayed wound healing or sores
Thin appearance with lack of subcutaneous fat
Muscle wasting
Edema of lower extremities
Weakened hand grasp
Depressed mood

Abnormal heart rate/rhythm and BP
Enlarged liver or spleen
Loss of balance and coordination
Presbyopia: farsighted
8. A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving haemodialysis. Which of the following instructions should the nurse include in the
teaching
A. Eat 1g/kg of protein per day
B. Take magnesium hydroxide for indigestion
C. Drink at least 3 L of fluid daily.
D. Consume foods high in K+
Answer: A. Eat 1g/kg of protein per day
Rationale:
Protein intake and haemodialysis protein is not routinely restricted.
Magnesium hydroxide. Please don’t chose this answer
Magnesium is excreted by the kidneys, and patients with CKD should not use OTC products
containing magnesium. The other mediations are appropriate for a patient with CKD.
9. A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following places the client at risk for aspiration?
A. Sitting in high-fowlers position during the feeding
B. History of gastroesophageal reflux disease (GERD)
C. Receiving a high osmolality formula
D. A residual of 65ml 1 hr postprandial
Answer: B. History of gastroesophageal reflux disease (GERD)
Rationale:
Pt with higher Risk of aspiration a in clients with GERD

10. A nurse is providing prenatal teaching to a client who is 12 weeks of gestation. The nurse
should tell the client she will undergo which of the following screening test at 16 weeks of
gestation
A. Chorionic villus sampling
B. Cervical cultures for chlamydia
C. Non-stress test
D. Maternal serum alpha-fetoprotein
Answer: D. Maternal serum alpha-fetoprotein(performed ideally at 16 to 18 weeks)
Rationale:
Screening is usually done by taking a sample of your blood between 15 and 20 weeks of
pregnancy (16 to 18 weeks is ideal). The multiple markers include: AFP screening. Also called
maternal serum AFP, this blood test measures the level of AFP in your blood during pregnancy.
High levels of alpha-fetoprotein: May indicate neural tube defects, anencephaly or abdominal
wall defect. Would follow up with ultrasound.
11. A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the
following findings is a complication of immobility?
A. Decreased serum calcium levels
B. Increased blood pressure
C. Swollen area on calf
D. Urinary frequency
Answer: C. Swollen area on calf
Rationale:
primary and serious effects of immobility on the musculoskeletal system atrophy (decreased
muscle size); contractures; ankylosis (fixation of a joint); osteoporosis (loss of bone density);
footdrop (plantar flexion)
12. A nurse in an acute care mental health facility is participating in a medication education
group. The leader of the group uses laissez-faire leadership style. Which of the following actions
should the nurse expect from the leader during the session?
A. The leader encourages group members to remain silent until questions are called for.

B. The leader lectures about medication adverse rxn to the group members.
C. The leader allows the group to discuss whatever they would like regarding their medications.
D. The leader has group members vote on what they would like to learn about during the session.
Answer: C. The leader allows the group to discuss whatever they would like regarding their
medications.
Rationale:
Laissez-Faire leader gives up control with free-run or permissive style
13. A nurse is providing teaching about digoxin administration to the parents of a toddler who
has heart failure. Which of the following statements should the nurse include in the teaching?
A. “You can add the medication to a half-cup of your child’s favourite juice”
B. “Repeat the dose if your child vomits within1 hour after taking the medication.”
(u don’t suppose to re administer, even if the dose is missed)
C. “Limit your child’s potassium intake while she is taking this medication.”
D. “Have your child drink a small glass of water after swallowing the medication.”
Answer: D. “Have your child drink a small glass of water after swallowing the medication.”(to
prevent tooth decay if child has teeth)
Rationale:
make the child to drink water and Brush the child's teeth after giving the medication
14. A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for phenelzine. Which of the following foods should the nurse instruct the client to avoid?
A. Grapefruit
B. Spinach
C. Cottage Cheese
D. Smoked Salmon
Answer: D. Smoked Salmon
Rationale:
Foods to avoid/restrict
Avocados, bananas, raisins, papaya, canned figs fava beans
cheese (cottage okay), sour cream, yogurt

beer, wine (esp. red)
beef or chicken liver, pate, meat extracts, pickled or kippered herring pepperoni, salami, sausage,
bologna/hot dogs soy sauce all yeast chocolate
Smoked fish should be avoided. Dried or cured fish, as well as fish that has been fermented,
smoked, or aged has a high amount of tyramine.
16. A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time in the day room
B. Withdraw the client’s TV privileges if he does not attend group therapy.
C. Encourage the client to take frequent rest periods
D. Place the client in seclusion when he exhibits signs of anxiety.
Answer: C. Encourage the client to take frequent rest periods.
Rationale:
The nurse should encourage the client to take frequent rest periods throughout the day. Clients
experiencing mania are at risk of exhaustion that can be life threatening. Give water: High
caloric finger food meals!!
17. A parish nurse is leading a support group for clients whose family members have committed
suicide. Which of the following strategies should the nurse plan to use during the group session?
A. Initiate a discussion with clients about ways to cope with the changes in the family dynamics
B. Encourage clients to establish a timeline for their own grieving process.
C. Discourage clients from sharing negative aspects of their own grieving process
D. Assist clients in identifying ways suicide could have been prevented.
Answer: B. encourage clients to establish a timeline for their own grieving process. Encourage
seems to be a key word!!
18. A nurse manager observes two staff nurses reviewing the computer records of a client who is
not under their care. Which of the following actions should the nurse manager take 1st?
A. Instruct the nurses to close the client’s computer record.
B. Request the nurses present an in-service on client confidentiality.

C. Advise the nurses to read the facility’s confidentiality policy.
D. Place documentation of the nurses’ actions in the personnel file.
Answer: A. Instruct the nurses to close the client’s computer record.
19. A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contradiction to the
administration of clozapine
A. Heart rate 58/min
B. Fasting blood glucose 100mg/dL
C. Hgb 14 g/dL
D. WBC count 2900/mm3
Answer: D. WBC count 2900/mm3
Rationale:
Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The
nurse should identify a WBC count below 3000/mm3 as a possible manifestation of
agranulocytosis and should withhold the medication and notify the provider.
Clozapine: Antipsychotics second generation(atypical)
Use: Schizophrenia S/E: Hypotension, constipation, tachycardia, sedation, agranulocytosis,
seizures.
20. A nurse is caring for multiple clients on a medical surgical unit. For which of the following
nursing activities is it required that the nurse use sterile gloves?
A. Inserting an NG tube
B. Administering total parental nutrition through a central venous access device
C. Initiating IV access
D. Performing tracheostomy care
Answer: D. Performing tracheostomy care(according to med/surg book u wear sterile gloves)
Rationale:
1. tracheostomy patient should never lie flat
2. increase oxygenation, before, during and after procedure
3. poor NS in the basin

4. do sterile gloves
5. make sure suction does not exceed 120 mm hg
6. flush suction catheter
7. insert into the tracheostomy tubing until you meet resistance or until patient coughs
21. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunizations should the nurse recommend?
A. Influenza
B. Measles, mumps and rubella
C. Human papilloma virus
D. Varicella
Answer: A. Influenza
Pregnant and postpartum women are at higher risk for severe illness and complications from
influenza than women who are not pregnant because of changes in the immune system, heart,
and lungs during pregnancy…. Influenza vaccination can be administered at any time during
pregnancy, before and during the influenza season. Women who are or will be pregnant during
influenza season should receive IIV(11wks Influenza)
22. A nurse is inserting an indwelling urinary catheter for a male client. Which of the following
actions should the nurse take?
A. Perform the cleansing procedure with the fresh swab two times.
B. Lift the penis so it is perpendicular to the client’s body.
C. Cleanse the tip of the penis in the side to side motion.
D. Pick up the catheter 13 cm (5 in) from its tip.
Answer: B. Lift the penis so it is perpendicular to the client’s body.
Rationale:
Using the sterile dominant hand, pick up the catheter with a gloved hand. Holding the catheter
loosely, insert it into the urethral opening of a female patient. For a male patient, life his penis to
a perpendicular position and lightly apply traction in an upward position using the non-dominant
hand. Gently insert the catheter one to two inches past where the patient’s urine is located

23. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to
report to the provider. Which of the following findings should the nurse include in the teaching
A. Bleeding gums
B. Faintness upon rising
C. Swelling of the face
D. Urinary frequency
Answer: C. Swelling of the face
Rationale:
14 weeks gestation, what should patient report to the MD ,Swelling of the face (sign of
preeclampsia)
24. A nurse has received change of shift report for a group of clients. Which of the following
actions should the nurse take to manage time effectively?
A. Document client care at the end of the shift.
B. Make a client to do list for the day.
C. Skip breaks until client tasks are complete.
D. Focus on several client tasks at a time
Answer: B. make a client to do list for the day.
25. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy the newborn is experiencing neonatal abstinence syndrome which of the
following actions should the nurse include in the plan?
A. Minimize noise and the newborns environment.
B. Administer naloxone to the newborn. ( u give phenobarbitol not naloxone for withdrawals)
C. Swaddled the newborn with his legs extended (legs flexed)
D. Maintain eye contact with the newborn during feeding. (no eye contact)
Answer: A. Minimize noise and the newborns environment.
Rationale:
Neonatal substance withdrawal: Nursing Care Nursing care for maternal substance use and
neonatal effects or withdrawal include the following in addition to normal newborn care.

● Perform ongoing assessment of the newborn using the neonatal abstinence scoring system
assessment, as RX'ed.
● Elicit and assess the newborn's reflexes.
● Monitor the newborn's ability to feed and digest intake.
Offer small frequent feedings.
● Swaddle the newborn with legs flexed.
● Offer non-nutritive sucking.
● Monitor the newborn's fluids and electrolytes with skin turgor, mucous membranes, fontanels,
daily weights, and I&O.
● Reduce environmental stimuli (decrease lights, lower noise level).
26. A nurse is assessing the fontanels of an eight-month-old infant. Which of the following
findings should the nurse recognized as an expected finding?
A. The anterior fontanel is open
B. The posterior fontanel is open (posterior closes between 6 to 8 weeks so they would be closed
at 8 months)
C. both fontanels are the same size
D. both fontanels show molding
Answer: A. The anterior fontanel is open ( anterior closes between 12 months and 18 months so
would be open)
Rationale:
Anterior fontanels close by 18 months old
Posterior fontanels 6-8 weeks
(posterior closes between 6 to 8 weeks so they would be closed at 8 months)
27. A nurse is caring for a client who has acute diverticulitis which of the following diet should
the nurse recommend to the client?
A. High residue
B. Lactose free
C. gluten-free
D. low fibre

Answer: D. Low fibre
Rationale:
As you start feeling better, your doctor will recommend that you slowly add low-fibre foods.
Examples of low-fibre foods include:
• Canned or cooked fruits without skin or seeds
• Canned or cooked vegetables such as green beans, carrots and potatoes (without the skin)
Eggs, fish and poultry
• Refined white bread
• Fruit and vegetable juice with no pulp
• Low-fibre cereals
• Milk, yogurt and cheese
• White rice, pasta and noodles
28. The nurses caring for a client who is 48 hrs post op following a total hip arthroplasty which
of the following actions should the nurse include in the plan of care
A. Administer low-dose heparin
B. Placed the client on a full liquid diet
C. using an incentive spirometer every three hours
D. Maintain the client on bed rest
Answer: A. Administer low-dose heparin
Rationale:
One of the possible complications of post op total hip arthroplasty is DVT to help prevent the
nurse should administer Low-dose heparin injections.
29. A nurse providing teaching to the parent of an infant who has a cleft lip palette. Which of the
following feeding technique should the nurse include in the teaching?
A. Burp the infant frequently during feedings
B. Position the nipple at the front of the infants mouth
C. Hold the infant in a supine position
D. used to feed devices without nipples
Answer: A. Burp the infant frequently during feedings

Rationale:
Feed in upright position in frequent, small amounts; burp frequently
30. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which
of the following client should the nurse first
A. A client who has depressive disorder and requires assistance with ADLs
B. A client who has obsessive-compulsive disorder and is upset about her change in daily routine
C. A client who taking clozapine to treat schizophrenia and reports a sore throat
D. A client who has narcissistic personality disorder and is mocking others during group therapy.
Answer: C. A client who taking clozapine to treat schizophrenia and reports a sore throat
Rationale:
Signs of a sore throat or an infection could indicate agranulocytosis, which is a life-threatening
side effect of clozapine (Clozaril). Yellowish halos around lights are not a side effect of clozapine
(Clozaril). Joint pain or swelling is not a side effect of clozapine (Clozaril). Narrowing of the
field of vision is not a side effect of clozapine (Clozaril).
31. The nurses planning care for a group of clients and is working with the one license practice
nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse
take first to manage her time effectively?
A. Develop an hourly timeframe for tasks
B. Scheduled daily activities
C. determine goals of the day
D. delegate tasks to the AP
Answer: C. determine goals of the day
32. A nurse is performing an admission assessment for a client whose in the manic phase of
bipolar disorder which of the following behaviours should the nurse expect?
A. Performance of ritualistic behaviours
B. suspiciousness and distress
C. distractibility and poor judgment
D. reports of physical discomfort

Answer: C. distractibility and poor judgment
Rationale:
During the manic phase The following may be present:
• Grandiose ideas.
• Pressure of speech.
• Excessive amounts of energy.
• Racing thoughts and flight of ideas.
• Overactivity.
• Needing little sleep, or an altered sleep pattern.
• Easily distracted - starting many activities and leaving them unfinished.
• Poor judgment
• Bright clothes or unkempt.
• Increased appetite.
• Sexual disinhibition.
• Recklessness with money
33. The nurse is calling for an infant who has coarctation of the aorta. Which of the following
should the nurse identify as an expected finding? (same in B)
A. Weak femoral pulses
B. Free print nosebleeds
C. upper extremity hypertension
D. increased intracranial pressure
Answer: A. weak femoral pulses
Rationale:
coarctation of the aorta s/s elevated arm BP, bounding arm pulses, decreased BP legs, cool skin
legs, weak or absent femoral pulses, heart failure in infants, dizziness, HA, fainting or
nosebleeds in older children
34. A nurse is developing an in service about personality disorders which of the following
information should the nurse include when discussing borderline personality disorder?
A. The client might act seductively

B. The client is overly concerned about minor details
C. The client exhibits impulsive behavior
D. The client is exceptionally clingy to others
Answer: C. The client exhibits impulsive behavior
Rationale:
Impulsive and Impulsive behavior, such as gambling, reckless driving, unsafe sex, spending
sprees, binge eating or drug abuse, or sabotaging success by suddenly quitting a good job or
ending a positive relationship
35. A nurse is assessing a client who has a chest tube with the water seal drainage system upon
assessment the nurse notes tidaling in the water seal which of the following is an explanation for
the tidaling?
A. There is a loop of tubing below the drainage system
B. This system is working properly
C. The lung has a re-expanded
D. The tubing is partially obstructed by clots
Answer: B. This system is working properly
Rationale:
When tidaling occurs, the drainage tubes are patient and the apparatus is functioning properly.
Tidaling stops when the lung has re expanded or if the chest drainage tubes are kinked or
obstructed.
36. A nurse in an emergency department is caring for a client whose experience stimulate
withdrawal.
Which of the following findings should the nurse expect
A. Runny nose
B. Decreased appetite
C. Muscle spasms
D. Fatigue
Answer: D. Fatigue
Rationale:

Stimulant withdrawal symptoms include: inability to feel pressure. FATIGUE. Difficulty
concentrating. Poor sleep quality. Depression. Loss of cognitive function.
37. A charge nurse is teaching new staff members about factors that increase the client’s risk to
become violent. Which of the following risk factors should the nurse include is the best predictor
of future violence
A. A history of being in prison
B. Experiencing delusions
C. Male gender
D. Previous violent behavior
Answer: D. Previous violent behavior
38. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the
following action should the nurse plan to take?
A. Instruct client to lift her chin when swallowing.
B. Talk with the client during her feeding
C. Discourage a client from coughing during feedings
D. Sit at or below the clients I levelled during feedings
Answer: D. sit at or below the clients I levelled during feedings
Rationale:
Sit at or below patient’s eye level
When feeding patients sit down so you are positioned at the same level, or slightly below the
patients eye level, this will make it easier for him/her to maintain their head in the most
appropriate position.
39. The nurses providing teaching to a client who has a depressive disorder and a new
prescription for amitriptyline. Which of the following statements by the client indicates an
understanding of the teaching
A. I expect this medication to raise my blood pressure
B. I should take this medication on an empty stomach
C. I can continue to take a St. John’s wort while taking this medication

D. I know it will be a couple of weeks before the medication helps me feel better
Answer: D. I know it will be a couple of weeks before the medication helps me feel better
Rationale:
given orally at bedtime, therapeutic effects after 1 to 3 weeks, expect long term use.
TCAs Tricyclic antidepressants-depression: AMITRYPTYLINE ACTION: block reuptake of NE
& serotonin.
AMITRIPTYLINE side/adverse effects: Orthostatic hypotension,
Anticholinergic effects(dry mouth, blurred vision, photophobia, tachycardia, etc), Sedation,
Toxicity resulting in cholinergic blockage & cardiac tox. evidenced by dysrhythmias, mental
confusion, & agitation, followed by seizures, coma, & possible death.
40. The nurses developing a nutritional care plan for a client who has COPD and severe dyspnea.
To promote intake, which of the following action should the nurse include in the plan of care?
A. Ambulate the client before each meal
B. Offer the client three large meals each day
C. Administer a bronchodilator after meals
D. Limit fluid intake with meals
Answer: C. Administer a bronchodilator after meals
41. A nurse in the emergency department is assessing a client who has major depressive disorder.
Which of the following action should the nurse take first?
A. Establish a therapeutic rapport with the client.
B. Assess the client for suicidal ideation.
C. Encourage the client to participate in group activities.
D. Educate the client about their medication regimen.
Answer: B. Assess the client for suicidal ideation.
Rationale:
In clients with major depressive disorder, assessing for suicidal ideation is a critical first step to
ensure the client's safety. Once safety is established, other interventions such as establishing
rapport, encouraging participation in activities, and educating about medication can follow.

42. A home health nurse is completing screenings for elder abuse during client visits. Which of
the following findings should the nurse identify as an indication of potential elder abuse?
A. A client who lives with family members and begins to take more responsibility for self-care
B. A client who reports being given sedative medications by family members
C. A client who is taking up warfarin and has several small bruises on his shins and hands
D. A client who schedules multiple visits with his provider every month
Answer: B. A client who reports being given sedative medications by family members
43. The nurses planning care for a client who is to receive alteplase recombinant for a thrombus
in the coronary artery. Which of the following actions should the nurse include in the plan of
care?
A. Administer medications intramuscularly
B. Provided diet low in protein
C. Observe for bruising of the skin
D. Monitor vital signs every hour for the first four hours
Answer: C. Observe for bruising of the skin
Rationale:
Check for major and/or minor bleeding2
All body secretions should be tested for occult blood.3
• Major bleeding: intracranial, retroperitoneal, gastrointestinal, or genitourinary hemorrhages2
• Minor bleeding: gums, venipuncture sites, haematuria, haemoptysis, skin hematomas, or
ecchymosis2
• Arterial and venous punctures should be minimized and checked frequently
44. A nurses caring for a client whose postoperative following in appendectomy and is receiving
gentamicin.
Which of the following assessment findings should the nurse identify as an adverse effect of this
medication
A. Creatinine 2.3 mg/dL
B. Respiratory rate 22/min
C. 2+ pitting edema of the ankles

D. Hbg 8.7 g/dL
Answer: A. Creatine 2.3mg/dl ( normal creatine 0.6-1.2)
45. A nurse in an acute care facility is caring for a client who is homeless and has a decubitus
ulcer. Which of the following actions should the nurse take as a client advocate?
A. Gathered dressing supplies for the client’s discharge
B. Provide client teaching about nutrition
C. Consult with the facilities quality improvement team
D. Contact the facilities case management department
Answer: D. Contact the facilities case management department
46. The nurse caring for a client who has diarrhoea and is receiving intermittent enteral feedings.
Which of the following action should the nurse take?
A. Discard the open can of formula after 36 hours
B. Administer feedings at a slower rate
C. flush the tube with 10 mL of water after feedings
D. provide chilled formula
Answer: B. Administer feedings at a slower rate
Rationale:
If nurse noted patient is complaining of diarrhoea, slower the nutrition rate and notify the MD
47. A nurse is caring for a client who’s postoperative and has a new prescription for
hydromorphone. Which of the following actions should the nurse take?
A. Withhold the medication if the client does not appear to be in pain
B. Withhold the medication of the client has a fever
C. Document administration of the medication upon removal of the medication dispensing
system
D. Count the current number of unit doses available in the medication dispensing system
Answer: D. Count the current number of unit doses available in the medication dispensing
system

48. And there’s snow provider’s office is caring for a client who asks about using acupuncture to
manage his osteoarthritis pain. The nurse should identify which of the following conditions as a
contradiction for receiving this treatment?
A. Herpes zoster
B. Hypertension
C. obesity
D. hypothyroidism
Answer: A. Herpes zoster
Rationale:
acupuncture is contraindicated in clients with herpes zoster or any skin infection
49. The nurse is assessing A client following abdominal surgery. which the following findings
should the nurse report to the provider?
A. Temperature 37.6°C (99.7°F)
B. Urinary output 20 mL/ hour
C. blood pressure 100/70 mm Hg
D. serious drainage on abdominal dressing
Answer: B. Urinary output 20 ml/hour
50. A nurse long-term care facility is admitting a client who has dementia. Which of the
following actions should the nurse take to reduce the risk for client injury?
A. Place the bedside table at the foot of the bed
B. Keep the television on during tonight
C. Assist the client to the toilet frequently
D. Raise the side rails up when the client is in bed
Answer: C. Assist the client to the toilet frequently
51. Certified IV nurse is providing education about peripherally inserting central catheters(PICC)
to a newly licensed nurse. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
A. Use a vein in the middle of the lower arm to insert a PICC

B. Flush A PICC using a 3 millimetre syringe
C. Informed consent is required prior to PICC placement
D. Position the client arm in adduction for PICC placement
Answer: C. Informed consent is required prior to PICC placement
52. A nurse teaching self-administration of insulin glargine to a client who has type I diabetes
mellitus. Which of the following statements by this client indicated understanding of teaching?
A. I will take this insulin before meals
B. I will not mix this insulin with other types of insulin
C. I will rotate the injection sites between my arm and my thigh
D. I will shake the vial to mix the insulin
Answer: B. I will not mix this insulin with other types of insulin
Rationale:
insulin glargine (Lantus) drug interactions do not mix Lantus with another insulin or solution.
53. A nurse is auscultating for crackles on a client who has pneumonia. Which of the following
anterior chest wall locations should the nurse auscultate

Answer:
1. Upper anterior chest: Just above the clavicles.
2. Mid-anterior chest: Around the second intercostal space at the sternal border.
3. Lower anterior chest: Around the fifth intercostal space at the mid-clavicular line.
54. A nurses caring for a client who is immunocompromised which of the following antiseptic
solutions should the nurse use to perform hand hygiene
A. Isopropyl alcohol
B. Bleach
C. Chlorhexidine

D. Povidone iodine
Answer: C. Chlorohexidine
55. The nurse is assessing A client in the emergency department. Which of the following actions
should the nurse take first?
A. Assess the client's vital signs.
B. Obtain a detailed health history.
C. Perform a focused physical examination.
D. Check the client's medical records.
Answer: A. Assess the client's vital signs.
Rationale:
Assessing the client's vital signs is the priority action when initially assessing a client in the
emergency department. Vital signs, including heart rate, blood pressure, respiratory rate, and
temperature, provide essential information about the client's physiological status and can help
identify any immediate concerns or life-threatening conditions that require prompt intervention.
56. A nurse is providing teaching to the parents of a newborn about newborn genetic screening.
Which of the following statement should the nurse include in the teaching?
A. This test should be performed after your babies 24 hours old
B. A nurse will draw blood from your baby’s inner elbow
C. Your baby will be given 2 ounces of water you to the test
D. This test will be repeated when your babies two months old
Answer: A. This test should be performed after your babies 24 hours old
Rationale:
best time is 24 to 72 hours
(A capillary heel stick should be done 24 hr following birth.)
57. The Nurse’s teaching the parental class about infection prevention at a community centre,
which of the following statements by a client indicates an understanding of the teaching?
A. I can visit my nephew who has chickenpox five days after the sores have crusted
B. I can clean my cat litter box during my pregnancy

C. I should take antibiotics when I have a virus
D. I should wash my hands for 10 seconds of hot water after working in the garden
Answer: A. I can visit my nephew who has chickenpox five days after the sores have crusted
Rationale:
Chicken pox duration: Chicken pox generally lasts 5-7 days. One is not contagious once all sores
have crusted over- usually about a week
58. The nurses caring for A client who has end stage kidney disease. The client’s adult child
asked the nurse about becoming a living kidney donor for her father. Which of the following
conditions in the child’s medical history should the nurse identify the contradiction to the
procedure? (same in B)
A. Primary glaucoma
B. Amputation
C. Hypertension
D. Osteoarthritis
Answer: C. Hypertension
Rationale:
• recent malignancy
• active or chronic inf
• severe irreversible extrarenal disease (inoperable cardiac disease, chronic lung disease, severe
PVD) - active inf (HIV, Hep B and C)
• morbid obesity (BMI >35)
• current substance abuse
• inability to give informed consent
• h/x of nonadherence to tx regimens
• htn
• diabetes
59. A home health nurse is planning to care for a client who has Alzheimer’s disease.
Which of the following actions should the nurse including the plan of care?
A. Replace the carpet with hardwood floors.

B. Place locks at the top of the exterior doors.
C. Wear clothing with zippers instead of buttons.
D. Encourage physical activity prior to bedtime.
Answer: B. Place locks at the top of the exterior doors.
60. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears and assistive
personnel AP telling the client, “If you don’t eat, I’ll put restraints on your face and feed you” the
nurse should intervene and explain to the AP that this statement constitutes which of the
following torts
A. Malpractice
B. Negligence
C. Assault
D. Battery
Answer: C. Assault
61. A nurse is reviewing the clients laboratory results prior to surgery. The following findings
should the nurse reported to the provider?
A. Bicarbonate 26 mEq/L
B. Chloride 100 mEq/L
C. Potassium 3.8 mEq/L
D. Sodium 160 mEq/L
Answer: D. sodium 160 meq/L
Rationale:
normal sodium ranges 135-145 mEq/L
62. A charge nurse is evaluating a newly licensed understanding of advance directives. Which of
the following statements by the newly licensed nurse indicates an understanding of advance
directives?
A. I’ll refer clients who do not have advance directives for legal assistance
B. I have to witness a client signature on his advanced directives
C. I have to document whether or not a client has prepared his advance directives

D. I’ll encourage clients to follow their providers wishes for an end-of-life care
Answer: C. I have to document whether or not a client has prepared his advance directives
Rationale:
An advance directive is a legal document intended to ensure that healthcare providers honor a
patient's decisions regarding treatment, even when he or she is no longer able to communicate
those decisions
63. A clinic nurse is addressing an eight-year-old child during an annual physical examination.
Which of the following findings indicates the need for intervention by the nurse?
A. The client eat at least one snack daily
B. The client’s height has increased 6.35 cm (2.5 in)
C. The client’s weight has increased 0.9 kg ( 2 lb)
D. The client drinks 3 cups of 1 % milk per day
Answer: D. the client drinks 3 cups of 1% milk per day
64. A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of
contractions. Which of the following findings should the nurse identify as a manifestation of
false labor
A. Presence of bloody show
B. Intermittent painless contractions
C. Slow changing dilation and effacement
D. Contraction intensity increased by ambulation
Answer: B. Intermittent painless contractions
Rationale:
false contractions; painless, irregular, and usually relieved by walking
True contractions: -walking can increase contraction intensity-Continue despite comfort
measures
65. A nurse is caring for a client who has a urinary tract infection and has been taking cefaclor.
Which of the following serum laboratory results indicate stem medication is it effective?
A. Creatinine 2.3 mg/dL

B. BUN 32 mg/dL
C. Eosinophils 3.9%
D. WBC 9200/mm3
Answer: D.WBC 9200/mm3
66. A charge nurse is mentoring a newly licensed nurse. Which of the following actions by the
newly licensed nurse indicates the need for intervention by the charge nurse?
A. Uses an IV infusion pump to administer total Parenteral nutrition to a client
B. Inserts in NG tube to a client using clean technique
C. Crushes an SL tablet to administer into a client’s feeding tube
D. Stabilize the clients indwelling urinary catheter with the nondominant hand prior to inflation
of the balloon
Answer: C. Crushes an SL tablet to administer into a client’s feeding tube
67. A nurse is reviewing laboratory results for a client who has heart failure and notes a serum
potassium level of 5.2 mEq/L. which of the following medication should the nurse withhold
A. Furosemide
B. Spironolactone
C. Atorvastatin
D. Metoprolol
Answer: B. spironolactone
Rationale:
adverse effects of spironolactone (spareing Potassium)
hyperkalemia gynecomastia menstural irregularities imp otence hirutism and deepining of the
voice
68. A nurse is teaching the client who has migraine headaches how to use biofeedback to reduce
the need of pharmacological interventions. Which of the following information should the nurse
include in the teaching?
A. Biofeedback stimulates certain pressure points to relax muscles
B. Biofeedback improves energy flow through soft tissue manipulation to increase circulation

C. Biofeedback requires concentration to control psychological responses
D. Biofeedback uses herbs to reduce inflammation
Answer: C. Biofeedback requires concentration to control psychological responses
Rationale:
Biofeedback: a technique you can use to learn to control your body's functions, such as your
heart rate.
You're connected to electrical sensors that help you receive information (feedback) about your
body (bio)
69. A nurses teaching the parents of a child who has a new onset of seizures and is to undergo an
electroencephalogram (EEG) about the procedure. Which of the following instructions should
the nurse include in the teaching?
A. Give the child acetaminophen for pain following the procedure
B. Ensure the child’s hair is clean without conditioner before the procedure
C. Keep the child out of the sun for four hours following the procedure
D. Make the child NPO before the procedure
Answer: B .Ensure the child’s hair is clean without conditioner before the procedure
Rationale:
INSTRUCTIONS FOR PATIENT:
1) Wash your hair and scrub the scalp thoroughly. Do not apply hair oil, gels or sprays.
2) Continue your normal medications and bring a list of medications with you.
3) Continue normal diet. Attempt to eat a meal within two hours of your scheduled test.
4) Do not drink caffeinated beverages on the day of your test. No alcoholic beverages within 48
hours prior to testing.
5) The night before the test stay up until 1:00 a.m., and sleep until 5:00 a.m. (4 hours sleep).
After waking at 5:00 a.m., stay awake until your test time. PLEASE NO NAPS
6) After the test it will be advisable to wash your hair again when you return home to insure all
of the paste is removed before it has a chance to dry on the scalp. (You might want to bring a
scarf or hat to wear when leaving the testing centre).

70. The school nurse is teaching a parent about absence seizures. Which of the following
information should the nurse include?
A. This type of seizure can be mistaken for daydreaming.
B. This type of seizure last 30 to 60 seconds
C. The child usually has an aura prior to onset
D. This type of seizure has a gradual onset
Answer: A. This type of seizure can be mistaken for daydreaming.
Rationale:
Absence seizures
General seizure that lasts from seconds to minutes in which the patient shows a brief loss of
contact with their surroundings
71. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents.
Which of the following statements about client indicated understanding of the teaching?
A. I will limit my alcohol use to one drink daily while taking disulfiram
B. I will take my lithium on an empty stomach
C. I will take the sustained release methylphenidate every morning
D. I will avoid foods containing tyramine while taking fluoxetine
Answer: C. I will take the sustained release methylphenidate every morning
72. A nurse is caring for a client who is four days postpartum. Which of the following assessment
findings should the nurse expect? (Select all that apply.)
A. Foul perineal older
B Lochia serosa
C. Postpartum chill
D. Fundus displaced to the right (should be midline)
E. Fundus 4 cm (1.6 in) below the umbilicus
Answer: B. Lochia serosa and E. Fundus 4cm (1.6 in )below the umbilicus
Rationale:
Fundus will decrease one fingerbreadth account 1 cm. First day, 2nd day 2……. Lochia serosa is
noted after the 4 day

73. A nurse is providing discharge teaching to a client following the total gastrectomy. The nurse
should instruct the client about which of the following medications
A. Vitamin K
B. Ranitidine
C. metoclopramide
D. vitamin B 12
Answer: D. Vitamin B12
Rationale:
Vitamin B12 because of low B12
• celiac disease
• terminal ileac disease (e.g. Crohn's)
• bac. overgrowth (B12 & B12/IF complex utilized by intestinal bac.)
• chronic pancreatitis
• total gastrectomy (+ weight loss procedures)
• some drugs (omeprazole, metformin)
74. A nurse is caring for A child who has cystic fibrosis and requires postural drainage which of
the following actions should the nurse take?
A. Hold hands flat to perform percussions on the child
B. Perform the procedure twice a day
C. Administer a Bronchodilator after the procedure
D. Perform the procedure prior to meals
Answer: B. Perform the procedure twice a day
Rationale:
Before meals avoid the possibility of vomiting or regurgitating food
Postural drainage: Bronchodilator or nebulizer PRIOR to treatment Should be done 1 hour before
meals or 2 hours after Perform twice daily

75. A nurse at a community health clinic is planning care for an adolescent who recently learned
that she’s pregnant and is concerned about her ability to afford and care for her baby. Which of
the following actions should the nurse take?
A. Contact the adolescents parents for assistance
B. Advise the adolescent to place the newborn for adoption
C. Assist the adolescent in applying for Medicaid
D. Referred the adolescent to a local mental health clinic
Answer: C. Assist the adolescent in applying for Medicaid
Rationale:
Medicaid: gov funded insurance for clients who have low income - individual states determine
eligibility requirements
76. Under submitting an older adult client who is transferring from another facility.
Nursing notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of
the following actions should the nurse take to address suspicions of elder abuse?
A. Contact the family regarding the client’s condition
B. Notify risk management
C. Privately interviewed the client about her condition
D. Inform the transferring agency of the client’s condition
Answer: C. Privately interviewed the client about her condition
77. A nurses caring for a client who is experiencing expressive aphasia and right hemiparesis
following a cerebrovascular accident. Which is the phone actions by the nurse best promote
communication among staff caring for the client?
A. Noting changes in the treatment plan and the client’s medical records
B. Recording the client’s progress in the nurses notes
C. Posting swallowing precautions at the head of the clients in bed
D. Having interdisciplinary team meetings for the client on a regular basis
Answer: C. Posting swallowing precautions at the head of the clients in bed

78. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following
actions should the nurse take to provide catheter care?
A. Empty the collected urine once every 24 hours
B. Hang the drainage bag on the bed rail
C. Provide perineal hygiene after defecation
D. Change the indwelling catheter in every eight hours
Answer: C. Provide perineal hygiene after defecation
79. A nurse is assisting a client who has acute glomerulonephritis to choose menu items for
breakfast.
Which of the following food choices should the nurse recommend
A. Eggs
B. Banana
C. Smoked salmon
D. Bagel
Answer: D. Bagel
Rationale:
• fluid restriction
• protein regulated according to BUN/creatinine
• protein may not have to be restricted
• K will need to be replaced if
• diuretic promotes excretion
• Na may be restricted to prevent fluid retention
• strict I & O to monitor kidney function
80. And Newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her
position at the clinic. Which of the following tasks should the nurse identify as tertiary
prevention?
A. Helping clients understand health screenings covered by their insurance plans
B. Using an electronic messaging system to remind clients went to take medications
C. Educating client about contraindications to specific immunizations

D. Providing clients with information about the benefits of exercise
Answer: B. Using an electronic messaging system to remind clients went to take medications
Rationale:
Primary prevention: Immunizations(vaccines) and education
Secondary prevention: Screening and early treatment/ exercise
Tertiary prevention: They are already sick prevent from other conditions to appear.
81 A nurse in a long-term care facility is managing the care of an older adult client who has
difficulty swallowing and occasional choking during meals the nurse should initiate a referral to
which of the following members of the interprofessional care team
A. Occupational therapist
B. Respiratory therapist
C. Social worker
D. Speech language pathologist
Answer: D. Speech language pathologist
82. A nurse is performing A preoperative assessment for a client who reports having an allergy to
several foods. Which of the following food allergies indicate a risk factor for a latex allergy
A. Peanuts
B. Eggs
C. Bananas
D. Shrimp
Answer: C. Bananas
Rationale:
Avocado
Papaya
Banana
Eggplant
Chestnut
Melon
Potato

Passion fruit
Tomato
Mango
Kiwi
Wheat
Pineapple
Cherimoya
Green Pepper
83. A nurse is planning care for a client who is scheduled to receive a peripherally inserted
central catheter in the arm. Which of the following interventions is appropriate for the nurse to
include in the plan of care?
A. Measure of the arm circumference above the incision site daily
B. Schedule an MRI post procedure to verify placement
C. Administer sedation for the procedure
D. Use gauze to secure an arm board to the involved extremity
Answer: A. Measure of the arm circumference above the incision site daily
84. A nurse is caring for a group of clients, which of the following wounds should the nurse
expect to heal by primary intention
A. Approximated surgical incision
B. Infected laceration
C. Stage II pressure ulcer
D. Partial thickness burn
Answer: A. Approximated surgical incision
Rationale:
A wound that would heal be primary intention
A surgical incision
85. A nurse is performing A change of shift assessment. Which of the following clients has the
priority finding?

A. A client who has a first-degree heart block and a heart rate of 62/min
B. A client who is two hr post-cast placement and has 2+ pitting edema and pallor
C. A client who has pneumonia with a productive cough and a fever of 38.8°C (101.8°F)
D. A client who has type II diabetes mellitus and a blood glucose of 250 mg/dL
Answer: C. A client who has pneumonia with a productive cough and a fever of 38.8°C
(101.8°F)
86. A nurse on a medical surgical unit is delegating tasks to assistive personnel (AP). Which of
the following client care tasks is within the scope of practice for the AP? (same in B)
A. Interpreting blood glucose values
B. Performing postmortem care
C. Explaining the steps for a 24 hr urine collection
D. Assisting with low carbohydrate diet selections
Answer: B. Performing postmortem care
87. A nurse in a mental health clinic received a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist notes which of the following responses should
the nurse make?
A. We can provide a copy of your records, but that therapist’s notes are not included
B. I don’t think you will benefit from reviewing your therapist’s notes right now
C. Why are you interested in seeing your therapist’s notes?
D. Are you not happy with your treatment?
Answer: A. We can provide a copy of your records, but that therapist’s notes are not included.
88. A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy
which of the following statements indicates in understanding of the teaching?
A. I will wipe my nose instead of blowing it
B. I will remove my shoes when I’m inside my house
C. I will floss between my teeth every time I brush
D. I will use an enema to manage my constipation
Answer: A. I will wipe my nose instead of blowing it

89. A home care nurse is making the follow-up visit with a client who has COPD and is using a
compressed oxygen system in his home. Which of the following actions should the nurse take?
A. Store the oxygen tank wrench in a locked cabinet
B. Have the client store smaller tanks under his bed
C. Make sure that the client checks to gauge weekly
D. Placed the oxygen tank away from curtains or drapes
Answer: C. Make sure that the client checks to gauge weekly
90. A nurse is conducting Health promotion and education regarding contraindication to
combination oral contraceptive use to the group of women. Which of the following conditions
should the nurse including the teaching?
A. Renal calculi
B. Fibrocystic breast disease
C. Fibromyalgia
D. Hypertension
Answer: B. Fibrocystic breast disease
91. A nurse is caring for a client following a thyroidectomy. For which of the following
complications should the nurse assess the client?
A. Hypokalaemia
B. Muscular depression
C. Laryngeal stridor
D. Hyperglycaemia
Answer: C. Laryngeal stridor
92. A nurse ls teaching a client who is to start a new prescription for carbidopa levodopa. Which
of the following instructions should the nurse include?
A. "Take with a protein snack."
B. "Report dark-coloured urine."
C. "Monitor for hyperglycaemia."

D. "Change positions slowly."
Answer: B: "Report dark-coloured urine."
Rationale:
Relief of timer and rigidity and Parkinson's syndrome.
CNS: involuntary movements, anxiety, dizziness, hallucinations, memory loss, psychiatric
problems, urges, gambling, sexual. Darkening of urine or sweat
93. A nurse is caring for a school-age child who is postoperative and received morphine via IV
bolus for pain 10 min ago. Which of the following findings is the nurse's priority
A. Constipation
B. Sedation
C. Euphoria
D. Bradypnea
Answer: D. Bradypnea:
Rationale:
A rate slower than 12 breaths per minute is called?
94. A nurse is teaching the parents of a 6-year-old child who has sickle cell anaemia about
managing the disease. The nurse should emphasize the importance of which of the following
factors to prevent a sickle cell crisis?
A. Adequate hydration
B. Calorie restriction
C. Increased iron intake
D. A low-protein diet
Answer: A. adequate hydration
95. A community health nurse is working with a group of clients. The nurse practices the ethical
principle of distributive justice by performing which of the following tasks?
A. Accepting the decision of an older adult client to live alone in her home
B. Ensuring that a client who is homeless receives preventive medical care
C. Keeping a promise to visit with a client who is housebound after the delivery of care

D. Being honest with the parents of a child about the need to report suspected abuse
Answer: B. Ensuring that a client who is homeless receives preventive medical
96. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and
has had recent weight loss. Which of the following is the priority admission data for the nurse to
obtain
A. Changes in appetite
B. Prescribed medications
C. Swallowing ability
D. Daily fluid intake
Answer: C. Swallowing ability
Rationale:
ALS is a disease of the upper and lower motor neurons characterized by muscle weakness
progressing to muscle atrophy and eventually paralysis and death. ALS does not involve
autonomic changes, sensory alterations, or cognitive changes.
97. A nurse is caring for a client who has a new prescription for piperacillin/tazobactam 3.75 g
intermittent IV bolus Q6H to infuse over 30 min. Available is piperacillin/ tazobactam 3. 75 g in
50 ml 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many ml/hr?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a
trailing zero.) ml/hr
Answer: 100ml/hr
98. A nurse is assessing a client who has acute angle-closure glaucoma. Which of the following
findings should the nurse expect?
A. Increased light perception
B. Reddened cornea
C. Severe periocular pain
D. Gray cast to sclera
Answer: C. Severe periocular pain
Rationale:

Sign of glaucoma is loss of peripheral vision loss
99. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last
5 days. The client 's laboratory values this morning are the following: WBC 10, 00 0/ m m3 ,
RBC 5.2 million/ mm3, platelets 250,000/ mm3 , BUN 32 mg/dl, and serum creatinine 2.1 mg/dl.
The nurse should report these findings to which of the following members of the
interdisciplinary team?
A. Dietitian
B. Infection control nurse
C. Nephrologist
D. Cardiologist
Answer: C. Nephrologist
Rationale:
BUN: 10-20
Creatine 0.6-1.2
BUN and Creatinine are high
100. A nurse is caring for toddler who has retinoblastoma. Which of the following findings
should the nurse expect?
A. Hyphema
B. Opacity of the lens
C. Nystagmus
D. White eye reflex
Answer: D. White eye reflex
101. A nurse ls providing discharge teaching about home care of a surgical incision to a client
who does not speak the same language as the nurse. The nurse is communicating with the client
using an interpreter. Which of the following actions should the nurse take?
A. Use gestures to convey meaning.
B. Speak directly to the client.
C. Pause in the middle of sentences.

D. Speak slowly when talking to the interpreter.
Answer: B. Speak directly to the client
102 A nurse is providing teaching about exercise to a client who is at 28 weeks of gestation.
Which of the following statement s by the client indicates an understanding of the teaching?
A. "I can continue to do exercises that require the supine position."
B. "I should check my pulse rate once every hour while exercising."
C. "I should increase my exercise level to prepare for labor."
D. "I should drink 16 to 24 ounces of water after I exercise."
Answer: D.” I should drink 16 to 24 ounces of water after I exercise.”
103. A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis.
Which of the following instructions should the nurse include?
A. "Use a nebulizer to administer a bronchodilator following airway clearance therapy."
B. "Restrict intake of foods that contain gluten."
C. "Perform chest percussion and postural drainage at least twice daily."
D. "Administer pancreatic enzymes on an empty stomach." (admin 30min before eating)
Answer: C. "Perform chest percussion and postural drainage at least twice daily."
104. A nurse ls developing a plan of care for a client who has preeclampsia and is to receive
magnesium sulphate via continuous IV infusion. Which of the following actions should the nurse
include in the plan?
A. Monitor the FHR via Doppler every 30 min.
B. Restrict the client's total fluid intake to 250 ml / hr.
C. Give the client protamine if signs of magnesium sulphate toxicity occur.
D. Measure the client's urine output every hour.
Answer: D. Measure the client’s urine output every hour.
105. A nurse is planning discharge teaching for a client who is to start a new prescription for
metoprolol. For which of the following should the nurse instruct the client to monitor and report
to the provider

A. Tinnitus
B. Polyuria
C. Hyperglycaemia
D. Bradycardia
Answer: D. Bradycardia
Rationale:
Check pulse before administering betablockers.
106. A nurse is providing teaching to the parents of a newborn who has been circumcised. Which
of the following instructions should the nurse include in the teaching?
A. "Remove yellow exudate around the penis." (important not to wash it off;)
B. "Wrap sterile gauze around the penis if bleeding occurs." (doesn’t have to be sterile; )
C. "Use soap to cleanse the site." (keep area dry)
D. "Apply petroleum jelly to the glans with diaper changes."
Answer: D. "Apply petroleum jelly to the glans with diaper changes."
Rationale:
C to cleanse siteircumcised: petroleum jelly
Uncircumcised: use soap
107. A nurse ls developing a care plan for a client who is in Buck's traction and is scheduled for
surgery for a fractured femur of the right leg. Which of the following interventions should the
nurse delegate to an assistive personnel?
A. Remind the client to use the incentive spirometer.
B. Ask the client to describe her pain.
C. Observe the position of the suspended weight.
D. Check the client's pedal pulse on the right leg.
Answer: D. Check the client’s pedal pulse on the right leg.
Rationale:
• Remind the client to use the incentive spirometer.
• Ask the client to describe her pain. (assessment/evaluation; RN)
• Observe the position of the suspended weight.

• Check the client's pedal pulse on the right leg. Vital signs
108. A nurse is assessing the growth and development of a 3-year-old child. Which of the
following questions should the nurse ask the parent to determine if the child is exhibiting typical
developmental expectations?
A. "Can your child catch and throw a small ball?" (5 y/o)
B. "Can your child ride a tricycle?"
C. "Can your child name five colours?"
D. "Can your child draw a stick figure?"
Answer: B. "Can your child ride a tricycle?"
109. A nurse is caring for a newborn whose mother was taking methadone during her pregnancy.
Which of the following findings indicates the newborn is experiencing withdrawal? (same in B)
A. Bradycardia
B. Acrocyanosis
C. Hypertonicity
D. Bulging fontanels
Answer: C. Hypertonicity
110. A charge nurse is admitting four clients to an acute care unit. Which of the following client s
should the nurse place near the nurses' station?
A. A client who is on fluid restriction
B. A client who is in Buck's traction
C. A client who has orthostatic hypotension
D. A client who has an open wound
Answer: C. A client who has orthostatic hypotension (fall risk?)
111. A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant
is sitting on my chest." The client is weak and unable to walk. After the nurse initiates chest pain
protocol, which of the following is the priority diagnostic test
A. Serum potassium

B. 12-lead ECG
C. PT and INR
D. Chest x-ray
Answer: B. 12-lead ECG
112. A charge nurse on a medical-surgical unit is assisting with the emergency response plan
following an external disaster in the community. In anticipation of multiple client admissions,
which of the following current clients should the nurse recommend for early discharge?
A. A client who has COPD and a respiratory rate of 44/min (respiratory problem/ Ambulatory)
B. A client who has cancer with a sealed implant for radiation therapy
C. A client who is receiving heparin for deep-vein thrombosis (not ambulatory/circulatory
problem)
D. A client who is 1 day postoperative following a vertebroplasty (unstable/needs continues
monitoring)
Answer: B. client who has cancer with a sealed implant for radiation therapy
Rationale:
Radiation implant precautions
Private room with radiation sign
Wear dosimeter film badge
Limit visitors to 30 min & remain 6ft away from the patient
Keep lead container in room & tongs
No pregnant ladies or anyone under 16 yrs. should come in contact with patient
113. A home health nurse is caring for a child who has Lyme disease. Which of the following is
an appropriate action for the nurse to take?
A. Assess for skin necrosis. (not necrosis/ is rash)
B. Educate the family to avoid sharing personal belongings. (not contagious)
C. Ensure the state health department has been notified.
D. Administer antitoxin.
Answer: C. Ensure the state health department has been notified.
Rationale:

Lyme disease: Lyme disease usually causes symptoms such as a rash, fever, headache, and
fatigue. But if it is not treated early, the infection can spread to your joints, heart, and nervous
system.
114. A nurse is reviewing annual educational requirements for fire safety. Identify the sequence
the nurse should use when operating a fire extinguisher. (Move the steps of using a fire
extinguisher into the box on the right, placing them in the selected order of performance. Use all
steps. )
A. Unlock the handle by pulling on the pin.
B. Point the hose at the base of the fire.
C. Squeeze the handles together.3
D. Sweep the extinguisher from side to side.4
Answer: A. Unlock the handle by pulling on the pin.
C. Squeeze the handles together.3
B. Point the hose at the base of the fire.
D. Sweep the extinguisher from side to side.4
115. A nurse is caring for a client who has a nasogastric tube. Which of the following actions
should the nurse take to verify tube placement prior to each feeding? CHECK THIS
A. Auscultate air insertion into the tube.
B. Test the bilirubin level of gastric contents.
C. Palpate the abdomen for tube placement.
D. Test the pH of gastric contents.
Answer: D. Test the Ph of gastric contents
116. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation.
Which of the following actions should the nurse take?
A. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
B. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
C. Measure the fundal height to determine the placement of the ultrasound stethoscope.
D. Place the client in a side-lying position prior to assessing the fetal heart rate.

Answer: C. Measure the fundal height to determine the placement of the ultrasound stethoscope
117. While performing a routine assessment, a nurse notices fraying on the electrical cord of a
client's continuous passive motion (CPM) device. Which of the following actions should the
nurse take first
A. Ensure the device inspection sticker is current.
B. Report the defect to the equipment maintenance staff.
C. Remove the device from the room.
D. Initiate a requisition for a replacement CPM device.
Answer: C. Remove the device from the door
118. A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the
following actions should the nurse take?
A. Implement seizure precautions.
B. Monitor the client for hypoglycaemia.
C. Perform range-of-motion exercises once per shift.
D. Place the client in high-Fowler's position.
Answer: A. Implement seizure precautions.
119. A nurse is providing teaching to a client about the adverse effects of sertraline.
Which of the following adverse effects should the nurse include? (=in B/C)
A. Excessive sweating
B. Increased urinary frequency
C. Dry cough
D. Metallic taste in mouth
Answer: A. Excessive sweating
Rationale:
Sertraline is a ssri which is a first class of treatment for depression.
Some of the complications are: anorgasmia, impotence, decreased libido.
Because it’s a upper it can cause inability to sleep, agitation, and anxiety. Weight loss early then
weight gain long run. Can cause fever and diaphoresis/ sweating!! Serotonin syndrome.

120. A nurse ls assessing a client who is in active labor. Which of the following findings should
the nurse report to the provider? (=in B/C)
A. Contractions lasting 80 seconds
B. FHR baseline 170/min
C. Early decelerations in the FHR
D. Temperature 37.4° c (99.3° F)
Answer: A. Contractions lasting 80 seconds
121. A nurse ls preparing a client to undergo a cardiac catheterization. Which of the following
tasks should the nurse perform prior to the
A. Draw blood specimens for culture and sensitivity.
B. Administer nitro-glycerine 0.4 mg SL 30 min before the procedure.
C. Transport the client to radiology for a CT scan.
D. Obtain a CBC with differential.
Answer: D. Obtain a CBC with differential
Rationale:
If client is taking any anticoagulants it can cause severe bleeding.
122. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing
auditory hallucinations. Which of the following actions should the nurse include in the plan?
A. Ask the client directly what he is hearing.
B. Encourage the client to lie down in a quiet room.
C. Avoid eye contact with the client .
D. Refer to the hallucinations as if they are real.
Answer: A. ask the client directly what he is hearing.
Rationale:
The nurse should not argue or agree with the client’s view of the situation. Offer comments such
as: “I don’t hear anything, but you seem to be feeling frightened.”

123. A nurse is reviewing the preadmission laboratory test results of a client who is to undergo
hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider
A. Sodium 142 mEq/L
B. Potassium 3.3 mEq/L
C. Blood glucose 80 mg/dl
D. PT 11.5 seconds
Answer: B. potassium 3.3 meq/L
Rationale:
Normal = 3.5-5
124. A nurse in the emergency department is caring for a client who has a new diagnosis of acute
myocardial infarction and is being treated with a thrombolytic, aspirin, and IV heparin. Which of
the following findings should indicate to the nurse that the client is experiencing a satisfactory
response to these interventions?
A. The client's stool is guaiac positive.
B. S3 heart sounds are present.
C. The client's aPTT is two times the control.
D. Q wave is noted on the cardiac monitor tracing.
Answer: C. The client's aPTT is two times the control.
Rationale:
therapeutic range for pt and (aPTT)
1.5 to 2 times the normal or control value
A S3 heart sounds can indicate a heart valve isn’t working properly. Guaiac positive stool is
indication of bleeding in the stool.
125. A nurse observes a client on the psychiatric unit muttering and standing near a window. The
client states, "The voices are telling me the following is an appropriate response by the nurse?
A. "I understand the voices are frightening you, but I do not hear any voices."
B. "Do you recognize the voices as belonging to anyone you know?"
C. "You shouldn't be afraid when you think the voices are telling you to hurt yourself."
D. "That can't be true. The only voices in this room are yours and mine."

Answer: A.“I understand the voices are frightening you, but I do not hear any voices.”
126. A home health nurse is visiting a client whose partner states that she is overwhelmed by
caring for him. When suggesting respite care, which of the following explanations should the
nurse provide?
A. "Respite care includes volunteers who will perform household tasks."
B. "Respite care provides clinicians to work with you in caring for your husband."
C. "Respite care offers financial resources to help care for your husband."
D. "Respite care allows for time away from caring for your husband."
Answer: D. “Respite care allows for time away from caring for your husband.”
127. A nurse working in the postpartum unit is reviewing a client's new prescription for
methylergonovine. The nurse should recognize that which of the following is a contraindication
for this medication
A. Hypertension
B. Confusion
C. Chlamydia
D. Polyuria
Answer: A. Hypertension
Rationale:
Should NEVER be used during pregnancy to induce labor. Do NOT use IM in the mother is
hypersensitive to ergot. Contraindicated for women with hypertension, severe hepatic or renal
disease, thrombophlebitis, coronary artery disease, peripheral vascular disease, hypocalcaemia,
or sepsis or before the fourth stage of labor.
Used for the prevention and treatment of postpartum or postabortion haemorrhage caused by
uterine atony or subinvolution
128. A nurse is caring for a client who is in labor and has received an epidural. Which of the
following actions should the nurse take?
A. Decrease the maintenance infusion rate of IV fluid. (administer to decrease offs dert of
hypotension)

B. Have protamine sulphate available at the bedside. (ephedrine)
C. Reposition the client side-to-side each hour.
D. Monitor the client for hypertension. (hypotension)
Answer: C. Reposition the client side-to-side each hour.
Rationale:
Epidural helps relieve discomfort during uterine contractions. Local anaesthetic is given,
morphine and fentanyl. Keep patient in a side lying position after insertion to avoid supine
hypotension syndrome with compression of the vena cava. The reversal agent is ephedrine a
vasopressor which helps in case patients’ blood pressure drops significantly. Fluids are needed to
help keep a normal blood pressure!!
Decrease the maintenance infusion rate of IV fluid. (administer to decrease offs dert of
hypotension)
Have protamine sulphate available at the bedside. (ephedrine) Reposition the client side-to side
each hour.
Monitor the client for hypertension. (hypotension)
129. A charge nurse observes a coworker who has impaired coordination and is drowsy while
performing routine tasks. Which of the following actions should the charge nurse take first?
A. Document observations about the nurse's behavior.
B. Report the nurse's behavior to the nurse manager.
C. Reassign the nurse's client -care duties to another nurse.
D. Obtain support from another nurse before filing a report.
Answer: B. report the nurse’s behavior to the nurse manager.
130. A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving cardiac monitoring
B. A client who has epidural analgesia and weakness in the lower extremities
C. A client who has a hip fracture and a new onset of tachypnoea
D. A client who has diabetes mellitus and a haemoglobin AlC of 6.8%
Answer: C. A client who has a hip fracture and a new onset of tachypnoea

131 A nurse is caring for a client who has an implanted venous access port. Which of the
following should the nurse use to access the port?
A. A non-coring needle
B. A butterfly needle
C. An Angio catheter
D. A 25-gauge needle
Answer: A. non-coring needle.
Rationale:
use only noncoring (huber) needle to avoid damaging the mesh on implanted ports.
132. A nurse is receiving change-of-shift report for four client s. Which of the following clients
should the nurse assess first?
A. A client who has leukaemia and a platelet level of 95,000/ mm3
B. A client who has hepatitis B and a total bilirubin of 1.2 mg/dl
C. A client who has diabetes mellitus and a HbAlc of 5.2% (normal)
D. A client who received IV furosemide and has a serum potassium of 3.6 mEq/L (normal)
Answer: A. A client who has leukaemia and a platelet level of 95,000/mm3
Rationale:
A low bilirubin is expected for hep B.
Potassium 3.5-5.5 is normal.
Glycosylated haemoglobin (hba1C): expected range 4% to 6%.
But an acceptable reference range for a clients who have diabetes can be 6.5% to 8% with a
target goal of less than 7% This is the best indicator.
133. A nurse is admitting a client who has a history of atrial fibrillation. The nurse should
recognize that atrial fibrillation places the client the following conditions?
A. Cardiac tamponade
B. Pulmonary emboli
C. Hemothorax
D. Widened pulse pressure

Answer: B. Pulmonary emboli
134. A nurse is teaching about home care to the parents of an infant who has a tracheostomy.
Which of the following instructions should the nurse include in the teaching?
A. "Set the suction machine to 60 mm Hg."
B. "Advance the suction catheter just past the point of resistance."
C. "In still 2 ml of saline in the tracheostomy prior to suctioning."
D. "Apply suction for 30 seconds after advancing the catheter."
Answer: A. "Set the suction machine to 60 mm Hg."
Rationale:
Apply suction for 10-15 second. Apply suction only when withdrawing and rotating with thumb
and forefinger. Advance catheter until resistance!!
135. A nurse is caring for a client who has given informed consent for electroconvulsive therapy.
Just before the procedure, the client tells the nurse she is considering not going forward with the
treatment. Which of the following statements by the nurse is appropriate?
A. "You don't have to go through with the treatment."
B. "It's okay to be nervous before this treatment."
C. "Most people who have this procedure feel better following the treatment."
D. "Your doctor wouldn't have ordered this treatment unless it was necessary."
Answer: A. “ You don’t have to go through with the treatment.”
136. A home health nurse is providing teaching about home safety to an older adult client. Which
of the following statements by the client indicates that the teaching has been effective?
A. "I put on socks when getting out of bed at night."
B. "I have marked the steps with black tape."
C. "I have grab bars next to my tub."
D. "I have placed throw rugs in the hallways."
Answer: C. "I have grab bars next to my tub."

137. A nurse ls providing teaching to a client who is undergoing radiation therapy and has
stomatitis. Which of the following responses by an understanding of the teaching?
A. "I should gargle with an alcohol- based mouthwash to kill germs."
B. "I should use a soft -bristle toothbrush to clean my teeth after meals."
C. "I should limit my intake of dairy products to prevent nausea."
D. "I should moisten my lips with lemon-glycerine swabs."
Answer: B. "I should use a soft -bristle toothbrush to clean my teeth after meals."
Rationale:
Stomatitis is inflammation of the mouth and lips. It refers to any inflammatory process affecting
the mucous membranes of the mouth and lips, with or without oral ulceration. In its widest
meaning, stomatitis can have a multitude of different causes and appearances.
138. A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a
client. Which of the following actions should the nurse take first?
A. Check the compatibility of cefazolin with the client's existing IV fluids.
B. Obtain the reconstituted antibiotic from the pharmacy.
C. Review the client's allergy history.
D. Assess the IV for patency.
Answer: C. Review the client's allergy history.
139. A nurse ls caring for a child who reports migraine headaches for the past 4 months. Which
of the following actions should the nurse take first?
A. Review the child's electronic pain diary.
B. Set up an appointment with the school nurse.
C. Refer the family to a chronic pain support group.
D. Request a change in medication from the provider.
Answer: A. Review the child's electronic pain diary.
140. A nurse ls providing teaching to a client who is receiving misoprostol for induction of labor.
Which of the following information should the teaching?
A. "You will have intermittent fetal monitoring while you receive the medication."

B. "You will lie on your side for 30 minutes after the medication is inserted."
C. "You will have a urinary catheter inserted prior to the placement of the medication."
D. "You will have oxytocin initiated within 3 hours of administration of the medication."
Answer: A. "You will have intermittent fetal monitoring while you receive the medication."
Rationale:
Chemical agents based on Prostaglandins are used to soften and thin the cervix. They can be in
the form of oral medication or vaginal suppositories/gels.
Misoprostol and dinoprostone.
Obtain inform consent, obtain baseline on patient and fetal. The nurse should monitor Fhr and
uterine activity after administration of cervical ripening
141. A nurse ls assessing the peripheral catheter insertion site of a client who is receiving an
infusion. The nurse notices redness and warmth to touch around the insertion site. The nurse
should document the finding as which of the following complications?
A. Phlebitis
B. Extravasation
C. Circulatory overload
D. Infiltration
Answer: A. Phlebitis
Rationale:
Phlebitis: Edema, Throbbing/Burning/Pain @ site,>Skin temp
Erythema, Slowed infusion, Palpable hard mass ^ insertion site Infiltration:
pallor, local swelling, low temp Extravastation:pain, burning, redness, swelling.
142. A nurse ls caring for a client who is in active labor and notes the FHR baseline has been
100/ mln for the past 15 min. The nurse should identify which of the following conditions as a
possible cause of fetal bradycardla?
A. Maternal fever
B. Fetal anaemia
C. Maternal hypoglycaemia
D. Chorioamnionitis

Answer: C. Maternal hypoglycaemia
143. A nurse ls preparing to administer an IV medication to a client and accidentally punctures
the I V bag causing the medication to leak on the counter. Which of the following medications
requires the nurse to follow facility procedures in the safe handling of a biohazardous material
spill?
A. Doxorubicin hydrochloride
B. Ampicillin sodium
C. Metronidazole
D. Phenytoin
Answer: A. Doxorubicin hydrochloride
144. A nurse ls reviewing the medication administration record of a client who has rheumatoid
arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following
medications places the client at risk for delayed wound healing
A. Omeprazole
B. Morphine
C. Prednisone
D. Digoxin
Answer: C Prednisone
145. A nurse in an emergency department is reviewing the medical record of a client who is
having an acute myocardial infarction. Which findings places the client at risk if he receives
alteplase
A. Hip arthroplasty 1 week ago
B. Family history of malignant hypertension
C. Chronic obstructive pulmonary disease
D. Acute renal failure 6 months ago
Answer: A. Hip arthroplasty 1 week ago

146. A nurse ls caring for a client who has permanent drooping on the left side of the face
following a cerebrovascular accident (CVA). The client refuses to see any family members.
Which of the following interventions will best assist the client to adapt to this body image
change?
A. Establish short-term goals that will enable the client to look in a mirror.
B. Offer contact information for CVA recovery support groups.
C. Initiate a family conference to address the issue.
D. Educate the client about short- and long-term effects of a CVA.
Answer: B. Offer contact information for CVA recovery support groups.
147. A nurse ls teaching the parent of an infant who has positional plagiocephaly. Which of the
following statements by the parent indicates an understanding of the teaching?
A. "I should avoid tummy time when my baby is wearing the helmet."
B. "I should place my baby in the left side-lying position at night when using the helmet."
C. "I should keep the helmet on my baby for 23 hours a day."
D. "I should expect to have my baby wear this helmet for 10 months."
Answer: C. "I should keep the helmet on my baby for 23 hours a day."
148. A nurse manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse include?
A. Remove the client's restraint every 4 hr.
B. Document the client's condition every 15 min.
C. Attach the restraint to the bed's side rails.
D. Request a PRN restraint prescription for clients who are aggressive.
Answer: B. Document the client's condition every 15 min.
149.. A nurse is assessing a client who has fine hair, exophthalmos, and reports intolerance to
heat. Which of the following endocrine disorders is associated with these findings?
A. Hyperparathyroidism
B. Hyperthyroidism
C. Hypoparathyroidism

D. Hypothyroidism
Answer: B. Hyperthyroidism
150. A nurse ls preparing an in-service for a group of nurses about malpractice issues in nursing.
Which of the following examples should the teaching?
A. Leaving a nasogastric tube clamped after administering oral medication
B. Documenting communication with a provider in the progress notes of the client's medical
record
C. Administering potassium via IV bolus
D. Placing a yellow bracelet on a client who is at risk for falls
Answer: C. Administering potassium via IV bolus
151. A nurse in an acute care facility is caring for four clients. Which of the following clients
should the nurse refer for speech therapy?
A. A client who has dysphagia following a stroke
B. A client who has sensorineural hearing loss
C. An older adult client who has stage III Alzheimer's disease
D. A client who is postoperative following a tonsillectomy and adenoidectomy
Answer: A. A client who has dysphagia following a stroke
152. A nurse ls assessing a client who has hypervolemia. Which of the following findings should
the nurse expect?
A. Bounding pulse
B. Bradycardia
C. Decreased blood pressure
D. Urinary frequency
Answer: A. Bounding pulse
153. A nurse ls assessing a client who is experiencing a pulmonary embolism. Which of the
following manifestations should the nurse expect?
A. Hypertension

B. Frothy sputum
C. Bradycardia
D. Dyspnea
Answer: D. Dyspnea
154. A nurse ls building a therapeutic relationship with a newly admitted client. Which of the
following actions should the nurse plan to take during the orientation phase of the relationship?
A. Determine previous coping skills used by the client.
B. Establish the responsibilities of the nurse and client.
C. Facilitate the client's problem-solving skills.
D. Assist the client in expressing alternative behaviours.
Answer: B. Establish the responsibilities of the nurse and client.
155. A nurse is providing nutritional teaching for an older adult client who has seizure disorder
and a new prescription for phenytoin. Which of the following instructions by the nurse is
appropriate?
A. "You should expect a change in the colour of your stool while taking this medication."
B. "Plan to take this medication with antacids."
C. "Limit foods that contain folic acid while taking this medication."
D. "Increase your intake of vitamin D while taking this medication."
Answer: D. "Increase your intake of vitamin D while taking this medication."
156. A nurse is caring for a group of clients. The nurse should recognize that which of the
following clients is at greatest risk for developing acute poststreptococcal glomerulonephritis?
A. An 18- year-old girl who is in the second trimester of pregnancy
B. A 16-year -old boy who has appendicitis
C. A 2 - month - old girl who has pyloric stenosis
D. A 7-year-old boy who is recovering from impetigo
Answer: D. A 7-year-old boy who is recovering from impetigo

157. A nurse ls caring for a client who is experiencing acute mania. Which of the following foods
should the nurse provide for this client?
A. Peanut butter sandwich
B. Oatmeal with butter
C. Chicken noodle soup
D. Celery sticks
Answer: A. Peanut butter sandwich
158. A nurse is caring for a client who asks for information regarding organ donation. Which of
the following responses should the nurse make?
A. "I cannot be a witness for your consent to donate."
B. "Your name cannot be removed once you are listed on the organ donor list."
C. "Your desire to be an organ donor must be documented in writing."
D. "You must be at least 21 years of age to become an organ donor."
Answer: C. "Your desire to be an organ donor must be documented in writing."
159. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving
because the facility policy prohibits smoking inside. Which of the following actions should the
nurse take
A. Place the client in seclusion.
B. Call the provider for a discharge prescription.
C. Notify security to monitor the facility's exits.
D. Inform the client of the risks involved if she leaves.
Answer: D. Inform the client of the risks involved if she leaves.
160. A nurse ls providing an in-service about client evacuation during a fire. Which of the
following clients should the nurse instruct the staff to evacuate first?
A. A client who has a fracture and is in balance suspension traction
B. A client who is bedridden and wears a hearing aid
C. A client who uses a wheelchair and is confused
D. A client who is ambulatory and receiving oxygen

Answer: D. A client who is ambulatory and receiving oxygen
161. A nurse ls caring for a client who has Crohn's disease. Which of the following diagnostic
procedures should the nurse plan to teach the client regarding pernicious anaemia
A. Schilling test
B. Thyroid scan
C. Oral glucose tolerance test
D. D-dimer test
Answer: A. Schilling test
162. A nurse ls providing dietary teaching to a client who has a new diagnosis of irritable bowel
syndrome. Which of the following recommendations should the nurse include?
A. Increase intake of foods high in gluten.
B. Increase intake of milk products.
C. Sweeten foods with fructose corn syrup.
D. Consume food high in bran fibre.
Answer: D. Consume food high in bran fibre.
163. A nurse ls teaching a client who is at 41 weeks of gestation about a nonstress test.
Which of the following information should the nurse include in the teaching?
A. "You will need blood work before and after the test."
B. "You should avoid eating or drinking for 4 hours before the test."
C. "You will have a Doppler transducer applied to your abdomen during the test."
D. "You should massage one of your nipples to stimulate contractions of your uterus."
Answer: C. "You will have a Doppler transducer applied to your abdomen during the test."
164. A nurse ls creating a plan of care for a client who is postoperative following a coronary
artery bypass graft (CABG). To prevent complications of cardiac surgery, which of the following
instructions should the nurse include in the plan of care?
A. Prepare for fluid volume replacement if the central venous pressure steadily increases.
B. Administer atropine to the client if tachycardia is present.

C. Maintain the indwelling urinary catheter until the client is ready for discharge.
D. Check the client's haemoglobin level if chest tube drainage is 300 ml in the first 1 hr.
Answer: D. Check the client's haemoglobin level if chest tube drainage is 300 ml in the first 1
hr.
165. A nurse in an acute care mental health facility is placing a client in seclusion and restraints.
Which of the following actions should the nurse plan to take?
A. Have a provider evaluate the client in person within 1 hr.
B. Complete a written record regarding the seclusion and restraint every 2 hr.
C. Plan to monitor the client every 30 min while restrained.
D. Ensure that the prescription for restraints be renewed every 6 hr.
Answer: B. Complete a written record regarding the seclusion and restraint every 2 hr.
166. A nurse is caring for a child who has just been admitted to the acute care medical unit .
Which of the following laboratory findings should the nurse recognize as indicative of rheumatic
fever?
A. Decreased myoglobin and antinuclear antibody titter
B. Decreased Hgb and platelet count
C. Elevated creatine kinase and troponin
D. Elevated sedimentation rate and C-reactive protein
Answer: D. Elevated sedimentation rate and C-reactive protein
167. A nurse is reviewing a client's laboratory values. Which of the following should the nurse
review to evaluate the client's nutritional status?
A. Erythrocyte sedimentation rate
B. Troponin level
C. Serum sodium
D. Serum albumin
Answer: D. Serum albumin

168. A nurse ls teaching a client who is trying to conceive. Which of the following should the
nurse instruct the client to increase in her diet to prevent a neural tube defect
A. Folate
B. Zinc
C. Iron
D. Calcium
Answer: A. Folate
169. A nurse in an emergency department is receiving report for four clients. Which of the
following clients should the nurse see first ?
A. A client who reports frequent and painful urination
B. A client who reports left arm pain following a fall
C. A client who has heart failure and received a diuretic 30 min ago
D. A client who has hypertension and reports a severe headache
Answer: D. A client who has hypertension and reports a severe headache
170. A nurse ls reviewing the laboratory results of a client who has osteomyelitis and is receiving
tobramycin. Which of the following findings indicate the client is experiencing an adverse effect
of the medication
A. BUN 30 mg/dl
B. Serum creatinine 0.4 mg/dL
C. Albumin 3.2 g/dL
D. Total bilirubin 0.08 mg/dL
Answer: A. Bun 30 mg/dl
171. A nurse ls completing an admission assessment for a client who has narcissistic personality
disorder. Which of the following findings should the nurse expect
A. Ritualistic behavior
B. Suspicious of others
C. Exhibits separation anxiety
D. Preoccupied with aging

Answer: D. preoccupied with aging.
172. A mental health nurse is caring for a client who recently attempted suicide. The client states,
"I wish I was dead." Which of the following is an appropriate response by the nurse?
A. "Did you take your medications today?"
B. "Suicide is not the answer to your problems."
C. "Don't worry. Everything will be just fine."
D. "You seem like you're feeling hopeless."
Answer: D. "You seem like you're feeling hopeless."
173. A nurse ls reviewing the medical records of four clients. The nurse should identify that
which of the following client findings requires
A. A client who received a Mantoux test 48 hr ago and has an induration
B. A client who is scheduled for a colonoscopy and is taking sodium phosphate
C. A client who is taking warfarin and has an INR of 1.8
D. A client who is taking bumetanide and has a potassium level of 3.6 mEq/ L
Answer: C. A client who is taking warfarin and has an INR of 1.8
174. A nurse ls caring for a client who has undergone a modified radical mastectomy. The client
has a closed-suction drain. Which of the following actions should the nurse take?
A. Secure the drain to the bedding.
B. Position the affected extremity below the level of the client's heart.
C. Maintain the client in supine position for the first 24 hr.
D. Reset the vacuum by compressing the container.
Answer: D. Reset the vacuum by compressing the container.
175. A nurse ls planning to administer 2 units of packed RBCs to an older adult client who has
anaemia. Which of the following actions should the nurse plan to take? (Select all that apply.)
A. Assess the client's lung sounds prior to the infusion.
B. Prime the infusion tubing with 0.45% sodium chloride.
C. Don sterile gloves to prepare the blood administration setup.

D. Infuse the blood over 4 hr.
E. Verify with another nurse that the unit of blood is compatible with the client's blood type.
Answer: A. Assess the client's lung sounds prior to the infusion.
C. Don sterile gloves to prepare the blood administration setup.
E. Verify with another nurse that the unit of blood is compatible with the client's blood type.
176. A nurse ls caring for a client who has a Clostridium difficile infection. Which of the
following actions should the nurse take? (Select all that apply.)
A. Change gloves after contact with infectious material.
B. Wear a gown when providing care.
C. Wash hands with an alcohol-based cleaner.
D. Remove the thermometer from client's room for use on another client.
E. Wear an N95 respirator when providing care.
Answer: A. Change gloves after contact with infectious material.
B. Wear a gown when providing care.
177. A community health nurse receives a referral for a family home visit. Which of the
following tasks should the nurse perform first?
A. Schedule a time for the home visit.
B. Implement the nursing process.
C. Clarify the source of the referral.
D. Contact the family by phone.
Answer: C. Clarify the source of the referral
178. A nurse in a maternal newborn unit is admitting a client who is in labor and at 38 weeks of
gestation. The client has a history of herpes simplex virus 2. Which of the following questions is
most important for the nurse to ask the client?
A. "Do you have an active lesion' "
B. "Are you currently taking acyclovir?"
C. "When did your labor begin?"
D. "How long ago were you first diagnosed?"

Answer: A. “Do you have an active lesion”
179. A nurse ls monitoring for complications for a client who ls receiving IV potassium chloride.
Which of the following electrocardiogram images should the nurse identify as indicating
potassium toxicity?
A. WIDENED (QRS)
B. ECG with Hyperkalemia
C. tall T wave
D. widened QRS
E. premature vent contraction
F. vfib
G. dysrhythmias
Answer: A. WIDENED (QRS)
180. A nurse ls caring for a 3-day-old newborn who has a congenital heart defect. Which of the
following interventions should the nurse include to decrease cardiac demands for the newborn?
A. Encourage the infant's parents to limit visitation and physical touch.
B. Maintain the infant's temperature at 37° C (98.6° F).
C. Keep the infant's bed in a flat position.
D. Feed the infant when she is awake and crying.
Answer: D. Feed the infant when she is awake and crying.