ATI PN COMPREHENSIVE PREDICTOR 2023
RETAKE GUIDE GRADED A LATEST VERSION 180 QUESTIONS AND
ANSWERS
1. A nurse in a long term care facility notices a client who has alzheimers disease standing
at the exit doors at the end of the hallway. The clients 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
2. A nurse is assisting with the plan of care for a client who has a continent urinary division.
Which of the following interventions should the nurse plan to implement to facilitate
urinary elimination?
Answer: Use intermittent urinary catheterization for a client at regular intervals
3. A nurse is assisting with a 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
4. 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
5. A nurse is supervising an assistive personnel who is preparing to remove her personal
protective equipment after providing direct care to a client who requires airborne and
contact precautions. The nurse should recognize that the AP understands the procedure
when she removes which of the following PPE first?
Answer: Gloves
6. A nurse is caring for a client who is crying and states that his provider informed him
that he has a tumor and will need a biopsy. Which of the following responses should the
nurse make?
Answer: What have you done in the past to help yourself get through stressful situations
before?
7. A nurse is inspecting the skin of a newborn. Which of the following findings should the
nurse report to the provider
Answer: Generalized petechiae
8. 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
9. A nurse is reinforcing teaching with an older adult client who has a severe left sided
heart failure. Which of the following statements should the nurse make
Answer: Rest 15 minutes between activities
10. A nurse in a long term care facility is documenting the care of an older client. Which
of the following information should the nurse include in the weekly nursing care summary
Answer: Hydration status
11. A nurse is caring for a client who has a head injury. Using the Glasgow coma scale
collection data, the nurse should obtain which of the following information
Answer: Motor response
12. 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 stockings in the morning
13. A nurse in a providers office is obtaining a health history from a client who is scheduled
to undergo a cardiac catheterization in 2 days. Which of the following questions is the
Answer: Do you know if your allergic to iodine
14. 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
15. 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
16. A nurse is preparing to witness a client who is scheduled for surgery sign a informed
consent. Which of the following actions should the nurse take?
Answer: Ask the client if he understands the procedure
17. A nurse in an inpatient mental health clinic is caring for a newly admitted client who
has alcohol use disorder. During a therapy session, the client asks about alcoholics
anonymous. Which of the following responses should the nurse make?
Answer: What is your current understanding about the purpose of AA
18. A nurse is assisting with the care of a client who is 2 days postop following a total
knee arthroplasty. Which of the following tasks should the nurse assign to an assistive
personnel?
Answer: Reapply anti-embolic stockings to the client following a shower
19. A client in a mental health facility unjustly accuses a nurse of stealing money from his
room. Which of the following therapeutic responses should the nurse make?
Answer: Tell me how you decided who took your money
20. 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
understanding of the teaching?
Answer: I will wear a soft scarf around my neck when I am outside
21. A nurse is using the FLACC scale to determine the level of pain for an 11 month old
infant who is postop. Which of the following factors should the nurse consider when using
this pain scale
Answer: Level of activity
22. A nurse is reviewing the techniques for transferring a client from bed to chair with a
group of assistive personnel. Which of the following instructions should the nurse include
Answer: Use lower body strength
23. 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
24. A nurse is collecting data from a 5 year old child at a well child visit. The parents
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
25. A nurse assisting with the care of a school age child immediately following surgery.
The child weighs 21.8kg and has a chest tube applied to suction. Which of the following
findings should the nurse report to the provider
Answer: 250ml of sanguineous drainage over the last 3hr
26. A nurse is reinforcing teaching about advanced 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 advanced directives
27. 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: Airbourne
28. A nurse is administering morning medications to clients on the unit. A client questions
the nurse regarding a medication that she does not recognize. Which of the following
actions should the nurse take first
Answer: Verify the prescription in the clients medical record
29. 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
30. A nurse enters a clients 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
31. A nurse is caring for a client who is in the final stages of cancer. Which of the following
situations should the nurse identify as an ethical dilemma
Answer: The client asks the nurse to help her die peacefully in her sleep
32. A nurse is reinforcing teaching with an older adult client who has osteoarthritis. Which
of the following instructions should the nurse includes
Answer: Apply capsaicin cream 4 times daily
33. A nurse in a 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?
Answer: 1. clean the burn with soap and tepid water
2. Remove any embedded debris
3. Apply an antimicrobial ointment
4. Wrap the hand in a gauze dressing
5. Inform the parent of dressing change schedule
34. A nurse on a medical unit is reviewing a clients medical record. Which of the following
procedures should the nurse identify requires the client to sign a separate informed consent
Answer: Lumbar puncture
35. 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
36. A nurse is performing a dressing change for a client who is 3 days postop. Which of
the following findings should the nurse report to the provider
Answer: Yellow green drainage at the incision line
37. A nurse in a long term care facility is collecting data from a client who has been
receiving betaxolol to treat glaucoma. Which of the following findings in an adverse effect
of this medication
Answer: Bradycardia
38. 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
39. A nurse is caring for a client who is scheduled for a peritoneal dialysis. Which of the
following actions should the nurse take first
Answer: Ensure the dialysate solution is at room temperature
40. A nurse in a providers 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
41. A nurse enters the room of an adolescent client and finds him 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
42. 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 she should not experience any discomfort
43. 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
44. A nurse is contributing to the plan of care for a client who has a prescription for range
of motion exercises of the shoulder. Which of the following exercises should the nurse
recommend to promote shoulder hyper-extension
Answer: Move her arm behind her body with her elbow straight
45. A nurse is receiving 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 frequently exacerbation on the previous shift
46. A nurse in a providers 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 are daily
47. 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
48. 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 clients respiratory secretions
49. 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
50. A nurse is contributing to the plan of care for a client who is receiving continuous
bladder irrigation immediately following a transurethral resection of the prostate. 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
51. 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 she is 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
52. 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
53. A nurse is assisting with a community education program for parents of preschoolers
about recommend 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
54. A nurse 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 an really cold. May I have another warm blanket
55. A nurse is collecting data from a client who is at 30 weeks of gestation and has
gestational diabetes. The nurse should report which of the following findings as an
indication of hyperglycemia
Answer: Polyuria
56. A nurse is collecting data from a client who has chronic pancreatitis and is receiving
pancrelipase. Which of the following indicates the client is experiencing a therapeutic
response to the medication
Answer: Reports decrease in number of stools
57. A nurse is caring for a client who is 12hr postop following a total hip arthroplasty.
Which of the following actions should the nurse take?
Answer: Place an abduction wedge between the clients legs when he is in bed
58. A nurse in a providers 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
59. A nurse is reinforcing teaching with a client about how to replace her 2 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
60. A nurse is instructing an assistive personnel 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
61. A nurse is assisting in the plan of care for a client who has a viral meningitis. Which
of the following interventions should the nurse include in the plan of care?
Answer: Place the client in a private room
62. A nurse is reinforcing teaching regarding puberty with a group of prepubescent female
clients. Which of the following information should the nurse include in the teaching
Answer: You will likely gain weight before you start to get taller
63. A nurse in a providers 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
64. 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?
65. 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
66. 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
67. 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
68. 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 place the client for
the provider?
Answer: Upright with arms resting on the overbed table
69. 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
70. 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
71. A nurse is reinforcing preop 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
72. 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 clients partner is the priority for the nurse to address
Answer: Her prescription isn’t generic so we can’t afford it anymore
73. 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 her head following a syncopal episode
74. 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 which
of the following interprofessional team members
Answer: Occupational therapist
75. 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
76. A nurse in a paediatric 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
77. 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 health care decisions when the client is no
longer able to make decisions herself
78. 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
79. A nurse is reviewing the laboratory reports for a client who is 2 days postop following
thoracic surgery. Which of the following results should the nurse report to the provider
Answer: WBC 25000
80. 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
81. A nurse is caring for a client who is in an inpatient mental health unit and has dependent
personality disorder. Which of the following client behaviors should the nurse expect
Answer: The client calls her partner to ask what she should wear each day
82. 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
83. A nurse is using an interpreter to reinforce discharge teaching with a client who does
not speak the same language as the nurse. Which of the following actions should the nurse
take
Answer: Observe the clients facial expressions during communication
84. A nurse is assisting with the development of an in service for newly licensed nurses
about seclusion. The nurse should identify the need to request a prescription for seclusion
for which of the following situations
Answer: A client hits another client because she thought he was talking about her
85. A nurse is caring for a client who has a phobia of elevators. Which of the following
should the nurse recognize as indicative of a positive client response to a systemic
desensitization
Answer: The client remains relaxed when thinking of the phobia
86. A nurse is assisting with the care of a client who is postpartum and has deep vein
thrombosis. The client has been receiving heparin via IV infusion. Which of the following
medications should the nurse ensure is readily available
Answer: Protamine sulfate
87. 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
88. A nurse in a providers office is reviewing pediculosis capitis management and
prevention strategies with the parent of a school aged child. Which of the following should
the nurse include
Answer: Store the child’s clothing in a separate cubicle when at school. Boil brushes and
combs in water for 10min. Dry bed lines and clothing in a hot dryer for at least 20min
89. A nurse is caring for a client who has a gastrostomy tube. Which of the following
actions should the nurse plan to take
Answer: Flush the tube with 60ml of water if the tube becomes clogged
90. A nurse is preparing to insert an indwelling catheter for a female adult client. 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 5-7in into the clients urinary
meatus
Answer: Ask the client to bear down while inserting the catheter
91. A nurse is caring for a client who is 4hr 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
92. A nurse is monitoring a client who is receiving lactated ringers 500ml iv over 4hr. The
drop factor of the manual iv tubing is 10gtt/ml. The nurse should check that the manual iv
infusion is delivering how many gtt/min?
Answer: 21
93. A nurse is assisting a client who is postop to sit on the side of the bed. Which of the
following actions should the nurse take
Answer: Elevate the head of the clients bed
94. 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
95. 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
96. 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 make?
Answer: Recommend the client wear comfortable shoes during the test
97. 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 his body after death
98. 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
99. A nurse is caring for a newborn who is 1hr old. The mother received fentanyl 30 min
before delivery. For which of the following adverse effects should the nurse monitor the
newborn
Answer: Respiratory depression
100. 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
101. 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
102. A nurse is assisting with the care of a client who has a terminal cancer. Which of the
following statements by the clients 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
103. A nurse observes a client in labor. Which of the following interventions should the
nurse recommend for this client
Answer: Squatting using a birth ball counterpressure to the sacral area leaning forward
while kneeling
104. A nurse in a providers office is collecting growth and development data from a 7
month 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
105. 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 teaching
the client
Answer: I will dispose of my needles in a plastic laundry detergent container
106. A nurse is preparing to admin amoxicillin 875mg po every 12hr. The amount available
is amoxicillin oral suspension 400mg/5ml. How many ml should the nurse administer per
dose
Answer: 11ml
107. A nurse is preparing to perform blood glucose monitoring for a client who has type 2
diabetes mellitus. Which of the following actions should the nurse take first
Answer: Hold the finger for testing in a dependent position
108. 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 sons toothbrush in warm water to soften it for him before he uses
it
109. 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
110. A nurse is reinforcing teaching on self admin of enoxaparin. Which of the following
instructions should the nurse give the client
Answer: Admin by subq injection
111. A nurse is talking with a client who says the provider agreed to initiate a DNR
prescription. After leaving the clients 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
112. A nurse caring for a client who has hiv and lost 15% of his body weight in the last 3
months. The nurse should offer a serving of which of the following foods to add the most
protein to the clients diet
Answer: Peanut butter
113. 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
114. A nurse is observing an assistive personnel apply anti-embolic stockings for a client
who is at risk for deep vein thrombosis. Which of the following actions indicates the AP
is applying the stockings correctly
Answer: The AP applies the stockings before getting the client out of bed
115. A nurse is preparing to admin 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
116. A nurse is caring for a client who is recovering from a motor vehicle crash. The clients
employer calls to ask if the clients injuries will prevent him 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
117. A nurse is caring for a newborn who is 12hr old. Which of the following stools should
the nurse instruct the parents to expect during the first 24hr after birth
Answer: Dark green and viscous
118. 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
119. 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
120. A nurse is assisting with a discussion about STI’s 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
121. 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
122. 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
123. A nurse in a long term care facility is reviewing standard precaution guidelines with
an assistive personnel. The nurse should instruct the AP that which of the following should
be used to clean up a blood spill
Answer: Chlorine bleach solution
124. A nurse in a paediatric clinic is collecting data from a toddler. Which of the following
findings should the nurse identify as possible physical neglect
Answer: The toddler is inadequately dressed for the weather
125. A nurse is reviewing a clients medication record. He recognizes that a double dose of
oral digoxin was given 1hr ago. Which of the following actions should the nurse take first
Answer: Obtain a set of the clients vitals
126. When preparing a client for an enteral feeding a nurse notices that the pump at the
clients bedside is warm to touch. Which of the following actions should the nurse take
Answer: Unplug the equipment and remove it from the room
127. A nurse is working at a inpatient mental health facility is contributing to plan of care
for a newly admitted patient 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
128. A nurse is documenting client care in the medical record. Which of the following
entries should the nurse make
Answer: Client remains NPO until xray is complete’
129. A nurse is checking reflexes of a newborn. Which of the following techniques should
the nurse use to elicit babinski reflex
Answer: Stroke the sole of the infants foot upward toward the great toe
130. 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
131. A nurse is reviewing various defense mechanisms with 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 does not like me
132. 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 test
should the nurse expect the provider to prescribe
Answer: Cerebrospinal fluid analysis
133. 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
134. 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 the client is complying
with this regimen?
Answer: The client takes the medication once daily at bedtime
135. A nurse is reinforcing teaching with a client who has a 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 gum massage
136. A nurse in an urgent care clinic is completing a client examination. After listening to
the clients lungs, which of the following adventitious sounds should the nurse document
Answer: Wheeze
137. A nurse is monitoring a client who is 12hr postop 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
138. A nurse is reviewing the critical pathway of a client who is 4 days postop following
a total knee arthroplasty. The clients vital signs are oral temp 102.4 heart rate 116/min
respiratory rate 24 and blood pressure 152/92. Which of the following actions should the
nurse take?
Answer: Document the findings as a variance
139. 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
140. A nurse is assisting with an educational session for a newly licensed nurses about
intimate partner violence. Which of the following characteristics should the nurse include
as placing a vulnerable person at risk for intimate partner violence
Answer: Recent confirmation of pregnancy
141. 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 doctors glasses have lasers that will burn holes in my brain if I look at him
142. A LPN is reviewing her client assignments for the upcoming shift. Which of the
following clients should the LNP ask the charge nurse reassign to a registered nurse
Answer: A client who has a new colostomy and requires the development of a teaching
plan
143. A nurse is caring for a client who is expressing sadness about 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
144. A nurse is caring for a client who practices orthodox Judaism and adheres to a kosher
diet. Which of the following food selections should the nurse expect to see on the clients
meal tray
Answer: Spaghetti noodles with red meat sauce
145. 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
146. 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
147. 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
148. 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
149. 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
150. 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
