2023 ATI PN COMPREHENSIVE PREDICTOR EXAM WITH
NGN QUESTIONS AND VERIFIED DETAILED SOLUTIONS/A+GRADE
1. A nurse us caring for a client who has a recent diagnosis of terminal illness. The nurse should
identify which of the following as an indication of hopelessness?
A. The client wants to talk about the diagnosis with nursing staff
B. The client has a decreased energy level
C. The client makes funeral arrangements
D. The nurse requests a second opinion
Answer: B. The client has a decreased energy level
2. A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the
child indicates that he is ready to cooperate? (SATA)
A. Allows the nurse to touch him on the arm
B. Plays with toys in the examining room
C. Answers questions asked by the nurse
D. Sits on his parent’s lap when the nurse enters the room
E. Makes eye contact with the nurse
Answer: A. Allows the nurse to touch him on the arm
C. Answers questions asked by the nurse
E. Makes eye contact with the nurse
3. A nurse on a mental health unit is planning care for a group of clients. Which of the following
clients should see the nurse first?
A. A client who has bipolar disorder and is displaying flight of ideas
B. A client who has ADHD and has an inability to concentrate
C. A client who has schizophrenia and is having command hallucinations
D. A client who has depressive disorder and is withdrawn
Answer: C. A client who has schizophrenia and is having command hallucinations
4. A nurse is caring for a client who recently gave birth to her first child. The newborn is crying
and the client states, “I can’t seem to do anything right. What should I do?” which of the
following responses should the nurse make?
A. “I’ll take him back to the nursery, so you can get some rest”
B. “Babies need to cry soon after they are born to develop their lungs”
C. “Let me show you how to swaddle and cuddle him, then you try”
D. “If I turn him on his side, maybe he’ll go back to sleep”
Answer: C. “Let me show you how to swaddle and cuddle him, then you try”
5. A nurse is using a glucometer to measure a client’s capillary blood glucose level. Which of the
following actions should the nurse take?
A. Test the first drop of blood that forms after the puncture
B. Wear sterile gloves
C. Keep the finger in a dependent position
D. Select the central tip of the finger
Answer: C. Keep the finger in a dependent position
6. A nurse is reviewing the home medications of a client who recently had transient ischemic
attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the
following OTC medications interacts adversely with clopidogrel?
A. Docusate Sodium
B. Ranitidine
C. Vitamin D3
D. Naproxen
Answer: D. Naproxen
7. A nurse is collecting data from a client who has a long leg cast the was applied 2 days ago. The
client’s foot is pale with a weak pedal pulse, and the client reports foot numbness. Which of the
following actions should the nurse plan to take?
A. Administer opioid pain medication
B. Apply an ice pack to the affected extremity
C. Check for pain with passive movement of the affected extremity
D. Elevate the affected extremity with several pillows
Answer: D. Elevate the affected extremity with several pillows
8. A nurse in a provider’s office is reinforcing teaching about cigarette smoking with a client.
Which of the following adverse Effects should the nurse include in the teaching?
A. Decreased hemoglobin
B. Somnolence
C. Bradycardia
D. Decreased blood pressure
Answer: B. Somnolence
9. A nurse is contributing to the development of an in-service program for mental health nursing
staff. The nurse should include that the staff can medicate a client against his will, without a
court hearing, in which of the following situations?
A. A client who has a serious mental illness
B. A client who is having difficulty making decision about his treatment
C. A client whom the benefits of the medication outweigh the risks
D. A client who is attempting to hurt himself or others
Answer: D. A client who is attempting to hurt himself or others
10. A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which
of the following instructions should the nurse include in the teaching?
A. “Monitor for muscle weakness while taking this medication.”
B. “Rotate the injection sites when administering the medication.”
C. “Withhold the medication if your pulse rate is above 100 bpm.”
D. “Increase your intake of dietary fiber to increase absorption.”
Answer: A. “Monitor for muscle weakness while taking this medication.”
11. A charge nurse is discussing confidentiality requirement with a newly licensed nurse when
sharing a client’s medical information. Which of the following individuals should the charge
nurse identify as appropriate with whom to share client information?
A. A nurse from another unit after client commits suicide
B. A social worker who is assigned to an involuntary committed school-age client
C. A client’s partner after the client reports intimate partner abuse
D. A client’s employer who is concerned about safety due to substance abuse
Answer: B. A social worker who is assigned to an involuntary committed school-age client
12. A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of
the following findings should the nurse report to the provider?
A. Hgb 13.2 g/dL
B. Urine protein 3 plus
C. Fasting blood glucose 72 mg/dL
D. BUN 15 mg/Dl
Answer: B. Urine protein 3 plus
13. A nurse is collecting data from a client who is 4 hr postoperative following a hemicolectomy.
Which of the following findings should the nurse report to the provider immediately?
A. Pain rating of 9 on a scale of 0 to 10
B. Blood pressure 160/90mmHg
C. Oxygen saturation 89%
D. Abdominal dressing with a moderate amount of bright head drainage
Answer: C. Oxygen saturation 89%
14. A nurse in a provider’s office is collecting data from a client who has a history of
hypertension during his annual physical examination. Which of the following findings should the
nurse report immediately to the provider?
A. kg(4.4 lb) weight gain
B. Blurred vision
C. Potassium 3.6 mEq/L
D. Resumption of cigarette smoking e.
Answer: A. kg(4.4 lb) weight gain
15. A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the
following actions should the nurse take first?
A. Place the client on bedrest
B. Obtain ABG levels
C. Prepare the client for a ventilation- perfusion scan
D. Elevate the head of the client’s bed
Answer: D. Elevate the head of the client’s bed
16. A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following
laboratory tests is the most accurate of blood glucose effective management?
A. Urine Ketones
B. Glucose Tolerance test
C. Glycosylated hemoglobin
D. Fasting blood glucose
Answer: C. Glycosylated hemoglobin
17. A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of
the following actions by the newly licensed nurse should the supervising nurse intervene?
A. Requests a client to assist with distributing lunch trays
B. Tells a client he will lose his phone privileges if he does not take his medication
C. Encourages a client to participate in a recreational group therapy
D. Places mechanical restraints on a client who is hitting another staff member
Answer: B. Tells a client he will lose his phone privileges if he does not take his medication
18. A nurse is supervising assistive personnel (AP) obtain supplies for a client who is on seizure
precautions. Which of the following materials should the AP place in the client’s room?
A. Oral Suction
B. Wrist restraints
C. Tongue depressor
D. Tracheostomy tray
Answer: A. Oral Suction
19. A nurse is reinforcing discharge teaching with the facility of a client who has dependent
personality disorder. Which of the following instructions should the nurse indicate in the
teaching?
A. Maintain a verbal no-harm contract with the client
B. Assume responsibility for making the client’s decision
C. Encourage the client to be assertive
D. Limit the client’s social interactions
Answer: C. Encourage the client to be assertive
20. A nurse is reinforcing discharge teaching with a clint who had a right total hip arthroplasty.
Which of the following instructions should the instructions should the nurse indicate?
A. “You should avoid crossing your legs for 3 months”
B. “You should avoid putting a pillow between your legs when in bed”
C. “You should avoid exercising for the next 6 weeks”
D. “You should avoid lying on your right side”
Answer: B. “You should avoid putting a pillow between your legs when in bed”
21. A nurse reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of
the following instructions should the nurse include in the teaching?
A. Drink 240mL (8oz) of water each meal
B. Eat a small meal every 2 to 3 hr
C. Avoid eating diary products
D. Choose foods that are high in fat
Answer: B. Eat a small meal every 2 to 3 hr
22. A nurse reinforcing teaching with a client who has GERD and a prescription for ranitidine.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I have to remain upright for 1 hour after taking the medication.”
B. “I should take this medication in the morning and at night”
C. “I should expect my tongue to turn black after I take this medication”
D. “I have to take this medication on an empty stomach.”
Answer: B. “I should take this medication in the morning and at night”
23. A nurse is assisting with admission of a client who has pulmonary tuberculosis. Which of the
following types of isolation precautions should the nurse include?
A. Airborne
B. Droplet
C. Protective
D. Contact
Answer: B. Droplet
24. A nurse is reinforcing discharge teaching with a client who has COPD and reports problems
with maintaining adequate nutrition. Which of the following instructions should the nurse
include?
A. “Self administer oxygen through your nasal cannula at 6 milliliters per minute during meals”
B. “Perform pulmonary hygiene 1 hour before meals”
C. “Drink at least 240 mililiters of water during each meal.”
D. “Lie down for 30 minutes after eating.”
Answer: B. “Perform pulmonary hygiene 1 hour before meals”
25. A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which for the
following outcomes should the nurse expect as a therapeutic effect of the treatment?
A. Decreased sodium excretion
B. Improved absorption of vitamins B and C
C. Improved respiratory function
D. Reduced fat in the stools
Answer: D. Reduced fat in the stools
26. A nurse is caring for a client who has paranoid schizophrenia and believes that she is being
followed by FBI agents who are pretending to psychiatric staff. Which of the following
responses should the nurse make?
A. “Why do you feel the staff is the FBI?”
B. “What makes you think the staff is following you?”
C. “The psychiatric staff is not FBI. The are here to help you.”
D. “The must be very frightening for you. Let’s talk more about it.”
Answer: D. “The must be very frightening for you. Let’s talk more about it.”
27. A nurse is assisting in the care of a client who has a fractured femur and is in Buck’s traction,
which of the following actions should the nurse take?
A. Clean the pin insertion sites on a daily basis
B. Ensure that the weights are hanging freely
C. Apply a 9kg(20lb) weight to the traction
D. Remove the weights while the client is eating
Answer: B. Ensure that the weights are hanging freely
28. A nurse is reviewing the medication record of a client who requires continuous oxygen
saturation monitoring. Which of the following should the nurse identify as a factor that affects
the validity of the readings?
A. Calcium level 8.0mg/dL
B. Peripheral vascular disease
C. Taking anticoagulant medication
D. IV access on the same extremity
Answer: B. Peripheral vascular disease
29. A nurse is collecting data from a group of clients. which of the following clients should nurse
identify as having xanthelasma?
A. A lady with an eye closed and a nodule on the eyelid.
B. A man with a red, raised rash on the inner elbow.
C. A child with scaly patches behind the ears.
D. A teenager with a cluster of acne on the forehead.
Answer: A. A lady with an eye closed and a nodule on the eyelid.
30. A nurse is assisting with the admission of a client who has vancomycin-resistant
enterococcus of the urine. Which of the following types of precautions should the nurse
implement for client?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Protective precautions
Answer: A. Contact precautions
31. A community health nurse is assisting in the development of a brochure about hypertension.
Which of the following actions should the nurse take?
A. Use a 12-point font size
B. Present information from complex to simple
C. Explain medical terminology using basic, one-syllable words
D. Write the information at an 8th-grade reading level
Answer: C. Explain medical terminology using basic, one-syllable words
32. A nurse is collecting data from an adolescent during an annual physical examination. Which
of the following statements by the client is the nurses priority?
A. I'm angry with my girlfriend about an argument we have last night
B. I have anxiety when I'm in a large group
C. I'm not sleeping much because all of my homework I have
D. I would rather not be alone and with my friends
Answer: D. I would rather not be alone and with my friends
33. A nurse is placing in dressing over stage one pressure ulcer on a clients heal, which of the
following types of blue dressing with the nurse use?
A. Gauze packing
B. Calcium alginate
C. Transparent film
D. Adhesive strips
Answer: C. Transparent film
34. A nurse is caring for an elder don't client who reports pain and has prescription for ketorolac
15mg IM every 5 hr PRN. The client’s current blood pressure is 114/55mmHg. Which of the
following actions should the nurse take?
A. Request a prescription for a different pain medication for the client
B. administer the medication to the client
C. place the client on strict bed rest
D. repeat the clients blood pressure measurement
Answer: D. repeat the clients blood pressure measurement
35. The charge nurse in a long term care facility is developing a performance improvement plan
for an assistive personnel period which of the following action should the nurse take when
developing the plans?(SATA)
A. Set a specific time frame for meeting performance goals
B. Ask the nurse supervisor to review the plan
C. Request clients complete an evaluation about an AP’s quality of care
D. Include the performance standard that the AP should meet
Answer: A. Set a specific time frame for meeting performance goals
B. Ask the nurse supervisor to review the plan
D. Include the performance standard that the AP should meet
36. Nurse is reinforcing teaching with a client who is either going radiation therapy to the neck
which of the following instructions should the nurse include in the teaching?
A. Cleanse the neck by rubbing with a washcloth
B. Limit fluid and take two 750 mL per day
C. Eat three large meals each day
D. Avoid exposing the neck to the cold
Answer: D. Avoid exposing the neck to the cold
37. A nurse is assisting with the admission of an older adult client who has impaired mobility and
is at risk for falls. Which of the following fall precautions should the nurse plan to implement?
A. Create a schedule with an assistive to do hourly rounding for client
B. Apply rubber-soled slippers before ambulation
C. Move the bedside table with the client’s personal items close to the bed
D. Determine the client’s ability to use the call light
Answer: C. Move the bedside table with the client’s personal items close to the bed
38. A nurse is reinforcing teaching with a client about intermittent catheterization to measure
residual urine. Which of the following information should the nurse include in the teaching?
A. “You cannot drink fluids for 4 hours after procedure”
B. “You will need to urinate before the procedure”
C. “You will have a leg bag to collect the urine”
D. “You will feel pressure when I inflate the catheter balloon”
Answer: B. “You will need to urinate before the procedure”
39. A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse
attempts to convince the client to reconsider his decision and discusses this attempt with the
charge nurse. Which of the following actions should the charge nurse take?
A. Meet with the client’s family to discuss treatment options
B. Perform a mental status examination to establish the client’s competency
C. Ask the client if he has any financial concerns
D. Talk with the nurse about the need to support the client’s decision
Answer: D. Talk with the nurse about the need to support the client’s decision
40. A nurse is reinforcing teaching about breastfeeding with a client who gave birth 2 days ago.
Which of the following information should the nurse include?
A. Allow the newborn to nurse for no more than 10 min on each breast
B. Store expressed breast milk in the refrigerator for up to 72 hr
C. Feed the newborn 8-12 times every 24 hours
D. Supplement feedings with 30 mL (1 oz) of water four times per day
Answer: C. Feed the newborn 8-12 times every 24 hours
41. A nurse is assisting with the admission of a school-aged child. Which of the following actions
should the nurse plan to take?
A. Initiate contact precautions for the child
B. Place the child on bedrest for 24-48 ht
C. Restrict the child’s intake of foods containing vitamin K
D. Keep the child on NPO status for 8 hr
Answer: A. Initiate contact precautions for the child
42. A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which
of the following interventions should the nurse recommend to include in the plan?
A. Keep the client’s daily protein intake below 0.8g/kg
B. Position the client supine with his legs elevated
C. Measure the client’s abdominal girth daily
D. Restrict the clients sodium intake to 3g per day
Answer: C. Measure the client’s abdominal girth daily
43. A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The
client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the
following food choices should the nurse recommend to lessen the occurrence of diarrhea?
A. Apple juice
B. Ice cream
C. Coffee
D. Yogurt
Answer: D. Yogurt
44. A nurse is assisting with the care of a client who has increased intracranial pressure following
a closed head injury. Which of the following actions should the nurse take?
A. Monitor the client’s temperature every 4 hr
B. Wake the client every 6 to 8 hr
C. Elevate the head of the bed to 30 degrees
D. Place the client in lateral sim’s position
Answer: C. Elevate the head of the bed to 30 degrees
45. A nurse is assisting with the plan of care for a client who is in the third trimester of
pregnancy and has ankle edema. Which of the following interventions should the nurse include
in the client’s plan of care?
A. Administer diuretics
B. Limit fluid intake
C. Apply support stockings
D. Place on bedrest
Answer: C. Apply support stockings
46. A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of
the following interventions should the nurse recommend?
A. Remind the client of the day and time often
B. Alternate daily caregivers
C. Avoid discussing the client’s fear
D. Offer the client several choices at mealtimes
Answer: A. Remind the client of the day and time often
47. A community health nurse is assisting with the development of a pamphlet regarding
chocking hazards for toddlers. Which of the following foods should the nurse include?
A. Potatoes
B. Oranges
C. Grapes
D. Corn
Answer: C. Grapes
48. A nurse is reinforcing discharge teaching with a client who has a new diagnosis of
tuberculosis. Which of the following instructions should the nurse include?
A. “You should have some sputum examination every 4 weeks.”
B. “You should obtain a chest x-ray every 3 months.”
C. “You should schedule a tuberculin skin test every 6 months”
D. “You should stop taking your anti-tuberculin medication after 2 weeks.
Answer: B. “You should obtain a chest x-ray every 3 months.”
49. A nurse is assisting with the care of a client who is at 37 weeks of gas station and is
undergoing a non stress test. Which of the following action should the nurse take?
A. Explain that non reactivity might require immediate medication administration
B. Tell the client the test should take about 10 minutes
C. Remind the client to press the button once she feels fetal movement
D. Assist the client in two supplying position a line
Answer: C. Remind the client to press the button once she feels fetal movement
50. A nurse is contributing to the plan of care for a client who has dysphasia. Which of the
following intervention should the nurse include?
A. Encourage socialization during meal times
B. Elevate the head of the clients bed to 30 degrees
C. Tilt the clients head forward during meals
D. Provide three large meals per day
Answer: C. Tilt the clients head forward during meals
51. A nurse is reinforcing teaching with a client who is at 18 weeks of gas station and has a
medical history of mild hypertension. For which of the following findings should the nurse
instruct the client to monitor and report to the provider?
A. Leukorrhea
B. Epistaxis
C. Fatigue
D. Persistent headache
Answer: D. Persistent headache
52. Talking with the partner of a client who recently died, which of the following statements
should the nurse make?
A. “I will call the chaplain speak to you.”
B. “It seems bad right now, but things will get better overtime.”
C. “Tell me what I can do for you at this time.”
D. “I think you should attend a grief support group.”
Answer: C. “Tell me what I can do for you at this time.”
53. Assisting with the admission of a client who states, “the last time I was in the hospital, the
nurse took forever to answer my call light.” Which of the following is an appropriate response by
the nurse?
A. “That must has been a difficult experience for you.”
B. “It will not happen this time because we have more staff.”
C. “I am sure no one meant to ignore you.”
D. “Let’s discuss what brought you to the hospital this time.”
Answer: A. “That must has been a difficult experience for you.”
54. A nurse in a providers office is caring for a group of clients who have communicable
diseases. Which of the following infection should the nurse report to this state health
department?
A. Neisseria gonorrhoeae
B. Sarcoptes scabiei
C. Human papillomavirus
D. Impetigo contagiosa
Answer: A. Neisseria gonorrhoeae
55. A nurse is assisting with the admission of an adolescent client who is suspected to have
bacterial meningitis. Which of the following findings should the nurse expect?
A. Hematuria
B. Nuchal Ridity
C. Jaundice
D. 2 plus pedal edema
Answer: B. Nuchal Ridity
56. A nurse is reviewing laboratory findings for four clients. Which of the following laboratory
values is an expected finding for a client who as end stage kidney disease?
A. Creatinine 15 mg/dL
B. Potassium 4.0 mEq/L
C. BUN 15 mg/dL
D. Phosphorus 4.0 mg/Dl
Answer: A. Creatinine 15 mg/dL
57. A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should
expect which of the following instructions from the provider?
A. Obtain an aPTT level
B. Change the medication to heparin IV
C. Administer protamine sulfate
D. Reduce the dosage of the medication
Answer: D. Reduce the dosage of the medication
58. A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which
of the following indicates fluid volume excess?
A. Urine output of 360 mL/ 12 hr
B. Blood pressure of 100/74 mmHg
C. Distended neck veins
D. Decreased bowel sounds
Answer: C. Distended neck veins
59. A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which
of the following statements should the nurse include in the teaching?
A. “You should place the diaper over the strap of the harness.”
B. “You can apply lotion under the straps of the harness.”
C “The harness can be removed for sleeping each night.”
D. “The harness can promote hip joint developing.”
Answer: D. “The harness can promote hip joint developing.”
60. A nurse is caring for a client who is 2 days postoperative. The client has a prescription for
acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse
inadvertently administers 2 tablets to the client. In which of the following locations should the
nurse document this error?
A. Provider’s progress notes
B. Nursing care plan
C. Incident report
D. Controlled substance inventory record
Answer: C. Incident report
61. A nurse is preparing a sterile field to perform a dressing change for a client’s leg wound,
which of the following actions should the nurse take?
A. Place sterile objects at least 2.5 cm(1in) from the edge of the sterile field
B. Hold the irrigation solution bottle 5 cm (2in) above the sterile container
C. Place the irrigation solution bottle cap on the sterile field
D. Open the outer wrapper of the sterile package toward her body
Answer: A. Place sterile objects at least 2.5 cm(1in) from the edge of the sterile field
62. A nurse begins to bath a newly admitted client who reports that she has not had anything to
eat that day. The nurse interrupts the bath an obtains a healthy meal for the client. This action by
the nurse is an example of which of the following?
A. Boundary crossing
B. Countertransference
C. Veracity
D. Promoting trust
Answer: B. Countertransference
63. A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse
should plan to initiate which of the following isolation precautions when caring for this client?
A. Contact precautions
B. Airborne Precautions
C. Droplet precautions
D. Protective environment
Answer: A. Contact precautions
64. A nurse is documented client care in the nurses’ notes and notices that a space was left blank.
Which of the following actions should the nurse take?
A. Draw horizontal line through the space and sign at the end of the line
B. Leave the space as it is within the entry
C. Place the date at the beginning of the space, followed by double line
D. Black out the line with a felt-tip pen
Answer: A. Draw horizontal line through the space and sign at the end of the line
65. A nurse is caring for a client who has AIDS. Which of the following solutions should the
nurse disinfect the client’s overhead table following a blood spill?
A. Chlorhexidine
B. Bleach
C. Hydrogen peroxide
D. Isopropyl alcohol
Answer: B. Bleach
66. A home health nurse is caring for an older adult client who has rheumatoid arthritis. Which of
the following findings should the nurse identify as a safety risk?
A. The client’s daughter fills the medication organizer once weekly
B. The client’s electrical wires are run under carpeting
C. The client has a smoke detector in his bedroom
D. The client has a raised toilet seat in his bathroom
Answer: B. The client’s electrical wires are run under carpeting
67. A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the
following statements about informed consent should the nurse include in the teaching?
A. “A family member must witness your signature on the informed consent form.”
B. “We require informed consent for all routine treatments.”
C. “You can sign the informed consent form after the provider explains the pros and cons of the
procedure.”
D. “We can accept verbal consent unless the surgical procedure is an emergency.”
Answer: C. “You can sign the informed consent form after the provider explains the pros and
cons of the procedure.”
68. A nurse is reinforcing teaching with a client who has a trichomoniasis vaginalis infection and
a new prescription for metronidazole. Which of the following instructions should the nurse
include in the teaching?
A. “You should expect your urine to turn brown.”
B. “You might develop constipation.”
C. “You will need to take the medication for 3 weeks.”
D. “you might have increased saliva production while taking this medication.”
Answer: A. “You should expect your urine to turn brown.”
69. A nurse is obtaining informed consent from a client who is scheduled for an invasive
procedure. The client states, “I don’t understand why this procedure is necessary.” Which of the
following actions should the nurse take?
A. Remind the client about the specifics of the procedure
B. Explain to the client that the procedure will help treat his diagnosis
C. Ask the client to sign the consent form anyways
D. Notify the charge nurse about the situation
Answer: D. Notify the charge nurse about the situation
70. A nurse is reviewing information about advance directives with a newly admitted client.
Which of the following statements by the client indicates an understanding of the information?
A. “Advance directives include a living will”
B. “Federal legislation dictates the legal guidelines for advance directives.”
C. “My medical record should not include in my advance directives.”
D. “Advance directive include instructions for resolving financial matters after my death.”
Answer: A. “Advance directives include a living will”
71. A nurse is collecting data from the caregivers of client who has Alzheimer’s disease. The
caregiver reports the client has difficulty sleeping at night and wanders throughout the house.
Which of the following interventions should the nurse recommend?
A. Encourage the client to take frequent walks during the day
B. Give the client a barbiturate medication at bedtime
C. Allow the client to nap for at least 1 hr during the day
D. Put a simple lock on the clients bedroom
Answer: A. Encourage the client to take frequent walks during the day
72. A nurse is assisting in the care of a client who is 8 hr postpartum and has a uterine atony with
increased bleeding. Which of the following actions should the nurse take?(SATA)
A. Encourage the client to take frequent walks during the day
B. Administer terbutaline 0.25 mg subcut
C. Give the client 800 mg of ibuprofen
D. Massage the client’s fundus
E. Assist the client to empty her bladder
Answer: D. Massage the client’s fundus
E. Assist the client to empty her bladder
73. A nurse is reinforcing teaching with the support person of client who is in the first stage of
labor. Which of the following instructions should the nurse include regarding effleurage?
A. “Apply steady pressure with this tennis ball to her sacral area.”
B. “Assisting her to breathe in deeply at the beginning of each contraction.”
C. “Gently stroke her abdomen during contractions.”
D. “Help her focus on an object in the room.”
Answer: C. “Gently stroke her abdomen during contractions.”
74. A nurse is caring for an adult client who is postoperative following a total hip arthroplasty.
The client is incontinent of stool and urine. Which of the following actions should the nurse take
to prevent skin breakdown.?
A. Massage the area around the client’s coccyx
B. Limit the client’s fluid intake
C. Use a moisture barrier on a client’s skin
D. Clean the client’s skin with soap and hot water
Answer: C. Use a moisture barrier on a client’s skin
75. A nurse is caring for a client who has terminal cancer. Which of the following actions should
the nurse take to promote the client’s autonomy?
A. Be honest with the client about prognosis
B. allow the client to choose treatment times
C. provide privacy during client care procedures
D. administer pain medication on a routine schedule
Answer: B. allow the client to choose treatment times
76. A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a
sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric
complication?
A. Turn nitrazine strip blue
B. appears greenish-brown in color
C. preceded by bloody mucus
D. has a pH of 7
Answer: B. appears greenish-brown in color
77. A nurse is assisting the care of an adolescent client immediately following a lumbar puncture.
Which of the following actions should the nurse take?
A. Administer opioids to the adolescent on a schedule
B. position that adolescent with his neck hyper extended
C. keep the adolescent NPO
D. inform the adolescent that he might experience a headache
Answer: D. inform the adolescent that he might experience a headache
78. A nurse is reinforcing teaching about advanced directives with a client who has end stage
heart failure. Which of the following statements by the client indicates an understanding of the
teaching?
A. “I am not allowed to change my mind once I sign this document”
B. “My partner needs to be present when I sign this document.”
C. “I should discuss this document with my family after I sign it”
D. “An attorney will need to notarize this document for it to be valid”
Answer: C. “I should discuss this document with my family after I sign it”
79. A nurse is caring for a client who has continuous bladder irrigation following a transurethral
resection of the prostate. The nurse notices clots and dark red blood in the catheter collection
bag. Which of the following actions should the nurse take?
A. Clamp the urinary catheter tubing
B. irrigate the bladder with 20 to 30 mil of 0.9% sodium chloride irrigation
C. replace the indwelling catheter with a smaller diameter catheter
D. allow the tubing to hang below the drainage bag
Answer: B. irrigate the bladder with 20 to 30 mil of 0.9% sodium chloride irrigation
80. A nurse is planning to obtain a 12 lead ECG for a client who has a history of cardiac
dysrhythmias. Which of the following actions should the nurse plan to take?
A. Instruct the client to remain as still as possible during the recording
B. assist the client to the orthopneic position
C. tell the client to expect a mild stinging sensation
D. attach a blood pressure cuff to the client’s upper arm
Answer: A. Instruct the client to remain as still as possible during the recording
81. A nurse is reinforcing teaching with a client who has genital herpes. Which of the following
information should the nurse include in the teaching?
A. “You should increase fluid intake to relieve your dysuria”
B. “you should no longer be infectious once you have completed the course of antibiotics”
C. “you should wear nylon underwear until the lesions have healed”
D. “you should have the lesions drained as they appear”
Answer: A. “You should increase fluid intake to relieve your dysuria”
82. A nurse is preparing to empty a postoperative client closed wound drainage system. Which of
the following actions should the nurse plan to take?
A. Apply sterile gloves prior to handling the drainage system
B. attach the drainage tube to lower intermittent suction
C. cleanse the drainage port with soap and warm water
D. compress the container before replacing the drainage plug
Answer: C. cleanse the drainage port with soap and warm water
83. A nurse is reinforcing teaching with parents of a toddler who has a new diagnosis of asthma
and a prescription for montelukast. which of the following instructions should the nurse include
in the teaching?
A. Administer the medication when the toddler has an acute asthma attack
B. mix the medication induced prior to administration
C. provide an additional dose of the medication prior to physical activity
D. administer the medication to the toddler each evening
Answer: D. administer the medication to the toddler each evening
84. A nurse in acute mental health facility is caring for a newly admitted client. Which of the
following should occur during the orientation phase of the nurse client relationship?
A. Overcoming resistance
B. promoting insight
C. defining responsibilities
D. examining one's feelings
Answer: C. defining responsibilities
85. A nurse is caring for a client who reports having a decrease in fetal movement following an
external cephalic version six hours ago. The nurse identifies the fetus is in the right occiput
anterior position. The nurse should place the fetal heart monitor on which of the following sites
to auscultate the fetal heart rate?
A. Lower left
B. Upper right
C. Upper left
D. Lower right
Answer: A. Lower left
86. A charge nurse is observing a newly licensed nurse performed suctioning for a client who has
a tracheostomy. For which of the following actions by the newly licensed nurse should the
charge nurse intervene?
A. Preoxygenates with 100% oxygen
B. suctions for 30 seconds
C. auscultates breath sounds
D. apply suction during the catheter removal
Answer: B. suctions for 30 seconds
87. A nurse is reviewing the medication administration record of a client who takes atenolol PO
and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should
the nurse monitor with this client?
A. Thrombocytopenia
B. dry cough
C. hypotension
D. hyperglycemia
Answer: C. hypotension
88. A nurse in an acute care setting is preparing to administer medications to a client. Which of
the following actions should the nurse verify the client's identity?
A. Verify the client's identity with a family member
B. ask the client the name of the facility
C. ask the client to state her first name
D. verify the client's identity using a photograph
Answer: D. verify the client's identity using a photograph
89. A nurse in a providers office is collecting data from a client who has psoriasis . Which of the
following statements made by the client should report to the provider?
A. “I do not use fabric softener when I wash my clothing.”
B. “I limit my time spent out in the sunlight”
C. “I remove bold medication on my skin before applying a new dose”
D. “I try not to look at my scales on my body”
Answer: D. “I try not to look at my scales on my body”
90. A nurse is completing chart reviews in a long term care facility in response to an increased in
falls. Which of the following responses in the chart should the nurse used to determine potential
cause of falls?
A. Medication record
B. Admission face sheet
C. Pastoral care notes
D. Social activities report
Answer: A. Medication record
91. A nurse is making client care assignments for an assisted personnel(AP). which of the
following tasks should the nurse assign today AP?
A. Evaluate the need to suction the airway of a client who has a new tracheostomy
B. Inspect the incision of a client who is postoperative following a leg amputation
C. Feed the client who has difficulty swallowing liquids following a stroke
D. Complete postmortem care for a client who has died
Answer: D. Complete postmortem care for a client who has died
92. A nurse is reinforcing teaching with a client who is taking allpurinol about the risk for
developing Steven-Johnson syndrome. for which of the following manifestations should the
nurse instruct the client to monitor and report?
A. Hyperreflexia
B. skin rash with fever
C. Tinnitus with ear pain
D. Diplopia
Answer: B. skin rash with fever
93. The chargers in a long term care facility is reinforcing teaching with a group of nurses about
fall precautions. Which of the following statements made by the nurse indicates an understanding
of the teaching?
A. “I will instruct the client to sit when putting on a pair of pants”
B. “I will instruct the client to sit in a low rise chair”
C. “I will instruct the client to wear socks when ambulating to the bathroom at night”
D. “I will instruct the client to bend at the waist when picking up an object"
Answer: A. “I will instruct the client to sit when putting on a pair of pants”
94. A nurse is recommending clients for discharge to allow for admission of clients following a
tornado disaster. Which of the following clients should the nurse recommend for discharge?
A. Client who reports chest pain
B. a client who has atrial fibrillation and an INR of 4
C. a client who has a sodium level of 140mEq/L after one episode of diarrhea
D. a client who is 3 days postoperative following a hip off arthroplasty and has a warm, red area
on his left calf
Answer: C. a client who has a sodium level of 140mEq/L after one episode of diarrhea
95. A nurse is assisting with the plan of care for a newly admitted client who has anorexia
nervosa. Which of the following interventions should the nurse include in the plan?
A. Obtain vital signs once per day
B. Administer liquid supplements
C. Weigh the client weekly
D. Discuss food topics during mealtime
Answer: B. Administer liquid supplements
96. The charge nurse is reinforcing teaching with a newly licensed nurse about floating to a
different unit. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
A. “I will delegate any task I do not have the skill to perform to assistive personnel”
B. “I will be protected from liability if I am appointed with a resource nurse when I float.”
C. “I will document in the medical record the support nurse who assist with planning care for my
remove clients”
D. “I am not liable if I perform delegated functions when supervision is not provided”
Answer: B. “I will be protected from liability if I am appointed with a resource nurse when I
float.”
97. A nurse is caring for a client who has dehydration due to diarrhea. Which of the following
findings should the nurse report to the provider?
A. Serum creatinine 1.0 mg/ dL
B. Urine specific gravity 1.020
C. Urine an output 12 mL/hr
D. BUN 18 mg/Dl
Answer: C. Urine an output 12 mL/hr
98. A nurse is participating in a performance improvement program. Which of the following
actions should the nurse take to evaluate the effectiveness of the program?
A. Define the problem
B. Identify data collection methods
C. Perform chart audits
D. Review the facilities policy and procedure manual
Answer: C. Perform chart audits
99. A nurse in a assisted living facility is reinforcing teaching with staff members about
preparing for an external chemical disaster. Which of the following instruction should the nurse
include?
A. “Cover the electrical outlets with wet towels”
B. “turn on fans in the facility to circulate air
C. “open the fireplace dampers in the day room
D. “move clients to a room above ground with few windows”
Answer: D. “move clients to a room above ground with few windows”
100. A nurse is assisting care of a client who has an arteriovenous shunt in his right arm. Which
of the following actions should the nurse take?
A. Give Ivy fluids through the AV shunt
B. obtain blood pressure from the right arm
C. check a brute over the shunt on a regular basis
D. avoid range of motion in the right arm
Answer: C. check a brute over the shunt on a regular basis
101. A nurse is caring for a client who has been admitted to the mental health unit. While
reinforcing teaching about the clients prescribed exacerbations, the nurse communicates
truthfully about the adverse effects of the medication. Which of the following ethical concepts is
the nurse exhibiting?
A. Veracity
B. Autonomy
C. Justice
D. Beneficence
Answer: A. Veracity
102. The nurse is caring for a client who is postoperative following a subtotal thyroidectomy.
The nurse should place the client in which of the following positions?
A. Dorsal recumbent
B. Left lateral
C. Semi-fowlers
D. Supine
Answer: C. Semi-fowlers
103. A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of
Wilms tumor. Which of the following interventions should the nurse include in the teaching?
A. “You should not palpate your child's abdomen prior to surgery”
B. “you should give your child Captopril 200 mg PO Daily”
C. “your child should have surgery in 7 to 10 days to remove the tumor”
D. “ Your child will not require further treatment after removal of the tumor”
Answer: A. “You should not palpate your child's abdomen prior to surgery”
104. A nurse enters a room of a school age child and finds him on the floor experiencing a tonic
clonic seizure. Which of the following actions should the nurse take?
A. place a pillow under the child's head
B. restrain the child's upper extremities
C. place a padded tongue blade in the child's mouth
D. turn the child onto his back
Answer: A. place a pillow under the child's head
105. A nurse is contributing to the plan of care row client who is to begin receiving intermittent
internal feedings. Which of the following actions should the nurse recommend?
A. place the client high fowlers position during feedings
B. dilute the formula with water for the first 24 hours of therapy
C. check the clients gastric residual 15 minutes after each feeding
D. show the formula before initiating feedings
Answer: A. place the client high fowlers position during feedings
106. A nurse is collecting data from a client and an outpatient clinic and observes extensive
bruising on the client's arms. The nurse suspects the client is experiencing intimate partner abuse.
Which of the following is the nurse’s priority action?
A. Provide information about moving to a shelter
B. offer support and create a safe, trusting environment
C. document the client’s injury and include a photograph
D. Determine if there is a gun in the client's home
Answer: B. offer support and create a safe, trusting environment
107. A nurse in an urgent care clinic is caring for a client who reports recently using
methylenedioxy- methamphetamine. Which of the following findings should the nurse expect?
A. Hypothermia
B. Somnolence
C. muscle weakness
D. hallucinations
Answer: D. hallucinations
108. A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir.
Which of the following statements by the client indicates an understanding of the teaching?
A. I will report black stools to my doctor
B. I will mix the medications with water
C. I can prevent Constipation if I drink more milk while taking this medication
D. I can prevent nausea if I take this medication on an empty stomach
Answer: B. I will mix the medications with water
109. A nurse is collecting data from a client who is receiving oxytocin 10 units IM 30 minutes
ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?
A. client reports of burning with urination
B. client report of uterine cramping
C. boggy fundus 3 fingerbreadths above them umbllicus
D. saturation of perineal pad in 15 minutes
Answer: C. boggy fundus 3 fingerbreadths above them umbllicus
110. A nurse is attending an educational workshop about a client's confidentiality. Which of the
following actions by the nurse indicates an understanding of the teaching?
A. Changes her personal login password at random intervals
B. gathers data from clients on other units who have same diagnosis
C. uses a personal digital assistant to record client information
D. disable the use of the speed dial function on fax machines
Answer: A. Changes her personal login password at random intervals
111. I'm nurse is assisting with discharge plans for a group of clients. Which of the following
clients should the nurse recommend to a home health referral?
A. A young adult client who has substance abuse disorder
B. an older adult client who has heart failure and lives alone
C. a middle adult client who has a mastectomy and requires chemotherapy
D. an adolescent client who has a tibia fracture and requires crutches
Answer: B. an older adult client who has heart failure and lives alone
112. A nurse is reinforcing teaching with a female client who is taking phenytoin. which of the
following instructions should the nurse include in the teaching?
A. You can safely take the medication if you become pregnant
B. you can skip a dose of this medication if you are nauseated
C. you might experience swollen gums while taking this medication
D. you should expect to have blood work every six months while taking this medication
Answer: C. you might experience swollen gums while taking this medication
113. A nurse is preparing to administer paroxetine 15mg PO or else suspension to a client who
has depressive disorder. The amount available is 10mg/ 5 mL. how many mL should the nurse
administer?
Answer: 7.5 mL
114. A nurse is reinforcing teaching with a client who is at 38 weeks of guest station and is to
undergo contraction stress test. Which of the following statements by the client indicates
understanding of the teaching?
A. I am having this test to check if my babies lungs are mature
B. the nurse will draw my blood after the procedure
C. I am having this test because my baby was not reactive during a non stress test
D. I will need to fast for six hours prior to the procedure
Answer: C. I am having this test because my baby was not reactive during a non stress test
115. A nurse is discussing health practices with the mother of a toddler who is from a different
cultural background than a nurse. Which of the following statements by the mother indicates that
she practices cupping?
A. I apply petroleum Jelly with garlic along my Childs wrist to treat infections
B. I insert needles into the meridian lines of my child body to help with pain relief
C. I rubbed the edge of a coin lengthwise on my child back when he is sick
D. I sometimes place a bottle containing steam against my child skin
Answer: D. I sometimes place a bottle containing steam against my child skin
116. A nurse is reinforcing teaching with a client who has primary open angle glaucoma and has
a prescription for timolol eyedrops. Which of the following statements by the client indicates an
understanding of the teaching?
A. I should take a zinc supplement while taking this medication
B. this medication will dilate my eyes
C. I should check my heart rate while taking this medication
D. this medication will darken the color of my eyes
Answer: C. I should check my heart rate while taking this medication
117. A nurse is collecting data from a preschooler who has severe dehydration. Which of the
following findings should the nurse expect?
A. Jugular vein distention
B. moist mucous membranes
C. weight loss of 10%
D. capillary refill of two seconds
Answer: C. weight loss of 10%
118. A nurse is contributing to the plan of care for an older adult client which of the following
Physiological changes should the nurse consider when administering medication?
A. Decreased liver function
B. Decreased kidney function
C. Increased metabolism
D. Decreased pulmonary function
Answer: B. Decreased kidney function
119. A nurse is caring for a client who is taking multiple medications and asks about possible
interactions. two which of the following members of the interdisciplinary team should the nurse
make a referral?
A. social worker
B. advanced practice nurse
C. patient care technician
D. psychologist
Answer: B. advanced practice nurse
120. A nurse is collecting data from a client who just received his first dose of sulfasalazine to
treat ulcerative colitis. which of the following findings should the nurse identify as an indication
of an allergic reaction to the medication?
A. Arthralgia
B. Fever
C. Dyspnea
D. Nausea
Answer: C. Dyspnea
121. A nurse is collecting nutritional data from a group of adult clients. For which of the
following clients should the nurse recommend and interpersonal care conference with a
dietician?
A. a client who has a body mass index of 32
B. a client who has a sodium intake of 1200 mg/day
C. a client who has a total fat intake of 25% of daily calories
D. a client who has a serum albumin level of 4.5 g/Dl
Answer: A. a client who has a body mass index of 32
122. I charge nurse is reinforcing teaching with a newly licensed nurse about infection control
measures. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
A. Soil dressing should be placed in a biohazard trash receptacle
B. travel precautions require that I wear a gown and gloves when providing care
C. following a blood spill, I should use a bleach solution with a ratio of 1 to 20
D. for a client who has Clostridium difficile, I will clean my hands with alcohol based rub
Answer: A. Soil dressing should be placed in a biohazard trash receptacle
123. A nurse is preparing a vitamin K injection to give a newborn. The newborn mother
questions the purpose of the medication. Which of the following responses should the nurse
make?
A. this medication will decrease the risk of hemorrhage and your newborn
B. this medication will increase the immunity of your newborn
C. this medication will increase the absorption of nutrients and the intestines
D. this medication will decrease the possibility of your newborn developing jaundice
Answer: A. this medication will decrease the risk of hemorrhage and your newborn
124. A nurse is collecting data from a client who has diabetic keto acidosis. Which of the
following findings should the nurse report to the provider?
A. fruity breath odor
B. elevated blood pressure
C. clammy skin
D. bounding pulse
Answer: A. fruity breath odor
125. The nurse is caring for a client who has a vacuum assisted closure system to treat a pressure
ulcer. Which of the following actions should the nurse take?
A. Cover the wound with transparent film extending outward 5 cm(2 in)
B. replace the wound dressing every 12 hours.
C. using adhesive remover to remove tape before reapplying a dressing
D. Pack the wound tightly with sterile gauze
Answer: C. using adhesive remover to remove tape before reapplying a dressing
126. A nurse is verifying informed consent for a client who is preoperative for a vaginal
hysterectomy. Which of the following statements should the nurse identify as an indication that
the client has given informed consent?
A. I should expect my periods to resume in one month
B. I am thankful I am done having children
C. I will have a large scar on my stomach after this procedure
D. I will no longer need a regular gynecological exam
Answer: B. I am thankful I am done having children
127. The nurse is caring for a client who is experiencing a tonic clonic seizure. Which of the
following actions should the nurse take?
A. measure the duration of the seizure
B. restrain the clients arms and legs to prevent injury
C. lower the side rails of the bed when the seizure begins
D. insert an oral airway into the client's mouth
Answer: A. measure the duration of the seizure
128. I'm nurse is collecting data from a client who is at 12 weeks gestation. the client states
“we've been trying to get pregnant for several months, but now I'm not sure I'm ready.” which of
the following responses should the nurse make?
A. I wouldn't worry about it if I were you. You'll be a good mother
B. you need to talk to a therapist about how you're feeling.
C. why do you feel that way if you've been trying to get pregnant
D. many women experience feelings of ambivalence during pregnancy
Answer: D. many women experience feelings of ambivalence during pregnancy
129. A nurse is caring for four clients. Which of the following situations required a consent
form?
A. Performing a wound irrigation with an antibiotic solution
B. Giving a haemophiles influenzae B Vaccine to an infant
C. administering an iron injection Z track method
D. inserting a nasogastric tube
Answer: C. administering an iron injection Z track method
130. A nurse for receiving of report on four clients. The nurse should plan to collect data from
which of the following clients first?
A. A preschooler who has epiglottis and is drooling
B. an adolescent who is postoperative and requesting pain medication
C. and infant who is dehydrated and has a heart rate of 160/minute
D. a school age child who has broken ankle and reports pruritus under his cast
Answer: A. A preschooler who has epiglottis and is drooling
131. A nurse is caring for a client who reports frequent headaches after taking chewable
isosorbide dinitrate. which of the following statements should the nurse make?
A. The headache should decrease as you get used to the medication
B. swallow the tablet holder minimize your headaches
C. you shouldn't take the medication on an empty stomach to prevent a headache
D. you can't discontinue the medication until the headaches go away
Answer: A. The headache should decrease as you get used to the medication
132. A nurse is implementing a bladder training program for a client who had a stroke. Which of
the following interventions with the nurse take?
A. After toileting every six hours
B. encourage intake of caffeinated beverages
C. limit fluid intake to 1500 mL a day
D. check for residual urine after voiding
Answer: D. check for residual urine after voiding
133. The nurse is contributing to the plan of care of a client who is pregnant and reports having
trouble sleeping. Which of the following instructions should the nurse include in the plan of
care?
A. Use a transcutaneous electrical nerve stimulator
B. soak in a bathtub of hot water each night
C. obtain a prescription for pramipexole
D. lie on your left side with your top leg forward
Answer: D. lie on your left side with your top leg forward
134. A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline.
which of the following findings should the nurse include in the teaching as an adverse effect of
this medication?
A. increase salivation
B. Orthostatic hypotension
C. alopecia
D. polyuria
Answer: B. Orthostatic hypotension
135. A nurse is contributing to the plan of care for a client has major depressive disorder. Which
of the following recommendations should the nurse include in the plan of care?
A. Suggest the client exercise before going to bed
B. Recommend the client spend time alone in his room
C. Encourage the client to use positive self talk
D. Offer the client low protein snacks throughout the day
Answer: C. Encourage the client to use positive self talk
136. A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant
who is febrile. Available is ibuprofen 50mg/1.25 mL. how many mL should the nurse
administer?
Answer: The nurse should administer 1.5 mL.
137. A nurse is caring for a child who has terminated cancer. which of the following responses by
the child school age brother should the nurse expect?
A. believes his brother's death will be reversible
B. alternates himself from his peers
C. believes his bad behavior is causing his brother's death
D. progresses to an earlier developmental level
Answer: C. believes his bad behavior is causing his brother's death
138. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the
following medication should anticipate administering to prevent complications of withdrawal?
A. Lorazepam
B. Methmimazole
C. Potassium
D. Naloxone
Answer: D. Naloxone
139. A nurse is reinforcing dietary teaching with a client whose pre pregnancy BMI was 30.5.
The nurse should recognize that the client understands the teaching when she states that she
should expect to gain how many pounds during her pregnancy?
A. 32 lb
B. 24 lb
C. 8 lb
D. 16 lb
Answer: D. 16 lb
140. A nurse is assisting with the care of a client following electroconvulsive therapy for the
treatment of a depressive disorder. Which of the following findings should the nurse expect 15
minutes following the procedure?
A. parasthesias
B. Tonic-Clonic seizures
C. Disorientation
D. sleep apnea
Answer: C. Disorientation
141. A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following
action should the nurse take first?
A. Instruct the client about effective coping strategies
B. suggest that the client assist with meal planning
C. observe the client during and after meals
D. refer the client to a support group for adolescents who have eating disorders
Answer: C. observe the client during and after meals
142. A nurse is monitoring a client who is postoperative. Which of the following actions should
the nurse take when collecting data about the client's respirations?
A. Inform the client when beginning to observe respirations
B. count the clients respirations for 15 seconds
C. place the client in a supine position
D. observe the movements of the clients chest wall
Answer: D. observe the movements of the clients chest wall
143. A nurse is preparing to give change of shift report on a client who is 2 days postoperative
following a total knee arthroplasty. Which of the following information about the client should
the nurse include in the report?
A. Steps required for dressing change
B. admission vital signs
C. preferred bath time
D. time of last pain medication
Answer: D. time of last pain medication
144. A nurse is reinforcing discharge teaching with a client who has bipolar disorder and new
prescription for carbamazepine. Which of the following statements by the client indicates an
understanding of the teaching?
A. I will plan to increase my intake of green, leafy vegetables
B. I will follow a gluten free diet while on this medication
C. I should take this medication on an empty stomach
D. I will plan to avoid grapefruit juice while taking this medication
Answer: D. I will plan to avoid grapefruit juice while taking this medication
145. An assistive personnel tells the charge nurse that her assignment is 2 demanding. she angrily
tells the nurse to reassign one of her tasks to another AP. Which of the following actions should
the nurse take to resolve the conflict?
A. Grand the AP’s request to reassign the task
B. Ask the AP to discuss the issue in a private area
C. Perform the task personally rather than reassigning them
D. Recommend the AP for failure to perform the tasks
Answer: B. Ask the AP to discuss the issue in a private area
146. The nurse is reinforcing teaching with a client who has arthritis. Which of the following
instructions should the nurse include in the teaching?
A. Engage in a low impact aerobic exercises
B. apply ice to the inflamed joint
C. sleep on a soft mattress
D. use fingers to push off from the bed or chair
Answer: B. apply ice to the inflamed joint
147. And nurses caring for a female client who has an indwelling catheter with a urinary
drainage system. Which of the following actions should the nurse take?
A. Collect a sterile specimen from the urinary drainage bag
B. secure the tubing with adhesive tape to lower the abdomen
C. instruct the client to hold the drainage bag at waist height when ambulating
D. coil the tubing on the bed above the collection bag
Answer: B. secure the tubing with adhesive tape to lower the abdomen
148. The nurse is assisting with the support group for clients who have experienced intimate
partner violence. The nurse should identify which of the following client statements as indicating
the greatest risk for violence?
A. I am going to get a job and make some extra money
B. I plan to visit my friends while my husband is at work
C. I have decided to tell my husband that I am leaving him
D. I just got accepted to our local college
Answer: C. I have decided to tell my husband that I am leaving him
149. A nurse is collecting data from a client who is receiving magnesium sulfate via continuous
Ivy infusion for preterm labor. Which of the following findings should the nurse expect?
A. Tachypnea
B. Tachycardia
C. Hypertension
D. Hyperthermia
Answer: C. Hypertension
150. A charge nurse working in a long term care facility over here is 2 AP’s in the nurses station
discussing a client who was just admitted. Which of the following action should the charge nurse
take?
A. Inform the client so that AP’s actions
B. tell the APS to stop their conversation
C. document the event and the clients progress notes
D. submit an incident report to their risk manager
Answer: B. tell the APS to stop their conversation
151. A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram.
which of the following statements made by the client indicates an understanding of the teaching?
A. I do not need to sign a consent form before the procedure
B. I will feel warming sensation after the injection of the dye
C. I can have a meal up to two hours before the procedure
D. I should limit my fluid intake for two days after the procedure
Answer: B. I will feel warming sensation after the injection of the dye
152. A nurse is assisting with the plan of care for a client who has end stage amyotrophic lateral
sclerosis And has developed pneumonia. Which of the following action should the nurse take?
A. Initiate a referral to the speech therapist
B. request a prescription for a glutamate antagonist
C. Verify the status of the clients advance directive
D. suggest a genetic counseling for clients family
Answer: C. Verify the status of the clients advance directive
153. A nurse is reinforcing teaching with a new mother on facility security measures. Which of
the following statements by the mother indicates an understanding of the teaching?
A. I can take my baby to the lobby to visit my family
B. I will carry my baby to the nursery
C. I can remove my security ban and give it to a family member
D. I will have an identification band that matches the one my baby wears
Answer: D. I will have an identification band that matches the one my baby wears
154. A nurse is caring for a client who is 2 days postoperative following a total bilateral
mastectomy. The client is tearful and looks away from her surgical dressings are removed. the
nurse should place the priority action on which of the following actions?
A. providing the client with information on community resources that will strengthen her coping
skills
B. identifying the clients perception of the changes in her physical appearance
C. demonstrating a non judgmental attitude towards the client when providing care for her
surgical wounds
D. encouraging the client to write about her feelings in a journal each day
Answer: C. demonstrating a non judgmental attitude towards the client when providing care for
her surgical wounds
155. A nurse is reinforcing teaching with a client who is at risk for hypertension which of the
following risk reduction strategies should the nurse include in the teaching?
A. Increase dietary intake of canned vegetables
B. limit caloric intake to 2500 calories per day
C. restrict alcohol intake to 360mL (12 oz) of wine per day
D. walk for 30 minutes 5 days per week
Answer: D. walk for 30 minutes 5 days per week
156. The nurse is caring for a client who has dependent personality disorder. Do the following
manifestation should the nurse expect?
A. reclusive
B. perfectionistic
C. submissive
D. impulsive
Answer: C. submissive
157. A nurse is assisting with the admission of a client who has Varicella Zoster. Which of the
following intervention should the nurse plan to implement?
A. Assign the client to a positive airflow room
B. have visitors remain at least 0.91 m(3 ft) away from the client
C. administer aspirin at the client develops a fever
D. initiate contact precautions for this client
Answer: D. initiate contact precautions for this client
158. The nurse is planning to administer four different medications to client via gastrostomy
tube. Which of the following actions should the nurse take?
A. Let timed- release Medication dissolved for 30 minutes prior to administration
B. mix crush medications in 20 mL of water
C. flush with 10 mL of tap water after administration
D. allow separate medications to flow through the tube by gravity
Answer: C. flush with 10 mL of tap water after administration
159. A nurse is preparing to administer medications to a client who has pneumonia and is on
droplet precautions. Which of the following supplies should the nurse use while caring for this
client?
A. surgical mask
B. gown
C. sterile gloves
D. N95 respirator
Answer: A. surgical mask
160. A nurse is reinforcing dietary teaching with a client who is at risk for cardiovascular disease.
Which of the following statements by the client indicates an understanding of the teaching?
A. I drink whole milk every day
B. I may have four egg yolks per week
C. I make toast using enriched white bread
D. I have unsalted pretzels for a snack
Answer: D. I have unsalted pretzels for a snack
161. A nurse in an inpatient psychiatric unit is caring for a client who is raised in an Asian
culture. Which of the following communication techniques by the nurse demonstrates cultural
sensitivity?
A. sitting closer than arms length
B. padding the clients shoulder for reassurance
C. using social conversation to fill periods of silence
D. holding eye contact for brief instances
Answer: D. holding eye contact for brief instances
162. A nurse is reinforcing teaching about safe food handling with a client who is recovering
from food poisoning. Which of the following statements by the client indicates an understanding
of the teaching?
A. I will set my refrigerator to 50 degrees Fahrenheit
B. I will be sure to cook chicken to 180 degrees Fahrenheit
C. it is safe to eat unpasteurized dairy products
D. it is safe to use uncooked ground beef that has been refrigerated for four days
Answer: B. I will be sure to cook chicken to 180 degrees Fahrenheit
163. A nurse is assisting with the discharge plan of a client who has burns on his arms and hands.
Which of the following referrals should the nurse recommend to improve the clients ADL’s?
A. social worker
B. occupational therapist
C. case manager
D. registered dietitian
Answer: B. occupational therapist
164. A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation.
the nurse knows that the client's vagina and vulva are purplish color. the nurse should document
this finding as which of the following?
A. Chadwick sign
B. Hegar’s sign
C. Chloasma
D. Ballottement
Answer: A. Chadwick sign
165. We should recognize that the client's right to confidentiality has been breached when which
of the following occurs?
A. A nurse tells the chaplain that her assigned client has a diagnosis of cancer
B. the social worker reads a clients chart as a follow up to requested consultation
C. the facility risk manager includes the information from a clients medical record and a written
report
D. the newly licensed nurse discusses the clients post operatively complications during shift
Answer: A. A nurse tells the chaplain that her assigned client has a diagnosis of cancer
166. A nurse on a medical surgery unit is preparing to assist but the with the admission of clients
who were injured in a tornado. Which of the following clients should the nurse recommend for
discharge to make the room for a new admissions?
A. the client who had a lobectomy and has a chest tube drainage system
B. the client who had a radical mastectomy 36 hours ago and has a surgical drain
C. a client who has cervical cancer and internal radioactive implant
D. a client who has a cerebral vascular accident 8 hours ago and received from thrombolytic
therapy
Answer: C. a client who has cervical cancer and internal radioactive implant
167. A nurse is reviewing laboratory values for a client who has respiratory acidosis. Which of
the following arterial blood gas values should the nurse expect?
A. pH 7.45, PaCO2 35 mmHg
B. pH 7.35 PaCO2 52 mmHg
C. pH 7.28, PaCO2 28 mmHg
D. pH 7.30, PaCO2 50 mmHg
Answer: D. pH 7.30, PaCO2 50 mmHg
168. A nurse is caring for a client who is receiving oxygen when a fire starts an adjacent room.
Identify the sequence of actions the nurse should take.( move steps and order)
A. Move the clients to a safe location
B. pull the nearest fire alarm
C. shut all the doors and windows
D. attempt to extinguish the fire
Answer: The correct sequence of actions the nurse should take is:
1. B. Pull the nearest fire alarm
2. A. Move the clients to a safe location
3. C. Shut all the doors and windows
4. D. Attempt to extinguish the fire
169. The nurse is caring for a client who is receiving morphine for pain. Which of the following
indicate that the client is experiencing adverse effects of this medication?
A. Lacrimation
B. Hypertension
C. Urinary retention
D. Tachycardia
Answer: C. Urinary retention
170. The nurse is reinforcing dietary teaching with a client who has cholecystitis. Which of the
following food choices should indicate that the client understands the teaching?
A. Peanut butter
B. dark chocolate
C. cream of potato soup
D. skim milk
Answer: D. skim milk
171. A nurse is caring for a client who has a new mastectomy. Which of the following statements
by the client should indicate to the nurse but the client is beginning to cope with the changes of
her body image?
A. I am afraid to discuss my concerns with my husband
B. I am angry I had to lose my breast
C. I am worried I will never be able to take care of myself
D. I am not ready to change my own dressing
Answer: A. I am afraid to discuss my concerns with my husband
172. A nurse is caring for an adult client who reports having trouble getting sleep at night. Which
of the following recommendation should the nurse make?
A. Establish a daily exercise routine
B. keep the telephone volume low while you are trying to fall asleep
C. remain in bed until you fall asleep
D. sleep longer hours on the weekend
Answer: A. Establish a daily exercise routine
173. A nurse is caring for an adolescent that states “I joined the track and field team, so I won't
argue with my brothers anymore.” the nurse should identify that the client is using which of the
following defense mechanisms?
A. regression
B. repression
C. denial
D. Sublimination
Answer: C. denial
174. Her nurse is reinforcing teaching with a client who has a new prescription for transdermal
nitroglycerin patches. which of the following statements by the client indicates an understanding
of his medication?
A. I will replace the patch every 12 hours
B. I will apply the patch in the same place every day
C. I will place the patch on a hairless area of skin
D. I won't remove the patch if I develop a headache
Answer: C. I will place the patch on a hairless area of skin
