2023 ATI PN NGN Fundamentals Proctored Practice Exams With Answers-211 Solved Questions Version 1-4

NGN 2023 ATI PN FUNDAMENTALS PROCTORED DIFFERENT VERSIONS
EXAMS/ ATI PN FUNDAMENTALS STUDYGUIDE/ PN FUNDAMENTALS
PRACTICE QUESTIONS GRADED A
VERSION 1
1. A confused client with carbon monoxide poisoning experiences dizziness when ambulating
to the bathroom. The nurse should:
a. Put all four side rails up on the bed
b. Ask the unlicensed assistive personnel to place restraints on the client’s upper extremities
c. Request that the client’s roommate put the call light on when the client is attempting to get
out of bed
d. Check on the client at regular intervals to ascertain the need to use the bathrooms
Answer: c. Request that the client’s roommate put the call light on when the client is
attempting to get out of bed
Rationale:
This option allows the client to call for assistance when needed, ensuring safety and
preventing falls.
2. The nurse should use which type of precautions for a client being admitted to the hospital
with suspected tuberculosis?
a. Hand hygiene
b. Contact precautions
c. Droplet precautions
d. Airborne precautions
Answer: d. Airborne precautions
Rationale:
Tuberculosis is spread through the airborne route, so airborne precautions are necessary to
prevent its transmission.

3. The nurse is teaching a client with stomatitis about mouth care. Which instruction is most
appropriate?
a. Drink hot tea at frequent intervals
b. Gargle with antiseptic mouthwash
c. Use an electric toothbrush
d. Eat a soft, bland diet
Answer: d. Eat a soft, bland diet
Rationale:
A soft, bland diet reduces irritation and discomfort associated with stomatitis.
4. A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which indicates
the client is ready to try a liquid diet? The client:
a. Is hungry
b. Has not requested pain medication for 8 hours
c. Has frequent bowel sounds
d. Has had a bowel movement
Answer: c. Has frequent bowel sounds
Rationale:
Frequent bowel sounds indicate return of gastrointestinal motility, suggesting that the client's
digestive system is ready for a liquid diet.
5. A client has returned from surgery during which the jaws were wired as treatment for a
fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed
assistive personnel (UAP) on how to properly position the client. Which instructions about
positioning would be appropriate for the nurse to give to the UAP?
a. Keep the client in a side-lying position with the head slightly elevated
b. Do not reposition the client without the assistance of a registered nurse
c. The client can assume any position that is comfortable

d. Keep the client’s head elevated on two pillows at all times
Answer: a. Keep the client in a side-lying position with the head slightly elevated
Rationale:
Keeping the client in a side-lying position with the head slightly elevated helps prevent
aspiration and facilitates drainage.
6. The nurse’s best explanation for why the severely neutropenic client is placed in reverse
isolation is that reverse isolation helps prevent the spread of organisms:
a. To the client from sources outside the client’s environment
b. From the client to healthcare personnel, visitors, and other clients
c. By using special techniques to handle the client’s linens and personal items
d. By using special techniques to dispose of contaminated materials
Answer: b. From the client to healthcare personnel, visitors, and other clients
Rationale:
Reverse isolation protects immunocompromised clients from potential infections carried by
others.
7. Which statement indicates to the nurse that a client has understood the discharge
instructions provided after nasal surgery?
a. “I should not shower until my packing is removed.”
b. “I will take stool softeners and modify my diet to prevent constipation.”
c. “Coughing every 2 hours is important to prevent respiratory complications.”
d. “It is important to blow my nose each day to remove the dried secretions.”
Answer: a. “I should not shower until my packing is removed.”
Rationale:
Showering can dislodge packing and lead to complications, so the client should avoid
showering until the packing is removed.

8. The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of
time the nurse should suction the client?
a. 10 seconds
b. 20 seconds
c. 25 seconds
d. 30 seconds
Answer: a. 10 seconds
Rationale:
Prolonged suctioning can lead to hypoxia and tissue trauma. Therefore, suctioning should not
exceed 10 seconds to prevent complications.
9. A client with a history of asthma is admitted to the emergency department. The nurse notes
that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of
accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds.
What should the nurse do first?
a. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes
b. Draw blood for arterial blood gas
c. Encourage the client to relax and breathe slowly through the mouth
d. Administer bronchodilators as prescribed
Answer: a. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes
Rationale:
The priority is to ensure adequate oxygenation. Therefore, the nurse should initiate oxygen
therapy as prescribed.
10. A confused client with carbon monoxide poisoning experiences dizziness when
ambulating to the bathroom. The nurse should:
a. Put all four side rails up on the bed
b. Ask the unlicensed assistive personnel to place restraints on the client’s upper extremities

c. Request that the client’s roommate put the call light on when the client is attempting to get
out of bed
d. Check on the client at regular intervals to ascertain the need to use the bathrooms
Answer: c. Request that the client’s roommate put the call light on when the client is
attempting to get out of bed
Rationale:
This option allows the client to call for assistance when needed, ensuring safety and
preventing falls.
11. The nurse should use which type of precautions for a client being admitted to the hospital
with suspected tuberculosis?
a. Hand hygiene
b. Contact precautions
c. Droplet precautions
d. Airborne precautions
Answer: d. Airborne precautions
Rationale:
Tuberculosis is spread through the airborne route, so airborne precautions are necessary to
prevent its transmission.
12. The nurse is teaching a client with stomatitis about mouth care. Which instruction is most
appropriate?
a. Drink hot tea at frequent intervals
b. Gargle with antiseptic mouthwash
c. Use an electric toothbrush
d. Eat a soft, bland diet
Answer: d. Eat a soft, bland diet
Rationale:

A soft, bland diet reduces irritation and discomfort associated with stomatitis.
13. A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which
indicates the client is ready to try a liquid diet? The client:
a. Is hungry
b. Has not requested pain medication for 8 hours
c. Has frequent bowel sounds
d. Has had a bowel movement
Answer: c. Has frequent bowel sounds
Rationale:
Frequent bowel sounds indicate return of gastrointestinal motility, suggesting that the client's
digestive system is ready for a liquid diet.
14. A client has returned from surgery during which the jaws were wired as treatment for a
fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed
assistive personnel (UAP) on how to properly position the client. Which instructions about
positioning would be appropriate for the nurse to give to the UAP?
a. Keep the client in a side-lying position with the head slightly elevated
b. Do not reposition the client without the assistance of a registered nurse
c. The client can assume any position that is comfortable
d. Keep the client’s head elevated on two pillows at all times
Answer: a. Keep the client in a side-lying position with the head slightly elevated
Rationale:
Keeping the client in a side-lying position with the head slightly elevated helps prevent
aspiration and facilitates drainage.
15. The nurse is caring for an older adult with mild dementia with heart failure. What nursing
care will be helpful for this client in reducing potential confusion related to hospitalization
and change in routine? Select all that apply.
a. Reorient frequently to time, place, and situation.

b. Put the client in a quiet room furthest from the nursing station.
c. Perform the necessary procedures quickly.
d. Arrange for familiar pictures or special items at bedside.
e. Limit the client’s visitors.
f. Spend time with the client, establishing a trusting relationship.
Answers:
a. Reorient frequently to time, place, and situation
d. Arrange for familiar pictures or special items at bedside.
f. Spend time with the client, establishing a trusting relationship.
Rationale:
a. Reorientation to time, place, and situation can help reduce confusion.
d. Familiar pictures or special items at the bedside can provide comfort and familiarity.
f. Spending time with the client and establishing a trusting relationship can help reduce
anxiety and confusion.
16. Which would be most helpful when coaching a client to stop smoking?
a. Review the negative effects of smoking on the body.
b. Discuss the effects of passive smoking on environmental pollution.
c. Establish the client’s daily smoking pattern.
d. Explain how smoking worsens high blood pressure.
Answer: a. Review the negative effects of smoking on the body.
Rationale:
Educating the client about the negative effects of smoking on health can be a powerful
motivator for smoking cessation.
17. A nurse is helping a suspected choking victim. The nurse should perform the Heimlich
maneuver when the victim:

a. Starts to become cyanotic
b. Cannot speak due to airway obstruction
c. Can make only minimal vocal noises
d. Is coughing vigorously
Answer: b. Cannot speak due to airway obstruction
Rationale:
The Heimlich maneuver is performed when the victim is unable to speak or make any noise
due to airway obstruction.
18. While the nurse is providing preoperative teaching for a client with peripheral vascular
disease who is to have a below-the-knee amputation, the client says, “I hate the idea of being
an invalid after they cut off my leg.” The nurse’s most therapeutic response should be:
a. “Focusing on using your one good leg will make your recovery easier.”
b. “Tell me more about how you are feeling.”
c. “We will talk more about this after your surgery.”
d. “You are fortunate to have a wife who can take care of you.”
Answer: b. “Tell me more about how you are feeling.”
Rationale:
This response allows the nurse to understand the client's feelings and concerns, providing an
opportunity for therapeutic communication and support.
19. Which indicates that a client has achieved the goal of correctly demonstrating deep
breathing for an upcoming splenectomy? The client:
a. Breathes in through the nose and out through the mouth
b. Breathes in through the mouth and out through the nose
c. Uses diaphragmatic breathing in the lying, sitting, and standing positions.
d. Takes a deep breath in through the nose, holds it for seconds, and blows it out through
pursed lips

Answer: d. Takes a deep breath in through the nose, holds it for seconds, and blows it out
through pursed lips
Rationale:
This technique maximizes lung expansion and prevents alveolar collapse, promoting optimal
oxygenation.
20. Which nursing action is most important in preventing cross-contamination?
a. Changing gloves immediately after use
b. Standing 2 feet (61cm) from the client
c. Speaking minimally when in the room
d. Wearing protective coverings
Answer: a. Changing gloves immediately after use
Rationale:
Changing gloves immediately after use helps prevent the transmission of microorganisms
between clients.
21. The nurse’s best explanation for why the severely neutropenic client is placed in reverse
isolation is that reverse isolation helps prevent the spread of organisms:
a. To the client from sources outside the client’s environment
b. From the client to healthcare personnel, visitors, and other clients
c. By using special techniques to handle the client’s linens and personal items
d. By using special techniques to dispose of contaminated materials
Answer: b. From the client to healthcare personnel, visitors, and other clients
Rationale:
Reverse isolation protects immunocompromised clients from potential infections carried by
others.
22. Which statement indicated to the nurse that a client has understood the discharge
instructions provided after nasal surgery?

a. “I should not shower until my packing is removed.”
b. “I will take stool softeners and modify my diet to prevent constipation.”
c. “Coughing every 2 hours is important to prevent respiratory complications.”
d. “It is important to blow my nose each day to remove the dried secretions.”
Answer: a. “I should not shower until my packing is removed.”
Rationale:
Showering can dislodge packing and lead to complications, so the client should avoid
showering until the packing is removed.
23. The nurse is suctioning a client who had a laryngectomy. What is the maximum amount
of time the nurse should suction the client?
a. 10 seconds
b. 20 seconds
c. 25 seconds
d. 30 seconds
Answer: a. 10 seconds
Rationale:
Prolonged suctioning can lead to hypoxia and tissue trauma. Therefore, suctioning should not
exceed 10 seconds to prevent complications.
24. A client with a history of asthma is admitted to the emergency department. The nurse
notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and
use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath
sounds. What should the nurse do first?
a. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes
b. Draw blood for arterial blood gas
c. Encourage the client to relax and breathe slowly through the mouth
d. Administer bronchodilators as prescribed

Answer: a. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes
Rationale:
The priority is to ensure adequate oxygenation. Therefore, the nurse should initiate oxygen
therapy as prescribed.
25. A confused client with carbon monoxide poisoning experiences dizziness when
ambulating to the bathroom. The nurse should:
a. Put all four side rails up on the bed
b. Ask the unlicensed assistive personnel to place restraints on the client’s upper extremities
c. Request that the client’s roommate put the call light on when the client is attempting to get
out of bed
d. Check on the client at regular intervals to ascertain the need to use the bathrooms
Answer: c. Request that the client’s roommate put the call light on when the client is
attempting to get out of bed
Rationale:
This option allows the client to call for assistance when needed, ensuring safety and
preventing falls.
26. The nurse should use which type of precautions for a client being admitted to the hospital
with suspected tuberculosis?
a. Hand hygiene
b. Contact precautions
c. Droplet precautions
d. Airborne precautions
Answer: d. Airborne precautions
Rationale:
Tuberculosis is spread through the airborne route, so airborne precautions are necessary to
prevent its transmission.

27. The nurse is teaching a client with stomatitis about mouth care. Which instruction is most
appropriate?
a. Drink hot tea at frequent intervals
b. Gargle with antiseptic mouthwash
c. Use an electric toothbrush
d. Eat a soft, bland diet
Answer: d. Eat a soft, bland diet
Rationale:
A soft, bland diet reduces irritation and discomfort associated with stomatitis.
28. A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which
indicates the client is ready to try a liquid diet? The client:
a. Is hungry
b. Has not requested pain medication for 8 hours
c. Has frequent bowel sounds
d. Has had a bowel movement
Answer: c. Has frequent bowel sounds
Rationale:
Frequent bowel sounds indicate return of gastrointestinal motility, suggesting that the client's
digestive system is ready for a liquid diet.
29. A client has returned from surgery during which the jaws were wired as treatment for a
fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed
assistive personnel (UAP) on how to properly position the client. Which instructions about
positioning would be appropriate for the nurse to give to the UAP?
a. Keep the client in a side-lying position with the head slightly elevated
b. Do not reposition the client without the assistance of a registered nurse
c. The client can assume any position that is comfortable

d. Keep the client’s head elevated on two pillows at all times
Answer: d. Keep the client’s head elevated on two pillows at all times
Rationale:
Keeping the client's head elevated on two pillows helps prevent aspiration and facilitates
drainage.
30. The nurse’s best explanation for why the severely neutropenic client is placed in reverse
isolation is that reverse isolation helps prevent the spread of organisms:
a. To the client from sources outside the client’s environment
b. From the client to healthcare personnel, visitors, and other clients
c. By using special techniques to handle the client’s linens and personal items
d. By using special techniques to dispose of contaminated materials
Answer: b. From the client to healthcare personnel, visitors, and other clients
Rationale:
Reverse isolation protects immunocompromised clients from potential infections carried by
others.
31. Which statement indicated to the nurse that a client has understood the discharge
instructions provided after nasal surgery?
a. “I should not shower until my packing is removed.”
b. “I will take stool softeners and modify my diet to prevent constipation.”
c. “Coughing every 2 hours is important to prevent respiratory complications.”
d. “It is important to blow my nose each day to remove the dried secretions.”
Answer: a. “I should not shower until my packing is removed.”
Rationale:
Showering can dislodge packing and lead to complications, so the client should avoid
showering until the packing is removed.

32. The nurse is suctioning a client who had a laryngectomy. What is the maximum amount
of time the nurse should suction the client?
a. 10 seconds
b. 20 seconds
c. 25 seconds
d. 30 seconds
Answer: a. 10 seconds
Rationale:
Prolonged suctioning can lead to hypoxia and tissue trauma. Therefore, suctioning should not
exceed 10 seconds to prevent complications.
33. A client with a history of asthma is admitted to the emergency department. The nurse
notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and
use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath
sounds. What should the nurse do first?
a. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes
b. Draw blood for arterial blood gas
c. Encourage the client to relax and breathe slowly through the mouth
d. Administer bronchodilators as prescribed
Answer: a. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes
Rationale:
The priority is to ensure adequate oxygenation. Therefore, the nurse should initiate oxygen
therapy as prescribed.
34. A confused client with carbon monoxide poisoning experiences dizziness when
ambulating to the bathroom. The nurse should:
a. Put all four side rails up on the bed
b. Ask the unlicensed assistive personnel to place restraints on the client’s upper extremities

c. Request that the client’s roommate put the call light on when the client is attempting to get
out of bed
d. Check on the client at regular intervals to ascertain the need to use the bathrooms
Answer: c. Request that the client’s roommate put the call light on when the client is
attempting to get out of bed
Rationale:
This option allows the client to call for assistance when needed, ensuring safety and
preventing falls.
35. The nurse should use which type of precautions for a client being admitted to the hospital
with suspected tuberculosis?
a. Hand hygiene
b. Contact precautions
c. Droplet precautions
d. Airborne precautions
Answer: d. Airborne precautions
Rationale:
Tuberculosis is spread through the airborne route, so airborne precautions are necessary to
prevent its transmission.
36. The nurse is teaching a client with stomatitis about mouth care. Which instruction is most
appropriate?
a. Drink hot tea at frequent intervals
b. Gargle with antiseptic mouthwash
c. Use an electric toothbrush
d. Eat a soft, bland diet
Answer: d. Eat a soft, bland diet
Rationale:

A soft, bland diet reduces irritation and discomfort associated with stomatitis.
37. A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which
indicates the client is ready to try a liquid diet? The client:
a. Is hungry
b. Has not requested pain medication for 8 hours
c. Has frequent bowel sounds
d. Has had a bowel movement
Answer: c. Has frequent bowel sounds
Rationale:
Frequent bowel sounds indicate the return of gastrointestinal motility, suggesting that the
client's digestive system is ready for a liquid diet.
38. A client has returned from surgery during which the jaws were wired as treatment for a
fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed
assistive personnel (UAP) on how to properly position the client. Which instructions about
positioning would be appropriate for the nurse to give to the UAP?
a. Keep the client in a side-lying position with the head slightly elevated
b. Do not reposition the client without the assistance of a registered nurse
c. The client can assume any position that is comfortable
d. Keep the client’s head elevated on two pillows at all times
Answer: d. Keep the client’s head elevated on two pillows at all times
Rationale:
Keeping the client's head elevated on two pillows helps prevent aspiration and facilitates
drainage.
39. Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia?
Answer: Yes.
Rationale:

Yes, an RN can delegate tracheostomy care to an LPN for a client with pneumonia, as long as
the LPN is trained and competent to perform the delegated tasks. Tracheostomy care typically
involves suctioning, cleaning around the tracheostomy site, changing tracheostomy ties, and
monitoring for signs of infection or other complications. However, the RN remains
responsible for the overall assessment and care plan for the client.
40. A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients.
Which of the following client's needs may the nurse assign to a assistive personnel (AP)?
a. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
b. Reinforcing teaching w/a client who is learning to walk using a quad cane
c. Reapplying a condom catheter for a client who has urinary incontinence
d. Applying a sterile dressing to a pressure ulcer
Answer: c. Reapplying a condom catheter for a client who has urinary incontinence
Rationale:
The application of a condom catheter is a non invasive, routine procedure that the nurse may
delegate to the AP
41. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to
an AP. Which of the following information should the nurse share with the AP? Select All.
a. The roommate is up independently.
b. The client ambulates w/his slippers on over his antiembolic stockings
c. The client uses a front-wheeled walker when ambulating
d. The client had pain medication 30 min ago
e. The client is allergic to codeine
f. The client ate 50% of his breakfast this morning
Answer: b: The client ambulates w/his slippers on over his antiembolic stockings
c. The client uses a front-wheeled walker when ambulating
d. The client had pain medication 30 min ago

Rationale:
b. The client ambulates with his slippers on over his antiembolic stockings - This information
is important for the AP to know to ensure the client's safety during ambulation. Ambulating
with slippers over antiembolic stockings can increase the risk of slipping and falling.
c. The client uses a front-wheeled walker when ambulating - This information is important
for the AP to know to provide the appropriate assistive device for ambulation.
d. The client had pain medication 30 minutes ago - This information is important for the AP
to know to monitor the client for signs of medication effectiveness and potential side effects.
42. An RN is making assignments for client care to a LPN at the beginning of the shift.
Which of the following assignments should the LPN question?
a. Assisting a client who is 24hr postop to use an incentive spirometer
b. Collecting a clean-catch urine specimen from a client who was admitted on the previous
shift
c. Providing nasopharyngeal suctioning for a client who has pneumonia
d. Replacing the cartridge and tubing on a PCA pump
Answer: d. Replacing the cartridge and tubing on a PCA pump
Rationale:
The RN is responsible for the PCA pump
43. A nurse is preparing an in-service program about delegation. Which of the following
elements should she identify when presenting the 5 rights of delegation? Select all.
a. Right client
b. Right supervision/evaluation
c. Right direction/communication
d. Right time
e. Right circumstances
Answer: b. Right supervision/evaluation

c. Right direction/communication
e. Right circumstances
Rationale:
A and D are rights of medication administration
44. A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming
shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery.
To which staff member should the nurse assign to this client?
a. Charge nurse
b. RN
c. LPN
d. AP
Answer: b. RN
Rationale:
A client returning from surgery requires assessment and establishment of a plan of care. RNs
are responsible for this, especially if the client is potentially unstable.
45. A nurse observes an AP reprimanding a client for not using the urinal properly. The AP
tells him she will put a diaper on him if he does not use the urinal more carefully next time.
Which of the following torts is the AP committing?
a. Assault
b. Battery
c. False imprisonment
d. Invasion of privacy
Answer: a. Assault
Rationale:
By threatening the client, the AP is committing assault.

46. An adult client who is competent tells the nurse that he is thinking about leaving the
hospital against medical advice. The nurse believes that this is not in the client's best interest,
so she administers a PRN sedative med that the client has not requested along w/his usual
meds. Which of the following tort has the nurse committed?
a. Assault
b. False imprisonment
c. Negligence
d. Breach of confidentiality
Answer: b. False imprisonment
Rationale:
The nurse gave the med as a chemical restraint to keep the client from leaving the facility
against medical advice. The client did not consent.
47. A client who will undergo neurosurgery the following week tells the nurse in the
surgeon's office that he will prepare his advance directives before he goes to the hospital.
Which of the following statements by the client indicates to the nurse that he understands
advance directives?
a. "I'd rather have my brother make decisions for me, but I know it has to be my wife."
b. "I know they won't go ahead w/the surgery unless I prepare these forms."
c. "I plan to write that I don't want them to keep me on a breathing machine."
d. "I will get my regular doctor to approve my plan before I hand it in at the hospital."
Answer: c. "I plan to write that I don't want them to keep me on a breathing machine."
Rationale:
The client has the right to decide and specify which medical procedures he wants when a lifethreatening situation arrives
48. A client is about to undergo an elective surgical procedure. Which of the following
actions are appropriate for the nurse who is providing pre-op care regarding informed
consent? Select all.

a. Make sure the surgeon obtained the client's consent
b. Witness the client's signature on the consent form
c. Explain the risks and benefits of the procedure
d. Describe the consequences of choosing not to have the surgery
e. Tell the client about alternatives to having the surgery
Answer: a. Make sure the surgeon obtained the client's consent
b. Witness the client's signature on the consent form
Rationale:
The rest of the choices are the surgeon's responsibility, not the nurse
49. A nurse has noticed several occasions in the past week when another nurse on the unit
seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a
chair in the break room when she was not on break. Which of the following actions should
the nurse take?
a. Remind the nurse that safe client care is a priority on the unit
b. Ask others on the team whether they have observed the same behavior
c. Report observations to the nurse manager on the unit
d. Conclude that her coworker's fatigue is not her problem to solve
Answer: c. Report observations to the nurse manager on the unit
Rationale:
Any nurse who notices behavior that could possibly jeopardize client care or indicate a
substance abuse problem has a duty to report the situation immediately to the nurse manager
50. A nurse is preparing info for a change-of-shift report. Which of the following info should
the nurse include in the report?
a. The client's input & output for the shift
b. The client's BP from the previous day
c. A bone scan that is scheduled for today

d. The med routine from the med administration record
Answer: c. A bone scan that is scheduled for today
Rationale:
This is important because the nurse might have to modify the client's care to accommodate
them leaving the unit
51. A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the
shower, but I got myself back up & into my chair." How should the nurse document this in
the client's chart?
a. The client fell in the shower.
b. The client states he fell in the shower & was able to get himself back into his chair
c. The nurse should not document this info because she did not witness the fall
d. The client fell in the shower & is now resting comfortably
Answer: b. The nurse should not document this info because she did not witness the fall
Rationale:
By writing what the client states, the info is subjective data
52. A nursing instructor is reviewing documentation with a group of nursing students. Which
of the following legal guidelines should they follow when documenting a client's record?
Select all that apply
a. Cover errors with correction fluid, and write in the correct info
b. Put the date and time on all entries
c. Document objective data, leaving out opinions
d. Use as many abbreviations as possible
e. Wait until the end of the shift to document
Answer: b. Put the date and time on all entries
c. Document objective data, leaving out opinions
Rationale:

b. Documenting the date and time on all entries is essential for accuracy and legal purposes.
c. Objective data should be documented to provide an accurate picture of the client's
condition, while opinions should be avoided to maintain objectivity and professionalism.
53. The skin barrier covering a client's intestinal fistula keeps falling off when she stands up
to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when
the client is supine in bed. The nurse telephoned the physical therapist about the difficulties
containing the drainage from the fistula, so the therapist didn't ambulate the client today. The
client sat in a chair during lunch with an absorbent pad over the fistula. The client ate all the
food on her tray. The wound care nurse confirmed that she will see the client later today. The
client states she feels frustrated at not having physical therapy, but the nurse thinks the client
welcomed having a day to rest. Which of the following information should the nurse include
in the change-of-shift report? Select all that apply.
a. The physical therapist didn't ambulate the client today
b. The skin barrier's seal stays on in bed but loosens when the client stands.
c. The client seemed to welcome having a "day off" from physical therapy
d. The wound care nurse will see the client later today
e. The client ate all the food on her lunch tray
Answer: a. The physical therapist didn't ambulate the client today
b. The skin barrier's seal stays on in bed but loosens when the client stands.
d. The wound care nurse will see the client later today
Rationale:
a. The physical therapist's decision not to ambulate the client is an important aspect of the
client's care and should be included in the report.
b. The information about the skin barrier is relevant as it indicates a problem that needs to be
addressed.
d. The plan for the wound care nurse to see the client is essential information for the
oncoming shift.

54. A nurse is receiving a provider's prescription by telephone for morphine for a client who
is reporting moderate to severe pain. Which of the following nursing actions are appropriate?
Select all that apply.
a. Repeat the details of the prescription back to the provider
b. Have another nurse listen to the telephone prescription
c. Obtain the prescriber's signature on the prescription within 24 hours
d. Decline the verbal prescription because it is not an emergency situation
e. Tell the charge nurse that the provider has prescribed morphine by telephone
Answer: a. Repeat the details of the prescription back to the provider
b. Have another nurse listen to the telephone prescription
c. Obtain the prescriber's signature on the prescription within 24 hours
Rationale:
a. Repeating the details of the prescription back to the provider ensures that both parties are
in agreement and helps prevent errors.
b. Having another nurse listen to the telephone prescription provides an additional layer of
safety by ensuring accuracy.
c. Obtaining the prescriber's signature on the prescription within 24 hours is necessary for
documentation and legal purposes.
55. A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days.
He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To
which of the following members of the health care team should the nurse refer him?
a. Registered dietitian
b. Occupational therapist
c. Physical therapist
d. Social worker
Answer: d. social worker

Rationale:
A social worker can make arrangements for a meal delivery service to provide nutritious
meals daily, or recommend a congregate meal site near the client's home
56. A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use
adaptive devices. The nurse caring for the client should initiate a referral w/which of the
following members of the inter-professional care team?
a. Social worker
b. Certified nursing assistant
c. Registered dietitian
d. Occupational therapist
e. Registered dietitian
Answer: d. Occupational therapist
Rationale:
An occupational therapist can assist clients who have physical challenges to use adaptive
devices & strategies to help w/self-care activities
57. A client who is postop following a knee arthroplasty is concerned about the adverse
effects of the medication he is receiving for pain management. Which of the following
members of the inter-professional care team may assist the client in understanding the
medication's effects? Select all that apply.
a. Provider
b. CNA
c. Pharmacist
d. RN
e. Respiratory therapist
Answer: a. Provider
c. Pharmacist

d. RN
Rationale:
a. Provider: The provider can explain the medication's effects and address the client's
concerns.
c. Pharmacist: Pharmacists are knowledgeable about medications and can provide detailed
information about their effects.
d. RN: Registered nurses are responsible for medication administration and patient education,
making them well-suited to explain medication effects and address patient concerns.
58. A client who has had a cerebrovascular accident has persistent problems w/dysphagia.
The nurse caring for the client should initiate a referral w/which of the following members of
the inter-professional care team?
a. Social worker
b. CNA
c. Occupational therapist
d. Speech-language pathologist
Answer: d. Speech-language pathologist
Rationale:
A speech-language pathologist can initiate specific therapy for clients who have difficulty
feeding due to swallowing difficulties
59. A nursing instructor is acquainting a group of nursing students w/the roles of the various
members of the health care team they will encounter on a medical-surgical unit. When she
gives examples of the types of tasks CNAs may perform, which of the following client
activities should she include? Select all.
a. Bathing
b. Ambulating
c. Toileting
d. Determining Pain Level

e. Measuring vital signs
Answer: a. Bathing
b. Ambulating
c. Toileting
e. Measuring vital signs
Rationale:
Determining pain level requires assessment, which is the job of the licensed personnel.
60. A nurse in a provider's office is preparing to assess a young adult male client's
musculoskeletal system as part of a comprehensive physical examination. Which of the
following findings should the nurse expect? Select all.
a. A concave thoracic spine posteriorly
b. An exaggerated lumbar curvature
c. A concave lumbar spine posteriorly
d. An exaggerated thoracic curvature
e. Muscles slightly larger on his dominant side
Answer: c. A concave lumbar spine posteriorly
e. Muscles slightly larger on his dominant side
Rationale:
c. A concave lumbar spine posteriorly - The lumbar spine normally has a concave curvature
posteriorly, which is considered normal.
e. Muscles slightly larger on his dominant side - It is common for muscles to be slightly
larger on the dominant side due to increased use. This is a normal finding.
61. A nurse is evaluating a client's neurosensory system. To evaluate stereo-gnosis, she would
ask the client to close his eyes & identify which of the following items?
a. A word she whispers 30cm from his ear
b. A number she traces on the palm of his hand

c. The vibration of a tuning fork she places on his foot
d. A familiar object she places in his hand
Answer: d. A familiar object she places in his hand
Rationale:
Stereognosis is tactile recognition
62. A nurse is assessing a client who reports pain when the nurse evaluates the internal
rotation of her right shoulder. Which of the following activities is this problem likely to
affect?
a. Mopping her floors
b. Brushing the back of her hair
c. Fastening her bra behind her back
d. Reaching into a cabinet above her sink
Answer: c. Fastening her bra behind her back
Rationale:
Fastening a bra from behind requires internal rotation of the shoulder, so this activity will
illicit pain
63. A nurse is preforming a neurosensory examination for a client. Which of the following
tests should the nurse preform to test the client's balance? Select all.
a. Romberg test
b. Heel-to-toe walk
c. Snellen test
d. Spinal accessory function
e. Rosenbaum test
Answer: a. Romberg test
b. Heel-to-toe walk

Rationale:
C and E test visual acuity, D tests cranial nerve XI is intact by asking the client to shrug
shoulders without complication.
64. A nurse is collecting data from an older adult client as part of a neurosensory
examination. Which of the following findings should the nurse expect as changes associated
w/aging? Select all.
a. Slower light touch sensation
b. Some vision & hearing decline
c. Slower fine finger movement
d. Some short-term memory decline
e. Slower superficial pain sensation
Answer: b. Some vision & hearing decline
c. Slower fine finger movement
d. Some short-term memory decline
Rationale:
b. Some vision & hearing decline - Visual and auditory acuity tends to decline with aging. It
is common for older adults to experience changes such as presbyopia (difficulty focusing on
close objects) and age-related hearing loss (presbycusis).
c. Slower fine finger movement - With aging, there is a decrease in the speed and
coordination of fine motor movements. This can affect tasks such as writing, buttoning
clothes, or using utensils.
d. Some short-term memory decline - Mild changes in memory are often associated with
aging. Older adults may experience difficulties with short-term memory, such as forgetfulness
or difficulty recalling recent events or information.
65. A nurse is providing discharge instructions to a client who has a prescription for the use of
oxygen in his home. Which of the following should the nurse teach the client about using
oxygen safely in his home? Select all.

a. Family members who smoke must be at least 10 ft from the client when the oxygen is in
use
b. Nail polish should not be used near a client who is receiving oxygen
c. A "No smoking" sign should be placed on the front door
d. Cotton bedding & clothing should be replaced w/items made from wool
e. A fire extinguisher should be readily available in the home
Answer: b. Nail polish should not be used near a client who is receiving oxygen
c. A "No smoking" sign should be placed on the front door
e. A fire extinguisher should be readily available in the home
Rationale:
Family members that smoke should do so outside, and wool creates static electricity so it
should be avoided.
66. A nurse educator is conducting a parenting class for new parents. Which of the following
statements made by a participant indicates a need for further clarification & instruction?
a. "I will begin swimming lessons as soon as my baby can close her mouth under water."
b. "Once my baby can sit up, he should be safe in the bathtub."
c. "I will test the temp of the water before placing my baby in the bath."
d. "Once my infant starts to push up, I will remove the mobile from over the bed."
Answer: b. "Once my baby can sit up, he should be safe in the bathtub."
Rationale:
Although the baby can hold his head above the water by sitting up, this does not make the
baby safe in the tub. Parents should never leave a child unattended in a tub.
66. A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client.
Which of the following information should the nurse include in her counseling?
a. Carbon monoxide has a distinct odour
b. Water heaters should be inspected every 5 years

c. The lungs are damaged from carbon monoxide inhalation
d. Carbon monoxide binds w/haemoglobin in the body
Answer: d. Carbon monoxide binds w/haemoglobin in the body
Rationale:
Carbon monoxide is a very dangerous gas because it binds w/haemoglobin & ultimately
reduces the oxygen supplied to the tissues in the body. Carbon monoxide is tasteless, has no
scent, and cannot be seen. The water heaters, gas burning furnaces, and appliances should be
inspected annually the lungs are not damaged in the process of inhalation.
67. A nurse educator is presenting a module on basic first aid for newly licensed home health
nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse
states the client who has heat stroke will have which of the following?
a. Hypotension
b. Bradycardia
c. Clammy skin
d. Bradypnea
Answer: a. Hypotension
Rationale:
Tachycardia, hot dry skin, and tachypnea are other manifestations of heat stroke
68. A home health nurse is discussing the dangers of food poisoning w/a client. Which of the
following info should the nurse include in her counseling? Select all.
a. Most food poisoning is caused by a virus
b. Immunocompromised individuals are at risk for complications from food poisoning
c. Clients who are especially at risk are instructed to eat or drink only pasteurized milk,
yogurt, cheese, or other dairy products
d. Healthy individuals usually recover from the illness in a few weeks
e. Handling raw & fresh food separately to avoid cross contamination may prevent food
poisoning

Answer: b. Immunocompromised individuals are at risk for complications from food
poisoning
c. Clients who are especially at risk are instructed to eat or drink only pasteurized milk,
yogurt, cheese, or other dairy products
e. Handling raw & fresh food separately to avoid cross contamination may prevent food
poisoning
Rationale:
Most food poisoning is caused by a bacteria such as
e. coli. Healthy individuals usually recover in a few days.
69. A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The
nurse is aware that health care professionals are required to report communicable &
infectious diseases. Which of the following illustrate the rationale for reporting? Select all.
a. Planning & evaluating control & prevention strategies
b. Determining public health priorities
c. Ensuring proper medical treatment
d. Identifying endemic disease
e. Monitoring for common-source outbreaks
Answer: a. Planning & evaluating control & prevention strategies
b. Determining public health priorities
c. Ensuring proper medical treatment
e. Monitoring for common-source outbreaks
Rationale:
Not D because endemic disease is already prevalent within a population, so reporting is not
necessary
70. A nurse is contributing to the plan of care for a client who is being admitted to the facility
w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the
plan of care? Select all.

a. Place the client in a room that has negative air pressure of at least 6 exchanges/hr
b. Wear a mask when providing care within 3 ft of the client
c. Place a surgical mask on the client if transportation to another dept is unavoidable
d. Use sterile gloves when handling soiled linens
e. Wear a gown when preforming care that may result in contamination from secretions
Answer: b. Wear a mask when providing care within 3 ft of the client
c. Place a surgical mask on the client if transportation to another dept is unavoidable
e. Wear a gown when preforming care that may result in contamination from secretions
Rationale:
Private room w/droplet precautions indicated for this client.
The nurse should wear a gown when contamination from body fluids might happen
71. A nurse is caring for a client who presents w/linear clusters of fluid-containing vesicles
w/some crusting. Which of the following should the nurse suspect?
a. Allergic reaction
b. Ringworm
c. Systemic lupus erythematosus
d. Herpes zoster
Answer: d. Herpes zoster
Rationale:
pink body rash=allergic reaction, red circles w/white centers=ringworm, red cheek rash
bilaterally=lupus
72. A nurse is caring for a client who reports severe sore throat, pain when swallowing, &
swollen lymph nodes. The client is experiencing which of the following stages of infection?
a. Prodromal
b. Incubation

c. Convalescence
d. Illness
Answer: d. Illness
Rationale:
specific s/s present is the illness stage
73. A nurse educator is reviewing w/a newly hired nurse the difference in clinical
manifestations of a localized vs. a systemic infection. The nurse indicates understanding
when she states that which of the following are clinical manifestations of a systemic
infection? Select all.
a. Fever
b. Malaise
c. Edema
d. Pain or tenderness
e. Increase in pulse & respiratory rate
Answer: a. Fever
b. Malaise
e. Increase in pulse & respiratory rate
Rationale:
Edema and pain and tenderness is localized
74. A nurse is teaching a young adult client about health promotion & illness prevention.
Which of the following statements by the client indicates an understanding of the teaching?
a. "I already had my immunizations as a child, so I'm protected in that area."
b. "It is important to schedule routine health care visits even if I'm feeling well."
c. "If I'm having any discomfort, I'll just got to an urgent care center."
d. "If I am felling stressed, I will remind myself that this is something I should expect."

Answer: b. "It is important to schedule routine health care visits even if I'm feeling well."
Rationale:
Routine health screenings are important at any age
75. A nursing instructor is explaining the various stages of the lifespan to a group of nursing
students. The nurse should offer which of the following behaviors by a young adult as an
example of appropriate psychosocial development?
a. Becoming actively involved in providing guidance to the next generation
b. Adjusting to major changes in roles and relationships due to losses
c. Devoting a great deal of time to establishing an occupation
d. Finding oneself "sandwiched" in between & being responsible for 2 generations
Answer: c. Devoting a great deal of time to establishing an occupation
Rationale:
Exploring and establishing career options & establishing oneself is important developmental
task in a young adult
76. A nurse is counseling a young adult who describes having difficulty dealing w/several
issues. Which of the following problems the client verbalized should the nurse identify as the
priority for further assessment & intervention?
a. "I have my own apartment now, but it's not easy living away from my parents."
b. "It's been so stressful for me to even think about having my own family."
c. "I don't even know who I am yet, & now I'm supposed to know what to do."
d. "My girlfriend is pregnant, & I don't think I have what it takes to be a good father."
Answer: c. "I don't even know who I am yet, & now I'm supposed to know what to do."
Rationale:
Applying Erikson stages of development, knowing oneself is done in adolescence, and this
requires the most urgent help

77. A nurse is reviewing safety precautions w/a group of young adults at a community health
fair. Which of the following recommendations should the nurse include specifically for this
age group? Select all.
a. Install bath rails & grab bars in bathrooms
b. Wear a helmet while skiing
c. Install a carbon monoxide detector
d. Secure firearms in a safe location
e. Remove throw rugs from the home
Answer: b. Wear a helmet while skiing
c. Install a carbon monoxide detector
d. Secure firearms in a safe location
Rationale:
A is recommended for older adults and E as well for risk of falls
78. A nurse is reviewing the CDC's immunization recommendations w/a young adult client.
Which of the following recommendations should the nurse include in this discussion? Select
all.
a. Human papillomavirus
b. Measles, mumps, rubella
c. Varicella
d. Haemophilus influenzae type b
e. Polio
Answer: a. Human papillomavirus
b. Measles, mumps, rubella
c. Varicella
Rationale:

D is not for after 18 months of age and polio is also given as a child and not usually beyond
18 yrs. old
79. A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C
(101 F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which
of the following are appropriate nursing interventions for this client? Select all.
a. Obtain culture specimens before initiating antimicrobials
b. Restrict the client's oral fluid intake
c. Encourage the client to limit activity & rest
d. Allow the client to shiver to dispel excess heat
e. Assist the client w/oral hygiene frequently
Answer: a. Obtain culture specimens before initiating antimicrobials
c. Encourage the client to limit activity & rest
e. Assist the client w/oral hygiene frequently
Rationale:
The nurse should prevent shivering & encourage the client to increase fluids. Oral hygiene
helps prevent cracking of dry mucous membranes of the mouth & lips.
80. A nurse is instructing an AP in caring for a client who has a low platelet count as a result
of chemo. Which of the following is the nurse's priority instruction for measuring vital signs
for this client?
a. "Don't measure the client's temp rectally."
b. "Count the client's radial pulse for 30 sec & multiply by 2."
c. "Don't let the client know you are counting her respirations."
d. "Let the client rest for 5 mins before you measure her BP."
Answer: a. "Don't measure the client's temp rectally."
Rationale:

The greatest risk to a client w/a low platelet count is injury that results in bleeding, obtaining
a temp this way increases the risk for bleeding.
81. A nurse is instructing a group of nursing students in measuring a client's RR. Which of the
following guidelines should the nurse include? Select all.
a. Place the client in semi-Fowler's position
b. Have the client rest an arm across the abdomen
c. Observe 1 full respiratory cycle before counting the rate
d. Count the rate for 1 min if it is regular
e. Count & report any signs the client demonstrates
Answer: a. Place the client in semi-Fowler's position
b. Have the client rest an arm across the abdomen
c. Observe 1 full respiratory cycle before counting the rate
Rationale:
As for D, this is if the rate is irregular after initial count, for E, sighs are expected & don't
need to be reported
82. A nurse who is admitting a client who has a fractured femur obtains a BP reading of
140/94 mmHg. The client denies any history of HTN. Which of the following actions should
the nurse take next?
a. Request a prescription for an antihypertensive med
b. Ask the client if she is having pain
c. Request a prescription for an anti-anxiety med
d. Return in 30min to recheck the client's BP
Answer: b. Ask the client if she is having pain
Rationale:
Perform a pain assessment would be the appropriate action to take next

83. A nurse is performing an admission assessment on a client. When measuring her vital
signs, the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse rate is
84/min. What is the client's pulse deficit?
Answer: 16/min
Rationale:
The pulse deficit is the difference between the apical & radial pulse rates. 84-68=16
84. A nurse is caring for a client who will perform fecal occult blood testing at home. Which
of the following info should the nurse include when explaining the procedure to the client?
a. Eating more protein is optimal prior to testing
b. One stool specimen is sufficient for testing
c. A red color change indicates a positive test
d. The specimen cannot be contaminated
Answer: d. The specimen cannot be contaminated
Rationale:
The stool specimens cannot be contaminated with water or urine
85. A nurse is talking w/a client who reports constipation. When the nurse discusses dietary
changes that can help prevent constipation, which of the following foods should the nurse
recommend?
a. Macaroni & cheese
b. Fresh fruit & whole wheat toast
c. Rice pudding & ripe bananas
d. Roast chicken & white rice
Answer: b. Fresh fruit & whole wheat toast
Rationale:
A high-fiber diet promotes normal bowel elimination

86. A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the
client, the nurse should expect which of the following findings? Select all.
a. Bradycardia
b. Hypotension
c. Fever
d. Poor skin turgor
e. Peripheral edema
Answer: b. Hypotension
c. Fever
d. Poor skin turgor
Rationale:
fever=caused by dehydration tachycardia not bradycardia hypotension because of decreased
BP from dehydration fluid overload=peripheral edema
87. A nurse is preparing to administer a cleansing enema to an adult client in preparation for a
diagnostic procedure. Which of the following are appropriate steps for the nurse to take?
Select all.
a. Warm the enema prior to instillation
b. Position the client on the left side w/the right leg flexed forward
c. Lubricate the rectal tube or nozzle
d. Slowly insert the rectal tube about 2 inches
e. Hang the enema container 24 inches above the client's anus
Answer: a. Warm the enema prior to instillation
b. Position the client on the left side w/the right leg flexed forward
c. Lubricate the rectal tube or nozzle
Rationale:

D is the appropriate length of insertion for a child, 3-4 for an adult. 24 inches is too high &
will cause it to run to fast & possible painful distention of the colon, 18 inches is the
recommended height
88. While a nurse is administering a cleansing enema, the client reports abdominal cramping.
Which of the following is the appropriate intervention?
a. Have the client hold his breath briefly
b. Discontinue the fluid instillation
c. Remind the client that cramping is common at this time
d. Lower the enema fluid container
Answer: d. Lower the enema fluid container
Rationale:
This will slow the rate of instillation & relieve some discomfort
89. A nurse is caring for a client who has been sitting in a chair for 3 hrs. Which of the
following problems is the client at risk for developing?
a. Stasis of secretions
b. Muscle atrophy
c. Pressure ulcer
d. Fecal impaction
Answer: c. Pressure ulcer
Rationale:
Unrelieved pressure over a bony prominence for too long increases the risk of a pressure
ulcer, sitting will help prevent stasis of secretions
B and D-these are from prolonged bed rest
90. A nurse is caring for a client who is on bed rest. Which of the following interventions
should the nurse implement to maintain the patency of the client's airway?
a. Encourage isometric exercises

b. Suction Q8 hr
c. Give low-dose heparin
d. Promote incentive spirometer use
Answer: d. Promote incentive spirometer use
Rationale:
helps keep airways open and prevent atelectasis, this strengthens skeletal muscles B-this is
not indicated, C-helps prevent thrombus formation
91. A nurse is caring for a client who is postop. Which of the following nursing interventions
reduce the risk of thrombus development? Select all.
a. Instruct the client not to use the Valsalva maneuver
b. Apply elastic stockings
c. Review lab values for total protein level
d. Place pillows under the client's knees & lower extremities
e. Assist the client to change position often
Answer: b. Apply elastic stockings
e. Assist the client to change position often
Rationale:
A nurse is instructing a postop client about the sequential compression device the provider
has prescribed.
92. Which of the following statements should indicate to the nurse that the client understands
the teaching?
a. "This device will keep me from getting sores on my skin."
b. "This thing will keep the blood pumping through my leg."
c. "With this thing on, my leg muscles won't get weak."
d. "This device is going to keep my joints in good shape."

Answer: b. "This thing will keep the blood pumping through my leg."
Rationale:
sequential pressure devices promote venous return in the deep veins of the legs & thus help
prevent thrombus formation.
93. To promote the safe use of a cane for a client who is recovering from a minor
musculoskeletal injury of the left lower extremity, which of the following instructions should
the nurse provide? Select all that apply.
a. Hold the cane on the right side
b. Keep 2 points of support on the floor
c. Place the cane 15in in front of the feet before advancing
d. After advancing the cane, move the weaker leg forward
e. Advance the stronger leg so that it aligns evenly w/the cane
Answer: a. Hold the cane on the right side
b. Keep 2 points of support on the floor
d. After advancing the cane, move the weaker leg forward
Rationale:
C-the client should place the cane 6-10 inches in front before advancing not 15 E-the client
should advance the stronger leg past the cane not aligned w/it
94. A nurse is assessing the pain level of a client who has come to the ER reporting severe
abd. pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is
assessing which of the following?
a. Presence of associated symptoms
b. Location of the pain
c. Pain quality
d. Aggravating & relieving factors
Answer: a. Presence of associated symptoms

Rationale:
this is a common symptom people have when experiencing pain
95. A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can
best assess the intensity of the client's pain by:
a. asking what precipitates the pain
b. questioning the client about the location of the pain
c. offering the client a pain scale to measure his pain
d. using open-ended questions to identify the situation
Answer: c. offering the client a pain scale to measure his pain
Rationale:
pain scale can measure the amount and intensity of the pain
96. A nurse is obtaining history from a client who has pain. The nurse's guiding principle
throughout this process should be that:
a. some clients exaggerate their level of pain
b. pain must have an identifiable source to justify the use of opioids.
c. objective data are essential in assessing pain
d. pain is whatever the client says it is
Answer: d. pain is whatever the client says it is
Rationale:
the client is the best source of information in their pain, it is a subjective experience
97. A nurse is caring for a client who is receiving morphine via a PCA infusion device after
abdominal surgery. Which of the following statements indicates that the client knows how to
use the device?
a. "I'll wait to use the device until it's absolutely necessary."
b. "I'll be careful about pushing the button so I don't get an overdose."

c. "I should tell the nurse if the pain doesn't stop after I use this device."
d. "I will ask my son to push the dose button when I am sleeping."
Answer: c. "I should tell the nurse if the pain doesn't stop after I use this device."
Rationale:
The client should let the nurse know if not receiving adequate pain control, so they can
reevaluate the pain control plan
98. A nurse is monitoring a client who is receiving opioid analgesia for adv effects of the
med. Which of the following effects should the nurse anticipate? Select all.
a. Urinary incontinence
b. Diarrhea
c. Bradypnea
d. Orthostatic hypotension
e. Nausea
Answer: c. Bradypnea
d. Orthostatic hypotension
e. Nausea
Rationale:
Urinary retention, not incontinence is an adverse effect of these meds as well as constipation,
not diarrhea.
99. A nurse is assessing a client who takes haloperidol (Haldol) for the tx of schizophrenia.
Which of the following findings should the nurse document as extrapyramidal symptoms
(EPS)? Select all.
a. Orthostatic hypotension
b. Fine motor tremors
c. Acute dystonias
d. Decreased level of consciousness

e. Uncontrollable restlessness
Answer: b. Fine motor tremors
c. Acute dystonias
e. Uncontrollable restlessness
Rationale:
A and D are adverse effects, but not EPS
100. A nurse is providing teaching about managing anticholinergic effects for a client who
has a new prescription for oxybutunin (Ditropan XL). Which of the following are appropriate
to include in the teaching? Select all.
a. Take frequent sips of water
b. Wear sunglasses when exposed to sunlight
c. Use a soft toothbrush when brushing teeth
d. Take the medication w/an antacid
e. Urinate prior to taking the med
Answer: a. Take frequent sips of water
b. Wear sunglasses when exposed to sunlight
d. Take the medication w/an antacid
Rationale:
side effects of this med include: dry mouth, photophobia, and urinary retention
101. A nurse is reviewing the reported meds of a client who was recently admitted. The meds
include cimetidine (Tagamet) & imipramine hydrochloride (Tofranil). Knowing that
cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify
that this combination is likely to result in which of the following effects?
a. Decreased therapeutic effects of cimetidine
b. Increased risk of imipramine hydrochloride toxicity
c. Decreased risk of adv effects of cimetidine

d. Increased therapeutic effects of imipramine hydrochloride
Answer: b. Increased risk of imipramine hydrochloride toxicity
Rationale:
med that decreases the metabolism of a 2nd med increases the serum level of the 2nd med,
increasing risk for toxicity
102. A nurse in an outpatient clinic is caring for a client who states she is trying to get
pregnant. The client currently takes a Category D pregnancy risk med for the control of
seizures. Which of the following statements by the nurse is appropriate?
a. "This med is prescribed if necessary but it is known to cause adverse effects to the fetus."
b. "This med has evidence indicating that it is safe to take during pregnancy & will not harm
the fetus."
c. "This med cannot be taken during pregnancy because the risk outweighs the potential
benefits."
d. "This med hasn't been studied in pregnant women but is believed to be safe for the fetus."
Answer: a. "This med is prescribed if necessary but it is known to cause adverse effects to
the fetus."
Rationale:
Category D meds are known to cause harm to fetuses, however the use during pregnancy may
be warranted based on potential benefits.
103. A nurse in an outpatient surgical center is admitting a client for a laparoscopic
procedure. The client has a prescription for preoperative diazepam (Valium). Prior to
administering the med, which of the following actions is the highest priority?
a. Teaching the client about the purpose of the med
b. Administering the med to the client at the prescribed time
c. Identifying the client's med allergies
d. Documenting the client's anxiety level
Answer: c. Identifying the client's med allergies

Rationale:
The greatest risk to the client is an allergic reaction to the med
104. A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by
IV bolus. The amount available is 40 mg/mL. How many mL should the nurse administer?
(round to nearest tenth)
Answer: 0.3 mL
Rationale:
To calculate the volume of methylprednisolone acetate (Depo-Medrol) 10 mg needed:
Given:
Amount available: 40 mg/mL
Desired dose: 10 mg

Rounded to the nearest tenth, the nurse should administer 0.3 mL.
105. A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15min. The
nurse should set the infusion pump to deliver how many mL/hr? (round to nearest whole
number)
Answer: 400 mL/hr
Rationale:
To calculate the mL/hr for an IV infusion:
Given:
Volume to be infused: 100 mL
Infusion time: 15 minutes
First, convert the infusion time to hours:

Rounded to the nearest whole number, the nurse should set the infusion pump to deliver 400
mL/hr.
106. A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to
infuse over 30min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should
set the manual IV infusion to deliver how many gtt/min? (round to nearest whole number)
Answer: 83 gtt/min
Rationale:
To calculate the drip rate for an IV infusion:
Given:
Volume to be infused: 250 mL
Infusion time: 30 minutes
-Drop factor: 10 gtt/mL
First, convert the infusion time to hours:

Rounded to the nearest whole number, the nurse should set the manual IV infusion to deliver
500 gtt/hr.

Rounded to the nearest whole number, the nurse should set the manual IV infusion to deliver
83 gtt/min.
107. A nurse is caring for a client who is at high risk for aspiration. Which of the following is
an appropriate nursing intervention?
a. Give the client thin liquids.
b. Instruct the client to tuck her chin when swallowing.
c. Have the client use a straw.
d. Encourage the client to lie down & rest after meals.
Answer: b. Instruct the client to tuck her chin when swallowing.
Rationale:
Tucking when swallowing allows food to pass down esophagus more easily.
108. A nurse is preparing a presentation about basic nutrients for a group of high school
athletes. She should explain that which of the following is the body's priority energy reserve?
a. Fat
b. Protein
c. Glycogen
d. Carbohydrates
Answer: d. Carbohydrates
Rationale:
Carbs provide glucose

109. A nurse is caring for a client who is on a low-residue diet. The nurse should expect to
see which of the following foods on the client's meal tray?
a. Cooked barley
b. Pureed broccoli
c. Vanilla custard
d. Lentil soup
Answer: c. Vanilla custard
Rationale:
low-residue diets are low in fiber and easy to digest: dairy products especially
110. A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall.
Calculate her BMI & determine whether this client is obese based on her BMI.
Answer: BMI=30
Rationale:
above 30 equals obese so yes.
111. A nurse in a senior center is counseling a group of older adults about their nutritional
needs & considerations. Which of the following info should the nurse include? Select all.
a. Older adults are more prone to dehydration than younger adults are
b. Older adults need the same amount of most vitamins & minerals as younger adults do
c. Many older men & women need calcium supplementation
d. Older adults need more calories than they did when they were younger
e. Older adults should consume a diet low in carbs
Answer: a. Older adults are more prone to dehydration than younger adults are
b. Older adults need the same amount of most vitamins & minerals as younger adults do
c. Many older men & women need calcium supplementation
Rationale:

D-they need fewer calories not more E-they need more carbs & fiber
112. A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The
client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication
administration record, which of the following medications should the nurse administer?
a. Meperidine (Demerol) 75 mg IM
b. Fentanyl 50 mcg/hr transdermal patch
Morphine 2 mg IV
d. Oxycodone 10 mg PO
Answer: c. Morphine 2 mg IV
Rationale:
IV morphine is the best because the onset is rapid and absorption to the blood is immediate,
which is adequate for a client with a 10 pain severity
113. A nurse is teaching a client about taking multiple oral meds at home to include timerelease capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following
statements by the client indicates an understanding of the teaching?
a. "I can open the capsule w/the beads in it & sprinkle them on my oatmeal."
b. "If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding."
c. "The pills w/the coating on them can be crushed."
d. "I will eat 2 crackers w/the pain pills."
Answer: d. "I will eat 2 crackers w/the pain pills."
Rationale:
this will prevent N&V from the narcotic
114. A nurse is teaching a client how to administer medication through a jejunostomy tube.
Which of the following instructions should the nurse include in the teaching?
a. "Flush the tube before & after each med."
b. "Administer your meds w/your enteral feeding."

c. "Administer tablets through the tube slowly."
d. "Mix all the crushed meds prior to dissolving in water."
Answer: a. "Flush the tube before & after each med."
Rationale:
The client should flush the tube w/15-30 mL of water to prevent clogging of the tube
105. A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed
nurses. Which of the following statements by a newly licensed nurse indicates an
understanding of the 1st-pass effect?
a. "Some meds block normal receptor activity regulated by endogenous compounds or
receptor activity caused by other meds."
b. "Some meds may have to be administered by a non-enteral route to avoid inactivation as
they travel through the liver."
c. "Some meds leave the body more slowly & therefore have a greater risk of accumulation &
toxicity."
d. "Some meds have a wide safety margin, so there is no need for routine serum medication
level monitoring."
Answer: b. "Some meds may have to be administered by a non-enteral route to avoid
inactivation as they travel through the liver."
Rationale:
first pass deals with the liver
106. A nurse is teaching an adult client how to administer ear drops. Which of the following
statements by the client indicates understanding of the proper technique?
a. "I will straighten my ear canal by pulling my ear down & back."
b. "I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops."
c. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops
in."
d. "After the drops are in, I will place a cotton ball all the way into my ear canal."

Answer: b. "I will gently apply pressure w/my finger to the tragus of my ear after putting in
the drops."
Rationale:
The client should apply gentle pressure w/the finger to the tragus of the ear after
administering the drops to help the drops go into the ear canal.
107. A nurse prepares to administer an injection of morphine (Duramorph) to a client who
reports pain. Prior to administering, the nurse is called to another room to assist another client
onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions
should the 2nd nurse take?
a. Offer to assist the client needing the bedpan.
b. Administer the injection prepared by the other nurse
c. Prepare another syringe & administer the injection
d. Tell the client needing the bedpan she will have to wait for her nurse
Answer: a. Offer to assist the client needing the bedpan.
Rationale:
When asked to administer a medication prepared by another nurse, the second nurse should
not administer the medication. Instead, the second nurse should offer assistance to the client
needing the bedpan. This ensures that the client's needs are met promptly and that the
medication is administered by the nurse who prepared it. Additionally, administering
medications prepared by another nurse without verifying them violates the principles of
medication safety.
108. A nurse is preparing to administer a med to a client. The med was scheduled for
administration at 0900. Which of the following are acceptable administration times for this
med? Select all.
a. 0905
b. 0825
c. 1000
d. 0840

e. 0935
Answer: a. 0905
d. 0840
Rationale:
30min time frame for meds
109. A nurse is working w/a newly hired nurse who is administering meds to clients. Which
of the following actions by the newly hired nurse indicates an understanding of med error
prevention?
a. Taking all meds out of the unit-dose wrappers before entering the client's room
b. Checking w/the provider when a single dose requires administration of multiple tablets
c. Administering a med, then looking up the usual dosage range
d. Relying on another nurse to clarify a med prescription
Answer: b Checking w/the provider when a single dose requires administration of multiple
tablets
Rationale:
this could indicate a possible error so it should be checked w/the provider
110. A nurse educator is teaching a module on safe med administration to newly hired nurses.
Which of the following statements by the newly hired nurse indicate understanding of the
nurse's responsibility when implementing med therapy? Select all.
a. "I will observe for med side effects."
b. "I will monitor for therapeutic effects."
c. "I will prescribe the appropriate dose."
d. "I will change the dose if adverse effects occur."
e. "I will refuse to give a med if I believe it is unsafe."
Answer: a. "I will observe for med side effects."
b. "I will monitor for therapeutic effects."

e. "I will refuse to give a med if I believe it is unsafe."
Rationale:
a. "I will observe for med side effects." - Nurses are responsible for monitoring patients for
any adverse effects or side effects of medications they administer.
b. "I will monitor for therapeutic effects." - Nurses should assess the patient to ensure that the
medication is achieving the desired therapeutic effects.
e. "I will refuse to give a med if I believe it is unsafe." - Nurses have the responsibility to
refuse to administer a medication if they believe it is unsafe for the patient. This is an
important aspect of patient advocacy and medication safety.
111. A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want
to take that med. I do not want one more pill." Which of the following responses by the nurse
is appropriate in this situation?
a. "Your physician prescribed it for you, so you really should take it."
b. "Well, let's just get it over w/quickly then."
c. "Okay, I'll just give you your other meds."
d. "Tell me your concerns w/taking this med."
Answer: d. "Tell me your concerns w/taking this med."
Rationale:
In this situation, the nurse should address the client's concerns and explore the reasons behind
the refusal to take the medication. Option d allows the nurse to open a dialogue with the
client, identify the client's concerns, and provide appropriate education or support. It
demonstrates patient-centered care and respects the client's autonomy and right to refuse
treatment.
112. A nurse is assessing a client who has an acute resp. infection that puts her at risk for
hypoxemia. Which of the following findings are early indications that should alert the nurse
that the client is developing hypoxemia? Select all.
a. Restlessness
b. Tachypnea

c. Bradycardia
d. Confusion
e. Pallor
Answer: a. Restlessness
b. Tachypnea
e. Pallor
Rationale:
C and D are late manifestations of hypoxemia.
113. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed
& is already receiving oxygen therapy via nasal cannula. Which of the following
interventions is the nurse's priority?
a. Increase the oxygen flow
b. Assist the client to Fowler's position
c. Promote removal of pulmonary secretions
d. Obtain a specimen for arterial blood gases
Answer: b. Assist the client to Fowler's position
Rationale:
Fowler's facilitates better breathing
114. A nurse is preparing to preform endotracheal suctioning for a client. Which of the
following are appropriate guidelines for the nurse to follow? Select all.
a. Apply suction while withdrawing the catheter
b. Perform suctioning on a routine basis, Q2-3 hours
c. Maintain medical asepsis during suctioning
d. Use a new catheter for each suctioning attempt
e. Limit suctioning to 2-3 attempts

Answer: a. Apply suction while withdrawing the catheter
d. Use a new catheter for each suctioning attempt
e. Limit suctioning to 2-3 attempts
Rationale:
B-Suctioning is not w/out risk so it should be done as needed, not routinely. Cendotracheal
suctioning requires surgical asepsis
115. A nurse is caring for a client who has a tracheostomy. Which of the following actions
should the nurse take each time he provides tracheostomy care? Select all.
a. Apply the oxygen source loosely if the SPO2 decreases during the procedure
b. Use surgical asepsis to remove & clean the inner cannula
c. Clean the outer surfaces in a circular motion from the stoma site onward
d. Replace the tracheostomy ties w/new ties
e. Cut a slit in gauze squares to place beneath the tube holder.
Answer: a. Apply the oxygen source loosely if the SPO2 decreases during the procedure
b. Use surgical asepsis to remove & clean the inner cannula
c. Clean the outer surfaces in a circular motion from the stoma site onward
d. Replace the tracheostomy ties w/new ties
Rationale:
D-only replace ties if soiled or wet E-use a commercially prepared gauze w/slit not one nurse
makes
116. A provider is discharging a client with a prescription from home oxygen therapy via
nasal cannula. Client & family teaching by the nurse should include which of the following?
Select all.
a. Apply petroleum jelly around the inside of the nares
b. Remove the nasal cannula during mealtimes
c. Check the position of the cannula often

d. Report any nasal stuffiness, nausea, or fatigue
e. Post "no smoking" signs in a prominent location
Answer: c. Check the position of the cannula often
d. Report any nasal stuffiness, nausea, or fatigue
e. Post "no smoking" signs in a prominent location
Rationale:
Check the position of the cannula often: Ensures that the oxygen delivery is effective and the
cannula is properly positioned.
Report any nasal stuffiness, nausea, or fatigue: These symptoms may indicate oxygen toxicity
or inadequate oxygen delivery.
Post "no smoking" signs in a prominent location: Oxygen supports combustion, so smoking
near oxygen can cause a fire or explosion.
117. A nurse is delivering an enteral feeding to a client who has an NG tube in place for
intermittent feedings. When the nurse pours water into the syringe after the formula drains
from the syringe, the client asks the nurse why the water is necessary. Which of the following
is an appropriate response by the nurse?
a. "Water helps clear the tube so it doesn't get clogged."
b. "Flushing helps make sure the tube stays in place."
c. "This will help you get enough fluids."
d. "Adding water makes the formula less concentrated."
Answer: a. "Water helps clear the tube so it doesn't get clogged
Rationale:
this action clears the excess formula preventing any clumps/clogging
118. A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place.
Which of the following is the nurse's highest assessment priority before performing this
procedure?
a. Check how long the feeding container has been opened

b. Verify the placement of the NG tube
c. Confirm that the client doesn't have diarrhea
d. Make sure the client is alert & oriented
Answer: b. Verify the placement of the NG tube
Rationale:
The greatest risk is aspiration so verifying the placement of the tube is most important
119. A nurse is caring for a client who is receiving continuous enteral feedings. Which of the
following nursing interventions is the highest priority when the nurse suspects aspiration of
the feeding?
a. Auscultate breath sounds
b. Stop the feeding
c. Obtain a chest xray
d. Initiate oxygen therapy
Answer: b. Stop the feeding
Rationale:
The highest priority nursing intervention when aspiration of enteral feeding is suspected is to
stop the feeding immediately. Aspiration can lead to serious respiratory complications such as
pneumonia. Once the feeding is stopped, the nurse can assess the client's condition, including
auscultating breath sounds, obtaining a chest x-ray, and initiating oxygen therapy as needed.
However, stopping the feeding is the first and most immediate action to prevent further
aspiration.
120. A nurse is caring for a client in a long-term care facility who is receiving enteral
feedings via NG tube. Which of the following is an appropriate nursing action prior to
administering the tube feeding? Select all that apply
a. Auscultate bowel sounds.
b. Assist the client to an upright position.
c. Test the pH of gastric aspirate.

d. Warm the formula to body temp.
e. Discard any residual gastric contents.
Answer:
a. Auscultate bowel sounds.
b. Assist the client to an upright position.
c. Test the pH of gastric aspirate.
Rationale:
D-the formula should be room temp not body, E-unless the volume of the contents is more
than 250 mL, the nurse should the residual content to the client's stomach
121. A nurse is preparing to insert an NG tube for a client who requires gastric
decompression.
Which of the following actions should the nurse perform prior to beginning the procedure?
Select all.
a. Review a signal the client can use if feeling any distress
b. Lay a towel across the client's chest
c. Administer oral pain meds
d. Obtain a Dobhoff tube for insertion
e. Have a petroleum-based lubricant available
Answer: a. Review a signal the client can use if feeling any distress
b. Lay a towel across the client's chest
Rationale:
Review a signal the client can use if feeling any distress: It is essential to establish a method
of communication with the client before starting the procedure to ensure the client can
indicate if they are experiencing distress during the insertion.

Lay a towel across the client's chest: Placing a towel across the client's chest helps protect
their clothing and bedding from any gastric contents that may be expelled during the
procedure.
122. An adolescent who has diabetes mellitus is 2 days postop following an appendectomy.
The client is tolerating a regular diet. He has ambulated successfully around the unit
w/assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10
after receiving the med. His incision is approximated & free of redness, w/scant serous
drainage on the dressing. Which of the following risk factors for poor wound healing does
this client have? Select all.
a. Extremes in age
b. Impaired circulation
c. Impaired/suppressed immune system
d. Malnutrition
e. Poor wound care
Answer: b. Impaired circulation
c. Impaired/suppressed immune system
Rationale:
Impaired circulation: The client's diabetes mellitus puts him at risk for impaired circulation,
which an compromise wound healing.
Impaired/suppressed immune system: Diabetes mellitus and recent surgery can impair the
immune system, increasing the risk of infection and delaying wound healing.
123. A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon
suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to
initiate after collecting wound & blood specimens for culture & sensitivity. Which of the
following assessment findings should the nurse expect? Select all.
a. Increase in incisional pain
b. Fever & chills
c. Reddened wound edges

d. Increase in serosanguineous drainage
e. Decrease in thirst
Answer: a. Increase in incisional pain
b. Fever & chills
c. Reddened wound edges
Rationale:
Increase in incisional pain: Pain is often a significant indicator of wound infection as
inflammation and infection increase sensitivity in the area.
Fever & chills: Systemic signs of infection, such as fever and chills, are common indicators
of wound infection.
Reddened wound edges: Redness around the wound indicates inflammation, which is often
associated with infection.
124. A nursing instructor is reviewing the wound healing process w/a group of nursing
students. They should be able to identify which of the following alterations as a wound or
injury that heals by secondary intention? Select all.
a. Stage III pressure ulcer
b. Sutured surgical incision
c. Casted bone fracture
d. Laceration sealed w/adhesive
e. Open burn area
Answer: a. Stage III pressure ulcer
e. Open burn area
Rationale:
B and D are healed w/primary intention, C is not a skin wound unless bone has pierced the
skin

125. A client who had abd. surgery 24 hr ago reports a pulling sensation & pain in his surgical
incision. The nurse checks the client's surgical wound & finds the wound separated w/viscera
protruding. Which of the following interventions is appropriate? Select all.
a. Cover the area w/saline-soaked sterile dressings
b. Apply an abdominal binder snugly around the abd.
c. Use sterile gloves to apply gentle pressure to the exposed tissues
d. Position the client supine w/his hips & knees bent
e. Offer the client a warm beverage, such as herbal tea
Answer: a. Cover the area w/saline-soaked sterile dressings
d. Position the client supine w/his hips & knees bent
Rationale:
Cover the area w/saline-soaked sterile dressings: This helps keep the exposed tissue moist
and reduces the risk of infection.
Position the client supine w/his hips & knees bent: This position helps to relieve tension on
the wound site and can reduce the risk of further damage or injury.
126. A nurse is caring for an older adult client who is at risk for developing pressure ulcers.
Which of the following interventions should the nurse use to help maintain the integrity of
the client's skin? Select all.
a. Keep the head of the bed elevated 30 degrees
b. Massage the client's bony prominences often
c. Apply cornstarch liberally to the skin after bathing
d. Have the client sit on a gel cushion when in a chair
e. Reposition the client at least Q 3 hr while in bed
Answer: a. Keep the head of the bed elevated 30 degrees
d. Have the client sit on a gel cushion when in a chair
Rationale:

Not E because it should be at least every 2 hours

VERSION 2
39. The nurse is caring for an older adult with mild dementia with heart failure. What nursing
care will be helpful for this client in reducing potential confusion related to hospitalization
and change in routine? Select all that apply.
a. Reorient frequently to time, place, and situation.
b. Put the client in a quiet room furthest from the nursing station.
c. Perform the necessary procedures quickly.
d. Arrange for familiar pictures or special items at bedside.
e. Limit the client’s visitors.
f. Spend time with the client, establishing a trusting relationship.
Answer: a, d, f
Rationale:
a. Reorient frequently to time, place, and situation: Reorientation helps the client stay
oriented to the surroundings and reduces confusion.
d. Arrange for familiar pictures or special items at bedside: Familiar items can provide
comfort and enhance orientation.
f. Spend time with the client, establishing a trusting relationship: Spending time with the
client builds trust and enhances the client's sense of security and well-being.
40. Which would be most helpful when coaching a client to stop smoking?
a. Review the negative effects of smoking on the body.
b. Discuss the effects of passive smoking on environmental pollution.
c. Establish the client’s daily smoking pattern.
d. Explain how smoking worsens high blood pressure.
Answer: a

Rationale:
a. Review the negative effects of smoking on the body: Providing information about the
negative health effects of smoking can motivate the client to quit.
41. A nurse is helping a suspected choking victim. The nurse should perform the Heimlich
maneuver when the victim:
a. Starts to become cyanotic
b. Cannot speak due to airway obstruction
c. Can make only minimal vocal noises
d. Is coughing vigorously
Answer: b
Rationale:
b. Cannot speak due to airway obstruction: The inability to speak indicates a severe airway
obstruction and the need for the Heimlich maneuver.
42. While the nurse is providing preoperative teaching for a client with peripheral vascular
disease who is to have a below-the-knee amputation, the client says, “I hate the idea of being
an invalid after they cut off my leg.” The nurse’s most therapeutic response should be:
a. “Focusing on using your one good leg will make your recovery easier.”
b. “Tell me more about how you are feeling.”
c. “We will talk more about this after your surgery.”
d. “You are fortunate to have a wife who can take care of you.”
Answer: b
Rationale:
b. “Tell me more about how you are feeling.” This response encourages the client to express
feelings and concerns, promoting therapeutic communication.
43. Which indicates that a client has achieved the goal of correctly demonstrating deep
breathing for an upcoming splenectomy? The client:

a. Breathes in through the nose and out through the mouth
b. Breathes in through the mouth and out through the nose
c. Uses diaphragmatic breathing in the lying, sitting, and standing positions.
d. Takes a deep breath in through the nose, holds it for seconds, and blows it out through
pursed lips
Answer: d
Rationale:
d. Takes a deep breath in through the nose, holds it for seconds, and blows it out through
pursed lips: This breathing technique promotes lung expansion and prevents alveolar
collapse.
44. Which nursing action is most important in preventing cross-contamination?
a. Changing gloves immediately after use
b. Standing 2 feet (61cm) from the client
c. Speaking minimally when in the room
d. Wearing protective coverings
Answer: a
Rationale:
a. Changing gloves immediately after use: Changing gloves between patient contacts prevents
the spread of microorganisms and cross-contamination.
45. The nurse’s best explanation for why the severely neutropenic client is placed in reverse
isolation is that reverse isolation helps prevent the spread of organisms:
a. To the client from sources outside the client’s environment
b. From the client to healthcare personnel, visitors, and other clients
c. By using special techniques to handle the client’s linens and personal items
d. By using special techniques to dispose of contaminated materials
Answer: b

Rationale:
b. From the client to healthcare personnel, visitors, and other clients: Reverse isolation is
used to protect immunocompromised patients from infectious organisms carried by others.
46. Which statement indicates to the nurse that a client has understood the discharge
instructions provided after nasal surgery?
a. “I should not shower until my packing is removed.”
b. “I will take stool softeners and modify my diet to prevent constipation.”
c. “Coughing every 2 hours is important to prevent respiratory complications.”
d. “It is important to blow my nose each day to remove the dried secretions.”
Answer: a
Rationale:
a. “I should not shower until my packing is removed.” After nasal surgery, it's essential to
avoid getting the packing wet to prevent infection and ensure proper healing.
47. The nurse is suctioning a client who had a laryngectomy. What is the maximum amount
of time the nurse should suction the client?
a. 10 seconds
b. 20 seconds
c. 25 seconds
d. 30 seconds
Answer: b
Rationale:
b. 20 seconds: Prolonged suctioning can lead to hypoxia, so the maximum suctioning time for
a laryngectomy patient is typically 20 seconds.
48. A client with a history of asthma is admitted to the emergency department. The nurse
notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and
use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath
sounds.

What should the nurse do first?
a. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes
b. Draw blood for arterial blood gas
c. Encourage the client to relax and breath slowly through the mouth
d. Administer bronchodilators as prescribed
Answer: a
Rationale:
a. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes: Oxygen
therapy is the priority to correct hypoxemia and support respiratory function.
49. A confused client with carbon monoxide poisoning experiences dizziness when
ambulating to the bathroom. The nurse should:
a. Put all four side rails up on the bed
b. Ask the unlicensed assistive personnel to place restraints on the client’s upper extremities
c. Request that the client’s roommate put the call light on when the client is attempting to get
out of bed
d. Check on the client at regular intervals to ascertain the need to use the bathrooms
Answer: d
Rationale:
d. Check on the client at regular intervals to ascertain the need to use the bathrooms: This
action ensures the client's safety while allowing some independence and mobility.
50. The nurse should use which type of precautions for a client being admitted to the hospital
with suspected tuberculosis?
a. Hand hygiene
b. Contact precautions
c. Droplet precautions
d. Airborne precautions

Answer: d
Rationale:
d. Airborne precautions: Tuberculosis is transmitted via airborne droplet nuclei, so airborne
precautions are necessary to prevent the spread of infection.
51. The nurse is teaching a client with stomatitis about mouth care. Which instruction is most
appropriate?
a. Drink hot tea at frequent intervals
b. Gargle with antiseptic mouthwash
c. Use an electric toothbrush
d. Eat a soft, bland diet
Answer: d
Rationale:
d. Eat a soft, bland diet: Stomatitis causes inflammation of the mouth, making it painful to
eat. A soft, bland diet minimizes discomfort and promotes healing.
52. A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which
indicates the client is ready to try a liquid diet? The client:
a. Is hungry
b. Has not requested pain medication for 8 hours
c. Has frequent bowel sounds
d. Has had a bowel movement
Answer: c
Rationale:
c. Has frequent bowel sounds: Frequent bowel sounds indicate the return of gastrointestinal
function, which is necessary before advancing the diet to liquids.
53. A client has returned from surgery during which the jaws were wired as treatment for a
fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed

assistive personnel (UAP) on how to properly position the client. Which instructions about
positioning would be appropriate for the nurse to give to the UAP?
a. Keep the client in a side-lying position with the head slightly elevated
b. Do not reposition the client without the assistance of a registered nurse
c. The client can assume any position that is comfortable
d. Keep the client’s head elevated on two pillows at all times
Answer: a
Rationale:
a. Keep the client in a side-lying position with the head slightly elevated: This position helps
prevent aspiration and facilitates drainage, ensuring client safety and comfort.
ATI Fundamentals VERSION 3
1. A nurse is teaching a group of older adults about expected changes of aging. Which of the
following statements by a group member indicates that the teaching has been effective?
Answer: "I should expect my heart rate to take longer to return to normal after excessive as I
get older."
2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the
following abdominal assessments should the nurse expect?
Answer: Absent bowel sounds with distention
3. A nurse is planning care for a client who reports abdominal pain. An assessment by the
nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of
105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following
findings should be the nurse's priority?
Answer: Temperature
4. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
Answer: Administer analgesics to the child on a routine schedule throughout the day and
night.

5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both
systole and diastole with diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
Answer: Pericardial friction rub
6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the
following statements by the AP indicates an understanding of the teaching?
Answer: "There are times I should use soap and water rather than alcohol based hand rub to
clean my hands."
7. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes
by an electronic blood pressure machine. The nurse notices the machine begins to measure
the blood pressure at varied intervals and the readings are inconsistent. Which of the
following actions should the nurse take?
Answer: Discontinue the machine, and measure the blood pressure manually every 15 min.
8. A nurse is providing teaching to a client who has heart failure about how to reduce his
daily intake of sodium. Which of the following factors is the most important in determining
the client's ability to learn new dietary habits?
Answer: The involvement of the client in planning the change
9. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing
diarrhea and who might have a right ear infection. Which of the following routes should the
nurse use to obtain the temperature?
Answer: Temporal
10. A nurse is witnessing a client sign an informed consent form for surgery. Which of the
following describes what the nurse is affirming by this action?
Answer: The signature on the preoperative consent form is the client’s
11. A nurse on a medical-surgical unit is admitting a client. Which of the following
information should the nurse document in the client’s record first?
Answer: Assessment

12. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical
handwashing techniques?
Answer: The nurse washes with her hands held higher than her elbows.
13. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve?
Answer: Second intercostal space to the right of the sternum
14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which
of the following actions should the nurse take?
Answer: Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
15. A nurse is caring for an older adult client who becomes agitated when the nurse requests
the client’s dentures be removed prior to surgery. Which of the following responses should
the nurse make?
Answer: “What worries you about being without your teeth?”
16. A nurse is caring for a client who has a terminal illness. The client asks several questions
about the nurse’s religious beliefs related to death and dying. Which of the following actions
should the nurse take?
Answer: Encourage the client to express his thoughts about death and dying
17. A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to learning
self-injection of insulin. Which of the following statements should the nurse make?
Answer: “Tell me what I can do to help you overcome your fear of giving yourself
injections.”
18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
Answer: Confirm unresponsiveness.

19. A community health nurse is preparing a campaign about seasonal influenza. Which of
the following plans should the nurse include as a secondary prevention?
Answer: Screening groups of older adults in nursing care facilities for early influenza
manifestations
20. A nurse is preparing to provide tracheostomy care for a client. Which of the following
actions should the nurse take first?
Answer: Perform hand hygiene
21. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the
following actions should the nurse take?
Answer: Place the bladder of the cuff over the posterior aspect of the thigh
22. A nurse is caring for a client who requires a chest x-ray. Prior to the client being
transported for the procedure, which of the following actions should the nurse take first?
Answer: Identify the client using two identifiers
23. A nurse in an emergency department is assessing a client who reports diarrhea and
decreased urination for 4 days. Which of the following actions should the nurse take to assess
the client's skin turgor?
Answer: Grasp a skin fold on the chest under the clavicle, release it, and note whether it
springs back
24. A nurse is providing teaching to an older adult client who has constipation. Which of the
following statements should the nurse include in the teaching?
Answer: "Sit on the toilet 30 minutes after eating a meal."
25. A nurse on a medical-surgical unit is caring for a client. Which of the following actions
should the nurse take first when using the nursing process?
Answer: Obtain client information
26. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from
bed to a wheelchair. Which of the following techniques should the nurse use?
Answer: Place the wheelchair at a 45 degree angle to the bed

27. A nurse is planning weight loss strategies for a group of clients who are obese. Which of
the following actions by the nurse will improve the client's commitment to a longterm goal of
weight loss?
Answer: Attempt to increase the client's self-motivation
28. A nurse is caring for an older adult client who is violent and attempting to disconnect her
IV lines. The provider prescribes soft wrist restraints. Which of the following actions should
the nurse take while the client is in restraints?
Answer: Remove the restraints one at a time
29. A nurse is caring for a client who is in terminal stage of cancer. Which of the following
actions should the nurse take when she observes the client crying?
Answer: Sit and hold the client's hand
30. A nurse in an oncology clinic is assessing a client who is undergoing treatment for
ovarian cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
Answer: "I keep having nightmares about my upcoming surgery."
31. A nurse is performing an abdominal assessment for an adult client. Identify the correct
sequence of steps for this assessment.
Answer: Inspect, Auscultate, Percuss, Palpate
32. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a
client. Which of the following actions by the newly licensed nurse requires intervention?
Answer: Obtaining cotton balls for the tracheostomy care
33. A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
Answer: Evaluate pedal pulses
34. A nurse is preparing a client who is scheduled for hysterectomy for transport to the
operating room when the client states she no longer wants to have surgery. Which of the
following actions should the nurse take?
Answer: Notify the provider about the client's decision

35. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in
the next month that might require a blood transfusion. The client expresses concern about the
risk of acquiring an infection from the blood transfusion. Which of the following statements
should the nurse make to the client?
Answer: Donate autologous blood before the surgery
36. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client
who will have emergency surgery for appendicitis. Which of the following statements
indicates a lack of readiness to learn by the client?
Answer: The client reports severe pain
37. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a
regular size cuff for a client who is obese. Which of the following explanations should the
nurse give the AP
Answer: "Using a cuff that is too small will result in an inaccurately high reading."
38. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved
hand. The client has no documented bloodstream infection. Which of the following actions
should the nurse take?
Answer: Carefully remove the gloves and follow with hand hygiene
39. A nurse is receiving a client from the PACU who is postoperative following abdominal
surgery. Which of the following actions should the nurse take to transfer the client from
stretcher to the bed?
Answer: Lock the wheels on the bed and stretcher
40. A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take?
Answer: Raise the level of the bed
ATI fundamental 1 VERSION 4
A nurse is caring for a client who has a terminal illness. The client asks several questions
about the nurse's religious beliefs related to death and dying. Which of the following actions
should the nurse take?

a. Change the topic because the client is trying to divert attention from the illness to the
nurse.
b. Encourage the client to express his thoughts about death and dying?
c. Tell the client that religious beliefs are a personal matter.
d. Offer to contact the client's minister or the facility's chaplain.
Answer: b
Rationale:
A nurse should recognize the client's need to talk about impending death, and encourage the
client to discuss his thoughts on the subject. This is therapeutic technique of reflecting.
Depending on the situation, the nurse can also share some thoughts on this topic. Self
disclosure is a communication skill that can help open lines of communication when
appropriate. If the nurse does not want to share personal beliefs, the communication skills of
offering self and listening to the client's thoughts are appropriate.
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first?
a. Open all sterile supplies and solutions.
b. Stabilize the tracheostomy tube.
c. Don sterile gloves.
d. Perform hand hygiene.
Answer: d
Rationale:
According to evidence-based practice, the nurse should first perform hand hygiene before
touching the client or performing any skills, such as tracheostomy care. This is vital because
contamination of the nurse's hands is a primary source of infection.
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of
the following actions should the nurse take?
a. Measure the pulse using a Doppler ultrasound stethoscope.

b. Check the client's pedal pulses.
c. Count the apical pulse rate for a full minute and describe the rhythm in the chart.
d. Take the pulse at each peripheral site and count the rate for 30 seconds.
Answer: c
Rationale:
If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 1 minute to
obtain an accurate rate. The nurse should document irregularity in the client's medical record.
A nurse on a med-surg unit is caring for a client.
Which of the following actions should the nurse take first when using the nursing process?
a. Identify goals for client care.
b. Obtain client information
c. Document nursing care needs
d. Evaluate the effectiveness of care
Answer: b
Rationale:
The nursing process is based on scientific process. The first step in the scientific process is
the collection of data. Therefore, the first step is assessing and obtaining information about
the client.
A nurse is receiving a client from the PACU (post-anesthetic care unit) who is postoperative
following abdominal surgery. Which of the following actions should the nurse take to transfer
the client from stretcher to the bed?
a. Lock the wheels on the bed and stretcher
b. Instruct the client to raise his arms above his head
c. Elevate the stretch 2.5 cm (1 inch) above the height of the bed
d. Log roll the client
Answer: a

Rationale:
Locking the wheels prevents the client from falling to the floor by not allowing the cart of
bed to move apart or away from the client.
A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
a. Evaluate pedal pulses
b. Obtain medical history
c. Measure vital signs
d. Assess for leg pain
Answer: a
Rationale:
For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in
order to determine adequate blood supply to the foot. The nurse should apply the safety and
risk reduction priority-setting framework. This framework assigns priority to the factor
posing the greatest safety risk to the client. When there are several risks to client safety, the
one posing the greatest threat is the highest priority. The nurse should use Maslow's
Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify
which risk poses the greatest threat to the client.
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the
following abdominal assessments should the nurse expect?
a. Frequent bowel sounds with flatus
b. Absent bowel sounds with distention
c. Hyperactive bowel sounds with diarrhea
d. Normal bowel sounds with increased peristalsis
Answer: b
Rationale:

Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the
abdomen is distended
A nurse is providing teaching to an older adult client who has constipation. Which of the
following statements should the nurse include in the teaching?
a. "Drink a minimum of 1,000 ml of fluid daily"
b. "Increase your intake of refined-fiber foods"
c. "Sit on the toilet 30 mins after eating a meal"
d. "Take a laxative everyday to maintain regularity"
Answer: c
Rationale:
Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after
eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel
retraining to treat constipation
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. the nurse auscultates a high-pitched scratching sound during both
systole and diastole with diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
a. Audible click
b. Murmur
c. Third heart sound
d. Pericardial friction rub
Answer: d
Rationale:
A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound
heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial
friction rub is a manifestation of pericardial inflammation and can be heard with infective
pericarditis with myocardial infarction, following a cardiac surgery or trauma, and with some

autoimmune problems, such as rheumatic fever. The client who develops pericarditis
typically has chest pain which becomes worse with inspiration or coughing and which may be
relieved by sitting up and leaning forward.
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who
will have emergency surgery for appendicitis. Which of the following statements indicates a
lack of readiness to learn by the client?
a. The client asks the nurse to repeat the instructions before attempting the exercises.
b. The client reports severe pain
c. The client asks the nurse how often deep breathing should be done after surgery.
d. The client tells the nurse that this exercise will probably be painful after surgery.
Answer: b
Rationale:
A client who is experiencing severe pain is not able to concentrate and therefore, is not ready
to learn a new activity
A nurse is teaching a group of older adults about expected changes of aging. Which of the
following statements by a group member indicates that the teaching has been effective?
a. "I should expect my heart rate to take longer to return to normal after exercise as I get
older"
b. "Urinary incontinence is something I will have to live with as I grow older"
c. "I can expect to have less ear was as I get older"
d. "My stomach will empty more quickly after meals as I grow older"
Answer: a
Rationale:
Older adults experience decreased CO, which causes increased pulse rate during exercise.
The pulse rate also takes longer to return to normal after exercise.
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning
selfinjection of insulin. Which of the following statements should the nurse make?

a. "Tell me what I can do to help you overcome your fear of giving yourself injections"
b. "I am sure your provider will not be pleased that you refuse to give yourself insulin
injections"
c. "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections"
d. "You won't be able to go home unless you learn to give yourself insulin injections"
Answer: a
Rationale:
The response illustrates the therapeutic communication technique of clarifying and offering
of self. It is important for the nurse to allow the client to express feelings and fears and to
support the client in learning how to give the injections.
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the
next month that might require a blood transfusion. The client expresses concern about the risk
of acquiring an infection from the blood transfusion. Which of the following statements
should the nurse make to the client?
a. "Ask your provider to prescribe epoetin before the surgery"
b. "You should ask your provider about taking iron supplements prior to the surgery"
c. "Request a family member to donate blood for you"
d. "Donate autologous blood before the surgery"
Answer: d
Rationale:
Autologous blood transfusion is the collection and reinfusion of the client's blood. With
preoperative autologous blood donation, the blood is drawn from the client 3-5 week before
an elective surgical procedure and stored for transfusion at the time of the surgery.
Autologous blood is the safest form of blood transfusion because exclusive use of a client's
own blood eliminates exposure to transfusion-transmitted infection.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?

a. Obtaining hydrogen peroxide for the tracheostomy care.
b. Obtaining cotton balls for the tracheostomy care
c. Obtaining sterile gloves for the tracheostomy care
d. Obtaining a sterile brush for the tracheostomy care
Answer: b
Rationale:
Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a
tracheal abscess. The charge nurse should intervene for this action
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a
regular size cuff for a client who is obese. Which of the following explanations should the
nurse give the AP?
a. "The reading will be inaudible if the cuff is too small for the client"
b. "The width of the cuff bladder should be 75% of the circumference of the client's arm"
c. "As long as the cuff will circle the arm the reading will be accurate"
d. "Using a cuff that is too small will result in an inaccurately high reading"
Answer: d
Rationale:
Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a
reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for
the client. A nurse is caring for a client who requires a chest x-ray. Prior to the client being
transported for the procedure, which of the following actions should the nurse take first?
a. Explain the x-ray procedure to the client
b. Help the client into a wheelchair before the transporter arrives
c. Ask if the client has any questions
d. Identify the client using two identifiers
Answer: d

Rationale:
The nurse should apply the safety and risk reduction priority-setting framework. This
framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the
highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting
framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
Once the client's identity is determined, the nurse can then proceed with the other options.
This action is the priority action because it provides for the safety of the client. It is a nursing
responsibility to be certain that each client receives only what has been prescribed. The nurse
must assure that the correct client is being transported for the chest x-ray.
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
a. Auscultate for the BP at the dorsalis pedis artery
b. Measure the BP with the client sitting on the side of the bed
c. Place the cuff 7.6 cm (3 inches) above the popliteal artery
d. Place the bladder of the cuff over the posterior aspect of the thigh
Answer: d
Rationale:
This is the correct position for the nurse to place the bladder of the cuff when measuring a
lower extremity BP
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
a. Encourage the child to cough frequently to clear congestion from anesthesia
b. Place a heating pad at the child's neck for comfort
c. Administer analgesics to the child on a routine schedule throughout the day and night
d. Provide the child with icecream when oral intake is initiated
Answer: c

Rationale:
To sooth the client's throat following a tonsillectiomy, the nurse should administer pain
medication routinely around the clock. The nurse can provide the medication rectally or
intravenously to avoid the oral route.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV
lines. The provider prescribes soft wrist restraints. Which of the following actions should the
nurse take while the client is in restraints?
a. Tie restraints to the side rails
b. Perform ROM exercises to the wrists every 3hr
c. Remove restraints one at a time
d. Obtain a PRN prescription for the restraints
Answer: c
Rationale:
The nurse should remove one restraint at a time for a client who is violent or noncompliant A
charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses.
Which of the following actions should the charge nurse teach as the first response in CPR?
a. Call for assistance
b. Begin chest compressions
c. Confirm unresponsiveness
d. Give rescue breaths
Answer: c
Rationale:
The nurse should apply the nursing process priority-setting framework. The nurse can use the
nursing process to plan client care and prioritize nursing actions. Each step of the nursing
process builds on the previous step, beginning with the assessment or data collection. Before
the nurse can formulate a plan of action, implement a nursing intervention or notify a

provider of a change in the client's status, she must first collect adequate data from the client.
Assessing or collecting additional data will provide the nurse with knowledge to make an
appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a
client is unresponsive, the nurse should activate the emergency response team.
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea
and who might have a right ear infection. Which of the following routes should the nurse use
to obtain the temperature?
a. Rectal
b. Tympanic
c. Oral
d. Temporal
Answer: d
Rationale:
The temporal artery route, while not as accurate as the rectal route for obtaining a precise
body temperature, is noninvasive and can be used to obtain a temperature in a toddler who
might have an ear infection and who is having diarrhea. The nurse should place the probe
behind the ear if the client is diaphoretic, but should avoid placing it over an area covered
with hair.
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve?
a. 5th intercostal space just medial to the midclavicular line
b. 2nd intercostal space to the left of the sternum
c. 5th intercostal space to the left of the sternum
d. 2nd intercostal space to the right of the sternum
Answer: d
Rationale:

The aortic valve is located at the second intercostal space to the right of the sternum. Aortic
stenosis produces a mid systolic ejection murmur that can be heard clearly at the aortic area
with the client leaning forward.