ATI PN Comprehensive Predictor 154 QUESTIONS AND ANSWERS
GRADED A LATEST VERSION 2023/2024
"A nurse is caring for four clients. Which of the following client statements should the nurse attend
to first?
A) "My heartburn pain is going into my jaw now."
B) "I'm feeling a bit nauseous after breakfast."
C) "I need help getting out of bed to go to the bathroom."
D) "I'm feeling really itchy from this rash on my arm."
Answer: "My heartburn pain is going into my jaw now."
Rationale:
This statement indicates a possible symptom of a heart attack. Pain radiating to the jaw is a
concerning sign and could indicate a cardiac issue, requiring immediate attention to assess the
severity and provide appropriate intervention.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube.
Which of the following actions should the nurse take?
A) Suction the client's airway every 4 hr.
B). Provide passive range of motion exercises every 4 hr.
C). Perform oral care every 2 hr.
D). Administer lorazepam (Ativan) every 8 hr.
Answer: C. Perform oral care every 2 hr.
Rationale:
Performing oral care every 2 hours helps prevent ventilator-associated pneumonia (VAP) by
reducing the risk of oral bacteria being aspirated into the lungs.
A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of the following
laboratory values should the nurse check prior to administering the medication?
A). Platelet count
B). Serum electrolytes
C). Serum creatinine
D). PT-INR
Answer: D. PT-INR
Rationale:
Warfarin affects the blood's ability to clot. The PT-INR (Prothrombin Time-International
Normalized Ratio) measures the effectiveness of warfarin therapy.
A nurse is collecting data from a client who is at 9 weeks of gestation and has hyperemesis
gravidarum. Which of the following findings should the nurse expect?
A). Hypotension
B). Weight gain
C). Proteinuria
D). Weight loss
Answer: D. Weight loss
Rationale:
Hyperemesis gravidarum is characterized by severe nausea, vomiting, weight loss, electrolyte
disturbances, and ketonuria.
A nurse is reinforcing teaching with a client about the importance of a low sodium diet. Which of
the following foods should the nurse recommend as the best choice to include in a low sodium diet?
A). 1 medium banana
B). 1 cup of cottage cheese
C). 1 cup of canned chicken noodle soup
D). 2 tbsp of peanut butter
Answer: D. 2 tbsp of peanut butter
Rationale:
Peanut butter is a good choice for a low-sodium diet because it is naturally low in sodium.
A nurse is collecting data from an 18-month-old toddler at a well-child visit. Which of the
following findings should the nurse report to the provider?
A) The toddler weighs 22 pounds.
B) The toddler has a vocabulary of four words.
C) The toddler has a temperature of 99.5°F.
D) The toddler has a heart rate of 120 beats per minute.
Answer: B) The toddler has a vocabulary of four words.
Rationale:
At 18 months, a toddler should typically have a vocabulary of about 10 words. A vocabulary of
only four words might indicate a delay in language development, so the nurse should report this
finding to the provider for further evaluation.
A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings
indicates that the client might be experiencing diabetic ketoacidosis?
A) Capillary blood glucose level of 150 mg/dL
B) Serum bicarbonate level of 26 mEq/L
C) Kussmaul respirations
D) Blood pressure of 140/90 mm Hg
Answer: C) Kussmaul respirations
Rationale:
Kussmaul respirations, deep and rapid breathing, are a compensatory mechanism for metabolic
acidosis, which occurs in diabetic ketoacidosis.
A nurse is reinforcing teaching with a client who has a permanent pacemaker in place. Which of the
following statements by the client indicates an understanding of the teaching?
A) "I should avoid drinking caffeinated beverages."
B) "I need to avoid microwave ovens."
C) "I need to record my pulse rate daily."
D) "I can participate in contact sports."
Answer: C) "I need to record my pulse rate daily."
Rationale:
Recording daily pulse rate is important for the client with a pacemaker to monitor for signs of
pacemaker malfunction or battery depletion.
A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff
member. Which of the following actions should the nurse take?
A) Remove the restraints every 2 hours.
B) Document in the client's medical record every 15 minutes.
C) Apply lotion to the client's skin every 4 hours.
D) Secure the restraints to the side rails of the bed.
Answer: B) Document in the client's medical record every 15 minutes.
Rationale:
Documentation of the client's condition and the restraints' necessity should occur at least every 15
minutes according to most institutional policies and guidelines.
A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which of the
following positions should the nurse recommend for instillation of the drops?
A) Trendelenburg
B) Supine
C) Prone
D) Fowler's
Answer: B) Supine
Rationale:
Instillation of nasal drops should be done with the client in a supine position to ensure proper
administration and absorption of the medication.
A nurse is preparing to administer furosemide to a client who has heart failure. Which of the
following laboratory results should the nurse review prior to administering the medication?
A) Sodium
B) Potassium
C) Calcium
D) Phosphorus
Answer: B) Potassium
Rationale:
Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the
nurse should review the client's potassium levels before administering furosemide.
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA)
infection. Which of the following actions should the nurse plan to take?
A) Wear a mask during all client contact.
B) Don a gown and gloves when providing perineal care.
C) Limit visitors to immediate family members only.
D) Place the client in a negative-pressure room.
Answer: B) Don a gown and gloves when providing perineal care.
Rationale:
Standard precautions, including wearing gloves and gowns, should be followed when caring for a
client with MRSA to prevent the spread of infection.
A nurse is assisting with the plan of care for a client who has dementia and often wanders in the
halls at night. Which of the following interventions should the nurse recommend including in the
plan of care?
A) Offering the client caffeinated beverages during the day
B) Providing the client with a television in their room
C) Labeling the client's bathroom door
D) Encouraging the client to take frequent naps during the day
Answer: C) Labeling the client's bathroom door
Rationale:
Labeling the client's bathroom door can help the client with dementia recognize and locate the
bathroom easily, reducing the risk of wandering and promoting safety.
A charge nurse is reinforcing teaching with a newly hired licensed practical nurse about scope of
practice. Which of the following responsibilities should the nurse include in the teaching?
A) Creating the client's plan of care
B) Prescribing medications for clients
C) Providing direct client care
D) Performing triage in the emergency department
Answer: C) Providing direct client care
Rationale:
Providing direct client care, such as performing assessments, administering medications, and
providing treatments, is within the scope of practice for a licensed practical nurse.
A nurse working on a mental health unit is meeting with a client who has been in the unit for 2
days. The nurse greets the client and asks, "What has been happening with you today?" Which of
the following therapeutic techniques is the nurse using?
A) Reframing
B) Reflecting
C) Active listening
D) Clarifying
Answer: B) Reflecting
Rationale:
Reflecting involves restating the client's feelings or thoughts to encourage further exploration of
their feelings and promote communication.
A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a car
seat. Which of the following statements by a parent indicates an understanding of the teaching?
A) "I will place the car seat in the front passenger seat."
B) "I will secure the seat belt across my newborn's chest."
C) "I will adjust the car seat so it is facing backward until my baby is 6 months old."
D) "I will secure the seat belt across my newborn's lap."
Answer: D) "I will secure the seat belt across my newborn's lap."
Rationale:
Securing the seat belt across the newborn's lap is the correct way to secure the car seat and ensure
the baby's safety.
A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients
is an appropriate assignment for the nurse to accept?
A) A client who delivered a preterm infant 12 hours ago
B) A client who is 1 day postpartum and has a suspected deep vein thrombosis
C) A client who delivered a healthy newborn 2 days ago and is preparing for discharge
D) A client who is 6 hours postpartum and is experiencing postpartum hemorrhage
Answer: B) A client who is 1 day postpartum and has a suspected deep vein thrombosis
Rationale:
The nurse from the medical-surgical unit would likely have experience and skills to care for a
postpartum client with a suspected deep vein thrombosis.
A nurse is assisting with planning care for a newly admitted client who has anorexia nervosa.
Which of the following interventions should the nurse recommend to include in the plan of care?
A) Encourage the client to select food items from the menu
B) Provide privacy during meals
C) Reinforce teaching about healthy eating during meals
D) Administer appetite stimulants before meals
Answer: C) Reinforce teaching about healthy eating during meals
Rationale:
Reinforcing teaching about healthy eating during meals helps the client with anorexia nervosa
develop healthy eating habits and attitudes toward food.
A nurse is admitting a client who is scheduled for an elective surgery. Which of the following
actions should the nurse take to verify the status of the client's advance directives?
A) Ask the client whether they have advance directives
B) Check the client's medical record for advance directives
C) Call the client's primary care provider to verify advance directives
D) Ask the client's family members about advance directives
Answer: A) Ask the client whether they have advance directives
Rationale:
Asking the client directly about their advance directives ensures the nurse receives the most
accurate and up-to-date information. It is essential to verify the client's wishes before any
procedures or treatments are performed.
A nurse is collecting data from a client who is receiving a continuous IV infusion of 0.9% sodium
chloride. The nurse discovers the IV infusion pump was set incorrectly, and the client received 200
ml more than prescribed. Data collection reveals that the client is stable. The nurse recognizes that
this incident is not considered malpractice for which of the following reasons?
A) The client did not notice the error
B) The client was not harmed as a result of the incident
C) The error was reported immediately
D) The nurse documented the error in the client's medical record
Answer: B) The client was not harmed as a result of the incident
Rationale:
Malpractice occurs when a patient is harmed due to negligence or a deviation from the standard of
care. Since the client remained stable and was not harmed by the excess IV fluid, this incident does
not constitute malpractice.
A nurse is caring for a client who has COPD. The nurse should identify that which of the following
findings is the priority to report?
A) Increased respiratory rate
B) Productive cough with green sputum
C) Oxygen saturation of 92%
D) Use of accessory muscles for breathing
Answer: B) Productive cough with green sputum
Rationale:
Green or yellow sputum in a client with COPD can indicate a respiratory infection. Infection can
exacerbate COPD symptoms and lead to further respiratory compromise, making it a priority for the
nurse to report.
A nurse is caring for a newborn who just had a circumcision. Which of the following findings
should the nurse identify as a nonverbal sign of pain?
A) The newborn turns away from the caregiver
B) The newborn grimaces
C) The newborn sleeps more than usual
D) The newborn continues to cry despite efforts to console
Answer: D) The newborn continues to cry despite efforts to console
Rationale:
Persistent crying despite attempts to soothe is a common nonverbal sign of pain in newborns. It
indicates that the newborn is experiencing discomfort.
A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the
following foods should the nurse include?
A) Popcorn
B) Grapes
C) Graham crackers
D) Hard candy
Answer: C) Graham crackers
Rationale:
Graham crackers are a suitable snack for toddlers as they are easy to chew and swallow, and they
are not a choking hazard like popcorn or grapes. Hard candy should be avoided due to the risk of
choking.
A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following
should the nurse identify as an indication that the newborn is breastfeeding effectively?
A) The newborn falls asleep during feeding
B) The newborn is latching on and off repeatedly
C) The newborn is feeding for 15 minutes on each breast
D) The newborn makes audible swallowing sounds
Answer: D) The newborn makes audible swallowing sounds
Rationale:
Audible swallowing sounds indicate that the newborn is effectively transferring milk during
breastfeeding, which is a sign of successful breastfeeding.
A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG)
and a prescription for neostigmine. Which of the following information should the nurse include
about the action of the medication?
A) Causes muscle weakness
B) Improves muscle strength
C) Increases heart rate
D) Decreases respiratory rate
Answer: B) Improves muscle strength
Rationale:
Neostigmine is a cholinesterase inhibitor that improves muscle strength by increasing the
availability of acetylcholine at the neuromuscular junction, which is beneficial for clients with
myasthenia gravis.
A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the
following client statements indicates understanding of the teaching?
A) "I will leave the circumcision site uncovered."
B) "I will clean the circumcision site with alcohol after each diaper change."
C) "I will avoid giving my baby sponge baths until the circumcision site is healed."
D) "I will apply petroleum jelly to the penis with each diaper change."
Answer: D) "I will apply petroleum jelly to the penis with each diaper change."
Rationale:
Applying petroleum jelly to the circumcision site with each diaper change helps to keep the area
clean and prevents the diaper from sticking to the healing tissue.
A nurse is collecting data from a 3-month-old infant who is 6 hours postoperative following a cleft
palate repair. Which of the following pain rating tools should the nurse use?
A) Numeric Rating Scale (NRS)
B) Visual Analog Scale (VAS)
C) Wong-Baker FACES Scale
D) FLACC scale
Answer: D) FLACC scale
Rationale:
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a pain assessment tool suitable for
infants and nonverbal children. It assesses five behavioral categories to determine the level of pain.
A nurse is collecting data from a client who has substance use disorder and reports recently taking
opioids. Which of the following findings should the nurse identify as a manifestation of opioid
intoxication?
A) Pupillary dilation
B) Pinpoint pupils
C) Hypertension
D) Bradypnea
Answer: B) Pinpoint pupils
Rationale:
Pinpoint pupils are a classic sign of opioid intoxication. Opioids cause constriction of the pupils
(miosis).
A nurse is checking the home environment of a client for safety hazards. Which of the following
items require intervention by the nurse?
A) The living room carpet has several small rugs on it
B) The dining room table has low chairs with no armrests
C) The kitchen sink has a childproof lock
D) The bathroom has a non-slip mat in the bathtub
Answer: B) The dining room table has low chairs with no armrests
Rationale:
Low chairs without armrests can make it difficult for clients to get up from the table, increasing the
risk of falls, especially for clients with mobility issues.
A nurse is preparing to administer medication to a newborn. Which of the following information
should the nurse use to identify the newborn?
A) Birth weight and length
B) Name and medical record number
C) Footprints and identification number
D) Mother's name and room number
Answer: B) Name and medical record number
Rationale:
The newborn should be identified by their name and medical record number to ensure the correct
medication is administered.
A nurse is reinforcing teaching with a client who has a prescription for a combination contraceptive
transdermal patch. Which of the following should the nurse include in the teaching?
A) "Apply the patch to the same site every time."
B) "Change the patch once a week for 3 weeks, then take a week off."
C) "Apply the patch to a hairy area of skin to help it stick better."
D) "Start the first patch on the seventh day of the menstrual cycle."
Answer: D) "Start the first patch on the seventh day of the menstrual cycle."
Rationale:
Starting the first patch on the seventh day of the menstrual cycle helps to ensure contraceptive
effectiveness. It syncs with the natural menstrual cycle and reduces the risk of unintended
pregnancy.
A nurse is caring for a client who attempted suicide. Which of the following actions should the
nurse take?
A) Assign the client to a private room.
B) Provide the client with sharp objects.
C) Leave the client alone for a brief period.
D) Allow the client to keep personal belongings.
Answer: A) Assign the client to a private room.
Rationale:
Assigning the client to a private room helps ensure their safety and privacy, reducing the risk of
further harm to themselves.
A nurse is reinforcing teaching with a newly licensed nurse about the HIPAA privacy rule. Which
of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A) "A client's medical information can be shared with anyone who asks for it."
B) "A client's family members have access to the client's medical record without permission."
C) "A client's healthcare information must be kept confidential."
D) "A client has the right to view their medical record."
Answer: D) "A client has the right to view their medical record."
Rationale:
The HIPAA privacy rule grants clients the right to access their medical records upon request.
A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took
all my money." Which of the following actions should the nurse take?
A) Reassure the client that everything will be okay.
B) Discuss financial options with the client.
C) Report the possible abuse to adult protective services.
D) Suggest the client talk to their family about the situation.
Answer: C) Report the possible abuse to adult protective services.
Rationale:
The nurse is obligated to report suspected financial abuse of an older adult to adult protective
services.
A nurse is reinforcing with a client who is 12 hours postpartum and has an episiotomy. Which of
the following instructions should the nurse include?
A) Change the perineal pad every 4 hours.
B) Change the perineal pad with each void.
C) Avoid cleaning the perineal area.
D) Apply heat to the perineum to reduce swelling.
Answer: B) Change the perineal pad with each void.
Rationale:
Changing the perineal pad with each void helps maintain cleanliness and prevents infection in the
episiotomy site.
A nurse in a pediatric clinic is reviewing the urine laboratory results for an adolescent. For which of
the following results should the nurse notify the provider?
A) Glucose negative
B) Ketones positive
C) Specific gravity 1.020
D) pH 6.0
Answer: B) Ketones positive
Rationale:
Positive ketones in the urine may indicate diabetic ketoacidosis or inadequate carbohydrate intake
and should be reported to the provider for further evaluation.
A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation. For which of
the following results should the nurse notify the provider?
A) Hemoglobin 12 g/dL
B) Platelet count 90,000/mm3
C) White blood cell count 10,000/mm3
D) Blood glucose 110 mg/dL
Answer: B) Platelet count 90,000/mm3
Rationale:
A platelet count of 90,000/mm3 is below the normal range and could indicate thrombocytopenia,
which requires further evaluation and management, especially in pregnancy.
A nurse is assisting with the admission of an older adult client who has impaired mobility and is at
risk for falls. Which of the following actions should the nurse plan to perform first?
A) Document the client's risk in the medical record.
B) Place the client in a wheelchair.
C) Apply nonskid socks to the client's feet.
D) Educate the client about fall prevention measures.
Answer: A) Document the client's risk in the medical record.
Rationale:
Documenting the client's risk for falls is the first step in ensuring that appropriate measures are
taken to prevent falls and ensure the client's safety.
A nurse is collecting data from a newly admitted client. Which of the following questions should
the nurse ask to assess the client's abstract thinking ability?
A) "What day is it today?"
B) "What does the phrase 'butterflies in my stomach' mean?"
C) "Can you repeat these numbers backward: 7, 4, 2?"
D) "What did you eat for breakfast today?"
Answer: B) "What does the phrase 'butterflies in my stomach' mean?"
Rationale:
Assessing the client's understanding of abstract concepts, like idiomatic expressions, helps the nurse
evaluate the client's higher cognitive function.
A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions
when administering a tap water enema to the client. Which of the following should the nurse
include in the instructions?
A) Insert the rectal tube as far as possible into the rectum.
B) Insert the rectal tube parallel to the bed.
C) Insert the rectal tube in the direction of the client's head.
D) Insert the rectal tube in the direction of the client's umbilicus.
Answer: D) Insert the rectal tube in the direction of the client's umbilicus.
Rationale:
Inserting the rectal tube in the direction of the client's umbilicus ensures proper positioning and
reduces the risk of injury.
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a wheelchair.
Which of the following actions should the nurse take first?
A) Lock the wheels on the wheelchair.
B) Position the wheelchair at a 45-degree angle to the bed.
C) Place a gait belt around the client's waist.
D) Lock the wheels on the bed.
Answer: D) Lock the wheels on the bed.
Rationale:
Locking the wheels on the bed ensures stability and safety during the transfer process.
A nurse is caring for a client who has a new prescription for furosemide and asks the nurse about
the purpose of the medication. The nurse states, "This medication is a diuretic that removes excess
fluid from your body." Which of the following ethical concepts is the nurse exhibiting?
A) Beneficence
B) Nonmaleficence
C) Autonomy
D) Veracity
Answer: D) Veracity
Rationale:
Veracity is the ethical principle of truth-telling. The nurse is being truthful and providing the client
with accurate information about the medication.
A nurse is reinforcing teaching with a client who plans to bottle-feed her newborn. Which of the
following statements indicates an understanding of the instructions?
A) "I will feed my baby every four hours."
B) "I will feed my baby six to eight times a day."
C) "I will warm the formula in the microwave before feeding."
D) "I will prop the bottle so my hands are free."
Answer: B) "I will feed my baby six to eight times a day."
Rationale:
Newborns should be fed approximately every 2 to 3 hours, which typically amounts to 6 to 8
feedings per day.
A nurse is caring for a client who is asking about the techniques of effleurage and its use in labor
and delivery. Which of the following responses should the nurse make regarding this technique?
A) "It is a deep massage technique used between contractions."
B) "It is a method of breathing control during labor."
C) "It is a light stroking of the skin during a uterine contraction."
D) "It is a position used to promote comfort during labor."
Answer: C) "It is a light stroking of the skin during a uterine contraction."
Rationale:
Effleurage involves light, rhythmic stroking of the skin during contractions to provide comfort and
relaxation during labor.
A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair.
Which of the following actions should the nurse include?
A) Remove the elbow restraints every 2 hours.
B) Allow the infant to self-feed with a spoon.
C) Place the infant in a supine position.
D) Maintain elbow restraints on the infant.
Answer: D) Maintain elbow restraints on the infant.
Rationale:
Elbow restraints prevent the infant from touching the surgical site and causing injury.
A nurse is preparing to assist with the insertion of a nasogastric tube for a client who has a small
bowel obstruction. Which of the following supplies should the nurse gather?
A) Sterile gloves
B) Tongue depressor
C) pH test strips
D) Alcohol swabs
Answer: C) pH test strips
Rationale:
pH test strips are used to confirm correct placement of the nasogastric tube by testing the pH of
aspirated gastric contents.
A nurse is reinforcing teaching with a school-age child who has hemophilia about participating in
school sports. Which of the following sports should the nurse recommend for the child?
A) Basketball
B) Swimming
C) Football
D) Wrestling
Answer: B) Swimming
Rationale:
Swimming is a low-impact sport that is less likely to result in injuries for a child with hemophilia. It
also helps improve cardiovascular health and muscle strength without putting excessive stress on
the joints.
A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the
following statements by the client indicates an understanding of the teaching?
A) "I will be sure to wear tight-fitting shoes."
B) "I will check my feet for blisters and sores every day."
C) "I will soak my feet in hot water to relieve any pain."
D) "I will be sure to wear nylon socks."
Answer: B) "I will check my feet for blisters and sores every day."
Rationale:
Daily foot checks help prevent diabetic foot complications by identifying any injuries or
abnormalities early.
A nurse is collecting data from a guardian of a toddler during a well-child visit. The guardian
expresses concern to the nurse because his child has a poor appetite but drinks a quart of milk each
day. The nurse should identify that this practice places the toddler at risk for which of the following
conditions?
A) Rickets
B) Osteoporosis
C) Iron-deficiency anemia
D) Vitamin C deficiency
Answer: C) Iron-deficiency anemia
Rationale:
Excessive milk intake can lead to iron-deficiency anemia because it can interfere with the
absorption of iron from other foods.
A nurse is reinforcing teaching with a client who was diagnosed with diabetes mellitus and requires
insulin injections. Which of the following client statements indicates an understanding of the
teaching?
A) "I will store my current bottle of insulin in the freezer."
B) "I will store my current bottle of insulin in the refrigerator."
C) "I will store my current bottle of insulin in direct sunlight."
D) "I will store my current bottle of insulin at room temperature on the kitchen counter."
Answer: B) "I will store my current bottle of insulin in the refrigerator."
Rationale:
Insulin should be stored in the refrigerator to maintain its effectiveness. Freezing or exposure to
direct sunlight can degrade insulin.
A nurse is caring for a client who has urolithiasis. Which of the following actions should the nurse
take?
A) Encourage the client to limit fluid intake.
B) Apply heat to the client's lower abdomen.
C) Strain the client's urine.
D) Encourage the client to maintain a low-fiber diet.
Answer: C) Strain the client's urine.
Rationale:
Straining the client's urine allows for the collection and analysis of any stones passed, which can
help guide treatment and prevent recurrence.
A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the
following instructions should the nurse include in the teaching?
A) Wear a tight-fitting bra on the day of the test.
B) Refrain from using deodorant on the morning of the test.
C) Apply lotion to the breasts before the test.
D) Avoid drinking water on the morning of the test.
Answer: B) Refrain from using deodorant on the morning of the test.
Rationale:
Deodorants, antiperspirants, powders, creams, and lotions can interfere with the quality of the
mammogram images. Therefore, it is important to advise clients to refrain from using these
products on the day of the test.
A nurse is caring for a school-age child whose family adheres to a vegan diet in the home. The
nurse should recognize the child is at risk for a deficiency of which of the following?
A) Vitamin A
B) Vitamin D
C) Vitamin E
D) Vitamin K
Answer: B) Vitamin D
Rationale:
Vitamin D is mainly obtained through exposure to sunlight and is found in few food sources. Since
the child's family adheres to a vegan diet, the child may be at risk for vitamin D deficiency.
A nurse is reinforcing teaching with a client who is about to undergo a thoracentesis. Which of the
following statements by the client indicates an understanding of the information?
A) "I will have general anesthesia during the procedure."
B) "I will need to fast for 24 hours before the procedure."
C) "I will need to lie on my side during the procedure."
D) "I will need to empty my bladder before the procedure."
Answer: C) "I will need to lie on my side during the procedure."
Rationale:
The client undergoing a thoracentesis will typically need to lie on their side with the affected side
elevated to facilitate access to the pleural space.
A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following
findings should the nurse expect?
A) Bradycardia
B) Hypertension
C) Hypoalbuminemia
D) Periorbital edema
Answer: D) Periorbital edema
Rationale:
Periorbital edema (swelling around the eyes) is a common finding in children with acute
glomerulonephritis due to fluid retention.
A nurse is assisting with the discharge planning for a client following a myocardial infarction.
Which of the following is an appropriate referral for this client?
A) Nutritionist for dietary planning
B) Occupational therapist for medication management
C) Speech therapist for dysphagia evaluation
D) Physical therapist for range-of-motion exercises
Answer: D) Physical therapist for range-of-motion exercises
Rationale:
Range-of-motion exercises are important for maintaining muscle strength and joint flexibility
following a myocardial infarction. Therefore, referral to a physical therapist is appropriate.
A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse
should identify that which of the following actions by the AP indicates an understanding of the
procedure?
A) Apply the stockings with wrinkles or creases.
B) Apply the stockings with the toe seam over the toes.
C) Apply the stockings with the client's legs dependent.
D) Elevate the client's legs before applying the stockings.
Answer: D) Elevate the client's legs before applying the stockings.
Rationale:
Elevating the client's legs before applying antiembolic stockings helps facilitate venous return,
making it easier to apply the stockings and ensuring a proper fit.
A nurse is contributing to the plan of care for a client with bulimia nervosa. Which of the following
interventions should the nurse recommend?
A) Encourage the client to eat quickly to avoid feelings of guilt.
B) Monitor the client's weight weekly.
C) Observe the client for 1 hour after meals.
D) Provide the client with a high-fat diet.
Answer: C) Observe the client for 1 hour after meals.
Rationale:
Observing the client for 1 hour after meals helps prevent purging behaviors and ensures that the
client is receiving adequate nutrition.
A nurse in a newborn nursery is collecting data about a newborn's Moro reflex. Which of the
following actions should the nurse take to elicit the reflex?
A) Tap the newborn's cheek.
B) Stroke the newborn's foot from heel to toe.
C) Startle the newborn by clapping hands after laying the newborn on a flat surface.
D) Touch the newborn's palm with a finger.
Answer: C) Startle the newborn by clapping hands after laying the newborn on a flat surface.
Rationale:
The Moro reflex, also known as the startle reflex, is elicited by sudden movements or loud noises.
Clapping hands after laying the newborn on a flat surface can elicit this reflex.
A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse
should recognize that the client needs a referral for diabetic education when the client does which of
the following?
A) States they will check their blood glucose level once a week.
B) Lists sweating, shaking, and palpitations as signs of hyperglycemia.
C) Reports they will administer insulin when they feel unwell.
D) Plans to eat a consistent carbohydrate diet.
Answer: B) Lists sweating, shaking, and palpitations as signs of hyperglycemia.
Rationale:
Sweating, shaking, and palpitations are symptoms of hypoglycemia, not hyperglycemia. This
indicates a need for further education.
A nurse has received a report for a group of clients. Which of the following clients should the nurse
ask the charge nurse to reassign?
A) A client who has a new prescription for a blood transfusion.
B) A client who has a new prescription for two units of packed RBCs.
C) A client who has a history of chronic obstructive pulmonary disease (COPD) and reports
shortness of breath.
D) A client who has a new prescription for physical therapy.
Answer: B) A client who has a new prescription for two units of packed RBCs.
Rationale:
The nurse should request reassignment of this client because administering blood products requires
special training and additional nursing responsibilities.
A nurse is preparing to insert a nasogastric tube for a client. In which order should complete the
following steps? (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.)
• Position the client with pillows behind their head in high-fowler's position
• Instruct the client to place their head against a pillow while inserting the tube into one nostril
• Check the patency of the client's nares
• Measure the tube from the tip of the client's nose, to the earlobe, then the xiphoid process
• Lubricate the end of the tube with water-soluble lubricant
Answer:
1. Check the patency of the client's nares
2. Position the client with pillows behind their head in high-fowler's position
3. Measure the tube from the tip of the client's nose, to the earlobe, then the xiphoid process
4. Lubricate the end of the tube with water-soluble lubricant
5. Instruct the client to place their head against a pillow while inserting the tube into one nostril
Rationale:
• Before inserting the nasogastric tube, the nurse should check the patency of the client's nares to
ensure proper placement.
• The client should be positioned in high-fowler's position to facilitate tube insertion.
• Measuring the tube from the tip of the client's nose to the earlobe and then to the xiphoid process
ensures that the tube is inserted to the appropriate length.
• Lubricating the end of the tube with water-soluble lubricant facilitates insertion.
• Instructing the client to place their head against a pillow while inserting the tube into one nostril
helps to ease insertion and ensures proper placement.
A nurse is preparing to administer amikacin 5 mg/kg IM every 8 hr to a client. The client weighs
70.8 kg. How many mg should the nurse administer per dose?
A) 354 mg
B) 358 mg
C) 364 mg
D) 370 mg
Answer: A) 354 mg
Rationale:
To calculate the dose, use the formula: Dose = Weight (kg) × Dosage (mg/kg).
Dose = 70.8 kg × 5 mg/kg = 354 mg
A nurse is caring for a newborn following a circumcision. Which of the following manifestations
indicates the newborn is experiencing pain?
A) Pink color of the surgical area
B) Diaphoresis
C) Lip smacking
D) Decreased heart rate
Answer: C) Lip smacking
Rationale:
Lip smacking can be a sign of pain in newborns.
A nurse in a provider's office is collecting data from a client who has deep vein thrombosis?
A) The client is a vegetarian
B) The client takes ibuprofen daily to treat musculoskeletal pain
C) The client wears compression stockings during the day
D) The client's mother has a history of varicose veins
Answer: B) The client takes ibuprofen daily to treat musculoskeletal pain
Rationale:
Taking ibuprofen daily to treat musculoskeletal pain can increase the risk of bleeding, which is a
concern for clients with deep vein thrombosis.
A nurse is contributing to the discharge plan of an older adult client who had a total hip
arthroplasty, is unable to walk independently, and lives alone.
A) Home health care with a visiting nurse
B) Assisted living facility
C) Skilled nursing facility
D) Outpatient physical therapy
Answer: C) Skilled nursing facility
Rationale:
Since the client is unable to walk independently and lives alone, they will require a higher level of
care and assistance with activities of daily living. A skilled nursing facility can provide the
necessary rehabilitation and support until the client is able to safely return home.
A nurse on a mental health unit is discussing client rights with a group of coworkers.
A) "A client must withdraw consent for treatment in writing if he is competent to do so."
B) "A client must be medicated against his will if he is considered a danger to himself or others."
C) "A client cannot refuse treatment if it is deemed necessary by the healthcare provider."
D) "A client can be restrained for any reason if he becomes agitated or aggressive."
Answer: A) "A client must withdraw consent for treatment in writing if he is competent to do so."
Rationale:
Informed consent is a fundamental right of clients. If a client is competent, they must provide
written consent to withdraw from treatment.
A nurse is reinforcing teaching with a client who is 35 weeks gestation and has a prescription for
lecithin/sphingomyelin ratio.
A) "This test will determine fetal growth and development."
B) "This test will assess for fetal heart rate abnormalities."
C) "This test will determine fetal lung maturity."
D) "This test will assess for amniotic fluid volume."
Answer: C) "This test will determine fetal lung maturity."
Rationale:
The lecithin/sphingomyelin (L/S) ratio is a test used to assess fetal lung maturity.
A prenatal clinic is reinforcing teaching with a client about a nonstress test.
A) "Press a button every time you feel the baby move."
B) "Lie on your back during the test."
C) "Consume a high-sugar snack before the test."
D) "Keep the fetal monitor dry during the test."
Answer: A) "Press a button every time you feel the baby move."
Rationale:
In a nonstress test, the client presses a button each time they feel fetal movement to correlate fetal
movement with fetal heart rate accelerations.
A client who is taking heparin to prevent deep vein thrombosis has bloody stools. Which laboratory
values should the nurse report to the provider?
A) Hemoglobin 12.2 g/dL
B) Platelets 250,000/mm³
C) INR 5.2
D) PTT 30 seconds
Answer: C) INR 5.2
Rationale:
An INR value of 5.2 indicates excessive anticoagulation and an increased risk of bleeding, which is
consistent with the client's symptoms of bloody stools.
A nurse is reinforcing teaching with a client who has a new prescription for alprazolam. The client
should avoid which of the following while taking this medication?
A) Caffeine
B) Alcohol
C) Dairy products
D) Fresh fruits
Answer: B) Alcohol
Rationale:
Alcohol should be avoided while taking alprazolam because both substances can cause central
nervous system depression and increase the risk of respiratory depression and sedation.
Client who has bipolar disorder. The nurse should identify that which of the following findings
places the client at an increased risk for injury due to mania?
A) The client is able to sit still for long periods.
B) The client expresses feelings of sadness and hopelessness.
C) The client is easily distracted by external stimuli.
D) The client reports decreased need for sleep.
Answer: C) The client is easily distracted by external stimuli.
Rationale:
Clients experiencing mania are often easily distracted by external stimuli, which can lead to
impulsive behaviors and increased risk for injury.
Collecting data from a client who has asthma with exacerbation.
A) Encourage the client to take slow, deep breaths.
B) Administer a short-acting bronchodilator.
C) Administer a long-acting bronchodilator.
D) Instruct the client to avoid using the rescue inhaler.
Answer: B) Administer a short-acting bronchodilator.
Rationale:
During an asthma exacerbation, a short-acting bronchodilator is used to relieve bronchospasm and
improve airflow.
A nurse is caring for a client diagnosed with hyperemesis gravidarum. Which of the findings should
the nurse anticipate?
A) Increased appetite
B) Weight gain
C) Poor skin turgor
D) Normal electrolyte levels
Answer: C) Poor skin turgor
Rationale:
Hyperemesis gravidarum can lead to dehydration, which may result in poor skin turgor.
A female newly diagnosed with breast cancer is concerned about potential changes to her body
image.
A) Provide information about mastectomy.
B) Initiate a client referral to Reach to Recovery.
C) Recommend immediate breast reconstruction.
D) Encourage the client to avoid discussing her feelings.
Answer: B) Initiate a client referral to Reach to Recovery.
Rationale:
Reach to Recovery is a program that matches newly diagnosed breast cancer patients with
volunteers who have experienced similar circumstances. This support can help the client cope with
changes to her body image.
Teaching about allergies with the guardian of a newborn. Findings indicate that the nurse has a milk
allergy.
A) Loose, mucousy stools
B) Projectile vomiting
C) Constipation
D) Dry, scaly skin
Answer: A) Loose, mucousy stools
Rationale:
Loose, mucousy stools can be a sign of a milk allergy in infants.
Collecting data from a client who has heart failure and is receiving 2 liters of oxygen via nasal
cannula. Oxygen saturation of 93%.
A) Compare the result with the baseline reading.
B) Increase the oxygen flow rate.
C) Document the findings as normal.
D) Notify the healthcare provider immediately.
Answer: A) Compare the result with the baseline reading.
Rationale:
Oxygen saturation of 93% may be normal for this client or it could represent a change from
baseline. The nurse should compare this reading with the client's baseline to determine if
intervention is needed.
A nurse working at a crisis hotline call center receives a call stating, "I cannot take it. My life is
over."
A) "Would you like to talk more about what's been going on?"
B) "I'm sorry to hear that. Have you talked to anyone else about how you're feeling?"
C) "Are you thinking of harming yourself?"
D) "It sounds like you're feeling really overwhelmed right now."
Answer: C) "Are you thinking of harming yourself?"
Rationale:
Directly asking the caller if they are thinking of harming themselves is essential to assess their level
of risk and provide appropriate intervention.
Providing preoperative teaching for an adolescent who is scheduled for a cardiac catheterization.
A) "You can return to school 1 week after your procedure."
B) "You can shower 1 day after your procedure."
C) "You should avoid any physical activity for 2 weeks after your procedure."
D) "You should avoid eating or drinking anything for 24 hours before your procedure."
Answer: B) "You can shower 1 day after your procedure."
Rationale:
Showering 1 day after the procedure is appropriate, but returning to school may depend on the
individual's recovery and physician's recommendation.
Reinforcing teaching about infection control with the guardian of a school-age child who has
varicella. No longer contagious.
A) All vesicles have crusted over.
B) The child has been fever-free for 24 hours.
C) The child's cough has improved.
D) The child's appetite has returned to normal.
Answer: A) All vesicles have crusted over.
Rationale:
Varicella is considered no longer contagious once all vesicles have crusted over.
Preschooler who is about to undergo an incision and drainage for cellulitis on the left arm.
A) Help the child put a dressing on a doll.
B) Explain the procedure using medical terminology.
C) Allow the child to watch a video of the procedure.
D) Leave the room to give the child privacy.
Answer: A) Help the child put a dressing on a doll.
Rationale:
Allowing the child to practice putting a dressing on a doll can help reduce anxiety and increase
understanding of the procedure.
Recovering from electroconvulsive therapy. Adverse effect of the treatment.
A) Confusion
B) Euphoria
C) Bradycardia
D) Hypertension
Answer: A) Confusion
Rationale:
Confusion is a common adverse effect of electroconvulsive therapy.
Asks a client who has schizophrenia, "How are you?" The nurse should identify this as echolalia.
A) "How are you?"
B) "What's your name?"
C) "Where are you from?"
D) "Are you feeling okay?"
Answer: A) "How are you?"
Rationale:
Echolalia is the repetition of words or phrases spoken by others.
Client who has bipolar disorder and is experiencing mania. Which of the following actions should
the nurse take?
A) Choose the client's clothing for her.
B) Allow the client to pick her own choice of clothing.
C) Restrict the client to wearing hospital gowns.
D) Provide the client with only one choice of clothing.
Answer: B) Allow the client to pick her own choice of clothing.
Rationale:
Allowing the client to choose her own clothing can help maintain her sense of autonomy and
independence.
Providing postmortem care for a client prior to the family viewing the body.
A) Raise the head of the client's bed 30 degrees.
B) Position the client's body flat on the bed.
C) Cover the client's body with a sheet.
D) Remove all tubes and equipment.
Answer: A) Raise the head of the client's bed 30 degrees.
Rationale:
Elevating the head of the bed can provide a more natural appearance for the deceased client when
the family views the body.
Difficulty finishing client care tasks during their shift.
A) Perform quick tasks before time-consuming tasks.
B) Prioritize tasks based on client acuity.
C) Take frequent breaks throughout the shift.
D) Delegate tasks to other staff members.
Answer: A) Perform quick tasks before time-consuming tasks.
Rationale:
Prioritizing quick tasks first can help manage time more efficiently and ensure that essential client
care tasks are completed.
Administer an ophthalmic medication. Minimize systemic absorption.
A) Apply light pressure to the inner canthus.
B) Apply the medication directly to the cornea.
C) Administer the medication as a nasal spray.
D) Massage the eyelid after instillation.
Answer: A) Apply light pressure to the inner canthus.
Rationale:
Applying light pressure to the inner canthus helps minimize systemic absorption of the medication.
Assisting with planning care for a group of clients. Which should the nurse delegate to an assistive
personnel?
A) Evaluate clients' risk.
B) Changing the dressing on a client's IV site.
C) Administering medication to a client.
D) Assisting with ambulation.
Answer: B) Changing the dressing on a client's IV site.
Rationale:
Changing a dressing on an IV site is within the scope of practice for an assistive personnel.
Removing a female client's indwelling urinary catheter.
A) Withdraw the fluid from the balloon.
B) Administer an antibiotic.
C) Provide perineal care.
D) Document the procedure.
Answer: A) Withdraw the fluid from the balloon.
Rationale:
Before removing the urinary catheter, the balloon must be deflated by withdrawing the fluid.
Teaching about colostomy care with a client. Understanding of how to care for colostomy.
A) Empty bag.
B) Cut a wafer opening 1 inch bigger than my stoma.
C) Change the entire pouching system daily.
D) Use adhesive remover to clean around the stoma.
Answer: B) Cut a wafer opening 1 inch bigger than my stoma.
Rationale:
Cutting the wafer opening 1 inch bigger than the stoma ensures a proper fit and prevents irritation
of the stoma.
New prescription for digoxin to treat heart failure.
A) Decreased cardiac output.
B) Decreased heart rate.
C) Increased cardiac output.
D) Decreased blood pressure.
Answer: C) Increased cardiac output.
Rationale:
Digoxin helps increase cardiac output by increasing the force of myocardial contraction.
Standard precautions with an assistive personnel who is new to the newborn nursery. Which of the
following should the nurse remind the AP to wear clean gloves?
A) Changing wet gloves.
B) Holding the newborn during feeding.
C) Taking the newborn's temperature.
D) Diapering the newborn.
Answer: A) Changing wet gloves.
Rationale:
It is important to change wet gloves to maintain infection control practices.
Providing change of shift report for a client who has COPD. Which of the following information
should the nurse include?
A) Oxygen saturation of 95% on room air.
B) Output of 400 ml over the past 8 hours.
C) New onset of restlessness.
D) History of hypertension.
Answer: C) New onset of restlessness.
Rationale:
New onset of restlessness could indicate worsening respiratory distress in a client with COPD.
Deep vein thrombosis. Findings should the nurse expect in the affected extremity?
A) Pallor of the skin.
B) Warmth and redness.
C) Swelling and edema.
D) Dull aching pain.
Answer: D) Dull aching pain.
Rationale:
Dull aching pain is a common finding in the affected extremity in deep vein thrombosis.
Vitamin C deficiency. Highest vitamin C concentration?
A) 1 cup raw broccoli.
B) 1 medium orange.
C) 1 cup raw strawberries.
D) 1 cup raw spinach.
Answer: A) 1 cup raw broccoli.
Rationale:
Raw broccoli contains the highest concentration of vitamin C among the options provided.
Identify that massage therapy is indicated for the treatment of the following mental health disorders:
A) Depression.
B) Schizophrenia.
C) Bipolar disorder.
D) Obsessive-compulsive disorder.
Answer: A) Depression.
Rationale:
Massage therapy has been shown to be effective in reducing symptoms of depression.
Preschool-age child who has a new diagnosis of celiac disease.
A) Corn tortillas with black beans.
B) Grilled cheese sandwich on wheat bread.
C) Macaroni and cheese.
D) Peanut butter and jelly sandwich on white bread.
Answer: A) Corn tortillas with black beans.
Rationale:
Corn tortillas are gluten-free and suitable for a child with celiac disease.
A client who is experiencing alcohol withdrawal. Administer PRN dose of chlordiazepoxide.
A) Tremors.
B) Hypertension.
C) Tachycardia.
D) Hyperactivity.
Answer: A) Tremors.
Rationale:
Chlordiazepoxide is often used to manage alcohol withdrawal symptoms such as tremors.
Decrease the rate of health care-associated infections within the facility.
A) Client data indicates a decreased rate of infection.
B) Staff members are encouraged to wash their hands frequently.
C) Visitors are limited to reduce the risk of transmission.
D) Increase the use of personal protective equipment.
Answer: A) Client data indicates a decreased rate of infection.
Rationale:
Monitoring client data for rates of infection allows the facility to assess the effectiveness of
infection control measures.
Transmission precautions with a client who has Hepatitis C.
A) Avoid sharing razors with other family members.
B) Wear a mask when in close contact with others.
C) Wash hands frequently with soap and water.
D) Avoid sharing eating utensils.
Answer: A) Avoid sharing razors with other family members.
Rationale:
Sharing razors can lead to blood-to-blood transmission of Hepatitis C.
Participating in a therapy session for anger management. Recent behavior is due to the loss of their
job.
A) Rationalization.
B) Projection.
C) Displacement.
D) Sublimation.
Answer: A) Rationalization.
Rationale:
Rationalization is a defense mechanism where a person tries to justify their behavior by providing
logical reasons for it.
The nurse states that he has more work to do than anyone else.
A) "Well, let's take a look at the assignments together."
B) "I'm sure you do, but we all have our fair share of work."
C) "I'll talk to the manager about redistributing the workload."
D) "Why do you feel like you have more work than anyone else?"
Answer: A) "Well, let's take a look at the assignments together."
Rationale:
Collaborating with the nurse to review assignments can help identify workload discrepancies and
find solutions.
Reviewing the medication record of a client who has a prescription for fluoxetine 2 weeks before.
A) Levothyroxine.
B) Phenytoin.
C) Phenelzine.
D) Lisinopril.
Answer: C) Phenelzine.
Rationale:
Phenelzine is an MAOI antidepressant that can cause serious interactions with fluoxetine.
Condom catheter to a male client who is incontinent.
A) Leave space between the tip of the penis and the end.
B) Ensure the catheter is snug against the penis.
C) Apply adhesive tape tightly around the penis.
D) Use a larger-sized condom catheter for better fit.
Answer: A) Leave space between the tip of the penis and the end.
Rationale:
Leaving space between the tip of the penis and the end of the condom catheter prevents urinary
reflux and skin irritation.
Collecting health history data from a client who has hemorrhoids.
A) Chronic constipation.
B) Recent weight loss.
C) Allergic rhinitis.
D) Frequent nosebleeds.
Answer: A) Chronic constipation.
Rationale:
Chronic constipation is a risk factor for developing hemorrhoids.
Discussing informed consent with a client prior to their surgical procedure.
A) Ensure the client gives voluntary consent for the surgery.
B) Provide detailed information about the surgeon's qualifications.
C) Obtain consent from the client's family.
D) Explain the risks of the surgery.
Answer: A) Ensure the client gives voluntary consent for the surgery.
Rationale:
Informed consent requires that the client gives consent voluntarily, without coercion or duress.
Colostomy; the client tells the nurse "I don't want anyone to see me with this bag."
A) "Would it help to speak with someone else who has a colostomy?"
B) "Let's discuss ways to conceal the bag under your clothing."
C) "I understand. We can keep this conversation confidential."
D) "It's important to remember that the bag helps you maintain your health."
Answer: A) "Would it help to speak with someone else who has a colostomy?"
Rationale:
Connecting the client with someone who has a colostomy can provide valuable support and
reassurance.
Following a vaginal delivery, the client has a second-degree perineal laceration.
A) Apply cold packs.
B) Apply warm compresses.
C) Encourage sitz baths.
D) Administer opioid pain medication.
Answer: A) Apply cold packs.
Rationale:
Cold packs can help reduce swelling and discomfort associated with perineal lacerations.
Instill otic suspension into an adult client's ear.
A) Pull upward and backward.
B) Pull downward and backward.
C) Pull upward and forward.
D) Pull downward and forward.
Answer: A) Pull upward and backward.
Rationale:
Pulling upward and backward helps straighten the ear canal for proper medication administration.
Collecting data from a client who has Hepatitis A.
A) Abdominal pain.
B) Joint pain.
C) Chest pain.
D) Headache.
Answer: A) Abdominal pain.
Rationale:
Abdominal pain is a common symptom of Hepatitis A infection.
He is not coming out of his room anymore because other clients on the unit make fun of him.
A) "You feel upset by the response of others."
B) "You should confront those who make fun of you."
C) "You should try to ignore them."
D) "You should report this behavior to the staff."
Answer: A) "You feel upset by the response of others."
Rationale:
Acknowledging the client's feelings validates their experience and opens the door for further
discussion and support.
Contraindication for oral contraceptives.
A) History of renal calculi.
B) Family history of breast cancer.
C) History of migraines with aura.
D) Obesity.
Answer: A) History of renal calculi.
Rationale:
Oral contraceptives can increase the risk of renal calculi formation in individuals with a history of
kidney stones.
Open heart surgery; "I am confident I will be able to go home a few hours after the surgery."
A) Denial.
B) Rationalization.
C) Acceptance.
D) Bargaining.
Answer: A) Denial.
Rationale:
Denial is a defense mechanism commonly seen in clients facing serious health issues, like openheart surgery.
Client who is receiving IV fluids. The nurse realizes that the incorrect IV solution is infusing.
A) Complete an incident report.
B) Notify the charge nurse immediately.
C) Increase the rate of the IV infusion.
D) Assess the client for signs of fluid overload.
Answer: A) Complete an incident report.
Rationale:
Completing an incident report is a crucial step in documenting and addressing errors in client care.
Take to demonstrate sensitivity to age-related changes.
A) Use paper tape for securing the new dressing.
B) Apply lotion liberally to dry skin.
C) Administer a mild sedative before bedtime.
D) Encourage the client to walk unassisted.
Answer: A) Use paper tape for securing the new dressing.
Rationale:
Paper tape is less likely to cause skin tears or irritation in older adults with fragile skin.
Long-term care facility has received a change of shift report.
A) COPD and agitated during the night shift.
B) Diabetes and requires insulin injections.
C) History of stroke and needs assistance with bathing.
D) Recovering from pneumonia and requires oxygen therapy.
Answer: A) COPD and agitated during the night shift.
Rationale:
Knowing that the client has COPD and becomes agitated during the night helps the night shift staff
to plan appropriate care and interventions.
Guardian of a preschooler who has a new diagnosis of enterobiasis.
A) Everyone who lives in the home will need medication.
B) The child will need to be isolated from other children.
C) The child should not attend preschool for at least a month.
D) Only the affected child needs medication.
Answer: A) Everyone who lives in the home will need medication.
Rationale:
Enterobiasis is highly contagious, and all household members should be treated to prevent
reinfestation.
Change of shift report.
A) Command hallucinations.
B) Delusions of grandeur.
C) Suicidal ideation.
D) Violent behavior.
Answer: A) Command hallucinations.
Rationale:
Command hallucinations represent a significant risk for the client and need to be addressed
promptly by the staff.
In-service for a group of unit nurses about ethical principles; fidelity.
A) Shares her time fairly among clients.
B) Provides care according to the standards of practice.
C) Reports any errors or incidents promptly.
D) Honors commitments to clients.
Answer: D) Honors commitments to clients.
Rationale:
Fidelity refers to the nurse's duty to fulfill commitments made to clients.
Postpartum client about bathing her newborn.
A) Clean head under running water.
B) Use soap and water to clean the umbilical cord.
C) Bathe the newborn every other day.
D) Apply lotion to the newborn's skin after bathing.
Answer: A) Clean head under running water.
Rationale:
Cleaning the newborn's head under running water helps prevent irritation and infection.
A nurse is collecting data from a client who received a 50 mg dose of metoprolol instead of the
prescribed 25 mg.
A) Decreased heart rate.
B) Increased blood pressure.
C) Increased heart rate.
D) Hypertension.
Answer: A) Decreased heart rate.
Rationale:
Metoprolol is a beta-blocker used to decrease heart rate and blood pressure.
Recently had a stroke and states, "I am having trouble swallowing my food." Which should the
nurse initiate a referral?
A) Speech-language pathologist.
B) Occupational therapist.
C) Physical therapist.
D) Dietitian.
Answer: A) Speech-language pathologist.
Rationale:
Difficulty swallowing (dysphagia) is a common complication after a stroke, and a speech-language
pathologist can assess and help manage this issue.
Newborn who is experiencing heroin withdrawal. Should expect a prescription for which of the
following medications?
A) Methadone.
B) Naloxone.
C) Buprenorphine.
D) Clonidine.
Answer: A) Methadone.
Rationale:
Methadone is commonly used to manage neonatal abstinence syndrome, including withdrawal from
heroin.
Reinforcing teaching about a safety plan for a client who reports partner violence.
A) Rehearse your escape route.
B) Confront your partner about the violence.
C) Try to calm your partner during a violent episode.
D) Keep a record of the violence.
Answer: A) Rehearse your escape route.
Rationale:
Rehearsing an escape route is an essential part of a safety plan for someone experiencing partner
violence.
In which phase of the therapeutic relationship should the nurse help the client develop problemsolving skills?
A) Working phase.
B) Orientation phase.
C) Termination phase.
D) Pre-interaction phase.
Answer: A) Working phase.
Rationale:
In the working phase, the nurse and client collaborate to identify problems and develop solutions.
Preparing for a Papanicolaou smear. The client will be placed in which of the following positions?
A) Lithotomy.
B) Dorsal recumbent.
C) Prone.
D) Sims'.
Answer: A) Lithotomy.
Rationale:
Lithotomy position provides optimal access for a Papanicolaou smear.
Collecting data on a client who has swelling of the lower leg. Identify which of the following is a
manifestation of compartment syndrome?
A) Palpation of +1 dorsal pedal pulse.
B) Pain with passive stretch of the toes.
C) Redness and warmth over the calf.
D) Decreased capillary refill of the toes.
Answer: B) Pain with passive stretch of the toes.
Rationale:
Pain with passive stretch of the toes is a classic symptom of compartment syndrome.
A nurse receives a call from a client's partner to inquire about their condition. Which of the
following actions?
A) Provide information about the client's condition.
B) Verify the client has authorized release of their information to their partner.
C) Ask the partner to come to the hospital for an update.
D) Request the partner to wait for the next visiting hours.
Answer: B) Verify the client has authorized release of their information to their partner.
Rationale:
Protecting the client's privacy and confidentiality is paramount. Before providing any information,
the nurse must ensure that the client has authorized the release of their information to their partner.
Client who has a cast on their lower leg. Which of the following actions should the nurse take?
A) Keep the cast uncovered to allow air circulation.
B) Apply ice directly to the cast to reduce swelling.
C) Massage areas around the edge of the client's cast with lotion.
D) Use a heating pad over the cast to relieve discomfort.
Answer: C) Massage areas around the edge of the client's cast with lotion.
Rationale:
Massaging areas around the edge of the cast with lotion can help relieve itching and discomfort.
Client who is experiencing a postpartum hemorrhage; which of the following medications should
the nurse plan to administer?
A) Oxytocin.
B) Misoprostol.
C) Methylergonovine.
D) Carboprost.
Answer: C) Methylergonovine.
Rationale:
Methylergonovine is a medication used to treat postpartum hemorrhage by causing uterine
contractions.
Postoperative and received hydromorphone 4 mg PRN 15 min ago.
A) Reevaluate the client's response.
B) Administer another dose of hydromorphone.
C) Document the administration of hydromorphone.
D) Offer the client a warm blanket.
Answer: A) Reevaluate the client's response.
Rationale:
After administering pain medication, it's essential to reassess the client's pain level and response
before administering additional doses.
Teach the client relaxation techniques.
A) Provide the client with a list of over-the-counter pain medications.
B) Encourage the client to remain in bed for the entire day.
C) Instruct the client to avoid deep breathing exercises.
D) Demonstrate relaxation techniques such as deep breathing and progressive muscle relaxation.
Answer: D) Demonstrate relaxation techniques such as deep breathing and progressive muscle
relaxation.
Rationale:
Teaching relaxation techniques such as deep breathing can help the client manage anxiety and stress
effectively.
Collecting a sputum specimen for a client for culture and sensitivity.
A) Keep the specimen at room temperature until transport.
B) Refrigerate the specimen until the time of transport.
C) Mix the specimen with saline solution.
D) Place the specimen in a biohazard bag and seal it tightly.
Answer: B) Refrigerate the specimen until the time of transport.
Rationale:
Refrigerating the sputum specimen helps preserve the integrity of the sample until it is transported
to the laboratory.
Observes a client having a panic attack.
A) Administer a sedative medication.
B) Instruct the client to use abdominal breathing.
C) Leave the client alone until the panic attack subsides.
D) Offer the client caffeine-free herbal tea.
Answer: B) Instruct the client to use abdominal breathing.
Rationale:
Abdominal breathing can help the client to calm down and reduce the symptoms of a panic attack.
Postoperative following laser surgery for open-angle glaucoma.
A) Administer a stool softener to prevent constipation.
B) Provide the client with a heating pad for the surgical site.
C) Encourage the client to sleep on the side of the surgical site.
D) Apply pressure to the surgical site to reduce bleeding.
Answer: A) Administer a stool softener to prevent constipation.
Rationale:
Stool softeners can help prevent constipation, which is a common side effect of opioid pain
medications often used postoperatively.
Dietary teaching with an adolescent who is at 10 weeks of gestation.
A) You should consume 1,300 milligrams of calcium each day.
B) You should avoid all dairy products.
C) You should consume 500 extra calories each day.
D) You should restrict your fluid intake.
Answer: A) You should consume 1,300 milligrams of calcium each day.
Rationale:
Adequate calcium intake is essential during pregnancy for the development of the baby's bones and
teeth.
Caring for an infant who has a nasogastric feeding tube.
A) Confirm placement by flushing with air prior to feeding.
B) Administer the feeding tube without verifying placement.
C) Check placement by aspirating stomach contents.
D) Insert the tube without confirming placement.
Answer: A) Confirm placement by flushing with air prior to feeding.
Rationale:
Flushing the tube with air before feeding helps to confirm proper placement of the nasogastric tube.
Full-thickness burns and is in the emergent phase of the burn.
A) Hypernatremia.
B) Hypocalcemia.
C) Hypokalemia.
D) Hyperkalemia.
Answer: D) Hyperkalemia.
Rationale:
During the emergent phase of burn injury, potassium ions are released from damaged cells, leading
to hyperkalemia.
Bipolar disorder and is experiencing mania.
A) Increase the level of environmental stimuli.
B) Decrease the level of environmental stimuli.
C) Provide complex, detailed instructions.
D) Encourage participation in group activities.
Answer: B) Decrease the level of environmental stimuli.
Rationale:
Decreasing environmental stimuli can help reduce agitation and hyperactivity in clients
experiencing mania.
Stat dose of meperidine but instead got phenytoin.
A) Administer another dose of meperidine.
B) Check the client's vital signs.
C) Document the administration of meperidine.
D) Notify the charge nurse.
Answer: B) Check the client's vital signs.
Rationale:
In case of medication error, the nurse should assess the client's condition and vital signs
immediately.
Safety with the parent of a newborn.
A) Take the newborn to the nursery before showering.
B) Take the newborn into the shower with you.
C) Wait until someone else is available to watch the newborn.
D) Shower with the newborn in your arms.
Answer: A) Take the newborn to the nursery before showering.
Rationale:
It's safest to place the newborn in a secure environment, such as a crib, before showering.
Admission interview with a client who has schizophrenia.
A) Hallucinations.
B) Delusions.
C) Disorganized speech.
D) Catatonia.
Answer: A) Hallucinations.
Rationale:
Hallucinations are sensory perceptions that occur in the absence of external stimuli and are a
common symptom of schizophrenia.
New prescription for lithium carbonate.
A) I will notify my provider if I develop a hand tremor.
B) I will increase my intake of foods high in tyramine.
C) I will avoid foods high in vitamin K.
D) I will stop taking my St. John's wort.
Answer: A) I will notify my provider if I develop a hand tremor.
Rationale:
Hand tremors are a common side effect of lithium carbonate and should be reported to the provider.
Assisting with the plan of care for a client who has Alzheimer's disease.
A) Give directions using simple phrases.
B) Provide complex, detailed instructions.
C) Speak loudly to ensure understanding.
D) Engage the client in lengthy conversations.
Answer: A) Give directions using simple phrases.
Rationale:
Clients with Alzheimer's disease often have difficulty processing complex information, so simple,
straightforward communication is most effective.
Sterile field prior to performing a dressing change.
A) Pour liquids from 4-6 inches.
B) Pour liquids directly onto the dressing.
C) Hold the bottle or container 12 inches above the sterile field.
D) Pour liquids from 8-10 inches.
Answer: A) Pour liquids from 4-6 inches.
Rationale:
Pouring liquids from 4-6 inches above the sterile field helps to prevent splashing and contamination
of the field.
Charge nurse in a long-term care facility; which of the following should the nurse delegate to an
assistive personnel?
A) Administering medications.
B) Measuring the output every 2 hr.
C) Performing dressing changes.
D) Developing the plan of care.
Answer: B) Measuring the output every 2 hr.
Rationale:
Measuring the output every 2 hours is within the scope of practice of an assistive personnel.
Client who has mononucleosis.
A) Airborne.
B) Droplet.
C) Contact.
D) Standard.
Answer: C) Contact.
Rationale:
Infectious mononucleosis is transmitted through direct contact with saliva, so contact precaution are
necessary.
How many baby aspirin should I give a toddler?
A) You should give your child one baby aspirin.
B) You should avoid giving aspirin to your child.
C) You should give your child two baby aspirin.
D) You should give your child three baby aspirin.
Answer: B) You should avoid giving aspirin to your child.
Rationale:
Giving aspirin to children, especially those with fever or viral infections, is associated with Reye's
syndrome, a rare but serious condition.
Epidural PCA.
A) This machine is programmed to prevent you from administering more than a safe dose.
B) You can push the button as often as you like.
C) You will need to ask the nurse each time you want more pain medication.
D) You will receive a continuous dose of pain medication.
Answer: A) This machine is programmed to prevent you from administering more than a safe dose.
Rationale:
Epidural PCA machines are programmed to prevent the administration of more than a safe dose of
medication within a specific timeframe.
A nurse is caring for a child who has terminal cancer.
A) The school-age sister is concerned about the impact of her sibling's death on herself.
B) The school-age sister is not old enough to understand what is happening.
C) The school-age sister does not need any information about her sibling's condition.
D) The school-age sister should not be allowed to visit her sibling in the hospital.
Answer: A) The school-age sister is concerned about the impact of her sibling's death on herself.
Rationale:
Siblings of children with terminal illness may experience significant emotional distress and need
support and information.
An infant postoperative. Evaluate the infant's pain level.
A) Visual Analog Scale (VAS).
B) Numerical Rating Scale (NRS).
C) Faces Pain Scale-Revised (FPS-R).
D) FLACC.
Answer: D) FLACC.
Rationale:
The FLACC scale is a pain assessment tool commonly used for infants and nonverbal children.
Schizophrenia; "Government agents are out to get me."
A) "It must be frightening to believe that someone is after you."
B) "There are no government agents here."
C) "Why do you think government agents are after you?"
D) "I'm sure you're mistaken about that."
Answer: A) "It must be frightening to believe that someone is after you."
Rationale:
This response acknowledges the client's feelings and experiences without affirming or denying the
delusion.
New prescription for phenelzine.
A) The patient is taking St. John's wort.
B) The patient is allergic to shellfish.
C) The patient is allergic to penicillin.
D) The patient is allergic to iodine.
Answer: A) The patient is taking St. John's wort.
Rationale:
St. John's wort is an herbal supplement that interacts with many medications, including phenelzine,
and can cause serotonin syndrome.
Patient has active tuberculosis.
A) Standard Precautions.
B) Airborne Precautions.
C) Droplet Precautions.
D) Contact Precautions.
Answer: B) Airborne Precautions.
Rationale:
Tuberculosis is spread through the air, so airborne precautions are necessary.
