2023-2024 ATI PN Comprehensive Exam with Answers-261 Solved Questions

ATI PN COMPREHENSIVE PREDICTOR ACTUAL EXAM WITH NGN 2023-2024
UPDATE(JUNE) ALL 180 QUESTIONS AND CORRECT ANSWERS ALREADY A
GRADED WITH EXPERT FEEDBACK
1. A nurse is caring for a client who has dehydration due to diarrhea. Which of the following
findings should the nurse report to the provider?
a. urine specific gravity 1.035
b. BUN 25 mg/dL
c. serum creatinine 0.8 mg/dL
d. hematocrit 42%
Answer: a. urine specific gravity 1.035
Rationale:
A urine specific gravity of 1.035 indicates concentrated urine, suggesting significant dehydration.
This finding requires immediate attention from the provider as it indicates inadequate fluid
intake or excessive fluid loss.
2. A nurse is providing pre-op care to a client who reports he has no one at home to help him
after his outpatient surgery. Which of the following actions should the nurse take?
a. assist with a referral to a home health care agency
b. inform the client that he must arrange for someone to assist him after surgery
c. advise the client to consider delaying the surgery until he has support at home
d. suggest that the client consider hiring a private duty nurse
Answer: a. assist with a referral to a home health care agency
Rationale:
Referring the client to a home health care agency ensures that he will have the necessary support
and care at home following his outpatient surgery. This is important for the client's safety and
well-being during the postoperative period.
3. A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of
the following findings indicates the client is experiencing a transfusion reaction?
a. temperature 38.8°C (101.8°F)
b. blood pressure 130/80 mm Hg
c. respiratory rate 16/min

d. heart rate 90 bpm
Answer: a. temperature 38.8°C (101.8°F)
Rationale:
An elevated temperature is indicative of a transfusion reaction, such as a febrile non-hemolytic
reaction or bacterial contamination of the blood product. This requires immediate intervention,
including stopping the transfusion and notifying the healthcare provider.
4. A nurse is monitoring a client who is post-op. Which of the following actions should the nurse
take when collecting data about the client's respirations?
a. count the client's respiratory rate for 15 seconds and multiply by 4
b. auscultate the client's lung sounds with a stethoscope
c. observe the movements of the client's chest wall
d. assess the client's oxygen saturation using a pulse oximeter
Answer: c. observe the movements of the client's chest wall
Rationale:
Observing the movements of the client's chest wall provides valuable information about the
depth, rhythm, and effort of breathing. This allows the nurse to assess the client's respiratory
status effectively.
5. A nurse is reinforcing teaching with a client who is postop following a partial gastrectomy.
Which of the following instructions should the nurse include to prevent dumping syndrome?
a. Include one serving of protein with each meal
b. Increase fluid intake with meals
c. Consume meals quickly
d. Lie down for 30 minutes after meals
Answer: a. Include one serving of protein with each meal
Rationale:
Dumping syndrome is a complication that can occur after gastrectomy. Including a serving of
protein with each meal can help slow gastric emptying, reducing the risk of dumping syndrome.
6. A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a
form of contraception. Which of the following statements by the client indicates an
understanding of the teaching?
a. "I can reuse the cap for up to a year."

b. "I should use petroleum jelly as a lubricant with the cap."
c. "I need to keep the cap in place for at least 6 hours after intercourse."
d. "I should wash the cap with hot water and soap after each use."
Answer: c. "I need to keep the cap in place for at least 6 hours after intercourse."
Rationale:
Keeping the cervical cap in place for at least 6 hours after intercourse helps ensure effectiveness
by providing sufficient time for sperm immobilization.
7. A nurse is preparing to apply a thigh-length sequential compression device for a client who is
postop. Which of the following actions should the nurse take?
a. Measure the circumference of the client's upper leg
b. Apply lotion to the client's legs before applying the device
c. Position the client's legs dependent
d. Apply the device loosely to ensure comfort
Answer: a. Measure the circumference of the client's upper leg
Rationale:
Measuring the circumference of the client's upper leg ensures the correct size of the sequential
compression device, optimizing its effectiveness and preventing complications.
8. A nurse is collecting data from a client during a routine prenatal visit. The client is in their
second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale
while lying on their back. Which of the following actions should the nurse take?
a. Instruct the client to perform Kegel exercises
b. Obtain a urine sample for testing
c. Assess the client's blood pressure while lying on their back
d. Position the client on their left side
Answer: d. Position the client on their left side
Rationale:
The client's symptoms suggest supine hypotensive syndrome. Positioning the client on their left
side will relieve pressure on the vena cava, improving blood flow and alleviating symptoms.
9. A nurse in an acute setting is assisting in collecting client information to include in a referral
for a physical therapist. Which of the following information should the nurse plan to include?
a. Client's dietary preferences

b. Physical assessment findings
c. Client's preferred method of communication
d. Client's cultural background
Answer: b. Physical assessment findings
Rationale:
Physical assessment findings are crucial information for a physical therapist to develop an
appropriate treatment plan. It provides insights into the client's physical condition and helps
tailor therapy to their needs.
10. A nurse is collecting data from a client who has acute cholecystitis. Which of the following
findings should the nurse expect?
a. Pain in the left upper abdomen
b. Pain in the right upper abdomen
c. Pain in the lower abdomen
d. Pain in the epigastric region
Answer: b. Pain in the right upper abdomen
Rationale:
Acute cholecystitis typically presents with severe, steady pain in the right upper abdomen, often
radiating to the back or right scapula.
11. A nurse is reinforcing teaching about newborn care with a new guardian. Which of the
following statements by the guardian indicates an understanding of the teaching?
a. "I will wash my baby's face with soap and water twice a day."
b. "I will clean my baby's umbilical cord stump with alcohol swabs after each diaper change."
c. "I will wash my baby's face with a warm wet washcloth without soap."
d. "I will apply lotion to my baby's skin after each bath."
Answer: c. "I will wash my baby's face with a warm wet washcloth without soap."
Rationale:
Newborns have sensitive skin, and using soap on their face can cause irritation. Washing the
baby's face with a warm wet washcloth without soap is recommended.
12. A nurse is reinforcing teaching with new parents about car seat safety. Which of the following
instructions should the nurse include?
a. Place the shoulder harness below the infant's shoulders

b. Position the car seat facing forward for infants under 1 year old
c. Place the car seat in the front seat of the vehicle
d. Place the shoulder harness at the level of the infant's shoulders
Answer: d. Place the shoulder harness at the level of the infant's shoulders
Rationale:
Placing the shoulder harness at the level of the infant's shoulders helps ensure proper restraint
and protection in case of a crash.
13. A nurse is reinforcing teaching with a client who has a new prescription for albuterol PRN.
The nurse should reinforce with the client that the medication can help treat which of the
following manifestations?
a. Shortness of breath
b. Hypertension
c. Hyperglycemia
d. Constipation
Answer: a. Shortness of breath
Rationale:
Albuterol is a bronchodilator that helps relieve symptoms of shortness of breath, wheezing, and
chest tightness associated with asthma and other respiratory conditions.
14. A nurse is contributing to an in-service for newly licensed nurses about situations requiring
an incident report. Which of the following examples should the nurse include?
a. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to
a child
b. A nurse administers a medication to a client at the wrong time
c. A nurse assists a client to ambulate for the first time after surgery
d. A nurse educates a client about managing diabetes
Answer: a. A nurse discovers that an electronic IV pump delivered twice the prescribed amount
of fluid to a child
Rationale:
This situation involves a medication error that compromised patient safety, making it necessary
to file an incident report for investigation and to prevent future occurrences.

15. A nurse is collecting data from a client who is at 12 weeks of gestation. The client states,
"We've been trying to get pregnant for several months, but now I'm not sure I'm ready." Which of
the following responses should the nurse make?
a. "You should be happy! Pregnancy is a blessing."
b. "Don't worry; these feelings will pass once the baby is born."
c. "Many women experience feelings of ambivalence during pregnancy."
d. "You should talk to your partner about your doubts."
Answer: c. "Many women experience feelings of ambivalence during pregnancy."
Rationale:
Validating the client's feelings and letting them know that feelings of ambivalence during
pregnancy are common can help alleviate anxiety and stress.
16. A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for
advanced breast cancer. The client states, "I am thinking about stopping the treatment." Which of
the following responses should the nurse make?
a. "You need to continue with your treatment; stopping now could be dangerous."
b. "Tell me more about what you are thinking."
c. "I understand how you feel, but you should really think this through."
d. "Why would you want to stop your treatment now?"
Answer: b. "Tell me more about what you are thinking."
Rationale:
Open-ended questions encourage the client to express their feelings and concerns, allowing the
nurse to better understand the client's perspective and provide appropriate support and education.
17. A nurse enters a room of a school-age child and finds them on the floor experiencing a tonicclonic seizure. Which of the following actions should the nurse take?
a. Restrain the child's limbs to prevent injury
b. Attempt to insert a tongue depressor to prevent tongue biting
c. Place a pillow under the child's head
d. Administer a benzodiazepine medication rectally
Answer: c. Place a pillow under the child's head
Rationale:

Placing a pillow under the child's head helps prevent head injury during a seizure by providing
support and cushioning.
18. A nurse is collecting data from a client who has DKA. Which of the following findings
should the nurse expect?
a. Hypoventilation
b. Bradycardia
c. Hypertension
d. Fruity breath odor
Answer: d. Fruity breath odor
Rationale:
Fruity breath odor (like acetone or nail polish remover) is a classic sign of diabetic ketoacidosis
(DKA) due to the presence of ketones in the breath.
19. A charge nurse is monitoring a group of assistive personnel regarding the use of gloves in
contact isolation. For which of the following actions by an AP should the charge nurse intervene?
a. Removes gloves last after other personal protective equipment
b. Changes gloves between caring for different clients in contact isolation
c. Washes hands after removing gloves
d. Wears gloves when emptying a client's urinary drainage bag
Answer: a. Removes gloves last after other personal protective equipment.
Rationale:
Gloves should be the first item removed after providing care to a client in contact isolation to
prevent the spread of microorganisms.
20. A nurse is reinforcing teaching with a parent of a newborn about home safety precautions.
Which of the following statements by the parent indicates an understanding of the teaching?
a. "I will make sure that I can fit two fingers between the mattress and the side of my newborn's
crib."
b. "I will place the crib near the window so my baby can enjoy the view."
c. "I will use a soft pillow to prop my baby's head up while sleeping."
d. "I will make sure that I can fit one finger between the mattress and the side of my newborn's
crib."

Answer: d. "I will make sure that I can fit one finger between the mattress and the side of my
newborn's crib."
Rationale:
Ensuring that there is only one finger's width between the mattress and the side of the crib
prevents the risk of the baby getting trapped or suffocating.
21. A nurse is collecting data from a 9-year-old during a well-child visit. Which of the following
findings should the nurse expect?
a. Grasps concept of cause and effect
b. Demonstrates self-centered control
c. Expresses conflict over independence and control
d. Displays emotional detachment from parents
Answer: a. Grasps concept of cause and effect
Rationale:
According to Piaget's theory of cognitive development, children around the age of 9 typically
grasp the concept of cause and effect, understanding that actions have consequences.
22. A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has
hyperemesis gravidarum. Which of the following client statements indicate an understanding of
the nurse's instructions?
a. "I will eat or drink something every 2 to 3 hours throughout the day."
b. "I will avoid drinking fluids to prevent vomiting."
c. "I will eat large meals to reduce the frequency of eating."
d. "I will skip meals to avoid feeling nauseous."
Answer: a. "I will eat or drink something every 2 to 3 hours throughout the day."
Rationale:
Eating or drinking small amounts frequently can help manage hyperemesis gravidarum by
keeping the stomach partially full, which may help reduce nausea and vomiting.
23. A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of
dying. Which of the following findings requires intervention by the nurse?
a. An AP is encouraging intake of oral fluids
b. The client expresses a desire to have family members present
c. The client's skin is warm and dry

d. The client's respirations are shallow and irregular
Answer: a. An AP is encouraging intake of oral fluids
Rationale:
Encouraging oral fluids in a client who is actively dying and likely in the terminal phase is
inappropriate and can contribute to discomfort, aspiration, and distress.
24. A nurse is assisting with the care of a client who has schizophrenia and auditory
hallucinations. Which of the following responses should the nurse make?
a. "Ignore the voices; they're not real."
b. "Let's focus on something else; the voices will go away."
c. "Let's talk about what the voices are saying to you."
d. "You need to realize that the voices are just a part of your illness."
Answer: c. "Let's talk about what the voices are saying to you."
Rationale:
Engaging the client in discussion about the content of their hallucinations can help the nurse
understand the client's experience and provide appropriate support and intervention.
25. A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which
of the following indicates fluid volume excess?
a. Decreased blood pressure
b. Flat neck veins
c. Distended neck veins
d. Decreased urine output
Answer: c. Distended neck veins
Rationale:
Distended neck veins are a clinical manifestation of fluid volume excess, indicating increased
venous pressure due to an overload of circulating fluid.
26. A nurse is caring for a client who has a femur fracture with the leg in Buck's traction. Which
of the following actions should the nurse take?
a. Apply lotion to the skin under the traction
b. Elevate the foot of the bed
c. Compare bilateral pedal pulses
d. Loosen the traction straps every 4 hours

Answer: c. Compare bilateral pedal pulses
Rationale:
Comparing bilateral pedal pulses helps assess circulation and neurovascular status, ensuring
adequate perfusion to the affected extremity.
27. A nurse is caring for a client who is 2 days post-op following an above-the-knee amputation.
Which of the following actions should the nurse take to promote progression toward
independence and mobility for the client?
a. Assist the client with passive range of motion exercises
b. Keep the residual limb elevated on a pillow at all times
c. Apply a compression bandage to the residual limb
d. Encourage the client to use the overbed trapeze
Answer: d. Encourage the client to use the overbed trapeze
Rationale:
Using the overbed trapeze helps the client strengthen their upper body and promotes mobility
and independence by allowing them to reposition themselves in bed.
28. A nurse is reinforcing teaching with the guardian of a 2-month-old infant about
immunizations. Which of the following statements by a guardian indicates an understanding of
the teaching?
a. "My baby will receive the rotavirus immunization orally."
b. "I should expect my baby to have a high fever for 24 hours after an immunization."
c. "I should not feed my baby anything for 2 hours prior to an immunization."
d. "My baby will receive three doses of the meningococcal immunization before kindergarten."
Answer: a. "My baby will receive the rotavirus immunization orally."
Rationale:
Rotavirus immunization is administered orally, not as an injection like many other
immunizations. This response indicates an understanding of the specific route of administration.
29. A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the
following statements should the nurse make?
a. "It enhances quality of life by promoting comfort."
b. "It focuses on aggressive treatment to cure the cancer."
c. "It aims to prolong life at all costs."

d. "It is only provided during the end stage of illness."
Answer: a. "It enhances quality of life by promoting comfort."
Rationale:
Palliative care focuses on providing relief from the symptoms and stress of the illness to improve
quality of life for both the patient and the family.
30. A community health nurse is assisting with the development of a pamphlet regarding choking
hazards for toddlers. Which of the following foods should the nurse include?
a. Grapes
b. Cooked carrots
c. Raisins
d. Cereal
Answer: a. Grapes
Rationale:
Grapes are a common choking hazard for toddlers due to their size, shape, and slippery texture.
They can easily block a child's airway if not cut into small, manageable pieces.
31. A nurse is reinforcing teaching with a client who has cystocele. Which of the following
statements by the client indicates an understanding of the teaching?
a. "I will avoid drinking fluids to decrease urinary leakage."
b. "I will limit my physical activity to prevent worsening of the cystocele."
c. "I will ignore the urinary leakage; it's a normal part of aging."
d. "I will practice perineal exercises to decrease urinary leakage."
Answer: d. "I will practice perineal exercises to decrease urinary leakage."
Rationale:
Perineal exercises, such as Kegel exercises, help strengthen the pelvic floor muscles, which can
reduce symptoms of urinary leakage associated with cystocele.
32. A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the
following actions should the nurse take first?
a. Administer oxygen
b. Call the rapid response team
c. Elevate the head of the client's bed
d. Assess the client's vital signs

Answer: c. Elevate the head of the client's bed
Rationale:
Elevating the head of the bed helps improve ventilation and oxygenation, which is crucial for a
client experiencing chest pain and dyspnea.
33. A nurse is caring for a client who has dementia. Which of the following findings should the
nurse expect?
a. Stable cognitive function
b. Acute onset of confusion
c. Improved memory retention
d. Increased ability to learn new tasks
Answer: b. Acute onset of confusion
Rationale:
Clients with dementia often experience acute episodes of confusion, especially when faced with
unfamiliar environments, people, or situations. This is commonly known as "sundowning" or
"sundown syndrome."
34. A nurse is caring for a client who was admitted for observation following a head injury.
Which of the following findings by the nurse indicates the client is experiencing increased ICP?
a. Bradycardia
b. Hypotension
c. Hypoventilation
d. Irritability
Answer: d. Irritability
Rationale:
Irritability can be an early sign of increased intracranial pressure (ICP) as the brain becomes
increasingly compressed within the skull.
35. A nurse is caring for a client who has recently died. Which of the following actions should
the nurse take?
a. Leave the client's dentures in place
b. Place a pillow under the client's head
c. Remove all equipment from the room immediately
d. Notify the mortuary

Answer: b. Place a pillow under the client's head
Rationale:
Placing a pillow under the client's head helps maintain dignity and proper positioning after death.
36. A nurse on a med-surgical unit is assisting with the admission of a client who has advanced
lung cancer. Which of the following statements regarding advance directives should the nurse
take?
a. Encourage the client to wait to make decisions about end-of-life care until they feel better
b. Document the client's decisions about end-of-life care in the medical record
c. Discourage the client from making advance directives until the family is present
d. Advise the client to leave end-of-life decisions to their healthcare provider
Answer: b. Document the client's decisions about end-of-life care in the medical record
Rationale:
Documenting the client's advance directives ensures that their wishes regarding end-of-life care
are known and followed.
37. A nurse is collecting data from a client who is 12 hours post-op following intestinal surgery.
Which of the following findings should the nurse report to the charge nurse prior to the client's
ambulation?
a. Blood pressure 130/80 mmHg
b. Heart rate 90 bpm
c. Respiratory rate 18/min
d. Oxygen saturation 90%
Answer: d. Oxygen saturation 90%
Rationale:
An oxygen saturation of 90% indicates hypoxemia and may require intervention before the client
can safely ambulate.
38. A nurse is caring for a client who speaks a different language than the nurse. The client's
partner tells the nurse that the client would like to go home against medical advice. Which of the
following actions should the nurse take?
a. Explain to the client's partner why leaving AMA is not recommended
b. Request the services of an interpreter to determine the client's wishes
c. Ask the client's partner to sign the necessary discharge paperwork

d. Inform the client's healthcare provider
Answer: b. Request the services of an interpreter to determine the client's wishes
Rationale:
It is essential to ensure clear communication and understanding of the client's wishes, especially
when they speak a different language.
39. A nurse in a provider's office is caring for a group of clients who have communicable
diseases. Which of the following infections should the nurse report to the state health
department?
a. Influenza
b. Staphylococcus aureus
c. Neisseria gonorrhoeae
d. Streptococcus pneumoniae
Answer: c. Neisseria gonorrhoeae
Rationale:
Neisseria gonorrhoeae is a reportable sexually transmitted infection that must be reported to the
state health department for tracking and control.
40. A nurse is preparing to delegate the client care to an AP. Which of the following information
should the nurse verify prior to delegation?
a. The AP's work schedule
b. The AP's job description
c. The AP's educational background
d. The AP's personal preferences
Answer: b. The AP's job description
Rationale:
Verifying the AP's job description ensures that the tasks being delegated fall within their scope of
practice and competency level.
41. A home health nurse is conducting a home inspection for a client who is at risk for falls.
Which of the following instructions should the nurse provide for the client?
a. Install scatter rugs on hardwood floors
b. Use a cane on the stairs for support
c. Keep the bathroom floor dry and free of clutter

d. Move the client's bed to the main floor of the house
Answer: d. Move the client's bed to the main floor of the house
Rationale:
Moving the client's bed to the main floor of the house reduces the risk of falls associated with
navigating stairs.
42. A nurse is collecting data from a client who received oxytocin 10 units IM 30 mins ago for
excessive vaginal bleeding. Which of the following findings should the nurse expect?
a. Decreased uterine contractions
b. Increased vaginal bleeding
c. Client report of uterine cramping
d. Bradycardia
Answer: c. Client report of uterine cramping
Rationale:
Oxytocin stimulates uterine contractions, so the client may experience uterine cramping after
receiving the medication.
43. A nurse in a provider's office is reinforcing teaching about skin care with a client who has a
new diagnosis of systemic lupus erythematosus. Which of the following statements by the client
indicates an understanding of the teaching?
a. "I will use a loofah sponge to exfoliate my skin daily."
b. "I will apply heating pads to relieve joint pain."
c. "I will use hot water to cleanse my face."
d. "I will dry my skin by patting it with a towel."
Answer: d. "I will dry my skin by patting it with a towel."
Rationale:
Patting the skin dry rather than rubbing helps prevent skin irritation and damage, which is
important for clients with systemic lupus erythematosus who may have sensitive skin.
44. A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the
following findings should the nurse notify the provider?
a. Presence of grasp reflex
b. Weight gain of 1 pound since the last visit
c. Head circumference within the 50th percentile for age

d. Rolling from back to front
Answer: a. Presence of grasp reflex
Rationale:
The grasp reflex typically disappears by 3 to 4 months of age. Its presence at 4 months may
indicate delayed neurological development and should be reported to the provider.
45. A nurse is collecting data from a client who is 8 hours postoperative following an
appendectomy. Which of the following manifestations is the best indication that the client needs
a PRN analgesic?
a. Respiratory rate of 16/min
b. Blood pressure of 130/80 mmHg
c. Heart rate of 90 bpm
d. The client reports pain as 7 on a scale of 0-10
Answer: d. The client reports pain as 7 on a scale of 0-10
Rationale:
The client's self-report of pain is the most reliable indicator of pain intensity and the need for
analgesia.
46. A nurse is reinforcing teaching with the support person of a client who is in the first stage of
labor. Which of the following instructions should the nurse include regarding effleurage?
a. Apply firm pressure to the lower back during contractions
b. Encourage the client to rock back and forth during contractions
c. Gently stroke her abdomen during contractions
d. Assist the client with focused breathing during contractions
Answer: c. Gently stroke her abdomen during contractions
Rationale:
Effleurage involves gentle stroking or circular massage of the abdomen during contractions to
provide comfort and relaxation.
47. A nurse is assisting with the admission of an adolescent client who is suspected to have
bacterial meningitis. Which of the following findings should the nurse expect?
a. Hypotension
b. Nuchal rigidity
c. Bradycardia

d. Hyperactive bowel sounds
Answer: b. Nuchal rigidity
Rationale:
Nuchal rigidity (stiff neck) is a classic sign of meningitis and should be assessed in any client
suspected of having the condition.
48. A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube
in place. Besides obtaining an x-ray, which of the following methods should the nurse use to
verify placement?
a. Auscultate for bowel sounds
b. Test the pH of the gastric aspirate
c. Check for tube placement in the throat
d. Measure the length of the external portion of the tube
Answer: b. Test the pH of the gastric aspirate
Rationale:
Testing the pH of the gastric aspirate (pH less than or equal to 5) confirms placement of the NG
tube in the stomach.
49. A nurse working in a clinic is reinforcing with a client who has hepatitis A. Which of the
following client statements indicates an understanding of the teaching?
a. "I will wash my hands frequently throughout the day."
b. "I will use different hand towels than others in my home."
c. "I will avoid sharing eating utensils with my family."
d. "I will cover my mouth and nose when I cough or sneeze."
Answer: b. "I will use different hand towels than others in my home."
Rationale:
Using separate hand towels helps prevent the spread of hepatitis A to others in the household.
50. A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir.
Which of the following statements by the client indicates an understanding of the teaching?
a. "I will take the medication on an empty stomach."
b. "I will mix the medication with a full glass of water."
c. "I will take the medication with milk."
d. "I will take the medication with my morning coffee."

Answer: b. "I will mix the medication with a full glass of water."
Rationale:
Mixing ferrous sulfate elixir with a full glass of water helps prevent gastrointestinal irritation and
improves absorption.
51. A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has
a history of dysphagia. Which of the following instructions should the nurse include in the
teaching?
a. Encourage the client to eat quickly to prevent aspiration
b. of fer large, solid pieces of food to encourage chewing
c. Provide thin liquids to facilitate swallowing
d. Place oral suction equipment next to the client's bedside
Answer: d. Place oral suction equipment next to the client's bedside
Rationale:
Placing oral suction equipment next to the client's bedside is essential for immediate access in
case of aspiration or difficulty swallowing.
52. A nurse is assisting with the care of a client who is 6 hours postoperative following a right
total knee arthroplasty. Which of the following actions should the nurse take?
a. Keep the client's leg extended
b. Apply ice to the client's surgical incision
c. Keep the head of the bed flat
d. Maintain the head of the bed in high Fowler's position
Answer: d. Maintain the head of the bed in high Fowler's position
Rationale:
Keeping the head of the bed elevated in high Fowler's position helps reduce swelling and
promotes comfort and circulation following knee arthroplasty.
53. A nurse is providing a client with IV fluids and finds that the IV pump screen is
malfunctioning. Which of the following actions should the nurse take?
a. Attempt to recalibrate the IV pump
b. Continue to monitor the IV site closely
c. Discontinue use and tag the IV pump
d. Increase the IV infusion rate manually

Answer: c. Discontinue use and tag the IV pump
Rationale:
If the IV pump is malfunctioning, it should be discontinued to prevent harm to the patient, and
the pump should be tagged for repair or replacement.
54. A nurse in an acute mental health facility is caring for an adolescent who is exhibiting
destructive behavior. Which of the following actions should the nurse take after applying
physical restraints to the client?
a. Leave the client alone to calm down
b. Monitor the client's range of motion every 4 hours
c. Check the restraints every 2 hours for skin integrity
d. Monitor the client's range of motion every 60 minutes
Answer: d. Monitor the client's range of motion every 60 minutes
Rationale:
Monitoring the client's range of motion every 60 minutes helps ensure that the restraints are not
causing injury or compromising circulation.
55. A nurse is collecting data from a client who is 1 day post-op following a TURP. Which of the
following findings should the nurse report to the provider?
a. Client reports mild discomfort at the incision site
b. Urinary output is 200 mL over the past 4 hours
c. Client reports feeling the urge to void
d. Dark red urine
Answer: d. Dark red urine
Rationale:
Dark red urine following a TURP may indicate active bleeding and should be reported to the
provider immediately.
56. A nurse is contributing to the plan of care for a client who is scheduled to receive ECT for the
treatment of depression. Which of the following actions should the nurse recommend to include
in the plan?
a. Administer benzodiazepines prior to ECT
b. Encourage the client to avoid eating before the procedure
c. Provide frequent reorientation after ECT

d. Limit the client's fluid intake before ECT
Answer: c. Provide frequent reorientation after ECT
Rationale:
Providing frequent reorientation after ECT helps reduce confusion and disorientation associated
with the procedure.
57. A charge nurse is discussing confidentiality requirements with a newly licensed nurse when
sharing a client's medical information. Which of the following individuals should the charge
nurse identify as appropriate with whom to share client information?
a. A social worker who is assigned to an involuntarily committed school-age client
b. A hospital volunteer who is assigned to the unit
c. A client's neighbor who is a healthcare provider
d. A friend of the client's family who is a member of the clergy
Answer: a. A social worker who is assigned to an involuntarily committed school-age client
Rationale:
Sharing client information with other healthcare providers involved in the client's care is
appropriate, particularly when necessary for treatment planning and coordination.
58. A nurse is reviewing the home medications of a client who recently had a transient ischemic
attack and is to begin taking clopidogrel. The nurse should instruct the client that which of the
following over-the-counter medications interacts adversely with clopidogrel?
a. Aspirin
b. Ibuprofen
c. Acetaminophen
d. Naproxen
Answer: d. Naproxen
Rationale:
Naproxen can increase the risk of bleeding when taken with clopidogrel and should be avoided
unless directed by a healthcare provider.
59. A nurse is reviewing the medical record of five clients. For which of the following events
should the nurse write an incident report? SATA
a. A client fell when ambulating to the bathroom alone
b. A client received an 0900 daily medication at 1000

c. An approximate amount of urine was recorded after the urine leaked from the client's catheter
bag
d. A client who has an infection refused the evening meal
e. A client received the first dose of antibiotic 1 hour before the collection of blood for culture
and sensitivity testing
Answer: a. A client fell when ambulating to the bathroom alone
c. An approximate amount of urine was recorded after the urine leaked from the client's catheter
bag
Rationale:
Incidents such as falls and documentation errors should be reported via an incident report to
ensure proper follow-up and prevention.
60. A nurse is participating in an interprofessional client care conference for a client who has
experienced a stroke. The nurse should identify that which of the following client care requires
reporting to the interprofessional team?
a. The client is unable to grasp eating utensils
b. The client's blood pressure is 140/90 mmHg
c. The client's speech is slurred
d. The client's dressing is intact
Answer: a. The client is unable to grasp eating utensils
Rationale:
Inability to grasp eating utensils may indicate motor impairment and requires input from the
interprofessional team for rehabilitation planning and support.
61. A nurse is reinforcing teaching about preventing dental caries with the parent of a 12-monthold toddler. Which of the following instructions should the nurse provide?
a. Use fluoride mouthwash twice daily
b. Clean the teeth with a small soft-bristled toothbrush
c. Limit fruit juice intake to one serving per day
d. Avoid giving the toddler any snacks
Answer: b. Clean the teeth with a small soft-bristled toothbrush
Rationale:

Using a small soft-bristled toothbrush helps to clean the toddler's teeth effectively without
causing injury to the gums.
62. A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which
of the following interventions should the nurse recommend to include in the plan?
a. Encourage increased intake of sodium-rich foods
b. Limit fluid intake to 1 liter per day
c. Measure the client's abdominal girth daily
d. Encourage the client to lie flat as much as possible
Answer: c. Measure the client's abdominal girth daily
Rationale:
Measuring the client's abdominal girth daily helps monitor for changes in ascites accumulation,
which is essential for assessing the client's condition and response to treatment.
63. A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular
insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of
the following actions should the nurse take next?
a. Inject 15 units of air into the regular insulin vial
b. Withdraw 15 units of regular insulin into the syringe
c. Withdraw 10 units of NPH insulin into the syringe
d. Inject 10 units of regular insulin into the NPH insulin vial
Answer: a. Inject 15 units of air into the regular insulin vial
Rationale:
Injecting air into the regular insulin vial equal to the dose of insulin to be withdrawn prevents
creating a vacuum in the vial, making it easier to withdraw the correct dose.
64. A nurse is caring for a client who recently gave birth to her first child. The newborn is crying,
and the client states, "I can't seem to do anything right. What should I do?" Which of the
following responses should the nurse make?
a. "Don't worry; you'll get the hang of it eventually."
b. "Why don't you let me take the baby for a while?"
c. "Let me show you how to swaddle and cuddle him, then you try."
d. "It's normal to feel overwhelmed; just take a deep breath."
Answer: c. "Let me show you how to swaddle and cuddle him, then you try."

Rationale:
Encouraging the client to participate in caring for her newborn and providing guidance can help
build her confidence as a new parent.
65. A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the
following foods should the nurse include as the lowest in potassium?
a. Orange juice
b. Sweet potato
c. Canned green beans
d. Wheat bread
Answer: a. Orange juice
Rationale:
Orange juice is lower in potassium compared to sweet potato, canned green beans, and wheat
bread, making it the best choice for a client with an electrolyte imbalance.
66. A nurse in a mental health facility is caring for a client who reports palpitations and a sense
of impending doom. Which of the following actions should the nurse take first?
a. Administer a PRN anxiolytic medication
b. Explain to the client that anxiety causes physical manifestations
c. Obtain a baseline set of vital signs
d. Notify the provider
Answer: b. Explain to the client that anxiety causes physical manifestations
Rationale:
Providing education about the physical manifestations of anxiety can help the client understand
their symptoms and alleviate anxiety.
67. A nurse is assisting with the plan of care for a client who has burns to his lower extremities.
Which of the following actions should the nurse include in the plan?
a. Apply topical antibiotics with bare hands
b. Elevate the affected extremities above the level of the heart
c. Remove any blisters that form on the burns
d. Apply dressings with sterile gloves
Answer: d. Apply dressings with sterile gloves
Rationale:

Applying dressings with sterile gloves helps prevent infection and promotes optimal wound
healing for the client with burns.
68. A nurse is completing postmortem documentation for a client. Which of the following
information should the nurse include in the documentation?
a. Number of family members present at the time of death
b. Time the client was last seen alive
c. Location of the identification tag on the client's body
d. Client's cause of death
Answer: c. Location of the identification tag on the client's body
Rationale:
Documenting the location of the identification tag ensures proper identification of the deceased
client and is an important part of postmortem documentation.
69. A nurse is collecting data from a client who has alcohol use disorder and is experiencing
withdrawal. Which of the following manifestations should the nurse expect?
a. Bradycardia
b. Polyuria
c. Hypertension
d. Constipation
Answer: a. Bradycardia
Rationale:
Bradycardia is a common manifestation of alcohol withdrawal due to the depressant effects of
alcohol on the central nervous system.
70. A nurse is caring for a child who has terminal cancer. Which of the following responses by
the child's school-age brother should the nurse expect?
a. "I think my brother is going to be okay."
b. "I feel sad that my brother is sick."
c. "I'm afraid my bad behavior is causing my brother's death."
d. "I'm angry that my brother is always sick."
Answer: c. "I'm afraid my bad behavior is causing my brother's death."
Rationale:

Children may express feelings of guilt or responsibility for a sibling's illness or death, believing
their actions somehow caused the situation.
71. A charge nurse is reinforcing teaching with a newly licensed nurse about infection control
measures. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
a. "Soiled dressings can be disposed of in any trash receptacle."
b. "Soiled dressings should be left on the bedside table for housekeeping to dispose of."
c. "Soiled dressings should be placed in the regular trash can."
Answer: d. "Soiled dressings should be placed in a biohazard trash receptacle."
Rationale:
Proper disposal of soiled dressings is crucial in preventing the spread of infection. Biohazard
trash receptacles are designated for items that may be contaminated with infectious materials,
such as soiled dressings.
72. A nurse is caring for a client who has major depressive disorder and is taking an
antidepressant. The nurse should identify which of the following findings as the priority to report
to the provider?
a. The client has gained 2 pounds in the past week.
b. The client reports feeling more anxious than usual.
c. The client has a sudden increase in energy.
d. The client has been experiencing dry mouth.
Answer: c. The client has a sudden increase in energy.
Rationale:
A sudden increase in energy can indicate that the client is experiencing a switch from depression
to mania, which could be a sign of bipolar disorder. This change in mental status should be
reported to the provider immediately for further evaluation and management.
73. A nurse is reinforcing teaching about common discomforts during the first trimester with a
client who is at 10 weeks of gestation. Which of the following examples should the nurse
include?
a. Quickening
b. Leukorrhea

c. Braxton Hicks contractions
d. Urinary frequency
Answer: b. Leukorrhea
Rationale:
Leukorrhea, which is an increase in vaginal discharge, is a common discomfort experienced
during the first trimester of pregnancy due to hormonal changes. It is important for the nurse to
include this in the teaching to reassure the client that it is normal.
74. A nurse enters a client's room and finds her sitting on the floor next to the shower. The client
states that she slipped on some water outside of the shower. Which of the following actions
should the nurse take first?
a. of fer the client pain medication.
b. Measure the client's vital signs.
c. Help the client back into bed.
d. Assess the client for injuries.
Answer: b. Measure the client's vital signs.
Rationale:
Before providing any interventions, the nurse should first assess the client's vital signs to
determine if there are any signs of distress or injury that require immediate attention.
75. A nurse is receiving change of shift report on four clients. Which of the following clients
should the nurse plan to see first?
a. A client who has pneumonia and needs a dose of antibiotics.
b. A client who is scheduled for a dressing change on a stage III pressure ulcer.
c. A client who has a femur fracture and reports numbness of the toes.
d. A client who is receiving a blood transfusion and has developed a rash.
Answer: c. A client who has a femur fracture and reports numbness of the toes.
Rationale:
Numbness of the toes in a client with a femur fracture could indicate impaired circulation or
nerve damage, which requires immediate assessment by the nurse to prevent complications such
as compartment syndrome. Therefore, this client should be seen first.

76. A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which
of the following findings should the nurse expect?
a. Depressed mood
b. Poor concentration
c. Rapid speech
d. Decreased energy
Answer: c. Rapid speech
Rationale:
Rapid speech is a common manifestation of the manic phase of bipolar disorder. Clients may
speak rapidly and incoherently, making it difficult for others to interject or understand.
77. A nurse is reinforcing teaching with a client about monitoring her blood pressure at home
with a digital device. Which of the following statements by the client indicate an understanding
of the teaching?
a. "I will take my blood pressure right after I wake up in the morning."
b. "I will take my blood pressure after I drink my morning coffee."
c. "I will sit quietly for 5 minutes before taking my blood pressure."
d. "I will take my blood pressure immediately after exercising."
Answer: c. "I will sit quietly for 5 minutes before taking my blood pressure."
Rationale:
Sitting quietly for 5 minutes before taking blood pressure helps to ensure an accurate reading.
Movement, caffeine, and exercise can all affect blood pressure readings.
78. A nurse on a medical surgical unit is preparing to assist with the admission of clients who
were injured in a tornado. Which of the following clients should the nurse recommend for
discharge to make room for the new admission?
a. A client who had a radical mastectomy 36 hours ago and has a surgical drain
b. A client who had a lobectomy and has a chest tube drainage system
c. A client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy
d. A client who has cervical cancer and an internal radioactive implant
Answer: b. A client who had a lobectomy and has a chest tube drainage system
Rationale:

Discharging a client who had a lobectomy and has a chest tube drainage system would free up a
bed for the new admissions. Clients with recent surgeries or critical conditions should not be
discharged.
79. A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the
following actions should the nurse take first?
a. Don sterile gloves
b. Open the sterile dressing package
c. Perform hand hygiene
d. Remove the old dressing
Answer: c. Perform hand hygiene
Rationale:
Performing hand hygiene is the first step in any sterile procedure to prevent the introduction of
pathogens to the wound.
80. A nurse is collecting data from a client who is in renal failure. The nurse should identify that
which of the following findings is a manifestation of hyperkalemia?
a. Muscle weakness
b. Diarrhea
c. Irregular heart rate
d. Hypoventilation
Answer: c. Irregular heart rate
Rationale:
An irregular heart rate is a manifestation of hyperkalemia, which can lead to life-threatening
cardiac dysrhythmias.
81. A nurse is caring for a client who has been given methylegonivine intramuscularly for a
postpartum hemorrhage. The nurse should monitor for which of the following adverse effects?
a. Bradycardia
b. Hypertension
c. Hematuria
d. Respiratory depression
Answer: c. Hematuria
Rationale:

Methylegonivine, a uterine stimulant, can cause vasoconstriction, which may lead to decreased
blood flow to the kidneys and result in hematuria. Monitoring for this adverse effect is important
to ensure the client's safety.
82. A nurse is supervising an AP who is providing client care. The nurse should identify that
which of the following actions by the AP demonstrate effective use of supplies?
a. Uses a basin of water that was obtained 1 hour ago to perform perineal care.
b. Wears clean gloves when performing oral care.
c. Changes the client's indwelling urinary catheter drainage bag every 12 hours.
d. Applies a clean dressing to a surgical wound without washing hands.
Answer: b. Wears clean gloves when performing oral care.
Rationale:
Wearing clean gloves when performing oral care helps to prevent the spread of infection and
demonstrates effective use of supplies and infection control practices.
83. A nurse is contributing to the plan of care for a client who is experiencing panic level anxiety
and reports visual hallucinations. Which of the following actions should the nurse recommend
including in the plan of care?
a. Use a low pitched voice when speaking to the client
b. Provide frequent touch to the client
c. Encourage the client to discuss the content of the hallucinations
d. of fer the client a variety of food choices
Answer: a. Use a low pitched voice when speaking to the client
Rationale:
Using a low pitched voice when speaking to the client can help to decrease anxiety and provide a
calming presence during a panic attack.
84. A nurse determines that clients who receive zolpidem post-op have an increased fall rate
compared to other postoperative clients. To which of the following members of the healthcare
team should the nurse report these findings?
a. The charge nurse
b. The pharmacist
c. The risk manager
d. The primary care provider

Answer: c. The risk manager
Rationale:
Reporting findings of increased fall rates associated with zolpidem post-op to the risk manager
ensures that appropriate actions can be taken to prevent further falls and ensure patient safety.
85. A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking
methylphenidate. Which of the following statements by the parents indicates that the medication
is effective?
a. "Our child is more talkative at home."
b. "Our child is more aggressive with his siblings."
c. "Our child is sleeping longer at night."
d. "Our child is able to complete his homework on time."
Answer: d. "Our child is able to complete his homework on time."
Rationale:
Improved ability to concentrate and complete tasks, such as homework, is an indicator that the
medication is effective in managing ADHD symptoms.
86. A nurse is assisting with a community health program for caregivers of clients who have
Alzheimer's disease. Which of the following information should the nurse include?
a. Encourage the client to make decisions independently.
b. Provide a variety of food choices at each meal.
c. Limit physical activity to prevent fatigue.
d. Limit the number of choices for the client.
Answer: d. Limit the number of choices for the client.
Rationale:
Limiting the number of choices can help reduce confusion and agitation in clients with
Alzheimer's disease, making it easier for them to make decisions.
87. A nurse is caring for a client who is on isolation precautions. Which of the following pieces
of personal protective equipment should the nurse remove first?
a. Gloves
b. Gown
c. Mask
d. Goggles

Answer: a. Gloves
Rationale:
Gloves should be removed first to prevent the spread of contamination from the gloves to other
parts of the nurse's body or the environment when removing other protective equipment.
88. A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the
following outcomes should the nurse expect as a therapeutic effect of the treatment?
a. Reduced fat in the stools
b. Increased appetite
c. Decreased respiratory rate
d. Improved skin turgor
Answer: a. Reduced fat in the stools
Rationale:
Pancrelipase helps the body digest food by replacing the digestive enzymes that are lacking in
clients with cystic fibrosis. Reduced fat in the stools indicates improved digestion and absorption
of fats.
89. A nurse is collecting data from a client who has left-sided heart failure. For which of the
following findings should the nurse notify the provider?
a. Productive cough with pink, frothy sputum
b. Bilateral ankle edema
c. Complaints of difficulty sleeping
d. Weight gain of 2 pounds in 1 week
Answer: a. Productive cough with pink, frothy sputum
Rationale:
Pink, frothy sputum is indicative of pulmonary edema, a severe complication of left-sided heart
failure that requires immediate medical attention.
90. A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother
questions the purpose of the medication. Which of the following responses should the nurse
make?
a. "This medication will help your baby sleep better."
b. "This medication will decrease the risk of hemorrhage in your newborn."
c. "This medication will increase your baby's appetite."

d. "This medication will prevent your baby from developing jaundice."
Answer: b. "This medication will decrease the risk of hemorrhage in your newborn."
Rationale:
Vitamin K injection is given to newborns to prevent vitamin K deficiency bleeding, which can
lead to serious bleeding problems, including intracranial hemorrhage.
91. A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic
pain with contractions. Which of the following actions should the nurse take?
a. Apply a warm compress to the client's abdomen.
b. Encourage the client to take deep breaths during contractions.
c. Administer intravenous pain medication as prescribed.
Answer: d. Instruct the client to change positions frequently.
Rationale:
Changing positions frequently during labor can help relieve pelvic pain and discomfort by
promoting optimal fetal positioning and improving blood flow to the pelvic area.
92. A nurse is caring for a client who is postoperative following abdominal surgery and has a
wound evisceration. Which of the following actions should the nurse take?
a. Cover the wound with sterile saline soaked gauze.
b. Apply a dry, sterile dressing over the evisceration.
c. Attempt to push the protruding organs back into the abdomen.
d. Leave the wound exposed to air.
Answer: a. Cover the wound with sterile saline soaked gauze.
Rationale:
Covering the wound with sterile saline soaked gauze helps to keep the exposed organs moist and
reduces the risk of infection while awaiting surgical intervention.
93. A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve
headache pain. Which of the following conditions in the client's history should the nurse identify
as a contraindication?
a. Hypothyroidism
b. Hepatitis C
c. Allergy to penicillin
d. History of migraine headaches

Answer: b. Hepatitis C
Rationale:
Hepatitis C is a contraindication for acetaminophen use due to the potential for liver toxicity, as
the medication is metabolized by the liver.
94. A nurse is reinforcing teaching about passive range of motion exercises with the family of a
client who has had a stroke. Which of the following instructions should the nurse include in the
teaching?
a. "Perform exercises quickly to prevent muscle stiffness."
b. "Stop exercising if your family member complains of pain."
c. "Use jerking motions to help increase range of motion."
Answer: d. Support the extremity.
Rationale:
Supporting the extremity during passive range of motion exercises helps prevent injury and
provides stability to the limb.
95. A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck.
Which of the following instructions should the nurse include in the teaching?
a. "Expose the neck to direct sunlight for 30 minutes daily."
b. "Apply lotion to the treatment area before each session."
c. Avoid exposing the neck to the cold.
d. "Wash the treatment area with warm water and soap after each session."
Answer: c. Avoid exposing the neck to the cold.
Rationale:
Avoiding exposure to cold helps prevent vasoconstriction and reduces the risk of tissue damage
in the irradiated area.
96. A nurse is caring for a client who is unable to perform ADLs and wears dentures. Which of
the following actions should the nurse take when providing denture care?
a. Clean the dentures with hot water to remove debris.
b. Store the dentures in a dry container when not in use.
c. Brush the dentures using toothpaste twice a day.
d. Place a towel in the sink when cleaning the dentures.
Answer: d. Place a towel in the sink when cleaning the dentures.

Rationale:
Placing a towel in the sink helps prevent the dentures from breaking if dropped during cleaning.
97. A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an
esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the
procedure?
a. Ensure that the client gave informed consent.
b. Administer a sedative as prescribed.
c. Withhold food and fluids for 8 hours before the procedure.
d. Insert an intravenous catheter for conscious sedation.
Answer: a. Ensure that the client gave informed consent.
Rationale:
Ensuring that the client gave informed consent is a critical step before any invasive procedure.
98. A nurse is monitoring a client who has received external radiation for throat cancer. Which of
the following findings should the nurse expect?
a. Increased appetite
b. Loss of taste
c. Weight gain
d. Improved sense of smell
Answer: b. Loss of taste
Rationale:
Loss of taste, or dysgeusia, is a common side effect of radiation therapy to the head and neck
area.
99. A nurse is reviewing lab values for a client who is at 34 weeks of gestation. Which of the
following findings should the nurse report to the provider?
a. Blood glucose 90 mg/dL
b. Hemoglobin 12 g/dL
c. Urine protein 3+
d. White blood cell count 8,000/mm³
Answer: c. Urine protein 3+
Rationale:

Urine protein of 3+ at 34 weeks of gestation is indicative of proteinuria and may suggest
preeclampsia, a serious complication of pregnancy that requires medical intervention.
100. A nurse is reinforcing teaching with a client who has GERD and a prescription for
pantoprazole. Which of the following statements indicates an understanding of the teaching?
a. "I can crush the medication and sprinkle it on my food."
b. "I have to take this medication on an empty stomach."
c. "I should take this medication at bedtime."
d. "I can stop taking this medication once my symptoms resolve."
Answer: b. "I have to take this medication on an empty stomach."
Rationale:
Pantoprazole should be taken on an empty stomach, preferably 30 minutes before a meal, to
maximize its effectiveness in reducing gastric acid secretion.
101. A nurse is caring for an older adult client who has acute delirium. Which of the following
actions should the nurse take first?
a. Administer antipsychotic medication as prescribed.
b. Assess the client's vital signs.
c. Determine the client's level of consciousness.
d. Obtain a urine specimen for analysis.
Answer: c. Determine the client's level of consciousness.
Rationale:
Determining the client's level of consciousness is the priority to assess the severity of the
delirium and ensure appropriate intervention.
102. A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1
week. Which of the following client statements indicates an understanding of the teaching?
a. "I will eat a large meal the night before the procedure."
b. "I can take my medications with a small sip of water on the morning of the procedure."
c. "I will have a heavy breakfast on the day of the procedure."
d. "I'll have my friend drive me home after the procedure."
Answer: d. "I'll have my friend drive me home after the procedure."
Rationale:

After a colonoscopy, the client will be sedated, and driving is not safe. Having someone to drive
the client home is a necessary precaution.
103. A nurse is reinforcing teaching with a parent of a 4-month-old infant during a home visit.
Which of the following statements by the parent indicates an understanding of the teaching?
a. "I will prop a bottle in my baby's mouth during feedings."
b. "I will add honey to my baby's formula to help with digestion."
c. "I will place my baby to sleep on their stomach to prevent choking."
d. "I will use a cool mist vaporizer in my baby's room."
Answer: d. "I will use a cool mist vaporizer in my baby's room."
Rationale:
Using a cool mist vaporizer can help keep the air moist, which can ease congestion and make it
easier for the baby to breathe.
104. A nurse at a long-term care facility is reviewing the plan of care for a client who has a
prescription for mitten restraints. Which of the following tasks should the nurse assign to an
assistive personnel?
a. Apply the mittens to the client's hands.
b. Remove the mittens every 2 hours to assess skin integrity.
c. Assist the client with range of motion exercises of the hands.
d. Document the client's behavior every 4 hours.
Rationale:
Assisting the client with range of motion exercises of the hands helps prevent contractures and
maintains circulation while the client is wearing mittens.
Answer: c. Assist the client with range of motion exercises of the hands.
105. A nurse is caring for a client who has anorexia nervosa and a behavioral management plan
in place. Which of the following findings should the nurse identify as an indication that the
behavioral plan is effective?
a. Sodium 138 mEq/L
b. Hematocrit 42%
c. Potassium 3.5 mEq/L
d. Blood glucose 100 mg/dL
Answer: c. Potassium 3.5 mEq/L

Rationale:
Potassium within the normal range indicates that the client is maintaining appropriate nutrition
and electrolyte balance, which is a positive outcome in the treatment of anorexia nervosa.
106. A community health nurse is developing a brochure about hypertension. Which of the
following actions should the nurse take?
a. Present information from complex to simple.
b. Use a 12-point font size.
c. Explain medical terminology using basic one-syllable words.
d. Write the information at an 8th-grade reading level.
Answer: d. Write the information at an 8th-grade reading level.
Rationale:
Writing the information at an 8th-grade reading level ensures that it is accessible to a wide
audience and promotes understanding among readers with varying literacy levels.
107. A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin
via IV infusion. Which of the following manifestations should the nurse identify as an adverse
effect of the treatment?
a. Nausea and vomiting
b. Diarrhea
c. New onset of hearing loss
d. Dizziness
Answer: c. New onset of hearing loss
Rationale:
Gentamicin is known to cause ototoxicity, which can manifest as new onset of hearing loss. This
adverse effect should be closely monitored during treatment.
108. A nurse is caring for a preschooler who recently experienced the death of a parent. Which of
the following findings should the nurse identify as consistent with this age group?
a. Believes the death is punishment for bad behavior
b. Understands the finality of death
c. Experiences guilt about being alive
d. Accepts the death as part of the natural life cycle
Answer: a. Believes the death is punishment for bad behavior

Rationale:
Preschoolers often see death as punishment for bad behavior because they lack a mature
understanding of death and its causes.
109. A nurse is caring for a client who has toxoplasmosis and asks the cause of the infection.
Which of the following responses should the nurse make?
a. Handling cat feces
b. Drinking contaminated water
c. Eating undercooked meat
d. Contact with contaminated soil
Answer: a. Handling cat feces
Rationale:
Toxoplasmosis is commonly transmitted through the handling of cat feces containing the
Toxoplasma gondii parasite.
110. A nurse is administering hydromorphone to a client who is experiencing postoperative pain.
Which of the following findings is an adverse effect of this medication?
a. Bradycardia
b. Hypertension
c. Urinary retention
d. Hypoventilation
Answer: c. Urinary retention
Rationale:
Urinary retention is a common adverse effect of opioid medications such as hydromorphone.
Opioids can cause urinary sphincter constriction, leading to difficulty urinating.
111. A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of
the following actions should the nurse take?
a. Apply pressure to the puncture site after obtaining the blood sample.
b. Cleanse the puncture site with alcohol before obtaining the blood sample.
c. Keep the finger in a dependent position.
d. Milk the finger to obtain an adequate blood sample.
Answer: c. Keep the finger in a dependent position.
Rationale:

Keeping the finger in a dependent position helps to promote blood flow and ensures an adequate
sample for glucose monitoring.
112. A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which
of the following supplies should the nurse plan to use for this task?
a. Oxygen tubing
b. Tracheostomy tube
c. Yankauer catheter
d. Nasogastric tube
Answer: c. Yankauer catheter
Rationale:
A Yankauer catheter is a clean suction catheter used when performing oral and oropharyngeal
suctioning to remove secretions from the client's mouth to facilitate breathing or obtain a sample
for diagnostic evaluation.
113. A nurse in a long-term care facility is serving on the ethics committee, which is addressing a
client care dilemma. Which of the following strategies will facilitate resolving the dilemma?
(Select all that apply.)
1. Determine the facts related to the dilemma.
2. Identify possible solutions
3. Consider the client's wishes
4. Choose the solution that is the least restrictive.
Answer: 2. Identify possible solutions, 3. Consider the client's wishes
Rationale:
When faced with an ethical dilemma, it's important to gather all the relevant facts, identify
possible solutions, and consider the wishes of the client involved.
114. A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The
client states, "I really thought I'd be back to my usual routines by now, but I can't think of
anything else except that my son is gone." Which of the following responses should the nurse
make?
a. "You need to keep busy and get back to your routine as soon as possible."
b. "It's been 2 weeks. It's time to move on and focus on other things."
c. "Try not to dwell on the past. Focus on the present and the future."

d. "Grieving for your son is hard work. It will take as much time as you need to come to terms
with your loss."
Answer: d. "Grieving for your son is hard work. It will take as much time as you need to come
to terms with your loss."
Rationale:
This response acknowledges the client's grief, validates their feelings, and assures them that it's
normal to need time to grieve and heal.
115. A nurse is reinforcing teaching with a client about cancer prevention. The nurse should
include that frequent consumption of which of the following foods increases the risk for
developing cancer?
a. Tuna fish
b. Poultry
c. Lamb
d. Whole grains
Answer: c. Lamb
Rationale:
Frequent consumption of lamb has been associated with an increased risk of developing certain
types of cancer, such as colorectal cancer.
116. A nurse notices an assistive personnel (AP) taking a nap in the break room during mealtime.
The nurse also notes that the AP is drowsy while performing routine tasks. Which of the
following actions should the nurse take?
a. Ask the AP if they are feeling unwell.
b. Report the observation about the AP to the unit nurse manager.
c. of fer the AP a cup of coffee to help them stay awake.
d. Allow the AP to take a longer break to rest.
Answer: b. Report the observation about the AP to the unit nurse manager.
Rationale:
Reporting the observation to the unit nurse manager ensures that appropriate action can be taken
to address the situation and prevent potential patient harm.
117. A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the
following clients should the nurse identify as being at risk for urinary retention?

a. An infant who has gastroenteritis and is receiving intravenous (IV) fluids.
b. A toddler who has asthma and is taking albuterol via metered-dose inhaler.
c. A school-age child who has allergic rhinitis and is taking diphenhydramine.
d. An adolescent who has a fractured femur and is receiving morphine for pain.
Answer: c. A school-age child who has allergic rhinitis and is taking diphenhydramine.
Rationale:
Diphenhydramine, an antihistamine, has anticholinergic effects that can lead to urinary retention.
118. A nurse is caring for a client following a bronchoscopy. Which of the following actions
should the nurse take first?
a. Administer oxygen via nasal cannula at 2 L/min.
b. Encourage the client to drink clear liquids.
c. Check for gag reflex.
d. Position the client on the right side.
Answer: c. Check for gag reflex.
Rationale:
Assessing the client's gag reflex is the priority to ensure the client's airway protection and safety
following the bronchoscopy procedure.
119. A nurse is assisting with the admission of a client who has a latex allergy. The nurse should
identify that which of the following supplies has the potential to contain latex?
a. Non-adherent dressing
b. Transparent dressing
c. Indwelling urinary catheter
d. Silk suture
Answer: c. Indwelling urinary catheter
Rationale:
Indwelling urinary catheters often contain latex, which can cause an allergic reaction in clients
with a latex allergy.
120. A nurse is performing postmortem care for a client prior to the arrival of the client's family
for viewing of the body. Which of the following actions should the nurse take?
a. Remove the client's dentures and place them in a denture cup.
b. Apply lotion to the client's skin to prevent dryness.

c. Gently close the client's eyelids.
d. Straighten the client's limbs and cover them with a clean sheet.
Answer: c. Gently close the client's eyelids.
Rationale:
Gently closing the client's eyelids provides a more peaceful appearance and is a common practice
in postmortem care.
121. A nurse is reinforcing teaching with a client who has dumping syndrome about measures to
reduce manifestations. Which of the following instructions should the nurse include in the
teaching?
a. Consume large meals with plenty of fluids.
b. Lie down for at least 30 minutes after meals.
c. Avoid foods high in sugar content.
d. Consume high-fat foods to slow digestion.
Answer: c. avoid foods high in sugar content.
Rationale:
The nurse should instruct the client to avoid sweet foods, which often increase the manifestations
of dumping syndrome. These manifestations include nausea, sweating, abdominal pain, diarrhea,
and weakness.
122. A nurse is collecting data from a client who is experiencing a situational crisis following the
loss of a job. The client states, "I don't think I can go through this again." Which of the following
actions is the nurse's priority?
a. Assess the client's past coping mechanisms.
b. Determine if the client is experiencing psychotic thinking.
c. Assess the client's support systems.
d. Explore the client's feelings about the job loss.
Answer: b. Determine if the client is experiencing psychotic thinking.
Rationale:
The priority is to determine if the client is experiencing psychotic thinking, as this could indicate
a need for immediate psychiatric intervention.
123. A nurse is contributing to the plan of care for a client following a transurethral resection of
the prostate (TURP). Which of the following interventions should the nurse include?

a. Encourage increased intake of dairy products.
b. Provide a diet high in protein.
c. Irrigate the bladder using sterile technique.
d. Encourage the client to perform Kegel exercises.
Answer: c. Irrigate the bladder using sterile technique.
Rationale:
After a TURP, irrigation of the bladder using sterile technique helps to prevent obstruction from
blood clots and maintains urinary flow.
124. A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the
following should the nurse recognize as a positive response to the therapy?
a. Decreased urine output
b. Moist mucous membranes.
c. Sunken fontanelles
d. Decreased skin turgor
Answer: b. Moist mucous membranes.
Rationale:
Moist mucous membranes indicate improved hydration status in a dehydrated infant.
125. A nurse is assisting with the admission of a client who is experiencing alcohol withdrawal.
Which of the following medications should the nurse expect the provider to prescribe for the
client?
a. Haloperidol
b. Diazepam
c. Chlordiazepoxide
d. Naloxone
Answer: c. Chlordiazepoxide
Rationale:
Chlordiazepoxide is a benzodiazepine used to manage alcohol withdrawal symptoms, including
anxiety and the risk for seizures.
126. A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns
that the client has decided not to have surgery even though they have already signed the
informed consent form. Which of the following actions should the nurse take?

a. Persuade the client to reconsider the decision.
b. Explain the risks of not having the surgery.
c. Report the situation to the provider who obtained informed consent.
d. Document the client's decision in the medical record.
Answer: c. Report the situation to the provider who obtained informed consent.
Rationale:
The nurse should report the situation to the provider who obtained informed consent so that
appropriate action can be taken, and the client's decision can be reassessed.
127. A nurse is collecting data from a client who is in severe pain. Which of the following
questions should the nurse ask first?
a. "What does your pain feel like?"
b. "Where is your pain located?"
c. "How would you rate your pain on a scale of 1 to 10?"
d. "What makes your pain worse?"
Answer: b. "Where is your pain located?"
Rationale:
When assessing pain, determining the location of the pain is the first step in understanding the
client's experience and planning appropriate interventions.
128. A nurse in a provider's office is reinforcing teaching with a client who has a new
prescription for ferrous sulfate elixir. Which of the following statements by the client should
indicate to the nurse an understanding of the teaching?
a. "I will take this medication with my morning coffee."
b. "I will take this medication on an empty stomach."
c. "I will rinse my mouth after taking this medication."
d. "I will take this medication with my evening meal."
Answer: c. "I will rinse my mouth after taking this medication."
Rationale:
Rinsing the mouth after taking ferrous sulfate elixir helps to prevent staining of the teeth.
129. A nurse is contributing to the plan of care for a client who is postoperative following a
rhinoplasty. Which of the following interventions should the nurse recommend?
a. Apply cold compresses to the surgical site.

b. Encourage the client to perform Valsalva maneuver to clear secretions.
c. Encourage the client to blow the nose gently.
d. Provide nasal decongestants to relieve congestion.
Answer: a. Apply cold compresses to the surgical site.
Rationale: Cold compresses help reduce swelling and inflammation at the surgical site,
promoting comfort and facilitating the healing process. They can also help alleviate pain. It is
essential to avoid any actions that increase pressure in the nasal area, such as blowing the nose
(option c) or performing the Valsalva maneuver (option b), as these actions can increase the risk
of bleeding or damage to the surgical site. Additionally, nasal decongestants (option d) may
increase the risk of bleeding and should be avoided unless specifically prescribed by the surgeon.
130. A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago.
Which of the following findings is the nurse's priority to report to the provider?
a. Temperature of 99.6°F (37.6°C)
b. Lochia serosa with small clots
c. Fundus firm and midline at the umbilicus
d. Blood pressure of 138/88 mm Hg
Answer: d. Blood pressure of 138/88 mm Hg
Rationale:
The nurse's priority is to report a blood pressure of 138/88 mm Hg to the provider. Elevated
blood pressure in the postpartum period could indicate preeclampsia, a serious complication that
requires immediate attention to prevent further complications such as seizures or stroke. It is
essential to rule out preeclampsia promptly to ensure the client's safety.
131. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the
following findings should indicate to the nurse that the medication has been effective?
a. Decreased respiratory rate
b. Increased urinary output
c. Decreased blood pressure
d. Decreased heart rate
Answer: d. Decreased heart rate
Rationale:

The nurse should assess for a decreased heart rate as an indication that digoxin, a medication
used to treat heart failure, has been effective. Digoxin helps to increase the force of myocardial
contraction and decrease heart rate, improving cardiac output. Monitoring the heart rate is
essential to evaluate the medication's effectiveness and to prevent adverse effects such as
bradycardia or toxicity.
132. A nurse is reinforcing teaching about stress management techniques with a client who has
moderate anxiety disorder. Which of the following responses by the client indicates an
understanding of the teaching?
a. "I'll make sure to avoid situations that make me anxious."
b. "I'll practice deep-breathing exercises when I start to feel anxious."
c. "I'll increase my caffeine intake to help keep me alert."
d. "I'll drink alcohol when I feel overwhelmed to help me relax."
Answer: b. "I'll practice deep-breathing exercises when I start to feel anxious."
Rationale:
Deep-breathing exercises are an effective stress management technique for anxiety. Deep
breathing helps activate the body's relaxation response, reducing anxiety and promoting a sense
of calmness. It is a simple and efficient technique that clients can use anytime and anywhere
when they start to feel anxious.
133. A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation.
Which of the following statements by the client indicates an understanding of the teaching?
a. "I will take my warfarin with a glass of grapefruit juice every morning."
b. "I will avoid eating green, leafy vegetables while taking warfarin."
c. "I will monitor my blood pressure regularly while taking warfarin."
d. "I will use a soft-bristled toothbrush to brush my teeth while taking warfarin."
Answer: d. "I will use a soft-bristled toothbrush to brush my teeth while taking warfarin."
Rationale:
Clients taking warfarin should be advised to use a soft-bristled toothbrush to minimize the risk of
bleeding gums or other oral bleeding. Warfarin is an anticoagulant that works by interfering with
the blood-clotting process, increasing the risk of bleeding. Using a soft-bristled toothbrush helps
prevent gum injury and bleeding.

134. A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated
failure to provide oral care for clients. Which of the following actions should the charge nurse
take?
a. Provide education to the AP about the importance of oral care
b. Assign the AP to tasks other than client care
c. Document the AP's behavior in the employee's file
d. Reassign the AP to a different unit within the facility
Answer: a. Provide education to the AP about the importance of oral care
Rationale:
The charge nurse should provide education to the assistive personnel (AP) about the importance
of oral care for clients. Proper oral care is essential for maintaining oral hygiene, preventing
infections, and promoting the overall health and well-being of clients. Educating the AP about
the significance of oral care and providing guidance on how to perform it effectively can help
improve client care and prevent further lapses in care.
135. A nurse in a long-term care facility is observing a newly licensed nurse who is providing
tracheostomy care for a client. The nurse identifies proper performance of the procedure when
the newly licensed nurse selects which of the following solutions to clean the inner cannula?
a. Sterile water
b. Hydrogen peroxide
c. Normal saline
d. Betadine solution
Answer: c. Normal saline
Rationale:
Normal saline is the appropriate solution for cleaning the inner cannula during tracheostomy
care. It is isotonic and compatible with the body's tissues, making it safe for mucous membrane
irrigation. Using normal saline helps prevent irritation or damage to the tracheal mucosa.
136. A nurse is caring for a client who took an overdose of acetaminophen. Which of the
following medications should the nurse plan to administer to the client?
a. Naloxone
b. Acetylcysteine
c. Flumazenil

d. Protamine sulfate
Answer: b. Acetylcysteine
Rationale:
Acetylcysteine is the antidote for acetaminophen overdose. It works by replenishing hepatic
stores of glutathione, which then binds with the toxic metabolite of acetaminophen, preventing
liver damage. Administering acetylcysteine within 8-10 hours of acetaminophen ingestion is
essential to prevent or minimize hepatic injury.
137. A nurse is caring for a client who is in Buck's traction. Which of the following actions
should the nurse take?
a. Remove weights periodically for 20 min every 8 hr
b. Check capillary refill of the affected extremity every 4 hr
c. Ensure that the client's knee is in 90-degree flexion
d. Keep the client in a supine position with the knee slightly flexed
Answer: b. Check capillary refill of the affected extremity every 4 hr
Rationale:
When caring for a client in Buck's traction, the nurse should check the capillary refill of the
affected extremity every 4 hours to assess for adequate circulation. Buck's traction is used to
immobilize and align the lower extremity, usually for the treatment of hip fractures or certain
types of lower extremity injuries. Monitoring capillary refill helps detect circulatory
compromise, ensuring early intervention if necessary.
138. A nurse is preparing to administer metoclopramide 10 mg IM. Available is metoclopramide
5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero.)
a. 0.5 mL
b. 1 mL
c. 2 mL
d. 3 mL
Answer: b. 2 mL
Rationale:
To administer 10 mg of metoclopramide, the nurse should administer 2 mL of the available
solution (10 mg ÷ 5 mg/mL = 2 mL).

139. A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus.
Which of the following statements by the parent indicates an understanding of the teaching?
a. "I'll continue to breastfeed my baby as usual."
b. "I'll give my baby a bottle of water after each feeding."
c. "I'll give my baby over-the-counter medications for diarrhea."
d. "I'll avoid giving my baby any fruit or fruit juices for the next week."
Answer: a. "I'll continue to breastfeed my baby as usual."
Rationale:
Continuing to breastfeed the infant is essential when they have rotavirus. Breast milk provides
necessary hydration, nutrition, and antibodies to help fight the infection. It also helps soothe the
infant's digestive system. Avoiding fruit juices and over-the-counter medications for diarrhea is
also important.
140. A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the
following actions by the newly licensed nurse demonstrates sterile technique?
a. Touching the inside of the sterile gloves with the ungloved hand
b. Keeping the hands above the waist at all times during the procedure
c. Using the thumb and index finger of one hand to grasp the cuff of the other glove
d. Rolling the gloves down over the hands to ensure a snug fit
Answer: c. Using the thumb and index finger of one hand to grasp the cuff of the other glove
Rationale:
Using the thumb and index finger of one hand to grasp the cuff of the other glove while avoiding
contact with the outside surface of the gloves maintains the sterility of the gloves. This technique
prevents contamination of the gloves during the donning process. Touching the inside of the
gloves with the ungloved hand contaminates them, and rolling the gloves down can introduce
contaminants from the outer surface to the inner surface. Keeping the hands above the waist at
all times is a general guideline for maintaining asepsis but is not directly related to the donning
of gloves.
141. A nurse is reviewing laboratory reports for a client who has an Escherichia coli infection
and is receiving gentamicin. Which of the following results should the nurse report to the
provider before administering the next dose?
a. Serum creatinine 0.8 mg/dL

b. Potassium 3.8 mEq/L
c. White blood cell count 7,500/mm³
d. Peak serum gentamicin level 10 mcg/mL
Answer: d. Peak serum gentamicin level 10 mcg/mL
Rationale:
The nurse should report a peak serum gentamicin level of 10 mcg/mL to the provider before
administering the next dose. Gentamicin is an aminoglycoside antibiotic, and monitoring peak
and trough levels is essential to prevent toxicity and ensure therapeutic effectiveness. A peak
level of 10 mcg/mL is higher than the therapeutic range (5-10 mcg/mL), indicating a risk of
toxicity, which requires further evaluation and possible dose adjustment to prevent adverse
effects such as nephrotoxicity and ototoxicity.
142. A nurse is reinforcing teaching with a client regarding prescribed asthma medications. The
nurse should instruct the client to use which of the following medications for treatment of an
acute asthma attack?
a. Formoterol (Foradil)
b. Budesonide (Pulmicort)
c. Montelukast (Singulair)
d. Albuterol (Proventil)
Answer: d. Albuterol (Proventil)
Rationale:
Albuterol is a short-acting beta agonist (SABa. and is the medication of choice for the treatment
of an acute asthma attack. It works quickly to relax the muscles in the airways, making it easier
to breathe during an asthma attack. Albuterol is also used as a rescue inhaler to relieve acute
asthma symptoms such as wheezing, shortness of breath, and chest tightness.
143. A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a
school-age child. Which of the following information should the nurse include?
a. "Apply warm compresses to the affected eye every 2 hours."
b. "Administer over-the-counter antihistamine eye drops as needed."
c. "Use a cotton swab to clean discharge from the eye, moving from the inner to the outer
corner."
d. "Wash your hands frequently, and avoid touching the infected eye."

Answer: d. "Wash your hands frequently, and avoid touching the infected eye."
Rationale:
The nurse should instruct the parent to wash their hands frequently and to avoid touching the
infected eye to prevent the spread of conjunctivitis to other family members or individuals.
Conjunctivitis is highly contagious, and proper hand hygiene is essential to prevent its
transmission. Warm compresses can help relieve discomfort, but they should not be applied as
frequently as every 2 hours. Over-the-counter antihistamine eye drops are not indicated for
infectious conjunctivitis. Using a cotton swab to clean discharge from the eye can introduce
bacteria and should be avoided.
144. A nurse is preparing to administer an influenza virus immunization to a client by the
intradermal route. Which of the following actions should the nurse take?
a. Insert the needle at a 45-degree angle.
b. Administer the medication into the subcutaneous tissue of the upper arm.
c. Select a site on the ventral aspect of the forearm.
d. Aspirate for blood return before administering the medication.
Answer: c. Select a site on the ventral aspect of the forearm.
Rationale:
When administering an influenza virus immunization by the intradermal route, the nurse should
select a site on the ventral aspect of the forearm. The recommended site for intradermal injection
is the middle third of the non-dominant forearm, approximately 3-4 finger widths below the
antecubital space. The needle should be inserted at a 5-15-degree angle, not a 45-degree angle.
Aspiration for blood return is not necessary for intradermal injections, and the medication should
be injected into the dermal layer of the skin, not the subcutaneous tissue.
145. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of
the following actions should the nurse take?
a. Lubricate the catheter for the first 5 cm (2 in) of the length.
b. Cleanse the urethral meatus from back to front.
c. Inflate the balloon with 10 mL of sterile water.
d. Insert the catheter until urine flows, then advance it an additional 5 cm (2 in).
Answer: d. Insert the catheter until urine flows, then advance it an additional 5 cm (2 in).
Rationale:

When inserting an indwelling urinary catheter for a female client, the nurse should insert the
catheter until urine flows, then advance it an additional 5 cm (2 in) to ensure it is positioned in
the bladder. Cleaning the urethral meatus from back to front can introduce bacteria into the
urinary tract, increasing the risk of infection. The catheter should be lubricated along its entire
length to ease insertion. The balloon should be inflated with the amount of sterile water specified
by the manufacturer, usually 5-10 mL, to secure the catheter in the bladder.
146. A nurse is reinforcing teaching about food selection with a client who has a moderate burn
injury. Which of the following foods should the nurse recommend as being high in vitamin C?
a. Chicken breast
b. White rice
c. Orange
d. Whole wheat bread
Answer: c. Orange
Rationale:
Oranges are high in vitamin C, which is essential for wound healing and collagen synthesis.
Clients with burn injuries require adequate amounts of vitamin C to support tissue repair and
regeneration. Chicken breast, white rice, and whole wheat bread are not significant sources of
vitamin C compared to fruits like oranges.
147. A nurse is collecting data from a client who has multiple fractures following a motor vehicle
crash. For which of the following client statements should the nurse recommend a referral to an
occupational therapist?
a. "I have a hard time remembering to take my pain medication."
b. "I feel really anxious whenever I think about driving again."
c. "I have trouble buttoning my shirt because of the cast on my arm."
d. "I feel like I'm going to pass out when I try to stand up."
Answer: c. "I have trouble buttoning my shirt because of the cast on my arm."
Rationale:
The client's statement about having trouble buttoning their shirt because of the cast on their arm
indicates difficulty with activities of daily living (ADLs) and would benefit from occupational
therapy. Occupational therapists can assist clients in regaining independence in ADLs and

provide adaptive equipment or techniques to facilitate self-care while accommodating for
physical limitations.
148. A nurse is assisting with the admission of an adolescent who has bulimia nervosa. Which of
the following manifestations should the nurse expect?
a. Hypertension
b. Bradycardia
c. Hypokalemia
d. Peripheral edema
Answer: c. Hypokalemia
Rationale:
Clients with bulimia nervosa often experience electrolyte imbalances, including hypokalemia,
due to recurrent episodes of vomiting and laxative abuse. Hypokalemia can lead to cardiac
dysrhythmias, muscle weakness, and other serious complications. Therefore, the nurse should
expect to assess for signs and symptoms of hypokalemia and monitor the client's potassium
levels closely.
149. A nurse is collecting data from a client who is in the diagnostic center and is scheduled to
undergo a colonoscopy. Based on the information provided in the client's chart, which of the
following pieces of data places this client at risk for colorectal cancer? (Click on the "Exhibit"
button for additional information about the client. There are three tabs that contain separate
categories of data.)
a. Age 55 years
b. History of Crohn's disease
c. Body mass index (BMI) of 24
d. Routine colonoscopies every 10 years
Answer: b History of Crohn's disease
Rationale:
A history of Crohn's disease is a risk factor for colorectal cancer. Individuals with Crohn's
disease have an increased risk of developing colorectal cancer, particularly if the disease affects
the colon or has been present for a long duration. Therefore, a history of Crohn's disease places
the client at risk for colorectal cancer and may necessitate more frequent colonoscopies for
screening and surveillance. Other risk factors for colorectal cancer include a personal or family

history of colorectal cancer or polyps, inflammatory bowel disease (e.g., Crohn's disease,
ulcerative colitis), and certain genetic syndromes (e.g., Lynch syndrome, familial adenomatous
polyposis).
150. A nurse is caring for a client who has an altered mental status and has become aggressive.
Which of the following prescriptions should the nurse clarify with the provider prior to
administration?
a. Lorazepam (Ativan) 2 mg IV as needed for agitation
b. Haloperidol (Haldol) 5 mg IM every 4 hours as needed for agitation
c. Olanzapine (Zyprexa) 10 mg PO twice daily for agitation
d. Diphenhydramine (Benadryl) 50 mg IM as needed for agitation
Answer: c. Olanzapine (Zyprexa) 10 mg PO twice daily for agitation
Rationale:
Olanzapine is an oral medication, and the client's altered mental status and aggression suggest
that they may not be able to take oral medications reliably. Therefore, the nurse should clarify the
prescription for olanzapine with the provider and discuss the need for alternative routes of
administration, such as intramuscular or intravenous, to ensure the client receives the medication
safely and effectively.
151. A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription
for levothyroxine. Which of the following instructions should the nurse include in the teaching?
a. "Take the medication on an empty stomach."
b. "Take the medication with calcium supplements."
c. "Take the medication only when you experience symptoms."
d. "You will need to take the medication for the rest of your life."
Answer: d. "You will need to take the medication for the rest of your life."
Rationale:
Levothyroxine is a lifelong replacement therapy for hypothyroidism. The nurse should instruct
the client that they will need to take the medication for the rest of their life to maintain thyroid
hormone levels within the normal range. It is important for the client to understand the chronic
nature of hypothyroidism and the need for consistent medication adherence to prevent
complications and maintain optimal health.

152. A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the
following images should the nurse identify as an indication that the client is experiencing ptosis?
a. both eyes open
b. closed eyes
c. one drooping eye
d. both eyes closed
Answer: c. one drooping eye
Rationale:
Ptosis, or drooping of the eyelid, is a common symptom of myasthenia gravis (MG). In Image C,
the client's right eye is drooping, which is consistent with ptosis. Ptosis can affect one or both
eyelids and may worsen with prolonged use of the affected muscles, such as during activities like
reading or driving.
The male with a unibrow in Image C indicates ptosis, a common symptom of myasthenia gravis.
This drooping of the eyelid is characteristic of the condition.
153. A nurse is assisting with the admission of a client who has major depressive disorder.
Which of the following communication techniques should the nurse use to establish a trusting
relationship with the client?
a. offering general leads
b. Using open-ended questions
c. Reflecting feelings
d. Providing false reassurance
Answer: a. offering general leads
Rationale:
offering general leads encourages the client to continue talking and provides them with an
opportunity to express themselves. It demonstrates empathy, active listening, and a willingness to
understand the client's perspective. This technique can help establish trust and rapport between
the nurse and the client, which is essential for effective communication and therapeutic
relationship building.
154. A nurse is preparing to administer a client's morning medications. Which of the following
actions should the nurse take to verify the client's identity?
a. Ask the client to state their name and date of birth.

b. Check the client's room number on the door.
c. Verify the client's identity with another nurse.
d. Scan the client's facility identification band.
Answer: d. Scan the client's facility identification band.
Rationale:
Scanning the client's facility identification band is an effective way to verify the client's identity
before administering medications. The identification band contains the client's unique
identification information, such as their name and medical record number, which can be matched
with the electronic medication administration record (eMAR) to ensure the right medication is
given to the right patient. This process enhances medication safety and reduces the risk of
medication errors.
155. A nurse is collecting data from a client who has iron deficiency anemia. Which of the
following findings should the nurse expect?
a. Hypertension
b. Tachycardia
c. Hypoglycemia
d. Difficulty concentrating
Answer: b. Tachycardia
Rationale:
Tachycardia is a common manifestation of iron deficiency anemia. In response to decreased
oxygen-carrying capacity due to reduced hemoglobin levels, the heart rate increases to
compensate and improve tissue oxygenation. Other expected findings of iron deficiency anemia
include fatigue, weakness, pallor, shortness of breath, and cold intolerance. Hypertension,
hypoglycemia, and difficulty concentrating are not typically associated with iron deficiency
anemia.
156. A nurse is caring for a client who has expressive aphasia following a stroke. Which of the
following methods should the nurse use when communicating with the client?
a. Use complex sentences to stimulate language production.
b. Speak loudly and slowly to ensure the client understands.
c. Provide a picture board.
d. Use written communication to convey messages.

Answer: c. Provide a picture board.
Rationale:
A client who has expressive aphasia has difficulty expressing needs or wants through
verbalization or writing. The use of a picture board provides an alternative means of
communication that might be less frustrating for the client. Picture boards allow the client to
point to pictures or symbols to communicate their needs, facilitating effective communication
despite the language impairment.
157. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of
the following actions should the nurse take to promote the client's venous return?
a. Elevate the client's legs on pillows.
b. Encourage the client to perform ankle pumps.
c. Apply antiembolic stockings.
d. Maintain a sequential compression device.
Answer: d. Maintain a sequential compression device.
Rationale:
To promote venous return and prevent venous stasis and deep vein thrombosis (DVT) in a
postoperative client who is unable to ambulate, the nurse should maintain a sequential
compression device (SCD). SCDs intermittently inflate and deflate, applying pressure to the legs
and promoting venous blood return to the heart. Elevating the client's legs, encouraging ankle
pumps, and applying antiembolic stockings are also important interventions but may not be as
effective as SCDs in this scenario.
158. A nurse is observing an assistive personnel (AP) caring for a client. For which of the
following actions by the AP should the nurse intervene?
a. The AP assists the client with ambulation to the bathroom.
b. The AP reports client information to the oncoming AP in the hallway.
c. The AP provides oral care to the client.
d. The AP positions the client in a side-lying position.
Answer: b. The AP reports client information to the oncoming AP in the hallway.
Rationale:

Reporting client information in a public area violates the client's right to privacy and
confidentiality. The nurse should intervene and remind the AP to discuss client information in a
private, secure area to protect the client's confidentiality and comply with HIPAA regulations.
159. A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which
of the following statements by a parent indicates an understanding of the instructions?
a. "I will clean the umbilical cord stump with alcohol after every diaper change."
b. "I will keep the diaper folded down below the umbilical cord until it falls off."
c. "I will give our baby sponge baths until the cord falls off."
d. "I will cover the umbilical cord stump with gauze until it falls off."
Answer: c. "I will give our baby sponge baths until the cord falls off."
Rationale:
Sponge baths are recommended until the umbilical cord stump falls off to keep it clean and dry.
Cleaning the umbilical cord stump with alcohol or covering it with gauze is not recommended as
it may delay the drying process and increase the risk of infection. Keeping the diaper folded
down below the umbilical cord can help keep the area clean and dry.
160. A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and
stripping to treat varicose veins. Which of the following instructions should the nurse include in
the teaching?
a. Elevate the legs above the heart for 15 minutes twice daily.
b. Apply warm, moist compresses to the legs.
c. Avoid walking for prolonged periods.
d. Walk for 1-2 hours each day.
Answer: d. Walk for 1-2 hours each day.
Rationale:
Walking for 1-2 hours each day promotes circulation and helps prevent blood clots and swelling
in the legs after vein ligation and stripping. This activity also strengthens the leg muscles and
improves overall vascular health. Elevating the legs above the heart, applying warm, moist
compresses, and avoiding prolonged periods of walking are not recommended interventions after
vein ligation and stripping.
161. A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At
which of the following times should the nurse instruct the AP to collect the specimen?

a. Before the client's morning care
b. After the client eats breakfast
c. Before the client receives morning medications
d. After the client performs oral hygiene
Answer: c. Before the client receives morning medications
Rationale:
To obtain the best sputum sample, it is important to collect it before the client performs oral
hygiene or eats breakfast, as these actions can dilute or remove the sputum. Collecting the
specimen before the client receives morning medications ensures that the sputum is not
contaminated by medications or food particles.
162. A nurse at a long-term care facility is part of a team preparing a report on the quality of care
at the facility. Which of the following information should the nurse recommend including in the
report to demonstrate improvement in care quality?
a. The number of adverse events reported in the past year
b. The percentage of residents who experienced pressure ulcers in the past month
c. The implementation of a fall prevention program
d. The total number of resident complaints received
Answer: c. The implementation of a fall prevention program
Rationale:
Including the implementation of a fall prevention program in the report demonstrates the
facility's proactive approach to improving resident safety and quality of care. Fall prevention
programs are essential in reducing the incidence of falls and fall-related injuries among residents,
which is an important quality indicator in long-term care facilities.
163. A nurse is maintaining droplet precautions for a client who has meningitis. Which of the
following actions should the nurse take?
a. Place the client in a negative-pressure room.
b. Wear a surgical mask when providing care within 3 feet of the client.
c. Wear a gown when providing direct client care.
d. Wear gloves when assisting with client care activities.
Answer: b. Wear a surgical mask when providing care within 3 feet of the client.
Rationale:

Droplet precautions are used for clients with infections transmitted by large-particle droplets
expelled during coughing, sneezing, or talking. For clients with meningitis, wearing a surgical
mask when providing care within 3 feet of the client is essential to prevent the transmission of
droplets. Negative-pressure rooms, gowns, and gloves are not necessary for droplet precautions.
164. A nurse is reinforcing teaching with a client who has a new diagnosis of type 2 diabetes
mellitus and inquires about information concerning oral antidiabetic agents. In addition to the
provider, where should the nurse refer the client for information? (Select all that apply.)
a. Pharmacist
b. Certified diabetes educator
c. Registered dietitian
d. Social worker
Answer:
a. Pharmacist
b. Certified diabetes educator
c. Registered dietitian
Rationale:
Clients with diabetes can benefit from additional education and support from various healthcare
professionals. Referring the client to a pharmacist, certified diabetes educator, and registered
dietitian can provide valuable information on oral antidiabetic agents, medication management,
glucose monitoring, dietary management, and lifestyle modifications. These professionals can
work collaboratively with the client's healthcare provider to optimize diabetes management and
improve health outcomes.
165. A nurse is collecting data from a client who has bipolar disorder and is experiencing acute
mania. Which of the following findings is the nurse's priority?
a. Grandiose delusions
b. Flight of ideas
c. Rapid speech
d. High energy level
Answer: a. Grandiose delusions
Rationale:

Grandiose delusions can pose a risk to the client's safety and the safety of others. During acute
manic episodes, clients with bipolar disorder may experience inflated self-esteem and
grandiosity, leading to delusions of grandeur. These delusions may result in reckless behavior,
poor judgment, and impaired decision-making. Therefore, addressing the client's grandiose
delusions is the nurse's priority to ensure the safety and well-being of the client and others.
166. A nurse is preparing a client for surgery. The client states, "I'm sure this surgery will not
help me get better." Which of the following responses should the nurse make?
a. "You seem anxious about the surgery."
b. "Why do you feel that the surgery won't help?"
c. "Everything will be fine. Try not to worry."
d. "Let's talk about your concerns regarding the surgery."
Answer: d. "Let's talk about your concerns regarding the surgery."
Rationale:
The client's statement indicates apprehension and uncertainty about the outcome of the surgery.
The nurse should acknowledge the client's concerns and provide an opportunity for open
communication. By inviting the client to discuss their concerns, the nurse can address any
misconceptions, provide information, and offer support, thereby promoting the client's
understanding and coping abilities.
167. A nurse is reinforcing discharge teaching about car seat safety with the guardian of a Which
of the following statements by the guardian indicates an understanding of the teaching?
a. "I will put my child in a rear-facing car seat until he is 2 years old."
b. "I will place my child in the front seat of the car to keep an eye on him."
c. "I will use a booster seat for my child until he is 6 years old."
d. "I will secure my child in a seatbelt once he is 4 feet 9 inches tall."
Answer: a. "I will put my child in a rear-facing car seat until he is 2 years old."
Rationale:
Placing a child in a rear-facing car seat until they are 2 years old or until they reach the
maximum height and weight limit recommended by the car seat manufacturer is the safest
practice. This position supports the child's head, neck, and spine and reduces the risk of injury in
the event of a crash. Transitioning to a forward-facing car seat, booster seat, and then a seatbelt

follows the child's growth and developmental milestones and ensures optimal safety during car
travel.
168. A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple
sclerosis. The client states, "I am very upset and I want to be alone for a little while." Which of
the following responses should the nurse make?
a. "I understand you're upset. I'll stay with you for a while."
b. "You shouldn't isolate yourself. It's important to talk about your feelings."
c. "Why don't you want to be around other people right now?"
d. "Let me know when you're ready to talk about your feelings."
Answer: a. "I understand you're upset. I'll stay with you for a while."
Rationale:
The nurse's response demonstrates empathy, understanding, and support for the client's emotional
needs. Respect for the client's request for privacy while offering the nurse's presence conveys
empathy and provides the client with a sense of comfort and security. It is important for the nurse
to respect the client's wishes for solitude while making it clear that support is available when
needed.
169. A nurse is reinforcing teaching with a client who has a new prescription for prednisone for
the treatment of Addison's disease. Which of the following instructions should the nurse include
in the teaching?
a. "Take the medication on an empty stomach."
b. "Avoid foods high in sodium."
c. "Weigh yourself weekly and report sudden weight gain."
d. "Stop taking the medication if you experience muscle weakness."
Answer: c. "Weigh yourself weekly and report sudden weight gain."
Rationale:
Prednisone, a corticosteroid medication, can cause fluid retention and weight gain. Instructing
the client to weigh themselves weekly and report sudden weight gain helps monitor for fluid
retention, which can indicate the need for medication adjustment. It is important for the client to
maintain a consistent sodium intake and take the medication with food to minimize
gastrointestinal upset. Additionally, abrupt discontinuation of prednisone can result in adrenal

insufficiency; therefore, the client should never stop taking the medication suddenly and should
follow the provider's instructions for tapering the dose.
170. A nurse in a long-term care facility is contributing to the plan of care for a client who has a
new ostomy. Which of the following interventions should the nurse include?
a. Apply adhesive remover to the skin around the stoma.
b. Cut the ostomy appliance 1/8 inch larger than the stoma.
c. Change the ostomy pouch every 5 days.
d. Empty the ostomy pouch when it is one-third full.
Answer: d. Empty the ostomy pouch when it is one-third full.
Rationale:
Emptying the ostomy pouch when it is one-third full helps prevent leakage and skin irritation.
Applying adhesive remover to the skin around the stoma can help with pouch removal, but it
should be done cautiously to avoid skin irritation. The ostomy appliance should be cut to fit the
size and shape of the stoma, with an opening that is 1/8 inch larger than the stoma to allow for
proper fit and to prevent pressure on the stoma. The ostomy pouch should be changed as needed,
typically every 3-7 days, depending on the client's individual needs and the type of ostomy.
171. A nurse is contributing to the plan of care for a client who is receiving mechanical
ventilation. Which of the following interventions should the nurse recommend?
a. Suction the client's airway every 4 hours.
b. Administer a sedative to promote rest.
c. Provide oral care every 8 hours.
d. Implement a sedation vacation protocol.
Answer: d. Implement a sedation vacation protocol.
Rationale:
Implementing a sedation vacation protocol involves periodically interrupting sedative infusions
to assess the client's level of consciousness and readiness for weaning from mechanical
ventilation. Sedation vacations help prevent oversedation, facilitate early mobility, reduce the
duration of mechanical ventilation, and improve patient outcomes. It is important to assess and
manage pain, provide oral care, and suction the client's airway as needed, but implementing a
sedation vacation protocol is essential for optimizing the client's respiratory status and promoting
weaning from mechanical ventilation.

172. A nurse is receiving report on four clients. Which of the following clients should the nurse
plan to see first?
a. A client who has a history of heart failure and is reporting increased shortness of breath.
b. A client who has a prescription for pain medication following knee replacement surgery.
c. A client who has pneumonia and a new onset of confusion.
d. A client who has diabetes mellitus and reports tingling in the feet.
Answer: c. A client who has pneumonia and a new onset of confusion.
Rationale:
A new onset of confusion in a client with pneumonia may indicate hypoxemia or sepsis and
requires immediate assessment and intervention. Confusion is a significant change in mental
status that warrants urgent evaluation to determine the underlying cause and prevent further
deterioration. Clients with pneumonia are at risk for respiratory compromise, and sudden
confusion may indicate a decline in respiratory status, sepsis, or another serious complication
requiring immediate attention.
173. A nurse in a provider's office is collecting data from a preschooler. Which of the following
findings should the nurse report to the provider?
a. Heart rate 90/min
b. Respiratory rate 26/min
c. Blood pressure 90/60 mm Hg
d. Temperature 37.5°C (99.5°F)
Answer: d. Temperature 37.5°C (99.5°F)
Rationale:
A temperature of 37.5°C (99.5°F) is slightly elevated and may indicate a low-grade fever in a
preschool-age child. Fever is often the body's response to infection or inflammation. While a
temperature of 37.5°C (99.5°F) may not be considered high-grade, it is important to report any
fever in a preschooler to the provider for further evaluation and management. The other vital
signs are within the expected range for a preschool-age child.
174. A nurse is contributing to the plan of care for an older adult client who has difficulty
sleeping. Which of the following interventions should the nurse include?
a. Encourage the client to take a daytime nap.
b. Limit fluid intake in the evening.

c. Provide a large evening meal.
d. Increase daily caffeine consumption.
Answer: b. Limit fluid intake in the evening.
Rationale:
Limiting fluid intake in the evening can help reduce nighttime awakenings due to the need to
urinate. Older adults are more prone to nocturia, which can disrupt sleep patterns. Avoiding large
evening meals and excessive caffeine consumption can also contribute to improved sleep quality.
Daytime napping should be limited to short periods to avoid interfering with nighttime sleep.
175. A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin
sublingual tablets. Which of the following instructions should the nurse include in the teaching?
a. "Swallow the tablet with a glass of water."
b. "Store the tablets in the refrigerator."
c. "Take one tablet every 5 minutes for chest pain."
d. "Place the tablet under your tongue at the onset of chest pain."
Answer: d. "Place the tablet under your tongue at the onset of chest pain."
Rationale:
Nitroglycerin sublingual tablets are used to relieve angina by dilating blood vessels and
increasing blood flow to the heart. The client should be instructed to place the tablet under the
tongue at the onset of chest pain for rapid absorption. The client should not swallow the tablet or
store it in the refrigerator. The frequency of nitroglycerin administration should be limited to
three doses, taken 5 minutes apart, and the client should seek emergency medical assistance if
chest pain persists after three doses.
176. A nurse is performing vision testing for a client following a head injury. Which of the
following findings should the nurse identify as a problem with pupil accommodation?
a. Constriction of the pupils in response to light
b. Unequal pupil size
c. Lack of reaction to light
d. Inability of the pupils to constrict when focusing on near objects
Answer: d. Inability of the pupils to constrict when focusing on near objects
Rationale:

Pupil accommodation refers to the ability of the pupils to constrict when focusing on near objects
and dilate when focusing on distant objects. Inability of the pupils to constrict when focusing on
near objects indicates a problem with pupil accommodation, which can occur following a head
injury. Constriction of the pupils in response to light (pupillary light reflex), unequal pupil size
(anisocoria), and lack of reaction to light (fixed pupils) are different assessments related to
pupillary function.
177. A nurse is contributing to the plan of care for a client who is at risk of developing pressure
injuries. Which of the following interventions should the nurse include?
a. Reposition the client every 4 hours.
b. Elevate the head of the bed to 30 degrees.
c. Massage bony prominences every 8 hours.
d. Use a donut-shaped cushion for sitting.
Answer: a. Reposition the client every 4 hours.
Rationale:
Repositioning the client every 4 hours helps relieve pressure on bony prominences, reduces the
risk of pressure injuries, and promotes circulation and tissue perfusion. Elevating the head of the
bed to 30 degrees helps reduce shear and friction forces but is not sufficient as the sole
intervention for preventing pressure injuries. Massaging bony prominences can increase the risk
of skin breakdown and pressure injuries and should be avoided. Donut-shaped cushions can
increase pressure on vulnerable areas and should not be used for clients at risk of developing
pressure injuries.
178. A nurse is checking a newborn's vital signs. Which of the following methods of temperature
measurement should the nurse use?
a. Rectal
b. Tympanic
c. Axillary
d. Temporal artery
Answer: c. Axillary
Rationale:
Axillary temperature measurement is the most appropriate method for assessing the temperature
of a newborn. It is non-invasive, safe, and comfortable for the newborn. Rectal temperature

measurement is also accurate but may cause discomfort and is generally reserved for specific
situations. Tympanic and temporal artery temperature measurements are less accurate in
newborns and may not provide reliable results.
179. A nurse is transferring a client from a bed to a wheelchair. The client has right-side
weakness following a recent stroke. Which of the following actions should the nurse take?
a. Position the wheelchair on the client's left side.
b. Stand on the client's right side.
c. Assist the client to stand on the weak side.
d. Pivot on the client's weak side.
Answer: a. Position the wheelchair on the client's left side.
Rationale:
Positioning the wheelchair on the client's left side allows the nurse to facilitate the transfer from
the client's strong side. By standing on the client's left side, the nurse can provide support and
assistance while the client moves from the bed to the wheelchair. Assisting the client to stand on
the weak side or pivoting on the weak side may increase the risk of falls or injury.
180. A nurse is collecting data from a client who has hypokalemia. Which of the following
findings should the nurse expect?
a. Bradycardia
b. Hypoactive bowel sounds
c. Increased urine specific gravity
d. Muscle weakness
Answer: d. Muscle weakness
Rationale:
Hypokalemia is a serum potassium level below 3.5 mEq/L and can cause muscle weakness,
fatigue, and cramping. Bradycardia is not typically associated with hypokalemia; instead,
tachycardia may occur. Hypoactive or absent bowel sounds and decreased motility can occur
with hypokalemia, leading to constipation or ileus. Increased urine specific gravity is associated
with dehydration, not hypokalemia.
181. A nurse is contributing to the plan of care for a client who is newly diagnosed with iron
deficiency anemia. Which of the following foods should the nurse include in the plan as having
the highest amount of iron?

a. White rice
b. Green beans
c. Beef liver
d. Whole wheat bread
Answer: c. Beef liver
Rationale:
Beef liver is an excellent source of iron and is one of the best dietary sources for individuals with
iron deficiency anemia. It contains a highly absorbable form of iron called heme iron. Other
good sources of iron include lean meats, poultry, fish, fortified cereals, legumes, and dark green
leafy vegetables. White rice, green beans, and whole wheat bread are not significant sources of
dietary iron.
182. A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After
drawing up the medication, the nurse accidentally brushes the needle on the counter's surface.
Which of the following actions should the nurse take?
a. Recap the needle and administer the medication.
b. Discard the syringe and medication, and prepare a new dose.
c. Wipe the needle with an alcohol swab and then administer the medication.
d. Flush the needle with sterile saline and then administer the medication.
Answer: b. Discard the syringe and medication, and prepare a new dose.
Rationale:
Accidentally brushing the needle on the counter's surface contaminates the needle, requiring the
nurse to discard the syringe and medication and prepare a new dose. Contaminated needles can
introduce pathogens into the medication, increasing the risk of infection when administered to
the client. Wiping the needle with an alcohol swab or flushing it with sterile saline is insufficient
to remove surface contaminants and does not ensure the sterility of the needle.
183. A nurse is reinforcing teaching with a client who has asthma and a new prescription for an
ipratropium inhaler. Which of the following statements by the client indicates an understanding
of the teaching?
a. "I will use this inhaler at the first sign of an asthma attack."
b. "I will shake the inhaler well before each use."
c. "I will rinse my mouth with water after each use."

d. "I will take a deep breath and hold it for 10 seconds after using the inhaler."
Answer: c. "I will rinse my mouth with water after each use."
Rationale:
Ipratropium is an anticholinergic bronchodilator used to relieve bronchospasm associated with
asthma and chronic obstructive pulmonary disease (COPd.). Rinsing the mouth with water after
each use helps minimize the risk of dry mouth, throat irritation, and oral fungal infections, which
can occur as side effects of the medication. Using the inhaler at the first sign of an asthma attack
(early intervention), shaking the inhaler well before each use, and taking a deep breath and
holding it for 10 seconds after using the inhaler are appropriate techniques for using metereddose inhalers but do not apply specifically to ipratropium inhalers.
184. A nurse is contributing to the plan of care for a client who has a chest tube connected to a
closed drainage system. Which of the following interventions should the nurse include?
a. Strip the chest tube every 4 hours.
b. Keep the drainage system below the level of the client's chest.
c. Clamp the chest tube during transport.
d. Irrigate the chest tube with sterile saline solution every shift.
Answer: b. Keep the drainage system below the level of the client's chest.
Rationale:
Keeping the drainage system below the level of the client's chest ensures proper drainage of air
and fluid from the pleural space and prevents backflow of drainage into the client's chest.
Stripping the chest tube is no longer recommended, as it can cause damage to lung tissue and
increase the risk of pneumothorax. The chest tube should not be clamped during transport, as this
can lead to tension pneumothorax. Irrigating the chest tube with sterile saline solution is
unnecessary and can introduce pathogens into the pleural space.
185. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For
which of the following results should the nurse notify the provider?
a. Hemoglobin 12.5 g/dL
b. White blood cell count 10,000/mm3
c. Platelet count 180,000/mm3
d. Glucose 160 mg/dL
Answer: d. Glucose 160 mg/dL

Rationale:
A glucose level of 160 mg/dL indicates hyperglycemia, which requires further evaluation and
management, especially in a pregnant client. Hyperglycemia during pregnancy can lead to
complications for both the mother and the fetus, including macrosomia, preterm birth,
preeclampsia, and fetal hyperinsulinemia. The other laboratory results are within the expected
range for a client at 29 weeks of gestation.
186. A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy.
Which of the following statements should the nurse make?
a. "Your hair will start to grow back within a few weeks after chemotherapy ends."
b. "There is nothing you can do to prevent hair loss during chemotherapy."
c. "You should consider shaving your head before starting chemotherapy."
d. "Your oncologist might prescribe a cold cap to wear during treatment to reduce hair loss."
Answer: d. "Your oncologist might prescribe a cold cap to wear during treatment to reduce hair
loss."
Rationale:
Using a cold cap (scalp cooling) during chemotherapy can reduce the risk of hair loss by
constricting blood vessels in the scalp, which decreases the amount of chemotherapy drugs that
reach the hair follicles. While not all chemotherapy drugs are suitable for use with scalp cooling,
it can be an effective option for some clients. It is important for the nurse to provide accurate
information about available interventions to help the client make informed decisions about
managing chemotherapy-induced alopecia. Statements A, B, and C do not provide the client with
proactive strategies for managing chemotherapy-induced alopecia.
187. A nurse in a long-term care facility is auscultating the lung sounds of a client who reports
shortness of breath and increased fatigue. The nurse should report which of the following to the
provider after hearing this sound? (Click on the audio button to listen to the clip.)
Answer: Fine crackles
{audio}
Rationale:
Fine crackles are discontinuous, high-pitched, short crackling sounds heard during inspiration
that are not cleared with coughing. They are typically associated with conditions such as
pneumonia, heart failure, and interstitial lung disease.

The rationale for reporting fine crackles to the provider when auscultating the lung sounds of a
client who reports shortness of breath and increased fatigue is that they can indicate fluid
accumulation in the lungs, worsening the client's respiratory status and requiring prompt
intervention.
When fine crackles are heard during auscultation, it suggests fluid-filled alveoli and small
airways. This can indicate conditions such as pulmonary edema, interstitial fibrosis, or
pneumonia. Reporting this finding promptly to the provider is crucial for timely intervention and
appropriate management of the client's respiratory condition.
188. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and
has a new prescription for a regular diet. For which of the following findings should the nurse
notify the provider?
a. White blood cell count 12,000/mm3
b. Temperature 37.8°C (100.0°F)
c. Heart rate 88/min
d. Respiratory rate 16/min
e. Serum sodium 136 mEq/L
Answer: b. Temperature 37.8°C (100.0°F)
Rationale:
A temperature of 37.8°C (100.0°F) may indicate an early sign of infection, especially in a
postoperative patient. Surgical patients are more prone to developing infections due to the
surgical incision and manipulation of tissues during surgery. Therefore, the nurse should notify
the provider about this elevated temperature for further evaluation and management.
The other options are within normal ranges and are not indicative of immediate complications
post abdominal surgery.
189. A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the
following statements should the nurse include in the instructions?
a. "Place your baby to sleep on their back."
b. "Keep small objects, such as coins and buttons, out of your baby's reach."
c. "Place your baby's crib near a window to provide fresh air."
d. "Cover your baby's face with a blanket to keep them warm at night."
Answer: a. "Place your baby to sleep on their back."

Rationale:
Placing the baby to sleep on their back reduces the risk of sudden infant death syndrome (SIDS).
This recommendation is supported by the American Academy of Pediatrics (AAP) and is an
essential component of newborn safety.
190. A nurse is collecting data from a client who has Tourette syndrome. The client reports taking
haloperidol 0.5 mL orally three times a day at home. Which of the following components of the
prescription should the nurse question?
a. Dose
b. Route
c. Medication
d. Frequency
Answer: b. Route
Rationale:
Haloperidol is typically administered orally in tablet or liquid form. However, the route "0.5 mL
orally" seems incorrect, as it suggests a liquid concentration rather than a standard oral dose. The
nurse should question the route of administration to ensure the client is taking the medication as
prescribed.
191. A nurse is receiving change-of-shift report for four clients. Which of the following clients
should the nurse see first?
a. A client who has a stage III pressure injury on the sacrum and a temperature of 37.8°C
(100°F).
b. A client who has a new diagnosis of diabetes mellitus and is scheduled for discharge.
c. A client who has a prescription for morphine 2 to 4 mg IV bolus every 2 hours as needed for
pain.
d. A client who has a nasogastric tube and continuous gastric suction and has absent bowel
sounds.
Answer: a. A client who has a stage III pressure injury on the sacrum and a temperature of
37.8°C (100°F).
Rationale:

The client with a stage III pressure injury and an elevated temperature may indicate an infection,
which needs prompt assessment and intervention. Infection can exacerbate pressure injuries, and
prompt treatment is essential to prevent further complications.
192. A community health nurse is helping to reinforce teaching about hepatitis A with a group of
employees at a childcare facility. Which of the following characteristics should the nurse identify
as an external factor that can impede learning for the participants?
a. Noise level in the room
b. Prior knowledge of the topic
c. Motivation to learn
d. Physical comfort
Answer: a. Noise level in the room
Rationale:
External factors, such as a high noise level, can impede learning by interfering with the
participants' ability to concentrate and process information effectively. Therefore, the nurse
should identify the noise level in the room as an external factor that can impede learning.
193. A nurse in a long-term care facility is reviewing information about health care-associated
infections with a newly licensed nurse. Which of the following information should the nurse
include?
a. The client's age and gender
b. The length of the client's stay in the facility
c. The client's medical diagnosis
d. The client's hand hygiene practices
Answer: d. The client's hand hygiene practices
Rationale:
Hand hygiene is one of the most critical factors in preventing healthcare-associated infections.
Therefore, it is essential for the nurse to include information about the client's hand hygiene
practices in the education provided to the newly licensed nurse.
194. A nurse is caring for a female client who has an indwelling urinary catheter. Which of the
following actions should the nurse take?
a. Secure the catheter to the client's thigh with tape.
b. Ensure the catheter drainage bag is positioned below the level of the bladder.

c. Cleanse the catheter and perineal area once a week.
d. Irrigate the catheter with sterile saline every 4 hours.
Answer: b. Ensure the catheter drainage bag is positioned below the level of the bladder.
Rationale:
Positioning the drainage bag below the level of the bladder ensures continuous drainage of urine,
prevents reflux of urine into the bladder, and reduces the risk of urinary tract infections. This
action is essential for proper catheter care and preventing complications.
195. A nurse is reinforcing teaching with a client who has left-sided weakness and is learning
how to ambulate with a cane. The nurse should identify that the client understands the teaching
when the client places the cane in which of the following positions when advancing forward?
(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds
to your answer.)
a. Right side
b. Left side
c. Midline
d. Behind the feet
Answer: a. Right side
Rationale:
When a client with left-sided weakness is learning to ambulate with a cane, the cane should be
placed on the opposite side of the weakness to provide support. Therefore, the client should place
the cane on the right side when advancing forward. Placing the cane on the right side provides
support for the weak left side and helps to improve balance and stability.
196. A home health nurse is caring for an older adult client who just returned home following a
total knee arthroplasty. Which of the following actions should the nurse take first?
a. Administer prescribed pain medication.
b. Evaluate the client's ability to perform activities of daily living.
c. Instruct the client to perform range-of-motion exercises.
d. Assess the client's incision site for signs of infection.
Answer: d. Assess the client's incision site for signs of infection.
Rationale:

Assessing the incision site for signs of infection is the priority to ensure early detection and
intervention if any complications arise postoperatively, especially in an older adult who may
have a compromised immune system and increased susceptibility to infections.
197. A school nurse is having a conversation with the parents of an adolescent. The nurse should
identify which of the following situations as an ethical dilemma for the parents?
a. The adolescent has been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and
requires medication during school hours.
b. The adolescent refuses to participate in physical education classes due to body image issues.
c. The adolescent has expressed a desire to receive confidential counseling for issues related to
sexual orientation.
d. The adolescent's parents are divorced, and there is disagreement regarding the adolescent's
healthcare decisions.
Answer: c. The adolescent has expressed a desire to receive confidential counseling for issues
related to sexual orientation.
Rationale:
This situation poses an ethical dilemma for the parents because they must balance their child's
right to confidential care with their own desire to be involved in their child's healthcare
decisions.
198. A nurse has administered medications to a group of clients. For which of the following
client situations should the nurse complete an incident report?
a. The client received an extra dose of acetaminophen due to a documentation error.
b. The client received their scheduled dose of warfarin at the correct time.
c. The client refused to take their prescribed antibiotic.
d. The client experienced temporary dizziness after receiving their prescribed antihypertensive
medication.
Answer: a. The client received an extra dose of acetaminophen due to a documentation error.
Rationale:
Administering an extra dose of medication due to a documentation error is a medication error
and should be reported via an incident report to ensure proper documentation and investigation
of the error.

199. A nurse is reinforcing teaching with a client who has tuberculosis (TB). Which of the
following statements by the client indicates an understanding of the teaching?
a. "I will take my medication until I start feeling better."
b. "I will avoid close contact with others until I am no longer contagious."
c. "I will stop taking my medication once my cough goes away."
d. "I will make sure to cover my mouth with my hand when I cough."
Answer: b. "I will avoid close contact with others until I am no longer contagious."
Rationale:
This statement indicates that the client understands the importance of infection control measures
and the need to prevent the spread of tuberculosis to others.
200. A nurse is collecting data from a male client who is scheduled for a left inguinal
herniorrhaphy. Which of the following findings is the priority for the nurse to report to the
provider?
a. Urinary retention
b. A history of tobacco use
c. Scrotal swelling
d. Surgical site drainage
Answer: a. Urinary retention
Rationale:
Urinary retention can be a sign of urinary tract obstruction, which could lead to complications
such as bladder distention or infection. Therefore, it is the priority for the nurse to report this
finding to the provider for further evaluation and management.
201. A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD.)
Which of the following manifestations should the nurse expect?
a. Hypersomnia
b. Anhedonia
c. Hypervigilance
d. Euphoria
Answer: c. Hypervigilance
Rationale:

Hypervigilance is a common manifestation of PTSD. It involves being in a state of increased
alertness and sensitivity to potential threats or danger in the environment.
202. A nurse is reinforcing teaching with the adult children of a client who is dying. Which of the
following statements should the nurse make?
a. "Your mother will be more comfortable if you avoid touching her."
b. "Your father is receiving enough pain medication to prevent him from feeling any discomfort."
c. "Your mother is showing signs that she is in the final stage of dying."
d. "Your father may still be able to hear you even if he is no longer responsive."
Answer: d. "Your father may still be able to hear you even if he is no longer responsive."
Rationale:
Encouraging communication with the dying person is important. Even if a dying person is not
responsive, hearing may be intact, and hearing familiar voices can provide comfort.
203. A nurse is preparing to discharge a client who is immunocompromised. Which of the
following vaccines should the nurse plan to administer?
a. Measles, mumps, and rubella (MMR) vaccine
b. Varicella vaccine
c. Pneumococcal vaccine
d. Human papillomavirus (HPV) vaccine
Answer: c. Pneumococcal vaccine
Rationale:
Clients who are immunocompromised are at increased risk for infections, including
pneumococcal disease. Therefore, the nurse should plan to administer the pneumococcal vaccine
before discharge to help prevent this serious infection.
204. A nurse is assisting with a presentation at a community center about personal disaster
preparedness. Which of the following strategies should the nurse recommend for preparing a
home disaster supply kit?
a. Storing canned foods in an area that is difficult to access
b. Including a 3-day supply of prescription medications
c. Using glass containers for storing water
d. Storing the supply kit in the basement
Answer: b. Including a 3-day supply of prescription medications

Rationale:
Including a 3-day supply of prescription medications in a home disaster supply kit is essential for
individuals who rely on medications for chronic conditions. It ensures that they have access to
necessary medications in the event of a disaster or emergency.
205. A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned
about weight gain during pregnancy. Which of the following responses should the nurse make?
a. "You should increase your insulin dosage to prevent hyperglycemia."
b. "You may need to decrease your carbohydrate intake to help control your weight."
c. "It is important to increase your calorie intake to support your growing baby."
d. "You should avoid exercising during pregnancy to prevent complications."
Answer: b. "You may need to decrease your carbohydrate intake to help control your weight."
Rationale:
Decreasing carbohydrate intake can help control weight gain in clients with type 2 diabetes
mellitus during pregnancy while still providing adequate nutrition for the growing baby.
206. A nurse is reviewing a client's electronic medical record and finds that an assistive personnel
(AP) recorded the client's temperature as 35.3°C (95.5°F) 2 hr earlier. Which of the following
actions should the nurse take first?
a. Recheck the client's temperature using a different thermometer.
b. Notify the provider of the client's temperature.
c. Administer acetaminophen to the client.
d. Document the temperature in the client's chart.
Answer: a. Recheck the client's temperature using a different thermometer.
Rationale:
The nurse should first verify the accuracy of the temperature reading by rechecking it with a
different thermometer before taking any further action.
207. A charge nurse on a long-term care unit is preparing to delegate tasks to a licensed practical
nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the charge
nurse delegate to the LPN?
a. Providing oral care to a client who has a stage III pressure injury.
b. Ambulating a client who is 12 hr postoperative following a total knee arthroplasty.
c. Reinforcing teaching about the use of a walker to a client who has a new prescription.

d. Administering a subcutaneous injection of enoxaparin to a client who has deep vein
thrombosis.
Answer: d. Administering a subcutaneous injection of enoxaparin to a client who has deep vein
thrombosis.
Rationale:
Administering subcutaneous injections is within the scope of practice for an LPN.
208. A nurse is preparing to administer purified protein derivative (PPD. to a client who has
suspected tuberculosis. Which of the following actions should the nurse plan to take?
a. Administering the PPD in the deltoid muscle.
b. Measuring the size of any induration 24 hr after administration.
c. Applying a sterile dressing over the injection site.
d. Obtaining a sputum culture after administering the PPD.
Answer: b. Measuring the size of any induration 24 hr after administration.
Rationale:
Measuring the size of any induration at the injection site 24-48 hours after PPD administration is
the standard method for assessing the client's response to the test.
209. A nurse is reinforcing teaching with a female client who requests information about how to
lose weight. Which of the following statements should the nurse make?
a. "You should skip meals to reduce your calorie intake."
b. "You should avoid snacks between meals."
c. "You should decrease your physical activity to conserve energy."
d. "You should aim to lose more than 2 pounds per week."
Answer: b. "You should avoid snacks between meals."
Rationale:
Avoiding snacks between meals can help reduce calorie intake and support weight loss.
210. A nurse in a long-term care facility is assisting with an in-service for newly hired assistive
personnel about legal issues within the facility. Which of the following should the nurse include
as an example of assault?
a. Administering medication without the client's consent
b. Threatening to place a client in restraints against their will
c. Failing to provide appropriate care to a client

d. Physically restraining a client during a violent outburst
Answer: b. Threatening to place a client in restraints against their will
Rationale:
Assault involves the threat of bodily harm or physical contact without consent. Threatening to
place a client in restraints against their will is an example of assault.
211. A nurse is assisting in the plan of care for a female client who is to undergo a 12-lead ECG.
Which of the following actions should the nurse include in the plan of care?
a. Remove all jewelry from the client.
b. Instruct the client to take slow, deep breaths during the procedure.
c. Place the client in a supine position.
d. Apply ice packs to the client's chest prior to the procedure.
Answer: a. Remove all jewelry from the client.
Rationale:
Removing jewelry is important to ensure an accurate reading during the 12-lead ECG procedure.
Metal objects can interfere with the electrical signals recorded by the ECG.
212. A nurse is collecting data from a client who has multiple sclerosis. Which of the following
findings should the nurse expect?
a. Bradycardia
b. Hypertonic bladder
c. Hyperreflexia
d. Ataxic gait
Answer: d. Ataxic gait
Rationale:
Ataxic gait, characterized by unsteady and uncoordinated movements, is a common finding in
clients with multiple sclerosis due to demyelination of nerve fibers.
213. A nurse is reinforcing teaching with a client who is bottle feeding their full-term newborn
with formula. Which of the following instructions should the nurse include in the teaching?
a. "Hold the bottle so the nipple is completely filled with formula to prevent air intake."
b. "Burp your baby every 30 minutes throughout the feeding."
c. "Feed your baby every 4 hours during the day and every 6 hours at night."
d. "Discard any formula remaining in the bottle after 2 hours."

Answer: d. "Discard any formula remaining in the bottle after 2 hours."
Rationale:
Discarding any formula remaining in the bottle after 2 hours helps prevent bacterial growth and
reduces the risk of feeding the baby spoiled formula.
214. A nurse is preparing to administer a rectal suppository to a school-age child. Which of the
following actions should the nurse plan to take?
a. Insert the suppository 2.5 cm (1 inch) into the rectum.
b. Have the child take deep breaths while inserting the suppository.
c. Hold the buttocks together for 5 minutes after inserting the suppository.
d. Administer a cleansing enema prior to inserting the suppository.
Answer: a. Insert the suppository 2.5 cm (1 inch) into the rectum.
Rationale:
Inserting the suppository 2.5 cm (1 inch) into the rectum is the correct technique for
administering a rectal suppository to a school-age child.
215. A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active
labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the
following actions should the nurse take?
a. Assist the client to change positions.
b. Administer oxygen via face mask at 10 L/min.
c. Prepare for immediate delivery.
d. Increase the rate of the intravenous infusion.
Answer: a. Assist the client to change positions.
Rationale:
Late decelerations are concerning for uteroplacental insufficiency. Changing the client's position,
such as turning her onto her left side, can help improve placental perfusion and oxygenation to
the fetus.
216. A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The
nurse should include that hepatitis A is transmitted through which of the following methods?
a. Sexual contact
b. Sharing needles
c. Fecal-oral route

d. Blood transfusion
Answer: c. Fecal-oral route
Rationale:
Hepatitis A is primarily transmitted through the fecal-oral route, typically through ingestion of
contaminated food or water.
217. A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment.
The nurse should include that which of the following characteristics increases a child's risk of
physical maltreatment?
a. Being the youngest child in the family
b. Having a single parent
c. Being of the same gender as the caregiver
d. Having a developmental disability
Answer: d. Having a developmental disability
Rationale:
Children with developmental disabilities are at increased risk for physical maltreatment due to
caregiver stress, frustration, and lack of coping skills.
218. A nurse is reinforcing teaching with a client who has coronary artery disease (CAD. and is
taking a low-dose aspirin daily. The nurse should include that this medication has which of the
following therapeutic effects?
a. Reducing blood pressure
b. Decreasing platelet aggregation
c. Increasing HDL cholesterol levels
d. Dilating coronary arteries
Answer: b. Decreasing platelet aggregation
Rationale:
Low-dose aspirin reduces the risk of blood clot formation by decreasing platelet aggregation,
which can help prevent complications such as myocardial infarction and stroke in clients with
CAD.
219. A nurse at a long-term care facility is transcribing new prescriptions for four clients. Which
of the following prescriptions is accurately transcribed by the nurse?
a. Acetaminophen 325 mg PO every 6 hours PRN for pain

b. Furosemide 40 mg IV push daily
c. Warfarin 5 mg PO daily at 0800
d. Metoprolol 25 mg IV every 12 hours
Answer: c. Warfarin 5 mg PO daily at 0800
Rationale:
This prescription is accurately transcribed with the medication, dose, route, frequency, and time
specified.
220. A nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a
clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct
the client to take after washing their hands.
a. Hold the labia apart.
b. Begin urinating into the toilet.
c. Cleanse the urethral meatus from front to back.
d. Collect urine in the sterile specimen cup.
Answer: c. Cleanse the urethral meatus from front to back.
b. Begin urinating into the toilet.
d. Collect urine in the sterile specimen cup.
a. Hold the labia apart.
Rationale:
This sequence of actions ensures that the urine specimen is collected in a sterile manner,
minimizing the risk of contamination.
221. A nurse is caring for a client who is being discharged home following a cerebrovascular
accident. Which of the following documents should the nurse plan to include with the discharge
report?
a. Medication reconciliation form
b. Advance directive form
c. Home health referral form
d. Stroke education materials
Answer: d. Stroke education materials
Rationale:

Providing stroke education materials ensures that the client and their caregivers have information
about stroke recovery, signs of complications, and strategies for managing activities of daily
living after discharge.
222. A nurse is reinforcing teaching with a client who is scheduled for a barium enema. Which of
the following statements should the nurse make?
a. "You should eat a low-fiber diet for 24 hours before the procedure."
b. "You may experience diarrhea following the procedure."
c. "You will need to have a bowel cleansing before the procedure."
d. "You should avoid drinking fluids for 8 hours before the procedure."
Answer: c. "You will need to have a bowel cleansing before the procedure."
Rationale:
A bowel cleansing is necessary before a barium enema to ensure that the colon is clear of stool
and allows for better visualization during the procedure.
223. A nurse is preparing to administer medications to a client who is NPO and is receiving
enteral feedings through an NG tube. Which of the following prescriptions should the nurse
clarify with the provider?
a. Pantoprazole delayed-release tablet via NG tube every day
b. Lisinopril 10 mg tablet PO every day
c. Acetaminophen 650 mg suppository PR every 6 hours PRN for fever
d. Warfarin 5 mg tablet PO every day
Answer: b. Lisinopril 10 mg tablet PO every day
Rationale:
Lisinopril is typically administered orally, but since the client is NPO, the nurse should clarify
with the provider if the medication should be held or administered via an alternative route.
224. A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which
of the following tasks should the nurse delegate to the AP?
a. Reinforce teaching about insulin administration to a client newly diagnosed with diabetes.
b. Assist a client with meals and oral hygiene.
c. Perform a sterile dressing change for a postoperative client.
d. Administer IV medication to a client who is receiving continuous IV infusion.
Answer: b. Assist a client with meals and oral hygiene.

Rationale:
Assisting a client with meals and oral hygiene is within the scope of practice for an assistive
personnel (AP) and can help promote client comfort and nutrition.
225. A nurse in a provider's office is reinforcing discharge teaching with a client who is
postoperative following cataract removal from one eye. Which of the following instructions
should the nurse include?
a. "Avoid bending at the waist for the next 24 hours."
b. "You may resume driving immediately."
c. "Wear an eye patch at night for the next week."
d. "Avoid all screen time until your follow-up appointment."
Answer: a. "Avoid bending at the waist for the next 24 hours."
Rationale:
Avoiding bending at the waist helps prevent increased intraocular pressure, which can increase
the risk of complications after cataract surgery.
226. A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of the
teaching?
a. "I will apply suction while inserting the catheter into the trachea."
b. "I will hyperoxygenate the client before and after suctioning."
c. "I will suction the client's trachea for no longer than 10 seconds."
d. "I will perform endotracheal suctioning every 2 hours."
Answer: b. "I will hyperoxygenate the client before and after suctioning."
Rationale:
Hyperoxygenating the client before and after suctioning helps prevent hypoxemia and is an
important aspect of endotracheal suctioning.
227. A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports
waking during the night with tremors and anxiety. Which of the following information should the
nurse include?
a. "You may need to increase your insulin dosage."
b. "Avoid eating carbohydrates before bedtime."
c. "Eat a snack containing protein and carbohydrates before bedtime."

d. "Check your blood glucose level before bedtime."
Answer: c. "Eat a snack containing protein and carbohydrates before bedtime."
Rationale:
Eating a snack containing protein and carbohydrates before bedtime can help prevent nighttime
hypoglycemia in clients with diabetes.
228. A nurse is caring for a client who requests information about advance directives. Which of
the following responses should the nurse make?
a. "Advance directives are legally binding documents that appoint someone to make healthcare
decisions for you if you are unable to do so."
b. "Advance directives are only necessary if you have a terminal illness."
c. "Advance directives can only be completed by an attorney."
d. "Advance directives must be notarized to be valid."
Answer: a. "Advance directives are legally binding documents that appoint someone to make
healthcare decisions for you if you are unable to do so."
Rationale:
This response provides an accurate description of advance directives and their purpose.
229. A nurse is working with an interpreter to assist the provider with explaining a diagnostic
procedure to a client who speaks a different language than the nurse. Which of the following
actions should the nurse take?
a. Ask the interpreter to summarize the information for the client.
b. Speak directly to the client while the interpreter is translating.
c. Speak quickly to allow time for translation.
d. Use medical jargon and abbreviations to ensure accuracy.
Answer: a. Ask the interpreter to summarize the information for the client.
Rationale:
Asking the interpreter to summarize the information for the client ensures that the client receives
the necessary information in a clear and understandable manner.
230. A nurse is collecting data from a newly-admitted infant who is 3 months old and has
diarrhea. Which of the following findings should the nurse report to the provider?
a. Respiratory rate 40/min
b. Weight 500 g (1 lb) less than birth weight

c. Capillary refill time 2 seconds
d. Rectal temperature 37.2°C (99°F)
Answer: b. Weight 500 g (1 lb) less than birth weight
Rationale:
A weight loss of 500 g (1 lb) since birth is a significant finding in a 3-month-old infant and
should be reported to the provider as it may indicate dehydration associated with diarrhea.
231. A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and will
undergo routine abdominal ultrasonography the following day. Which of the following
statements should the nurse include in the teaching?
a. "You should avoid eating or drinking for 8 hours before the procedure."
b. "You may experience slight discomfort during the procedure."
c. "You will need to have a full bladder for the procedure."
d. "You should lie on your back during the procedure."
Answer: c. "You will need to have a full bladder for the procedure."
Rationale:
Having a full bladder helps improve visualization during abdominal ultrasonography by
providing an acoustic window for the sound waves to travel through.
232. A nurse is receiving change-of-shift report for a group of clients. The nurse should plan to
implement which of the following time-management strategies?
a. Perform non-urgent client care tasks first.
b. Cluster nursing care activities.
c. Document care provided at the end of the shift.
d. Delegate client care tasks to another nurse.
Answer: b. Cluster nursing care activities.
Rationale:
Clustering nursing care activities involves grouping similar tasks together, which helps save time
and promotes efficiency in delivering care.
233. A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance.
Which of the following statements by the parent indicates an understanding of the teaching?
a. "I will give my child lactose-free milk instead of regular milk."
b. "I will encourage my child to eat more cheese and yogurt."

c. "I will limit my child's intake of fruits and vegetables."
d. "I will avoid giving my child any dairy products."
Answer: a. "I will give my child lactose-free milk instead of regular milk."
Rationale:
Lactose-free milk is a suitable alternative for children with lactose intolerance as it contains the
same nutrients as regular milk but without lactose.
234. A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client.
Which of the following actions by the AP demonstrates an understanding of how to perform this
skill?
a. Rolling the stockings over the client's feet and ankles
b. Leaving a 2-inch gap between the client's skin and the top of the stockings
c. Applying the stockings while the client is sitting with the legs dependent
d. Ensuring the stockings are tight around the client's thighs
Answer: c. Applying the stockings while the client is sitting with the legs dependent
Rationale:
Applying antiembolic stockings while the client is sitting with the legs dependent helps facilitate
proper fitting and ensures optimal effectiveness.
235. A nurse is collecting data from a school-age child who has sustained a skull fracture. Which
of the following is a manifestation of increased intracranial pressure?
a. Bradycardia
b. Increased urine output
c. Dilated pupils
d. Hypotension
Answer: c. Dilated pupils
Rationale:
Dilated pupils are a manifestation of increased intracranial pressure and can indicate
compression of cranial nerves.
236. A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the
following statements by the client indicates an understanding of the instructions?
a. "I will increase my intake of high-fiber foods, such as fruits and vegetables."
b. "I will limit my fluid intake to avoid increasing abdominal pressure."

c. "I will take laxatives regularly to prevent constipation."
d. "I will avoid taking antibiotics unless absolutely necessary."
Answer: a. "I will increase my intake of high-fiber foods, such as fruits and vegetables."
Rationale:
Increasing intake of high-fiber foods can help prevent constipation and reduce the risk of
diverticulitis flare-ups.
237. A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy. Which of
the following client statements indicates an understanding of the teaching?
a. "I will need to have someone drive me home after the procedure."
b. "I should not eat or drink anything for 24 hours before the procedure."
c. "I will need to drink a special solution to clean out my bowels before the procedure."
d. "I should take my regular medications with a small sip of water on the morning of the
procedure."
Answer: c. "I will need to drink a special solution to clean out my bowels before the procedure."
Rationale:
Drinking a special solution to clean out the bowels is a necessary preparation for a colonoscopy
to ensure that the colon is clear for the procedure.
238. A nurse is reinforcing teaching with a client who has fluid volume deficit about selecting
foods that have a high water content. The nurse should include that which of the following raw
foods contains the highest amount of water per 1 cup serving?
a. Cucumber
b. Watermelon
c. Carrot
d. Apple
Answer: b. Watermelon
Rationale:
Watermelon has the highest water content among the options listed, with approximately 92%
water per 1 cup serving.
239. A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of
gestation. Which of the following instructions should the nurse reinforce with the client?
a. "You should press the button every time you feel the baby move."

b. "You will need to have a full bladder for the test."
c. "You should eat a full meal before the test."
d. "You may need to have an IV line inserted for the test."
Answer: a. "You should press the button every time you feel the baby move."
Rationale:
Pressing the button every time the client feels fetal movement helps correlate fetal heart rate
changes with fetal movement during a nonstress test.
240. A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of
membranes following a vaginal examination. The provider reports the client's cervix is dilated to
1 cm with an unengaged presenting part. Which of the following actions should the nurse take?
a. Prepare the client for immediate cesarean birth.
b. Assist the client with pushing during contractions.
c. Monitor the client's vital signs every 30 minutes.
d. Document the findings and continue to monitor the client's progress.
Answer: d. Document the findings and continue to monitor the client's progress.
Rationale:
With an unengaged presenting part and a cervix dilated to 1 cm, the client is not yet in active
labor. Documenting the findings and continuing to monitor the client's progress is appropriate at
this time.
A nurse is preparing to administer a medication to a client. The client states, "I'm sick of all these
medications, and I'm not taking any more today!" Which of the following actions should the
nurse take?
a. Administer the medication as prescribed.
b. Encourage the client to take the medication.
c. Ask the client why they do not want to take the medication.
d. Hold the medication and contact the healthcare provider.
Answer: d. Hold the medication and contact the healthcare provider.
Rationale:
The nurse should respect the client's right to refuse medication. Holding the medication and
contacting the healthcare provider allows for further assessment of the situation and

determination of the appropriate course of action. This ensures the client's safety and well-being
and helps to address any concerns or reasons for refusal.
242. A nurse is positioning a client who is scheduled for a lumbar puncture. The nurse should
assist the client into which of the following positions?
a. Prone with the head turned to the side and knees flexed toward the abdomen.
b. Supine with the head elevated 30 degrees.
c. Lateral with the knees flexed toward the chest and the head flexed.
d. Sitting on the edge of the bed with the legs dangling.
Answer: c. Lateral with the knees flexed toward the chest and the head flexed.
Rationale:
Positioning the client in a lateral position with the knees flexed toward the chest and the head
flexed allows for better visualization of the spinal landmarks during the lumbar puncture
procedure and facilitates the opening of the intervertebral spaces, reducing the risk of trauma to
the spinal cord and nerves.
243. A nurse manager is providing an in-service on hand hygiene to assistive personnel. Which
of the following information should the nurse manager include in the in-service?
a. Use soap and water when hands are visibly soiled.
b. Rub hands together vigorously for at least 10 seconds when using an alcohol-based hand rub.
c. Rinse hands with hot water after using soap.
d. Apply lotion before performing hand hygiene.
Answer: a. Use soap and water when hands are visibly soiled.
Rationale:
When hands are visibly soiled, soap and water should be used for hand hygiene to effectively
remove dirt, organic material, and microorganisms. Alcohol-based hand rubs are not effective on
visibly soiled hands.
244. A nurse is collecting data from a client who has a newly applied cast to the right lower
extremity. Which of the following findings should the nurse expect?
a. Pallor of the toes.
b. Warmth of the toes.
c. Capillary refill of the toes within 5 seconds.
d. Paresthesia of the toes.

Answer: b. Warmth of the toes.
Rationale:
Warmth of the toes indicates adequate circulation to the extremity. Pallor, delayed capillary refill,
and paresthesia are signs of impaired circulation and should be reported to the provider
immediately.
245. A nurse is reinforcing teaching with a group of clients about the Heimlich maneuver during
a first-aid class. The nurse should include in the teaching that which of the following
manifestations indicates the need for the Heimlich maneuver to be performed? (Select all that
apply.)
a. Inability to speak.
b. Coughing forcefully.
c. Wheezing.
d. Cyanosis.
e. Clutching at the throat.
Answer:
a. Inability to speak.
d. Cyanosis.
e. Clutching at the throat.
Rationale:
Inability to speak, cyanosis, and clutching at the throat are signs that the airway is obstructed and
the Heimlich maneuver should be performed. Coughing forcefully and wheezing indicate partial
airway obstruction and do not require the Heimlich maneuver.
246. A nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma.
The nurse should plan to monitor the client for which of the following adverse effects?
a. Bradycardia.
b. Hypoglycemia.
c. Weight gain.
d. Hypertension.
Answer: c. Weight gain.
Rationale:

Weight gain is a common adverse effect of long-term corticosteroid therapy such as prednisone.
Other potential adverse effects include hypertension, hyperglycemia, and osteoporosis.
247. A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client
who has an elevated cholesterol level. Which of the following instructions should the nurse
include?
a. Select lean cuts of meat such as beef brisket.
b. Use olive oil for cooking and salad dressings.
c. Limit intake of nuts and seeds.
d. Choose whole milk and full-fat dairy products.
Answer: b. Use olive oil for cooking and salad dressings.
Rationale:
Olive oil is a monounsaturated fat and can help reduce LDL cholesterol levels when used in
place of saturated and trans fats. Lean cuts of meat, limiting nuts and seeds, and choosing low-fat
or fat-free dairy products are also recommended for reducing solid fat consumption.
248. A nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hr ago
and has a fourth-degree perineal laceration. Which of the following interventions should the
nurse recommend?
a. Encourage the client to sit with her legs elevated.
b. Instruct the client to use a sitz bath every 4 hr.
c. Apply ice packs to the perineum for the first 24 hr.
d. Administer a stool softener as prescribed.
Answer: d. Administer a stool softener as prescribed.
Rationale:
Administering a stool softener as prescribed helps prevent constipation and reduces strain during
bowel movements, which can increase discomfort and the risk of dehiscence in clients with
perineal lacerations.
249. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used
during labor. Which of the following statements by a client indicates an understanding of
cutaneous stimulation?
a. "I plan to walk around during my contractions."
b. "I'll bring some music to listen to during labor."

c. "My partner will massage my lower back."
d. "I want to use a warm shower to help with the pain."
Answer: c. "My partner will massage my lower back."
Rationale:
Cutaneous stimulation, such as massage, can help relieve discomfort during labor by stimulating
sensory nerves and reducing the perception of pain. Walking, music, and warm showers are other
nonpharmacological pain relief methods commonly used during labor.
250. A nurse is reinforcing discharge teaching with a client who has dependent personality
disorder. Which of the following instructions should the nurse include in the discharge teaching?
a. "Avoid seeking reassurance from others."
b. "Set realistic goals for yourself."
c. "Limit contact with family and friends."
d. "Make decisions independently without consulting others."
Answer: b. "Set realistic goals for yourself."
Rationale:
Setting realistic goals helps the client with dependent personality disorder to develop a sense of
independence and self-reliance. Avoiding seeking reassurance from others, limiting contact with
family and friends, and making decisions independently without consulting others are not
recommended because they can exacerbate symptoms of dependency.
251. A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr.
Which of the following actions should the nurse take after administering the medication?
a. Administer a sedative.
b. Encourage the client to ambulate.
c. Monitor the client for respiratory depression.
d. Provide a high-protein meal.
Answer: c. Monitor the client for respiratory depression.
Rationale:
Lorazepam is a benzodiazepine that can cause respiratory depression, especially when given
before surgery. The nurse should monitor the client closely for signs of respiratory depression,
such as decreased respiratory rate and depth, and be prepared to intervene if necessary.

252. A nurse is collecting data from an older adult client during a routine physical examination.
Which of the following client statements should the nurse identify as a possible indication of
maltreatment?
a. "I've been feeling more tired lately."
b. "My son helps me with my medications."
c. "I fell at home and bruised my arm."
d. "I don't see my family very often."
Answer: d. "I don't see my family very often."
Rationale:
Social isolation, such as not seeing family or friends, can be an indication of elder maltreatment.
The nurse should further assess the client's living situation and support system to determine if
there are any signs of neglect or abuse.
253. A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are
inconsistent with the parent's stated cause. Which of the following actions should the nurse take?
a. Document the findings.
b. Ask the parent to explain the inconsistencies.
c. Report the findings to the charge nurse.
d. Notify the authorities of suspected child abuse.
Answer: d. Notify the authorities of suspected child abuse.
Rationale:
Injuries that are inconsistent with the parent's stated cause can be a sign of child abuse. The nurse
is mandated to report suspected child abuse to the appropriate authorities for further investigation
and intervention.
254. A nurse is caring for a client who has a prescription for ranitidine 150 mg PO BId. Available
is ranitidine syrup 15 mg/mL. How many mL should the nurse administer each day? (Round the
answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
a. 10 mL/day
b. 20 mL/day
c. 5 mL/day
d. 15 mL/day
Answer: d. 15 mL/day

Rationale:
To calculate the total daily dose, multiply the dose per administration (150 mg) by the number of
administrations per day (2), then divide by the concentration of the syrup (15 mg/mL): (150 mg
× 2) / 15 mg/mL = 300 mg / 15 mg/mL = 20 mL/day
255. A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee
amputation of the right leg. Which of the following instructions should the nurse include?
a. "Apply lotion to the residual limb daily."
b. "Keep the prosthesis on at all times, even when sleeping."
c. "Inspect the skin for redness or irritation."
d. "Soak the prosthesis in warm water daily to clean it."
Answer: c. "Inspect the skin for redness or irritation."
Rationale:
Inspecting the skin for redness or irritation helps to identify any signs of pressure sores or skin
breakdown early, allowing for prompt intervention and prevention of complications. Applying
lotion to the residual limb, keeping the prosthesis on at all times, and soaking the prosthesis in
warm water daily are not recommended and may lead to skin irritation or damage.
256. A nurse is speaking with the partner of a client who has Alzheimer's disease. The partner
states, "I love him, but caring for him is wearing me out." Which of the following responses
should the nurse make?
a. "Have you considered placing him in a long-term care facility?"
b. "It sounds like you're feeling overwhelmed. Let's discuss some options for respite care."
c. "Caring for someone with Alzheimer's disease can be challenging, but you're doing a great
job."
d. "You should take some time for yourself and go on a vacation."
Answer: b. "It sounds like you're feeling overwhelmed. Let's discuss some options for respite
care."
Rationale:
Acknowledging the partner's feelings of being overwhelmed and offering options for respite care
shows support and provides practical solutions to help alleviate caregiver stress. Placing the
client in a long-term care facility or suggesting a vacation may not be appropriate or feasible at
this time.

257. A nurse on an acute care unit is collecting data from a school-age child who has cystic
fibrosis (CF). Which of the following findings is the priority for the nurse to report to the
provider?
a. Clubbing of the fingers.
b. Persistent cough with thick sputum.
c. Poor weight gain.
d. Wheezing on auscultation.
Answer: d. Wheezing on auscultation.
Rationale:
Wheezing on auscultation can indicate airway obstruction, which is a serious complication in a
child with cystic fibrosis. The nurse should report this finding to the provider immediately for
further evaluation and intervention.
258. A nurse is reinforcing discharge teaching with a client who is postoperative following an
open radical prostatectomy. Which of the following instructions should the nurse include in the
teaching?
a. "Avoid deep breathing and coughing to prevent strain on the incision."
b. "Limit fluid intake to decrease the risk of bladder irritation."
c. "Use a sitz bath to promote comfort and healing."
d. "Refrain from driving for 6 weeks after surgery."
Answer: c. "Use a sitz bath to promote comfort and healing."
Rationale:
Using a sitz bath promotes comfort and healing of the perineal area following a prostatectomy.
Deep breathing and coughing should be encouraged to prevent respiratory complications.
Increased fluid intake helps prevent urinary tract infections. Driving restrictions may vary
depending on the client's recovery and the type of surgery performed.
259. A nurse is reinforcing teaching with a client about how to use an incentive spirometer.
Which of the following actions by the client indicates an understanding of the teaching?
a. Inhaling slowly and evenly through the mouthpiece.
b. Exhaling forcefully into the mouthpiece.
c. Holding the breath for 10 seconds after inhaling.
d. Performing the exercise every 2 hours.

Answer: a. Inhaling slowly and evenly through the mouthpiece.
Rationale:
Inhaling slowly and evenly through the mouthpiece maximizes lung expansion and encourages
the client to take deep breaths. Exhaling forcefully into the mouthpiece, holding the breath after
inhaling, and performing the exercise every 2 hours are not correct techniques for using an
incentive spirometer.
260. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The
nurse notes excessive lochia discharge. Which of the following actions should the nurse take
first?
a. Assess the client's vital signs.
b. Massage the client's fundus.
c. Administer oxytocin as prescribed.
d. Check the client's perineum for lacerations.
Answer: a. Assess the client's vital signs.
Rationale:
Excessive lochia discharge may indicate postpartum hemorrhage. The nurse should assess the
client's vital signs first to determine the severity of the bleeding and the need for further
intervention. Massaging the fundus, administering oxytocin, and checking for perineal
lacerations may be necessary interventions but should not take priority over assessing the client's
vital signs.
261. A nurse manager is preparing to complete a performance analysis for a group of assistive
personnel (AP). The manager asks a staff nurse for feedback on each AP's abilities. Which of the
following actions should the staff nurse take?
a. Provide feedback based on the AP's clinical competence.
b. Offer feedback only on areas needing improvement.
c. Withhold feedback until the AP's annual performance review.
d. Provide feedback in writing to the AP.
Answer: a. Provide feedback based on the AP's clinical competence.
Rationale:
Providing feedback based on the AP's clinical competence allows for ongoing performance
improvement and ensures that the AP is meeting the expectations of the role. Feedback should be

timely, specific, and focused on both areas of strength and areas needing improvement. Waiting
until the annual performance review or providing feedback only on areas needing improvement
may not be as effective in promoting professional growth and development. Providing feedback
in writing may be appropriate in some situations but should not replace verbal feedback and
discussion.