Preview Extract
ATI RN VATI Comprehensive Predictor 2023/2024 Form A and B 255 Questions and
Answers
A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
Answer: bounding pulse
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the purpose of
the technique
Answer: This technique decreases the risk of subcutaneous infiltration
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan?
Answer: Monitor the client for 1 hr after meals
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After
moving the client to safety, which of the followings is the priority action?
Answer: Close the fire door on the unit
A nurse is assessing a client who has delirium due to a febrile illness. Which of the following
findings should the nurse expect?
Answer: Hallucinations
A nurse is caring for a client following an open colectomy. Which of the following findings
places the client at risk for delayed wound healing?
Answer: hyperemesis
A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The
nurse should evaluate which of the following laboratory tests to determine effective long-term
management of blood glucose levels?
Answer: A1C
A nurse is caring for a client who has neutropenia due to HIV. Which of the following
precautions should the nurse take while caring for this client?
Answer: Use a dedicated stethoscope
A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following
actions should the nurse take?
Answer: Tell the client to avoid drinking fluids 1 hr before bedtime
A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive
phototherapy. Which of the following interventions should the nurse include?
Answer: Place the newborn 45 cm from the light source
A nurse is planning care for a client who has schizophrenia and is having difficulty expressing
their feelings. Which of the following referrals should the nurse make?
Answer: social worker
A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which
of the following findings indicates the client is experiencing an adverse effect of the medication
Answer: decreased reflexes
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list
of client reports. Which of the following client reports should the nurse assess first?
Answer: indigestion
A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which
of the following actions by the assistive personnel requires the nurse to intervene?
Answer: offer oral fluids to the client
A nurse on a medical unit has just received change-of-shift report. Which of the following clients
should the nurse assess first?
Answer: A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain
as a 4 on a scale of 0 to 10
A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an
allergy to which of the following food can indicate that the client has an allergy to latex?
Answer: avocados
A nurse is preparing to witness a client's signature on an informed consent for a total knee
arthroplasty. Which of the following client statements indicates the nurse should contact the
surgeon?
Answer: I am thankful there are no serious complications from this type of surgery
A nurse is admitting a client who has antisocial personality disorder. Which of the following
client behaviors should the nurse identify as consistent with this disorder?
Answer: Uses others for personal gain
A nurse is teaching the parent of a school-age child who has scabies about the application of
permethrin 5% cream. The nurse should include which of the following as a potential adverse
effect of the medication?
Answer: burning
A nurse is teaching a client who has a new prescription for digoxin. Which of the following
statements should the nurse include in the teaching?
Answer: muscle weakness
A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of
urinary tract infections. Which of the following information should the nurse plan to include in
the teaching about UTI prevention?
Answer: Empty the bladder before and after intercourse
A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed.
Which of the following should the nurse recommend the client increase in their diet during
lactation?
Answer: Calcium
A nurse is providing teaching about preventing mastitis to a client who is postpartum and
breastfeeding her newborn. Which of the following instructions should the nurse include?
Answer: Try to have your baby empty your breasts with each feeding."
A nurse is caring for a client who reports chest pain. Which of the following findings indicates
myocardial damage?
Answer: Troponin I 1.8 ng/mL
A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the
following statements by the parent indicates an understanding of the teaching?
Answer: "I should place my baby's car seat rear-facing until 6 months of age."
A nurse is performing high-frequency chest compressions using a mechanical chest compression
device for a child who has cystic fibrosis. Which of the following findings indicates the
treatment has been effective?
Answer: The child has increased sputum production
A nurse is caring for a client following a possible exposure to anthrax. Which of the following
actions should the nurse take?
Answer: antitoxin
A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat
cervical cancer. Which of the following is an appropriate action for the nurse to take?
Answer: Keep a 3 foot distance from the radiation implant
A nurse is admitting a client to the medical-surgical unit. Which of the following actions should
the nurse take first?
Answer: Observe the client's level of mobility
A nurse at a public health clinic is caring for a group of clients. Which of the following should
the nurse identify as a reportable diagnosis to the CDC?
Answer: hep A
A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the
following actions should the charge nurse identify as an effective time management skill?
Answer: Completes activities for one client before moving to the next client
A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which
of the following findings should the nurse expect?
Answer: Hyperreflexia
A nurse is planning to perform wound irrigation for a client who has an open secondary wound.
When creating a sterile field, which of the following actions should the nurse take?
Answer: Hold the bottle of sterile solution with the palm over the label while pouring
A nurse is planning care for a client who has a sealed radiation implant and is to remain in the
hospital for 1 week. Which of the following should the nurse include in the plan of care?
Answer: Wear a dosimeter film badge while in the client's room
A nurse is assessing a client who was brought to the emergency department by his adult child.
The client has visible contusions on all four extremities. Which of the following actions should
the nurse take?
Answer: Report the incident to Adult Protective Services
A nurse is assessing a client who is postoperative following abdominal surgery. The client states,
"I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the
following actions should the nurse take?
Answer: Extend the client's legs above heart level
A nurse is providing teaching to the parent of a 6 month old infant who is teething and having
difficulty sleeping. Which of the following instructions should the nurse include?
Answer: Administer acetaminophen drops to your child before bedtime
A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of
the following foods should the nurse recommend?
Answer: egg whites
A home health nurse is teaching a guardian about administering tube feedings to their 3 month
old infant. Which of the following information should the nurse include in the teaching?
Answer: Allow the infant to suck on a pacifier during feedings
A charge nurse is creating assignments for the next shift for several nurses and one of the nurses
is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not
pregnant?
Answer: A 60 year old client who is recovering from shingles
A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following
findings should the nurse expect?
Answer: Hypotension
A nurse is reviewing the medical record of a client who has a new prescription for gentamicin.
The nurse should identify that concurrent use with which of the following current medications
can increase the client's risk for ototoxicity?
Answer: Furosemide
A nurse is performing triage following a natural disaster. Which of the following clients should
the nurse identify as the highest priority to receive care?
Answer: A client who has a traumatic arm amputation
A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is
receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for
which of the following findings?
Answer: Contractions occur every 90 seocnds
A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood
pressure. The nurse should identify that these findings are potential manifestations of which of
the following?
Answer: Opioid intoxication
A nurse is precepting a nursing student who brings the following client observations to the
nurse's attention. Which of the following clients should the nurse assess first?
Answer: A client who is coughing up pink-tinged sputum following a bronchoscopy and lung
biopsy 1 hr ago
A nurse manager is reviewing documentation standards with a group of newly licensed nurses.
Which of the following statements should the nurse manager include in the teaching?
Answer: Include the complete name of the medication morphine sulfate
A community health nurse is performing a vision screening on a 4 month old infant.
When shining a light source into the infant's visual field, which of the following is an expected
finding?
Answer: the infant closes their eyes
A nurse is teaching a client and their family about home hospice care. Which of the following
information should the nurse include in the teaching?
Answer: Hospice care improves quality of life through palliative care
A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is
appropriate?
Answer: Use aseptic technique and drop the medication into the conjunctival sac
A nurse manager at a public health clinic is concerned about the rising number of sexually
transmitted infections in the community. The purpose of which of the following is to generate
new ideas to address the public health concern?
Answer: A brainstorming session with nurses
A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure.
Which of the following information should the nurse include in the teaching?
Answer: Change clothes after working in the field
A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should
the nurse take?
Answer: Monitor for abdominal ascites
A nurse is caring for a client who is receiving systematic desensitization therapy to treat
agoraphobia. Which of the following client statements should indicate to the nurse that the
treatment has been effective?
Answer: I was able to sit on a park bench for 30 minutes
A nurse is caring for a client who is receiving a blood transfusion at 125mL/hr and develops a
hemolytic reaction. Which of the following actions should the nurse perform?
Answer: Infuse 0.9% sodium chloride IV
A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral
feedings at 65mL/hr through a gastrostomy tube. Which of the following findings requires
immediate intervention by the nurse?
Answer: The gastric residual volume is 250 mL following 2 hr of infusion
A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker.
Which of the following statements by the client indicates that the teaching has been effective?
Answer: I will go to my cardiologist's office when the battery needs to be changed
A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a
client who threw a chair in the day room. The nurse should identify which of the following
findings as an indication to remove the restraints?
Answer: The client apologizes for their aggressive behavior
A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a
continuous IV infusion. After confirming compatibility, which of the following actions should
the nurse take?
Answer: Occlude the IV tubing above the injection port
A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine
for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's
medical history, the nurse should recognize which of the following diagnoses as a
contraindication to the administration of methylergonovine?
Answer: hypertensio
A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12
hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the
trough level to be drawn at which of the following times?
Answer: 1800
A nurse is performing a skin assessment for a client who is on bedrest. Which of the following
actions should the nurse take to prevent a pressure injury?
Answer: Apply a donut ring pillow under the client's sacral area
A nurse from the State Health Development is instructing a group of nurses regarding reportable
infections. Which of the following infections should the nurse report to the Centers for Disease
Control and Prevention?
Answer: lyme disease
A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the
following actions should the nurse take first?
Answer: Demonstrate how to perform the procedure
A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The
client informs the nurse that he took his prescribed medications before coming to the clinic.
Which of the following medications is the priority to report to the provider?
Answer: Metformin
A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for
which of the following potential contraindications?
Answer: shellfish allergy
A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy
with clozapine. Which of the following is the highest priority for the client to report to the
provider?
Answer: fever
2 hr postoperative following an ileal conduit procedure bladder cancer
Answer: dusky colored stoma
Administer an injection to a client when the client states, "I don’t want that injection. The last
time I got that was sore for a week
Answer: battery
Assessing client who systemic lupus erythematous SLE which of the following is an expected
findings
Answer: dry rasied fasical rash
Caring for a client who has a new prescription for chlorpromazine by IM injection
Answer: check ortho bp 1 hr after administration
Charge nurse on paediatric unit is making assignments for a float nurse from the medical unit. Pt
to see first?
Answer: a 10-year old who has pneumonia and is receiving respiratory treatments.
Child who is unresponsive has increased intracrainal pressure
Answer: pad rails
A client hopitialized for a bone marrow transplant is in protective isolation while undergoing
total body radiation and intense chemotherapy. The clients sibling comes to visit but has obvious
manifestations of an upper respiratory infection.
Answer: Allow the sibling to visit after donning a sterile gown, mask, gloves but prohibits
physical contact
Client who has given birth to a stillborn
Answer: Acknowledging the reality of the nb death
Client who is receving a controlled epidural analgesia infusion
Answer: Covering the insertion site with a transparent dressing
delegates the following tasks to the assistive personnel bathe four clients distribute fresh water
obtain morning vital signs
Answer: set a clear time frame for the completion of each task
Diagnosis of antisocial personality disorder
Answer: poor impulse control
Haloperidol for the treatment of schizophrenia
Answer: screen the client for tardive dyskinesia
In patient psychiatric unit is setting short-term goals for an adolescent who was admitted for
treatment of anorexi nervosa
Answer: The client will develop personalized meal plan
A nurse in a pediatric unit is caring for a group of clients. Which of the following diseases should
the nurse implement droplet precautions?
Answer: Pertussis
A nurse in the emergency department is caring for a client following a motor vehicle crash.
priority?
Answer: c spine
A nurse is admitting a client who has chronic gout what med should the nurse admin?
Answer: allopurinol
nurse is admitting an unidentified female who was brought to the emergency department
Answer: 3 month old
A nurse is caring for a client who has a typical depression and is taking phenelzine. what can you
eat?
Answer: low fat yogurt
A nurse is caring for a client who is manic. Which of the following activities is appropriate for
the nurse to suggest?
Answer: taking walks
a nurse is caring for a client who is receiving gentamicin. Which of the following findings
indicates the client is developing toxicity
Answer: tinnitus
nurse is caring for a client who will be, receiving a transfusion of platelets
Answer: Decrease in bleeding from puncture sites
nurse is caring for a client with fractured ribs, has developed thrombophlebitis, and is being
treated with a heparin drip. The client develops hematuria and has an activated partial
thromboplastin time aPTT of 100 seconds
Answer: turn off heparin drip
A nurse is caring for a postoperative client. Which of the following interventions will reduce the
risk of deep-vein thrombosis
Answer: boots
nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1 hr ago.
Answer: pillow
a nurse is interviewing a client who presents with multiple injuries that are consistent with
intimate partner abuse. After establishing trust and rapport, which of the following should the
nurse say?
Answer: lets talk about what happened to you
a nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parent
Answer: swallowing sounds are audible stool are yellow and seedy after 7 days maternal breasts
become soft following feeds
Windshield survey
Answer: religous
A nurse is reviewing the lab report of a client who has a mag level of 1.0mEq/L. Which of the
following should the nurse expect?
Answer: Cardiac dysrrhythmia
A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. which
of the lab values will you report to the provider?
Answer: WBC 3,000
A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of
urinary tract infections. Which of the following information should the nurse plan to include in
the teaching about UTI prevention?
Answer: Empty the bladder before and after intercourse
A nurse is teaching a client about nutritional intake. include in the teaching
Answer: Carbs should be atleast 45%-65% of you caloric intake
A nurse is performing high-frequency chest compressions using a mechanical chest compression
device for a child who has cystic fibrosis. Which of the following findings indicates the
treatment has been effective?
Answer: The child has increased sputum production
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the purpose of
the technique?
Answer: This technique decreases the risk of subcutaneous infiltration
A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which
of the following findings indicates the client is experiencing an adverse effect of the medication
Answer: Decreased reflexes
client who had a CVA. perform to prevent foot dropping
Answer: Place positing boots on the client's feet
A nurse in a provider's office is teaching a client 16 weeks of gestation and has a new
prescription for ferrous sulfate. What should the nurse include in the teaching
Answer: Take you iron with fluids other than coffee and tea
A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat
cervical cancer. Which of the following is an appropriate action for the nurse to take?
Answer: Keep a 3 foot distance from the radiation implant
A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the
following actions should the charge nurse identify as an effective time management skill?
Answer: Completes activities for one client before moving to the next client
A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The
client states he took all his meds before coming. which of the following medication is priority to
report to the provider
Answer: Clopidegrel
Four clients to an emergency department. The nurse should plan to see which of the following
first?
Answer: 50-year old client who has slurred speech, disoriented and reports a headache
placenta previa. Which of the following client findings should the nurse include?
Answer: Bring red vaginal bleeding
A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood
pressure. The nurse should identify that these findings are potential manifestations of which of
the following?
Answer: Opioid intoxication
A nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy. What
should the nurse include in the teaching
Answer: estrogen therapy increase the risk for thrombus formation
A nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The
client develops uncontrolled contraction of the head and neck muscles. Which of the following
medications should the nurse administer
Answer: diphenhydramine
A nurse on a med-surg unit is caring for a group of clients. Which of the following clients would
benefit from a three-way indwelling catheter
Answer: female who is prone to development of blood clots in the urine
A nurse is assessing the vital signs of a newborn who was born 8hrs ago. Which of the following
findings require interventions by the nurse?
Answer: blood pressure
windshield survey
Answer: The availability of religious facilities.
A nurse is caring for a postoperative client. Which of the following interventions will reduce the
risk of DVT
Answer: apply venous plexus foot pumps
A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the
following statements by the parent indicates an understanding of the teaching?
Answer: "I should place a rolled blanket along each side of my baby's head in the car seat."
A nurse is providing teaching about nutrition to the parents of a preschooler who has chronic
renal failure. Which of the following indicates understanding teaching
Answer: I should limit my child's intake of protein
A nurse is assessing a client who has COPD and experienced recent weight loss. Which of the
following findings should the nurse report to the provider?
Answer: Coughing and wheezing after eating
Risk for metabolic alkalosis
Answer: A client who has severe hyperemesis
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list
of client reports. Which of the following client reports should the nurse assess first?
Answer: Indigestion
A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
Answer: elevated urine specific gravity
A nurse is caring for a group of clients in an inpatient mental health facility. Which of the
following task should the nurse delegate to the AP
Answer: Sit with the client who has anorexia nervosa during meals
obtaining a culture
Answer: 1. Assess the appearance of the wound
2. Obtain the specimen from granulation tissue of the wound
3. Place the swab in the culture tube.
4. Cleanse the would with 0.9%
5. Cover the wound with a sterile dressing
A nurse is teaching the parent of a school-age child who has scabies about the application of
permethrin 5% cream. The nurse should include which of the following as a potential adverse
effect of the medication?
Answer: burning
A community health nurse is performing a vision screening on a 4 month old infant. When
shining a light source into the infant's visual field, which of the following is an expected finding?
Answer: the infant closes their eyes
A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which
of the following findings should the nurse expect?
Answer: hyperreflexia
The patient states they do not want the injection but the nurse gives it anyways
Answer: battery
Client taking phenelzine
Answer: cheddar cheese
A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The
nurse should evaluate which of the following laboratory tests to determine effective long-term
management of blood glucose levels?
Answer: HbA1C
A nurse manager at a public health clinic is concerned about the rising number of sexually
transmitted infections in the community. The purpose of which of the following is to generate
new ideas to address the public health concern?
Answer: A brainstorming session with nurses
hip arthroplasty and notes the dressing is saturated with sanguineous drainage. Which of the
following actions should the nurse take?
Answer: Reinforce the dressing with sterile gauze
bathe four clients, distribute fresh water, and obtain the morning vital signs. At noon the nurse
ask the AP to transport one client to physical therapy. The nurse delegate more effectively in the
future?
Answer: Plan a more reasonable job assignment
A nurse is preparing to administer enoxaprin to a client. Which of the following actions should
the nurse plan to take?
Answer: Inject the medication in the lateral abdominal wall
systemic lupus
Answer: dry raised facial rash
common manifestation of food allergies
Answer: vomiting
sterile field
Answer: open the first flap away from the body
A nurse on a mental health unit receives report on four client. Which of the following clients
should the nurse attend to first
Answer: A client who is having auditory hallucination and is becoming agitated
A nurse is assessing a full-term newborn who is 24hr old. What should be reported to the
provider
Answer: newborn neck is short and surrounded by skin folds
A nurse on an orthopedic floor is completeing the morning assessments on several clients. Which
client is more at risk for a fat embolism
Answer: 24 yr old male who has a casted femur fracture
A community health nurse is caring for a client who request a referral for family therapy.
The nurse should include who from interdisciplinary team?
Answer: Social worker
A nurse manager is reviewing documentation standards with a group of newly licensed nurses.
Which of the following statements should the nurse manager include in the teaching?
Answer: Include the complete name of the medication morphine sulfate
A nurse is performing triage following a natural disaster. Which of the following clients should
the nurse identify as the highest priority to receive care?
Answer: A client who has a traumatic arm amputation
A nurse is caring for a client who is manic. Which of the following activities is appropriate for
the nurse to suggest?
Answer: take a daily walk on the hospital grounds
A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure.
Which of the following information should the nurse include in the teaching?
Answer: Change clothes after working in the field
A nurse is admitting a client to a med-surg unit. What action should the nurse take first
Answer: Assess the clients level of mobility
A nurse is reviewing the medical records of four clients. Which of the following prescriptions
correct documentation?
Answer: Enoxaparin 30 mg SC every 12 hr
Adolescent who has anorexia nervosa
Answer: hypokalemia
a nurse is preparing to discharge a newborn who has atrial septal defect. Who should the nurse
expect the provider to recommend
Answer: occupational manager
gentamicin toxicity
Answer: tinnitus
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan?
Answer: Monitor the client for 1 hr after meals
A nurse is caring for a client following a possible exposure to anthrax. Which of the following
actions should the nurse take?
Answer: Begin prophylactic treatment with ciprofloxacin
Report to the CDC
Answer: Hepatitis A
levels a depression in the skin 8mm deep
Answer: 4+edema
A nurse is teaching a client who is at 35 week of gestation about amniocentesis. Which of the
following statements should the nurse include in the teaching?
Answer: you should monitor for the onset of contractions after the test
A nurse is caring for a client who has heart failure and a potassium level of 3 mEq/L. The nurse
should obtain verification of which of the following prescriptions from the provider
Answer: digoxin 0.125mg po daily
A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the
following actions should the nurse take first
Answer: Clarify the client's actual and perceived health needs.
A nurse is assessing a client who has delirium due to a febrile illness. Which of the following
findings should the nurse expect?
Answer: Hallucinations
diagnosis of antisocial personality disorder
Answer: poor impulse control
A nurse is caring for a client who is post right-modified radial mastectomy. Which of the
following should the nurse recognize as a priority finding.
Answer: emesis of 110ml of thick yellow fluid
dysphagia, what should the client recommend
Answer: oatmeal
A nurse is assessing a client who was brought to the emergency department by his adult child.
The client has visible contusions on all four extremities. Which of the following actions should
the nurse take?
Answer: Report the incident to Adult Protective Services
Run cats spin the rain throwing procedures mechanical paper lake
Answer: word salad
eye drops
Answer: maintain the child in a sitting position 3 mins after
report to the CDC
Answer: syphilis
A nurse is teaching a client who has a new prescription for digoxin. Which of the following
statements should the nurse include in the teaching?
Answer: notify your provider if you experience muscle weakness
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via
continuous IV fusion. Which of the following should be reported to the provider
Answer: Mag levels 9mEq/L
meningitis. What assessment to perform?
Answer: Brudzinski sign
A nurse is providing dietary teaching to a client who has an increased cholesterol level.
Which of the following foods should the nurse recommend?
Answer: egg whites
A nurse is planning care for a child who is unresponsive and has increased ICP. Which of the the
following actions should the nurse take?
Answer: place the child in Trendelenburg position
A nurse is caring for a child who has a new prescription for chlorpromazine by IM injection.
Which of the following is an appropriate action?
Answer: Check orthostatic blood pressure 1hr after administration
mononucleosis . What findings
Answer: splenomegaly malaise sore throat
meningitis
Answer: initiate droplet precaution
continuous bubbling in the water-seal chamber
Answer: check for an air leak
A client asks the nurse if it is safe for him to take a glucosamine supplement
Answer: shellfish allergy
A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to
administering the first dose, which of the following laboratory values should the nurse evaluate?
Answer: Thyroid hormones
A nurse is preparing to administer an IV bolus of albumin 5% to a client receiving a continuous
IV infusion. What action should the nurse take
Answer: use the injection site farthest away from the IV insertion site
breech of client confidentiality
Answer: Discussing the clients reaction to the transfer with another staff nurse
A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should
the nurse take?
Answer: Monitor for abdominal ascites
A nurse is caring for a client following an open colectomy. Which of the following findings
places the client at risk for delayed wound healing?
Answer: Hyperemesis
A nurse is delegating task to an AP. For which of the following can the nurse assign to the AP to
measure vital signs
Answer: A client who is requisition pain medication 2 days after surgery
A circulating nurse is implementing a "time-out" before moving a client who is having total hip
arthroplasty to the surgical site. Which of the following actions should the nurse take.
Answer: confirm the provider has market the surgical site
A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an
allergy to which of the following food can indicate that the client has an allergy to latex?
Answer: avocados
allopurinol. Which of the following lab findings to determine the effectiveness
Answer: uric acid level
haloperidol for the treatment of schizophrenia
Answer: screen the client for tardive dyskinesia
A nurse is caring for a preschool-age child who has a short-leg plaster cast applied 1 hr ago.
Which of the following is an appropriate intervention
Answer: support the affected leg on a pillow
A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
Answer: substernal chest pain
bone marrow transplant is in protective isolation while undergoing total body radiation and
intense chemo.
Answer: Allow the sibling to wave at the client through the window of the door
A client who is 8hr postpartum asks the nurse id she will nee to receive Rh immune globulin. The
client is gravid 2, para 2, and her blood type is AB negative. The newborn's blood type is B
positive. Which of the following statement is appropriate ?
Answer: should be given 72 hrs after delivery
receiving lasted Ringer's to treat fluid volume deficit. Indicates a therapeutic response to the
treatment
Answer: Increased blood pressure
neutropenia about food safety to prevent food borne illness
Answer: Refrigerate leftover with 2 hrs
A nurse is caring for a female client who has bruises on her arms that she explains are result of
physical abuse by her partner.
Answer: Insite that the client report the abusive behavior to the proper authority
providing postoperative teaching to a client who has a newly inserted pacemaker
Answer: I will use my cellphone on the ear opposite of my pacemaker
a nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy
with clozapine. Which of the following is priority to report to the provider
Answer: blurred vision/ fever
A nurse is performing a vision screening for a client. Which of the following finding should the
nurse identify as an indication that the client has cataract
Answer: increased opacity of the lens of the eye
A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following
actions should the nurse take?
Answer: Tell the client to avoid drinking fluids 1 hr before bedtime
A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed.
Which of the following should the nurse recommend the client increase in their diet during
lactation?
Answer: calcium
A nurse is planning to perform wound irrigation for a client who has an open secondary wound.
When creating a sterile field, which of the following actions should the nurse take?
Answer: Hold the bottle of sterile solution with the palm over the label while pouring
A nurse is assessing a client who is postoperative following abdominal surgery. The client states,
"I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the
following actions should the nurse take?
Answer: place the client in low fowler's
A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat
cervical cancer. Which of the following is an appropriate action for the nurse to take?
Answer: Wear a lead apron
A nurse is planning an educational session for a client who has type 1 diabetes mellitus. Which of
the following should the nurse plan to include when teaching the client to monitor for
hypoglycemia
Answer: diaphoresis
A nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the
following actions should the nurse take
Answer: Apply the tourniquet 15cm(6in) about the insertion site
fetal lung maturation
Answer: betamethsone
A nurse is planning care for a newborn who is receiving phototherapy. Which of the following
actions should the nurse include in the plan of care
Answer: Assess the infants eyes for corneal irritation every 4hrs
A nurse is caring for a client who is receiving a blood transfusion at 125 ml/hr and develops a
hemolytic reaction. which of the following action should the nurse perform
Answer: infuse 0.9% sodium chloride IV
A nurse is planning care for a client who has schizophrenia and is having difficulty expressing
their feelings. Which of the following referrals should the nurse make?
Answer: art therapist
report to the cdc
Answer: lyme disease
a client who has dysphasia and a new prescription for divalproex sodium extended release
Answer: administer with applesauce
education about electroconvulsive therapy ECT major depressive disorder
Answer: general anesthetic administered prior to ECT treatments
A nurse is teaching a client and their family about home hospice care. Which of the following
information should the nurse include in the teaching?
Answer: Hospice care improves quality of life through palliative care
A nurse is caring for a client who is taking alprozolam. Which prescription needs clarifying with
the provider
Answer: lorazepam
Jewish
Answer: meat and dairy are eaten separate
A nurse is assessing a client who has non-Hodgkin's lymphoma. Which of the following findings
should indicate to the nurse that the client might be experiencing syndrome of inappropriate
antidiuretic hormone
Answer: diminished deep tendon reflexes
Which of the following methods should the nurse use to confirm placement prior to imitating
feeding
Answer: Test pH level from client gastric aspirate
a home health nurse is teaching a guardian about administering tube feedings to their 3-monthold infant. Which of the following information should the nurse include in the teaching?
Answer: Allow the infant to suck on a pacifier during feedings.
A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescence client who
was admitted for treatment of anorexia nervosa. Which of the following is an appropriate shortterm goal the nurse should set?
Answer: The client will gain 2 to 3lbs weekly
A nurse is preparing to witness a client's signature on an informed consent for a total knee
arthroplasty. Which of the following indicates the nurse should contact the surgeon
Answer: I am thankful there are no serious complications from this type of surgery
A nurse is caring for a client who reports chest pain. Which of the following findings indicates
myocardial damage?
Answer: Troponin I 1.8 ng/mL
A nurse is caring for a client who has a femur fracture and is on bedrest with Buck's extension
traction. Which of the following actions should the nurse take?
Answer: Inspect the clients skin under the device every 8 hrs
A nurse receives change-of-shift report on four clients. Based on the shift report information,
which of the following clients should the nurse place to assess first?
Answer: A client who had a hip arthroplasty reports pain and erythema in their calf
A nurse in the post anesthesia care unit is caring for four postop clients. The nurse realizes that
coughing poses a risk to which of the following clients?
Answer: A client who had a thyroidectomy
A nurse on a medical unit has just received change-of-shift report. Which of the following clients
should the nurse assess first?
Answer: A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain
as a 4 on a scale of 0 to 10
A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which
of the following actions by the assistive personnel requires the nurse to intervene?
Answer: Offers oral fluids to the client
2 hr postoperative following an ileal conduit procedure bladder cancer
Answer: dusky color stoma
A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a
continuous IV infusion. After confirming compatibility, which of the following action should the
nurse take?
Answer: Occlude the IV tubing about the injection port
A nurse is admitting a client who has antisocial personality disorder. Which of the following
client behaviors should the nurse identify as consistent with this disorder
Answer: use other for personal gain
A nurse is providing teaching to the parent of a 6 month old infant who is teething and having
difficulty sleeping. Which of the following instructions should the nurse include?
Answer: Administer acetaminophen drops to your child before bedtime
droplet precautions
Answer: pertussis
A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive
phototherapy. Which of the following interventions should the nurse include?
Answer: Place the newborn 45 cm from the light source
nurse is caring for a client who will be receiving a transfusion of platelets
Answer: Decrease in bleeding from puncture sites
A nurse is caring for a client who has just given birth to a stillborn newborn. Which of the
following is the priority task for the nurse to facilities in the client grief process
Answer: Acknowledging the reality of the newborn's death
A nurse is teaching a client about smoking cessation. Which of the following client statements
should the nurse identify as an understanding of teaching?
Answer: Will use high carbohydrate snacks as a substitute for cigarette.
A nurse is providing teaching about preventing mastitis to a client who is postpartum and
breastfeeding her newborn. Which of the following instructions should the nurse include?
Answer: Try to have your baby empty your breasts with each feeding
A nurse is caring for a client who is who is receiving continuous feeding via NG tube. Which of
the following actions would the nurse take?
Answer: Check the clients gastric residual every 4hrs
A nurse is teaching a client who has low-literacy level about home managements of diabetes
mellitus. Which of the following action sis appropriate?
Answer: Show the client as educational video
A nurse is caring for a group of clients. The nurse should request a referral for a speech language
pathologist for which of the following clients?
Answer: A client who has difficulty swallowing
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate by
continuous IV infusion. Which of the following findings indicate medication toxicity?
Answer: Urine output 20 ml/hr
A charge nurse is creating assignments for the next shift for several nurses and one of the nurses
is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not
pregnant?
Answer: A 60 year old client who is recovering from shingles
A client at 38 weeks of gestation enters the emergency department. The nurse should recognize
that which of the following indicates that the client is in the latent phase of labor
Answer: Cervix dilated 2cm
A home health nurse is teaching the parents of a school age child who has legg-calve-perthes
disease. Which of the following information should the nurse include
Answer: Your child should continue to attend school
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After
moving the client to safety, which of the followings is the priority action?
Answer: notify the facility operator
wrong dosage of medication was given
Answer: fidelity
A nurse is caring for a client who is racing a controlled epidural analgesia infusion. Which of the
following nursing action is appropriate?
Answer: Replacing the infusion tubing every 72 hrs
A nurse is caring for a school age child who has a blood pressure of 68/50 mm Hg and develop
sepsis shock. Which of the following medication should the nurse expect to be prescribed?
Answer: Dopamine
A nurse is caring for a toddler who has RSV. Which of the following actions should the nurse
plan to take?
Answer: use a designated stethoscope when caring for the toddler
A nurse is precepting a nursing student who brings the following client observations to the
nurse's attention. Which of the following client should the nurse assess first?
Answer: a client who is coughing up pink-tinged sputum following a bronchoscopy and lung
biopsy 1 hr ago
A nurse is assessing a client who has pneumonia. Which of the following findings is the priority
for the nurse to report to the provider?
Answer: Weight loss of 4lbs in 1 month
A nurse manager is making staffing assignments for the medical-surgical unit. Which of the
following clients is appropriate to assign to a float nurse from the postpartum unit?
Answer: A client who is 2 days post following a colon resection.
A nurse is assessing a client who is gravida 2, para 1. This client is at 41 weeks of gestation and
is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate
for which of the following findings?
Answer: Contractions are strong to palpatation
A nurse is caring for a client who has fractured ribs, has developed thrombophlebitis, and is
being treated with a heparin drip. The client develops hematuria and has an activated ptt of 100
seconds. Which of the following actions should the nurse take first ?
Answer: Turn of the heparin drip
A nurse in a mental health facility is interviewing a newly admitted client. Which of the
following actions should the nurse take when conducting the interview?
Answer: Seat the client at least 12 feet from the nurse
atrial fibrillation
Answer: Atrial fibrillation is a common heart rhythm disorder characterized by irregular and
often rapid heartbeats, increasing the risk of stroke and other heart-related complications.
Treatment typically involves medications to control heart rate and rhythm, along with strategies
to reduce stroke risk.
A nurse is assessing a client who has minor injuries following a motor-vehicle crash and appears
agitated and apprehensive. The nurse identifies that the client is in the alarm stage of general
adaption syndrome and should expect which of the following findings?
Answer: tachycardia
A nurse is caring for a client who is postpartum and has a new prescription for methylergovine
for vaginal bleeding refectory to fundal massage and oxytocin.
Answer: hypertension
A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral
feedings at 65ml/hr through gastrostomy tube. Which of the following findings requires
immediate interventions by the nurse?
Answer: The infusion pump for administering continuous feeding is turned off
A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of
parents. Which of the following information should be included
Answer: Newborn swelling sound are audible while breastfeeding Newborn stools are yellow
and seedy after 7 days of breastfeeding Maternal breast become soft following feedings.
