VATI PN COMPREHENSIVE PREDICTOR LATEST
2023-2024 WITH 180 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES( 100% CORRECT AND VERIFIED ANSWERS)
|GRADED A
1. 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?
Answer: 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.
2. 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.)
Answer: [1] determine the facts related to the dilemma.
[2] identify possible solution
[3]consider the client wishes
3. A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The
client states, "l 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?
Answer: Grieving for your son is hard work. it will take as much time as you need to come to
terms with your loss.
4. 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?
Answer: Lamb
Rationale: including tuna fish reduces risk of developing cancer including poultry reduces
risk
5. A nurse notices an assistive personnel (AP) taking a nap in the break room during meal
time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the
following actions should the nurse take?
Answer: Report the observation about the AP to the Unit nurse manager
6. 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?
Answer: A school age child who has allergic rhinitis and is taking diphenhydramine.
7. A nurse is caring for a client following a bronchoscopy. Which of the following actions
should the nurse take first?
Answer: check for gag reflex
8. 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?
Answer: Indwelling urinary catheter
9. 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?
Answer: Gently close the client's eyelids
10. 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?
Answer: 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.
11. A nurse is collecting data from a client who is experiencing a situational crisis following
the loss of a job. The client states, "l don't think I can go through this again." Which of the
following actions is the nurse's priority?
Answer: Determine if the client is experiencing psychotic thinking.
12. 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?
Answer: Irrigate the bladder using sterile technique
13. 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?
Answer: Moist mucus membranes.
14. 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?
Answer: Chlordiazepoxide
Rationale: The nurse should expect to administer chlordiazepoxide to decrease anxiety and
the risk for seizures associated with alcohol withdrawal.
15. 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?
Answer: report the situation to the provider who obtained informed consent.
16. A nurse is collecting data from a client who is in severe pain. Which of the following
questions should the nurse ask first?
Answer: where is your pain located
17. 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?
Answer: I will rinse my mouth after taking this medication
18. 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?
Answer: Instruct the client to avoid the Valsalva maneuver.
Rationale: Valsalva is such as straining during defecation or playing the saxophone entail
performance of Valsalva maneuver
19. 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?
Answer: client reports burning with urination.
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine that dysuria is a manifestation of a urinary tract infection. Therefore, the nurse
should identify this as the priority finding to report to the provider.
20. 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?
Answer: cardiac workload decreases
21. 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?
Answer: I will imagine myself in a calm place when i cant concentrate
22. 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?
Answer: If I forget to take a dose i can take it later on the same day.
23. 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?
Answer: Discuss this behavior with the AP while reinforcing expectaions.
24. 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?
Answer: Hydrogen peroxide
25. 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?
Answer: acetylcysteine
26. A nurse is caring for a client who is in Buck's traction. Which of the following actions
should the nurse take?
Answer: allow the weight to hang freely
27. 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.)
Answer: 2 ml
28. 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?
Answer: I will apply diaper cream to my baby skin during each diaper change
Rationale: The nurse should reinforce to the parent that applying a skin barrier, such as zinc
oxide, during diaper changes will minimize skin irritation from frequent stools.
29. 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?
Answer: putting a glove on their dominant hand first.
30. 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?
Answer: creatinine 2.5mg/dl
31. 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?
Answer: albuterol
32. 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?
Answer: separate the Childs used washcloth form those of others.
33. 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?
Answer: avoid massaging the site after injecting vaccine.
Rationale: The nurse should not massage the site following an intradermal injection because
this can spread the vaccine into the tissue or out through the needle insertion site.
34. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of
the following actions should the nurse take?
Answer: open the outer package flap of the catheterization kit away form the body
35. 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?
Answer: tomatoes.
Rationale: Apricots = Vit A
Avocados = Vit E
Carrots = Vit A
36. A nurse is collecting data from a client who has multiple fractures following a motorvehicle crash. For which of the following client statements should the nurse recommend a
referral to an occupational therapist?
Answer: I am so frustrated i cannot even open my milk carton for breakfast
37. A nurse is assisting with the admission of an adolescent who has bulimia nervosa. Which
of the following manifestations should the nurse expect?
Answer: Hematemesis
38. 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.)
Answer: BMI
Rationale: 33 indicates obesity
39. 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?
Answer: Zolipedem
40. 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?
Answer: you will need to take the medication for the rest of your life
41. 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. One eyelid drooping lower than the other
B. Eyes appearing red and watery
C. Inability to focus on nearby objects
D. Bulging of one or both eyes
Answer: A. One eyelid drooping lower than the other
42. 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?
Answer: offering general leads
43. 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?
Answer: scan the client facility identification band.
44. A nurse is collecting data from a client who has iron deficiency anemia. Which of the
following findings should the nurse expect?
Answer: Difficult concentrating
45. 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?
Answer: 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.
46. 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?
Answer: maintain a sequential compression device..
47. 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?
Answer: the AP reports client information to the oncoming AP in the hallway.
48. 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?
Answer: I will give our baby sponge baths until the cord falls off.
49. 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?
Answer: walk for 1-2 hrs each day.
Rationale: it promotes venous return
50. 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?
Answer: as soon as the client awakens in the morning
51. 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?
Answer: the facility has 12% fewer urinary tract infection over the past 6 months.
52. A nurse is maintaining droplet precautions for a client who has meningitis. Which of the
following actions should the nurse take?
Answer: wear a surgical mask within 3 feet of the client.
53. 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.)
Answer: [1] a pharmacist.
[2] package inserts.
[3] American diabetes association.
54. 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?
Answer: Lack of sleep.
Rationale: The greatest risk for this client is exhaustion or death from lack of sleep:
therefore, this is the priority finding. The nurse should encourage frequent periods of rest for
the client throughout the day.
55. 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?
Answer: You're saying that you are doubtful that this procedure will benefit you.
56. 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?
Answer: I will secure the car seat in the car by using the seatbelt.
57. A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple
sclerosis. The client states, "l am very upset and I want to be alone for a little while." Which
of the following responses should the nurse make?
Answer: I see that you are feeling overwhelmed.
I will come back when you are ready.
58. 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?
Answer: you will need to schedule a bone density test.
59. 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?
Answer: Change the appliance two times each week
60. 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?
Answer: Position the head of the bed at 30 angle
61. A nurse is receiving report on four clients. Which of the following clients should the nurse
plan to see first?
Answer: a client who has pneumonia and a new onset of confusion.
62. 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?
Answer: heart rate 146/min
63. 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?
Answer: Establish a regular exercise routine 2 hr or more before bedtime
64. 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?
Answer: take up to three tablets during a single angina episode.
65. 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?
Answer: lack of change in the pupil size when the client looks form a far to near object.
66.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?
Answer: place the client in a 30 lateral position
67. A nurse is checking a newborn's vital signs. Which of the following methods of
temperature measurement should the nurse use?
Answer: axillary
68. A nurse is transferring a client from a bed to a wheelchair. The client has right-sided
weakness following a recent stroke. Which of the following actions should the nurse take?
Answer: Place the wheelchair on the clients left side.
69. A nurse is collecting data from a client who has hypokalemia. Which of the following
findings should the nurse expect?
Answer: Muscle weakness..
Rationale: The nurse should expect a client who has hypokalemia to have bilateral muscle
weakness. Other manifestations of hypokalemia include hyporeflexia, muscle stiffness,
cramping, and paralysis.
70. 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?
Answer: boiled spinach
71. 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?
Answer: prepare a new dose of insulin injection
72. 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?
Answer: I should wait 1 minute before taking a second puff of the medication/
73. 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?
Answer: maintain the drainage below the level of the clients chest.
74. 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?
Answer: platelet count of 95,000
75. A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy.
Which of the following statements should the nurse make?
Answer: your oncologist might prescribe a cold cap to war during treatment to reduce hair
loss
76. 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
77. 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?
Answer: the client has absent bowel sounds
78. 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?
Answer: place your baby's crib away form heat vents
79. 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?
Answer: Dosage
80. A nurse is receiving change-of-shift report for four clients. Which of the following clients
should the nurse see first?
Answer: a client whose urinary output was 100 ml for the past 12 hr
81. 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?
Answer: poor lighting in the learning setting
82. 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?
Answer: Prolonged use of corticosteroids is a risk factor for infection
83. A nurse is caring for a female client who has an indwelling urinary catheter. Which of the
following actions should the nurse take?
Answer: wipe the drainage port with an antiseptic wipe after emptying urine form the bag
84. 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.)
Answer: the foot on your right side.
B is correct. The client should hold the cane on the stronger side of the body: in this scenario.
it would be in the right hand. When ambulating forward, the client should move the cane
forward first (in front of right foot) and then advance the weaker leg forward next so that the
client's body weight is evenly distributed between the cane and stronger leg.
85. 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?
Answer: determine the client's mobility status
86. 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?
Answer: we can’t decide whether to try homeschool our child or move them to a private
school
87. A nurse has administered medications to a group of clients. For which of the following
client situations should the nurse complete an incident report?
Answer: the nurse administered insulin lispro to a client who has diabetes mellitus and is
NPO
88. 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?
Answer: the people i live with should be tested for TB
89. 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?
Answer: Decreased bowel sounds
90. A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD).
Which of the following manifestations should the nurse expect?
Answer: Hypervigilance
91. A nurse is reinforcing teaching with the adult children of a client who is dying. Which of
the following statements should the nurse make?
Answer: you can continue talking to your prater until they are gone
92. A nurse is preparing to discharge a client who is immunocompromised. Which of the
following vaccines should the nurse plan to administer?
Answer: Pneumococcal polysaccharide (PPSV)
93. 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?
Answer: have a supply of prescribed medications
94. 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?
Answer: your weight gain should be the same as for someone without diabetes
95. A nurse is reviewing a client's electronic medical record and finds that an assistive
personnel (AP) recorded the client's temperature as 35.30 C (95.50 F) 2 hr earlier. Which of
the following actions should the nurse take first?
Answer: Check the clients temperature
96. 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?
Answer: administer an initial NG tube feeding to a client who has a stroke
97. 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?
Answer: ensure the injection produces wheal on the skin
98. 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?
Answer: keep fat intake to no more than 30 percent of your daily caloric intake
99. 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?
Answer: Informing a client the nurse is going to administer an injection even through the
client refuses.
100. 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?
Answer: Instruct the client to remain still while the test is performed,
101. A nurse is collecting data from a client who has multiple sclerosis. Which of the
following findings should the nurse expect?
Answer: ataxia
Rationale: The nurse should expect a client who has multiple sclerosis to manifest ataxia,
which is a lack of coordination and movement. Other manifestations include fatigue,
impaired memory, diplopia, and bowel and bladder incontinence.
102. 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?
Answer: feeding newborn at least every 3 - 4 hrs
103. 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?
Answer: use one finger to insert the suppository past the anal sphincters
104. 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?
Answer: place the client in a lateral position
105. 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?
Answer: Consumption of contaminated food
106. 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?
Answer: the child was born at 34 weeks of gestation
107. 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?
Answer: Antiplatelet
108. 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?
Answer: Potassium chloride 20 mEq PO every morning
109. 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. (Move the steps into the box on the right,
placing them in the order of performance. Use all the steps.)
Answer: [1] expose the glans of the penis [2] cleanse the penis using and antiseptic swab.
[3]Begin urination
[4] pass the cup into the urine stream
[5] move the cup out of the urine stream.
[6] replace the foreskin
110. 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?
Answer: List of potential complications to report
111. A nurse is reinforcing teaching with a client who is scheduled for a barium enema.
Which of the following statements should the nurse make?
Answer: this procedure uses diagnostic imaging to locate and obstruction
112. 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?
Answer: metoprolol ER 50mg per NG tube BID
113. 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?
Answer: obtaining clients vital signs prior to discharge
114. 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?
Answer: avoid lying on the affected side
115. 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?
Answer: I should apply sterile saline to lubricate the suction catheter
116. 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?
Answer: eat a bedtime snack
117. A nurse is caring for a client who requests information about advance directives. Which
of the following responses should the nurse make?
Answer: advanced directives are written instruction regarding end of life care
118. 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?
Answer: ensure the interpreter is culturally compatible with the client
119. 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?
Answer: Irritability
120. 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?
Answer: you will need to have a full bladder for the procedure
121. 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?
Answer: prepare a priority list of client needs for the shift
122. 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?
Answer: I should offer my child yogurt that has a probiotic as a snack
123. 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?
Answer: applying the stocking before the client gets out of bed
124. 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?
Answer: confusion about knowing their own name
125. 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?
Answer: I will receive the nutrients i need through my IV fluid.
126. 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?
Answer: I will undergo bowel cleansing prior to the procedure
127. 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?
Answer: Cherry tomatoes
128. 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?
Answer: "You should depress the button on the handheld marker when you feel your baby
move."
129. 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?
Answer: Apply the external fetal heart rate monitor.
130. 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?
Answer: Inform the client of the possible consequence of the medication refusal
131. 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?
Answer: Lateral recumbent
132. 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?
Answer: remove rings when washing hands with soap and water
133. 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?
Answer: cap refil of 5 seconds to the client toes
134. 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.)
Answer: [1] difficulty breathing
[2] coughing
[3] presence of stridor
135. 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?
Answer: gastric ulcer formation
136. 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?
Answer: purchase beef that is a loin cut
137. 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?
Answer: Instruct the client to use a sitz bath at least twice a day
138. 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?
Answer: I should use counter pressure for back pain during labour
139. 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?
Answer: demonstrate assertiveness
140. 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?
Answer: Instruct the client not to get out of bed
141. 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?
Answer: my son took my wallet so he can keep track of what i'm spending
142. 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?
Answer: report the suspected abuse to the appropriate agency
143. 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.)
Answer: 20
144. A nurse is reinforcing teaching with a client who has a new prosthesis for an above-theknee amputation of the right leg. Which of the following instructions should the nurse
include?
Answer: apply the prosthesis immediately upon waking each day
145. A nurse is speaking with the partner of a client who has Alzheimer's disease. The partner
states, "l love him, but caring for him is wearing me out." Which of the following responses
should the nurse make?
Answer: lets discuss how caring for your partner is affecting your health
146. 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?
Answer: report lack of appetite
147. 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?
Answer: perform Kegel exercise daily
148. 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?
Answer: the client attempts to elevate the cylinder by inhaling deeply
149. 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?
Answer: perform a fundal massage for the client
150. 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?
Answer: discuss how each AP action measure against the job description
