ATI Comprehensive Exit Exam 2023 With NGN
1. A home health nurse is caring for a child who has Lyme disease. Which of the following is an
appropriate action for the nurse to take
A. Ensure the state health department has been notified.
B. Administer antitoxin.
C. Educate the family to avoid sharing personal belongings.
D. Assess for skin necrosis.
Answer: A. Ensure the state health department has been notified.
2.
3.
4. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has
vomited. nurse perform first?
A. Administer an antiemetic medication,
B. Evaluate functioning of the suction device.
C. Provide oral hygiene care.
D. Replace the NG tube.
Answer: B. Evaluate functioning of the suction device.
5. While performing a routine assessment, a nurse notices fraying on the electrical cord of a
client's continuous passive motion (CPM) device. Which of the following actions should the
nurse take first?
A. Initiate a requisition for a replacement CPM device.
B. Report the defect to the equipment maintenance staff.
C. Remove the device from the room.
D. Ensure the device inspection sticker is current,
Answer: C. Remove the device from the room.
6. A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the
following actions should the nurse take when pouring the sterile solution?
A. Remove the cap and place it sterile-side up on a clean surface,
B. Place sterile gauze over areas of spilled solution within the sterile field.
C. Hold the bottle in the center of the sterile field when pouring the solution.
D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Answer: A. Remove the cap and place it sterile-side up on a clean surface,
7. A nurse is creating a plan of care for a female client who has recurrent urinary tract infections.
Which of the following interventions should the nurse include in the plan?
A. Wear loose-fitting underwear.
B. Take a bubble bath after intercourse.
C. Drink four 240 mL (8 02) glasses of water each day.
D. Void every 5 to 6 hr. during the day.
Answer: A. Wear loose-fitting underwear.
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11. A nurse is caring for and infant who has gastroenteritis. Which of the following assessment
findings should the nurse report to the provider?
A. Pale and a 24 hr. fluid deficit of 30 mL
B. Sunken fontanels and dry mucous membranes.
C. Decreased appetite and irritability.
D. Temperature 38° C(100.4°F) and pulse rae 124/min
Answer: B. Sunken fontanels and dry mucous membranes.
12. A nurse is conducting health promotion education regarding contraindications to combination
oral contraceptive use to a group of women. Which of the following conditions should the nurse
include in the teaching?
A. Hypertension
B. Fibromyalgia
C. Renal calculi
D. Fibrocystic breast disease
Answer: A. Hypertension
13. A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for amitriptyline. Which of the following statements by the client indicates an understanding of
the teaching?
A. “I can continue to take St. John's wort while taking this medication.”
B. “I know it Will be a couple of weeks before the medication helps me feel better.”
C. “I Expect this medication to raise my blood pressure.”
D. "l should take this medication on an empty stomach."
Answer: B. “I know it Will be a couple of weeks before the medication helps me feel better.”
14. A nurse is caring for a client who is immobile. Which of the following interventions is
appropriate to prevent contracture?
A. Position a pillow under the client's knees.
B. Place a towel roll under the client's neck.
C. Align a trochanter wedge between the client's legs.
D. Apply an orthotic to the client's foot.
Answer: D. Apply an orthotic to the client's foot.
15. A nurse is assessing a client Who is postoperative following abdominal surgery and has an
indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the
following interventions should the nurse anticipate?
A. Initiate continuous bladder irrigation.
B. Administer a fluid bolus.
C. Clamp the catheter tubing for 30 min.
D. Obtain a urine specimen for culture and sensitivity
Answer: B. Administer a fluid bolus.
16. A nurse is reporting a client's laboratory tests to the provider to Obtain a prescription for the
client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to
obtain the prescription for the warfarin?
A. Fibrinogen level
B. aPTT
C. INR
D. Platelet count
Answer: C. INR
17. A nurse is assessing a client Who is taking haloperidol and is experiencing
pseudoparkinsonism. Which of the following findings should the nurse document as a
manifestation of pseudoparkinsonism?
A. Serpentine limb movement
B. Shuffling gait
C. Nonreactive pupils
D. Smacking lips
Answer: B. Shuffling gait
18. A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis
following a stroke. Which of the following actions by the nurse best promotes communication
among staff caring for the client?
A. Posting swallowing precautions at the head of the client's bed
B. Noting changes in the treatment plan in the client's medical record
C. Recording the client's progress in the nurses' notes
D. Having interdisciplinary team meetings for the client on a regular basis
Answer: D. Having interdisciplinary team meetings for the client on a regular basis
19. A nurse is caring for a 2-year.old toddler. Which of the following food choices should the
nurse recommend to promote independence in eating?
A. Banana slices
B. Grapes
C. Hot dog
D. popcorn
Answer: A. Banana slices
20. A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the
community. Which of the following actions should the nurse plan to take?
A. Act as a liaison between the facility and the media.
B. Recommend to the provider specific acute care clients for discharge.
C. Determine the medical needs of incoming clients through the emergency department.
D. Call in additional medical-surgical unit nursing care staff.
Answer: C. Determine the medical needs of incoming clients through the emergency
department.
21. A nurse has just received change-of-shift report for four clients. Which of the following
clients should the nurse assess first?
A. A client who is scheduled for a procedure in 1 hr
B. A client who received a pain medication 30 min ago for postoperative pain
C. A client Who was just given a glass or orange juice for a low blood glucose level
D. A client who has 100 mL of fluid remaining in his IV bag
Answer: C. A client Who was just given a glass or orange juice for a low blood glucose level
22. A nurse is performing postmortem care for a recently deceased client prior to the client's
family visit. Which of the following actions should the nurse plan to take?
A. Cross the client's arms across their chest.
B. Hold the client's eyes shut for a few seconds.
C. Place the client in a high-fowler's position,
D. Remove the client's dentures from their mouth
Answer: B. Hold the client's eyes shut for a few seconds.
23. A nurse is admitting a client Who has schizophrenia. The client States, "I'm hearing voices."
Which of the following responses is the priority for the nurse to state?
A. “What are the voices telling you?”
B. “I realize the voices are real to you, but I don't hear anything."
C. "Have you taken your medication today?"
D. "How long have you been hearing the voices?"
Answer: B. “I realize the voices are real to you, but I don't hear anything."
24. A nurse is administering furosemide IV bolus to a client Who has fluid volume excess. The
nurse should recognize which of the following findings as an indication that the medication has
been effective?
A. Increased blood Pressure
B. Weight loss
C. Decreased inflammation
D. Decreased pain
Answer: B. Weight loss
25. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the
nurse should follow to perform suctioning. Move the steps into the box on the right. Placing
them in the order of performance. Use all the steps.
Answer:
Here is the correct sequence for performing nasotracheal suctioning:
1. Don sterile gloves.
2. Turn on the suction and set the pressure.
3. Insert the catheter during the client’s inspiration.
4. Apply suction while rotating the catheter.
5. Rinse the catheter to remove secretions.
26. A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure.
Which of the following actions should the nurse take?
A. Send the unsigned informed consent form to the facility's risk manager.
B. Determine if the client's health care surrogate is aware of the risks and benefits of the
procedure.
C. Ensure that the client's family supports the provider's decision for surgery.
D. Determine if the procedure is medically necessary for the client.
Answer: B. Determine if the client's health care surrogate is aware of the risks and benefits of
the procedure.
27. A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse
if the medication can be given 2 hr. earlier. Which of the following statements should the nurse
make?
A. "l can start the medication 30 minutes earlier."
B. "l can adjust the time and schedule for when it's convenient for you."
C. "l can infuse the medication at a faster rate."
D. "1 have up to 2 hours after the usual schedule time to give you this medication."
Answer: D. "1 have up to 2 hours after the usual schedule time to give you this medication."
28. A nurse is caring for client who requires seclusion to prevent harm to others on the unit.
Which of the following is an appropriate action for the nurse to take?
A. Document the client's behavior prior to being placed in seclusion.
B. Assess the client's behavior once every hour.
C. offer fluids every 2 hr.
D. Discuss with the client his inappropriate behavior prior to seclusion.
Answer: C. offer fluids every 2 hr.
29. A nurse is caring for an adolescent who has hyperthermia. Which of the following actions
should the nurse take?
A. Administer oral acetaminophenB. Cover the adolescent with a thermal blanket.
C. Submerge the adolescents feet in ice water.
D. Initiate seizure precautions.
Answer: C. Submerge the adolescents feet in ice water.
30. A nurse is caring for a client Who asks for information regarding organ donation. Which of
the following responses should the nurse make?
A. "l cannot be a witness for your consent to donate."
B. "You must be at least 21 years of age to become an organ donor."
C. "Your desire to be an organ donor must be documented in writing."
D. "Your name cannot be removed once you are listed on the organ donor list."
Answer: C. "Your desire to be an organ donor must be documented in writing."
31. A parish nurse is leading a support group for clients whose family members have committed
suicide. Which of the following strategies should the nurse plan to use during the group session?
A. Encourage clients to establish a timeline for their own grieve ng process.
B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
C. Assist clients in identifying ways suicide could have been prevented.
D. Discourage clients from sharing negative aspects of their relationship with the deceased
persons.
Answer: B. Initiate a discussion with clients about ways to cope with changes in family
dynamics.
32. A nurse developing care plan for a client who is in Buck's traction and is scheduled for
surgery for a fractured femur of the right leg. Which of the following interventions should the
nurse delegate to an assistive personnel?
A. Ask the client to describe her pain.
B. Check the client's pedal pulse on the right leg.
C. Observe the position of the suspended weight.
D. Remind the client to use the incentive spirometer.
Answer: D. Remind the client to use the incentive spirometer.
33. A nurse is caring for a client Who repeatedly refuses meals. The nurse overhears an assistive
personnel (AP) telling the client, "If you don't eat, put restraints on your wrists and feed you."
The nurse should intervene and explain to the AP that this statement constitutes which of the
following torts?
A. Battery
B. Assault
C. Negligence
D. Malpractice
Answer: B. Assault
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46.
History and Physical
Day 1, 0900:
30-year-old client at 33 Weeks gestation, Gravida 4 Para 3
Maternal blood type: Rh+
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation
NKA
The Nurse continues to care for the client:
Laboratory Results
Day 1, 1000:
WBC 16,000/mm3(5,000 to 10,000/mm3)
RBC count 5.1 million/mm3 (4.2 to 5.4 per million/mm 3)
Hgb 11.5 g/dL (>1 1 g/dL)
Hct 34%(>33%)
Platelet count 175,000/mm3 (150,000 to 400,000/mm3)
Urinalysis appearance cloudy, color is amber yellow, pH 6. Protein, leukocyte esterase: positive.
WBC casts, glucose: negative. Ketones: negative.
Vital Signs
Day 1, 0900:
Admission:
Temperature 38.4°C (1 01.1°F)
Heart rate 92/min
Respiratory rate 18/min
Blood pressure 130/78 mm Hg
Pre-pregnancy BMI 27.6
Current BMI 29.9
47.
Day 1, 1000:
Client voided and reports pain and discomfort upon urination. Client states, "I've noticed burning
when I urinate for the past 2 days."
Day 2, 0800:
Client rates lower back pain a 0 on a scale from 0 to 10.
No reports of vaginal discharge. Membranes intact.
No uterine contractions noted.
FHR baseline 138, minimal variability.
Cervical exam indicates 2 cm, 50% effaced, 0 station.
No further reports of burning with urination.
History and Physical:
Day 1.0900:
Vital Signs
30 year old client at 33 weeks, gestation, Gravida 4 para 3 Maternal blood Type: Rh+
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
NKA
Vital Signs
Day 1, 0900:
Admission:
Temperature 38.4°C (101.1°F)
Heart rate 92/min
Respiratory rate 18/min
Blood pressure 130/78 mm Hg
Pre-pregnancy BMI 27.6
Current BMI 29.9
Day 2, 0800:
Temperature 37.1°C (98.7°F)
Heart rate 85/min
Respiratory rate 16/min
Blood pressure 120/78 mm Hg
The nurse continues to care for the client.
Laboratory Results
Day 1, 1000:
WBC 16,000/mm3 (5,000 to 10,000/mm3)
RBC count 5.1 million/mm3 (4.2 to 5.4 per million/mm3)
Hgb 1 1.5 g/dL (>1 1 g/dL)
Hct 34%(>33%)
Platelet count 175,000/mm3 (150,000 to 400,000/mm3)
Urinalysis appearance cloudy, color is amber yellow, pH 6.
Protein, leukocyte esterase: positive. WBC casts, glucose: negative.
Ketones: negative.
Day 2, 0800:
WBC 12,000/mm3 (5,000 to 10,000/mm3)
RBC count 4.9 million/mm3 (4.2 to 5.4 per million/mm3)
Hgb 1 1 g/dL (>1 1 g/dL)
Hct 35%(>33%)
Platelet count 188,000/mm3 (150,000 to 400,000/mm3)
Urine culture pending
48. A nurse is teaching who has a new diagnosis of diabetes mellitus about foot care. Which of
the following instructions should the nurse include in the teaching?
A. Soak feet twice daily.
B. Round the edges of toenails when trimming.
C. Use moisturizing lotion between the toes.
D. Wear clean cotton socks every day.
Answer: D. Wear clean cotton socks every day.
49. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the
following actions should the nurse plan to take?
A. Instruct the client to lift her chin when swallowing.
B. Talk with the client during her feeding.
C. Sit at or below the client's eye level during feedings.
D. Discourage the client from coughing during feedings.
Answer: A. Instruct the client to lift her chin when swallowing.
50. A nurse is caring for a client who has acute glomerulonephritis. Which of the following
findings should the nurse expect?
A. Polyuria
B. Hypotension
C. Weight loss
D. Hematuria
Answer: D. Hematuria
51. A nurse is caring for whose partner recently died. The nurse sits with the client to provide
comfort. Which of the following ethical principles is the nurse demonstrating?
A. Fidelity
B. Veracity
C. Autonomy
D. Beneficence
Answer: D. Beneficence
52. A nurse in an emergency department is caring for a child who reports being sexually abused
by a family member. Which of the following actions should the nurse take?
A. Use leading statements to obtain information from the child.
B. Ensure that multiple nurses are present for the physical examination.
C. Explain to the child what Will happen when the abuse is reported.
D. Reassure the child that no one will be told about the abuse.
Answer: C. Explain to the child what Will happen when the abuse is reported.
53. A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her
position at the clinic. Which of the following tasks should the nurse identify as tertiary
prevention?
A. Using an electronic messaging system to remind clients when to take medications
B. Educating clients about contraindications to specific immunizations
C. Helping clients understand health screenings covered by their insurance plans
D. Providing clients with information about the benefits of exercise
Answer: A. Using an electronic messaging system to remind clients when to take medications
54. A nurse is caring for who has given informed consent for electroconvulsive therapy. Just
before the procedure, the client tells the nurse she is considering not going forward with the
treatment. Which of the following statements by the nurse is appropriate?
A. Most people who have this procedure feel better following the treatment."
B. "Your doctor wouldn't have ordered this treatment unless it was necessary."
C. “It's okay to be nervous before this treatment.”
D. "You don't have to go through with the treatment. "
Answer: D. "You don't have to go through with the treatment. "
55. A nurse is teaching a new parent about breastfeeding her 2.week-old infant. Which of the
following statements by the parent indicates an understanding of the teaching?
A. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the
breast."
B. Manually expressing my milk Will decrease my milk supply,"
C. “My baby should always start on the same breast when feeding.”
D. "The more my baby is at the breast sucking, the more milk will produce."
Answer: D. "The more my baby is at the breast sucking, the more milk will produce."
56. A nurse is preparing to reposition a client who had a stroke. Which of the following actions
should the nurse take?
A. Evaluate the client's ability to help with repositioning
B. Reposition the client without the use of assistive devices.
C. Raise the side rails on both sides of the client's bed during repositioning.
D. Discuss the client's preferences for determining a repositioning schedule.
Answer: A. Evaluate the client's ability to help with repositioning
57. A nurse is providing discharge teaching to a client who is postoperative following the
surgical repair of a detached retina. Which of the following statements by the client indicates an
understanding of the teaching?
A. I can go jogging after 2 weeks."
B. I should bend at the waist when putting on my shoes."
C. "l can lift objects that are less than 10 pounds."
D. "l can resume activities, such as sewing."
Answer: C. "l can lift objects that are less than 10 pounds."
58. A nurse is providing discharge teaching about home care of a surgical incision to a client
Who speaks a different language from the nurse. The nurse is communicating with the client
using an interpreter. Which of the following actions should the nurse take?
A. Speak slowly when talking to the interpreter.
B. Pause in the middle of sentences.
C. Speak directly to the client.
D. use gestures to convey meaning.
Answer: C. Speak directly to the client.
59. A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of
the following medications for pain relief should the nurse include in the teaching that can be
taken concurrently with enoxaparin?
A. ibuprofen
B. Naproxen sodium
C. Acetaminophen
D. Aspirin
Answer: C. Acetaminophen
60. A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A. A client who has epidural analgesia and weakness in the lower extremities
B. A client who has a hip fracture and a new onset of tachypnea
C. A client who has sinus arrhythmia and is receiving cardiac monitoring
D. A client who has diabetes mellitus and an HbA1cof 6.8%
Answer: B. A client who has a hip fracture and a new onset of tachypnea
61. A nurse is performing a skin assessment on a client Who has dark skin. Which of the
following locations on the client's body should the nurse observe to assess for cyanosis?
A. Sacrum
B. Palms of the hands
C. Shoulders
D. Area of trauma
Answer: B. Palms of the hands
62. A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best predictor
of future violence?
A. A history of being in prison
B. Male gender
C. Experiencing delusions
D. Previous violent behavior
Answer: D. Previous violent behavior
63. A nurse is assessing a client who is in active labor. Which of the following findings should
the nurse report to the provider?
A. Temperature 37,40 C (99,30 F)
B. Early decelerations in the EHR
C. FHR baseline 170/min
D. Contractions lasting 80 seconds
Answer: C. FHR baseline 170/min
64. A quality control nurse is reviewing medication prescriptions for a group of clients. Which of
the following medication prescriptions should the nurse identify as being complete?
A. Tetracycline 200 mg PO
B. Epoetin alfa 150 units/kg three times weekly
C. Digoxin 0.25 mg PO daily
D. Cimetidine PO twice daily
Answer: C. Digoxin 0.25 mg PO daily
65.
Day 2
041 5:
Client tearfully agreed to be admitted to the mental health unit.
Day 2
1000:
Client states, "l feel a bit better. I get these thoughts sometimes when I am stressed. Smoking
sometimes helps, but not yesterday. I have not been sleeping well."
Client reports recent job loss and concern about having money for food. Reports first episode at
age 19 as a freshman in college, which lasted for a few days. After several episodes, they
dropped out of school. Client states, "My parent told me they had episodes like this years ago
and were glad I didn't have brain problems too. But maybe I do."
A nurse is caring for a client in an emergency department.
Laboratory Results
0445:
Blood alcohol 0 mg/dL (0 to 50 mg/dL)
Sodium 140 mEq/L (1 36 to 145 mEq/L)
Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L)
Chloride 100 mEq/L (98 to 106 mEq/L)
BUN 18 mg/dl (10 to 20 mg/dl)
WBC count 5,500/mm3 (5,000 to 10,OOO/mm3)
Glucose 94 mg/dL (74 to 106 mg/dL)
C-reactive protein 0.8 mg/L (less than 1.0mg/dL)
A nurse is caring for a client in an emergency department.
Vital Signs
0415:
Temperature 37°C (98.6°F)
BP 128/66 mm Hg
Heart rate 88/min
Respiratory rate 20/min
Oxygen saturation 98% room air
66. A nurse is providing an in-service about client evacuation during a fire. Which of the
following clients should the nurse instruct the staff to evacuate first?
A. A client who is ambulatory and receiving oxygen
B. A client who has a fracture and is in balance suspension traction
C. A client who is bedridden and Wears a hearing aid
D. A Client Who uses a Wheelchair and is confused
Answer: A. A client who is ambulatory and receiving oxygen
67. A nurse is planning care for an older adult client who has dementia. Which of the following
interventions should the nurse include in the plan of care? (Select all that apply.)
A. Give the client one simple direction at a time.
B. Refute the client’s delusions using logic.
C. Allow the client to choose among a variety of activities each day.
D. Reinforce orientation to time, place, and person.
E. Establish eye contact when communicating with the client.
Answer: A. Give the client one simple direction at a time.
C. Allow the client to choose among a variety of activities each day.
D. Reinforce orientation to time, place, and person.
E. Establish eye contact when communicating with the client.
68. A nurse is providing discharge teaching to the partner of a client who has a tracheostomy.
Which of the following information should the nurse include in the teaching?
A. How to operate the portable suction machine
B. How to secure the tracheostomy tube with ties at the back of the neck
C. How to change the nondisposable tracheostomy tube daily
D. How to change the tracheostomy dressing using clean technique
Answer: A. How to operate the portable suction machine
69. A nurse is caring for a client who reports xerostomia following radiation therapy to the
mandible. Which of the following is an appropriate action by the nurse?
A. Suggest rinsing his mouth with an alcohol-based mouth wash.
B. Provide humidification of the room air.
C. offer the client saltine crackers between meals.
D. Instruct the client on the use of esophageal speech.
Answer: B. Provide humidification of the room air.
70. A public health nurse working in a rural area is developing a program to improve health for
the local population. Which of the following actions should the nurse plan to take?
A. Launch a media campaign to increase awareness about industrial pollution.
B. Have a nurse from outside the community provide health lectures at the county hospital
C. Encourage rural residents to focus health spending on tertiary health interventions.
D. Provide anticipatory guidance classes to parents through public schools.
Answer: D. Provide anticipatory guidance classes to parents through public schools.
71. A nurse is assessing a child who has bacterial pneumonia. Which of the following
manifestations should the nurse expect?
A. Drooling
B. Malaise
C. Tinnitus
D. Rhinorrhea
Answer: B. Malaise
72.
A nurse is an emergency department is caring for a client
Vital Signs:
0330:
Temperature 38.4°C (101 .1°F)
Heart rate 120/min
Respiratory rate 24/min
Blood pressure 100/66 mm Hg
Sp02 94% on room air
0745:
Temperature 38°C (100.4°F)
Heart rate 106/min
Respiratory rate 22/min
Blood pressure 106/68 mm Hg
Sp02 98% on 02 @ 2 L/min via nasal cannula
A nurse in an emergency department is caring for a client.
Nurses' Notes
Day 1, 0330:
Client presents for evaluation of severe pain in upper abdomen that radiates into his back. States
pain began approximately 12 hr ago and is worse when he is supine or after he eats. Rates pain as
a 7 on a O to 10 pain scale. Sclera noted to be yellow. Heart rate regular, lungs clear to
auscultation. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces
during palpation. Reports last bowel movement was yesterday. Denies recent illnesses, takes no
prescribed medications. Client is alert and oriented x 4.
Day 1, 0800:
Report provided to medical-surgical nurse. Client transferred to medical-surgical unit via gurney.
A nurse in an emergency department is caring for a client
Laboratory Results
Day 1, 0430:
Amylase 640 units/L (30 to 220 units/L)
Lipase 220 units/L (0 to 160 units/L)
Bilirubin (total) 3.7 mg/dL (0.3 to 1 mg/dL)
Calcium 8.1 mg/dL (9 to 10.5 mg/dL)
Glucose (casual) 215 mg/dL (< 200 mg/dL)
Hemoglobin 20 g/dL (14 to 18 g/dL)
Hematocrit 60% (42% to 52%)
WBC count 18,000/mm3 (5,000 to 10,000/mm3)
Platelet count 160,000/mm3 (150,000 to 400,000/mm3)
73.
74.
75.
A nurse is an emergency department is caring for a client.
Vital Signs
0330:
Temperature 38.4°C (101.1°F)
Heart rate 120/min
Respiratory rate 24/min
Blood pressure 100/66 mm Hg
Sp02 94% on room air
0745:
Temperature 38°C (100.4° F)
Heart rate 106/min
Respiratory rate 22/min
Blood pressure 106/68 mm Hg
Sp02 98% on 02 @ 2 L/min via nasal cannula
1200:
Temperature 39 0 C (102.2 0 F)
Heart rate 120/min
Respiratory rate 24/min
Blood pressure 86/48 mm Hg
Sp02 93% on 02 @ 2 L/min via nasal cannula
76.
A nurse in an emergency department is caring for a client
Labaratory Results
Day 1, 0430:
Amylase 640 units/L (30 to 220 units/L)
Lipase 220 units/L (0 to 1 60 units/L)
Bilirubin (total) 3.7 mg/dL (0.3 to 1 mg/dL)
Calcium 8.1 mg/dL (9 to 10.5 mg/dL)
Glucose (casual) 215 mg/dL (< 200 mg/dL)
Hemoglobin 20 g/dL (14 to 18 g/dL)
Hematocrit 60% (42% to 52%)
WBC count 18,000/mm3 (5,000 to 10,000/mm3)
Platelet count 160,000/mm3 (1 50,000 to 400,000/mm3)
A nurse in an emergency department is caring for a client
Diagnostic Results
Day 1, 1200:
Capillary blood glucose level (casual) 204 mg/dL (< 200 mg/dL)
A nurse in an emergency department is caring for a client
Nurses' Notes
Day 1, 0330:
Client presents for evaluation of severe pain in upper abdomen that radiates into his back. States
pain began approximately 12 hr ago and is worse when he is supine or after he eats. Rates pain a
7 on a 0 to 10 pain scale. Sclera noted to be yellow. Heart rate regular, lungs clear to
auscultation. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces
during palpation. Reports last bowel movement was yesterday. Denies recent illnesses, takes no
prescribed medications. Client is alert and oriented x 4.
Day 1, 0800:
Report provided to medical-surgical nurse. Client transferred to medical-surgical unit via gurney.
Day 1, 1200:
Client reports epigastric pain that radiates into his back, rates pain a 9 on 0 to 10 pain scale.
Diminished breath sounds noted in lower lobes bilaterally. Scattered rhonchi heard throughout
remaining lung lobes. Client with nonproductive cough. Abdomen remains firm and distended
with hypoactive bowel sounds. Client has had three episodes of emesis over past 2 hr.
77.
78.
Labaratory Results
Day 1, 0430:
Amylase 640 units/L (30 to 220 units/L)
Lipase 220 units/L (0 to 1 60 units/L)
Bilirubin (total) 3.7 mg/dL (0.3 to 1 mg/dL)
Calcium 8.1 mg/dL (9 to 10.5 mg/dL)
Glucose (casual) 215 mg/dL (< 200 mg/dL)
Hemoglobin 20 g/dL (14 to 18 g/dL)
Hematocrit 60% (42% to 52%)
WBC count 18,000/mm3 (5,000 to 10,000/mm3)
Platelet count 160,000/mm3 (150,000 to 400,000/mm3)
Day 5, 0600:
Amylase 280 units/L (30 to 220 units/L)
Lipase 170 units/L (0 to 160 units/L)
Bilirubin (total) 2 mg/dL (0.3 to 1 mg/dL)
Calcium 9.2 mg/dL (9 to 10.5 mg/dL)
Hemoglobin 17 g/dL (14 to 18 g/dL)
WBC count 1 1 ,OOO/mm3 (5,000 to 10,000/mm3)
Platelet count 200,000/mm3 (150,000 to 400,000/mm3)
79.A nurse is planning care for a client Who is scheduled for a thoracentesis. Which of the
following actions should the nurse plan to take?
A. Position the client on the affected side for 4 hr following the procedure.
B. Instruct the client to avoid coughing during the procedure.
C. Inform the client that he will be NPO for 6 hr prior to the procedure.
D. place the client the prone position during the procedure.
Answer: B. Instruct the client to avoid coughing during the procedure.
80. A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse
expect?
A. Head circumference exceeds chest circumference
B. Palpable fontanels
C. Natural loss of deciduous teeth
D. Nontender, protruding abdomen
Answer: D. Nontender, protruding abdomen
81. A nurse manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse manager include?
A. Remove the client's restraint every 4 hr:
B. Document the client's condition every 15 min.
C. Request a PRN restraint prescription for clients who are aggressive.
D. Attach the restraint to the bed's side rails.
Answer: B. Document the client's condition every 15 min.
82. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit.
Which of the following statements should the nurse include in the hand-off report?
A. "The estimated blood loss was 250 milliliters."
B. "The client is a member of the board of directors,"
C. "There was a total of 10 sponges used during the procedure."
D. "The client was intubated without complications. "
Answer: A. "The estimated blood loss was 250 milliliters."
83. A nurse in an emergency department is caring for a client who has a closed head injury.
Which of the following actions should the nurse take first?
A. Determine the client's Glasgow Coma Scale score.
B. Insert an indwelling urinary catheter for the client.
C. Administer mannitol IV bolus to the client
D. Prepare the client for an MRI of the brain.
Answer: A. Determine the client's Glasgow Coma Scale score.
84. A nurse in an emergency department is caring for a client following a motor-vehicle crash.
The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse
expect?
A. The client is oriented times three.
B. The client opens eyes to sound.
C. The client is unable to obey commands.
D. The client withdraws from pain.
Answer: A. The client is oriented times three.
85. A nurse is reviewing a client's cardiac rhythm strips and notes a constant P.R interval of 0.35
seconds. Which of the following dysrhythmias is the client displaying?
A. First-degree atrioventricular block
B. Complete heart block
C. premature atrial complexes
D. Atrial fibrillation
Answer: B. Complete heart block
86. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks
the nurse about becoming a living kidney donor for their parent. Which of the following
conditions in the child's medical history should the nurse identify as a contraindication to the
procedure?
A. Amputation
B. Osteoarthritis
C. Hypertension
D. Primary glaucoma
Answer: C. Hypertension
87.
88.
89. A case manager is meeting with a client who asks about using alternative therapies to manage
her rheumatoid arthritis. Which of the following statements should the nurse make?
A. "We can review some information to help you select a safe alternative practitioner."
B. "If there are therapies available to you, your provider Will tell you about them."
C. "Feel free to try whatever therapies that fit within your personal belief system."
D. “I’m sure you can find alternative remedies through an online support group.”
Answer: A. "We can review some information to help you select a safe alternative practitioner."
90. A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the
following positions should the nurse take to place the client at ease?
A. Sit in a chair next to the bed.
B. Stand at the side of the bed.
C. Sit on the bed next to the client,
D. Stand at the foot of the bed.
Answer: A. Sit in a chair next to the bed.
91. A nurse is caring for a newborn whose mother was taking methadone during her pregnancy.
Which of the following findings indicates the newborn is experiencing withdrawal?
A. Bulging fontanels
B. Acrocyanosis
C. Bradycardia
D. Hypertonicity
Answer: D. Hypertonicity
92. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20
mL remaining to infuse, but a new bag is not readily available. Which of the following actions
should the nurse take?
A. Administer dextrose 10% in water.
B. Give 500 mL of lactated Ringer's solution
C. Slow the TPN infusion rate.
D. Temporarily discontinue the infusion.
Answer: A. Administer dextrose 10% in water.
93. A nurse is auscultating for crackles on a client Who has pneumonia. Which of the following
anterior chest wall locations should the nurse auscultate? (You will find hot Spots to select in the
artwork below. Select only the hot spot that corresponds to your answer.)
A. Upper right lung field (second intercostal space, right of the sternum)
B. Lower left lung field (sixth intercostal space, midclavicular line)
C. Right middle lobe (fourth intercostal space, right of the sternum)
D. Posterior lung bases (between the scapulae)
Answer: A. Upper right lung field (second intercostal space, right of the sternum)
C. Right middle lobe (fourth intercostal space, right of the sternum)
94. A nurse is providing teaching about immunizations to a client who is pregnant. Which of the
following statements should the nurse include in the teaching?
A. "The immunization for varicella should be given at least 1 month prior to delivery."
B. "You can receive the rubella immunization during the third trimester of pregnancy."
C. “The hepatitis B immunization should not be obtained until after you finish breastfeeding.”
D. "You can receive the immunization for influenza at any time during your pregnancy,"
Answer: D. "You can receive the immunization for influenza at any time during your
pregnancy,"
95. A nurse is planning teaching for a client and their family about home oxygen therapy. Which
of the following information should the nurse plan to include in the teaching?
A. Apply petroleum jelly to soothe the mucous membranes.
B. Use synthetic fabrics for the client's bedding.
C. Clean the equipment with an alcohol-based cleaning product.
D. Avoid using nail polish remover around the client.
Answer: D. Avoid using nail polish remover around the client.
96. A nurse is instructing a school-age child who has asthma about the use of a peak expiratory
flow meter. Which of the following instructions should the nurse include in the teaching?
A. Place tongue on the mouthpiece of the meter.
B. Maintain a semi-Fowler's position during testing.
C. Record the average of the readings.
D. Blow into the meter as hard and quickly as possible.
Answer: D. Blow into the meter as hard and quickly as possible.
97. A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal
laceration. The client reports not having a bowel movement for 4 days. Which of the following
medications should the nurse administer?
A. Bisacodyl I O mg rectal suppository
B. Magnesium hydroxide 30 ml PO
C. Famotidine 20 mg PO
D. Loperamide 4 mg PO
Answer: A. Bisacodyl I O mg rectal suppository
98. A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis.
Which of the following instructions should the nurse include?
A. "Perform chest percussion and postural drainage at least twice daily."
B. "Restrict intake of foods that contain gluten."
C. "Administer pancreatic enzymes on an empty stomach."
D. "Use a nebulizer to administer a bronchodilator following airway clearance therapy."
Answer: D. "Use a nebulizer to administer a bronchodilator following airway clearance
therapy."
99. A nurse is caring for a client who has an implanted venous access port. Which of the
following should the nurse use to access the port?
A. An Angio catheter
B. A 25-gauge needle
C. A butterfly needle
D. A noncoring Needle
Answer: D. A noncoring Needle
100. A nurse is assessing a client immediately following a cardiac catheterization. The nurse
should notify the provider for which of the following findings?
A. Report of discomfort at the insertion site
B. Heart rate 90/min
C. Bounding pulses in the affected extremity
D. Hematoma over the insertion site
Answer: D. Hematoma over the insertion site
101. A nurse is assessing a client Who has preeclampsia and is receiving magnesium sulfate Via
continuous IV infusion. For Which of the following therapeutic effects should the nurse monitor
the client?
A. Deep tendon reflexes 2+
B. Pulse rate 100/min
C. Urine output 20 mL/hr
D. 1+ proteinuria Via urine dipstick
Answer: A. Deep tendon reflexes 2+
102. A nurse is teaching a newly licensed nurse about caring for clients in the emergency
department. Which of the following actions should the nurse include when teaching about
interacting with a client who is aggravated. pacing, and speaking loudly?
A. use a face shield with a mask when providing care to the client.
B. Tell the client, "You seem to be very upset."
C. Engage the panic alarm.
D. Initiate seclusion protocol.
Answer: B. Tell the client, "You seem to be very upset."
103.
A nurse is caring for a client who is admitted to the medical-surgical unit.
Laboratory Results
0900.
Hemoccult stool positive (negative)
H. pylori positive (negative)
WBC count 6,700/mm3 (5,000 to 10,000/mm3)
Hemoglobin 9.1 g/dL (14 to 18 g/dL)
Hematocrit 27% (40% to 52%)
A nurse is caring for a client who is admitted to the medical-surgical unit.
Vital Signs
0900:
Blood pressure 90/50 mm
Hg Heart rate 1 18/min
Respiratory rate 18/min
Temperature 37.5°C (99.5°F)
Pain rated as 7 on a scale of 0 to 10
Oxygen saturation 98% on room air
104.
Vital Signs
0900:
Blood pressure 90/50 mm Hg
Heart rate 118/min
Respiratory rate 1 8/min
Temperature 37.5°C (99.5°F)
Pain rated as 7 on a scale of 0 to 10
Oxygen saturation 98% on room air
105.
106.
Laboratory Results
0900:
Hemoccult stool positive (negative)
H. pylori positive (negative)
WBC count 6,700/mm3 (5,000 to 10,000/mm3)
Hemoglobin 9.1 g/dL (14 to 18 g/dL)
Hematocrit 27% (40% to 52%)
The nurse is obtaining the client's vital signs prior to an endoscopy.
Vital Signs
0900:
Blood pressure 90/50 mm Hg
Heart rate 1 18/min
Respiratory rate 18/min
Temperature 37.5°C (99.5°F)
Pain rated as 7 on a scale of 0 to 10
Oxygen saturation 98% on room air
1200:
Blood pressure 76/45 mm Hg
Heart rate 121/min
Respiratory rate 18/min
Temperature 37.5°C (99.5°F)
Pain rating of 5 on a scale from 0 to 10
Oxygen saturation 98% on room air
The nurse is obtaining the client's vital signs prior to an endoscopy.
Procedures
Planned endoscopy at 1300
107.
108.
109.
110.
111. The nurse is assessing the client following the transfusion of 2 units of packed RBCs.
Laboratory Results:
0900:
Hemoccult Stool positive (negative)
H. pylori positive(negative)
WBC count 6,700/mm3(5,000 to 10,000/mm3)
Hemoglobin 9.1 g/dL(14 to 18 g/dL)
Hematocrit 27%(40% to 52%)
1300:
WBC count 6,700/mm3(5,000 to 10,000/mm3)
Hemoglobin 7.8 g/dL(14 to 18 g/dL)
Hematocrit 24%(40% to 52%)
1800:
WBC count 6,700/mm3(5,000 to 10,000/mm3)
Hemoglobin 12 g/dL(14 to 18 g/dL)
Hematocrit 36%(40% to 52%)
112. The nurse is assessing the client following the transfusion of 2 units of packed RBCs.
Vital Signs:
0900:
Blood pressure 90/50 mm Hg
Heart rate 118/min
Respiratory rate 18/min
Temperature 37.5°C(99.5°F)
Pain rated as 7 on a scale of 0 to 10
Oxygen saturation 98% on room air
1200:
Blood pressure 76/45 mm Hg
Heart rate 121/min
Respiratory rate 18/min
Temperature 37.5°C(99.5°F)
Pain rating of 5 on a scale of 0 to 10
Oxygen saturation 98% on room air
1230:
Blood pressure 74/49 mm Hg
Heart rate 119/min
Respiratory rate 18/min
113. A nurse is caring for a client who has a placenta previa. Which of the following findings
should the nurse expect?
A. Spotting
B. Nausea
C. Polyhydramnios
D. uterine tenderness
Answer: A. Spotting
