ATI PN COMPREHENSIVE PREDICTOR FORM A, B AND C
QUESTIONS AND ANSWERS WITH RATIONALES | LATEST 2023
1. A nurse is reviewing the techniques for transferring a client from a bed to a chair with a group
of assistive personnel (AP). Which of the following instructions should the nurse include?
Answer: Use lower-body strength
Rationale: The nurse should instruct the AP to use lower-body strength when lifting a client to
reduce stress on the back
2. A nurse is participating in a quality improvement study about the effectiveness of client pain
management in the unit. Which of the following strategies should the nurse use to collect data?
Answer: Review clients' charts for their rating of pain before pain medication was administered
and 1 hr after administration
Rationale: The nurse should collect data from clients' charts about pain ratings before and after
pain management interventions
3. A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of
HIV. Which of the following information should the nurse include in the teaching?
Answer: "Your HIV status will be shared with members of your health care team."
Rationale: The diagnosis of HIV or AIDS is shared with every member of the healthcare team
who provides direct care for the client, just like any other diagnoses
4. A nurse is planning care for a client who has a history of seizures. Which of the following
pieces of equipment should the nurse place in the client's room?
Answer: Suction catheter
Rationale: The nurse should place suction equipment in the room of a client who has a history
of seizures. During a seizure, the client might have excessive oral secretions or might vomit. If
the client's airway becomes occluded, then the nurse will need to suction the oral cavity to
maintain a patent airway
5. A nurse in a provider's office is reviewing the medical record of a client who requests a
prescription for an oral contraceptive. Which of the following findings should the nurse identify
as a contraindication for oral contraceptive use?
Answer: Coronary artery disease
Rationale: Coronary artery disease is a contraindication to oral contraceptive use because it
increases the client's risk for myocardial infarction. Other contraindications for receiving oral
contraceptives include gallbladder disease, breast cancer, and hypertension
6. A nurse is assisting with the care of a school-age child immediately following surgery. The
child weighs 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following
findings should the nurse report to the provider?
Answer: 250 mL of sanguineous drainage over the last 3 hr
Rationale: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage
occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging.
Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse
should report this finding to the provider immediately
7. A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational
diabetes. Which of the following findings should the nurse report to the provider as an indication
of hyperglycemia?
Answer: Polyuria
Rationale: The nurse should identify polyuria as an expected finding of hyperglycemia and
report this finding to the provider
8. A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus.
Which of the following client statements indicates an understanding of the teaching?
Answer: "I will dispose of my needles in a plastic laundry detergent container."
Rationale: The nurse should instruct the client to dispose of needles in a puncture-proof
container, such as a plastic laundry detergent container.
9. A nurse is caring for a client who has Alzheimer's disease. Which of the following actions
should the nurse take?
Answer: Encourage the client to reminisce about the past
Rationale: The client who has Alzheimer's disease has progressive loss of short-term memory
and might not be able to recall recent happenings and events. This can lead to increased
frustration. However, remote memory remains in place for a longer period of time and can elicit
feelings of happiness
10. A nurse is monitoring a client who is receiving telemetry. Which of the following ECG
findings should the nurse report to the provider?
Answer: PR interval 0.24 seconds
Rationale: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval indicates a
heart block; therefore, the nurse should report this finding provider
11. A nurse on a medical unit is reviewing a client's medical record. Which of the following
procedures should the nurse identify requires the client to sign a separate informed consent form?
Answer: Lumbar puncture
Rationale: The nurse should identify that a client needs to provide consent for general treatment,
as well as a separate written, informed consent for any treatment that has an element of risk, such
as a lumbar puncture
12. A licensed practical nurse (LPN) is reviewing client assignments for the upcoming shift.
Which of the following clients should the LPN ask the charge nurse to reassign to a registered
nurse (RN)?
Answer: A client who has a new colostomy and requires the development of a teaching plan
Rationale: Developing a client teaching plan is not within the scope of practice for an LPN.
The nurse should contact the nursing supervisor to inform them of the client's need for a teaching
plan regarding the new colostomy and request that this client is reassigned to an RN. The scope
of practice of an LPN does allow the nurse to reinforce teaching once the plan has been
established
13. A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty
using eating utensils. The nurse should identify the need for a referral to one of the following
interprofessional team members?
Answer: Occupational therapist
Rationale: The nurse should identify the need for a referral to an occupational therapist to teach
the client how to use special eating utensils
14. A nurse is preparing to perform blood glucose monitoring for a client who has type 1diabetes
Mellitus. Which of the following actions should the nurse take first?
Answer: Hold the finger for testing in a dependent position
Rationale: Evidence-based practice indicates that the nurse should first position the testing site
to enhance blood flow, which improves the ability to collect an adequate specimen
15. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to
decrease peripheral edema. Which of the following instructions should the nurse include?
Answer: Apply the stockings in the morning
Rationale: The nurse should instruct the client to apply the elastic stockings in the morning and
remove them at the end of the day before bedtime
16. A nurse in a provider's office is reviewing pediculosis capitis management and prevention
strategies with the parent of a school-age child. Which of the following strategies should the
nurse include? (Select all that apply.)
Answer:
• Store the child's clothing in a separate cubicle when at school.
• Boil brushes and combs in water for 10 min.
• Dry bed linens and clothing in a hot dryer for at least 20 min.
Rationale: Transmission of lice occurs via contact with personal items. Boiling hair care items
in hot water for 10 min kills lice and nits. Exposing bedding and clothing to prolonged heat by
washing in hot dryer for at least 20 min is an appropriate strategy
17. A nurse is contributing to the plan of care for a client who has a continent urinary diversion.
Which of the following interventions should the nurse plan to implement to facilitate urinary
elimination?
Answer: Use intermittent urinary catheterization for the client on at regular intervals
Rationale: A continent urinary diversion contains valves that prevent urine from exiting the
pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain
urine from the client's pouch.
18. A nurse is preparing to perform a bladder scan for a client. Which of the following actions
should the nurse take?
Answer: Tell the client they should not experience any discomfort
Rationale: The nurse applies the handheld scanner over the area of the bladder when performing
a bladder scan. This noninvasive procedure should not cause the client any discomfort
19. A nurse is caring for a client who is crying and states that their provider informed them that
they have a tumor and will need a biopsy. Which of the following responses should the nurse
make?
Answer: "What have you done to help yourself get through stressful situations before?"
Rationale: This is a therapeutic response. The nurse is aware that the client is under stress and
encourages comparison to investigate whether they have experience dealing with a stressful
situation
20. A nurse is caring for a newborn who is 12 hr old. The nurse should expect the newborn's
stool to have which of the following characteristics within the first 24 hour following birth?
Answer: Dark greenish-black and viscous
Rationale: The first stool passed by a newborn is the meconium that develops in utero. It is dark
greenish-black and viscous, containing of amniotic fluid, cells, intestinal secretions, and blood
21. A licensed practical nurse is assisting with the preparation of a client for insertion of a
peripherally inserted central venous catheter (PICC). Which of the following actions should the
nurse take?
Answer: Witness the client's signature on the informed consent form.
Rationale: The insertion of a PICC is an invasive procedure with risks and benefits. The nurse
should witness the client's signature on the consent form after ensuring the client has an
understanding of the procedure, including its risks and benefits
22. A nurse is caring for a client who adheres to a kosher diet. Which of the following food
selections should the nurse expect to see on the client's meal tray?
Answer: Spaghetti noodles with red sauce
Rationale: The nurse should identify that spaghetti noodles with red sauce is appropriate for a
client who adheres to a kosher diet.
23. A nurse is contributing to the plan of care for a client who is receiving continuous bladder
irrigation following a transurethral resection of the prostate (TURP). Which of the following
interventions should the nurse include?
Answer: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color
Rationale: The nurse should maintain the flow rate of the bladder irrigation to keep the urine
diluted to a reddish-pink color and the tubing free of clots and bleeding
24. A nurse is assisting with the care of a client who is postpartum and has a deep-vein
thrombosis. The client has been receiving heparin IV infusion. Which of the following
medications should the nurse ensure is readily available?
Answer: Protamine sulfate
Rationale: The nurse should ensure that protamine sulfate is readily available. Protamine sulfate
is the antidote used to reverse the anticoagulant effects of heparin
25. A nurse is reinforcing teaching with a client about how to replace their two piece ostomy
pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the
following strategies should the nurse suggest?
Answer: Hold the skin taut while removing the barrier
Rationale: Gently and gradually peeling the skin barrier away while holding the skin taut
minimizes discomfort and trauma to the peristomal skin
26. A nurse in an inpatient mental health facility is caring for a newly admitted client who has
alcohol use disorder. During a therapy session, the client asks about Alcoholics Anonymous
(AA). Which of the following responses should the nurse make?
Answer: "What is your current understanding about the purpose of AA?"
Rationale: The nurse should identify the client's understanding about the purpose of AA to
provide further information about the program and meetings and to facilitate a referral if needed.
For treatment to be successful, the nurse should involve the client in the care decision-making
process. This ensures the treatment program meets the client's individual needs and demonstrates
caring by the nurse
27. A nurse is performing a dressing change for a client who is 3 days postoperative. Which Of
the following findings should the nurse report to the provider?
Answer: Yellow-green drainage at the incision line
Rationale: Yellow-green, purulent, or odorous drainage indicates the wound is infected. The
nurse should report this finding to the Provider
28. A nurse is providing comfort to the partner of a client who has died. Which of the following
statements should the nurse make?
Answer: "Journaling about your relationship might help with the grieving process."
Rationale: Journaling provides a means for the client to identify thoughts and feelings and to
recognize and come to terms with the positive and negative aspects the client's relationship with
their partner
29. A nurse is assisting with an educational session for newly licensed nurses about partner
violence. Which of the following characteristics should the Nurse included as placing a
vulnerable person at risk for partner violence?
Answer: Recent confirmation of pregnancy
Rationale: The nurse should include pregnancy as a characteristic placing a vulnerable person at
risk for partner violence. The perpetrator might view the pregnancy as a threat to the relationship
due to the attention the child receives
30. A nurse is reinforcing teaching for a client who is preparing to return to work after a back
injury. Which of the following instructions for safe lifting technique should the nurse include?
Answer: "You should hold a box close to your body when lifting it up."
Rationale: The client should hold the box as close to their body as possible to maintain balance
and prevent injury
31. A nurse is reinforcing discharge teaching with a client who has a prescription for home
oxygen therapy via nasal cannula. Which of the following instructions should the nurse include?
Answer: "Apply a water-based lubricant around the nostrils to prevent irritation."
Rationale: The client should protect their nares with a water-based lubricant to prevent irritation
from the nasal cannula. Petroleum and oil-based products are combustible and should not be
used with oxygen therapy
32. A nurse is caring for a client who is in an inpatient mental health facility and has dependent
personality disorder. Which of the following client behaviors should the nurse expect?
Answer: The client calls their partner to ask what they should wear each day
Rationale: Clients who have dependent personality disorder have problems making everyday
decisions without input from others
33. A nurse is caring for a client who is scheduled for a mastectomy the following day. The client
is tearful and tells the nurse that they are not ready to have this procedure done at this time.
Which of the following responses should the nurse make?
Answer: "Would you like for me to talk to the surgeon with you?"
Rationale: The nurse should advocate for the client's needs by offering to talk to the surgeon
with the client. The nurse should also offer moral support and encourage the client to express
their concerns and make a more informed decision
34. A nurse is documenting client care in the medical record. Which of the following entries
should the nurse make?
Answer: "Client remains NPO until x-ray procedure is complete."
Rationale: The nurse should use documentation that is specific and uses accepted terminology.
The nurse can use the abbreviation "NPO", which is an accepted abbreviation for "nothing by
mouth."
35. A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a
different language than the nurse. Which of the following actions should the nurse take?
Answer: Observe the client's facial expressions during communication
Rationale: The nurse should observe the client while the interpreter is speaking to the client.
Both verbal and nonverbal behaviors, such as facial expressions and body language, can indicate
whether the client understands what the interpreter is saying
36. A nurse is collecting data from a client who reports recent methamphetamine use. Which Of
the following manifestations should the nurse expect?
Answer: Dilated pupils
Rationale: The nurse should expect a client who has stimulant intoxication to have dilated
pupils. Other expected findings of stimulant intoxication include increased energy and
hypervigilance
37. A nurse is working in an acute care facility when a natural disaster occurs. The facility must
discharge clients to provide room for new admissions. Which of the following clients should the
nurse recommend to the charge nurse for discharge?
Answer: A client who has pneumonia and is currently receiving oral antibiotics
Rationale: The nurse should recognize that this client can continue oral antibiotics at home.
Therefore, this client is a candidate for discharge in a disaster situation
38. A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the
manic phase. Which of the following activities should the nurse recommend for the client?
Answer: Walking outside with a staff member
Rationale: During the manic phase of bipolar disorder, psychomotor activity is excessive. The
nurse should include physical activity, such as walking, in the plan of care. Additionally, the oneon-one nature of the activity provides the client with a sense of security
39. A nurse is supervising an assistive personnel (AP) who is preparing to remove personal
protective equipment (PPE) after providing direct care to a client who requires airborne and
contact precautions. The nurse should recognize that the AP understands the procedure when
which of the following PPE is removed first?
Answer: Gloves
Rationale: The greatest risk to the AP is contamination from pathogens that might be present on
the PPE. Therefore, the priority actions for the AP to take is to remove the gloves, which are
considered the most contaminated of the PPE.
40. A nurse in an outpatient surgery center is reinforcing discharge teaching with a client
following a lithotripsy for uric acid stones. Which of the following instructions should the nurse
plan to include in the teaching?
Answer: Strain the urine to collect stone fragments
Rationale: The client should verify passage of the stones by straining their urine. Laboratory
analysis of the stones can provide information to help prevent future stone formation
41. A nurse is reinforcing teaching with a client who has hypercholesterolemia and a new
prescription for atorvastatin. The nurse should instruct the client that which of the following
findings is an adverse effect of this medication and should be reported to the provider?
Answer: Muscle pain
Rationale: The nurse should instruct the client to report findings of muscle pain or tenderness to
the provider. These findings can be manifestations of myopathy, or muscle injury, which is a
potential serious adverse effect of atorvastatin
42. A nurse is caring for a client who is recovering from a motor vehicle crash. The client's
employer calls to ask if the client's injuries will prevent them from returning to work. Which of
the following responses should the nurse make?
Answer: "I cannot give you this information. You will need to speak with your employee."
Rationale: Sharing client information with an employer is a violation of client confidentiality.
HIPAA ensures that client information is kept confidential once it is disclosed in a health care
setting. The nurse should inform the employer they will need to speak with the client directly
43. A nurse is assisting a client who is scheduled for a nonstress test (NST). Which of the
following actions should the nurse take?
Answer: Provide the client with a handheld event marker to record fetal activity
Rationale: The nurse will provide the client with a handheld event marker for use in
documenting fetal movement. The client will press the button every time they feel the fetus move
throughout the test, which is then logged on the paper tracing recording the heart rate and
activity of the Fetus
44. A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of
the larynx. Which of the following statements made by the client indicates an understanding of
the teaching?
Answer: "I should wear a soft scarf around my neck when I am outside."
Rationale: A client receiving radiation therapy should cover the affected area with loose, soft
clothing to protect the skin from sun Exposure
45. A nurse is reinforcing teaching with an older adult client who has severe left-sided heart
failure. Which of the following statements should the nurse make?
Answer: "Rest for 15 minutes between activities."
Rationale: The nurse should instruct the client to increase activity gradually and tourist for a
period of 15 min if fatigue occurs. Clients who have heart failure should balance activity with
rest to reduce cardiac Workload.
46. A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural
effusion. In which of the following positions should the nurse plan to place the client during the
procedure?
Answer: Upright with arms resting on the overbed table
Rationale: The nurse should position the client upright with arms resting on the overbed table to
widen the intercostal spaces and improve access to the pleural fluid
47. A nurse is talking with a client who says the provider agreed to initiate a do-not- resuscitate
(DNR) prescription. After leaving the client's room, which of the following actions should the
nurse take first?
Answer: Check for documentation that the provider spoke with the client about the DNR
Rationale: The first action the nurse should take when using the nursing process is to determine
whether the provider documented the conversation appropriately. The nurse must ensure the
client made an informed decision and that documentation meets legal requirements
48. A nurse is observing a client who is in the first stage of labor. Which of the following
interventions should the nurse recommend for this client? (Select all that apply.)
Answer: Squatting using an exercise ball. Counterpressure to the sacral area. Pelvic rocking.
Rationale: Squatting using an exercise ball can help relax the pelvis and perineal area and can
relieve pain during contractions. Counterpressure to the sacral area can help decrease pain by
relieving pressure on the spinal nerves caused by the fetus's occiput. Pelvic rocking can relieve
backache during the first stage of labor. To perform this action, the client hollows their back and
then arches it to relieve back pain.
49. A nurse is caring for a group of clients. The nurse should fill out an incident report for which
of the following situations?
Answer: A visitor who develops a bruise on their head following a syncopal episode
Rationale: The nurse should complete an incident report for an injury involving a client or
visitor
50. A client is requesting information from a nurse about creating a health care proxy. Which Of
the following statements should the nurse make?
Answer: "The person you appoint will make healthcare decisions for you if you cannot do so
yourself."
Rationale: The nurse should instruct the client that a health care proxy designates a surrogate to
make health care decisions when the client is no longer able to make decisions for themselves.
51. A client in a mental health facility unjustly accuses a nurse of stealing money from their
room. Which of the following therapeutic responses Should the nurse make?
Answer: "Tell me how you decided who took your money."
Rationale: This response by the nurse is an example of therapeutic communication, in which the
nurse validates the client's concern by encouraging them to describe their perception
52. A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous
tube feedings. Which of the following actions should the nurse take?
Answer: Flush the feeding tube with water before and after administering the medication
Rationale: To maintain patency of the feeding tube and to ensure that the client receives all of
the medication, the nurse should flush the tubing before and after administration
53. A nurse is planning care for a 5-year-old child who is 8 hr postoperative following a
tonsillectomy. Which of the following interventions should the nurse include in the plan of care?
Answer: Administer PRN analgesics regularly for the first 24 hr.
Rationale: The nurse should administer analgesics for the first 24 hr even if they are ordered on
an as-needed basis. It is necessary to control pain postoperatively. Giving the analgesics
regularly provides a steady state of analgesia. With pain being managed, children are more likely
to consume fluids, remain hydrated, and avoid delayed discharge or readmissions for fluid
volume deficit.
54. A nurse is reinforcing preoperative teaching with a client who will receive morphine through
a PCA pump after surgery. Which of the following information should the nurse include?
Answer: "You should increase your fluid intake while receiving this medication through the
PCA pump."
Rationale: The client should increase their fluid intake to prevent or relieve the adverse effect of
constipation while receiving morphine through the PCA pump
55. A nurse is using the FLACC scale to determine the pain level of an 11-monthold infant who
is postoperative. Which of the following factors should the nurse consider when using this pain
scale?
Answer: Level of activity
Rationale: The nurse should consider the infant's activity level when using the FLACC pain
scale. The FLACC score is determined by five categories of behavior: facial expression (F), leg
movement (L), activity (A), cry (C), and consolability (C).
56. A nurse is receiving a change-of-shift report for four clients. The nurse should plan to collect
data from which of the following clients first?
Answer: A client who has asthma and had frequent exacerbations on the previous shift
Rationale: When using the airway, breathing, circulation (ABC) approach to client care, the
nurse should prioritize data collection from a client who has asthma. The client experienced
several exacerbations of asthma on the previous shift, which can result in an obstruction of the
client's airway
57. A nurse is caring for a newborn who is 1 hr old. The mother received fentanyl 30 min before
birth. For which of the following adverse effects should the nurse monitor the newborn?
Answer: Respiratory depression
Rationale: Fentanyl, an opioid agonist, rapidly crosses the placenta, and it is present in fetal
blood within 1 min. The nurse should monitor the newborn for respiratory depression, which is
an adverse effect of fentanyl
58. A nurse is caring for a client who has asthma and has been taking montelukast for 1 month.
Which of the following findings should indicate to the nurse that the client is complying with this
medication regimen?
Answer: The client takes the medication once daily at bedtime
Rationale: Montelukast, a leukotriene modifier, is taken once a day for maintenance at bedtime
59. A nurse is assisting with planning palliative care for a client who has stage IV cancer and is
in the active stage of dying. Which of the following interventions should the nurse include in the
plan of care?
Answer: Administer atropine to reduce the client's respiratory secretions
Rationale: The nurse should administer atropine to reduce terminal respiratory secretions and
reduce noisy ventilations called "the death rattle."
60. A nurse in a pediatric clinic is collecting data from a toddler. Which of the following findings
should the nurse identify as a possible indication of physical neglect?
Answer: The toddler is inadequately dressed for the weather
Rationale: Inappropriate dress is a suggestive finding of physical neglect. The nurse should
collect further data for other indicators of physical neglect
61. A nurse enters the room of an adolescent client and finds them on the floor experiencing a
tonic-clonic seizure. Which of the following actions should the nurse take when the seizure
subsides?
Answer: Keep the client in a side-lying position
Rationale: The nurse should keep the client in a side-lying position to facilitate drainage of any
secretions and prevent aspiration
62. A nurse is contributing to the plan of care for a client who has a prescription for range-ofmotion exercises of the shoulder. Which of the following exercises should the nurse recommend
to promote shoulder hyperextension?
Answer: Move the arm behind the body with the elbow straight
Rationale: Hyperextension of the shoulder involves the deltoid, teres major, and latissimus dorsi
muscles. The client performs this motion by moving their arm behind their body while keeping
the elbow straight
63. A nurse is reviewing various defense mechanisms with a newly licensed nurse. Which of the
following client statements should the nurse use as an example of rationalization?
Answer: "I didn't get a good grade because my teacher doesn't like me."
Rationale: The nurse should recognize this statement as the use of rationalization by a client.
Rationalization is used as a means of justifying unreasonable feelings, thoughts, or actions
64. A nurse is caring for an older adult client who is experiencing difficulty sleeping. Which Of
the following actions should the nurse take?
Answer: Offer the client a snack of whole grain crackers before bedtime
Rationale: The nurse should provide the client a light carbohydrate snack, such as whole grain
crackers, before bedtime
65. A nurse is preparing a client for an enteral feeding and notices that the pump at the client's
bedside is warm to the touch. Which of the following actions should the nurse take?
Answer: Unplug the equipment and remove it from the room
Rationale: If the nurse identifies a potential safety hazard with the equipment, the nurse should
remove the pump from the client's room to prevent injury to the client. The nurse should then
follow facility protocol regarding faulty equipment
66. A nurse is collecting data from a 5-year-old child at a well-child visit. The parent reports that
the child is having frequent nightmares. Which of the following statements by the parent
indicates to the nurse that the child is experiencing sleep terrors rather than nightmares?
Answer: "My child goes back to sleep right away."
Rationale: The nurse should realize that going back to sleep quickly is an indication of sleep
terrors, rather than nightmares. A child who is experiencing nightmares has difficulty returning to
sleep because of continued fear
67. A nurse is assisting with the admission of an older adult client. Which of the following
actions should the nurse take first?
Answer: Complete a fall risk assessment on the client
Rationale: The first action the nurse should take when using the nursing process is to collect
data from the client. By completing a fall risk assessment, the nurse can identify the client's risk
for falls and can then assist in planning interventions to prevent client injury
68. A nurse is reinforcing teaching about a high-protein diet with a client who has HIV. Which of
the following foods should the nurse recommend as containing the highest amount of protein per
serving?
Answer: 2 Tbsp peanut butter
Rationale: The nurse should recommend 2 Tbsp of peanut butter because it contains
approximately 7 g of proteins
69. A nurse is caring for a client who has a phobia of elevators. Which of the following should
the nurse recognize as an indication of a positive client response to systematic desensitization?
Answer: The client remains relaxed when thinking of the phobia
Rationale: The purpose of desensitization therapy is to teach the client to use relaxation
techniques to overcome the anxiety caused by the phobia. The nurse should recognize the client's
lack of anxiety when thinking about the phobia as a positive response to the therapy
70. A nurse is assisting with the admission of a client who has rubeola. Which of the following
transmission-based precautions should the nurse plan to initiate for this client?
Answer: Airborne
Rationale: The nurse should initiate airborne precautions for a client who has rubeola. This
includes a private room with negative-pressure airflow and an air filtration system. Facility
personnel are required to wear an N95 respirator while in the client's room
71. A nurse is reinforcing teaching about strategies to promote eating with a client who has
COPD. Which of the following instructions should the nurse include in the teaching?
Answer: Drink high-protein and high-calorie nutritional supplements
Rationale: The nurse should instruct the client to drink high-protein and high-calorie nutritional
supplements to maintain respiratory muscle function. COPD causes respiratory stress that can
lead to hypermetabolism and wasting of the client's muscle mass
72. A nurse is working in a long-term care facility. Which of the following actions should the
nurse take when using computer-based client records?
Answer: Shred printouts of client care information when they are no longer needed
Rationale: Nurses should destroy documents that contain information regarding client care when
they are no longer needed to avoid compromising client confidentiality
73. A nurse is assisting a client who is postoperative to sit on the side of the bed. Which of the
following actions should the nurse take?
Answer: Elevate the head of the client's bed
Rationale: The nurse should elevate the head of the client's bed to decrease the distance the
client has to move to sit on the side of the bed
74. A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty.
Which of the following actions should the nurse take?
Answer: Place an abduction wedge between the client's legs when in bed
Rationale: The nurse should place an abduction wedge between the client's legs while in bed to
prevent adduction of the legs and hip dislocation following a total hip arthroplasty
75. A nurse is assisting with teaching a group of local residents at a community health fair about
the Dietary Approaches to Stop Hypertension (DASH) diet. Which of the following statements
by a resident indicates an understanding of the teaching?
Answer: "I will keep my intake of sodium less than 2,300 milligrams per day."
Rationale: DASH principles include limiting daily sodium intake to less than 2,300mg/day.
Individuals who have an increased risk for hypertension such as clients who have kidney disease
and diabetes, should reduce intake of sodium to 1,500 mg/day
76. A nurse is reviewing the critical pathway of a client who is 4 days postoperative following a
total knee arthroplasty. The client's vital signs are oral temperature 102.4, heart rate 116/min,
respiratory rate 24/min, and blood pressure 152/92 mm Hg. Which of the following actions
should the nurse take?
Answer: Document the findings as a variance
Rationale: Whenever a client does not meet the goals or outcomes in the critical pathway due to
unexpected findings or a need for additional interventions, the nurse should document the details
as a variance in the critical pathway. In this case, it is a negative variance. If the client progresses
faster than the pathway specifies, it is a positive variance
77. A nurse in a long-term care facility notices a client who has Alzheimer's disease standing at
the exit doors at the end of the hallway. The client appears to be anxious and agitated. Which of
the following actions should the nurse take?
Answer: Escort the client to a quiet area on the nursing unit
Rationale: A client who has Alzheimer's disease experiences chronic confusion. Guiding the
client to a quiet, familiar area will help decrease agitation
78. A nurse is reviewing laboratory results for a client who is receiving mechanical ventilation.
Which of the following findings should the nurse recognize as a potential complication of
mechanical ventilation?
Answer: pH 7.5
Rationale: The nurse should identify that a pH level of 7.5 indicates alkalosis and is above the
expected reference range. Excessive ventilation can cause this finding
79. A nurse is administering morning medications to a client. The client questions the nurse
regarding a medication that they do not recognize. Which of the following actions should the
nurse take first?
Answer: Verify the prescription in the client's medical record
Rationale: The first action the nurse should take when using the nursing process is to collect
more data. By verifying the prescription in the client's medical record, the nurse can ensure that
the medication is prescribed for the Client
80. A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect
data, the nurse should obtain which of the following information?
Answer: Motor response
Rationale: The nurse should collect data about the client's motor response and assign the
response a score of 1 to 6, according to the Glasgow Coma Scale
81. A nurse is reinforcing teaching about self-administration of enoxaparin. Which of the
following instructions should the nurse include?
Answer: Administer by subcutaneous injection
Rationale: The nurse should include that enoxaparin should be injected into the subcutaneous
tissue
82. A nurse is monitoring a school-age child who has anemia and is receiving a transfusion of
packed RBCs. Which of the following statements by the child indicates a possible hemolytic
transfusion reaction that the nurse should report to the charge nurse and the provider?
Answer: "I am really cold. May I have another warm blanket?"
Rationale: The nurse should recognize that a report from the child of feeling cold or having
chills is a possible indication of a hemolytic transfusion reaction. This reaction occurs when the
RBCs being infused are destroyed by the child's immune system. The nurse should stop the
transfusion immediately, take a set of vital signs, and notify the charge nurse and provider
83. A nurse is reinforcing teaching with a client who has hypertension and is beginning
medication therapy with captopril. Which of the following over-the-counter medications should
the nurse instruct the client to avoid?
Answer: Ibuprofen
Rationale: Ibuprofen, or any other nonsteroidal anti-inflammatory medications, can reduce the
antihypertensive effects of this medication. Therefore, the nurse should instruct the client who is
taking captopril to avoid taking ibuprofen
84. A nurse is collecting data from a client who has chronic pancreatitis and is receiving
pancrelipase. Which of the following client findings indicates a therapeutic effect of this
medication?
Answer: Reports a decrease in the number of stools
Rationale: Pancrelipase is administered as replacement therapy for a deficiency in pancreatic
enzymes, which result in steatorrhea, or fatty stools. The nurse should monitor for improved
nutrition and a decrease in the number of bowel movements, which would indicate a therapeutic
response to the medication
85. A nurse is caring for a client who has borderline personality disorder and states, "I am going
to kill my partner when I get out of here." Which of the following actions should the nurse take?
Answer: Notify the client's care team about the threats against their partner
Rationale: The nurse should notify the client's care team about the threats the client makes
toward others. Failure of the nurse to report threats made toward others is considered negligence
86. A nurse is reinforcing teaching about advance directives with a client. Which of the following
statements by the client indicates an understanding of the teaching?
Answer: "I can change my health care decisions even if I have advance directives."
Rationale: The nurse should instruct the client that they are free to make changes to advance
directives at any time. Treatment decisions might change as a client's health status changes
87. A nurse is checking the reflexes of a newborn. Which of the following techniques should the
nurse use to elicit the Babinski reflex?
Answer: Stroke the sole of the newborn's foot upward and toward the great toe
Rationale: The nurse should stroke upward along the lateral aspect of the sole of the foot,
beginning at the heel, to elicit the Babinski reflex
88. A nurse is monitoring a client who is 12 hr postoperative following a cholecystectomy and
received morphine 30 min ago for pain. The nurse should identify which of the following
findings as an adverse effect of the medication?
Answer: Respiratory rate 10/min
Rationale: A respiratory rate of 10/min indicates respiratory depression, which is an adverse
effect of morphine
89. A nurse is caring for a client who is scheduled for peritoneal dialysis. Which of the following
actions should the nurse take first?
Answer: Ensure the dialysate solution is at room temperature
Rationale: Evidence-based practice indicates the nurse should administer the dialysate solution
at a temperature of 98.6; therefore, the first action the nurse should take to warm the prescribed
solution
90. A nurse is reviewing the laboratory report of a client who is 2 days postoperative following
thoracic surgery. Which of the following laboratory results should the nurse report to the
provider?
Answer: WBC 25,000/mm
Rationale: The nurse should identify a WBC of 25,000/mm is above the expected reference
range and is an indication that the client might have a postoperative infection; therefore, the
nurse should report this finding to the provider
91. A nurse in a long-term care facility is reviewing standard precaution guidelines with an
assistive personnel (AP). The nurse should instruct the AP to use which of the following to clean
up a blood spill?
Answer: Chlorine bleach solution
Rationale: The nurse should instruct the AP to use a bleach solution to clean up a blood spill. A
1:10 bleach-to-water solution will destroy all bloodborne pathogens
92. A nurse is reinforcing teaching with a client who has a new prescription for phenytoin. Which
of the following instructions should the nurse include as a measure to assist with the possible
adverse effects of this medication?
Answer: Perform daily gum massage
Rationale: Gingival hyperplasia is a common adverse effect of this medication. Massaging the
gums will help minimize this effect
93. A nurse is monitoring a client who is receiving IV fluids. For which of the following findings
should the nurse stop the infusion?
Answer: Edema above the catheter insertion site
Rationale: Edema above the catheter site indicates infiltration. The nurse should stop the IV
infusion
94. A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the
following interventions should the nurse include?
Answer: Place the client in a private room
Rationale: The nurse should place a client who has viral meningitis in a private room to prevent
the transmission of the virus. Direct contact with a contaminated surface or the saliva, mucus, or
feces of the person who has the infection transmits viral meningitis
95. A nurse is reviewing the medical history of a client who is scheduled for colonoscopy to
establish a diagnosis of diverticulitis. Which of the following findings should the nurse identify
as increasing the client's risk for developing diverticular disease?
Answer: Chronic constipation
Rationale: Diverticular disease is a disorder in which pouches or saclike projections occur in the
bowel mucosa through weakened areas of the muscular layer of the intestines. The nurse should
identify chronic constipation as a risk factor for diverticular disease
96. A nurse is making assignments for the upcoming shifts. Which of the following tasks should
the nurse plan to delegate to an assistive personnel(AP)?
Answer: Perform post mortem care for a client who died 1 hr ago
Rationale: Performing post mortem care is within the range of function for an AP. Therefore, the
nurse should delegate this task to an AP
97. A nurse is caring for a client who is in the final stages of cancer. Which of the following
client situations should the nurse identify as an ethical dilemma?
Answer: The client asks the nurse to help them die peacefully in their sleep
Rationale: This situation presents an ethical issue for the nurse because the client is asking for a
variation of active euthanasia, also known as assisted suicide, which is in violation of the Code
of Ethics for Nurses. The nurse is legally and ethically unable to support this decision by the
client and should ask for assistance with this dilemma
98. A nurse in a long-term care facility is collecting data from a client who has been receiving be
taxolol to treat glaucoma. Which of the following findings is an adverse effect of this
medication?
Answer: Bradycardia
Rationale: Betaxolol is a beta blocker that can produce systemic effects, such as bradycardia
99. A nurse in a long-term care facility is documenting the care of an older adult client. Which of
the following information should the nurse include in the weekly nursing care summary?
Answer: Hydration status
Rationale: Older adults are at risk for dehydration. Therefore, the nurse should be vigilant about
monitoring the client's hydration status and include this information in the weekly nursing care
summary
100. A nurse in an inpatient mental health facility is contributing to the plan of care for a newly
admitted client who has anorexia nervosa. Which of the following actions should the nurse
include in the plan of care?
Answer: Record the amount of food the client consumes
Rationale: The nurse should record the amount of food the client Cosumnes to ensure the client
is consuming adequate nutrition
101. A nurse is assisting with the care of a client who has a terminal illness. The client practices
Orthodox Judaism. Which of the following actions should the nurse take?
Answer: Assure the client that a family member will stay with the body after death
Rationale: The nurse should assure the client that a family member will remain with the body
until burial
102. A nurse is caring for a client who is receiving telemetry. Which of the following ECG
findings should the nurse report to the charge nurse?
Answer: PR interval 0.24 seconds.
103. A nurse in an urgent care clinic is collecting data from four clients. Which of the following
clients should the nurse recommend for treatment?
Answer: A client who is experiencing shortness of breath after taking Amoxicillin.
104. A nurse is assisting with the transfer of a client to a long term care facility. the nurse should
review which of the following sections of the electronic medical record to locate information
about the clients personal health insurance?
Answer: admission sheet.
105. A nurse is reinforcing teaching with a client who is scheduled for a lumbar puncture. Which
of the following statements should the nurse make?
Answer: you should increase your fluid intake after this procedure.
106. A nurse is reinforcing teaching about puberty with a group of prepubescent female clients.
Which of the following information Should the nurse be included in the teaching?
Answer: you will likely gain weight before you start to get taller.
107. A nurse is assisting with a discussion about STIs with a group of adolescents at a health fair.
Which of the following statements should the nurse make?
Answer: an infection with gonorrhea may result in infertility.
108. A nurse in a provider's office is caring for a client who is at 34 weeks of gestation. Which of
the following instructions should the nurse anticipate providing to the client?
Answer: monitor your blood pressure using your right arm daily.
109. A nurse is preparing to administer amoxicillin 875 mg PO every 12 hours. The amount
available is amoxicillin oral suspension 400 mg/5mL. How many mL should the nurse
administer per dose?
Answer: 11
110. A nurse is collecting data from a client who has chronic hepatitis. In which of the following
locations should the nurse expect the client to point to indicate hepatic tenderness?
Answer: The client with chronic hepatitis will experience hepatic tenderness in the upper right
quadrant, which is where the nurse should palpate. this is the area where the liver is located
111. A nurse is monitoring a client who is receiving lactated ringers 500 mL over 4 hr. The drop
factor of the manual IV tubing is 10gtt/mL. The nurse should check that the manual IV infusion
is delivered at how many gtt/min?
Answer: 21.
112. A nurse is reinforcing teaching with a client who has osteoarthritis. Which of the following
instructions should the nurse include?
Answer: apply capsaicin cream four times a day.
113. A nurse is reviewing a client's medication record and notices that a double dose of oral
digoxin was administered 1 hr ago. Which of the following actions should the nurse take first?
Answer: Obtain a set of the client's vital signs
Rationale: The first action the nurse should take when using the nursing process is to collect
data from the client. Digoxin can cause bradycardia. By obtaining the client's vital signs, the
nurse can identify the need for Intervention
114. A nurse is instructing an assistive personnel (AP) about caring for a client who has hepatitis
A and is incontinent of stool. Which of the following infection control precautions should the
nurse instruct the AP to use?
Answer: Contact
Rationale: Hepatitis A is spread by the fecal-oral route. Standard precautions are usually
sufficient to prevent the spread of infection. However, if the client who has hepatitis A is also
incontinent of stool, then contact precautions are indicated
115. A nurse is assisting with the transfer of a client to a long-term care facility. The Nurse
should review which of the following sections of the electronic health record to locate
information about the client's personal health insurance?
Answer: Admission sheet
Rationale: The nurse will find client data, such as date of birth, occupation, and the client's
source of health insurance, on the client's admission sheet
116. A nurse is inspecting the skin of a newborn. Which of the following findings should the
nurse report to the provider?
Answer: Generalized petechiae
Rationale: Petechiae are an expected finding over the presenting part of the newborn, such as on
the forehead in a brow presentation, and also anywhere on the head of the newborns who has a
nuchal cord, which is an umbilical cord around the neck. However, petechiae all over the
newborn's body can indicate infection or a decreased platelet count and should be reported to the
provider
117. A nurse in a provider's office is obtaining the health history from a client who is scheduled
to undergo a cardiac catheterization in 2 days. Which of the following questions is the priority
for the nurse to ask?
Answer: "Do you know if you're allergic to iodine?"
Rationale: The greatest risk to the client is an allergic reaction to the contrast agent, which
contains iodine. Therefore, the priority question is to identify the client's allergies
118. A nurse is reviewing the medical record of a client who is receiving warfarin and has atrial
fibrillation. Which of the following laboratory values should the nurse report to the provider?
Answer: INR 5.0
Rationale: The international normalized ratio (INR) is a measurement of the body's blood
clotting ability. A client receiving warfarin to prevent clot formation related to atrial fibrillation
should have an INR of 2.0 to 3.0.
An INR of 5.0 or greater indicates that the client is at risk for bleeding. Therefore, the nurse
should notify the provider about this laboratory value
119. A nurse is evaluating the safe use of electrical equipment by a newly hired assistive
personnel (AP). Which of the following actions by the AP demonstrates an understanding of the
proper use of electrical Equipment?
Answer: Grasps the plug of a device in the client's room to pull it straight out from the wall
Rationale: The nurse should recognize that by grasping the plug, rather than the cord, the AP is
demonstrating an understanding of proper equipment use and preventing risk of injury from
electronic equipment.
120. A nurse is reinforcing discharge teaching with the parents of a school age child who has
severe hemophilia A. Which of the following statements by the parents indicates an
understanding of the teaching?
Answer: "I will soak my child's toothbrush in warm water to soften it before my child uses it."
Rationale: The nurse should instruct the parents to soften their child's toothbrush in warm water
before they use it or allow them to use a sponge tipped disposable toothbrush. These actions will
minimize trauma to the gums and prevent bleeding of the oral cavity
121. A nurse is assisting with the development of an in-service for newly licensed nurses about
seclusion. In which of the following situations should the nurse identify the need to request a
prescription for seclusion?
Answer: A client hits another client because they thought the other client was talking about them
Rationale: The nurse should request a prescription for seclusion for a client who hits another
client to protect the client and others from physical Injury
122. A nurse in an urgent care clinic is completing a client examination. After listening to the
client's lungs, which of the following adventitious sounds should the nurse document?
Answer: Wheeze
123. A nurse in an urgent care clinic is caring for a child who has a minor burn on his palm after
touching the burner on a hot stove. Which of the following actions should the nurse take?
A. Clean the burn with mild soap and tepid water
B. Remove any embedded debris
C. Apply an antimicrobial ointment
D. Wrap the hand in a gauze dressing
E. Inform the parent of dressing change schedule
Answer: A. Clean the burn with mild soap and tepid water
124. A nurse in a provider's office is collecting growth and development data from a 7month old
infant during a well child visit. Which of the following images should the nurse identify indicates
expected gross motor skills for the infant
Answer: sitting and leaning forward using both hands for support is an expected finding for a 7
month old infant
125. A nurse in a provider's office is caring for a client who is at 34 weeks of gestation. Which of
the following instructions should the nurse anticipate providing to the client?
Answer: monitor your blood pressure using your right arm daily
126. A nurse is collecting data from a school age child who has hypoglycemia. Which of the
following clinical manifestations should the nurse expect?
Answer: sweating
127. A nurse is assisting with the care of a client who has terminal cancer. Which of the
following statements by the client's family should indicate to the nurse that they are coping with
their situation?
Answer: "Dad, I remember the time we all went fishing at the lake."
128. A nurse in a provider's office is caring for four clients. Which of the following clients should
the nurse see first?
Answer: A client who is 36 weeks of gestation and reports a painless vaginal Bleeding
129. A nurse is collecting a urine specimen from a female client who has diabetes insipidus. the
nurse should expect which of the following findings?
Answer: urine specific gravity of 1.002
130. A nurse is reinforcing teaching for a client who has Meniere's disease and a new
prescription for meclizine. The nurse should inform the client that which of the following is an
adverse effect of this medication?
Answer: Sedation
131. A nurse is reinforcing teaching with a client who is scheduled for an exercise ECG stress
test. which of the following actions should the nurse take?
Answer: Recommend the client wear comfortable shoes during the test
132. A nurse is collecting data from an older adult client who has a gastric ulcer. Which of the
findings should the nurse identify as a complication to report to the provider?
Answer: hematemesis
133. A nurse is reinforcing teaching with a client who has asthma and has a prescription for
theophylline. Which of the following statements should the nurse make?
Answer: Discontinue drinking caffeinated beverages
134. A nurse is caring for a client who is refusing a prescribed medication. Which of the
following actions should the nurse take first?
Answer: Identify the client's concerns about receiving the medication
135. A nurse is reviewing the electronic health records of four clients. Which of the following
client conditions should the nurse recognize as reportable to a regulatory agency?
Answer: A client who is newly diagnosed with tuberculosis
136. A nurse is caring for a client who is actively dying from cancer. Which of the following
actions should the nurse take?
Answer: Moisten the client's conjunctiva with sterile normal saline
137. A nurse is caring for a client who is receiving continuous feedings via a gastrostomy tube.
Which of the following actions should the nurse plan to take?
Answer: Flush the tube with 60 mL of water if it becomes clogged
138. A nurse is preparing to administer an IM immunization to a preschooler. Which of the
following statements should the nurse plan to make prior to performing the injection?
Answer: "Let's give the medicine to your doll first."
139. A nurse is collecting data from a client who has schizophrenia. Which of the following
statements by the client should the nurse identify as delusional?
Answer: "My doctor's glasses have lasers that will burn holes in my brain if I look at him."
140. A nurse is collecting data from an older adult client who has a hip fracture. Which of the
following findings should the nurse expect?
Answer: External rotation
141. A nurse is performing post mortem care for a client. Which of the following actions should
the nurse take?
Answer: Elevate the head of the client's bed.
142. A nurse is preparing to perform tracheostomy care for a client. which of the following
actions should the nurse take first?
Answer: Open sterile packages
143. A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea
and vomiting along with fever and chills. Which of the following diagnostic tests should the
nurse expect the provider to prescribe?
Answer: Cerebrospinal fluid analysis
144. A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa. Which of
the following instructions should the nurse include?
Answer: Administer the medication subcutaneously
145. A nurse enters a client's room and sees smoke coming from a wastebasket next to the bed.
Which of the following actions should the nurse take first?
Answer: Assist the client to a nearby waiting area
146. A nurse is caring for a client who is 12hr postop following gastrointestinal surgery and has
an NG tube for gastric decompression. Which of the following actions should the nurse take?
Answer: Keep the plugged tube above the level of the stomach when the client is ambulating
147. A nurse is caring for a client who is expressing sadness about the amputation of her leg 72
hr ago due to trauma. The nurse must leave the room but promises to return as soon as possible.
Which of the following ethical principles is the nurse demonstrating when he returns as
promised?
Answer: Fidelity
148. A nurse is reinforcing teaching with an older adult client who has osteoarthritis. Which of
the following instructions should the nurse include?
Answer: Apply capsaicin cream 4 times daily
149. A nurse in a provider's office is reinforcing teaching with a client who is to follow a 2000mg
sodium restricted diet. Which of the following client food selections indicates an understanding
of the teaching?
Answer: Canned peaches
150. A nurse is reinforcing teaching with a female client who has tuberculosis and a new
prescription for rifampin. Which of the following statements by the client indicates
understanding of the teaching?
Answer: "I will use condoms in addition to birth control pills to decrease my risk of becoming
pregnant."
151. A nurse is reinforcing teaching about managing manifestations of anxiety with a client who
has generalized anxiety disorder. Which of the following information should the nurse include?
Answer: Say the word "stop" when upsetting thoughts occur.
152. A nurse is collecting data from a client following a lumbar puncture. For which of the
following adverse effects should the nurse monitor?
Answer: Headache
153. A nurse is preparing to insert an indwelling catheter for a female adult client. Which of the
following actions should the nurse take? (Select all that apply.)
Answer: • Cleanse the clients labia and meatus using a front to back motion
• Use the nondominant hand to expose the clients urinary meatus
• Advance the catheter 5-7 in into the client's urinary meatus
• Ask the client to bear down while inserting the catheter
154. A nurse is preparing to perform venipuncture to obtain a blood sample from a client. Which
of the following actions should the nurse take?
Answer: Select a site in the antecubital fossa
155. A nurse is assisting with an educational program about car restraint safety for a group of
parents. Which of the following statements by a parent indicates an understanding of the
instructions?
Answer: My 12 year old child should place the shoulder lap belt low across his hips
156. A nurse is reinforcing teaching about strategies to promote eating with a client who has
COPD. Which of the following instructions should the nurse include in the teaching?
Answer: Drink high protein and high calorie nutritional supplements
157. A nurse is contributing to a teaching plan for a group of male adolescents about the adverse
effects of anabolic steroid use. Which of the following manifestations should the nurse include?
Answer: Reduced height potential
158. A nurse is planning to administer nystatin oral suspension to a client who has oral
candidiasis. Which of the following instructions should the nurse give to the client?
Answer: Hold the medication in your mouth for several minutes prior to swallowing
159. A nurse is preparing to care for the assigned clients on her upcoming shift. Which of the
following time management strategies should the nurse plan to use?
Answer: prepare a priority list of client needs for the shift
160. A nurse is preparing to witness a client who is scheduled for surgery sign an informed
consent. Which of the following actions should the nurse take?
Answer: Ask the client if he understands the procedure
161. A nurse is assisting with the care of a client who is 2 days post op following a total knee
arthroplasty. Which of the following tasks should the nurse assign to an assistive personnel?
Answer: reapply antiembolic stockings to the client following a shower
162. A nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which of
the following statements by the newly licensed nurse indicates an understanding of this method
of pain control?
Answer: I should report leaking at the insertion site to the anesthesiologist
163. A nurse is assisting with a community education program for parents of preschoolers about
recommended activities to promote physical development. Which of the following statements
should the nurse make?
Answer: you should provide unorganized play activities for your child each day
164. A nurse is caring for a client who has just been diagnosed with a terminal illness. the client
states, I have nothing to live for. I just cannot go on. Which of the following responses should the
nurse make?
Answer: It sounds like you feel there is no hope. Are you thinking about harming yourself?
165. A nurse is contributing to the plan of care for a client who has a nasogastric tube and is
receiving continuous enteral feedings. Which of the following interventions should the nurse
include in the plan?
Answer: measure the pH of gastric tube aspirate prior to administering nutrition
166. A nurse is caring for a client who is at 34 weeks of gestation and has mild preeclampsia.
Which of the following findings indicates a progression from mild to severe preeclampsia?
Answer: Client reports blurred vision
167. A nurse is reinforcing teaching with a client who has a new prescription for metronidazole.
the nurse should instruct the client to expert which of the following adverse effects while taking
this medication?
Answer: reddish-brown urine
168. A home health nurse is collecting data from an older adult client who has generalized
anxiety disorder. The client lives at home with her partner and a sibling. Which of the following
responses by the client's partner is the priority for the nurse to address?
Answer: Her prescription isn't generic so we can't afford it anymore
169. A nurse is caring for a client who is being discharged home after experiencing a
cerebrovascular accident. Which of the following documents should the nurse plan to include
with discharge instructions?
Answer: List of symptoms to report
170. A nurse in a pediatric clinic receives a phone call from a parent whose child has just
ingested the contents of a full bottle of acetaminophen. Which of the following responses should
the nurse make?
Answer: take your child to the emergency department
171. A nurse is contributing to the plan of care for a client who has pneumonia. which of the
following entries should the nurse include in the plan
Answer: client prefers bathing in the evening
172. A nurse is reinforcing teaching about a therapeutic diet with a client who has iron deficiency
anemia. which of the following food items should the nurse recommend that the client consume?
Answer: red meats
173. A nurse is caring for a 3 year old toddler at a well child visit. the parent states that the child
will not eat a full meal. Which of the following responses should the nurse make?
Answer: offer healthy snacks more frequently rather than expecting him to eat full meals
174. A nurse is instructing an assistive personnel about caring for an older adult client who has
herpes zoster. Which of the following information should the nurse include?
Answer: the infection is contagious until blisters heal
175. A nurse is working on a unit with an assistive personnel. Which of the following actions by
the AP should the nurse recognize and report as assault
Answer: The ap threatens a client with insertion of an NG tube if she does not eat breakfast
176. A nurse is reinforcing teaching with a client who has alcohol use disorder and is to begin
disulfiram therapy. Which of the following statements should the nurse make?
Answer: you will need to sign an informed consent before starting this medication
177. A nurse is caring for a client who reports twelve liquid stools in the past 8hr. which of the
following findings should indicate to the nurse that the client is experiencing dehydration
Answer: potassium level of 2.5
